The Use of Methylphenidate During Inpatient Rehabilitation After Pediatric Traumatic Brain Injury: Population Characteristics and Prescribing Patterns.

OBJECTIVE: To understand how methylphenidate (MPH) is used in youth with traumatic brain injury (TBI) during inpatient pediatric rehabilitation. SETTING: Inpatient pediatric rehabilitation. PARTICIPANTS: In total, 234 children with TBI; 62 of whom received MPH and 172 who did not. Patients were on average 11.6 years of age (range, 2 months to 21 years); 88 of 234 were female; the most common mechanism of injury was motor vehicle collision (49%); median (IQR) acute hospital length of stay (LOS) and inpatient rehabilitation LOS were 16 (10-29) and 23 (14-39), respectively; 51 of 234 were in a disorder of consciousness cognitive state at time of inpatient rehabilitation admission. DESIGN: Multicenter, retrospective medical record review. MAIN MEASURES: Patient demographic data, time to inpatient pediatric rehabilitation admission (TTA), cognitive state, MPH dosing (mg/kg/day). RESULTS: Patients who received MPH were older (P = .011); TTA was significantly longer in patients who received MPH than those who did not (P =.002). The lowest recorded dose range by weight was 0.05 to 0.89 mg/kg/d, representing an 18-fold difference; the weight-based range for the maximum dose was 0.11 to 0.97 mg/kg/d, a 9-fold difference. Patients in lower cognitive states at admission (P = .001) and at discharge (P = .030) were more likely to receive MPH. Five patients had side effects known to be associated with MPH; no serious adverse events were reported. CONCLUSION: This multicenter study indicates that there is variable use of MPH during acute inpatient rehabilitation for children with TBI. Children who receive MPH tend to be older with lower cognitive states. Dosing practices are likely consistent with underdosing. Clinical indications for MPH use during inpatient pediatric rehabilitation should be better defined. The use of MPH, as well as its combination with other medications and treatments, during inpatient rehabilitation needs to be further explored.

An Initial Psychometric Evaluation of a Novel Upper Extremity Pediatric Stroke Hemiplegic Motor Impairment Scale.

BACKGROUND: Our team designed an innovative, observation-based motor impairment measure-the Pediatric Stroke Hemiplegic Motor Impairment Scale (Pedi HEMIs). Here we present the results of a survey describing common practices in the pediatric stroke community and the initial psychometric properties of the upper extremity subscale of the Pedi HEMIs (Pedi HEMIs-UE). METHODS: This is a cross-sectional study whereby participants completed a battery of assessments including the novel Pedi HEMIs-UE. Internal consistency was measured via Cronbach alpha (α). Intraclass correlation (ICC) was used to assess inter-rater reliability (IRR). Concurrent validity was investigated using Pearson or polychoric correlations and simple linear regressions. RESULTS: The study sample consisted of 18 children aged 1.08 to 15 years. Two participants completed two sets of evaluations, totaling 20 data sets. Cronbach α, a measure of internal consistency, was on average 0.91 (range: 0.89 to 0.92). IRR was excellent with the six raters in almost perfect agreement (ICC = 0.91; 95% confidence interval [CI]: 0.83 to 0.96). Pearson correlation coefficient between the Pedi HEMIs-UE and logit Assisting Hand Assessment (AHA)/mini-AHA was -0.938 (95% CI: -0.979 to -0.827, P < 0.001), indicating excellent concurrent validity. CONCLUSIONS: We found excellent feasibility, reliability, and validity of the Pedi HEMIs-UE in a convenience sample of youth with hemiparesis after stroke.

Efficacy of a virtual reality-based cognitive interactive training program for children with traumatic brain injuries: study protocol for a parallel-group randomized controlled trial.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of disability in children. Cognitive rehabilitation for this population is critical for their long-term health outcomes. This trial aims to evaluate the efficacy of a virtual reality-based program (VICT) for training executive functions in children with TBI. METHODS: A parallel group randomized controlled trial will be conducted among up to 32 children with TBI. Children in the intervention group will receive the VICT training while children in the control group will play a comparable VR game without executive function training. Each participant will be assessed at baseline, post-intervention, and 1-month follow-up. Outcomes will include core executive functions, attention, and health-related quality of life measured by computerized tasks or standardized questionnaires. DISCUSSION: Cognitive rehabilitation is among the top healthcare needs for pediatric TBI patients. Virtual reality-based training is promising due to its versatile content, flexibility, and potential cost savings for both patients and providers. Findings of this trial will provide data on the efficacy of the VICT program on core executive functions, attention problems, and health-related quality of life and serve as the empirical foundation for future larger multi-site effectiveness trials. TRIAL REGISTRATION: ClinicalTrials.gov NCT04526639 . Registered on August 18, 2020.

