Evaluating service delivery for speech and swallowing problems following paediatric brain injury: an international survey

Clinicians' perspectives on motor learning strategy selection and application in occupational therapy and speech-language pathology interventions for children with acquired brain injury

PURPOSE

Explore occupational therapists' (OTs) and speech language pathologists' (SLPs) process of selecting and applying motor learning strategies (MLS) in their interventions for children with acquired brain injury (ABI), and identify similarities and differences between OTs and SLPs in MLS selection and application.

METHODS

This qualitative descriptive study involved individual semi-structured interviews with OTs and SLPs from the ABI program at Holland Bloorview Kids Rehabilitation Hospital (Toronto, Canada). Interviews were analyzed using thematic analysis. A modified constant comparison method permitted comparison within and between professions.

RESULTS

Four OTs and three SLPs were interviewed. Four themes were developed: aligning MLS application with the child's cognitive ability, using MLS to promote success within a single session, adjusting MLS across treatment sessions, and promoting generalization and transfer of motor skills beyond the therapy session. MLS application was predominately based on child-specific factors with task-specific considerations. OTs and SLPs used similar clinical reasoning processes for selecting and applying MLS.

CONCLUSIONS

This study provides a greater understanding of OTs' and SLPs' clinical reasoning process when applying MLS in pediatric ABI interventions. The similarities in MLS selection and application between disciplines suggest that an interprofessional approach to MLS is suitable for pediatric ABI rehabilitation.

The Entity of Cerebellar Mutism Syndrome: A Narrative Review Centered on the Etiology, Diagnostics, Prevention, and Therapeutic Options

Cerebellar mutism syndrome (CMS), also known as posterior fossa syndrome, is an entity that entails a constellation of signs and symptoms which are recorded in a limited number of pediatric patients who have been operated on mainly for tumors involving the posterior cranial fossa, and more precisely, the region of the vermis. Medulloblastoma seems to constitute the most commonly recognized pathological substrate, associated with this entity. The most prevalent constituents of this syndrome are noted to be a, often transient, although protracted, language impairment, emotional lability, along with cerebellar and brainstem dysfunction. Apart from that, a definite proportion of involved individuals are affected by irreversible neurological defects and long-lasting neurocognitive impairment. A bulk of literature and evidence based on clinical trials exist, which reflect the continuous effort of the scientific community to highlight all perspectives of this complex phenomenon. There are several circumstances that intervene in our effort to delineate the divergent parameters that constitute the spectrum of this syndrome. In summary, this is implicated by the fact that inconsistent nomenclature, poorly defined diagnostic criteria, and uncertainty regarding risk factors and etiology are all constituents of a non-well-investigated syndrome. Currently, a preliminary consensus exists about the identification of a group of diagnostic prerequisites that are managed as sine qua non, in our aim to document the diagnosis of CMS. These include language impairment and emotional lability, as proposed by the international Board of the Posterior Fossa Society in their consensus statement. It is common concept that midline tumor location, diagnosis of medulloblastoma, younger age at diagnosis, and preoperatively established language impairment should be accepted as the most determinant predisposing conditions for the establishment of this syndrome. A well-recognized pathophysiological explanation of CMS includes disruption of the cerebellar outflow tracts, the cerebellar nuclei, and their efferent projections through the superior cerebellar peduncle. Despite the relative advancement that is recorded regarding the diagnostic section of this disease, no corresponding encouraging results are reported, regarding the available treatment options. On the contrary, it is mainly targeted toward the symptomatic relief of the affected individuals. The basic tenet of our review is centered on the presentation of a report that is dedicated to the definition of CMS etiology, diagnosis, risk factors, clinical presentation, and clinical management. Apart from that, an effort is made that attempts to elucidate the paramount priorities of the scientific forum, which are directed toward the expansion our knowledge in the era of diagnostics, prevention, and therapeutic options for patients suffering from CM, or who are at risk for development of this syndrome.

Using therapy outcome measures to identify the speech and language therapy needs of children and young people with severe acquired brain injury

Background/Aims

Children and young people often require speech and language therapy input following severe acquired brain injury. However, there is limited understanding of the impact of post-acute neurorehabilitation on children and young people's communication and swallowing, and how to measure this. The aim of this study was to evaluate the initial and ongoing speech and language therapy needs of children and young people in one specialist paediatric neurorehabilitation centre, and to determine the usefulness of therapy outcome measures for this population.

Methods

A retrospective review was performed of routinely collected data, including therapy outcome measures for children and young people admitted to the centre. Descriptive analysis was completed for all therapy outcome measures data, and statistical significance of change during rehabilitation was determined on those with sufficient data using Wilcoxon signed-rank tests.

Results

A total of 165 records of children and young people aged between 1 and 17 years were reviewed. The average length of stay at the centre was 19.7 weeks. The most prevalent therapy outcome measures were cognition and dysphagia. Highly significant differences were found between admission and discharge in all therapy outcome measures scores, including participation (Wilcoxon Z=-9.523, P<0.001) and wellbeing (Wilcoxon Z=-7.656, P<0.001). Median discharge scores did not exceed 4 (from a maximum of 5) for any scales.

