Effectiveness of a head injury program for children: a preliminary investigation

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.

Mapping global evidence on strategies and interventions in neurotrauma and road traffic collisions prevention: a scoping review

BACKGROUND

Neurotrauma is an important global health problem. The largest cause of neurotrauma worldwide is road traffic collisions (RTCs), particularly in low- and middle-income countries (LMICs). Neurotrauma and RTCs are preventable, and many preventative interventions have been implemented over the last decades, especially in high-income countries (HICs). However, it is uncertain if these strategies are applicable globally due to variations in environment, resources, population, culture and infrastructure. Given this issue, this scoping review aims to identify, quantify and describe the evidence on approaches in neurotrauma and RTCs prevention, and ascertain contextual factors that influence their implementation in LMICs and HICs.

METHODS

A systematic search was conducted using five electronic databases (MEDLINE, EMBASE, CINAHL, Global Health on EBSCO host, Cochrane Database of Systematic Reviews), grey literature databases, government and non-government websites, as well as bibliographic and citation searching of selected articles. The extracted data were presented using figures, tables, and accompanying narrative summaries. The results of this review were reported using the PRISMA Extension for Scoping Reviews (PRISMA-ScR).

RESULTS

A total of 411 publications met the inclusion criteria, including 349 primary studies and 62 reviews. More than 80% of the primary studies were from HICs and described all levels of neurotrauma prevention. Only 65 papers came from LMICs, which mostly described primary prevention, focussing on road safety. For the reviews, 41 papers (66.1%) reviewed primary, 18 tertiary (29.1%), and three secondary preventative approaches. Most of the primary papers in the reviews came from HICs (67.7%) with 5 reviews on only LMIC papers. Fifteen reviews (24.1%) included papers from both HICs and LMICs. Intervention settings ranged from nationwide to community-based but were not reported in 44 papers (10.8%), most of which were reviews. Contextual factors were described in 62 papers and varied depending on the interventions.

CONCLUSIONS

There is a large quantity of global evidence on strategies and interventions for neurotrauma and RTCs prevention. However, fewer papers were from LMICs, especially on secondary and tertiary prevention. More primary research needs to be done in these countries to determine what strategies and interventions exist and the applicability of HIC interventions in LMICs.

Multidisciplinary rehabilitation for children with brain tumors: A systematic review

BACKGROUND

There is an increasing need to assess the evidence of a multidisciplinary approach for both short-term and long-term management of neurological sequelae arising from the diagnosis and treatment of brain tumors in childhood.

METHODS

We performed a systematic review of the evidence base for multidisciplinary paediatric brain tumor rehabilitation using seven databases. PRISMA guidelines were adhered to and the review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42014015070).

RESULTS

The literature search identified 3,061 results. Three service evaluations were included. The review identified limited evidence in favor of multidisciplinary rehabilitation for children with brain tumors. Due to the lack of controlled trial data and heterogeneity of the interventions and outcome measures, no meta-analysis could be performed.

CONCLUSIONS

Studies utilising a coordinated multi-centre approach with standardized outcome measures are recommended in order to enable robust assessment of the efficacy of multidisciplinary rehabilitation services.

Occupational Therapy for Children with Acquired Brain Injury: A Review of the Literature

The aim of this literature review was to examine occupational therapy input for children with acquired brain injury (ABI). Although 3,462 citations were identified by the literature search, only 10 articles met the criteria and were relevant to the review. The studies found that children with ABI had continuing difficulties, post-injury and postdischarge, with motor skills, self-care skills, cognition and behaviour. However, substantial numbers of children with continuing problems did not access therapy, particularly in the year postdischarge.

Occupational therapy is often part of inpatient paediatric rehabilitation, but there is a lack of research investigating the effectiveness of therapy. The review notes the dearth of research and literature in this field and suggests that further research is needed to underpin practice.

Occupational Therapy for Children with Acquired Brain Injury: A Survey of Current Practice

This survey aimed to describe current occupational therapy practice for children with acquired brain injury in the Trent Region. Forty-three paediatric occupational therapists were sent questionnaires. Information was requested on referral patterns, amount of patient contact time, use of specific care pathways, assessments and the nature of interventions used, as well as contact with educational services.

