Top Papers in Pediatric Rehabilitation Amy Houtrow, MD, PhD, MPH Molly Fuentes, MD Matt McLaughlin, MD Session 414 Friday October 2, 2015 7-8:30 am

Top Papers in Pediatric Rehabilitation

Amy Houtrow, MD, PhD, MPHMolly Fuentes, MD

Matt McLaughlin, MD

Session 414Friday October 2, 2015

7-8:30 am

Disclosures

• We have no relevant financial disclosures

Session Outline

• Selection Schema• Review of Evidence Based Medicine Principles• Article Presentations (free articles are

attached as part of the handouts, other articles have a link)– Houtrow– Fuentes – McLaughlin

Evidence Based Medicine

• “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic search.” (David Sackett 2001)

• What is the level of evidence?• Evaluate the validity and applicability of evidence to the

circumstances• Understand that lack of evidence for treatment is not

the same as saying a treatment is ineffective

Asking a Good Clinical Question

• PICO!!– Patient or Problem– Intervention, prognostic factor or exposure– Comparison– Outcomes

• Example: in pediatric patients with concussion is strict rest better than early return to activities in getting children back to school within a week of injury?

Hierarchy of Studies

Meta-Analysis

Systematic Review

Randomized Controlled Trial

Cohort Study

Case Control Study

Case Series/Report

Description of Study Types

• Case series/report: no statistical validity, no comparison of outcomes.

• Case control: starts with subjects with the outcome and looks back to possible exposures. Looks at associations.

• Cohort study: starts with a large population with exposure and follows over time for the development of an outcome.

• Randomized controlled trial: assigns the exposure randomly to subjects and follows them for the outcome

• Systematic review: focuses on a clinical topic to answer a question. Reviews the literature for studies with good methodology. Studies identified, reviewed and assessed based on predetermined criteria.

• Meta-analysis: statistical approach to report multiple sound studies as one large study

Other Study Types

• Qualitative research: to describe, explore and explain phenomenon.

• Cross-sectional study: describes relationships at one point in time across a population (does not prove causality)

• Retrospective cohort: usually done from a database to look back at exposed group for the development of the outcome

Levels of Evidence• AAPMR uses Wright, Swiontkowski and Heckman’s

table (Journal of Bone and Joint Surgery 2003; 85(1).)

Levels of Evidence Continued

AACPDM Levels of Evidence

Selection Process

• Search Limited to January 2014-June 2015

• Keyword Pubmed searches limited to children, English and timeframe (disability, rehabilitation, brain injury, concussion, cerebral palsy, spasticity, spina bifida, spinal cord injury, brachial plexus, limb deficiency, amputation, transition, chronic pain, burns, quality improvement)

• Table of Contents searched (Pediatrics, JAMA Pediatrics, Journal of Pediatrics, Academic Pediatrics, Archives of PM&R, PM&R, Journal of PRM, Developmental Medicine and Child Neurology, Developmental Neurorehabilitation, Neurology, Muscle and Nerve, Journal of Pediatric Orthopedics, Pediatric Physical Therapy, Health Affairs, Medical Care, BMJ Quality and Safety)

Selection Process Continued

• Titles and then abstracts were reviewed by each of the presenters based on their assigned searches

• Full articles were read by each of the presenters based on their culling of abstracts

• 16 ‘finalists’ (one of which was identified by 2 reviewers) were reviewed by all 3 presenters who then voted

• Consensus was achieved via phone conference

Selected Articles• Hechler T et al. Systematic review of intensive interdisciplinary pain treatment of

children with chronic pain. Pediatrics 2015; 136(1):115-27. http://pediatrics.aappublications.org/content/136/1/115.long

• Choong K et al. Acute rehabilitation practices in critically ill children: a multicenter study. Pediatric Critical Care Medicine 2014; 15(6): e270-9. http://journals.lww.com/pccmjournal/pages/articleviewer.aspx?year=2014&issue=07000&article=00026&type=abstract

• Schechter MS et al. Sociodemographic attributes and spina bifida outcomes. Pediatrics 2015; 135(4):e957-64. http://pediatrics.aappublications.org/content/135/4/e957.long

• Ozturk OD et al. Disparities in health care utilization by race among teenagers and young adults with muscular dystrophy. Medical Care 2014; 52(10) supp 3: S32-39. http://journals.lww.com/lww-medicalcare/pages/articleviewer.aspx?year=2014&issue=10001&article=00008&type=abstract

• Greene NH et al. Variation in pediatric traumatic brain injury outcomes in the United States. Archives of Physical Medicine and Rehabilitation 2014. 95(6):1148-55.* http://www.sciencedirect.com/science/article/pii/S0003999314001804

http://pediatrics.aappublications.org/content/136/1/115.long

http://journals.lww.com/pccmjournal/pages/articleviewer.aspx?year=2014&issue=07000&article=00026&type=abstract


http://pediatrics.aappublications.org/content/135/4/e957.long

http://journals.lww.com/lww-medicalcare/pages/articleviewer.aspx?year=2014&issue=10001&article=00008&type=abstract

http://journals.lww.com/lww-medicalcare/pages/articleviewer.aspx?year=2014&issue=10001&article=00008&type=abstract

http://www.sciencedirect.com/science/article/pii/S0003999314001804

Selected Articles• Kurowski BG et al. Long-term benefits of an early online problem-solving

intervention for executive dysfunction after traumatic brain injury in children: a randomized controlled trial. JAMA Pediatrics 2014; 168(6):523-31.* http://archpedi.jamanetwork.com/article.aspx?articleid=1863908