Conclusions

Therapy outcome measures were able to capture the complex profiles of these children and young people and could measure changes during post-acute neurorehabilitation. Children and young people presented with a range of speech and language therapy needs following severe acquired brain injury. They made significant improvements in impairment, activity, participation and wellbeing scales during rehabilitation. Children and young people left with ongoing speech and language therapy needs in all areas, which require input from community services.

Occurrence of speech-language disorders in the acute phase following pediatric acquired brain injury: results from the Ghent University Hospital

AIMS

This study investigated the occurrence of speech-language disorders during the acute phase of recovery in children with acquired brain injury (ABI) with an age between 0 and 16 years.

METHODS

A retrospective chart analysis was performed including 228 children (n = 118 boys, n = 110 girls) who consecutively presented with ABI over a 10-year period (2006-2016) at the children's rehabilitation center at Ghent University Hospital. Descriptive statistical analyses were applied.

RESULTS

71.1% (162/228) of the children who were admitted to the rehabilitation center presented with a speech-language disorder. Within this sample (n = 162), results demonstrated the occurrence of acquired disorders in language (48.9%), speech (35.1%), learning (33.3%), swallowing (21.5%), and early communicative functions (17.4%). The proportion of children presenting with disturbances in early communicative functions differed by ABI cause. More than half (10/18, 58.8%) of the children who presented with ABI following inflammatory processes demonstrated disorders in early communicative functions.

CONCLUSIONS

Especially in young children who present with inflammatory processes as the ABI cause, speech-language pathologists (SLPs) must be aware of disorders in early speech-language development. The present findings allow the SLP to appropriately plan research, education, and clinical management.

The Cognitive-Communication Checklist for Acquired Brain Injury: A Means of Identifying, Recording, and Tracking Communication Impairments

Purpose The communication service needs of individuals with acquired brain injuries (ABIs) are frequently overlooked, leading to delays, denials, or premature discharge from communication interventions. This is particularly true for those with subtle cognitive-communication deficits, which may not be apparent until sufficiently challenged at work, in school, or in the community. The purpose of this study was to evaluate a referral tool that could promote understanding of the broad range of communication impairments that occur following ABI and lead to improved identification and referral. Method This study evaluated the Cognitive-Communication Checklist for Acquired Brain Injury (CCCABI) through a survey. The CCCABI is a referral tool that summarizes 45 communication difficulties in 10 areas of cognitive-communication functioning. One hundred sixteen speech-language pathologists, 34 multidisciplinary referral sources, and 41 individuals with lived experience of brain injury were surveyed to evaluate the utility of this referral tool. Results The need for such a referral tool was endorsed by 96% of speech-language pathology respondents, 91% of multidisciplinary respondents, and 100% of respondents with lived experience of brain injury. Responses supported the CCCABI as a clear, comprehensive, and accessible tool for education and identification of the communication impairments that can occur after ABI. Conclusion The CCCABI is a means of increasing understanding of communication service needs following ABI in a manner that is accessible to individuals, families, program designers, funding sources, administrators, and multidisciplinary referral sources.

Acute and Long-Term Services for Elementary and Middle School Children With Early Childhood Brain Injury

Purpose The purpose of this study was to investigate the rates of referral to and receipt of acute and long-term services and identify factors that could impact these rates for children who experienced an acquired brain injury (ABI) during early childhood who are now in elementary and middle school. Method This was a retrospective chart review and prospective phone survey of 29 caregivers of children with ABIs. Results Acutely, two thirds of this sample received hospital-based rehabilitation services, but only 44.8% of families reported receiving ABI-specific education or a referral to educational or rehabilitation services at the time of discharge. At an average of 8.5 years postinjury, children in this sample were largely reported to be performing positively in school. While special education rates did not change significantly over time, 20.7% of the sample reported having unmet educational needs. Additionally, service receipt decreased over time. Various injury and educational factors influenced rates of long-term special education and service receipt. Conclusions This study contributes to the emerging literature focusing on long-term outcomes of children with ABI. The results reinforce that children who experience an ABI in early childhood are unlikely to receive ABI-specific education or referrals to educational and rehabilitation services during their acute-care stay and, in the chronic stages of recovery, present with educational and therapy needs that can go unmet. To improve long-term service access for children who experience an early ABI, pathways need to be established within the acute-care setting for education and referrals that connect the child and family to treatment within early intervention and educational systems. Maintaining these pathways long term, particularly for potential social-behavioral and cognitive-communication concerns, could increase access to appropriate services and, thus, decrease unmet needs for children with ABI.

Post-operative cerebellar mutism syndrome: rehabilitation issues

INTRODUCTION

Tumors of the cerebellum are the most common brain tumors in children. Modern treatment and aggressive surgery have improved the overall survival. Consequently, growing numbers of survivors are at high risk for developing adverse and long-term neurological deficits including deficits of cognition, behavior, speech, and language. Post-operative cerebellar mutism syndrome (pCMS) is a well-known and frequently occurring complication of cerebellar tumor surgery in children. In the acute stage, children with pCMS may show deterioration of cerebellar motor function as well as pyramidal and cranial neuropathies. Most debilitating is the mutism or the severe reduction of speech and a range of neurobehavioral symptoms that may occur. In the long term, children that recover from pCMS continue to have more motor, behavioral, and cognitive problems than children who did not develop pCMS after cerebellar tumor surgery. The severity of these long-term sequelae seems to be related to the length of the mute phase.

