Predicting outcome after childhood brain injury

Hip displacement in children with post-neonatal cerebral palsy and acquired brain injury: a systematic review

AIM

To systematically review the prevalence, risk factors and timing of onset of hip displacement in children with a post-neonatal (PNN) brain injury with regards to hip surveillance recommendations.

METHOD

A search of PubMed, MEDLINE, Embase, CINAHL and Web of Science was conducted on 22nd February 2022. Studies were included if they reported presence of, and risk factors for, hip displacement in children with PNN brain injury. Data was extracted on patient characteristics, and analyzed in terms of risk factors of interest and timing of development of hip displacement.

RESULTS

Six studies met the inclusion criteria (n = 408 participants). All were cohort studies: five retrospective and one prospective. Rates of hip displacement ranged from 1% to 100%, and were higher in children with diffuse brain injury at an early age, who were non-ambulant and had spastic quadriplegia. Hip displacement and hip dislocation were first identified at one and three months respectively following PNN brain injury.

INTERPRETATION

Evidence on hip displacement in children with PNN brain injury is sparse and low quality. Children who remain non-ambulant after diffuse PNN brain injury before five years of age appear most at risk of developing progressive hip displacement and earlier hip surveillance is recommended.

Adapting TeachABI to the local needs of Australian educators - a critical step for successful implementation

Background The present study is the foundational project of TeachABI-Australia , which aims to develop and implement an accessible, nation-wide digital resource for educators to address their unmet acquired brain injury (ABI)-related professional learning needs. The aim of the present study was to identify the adaptations required to improve the suitability and acceptability of the TeachABI professional development module within the Australian education system from the perspectives of Australian educators. Methods The research design employed an integrated knowledge translation approach and followed the ADAPT Guidance for undertaking adaptability research. A purposive sample of eight educators eligible to teach primary school in Australia provided feedback on the module through a quantitative post-module feedback questionnaire and a qualitative semi-structured interview. Results Participants rated the acceptability of the module as 'Completely Acceptable ' (Mdn  = 5, IQR = 1), and reported 'only Minor' changes were required (Mdn  = 2, IQR = 0.25) to improve the suitability to the Australian context. Qualitative analysis of transcripts revealed three broad categories: (1) the usefulness of TeachABI , (2) the local fit of TeachABI , and (3) pathways for implementing TeachABI in the local setting. Recommended adaptations to the module collated from participant feedback included changes to language, expansion of content, and inclusion of Australian resources, legislation, and videos. Conclusions TeachABI is acceptable to Australian educators but requires modifications to tailor the resource to align with the unique schooling systems, needs, and culture of the local setting. The systematic methodological approach to adaptation outlined in this study will serve as a guide for future international iterations of TeachABI .

Intelligence and executive function are associated with age at insult, time post-insult, and disability following chronic pediatric acquired brain injury

Background

Pediatric acquired brain injury (pABI) profoundly affects cognitive functions, encompassing IQ and executive functions (EFs). Particularly, young age at insult may lead to persistent and debilitating deficits, affecting daily-life functioning negatively. This study delves into the intricate interplay of age at insult, time post-insult, and their associations with IQ and EFs during chronic (>1 year) pABI. Additionally, we investigate cognitive performance across different levels of global function, recognizing the multifaceted nature of developmental factors influencing outcomes.

Methods

Drawing upon insult data and baseline information analyzing secondary outcomes from a multicenter RCT, including comprehensive medical and neuropsychological assessments of participants aged 10 to 17 years with pABI and parent-reported executive dysfunctions. The study examined associations between age at insult (early, EI; ≤7y vs. late, LI; > 7y) and time post-insult with IQ and EFs (updating, shifting, inhibition, and executive attention). Additionally, utilizing the Pediatric Glasgow Outcome Scale-Extended, we explored cognitive performance across levels of global functioning.

Results

Seventy-six participants, median 8 years at insult and 5 years post-insult, predominantly exhibiting moderate disability (n = 38), were included. Notably, participants with LI demonstrated superior IQ, executive attention, and shifting compared to EI, [adjusted mean differences with 95% Confidence Intervals (CIs); 7.9 (1.4, 14.4), 2.48 (0.71, 4.24) and 1.73 (0.03, 3.43), respectively]. Conversely, extended post-insult duration was associated with diminished performances, evident in mean differences with 95% CIs for IQ, updating, shifting, and executive attention compared to 1-2 years post-insult [-11.1 (-20.4, -1.7), -8.4 (-16.7, -0.1), -2.6 (-4.4, -0.7), -2.9 (-4.5, -1.2), -3.8 (-6.4, -1.3), -2.6 (-5.0, -0.3), and -3.2 (-5.7, -0.8)]. Global function exhibited a robust relationship with IQ and EFs.

