Gillian Hotz

An evidence-based review of cognitive and behavioral rehabilitation treatment studies in children with acquired brain injury

ObjectiveThe aim of this study was to complete a systematic evidence-based review of published cognitive and behavioral treatment studies with pediatric subjects who have a history of an acquired brain injury (ABI). Data sourcesWe utilized PubMed and EMBASE to search peer-reviewed journals from 1980 to 2006. Data selectionTerms such as cognitive rehabilitation, speech therapy, language therapy, and behavior therapy were employed in the search and 28 studies met established criteria. Data extractionThe data extracted from each study included specific details about the cognitive or behavioral treatment, subjects, study design, outcome measurements, and treatment effectiveness. Data synthesisThe studies, involving 366 children and youth with ABI, were classified as 1 Class I study, 5 Class II studies, 6 Class III studies, and 16 Class IV studies. ConclusionsDespite a limited number of studies, 2 treatment recommendations and 1 option were developed from this systematic literature search.

The impact of a repealed motorcycle helmet law in Miami-Dade County

OBJECTIVE To study the impact of helmet nonuse in motorcycle crashes after the repeal of a mandatory helmet law in the state of Florida. METHODS We prospectively studied all patients evaluated at the University of Miami/Jackson Memorial Medical Center from July 1, 2000, through December 31, 2000, involved in motorcycle crashes, and compared them with those seen during the same time period the year before the helmet law change. RESULTS In 1999, before the repeal of the helmet law, there were 52 cases evaluated at our center compared with 94 after the law change. Helmet usage decreased from 1999 (83%) to 2000 (56%). The number of brain injuries (Abbreviated Injury Scale score > or = 2) during this same time period increased from 18 to 35, and the number of fatalities from 2 to 8. CONCLUSION The repeal of a motorcycle helmet law significantly increased the number and severity of brain injuries admitted to our trauma center.

Snoezelen: A controlled multi-sensory stimulation therapy for children recovering from severe brain injury

Objective: To investigate the effects of Snoezelen therapy on physiological, cognitive and behavioural changes in children recovering from severe traumatic brain injury (TBI). Methods: An observational study was conducted to assess the physiological, cognitive and behavioural changes of children recovering from severe TBI while receiving Snoezelen therapy. Fifteen subjects completed the pre- and post-Snoezelen treatment measurements computed over 10 consecutive sessions. Physiological, cognitive and behavioural measures were administered. Data was collected prospectively on each session in the Snoezelen room and were analysed by calculating the difference between pre- and post-treatment measurements for each Snoezelen session. Results: Results revealed significant changes on physiological measures. Heart rates decreased for each subject in each treatment session and were found to be significant (p = 0.032). Muscle tone was decreased in all the affected extremities (right upper extremity p = 0.009, left upper extremity p = 0.020, right lower extremity p = 0.036 and left lower extremity p = 0.018). Agitation levels decreased over time and the overall cognitive outcome measures showed significant improvement when comparing the beginning of treatment with the end. Conclusion: This study revealed a beneficial use of Snoezelen therapy with children recovering from severe brain injury. However, there continues to be a critical need for evidenced-based research for this patient population and others in this multi-sensory environment.

WalkSafe: a school-based pedestrian safety intervention program

Objective: To evaluate the effectiveness of the WalkSafe program, an elementary school-based pedestrian safety program in a single high-risk district in Miami-Dade County. Methods: Sixteen elementary schools were identified in a single high-risk district and enrolled in a one-year study. All schools implemented the WalkSafe program on the last week of January 2003. A pre, post, and three-month post testing of pedestrian safety knowledge was conducted. An observational component was also implemented at four schools that were randomly chosen. Engineering recommendations and law enforcement initiatives were also performed. Results: A total of 6467 children from K–5th grade from 16 elementary schools participated in the program. Of these 5762 tests were collected over three different testing times. A significant difference (p-value < 0.001) was found between the pre and post testing conditions across all grade levels. There was no significant difference found between the post and three-month post testing conditions across all grade levels (p-value > 0.05). The observational data collected at four schools across the different testing times demonstrated a significant difference found between pre and post testing conditions for Group A (stop at the curb and look left, right, left) and also for Group B (midstreet crossing and darting out) (p-value < 0.05). There was no difference found between comparing the pre-test or post-test condition with the three-month post-test time. There were many environmental modifications that were recommended and actually performed. Conclusion: The WalkSafe program implemented in a single high-risk district was shown to improve the pedestrian safety knowledge of elementary school children. The observational data demonstrated improved crossing behaviors from pre-test to post-testing conditions. Future research will focus on sustaining the program in this district and expanding the program throughout our county.

Preventing pediatric pedestrian injuries.

Pedestrian-related crashes cause an estimated 1.2 million deaths and 50 million injuries worldwide. There were 32,590 nonfatal injuries reported among children 0 to 14 years of age in the United States in 2006. The incidence of pedestrian injuries seems to be decreasing due to improvements in trauma care and a nationwide decline in walking. This article is a special communication and overview of selected literature regarding efforts to decrease the frequency of pediatric pedestrian trauma. WalkSafe an elementary school-based pedestrian injury prevention program will be discussed as an example of a program that has been able to demonstrate a decrease in injuries in children.