AIM OF THIS NARRATIVE REVIEW

The impact of pCMS on patients and families cannot be overstated. This contribution aims to discuss the present knowledge on the natural course, recovery, and rehabilitation of children with pCMS. We suggest future priorities in developing rehabilitation programs in order to improve the long-term quality of life and participation of children after cerebellar tumor surgery and after pCMS in particular.

Speech-Language Pathologists' Comfort Providing Intervention to Children With Traumatic Brain Injury: Results From a National Survey

Purpose This exploratory study examined speech-language pathologists' (SLPs) clinical experience and work environment characteristics impacting comfort with providing intervention to children with traumatic brain injury (TBI). Method This study included 162 SLPs who responded to a national survey about their comfort providing intervention to children with TBI, clinical experience (i.e., years of experience treating children with TBI, TBI preprofessional training and professional development, and licensure/credentialing), and work environment (i.e., work setting, caseload size, geographic location). Results Findings from latent class analysis revealed 3 distinct groups of SLPs based on their comfort with providing services to children with TBI: those with low comfort, moderate comfort, and high comfort. Further analyses revealed statistically significant differences across the 3 groups in the areas of years of experience treating children with TBI, professional development, work setting, TBI caseload size, and geographic location. Conclusions Our findings reveal that most SLPs feel comfortable providing intervention to children with TBI; however, differences in characteristics across groups suggest that specific steps can be taken to ensure increased comfort for all SLPs working with this population. Practicing SLPs may increase their level of comfort through professional development and hands-on, mentored experience with TBI. Efforts such as these may influence the quality of service provision and expand the population of SLPs who feel comfortable treating children with TBI. Future research is needed to further examine how comfort and SLP characteristics directly impact the quality of speech and language intervention and long-term outcomes of children with TBI.

Development of a Chronic Care Model for Neurological Conditions (CCM-NC)

Background

Persons with neurological conditions and their families face a number of challenges with the provision of health and community-based services. The purpose of this study was to understand the existing health and community service needs and gaps in care and to use this information to develop a model to specify factors and processes that may improve the quality of care and health and well-being for persons with neurological conditions.

Methods

We conducted semi-structured interviews with health care professionals, community-based non-health care professionals working with individuals with neurological conditions, and policy makers –from the Ministries of Health, Community and Social Services, Transportation and Education– across Canada. We used a purposive sampling and snowballing approach to obtain maximum variation across professions, sector and geography (provinces and territories, rural and urban). Data analysis was an iterative, constant comparative process involving descriptive and interpretive analyses and was initially guided by the components of the Expanded Chronic Care Model.

Results

A total of 180 individuals completed the interviews: 39% (n = 70) health care professionals, 47% (n = 85) community-based non-health care professionals, and 14% (n = 25) policy makers. Based on the data we developed the Chronic Care Model for Neurological Conditions (CCM-NC). The major needs/gaps are represented by the following themes: acceptance and openness to neurological conditions, evidence informed policy, investments and funding, supported transitions, caregiver support, and life enhancing resources (education, employment, housing and transportation), knowledge and awareness of neurological conditions and availability and access to health services. The model maintains that intersectoral collaboration across the health system, community and policy components is needed. It recognizes that attitudes, policies, enhanced community integration and health system changes are needed to develop activated patients and families, proactive service delivery teams, a person-centred health system and healthy public policy for persons with neurological conditions.

Conclusion

The CCM-NC will generate debate and discussion about the actions needed in each of the model components to enable people with neurological conditions to sustain healthier lives. Next steps include validating the model with persons with neurological conditions, in and outside of the Canadian context and developing and evaluating interventions to test the model.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-409) contains supplementary material, which is available to authorized users.

Assessment practices of speech-language pathologists for cognitive communication disorders following traumatic brain injury in adults: an international survey

PRIMARY OBJECTIVE

This study's objective was to examine the current assessment practices of SLPs working with adults with acquired cognitive communication impairments following a TBI.

METHODS AND PROCEDURES

Two hundred and sixty-five SLPs from the UK, the US, Canada, Australia and New Zealand responded to the online survey stating the areas of communication frequently assessed and the assessment tools they use.

MAIN OUTCOMES AND RESULTS

SLPs reported that they routinely assessed functional communication (78.8%), whereas domains such as discourse were routinely assessed by less than half of the group (44.3%). Clinicians used aphasia and cognitive communication/high level language tools and tools assessing functional performance, discourse, pragmatic skills or informal assessments were used by less than 10% of the group. The country and setting of service delivery influenced choice of assessment tools used in clinical practice.

CONCLUSIONS

These findings have implications for training of SLPs in a more diverse range of assessment tools for this clinical group. The findings raise questions regarding the statistical validity and reliability of assessments currently used in clinical practice. It highlights the need for further research into how SLPs can be supported in translating current evidence about the use of assessment tools into clinical practice.