Read Full Text: Unmet Rehabilitation Needs After Hospitalization for Traumatic Brain Injury
Journal: Pediatrics
Year Published: 2018
CEU Podcast: #48: Pediatric TBI and OT with Nelson Gonzalez (CE Course)
Children are not simply little adults.
One significant difference: kids’ brains are constantly and actively developing. This level of neuroplasticity might lead us to assume they’d recover from traumatic brain injury (TBI) more quickly than adults.
That’s not the case.
In fact, the same brain injury can make a more devastating impact on a child than it would on a mature adult. (Source: Brain Injury Association of America)
This is why comprehensive, ongoing rehab for pediatric TBI is so important. Unfortunately, as we will see in this week’s research, many of these children don’t get the care they need.
This is a problem we need to meet head on. There are many evidence-based strategies that can support these kids! We’ll discuss how OTs can step in to help this underserved population, when Nelson Gonzalez, OTR/L, RFS, CHHC, CCT, CPMT, CORE, CLT joins us on the podcast next week.
Let’s dive in.
Intro to unmet rehab needs following pediatric TBI
Children who suffer traumatic brain injury (TBI) can experience long-term impairments across functional domains.
Luckily, studies like this, this, and this have all shown that rehab CAN improve functional outcomes for these children.
Unfortunately, many children do not receive these services. In fact, less than half of hospitalized children with severe TBI receive rehab while hospitalized.
Unmet services needs after hospitalization
Past studies have shown that, following hospitalization, 31% of these kids have unmet or unrecognized needs for continued services.
Children with Medicaid are even more likely to have unmet needs.
Obviously, this problem has been studied before—but much of the research is more than 10 years old. Such studies also tended to have a narrow view of dysfunction. Case in point: education-related needs were not even considered in the aforementioned studies.
Which leads us to this paper…
What was the intent of this paper?
The authors sought to describe unmet service needs in the first 2 years for kids who had been hospitalized by stroke.
They divided the service needs into 6 specific areas:
- Occupational therapy (OT)
- Physical therapy (PT)
- Speech therapy (ST)
- Mental health services
- Educational services
- Physiatry services
Methods
This was a prospective cohort study.
Population
Children (ages 8-18) who were hospitalized at 6 major hospitals in the US from 2013-2015 were included in this study. All were admitted with one of the following:
- Complicated mild traumatic brain injury (cmTBI)
- Moderate TBI
- Severe TBI
Assessments
A baseline interview was conducted within 30 days from injury to gather data on demographics and pre-injury functional status.
Structured interviews were then conducted at 6, 12, and 24 months.
Here are the measures that were used to identify dysfunction and service needs:
OT/Physiatry
(for self care)
- The Pediatric Quality of Life Inventory (PedsQL) - Physical functioning, items 4-6
PT/Physiatry
(for mobility)
- PROMIS Physical Function Mobility short form
- The Pediatric Quality of Life Inventory (PedsQL) - Physical functioning, items 1-3
Speech Therapy/Physiatry/Educational Services
(for cognition and communication)
- Quality of Life in Neurological Disorders (Neuro-QoL), Pediatric Applied Cognition Scale
- Traumatic Brain Injury Quality of Life (TBI-QoL), Executive function form and Communication form
Educational Services/Physiatry
(for academics)
- The Pediatric Quality of Life Inventory (PedsQL) - School functioning
Mental Health Services/Physiatry
(for mental health)
- The Pediatric Quality of Life Inventory (PedsQL) - Emotional functioning
- PROMIS Anxiety
- PROMIS Depression
- UCLA PTSD Reaction Index
Results
170 parent-child dyads consented to participate in this study.
There were many layers of results that were presented, but I am going to zoom in on the OT-specific ones. Here is the key graph related to OT:
OT Needs After Hospitalization. See full graph here:
In all domains (as shown above), children with more severe TBIs had greater service needs than those with cmTBI.
But, as you can see in the graph, those with cmTBI actually had a higher proportion of unmet needs. In some domain areas, the percentage of unmet needs of the cmTBI cohort was higher than that of the severe TBI cohort. (See the education chart below.)
You can also see on the chart below that, counterintuitively, the percentage of unmet needs actually tended to increase over time. (One might speculate that this number would gradually decrease.)
Education Needs After Hospitalization. See full graph here.
Discussion
There were several important takeaways from this research.
Children hospitalized with TBI frequently have persistent dysfunction, with substantial levels of unmet needs across multiple domains.
But, children with cmTBI were more likely to have unmet needs than those with moderate to severe TBI. The authors hypothesized that those with more severe TBI may have had more obvious impairments, and therefore had their needs more readily identified.
Children with moderate to severe TBI showed an increase in the proportion of unmet needs across all domains from 6 to 24 months. The authors hypothesized that the level of unmet needs may have risen over time due to:
- Stopping therapy, as patients may have seemed to no longer appeared to benefitting
- OR the therapy was too costly
Overall, the high level of service needs at 24 months correlated with another study. The previous study found that, on average, 6.8 years after injury, 69% of children still had potential education service needs.
All of this data combines to suggest that all children who are hospitalized for TBI—but especially those with cmTBI or those in the chronic phase of recovery—should be assessed for functional impairments. Such assessment could determine whether additional services would improve outcomes.
Takeaways for OT practitioners
(Please note: These are my personal takeaways. They are not mentioned specifically in the article.)
1. A continued theme: Not everyone recovers.
Previously in the Club, we’ve covered research on post-concussion syndrome. The subtitle of the primary research was literally “not everyone recovers.”
This current article builds on that continued theme for TBI, and it specifically zooms in on pediatric cases. On one hand, the persistent impact of pediatric TBI makes a lot of sense. But, on the other hand, it can be surprising to see such a high level of impact so many years later.
This is why your knowledge of this diagnosis is so critical for these patients. Children, parents, and even other healthcare providers may not think to connect current struggles to a brain injury sustained 5 years ago. But, this is where your expertise and advocacy come in.
2. Building the right team is critical.
TBI impacts many domains, and it’s important to build the right team to meet the diverse needs of patients.
The 6 domains in this article could almost serve as a checklist you should consider for each of your post-TBI patients. Are their needs in each of these domains being met?
If you suspect they are not, the screens mentioned in the article could serve as a good starting point to build your case for expanding the care team.
3. More resources are needed for serving this specific population.
Over the next week, I am going to be gathering resources for pediatric TBI occupational therapy. (They are pretty scattered!) If you have any resources you have found to be helpful, please share them below. I’ll share them all in the supplementary materials of our upcoming podcast, in which I’ll discuss this research with Nelson Gonzalez, OTR/L, RFS, CHHC, CCT, CPMT, CORE, CLT.
In the meantime, here is our documentation example for an OT eval s/p concussion.
Here’s the full APA citation for this article:
Fuentes, M. M., Wang, J., Haarbauer-Krupa, J., Yeates, K. O., Durbin, D., Zonfrillo, M. R., Jaffe, K. M., Temkin, N., Tulsky, D., Bertisch, H., & Rivara, F. P. (2018). Unmet Rehabilitation Needs After Hospitalization for Traumatic Brain Injury. Pediatrics, 141(5), e20172859.
Earn one hour of continuing education by listening to the podcast on this article!!
In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Nelson Gonzalez. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!