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

Predicting and improving outcome in severe pediatric traumatic brain injury

INTRODUCTION

Severe pediatric traumatic brain injury (spTBI), including abusive head trauma (AHT) in young children, is a major public health problem. Long-term consequences of spTBI include a large variety of physical, neurological, biological, cognitive, behavioral and social deficits and impairments.

AREAS COVERED

The present narrative review summarizes studies and reviews published from January 2019 to February 2024 on spTBI. Significant papers published before 2019 were also included. The article gives coverage to the causes of spTBI, its epidemiology and fatality rates; disparities, inequalities, and socioeconomic factors; critical care; outcomes; and interventions.

EXPERT OPINION

There are disparities between countries and according to socio-economic factors regarding causes, treatments and outcomes of spTBI. AHT has an overall poor outcome. Adherence to critical care guidelines is imperfect and the evidence-base of guidelines needs further investigations. Neuroimaging and biomarker predictors of outcomes is a rapidly evolving domain. Long-term cognitive, behavioral and psychosocial difficulties are the most prevalent and disabling. Their investigation should make a clear distinction between objective (clinical examination, cognitive tests, facts) and subjective measures (estimations using patient- and proxy-reported questionnaires), considering possible common source bias in reported difficulties. Family/caregiver-focused interventions, ecological approaches, and use of technology in delivery of interventions are recommended to improve long-term difficulties after spTBI.

"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.

Effect of non-invasive brain stimulation in children with acquired brain injury-a scoping review

Background

Children and young people (CYP) with acquired brain injury (ABI) require early and effective neurorehabilitation to improve long-term functional outcomes. Non-invasive brain stimulation (NIBS), including transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), have been used to improve motor and sensory skills for children with cerebral palsy. However, there is limited evidence supporting its use in CYP with ABI.

Objective

To systematically review the TMS and tDCS intervention effects on motor, sensory and other functional issues in CYP with ABI as reported in the literature.

Methods

A comprehensive online bibliographic databases search was performed in various databases using keywords related to NIBS and CYP with ABI. Studies that examine the effect of NIBS intervention on motor function and other functional difficulties either as a primary or secondary objective were included in this review.

Results

Fourteen studies (10 single case reports, one retrospective analysis, one case series, one randomised and one quasi-randomised controlled trial) published between 2006 and 2023 were identified. These studies examined the use of NIBS to manage motor disorders, hearing, vision, headaches, speech and language and memory issues. Seventy-six children with mild to severe ABI had received NIBS. The session frequency (3-20), duration (10-45 min) was variable, and NIBS delivered between 3 and 28 days.

Conclusion

The literature describing NIBS interventions in CYP with ABI is scarce. An insufficient number of studies, inadequate information reported in them, and small sample sizes limit the ability to conclude how effective NIBS is in improving motor function and other functional issues in this cohort. Further studies are therefore necessary to examine the therapeutic effects of NIBS to manage various functional problems in the CYP with ABI.

Pediatric rehabilitation delivery: discussion is an antidote to disconnection and discontent

Pediatric rehabilitation is fundamentally different from that of adults. Child physiology differs significantly from that of adults, necessitating specialized rehabilitation approaches. Unique injuries and varying metabolic rates underscore the need for tailored care, which changes over the years as the child grows and develops. Waiserberg's paper, "When Everyone is Responsible, No One Takes Responsibility": Exploring Pediatric Physiotherapy Services in Israel," sheds light on a critical issue. While senior practitioners oversee policy implementation and service delivery, practical physiotherapy treatment lacks continuous monitoring. This is a critical issue. Ideally, every child who requires long-term clinical therapeutic interventions to keep up with peers in mobility, communication and cognitive skills should be assessed by specialists several times throughout the school years, and their personalized rehabilitation plan discussed, reviewed, and adjusted according to their progress. The absence of a standardized protocol for overseeing and directing comprehensive rehabilitation plans leaves therapists feeling alone and adrift, whether working in schools or medical settings. Such an assessment would be an opportunity to create a registry, which is currently nonexistent. The collected data would be a priceless resource in policy decision-making and service planning.