Conclusion

Early insults and prolonged post-insult durations impose lasting tribulations in chronic pABI. While confirmation through larger studies is needed, these findings carry clinical implications, underscoring the importance of vigilance regarding early insults. Moreover, they dispel the notion that children fully recover from pABI; instead, they advocate equitable rehabilitation offerings for pABI, tailored to address cognitive functions, recognizing their pivotal role in achieving independence and participation in society. Incorporating disability screening in long-term follow-up assessments may prove beneficial.

Using Billing Codes to Create a Pediatric Functional Status e-Score for Children Receiving Inpatient Rehabilitation

OBJECTIVE

Provide proof-of-concept for development of a Pediatric Functional Status eScore (PFSeS). Demonstrate that expert clinicians rank billing codes as relevant to patient functional status and identify the domains that codes inform in a way that reliably matches analytical modeling.

DESIGN

Retrospective chart review, modified Delphi, and nominal group techniques.

SETTING

Large, urban, quaternary care children's hospital in the Midwestern United States.

PARTICIPANTS

Data from 1955 unique patients and 2029 hospital admissions (2000-2020); 12 expert consultants representing the continuum of rehabilitation care reviewed 2893 codes (procedural, diagnostic, pharmaceutical, durable medical equipment).

MAIN OUTCOME MEASURES

Consensus voting to determine whether codes were associated with functional status at discharge and, if so, what domains they informed (self-care, mobility, cognition/ communication).

RESULTS

The top 250 and 500 codes identified by statistical modeling were mostly composed of codes selected by the consultant panel (78%-80% of the top 250 and 71%-78% of the top 500). The results provide evidence that clinical experts' selection of functionally meaningful codes corresponds with codes selected by statistical modeling as most strongly associated with WeeFIM domain scores. The top 5 codes most strongly related to functional independence ratings from a domain-specific assessment indicate clinically sensible relationships, further supporting the use of billing data in modeling to create a PFSeS.

CONCLUSIONS

Development of a PFSeS that is predicated on billing data would improve researchers' ability to assess the functional status of children who receive inpatient rehabilitation care for a neurologic injury or illness. An expert clinician panel, representing the spectrum of medical and rehabilitative care, indicated that proposed statistical modeling identifies relevant codes mapped to 3 important domains: self-care, mobility, and cognition/communication.

Functional Repetitive Neuromuscular Magnetic Stimulation (frNMS) Targeting the Tibialis Anterior Muscle in Children with Upper Motor Neuron Syndrome: A Feasibility Study

Non-invasive neurostimulation as an adjunctive intervention to task-specific motor training is an approach to foster motor performance in patients affected by upper motor neuron syndrome (UMNS). Here, we present first-line data of repetitive neuromuscular magnetic stimulation (rNMS) in combination with personalized task-specific physical exercises targeting the tibialis anterior muscle to improve ankle dorsiflexion (functional rNMS (frNMS)). The main objective of this pilot study was to assess the feasibility in terms of adherence to frNMS, safety and practicability of frNMS, and satisfaction with frNMS. First, during 10 training sessions, only physical exercises were performed (study period (SP) A). After a 1 week break, frNMS was delivered during 10 sessions (SPC). Twelve children affected by UMNS (mean age 8.9 ± 1.6 years) adhered to 93% (SPA) and 94% (SPC) of the sessions, and omittance was not related to the intervention itself in any case. frNMS was safe (no AEs reported in 88% of sessions, no AE-related discontinuation). The practicability of and satisfaction with frNMS were high. Patient/caregiver-reported outcomes revealed meaningful benefits on the individual level. The strength of the ankle dorsiflexors (MRC score) clinically meaningfully increased in four participants as spasticity of ankle plantar flexors (Tardieu scores) decreased in four participants after SPC. frNMS was experienced as a feasible intervention for children affected by UMNS. Together with the beneficial effects achieved on the individual level in some participants, this first study supports further real-world, large-scale, sham-controlled investigations to investigate the specific effects and distinct mechanisms of action of frNMS.

Cognitive rehabilitation in paediatric acquired brain injury-A 2-year follow-up of a randomised controlled trial

Background

Goal management training (GMT), a metacognitive rehabilitation method that has been demonstrated to improve executive function (EF) in adults with acquired brain injury (ABI), could potentially be effective for children in the chronic phase of ABI. In a previously published randomised controlled trial (RCT), the efficacy of a paediatric adaptation of GMT (pGMT) compared to a psychoeducative control intervention (paediatric Brain Health Workshop, pBHW) was investigated. Comparable improvements in EF in both groups were found at 6-month follow-up. However, a specific effect of pGMT could not be conclusively proven. The present study reports 2-year follow-up data (T4; T1: baseline, T2: post-intervention, T3: 6-month follow-up, and T4: 2-year follow-up) from this original RCT.