Screening for Delirium During Pediatric Brain Injury Rehabilitation.

OBJECTIVE: To assess feasibility of routine delirium screening using the Cornell Assessment of Pediatric Delirium (CAPD) in children admitted for rehabilitation with acquired brain injury (ABI), report on the prevalence of positive delirium screens in this population, and explore longitudinal trends in CAPD scores and their association with rehabilitation outcomes. DESIGN: Retrospective study. SETTING: Pediatric inpatient rehabilitation unit. PARTICIPANTS: 144 children (median 10.8 years) with ABI (N=144). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Percent compliance with twice daily delirium screening; prevalence of positive delirium screens; trajectories in CAPD scores and their relation with FIM for Children (WeeFIM) scores. RESULTS: Screening was feasible (mean 75% compliance for each of 144 children). Of 16,136 delirium screens, 29% were positive. 62% of children had ≥1 positive screen. Four primary patterns of CAPD trajectories were identified: Static Encephalopathy (10%), Episodic Delirium (10%), Improving (32%), and No Delirium (48%). Validity of these trajectories was demonstrated through association with WeeFIM and CALS outcomes. Younger age at admission was associated with positive delirium screens, and rehabilitation length of stay was significantly longer for the Improving group. CONCLUSIONS: Delirium occurs frequently in children with ABI during inpatient rehabilitation. Routine delirium screening provides clinically relevant information including the potential to facilitate early detection and intervention for medical complications. Longitudinal ratings of delirium symptoms may also have a role in developing a standardized definition for Post Traumatic Confusional State (PTCS) stage of recovery in children.

Caregiver and family functioning after pediatric disorder of consciousness: telephone-based outcome assessment.

OBJECTIVE: Examine initial feasibility/utility of a telephone-administered measure in describing impact of child health on caregiver/family functioning in patients with a history of a disorder of consciousness (DoC) due to severe-acquired brain injury (ABI). METHOD: Caregivers of patients admitted at least 1 year prior for inpatient rehabilitation with DoC completed a battery of measures administered via telephone examining the impact of child health on caregiver/family functioning (Pediatric Quality of Life Family Impact Module; PedsQL-FIM) and child functioning. RESULTS: Forty-one caregivers of unique patients (age = 5-22 years; M = 14.9, SD = 5.1; 63% male; time since injury = 1-18 years; M = 5.3; SD = 4.2) completed the telephone measures. PedsQL-FIM floor and ceiling effects were minimal (administration time = 5-16 min, M = 7.4; SD = 2.8). Family functioning was lowest in Daily Activities and highest in Family Relationships. Relative to caregivers of patients with mild-severe ABI, caregivers reported lower caregiver/family functioning. Correlations were moderate between child functioning and caregiver/family functioning on some PedsQL-FIM scales. CONCLUSIONS: Within this relatively small convenience sample, results indicate the PedsQL-FIM administered via telephone is feasible and useful in describing the impact of child health on caregiver/family functioning long after DoC associated with ABI. Future studies are needed to understand factors contributing to caregiver/family functioning to inform targeted interventions.

Head Control Contributes to Prediction of Emergence From the Minimally Conscious State in Children Admitted to Inpatient Rehabilitation.

OBJECTIVE: To examine the utility of head and trunk control, assessed using the Physical Abilities and Mobility Scale, for predicting emergence from a minimally conscious state (eMCS) among children with acquired brain injury admitted to inpatient rehabilitation in a disorder of consciousness (DoC). DESIGN: Retrospective study. SETTING: Pediatric inpatient rehabilitation hospital. PARTICIPANTS: Forty patients (2-21 years-old) directly admitted from acute care to pediatric inpatient brain injury rehabilitation in a DoC (average length of stay=85 days; N=40). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: State of consciousness (eMCS vs not) at discharge from inpatient rehabilitation. RESULTS: Forty-five percent of patients emerged from a minimally conscious state during inpatient rehabilitation. Admission state of consciousness and head control (but not trunk control) were significantly associated with eMCS and provided complementary prognostic information. Admission state of consciousness (ie, admitting in a vegetative state/unresponsive wakefulness syndrome) afforded the greatest negative predictive value (93.8%), whereas admission head control ability afforded the greatest positive predictive value (81.8% for any independent head control; 100% for maintaining head-up position for >30 seconds). Fifty percent of patients who emerged during the inpatient stay did not have independent head control at admission, highlighting the importance of exploring head control as a prognostic marker in conjunction with indicators with greater sensitivity (eg, state of consciousness at admission). CONCLUSIONS: A brief measure of head control at admission may contribute to identification of a subgroup of patients who are likely to emerge.