Eighteen therapists replied and their responses illustrated the difficulties involved in providing a service for this population. The therapists reported low referral rates, service pressures, difficulty in obtaining specialist paediatric equipment and inadequate training. It is suggested that services should provide and network with appropriate training for therapists, and continue the development of care pathways and outcome measures.

Outcome Rating Scales for Pediatric Head Injury

Intensivists, surgeons, neurologists, and others involved in pediatric intensive care units (PICUs) have an important investment in both short-and long-term outcomes of children and adolescents with head injury who are treated under their care. Outcomes are most often documented by either single-or multiple-item rating scales and are implemented both during and after hospital care. For this review, the authors have organized the content of rating scales into 6 general classes: (1) mortality prediction, (2) severity, (3) global recovery, (4) activity restrictions, (5) secondary adverse conditions, and (6) limitations in participation, quality of life, and health status. Rating scales that describe the outcomes of children and adolescents after head injury are used to monitor medical and functional recovery, guide clinical management, drive quality assurance initiatives, and conduct clinical research. The authors restrict their selective review to rating scales that describe child outcomes (vs family) and that have been reported and applied in the outcome literature. Although head injury is a major cause of mortality and short-and long-term morbidity in children and adolescents, there is no consensus on which rating scales are optimal for hospital care or community follow-up. Major considerations for clinical use are feasibility, type of outcome information needed, content breadth across multiple ages and levels of recovery, and utility in determining the short-term impact of PICU care on long-term outcome.

Functional independence after inpatient rehabilitation for traumatic brain injury among minority children and adolescents

OBJECTIVE

To compare motor and cognitive functional independence scores between Hispanic, non-Hispanic black (NHB), and non-Hispanic white (NHW) children with traumatic brain injury (TBI) after discharge from inpatient rehabilitation.

DESIGN

Retrospective cohort study using the Uniform Data System for Medical Rehabilitation national dataset from the years 2002 to 2012.

SETTING

Inpatient rehabilitation units.

PARTICIPANTS

Children (N=10,141) aged 6 months to 18 years who received inpatient rehabilitation for TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Motor and cognitive functional independence after discharge from inpatient rehabilitation, adjusting for age, sex, admission function, length of stay, insurance, and region.

RESULTS

Inpatient rehabilitation therapy improved functional independence for all children. Younger age, lower admission functional independence scores, and Medicaid insurance were associated with lower functional independence at discharge. Hispanic and NHB children had lower discharge cognitive scores compared with NHW children; however, differences were small and were partially explained by insurance status and region. Children who received rehabilitation therapy at pediatric facilities had greater cognitive improvement.

CONCLUSIONS

While racial/ethnic disparities are small, minority children are more likely to be younger, to have Medicaid, and to be cared for at nonpediatric facilities, factors that increase their risk for lower functional outcomes.

A survey of program evaluation practices in family-centered pediatric rehabilitation settings

Program evaluation is becoming increasingly important in pediatric rehabilitation settings that adhere to the family-centered service (FCS) philosophy. However, researchers know little about the specific evaluation activities occurring in these settings or the extent to which evaluators/service providers uphold FCS in their program evaluation activities. Through a questionnaire survey, this study aimed to document evaluators/service providers' perceptions of the level of program evaluation occurring in their Canadian pediatric rehabilitation centers. It also investigated the extent to which evaluators/service providers perceive program evaluation practices at their centers to be consistent with the FCS context of Canadian pediatric rehabilitation settings. The findings suggested that the amount of evaluation activities occurring within the respondents' centers is variable; that the majority of individuals working in program evaluation do not have formal training in it; and that the respondents' centers have limited resources for evaluation. The study also showed that staff members believe their centers' evaluation activities are somewhat consistent with FCS philosophy, but that improvements are needed.

Home safety education and provision of safety equipment for injury prevention (Review)

BACKGROUND

In industrialised countries injuries (including burns, poisoning or drowning) are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home but there is little meta-analytic evidence that child home safety interventions reduce injury rates or improve a range of safety practices, and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment (hereafter referred to as home safety interventions), in reducing child injury rates or increasing home safety practices and whether the effect varied by social group.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2009, Issue 2) in The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Social Sciences Citation Index (SSCI), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S), CINAHL (EBSCO) and DARE (2009, Issue 2) in The Cochrane Library. We also searched websites and conference proceedings and searched the bibliographies of relevant studies and previously published reviews. We contacted authors of included studies as well as relevant organisations. The most recent search for trials was May 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after (CBA) studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, and which reported injury, safety practices or possession of safety equipment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. Pooled incidence rate ratios (IRR) were calculated for injuries which occurred during the studies, and pooled odds ratios were calculated for the uptake of safety equipment or safety practices, with 95% confidence intervals.

