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

"Your brain can't wait": perspectives of children and adolescents with acquired brain injury and their parents on physical rehabilitation during the subacute phase

PURPOSE

Physical interventions during subacute rehabilitation have potential to improve functional recovery. This study explored the perspectives of children and adolescents with acquired brain injury (ABI) and their parents with respect to physical rehabilitation during the subacute phase.

METHODS

Thirteen children and adolescents with ABI and their parents were included and interviewed using semi-structured interviews. Interview transcripts were analysed using inductive thematic analysis approach.

RESULTS

Six themes were identified: 1) beliefs of physical rehabilitation, 2) content of physical rehabilitation, 3) tailored care, 4) impact of context, 5) communication and 6) transition. The importance of intensive physical practice was widely supported. The positive can-do mentality was emphasised to create an atmosphere of hope, meaning that every effort would be made to achieve maximum recovery. Intensive involvement of parents is considered essential during subacute rehabilitation including an open and mutual dialogue about the focus of rehabilitation, therapy goals and future participation in their own environment.

CONCLUSIONS

Our findings highlight the need for an intensive rehabilitation approach, tailored to the individual's needs. The perspectives of children and adolescents and their parents in our study contribute to a better understanding of factors that are important for optimal recovery through physical rehabilitation during the subacute phase.

Integrating Transcranial Direct Current Stimulation into an Existing Inpatient Physiotherapy Program to Enhance Motor Learning in an Adolescent with Traumatic Brain Injury: A Case Report

PURPOSE

Describe how transcranial direct current stimulation (tDCS) was incorporated into an inpatient physiotherapy program for an adolescent with severe traumatic brain injury (TBI), detail the motor learning focus of the physiotherapy sessions, and summarize gross motor progress.

METHOD

This case report describes an adolescent who received 20 minutes of anodal tDCS immediately prior to 16 physiotherapy sessions over four weeks. Potential side effects were tracked pre/post tDCS. Gross motor outcomes were measured pre-intervention, post-intervention, and three months post-intervention. Physiotherapy session content was analyzed using therapist documentation and the Motor Learning Strategies Rating Instrument.

RESULTS

The youth tolerated tDCS well. The primary side effect was itchiness under the electrodes during tDCS sessions. His mobility progressed from wheelchair use pre- 'tDCS + physiotherapy' to ambulation with a walker post-intervention. His Gross Motor Function Measure score increased 33.1% points pre/post intervention. Session tasks often had several foci (e.g., skill acquisition, strength, and balance) with task focus changing as the youth progressed. Various motor learning strategies were layered within tasks to support performance and learning.

CONCLUSIONS

tDCS was successfully integrated into an existing inpatient physiotherapy program for an adolescent with TBI. This protocol provides a structure for implementing, monitoring, and measuring tDCS + physiotherapy in pediatric rehabilitation.

Profile of pediatric out-patients managed by physiotherapists at Federal Medical Center, Abeokuta: a retrospective review

Background

Pediatric physiotherapists help children to achieve their optimal physical development. The present study was aimed to evaluate the out-patient pediatric conditions managed by physiotherapists in Federal Medical Centre, Abeokuta, Nigeria (FMCA).

Methods

The present study included all children attended to at Pediatric Unit (outpatient) of FMCA in the period between the beginnings of May 20121 to the end of May 2022. The clinic runs every Tuesdays and Thursdays. All children below and equals to 15 years of age were included. Complete clinical, socio-demographic characteristics of patients and parents were manually scrapped from the electronic medical records (EMR) of the hospital. Descriptive statistics was used to present the results.

Results

During this period a total of 160 patients presented with different disorders were seen. There were 100 males (62.5%) and 60 females (37.5%). Cerebral palsy which can be classified as a neurological disorder was the most common condition managed (63.7%). Obstetric brachial palsy injury (OBPI), injection palsy, post-immobilization stiffness, congenital talipes equinivarus, and among others were managed during this period. Cerebral palsy was common among males, obstetric brachial palsy injury, and injection palsy. Cerebral palsy patients had late presentation for physiotherapy (1–5 years). Only 2 patients out of 11 with OBPI came for early physiotherapy. There is higher risk for cerebral palsy and OBPI among primiparous mothers.

Conclusions

It was concluded that neurological disorders are the most common pediatric cases managed by physiotherapists in Federal Medical Centre, Abeokuta, with cerebral palsy having higher prevalence.

