WeeFIM. Normative sample of an instrument for tracking functional independence in children

Associations between patient-reported functional disability and measures of physical ability in juvenile fibromyalgia

ABSTRACT

Juvenile fibromyalgia (JFM) is a chronic condition characterized by symptoms of pain and fatigue and is associated with sedentary behavior and functional disability. Adults with fibromyalgia exhibit deficits in physical fitness as evidenced by lower aerobic capacity and physical endurance, but it is unknown whether these impairments are apparent in adolescents with JFM. Furthermore, the extent to which functional disability and pain interference relate to measures of physical fitness has not been investigated in a pediatric pain population. During a baseline assessment for a clinical trial, 321 adolescents with juvenile fibromyalgia (M age = 15.14, 85.2% female) completed measures of pain intensity, fatigue, JFM symptom severity, functional disability, and pain interference. They also completed 2 validated fitness tasks: (1) the Harvard step test, which assesses aerobic fitness, and (2) the 6-minute walk test, a simple submaximal test of endurance. We examined associations among self-report measures and fitness assessments using bivariate correlations. We then employed hierarchical regression analyses to determine the unique contributions of physical fitness assessments to self-reported functional disability and pain interference. Results indicated that youth with JFM exhibited deficits in aerobic capacity and physical endurance. However, physical fitness explained negligible variance in functional disability and pain interference beyond that accounted for by pain, fatigue, and JFM symptom severity. Scores on available functional disability measures may reflect perceived difficulties in coping with symptoms during physical tasks rather than actual physical capability. Rigorous and sensitive assessments of physical fitness and endurance are needed to determine whether rehabilitation interventions for pediatric pain improve physical functioning.

Motor Development of Children in the Kurdistan Region of Iraq: Parent Survey

The actual literature highlights the importance of the socio-cultural context in the development of children. However, there is a lack of specific evidence about the middle East, especially regarding the development of Kurdish children who are living in a post-war scenario, in a country which is experiencing continuous instability due to the different crises. The main aim of this study is to identify the features of the motor development of Kurdish children according to parents' opinion. A comparison with Italian children is provided as a Western example, which reflects data from the literature. In the study, 331 parents of Kurdish and Italian children aged between 3 and 7 years were involved. Parents filled the questionnaire at kindergartens, after providing consent. The questionnaire was conceptualized, designed, tested and provided ad hoc for this study; it focused on the timing of development, concerning major milestones like head control, sitting and standing-up. The questionnaire consists of 15 questions and has not been standardized yet. A logistic regression showed several differences between Kurdish and Italian children, like head control (p = 0.007) or the manipulation of big objects (p < 0.0001). These results identify the effect of the socio-cultural context and the impact of the growing environment of the child. Moreover, the results of this survey show the need for introducing different adapted, translated and validated assessment tools for motor development, considering differences related to the socio-cultural context.

Utility of Early Magnetic Resonance Imaging to Enhance Outcome Prediction in Critically Ill Children with Severe Traumatic Brain Injury

BACKGROUND

Many children with severe traumatic brain injury (TBI) receive magnetic resonance imaging (MRI) during hospitalization. There are insufficient data on how different patterns of injury on early MRI inform outcomes.

METHODS

Children (3-17 years) admitted in 2010-2021 for severe TBI (Glasgow Coma Scale [GCS] score < 9) were identified using our site's trauma registry. We used multivariable modeling to determine whether the hemorrhagic diffuse axonal injury (DAI) grade and the number of regions with restricted diffusion (subcortical white matter, corpus callosum, deep gray matter, and brainstem) on MRI obtained within 7 days of injury were independently associated with time to follow commands and with Functional Independence Measure for Children (WeeFIM) scores at the time of discharge from inpatient rehabilitation. We controlled for the clinical variables age, preadmission cardiopulmonary resuscitation, pupil reactivity, motor GCS score, and fever (> 38 °C) in the first 12 h.

RESULTS

Of 260 patients, 136 (52%) underwent MRI within 7 days of injury at a median of 3 days (interquartile range [IQR] 2-4). Patients with early MRI were a median age of 11 years (IQR 7-14), 8 (6%) patients received cardiopulmonary resuscitation, 19 (14%) patients had bilateral unreactive pupils, the median motor GCS score was 1 (IQR 1-4), and 82 (60%) patients had fever. Grade 3 DAI was present in 46 (34%) patients, and restricted diffusion was noted in the corpus callosum in 75 (55%) patients, deep gray matter in 29 (21%) patients, subcortical white matter in 23 (17%) patients, and the brainstem in 20 (15%) patients. After controlling for clinical variables, an increased number of regions with restricted diffusion, but not hemorrhagic DAI grade, was independently associated with longer time to follow commands (hazard ratio 0.68, 95% confidence interval 0.53-0.89) and worse WeeFIM scores (estimate β - 4.67, 95% confidence interval - 8.33 to - 1.01).

CONCLUSIONS

Regional restricted diffusion on early MRI is independently associated with short-term outcomes in children with severe TBI. Multicenter cohort studies are needed to validate these findings and elucidate the association of early MRI features with long-term outcomes in children with severe TBI.

Leveraging monitoring, evaluation, and learning to scale the Enabling Inclusion® program for children with disabilities in India and globally

Introduction

Children with disabilities in low- and middle-income countries face many challenges and lack adequate services, including access to rehabilitation professionals. To address this lack of access, Amar Seva Sangam Ayikudy (ASSA), a non-governmental organization (NGO) in India, designed a technology-leveraged rehabilitation program called Enabling Inclusion® (EI®), and implemented it in one state (Tamil Nadu, India) before scaling it. The model is supported by the EI® app, which enables organizations to screen, assess and monitor progress of children with disabilities via rehabilitation specialists and community rehabilitation workers, and to provide family-centered, goal-based interventions. An extensive monitoring, evaluation, and learning (MEL) framework is embedded into the program. This paper explores how this MEL system supported the scaling of the EI® model, reaching additional beneficiaries nationally and globally.

Methods

This paper describes ASSA's MEL framework and demonstrates its use for decision-making in the process of scaling. It also explores how collaborations with various government departments, NGOs, and private partners contributed to the scaling of the EI® model and technology.

Results

Scaling of the EI® program was achieved by (1) expansion of the program in rural Tamil Nadu (vertical scale-up) in partnership with the Tamil Nadu government and private partners, and (2) by licensing the EI® app and model to other NGOs in various states in India and globally (horizontal scale-up). Systematic examination of key program and performance indicators, as well as stakeholder feedback, informed decisions to modify the EI® app over time. This included further customizing to the needs of children and service providers, covering a greater range of age groups and contexts, and modifying service delivery models. Child functional independence, participation, and inclusion was further strengthened by mobilizing parent empowerment groups, community awareness programs, school advocacy, and entitlements from the government. Flexibility in the implementation model of the EI® app allowed for adaptation to local contexts and organizations, and facilitated its scale-up.

Conclusion

A dynamic, inclusive, and locally grounded MEL system, a flexible and collaborative approach, and an adaptive implementation model increased the accessibility of an early intervention and childhood rehabilitation program for children with disabilities and their families throughout the state of Tamil Nadu, across India, and internationally.

Outcomes following intensive day rehabilitation for young people in Western Australia

PURPOSE

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.

The effect of functional independence levels on sleep and constipation in children with cerebral palsy

OBJECTIVE

The study aimed to examine the effect of functional independence levels on sleep behavior and constipation in children with cerebral palsy.

METHODS

This cross-sectional observational single-center study was carried out in a special rehabilitation center in Istanbul. Inclusion criteria were those aged between 4 and 18 years with Gross Motor Function Classification System III-IV-V functional independence levels. Those who had surgery concerning intestinal health, had a chronic infectious bowel disease, had congenital intestinal anomalies, had received botox treatment in the last 6 months, had uncontrolled epileptic seizures, had complained of constipation in the last 6 months, and had cardiopulmonary disease were excluded from the study. The sociodemographic characteristics of the participants and the Gross Motor Function Classification System were recorded. Pediatric Functional Independence Scale (Functional Independence Measure for Children) was used to measure the functional independence level, Pediatric Sleep Questionnaire was used to measure the level of sleep problems, and Constipation Severity Scale was used to measure constipation severity.