MAIN RESULTS

Ninety-eight studies, involving 2,605,044 people, are included in this review. Fifty-four studies involving 812,705 people were comparable enough to be included in at least one meta-analysis. Thirty-five (65%) studies were RCTs. Nineteen (35%) of the studies included in the meta-analysis provided IPD. There was a lack of evidence that home safety interventions reduced rates of thermal injuries or poisoning. There was some evidence that interventions may reduce injury rates after adjusting CBA studies for baseline injury rates (IRR 0.89, 95% CI 0.78 to 1.01). Greater reductions in injury rates were found for interventions delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), and for those interventions not providing safety equipment (IRR 0.78, 95% CI 0.66 to 0.92). Home safety interventions were effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.41, 95% CI 1.07 to 1.86), functional smoke alarms (OR 1.81, 95% CI 1.30 to 2.52), a fire escape plan (OR 2.01, 95% CI 1.45 to 2.77), storing medicines (OR 1.53, 95% CI 1.27 to 1.84) and cleaning products (OR 1.55, 95% CI 1.22 to 1.96) out of reach, having syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) or poison control centre numbers accessible (OR 3.30, 95% CI 1.70 to 6.39), having fitted stair gates (OR 1.61, 95% CI 1.19 to 2.17), and having socket covers on unused sockets (OR 2.69, 95% CI 1.46 to 4.96). Interventions providing free, low cost or discounted safety equipment appeared to be more effective in improving some safety practices than those interventions not doing so. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety interventions most commonly provided as one-to-one, face-to-face education, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Conflicting findings regarding interventions providing safety equipment on safety practices and injury outcomes are likely to be explained by two large studies; one clinic-based study provided equipment but did not reduce injury rates and one school-based study did not provide equipment but did demonstrate a significant reduction in injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective in those participants at greater risk of injury. Further studies are still required to confirm these findings with respect to injury rates.

Rehabilitation of children with traumatic brain injury: a critical review

The purpose of this critical review of the English literature published between 1975 and 2009 was to assess the quality of the evidence for the efficacy of rehabilitation intervention after traumatic brain injury in children. "Evidence for intervention studies" was used to classify the research strength of design and report. Only a minority (16/439) of the published studies has been related to traumatic brain injury in children and has used a scientific or quasiscientific design. Only one study met the criteria of class I "evidence for intervention" studies. However, this study included adults, as well as children. The other 15 studies, although reporting positive results, had many methodologic deficiencies, and consequently their validity is questionable. Although the methodologic and ethical difficulties involved are acknowleged, a multicenter approach is required to achieve valid conclusions. Use of designs such as comparative effectiveness research might prove to be a practical solution. High-quality intervention research would facilitate stronger evidence-based counseling for children and families requiring posttraumatic brain injury intervention and to policy makers.

Home safety education and provision of safety equipment for injury prevention

BACKGROUND

In industrialised countries injuries (including burns, poisoning or drowning) are the leading cause of childhood death and steep social gradients exist in child injury mortality and morbidity. The majority of injuries in pre-school children occur at home but there is little meta-analytic evidence that child home safety interventions reduce injury rates or improve a range of safety practices, and little evidence on their effect by social group.

OBJECTIVES

We evaluated the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment (hereafter referred to as home safety interventions), in reducing child injury rates or increasing home safety practices and whether the effect varied by social group.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2009, Issue 2) in The Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Social Sciences Citation Index (SSCI), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S), CINAHL (EBSCO) and DARE (2009, Issue 2) in The Cochrane Library. We also searched websites and conference proceedings and searched the bibliographies of relevant studies and previously published reviews. We contacted authors of included studies as well as relevant organisations. The most recent search for trials was May 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials and controlled before and after (CBA) studies where home safety education with or without the provision of safety equipment was provided to those aged 19 years and under, and which reported injury, safety practices or possession of safety equipment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We attempted to obtain individual participant level data (IPD) for all included studies and summary data and IPD were simultaneously combined in meta-regressions by social and demographic variables. Pooled incidence rate ratios (IRR) were calculated for injuries which occurred during the studies, and pooled odds ratios were calculated for the uptake of safety equipment or safety practices, with 95% confidence intervals.

