Gross Motor Function Measure-66 trajectories in children recovering after severe acquired brain injury

The effect of etiological and clinical characteristics on the rehabilitation process and functional gains in pediatric severe acquired brain injury

Objectives

The aim of this study was to investigate the etiological and clinical characteristics of pediatric patients with severe acquired brain injury and their effects on rehabilitation outcomes.

Patients and methods

A total of 67 pediatric patients (39 males, 28 females; mean age: 9.7±4.8 years; range, 3 to 18 years) who were hospitalized due to severe acquired brain injury between March 2020 and October 2021 were retrospectively analyzed. The patients were classified in five different groups according to the etiology: traumatic brain injury, anoxic brain injury (ABI), cerebrovascular accident, encephalitis, and brain tumors. The time of brain injury, etiology, length of stay in the intensive care unit, additional injuries, presence of operation, nutritional status, history of tracheotomy, duration of rehabilitation and complications were recorded. The factors affecting the difference between the Functional Ambulation Classification (FAC) scores of the patients before and after rehabilitation were evaluated.

Results

The mean time since injury was 83.04±57.29 days and the mean duration of rehabilitation was 55.37±37.15 days. Statistically significant improvements were found in all the groups in the functional levels and FAC scores after rehabilitation. In the inter-group comparisons, the ABI group showed statistically less improvement than the other groups. The functional level of the patients before rehabilitation, etiology and the presence of fecal incontinence were statistically significant factors that affected the change in FAC scores (p=0.043, p=0.049, p=0.048, and p=0.035, respectively).

Conclusion

Our study results show that rehabilitation yields in positive outcomes even in patients with severely acquired brain injury in the pediatric age group.

High-intensive physical rehabilitation approach in children and adolescents with acquired brain injury during subacute phase (REHABILITY): a feasibility study protocol

INTRODUCTION

While principles of neuroplasticity and motor learning emphasise the potential of high dosage of physical rehabilitation in children and adolescents with acquired brain injury (ABI) during the subacute phase, we lack empirical evidence to demonstrate its impact in terms of meaningful outcomes. Clinical research is needed to investigate adequate dosage of physical rehabilitation and its effects on outcomes with reliable and validated outcome measurements. In this study we will investigate the feasibility of a highly intensive physical rehabilitation intervention and outcomes with reliable and valid outcome measurements.

METHODS AND ANALYSIS

Our study with a prospective case-series design will evaluate (1) The safety and feasibility of a high-intensive physical rehabilitation programme to improve functioning and participation in children and adolescents with ABI, and (2) The feasibility of a core set of clinical outcome measures to assess recovery on relevant International Classification of Functioning, Disability, and Health domains during the subacute phase. We aim to include 10-15 children and adolescents aged 6-20 years with moderate-severe ABI during subacute rehabilitation in a specialised youth department for inpatient rehabilitation in The Netherlands. In the rehabilitation programme, we aim at a highly intensive approach of 3-5 hours physical rehabilitation per day during inpatient rehabilitation. Frequent and systematic assessment (baseline, each consecutive 6 weeks -if applicable- and at discharge) through a core set of outcome measures will provide insights into the degree of recovery of motor and cognitive functioning. We use descriptive and inferential statistics and thematic content analysis for analysis of the data.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Research Committee of the University Medical Hospital, Utrecht (reference number: 23U-0628). We aim to disseminate our findings in peer-reviewed journals and present at national and international conferences.

Defining paediatric neurorehabilitation: You cannot improve what you cannot characterize

Neurorehabilitation is the primary therapy for neurological impairment in children, yet its potential to achieve change remains incompletely understood and probably underestimated. Understanding 'the difference neurorehabilitation can make' against a background of neurological repair and recovery as well as ongoing neurological development is an enormous challenge, exacerbated to no small extent by the lack of a 'common currency' for the description and measurement of the neurorehabilitation services a child is receiving. This review addresses attempts to parse neurorehabilitation treatment content in theoretically and mechanistically valid ways that might help address this challenge.

