Clinical Practice (assessment, diagnosis, treatment, knowledge translation/EBP, implementation science, program development)
Todd Levy, MS, OTR/L, CBIST
Clinical Specialist, Occupational Therapy
Children's Hospital of Philadelphia
The CDC estimates that 5 million Americans are living with disability from brain injury. Many acquire their injury in the womb or during childhood. Pediatric stroke is a major cause of death and disability, with an overall incidence for all stroke subtypes of 4-12/100,00/year, a case fatality rate of 5-10%, and lasting functional sequelae in most survivors (Ferriero 2019). Our team will share expertise in pediatric stroke to guide clinicians in addressing the ever-changing needs of individuals and families coping with the effects of brain injury sustained perinatally or in childhood. This includes using assessment tools and strategies to prioritize family-centered goals and to guide intervention. Pediatric outcomes post-stroke differs from adults due to influences of age, development, and other complex psychosocial factors (Greenham 2017). Fifty to 80% of pediatric stroke survivors suffer long-term functional sequelae including motor, communication and neuropsychological impairments, and epilepsy (Kirton 2007). Recently, parents and patients reported unmet needs at the activity-level and participation-level of the International Classification of Functioning, Disability, and Health (ICF) relating to school and leisure activities, and social relationships (Gordon 2018).
The needs of children with stroke are unique and dynamic across development and transition to adulthood. In any given clinical encounter with a family it is imperative to understand their goals and concerns to select assessments that can guide treatment (Pritchard-Wiart, 2018). The presenters will provide a framework for the occupational and physical therapist to select assessment tools to elucidate and prioritize the needs of the family within the initial clinical encounter and to guide the course of care. Selecting measures relevant to their needs aids in shared decision making to set goals and select treatments (Novak 2013). We will discuss strategies to approach goal assessment to reflect the parent – child dynamic over the course of development and transition to adulthood (Costa, 2017). As the child grows the clinician must consider how to support and engage the child in therapy and discover what motivates them. Clinicians must balance caregiver and child goals to support the family in reaching their maximum functional potential across stages of development and through the transition to adulthood (Kruijsen‐Terpstra, A. J, 2014). We will present tools and strategies to ascertain the family’s top priorities, then select assessment tools to guide treatment.
To help the therapist choose assessment tools to guide treatment for reaching functional goals (Costa, 2017), we will present the use of the ICF framework. Parent and child goals range from improving physical impairments (e.g. “I want my elbow to look normal”) to participation-level (e.g. “I want to play basketball better”). While it is important to perform a comprehensive evaluation across all levels of the ICF, it is critical for clinicians to select assessment measures that will guide treatment aimed to achieve the family’s goals. For example, for the child with hemiparesis who wants to play basketball, the clinician might select treatments to improve bimanual coordination and mobility. Treatment at this activity-level (Bimanual therapy, CIMT, direct task practice, goal-directed and task-specific mobility training) has been shown to be the most efficacious approach to improve such functional goals (Novak 2013). Findings from functional neuroimaging studies can provide insight into the effects of training (Cole, 2018; Kuo 2018; Papadelis 2014). We will provide a review of these findings. When addressing goals at the activity- and participation-levels, clinicians must consider the gamut of person and environment factors.
Occupational and physical therapists often have the unique opportunity to interact with the child in the context of real-life activities. This gives us chances to recognize myriad barriers to functional goals, including neurocognitive, neurobehavioral, and social domains. We will present strategies to help the therapist guide the family towards addressing these domains (Greenham 2018; Schiariti 2014, Sköld 2004). If clinicians aim to measure the effects of activity-level interventions, activity-level assessments must be used (Novak 2013). We will include the findings of literature reviews of pediatric upper limb assessment tools for unilateral CP and bilateral CP, demonstrating a limited number of valid and reliable assessment tools with activity-level components (Gilmore 2009, Burgess 2019). We will also discuss the findings of a recent review of participation-level measures for children with acquired brain injury and cerebral palsy (Resch 2020) and present a number of validated assessment tools and strategies that can be used across development into adulthood. Participants will walk away with practical knowledge and a new perspective of assessment strategies for acquired brain injury in the pediatric population that they can apply in their own settings.