• Thomas DG et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015; 135(2): 213-23. http://www.sciencedirect.com/science/article/pii/S0003999314001804

• McLaughlin SE et al. Transition of adolescents with chronic health conditions to adult primary care: factors associated with physician acceptance. Journal of Pediatric Rehabilitation Medicine 2015; 7(1): 63-70. http://content.iospress.com/articles/journal-of-pediatric-rehabilitation-medicine/prm00275

• Copeland L et al. Botulinum Toxin A for nonambulatory children with cerebral palsy: a double blind randomized controlled trial. Journal of Pediatrics 2014; 165(1): 140-6. http://www.sciencedirect.com/science/article/pii/S002234761400078X

• Chen Y et al. Effect of virtual reality on upper extremity function in children with cerebral palsy: a meta-analysis. Pediatric Physical Therapy 2014; 26(3): 289-300. http://journals.lww.com/pedpt/pages/articleviewer.aspx?year=2014&issue=26030&article=00004&type=abstract

http://archpedi.jamanetwork.com/article.aspx?articleid=1863908

http://www.sciencedirect.com/science/article/pii/S0003999314001804

http://content.iospress.com/articles/journal-of-pediatric-rehabilitation-medicine/prm00275

http://content.iospress.com/articles/journal-of-pediatric-rehabilitation-medicine/prm00275

http://www.sciencedirect.com/science/article/pii/S002234761400078X

http://journals.lww.com/pedpt/pages/articleviewer.aspx?year=2014&issue=26030&article=00004&type=abstract

http://journals.lww.com/pedpt/pages/articleviewer.aspx?year=2014&issue=26030&article=00004&type=abstract

• http://pediatrics.aappublications.org/content/136/1/115.long

• Pediatrics 2015; 136:1 115-127; published ahead of print June 22 , 2015, doi:10.1542/peds.2014-3319





Background• Childhood chronic pain costs $19.5 billion

annually• Collaboration between multiple disciplines is

preferred• Intensive interdisciplinary pain treatment (IIPT) – At least 3 disciplines– Day or inpatient program– Goal to improve function (including participation)– Usually up to 8 hours of treatment a day for 1-3

weeks

Objectives

• Describe the nature of IIPT• Conduct a meta-analysis for– Pain intensity reduction– Disability– School Absences– Anxiety– Depressive symptoms

Methods• Search for studies– Interdisciplinary– Day or inpatient– Target of children– Chronic pain that

interfered with function– In English– At least 10 subjects

• Pooled estimates of effect

Results• Improvement in pain intensity from 4

treatment studies and 1 RCT 3 months later

Results• Improvement in functioning 3 months later

from 6 treatment studies and 1 RCT

Results• Moderate to large effects in school functioning

improvements

• Moderate to large effects in anxiety improvement

• Small effect in depressive symptoms improvement

Discussion

• Noted lack of RCTs• Stronger improvements in functioning versus

decreasing pain• Collaborative treatment toward improving

function can be achieved and maintained despite ongoing pain

• More research necessary

Impact on Clinical Practice

• Highlights the value of the interdisciplinary team and the ‘rehab approach’

• Demonstration of efficacy which may help with insurance denials

• Encourage rehab involvement on the chronic pain team

• When treating children, highlight the outcome of improved functioning






Background and Objective

• The adult literature supports early mobilization in the ICU setting (safe, effective, improves outcomes)

• Little data about children

• Evaluate rehabilitation in the pediatric critical care unit (PCCU) setting – Frequency of early mobilization– Barriers to early mobilization

Methods

• Retrospective cohort study of 6 regional PCCUs • Children 0-17 years with greater than 24hr

PCCU stay in 2011• Outcome measures: type, timing and

frequency of therapy services – PT (includes chest physiotherapy)– OT– SLP

• Early mobilization defined as mobility therapy performed within 48 hours of PCCU admission

Results –Patient Population

• 916 patients admitted to the 6 PCCUs, 600 cases included

• 56% male• Mean age 4.9 years• 64% medical diagnoses• 56% re-existing chronic conditions• 43% had abnormal baseline functioning

Results –Therapy Orders • 37% had some therapy ordered– Half for chest PT

• 29% PT – Request made 1 day after admission– IQR 0-3 days

• 4.8% OT– Request made 2 days after admission– IQR 0-6 days

• 1.5% SLP – Request made 6 days after admission– IQR 1-15 days

Results- Early Mobilization

• Mobilization interventions of 26.3% of patients• Early mobilization for 9.5% of patients– No difference in adverse events (hemodynamic

instability, respiratory decompensation, ET tube dislodgement)

• Older age, admission during the winter, neuromuscular blockade and sedative infusions were predictors of getting mobility therapy in the PCCU– Did not evaluate time in PCCU as a predictor

Results -Barriers

• Unknown• No orders• Too sick• Too well• Family refusal• Patient unavailable

Discussion

• Mobilization and early mobilization has not been a priority in PCCUs

• Most of the therapy provided is chest PT • Access to therapists may be an issue (not all

PCCUs have dedicated therapists)• Early mobilization appears safe• Need studies to assess functional outcomes

