Return to Learn After Traumatic Brain Injury Dichiaro, Michael; Baker, David; Tlustos, Sarah J
The Pediatric clinics of North America,
06/2023, Letnik:
70, Številka:
3
Journal Article
Recenzirano
A successful return of youth back to school after traumatic brain injury (TBI) is an important aspect of post-injury management. Regardless of the severity of the injury, returning to school is an ...important aspect of improving recovery and outcomes. Often temporary informal school adjustments suffice in supporting children returning to school after concussion. For those with more a significant TBI, often formal school supports and interventions are important. Given the resiliency and recovery often seen after pediatric brain injury, close monitoring, serial evaluations, and fluid supports are important in accurately identifying what specific sequelae require support in the school setting.
Professional challenges have been documented in broad surveys of neuropsychologists. While previous surveyors have included pediatric neuropsychologists, few, if any, have specifically examined ...practices among those who primarily work in pediatric inpatient rehabilitation settings. Therefore, the aim of this study was to survey neuropsychologists in this setting. Thirty neuropsychologists from the U.S. and one from Canada that work in inpatient pediatric rehabilitation participated in an online survey. Most respondents (83.3%) billed for their inpatient time. Sixty-four percent indicated that payor type (private vs. public) affected services a moderate amount to a lot; this was primarily due to payor's influence on length of stay. Most providers had productivity expectations (66.7%). Among those that had productivity expectations, three-quarters used "hours billed;" 37.5% were solely or additionally tracked by relative value units (RVUs). The majority of respondents conducted some type of clinical data collection, usually for research purposes. With respect to professional identity, most respondents indicated positivity about their role. The top challenges endorsed were related to workload/ability to meet the patients' needs and billing/productivity. Issues related to billing and payor may influence aspects of pediatric inpatient rehabilitation neuropsychological care. Managing challenges related to billing and the time demands associated with providing inpatient services were top concerns for many respondents. Most sites surveyed were involved in data collection, usually for research purposes; increased data collection efforts are needed to aid with program development and evaluation and to demonstrate the added value of neuropsychological services from a patient care perspective.
Celotno besedilo
Dostopno za:
BFBNIB, DOBA, NUK, PILJ, SAZU, UILJ, UKNU, UL, UM, UPUK
Psychologists have been applying neurorehabilitation models of care for many years. These practitioners come from different training backgrounds and use a variety of titles to refer to themselves ...despite considerable overlap in practice patterns, professional identification, and salary. Titles like 'neurorehabilitation psychologist' and 'rehabilitation neuropsychologist' are sometimes used by practitioners in the field to indicate their specialty area, but are not formally recognized by the American Psychological Association, the American Board of Professional Psychology, or by training councils in clinical neuropsychology (CN) or rehabilitation psychology (RP). Neither the CN or RP specialties alone fully address or define the competencies, skill sets, and clinical experiences required to provide high quality, comprehensive neurorehabilitation psychology services across settings. Therefore, irrespective of practice setting, we believe that both clinical neuropsychologists and rehabilitation psychologists should ideally have mastery of specific, overlapping competencies and a philosophical approach to care that we call neurorehabilitation psychology in this paper. Trainees and early career professionals who aspire to practice in this arena are often pressured to prioritize either CN or RP pathways over the other, with anxiety about perceived and real potential for falling short in their training goals. In the absence of an explicit training path or formal guidelines, these professionals emerge only after the opportunity, privilege, or frank luck of working with specific mentors or in exceptional patient care settings that lend themselves to obtaining integrated competencies in neurorehabilitation psychology. This paper reflects the efforts of 7 practitioners to preliminarily define the practice and philosophies of neurorehabilitation psychology, the skill sets and competencies deemed essential for best practice, and essential training pathway elements. We propose competencies designed to maximize the integrity of training and provide clear guideposts for professional development.
Neuropsychologists in inpatient pediatric rehabilitation settings collaborate with an interdisciplinary team to educate, evaluate, and provide intervention to patients with acquired brain injury and ...their families, but there are no known studies that describe or define these clinical services. Thirty-one neuropsychologists in pediatric inpatient rehabilitation settings completed an online survey. Neuropsychologists (68.2% female; 86.4% with PhD versus PsyD) from the U.S. and Canada, who represented 22 pediatric inpatient rehabilitation sites comprised the final sample. Most sites (63.6%) were embedded within medical centers, with providers dedicating 2 to 32 hours (M = 14.25, SD = 9.26) weekly to onsite inpatient rehabilitation efforts. Providers most often saw patients with traumatic brain injury and other acquired brain injuries, including stroke and brain tumor. Trainees from various levels, most commonly post-doctoral fellows, provided clinical services on inpatient units, many with some degree of independence. Clinical practices that were standard across all or most sites included targeted discharge evaluations, serial cognitive monitoring, neuropsychology consultation to rehabilitation and non-rehabilitation units, and follow-up clinics. Provision of services was influenced by multiple factors including patient diagnosis, timing of return to school, inpatient census, and payor's effect on length of stay. Findings highlight many programmatic consistencies across sites and serve as an important initial step to guiding pediatric neuropsychology providers seeking to understand the current landscape of clinical care. Future efforts are needed to establish a true clinical guideline for practice. Although preliminary, data also support establishment of neuropsychology training programs, justify administrative resources, and serve to educate recipients of neuropsychology services.
Celotno besedilo
Dostopno za:
BFBNIB, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
To understand how methylphenidate (MPH) is used in youth with traumatic brain injury (TBI) during inpatient pediatric rehabilitation.
Inpatient pediatric rehabilitation.