Multimodal Analysis of Secondary Cerebellar Alterations After Pediatric Traumatic Brain Injury.

Importance: Traumatic brain injury (TBI) is known to cause widespread neural disruption in the cerebrum. However, less is known about the association of TBI with cerebellar structure and how such changes may alter executive functioning. Objective: To investigate alterations in subregional cerebellum volume and cerebral white matter microstructure after pediatric TBI and examine subsequent changes in executive function. Design, Setting, and Participants: This retrospective cohort study combined 12 data sets (collected between 2006 and 2020) from 9 sites in the Enhancing Neuroimaging Genetics Through Meta-Analysis Consortium Pediatric TBI working group in a mega-analysis of cerebellar structure. Participants with TBI or healthy controls (some with orthopedic injury) were recruited from trauma centers, clinics, and institutional trauma registries, some of which were followed longitudinally over a period of 0.7 to 1.9 years. Healthy controls were recruited from the surrounding community. Data analysis occurred from October to December 2022. Exposure: Accidental mild complicated-severe TBI (msTBI) for those in the TBI group. Some controls received a diagnosis of orthopedic injury. Main Outcomes and Measures: Volume of 18 cerebellar lobules and vermal regions were estimated from 3-dimensional T1-weighted magnetic resonance imaging (MRI) scans. White matter organization in 28 regions of interest was assessed with diffusion tensor MRI. Executive function was measured by parent-reported scores from the Behavior Rating Inventory of Executive Functioning. Results: A total of 598 children and adolescents (mean [SD] age, 14.05 [3.06] years; range, 5.45-19.70 years; 386 male participants [64.5%]; 212 female participants [35.5%]) were included in the study, with 314 participants in the msTBI group, and 284 participants in the non-TBI group (133 healthy individuals and 151 orthopedically injured individuals). Significantly smaller total cerebellum volume (d = -0.37; 95% CI, -0.52 to -0.22; P < .001) and subregional cerebellum volumes (eg, corpus medullare; d = -0.43; 95% CI, -0.58 to -0.28; P < .001) were observed in the msTBI group. These alterations were primarily seen in participants in the chronic phase (ie, >6 months postinjury) of injury (total cerebellar volume, d = -0.55; 95% CI, -0.75 to -0.35; P < .001). Smaller cerebellum volumes were associated with higher scores on the Behavior Rating Inventory of Executive Functioning Global Executive Composite score (ß = -208.9 mm3; 95% CI, -319.0 to -98.0 mm3; P = .008) and Metacognition Index score (ß = -202.5 mm3; 95% CI, -319.0 to -85.0 mm3; P = .02). In a subset of 185 participants with longitudinal data, younger msTBI participants exhibited cerebellum volume reductions (ß = 0.0052 mm3; 95% CI, 0.0013 to 0.0090 mm3; P = .01), and older participants slower growth rates. Poorer white matter organization in the first months postinjury was associated with decreases in cerebellum volume over time (ß=0.52 mm3; 95% CI, 0.19 to 0.84 mm3; P = .005). Conclusions and Relevance: In this cohort study of pediatric msTBI, our results demonstrated robust cerebellar volume alterations associated with pediatric TBI, localized to the posterior lobe. Furthermore, longitudinal cerebellum changes were associated with baseline diffusion tensor MRI metrics, suggesting secondary cerebellar atrophy. These results provide further understanding of secondary injury mechanisms and may point to new opportunities for intervention.

Traumatic Brain Injury Positive Strategies for Families: A Pilot Randomized Controlled Trial of an Online Parent-Training Program.