Motor network dynamic resting state fMRI connectivity of neurotypical children in regions affected by cerebral palsy

Background

Normative childhood motor network resting-state fMRI effective connectivity is undefined, yet necessary for translatable dynamic resting-state-network-informed evaluation in pediatric cerebral palsy.

Methods

Cross-spectral dynamic causal modeling of resting-state-fMRI was investigated in 50 neurotypically developing 5- to 13-year-old children. Fully connected six-node network models per hemisphere included primary motor cortex, striatum, subthalamic nucleus, globus pallidus internus, thalamus, and contralateral cerebellum. Parametric Empirical Bayes with exhaustive Bayesian model reduction and Bayesian modeling averaging informed the model; Purdue Pegboard Test scores of hand motor behavior were the covariate at the group level to determine the effective-connectivity-functional behavior relationship.

Results

Although both hemispheres exhibited similar effective connectivity of motor cortico-basal ganglia-cerebellar networks, magnitudes were slightly greater on the right, except for left-sided connections of the striatum which were more numerous and of opposite polarity. Inter-nodal motor network effective connectivity remained consistent and robust across subjects. Age had a greater impact on connections to the contralateral cerebellum, bilaterally. Motor behavior, however, affected different connections in each hemisphere, exerting a more prominent effect on the left modulatory connections to the subthalamic nucleus, contralateral cerebellum, primary motor cortex, and thalamus.

Discussion

This study revealed a consistent pattern of directed resting-state effective connectivity in healthy children aged 5-13 years within the motor network, encompassing cortical, subcortical, and cerebellar regions, correlated with motor skill proficiency. Both hemispheres exhibited similar effective connectivity within motor cortico-basal ganglia-cerebellar networks reflecting inter-nodal signal direction predicted by other modalities, mainly differing from task-dependent studies due to network differences at rest. Notably, age-related changes were more pronounced in connections to the contralateral cerebellum. Conversely, motor behavior distinctly impacted connections in each hemisphere, emphasizing its role in modulating left sided connections to the subthalamic nucleus, contralateral cerebellum, primary motor cortex, and thalamus. Motor network effective connectivity was correlated with motor behavior, validating its physiological significance. This study is the first to evaluate a normative effective connectivity model for the pediatric motor network using resting-state functional MRI correlating with behavior and serves as a foundation for identifying abnormal findings and optimizing targeted interventions like deep brain stimulation, potentially influencing future therapeutic approaches for children with movement disorders.

Outcomes following intensive day rehabilitation for young people in Western Australia

OBJECTIVE

Intensive rehabilitation aims to improve and maintain functioning in young people who experience disability due to illness or injury. Day rehabilitation may have advantages for families and healthcare systems over inpatient models of rehabilitation.

METHODS

This study evaluated the goals and outcomes of a cohort of young people in Western Australia who attended a specialist intensive day rehabilitation programme ("iRehab") at Perth Children's Hospital. Analysis of the iRehab service database was performed. Rehabilitation goals and outcomes were recorded as per the Canadian Occupational Performance Measure (COPM), Children's Functional Independence Measure (WeeFIM), and Goal Attainment Scale (GAS).

RESULTS

There were 586 iRehab admissions between August 11, 2011, and December 31, 2018. Admissions were divided by diagnosis: Cerebral Palsy (228, 38.5%), Acquired Brain Injury (125, 21.3%), Spinal Cord Disorders (91, 15.5%), and Other (141, 24.2%). Mean COPM Performance increased by 2.78 points from admission to discharge (95% CI 2.58 to 2.98, p < 0.001). Mean COPM Satisfaction was 3.29 points higher at discharge than admission (95% CI 3.07 to 3.51, p < 0.001). Mean total WeeFIM score improved by 6.51 points between admission and discharge (95% CI 5.56 to 7.45, p < 0.001), and by 3.33 additional points by six months post discharge (95% CI 2.14 to 4.53, p < 0.001). Mean GAS T-scores increased by 27.85 (95% CI 26.73 to 28.97, p < 0.001) from admission to discharge, and by 29.64 (95% CI 28.26 to 31.02, p < 0.001) from admission to six months post discharge, representing improvement consistent with team expectations.