Impact on Clinical Practice

• Early identification of children who would benefit from therapy services in the PICU– Early consultation– Increased presence in the PICU

• Pediatrics 2015; 135:4 e957-e964; published ahead of print March 16, 2015, doi:10.1542/peds.2014-2576

Schechter MS et al. Sociodemographic attributes and spina bifida outcomes. Pediatrics 2015; 135(4):e957-64. http://pediatrics.aappublications.org/ content/135/4/e957.long




Background and Objectives

• Manifestations of spina bifida vary greatly• Intrinsic disease factors do not explain all of

the variations in functioning

• Objective: determine the impact of sociodemographic and intrinsic lesion characteristics on functional outcomes for children with spina bifida

Methods

• National Spina Bifida Patient Registry (NSBPR)• 2009-2012 on children <22 years• Myelomeningocele versus other (lipo, meningocele,

fatty filum)• Lesion level– Thoracic (no lower extremity movement)– High lumbar –hip flexion– Mid lumbar –knee extension– Low lumbar – dorsiflexion– Sacral –plantarflexion

• Age, gender, race/ethnicity, insurance (for SES)

Methods -Outcomes

• Urinary continence – Dry during the day

• Stool continence– No involuntary stool leakage

• Ambulation status– Community ambulator versus all others– Household ambulator– Therapeutic ambulator– Non-ambulator

• Pressure ulcers

Results• 2054 children from 10 centers

Functional Level-Thoracic-High lumbar-Mid lumbar-Low lumbar-Sacral

14.1%9.8%26.8%18.5%30.9%

Spina bifida type-Myelo 80.7%Bowel continence (age 5+) 42.6%Bladder continence (age 5+) 38%Ambulatory Status -Community 55.3%

Results-Predictors of Bowel Continence: older age, female, non blacks, private insurance,

sacral lesion, non-MM type

Results –Predictors of Bladder Continence: older age, whites versus blacks, private insurance, sacral lesion level, non-MM

Results- Predictors of Community Ambulation: middle childhood, girls, private insurance, low

lumbar and sacral lesions, non-MM

Results –Predictors of Pressure Ulcers: older age, higher lesion level

Discussion

• Variations in outcomes that cannot be explained by intrinsic condition factors– Center level differences warrant additional

research• Did not examine provider factors• Limitations in the data but most robust

dataset to date

Implications for Clinical Practice

• Develop strategies for identifying risk• Recognize the low levels of success for

continence• Evaluate why your clinic does things the way

that they do – What is this the evidence base?

Disparities in Health Care Utilization: Background

• Health care utilization expected to be high among people with muscular dystrophy

• African Americans with muscular dystrophy have a life expectancy 10 to 12 years shorter than Whites with muscular dystrophy

• Questionable adequacy of Medicaid for coverage of the multidisciplinary approach needed for management of muscular dystrophy

Kenneson et al. Widening gap in age at muscular-dystrophy associated death between Blacks and Whites. Neurology. 2010;75:982-989Mejia et al. Dying young: eliminating racial disparities in neuromuscular disease outcomes. Neurology. 2010;75:948-949

Disparities in Health Care Utilization: Objective

• Use South Carolina Medicaid and other administrative data to determine annual health care utilization patterns for people with muscular dystrophy by race

Disparities in Health Care Utilization : Methods

Inclusion criteria• In South Carolina Medicaid records– 2000 to 2010– Persons age 15-24 – Muscular dystrophy (ICD-9 code 359.0 and 359.1)

Exclusion criteria• Myotonic dystrophy because diagnosed older

than study population


Measures• Counts of health care utilization– Total and specific health encounters• Inpatient, Primary Care, ER, Therapy, Specialist, Surgery,

Developmental Rehabilitation/Intellectual Disability, Home Health/Community Long-Term Care

– Encounters not necessarily related to muscular dystrophy

• Race : Black, White, Other• Age group: Teenagers (15-18 yrs) and Young

Adult (19-24 yrs)


Measures• Entry into 12th grade (yes/no)• Supplemental Nutrition Assistance Program

(food stamps) (yes/no)• Urban county (yes if county of residence was

“mostly urban”)


Analysis• Reported annual mean total encounters and

mean encounters by category for each of the 3 racial groups

• T-tests to compare differences in mean between Black-White, Black-Other and Other-White


Analysis• Generalized estimating equation models to

assess comparisons by encounter type– Adjusts for repeated observations from same

individual during the study period• Independent variables in model– SNAP receipt, 12th grade enrollment, urban county– Interested in transition period, so entered

interaction of race with teenager/young adult

Disparities in Health Care Utilization : Results

• 1011 people with muscular dystrophy• Average age 19• 81% live in urban counties• 51% White, 35% Black, 14% Other


Age 15-18All encounters, annual avg• Blacks 24.28, Whites 72.36

Specialists, annual avg• Blacks 1.22, Whites 1.79

Developmental Rehab, annual avg• Blacks 4.13, Whites 10.96

Home Health/CLTC, annual avg• Blacks 1.90, Whites 40.39


Age 19-24All encounters, annual avg• Blacks 34.05, Whites 99.52

Emergency Room• Blacks 0.99, Whites 0.56

Specialists• Blacks 2.83, Whites 1.29

Therapy• Blacks 0.04, Whites 1.02

Home Health/CLTC• Blacks 12.56, Whites 76.54


After adjusting for socioeconomic variables:• Black teens 63% less likely to use care as White

teens• 56% less likely to use Developmental

Rehabilitation• 94% less likely to use Home Health/CLTC

• Black young adults 2x more likely to use ER, 3x more likely to have inpatient encounter