RESULTS

A total of 60 children who were diagnosed with cerebral palsy were included. According to Gross Motor Function Classification System, 46.7% of the cases were Level III, 35% were Level IV, and 18.3% were Level V. There was a negative moderate significant correlation between Functional Independence Measure for Children and Pediatric Sleep Questionnaire (r=-0.303; p=0.019) and between Functional Independence Measure for Children and Constipation Severity Scale (r=-0.342; p=0.007).

CONCLUSION

We described that lower functional independence levels were related to worse sleep and constipation symptoms. The results suggest that effective strategies for developing functional independence levels may be beneficial for both sleep and constipation symptoms in the concept of cerebral palsy management.

Effect of hippotherapy on balance, functional mobility, and functional independence in children with Down syndrome: randomized controlled trial

Impaired muscle strength, proprioceptive and vestibular deficits, and orthopedic dysfunction are common disorders associated with Down syndrome (DS). Hippotherapy uses the horses' multidimensional movement to improve posture, balance, and overall function, both motor and sensory. Research evidence supports hippotherapy as an effective, medically recognized intervention for the rehabilitation of gross motor skills. The aim of this study was to determine the effect of hippotherapy on balance, functional mobility, and functional independence in children with DS. Thirty-four children with DS were randomly assigned to the experimental (hippotherapy) and control groups after the initial assessment. Both groups received physiotherapy including balance exercises, and the experimental group also received hippotherapy as an integrative therapy. Pediatric Balance Scale (PBS), Timed Up and Go Test (TUG), and Functional Independence Measure for Children (WeeFIM) were used before and after the intervention. Baseline outcome measures (PBS, TUG, WeeFIM) were statistically similar between groups (p > 0.05). After the intervention, PBS and TUG scores improved in both groups (p < 0.05). On the other hand, WeeFIM scores improved just in the hippotherapy group (p < 0.05).   Conclusion: Therefore, providing hippotherapy as an integrative therapy to physiotherapy will be more effective in improving the functional independence of children with DS.    Trial registration: NCT05297149 (March 2022, retrospectively registered). What is Known: • Hippotherapy has an improvement effect on balance and functional independence in different diseases and age groups, but the evidence is limited in DS. • There is limited evidence about the effect of hippotherapy on functional mobility in different diseases and age groups, but there is no evidence in DS. What is New: • Hippotherapy is a safe and effective approach to support improvement in functional independence in children with DS.

Investigation of urinary disorders, functional independence, and quality of life in children with cerebral palsy

PURPOSE

The study aimed to investigate the relationship between voiding disorders, functional independence, and quality of life, according to the gross motor function classification system, in children with cerebral palsy (CP) aged 8-17.

METHODS

A total of 102 individuals (aged 8-17) with CP were included in the study. The Gross Motor Function Classification System (GMFCS), Dysfunctional Voiding and Incontinence Scoring System (DVISS), Wee Functional Independence Measure for Children (WeeFIM), and Pediatric Quality of Life Inventory (PedsQL) were used to evaluate the clinical parameters.

RESULTS

There is a statistically significant difference in DVISS (p = 0.010), WeeFIM (p = 0.001), and PedsQL (p = 0.001) scores of individuals with CP regarding GMFCS. According to the CP classification, there is a statistically significant difference between WeeFIM (p = 0.001) and PedsQL (p = 0.020) scores. Besides, there is a significant difference between DVISS (p = 0.048), WeeFIM (p = 0.001) and PedsQL (p = 0.001) according to the ambulation status of individuals with CP. On the other hand, there is a positive moderate, statistically significant correlation between WeeFIM and PedsQL scores (ρ = 0.306, r = 0.002). A moderately negative statistically significant relationship exists between PedsQL and DVISS (ρ = -0.266, r = 0.007). A negative, moderate, statistically significant correlation was shown between DVISS and WeeFIM scores (ρ = -0.323, r = 0.001).

CONCLUSIONS

As the gross motor functional level of individuals with CP increased, voiding dysfunction increased; on the other hand, functional independence and quality of life decreased.

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.

The effects of rehabilitation on functional independence of Eastern Taiwanese children with rare or genetic diseases

Objectives

This study investigated the effects of outpatient rehabilitation therapy (RT) on the functional performance of children from Eastern Taiwan with rare or genetic diseases.

Materials and Methods

This retrospective observational cohort study included 73 children from Eastern Taiwan who were affected with rare or genetic diseases, with an average age of 8.57 ± 5.33 years (47 boys and 26 girls). Each child received the goal-directed therapy known as outpatient RT, which was delivered by a multidisciplinary team of specialists. To assess the effectiveness of RT, the WeeFIM-C questionnaire data were collected and analyzed.

Results

After receiving outpatient RT, most of the children only required low-to-moderate assistance with self-care tasks (4.36 ± 2.38), and they could perform mobility-related activities under supervision or independently (5.70 ± 2.29). Moreover, most only required minimal assistance with tasks related to cognitive functioning and tended to complete such tasks under supervision (4.97 ± 2.05). The functional performance was significantly different among three studied groups, in terms of self-care (F[2, 68] = 5.42, P < 0.007), mobility (F[2, 68] = 8.17, P < 0.001), cognitive functioning (F[2, 68] = 3.31, P < 0.042), and overall (F[2, 68] = 6.44, P < 0.003) functional performance.

Conclusion

The results of this study demonstrated that the functional status was different among three studied groups in terms of self-care, mobility, and cognitive functioning after receiving outpatient RT.

20 Years of ICF-International Classification of Functioning, Disability and Health: Uses and Applications around the World

The International Classification of Functioning Disability and Health (ICF) was approved in 2001 and, since then, several studies reported the increased interest about its use in different sectors. A recent overview that summarizes its applications is lacking. This study aims to provide an updated overview about 20 years of ICF application through an international online questionnaire, developed by the byline authors, and sent to each World Health Organization Collaborating Centers of the Family of International Classifications (WHO-FIC CCs). Data was collected during October 2020 and December 2021 and descriptive content analyses were used to report main results. Results show how, in most of the respondent countries represented by WHO-FIC CCs, ICF was mainly used in clinical practice, policy development and social policy, and in education areas. Despite its applications in different sectors, ICF use is not mandatory in most countries but, where used, it provides a biopsychosocial framework for policy development in health, functioning and disability. The study provides information about the needs related to ICF applications, that can be useful to organize targeted intervention plans. Furthermore, this survey methodology can be re-proposed periodically to monitor the use of the ICF in the future.

The Stoplight Mobility Alert System for Safety and Prevention of Falls in Children With Physical and Cognitive Impairments

OBJECTIVES

This study aimed to decrease the rate of falls in children with cognitive and physical impairments on a pediatric acute inpatient rehabilitation unit (IRU) using a novel tool, the Stoplight Mobility Alert System (SMAS).

METHODS

We conducted a pilot, prospective, quality improvement study in an 8-bed (increased to 12 beds; October 1, 2019) acute inpatient pediatric IRU at a level 1 trauma center. All patients admitted between October 1, 2012, and October 1, 2020, were included as participants. Interventions used were as follows: (1) SMAS, a colored alert system placed on door slides and in-room for visual cues (red, assistance/hands on; yellow, supervision/eyes on; green, independent/hands off), and (2) handouts and one-on-one education for staff and patients/families. Main outcome measures included fall rate on the IRU.

RESULTS

Using the SMAS, the total fall rate decreased from 10.78 to 4.36 falls per 1000 patient-days. Longitudinally, the intrinsic fall rate decreased from 8.36 to 5.60 falls per 1000 patient-days, and the extrinsic fall rate decreased from 4.56 to 1.36 falls per 1000 patient-days.

CONCLUSIONS

The implementation of the SMAS is effective in decreasing total, intrinsic, and extrinsic fall rates in an acute pediatric inpatient rehabilitation program both acutely and longitudinally.

