Behavior problems 7 years after severe childhood traumatic brain injury: Results of the Traumatisme Grave de L'Enfant study.

PURPOSE/OBJECTIVE: To investigate the occurrence of behavioral problems 7 years after severe pediatric traumatic brain injury (TBI), and their evolution from 3 months to 7 years postinjury. METHOD/DESIGN: Thirty-four participants, 38% girls, M (SD) age at injury 7.6 (4.7) years, age at assessment 15 (4.6) years, underwent comprehensive assessments 7 years after severe TBI from March 2014 to March 2016 and were matched to a control group by age, gender, and parental education. A subgroup of 20 participants had available behavioral assessments at 3, 12, and 24 months postinjury. Internalizing, externalizing, and total behavioral problems were assessed with self- and parent reports of the Achenbach's Behavioral Checklist. Additional data included sociodemographic background, initial injury severity, and specific outcomes assessed concurrently 7 years postinjury. RESULTS: Compared to controls: (a) a significant proportion of participants with severe TBI fell above the clinical cutoff for self- (42%) and parent-reported (36%) externalizing problems, but not for self- (33%) or parent-reported (45%) internalizing problems; (b) withdrawn/depressed, intrusive behavior, and somatic complaints were significantly higher in self-reports; and (c) rule-breaking behavior, attention, and social problems were significantly higher in parent reports. Parent-reported internalizing problems were associated with older age at injury, whereas externalizing problems correlated with greater injury severity and concurrent levels of greater overall disability, lower intellectual ability, and poorer family functioning. In multiple hierarchical regression analyses, overall disability and worse family functioning significantly predicted externalizing problems. Parent-reported internalizing and externalizing problems persisted over time. CONCLUSIONS/IMPLICATIONS: These results highlight the importance of long-term follow-up and individualized behavioral interventions for children who sustained severe TBI. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Long-term burden of informal caregiver 7-years after severe childhood traumatic brain injury in the traumatisme grave de l'Enfant (TGE) study.

OBJECTIVE: To investigate reported burden by the Primary Family Caregiver (PFC) 7-years after severe pediatric traumatic brain injury in the TGE (Traumatisme Grave de l'Enfant) longitudinal study. METHODS: Subjective burden was estimated with the Zarit Burden Inventory (ZBI) in 36 PFC (parents), who rated their own health status (Medical Outcome Study Short Form-12), family functioning and their child's level of care and needs (Pediatric/Adult Care And Needs Scale [PCANS/CANS]). Data collection included: child and PFC sociodemographic characteristics, injury-related factors, 'objective' (e.g. overall level of disability: Glasgow Outcome Scale - Extended, GOS-E/GOS-E-Peds) and 'subjective' outcomes (e.g. participation, behavior, executive functions, quality of life and fatigue). RESULTS: 25% of PFC reported mild-moderate burden, and 19% moderate-severe burden. Higher burden correlated with worse outcomes in all 'subjective' PFC-rated outcomes, and with self-reported participation. The ZBI correlated strongly with CANS/PCANS and GOS-E/GOS-E-Peds. Overall level of disability and PFC-reported executive functioning explained 62% of the ZBI variance. For equal levels of disability, burden was higher when PFC reported a 'negative' picture of their child. CONCLUSION: Significant PFC-reported burden 7-years post-injury was associated with overall disability and 'subjective' PFC-rated outcomes. Factors influencing parental burden in the long term should be identified and psychological support implemented over time.

Cognitive Orientation to daily Occupational Performance to improve occupational performance goals for children with executive function deficits after acquired brain injury.

AIM: To determine the effectiveness of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach in improving the occupational performance goals of children and young people with executive function deficits after acquired brain injury (ABI) (e.g. etiologies such as stroke, encephalitis, brain tumor, and traumatic brain injury). METHOD: A replicated single-case experimental study using a randomized multiple baseline design across participants and goals was used. Three clusters of four participants (12 participants, nine males and three females, aged 8-16 years) were included. The intervention consisted of 14 individual CO-OP sessions. Each participant chose four goals; three goals were trained during the intervention sessions and a fourth goal served as the control. The Goal Attainment Scale (GAS) was used as a repeated measure to determine goal achievement while the Canadian Occupational Performance Measure (COPM) was used to identify the perceived goal achievement of children, young people, and their parents. RESULTS: For 26 of the 35 trained goals, the intervention led to statistically significant improvements in the GAS. Perceived occupational performance and satisfaction improved significantly for the trained goals (30 out of 35 goals for the COPM performance and satisfaction of participants; 26 out 31 goals for the COPM performance of parents; 24 out of 31 goals for the COPM satisfaction of parents) and were maintained at the follow-up. Almost all COPM control goal results were significant, but these changes were not supported by the GAS measures or the statistical analysis. INTERPRETATION: The generally positive results of this study provide evidence of the benefits of using the CO-OP approach with this population.