Disparities in Health Care Utilization : Conclusions

• Racial disparities in health care utilization among teens and young adults with muscular dystrophy with the same health care benefits

• Utilization disparities widen during transition from pediatric to adult care

• What could contribute to disparities?• Resource awareness• Health knowledge• Other access barriers (transportation)• Cultural preferences

Disparities in Health Care Utilization : Clinical correlation

Ask…• What services are being used• If there are services they are aware of but not

using or have questions about• What makes it possible for you (or what makes

it hard for you) to access a service

Help make a management plan for symptoms• Call PCP (or Rehab Medicine or Pulm) for…• Go to ER for…

Variations in TBI Outcomes: Background

• TBI is a leading cause of acquired disability• Rehabilitation can lead to improved functional

outcomes• Many children hospitalized for TBI need

further care after discharge• Regional variations in management of other

pediatric conditions

Variations in TBI Outcomes: Objective

• To determine if there was significant state-to-state variation in discharge disposition and outcomes among children hospitalized with TBI in the United States

Variations in TBI Outcomes: Methods

• Retrospective cohort study• Data source – Healthcare Cost and Utilization

Project (HCUP) State Inpatient Database (SID)– Four years of data: 2001 (13 states), 2004 (18

states), 2007 (16 states), 2010 (19 states)– All patients ≤ 19 years old hospitalized with TBI• ICD-9 codes defined as TBI by the CDC, with the

exception of excluding diagnostic codes limited to scalp injury


• Exclusion criteria:– ICD-9 codes referring to scalp injury only– Missing age (18 patients) or insurance status (241

patients)– Discharged to another acute care hospital to avoid

double count


Variables• State – 4 states excluded because no data on inpatient

rehabilitation• Discharge disposition

– Home, SNF, Inpatient Rehabilitation, Psych Facility– Death/Hospice– Another Acute Care Hospital

• Age (0-4, 5-9, 10-14, 15-19 years old)• Insurance status (Government, Private, Uninsured)• Injury severity

– Abbreviated Injury Scale score (minor, moderate, serious, severe, critical, unsurvivable)


• Primary outcome of interest: Discharge to inpatient rehabilitation among those discharged alive

• [Secondary outcome of interest: Inpatient mortality] – will not discuss because of time


Analysis• Multivariable Poisson regression with robust

standard error estimates, clustered by hospital• Relative risk of being discharged to inpatient

rehabilitation• Estimate number of children who could have

been discharged to rehab if all states had same “risk” of rehab as referent state

Variations in TBI Outcomes: ResultsCharacteristic N=71,476 %

Female 23,237 32.5

Age group (y)

0-4 17,959 25.1

5-9 8,718 12.2

10-14 13,076 18.3

15-19 31,723 44.4

Variations in TBI Outcomes: ResultsN %

Characteristic N=71,476 %

TBI severity

Minor 7,044 9.9

Moderate 27,226 38.1

Serious 24,905 34.8

Severe 11,150 15.6

Critical 1,121 1.6

Unsurvivable 30 0.04

Insurance

Private 41,197 57.6

Government 24,511 34.3

Uninsured 5,768 8.1

Variations in TBI Outcomes: ResultsCharacteristic N=71,476 %

Discharge Disposition

Home 64,799 90.7

Skilled Nursing 1,324 1.9

Inpatient Rehab 2,658 3.7

Psychiatric 72 0.1

Hospice 18 0.03

Died 2,605 3.6

Variations in TBI Outcomes: Results

Adjusted for age, injury severity, insurance status. *p<.05


Children without insurance were 68% less likely to receive inpatient rehabilitation. Uninsured children 32% more likely to die during hospitalization.


Estimate of additional children that could be discharged to rehab annually if all states performed at highest observed level• Among states in this dataset: 728

children• Extrapolated to United States

population: 1981 children

Variations in TBI Outcomes: Conclusions

There is significant variation between states in discharge to inpatient rehabilitation after pediatric TBI

What could drive these differences?

Variations in TBI Outcomes: Clinical Correlations

What could drive these differences?• Is rehab consulted similarly between states?• Differences in availability of appropriate

outpatient rehabilitation• Practice-dependent factors about candidacy

On-line Problem Solving in TBI: Background

• Neurocognitive and behavioral problems are common after TBI

• Executive dysfunction affects activity and participation in the home, school and community

• Barriers to accessing treatment (geography, transportation, etc.) contribute to unmet need


• Smaller RCTs of online family problem-solving therapy demonstrated feasibility, accessibility and benefit– Children/teens age 5-16 with TBI (n=40), reduced

behavior problems– Children/teens age 11-18 with TBI (n=35),

improved parent- and self-reported behavioral problems; improved self-rated executive dysfunction


• Counselor-Assisted Problem-Solving (CAPS) randomized controlled trial, n=132– At first assessment after this intervention, CAPS

associated with improved externalizing behavior and parent ratings of executive function compared to internet resources

– CAPS designed to prevent emergence of new problems, so expect to see greater benefit with time

See initial outcomes for CAPS in Kurowski et al. Online problem-solving therapy for executive dysfunction after child traumatic brain injury. Pediatrics. 2013;132(1):e158 -e166

On-line Problem Solving in TBI: Objective

• Extend earlier CAPS work and determine if improvements are maintained at 12 month follow-up

• Investigate if advantage of CAPS increases with time and as adolescents age

On-line Problem Solving in TBI: Methods

• Enrollment March 2007-January 2011 – 3 tertiary pediatric hospitals, 2 tertiary general medical centers– Cincinnati, Cleveland, Denver, Rochester

• Inclusion criteria– 12 to 17 years of age – Complicated mild to severe TBI.