OBJECTIVE: To determine program satisfaction and preliminary efficacy of Traumatic Brain Injury Positive Strategies (TIPS), a web-based training for parenting strategies after child brain injury. DESIGN: A randomized controlled trial with parallel assignment to TIPS intervention or usual-care control (TAU). The three testing time-points were pretest, posttest within 30 days of assignment, and 3-month follow-up. Reported in accordance with CONSORT extensions to randomized feasibility and pilot trials SETTING: Online. PARTICIPANTS: Eighty-three volunteers recruited nationally who were 18 years of age or older, U.S. residents, English speaking and reading, had access to high-speed internet, and were living with and caring for a child who was hospitalized overnight with a brain injury (ages 3-18 years, able to follow simple commands; N=83). INTERVENTIONS: Eight interactive behavioral training modules on parent strategies. The usual-care control was an informational website. MAIN OUTCOME MEASURES: The proximal outcomes were User Satisfaction, Usefulness, Usability, Feature Preference, Strategy Utilization and Effectiveness, and Learning and Self-Efficacy for TIPS program participants. The primary outcomes were: Strategy Knowledge, Application, and Strategy-Application Confidence; Family Impact Module of Pediatric Quality of Life Inventory (PedsQL); and Caregiver Self-Efficacy Scale. The secondary outcomes were TIPS vs TCore PedsQL and Health Behavior Inventory (HBI) RESULTS: Pre- and posttest assessments were completed by 76 of 83 caregivers; 74 completed their 3-month follow-up. Linear growth models indicated that relative to TAU, TIPS yielded greater increases in Strategy Knowledge over the 3-month study (d=.61). Other comparisons did not reach significance. Outcomes were not moderated by child age, SES, or disability severity measured by Cognitive Function Module of PedsQL. All TIPS participants were satisfied with the program. CONCLUSIONS: Of the 10 outcomes tested, only TBI knowledge significantly improved relative to TAU.

The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury.

OBJECTIVE: To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings. DESIGN: Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus. PARTICIPANTS: The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations. RESULTS: The first 2 Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.' CONCLUSIONS: New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

Rethinking recovery in adolescent concussions: Network-level functional connectivity alterations associated with motor deficits.

Adolescents who are clinically recovered from concussion continue to show subtle motor impairment on neurophysiological and behavioral measures. However, there is limited information on brain-behavior relationships of persistent motor impairment following clinical recovery from concussion. We examined the relationship between subtle motor performance and functional connectivity of the brain in adolescents with a history of concussion, status post-symptom resolution, and subjective return to baseline. Participants included 27 adolescents who were clinically recovered from concussion and 29 never-concussed, typically developing controls (10-17 years); all participants were examined using the Physical and Neurologic Examination of Subtle Signs (PANESS). Functional connectivity between the default mode network (DMN) or dorsal attention network (DAN) and regions of interest within the motor network was assessed using resting-state functional magnetic resonance imaging (rsfMRI). Compared to controls, adolescents clinically recovered from concussion showed greater subtle motor deficits as evaluated by the PANESS and increased connectivity between the DMN and left lateral premotor cortex. DMN to left lateral premotor cortex connectivity was significantly correlated with the total PANESS score, with more atypical connectivity associated with more motor abnormalities. This suggests that altered functional connectivity of the brain may underlie subtle motor deficits in adolescents who have clinically recovered from concussion. More investigation is required to understand the persistence and longer-term clinical relevance of altered functional connectivity and associated subtle motor deficits to inform whether functional connectivity may serve as an important biomarker related to longer-term outcomes after clinical recovery from concussion.

Functional Recovery During Inpatient Rehabilitation in Children With Anoxic or Hypoxic Brain Injury.