Methods

A total of 38 children and adolescents and also their parents completed questionnaires tapping into daily life EF. Explorative analyses were conducted comparing the 2-year follow-up data (T4) with the baseline (T1) and 6-month follow-up data (T3) for T4-participants in the two intervention groups (pGMT; n = 21, pBHW; n = 17), and we also assessed T4-participants vs. non-responders (n = 38) in the RCT. Primary outcome measures were the Behavioural Regulation Index (BRI) and the Metacognition Index (MI) derived from the Behaviour Rating Inventory of Executive Function (BRIEF) parent report.

Results

No difference between intervention groups was found (BRI, F = 2.25, p = 0.143, MI, F = 1.6, p = 0.213), and no time^*group interaction (BRI, F = 0.07, p = 0.976, MI, F = 0.137, p = 0.937) could be seen at the 2-year follow-up. Nevertheless, both pGMT and the pBHW groups improved daily EF as measured by parental reports over time from the baseline to T4 (p = 0.034). T4 participants and non-responders shared similar baseline characteristics.

Conclusion

Our results extend the findings from the 6-month follow-up previously published. Both pGMT and pBHW groups sustained their improvements in daily life EFs from the baseline, but additional effectiveness of pGMT relative to pBHW was not found.

Impact of transcranial magnetic stimulation on motor function in children with acquired brain injury: a scoping review protocol

BACKGROUND

Children with severe acquired brain injury (ABI) require early and effective neurorehabilitation provision to promote a good long-term functional outcome. Transcranial magnetic stimulation (TMS) has been used to improve motor skills for children with cerebral palsy but there is limited material supporting its use in children with ABI who have a motor disorder.

OBJECTIVE

To systematically answer what the TMS intervention effects are on motor function in children with ABI as reported in the literature.

METHODS AND ANALYSIS

This scoping review will follow Arksey and O'MaIIey's scoping review methodological framework. A comprehensive computerised bibliographic databases search will be performed in MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine, BNI, Ovid Emcare, PsyclNFO, Physiotherapy Evidence Database, Cochrane Central Register using keywords related to TMS and children with ABI.Studies that examine the effect of TMS intervention on motor function as either a primary or secondary objective will be included for this review. Study design and publication detail, participant demographic details, type and severity of ABI and other clinical information, TMS procedure, associated therapy intervention, comparator/control parameters and the outcome measure used data will be gathered.The International Classification of Functioning, Disability and Health for Children and Youth framework will be used to report the TMS effect in children with ABI. A narrative synthesis of the findings describing the therapeutic effects of TMS intervention, limitations and adverse effects will be synthesised and reported. This review will help to summarise the existing knowledge base and to guide further research areas. This review outcome may help to evolve therapists' role to next-generation technology-based neurorehabilitation programmes.

ETHICS AND DISSEMINATION

No ethical approval is required for this review as we will be collecting data from previously published studies. We will present the findings at scientific conferences and publish in a peer-review journal.

The influence of methylphenidate on sustained attention in paediatric acquired brain injury: a meta-analytical review

Impairment in sustained attention is a common consequence of childhood Acquired Brain Injury (ABI). Whilst methylphenidate provides promise in enhancing "attention" as a unitary construct, little work has explored its effectiveness upon individual attentional domains. The current systematic review and meta-analysis evaluates the utility of methylphenidate on sustained attentional performance across childhood ABI groups. Five databases (PsycINFO, MEDLINE, Embase, Scopus & Cochrane Library) were searched for relevant articles from their inception to March 2022. A purpose-developed evaluation tool was used to assess each study's research quality (QuEST:MAP). Nine of the 1600 identified articles were included within this review (n = 259). Meta-analytical findings reported an overall significant benefit of methylphenidate on sustained attention in childhood ABI (g = -0.33, 95% CI: -0.62 to -0.04). Associated summary effect sizes were relatively small, particularly when adjusting for outlier cases. Subgroup analyses identified a significantly greater benefit of methylphenidate in clinical subgroups with comorbid ADHD diagnoses (p < .01). The current evidence base is characterized by small-scale clinical trials with variable research quality and low generalizability. Further robust research is needed to quantify methylphenidate utility upon individual attentional domains in larger and more representative ABI samples.

Socioeconomic health disparities in pediatric traumatic brain injury on a national level

OBJECTIVE

Low socioeconomic status is a determinant of pediatric traumatic brain injury (TBI) incidence and severity. In this study, the authors used National (Nationwide) Inpatient Sample (NIS) data to evaluate socioeconomic and health disparities among children hospitalized after TBI.

METHODS

This retrospective study identified pediatric patients aged 0 to 19 years with ICD-9 codes for TBI in the NIS database from 2012 to 2015. Socioeconomic variables included race, sex, age, census region, and median income of the patient residential zip code. Outcomes included mechanism of injury, hospital length of stay (LOS), cost, disposition at discharge, death, and inpatient complications. Multivariate linear regressions in log scale were built for LOS and cost. Logistic regressions were built for death, disposition, and inpatient complications.