• Complicated mild TBI: GCS score >12 with evidence of a neurologic insult on MRI or CT

• Moderate TBI: GCS 9 to 12• Severe TBI: GCS score <9.

– 1 to 6 months after initial injury


• Exclusion criteria– Non-blunt trauma– Primary language other than English– History of significant intellectual disability before injury– History of child abuse– Insufficient recovery to allow participation in the study– History of parental or child psychiatric hospitalization within

1 year before enrollment– Family residence in an area without high-speed Internet

access– Child residence outside the home (eg, detention facility)– Resided >3 hours from the study site.

Non-participants more likely to be non-white (24.4% v. 19.7%) and have less severe TBI

Non-completion:35% of those who dropped out were non-White, whereas only 14% of those who completed study were non-White

Non-completers had lower median income ($52.8 K v. $73.4 K)


• Multisite, evaluator-blinded RCT• Participants randomly assigned to CAPS or

Internet resource condition (IRC) group• Randomization stratified by sex and race

(White/non-White) • All families provided with new computer, web

camera, high-speed internet access• All families taught how to log on to the

website, access TBI resources


CAPS Intervention• 6 months, counselor-assisted, web-based, family-centered• Initial face-to-face session in the family’s home, psychologist evaluation

and technological instruction (CAPS web site and Skype for videoconference sessions)

• Sessions weekly then biweekly; 6 sessions over 3 months – Self-guided didactic content regarding problems-solving skills, video clips

modeling these skills, and exercises to practice the skills. – During videoconference sessions, therapist reviewed the online materials

and practiced problem-solving skills using problems that the family identified.

• 7th online session, parent-reported measure of family burden and a self-assessment of problem solving and communication.

• Based on results of the self-assessment, therapist planned individualized sessions over remaining months of CAPS– Up to four supplemental sessions provided to address additional

unresolved issues.


CAPS Intervention• 8 core sessions– Getting started– Staying positive– Problem solving– Getting organized and working with school– Self-management– Verbal and non-verbal communication– Controlling behavior and handling crises– Self-assessment of skills, identifying supplemental

sessions, planning for future


CAPS Intervention• Up to 4 supplemental sessions– Talking with your teenager– Taking care of you/marital communication/guilt, grief,

and caregiver– Social skills– After high school– Sibling issues– Pain management– Sleep session– Memory session


Internet Resource Condition, control arm• Receive a home page with links to online TBI

resources• Families asked to spend 1 or more hours

online per week accessing TBI information throughout the 6 month period

• No access to CAPS content


Assessments• Baseline, 6 months (immediately after end of

intervention), 12 months, 18 months• Occurred in participants’ homes• Background questionnaire– Injury severity– Combined estimate of SES • Mean z-scores for family income using median income

of census tract• Primary caregiver educational level


Assessments• Behavior Rating Inventory of Executive

Function – completed by primary caregiver– Global Executive Composite of the BRIEF is

primary outcome measure– Behavioral Regulation Index, secondary outcome– Metacognition Index, secondary outcome– Higher score = greater dysfunction


Intention to Treat Analysis• Chi square and two-sided unpaired t-tests to

compare demographic variables• Mixed-model analysis to evaluate group

differences in executive function– Dependent variable: Global Executive Composite– Independent variables: interaction term of age at

injury (younger 12-14 v. older 14-17) by treatment group (CAPS v. IRC) by time since baseline• Significance of this interaction term to evaluate whether

groups differed in rate of change over time

On-line Problem Solving in TBI: Results

Demographics, no significant differences• Gender: CAPS 68% male, IRC 64% male• Race: CAPS 80% White, IRC 82% White• GCS average: CAPS 10.08, IRC 10.02• Severe TBI: CAPS 39%, IRC 39%• Median income: CAPS $71.3K, IRC $66.3K• Time since injury (at baseline assessment):

CAPS and IRC both ~4 months


Baseline Metacognition Index scores higher (worse) in IRC group

Baseline scores

Baseline scores


• Mean number of sessions completed in CAPS group: 7.23 (SD 2.99, range 0-13)

• Parent- and self-reported time spent viewing information on the internet did not differ between CAPS and IRC


Among older adolescents (14-17 yrs), CAPS group had lower GEC ratings at 12 and 18 months, trend toward lower GEC at 6 months


Primary variable of interest (interaction term for Group x TSB x Age), trending toward significance


Interaction term (group x TSB x age) trending toward significance for secondary outcomes of BRI, MI

On-line Problem Solving in TBI: Conclusions

• Online family problem solving therapy delivered in the months after TBI has sustained benefits in parent-reported executive function– For older adolescents (age 14-17 years old) only

On-line Problem Solving in TBI: Take Home Message

• Older adolescents have sustained benefit in executive function from problem-solving intervention

• Is CAPS ready for dissemination?– How can the rest of us use CAPS?