Integrative Review of Music and Music Therapy Interventions on Functional Outcomes in Children with Acquired Brain Injury

Acquired brain injury (ABI) can result in a multitude of impairments to physical, cognitive, communicative, psychological, and psychosocial functioning. Music interventions are emerging as a valuable form of intervention in the rehabilitation of children with ABI, stimulating brain functions involved in movement, cognition, speech, emotions, and sensory perceptions. To date, the literature detailing the impact of music and music therapy interventions on functional outcomes in children with ABI has not been reviewed systematically. To address this, Whittemore and Knafl's five-stage integrative review framework was employed, which includes (a) problem identification, (b) literature search, (c) data evaluation, (d) data analysis and synthesis, and (e) presentation of the findings. A total of 388 articles were retrieved, and 8 studies met the inclusion criteria. Analysis and synthesis resulted in 3 overarching themes: outcomes of using music therapy in pediatric ABI, music therapy as a motivator in pediatric ABI rehabilitation, and collaboration. The review highlights the pivotal role of music as a motivational catalyst that promotes adherence to rehabilitative intervention. Nevertheless, it underscores a significant gap in empirical research within the field, emphasizing the necessity for larger, more rigorous studies.

Strategies supporting parent-delivered rehabilitation exercises to improve motor function after paediatric traumatic brain injury: A systematic review

AIM

To identify and analyse ways in which parents are supported to deliver rehabilitation exercises to their child after traumatic brain injury (TBI), conceptualized as strategies.

METHOD

A systematic search was completed using seven online databases and three grey literature databases, from inception to November 2021. The included studies focused on physical rehabilitation in children after TBI with the involvement of parents as hands-on deliverers or facilitators of rehabilitation (e.g. supervising the exercise). Intervention descriptions were reviewed to identify strategies; this was followed by fine-grained analysis using the Behaviour Change Wheel to identify intervention components. Risk of bias was analysed using the revised Cochrane Risk-of-Bias Tool for Randomized Trials or the Risk Of Bias In Non-randomized Studies - of Interventions.

RESULTS

Six interventions including 211 participants and one trial protocol met the inclusion criteria. All studies included a proportion of children diagnosed with TBI and four studies included mixed samples of acquired brain injury or cerebral palsy. All interventions included elements of goal setting and instruction.

INTERPRETATION

Interventions focus heavily on the initiation of physical rehabilitation, but focus less on the longer-term maintenance of rehabilitation delivery. Further research should integrate perspectives from parents to inform the development of new interventions.

WHAT THIS PAPER ADDS

Parents need support to deliver or supervise rehabilitation exercises. The interventions identified in this review supported goal setting, action planning, and learning rehabilitation exercises. Interventions focused primarily on the initiation of exercises but less on maintenance. Rehabilitation is complex and new approaches are needed to better support parents.

Emerging methods for measuring physical activity using accelerometry in children and adolescents with neuromotor disorders: a narrative review

BACKGROUND

Children and adolescents with neuromotor disorders need regular physical activity to maintain optimal health and functional independence throughout their development. To this end, reliable measures of physical activity are integral to both assessing habitual physical activity and testing the efficacy of the many interventions designed to increase physical activity in these children. Wearable accelerometers have been used for children with neuromotor disorders for decades; however, studies most often use disorder-specific cut points to categorize physical activity intensity, which lack generalizability to a free-living environment. No reviews of accelerometer data processing methods have discussed the novel use of machine learning techniques for monitoring physical activity in children with neuromotor disorders.

METHODS

In this narrative review, we discuss traditional measures of physical activity (including questionnaires and objective accelerometry measures), the limitations of standard analysis for accelerometry in this unique population, and the potential benefits of applying machine learning approaches. We also provide recommendations for using machine learning approaches to monitor physical activity.

CONCLUSIONS

While wearable accelerometers provided a much-needed method to quantify physical activity, standard cut point analyses have limitations in children with neuromotor disorders. Machine learning models are a more robust method of analyzing accelerometer data in pediatric neuromotor disorders and using these methods over disorder-specific cut points is likely to improve accuracy of classifying both type and intensity of physical activity. Notably, there remains a critical need for further development of classifiers for children with more severe motor impairments, preschool aged children, and children in hospital settings.

Child and family health-related quality of life and participation outcomes and goals after acquired brain injury: a cross-sectional survey

OBJECTIVE

To explore longer-term health-related quality of life (HRQoL) and participation outcomes and goals of children and young people (CYP) with acquired brain injuries (ABI) and their families in a region of the UK and the impact of the COVID-19 pandemic.

METHODS

Cross-sectional survey of (5-18 CYP) and their parent-carers 12-43 months following ABI. Included measures of HRQoL, participation, family function and parental wellbeing and demographic and free text questions.