Comprehensive assessment of executive functioning following childhood severe traumatic brain injury: clinical utility of the child executive functions battery.

Objectives: To perform a detailed description of executive functioning following moderate-to-severe childhood traumatic brain injury (TBI), and to study demographic and severity factors influencing outcome. Methods: A convenience sample of children/adolescents aged 7-16 years, referred to a rehabilitation department after a TBI (n = 43), was compared to normative data using a newly developed neuropsychological test battery (Child Executive Functions Battery-CEF-B) and the BRIEF. Results: Performance in the TBI group was significantly impaired in most of the CEF-B subtests, with moderate to large effect sizes. Regarding everyday life, patients were significantly impaired in most BRIEF clinical scales, either in parent or in teacher reports. Univariate correlations in the TBI group did not yield significant correlations between the CEF-B and socio-economic status, TBI severity, age at injury, or time since injury. Conclusion: Executive functioning is severely altered following moderate-to-severe childhood TBI and is best assessed using a combination of developmentally appropriate neuropsychological tests and behavioral ratings to provide a comprehensive understanding of children's executive functions.

Impact of Subarachnoid Hemorrhage on the Cardiac Autonomic Function During Rehabilitation in Children After Severe Traumatic Brain Injury.

This study aimed to investigate the impact of traumatic subarachnoid hemorrhage (tSAH) on cardiac autonomic control system (CACS) function in children after severe traumatic brain injury (TBI) during the subacute rehabilitation period. Thirty-three participants, 8-18 years of age, 42 (14-149) days after severe TBI at the beginning of the subacute rehabilitation, were included in the study. Six participants were diagnosed with tSAH during acute medical care (tSAH group). Heart rate variability (HRV) was assessed by the standard deviation of the N-N interval (SDNN) and the square root of the mean square differences of successive R-R interval (RMSSD) using a Polar RS800CX device while sitting at rest for 5 min. A second assessment was performed 8 weeks later. No significant difference between the tSAH and non-tSAH groups were found in the demographic and functional characteristics or injury severity. However, in comparison to the non-tSAH group, the tSAH group had lower SDNN (23.9 [10.5-47.3] vs. 43.9 [21.8-118.8], respectively; p = 0.005) and RMSSD values (11.8 [5.9-24.5] vs. 29.6 [8.9-71.7], respectively; p = 0.004). Neither group demonstrated changes in HRV values at rest in the second assessment, whereas the significant difference in SDNN (p = 0.035) and RMSSD (p = 0.008) remained. Children diagnosed with SAH after severe TBI presented poorer CACS function during the subacute rehabilitation. Given that reduced HRV values may be a marker for potential heart disease, the medical team should be aware of the influence of existing tSAH. Future studies with larger sample sizes and longer follow-up periods are warranted to further investigate this topic. ClinicalTrials.gov number: NCT03215082.

The impact of childhood acquired brain injury on siblings: a scoping review.

OBJECTIVE: (a) To analyze the extent and nature of research on the impact of childhood acquired brain injury (ABI) on siblings, (b) to synthetize in a descriptive way the results of these studies and propose perspectives of care/support. METHOD: A literature search of 3 databases was performed up to August 2022. Studies addressing issues around siblings of children with ABI were included in the scoping review. RESULTS: 25 articles were identified and analyzed. Results indicate that there is a paucity of research on this issue. However, interest in the subject has increased over past decades. Despite variable results, the current literature highlights the negative impact of ABI on family functioning and relationships. The trajectory and quality of life of siblings of children with ABI are modified. ABI causes intense and mixed emotions, psychological distress, behavioral difficulties and social stigma. Siblings have varied ways of coping with ABI and express particular needs that must be addressed. CONCLUSION: There is a significant impact of childhood ABI on siblings' subsequent life. Existing studies on this subject are few, heterogeneous, and sometimes contradictory. Further studies on this theme therefore appear necessary in order to propose appropriate support for patients' siblings according to their age and situation.

