Rehabilitation and follow-up of children with severe traumatic brain injury

Functioning and disability 6-15 years after traumatic brain injuries in northern Sweden

OBJECTIVES

To assess long-term functioning and disability after traumatic brain injury (TBI).

MATERIAL AND METHODS

Individuals (n = 88) in Norrbotten, northern Sweden, who had been transferred for neurosurgical care were assessed with internationally established TBI outcome measures 6-15 years post-injury.

RESULTS

There was an improvement in overall outcome from discharge from inpatient rehabilitation to follow-up. Many individuals had a high degree of motor and cognitive functioning, which enabled them to live independently in their own home without assistance, but there remained a disability related to community reintegration and social participation. This affected their productivity and to some degree their marital stability. The remaining disability and reduced productivity were related to the age at injury and the injury severity.

CONCLUSIONS

Our data showed that individuals with a TBI can achieve and maintain a high degree of functioning many years after the injury. Increasing age and a greater injury severity contributed to their long-term disability.

Validation of the Gross Motor Function Measure for use in children and adolescents with traumatic brain injuries

OBJECTIVES

Motor function recovery is a key goal during rehabilitation of children and adolescents with traumatic brain injury. To evaluate how well treatment strategies improve motor function, we need validated outcome measures that are responsive to change in pediatric patients with traumatic brain injury. The Gross Motor Function Measure has demonstrated excellent psychometric properties in children with cerebral palsy and Down syndrome, yet its responsiveness in patients with pediatric traumatic brain injury has not been proven irrefutably. Our aim was to validate the Gross Motor Function Measure for this patient group.

METHODS

Seventy-three patients (mean age: 11.4 years; range: 0.8-18.9 years) with moderate-to-severe traumatic brain injury were recruited in 12 rehabilitation centers and assessed twice with the Gross Motor Function Measure-88 over 4 to 6 weeks. As an external standard, we used judgements of change made independently by parents, physiotherapists, and 2 video assessors who were not familiar with the patients. We formulated and statistically investigated a priori hypotheses of how Gross Motor Function Measure change scores would correlate with those judgements of change. Both Gross Motor Function Measure versions, the original Gross Motor Function Measure-88 and the more recently developed Gross Motor Function Measure-66, were evaluated.

RESULTS

Both Gross Motor Function Measure change scores correlated significantly with all of the clinical judgements of change. The degree of correlation that we postulated, that the Gross Motor Function Measure change score would correlate highest with the video rating followed by physiotherapists and parents, was fully confirmed by the Gross Motor Function Measure-88 and largely confirmed by the Gross Motor Function Measure-66. Both Gross Motor Function Measure versions revealed convincing discriminative capability. Test-retest reliability was excellent.

CONCLUSIONS

We demonstrate convincing evidence of responsiveness and validity to support the use of both Gross Motor Function Measure versions as evaluative measures of gross motor function in children and adolescents with traumatic brain injury.

Epidemiology and Etiology of Mental Retardation

Mental retardation (MR) is a manifestation of a heterogeneous set of impairments and conditions that result in cognitive limitation. It is a condition of medical, educational, and social importance. Physicians identify profound, severe, and moderate MR but rarely diagnose mild MR unless it is associated with a genetic or medical syndrome. From a medical perspective, the quest for etiology and the possibility of medical or surgical intervention to minimize deterioration are paramount. Educators, on the other hand are less concerned with causation than with academic achievement and school success. The majority of cases of mild MR is identified in school settings. Finally, the public uses the label to describe poor adaptive skills. Adults with MR who hold jobs, live independently, and participate in society are not always described as having MR. Thus some individuals characterized in childhood or adolescence as having mild MR become indistinguishable from the general population in adulthood.

Direct clinician-delivered versus indirect family-supported rehabilitation of children with traumatic brain injury: a randomized controlled trial

PRIMARY OBJECTIVES

To explore the relative effectiveness of clinician-delivered vs family-supported interventions for children with chronic impairment after TBI.

RESEARCH DESIGN

Randomized controlled clinical trial.

METHODS AND PROCEDURES

Children aged 5-12 years in the chronic phase of their recovery were randomly assigned to the clinician-delivered or to the family-supported intervention group; both samples received intensive services for 1 year; physical outcome was measured by the SARAH scales, cognitive outcome by the WISC-III.

MAIN OUTCOMES AND RESULTS

Parents in the family-supported intervention sample efficiently acquired the skills needed to deliver physical and cognitive interventions within the context of everyday routines of the child's life at home; family education level was not a factor. Although both groups demonstrated improvements, only the children in the family-supported intervention group demonstrated statistically significant--and clinically important--improvements on both outcome measures.

CONCLUSIONS

This RCT provides compelling evidence for organizing cognitive and physical interventions and supports for children with TBI around the everyday routines of their lives, with intensive supports for their families.

The relationship between functional mobility and the intensity of physical therapy intervention in children with traumatic brain injury

PURPOSE

The purposes of this study were to describe the types of physical therapy (PT) procedural interventions used during inpatient rehabilitation for children and adolescents with traumatic brain injury (TBI) and to examine the relationship between intensity of intervention and mobility changes.