RESULTS

Ninety-five responses (30% response) were received. 67% of CYP were at risk of impaired HRQoL, 72% had severely impaired participation. 53% of parent-carers reported reduced HRQoL and family functioning, 37% of parent-carers screened positive for anxiety/depression. Relationships exist between CYP participation and HRQoL and parental HRQoL and family functioning. Goals were overwhelmingly activity and participation focused. Participants described the global impact of an ABI on the CYP and family as well as the additional impact of the COVID-19 pandemic on CYP and family wellbeing.

CONCLUSION

ABI significantly impacts CYP participation and both CYP and parent-carer wellbeing in the long-term, potentially further impacted by the COVID-19 pandemic. Rehabilitation interventions should address both participation and the psychological wellbeing of CYP with ABI and their parent-carers.

Individual and contextual factors influencing children's effort in pediatric rehabilitation interventions

Rehabilitation clinicians strive to encourage children's sustained effort within challenging practice conditions. Effort influences intervention success, yet it is rarely defined or measured. Effort can be conflated with individual factors, such as motivation and engagement, that might influence it. Contextual factors that likely impact children's effort, such as practice conditions and therapeutic interactions, are generally under-described. Defining, describing, and measuring effort and its influencers is necessary to enhance understanding of differences in rehabilitation intervention outcomes across individuals and contexts and to support the development of personalized precision rehabilitation approaches. This narrative review describes effort conceptualization in rehabilitation, particularly in relation to intensity, engagement, and participation nomenclature. The review outlines individual and contextual factors that may influence children's effort in rehabilitation and describes potential next steps for effort description and measurement. Subsequent work should aim to identify factors that can be targeted in clinical practice to promote and sustain children's effort in the rehabilitation process, thereby individualizing interventions and potentially improving their effectiveness. WHAT THIS PAPER ADDS: Effort as it relates to rehabilitation is confusingly described and infrequently measured. Engagement, involvement, intensity, and participation are terms alluding to effort. Child-specific and therapy-specific factors, alone and in combination, may influence children's effort. Clearer conceptualization of effort and the factors that influence it will support personalization of interventions. Better measurement will enhance knowledge about relationships between effort and therapeutic outcomes.

The Effect of Web-Based Telerehabilitation Programs on Children and Adolescents With Brain Injury: Systematic Review and Meta-Analysis

BACKGROUND

Acquired brain injury (ABI) in children and adolescents can lead to motor and executive impairments that often require long-term treatment. The implementation of web-based telerehabilitation therapy at home is a method to improve the functional status of patients. Therefore, we performed a systematic review of the effects of web-based telerehabilitation programs on functional outcomes in children and adolescents with brain injury and supplemented the findings with a meta-analysis.

OBJECTIVE

This study evaluated the therapeutic effect of web-based telerehabilitation training on children and adolescents with brain injury to determine whether web-based telerehabilitation therapy improved motor function, executive function, physical activity level, lower limb strength, hand and upper limb function, visual processing skills, and occupational functional performance in children and adolescents with brain injury.

METHODS

PubMed, Embase, Scopus, Web of Science, and the Cochrane Library were searched for randomized controlled trials on web-based telerehabilitation programs in children and adolescents with brain injury until December 2022, and the risk of bias was evaluated using the Cochrane Collaboration Tool. Relevant data were extracted, and a meta-analysis was performed using RevMan5.3 software.

RESULTS

Overall, 17 studies involving 848 patients were included. Web-based telerehabilitation therapy improved the motor function (standardized mean difference [SMD] 0.29, 95% CI 0.01-0.57; P=.04), physical activity level (SMD 0.42, 95% CI 0.11-0.73; P=.007), lower limb strength (SMD 0.52, 95% CI 0.13-0.90; P=.009), and visual processing skills (SMD 0.26, 95% CI 0.02-0.50; P=.04) of children and adolescents with brain injury. It also improved executive function in letter-number sequencing (SMD 1.26, 95% CI 0.26-2.26; P=.01), attention (SMD 0.38, 95% CI 0.09-0.66; P=.009), and symbol search (SMD 1.18, 95% CI 0.43-1.93, P=.002).

CONCLUSIONS

Web-based telerehabilitation therapy improved motor function, physical activity level, lower limb strength, letter-number sequencing, attention, and symbol search, which improved the quality of life in children and adolescents with brain injury. Web-based telerehabilitation programs provide great convenience for children and adolescents with ABI who need long-term treatment and allow them to exercise at home for rehabilitation training. The widespread implementation of remote interventions also provides children and adolescents in remote areas with better access to rehabilitation services. This review provides evidence for the effectiveness of web-based telerehabilitation therapy, but there was heterogeneity in some of the results because of different disease types and intervention programs. Future studies can expand the sample size according to disease type and increase follow-up time according to different exercise prescriptions to further refine the long-term effects of this intervention on various functions of children and adolescents with ABI.