Transatlantic progress in measurement of cognitive outcomes in paediatric oncology trials.

The importance of measuring quality of survival within paediatric oncology trials is increasingly recognised. However, capturing neuropsychological outcomes and other aspects of quality of survival in the context of large or multinational trials can be challenging. We provide examples of protocols designed to address this challenge recently employed in clinical trials in the USA and Europe. We discuss their respective strengths and challenges, obstacles encountered and future opportunities for transatlantic collaboration.

Changes in the cardiac autonomic control system during rehabilitation in children after severe traumatic brain injury.

BACKGROUND: One of the sequalae of severe traumatic brain injury (TBI) in children is impaired function of the cardiac autonomic control system (CACS) at rest. The CACS response to conventional autonomic tests is little known. OBJECTIVE: To examine the CACS response to conventional autonomic tests in children after severe TBI during the rehabilitation period and to compare with typically developing (TD) children. METHODS: This study combined a case-control and follow-up design. The severe TBI group (cases) consisted of 33 children aged 9-18 years, 14-142 days after severe TBI who were followed for 8 weeks during rehabilitation. The control group consisted of 19 TD children matched for age and sex. Heart rate (HR) and heart rate variability (HRV) were evaluated with the Polar RS800CX device at rest (sitting), during a handgrip test and during a paced breathing test. RESULTS: At the first assessment, we found lower HRV values at rest and a lower HRV response during the paced breathing and handgrip tests in the TBI group than the TD group (p<0.01). After 8 weeks, HRV values did not change at rest in the TBI group, but the response to the autonomic tests improved significantly, with increased HRV values in response to the paced breathing test (p<0.01) and the handgrip test (p = 0.01). CONCLUSIONS: After severe TBI, children exhibited an impaired CACS response to autonomic tests, with parasympathetic suppression and sympathetic arousal. After 8 weeks of rehabilitation, CACS function recovered partially and the response to the autonomic tests improved with no change in CACS function at rest.

Parental report of levels of care and needs 7-years after severe childhood traumatic brain injury: Results of the traumatisme grave de l'Enfant (TGE) cohort study.

This study investigated parental reports of the level of care and needs 7-years following severe childhood traumatic brain injury (TBI), and the factors associated with this outcome. From the 65 children (0-15 years) consecutively admitted to the Parisian regional TBI reference intensive care unit following severe TBI, included in this prospective longitudinal study, 39 patients [M(SD) age at injury = 7.5 years (4.6) and assessment 15.3(4.4)] were followed 7-years post-injury and matched with a control group composed of typically developing participants (n = 34) matched by age, sex and parental education level. We used the Care and Need Scale (CANS) and its Pediatric version (PCANS) to assess the primary outcome 7-years post-injury. Concurrent measures included overall level of disability, and parent- and/or self-reported questionnaires assessing executive functioning, behavior, quality of life, fatigue, participation and caregivers' burden. The level of care and needs was significantly higher in the TBI group than in the control group, the difference being significant with the CANS only. PCANS scores were extremely variable in the control group. High level of dependency was associated with initial TBI severity (higher coma duration and initial Injury Severity Score), higher levels of behavioral problems, executive function deficits, fatigue, and lower participation levels. Caregivers' burden was strongly associated with the CANS. The CANS provides a simple and reliable measure of the support needed long-term after childhood TBI, in accordance with previous studies. The PCANS scores were not significantly different between the TBI and the control groups, which seems to illustrate the difficulty to assess accurately mild-to-moderate deficits of functional independence/adaptive behavior in children based exclusively on parental reports.

Determining the Agreement Between Common Measures Related to Vestibulo-ocular Reflex Function After a Mild Traumatic Brain Injury in Children and Adolescents.