METHODS

We examined a consecutive series of 80 records of children and adolescents (mean age = 10.3 years) with TBI. Intensity of PT was calculated as the number of 15-minute PT units of service per day/length of stay. We used the Pediatric Evaluation of Disability Inventory (PEDI) to calculate mobility change scores between admission and discharge and the achievement of a minimal clinically important difference (MCID) consisting of an 11-point change. We used a series of hierarchical and logistic regression analyses to identify the relationship of PT intensity to mobility changes, while controlling for potential confounding variables.

RESULTS

Therapeutic exercise was the most frequently recorded intervention. On average, PT intensity was provided at a level of 3.1 units (46.5 minutes) per day. After controlling for severity and age, intensity was significantly related to change in PEDI mobility scores; this effect was removed when controlling for admission scores. The MCID was related to PT intensity, even when controlling for initial status.

CONCLUSIONS

Although the magnitude of the correspondence is small, the intensity of PT intervention in an inpatient rehabilitation hospital is related to positive changes in functional mobility scores and the achievement of an MCID. However, initial mobility status is an essential factor in the interpretation of change scores. Future studies are needed to determine whether controlled variations of PT service intensity have a differential effect on mobility recovery during inpatient rehabilitation.

Lower extremity spasticity as an early marker of ambulatory recovery following traumatic brain injury

METHODS

A consecutive series of 107 children and young persons with traumatic brain injury (TBI) admitted to a hospital-based inpatient rehabilitation program was assessed to determine whether lower extremity spasticity could be utilized as an early clinical marker for recovery of ambulation. Presence of spasticity was determined by clinical examination at admission, and the ability to ambulate safely indoors (15.24 m) was evaluated at discharge. Sensitivity, specificity and positive and negative predictive values for spasticity were calculated.

RESULTS

Lower extremity spasticity is a sensitive (71.4%) and specific (81.5%) predictor of the inability to ambulate at discharge. The absence of lower extremity spasticity, however, was a better predictor of ambulation recovery than the presence of spasticity was a predictor of nonambulatory status at hospital discharge.

DISCUSSION

Implications for spasticity assessment and prognosis in terms of ambulation and recovery are discussed.

Functional recovery in pediatric traumatic brain injury during inpatient rehabilitation

OBJECTIVE

To examine changes in functional status of children with traumatic brain injury by identifying the pattern and amount of change between and within the domains of self-care, mobility, and social function during inpatient rehabilitation and to examine the relationships of age and injury severity to functional recovery.

DESIGN

Retrospective descriptive study. Seventy-nine children and adolescents with traumatic brain injury were assessed at inpatient rehabilitation hospital admission and discharge by using the Pediatric Evaluation of Disability Inventory's (PEDI) functional skills and caregiver assistance domains of self-care, mobility, and social function.

RESULTS

Admission self-care functional levels were significantly greater than mobility and social function for both PEDI scales. At discharge, significant improvement was noted within all three domains and the amount of change between domains was significantly greater for the mobility domain on both scales. Age was not related to the amount of recovery. Admission functional status was moderately negatively correlated to the change in PEDI scores (ranging from r = -0.432 to -0.681).

CONCLUSIONS

Variations exist in the recovery of self-care, mobility, and social function capability and independence during inpatient rehabilitation. Self-care was the least affected. Participants showed significant improvement in all domains, with the most recovery in mobility. Children with greater functional deficits demonstrated greater functional gains.

Late outcome after severe traumatic brain injury in children and adolescents

OBJECTIVES

Eighteen surviving adolescents with severe traumatic brain injury were re-examined a mean period of 7.1 years after their trauma in order to determine their life situation, motor, cognitive functions and pattern of handicap.

METHODS

A structured interview, the EB test of motor function, Ravens's progressive matrices, Peabody's neuropsychological test, SPIQ and the WHO classification of handicap were used.

RESULTS

The group had a mean WHO Classification of Handicap score of 1.61 (SD 1.60) revealing mild handicap, and performed as a group significantly subnormal (p < 0.0001) in gross motor, fine motor, sensibility and perception sub-tests. The EB test revealed a mean value of 2.23 (SD 0.89) corresponding to mild disability. The mean non-verbal IQ score of 93.1 (SD 13.9) and the verbal score of 93.4 (SD 14.8) were within normal limits.

CONCLUSIONS

Only 28% of the group of surviving adolescent TBI victims functioned within normal limits. The most crucial disabling component was poor social integration, which was clearly demonstrated in the WHO score.

Head injury in children

Trauma in the United States is the leading cause of death and disability in the pediatric population. Differences of age and development affect recovery and outcome following head injury. Mechanisms and pathophysiology of head injury are varied in both the pediatric and adult populations. Assessments of injury are varied and some measurements are more sensitive than others as well as more specific with regard to certain types of injury. Treatment and management should be tailored to each case in order to effect a positive outcome with respect to brain functioning. Aggressive intervention for prevention of primary and secondary injury must be continued and understanding of the impact of these injuries should provide for a brighter future for these patients.