MAIN RESULTS

Ninety-eight studies, involving 2,605,044 people, are included in this review. Fifty-four studies involving 812,705 people were comparable enough to be included in at least one meta-analysis. Thirty-five (65%) studies were RCTs. Nineteen (35%) of the studies included in the meta-analysis provided IPD.There was a lack of evidence that home safety interventions reduced rates of thermal injuries or poisoning. There was some evidence that interventions may reduce injury rates after adjusting CBA studies for baseline injury rates (IRR 0.89, 95% CI 0.78 to 1.01). Greater reductions in injury rates were found for interventions delivered in the home (IRR 0.75, 95% CI 0.62 to 0.91), and for those interventions not providing safety equipment (IRR 0.78, 95% CI 0.66 to 0.92).Home safety interventions were effective in increasing the proportion of families with safe hot tap water temperatures (OR 1.41, 95% CI 1.07 to 1.86), functional smoke alarms (OR 1.81, 95% CI 1.30 to 2.52), a fire escape plan (OR 2.01, 95% CI 1.45 to 2.77), storing medicines (OR 1.53, 95% CI 1.27 to 1.84) and cleaning products (OR 1.55, 95% CI 1.22 to 1.96) out of reach, having syrup of ipecac (OR 3.34, 95% CI 1.50 to 7.44) or poison control centre numbers accessible (OR 3.30, 95% CI 1.70 to 6.39), having fitted stair gates (OR 1.61, 95% CI 1.19 to 2.17), and having socket covers on unused sockets (OR 2.69, 95% CI 1.46 to 4.96).Interventions providing free, low cost or discounted safety equipment appeared to be more effective in improving some safety practices than those interventions not doing so. There was no consistent evidence that interventions were less effective in families whose children were at greater risk of injury.

AUTHORS' CONCLUSIONS

Home safety interventions most commonly provided as one-to-one, face-to-face education, especially with the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Conflicting findings regarding interventions providing safety equipment on safety practices and injury outcomes are likely to be explained by two large studies; one clinic-based study provided equipment but did not reduce injury rates and one school-based study did not provide equipment but did demonstrate a significant reduction in injury rates. There was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective in those participants at greater risk of injury. Further studies are still required to confirm these findings with respect to injury rates.

Recommendations for the use of common outcome measures in pediatric traumatic brain injury research

This article addresses the need for age-relevant outcome measures for traumatic brain injury (TBI) research and summarizes the recommendations by the inter-agency Pediatric TBI Outcomes Workgroup. The Pediatric Workgroup's recommendations address primary clinical research objectives including characterizing course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements (CDE) Workgroups, the Pediatric TBI Outcomes Workgroup adopted the standard three-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in pediatric TBI from each identified domain including academics, adaptive and daily living skills, family and environment, global outcome, health-related quality of life, infant and toddler measures, language and communication, neuropsychological impairment, physical functioning, psychiatric and psychological functioning, recovery of consciousness, social role participation and social competence, social cognition, and TBI-related symptoms. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

Documenting the content of physical therapy for children with acquired brain injury: development and validation of the motor learning strategy rating instrument

BACKGROUND

A goal of physical therapy interventions for children and youth with acquired brain injury (ABI) is the learning and relearning of motor skills. Therapists can apply theoretically derived and evidence-based motor learning strategies (MLSs) to structure the presentation of a task and organize the environment in ways that may promote effective, transfer-oriented practice. However, little is known about how MLSs are used in physical therapy interventions for children with ABI.

OBJECTIVE

The purpose of this study was to develop and validate an observer-rated Motor Learning Strategy Rating Instrument (MLSRI) quantifying the application of MLSs in physical therapy interventions for children with ABI.

DESIGN

A multi-stage, iterative, item generation and reduction approach was used.

METHODS

An initial list of MLS items was generated through literature review. Seven experts participated in face validation to confirm item comprehensiveness. In a content validation process, 12 physical therapists with pediatric ABI experience responded to a questionnaire evaluating feasibility and importance of items. Six physical therapy sessions with clients with ABI were videotaped at a children's rehabilitation center. The 12 physical therapists participated in a session where they: (1) rated session videos to test the MLSRI and (2) provided verbal feedback.