RESULTS

African American, Hispanic, and Native American patients experienced longer LOSs (β 0.06, p < 0.001; β 0.03, p = 0.03; β 0.13, p = 0.02, respectively) and increased inpatient costs (β 0.13, p < 0.001; β 0.09, p < 0.001; β 0.14, p = 0.03, respectively). Females showed increased rates of medical complications (OR 1.57, p < 0.001), LOS (β 0.025, p = 0.02), and inpatient costs (p = 0.04). Children aged 15 to 19 years were less likely to be discharged home (OR 3.99, p < 0.001), had increased mortality (OR 1.32, p = 0.03) and medical complications (OR 1.84, p < 0.001), and generated increased costs (p < 0.001).

CONCLUSIONS

The study results have demonstrated that racial minorities, females, older children, and children in lower socioeconomic groups were at increased risk of poor outcomes following TBI, including increased LOS, medical complications, mortality, inpatient costs, and worse hospital disposition. Public education and targeted funding for these groups will ensure that all children have equal opportunity for optimal clinical outcomes following TBI.

Acute Imaging Findings Predict Recovery of Cognitive and Motor Function after Inpatient Rehabilitation for Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children; survivors experience long-term cognitive and motor deficits. To date, studies predicting outcome following pediatric TBI have primarily focused on acute behavioral responses and proxy measures of injury severity; unsurprisingly, these measures explain very little of the variance following heterogenous injury. In adults, certain acute imaging biomarkers help predict cognitive and motor recovery following moderate to severe TBI. This multi-center, retrospective study, characterizes the day-of-injury computed tomographic (CT) reports of pediatric, adolescent, and young adult patients (2 months to 21 years old) who received inpatient rehabilitation services for TBI (n = 247). The study also determines the prognostic utility of CT findings for cognitive and motor outcomes assessed by the Pediatric Functional Independence Measure, converted to age-appropriate developmental functional quotient (DFQ), at discharge from rehabilitation. Subdural hematomas (66%), contusions (63%), and subarachnoid hemorrhages (59%) were the most common lesions; the majority of subjects had less severe Rotterdam CT scores (88%, ≤ 3). After controlling for age, gender, mechanism of injury, length of acute hospital stay, and admission DFQ in multivariate regression analyses, the highest Rotterdam score (β = -25.2, p < 0.01) and complete cisternal effacement (β = -19.4, p < 0.05) were associated with lower motor DFQ, and intraventricular hemorrhage was associated with lower motor (β = -3.7, p < 0.05) and cognitive DFQ (β = -4.9, p < 0.05). These results suggest that direct detection of intracranial injury provides valuable information to aid in prediction of recovery after pediatric TBI, and needs to be accounted for in future studies of prognosis and intervention.

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.

Investigating Brain Network Changes and Their Association With Cognitive Recovery After Traumatic Brain Injury: A Longitudinal Analysis

Traumatic brain injury (TBI) can result in acute cognitive deficits and diffuse axonal injury reflected in white matter brain network alterations, which may, or may not, later recover. Our objective is to first characterize the ways in which brain networks change after TBI and, second, investigate if those changes are associated with recovery of cognitive deficits. We aim to make initial progress in discerning the relationships between brain network changes, and their (dys)functional correlates. We analyze longitudinally acquired MRI from 23 TBI patients (two time points: 6 days, 12 months post-injury) and cross-sectional data from 28 controls to construct white matter brain networks. Cognitive assessment was also performed. Graph theory and regression analysis were applied to identify changed brain network metrics after injury that are associated with subsequent improvements in cognitive function. Sixteen brain network metrics were found to be discriminative of different post-injury phases. Eleven of those explain 90% (adjusted R 2) of the variability observed in cognitive recovery following TBI. Brain network metrics that had a high contribution to the explained variance were found in frontal and temporal cortex, additional to the anterior cingulate cortex. Our preliminary study suggests that network reorganization may be related to recovery of impaired cognitive function in the first year after a TBI.

[Formula: see text] Investigation of children and adolescents' mood and self-concept after acquired brain injury