OBJECTIVES: To (1) describe characteristics of children with anoxic or hypoxic brain injuries (AnHBI) who presented to an inpatient rehabilitation unit, (2) explore functional outcomes of children with AnHBI at discharge, and (3) examine differences between children with AnHBI associated with cardiac arrest (CA) vs those with respiratory arrest (RA) only. DESIGN: Retrospective cohort study. SETTING: Pediatric inpatient rehabilitation hospital in the Northeast United States. PARTICIPANTS: A total of 46 children and adolescents ages 11 months to 18 years admitted to an inpatient rehabilitation brain injury unit (1994-2018) for a first inpatient admission after AnHBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pediatric Cerebral Performance Category Scale (PCPC), Pediatric Overall Performance Category, and Functional Independence Measure for Children developmental functional quotients (WeeFIM DFQs) total and subscale scores. RESULTS: Most children had no disability before injury (PCPC=normal, n=37/46) and displayed significant functional impairments at admission to inpatient rehabilitation (PCPC=normal/mild, n=1/46). WeeFIM and PCPC scores improved significantly during inpatient rehabilitation (WeeFIM DFQ Total, P=.003; PCPC, P<.001), although many children continued to demonstrate significant impairments at discharge (PCPC=normal/mild, n=5/46). Functioning was better for the RA-only group relative to the CA group at admission (WeeFIM DFQ Total, P=.006) and discharge (WeeFIM DFQ Total, P<.001). Ongoing gains in functioning were noted 3 months after discharge compared with discharge (WeeFIM DFQ Cognitive, P=.008). CONCLUSIONS: In this group of children with AnHBI who received inpatient rehabilitation, functional status improves significantly between rehabilitation admission and discharge. By discharge, many children continued to display significant impairments, a minority of children had favorable neurologic outcomes, and children with CA have worse outcomes than those with RA-only. Given the small sample size, future research should examine functional recovery during inpatient rehabilitation in a larger, multisite cohort and include longer-term follow-up to examine recovery patterns over time.

Outcome Measurement in Children With a History of Disorders of Consciousness After Severe Brain Injury: Telephone Administration of the Vineland Adaptive Behavior Scales, Third Edition, and Glasgow Outcome Scale-Extended Pediatric Revision.

OBJECTIVES: Examine initial feasibility and utility of a battery of measures administered via telephone interview with a caregiver for describing long-term outcomes in individuals with a history of disorders of consciousness (DoC) after pediatric acquired brain injury (ABI). DESIGN: Cross-sectional. SETTING: Caregiver interview administered via telephone. PATIENTS: Convenience sample admitted to an inpatient pediatric neurorehabilitation unit with DoC after ABI at least 1 year prior to assessment (n = 41, 5-22 yr old at assessment). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The Vineland Adaptive Behavior Scales, Third Edition (Vineland-3), and Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds) were examined. Administration time of the Vineland-3 ranged from 13 to 101 minutes (m = 50) and the GOS-E Peds ranged from 2 to 10 minutes (m = 3). Vineland-3 Adaptive Behavior Composite (ABC) ranged from standard scores (SSs) of 20 (exceptionally low) to 100 (average) and GOS-E Peds scores ranged from 3 (i.e., upper moderate disability) to 7 (vegetative state). Lower adaptive functioning on the Vineland-3 ABC was strongly associated with greater disability on the GOS-E Peds (r = -0.805). On the Vineland-3 ABC, 19.5% earned the lowest possible score, whereas 12.2% obtained the lowest possible score for survivors on the GOS-E Peds; only 7.3% earned lowest scores on both measures. CONCLUSIONS: The Vineland-3 and GOS-E Peds were feasibly administered by telephone and were complementary in this cohort; the GOS-E provided a quick and easy measure of gross functional outcome, whereas the Vineland-3 took longer to administer but provided a greater level of detail about functioning. When both measures were used together, the range and variability of scores were maximized.

Inter-rater Reliability of the Revised Physical and Neurological Examination of Subtle Signs (PANESS) scored using video review.

The Physical and Neurological Examination of Subtle Signs (PANESS) is a brief neuromotor exam designed for use in children. This study examined the inter-rater reliability of PANESS scoring using video review in 23 typically developing youth, aged 10-18 years, who were either never-concussed or evaluated following clinical recovery from concussion. Moderate to excellent inter-rater reliability was identified across PANESS subscores and total score. The strongest inter-rater reliability was observed for the Timed Motor portion of the PANESS (ICCs >.90) suggesting that this section in particular may be a strong candidate for video-based scoring or telehealth administration.

Cannabidiol Treatment for Neurological, Cognitive, and Psychiatric Symptoms in Sturge-Weber Syndrome.