RESULTS

Revisions were made sequentially to the MLSRI based on these processes.

LIMITATIONS

The MLSRI was scored during videotape observation rather than being given a live rating, which may be onerous in certain settings and may influence therapist or child behavior.

CONCLUSIONS

Further reliability investigations will determine whether the 33-item MLSRI is of help in documenting strategy use during intervention, as an evaluation tool in research, and as a knowledge transfer resource in clinical practice.

Taking a developmental and systemic perspective on neuropsychological rehabilitation with children with brain injury and their families

This paper reviews current approaches and models in the neuropsychological rehabilitation of children following Traumatic Brain Injury (TBI) and cites a large evidence base for a developmental and family systems perspective to neuropsychological rehabilitation of children post-TBI. The paper describes the application and efficacy of a systemic and developmental perspective to rehabilitation of children with TBI, with a clinical case example of this approach. The paper describes the development of a community-based child neuropsychology rehabilitation service integrating applied developmental neuropsychology and systems ideas as a way of working effectively with children with TBI and their families.

A comparison of developmental versus functional assessment in the rehabilitation of young children

BACKGROUND

The purpose of this study was to explore the differences in and potential uses of information derived from developmental vs. functional assessment during the acute rehabilitation of very young children with acquired brain injury. Both methods of assessment are typically used during hospitalization in order to assist in developing individualized goals and outcome measures. With the trend of shortened hospital stays, effective assessment for determining optimal treatment goals and outcomes becomes increasingly important. The results from a developmental and a functional assessment obtained on 23 inpatient children below 6 years of age who had experienced either an acquired brain injury or encephalitis were compared. The data was collected through a retrospective chart review spanning 4 years.

METHODS AND OUTCOME MEASURES

Each child received a cognitive and a language test using either the Early Learning Accomplishment Profile (E-LAP) or the Learning Accomplishment Profile Diagnostic (LAP-D) for the developmental assessment measure. The Functional Independence Measure for Children (WeeFIM) was used as a functional assessment. Summary statistics and frequencies were calculated for variables including age and diagnosis. Partial Pearson correlations and 95% confidence intervals were calculated between the functional and developmental assessments, adjusting for the amount of time between administrations of the two exams. Pearson correlations were computed between length of hospital stay and performance on the developmental and functional quotients.

RESULTS

Moderate, statistically significant Pearson partial correlations were found between the E-LAP/LAP-D cognitive quotient and the WeeFIM cognitive quotient (r = 0.42, 95% CI (0, 0.72)), the E-LAP/LAP-D language quotient and the WeeFIM cognitive quotient (r = 0.55, 95% CI (0.17, 0.79)) and the E-LAP/LAP-D cognitive quotient and the WeeFIM total quotient (r = 0.50, 95% CI (0.10, 0.76)). An inverse correlation was found between the length of stay and the E-LAP/ LAP-D cognitive quotient (r = -0.68, 95% CI (-0.86, -0.34)) as well as the E-LAP/LAP-D language quotient (r = -0.61, 95% CI (-0.83, -0.23)).

CONCLUSIONS

The moderate but limited correlations between developmental and functional assessments may be attributed to differences in the two forms of assessment including the test items, their administration and scoring. While both forms of assessment were thought to be useful for developing individualized treatment goals and measuring outcomes, there were advantages and disadvantages to each.

An evaluation of the paediatric acquired brain injury community outreach programme (PABICOP)

PRIMARY OBJECTIVE

To examine the utility of a coordinated, family/community-focused programme (PABICOP) vs. a standard approach for improving outcomes for children with ABI and their families.

RESEARCH DESIGN

Pre-test-post-test design, with comparison group and follow-up.

METHODS AND PROCEDURES

Ninety-six children (64 children receiving PABICOP services and 32 children receiving standard care) participated in the study. Measures were completed at baseline and 3 and 12 months later.

MAIN OUTCOMES AND RESULTS

Parents/caregivers with more than 10 contacts with PABICOP scored significantly higher on an ABI knowledge quiz than either parents/caregivers with 10 contacts or less or the comparison group at post-test and follow-up. Parents/caregivers with 10 contacts or less with PABICOP reported significantly greater improvements in children's school and total competence on the CBCL than either parents/caregivers with more than 10 contacts or the comparison group at post-test and follow-up.