Few studies have examined the self-reported mental health of children with an acquired brain injury (ABI). The current study aimed to: 1) identify levels of child-reported depressive and anxiety symptoms and poor self-concept, 2) investigate demographic and injury-related factors associated with children's mood and self-concept, and 3) examine associations between children's self-reported mental health and parents' reports of children's emotional and behavioral functioning in children specifically with traumatic brain injury (TBI). 122 children (66% male) aged 8-16 years with ABI of mixed etiology were consecutively recruited through an outpatient rehabilitation clinic. Children were administered the Beck Youth Inventories - Second Edition, and parents completed the Adaptive Behavior Assessment System and the Child Behavior Checklist (CBCL). Relative to the norms, 16.4% of children scored in the clinical range for the depression and anxiety scales, and 24.6% reported clinically low self-concept. Children with lower functional status had greater anxiety symptoms. Older children (13-16 years) reported significantly higher depressive and anxiety symptoms and lower self-concept than younger children (8-12 years). A significant interaction between age and sex indicated that older girls reported greater depressive and anxiety symptoms than younger girls whereas no age-based differences were found for boys. Parent-reported total emotional and behavioral problems were positively associated with children's self-reported depressive and anxiety symptoms and were negatively correlated with self-concept. These findings indicate that adolescents, particularly girls, may be at heightened risk of poor mental health following ABI. Further research investigating the reasons for these demographic differences may inform developmentally sensitive interventions.

The Impact of Vocational Interventions on Vocational Outcomes, Quality of Life, and Community Integration in Adults with Childhood Onset Disabilities: A Systematic Review

Purpose Despite the desire and ability to work, individuals with childhood onset disabilities are under-represented in employment. Vocational interventions alleviate some barriers to obtaining and maintaining employment for this population. The research question addressed is: What is the impact of vocational interventions on vocational outcomes, quality of life (QoL), and community integration (CI) in adults with childhood onset neurological disabilities including cerebral palsy (CP), spina bifida, and acquired brain injury (ABI)? Methods A literature search was conducted in multiple electronic databases. All experimental and observational studies with comparator group(s) were included. Two reviewers independently completed titles and abstracts screening, full text screening, data abstraction, and risk of bias assessment. Results Seventeen studies were eligible for final inclusion including three randomized-controlled trials, four non-randomized studies, and ten observational studies. Sixteen of seventeen studies included only individuals with ABI, while one study included individuals with CP. Vocational interventions from experimental studies were mainly components of multi-faceted interventions. Most observational studies were from the United States Vocational Rehabilitation Service. Conclusions Vocational interventions may be effective in improving vocational outcomes, QoL, and CI for individuals with ABI. There is limited experimental evidence on interventions that specifically target employment. Observational data suggest that receiving job placement assistance, on-the-job training and supports, counselling/guidance, maintenance, and supported employment successfully predicted employment outcomes.

Adolescents' experiences of communication following acquired brain injury

BACKGROUND

Paediatric acquired brain injury (ABI) is one of the leading causes of neurodisability in childhood. The long-term effects of ABI on cognition, behaviour and emotions are well documented. Previous research has found that communication is difficult for adolescents with ABI compared with typically developing peers. Quantitative studies have identified deficits in specific domains of speech and language, but no research studies have sought to capture adolescents' lived experiences of communication or explored the multidimensional nature of this.

AIMS

To explore adolescents' everyday experiences of communication following ABI. This research also offered adolescents an opportunity to give their views on an issue that has not previously been explored in relation to paediatric ABI.

METHOD & PROCEDURES

A qualitative study was undertaken using interpretative phenomenological analysis (IPA) for in-depth exploration of the lived experiences of communication following ABI. Participants were recruited from an NHS Trust in England. Six adolescents (aged 11-18 years) participated in semi-structured interviews. Data analysis followed the guides for IPA.

OUTCOMES & RESULTS

The data revealed three main themes: the social world; communication competence; and life in the classroom. Adolescents experienced communication changes and challenges, which affected functioning and participation. Difficulties with communication affected identity, learning, relationships and confidence.

CONCLUSIONS & IMPLICATIONS

These findings provide an insight into how communication is experienced in everyday life from the perspectives of adolescents with ABI. The study revealed that adolescents' individual experiences of communication were dependent on contextual factors. Sensitivity to communication changes was associated with the age when the ABI occurred. Difficulties with communication impacted on identity. Negative communication experiences at school affected a sense of belonging; peer group support helped some adolescents to cope with the communication challenges they faced. Further research is needed to explore how participation in communication is affected by paediatric ABI and what could be done to support this. It is recommended that increased attention should be paid by professionals to the psychological impact of communication changes and difficulties experienced by this population.

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.

Using child- and family-centred goal setting as an outcome measure in residential rehabilitation for children and youth with acquired brain injuries: The challenge of predicting expected levels of achievement

PURPOSE

Collaborative, child- and family-centred goal setting is essential in paediatric, acquired brain injury (ABI) rehabilitation. This study aims to understand which goals children and families prioritize and how accurately therapists predict expected levels of achievement for these goals.

METHODS

Routinely collected Goal Attainment Scale-Light data from 122 children with severe ABI receiving residential rehabilitation were retrospectively analysed. Goals were mapped onto the International Classification of Functioning, Disability and Health. Descriptive analysis of accuracy of therapists' prediction of goal achievement was conducted.