Objective: To (1) determine the level of agreement between symptom provocation and performance-based tests of vestibulo-ocular reflex (VOR) function after pediatric mild traumatic brain injury (mTBI) and (2) describe the level of symptom provocation induced by a VOR task in individuals with and without cervical findings. Design: Cross-sectional. Setting: This study was conducted at a tertiary care pediatric hospital. Participants: A total of 101 participants (N=101) aged 6-18 years within 3 weeks of mTBI diagnosis were included (54.5% female; mean age, 13.92±2.63 years; mean time since injury at assessment, 18.26±6.16 days). Interventions: None. Main Outcome Measures: Symptom provocation (Vestibular/Ocular Motor Screening tool), performance (clinician-observed VOR performance, head thrust test [HTT], computerized dynamic visual acuity test, video head impulse test), and cervical impairment (cervical flexion-rotation test, range of motion test, self-reported neck pain). Agreement was evaluated using Cohen's κ statistic. Results: No outcomes demonstrated agreement with symptom provocation (κ=-0.15 to 0.14). Fair agreement demonstrated between clinician-observed VOR performance and HTT (κ=0.32), with little to no agreement demonstrated between other measures. Proportions reporting test-induced dizziness and headache were greater among individuals with cervical findings (29.1%-41.8%) than without (2.3%-6.8%). Conclusions: Findings support that symptom provocation and performance-based tests measure different constructs and thus have distinct roles when assessing VOR function. Findings suggest results from measures of symptom provocation may be influenced by coexisting cervical impairments, underlining the value of assessing for cervical injury after pediatric mTBI.

Balance impairment in patients with moderate-to-severe traumatic brain injury: Which measures are appropriate for assessment?

Left untreated, balance impairment following moderate-to-severe traumatic brain injury (TBI) can be highly debilitating and hinder activities of daily life. To detect impairments, clinicians need appropriate assessment tools. The objective of this study was to evaluate the feasibility and utility of a battery of clinical balance assessments in adults with moderate-to-severe TBI within 6-months of injury. Thirty-seven adults with TBI [Glasgow Coma Scale score ≤ 12 (33 M/4 F) age 18-50 years] participated in balance testing. Assessments included the Balance Error Scoring System (BESS), National Institutes of Health Standing Balance Test (NIH-SBT), Functional Gait Assessment (FGA), Advanced Functional Gait Assessment (FGA-A), Tandem Gait Test (TGT), Berg Balance Scale (BBS), and Walking While Talking Test (WWTT). We identified pronounced ceiling effects on the BBS and FGA, two widely used clinical balance assessments. The NIH-SBT, WWTT, and FGA used in conjunction with the FGA-A, offered versatility in their capacity to assess patients across the balance severity spectrum. This study provides evidence to support a stepwise approach to balance assessment that can be adapted to the broad range of balance ability found in moderate-to-severe TBI.

Characterizing the evolution of oculomotor and vestibulo-ocular function over time in children and adolescents after a mild traumatic brain injury.

Background: Impairments to oculomotor (OM) and vestibulo-ocular reflex (VOR) function following pediatric mTBI have been demonstrated but are poorly understood. Such impairments can be associated with more negative prognosis, affecting physical and mental wellbeing, emphasizing the need to more fully understand how these evolve. Objectives: to determine i) the extent to which performance on clinical and computerized tests of OM and VOR function varies over time in children and adolescents at 21 days, 3-, and 6-months post-mTBI; ii) the proportion of children and adolescents with mTBI presenting with abnormal scores on these tests at each timepoint. Design: Prospective longitudinal design. Setting: Tertiary care pediatric hospital. Participants: 36 participants with mTBI aged 6 to18. Procedures: Participants were assessed on a battery of OM and VOR tests within 21 days, at 3- and 6-months post injury. Outcome measures: Clinical measures: Vestibular/ocular motor screening tool (VOMS) (symptom provocation and performance); Computerized measures: reflexive saccade test (response latency), video head impulse test (VOR gain), and dynamic visual acuity test (LogMAR change). Analysis: Generalized estimating equations (parameter estimates and odd ratios) estimated the effect of time. Proportions above and below normal cut-off values were determined. Results: Our sample consisted of 52.8% females [mean age 13.98 (2.4) years, assessed on average 19.07 (8-33) days post-injury]. Older children performed better on visual motion sensitivity (OR 1.43, p = 0.03) and female participants worse on near point of convergence (OR 0.19, p = 0.03). Change over time (toward recovery) was demonstrated by VOMS overall symptom provocation (OR 9.90, p = 0.012), vertical smooth pursuit (OR 4.04, p = 0.03), voluntary saccade performance (OR 6.06, p = 0.005) and right VOR gain (0.068, p = 0.013). Version performance and VOR symptom provocation showed high abnormal proportions at initial assessment. Discussion: Results indicate impairments to the VOR pathway may be present and driving symptom provocation. Vertical smooth pursuit and saccade findings underline the need to include these tasks in test batteries to comprehensively assess the integrity of OM and vestibular systems post-mTBI. Implications: Findings demonstrate 1) added value in including symptom and performance-based measures in when OM and VOR assessments; 2) the relative stability of constructs measured beyond 3 months post mTBI.