• Unequal access risk of increasing disparities– What about families who don’t have access to high

speed internet, computers? (They may be at greater risk of poor outcomes to begin with.)

– Can CAPS be adapted for different cultural groups?

Strict Rest in Concussion: Background

• Animal models show early physical and mental activity can impair recovery after mTBI

• Rest after concussion to reduce re-injury• Consensus recommendations of 24 – 48 hours

of rest followed by stepwise return to activity• No studies of optimal rest period after acute

concussion

Strict Rest in Concussion: Objective

• Investigate the effectiveness of 5 days of strict rest versus 24 – 48 hours of rest after discharge from the ED with acute concussion.– Hypothesis: 5 days of rest would have improved

mean neurocognitive, balance and symptom outcomes

Strict Rest in Concussion: Methods

• RCT of patients presenting to Children’s Hospital of Wisconsin Emergency Department and Trauma Center between May 2010 – December 2012

• Screen for eligibility if chief complaint in ED was head injury with a mechanism of injury having sufficient force to cause mTBI


Inclusion criteria• Age 11 to 22 years old• Present to ED within 24 hours of head injury• Diagnosed with mild TBI/concussion based on

the Acute Concussion Evaluation form (available at http://www.cdc.gov/headsup/pdfs/providers/ace_ed-a.pdf)


Exclusion criteria• Non-English speaking• No legal guardian, or guardian unable to give consent in English• Intellectual disability (IQ<70)• Previous diagnosis of ADD/ADHD, learning disability• Intracranial bleeding or contusion (imaging at discretion of

treating clinician)• Admitted to hospital• Conditions that could interfere with valid assessment of

signs/symptoms, neurocognitive or balance tests• Treating clinician uncomfortable with study procedure• Lived > 1 hour from Medical College of Wisconsin


Interventions• Strict rest (intervention)– Instructions for 5 days of strict rest

• No school, work or physical activity• School and work excusal letters provided

– After 5 days, stepwise return to activity if symptoms resolved

• Usual care (control)– Attending physician recommend activity restrictions as they

see fit– Survey of physicians at that ED found most instruct rest for

1-2 days, followed by return to school, and if symptoms resolved, stepwise return to activity


Interventions• Both groups received the CDC’s Acute

Concussion Evaluation – Care Plan (available at http://www.cdc.gov/headsup/providers/discharge-materials.html)

• All encouraged to follow-up with PCP or Concussion Clinic

• Research assistants observed discharge instructions provided to each patient

http://www.cdc.gov/headsup/providers/discharge-materials.html

http://www.cdc.gov/headsup/providers/discharge-materials.html


Measures• ImPACT (day 0, 3 & 10) and paper neuropsych

battery (day 3 & 10)• Balance Error Scoring System (firm day 0,

firm/foam day 3 & 10)• Post-Concussive Symptoms Scale (day 1-10)– Scored 0 (symptom not present) to 6 (severe) for

19 symptoms


Measures• Energy expenditure: Activity Diaries – Record physical and mental activity in 15 min intervals (3-

day diary) and 1hr intervals (7-day diary)• Sleeping, sitting, standing, walking indoors/light home activity,

walking outdoors/light manual work, low intensity, moderate intensity, high intensity, max intensity

• Listening to music/Reading; Watching TV/Computer use/Video games; In class at school; After-school activities/work; Homework/studying; Tests/Presentations

– Reported activity level to calculate energy expenditure

Strict Rest in Concussion: Analysis

• All analyses were intention to treat• T-tests (normally distributed data) or Wilcoxon

rank sum test (not normally distributed data) for – Change in ImPACT & BESS from day 0 to day 3/10• Bonferroni multiple comparison adjustment p<.025

– Total number of symptoms reported– Symptoms reported in first 5 days

Strict Rest in Concussion: Analysis

Linear mixed-model analyses to determine if• Treatment group impacted outcomes• Treatment groups differed in recovery

trajectory– Accounts for correlations over time give multiple

observations on same subject.

Proportional Hazard Model for time to symptom resolution (PCSS ≤ 7)

Strict Rest in Concussion: Results

Demographics• Strict rest group slightly older (14.7 years versus

13.1 years, p<.01)• Similar proportion of girls (33% in strict rest, 36%

in usual care)• No other differences – in mechanism of injury– signs/symptoms present in ED– ED evaluation or treatment– Risk factors for prolonged recovery– Preinjury activity


• Nearly all participants had signs/symptoms at time of ED eval

• 36% of all participants reported LOC• Discharge instructions– In strict rest group, 94% were observed to receive

verbal instruction for strict rest for 5 days– In usual care group, 33% were observed to receive

verbal instruction about duration of rest; median duration of rest was 2 days


• No differences in calculated energy expenditure


• Usual care group had more hours of mental activity per day on day 2-5 (8.33 hrs vs 4.86 hrs, p=.03)


• Strict rest group took 3 days longer for 50% of group to have symptom resolution, but p=0.08