BACKGROUND: A prior drug trial of cannabidiol for treatment-resistant epilepsy in patients with Sturge-Weber syndrome (SWS), a rare neurovascular condition, implicated improvements in neurological, quality of life (QOL), neuropsychologic, psychiatric, and motor outcomes. METHODS: Ten subjects with SWS brain involvement, controlled seizures, and cognitive impairments received study drug in this Johns Hopkins institutional review board-approved, open-label, prospective drug trial. Oral cannabidiol was taken for six months (dose ranged from 5 to 20 mg/kg/day). SWS neuroscore, port-wine birthmark score, QOL, and adverse events were recorded every four to 12 weeks. Neuropsychologic, psychiatric, and motor assessments were administered at baseline and six months' follow-up. Most evaluations were conducted virtually due to the coronavirus disease 2019 pandemic. RESULTS: Cannabidiol was generally well tolerated. Six subjects reported mild to moderate side effects related to study drug and continued on drug; one subject withdrew early due to moderate side effects. No seizures were reported. Significant improvements in SWS neuroscore, patient-reported QOL, anxiety and emotional regulation, and report of bimanual ability use were noted. Migraine QOL scores were high at baseline in these subjects, and remained high. Neuropsychologic and other QOL and motor outcomes remained stable, with some within-subject improvements noted. CONCLUSIONS: Further studies are needed to determine whether Epidiolex can improve quality of life and be beneficial for neurological, anxiety, and motor impairments in SWS independent of seizure control. Large multicentered studies are needed to extend these preliminary findings.

Altered white matter diffusivity and subtle motor function in a pilot cohort of adolescents with sports-related concussion.

BACKGROUND AND OBJECTIVE: Adolescents with sports-related concussion (SRC) demonstrate acute and persistent deficits in subtle motor function. However, there is limited research examining related neurological underpinnings. This pilot study examined changes in motor-associated white matter pathways using diffusion tensor imaging (DTI) and their relationship with subtle motor function. METHODS: Twelve adolescents with SRC (12-17 years) within two-weeks post-injury and 13 never-injured neurotypical peers completed DTI scanning. A subset of 6 adolescents with SRC returned for a follow-up visit post-medical clearance from concussion. Subtle motor function was evaluated using the Physical and Neurological Examination of Subtle Signs (PANESS). RESULTS: Adolescents with SRC showed higher mean diffusivity (MD) of the superior corona radiata and greater subtle motor deficits compared to controls. Across all participants, greater subtle motor deficits were associated with higher (more atypical) MD of the superior corona radiata. Preliminary longitudinal analysis indicated reduction in fractional anisotropy of the corpus callosum but no change in the MD of the superior corona radiata from the initial visit to the follow-up visit post-medical clearance. CONCLUSIONS: These findings support preliminary evidence for a brain-behavior relationship between superior corona radiata microstructure and subtle motor deficits in adolescents with SRC that merits further investigation.

Rasch Properties of the Cognitive and Linguistic Scale and Optimization for Outcome Trajectory Modeling in Pediatric Acquired Brain Injury.

OBJECTIVES: To (1) determine if items on the Cognitive and Linguistic Scale (CALS) follow a Rasch distribution and (2) explore the relationship between Rasch-derived Cognitive Ability Estimates and outcome trajectory parameters using a nonlinear mixed-effects modeling approach. DESIGN: Retrospective study. SETTING: Pediatric inpatient rehabilitation hospital. PARTICIPANTS: A total of 252 children (N=252) aged of 2-21 years (median, 11.8 [IQR, 6.4-15.9] years) consecutively admitted to an inpatient rehabilitation brain injury unit (2008-2014) for a first inpatient admission after acquired brain injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rasch-derived Cognitive Ability Estimates from the CALS and associated outcome trajectory parameters. RESULTS: The CALS demonstrates adequate interval-scale properties with removal of scores from the arousal and responsivity items. Rasch-derived Cognitive Ability Estimates were associated with age (ß=0.025, P<.001) such that older age was associated with a faster rate of recovery and more complete ultimate recovery. Slower recovery initiation was associated with a less complete overall cognitive recovery (Spearman ρ=-0.31; P<.001). CONCLUSIONS: The Cognitive Ability Estimates derived from the CALS and associated outcome parameters (eg, rate of recovery) may serve as an ideal outcome measure for clinical trials evaluating interventions for acquired brain injury in a pediatric rehabilitation setting.

Prescribing Patterns of Amantadine During Pediatric Inpatient Rehabilitation After Traumatic Brain Injury: A Multicentered Retrospective Review From the Pediatric Brain Injury Consortium.