Functional Independence of Taiwanese Children with Osteogenesis Imperfecta

Osteogenesis imperfecta (OI) is a group of rare genetic disorders that affect bone formation. Patients with OI present mainly with increased bone fragility and bone deformities. Twenty-seven Taiwanese children between 2 and 21 years of age with OI and their parents were recruited at MacKay Memorial Hospital from January 2013 to December 2019. We used the Functional Independence Measure for Children (WeeFIM) questionnaire to assess the functional independence of the children and describe any functional limitations or additional burden of daily care. Out of a potential score of 126, the mean total WeeFIM score was 113.7. There was a statistically significant difference between the scores of type I, type III and type IV OI (121.88 [SD 7.01] vs. 80.8 [SD 26.25] vs. 119.17 [SD 10.89]; p < 0.001). There were no statistically significant differences between the scores in different age groups, the male and female participants, and patients with pathogenic variants in COL1A1 and COL1A2. The mean scores for the self-care, mobility, and cognition domains were 48.78 (maximum 56, mean quotient 91.14%), 30.44 (maximum 35, mean quotient 87.12%), and 34.44 (maximum 35, mean quotient 99.05%), respectively. The best performance was in the cognition domain (mean quotient 99.05%), and the worst was in the mobility domain (mean quotient 87.12%). There were no statistically significant correlations between WeeFIM scores and age, or age when symptoms began. The total WeeFIM score and 13 subscores for the self-care and mobility domains were all positively correlated with body height (p < 0.01). The correlation was lowest for bowel and walking/wheelchair tasks, and the highest for bathing and dressing-upper tasks. For tasks in bathing, over 40% of the patients needed help. For tasks in the cognition domain, most patients required no help. For the Taiwanese children with OI, some support and supervision were required for self-care and mobility tasks, and the functional independence in these two domains was correlated with body height and disease types. The WeeFIM questionnaire may be a useful tool to assess the functional strengths and weaknesses of children with OI.

An investigation of the psychometric properties of the Turkish adaptation of the activity limitations in cerebral palsy questionnaire

PURPOSE

To translate the ACTIVLIM-CP questionnaire, developed to assess global activity performance in children with Cerebral Palsy (CP), into Turkish and to investigate its psychometric properties.

METHODS

Eighty-nine children with CP, aged between 2 and 18 years (mean age: 10.08 ± 4.94 years), were included in the study. Internal consistency was measured by Cronbach's alpha and test-retest reliability was assessed using intraclass correlation coefficient (ICC). Convergent validity was evaluated through the pattern of correlations between the ACTIVLIM-CP with PEDI, ABILOCO-Kids, ABILHAND-Kids, and Wee-FIM scores. Known-group comparisons were made according to epilepsy existence and ambulation level measured by Gross Motor Function Classification System (GMFCS).

RESULTS

Internal consistency was excellent (Cronbach's α = 0.990), and the ICC for the test-retest reliability was 0.990. There was a very strong correlation between ACTIVLIM-CP and ABILHAND-Kids (r = 0.946), WeeFIM (r = 0.900), PEDI Functional Skills and Caregiver Assistance scores (r = 0.954, r = 0.937, respectively), and ABILOCO-Kids (r = 0.817) (p < 0.001) score. ACTIVLIM-CP score was lower in children with epilepsy (p = 0.001) and in the high-level group according to GMFCS (p < 0.001).

CONCLUSION

The Turkish adaptation of ACTIVLIM-CP is a valid and reliable scale for measuring activity limitations in children with CP and is compatible with other scales evaluating activity limitations.

CLINICAL TRIAL NUMBER

NCT05184244IMPLICATIONS FOR REHABILITATIONActivity limitation measurements are crucial and necessary to determine the global activity performance of children with CP.ACTIVLIM-CP was translated and culturally adapted to Turkish and showed good psychometric properties.ACTIVLIM-CP is a valid and reliable tool to evaluate activity performance in children with CP.

To what extent the Arabic WeeFIM is reliable and feasible in Egyptian children with burns? An observational cross-sectional study

This is an observational cross-sectional study design aimed to assess the feasibility and reliability of Arabic version of WeeFIM in Egyptian children with healed burns with two measurements within a 2-week time period in a sample of 53 patients with healed burns who were aged 3 to 16 years and treated in the outpatient burn clinic, Faculty of Physical Therapy, Cairo University and Om Elmisryeen Hospital. All patients met the inclusive criteria were enrolled in the study. The adaptation of the Arabic WeeFIM instrument to an interview format suitable for burned children with communicative and/or cognitive problems and evaluation of its feasibility and reliability. The reliability was assessed by a test-retest procedure. Feasibility was evaluated by the assessment of the frequency of missing answers per item and administration time. The Arabic Index of Content Validity (ICV) was used for content validity assessment. The Arabic version of WeeFIM has borderline reliability (Cronbach's Alpha = 0.619 and Pearson correlation coefficient: r = 0.986). There was an acceptable percent to have a feasible test as 83.963% of the filled questionnaires had no missing answers and the mean of administration time was 7.4, 5.5 for 1 st and 2 nd assessments, respectively. The ICV of adapted WeeFIM items showed that all the questions were relevant except for two questions only. The Arabic version of WeeFIM has high test-retest reliability, moderate internal consistency, and excellent feasibility in measuring and reporting the functional independence and burden of care for children with healed burns.

Clinical characteristics and effects of enzyme replacement therapy with elosulfase alfa in Korean patients with mucopolysaccharidosis type IVA

Mucopolysaccharidosis type IVA (MPS IVA) is a rare autosomal recessive disorder caused by a deficiency in N-acetylgalactosamine-6-sulfatase, which results in skeletal and connective tissue abnormalities, as well as various non-skeletal manifestations. Although enzyme replacement therapy (ERT) is recommended as the first-line treatment, the outcomes of ERT on bone pathology remain controversial. We report clinical characteristics and outcomes of ERT in 9 patients with MPS IVA (6 males and 3 females) from 7 unrelated families. During ERT, results from pulmonary function tests, echocardiography, the 6-min walk test, and the Functional Independence Measure were monitored biannually. Anthropometric data were compared with previously reported growth charts of subjects with MPS IVA.

Among the 9 patients (5 severe, and 4 slowly progressive form), 7 patients (5 severe, 2 slowly progressive) commenced ERT at a median age of 3.8 years (range: 0.8–13.7 years) and were treated for a median duration of 1.9 years (range: 1.2–5.7 years). Mean height standard deviation scores using MPS IVA growth charts were + 0.4 (+0.0 in severe phenotypes) at initiation and + 0.7 (+0.2 in severe phenotypes) at the last follow-up. Four patients with severe phenotypes underwent surgery for cervical myelopathy and 1 patient with a slowly progressive phenotype underwent a bilateral pelvic osteotomy for hip pain during ERT. The parameters of pulmonary and heart function, endurance, and Functional Independence Measure scores were maintained or increased after ERT. Overall, ERT was well tolerated without deterioration of cardiorespiratory and functional outcomes during treatment, although skeletal outcomes, including growth, were limited.

Inpatient Rehabilitation After Pediatric and Adolescent Trauma: Outcomes and Discharge Needs

INTRODUCTION

Traumatic injury is the leading cause of pediatric mortality and morbidity in the United States. Pediatric trauma survivors requiring inpatient rehabilitation (IPR) require coordinated, multispecialty follow-up. Knowledge of the nature and level of disability is necessary for planning this continued care that is specific to the needs of pediatric trauma patients. This study aims to describe the outcomes of pediatric and adolescent trauma patients using measures of functional progression.

MATERIALS AND METHODS

A retrospective review of trauma patients aged ≤18 y admitted to IPR between January 2018 and December 2020 at the only certified pediatric rehabilitation center in the region was performed.

RESULTS

Ninety five children and adolescents were admitted to IPR after traumatic injury with diagnoses of multitrauma (MT, N = 18), traumatic brain injury (TBI, N = 59), and spinal cord injury (SCI, N = 18). School aged children returned to school at high rates for all injury types (MT: 86.7%, TBI: 97.4%, SCI: 93.8%, P = ns). All groups had similar hospital and rehabilitation length of stay, and most patients required a durable medical equipment at discharge (79%). Using pediatric functional independence measure scoring progression from admission to discharge from IPR, SCI patients made significant improvement in bladder function and the least improvement in stair function. Patients sustaining a TBI made significant improvement in memory and comprehension tasks.