TRIAL REGISTRATION

PROSPERO CRD42023421917; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=421917.

Nurse Practitioners in a Canadian Pediatric Rehabilitation Hospital: A Description of Roles and Scope of Practice

The nurse practitioner role is strongly suited to meet the needs of children with complex developmental conditions in pediatric rehabilitation settings as they have a unique combination of clinical expertise. To meet the increasing demands in a large Canadian pediatric rehabilitation hospital, the NP role was implemented in several clinical program settings to improve access to care. This paper describes the contributions of NPs to nine specialized inpatient and outpatient programs in NP-led, collaborative NP and physician or interagency care team models of practice. The initial challenges of role implementation and implications for NP practice, research and leadership are discussed.

Development of expert consensus to guide physical rehabilitation in children and adolescents with acquired brain injury during the subacute phase

OBJECTIVE

To develop consensus among experts to guide physical rehabilitation in children and adolescents with acquired brain injury during the subacute phase.

DESIGN

International Delphi study.

METHODS

A 3-round online Delphi study was conducted with 11 international experts in rehabilitation for children and adolescents with acquired brain injury. The first round consisted of open-ended questions; the second and third round consisted of ranking 139 statements on a 5-point Likert scale.

RESULTS

The panel reached consensus on 116/139 statements. Consensus was reached on the importance of age, pre-injury developmental stage and the clinical presentation of the child when determining content and focus of physical rehabilitation. In addition, consensus was reached on the importance of participation-focused interventions, and involvement of family members in goal-setting and therapeutic activities. Although dosage was deemed very important, no consensus was reached for determination of dose-response variables to suit and influence the child's needs.

CONCLUSION

This study provides a framework for clinicians to design physical rehabilitation interventions in children with acquired brain injury in the sub-acute recovery phase. The promotion of physical activity in meaningful contexts and involvement of family members are considered as important components to optimize recovery.

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.

Circus Activities as a Health Intervention for Children, Youth, and Adolescents: A Scoping Review

Circus activities are emerging as an engaging and unique health intervention. This scoping review summarises the evidence on this topic for children and young people aged up to 24 years to map (a) participant characteristics, (b) intervention characteristics, (c) health and wellbeing outcomes, and (d) to identify evidence gaps. Using scoping review methodology, a systematic search of five databases and Google Scholar was conducted up to August 2022 for peer-reviewed and grey literature. Fifty-seven of 897 sources of evidence were included (42 unique interventions). Most interventions were undertaken with school-aged participants; however, four studies included participants with age ranges over 15 years. Interventions targeted both general populations and those with defined biopsychosocial challenges (e.g., cerebral palsy, mental illness, or homelessness). Most interventions utilised three or more circus disciplines and were undertaken in naturalistic leisure settings. Dosage could be calculated for 15 of the 42 interventions (range one-96 h). Improvements in physical and/or social-emotional outcomes were reported for all studies. There is emerging evidence of positive health outcomes resulting from circus activities used in general populations and those with defined biopsychosocial challenges. Future research should focus on detailed reporting of intervention elements and increasing the evidence base in preschool-aged children and within populations with the greatest need.

Ableism among children and youth with acquired brain injury and their caregivers: a systematic review

PURPOSE

Children and youth with acquired brain injury (ABI) experience persistent discrimination and ableism. The purpose of this systematic review was to understand the experiences and impact of ableism among children and youth with ABI.

METHOD

Six international databases were systematically searched for articles from 2002-2022. Studies were screened independently by four researchers who performed the data extraction. Study quality was appraised using the Standard quality assessment criteria for evaluating primary research.

RESULTS

Of the 2085 studies identified in the search, 15 met the inclusion criteria, which involved 1442 children and youth with brain injuries or caregivers representing them. Studies in the review showed the following key trends: (1) incidence of ableism among children and youth with ABI; (2) experiences of ableism at the individual and institutional levels, (3) impact of ableism (i.e., mental health, social relationships, quality of life) and (4) coping strategies (i.e., resources, supports).

CONCLUSIONS

Our findings reveal the alarming incidence of ableism among youth with ABI. Therefore, there is a critical need for more research to explore youth's lived experiences of ableism, especially from their perspectives along with the co-development of solutions to help enhance their social inclusion and well-being.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.