CONCLUSIONS

PABICOP may be more useful for enhancing knowledge of ABI for parents/caregivers and for integrating children into the community over a 1-year period than a standard approach. The amount of service received appears to influence outcomes.

Traumatic brain injury in childhood: rehabilitation considerations

OBJECTIVE

The aims of this review were to: (i) briefly outline common sequelae following childhood traumatic brain injury (TBI); (ii) provide a summary of models and research in the area of intervention; (iii) discuss issues and obstacles in the evaluation of research in the area of intervention; (vi) discuss integrative and translational aspects of research in this area; (v) provide an example of intervention studies being conducted in the laboratory; and (vii) highlight the need for continued and collaborative work in the paediatric intervention field.

CONCLUSIONS

When reviewing the literature, it is clear that while challenging, the development and evaluation of intervention programs for children post traumatic brain injury, must be encourage and pursued. This in turn will lead to improved quality of life for these children and their families.

Traumatic brain injury: a comparison of inpatient functional outcomes between children and adults

OBJECTIVES

To examine age-related differences in functional outcomes following traumatic brain injury. PARTICIPANTS AND PROCEDURE: Seventy-six patients admitted to a pediatric acute rehabilitation hospital were compared with 2548 adult patients in the National Institute on Disability and Rehabilitation Research-funded traumatic brain injury model systems national database.

MAIN OUTCOME MEASURES

Functional Independence Measure totals during inpatient rehabilitation.

RESULTS

Increasing age was significantly associated with improved outcome in children and with poorer outcome in adults.

CONCLUSION

The relationship between age and functional outcome is different within different age groups (pediatric vs adult), and the effect of moderating variables differs by age group.

Long-term outcome and clinical spectrum of 73 pediatric patients with mitochondrial diseases

OBJECTIVES

We sought to determine the clinical spectrum, survival, and long-term functional outcome of a cohort of pediatric patients with mitochondrial diseases and to identify prognostic factors.

METHODS

Medical charts were reviewed for 73 children diagnosed between 1985 and 2005. The functional status of living patients was assessed prospectively by using the standardized Functional Independence Measure scales.

RESULTS

Patients fell into 7 phenotypic categories: neonatal-onset lactic acidosis (10%), Leigh syndrome (18%), nonspecific encephalopathy (32%), mitochondrial (encephalo)myopathy (19%), intermittent neurologic (5%), visceral (11%), and Leber hereditary optic neuropathy (5%). Age at first symptoms ranged from prenatal to 16 years (median: 7 months). Neurologic symptoms were the most common (90%). Visceral involvement was observed in 29% of the patients. A biochemical or molecular diagnosis was identified for 81% of the patients as follows: deficiency of complex IV (27%), of pyruvate dehydrogenase or complex I (25% each), of multiple complexes (13%), and of pyruvate carboxylase (5%) or complexes II+III (5%). A mitochondrial DNA mutation was found in 20% of patients. At present, 46% of patients have died (median age: 13 months), 80% of whom were <3 years of age. Multivariate analysis showed that age at first symptoms was a major independent predictor of mortality: patients with first symptoms before 6 months had a highly increased risk of mortality. Cardiac or visceral involvement and neurologic crises were not independent prognostic factors. Living patients showed a wide range of independence levels that correlated positively with age at first symptoms. Among patients aged >5 years (n = 32), 62% had Functional Independence Measure quotients of >0.75.

CONCLUSIONS

Mitochondrial diseases in children span a wide range of symptoms and severities. Age at first symptoms is the strongest predictor mortality. Despite a high mortality rate in the cohort, 62% of patients aged >5 years have only mild impairment or normal functional outcome.

Previous head injury is a risk factor for subsequent head injury in children: a longitudinal cohort study

OBJECTIVE

The objective of this study was to determine whether children who sought care for a head injury were at greater risk of having a subsequent head injury within the following 6 and 12 months compared with children who sought care for an injury other than to the head.

DESIGN/SETTING

This was a longitudinal cohort study conducted in the emergency departments of 2 Montreal (Quebec, Canada) pediatric hospitals.

PARTICIPANTS

The parents of 11,867 injured children aged 1 to 18 years were interviewed by telephone at 6 (n = 10,315) and 12 (n = 9486) months after their child's injury to ascertain outcome (ie, subsequent head injury) and to provide information on potential risk factors (age, gender, chronic medical condition, activity level, and socioeconomic status).