CONCLUSIONS

Pediatric and adolescent trauma patients admitted to IPR had a positive progression during their therapy but required variable ongoing care depending on the mechanism of injury. Excellent rates of returning to school were seen across the three injury types.

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.

Cognitive Recovery During Inpatient Rehabilitation Following Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study

OBJECTIVES

To characterize the demographics, clinical course, and predictors of cognitive recovery among children and young adults receiving inpatient rehabilitation following pediatric traumatic brain injury (TBI).

DESIGN

Retrospective observational, multicenter study.

SETTING

Eight acute pediatric inpatient rehabilitation facilities in the United States with specialized programs for treating patients with TBI.

PARTICIPANTS

Children and young adults (0-21 years) with TBI (n = 234) receiving inpatient rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Admission and discharge status assessed by the WeeFIM Cognitive Developmental Functional Quotient (DFQ) and Cognitive and Linguistic Scale (CALS).

RESULTS

Patients admitted to pediatric inpatient rehabilitation are diverse in cognitive functioning. While the majority of patients make improvements, cognitive recovery is constrained for those admitted with the most severe cognitive impairments. Age, time since injury to rehabilitation admission, and admission WeeFIM Cognitive DFQ are significant predictors of cognitive functioning at discharge from inpatient rehabilitation.

CONCLUSIONS

This work establishes a multicenter Pediatric Brain Injury Consortium and characterized the demographics and clinical course of cognitive recovery during inpatient rehabilitation of pediatric patients with TBI to aid in prospective study design.

The Relationship Between Caregiver Workload and Stress Levels with Clinical Symptom Severity in Cerebral Palsy

The aim of this study is to compare the functional status, spasticity, motor function status of children with cerebral palsy and their caregivers' workload and stress levels. A single-center prospective cross-sectional study was carried out with 30 children with Cerebral Palsy (CP) and their 30 caregivers. The clinical status of the children was assessed with the Modified Ashworth Scale (MAS), Gross Motor Function Classification System (GMFCS), The Functional Independence Measure for Children (WeeFIM). The caregivers' workload and stress levels were evaluated with Bakas Caregiving Outcomes Scale (BCOS) and Perceived Stress Scale (PSS), respectively. The mean age of the children was 11.46±7.45 years. In correlation analysis, the caregivers' BCOS score was related to the children's MAS score (p&lt;0.05). On the other hand, there was a significant relationship between BCOS and PSS scores of the caregivers (p&lt;0.05). Greater levels of spasticity in the children were associated with greater levels of workload. Stress level is higher in caregivers with a high workload.

Concurrent validity of the Warner Initial Developmental Evaluation of Adaptive and Functional Skills and the Bayley Scales of Infant and Toddler Development, Third Edition

AIM

To determine the concurrent validity of the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA-FS), a criterion-specified questionnaire that assesses a child's adaptive skills in everyday contexts, and the Bayley Infant and Toddler Scales of Development, Third Edition (Bayley-III).

METHOD

In a prospective cohort study, 431 WIDEA-FS and Bayley-III assessments were completed among 341 children, aged 10 to 36 months corrected age (158 females, 183 males; median [interquartile range] gestational age at birth 32wks [29-38]), monitored in a high-risk neonatal intensive care unit follow-up clinic.

RESULTS

WIDEA-FS scores were significantly associated with Bayley-III scores in all domains. Lower scores on the WIDEA-FS were significantly associated with an increased risk of adverse developmental performance on all Bayley-III scales. The association was strongest for motor and language Bayley-III scores when tested at <30 months of age, and for cognitive Bayley-III scores when tested at ≥30 months of age.

INTERPRETATION

The WIDEA-FS has concurrent validity with the Bayley-III and may be a useful tool in high-risk follow-up settings.

WHAT THIS PAPER ADDS

WIDEA-FS mobility, communication, and social cognition domains are concurrently valid in infants at high-risk for neurodevelopmental disability. Bayley-III motor, language, and cognitive composite scores are concurrently valid in the same group. The WIDEA-FS mobility and communication domains may be most clinically useful in children <30 months.

Recommendations for Therapy following Nerve Transfer for Children with Acute Flaccid Myelitis

AIM

To provide recommendations for pre- and post-operative occupational and physical therapy for children with acute flaccid myelitis (AFM).

METHODS

Writing panel members consisted of an interdisciplinary team of seven healthcare professionals specializing in the care of children with AFM. The panel reviewed background material on AFM, nerve transfer, and rehabilitation principles applied to pediatrics. Recommendations were prioritized if evidence was available. Where there was no known evidence to support a recommendation, this was noted.

RECOMMENDATIONS

Communication and coordination among interprofessional team members are vital to a comprehensive family-centered rehabilitation program. Surgical planning should include team preparation accounting for frequency, duration, and timing of treatment, as well as individual characteristics and developmental status of the child. Recommendations for pre-operative and six phases of post-operative therapy address assessment, strengthening, range of motion, orthoses, performance of functional activity, and support of the family.

CONCLUSION

Rehabilitation following nerve transfer in children with AFM requires interdisciplinary collaboration and a multisystem approach to assessment and treatment. As new evidence becomes available, recommendations may be revised or replaced accordingly.

Drowning in Children: Retrospective Analysis of Incident Characteristics, Predicting Parameters, and Long-Term Outcome

BACKGROUND

Drowning is the second leading cause of unnatural death in childhood worldwide. More than half of the drowned children, who were in need of cardiopulmonary resuscitation (CPR) at the scene suffered from lifelong neurological sequelae. There are few data about prognostic predictors in the pediatric population of drowning victims. The objective of the study was to assess incident characteristics, prognostic parameters, and long-term outcome of children recovering from a drowning incident.

METHODS

We carried out a retrospective analysis of data of the cohort of pediatric cases (age 0-18) of drowning victims admitted in the years 2000-2015 to the emergency room/intensive care unit/pediatric ward at the University Children's Hospital of Zurich, Switzerland. Outcome was classified by the Pediatric Cerebral Performance Category Scale (PCPCS). New subcategories of severity for known prognostic parameters have been defined. A correlation analysis was performed between the subcategories of the prognostic parameters and the PCPCS.

RESULTS

A total of 80 patients were included in the analysis. Of these, 64% were male, most of the patients were at the age of 0-5 years. More than 80% of the patients were unattended at a public or private pool when the drowning incident happened. In all, 61% (n = 49) needed cardiopulmonary resuscitation (CPR). Of the resuscitated children, 63% showed good to mildly impaired long-term outcome (PCPCS 1-3). Furthermore, 15% (n = 12) were transferred to rehabilitation. Seven children died during the hospital stay and another four died due to complications in the ten years following the incident. The newly defined subcategories of the parameter submersion time, Glasgow Coma Scale (GCS) at time of admission, body temperature at time of admission, blood pH, blood glucose, and blood lactate level correlated significantly with the PCPCS.

CONCLUSIONS

Supervision of children, especially boys of the age 0-5 years, next to public or private pools is most important for prevention of drowning incidents in Switzerland. Cardiopulmonary resuscitation done by trained staff leads to a better long-term outcome. Medical decision making in severe cases of drowning should consider submersion time, GCS at time of admission, body temperature at time of admission, blood pH, blood glucose, and blood lactate levels, as these parameters correlate with long-term outcome.

Ability of the PILOT score to predict 6-month functional outcome in pediatric patients with moderate-severe traumatic brain injury

PURPOSE

To assess the Pediatric Intensity Level of Therapy (PILOT) score alone and in combination with Emergency Department (ED) GCS and Rotterdam score of initial head CT to predict functional outcomes in children with traumatic brain injury (TBI).

METHODS

Children (n=108) aged 31months-15years with moderate to severe TBI were prospectively enrolled at two sites. The ability of PILOT, ED GCS, and Rotterdam scores to predict the 6-month Pediatric Injury Functional Outcome Scale (PIFOS) was evaluated using multivariable regression models with enrollment site, age, and sex as covariates.