CONCLUSION

This study describes a model by which intensive rehabilitation can be delivered in a day rehabilitation setting. A diverse population of young people who experienced disability achieved significant improvements in occupational performance, independence, and goal attainment after accessing intensive day rehabilitation. Improvements were measured in all diagnostic subgroups and were maintained six months after discharge.

It's easier to relearn gross motor skills than learn them for the first time after injury: Empirical evidence informing the age at injury debate

The effect of age at injury on outcomes after brain injury has long been debated. Many have argued that the greater plasticity of the immature brain aids in its recovery from trauma, but others (notably Donald Hebb) have argued that early injury can impair the future ability of the brain to acquire new capabilities. This is difficult to assess empirically due to the presence of many age-dependent confounders. We performed Item Response Theory (IRT) analyses of two datasets of Gross Motor Function Measure (GMFM) observations, one in children with cerebral palsy (CP) and one in children with acquired brain injury (ABI) sustained at later ages. We used IRT to derive independent estimates of test item difficulty in the two populations. Additionally, where comparison between GMFM items and items in the Denver II Developmental Screening Test battery was possible we used the latter to obtain the ages at which these abilities are acquired in typically developing children. Item difficulty estimates for the two populations are highly correlated (adjusted r2=0.89, p<0.0005), but demonstrate significant bias with harder items (typically acquired at later ages) being more readily achieved by children with ABI compared to CP. These results support the Hebbian perspective that (when considering gross motor function) it is easier to maintain or recover previously established functions than to learn them for the first time in an injured brain. This argues for a more cautious outcome prognosis in injury at very young ages.

The association between cardiac autonomic system function at the entrance to rehabilitation and walking-endurance two months later among children following-ABI

BACKGROUND

The cardiac autonomic control system function is frequently impaired after brain injury. An association exists between the cardiac autonomic control system and endurance performance.

AIM

To evaluate the association between cardiac autonomic control system indices at the beginning of the inpatient rehabilitation and walking endurance two months later among children and adolescents following acquired brain injury.

METHODS

A prospective study included 28 children and adolescents following acquired brain injury in the sub-acute phase. A Polar device (RS800CX) records heart rate as a proxy measure of autonomic function at sitting and lying supine on admission and two months later. The 6-minute walk test was assessed at the second assessment in 25 participants. Non-parametric tests were used with statistical significance defined as p < 0.05.

RESULTS

There were statistically significant differences in heart rate variability between lying and sitting positions, which were positively correlated with the 6-minutes walk test results two months later, mainly in the parasympathetic components (r_s = 0.51 p-value <0.01).

CONCLUSIONS

At the beginning of the rehabilitation of children and adolescents following acquired brain injury, a simple manipulation - position change from sitting to lying, activates cardiac autonomic control system responses. These responses are positively associated with walking endurance two months later.

Proceedings of the First Pediatric Coma and Disorders of Consciousness Symposium by the Curing Coma Campaign, Pediatric Neurocritical Care Research Group, and NINDS: Gearing for Success in Coma Advancements for Children and Neonates

This proceedings article presents the scope of pediatric coma and disorders of consciousness based on presentations and discussions at the First Pediatric Disorders of Consciousness Care and Research symposium held on September 14th, 2021. Herein we review the current state of pediatric coma care and research opportunities as well as shared experiences from seasoned researchers and clinicians. Salient current challenges and opportunities in pediatric and neonatal coma care and research were identified through the contributions of the presenters, who were Jose I. Suarez, MD, Nina F. Schor, MD, PhD, Beth S. Slomine, PhD Erika Molteni, PhD, and Jan-Marino Ramirez, PhD, and moderated by Varina L. Boerwinkle, MD, with overview by Mark Wainwright, MD, and subsequent audience discussion. The program, executively planned by Varina L. Boerwinkle, MD, Mark Wainwright, MD, and Michelle Elena Schober, MD, drove the identification and development of priorities for the pediatric neurocritical care community.