In total, 234 children with ...TBI; 62 of whom received MPH and 172 who did not. Patients were on average 11.6 years of age (range, 2 months to 21 years); 88 of 234 were female; the most common mechanism of injury was motor vehicle collision (49%); median (IQR) acute hospital length of stay (LOS) and inpatient rehabilitation LOS were 16 (10-29) and 23 (14-39), respectively; 51 of 234 were in a disorder of consciousness cognitive state at time of inpatient rehabilitation admission.
Multicenter, retrospective medical record review.
Patient demographic data, time to inpatient pediatric rehabilitation admission (TTA), cognitive state, MPH dosing (mg/kg/day).
Patients who received MPH were older (P = .011); TTA was significantly longer in patients who received MPH than those who did not (P =.002). The lowest recorded dose range by weight was 0.05 to 0.89 mg/kg/d, representing an 18-fold difference; the weight-based range for the maximum dose was 0.11 to 0.97 mg/kg/d, a 9-fold difference. Patients in lower cognitive states at admission (P = .001) and at discharge (P = .030) were more likely to receive MPH. Five patients had side effects known to be associated with MPH; no serious adverse events were reported.
This multicenter study indicates that there is variable use of MPH during acute inpatient rehabilitation for children with TBI. Children who receive MPH tend to be older with lower cognitive states. Dosing practices are likely consistent with underdosing. Clinical indications for MPH use during inpatient pediatric rehabilitation should be better defined. The use of MPH, as well as its combination with other medications and treatments, during inpatient rehabilitation needs to be further explored.
To describe dosing practices for amantadine hydrochloride and related adverse effects among children and young adults with traumatic brain injury (TBI) admitted to pediatric inpatient rehabilitation ...units.
Eight pediatric acute inpatient rehabilitation units located throughout the United States comprising the Pediatric Brain Injury Consortium.
Two-hundred thirty-four children and young adults aged 2 months to 21 years with TBI.
Retrospective data revie.
Demographic variables associated with the use of amantadine, amantadine dose, and reported adverse effects.
Forty-nine patients (21%) aged 0.9 to 20 years received amantadine during inpatient rehabilitation. Forty-five percent of patients admitted to inpatient rehabilitation with a disorder of consciousness (DoC) were treated with amantadine, while 14% of children admitted with higher levels of functioning received amantadine. Children with DoC who were not treated with amantadine were younger than those with DoC who received amantadine (median 3.0 vs 11.6 years, P = .008). Recorded doses of amantadine ranged from 0.7 to 13.5 mg/kg/d; the highest total daily dose was 400 mg/d. Adverse effects were reported in 8 patients (16%); nausea/abdominal discomfort and agitation were most common, each reported in 3 patients. The highest reported dose without an adverse effect was 10.1 mg/kg/d.
During pediatric inpatient rehabilitation, amantadine was prescribed to children across a range of ages and injury severity and was most commonly prescribed to older children with DoC. Dosing varied widely, with weight-based dosing for younger/smaller children at both lower and higher doses than what had been previously reported. Prospective studies are needed to characterize the safety and tolerability of higher amantadine doses and optimize amantadine dosing parameters for children with TBI.
Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children; survivors experience long-term cognitive and motor deficits. To date, studies predicting outcome following ...pediatric TBI have primarily focused on acute behavioral responses and proxy measures of injury severity; unsurprisingly, these measures explain very little of the variance following heterogenous injury. In adults, certain acute imaging biomarkers help predict cognitive and motor recovery following moderate to severe TBI. This multi-center, retrospective study, characterizes the day-of-injury computed tomographic (CT) reports of pediatric, adolescent, and young adult patients (2 months to 21 years old) who received inpatient rehabilitation services for TBI (
= 247). The study also determines the prognostic utility of CT findings for cognitive and motor outcomes assessed by the Pediatric Functional Independence Measure, converted to age-appropriate developmental functional quotient (DFQ), at discharge from rehabilitation. Subdural hematomas (66%), contusions (63%), and subarachnoid hemorrhages (59%) were the most common lesions; the majority of subjects had less severe Rotterdam CT scores (88%, ≤ 3). After controlling for age, gender, mechanism of injury, length of acute hospital stay, and admission DFQ in multivariate regression analyses, the highest Rotterdam score (β = -25.2,
< 0.01) and complete cisternal effacement (β = -19.4,
< 0.05) were associated with lower motor DFQ, and intraventricular hemorrhage was associated with lower motor (β = -3.7,
< 0.05) and cognitive DFQ (β = -4.9,
< 0.05). These results suggest that direct detection of intracranial injury provides valuable information to aid in prediction of recovery after pediatric TBI, and needs to be accounted for in future studies of prognosis and intervention.
To characterize the demographics, clinical course, and predictors of cognitive recovery among children and young adults receiving inpatient rehabilitation following pediatric traumatic brain injury ...(TBI).
Retrospective observational, multicenter study.
Eight acute pediatric inpatient rehabilitation facilities in the United States with specialized programs for treating patients with TBI.
Children and young adults (0-21 years) with TBI (n = 234) receiving inpatient rehabilitation.
Not applicable.
Admission and discharge status assessed by the WeeFIM Cognitive Developmental Functional Quotient (DFQ) and Cognitive and Linguistic Scale (CALS).
Patients admitted to pediatric inpatient rehabilitation are diverse in cognitive functioning. While the majority of patients make improvements, cognitive recovery is constrained for those admitted with the most severe cognitive impairments. Age, time since injury to rehabilitation admission, and admission WeeFIM Cognitive DFQ are significant predictors of cognitive functioning at discharge from inpatient rehabilitation.
This work establishes a multicenter Pediatric Brain Injury Consortium and characterized the demographics and clinical course of cognitive recovery during inpatient rehabilitation of pediatric patients with TBI to aid in prospective study design.