RESULTS

Eight-hundred sixty goals were set: 82% in activities and participation domains, most commonly mobility, self-care, and communication chapters. Forty-six per cent of therapist-set expected levels of achievement for these goals were met at the expected level, and 24% were exceeded. Chapters with the highest prediction accuracy included two environmental chapters and one body structure and function. Accurate prediction of activity and participation goals varied (35% in general tasks and demands to 58.8% in major life areas).

CONCLUSIONS

Children and families prioritize mobility, self-care, and communication during ABI residential rehabilitation. Setting expected outcomes for these goals is challenging, as demonstrated by the variety in accurate prediction rates between and within chapters. Families need to be aware of this uncertainty during goal-setting discussions.

Sex-dependent and chronic alterations in behavior and mitochondrial function in a rat model of pediatric mild traumatic brain injury

OBJECTIVE

To determine if chronic changes in mitochondrial function occur following a mild traumatic brain injury in young rats.

RESEARCH DESIGN

Closed-head, weight drop model was used to cause mTBI by applying rotational forces to the brain without surgery. Behavioral battery was used to assess multiple dimensions of impairment across time. Analysis of brain tissue carried out at three-weeks post-injury represents a chronic time point to complement previous work examining acute time points.

METHODS AND PROCEDURES

Twenty-three male and 22 female rats one month of age were divided equally into sham and mTBI groups with the latter undergoing the weight drop. Multiple behavioral tests in combination with energetic (oxygen consumption), molecular (immunoblotting), and imaging (electron microscopy) characterization of brain mitochondria were performed.

MAIN OUTCOMES AND RESULTS

Mitochondria isolated from sham juvenile female rats had higher basal oxygen consumption compared to juvenile male rats (514.875 ± 171.091 pmol/min vs. 267 ± 73.906 pmol/min, p < 0.0001). Chronic sex-dependent differences were observed in females after mTBI in basal (514.875 ± 171.091 pmol/min vs. 600.688 ± 124.422 pmol/min, p = 0.0264) and maximal oxygen consumption (298.938 ± 119.964 pmol/min vs. 403.281 ± 112.922 pmol/min, p = 0.0001) and proton leak (59.46 ± 7.807 vs. 84.32 ± 5.80 pmol/min, p = 0.0001).

CONCLUSIONS

The juvenile rat brain displays sex differences in mitochondrial function at (1) baseline and (2) in long-term outcomes after mTBI. These results offer new insight into a potential mechanism for persistent, individualized impairments following pediatric mTBI.

Developmental trajectories of adaptive functioning following early mild traumatic brain injury

Adaptive behavior impairments have been reported in children with severe traumatic brain injury (TBI) but are not typically found following mild TBI. It is possible that mild TBI induces subtle changes in adaptive functioning that are not captured in conventional group comparisons. This study aimed to explore time course changes in adaptive functioning following early mild TBI. Parents of 63 children with mild TBI and 53 children with orthopedic injuries aged between 1.5 and 5 years at the time of injury completed the Adaptive Behavior Assessment System-II at three time points: retrospectively to assess pre-injury functioning, then at 6 and 18 months post-injury. Developmental trajectories of adaptive functioning domains (practical, conceptual, and social) reported by parents were modeled using linear mixed-model analyses. Findings suggest that mild TBI may disrupt the expected developmental progression of children's social adaptive behavior, but does not appear to alter practical and conceptual domains.

Case Management for Children and Adolescents with Acquired Brain Injury in Community Settings: A Scoping Review

Background: Acquired brain injury is the leading cause of death and disability in children after infancy. Childhood brain injury has long-term consequences for children and parents, including challenges with returning to school, ongoing health and behaviour concerns, family functioning and demands on carers. Community-based case management interventions are a vital contribution to community supports.

Aims: This scoping study aims to scope and map the literature on case management, to identify how case management is described in the literature for children and adolescents with acquired brain injury (0–17 years).

Methods: A scoping review was completed of published articles on case management from four major databases (CINAHL, MEDLINE, PUBMed and Embase) between 2005 and 2015. Articles were selected against inclusion criteria and reviewed.

Results: Eight articles of 2688 records met the inclusion criteria and were reviewed. Case management was provided by case managers and other health professionals. The case management interventions described were mapped to the International Classification of Health Interventions and the Brain Injury Case Management Taxonomy (BICM-T). Case management addressed a range of needs including return to school, family issues and ongoing medical needs. There were anecdotal reports of effectiveness of case management during the return to school process.

Conclusion: This scoping study reveals a lack of information on this topic. Improved reporting of case management interventions and more research on case management is needed for children and adolescents with brain injury.

Children and youth with non-traumatic brain injury: a population based perspective

BACKGROUND

Children and youth with non-traumatic brain injury (nTBI) are often overlooked in regard to the need for post-injury health services. This study provided population-based data on their burden on healthcare services, including data by subtypes of nTBI, to provide the foundation for future research to inform resource allocation and healthcare planning for this population.