• Over 60% of both groups had complete symptom resolution


Symptoms• Strict rest group had higher total PCSS score

over 10 days (187.9 vs 131.9, p<.03)• Strict rest group had higher daily mean PCSS

score– On day 4, strict rest group had mean PCSS 21.51 vs

13.95 in usual care group. P<.03


Objective assessments• No significant between group differences in

ImPACT or BESS scores at day 3 or 10. • Paper neuropsych battery– Strict rest group performed better on day 3 and

worse on day 10 on the Symbol Digit Modalities Test


Linear mixed-modeling• No significant effects over time based on

group for PCSS and neurocognitive measures• PCSS analyzed by domain (physical, emotional,

cognitive, sleep)– Strict rest group had higher (worse) physical

symptom scores– Strict rest group had trajectory of more emotional

symptoms during study period


Subgroup analyses• Present with immediate signs of concussion– Trend toward lower PCSS at day 10 for strict rest

(11.0 vs. 14.6, p=.22)• Concussion diagnosed on symptoms only– Higher PCSS at day 10 for strict rest (15.2 vs. 7.7,

p<.04)• Past history of concussion– Higher PCSS at day 10 for strict rest (15.1 vs. 5.6,

p<.05)

Strict Rest in Concussion: Conclusions

• Strict rest after ED discharge did not improve symptom burden, neurocognitive or balance outcomes.

• Those on strict rest reported more symptoms over the 10 day study period.

• Recommendation for strict rest did not alter physical activity patterns but did reduce hours of mental activity

Strict Rest in Concussion: Take home message

• Rest for 5 days does not improve outcomes after concussion compared to usual care

• Our patients may not be altering their physical activity patterns based on our recommendations

Top Papers in Pediatric Rehabilitation: a Discussion of the Most Influential Papers in Pediatric

Rehabilitation over the Past Year

© The Children's Mercy Hospital 2015 123

Matthew McLaughlin, MDAssistant Professor

Department of Pediatric Rehabilitation

Journal of Pediatric Rehabilitation Medicine, vol. 7, no. 1, pp. 63-70, 2014

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCOjj-7uQ28cCFQ9KkgodYjcLLA&url=http://www.iospress.nl/journal/journal-of-pediatric-rehabilitation-medicine/&psig=AFQjCNEXL4OOv8P5FEE4PfWKcYrLIhLkFw&ust=1441378762794538

Transition of AdolescentsBackground

• Problems identifying providers willing to accept young adults with special health care needs (YASHCN)

• Less than half of age-appropriate patients met goal of transition

• Issues from primary providers:- Lack of knowledge- Anticipated difficulties- Time demands of care coordination- Inadequate reimbursement

Transition of AdolescentsObjective

• To determine the willingness of Massachusetts primary care physicians (PCP) for adults to accept a young adult with a chronic health condition into their practice.

• Hypothesis: The willingness to accept would vary based on provider characteristics and sought to quantify the effects of patient condition and transition supports.

Transition of AdolescentsMethods

• Clinical vignette studies of YASHCN with a chronic condition

• Four clinical conditions and six transition supports

• PCPs responded to single randomized survey

Transition of AdolescentsMethods (cont.)

• Practice variables included:

• Outcome variable: Willingness to accept patient for transition

• Gender• Years in practice• Specialty• Percent of time

providing primary care

• Practice characteristics

• Non-clinical work activities

• History of caring for YASHCN

Transition of AdolescentsMethods (cont.)

• Sample of 1000 IM and 500 FPs from MA Board of Registration in Medicine

• A priori power analysis indicated sample size of 150 per specialty needed

• Projected 55% response rate• Sought to enroll 300 PCPs• Excluded if: Practicing at the VA, inactive license,

correctional facility• Survey mailing, 2 dollar incentive

Transition of Adolescents Results

• 404/601 mailed surveys (67% response rate)• Issues: 55% accepting new patients, 12% already

caring for YASCHN• Willingness to accept YASHCN 3.13 (+/- SD 1.3) on

5 point scale


1

2

1. Gender moderated the influence of support strategies to accept YASHCN2. Statistically significant trend toward decreased willingness based on years since residency


• No values maintained statistical significance after a Holm test (adjustment for number of tests run)

Conclusions

• Results validate issues of YASCHN

• High # not accepting new patients

• Did not detect differences between subset variables

• More willing to accept Trisomy 21 and CF than autism and SMA

• Gender specific transition support preferences

• Adult specific sub-specialists referrals may help aid PCPs

• Limitations: no specific reasons for refusal, individualized provider preferences

“I’ve got a good patient for you.”

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July 2014. Volume 165, Issue 1, Pages 140–146.e4

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Botulinum Toxin A in Cerebral PalsyBackground

• Gross Motor Functional Classification System levels IV and V (non-ambulatory patients)

• Treatment to improve comfort/ADLs

• Prior studies to reduce pain, reduce adductor spasticity/contracture

• Used to aid ease of care, comfort and positioning- No current evidence

• History of safety questioned in non-ambulatory children

• AIM: Examine the efficacy of intramuscular (IM) injections of Botulinum Toxin Type A (BoNT-A) when used to improve ease of care and comfort in non-ambulatory patients with Cerebral Palsy (CP)

• Hypothesis: IM BoNT-A injections as an adjunct to therapies will improve ease of care and comfort in children with non-ambulatory CP

• Secondary aim: Examine safety of injection with GMFCS levels IV and V

Botulinum Toxin A in Cerebral PalsyObjective

Botulinum Toxin A in Cerebral PalsyMethods

• Double blind, RCT with sham control• Treatment vs. control group• Randomization by concealed allocation, all

participants and researchers blinded• Inclusion criteria:

- Age 2-16 with non-ambulatory CP- Goals concerned with easy of care/comfort- Spasticity in UE and/or LE causing discomfort/increased burden of care


