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As the life expectancy of individuals with spina bifida increases, a lifelong need for management of many health issues in a rehabilitation setting has emerged in recent years. Physiatrists, in consultation with a variety of adult specialists, are particularly well suited to manage the common musculoskeletal, skin, bowel, bladder, renal, neurological, and other issues that arise in the adult population. This article reviews the last 20 yrs of literature pertinent to the rehabilitative care of this population, summarizes current evidence-based practice, and identifies key areas in which scientific evidence is lacking and future research is needed. [ABSTRACT FROM AUTHOR]

Objective: To examine the association of home and neighborhood environment with neurobehavioral outcomes after severe pediatric traumatic brain injury (TBI)., Setting: Domestic and international children's medical centers., Participants: Participants enrolled in the study were 18 years or younger at the time of their severe TBI (Glasgow Coma Scale [GCS] ≤ 8), admitted to the intensive care unit, and underwent placement of an intracranial pressure (ICP) monitor. Exclusionary criteria included less severe injury (GCS > 8), pregnancy, and/or ICP monitor placement occurred at a non-participating hospital., Design: A multicenter, observational cohort study., Main Measures: Outcomes assessed at 12 months post-injury included measures of global functioning, intellectual ability, caregiver-report measures of family functioning, executive functioning behaviors, behavior problems, and health-related quality of life. We examined mortality risk (assessed acutely after injury), family functioning (assessed at 12 months post-injury) and parenting practices, social environment, and neighborhood stressors (all assessed > 12 months post-injury), as correlates and moderators of the 12-month post-injury outcomes., Results: Home and neighborhood factors were associated with neurobehavioral outcomes (ie, intellectual ability, executive functioning, behavioral adjustment, and health-related quality of life) but not with global functioning outcomes. A negative association between a more vulnerable home and neighborhood environment and neurobehavioral outcomes was more consistent in older children compared with younger children, based on age of injury. The influence of mortality risk on neurobehavioral outcomes was variable., Conclusion: Parenting practices and quality of social and neighborhood environment are associated with neurobehavioral outcomes 12 months after severe pediatric TBI. More research is needed to better understand the relationship between home/neighborhood stressors and TBI recovery to develop and implement strategies for patients and families to optimize outcomes. Future intervention development should focus on addressing parenting practices and social environment in a developmentally sensitive way for children who have sustained a severe TBI., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Mental health (MH) issues in children with cerebral palsy (CP) are poorly understood compared with other pediatric populations., Objective: To examine MH diagnosis code assignment among children and young adults with CP and compare with typically developing (TD) and chronic condition (CC) pediatric populations., Design, Setting, and Participants: This case-control study used International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to create a CP case set and CC and TD control sets using electronic health record data of children and young adults from a large tertiary care children's hospital in the midwestern United States between 2010 and 2022. Case-control matching was performed to control for demographic factors. Data were analyzed from June to December 2023., Exposures: All MH diagnosis codes were mapped to ICD-10-CM and categorized using Clinical Classifications Software Refined (CCSR)., Main Outcomes and Measures: The incidence rates of MH CCSR categories were calculated. Descriptive and comparative statistics were used to evaluate the significance and odds associated with factors., Results: Data from 216 794 individuals (mean [SD] baseline age, 4.3 [5.1] years; 118 562 [55%] male) were analyzed, including 3544 individuals with CP, 142 160 individuals with CC, and 71 080 TD individuals. The CP cohort spread across Gross Motor Function Classification System (GMFCS) levels I (981 individuals [28%]), II (645 individuals [18%]), III (346 individuals [10%]), IV (502 individuals [14%]), and V (618 individuals [17%]). Rates varied significantly for anxiety (824 individuals with CP [23%]; 25 877 individuals with CC [9%]; 6274 individuals with TD [18%]), attention-deficit/hyperactivity disorder (534 individuals with CP [15%]; 22 426 individuals with CC [9%]; 6311 individuals with TD [16%]); conduct or impulse disorder (504 individuals with CP [14%]; 13 209 individuals with CC [5%]; 3715 individuals with TD [9%]), trauma or stress disorders (343 individuals with CP [10%]; 18 229 individuals with CC [8%]; 5329 individuals with TD [13%]), obsessive-compulsive disorder (251 individuals with CP [7%]; 3795 individuals with CC [1%]; 659 individuals with TD [3%]), depression (108 individuals with CP [3%]; 12 224 individuals with CC [5%]; 4007 individuals with TD [9%]), mood disorders (74 individuals with CP [2%]; 4355 individuals with CC [2%]; 1181 individuals with TD [3%]), and suicidal ideation (72 individuals with CP [2%]; 7422 individuals with CC [5%]; 3513 individuals with TD [5%]). There was significant variation in odds of MH diagnoses by GMFCS level (I-II vs III-V: odds ratio [OR], 1.23; 95% CI, 1.09-1.40; P = .001). Among individuals with CP, males were more likely than females to have diagnosis codes for conduct or impulse disorders (OR, 1.41; 95% CI, 1.16-1.73) and attention-deficit/hyperactivity disorder (OR, 1.41 [95% CI, 1.15-1.73]). Black individuals, compared with White individuals, were more likely to have diagnoses for obsessive-compulsive disorder (OR, 1.57 [95% CI, 1.14-2.16]), other mood disorders (OR, 1.85 [95% CI, 1.01-3.38]), and trauma or stress disorders (OR, 1.94 [95% CI, 1.44-2.63]). Odds for trauma or stress disorders were elevated for individuals who identified as other races compared with White individuals (OR, 2.80 [95% CI, 2.03-3.87])., Conclusions and Relevance: In this case-control study of children and young adults with CP and matched comparisons, anxiety and conduct or impulse diagnoses were higher in individuals with CP. The lower diagnosis rates of depression and suicidal ideation may indicate underdiagnosis among individuals with CP. There is likely a need for assessment tools that are more suitable for children with CP.