METHODS

A retrospective cohort study design was used. Children and youth with nTBI in population-based healthcare data were identified using International Classification of Diseases Version 10 codes. The rate of nTBI episodes of care, demographic and clinical characteristics, and discharge destinations from acute care and by type of nTBI were identified.

RESULTS

The rate of pediatric nTBI episodes of care was 82.3 per 100,000 (N = 17,977); the average stay in acute care was 13.4 days (SD = 25.6 days) and 35% were in intensive care units. Approximately 15% were transferred to another inpatient setting and 6% died in acute care. By subtypes of nTBI, the highest rates were among those with a diagnosis of toxic effect of substances (22.7 per 100,000), brain tumours (18.4 per 100,000), and meningitis (15.4 per 100,000). Clinical characteristics and discharge destinations from the acute care setting varied by subtype of nTBI; the proportion of patients that spent at least one day in intensive care units and the proportion discharged home ranged from 25.9% to 58.2% and from 50.6% to 76.4%, respectively.

CONCLUSIONS

Children and youth with nTBI currently put an increased demand on the healthcare system. Active surveillance of and in-depth research on nTBI, including subtypes of nTBI, is needed to ensure that timely, appropriate, and targeted care is available for this pediatric population.

Systematic review of physiotherapy interventions to improve gross motor capacity and performance in children and adolescents with an acquired brain injury

AIM

To systematically review the efficacy of physiotherapy interventions to improve gross motor capacity, performance and societal participation in children aged 5-17 years with an acquired brain injury (ABI).

METHODS

Randomized and non-randomized controlled trials, cohort, case series, case-control and case studies were included and classified according to grades of evidence. Methodological quality of studies was assessed using the Downs and Black (D&B) scale and quantitative data was analysed using effect sizes.

RESULTS

Two home-based studies investigated functional strength training (one randomized controlled trial, n = 20, level 2b, D&B = 16/32 and one non-randomized self-control study, n = 19, level 4, D&B = 15/32). Four studies evaluated virtual reality including: one pilot study, n = 50, level 4, D&B = 22/32; one single-subject, non-concurrent, randomized multiple baseline study, n = 3, level 4, D&B = 15/32; one case series study, n = 2, level 4, D&B = 15/32; one case study, n = 1, level 4, D&B = 15/32. Effect sizes for the randomized controlled trial ranged between 0.30-1.29 for the Functional Reach and Timed Up and Go outcome measures.

CONCLUSION

There is preliminary evidence to support the efficacy of physiotherapy interventions to improve gross motor outcomes in children with an ABI. Both functional strength training and virtual-reality based therapy are potential treatment options for clinicians to prescribe in either home or clinical settings.

Canadian pediatric emergency physician knowledge of concussion diagnosis and initial management

Introduction

The diagnosis of concussion is a critical step in the appropriate management of patients following minor head trauma. The authors hypothesized that wide practice variation exists among pediatric emergency medicine physicians in the application of physical and cognitive rest recommendations following an acute concussion.

Methods

The authors developed a 35-item questionnaire incorporating case vignettes to examine pediatric emergency physician knowledge of concussion diagnosis, understanding of initial management using return-to-play/school/work guidelines, use of existing concussion protocols, and perceived barriers to protocol use. Using a modified Dillman technique, the authors distributed an online survey to members of Pediatric Emergency Research Canada, a national association of pediatric emergency physicians.

Results

Of 176 potential participants, 115 (65%) responded to the questionnaire, 89% (95% confidence interval [CI]: 0.81, 0.93) of whom reported having diagnosed 20 or more concussions annually. Although 90% (95% CI: 0.83, 0.94) of respondents adequately diagnosed concussion, only 64% (95% CI: 0.54, 0.72) correctly applied graduated return-to-play guidelines. Cognitive rest recommendations were also frequently limited: 40% (95% CI: 0.31, 0.49) did not recommend school absence, 30% (95% CI: 0.22, 0.39) did not recommend schoolwork reduction, and 35% (95% CI: 0.27, 0.45) did not recommend limiting screen time. Eighty percent (95% CI: 0.72, 0.87) of respondents reported having used guidelines frequently or always to guide clinical decisions regarding concussion.

Conclusion

Despite a proficiency in the diagnosis of concussion, pediatric emergency physicians exhibit wide variation in recommending the graduated return to play and cognitive rest following concussion.

The promotion of recovery through rehabilitation after acquired brain injury in children

A degree of motor recovery is typically seen after acquired brain injury in children. The extent to which rehabilitation efforts can claim credit for this is disputed. Strong correlations between late impairment outcomes and early severity and impairment indices are seen both in adults and children. These correlations have been interpreted by some as evidence that recovery is largely intrinsic and that any additional rehabilitation effects are small. Such views are belied by published animal studies demonstrating the possibility of large rehabilitation effects. Animal models suggest that to achieve similar rehabilitation treatment effect sizes in clinical practice, rehabilitation 'doses' should be greater, rehabilitation efforts should start sooner, and premature accommodation of impairment should be avoided.