• Exclusion criteria:• < 10 kg• Medical contraindication (prior

reaction)• No BoNT-A injections or orthopedic

surgery within 6 months• No spasticity medication change for 2

months


• Muscles selected prior to randomization• Ultrasound or stimulator guidance• Dosing 0.5-4 units/kg/muscle group (max

dose 400 units)• Both groups of children received same

amount of therapies


• Assessments:- Modified Ashworth, Modified Tardieu at baseline, 4 weeks and 16 weeks- Canadian Occupational Performance Measure (COPM) – primary outcome- Secondary measures:Caregiver Priorities and Child

Health Index of Live with Disabilities Questionnaire (CPCHILD)

Care and Comfort Hypertonicity

Questionnaire (CCHQ)Cerebral Palsy Quality of Life

Questionnaire for Children (CPQOL-child)

Pediatric Pain Profile (PPP)

Botulinum Toxin A in Cerebral PalsyStatistics

• Sample size of 40 subjects gave 80% power to detect 2 point change in COPM

• Also sample size of 40 would have enough power to reject null hypothesis of safety

• Significance of 0.05, adjusted to 0.01 for secondary outcomes

• Regression model

Botulinum Toxin A in Cerebral PalsyResults

• 41 children (BoNT-A = 23, Sham = 18) – 0 patients withdrew from the study

• COPM Performance vs. Satisfaction differences

• Immediately after perceptions (BoNT-A/sham):- 12 parents guessed correctly (31.6%), 11 incorrect (29%), and 15 unsure- Nurse monitoring child: 19 correct guesses (51.5%), incorrect 15 (40.5%), and unsure for 3

• At 4 week follow-up- 35 parents, 27 (77%) were correct, 4 (11.4%) incorrect, 4 uncertain (11.4%)

Botulinum Toxin A in Cerebral PalsyResults

Botulinum Toxin A in Cerebral Palsy

Botulinum Toxin A in Cerebral PalsyDiscussion/Conclusions

• Efficacy of IM BoNT-A as a therapy adjunct

• Improved parental ‘guessing’ because of BoNT-A effects?

• Therapy improved goals; BoNT-A improved them farther on COPM

• Secondary outcomes showed varied benefit

• Level of moderate/severe adverse events same in both groups

• Limitations: underpowered for secondary outcomes

Volume 26(3), Fall 2014, p 289–300.

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Virtual Reality/Children with CPIntroduction

• Half of all patients with Cerebral Palsy (CP) have upper extremity impairments

• Virtual reality (VR) allows for unique way of performing and quantifying therapy sessions

• Several review articles published – noted many different outcomes

Virtual Reality/Children with CPMethods

• Include: CP patients, intervention with VR with focus on upper extremity function, outcome measurements for the upper extremity, English articles

• PubMed, CINAHL, Cochrane, and PsycINFO using key words: arm, upper extremity, upper arm, reach, grasp/grip, VR, computer game, virtual environment, Wii, Kinect, Playstation, EyeToy, video game, CP, and hemip*


• 72 articles found; added “virtual reality” and “children” to expand search to 231 articles

• 20 research articles; after reading 8 review articles, 4 more research articles selected yielding 24 total articles

• Of the 24 total articles, 6 were excluded because:- Participants were not children with CP- No experimental data included- Intervention/Outcome was not UE focused



• Canadian Outcome Performance Measure

• Quality of Upper Extremity Test

• Jebsen-Taylor Hand Functino Test

• Melbourne Assessment of Unilateral Upper Limb Function

• Bruininks-Oseretsky Test of

Motor Proficiency• ABILIHAND-Kids

Questionaire• Pediatric Motor Activity

Log• Shriner’s Hospital Upper

Extremity Evaluation• Reaching kinematics• Range of Motion• Grip and Pinch Strength


• Sample sizes from 1-31 patients• Aged 3-18• Varying types of Cerebral Palsy• Commercially available to engineer-built

systems• Dosage varied: usually <120 minutes/week• Length varied from 3 weeks to 14 months

Virtual Reality/Children with CPResults

• Effect of VR is promising (d = 1.00, 95% CI [0.45-1.56])

• I2 value of 56% - test to measure heterogeneity in meta-analysis

• Participation (d = 1.92, CI = 1.19, 2.66)• Activity (d = 0.46, CI = -0.08, 1.16)• Body structure and function (d = 0.70, 0.10-

1.30)

Virtual Reality/Children with CPResults

Better Worse

In home (d = 1.3, I2 = 40%)

Laboratory setting (d = 0.28, I2 = 0%)

Engineer built(d = 1.27, I2 = 55%)

Commercial (d = 0.31, I2 = 0%)

RCT design(d = 1.95, I2 = 85%)

Cohort(d = 0.21, I2 = 0%)

Virtual Reality/Children with CPDiscussion/Conclusion

• Gradually emerging evidence for VR• Potential strong effect pre- and post-VR• Less distress at home, natural setting, ease of

use in daily life• Cost of systems ($16,249 vs. $250-400)• Older children, smaller effect sizes• No association between effect sizes and

treatment dosing

For Reference

Documents

Top Papers in Pediatric Rehabilitation Amy Houtrow, MD, PhD, MPH Molly Fuentes, MD Matt McLaughlin, MD Session 414 Friday October 2, 2015 7-8:30 am