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.

Rehabilitation after paediatric acquired brain injury: Longitudinal change in content and effect on recovery

AIM

To describe cross-sectional and longitudinal variation in neurorehabilitation content provided to young people after severe paediatric acquired brain injury (pABI) and to relate this to observed functional recovery.

METHOD

This was an observational study in a cohort of admissions to a residential neurorehabilitation centre. Recovery was described using the Pediatric Evaluation of Disability - Computer Adaptive Testing instrument. Rehabilitation content was measured using the recently described Paediatric Rehabilitation Ingredients Measure (PRISM) and examined using multidimensional scaling.

RESULTS

The PRISM reveals wide variation in rehabilitation content between and during admissions primarily reflecting proportions of child active practice, child emotional support, and other management of body structure and function. Rehabilitation content is predicted by pre-admission recovery, suggesting therapist decisions in designing rehabilitation programmes are shaped by their initial expectations of recovery. However, significant correlations persist between plausibly-related aspects of delivered therapy and observed post-admission recovery after adjusting for such effects.

INTERPRETATION

The PRISM approach to the analysis of rehabilitation content shows promise in that it demonstrates significant correlations between plausibly-related aspects of delivered therapy and observed recovery that have been hard to identify with other approaches. However, rigorous, causal analysis will be required to truly understand the contributions of rehabilitation to recovery after pABI.

WHAT THIS PAPER ADDS

Rehabilitation content varies widely between, and during, admissions for neurorehabilitation after paediatric acquire brain injury. Strong correlations are seen between plausibly-related aspects of rehabilitation content and observed recovery, though careful interpretation is necessary.

Demonstration of functional rehabilitation treatment effects in children and young people after severe acquired brain injury

PURPOSE

To examine relationships between functional outcomes after pediatric acquired brain injury (ABI) and measures of rehabilitation dose.

METHODS

An observational study of children receiving residential neurorehabilitation after severe ABI.

RESULTS

Basic total rehabilitation dose shows a paradoxical inverse relationship to global outcome. This is due to confounding by both initial injury severity and length of stay, and variation in treatment content for a given total rehabilitation dose. Content-aware rehabilitation dose measures show robust positive correlations between fractions of rehabilitation treatment received and plausibly related aspects of outcome: specifically, between rates of recovery of gross motor function and the fraction of rehabilitation effort directed to active practice and motor learning. This relationship was robust to adjustment for therapists' expectations of recovery.

CONCLUSION

Content-aware measures of rehabilitation dose are robustly causally related to pertinent aspects of outcome. These findings are step toward a goal of comparative effectiveness research in pediatric neurorehabilitation.

Physical rehabilitation interventions in children with acquired brain injury: a scoping review

AIM

To synthesize the evidence about the characteristics (frequency, intensity, time, type) and effects of physical rehabilitation interventions on functional recovery and performance in daily functioning in children and young people with acquired brain injury (ABI), including traumatic brain injuries (TBI) and non-TBI, during the subacute rehabilitation phase.

METHOD

Using scoping review methodology, a systematic literature search was performed using four databases. Articles were screened by title and abstract and data from eligible studies were extracted for synthesis.

RESULTS

Nine of 3009 studies were included. The results demonstrated a variety of intervention characteristics: frequency varied between 1 and 7 days per week; time of intervention varied between 25 minutes and 6 hours a day; intervention types were specified in seven studies; and none of the included studies reported details of intensity of intervention. All studies reported positive results on the International Classification of Functioning, Disability and Health: Children and Youth (ICF-CY) levels of body function and activities after the intervention period, with study designs of included studies being cohort studies without concurrent controls (n=7) or case reports (n=2).