Gross motor change after inpatient rehabilitation for children with acquired brain injury: A 10-year retrospective review

AIM

To estimate gross motor change in inpatient school-aged children with subacute acquired brain injury (ABI), identify factors associated with gross motor change, and describe inpatient physiotherapy focus.

METHOD

This retrospective chart review involved inpatient children (5-18 years) with subacute ABI who had either two Gross Motor Function Measure (GMFM-88) assessments or one GMFM-88 with another pre/post gross motor outcome measure. Outcome change scores and Goal Attainment Scaling (GAS) T scores were calculated. Regression analyses examined factors predicting gross motor change. GAS goal areas were analysed to determine physiotherapy focus.

RESULTS

Of the 546 charts screened, 266 (118 female) met study criteria. The GMFM-88 was generally administered first, followed by other measures. GMFM-88 (n = 202), Community Balance and Mobility Scale (n = 89), and Six-Minute Walk Test (6MWT) (n = 98) mean change scores were 18.03% (SD 19.34), 17.85% (SD 10.77), and 142.3 m (SD 101.8) respectively. The mean GAS T score was 55.06 (SD 11.50). Lower baseline scores and increased time between assessments were most predictive of greater GMFM-88 change (r ≥ 0.40). Twenty-five percent of GAS goals were ambulation-based.

INTERPRETATION

Appropriate outcome measure selection is integral to detecting gross motor change in pediatric inpatient ABI rehabilitation. Mean change score estimates can be used to compare standard inpatient rehabilitation with new treatment approaches.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

Factors predicting rehabilitation outcomes after severe acquired brain injury in trauma, stroke and anoxia populations: A cohort study

Severe acquired brain injury has long-term physical and cognitive effects. Identifying patient variables predictive of recovery in different brain injury populations would generate improved prognostic information and help rehabilitation teams set appropriate therapeutic goals. This cohort study of 447 NHS neurorehabilitation inpatients aimed to identify functional and cognitive predictors of recovery following severe acquired brain injury caused by trauma, stroke and anoxia. Motor and cognitive impairment ratings were collected at admission and discharge using the Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and injury-related and demographic data were collated from medical records. Predictors of physical, cognitive and overall recovery were identified via hierarchical regression analyses. Several key findings emerged. Firstly, on-admission motor skills predicted functional and overall outcomes across groups. Secondly, on-admission social interaction skills predicted cognitive discharge outcomes in stroke and trauma, and overall outcomes for stroke, but did not predict anoxia outcomes. Thirdly, age predicted all forms of recovery for stroke only. Further group-specific factors were also identified as predicting motor and cognitive recovery, indicating that factors key to the rehabilitation trajectory may differ between populations. These variables should be considered in rehabilitation goal planning, although further research is required to explore their contributions to recovery.

Change in functional status among children treated in the intensive care unit after injury

BACKGROUND

Because pediatric trauma-related mortality continues to decline, metrics assessing morbidity are needed to evaluate the impact of treatment after injury. Based on its value for assessing children with traumatic brain injuries and other critical illnesses, Functional Status Scale (FSS), a tool that measures function in six domains (communication, feeding, mental, motor, sensory, and respiratory), was evaluated as an outcome measure for the overall population of injured children.

METHODS

Children with at least one injury (Abbreviated Injury Scale [AIS] severity ≥1) surviving to discharge between December 2011 and April 2013 were identified in a previous study of intensive care unit admissions. Morbidity was defined as additional morbidity in any domain (domain FSS change ≥2 or 'new domain morbidity') and additional overall morbidity (total FSS change ≥3) between preinjury status and discharge. Associations between injury profiles and the development of morbidity were analyzed.

RESULTS

We identified 553 injured children, with a mean of 2.0 ± 1.9 injuries. New domain and overall morbidity were observed in 17.0% and 11.0% of patients, respectively. New domain morbidity was associated with an increasing number of body regions with an injury with AIS ≥ 2 (p < 0.001), with severe (AIS ≥ 4) head (p = 0.04) and spine (p = 0.01) injuries and with at moderately severe (AIS ≥ 2) lower extremity injuries (p = 0.01). New domain morbidity was more common among patients with severe spine and lower extremity injuries (55.6% and 48.7%, respectively), with greatest impact in the motor domain (55.6% and 43.6%, respectively). New domain morbidity was associated with increasing injury severity score, number of moderately severe injuries and number of body regions with more than a moderately severe injury (p < 0.001 for all).

CONCLUSIONS

Higher morbidity measured by the FSS is associated with increasing injury severity. These findings support the use of the FSS as a metric for assessing outcome after pediatric injury.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, level III.