Knowledge of paediatric concussion among front-line primary care providers

OBJECTIVE

To assess the knowledge of paediatric concussion diagnosis and management among front-line primary care providers.

METHODS

Experts from the Concussions Ontario Diagnosis and Early Education Working Group developed a 34-item survey incorporating case vignettes with the collaboration of experts in medical education. Electronic surveys were distributed via FluidSurveys using a modified version of Dillman's tailored design method. The survey was distributed to five Ontario professional associations. The target participants were front-line health care providers (family physicians, emergency medicine physicians, general paediatricians, nurse practitioners and physician assistants) in Ontario; only providers who diagnose and/or manage paediatric concussions were eligible to participate.

RESULTS

The survey was fully completed by 577 health care providers who treat paediatric concussion. Of the respondents, 78% (95% CI 74% to 81%) reported diagnosing ≥5 concussions annually. Physicians and nonphysicians equally recognized concussion (90% [95% CI 86% to 92%]; 85% [95% CI 77% to 90%], respectively). Only 37% (95% CI 32% to 41%) of physicians correctly applied graduated return to play guidelines. Return to learn recommendations were also insufficient: 53% (95% CI 49% to 58%) neglected to recommend school absence and 40% (95% CI (35% to 44%) did not recommend schoolwork accommodations. Only 26% (95% CI 22% to 30%) of physicians reported regular use of concussion scoring scales.

CONCLUSIONS

Considerable gaps in knowledge exist in front-line primary care providers with inadequate application of graduated return to play and return to learn following concussion, as demonstrated by the present broad population-based survey. Consistent application of best evidence-based management using comprehensive guidelines may help to reduce the impact of concussion and persistent postconcussive problems in children and adolescents.

Hidden synaptic differences in a neural circuit underlie differential behavioral susceptibility to a neural injury

Individuals vary in their responses to stroke and trauma, hampering predictions of outcomes. One reason might be that neural circuits contain hidden variability that becomes relevant only when those individuals are challenged by injury. We found that in the mollusc, Tritonia diomedea, subtle differences between animals within the neural circuit underlying swimming behavior had no behavioral relevance under normal conditions but caused differential vulnerability of the behavior to a particular brain lesion. The extent of motor impairment correlated with the site of spike initiation in a specific neuron in the neural circuit, which was determined by the strength of an inhibitory synapse onto this neuron. Artificially increasing or decreasing this inhibitory synaptic conductance with dynamic clamp correspondingly altered the extent of motor impairment by the lesion without affecting normal operation. The results suggest that neural circuit differences could serve as hidden phenotypes for predicting the behavioral outcome of neural damage.

Predicting and preventing postconcussive problems in paediatrics (5P) study: protocol for a prospective multicentre clinical prediction rule derivation study in children with concussion

INTRODUCTION

Persistent postconcussive symptoms (PCSs) is the persistence of somatic, cognitive, physical, psychological and/or behavioural changes lasting more than 1 month following concussion. Persistent concussion impacts the quality of life through impaired cognition, memory and attention affecting school performance, mood and social engagement. No large epidemiological studies have determined the true prevalence of persistent concussion symptoms. Validated, easy-to-use prognosticators do not exist for clinicians to identify children at highest risk. The goal of Predicting and Preventing Postconcussive Problems in Pediatrics study is to derive a clinical prediction rule for the development of persistent postconcussion symptoms in children and adolescents presenting to emergency department following acute head injury.

METHODS AND ANALYSIS

This study is a prospective, multicentre cohort study across nine academic Canadian paediatric emergency departments. We will recruit the largest prospective epidemiological cohort of children with concussion. Eligible children will be followed using Post-Concussion Symptom Inventory, a validated tool in children as young as 5 years. Patients will follow-up at 1, 2, 4, 8 and 12 weeks postinjury. The main outcome will be the presence/absence of PCSs defined as three or more persistent concussion symptoms 1 month following the injury. 1792 patients provide adequate power to derive a clinical decision rule using multivariate analyses to find predictor variables sensitive for detecting cases of persistent postconcussion symptoms.

ETHICS AND DISSEMINATION

Results of this large prospective study will enable clinicians to identify children at highest risk, optimise treatment and provide families with realistic and appropriate anticipatory guidance. Ethics has been obtained through the Children's Hospital of Eastern Ontario Research Ethics Board. Results will be disseminated at international conferences and in four manuscripts to peer-reviewed journals.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.gov through the US National Institute of Health/National Library of Medicine (NCT01873287; http://clinicaltrials.gov/ct2/show/NCT01873287).