Objective: The aims of this study were to 1) assess and quantify white matter (WM) microstructural characteristics derived from diffusion tensor imaging (DTI) in children with cerebral palsy (CP) prior to selective dorsal rhizotomy (SDR), and 2) investigate potential associations between WM diffusion properties and gross motor function and spasticity in children with spastic CP who underwent SDR., Methods: This study is a multisite study based on DT images acquired prior to SDR as well as postoperative outcome data. DTI data collected from two sites were harmonized using the ComBat approach to minimize intersite scanner difference. The DTI abnormalities between children with spastic CP and controls were analyzed and correlated with the severity of impaired mobility based on the Gross Motor Function Classification System (GMFCS). The improvement in gross motor function and spasticity after SDR surgery was assessed utilizing the Gross Motor Function Measure-66 (GMFM-66), the Modified Tardieu Scale (MTS), and the modified Ashworth scale (MAS). Alterations in these outcome measures were quantified in association with DTI abnormalities., Results: Significant DTI alterations, including lower fractional anisotropy (FA) in the genu of the corpus callosum (gCC) and higher mean diffusivity (MD) in the gCC and posterior limb of the internal capsule (PLIC), were found in children in the SDR group when compared with the age-matched control group (all p < 0.05). Greater DTI alterations (FA in gCC and MD in gCC and PLIC) were associated with lower mobility levels as determined based on GMFCS level (p < 0.05). The pre- to post-SDR improvement in motor function based on GMFM-66 was statistically significant (p = 0.006 and 0.002 at 6-month and 12-month follow-ups, respectively). The SDR efficacy was also identified as improving spasticity in lower-extremity muscle groups assessed with the MTS and MAS. Partial correlation analysis presented a significant association between pre- to post-SDR MTS alteration and DTI abnormalities., Conclusions: The findings in the present study provided initial quantitative evidence to establish the WM microstructural characteristics in children with spastic CP prior to SDR surgery. The study generated data for the association between baseline DTI characteristics and mobility in children with CP prior to SDR surgery. The study also demonstrated SDR efficacy in improving motor function and spasticity based on the GMFM-66, MTS, and MAS, respectively, in association with DTI data.