MAIN OUTCOME MEASURE

The outcome of interest was a head injury requiring medical attention within the following year ascertained by parental recall or physician claims data.

RESULTS

A total of 245 and 386 previously head-injured children sustained a subsequent head injury within 6 and 12 months, respectively. Children who sought care for an initial head injury (n = 3599) were at higher risk of having a subsequent head injury within 6 months than children who sought care for an injury not to the head (n = 6716). The adjusted odds ratio suggested weak confounding by age, gender, and history of previous head injury. Results were consistent on the basis of physician claims data and 12-month follow-up interview data.

CONCLUSIONS

These results provide evidence that having a head injury increases a child's risk of having a subsequent head injury. Although age, gender, and history of previous head injury confound the relationship, the effect remains substantial.

Advances in Postacute Rehabilitation After Childhood-Acquired Brain Injury

Despite traditional views, children do not necessarily recover well from brain injury. Residual functional impairments are commonly documented in physical, cognitive, educational, behavioral, and social domains and result in a significant, ongoing social and economic burden for the child's family and for the broader community. More recent acknowledgment of the serious, and often permanent, consequences of acquired brain injury in childhood has been paralleled by rapid advances in evidence-based, acute medical care and diagnostic technology. In contrast, child-based postacute rehabilitation and long-term interventions are less well developed. To date, child services have borrowed substantially from adult models, combining both direct therapies and interdisciplinary approaches. Despite their proliferation, and strong clinical support, such services are rarely the subject of rigorous evaluation and have given little acknowledgment to the important developmental factors that need to be considered when working with children. Using a developmental framework, this review aims to consider the nature of functional impairments that result from childhood traumatic brain injury, the recovery process postinjury, and the scope and role of child-based rehabilitation. In addition, the relatively scarce body of literature describing the evaluation of child rehabilitation models are reviewed with an emphasis on identifying approaches that provide evidence of enhanced function in the child's everyday life and, in particular, in the home and school contexts.

An evaluation of the responsiveness of a comprehensive set of outcome measures for children and adolescents with traumatic brain injuries

The relative responsiveness of nine outcome measure scales was evaluated with 33 children and adolescents (aged 4-18 years) who had sustained traumatic brain injuries. Scales were selected to evaluate outcomes from each of the World Health Organization (WHO) International Classification of Functioning, Disability and Health domains. The outcome measures were administered to all participants during their inpatient rehabilitation stay and again at a follow-up clinic visit. No single outcome measure captured the diversity of improvement in this sample. The measures agreed that improvement had occurred, but did not agree about which children were improving. This result suggests that the scales were measuring different skills and outcomes. Three of the measures used in combination, either the Child Health Questionnaire or the Functional Independence Measure for Children, the American Speech-Language-Hearing Association National Outcome Measures System (Birth to Kindergarten NOMS/School-aged Health Care) and the Gross Motor Function Measure, are sufficient to detect change in each of the children where change occurred. The Pediatric Evaluation of Disability Inventory and the MultiAttribute Health Status Classification were the least responsive of the nine measures used.

Effect of Shortened Length of Stay on Functional and Educational Outcome After Pediatric Rehabilitation

OBJECTIVE

The purpose of this study was to assess changes in the length of stay and its effect on effectiveness and return to school in an inpatient pediatric rehabilitation unit during a 5-yr period from fiscal year 1997 through 2001.

DESIGN

We reviewed prospectively collected data for a cohort of 321 children during fiscal years 1997-2001.

RESULTS

Length of stay was significantly shortened, with mean lengths of stay of 58.9, 43.5, 30.7, 40.9, and 24.0 days in years 1997 through 2001, respectively. Change in length of stay remained significantly decreased after adjusting for age, sex, admission diagnosis, admission severity, and type of health insurance. There was no difference in mean change in effectiveness measured by change in admission and discharge WeeFIM ratings. There were significant differences across years in the educational placement of children at discharge, with a declining trend in the proportion of children discharged to classroom-based educational services.

CONCLUSION

There was a reduction in inpatient length of stay during a 5-yr period for children in this pediatric rehabilitation setting. During this time, there was no change in the effectiveness of rehabilitation as measured by functional outcome. However, using return to a classroom setting as a marker of reintegration into routine activities, fewer children returned to a similar level of community participation.

Functional recovery in pediatric traumatic brain injury during inpatient rehabilitation

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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