The Cardiac Autonomic Response Recovery to the Modified Tilt Test in Children Post Moderate-Severe Traumatic Brain Injury.

OBJECTIVE: To assess the recovery of the cardiac autonomic control system (CACS) response to the modified tilt-test during rehabilitation, in children post moderate-severe TBI at the subacute phase post-injury. METHOD: Thirty-seven children aged 6-18 years, 14-162 days post moderate-severe TBI, participated in the study. The assessment included CACS values evaluation (heart rate (HR), heart rate variability (HRV) and blood pressure) during the modified tilt-test: five minutes lying supine and five minutes passive standing. Re-assessment was performed after eight weeks of rehabilitation. RESULTS: In both assessments, only four children reported symptoms associated with orthostatic intolerance during the modified tilt-test. No change was found over time in the HR and HRV values at rest. In response to the modified tilt-test, the systolic blood pressure showed change over time, with a significant interaction effect (p=0.04); while in the first assessment the SBP values showed a hypertension trend in the second assessment the SBP values showed a hypotension trend. CONCLUSIONS: Children post moderate-severe TBI at the sub-acute phase post-injury, have a better systolic blood pressure response during the modified tilt-test after eight weeks of individually tailored rehabilitation program, despite no change in the CACS values at rest. CLINICAL TRIAL GOV. NUMBER: NCT03215082.

Factors associated with poor neurological outcome in children after abusive head trauma: A multicenter retrospective study.

BACKGROUND: Abusive Head Trauma (AHT) remains the leading cause of brain injury in infants. OBJECTIVE: This study aims to describe a cohort of patients with AHT and identify early risk factors associated with poor neurological outcome. PARTICIPANTS AND SETTING: Children under one year old admitted to a Pediatric Intensive Care Unit (PICU) with a suspected or confirmed diagnosis of AHT were included. Neurological outcome was assessed by the Pediatric Overall Performance Category score (POPC) at discharge from the hospital and at two years of follow-up. METHODS: A multicentre retrospective study was conducted over 8 years (from January 2012 to December 2020). RESULTS: A total of 117 patients (mean age 4.3 (+/- 2.5) months, 61 % boys) from three PICUs were included. A total of 99 (85 %) patients completed a 2-year follow-up. Sixty-one (52 %) and 47 (40 %) children with AHT had a POPC (pediatric overall performance category) score ≥ 2 at discharge from ICU and discharge from hospital, respectively (meaning they had at least a moderate disability). Fifty-one (44 %) had a POPC score ≥ 2 at 2-year follow-up, including 19 patients (19 %) with severe disabilities. The main neurological disabilities were neurodevelopmental (n = 38, 35 %), hyperactivity disorder (n = 36, 33 %) and epilepsy (n = 34, 31 %). After analysis according to the hierarchical model, the occurrence of a cardiorespiratory arrest and a low Glasgow Coma Score at admission stand out as factors of poor neurological outcome. CONCLUSION: This study highlights the wide range of neurological disabilities in children with AHT. Early and multidisciplinary follow-up is crucial to limit the impact of neurological disability.

Functional status 1 year after severe childhood traumatic brain injury predicts 7-year outcome: Results of the TGE study.