INTERPRETATION

Inconsistency in results hampers generalizability to guide clinical practice. Physical interventions during subacute rehabilitation have potential to improve functional recovery with intervention characteristics as an important factor influencing its effectiveness. Future well-designed studies are indicated to gain knowledge and optimize rehabilitation practice in paediatric ABI and high-quality research including outcomes across all ICF-CY domains is needed.

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 (CAE) and outcome trajectory parameters using a nonlinear mixed effects modeling approach.

DESIGN

Retrospective study.

SETTING

Pediatric inpatient rehabilitation hospital.

PARTICIPANTS

252 children between the ages of 2 and 21 years (median 11.8; interquartile range [IQR] 6.4-15.9) consecutively admitted to an inpatient rehabilitation brain injury unit (2008-2014) for a first inpatient admission following acquired brain injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rasch-derived CAE 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 CAE were associated with age (β =.025, p =.000) 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 =.000).

CONCLUSIONS

The CAE derived from the CALS and associated outcome parameters (e.g., rate of recovery) may serve as an ideal outcome measure for clinical trials evaluating interventions for acquired brain injury in a pediatric rehabilitation setting.

Individualized Prognostic Prediction of the Long-Term Functional Trajectory in Pediatric Acquired Brain Injury

In pediatric acquired brain injury, heterogeneity of functional response to specific rehabilitation treatments is a key confound to medical decisions and outcome prediction. We aimed to identify patient subgroups sharing comparable trajectories, and to implement a method for the early prediction of the long-term recovery course from clinical condition at first discharge. 600 consecutive patients with acquired brain injury (7.4 years ± 5.2; 367 males; median GCS = 6) entered a standardized rehabilitation program. Functional Independent Measure scores were measured yearly, until year 7. We classified the functional trajectories in clusters, through a latent class model. We performed single-subject prediction of trajectory membership in cases unseen during model fitting. Four trajectory types were identified (post.prob. > 0.95): high-start fast (N = 92), low-start fast (N = 168), slow (N = 130) and non-responders (N = 210). Fast responders were older (chigh = 1.8; clow = 1.1) than non-responders and suffered shorter coma (chigh = -14.7; clow = -4.3). High-start fast-responders had shorter length of stay (c = -1.6), and slow responders had lower incidence of epilepsy (c = -1.4), than non-responders (p < 0.001). Single-subject trajectory could be predicted with high accuracy at first discharge (accuracy = 0.80). In conclusion, we stratified patients based on the evolution of their response to a specific treatment program. Data at first discharge predicted the response over 7 years. This method enables early detection of the slow responders, who show poor post-acute functional gains, but achieve recovery comparable to fast responders by year 7. Further external validation in other rehabilitation programs is warranted.

Ataxia and mobility in children following surgical resection of posterior fossa tumour: A longitudinal cohort study

PURPOSE

To report the course of ataxia in children up to 2 years post-operatively, following surgical resection of a posterior fossa tumour (PFT).

METHODS

Thirty-five children, (median age 9 years, range 4-15) having resection of PFT, were assessed using the Scale for the Assessment and Rating of Ataxia (SARA), Brief Ataxia Rating Scale (BARS) and the mobility domain of the Paediatric Evaluation of Disability Index (PEDI-m) at initial post-operative period (baseline), 3 months, 1 year and 2 years post-operatively.

RESULTS

Baseline median scores of the SARA and BARS were 8.5 (range 0-35.5), and 7 (0-25) respectively. Ataxia improved at 3 months (median SARA and BARS reduction 3.5 and 4, respectively). Additional gradual improvements in SARA were recorded at 1 (median reduction 2) and 2 years post-operatively (median reduction 0.5). Median baseline PEDI-m was 54.75 (range 15.2-100) with improvement at 3 months (median increase 36.95) and small improvement at 1 year (median increase 2.5) and 2 years (median increase 5.8). Children with medulloblastoma and midline tumours (median baseline SARA 10 and 11, respectively) demonstrated more severe ataxia than children with low-grade gliomas and unilateral tumours (median baseline SARA 7.5 and 6.5, respectively).