RESULTS

PILOT total (sum) score was more predictive of PIFOS (R²=0.23) compared to mean (R² = 0.20) or peak daily PILOT scores (R²=0.11). PILOT total score predicted PIFOS better than ED GCS (R²=0.01) or Rotterdam score (R²=0.06) and was similar to PILOT, ED GCS, and Rotterdam score combined. PILOT total score performed better in patients with intracranial pressure monitors (n=30, R²=0.28, slope=0.30) than without (n=78, R²=0.09, slope=0.36).

CONCLUSIONS

The PILOT score correlated moderately with functional outcome following TBI and outperformed other common predictors. PILOT may be a useful predictor or moderator of functional outcomes.

LEVEL OF EVIDENCE

Prognosis study, Level II.

Association Between Pediatric Inpatient Rehabilitation Services and Children's Functional Outcomes: King Fahad Medical City Experience

Background:

Disability may affect children’s performance of functional activities. This may translate to difficulties in returning to home and/or school. It has been documented that intensive rehabilitation programs for children with disabilities lead to an improvement in their functional abilities. Wee-FIM is a valid and reliable outcome measure that is used commonly with children undergoing rehabilitation.

Objectives:

To study changes in the functional status of children admitted to a specialized pediatric inpatient rehabilitation unit.

Design:

A retrospective cohort study.

Setting:

King Fahad Medical City—Rehabilitation Hospital, Riyadh, Saudi Arabia.

Methods:

Investigators reviewed records of children admitted to a pediatric rehabilitation unit between January 1, 2012, and December 31, 2017. The outcome measures used were rehabilitation length of stay (LOS), Wee-FIM gain, and Wee-FIM efficiency.

Results:

The total number of records included in this study was 361 records. Sixty percent of the children were boys. The mean age was 8.7 ± 3.8 years (range, 3-17 years). Children with cerebral palsy accounted for 45.2% of the children. The mean LOS was 43 days. Children with brain tumors had the shortest LOS compared with children with other diagnoses. Mean (SD) Wee-FIM efficiency was 0.58 (±0.6). Highest Wee-FIM efficiency was observed in children with brain tumors. Average Wee-FIM gain was 20 (±15). The highest functional gain was 27 in children with brain tumors while the lowest was 16 in children with cerebral palsy.

Conclusions:

Intensive inpatient rehabilitation program is associated with improvement in functional performance in children with a variety of impairments and disabilities.

A Game-Based Rehabilitation System for Upper-Limb Cerebral Palsy: A Feasibility Study

Game-based rehabilitation systems provide an effective tool to engage cerebral palsy patients in physical exercises within an exciting and entertaining environment. A crucial factor to ensure the effectiveness of game-based rehabilitation systems is to assess the correctness of the movements performed by the patient during the game-playing sessions. In this study, we propose a game-based rehabilitation system for upper-limb cerebral palsy that includes three game-based exercises and a computerized assessment method. The game-based exercises aim to engage the participant in shoulder flexion, shoulder horizontal abduction/adduction, and shoulder adduction physical exercises that target the right arm. Human interaction with the game-based rehabilitation system is achieved using a Kinect sensor that tracks the skeleton joints of the participant. The computerized assessment method aims to assess the correctness of the right arm movements during each game-playing session by analyzing the tracking data acquired by the Kinect sensor. To evaluate the performance of the computerized assessment method, two groups of participants volunteered to participate in the game-based exercises. The first group included six cerebral palsy children and the second group included twenty typically developing subjects. For every participant, the computerized assessment method was employed to assess the correctness of the right arm movements in each game-playing session and these computer-based assessments were compared with matching gold standard evaluations provided by an experienced physiotherapist. The results reported in this study suggest the feasibility of employing the computerized assessment method to evaluate the correctness of the right arm movements during the game-playing sessions.

Joint Neuropsychological Assessment through Coma/Near Coma and Level of Cognitive Functioning Assessment Scales Reduces Negative Findings in Pediatric Disorders of Consciousness

The present study aimed to: (a) characterize the emergence to a conscious state (CS) in a sample of children and adolescents with severe brain injury during the post-acute rehabilitation and through two different neuropsychological assessment tools: the Rappaport Coma/Near Coma Scale (CNCS) and Level of Cognitive Functioning Assessment Scale (LOCFAS); (b) compare the evolution in patients with brain lesions due to traumatic and non-traumatic etiologies; and (c) describe the relationship between the emergence to a CS and some relevant clinical variables. In this observational prospective longitudinal study, 92 consecutive patients were recruited. Inclusion criteria were severe disorders of consciousness (DOC), Glasgow Coma Scale (GCS) score ≤8 at insult, age 0 to 18 years, and direct admission to inpatient rehabilitation from acute care. The main outcome measures were CNCS and LOCFAS, both administered three and six months after injury. The cohort globally shifted towards milder DOC over time, moving from overall 'moderate/near coma' at three months to 'near/no coma' at six months post-injury. The shift was captured by both CNCS and LOCFAS. CNCS differentiated levels of coma at best, while LOCFAS was superior in characterizing the emergence from coma. Agreement between scales was fair, and reduced negative findings at less than 10%. Patients with traumatic brain injury (TBI) vs. non-traumatic brain injury (NTBI) were older and had neurosurgical intervention more frequently. No relation between age and the level of consciousness was found overall. Concurrent administration of CNCS and LOCFAS reduced the rate of false negatives and better detected signs of arousal and awareness. This provides indication to administer both tools to increase measurement precision.

Pediatric intracranial arteriovenous malformations: Examining rehabilitation outcomes

PURPOSE

Arteriovenous malformation (AVM) rupture in children can cause debilitating neurological injury. Rehabilitation is key to recovery, though literature details little regarding rehabilitation outcomes. We examined a single-center experience with pediatric AVMs as related to acute inpatient rehabilitation outcomes.

METHODS

At our institution, a retrospective chart review was completed examining all cases of intracranial AVMs in patients age 18 and younger who completed our acute inpatient rehabilitation program between 2012-2018. Patient characteristics, clinical data, treatment modality, and functional outcomes were reviewed.

RESULTS

14 patients with AVMs underwent acute inpatient rehabilitation; nine (64.3%) treated surgically at our institution, two (14.3%) non-surgically at our institution, and three (21.4%) surgically at an outside facility prior to transitioning care at our institution. Eight (57.1%) were male, seven (50.0%) Caucasian, and seven (50.0%) Hispanic. Seven (50.0%) presented with AVM rupture; six (42.9%) were found incidentally on imaging. Clinical courses, treatment outcomes, and post-treatment complications varied. Several patients underwent repeat treatment or additional procedures. Neurological deficits identified included hemiparesis, dystonia, spasticity, epilepsy, hydrocephalus, and ataxia. Inpatient rehabilitation unit length of stay was on average 21 days (SD 9.02, range 9-41). Functional Independence Measure for Children (WeeFIM®) scores, including self-care, mobility, and cognition, demonstrated improvement upon discharge. The mean total change was 36.7 points in those treated surgically, 16.5 in those treated non-surgically, and 25.7 in those treated surgically at another facility.

CONCLUSION

We found that all pediatric patients with intracranial AVMs, across all treatment modalities, demonstrated improved outcomes across all functional domains after an acute inpatient rehabilitation program.

Gait abnormalities in people with Dravet syndrome: A cross-sectional multi-center study

OBJECTIVE

To quantify gait abnormalities in people with Dravet syndrome (DS).

METHODS

Individuals with a confirmed diagnosis of DS were enrolled, and stratified according to knee flexion at initial contact (IC) and range of motion (ROM) during stance (atypical crouch: knee flexion >20° at IC and knee ROM >15° during stance; straight: knee flexion <20° at IC). A 1D ANOVA (α = 0.05) was used to test statistical differences among the joint kinematics and spatio-temporal parameters of the cohort and an age-matched control group. Clinical (neurological and orthopaedic evaluation) and anamnestic data (seizure type, drugs, genetic mutation) were collected; distribution between the two gait phenotypes was assessed with the Fisher exact test and, for mutation, with the chi-squared test (p < 0.05). Linear regression between maximum knee flexion and normalised walking speed was calculated.

