Very Long-Term Outcomes in Children Admitted in a Disorder of Consciousness After Severe Traumatic Brain Injury.

OBJECTIVES: To investigate functional outcomes and state of consciousness at 1 year and ≥2 years postinjury in children who sustained a traumatic brain injury and were in a disorder of consciousness (DOC), either vegetative state (VS) or minimally conscious state (MCS), upon admission to inpatient rehabilitation. DESIGN: Retrospective chart review. SETTING: Pediatric inpatient rehabilitation unit. PARTICIPANTS: Children aged 2-18 years (N=37) who were admitted to inpatient rehabilitation with admission scores <30 on the Cognitive and Linguistic Scale (CALS). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Glasgow Outcome Scale- Extended, Pediatric Revision (GOS-E Peds), and state of consciousness based on previously established guidelines. RESULTS: At admission, 16 children were in VS (43.2%) and 21 (56.8%) were in MCS. Children admitted in VS had a significantly longer time from injury to inpatient rehabilitation admission, lower CALS admission scores, were more likely to be in a DOC ≥28 days, and had greater disability at both follow-up time points. At the 1-year follow-up, 3 patients were in VS, 7 were in MCS, and 27 had emerged from MCS. By the time of the most recent follow-up (≥2y), 2 more patients had emerged from MCS. Across the cohort, GOS-E Peds scores at 1 year ranged from VS (GOS-E Peds, 7) to upper moderate disability (GOS-E Peds, 3). Most patients were functioning in the lower severe disability category (GOS-E Peds, 6) at 1 year (43.2%) and at the time of the most recent follow-up (43.2%). Twenty-seven patients (73.0%) showed stable GOS-E Peds scores between the 2 time points, 6 (16.2%) improved, and 4 (10.8%) were deceased. CONCLUSIONS: Although a majority of patients emerged from a DOC by 1 year postinjury, most continued to demonstrate notable functional impairment at the 1-year follow-up that persisted to the most recent follow-up. A small subset demonstrated important improvements between 1 year and the most recent follow-up (2 patients emerged, 6 patients showed improvement in GOS-E Peds scores).

Rehabilitation Outcomes in Children With Acute Flaccid Myelitis From 2014 to 2019: A Multicenter Retrospective Review.

BACKGROUND: Acute flaccid myelitis (AFM) is a childhood illness characterized by sudden-onset weakness impairing function. The primary goal was to compare the motor recovery patterns of patients with AFM who were discharged home or to inpatient rehabilitation. Secondary analyses focused on recovery of respiratory status, nutritional status, and neurogenic bowel and bladder in both cohorts. METHODS: Eleven tertiary care centers in the United States performed a retrospective chart review of children with AFM between January 1, 2014, and October 1, 2019. Data included demographics, treatments, and outcomes on admission, discharge, and follow-up visits. RESULTS: Medical records of 109 children met inclusion criteria; 67 children required inpatient rehabilitation, whereas 42 children were discharged directly home. The median age was 5 years (range 4 months to 17 years), and the median time observed was 417 days (interquartile range = 645 days). Distal upper extremities recovered better than the proximal upper extremities. At acute presentation, children who needed inpatient rehabilitation had significantly higher rates of respiratory support (P < 0.001), nutritional support (P < 0.001), and neurogenic bowel (P = 0.004) and bladder (P = 0.002). At follow-up, those who attended inpatient rehabilitation continued to have higher rates of respiratory support (28% vs 12%, P = 0.043); however, the nutritional status and bowel/bladder function were no longer statistically different. CONCLUSIONS: All children made improvements in strength. Proximal muscles remained weaker than distal muscles in the upper extremities. Children who qualified for inpatient rehabilitation had ongoing respiratory needs at follow-up; however, recovery of nutritional status and bowel/bladder were similar.

Musculoskeletal and skin considerations in children with medical complexity: Common themes and approaches to management.

The term "children with medical complexity" (CMC) describes a population of heterogeneous genetic and metabolic disorders with multi-system involvement, with shared common abnormalities within the musculoskeletal system. Disorders that affect the central nervous system (CNS) result in abnormal muscular tone, ranging from dystonia and spasticity, to hypotonia, to combinations of both (axial hypotonia with appendicular hypertonia). Abnormal tone can impair movement and function and contribute to development of contractures, progressive scoliosis and hip dislocation. Impaired mobility, chronic illness and polypharmacy can result in fragile bones and increased risk of fracture, which can be difficult to diagnose and associated with pain. Additionally, CMC with impaired ability to communicate, total dependence on caregivers and frequent use of support devices can develop unintended skin injuries. There are a variety of treatments available for CMC with musculoskeletal disorders ranging from physical supports to pharmacologic treatments to surgeries. Medical and surgical treatments can promote changes in tone and support bone health to improve comfort, hygiene and proper positioning. These therapies may also carry significant risk in medically fragile patients. It is important for CMC to have a care team with a good understanding of the patient's overall health and goals of care and that can advocate for the patient to balance optimization of function and reduction of pain while also minimizing risk.

Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study.

OBJECTIVE: To assess the feasibility of recruiting and retaining cancer survivors with lower-limb lymphedema into an exercise intervention study. To develop preliminary estimates regarding the safety and efficacy of this intervention. We hypothesized that progressive weight training would not exacerbate leg swelling and that the intervention would improve functional mobility and quality of life. DESIGN: Before-after pilot study with a duration of 5 months. SETTING: University of Pennsylvania. PARTICIPANTS: Cancer survivors with a known diagnosis of lower-limb lymphedema (N=10) were directly referred by University of Pennsylvania clinicians. All 10 participants completed the study. INTERVENTION: Twice weekly slowly progressive weight lifting, supervised for 2 months, unsupervised for 3 months. MAIN OUTCOME MEASURES: The primary outcome was interlimb volume differences as measured by optoelectronic perometry. Additional outcome measures included safety (adverse events), muscle strength, objective physical function, and quality of life. RESULTS: Interlimb volume differences were 44.4% and 45.3% at baseline and 5 months, respectively (pre-post comparison, P=.70). There were 2 unexpected incident cases of cellulitis within the first 2 months. Both resolved with oral antibiotics and complete decongestive therapy by 5 months. Bench and leg press strength increased by 47% and 27% over 5 months (P=.001 and P=.07, respectively). Distance walked in 6 minutes increased by 7% in 5 months (P=.01). No improvement was noted in self-reported quality of life. CONCLUSIONS: Recruitment of patients with lower-limb-lymphedema into an exercise program is feasible. Despite some indications that the intervention may be safe (eg, a lack of clinically significant interlimb volume increases over 5 mo), the unexpected finding of 2 cellulitic infections among the 10 participants suggests additional study is required before concluding that patients with lower-extremity lymphedema can safely perform weight lifting.

Survey of parental acceptance of massage therapy, energy therapy and acupuncture for their children in the acute pediatric inpatient rehabilitation setting.

OBJECTIVE: To examine factors that influence parents' decision to accept or decline complementary therapies on an inpatient rehabilitation unit. DESIGN/SETTING: Parents of children aged 2-21 admitted for acute pediatric rehabilitation were provided a survey regarding their child's use of massage, energy therapy and acupuncture during admission. They were also asked about religious beliefs, education, perceived severity of injury and perceived response to the therapies. The study was conducted on the Inpatient Acute Pediatric Rehabilitation Unit at Kennedy Krieger Institute in Baltimore, Maryland, USA. RESULTS: Of those who completed the survey (n=38), 39% accepted massage services, 49% accepted energy therapy, and 16% accepted acupuncture for their child. Acceptance of massage services was significantly correlated with belonging to an organized religion (p<0.05). Participation in weekly religious services was associated with rejection of energy therapy (p<0.01). Prior parental experience with massage and acupuncture was associated with acceptance of these services for their child (p<0.01). Chronicity of condition and family education was not related to acceptance or rejection of services. Over 80% of parents felt massage and energy therapy helped the recovery process. In 63% of parents surveyed, acupuncture was felt to help the recovery process. CONCLUSIONS: Prior exposure to massage therapy and acupuncture was the most important factor in a parent accepting these services for their child. All three services were subjectively felt to have facilitated recovery. Future studies should assess subjective versus objective utility of these therapies in acute pediatric rehabilitation.

A family therapy perspective on mediation.

Many times, family therapists are both the first to learn that a couple may separate and the last to see them in the same consultation room, still relating to each other and the same professional before the adversarial system takes over. Mediation offers a viable alternative to that system because clients are helped to speak directly and craft the decisions that will delineate their move toward separate lives. Mediation is defined and the divorce process demystified, and the similarities and differences between mediation and therapy are discussed. Brief examples and a longer case discussion are provided to illustrate the mediation process. A familiarity with this process will enable therapists to hold more informed discussions about mediation with their clients and invite them to consider a process that is congruent with many of the values of family therapy.