CONCLUSION

The largest improvement in ataxia scores and functional mobility scores is demonstrated within the first 3 months post-operatively, but ongoing gradual improvement is observed at 2 years. Children with medulloblastoma and midline tumour demonstrated higher ataxia scores long term.

Evaluating functional change using the Physical Abilities and Mobility Scale in acute paediatric neurorehabilitation

Background/Aims

Childhood acquired brain injury is the leading cause of death and long-term disability among children and young people in the UK. Following a childhood brain injury, function is shown to improve within a specialist neurorehabilitation setting. Little evidence currently exists to demonstrate gross motor functional change within an acute hospital setting. The Physical Abilities and Mobility Scale is a valid and reliable outcome measure for use within inpatient paediatric neurorehabilitation following brain injury. The primary aim of this study was to evaluate how the gross motor function of paediatric patients with a new acquired brain injury changes during an acute hospital admission.

Methods

Data were collected for all patients admitted as an inpatient to one acute hospital over a 12-month period. The Physical Abilities and Mobility Scale was completed at baseline, at least weekly and again at discharge. Views relating to the utility of the Physical Abilities and Mobility Scale were sought among physiotherapists using the measure in order to inform acceptability.

Results

A total of 28 patients were included in this study. A Wilcoxon signed rank test was performed, which showed a highly significant improvement in function as scored on the Physical Abilities and Mobility Scale between baseline assessment (median 29.00, interquartile range 25.00–35.50) and discharge (median 85.00, interquartile range 75.00–95.00, Z=-4.624, P<0.001). A total of five patients (17.86%) were referred on for specialist residential neurorehabilitation. A post hoc analysis found that the rate of change of the Physical Abilities and Mobility Scale appeared to have an impact on final discharge destination, with slow improvers 18.60 times more likely to require specialist rehabilitation than others. The Physical Abilities and Mobility Scale was found to be acceptable among physiotherapists using it.

Conclusions

Children with a new acquired brain injury make significant improvements in gross motor function during a period of acute inpatient neurorehabilitation. Further work should look to refine the measure and gain a full understanding of its clinical utilities.

Factors Associated With Gains in Performance During Rehabilitation After Pediatric Brain Injury: Growth Curve Analysis

OBJECTIVE

Predicting recovery of functional performance within pediatric rehabilitation after brain injury is important for health professionals and families, but information regarding factors associated with change in functional skills ("what the child can do") and functional independence ("what the child does") is limited. The aim of the study was to examine change in functional skills and independence over time in children with moderate-severe brain injury during prolonged inpatient rehabilitation.

DESIGN

This study used a retrospective cohort design. Longitudinal data from 139 children (age 1.6-20.6 yrs), hospitalized for 115.4 ± 72 days, were examined. Growth curve analysis was used to examine factors associated with change in the Pediatric Evaluation of Disability Inventory (functional skills and caregiver assistance, ie, functional independence) in mobility and self-care. Typical estimates for change per hospitalization day were obtained.

RESULTS

Traumatic brain injury and older age at injury, but not sex, were associated with faster recovery. Length of stay was associated with rate of change in functional skills but not in functional independence, suggesting that improvement in functional independence during rehabilitation may be associated with other factors.

CONCLUSIONS

Identifying the factors associated with individual profiles of functional improvement can provide valuable information for clinicians and decision-makers to optimize performance after prolonged inpatient rehabilitation.

A reflective case review: Relearning handwriting after a traumatic brain injury

Statement of context

A retrospective single case study reflecting on a child relearning handwriting following a traumatic brain injury as part of an inpatient neuro-rehabilitation programme. Applying evidence-based handwriting guidelines and comparisons with community experiences are explored.

Critical reflection on practice

Relearning to write following a traumatic brain injury showed dramatic improvements in 36 sessions over 12 weeks, supporting the evidence. Progress in this timeframe contrasts with clinical experiences of working with children’s community services.