Objective: To understand how methylphenidate (MPH) is used in youth with traumatic brain injury (TBI) during inpatient pediatric rehabilitation., Setting: Inpatient pediatric rehabilitation., Participants: 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., Design: Multicenter, retrospective medical record review., Main Measures: Patient demographic data, time to inpatient pediatric rehabilitation admission (TTA), cognitive state, MPH dosing (mg/kg/day)., Results: 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., Conclusion: 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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Children with acquired brain injury (ABI) are at risk for poor therapeutic engagement due to cognitive impairment, affect lability, pain, and fatigue. Animal-assisted therapy (AAT) has the potential to improve patient engagement in rehabilitation therapies; however, the feasibility of integrating AAT into the rigorous therapy schedule of inpatient clinical care or its reception by patients, families, and staff is unknown., Objective: To examine the feasibility and acceptability of incorporating dogs into physical therapy and occupational therapy sessions with pediatric patients being treated on an inpatient rehabilitation unit for acquired brain injury., Design: A feasibility study of AAT within the context of a within-subjects crossover study., Setting: Pediatric inpatient rehabilitation unit., Participants: Sixteen patients, aged 7-28 years (mean = 13.6 years, standard deviation [SD] = 5.2 years; 50% male), being treated on the inpatient rehabilitation unit following ABI., Intervention: AAT - the integration of dogs into inpatient physical therapy and occupational therapy sessions., Main Outcome Measures: Feasibility measures: enrollment rate, the proportion of AAT sessions a dog attended, adverse events, instances where therapist or handler ended session early, patient animal closeness, and utilization of dog in session. Satisfaction measures: parent satisfaction questionnaires and therapist feedback., Results: Feasibility was supported by high enrollment rate (88.9%) and dog attendance rate of 93%-95%; 84.3% of sessions used the dog in multiple ways and patients reported a high level of closeness with the dog in session, indicating that the dogs were integrated in meaningful ways. No adverse events were noted, therapists reported that intervention was convenient, and clinical care was not negatively impacted. A high level of satisfaction was reported by families and therapists., Conclusions: Findings suggest that AAT is feasible and acceptable, and it may be a valuable tool for therapists working with patients with ABI on an inpatient rehabilitation unit., (© 2024 The Authors. PM&R published by Wiley Periodicals LLC on behalf of American Academy of Physical Medicine and Rehabilitation.)

Background: Children and adolescents with neuromotor disorders need regular physical activity to maintain optimal health and functional independence throughout their development. To this end, reliable measures of physical activity are integral to both assessing habitual physical activity and testing the efficacy of the many interventions designed to increase physical activity in these children. Wearable accelerometers have been used for children with neuromotor disorders for decades; however, studies most often use disorder-specific cut points to categorize physical activity intensity, which lack generalizability to a free-living environment. No reviews of accelerometer data processing methods have discussed the novel use of machine learning techniques for monitoring physical activity in children with neuromotor disorders., Methods: In this narrative review, we discuss traditional measures of physical activity (including questionnaires and objective accelerometry measures), the limitations of standard analysis for accelerometry in this unique population, and the potential benefits of applying machine learning approaches. We also provide recommendations for using machine learning approaches to monitor physical activity., Conclusions: While wearable accelerometers provided a much-needed method to quantify physical activity, standard cut point analyses have limitations in children with neuromotor disorders. Machine learning models are a more robust method of analyzing accelerometer data in pediatric neuromotor disorders and using these methods over disorder-specific cut points is likely to improve accuracy of classifying both type and intensity of physical activity. Notably, there remains a critical need for further development of classifiers for children with more severe motor impairments, preschool aged children, and children in hospital settings., (© 2024. The Author(s).)