BACKGROUND: Childhood severe traumatic brain injury (TBI) is a leading cause of long-lasting acquired disability, but predicting long-term functional outcome remains difficult. OBJECTIVES: This study aimed to 1) describe the functional outcome at 1 and 7 years post-TBI; 2) determine the initial and concurrent factors associated with long-term outcome; and 3) evaluate the predictive value of functional status, overall disability level and intellectual ability measured at 1 year post-injury to determine 7-year clinically meaningful outcomes. METHODS: Among the children (<16 years) consecutively included over 3 years in the Traumatisme Grave de l'Enfant (TGE) prospective longitudinal cohort study after accidental severe TBI, we studied the outcomes of 39 survivors at 1 and 7 years post-injury. Overall outcome included disability level (Glasgow Outcome Scale), functional status (Pediatric Injury Functional Outcome Scale), intellectual ability (Wechsler scales), executive functions (Behavior Rating Inventory of Executive Functions), behavior (Child Behavior Checklist) as well as neurological impairments and academic status. RESULTS: Mean (SD) age of the 39 survivors at injury was 7.6 (4.6) years, and long-term evaluation was conducted at a mean of 7.8 years post-injury (range 5.9-9.3); 36% of participants were adults (≥18 years old). Most of the neurological impairments remained stable beyond 1 year after TBI, whereas overall disability level improved significantly from 1 to 7 years but remained highly variable, with almost half of participants presenting significant disability levels (moderate: 26%, or severe: 21%). Almost half of participants had significant cognitive, behavior and/or academic difficulties at 7 years post-TBI. On multivariate regression analysis, functional impairment at 1 year was the best predictor of severe disability at 7 years (F(3,31)=13.18, p < 0.001, sensitivity=100%, specificity=78%). CONCLUSIONS: Our results confirm the significant long-term impact of childhood severe TBI. All children with TBI should benefit from systematic follow-up, especially those with persistent functional deficits at 1 year post-injury, because the severity of functional impairment at 1 year seems the best predictor of long-term significant disability up to 7 years post-TBI.

Memory functioning 7 years after severe childhood traumatic brain injury: Results of the Traumatisme Grave de l'Enfant study.

OBJECTIVE: To explore memory functioning 7 years after severe paediatric traumatic brain injury (TBI), associated factors, and relationships with other outcomes. METHOD: Children aged 0-15 years (n = 65), consecutively admitted over a 3-year period in a single trauma centre, who survived after severe non-inflicted TBI, were included in a prospective longitudinal study. Memory assessments were performed 7 years post-injury using the Children's Memory Scale or the Wechsler Memory Scale (WMS IV), according to age. The General Memory Score (GMS-7) was the primary outcome. RESULTS: Thirty-seven patients were available for assessment at 7 years post-injury. Mean GMS-7 was in the low average range (M = 84.9, SD = 12.1). Lower GMS-7 was significantly associated with markers of higher injury severity, such as length of coma. One year post-injury functional and disability outcomes explained 74% of the variance of GMS-7. Concurrent intellectual ability and type of ongoing education correlated strongly with GMS-7. Age at injury and parental education were not associated with memory outcome. CONCLUSIONS: Memory functioning is variable but often strongly impaired several years after severe paediatric TBI, and is mostly related to injury severity, functional outcomes measured 1 year post-injury, and concomitant cognitive and educational outcomes. GMS-7 was lower at 7 years than one year post-injury, supporting the importance of long term follow-up.

Virtual-Reality Performance-Based Assessment of Cognitive Functions in Adult Patients With Acquired Brain Injury: A Scoping Review.

Individuals with acquired brain injury (ABI) commonly present with impairments in cognitive abilities. As these competencies seem to be predictive of patients' abilities to reintegrate into the everyday settings, it is crucial to assess them properly. However, previous research has indicated that patients may perform relatively well on standard tests of cognitive functioning, but may nonetheless encounter significant difficulties in organizing and executing everyday tasks. In order to overcome this issue, virtual reality (VR) methods have been introduced in clinical practice with the aim of creating assessments that simulate real-world activities and thus, provide a clearer picture of patients' functioning in everyday settings. This review offers an overview of VR assessment tools described in the scientific literature between 2010 and 2019. Overall, 38 relevant records describing 31 different tools were found. Among these tools, 16 assessed executive functions and prospective memory, while the other 15 assessed visuo-spatial abilities. Although promising results have been reported, our analysis indicated that about half of the tools deliver tasks that differ from everyday activities, thus limiting the generalizability of patients' performance to the real-world. Moreover, a variety of methodological shortfalls related to study Internal and External Validity have been highlighted, which hamper the possibility of drawing definite recommendations on tool choice. These limitations suggest the importance of putting considerable efforts into the improvement or development of VR tools for patients with ABI for both research and clinical purposes, considering the great potential of this form of assessment.