Implications for practice

Whilst the literature on handwriting interventions does not include children with traumatic brain injury, following the recommendations was an effective intervention for this individual.

Rehabilitation of Upper Limb in Children with Acquired Brain Injury: A Preliminary Comparative Study

Acquired brain injuries (ABIs) can lead to a wide range of impairments, including weakness or paralysis on one side of the body known as hemiplegia. In hemiplegic patients, the rehabilitation of the upper limb skills is crucial, because the recovery has an immediate impact on patient quality of life. For this reason, several treatments were developed to flank physical therapy (PT) and improve functional recovery of the upper limbs. Among them, Constraint-Induced Movement Therapy (CIMT) and robot-aided therapy have shown interesting potentialities in the rehabilitation of the hemiplegic upper limb. Nevertheless, there is a lack of quantitative evaluations of effectiveness in a standard clinical setting, especially in children, as well as a lack of direct comparative studies between these therapeutic techniques. In this study, a group of 18 children and adolescents with hemiplegia was enrolled and underwent intensive rehabilitation treatment including PT and CIMT or Armeo®Spring therapy. The effects of the treatments were assessed using clinical functional scales and upper limb kinematic analysis during horizontal and vertical motor tasks. Results showed CIMT to be the most effective in terms of improved functional scales, while PT seemed to be the most significant in terms of kinematic variations. Specifically, PT resulted to have positive influence on distal movements while CIMT conveyed more changes in the proximal kinematics. Armeo treatment delivered improvements mainly in the vertical motor task, showing trends of progresses of the movement efficiency and reduction of compensatory movements of the shoulder with respect to other treatments. Therefore, every treatment gave advantages in a specific and different upper limb district. Therefore, results of this preliminary study may be of help to define the best rehabilitation treatment for each patient, depending on the goal, and may thus support clinical decision.

Requirements for and current provision of rehabilitation services for children after severe acquired brain injury in the UK: a population-based study

OBJECTIVES

Survival with brain injury is an outcome of severe illness that may be becoming more common. Provision for children in this situation has received little attention. We sought to estimate rates of severe paediatric acquired brain injury (ABI) requiring rehabilitation and to describe current provision of services for these children in the UK.

METHODS

This study conducted an analysis of Hospital Episode Statistics data between April 2003 and March 2012, supplemented by a UK provider survey completed in 2015. A probable severe ABI requiring rehabilitation (PSABIR) event was inferred from the co-occurrence of a medical condition likely to cause ABI (such as meningitis) and a prolonged inpatient stay (>=28 days).

RESULTS

During the period studied, 4508 children aged 1-18 years in England had PSABIRs. Trauma was the most common cause (30%) followed by brain tumours (19%) and anoxia (18.3%). An excess in older males was attributable to trauma. We estimate the incidence of PSABIR to be at least 2.93 (95%CI 2.62 to 3.26) per 100 000 young people (1-18 years) pa. The provider survey confirmed marked geographic variability in the organisation of services in the UK.

CONCLUSIONS

There are at least 350 PSABIR events in children in the UK annually, a health problem of similar magnitude to that of cerebral palsy. Service provision for this population varies widely around the UK, in contrast with the nationally coordinated approach to paediatric intensive care and major trauma provision.

Modular Open-Source Software for Item Factor Analysis

This paper introduces an Item Factor Analysis (IFA) module for OpenMx, a free, open-source, and modular statistical modeling package that runs within the R programming environment on GNU/Linux, Mac OS X, and Microsoft Windows. The IFA module offers a novel model specification language that is well suited to programmatic generation and manipulation of models. Modular organization of the source code facilitates the easy addition of item models, item parameter estimation algorithms, optimizers, test scoring algorithms, and fit diagnostics all within an integrated framework. Three short example scripts are presented for fitting item parameters, latent distribution parameters, and a multiple group model. The availability of both IFA and structural equation modeling in the same software is a step toward the unification of these two methodologies.