OBJECTIVES: To describe dosing practices for amantadine hydrochloride and related adverse effects among children and young adults with traumatic brain injury (TBI) admitted to pediatric inpatient rehabilitation units. SETTING: Eight pediatric acute inpatient rehabilitation units located throughout the United States comprising the Pediatric Brain Injury Consortium. PARTICIPANTS: Two-hundred thirty-four children and young adults aged 2 months to 21 years with TBI. DESIGN: Retrospective data revie. MAIN OUTCOME MEASURES: Demographic variables associated with the use of amantadine, amantadine dose, and reported adverse effects. RESULTS: Forty-nine patients (21%) aged 0.9 to 20 years received amantadine during inpatient rehabilitation. Forty-five percent of patients admitted to inpatient rehabilitation with a disorder of consciousness (DoC) were treated with amantadine, while 14% of children admitted with higher levels of functioning received amantadine. Children with DoC who were not treated with amantadine were younger than those with DoC who received amantadine (median 3.0 vs 11.6 years, P = .008). Recorded doses of amantadine ranged from 0.7 to 13.5 mg/kg/d; the highest total daily dose was 400 mg/d. Adverse effects were reported in 8 patients (16%); nausea/abdominal discomfort and agitation were most common, each reported in 3 patients. The highest reported dose without an adverse effect was 10.1 mg/kg/d. CONCLUSION: During pediatric inpatient rehabilitation, amantadine was prescribed to children across a range of ages and injury severity and was most commonly prescribed to older children with DoC. Dosing varied widely, with weight-based dosing for younger/smaller children at both lower and higher doses than what had been previously reported. Prospective studies are needed to characterize the safety and tolerability of higher amantadine doses and optimize amantadine dosing parameters for children with TBI.

Evidence-Based Medicine Training in United States-Based Physiatry Residency Programs.

ABSTRACT: Although the physiatric community increasingly embraces evidence-based medicine (EBM), the current state of EBM training for trainees in physiatry is unclear. The purposes of this article are to report the results of the Association of Academic Physiatrists' surveys of physiatry residency programs in the United States, to discuss the implications of their findings, and to better delineate the "baseline" upon which sound and clear recommendations for systematic EBM training can be made. The two Association of Academic Physiatrists surveys of US physiatry residency programs reveal that most survey respondents report that they include EBM training in their programs that covers the five recommended steps of EBM core competencies. However, although most respondents reported using traditional pedagogic methods of training such as journal club, very few reported that their EBM training used a structured and systematic approach. Future work is needed to support and facilitate physiatry residency programs interested in adopting structured EBM training curricula that include recommended EBM core competencies and the evaluation of their impact.

Thirty-Second Single-Leg Stance Identifies Impaired Postural Control in Children After Concussion: A Preliminary Report.

CONTEXT: Objective and expedient assessments of standing postural control incorporating static and dynamic tasks are necessary for identifying subtle motor deficits and clearing children to return to high-risk activities after concussion. The Revised Physical and Neurological Examination for Subtle Signs (PANESS) gaits and stations tasks evaluate both static and dynamic aspects of postural control. While the PANESS gaits and stations subscale is sensitive to concussion in youth, the benefit of each specific task for this purpose is unknown. PURPOSE: This study evaluated whether specific PANESS tasks identify postural impairments after youth concussion. DESIGN: Cross-sectional study. SETTING: Academicallyaffiliated research laboratory. PARTICIPANTS: Sixty youth, ages 10-17 years, comprised 3 groups: (1) youth symptomatic from concussion (4-14 d postinjury [n = 18]), (2) clinically-recovered youth (27-122 d postinjury [n = 15]), and (3) age- and gender-matched never-concussed controls (n = 27). MAIN OUTCOME MEASURE: PANESS gaits and stations tasks (6 dynamic and 3 static) at the time of the initial research visit. RESULTS: Kruskal-Wallis statistic identified a significant main effect of group on standing on one foot (a 30-s task). Both symptomatic and clinically-recovered youth showed deficits on standing on one foot relative to controls. CONCLUSIONS: Single-leg tasks of longer duration may maximize the ability to detect residual postural deficits after concussion and can be readily incorporated in targeted sport rehabilitation protocols.

Acquired Brain Injury in the Pediatric Intensive Care Unit: Special Considerations for Delirium Protocols.

The goal of this article was to highlight the overlapping nature of symptoms of delirium and acquired brain injury (ABI) in children and similarities and differences in treatment, with a focus on literature supporting an adverse effect of antipsychotic medications on recovery from brain injury. An interdisciplinary approach to education regarding overlap between symptoms of delirium and ABI is important for pediatric intensive care settings, particularly at this time when standardized procedures for delirium screening and management are being increasingly employed. Development of treatment protocols specific to children with ABI that combine both nonpharmacologic and pharmacologic strategies will reduce the risk of reliance on treatment strategies that are less preferred and optimize care for this population.