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.

Inpatient rehabilitation facilities: The 3-hour rule

The aim of this study was to determine whether patients whose treatment is consistent with the 3-hour rule have better outcomes than patients whose treatment is not consistent with the 3-hour rule.This is a retrospective review of the records of 581 patients. The authors compared the outcomes of 397 patients whose therapy was consistent with the 3-hour rule to the outcomes of 184 patients whose therapy was not consistent with the rule for at least one 7-day period during the stay on an inpatient rehabilitation facility.Patients whose care was consistent with the rule did not have more improvement in function or shorter length of stay than patients whose care was not consistent with the 3-hour rule.There is not good evidence to support the 3-hour rule as a determinant of the care that a patient at an IRF needs to achieve a good outcome.

Morbidity: Changing the Outcome Paradigm for Pediatric Critical Care

The focus of critical care has evolved from saving lives to preservation of function. Morbidity rates in pediatric critical care are approximately double mortality rates. Morbidity includes complications of disease and medical care. In pediatric critical care, functional status morbidity is an intermediate outcome in the progression toward death and is the result of the same factors associated with mortality, including physiologic profiles and case-mix factors. The Functional Status Scale developed by Collaborative Pediatric Critical Care Research Network is a validated, granular, age-independent measure of functional status that has proved valuable and practical even in large outcome studies.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Physical Therapy Dosing: Frequency and Type of Intervention in Pediatric Postacute Hospital Care

PURPOSE

To examine differences in physical therapy dosing frequency recommendations based on children's characteristics and to describe types of intervention recommended at postacute hospital admission.

METHODS

Demographic and clinical information, recommended physical therapy intervention frequency, and intervention types were collected for all admissions from April 1, 2015, to March 1, 2016. Differences across 2 groups, children with recommendations for "less" (≤3x/wk) or "more" (≥4x/wk) frequent therapy, were examined. Types of interventions recommended were described and the measure of association between frequency and type was determined.

RESULTS

Older children, those with higher admission functional scores, and children with less dependence on medical technology were recommended for "more." Therapeutic exercise was the most common intervention recommended. Greater physical therapy frequency was associated with Functional Training and Motor Function Training.

CONCLUSION

Children's age, functional level, and technology dependence influence dosing recommendations. Interventions focused on function are associated with greater physical therapy frequency.

Traumatic Brain Injury Patient, Injury, Therapy, and Ancillary Treatments Associated With Outcomes at Discharge and 9 Months Postdischarge

OBJECTIVE

To examine associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months postdischarge for patients with traumatic brain injury (TBI).

DESIGN

Prospective, longitudinal observational study.

SETTING

Inpatient rehabilitation centers.

PARTICIPANTS

Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after an index TBI injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge.

RESULTS

The admission FIM cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities and percentage of stay using specific medications explained approximately 20% more variation for discharge outcomes and 12.9% for 9-month outcomes. After patient, injury, and treatment characteristics were used to predict outcomes, center differences added only approximately 1.9% additional variance explained.

CONCLUSIONS

At discharge, greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM cognitive subgroups. At 9 months postdischarge, similar but less pervasive associations were observed for therapy activities, but not classes of medications. Further research is warranted to examine more specific combinations of therapy activities and medications that are associated with better outcomes.

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.

The motor learning strategy instrument: interrater reliability within usual and virtual reality physical therapy interventions

PURPOSE

To evaluate and compare the interrater reliability of the Motor Learning Strategy Rating Instrument (MLSRI) within usual and virtual reality (VR) interventions for children with acquired brain injury.

METHODS

Two intervention sessions for each of 11 children (total, 22) were videotaped; sessions were provided by 4 physical therapists. Videotapes were divided into usual and VR components and rated by 2 observers using the MLSRI. A generalizability theory approach was used to determine interrater reliability for each intervention.

RESULTS

Interrater reliability for usual interventions was high for the MLSRI total score (g-coefficient, 0.81), whereas it was low for the VR total score (g-coefficient, 0.28); MLSRI category g-coefficients varied from 0.35 to 0.65 for usual and from 0.17 to 0.72 for VR interventions.

CONCLUSION

Adequate reliability was achieved within ratings of usual interventions; however, challenges related to MLSRI use to rate VR-based interventions require further evaluation.

Reliability of the motor learning strategy rating instrument for children and youth with acquired brain injury

PURPOSE

To evaluate reliability and feasibility of the Motor Learning Strategy Rating Instrument (MLSRI) in children with acquired brain injury (ABI). The MLSRI quantifies the extent to which motor learning strategies (MLS) are used within physiotherapy (PT) interventions.