RESULTS

Seventy-one subjects were enrolled and evaluated with instrumented gait analysis. Fifty-two were included in final analysis (mean age 13.8 ± 7.3; M 26). Two gait patterns were detected: an atypical crouch gait (34.6%) with increased ankle, knee and hip flexion during stance, and reduced walking speed and stride length not associated with muscle-tendon retractions; and a pattern resembling those of healthy age-matched controls, but still showing reduced walking speed and stride length. No differences in clinical or anamnestic data emerged between the two groups.

SIGNIFICANCE

Objectively quantified gait in DS shows two gait patterns with no clear-cut relation to clinical data. Kinematics abnormalities may be related to stabilization issues. These findings may guide rehabilitative and preventive measures.

Long-term outcomes in children with moderate to severe traumatic brain injury: a single-centre retrospective study

Traumatic brain injury (TBI) is a significant cause of mortality and disability in the pediatric population. Non-accidental trauma (NAT) has specifically been reported to result in more severe injury as compared to accidental mechanisms of injury. We aim to investigate the long-term neurological outcomes in children with moderate to severe traumatic brain injury. Our secondary aim is to evaluate the difference in outcomes between children presenting with NAT and non-NAT, in our study population. We performed a retrospective study in a tertiary pediatric hospital between January 2008 to October 2017 of all patients with TBI <16 years old with a Glasgow Coma Scale (GCS) ≤13. The dual primary outcomes were mortality and Paediatric Functional Independence Measure (WeeFIM) scores, recorded at the start of rehabilitation, discharge, 3 months and 6 months post-injury. The secondary outcome was the development of post-traumatic epilepsy. There were 68 patients with a median age of 4.5 [interquartile range (IQR) 1.0-9.0] years old. The most common presenting symptom was vomiting for children <2 years (11/20, 55.0%) while confusion and disorientation were common for those ≥2 years (27/48, 56.3%). WeeFIM scores at the start of rehabilitation [median 122.0, IQR 33.8-126.0] improved at 6 months post-injury (median 126.0, IQR 98.5-126.0). There was a greater incidence of post-traumatic epilepsy in age <2 years (6/20, 30.0%) compared to age ≥2 years (1/48, 2.1%) (p = .002). When comparing NAT versus non-NAT survivors, cognition WeeFIM scores were significantly different at the start of rehabilitation (p = .017) and at 3 months post-injury (p = .025). NAT predicts for poorer long-term outcomes, specifically in cognition, as measured by WeeFIM scores. Younger children <2 years had a higher incidence of post-traumatic epilepsy compared to older children.

Functional independence of Taiwanese patients with mucopolysaccharidoses

BACKGROUND

Information on functional strengths and weaknesses of mucopolysaccharidosis (MPS) patients is important for early intervention programs and enzyme replacement therapy (ERT).

METHODS

We used the Functional Independence Measure for Children (WeeFIM) questionnaire to assess the functional skills of 63 Taiwanese MPS patients (median age, 13 years 3 months; range, 3-20 years) from January 2012 to December 2018.

RESULTS

Mean total WeeFIM score was 75.4 of a potential score of 126. Mean total WeeFIM scores of each type (MPS I, MPS II, MPS IIIB, MPS IVA, and MPS VI) were 103.8, 76.2, 41.6, 92.2, and 113.6, respectively. Mean scores for self-care, mobility, and cognition domains were 30 (maximum 56), 23 (maximum 35), and 22 (maximum 35), respectively. MPS type IIIB patients had the lowest scores in self-care, mobility, cognition, and total domains compared to other types of MPS. All patients with ERT in MPS I, II, and IVA had higher scores in self-care and mobility domains than patients without ERT. Most patients required assistance for self-care skills, especially in grooming and bathing.

CONCLUSION

MPS patients require support and supervision in self-care tasks. For cognition tasks, MPS IIIB patients also require help. This questionnaire is useful to identify the strengths and limitations of MPS patients.

The Association Between the Functional Status Scale and the Pediatric Functional Independence Measure in Children Who Survive Traumatic Brain Injury

OBJECTIVES

To determine the association between the Functional Status Scale and Pediatric Functional Independence Measure scores during the rehabilitation stay in children who survive traumatic brain injury.

DESIGN

Secondary analysis of a prospective observational cohort study.

SETTING

Tertiary care children's hospital with a level 1 trauma center and inpatient rehabilitation service.

PATIENTS

Sixty-five children less than 18 years old admitted to an ICU with acute traumatic brain injury and subsequently transferred to the inpatient rehabilitation service.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

Functional Status Scale and Pediatric Functional Independence Measure at transfer to rehabilitation and Pediatric Functional Independence Measure at discharge from rehabilitation. The median age of the cohort was 7.1 years (interquartile range, 0.8-12.3 yr), and 29% were female. Nearly all of the children were healthy prior to the traumatic brain injury: six patients (9.2%) had a baseline Functional Status Scale score greater than 6. At the time of transfer to inpatient rehabilitation, total Functional Status Scale and Pediatric Functional Independence Measure scores had the expected negative correlation due to increasing disability resulting in lower scores in Pediatric Functional Independence Measure and higher scores in Functional Status Scale (r = -0.49; 95% CI, -0.62 to -0.35). Among subjects with less disability as measured by lower total Functional Status Scale scores, we found substantial variability in the total Pediatric Functional Independence Measure scores. In contrast, Pediatric Functional Independence Measure scores were consistently low among subjects with a wide range of higher total Functional Status Scale scores (more disability).

CONCLUSIONS

Although proprietary and more time-intensive, the Pediatric Functional Independence Measure has advantages relative to the Functional Status Scale for less severely injured patients and task-specific measurements. The Functional Status Scale may have advantages relative to the Pediatric Functional Independence Measure for more severely injured patients. Further investigations are needed to characterize changes in the Functional Status Scale during the rehabilitation stay and after discharge.

Fetal surgery for spina bifida aperta

Spina bifida aperta (SBA) is one of the most common congenital malformations. It can cause severe lifelong physical and neurodevelopmental disabilities. Experimental and clinical studies have shown that the neurological deficits associated with SBA are not simply caused by incomplete neurulation at the level of the lesion. Additional damage is caused by prolonged exposure of the spinal cord and nerves to the intrauterine environment and a suction gradient due to cerebrospinal fluid leakage, leading to progressive downward displacement of the hindbrain. This natural history can be reversed by prenatal repair. A randomised controlled trial demonstrated that mid-gestational maternal-fetal surgery for SBA decreases the need for ventriculoperitoneal shunting and hindbrain herniation at 12 months and improves neurological motor function at 30 months of age. This came at the price of maternal and fetal risks, the most relevant ones being increased prematurity and a persistent uterine corporeal scar. Recently minimally invasive fetal approaches have been introduced clinically yet they lack extensive experimental or clinical trials. We aim to provide clinicians with the essential information necessary to counsel SBA parents as the basis for considering referral of selected patients to expert fetal surgery centres. We review the reported clinical outcomes and discuss recent developments of potentially less invasive fetal SBA approaches.

Five-year motor functional outcome in children with acquired brain injury. Yet to the end of the story?

PURPOSE

The description of motor changes and clinical evolution of a pediatric cohort with acquired brain injury (ABI) over 5 years by the functional independence measure for children (WeeFIM).

METHODS

We analyzed retrospective data from 496 patients (aged 0-18 years) with severe ABI admitted for rehabilitation. WeeFIM scores and disability rating scale (reference scale) were collected at admission, discharge and yearly, up to year 5.

RESULTS

Functional limitations gradually reduced after ABI, but children still had residual disabilities at the endpoint. Seventeen percent of patients demonstrated no improvement at WeeFIM. Gait analysis showed that decreased WeeFIM scores in the mobility domain are associated with slower and shorter steps, and increased step width, compensating for imbalance.

CONCLUSIONS

Five years after ABI, improvement is still found in the mobility domain of WeeFIM. This work adds evidence that margin still exists at least until year 5 after injury for profitably continuing the rehabilitation effort.