Perseveration. Part I: A review

Perseveration refers to the inappropriate continuation or repetition of a response or activity. It is associated with a variety of neurological disorders and, when pronounced, is thought to be pathognomonic of brain damage. Perseveration manifests itself in several different forms which have had various labels applied, and many hypotheses have been proposed to explain the mechanisms underlying these perseverative behaviours. In this article we review descriptions and classifications of perseveration as it occurs in various neurological disorders, and then discuss some of the neurobehavioural and neuropathological mechanisms thought to account for it.

Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015

BACKGROUND Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment. OBJECTIVE To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion. METHODS On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device. RESULTS A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%. CONCLUSION Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments. ABBREVIATIONS ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.

The WalkSafe Program: Developing and Evaluating the Educational Component

BACKGROUND Miami-Dade County, FL, has one of the highest numbers of pediatric pedestrian injuries in the country. To respond to this problem, WalkSafe an elementary school-based pedestrian injury prevention program was created. The purpose of this study was to evaluate the effectiveness of the 3-day WalkSafe educational curriculum in a high-risk district. METHODS Sixteen elementary schools were identified and enrolled in the study. Children (n = 10,621) in grades K-5 participated in the WalkSafe program in October 2006. Four of the 16 schools were randomly selected to receive pre-, post-, and 3-month posteducational testing of pedestrian safety knowledge. Teachers (n = 462) were asked to complete teacher surveys to gain feedback about the program. RESULTS A total of 2,987 tests were collected during the three different testing times. Grades were combined to form groups (K-1), (2-3), and (4-5). Significant differences were observed (p value <0.05) between pre- and posttesting for grades K-1 and 2-3. No significant differences were found between pre- and posttesting for (4-5) and between post- and 3-month testing across all grades (p value >0.05). There were 154 (30%) of the teacher surveys returned. CONCLUSION The 3-day WalkSafe educational curriculum implemented in a high-risk district was shown to increase the pedestrian safety knowledge of elementary school age children. From recommendations made by teachers and multiple agencies, the modified 3-day program was approved to implement on a yearly basis in all public elementary schools in Miami-Dade County. Further studies will investigate the transfer of knowledge gain to behavioral change among elementary school-aged children.

OUTCOME OF MOTORCYCLE RIDERS AT ONE YEAR POST-INJURY

Objective: There is little information about the long-term effects of injury on victims of motorcycle crashes. Following the repeal of the mandatory helmet law in Florida, we studied the impact of crashes on riders and their outcomes one year post-injury. Subjects: All patients involved in a motorcycle crash over a six-month time period were assessed at one year post-injury. Demographic information, health status, motorcycle and helmet usage, and employability were surveyed. Results: There were 94 patients evaluated at our center for the first six-month period following the repeal of the helmet law, where 50 (56%) were wearing a helmet at the time of injury. Of the 94, we were able to contact 45 (48%) at one-year follow up. Fourteen (31%) of those contacted were not wearing a helmet at the time of their crash. At one year post-injury, 23 (51%) reported physical deficits, while 39 (86%) were working. Only 12 (27%) were riding a motorcycle again, and 11 (92%) were wearing a helmet. Conclusions: Motorcycle riders at one year post-injury continue to experience physical deficits related to their accidents. There is a small percentage of riders that resume riding a motorcycle after injury. Being involved in a motorcycle accident has deterred the injured rider from riding a motorcycle again at one year post-injury.

Neuroimaging Correlates of Novel Psychiatric Disorders after Pediatric Traumatic Brain Injury.

OBJECTIVE To study magnetic resonance imaging (MRI) correlates of novel (new-onset) psychiatric disorders (NPD) after traumatic brain injury (TBI) and orthopedic injury (OI). METHOD Participants were 7 to 17 years of age at the time of hospitalization for either TBI or OI. The study used a prospective, longitudinal, controlled design with standardized psychiatric assessments conducted at baseline (reflecting pre-injury function) and 3 months post-injury. MRI assessments including diffusion tensor imaging (DTI)-derived fractional anisotropy (FA), volumetric measures of gray and white matter regions, volumetric measures of lesions, and cortical thickness were conducted. Injury severity was assessed by standard clinical scales. The outcome measure was the presence of an NPD identified during the first 3 months after injury. RESULTS There were 88 participants (TBI, 44; OI, 44). NPD occurred more frequently in the TBI (21/44; 48%) versus the OI (6/44; 14%) group (Fishers exact test, p = .001). NPD in TBI participants was not related to injury severity. Multivariate analysis of covariance of the relationship between FA in hypothesized regions of interest (bilateral frontal and temporal lobes, bilateral centrum semiovale, bilateral uncinate fasciculi) and NPD and group (TBI versus OI) was significant, and both variables (NPD, p < .05; group, p < .001) were jointly significantly related to FA. NPD was not significantly related to volumetric measures of white or gray matter structures, volumetric measures of lesions, or cortical thickness measures. CONCLUSIONS Lowered white matter integrity may be more important in the pathophysiology of NPD than indices of gray matter or white matter atrophic changes, macroscopic lesions, and injury severity.