METHODS

PT sessions conducted by ABI team physiotherapists with a convenience sample of children with ABI (4-18 years) were videotaped and independently scored later by two raters trained in MLSRI use. Intraclass correlation coefficients (ICCs) and 95% confidence intervals (CIs) estimated intra- and inter-rater reliability.

RESULTS

Eighteen PT sessions were evaluated. Intra- and inter-rater reliability ICCs for total score were 0.86 (95% CI: 0.66-0.94) and 0.50 (95% CI: 0.08-0.78), respectively. MLSRI category ICCs were 0.56-0.86 (intra-rater) and 0.16-0.84 (inter-rater).

CONCLUSIONS

Intra-rater reliability of MSLRI total score was excellent. Moderate inter-rater reliability may partially be due to inconsistent item interpretation between raters. Revisions and further reliability testing are required before recommending the MLSRI for clinical and research use.

Usual and virtual reality video game-based physiotherapy for children and youth with acquired brain injuries

Little is known about how therapists promote learning of functional motor skills for children with acquired brain injuries. This study explores physiotherapists' description of these interventions in comparison to virtual reality (VR) video game-based therapy. Six physiotherapists employed at a children's rehabilitation center participated in semi-structured interviews, which were transcribed and analyzed using thematic analysis. Physiotherapists describe using interventions that motivate children to challenge performance quality and optimize real-life functioning. Intervention strategies are influenced by characteristics of the child, parent availability to practice skills outside therapy, and therapist experience. VR use motivates children to participate, but can influence therapist use of verbal strategies and complicate interventions. Physiotherapists consider unique characteristics of this population when providing interventions that promote learning of motor skills. The VR technology has advantageous features but its use with this population can be challenging; further research is recommended.

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.

Lessons from use of the Pediatric Evaluation of Disability Inventory: where do we go from here?

PURPOSE

The purpose of this article is to review the innovations, applications, and effect of the original Pediatric Evaluation of Disability Inventory (PEDI) published in 1992 and to describe planned revisions.

SUMMARY OF KEY POINTS

During the past decade, the PEDI has helped to shift thinking from a developmental to a functional focus. Using the PEDI, researchers and clinicians worldwide have highlighted variations in functional skill acquisition in clinical populations, the importance of recognizing cultural differences, and the value of documenting functional progress in relation to interventions.

CONCLUSIONS

The PEDI has had a rich tradition in helping to document functional development. New methods are proposed for the next generation of the PEDI by using item banks and computer adaptive testing.

RECOMMENDATIONS FOR CLINICAL PRACTICE

The computer adaptive testing feature and the revised and expanded content of the new PEDI will enable therapists to more efficiently assess children's functioning to a broader age group of children.

Measuring children's health-related quality of life after trauma

Consideration of children's health-related quality of life (HRQOL) after injury is a critical aspect of outcome in assessing the effectiveness of trauma care. Numerous instruments are available today for measuring the HRQOL of injured children. HRQOL instruments reflect the subjective perspective of the impact an injury or disease has on a child's physical, emotional, and social well being. Most studies to date have examined children's HRQOL during the first year postinjury, relatively little is known about children's long-term HRQOL after trauma. Most trauma outcome studies have included children with heterogeneous injuries so the impact of specific injuries on HRQOL outcomes has not been well established. The majority of outcome studies have focused on injured children who have been hospitalized, however the research should be extended to the emergency department because a large proportion of injured children are treated and released from there. In addition to documenting recovery, investigators should use HRQOL instruments to evaluate the quality of care we offer injured children and their families. Rigorously conducted HRQOL assessment will provide valuable information that we can use to successfully optimize children's recovery after trauma.

Interpreting change scores of tests and measures used in physical therapy

Over the past decade, the methods and science used to describe changes in outcomes of physical therapy services have become more refined. Recently, emphasis has been placed not only on changes beyond expected measurement error, but also on the identification of changes that make a real difference in the lives of patients and families. This article will highlight a case example of how to determine and interpret "clinically significant change" from both of these perspectives. The authors also examine how to use item maps within an item response theory model to enhance the interpretation of change at a content level. Recommendations are provided for physical therapists who are interpreting changes in the context of clinical practice, case reports, and intervention research. These recommendations include a greater application of indexes that help interpret the meaning of clinically significant change to multiple clinical, research, consumer, and payer communities.