Functional independence of Taiwanese children with Prader-Willi syndrome

Prader-Willi syndrome (PWS) is a genetic disorder with obesity, developmental delay, short stature, and behavioral abnormalities. The study aimed to assess the functional independence in children with PWS. The Functional Independence Measure for Children (WeeFIM) was used to evaluate 81 children with PWS (44 boys and 37 girls) with a median age of 11 years 1 month (range 2 years 8 months to 20 years 2 months) were recruited between January 2013 and December 2016. The mean total WeeFIM score was 103.8 (maximum 126). Sixty-five patients (80%) had deletion type PWS, 16 (20.0%) had nondeletion type. The scores were 103.6 ± 18.5 for deletion and 104.8 ± 18.3 for nondeletion type (p = .405), 104.8 ± 19.3 in boys and 102.6 ± 17.3 in girls (p = .293). The mean self-care, mobility, and cognition scores were 47 (maximum 56), 33 (maximum 35), and 24 (maximum 35), respectively. All total scores and 18 subscores in the three functional domains were positively correlated with age (p < .05). Most children required assistance in problem-solving, comprehension, and expression. The WeeFIM identified the strengths and limitations of children with PWS and confirmed that support and supervision were needed in cognitive and self-care tasks.

Adaptive behaviour and motor skills in children with upper limb deficiency

BACKGROUND

The dysfunction of individuals with upper limb deficiencies affects their daily lives and social participation.

OBJECTIVES

To clarify the adaptive behaviours and motor skills of children with upper limb deficiencies.

STUDY DESIGN

Cross-sectional survey.

METHODS

The subjects were 10 children ranging from 1 to 6 years of age with unilateral upper limb deficiencies at the level distal to the elbow who were using only cosmetic or passive prostheses or none at all. To measure their adaptive behaviour and motor skills, the Vineland Adaptive Behavior Scales, Second Edition was used. They were evaluated on the domains of communication, daily living skills, socialization and motor skills. We also examined the relationship of the scores with age.

RESULTS

There were no statistically significant scores for domains or subdomains. The domain standard score of motor skills was significantly lower than the median scores of the domains and was negatively correlated with age.

CONCLUSION

Children with upper limb deficiencies have individual weaknesses in motor skill behaviours, and these weaknesses increase with age. It may be helpful in considering approaches to rehabilitation and the prescription of prostheses to consider the characteristics and course of children's motor skill behaviours. Clinical relevance Even if children with unilateral upper limb deficiencies seem to compensate well for their affected limb function, they have or will experience individual weaknesses in motor skills. We should take this into consideration to develop better strategies for rehabilitation and prostheses prescriptions.

A Web-based module and online video for pain management education for caregivers of children with fractures: A randomized controlled trial

IntroductionOver 80% of children experience compromise in functioning following a fracture. Digital media may improve caregiver knowledge of managing fracture pain at home.

OBJECTIVES

To determine whether an educational video was superior to an interactive web-based module (WBM) and verbal instructions, the standard of care (SOC).

METHODS

This randomized trial included caregivers of children 0-17 years presenting to the emergency department (ED) with non-operative fractures. Primary outcome was the gain score (pre-post intervention) on a 21-item questionnaire testing knowledge surrounding pain recognition and management for children with fractures. Secondary outcomes included survey of caregiver confidence in managing pain (five-item Likert scale), number of days with difficulty sleeping, before return to a normal diet, and work/school missed.

RESULTS

We analyzed 311 participants (WBM 99; video 108; SOC 104) with a mean (SD) child age of 9.6 (4.2) years, of which 125/311 (40.2%) were female. The video (delta=2.3, 95% CI: 1.3, 3.3; p<0.001) and WBM (delta=1.6; 95% CI: 0.5, 2.6; p=0.002) groups had significantly greater gain scores than the SOC group. The mean video gain score was not significantly greater than WBM (delta=0.7; 95% CI: -0.3, 1.8; p=0.25). There were no significant differences in caregiver confidence (p=0.4), number of absent school days (p=0.43), nights with difficulty sleeping (p=0.94), days before return to a normal diet (p=0.07), or workdays missed (p=0.95).

CONCLUSIONS

A web-based module and online video are superior to verbal instructions for improving caregiver knowledge on management of children's fracture pain without improvement in functional outcomes.

Comparing the WeeFIM and PEDI in neurorehabilitation for children with acquired brain injury: A systematic review

INTRODUCTION

We sought to compare the suitability of the Functional Independence Measure for Children (WeeFIM) and the Pediatric Evaluation of Disability Inventory (PEDI) as outcome measures in rehabilitation of children with acquired brain injury (ABI).

METHODS

We performed a systematic review of the evidence base using five databases. PRISMA guidelines were adhered to and the review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42015025370).

RESULTS

Twenty-six retrospective studies were included. Twelve studies utilized the PEDI, thirteen studies the WeeFIM, and one study included both. Statistically significant responsiveness was demonstrated for both the WeeFIM and PEDI, although significant ceiling effects were detected. Evidence of clinically significant responsiveness was limited to one center utilizing the PEDI.

CONCLUSION

Although requiring licensing to use, the WeeFIM is more suitable for the inpatient setting, is quicker to administer and showed minimal ceiling effects compared to the PEDI counterpart.

Rehabilitation of Conjoined Twins Pre- and Postsurgical Separation

PURPOSE

Describe the rehabilitation, including two episodes of inpatient rehabilitation, early intervention, and outpatient services, of conjoined twins.

CASE DESCRIPTION

The patients were 14-month-old female ischiopagus tripus twins that received 3 months of rehabilitation (mobility, feeding, communication, developmental skill training, developing adaptive equipment, educating caregivers) preseparation surgery. Surgery occurred at 24 months. At 27 months, the twins were admitted to inpatient rehabilitation, receiving 4 months of rehabilitation promoting strength, endurance, gait training, feeding, communication, developmental skill training, orthotics, adaptive equipment, and caregiver education. Presurgical WeeFIM was 18/126 (twin A) and 19/126 (twin B), and 28/126 (both twins A&B) postsurgical. Prior to surgery, patients performed supine to sit transfers with supervision.

OUTCOMES

Following surgery, each twin sat and performed bed mobility independently. Twin B performed wheelchair mobility and supported standing at anterior surface with assistance. Discharge WeeFIM was 42/126 (twin A) and 45/126 (twin B). Twins performed floor mobility by scooting, stood at an anterior surface with assistance (maximum for twin A, minimal for twin B), and propelled a manual wheelchair indoors (minimal assistance for both twins A & B).

CONCLUSION

Rehabilitation of conjoined twins improved presurgical functional status and addressed the unique functional needs of each twin postseparation.

Assessing psychosocial functioning following childhood acquired brain injury: The Sydney Psychosocial Reintegration Scale for Children

OBJECTIVE

The Sydney Psychosocial Reintegration Scale for Children (SPRS-C) assesses psychosocial functioning in children with acquired brain injury (ABI). This article aims to: (1) describe normative data for the parent-rated SPRS-C and, (2) evaluate the discriminant validity of the SPRS-C.

METHODS

For Aim 1, participants were parents of typically developing children (TDC) aged 5-14 years (N = 200). For Aim 2, participants with ABI were aged 5-14 years (n = 26). A matched group of TDC was sampled from the larger normative sample to serve as a control group (n = 26).

RESULTS

For Aim 1, SPRS-C scores across the 10 age-bands were in the higher ranges. Correlation coefficients of SPRS-C total score with child's age and parent occupational skill level were not statistically significant. For Aim 2, SPRS-C scores for the ABI group were significantly lower than the control group.

CONCLUSIONS

These data provide a guide for clinical interpretation of the SPRS-C for measuring psychosocial functioning in children with ABI.