The development and the inter-rater agreement of a treatment protocol for vestibular/oculomotor rehabilitation in children and adolescents post-moderate-severe TBI.

Introduction:There is limited evidence investigating the effect of vestibular/oculomotor rehabilitation programs in children and adolescents post moderate-severe TBI at the sub-acute stage.Objective:To describe the development of a treatment protocol for vestibular/oculomotor interventions in this population, and to assess the inter-rater agreement of this protocol as an initial step of a clinical trial.Method:The protocol was developed by 10 health professionals, address the high variability of balance performance, the high prevalence of vestibular/oculomotor abnormalities and the low prevalence of symptoms reported in this population.Results:The protocol enables the clinician to use the assessment during the treatment exercise selection. The training position was defined by the Pediatric Balance Scale. Vestibular/oculomotor exercises were selected using a quantified version of the Vestibular/Ocular Motor Screening. The exercise protocol was selected based on impairment in function or reproduction of symptoms. The protocol planning was implemented by two assessors in 27 children and adolescents post-moderate-severe TBI (median age 14.1 [6-18.4] years) in the sub-acute stage (median 40 [14-162] days since injury). Very high agreement was found (k > 0.72) in all the parameters.Conclusion: This protocol could reliably be used in a randomized control trial that assesses the effect of vestibular/oculomotor rehabilitation program in children and adolescents post moderate-severe TBI at the sub-acute stage.

Exploring the use of the Cognitive Orientation to daily Occupational Performance approach (CO-OP) with children with executive functions deficits after severe acquired brain injury: A single case experimental design study.

Children with acquired brain injury (ABI) often have cognitive and behavioral impairments that affect participation in everyday activities. Among them, executive function (EF) deficits are frequent. Cognitive Orientation to Daily Occupational Performance (CO-OP) is an individualized treatment that teaches cognitive strategies necessary to support successful performance. Few studies have examined the effectiveness of CO-OP in children with EF deficits after ABI. OBJECTIVES: to assess whether the use of CO-OP could be of interest in children with EF deficits after ABI, to improve their occupational performance, their executive functioning in everyday life and their cognitive processes constituting EF. METHODS: This was a single case experimental study with multiple baselines across individuals and behaviors. We included 2 children at least 6 months after severe ABI. The children received 14 individual sessions of the CO-OP intervention. Each child set 3 goals by using the Canadian Occupational Performance Measure; 2 goals were trained and the third was a control goal. The achievement of the goals was measured by using repeated measures of Goal Attainment Scales (GASs). Ecological assessments of EF included the Children's Cooking Task and parent and teacher ratings of the Behavior Rating Inventory of Executive Function (BRIEF) questionnaire. RESULTS: both children improved their performance on both trained goals (and, to a lesser extent, on untrained goals). We found significant improvement on tests of EF and on the BRIEF questionnaire, reflecting executive functioning in everyday life, at home and at school. CONCLUSIONS: these results are encouraging and suggest the feasibility and effectiveness of CO-OP for children with EF deficits after ABI. They should be replicated in a larger number of cases. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04718688).

Vestibular-ocular reflex dysfunction following mild traumatic brain injury: A narrative review.

Mild traumatic brain injury (mTBI) is a prevalent injury which occurs across many populations, including children and adolescents, athletes, military personnel, and the elderly. mTBI can result in various subjective symptoms and clinical deficits, such as abnormalities to the vestibulo-ocular reflex (VOR). Over 50% of individuals with mTBI are reported to have VOR abnormalities, which strongly contribute to feelings of dizziness and unsteadiness. Dizziness is a strong predictor for prolonged recovery following mTBI and is additionally linked with mental health difficulties and functional limitations affecting likelihood of return to work. Early diagnosis, and subsequent treatment, of VOR deficits following mTBI may greatly improve recovery outcomes and a patient's quality of life, but a thorough comprehension of the related pathophysiology is necessary to understand the assessments used to diagnose VOR abnormalities. Therefore, the purpose of this article is i) provide readers with an introduction on the VOR physiology to facilitate understanding about mTBI-related abnormalities, and ii) to discuss current assessments that are commonly used to measure VOR function following mTBI. As the VOR and oculomotor (OM) systems are heavily linked and often work in tandem, discussion of the relevant aspects of the OM system is also provided.