Functional Independence Measure for Children: A Comparison of Chinese and Japanese Children

The Functional Independence Measure for Children (WeeFIM) is a simple-to-administer scale for assessing functional independence across 3 domains (self-care, mobility, cognition) in children. There are normative data from America and Japan. In 2001 to 2002, the authors created a normative Chinese WeeFIM profile and compared this with the American one. In this study, they aimed to compare their Chinese normative data with the Japanese one. Methods. A random sampling of 445 normal Chinese children from different social classes in Hong Kong was conducted in the community. It was conducted via face-to-face interviews with the mother, and a normative database was created. Results. Similar to the Japanese children, the WeeFIM total score and 3 main domain subscores (self-care, mobility, and cognition) increased progressively with age. In the self-care domain, Chinese children achieved modified independence or level 6 earlier in all items except toileting. For the mobility domain, the item chair transfer was achieved earlier in the Chinese children, whereas toilet transfer, stair, tub transfer, and locomotion were achieved later in Chinese children. As for cognition domain, the item problem solving was achieved earlier but comprehension, social interaction, and memory were achieved later in the Chinese children. The authors’ results showed the same pattern of increasing WeeFIM score with increasing chronological age, which is similar to the Japanese children. There are 3 patterns of WeeFIM score achievement in this Chinese cohort. As for the Japanese children, the 3 patterns of WeeFIM score achievement from independent to dependent are 1) rapid change, 2) gradual change, and 3) linear change. Conclusions. WeeFIM is a validated standardized tool for assessing the outcome of rehabilitation programs. It should be widely used to assess rehabilitative achievement in children from different ethnic origins. The authors’ previous study and this current study demonstrated that the authors’ normative WeeFIM profile showed similar results to the American and Japanese children. However, there are minor differences in the WeeFIM scoring in the 3 main domains, which might be due to cultural differences between ethnic groups. Thus, usage of the WeeFIM with a different age criteria in achieving independence according to local culture should be adopted.

Development of a set of activities to evaluate the arm and hand function in children with obstetric brachial plexus lesion

Objective: To develop an observational instrument that can be used to evaluate the quality of arm and hand skills in daily functional activities in children with obstetric brachial plexus lesion (OBPL). A set of functional activities was constructed and standardized, and the intra-observer reliability of the assessment of this set of activities was studied.

Setting: Department of Occupational Therapy and Department of Rehabilitation Medicine, VU University Medical Centre.

Subjects: Twenty-six children with OBPL in the age range of 4 -6 years.

Interventions: The children were asked to perform 47 bimanual activities, which were recorded on videotape.

Main measures: The videotapes were scored twice by the same occupational therapist.

Results: The percentage of agreement in scoring ‘hand-use’, ‘speed’ and ‘assistance’ was over 80% for a substantial number of activities, indicating a strong agreement. However, in scoring ‘deviations in movements and body posture’ the percentage of agreement was insufficient in most activities.

Conclusions: This set of activities has good potential for assessment of the performance of functional activities in children with OBPL. This study, however, showed a number of difficulties in observing and scoring the activities that have to be considered when developing a standardized video observation.

Usefulness of the most popular neurodevelopmental tests in preschool assessment of children born with very low birth weight

BACKGROUND

The aim of our study was multifaceted neurodevelopmental examination of children born prematurely with very low birth weight (VLBW) in order to evaluate the usefulness of popularly used tests. The second aim of the study was exploration of risk and protective factors of neurodevelopmental impairment.

METHODS

Eighty-nine VLBW patients were evaluated at the age of 50 months. All children underwent anthropometric measurements and psychomotor tests: functional independence measure scale (WeeFIM), Gross Motor Function Measurement (GMFM), non-verbal psychometric evaluation (Leiter test), Developmental Test of Visual Perception (DTVP-2), temperament questionnaire (EAS-C) and children vocabulary test (TSD).

RESULTS

Most severe deficits in ex-preterms' neurodevelopment were associated with verbal abilities, visual perception and temper abnormalities. WeeFIM, DTVP-2, Leiter and vocabulary tests' results correlated with each other. The lowest percent of children with deficits in WeeFIM test indicates, that it seems to be the most valuable tool for identification of the most seriously impaired children. Due to the highest percent of children with visual perception deficits, DTVP test seems to be good second choice in assessment of children born prematurely. In motor assessment GMFM appears to be more adequate than cerebral palsy (CP) diagnosis. Almost one fifth of VLBW did not reach 85% in Gross Motor Function Measurement, although only 9% of children had CP.

CONCLUSIONS

Children born with VLBW had deficits in every part of psychometric evaluation. We believe that the most useful tests in assessment VLBW patients are WeeFIM, GMFM and DTVP. Children with severe prematurity complications could require more precise evaluation.

Functional independence of Taiwanese children with Down syndrome

AIM

Information regarding the functional strengths and weaknesses of children with Down syndrome is important for early intervention programmes and for agencies providing family support and educational services.

METHOD

This study used the Functional Independence Measure for Children (WeeFIM) questionnaire for the parents or caregivers of 166 Taiwanese children (101 males and 65 females; median age 12y 7mo; range 3y 2mo-19y 1mo) with Down syndrome to assess their functional skills.

RESULTS

Out of a potential score of 126, the mean total WeeFIM score was 101.2. There was no statistically significant difference between the scores from the male and female participants (100.4 [SD 21.4] vs 102.4 [SD 24.7]; p>0.05). The mean scores for three domains (self-care, mobility, and cognition) were 45, 33, and 23 respectively (maximum of 56, 35, and 35 respectively). Performance was strongest in the mobility domain and weakest in the cognition domain. The total WeeFIM scores and 18 subscores for the three domains all positively correlated with age (p<0.05).

INTERPRETATION

For children with Down syndrome, some support and supervision is required for cognition and self-care tasks. The WeeFIM questionnaire may be useful for identifying the strengths and limitations of children with developmental disabilities and their families.

Neurosurgical Management of Childhood Spasticity: Functional Posterior Rhizotomy and Intrathecal Baclofen Infusion Therapy

A paradigm shift is currently ongoing in the treatment of spasticity in childhood in Japan. Functional posterior rhizotomy (FPR), which was first introduced to Japan in 1996, is best indicated for children with spastic cerebral palsy, regardless of the clinical severity of spasticity. Surgery is generally carried out in the cauda equina, where the posterior root is separated from the anterior one, and neurophysiological procedures are used to judge which nerve root/rootlet should be cut. The outcome of FPR is favorable for reducing spasticity in the long-term follow-up. Intrathecal baclofen (ITB) treatment for childhood spasticity was approved in 2007 in Japan and the number of children undergoing ITB pump implantation has been gradually increasing. ITB treatment is best indicated for children with severe spasticity, especially those with dystonia, regardless of the pathological background. Since it is a surgery performed to implant foreign bodies, special attention should be paid to avoid perioperative complications such as CSF leakage, meningitis, and mechanical failure. Severely disabled children with spasticity would benefit most from ITB treatment. We would especially like to emphasize the importance of a strategic approach to the treatment of childhood spasticity. The first step is to reduce spasticity by FPR, ITB, and botulinum toxin injection. The second step is to aim for functional improvement after controlling spasticity. Traditional orthopedic surgery and neuro-rehabilitation form the second step of treatment. The combination of these treatments that allows them to complement each other is the key to a successful treatment of childhood spasticity.

Cross-cultural adaptation and validation of the Malay language version of the TZO-AZL Preschool Children Quality of Life questionnaire: A health-related quality of life instrument for preschool children

The aim of this study is to evaluate the psychometric properties of the translated Malay language version of TZO-AZL Preschool Children Quality of Life (TAPQOL) questionnaire in preschool children. Preterm children and term children aged between two and five years were enrolled into the study. The Malay language version of TAPQOL and a set of questions regarding the child's health status were answered by the caregivers. The internal consistency, Spearman's correlation coefficients and principal component analysis (PCA) with Varimax rotation and Mann-Whitney U test for group comparison were employed to evaluate the psychometric properties of this instrument. A total of 258 children (120 preterm children and 138 term children) were recruited to this study with a response rate of 94%. All (sub)domains except one had Cronbach's α coefficients of more than .7. The Spearman's correlation coefficients between 12 subdomains were generally low. PCA supported the structural unidimensionality of the items in the instrument. Preterm children had lower quality of life scores than that of term children. Malay version of TAPQOL has multidimensional construct. It is a reliable and valid instrument for preschool children, with almost similar psychometric properties to the original version.