Purpose: Through automated electronic health record (EHR) data extraction and analysis, this project systematically quantified actual care delivery for children with cerebral palsy (CP) and evaluated alignment with current evidence-based recommendations., Methods: Utilizing EHR data for over 8000 children with CP, we developed an approach to define and quantify receipt of optimal care, and pursued proof-of-concept with two children with unilateral CP, Gross Motor Function Classification System (GMFCS) Level II. Optimal care was codified as a cluster of four components including physical medicine and rehabilitation (PMR) care, spasticity management, physical therapy (PT), and occupational therapy (OT). A Receipt of Care Score (ROCS) quantified the degree of adherence to recommendations and was compared with the Pediatric Outcomes Data Collection Instrument (PODCI) and Pediatric Quality of Life Inventory (PEDS QL)., Results: The two children (12 year old female, 13 year old male) had nearly identical PMR and spasticity component scores while PT and OT scores were more divergent. Functional outcomes were higher for the child who had higher adjusted ROCS., Conclusions: ROCSs demonstrate variation in real-world care delivered over time and differentiate between components of care. ROCSs reflect overall function and quality of life. The ROCS methods developed are novel, robust, and scalable and will be tested in a larger sample.IMPLICATIONS FOR REHABILITATIONOptimal practice, with an emphasis on integrated multidisciplinary care, can be defined and quantified utilizing evidence-based recommendations.Receipt of optimal care for childhood cerebral palsy can be scored using existing electronic health record data.Big Data approaches can contribute to the understanding of current care and inform approaches for improved care.

Objective: Provide proof-of-concept for development of a Pediatric Functional Status eScore (PFSeS). Demonstrate that expert clinicians rank billing codes as relevant to patient functional status and identify the domains that codes inform in a way that reliably matches analytical modeling., Design: Retrospective chart review, modified Delphi, and nominal group techniques., Setting: Large, urban, quaternary care children's hospital in the Midwestern United States., Participants: Data from 1955 unique patients and 2029 hospital admissions (2000-2020); 12 expert consultants representing the continuum of rehabilitation care reviewed 2893 codes (procedural, diagnostic, pharmaceutical, durable medical equipment)., Main Outcome Measures: Consensus voting to determine whether codes were associated with functional status at discharge and, if so, what domains they informed (self-care, mobility, cognition/ communication)., Results: The top 250 and 500 codes identified by statistical modeling were mostly composed of codes selected by the consultant panel (78%-80% of the top 250 and 71%-78% of the top 500). The results provide evidence that clinical experts' selection of functionally meaningful codes corresponds with codes selected by statistical modeling as most strongly associated with WeeFIM domain scores. The top 5 codes most strongly related to functional independence ratings from a domain-specific assessment indicate clinically sensible relationships, further supporting the use of billing data in modeling to create a PFSeS., Conclusions: Development of a PFSeS that is predicated on billing data would improve researchers' ability to assess the functional status of children who receive inpatient rehabilitation care for a neurologic injury or illness. An expert clinician panel, representing the spectrum of medical and rehabilitative care, indicated that proposed statistical modeling identifies relevant codes mapped to 3 important domains: self-care, mobility, and cognition/communication., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings., Design: Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus., Participants: The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations., Results: The first 2 Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.', Conclusions: New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Children who experience traumatic brain injury (TBI) of any severity may need accommodations when they return to school-the setting that manages academic achievement and learning. However, variations exist in current return to school (RTS) programs that address a child's transition to school following TBI. This article describes some of these return to school (RTS) programs and how they vary by setting., Design: This article provides insights from a modified evaluability assessment that examined RTS programs and their readiness for rigorous evaluation. A secondary analysis was conducted to better describe the types and location of programs examined., Results: Differences exist in program structure, access, and how care for children is monitored over time. RTS programs that serve children following TBI are located in healthcare settings, schools, and state agencies and vary in models of care due to their location and organizational structure., Conclusions: Children who experience TBI benefit from a healthcare assessment and follow-up upon RTS that includes parental involvement. Models of care for this process vary based on program location and organizational structure. Further research and program evaluation are needed to better understand effectiveness and how to optimally monitor and care for children returning to school after a concussion or TBI., Competing Interests: The authors declare no conflicts of interests.

Competing Interests: The authors declare no conflicts of interest.

Objective: To synthesise the evidence regarding the risks and benefits of physical activity (PA), prescribed aerobic exercise treatment, rest, cognitive activity and sleep during the first 14 days after sport-related concussion (SRC)., Design: Meta-analysis was performed for PA/prescribed exercise interventions and a narrative synthesis for rest, cognitive activity and sleep. Risk of bias (ROB) was determined using the Scottish Intercollegiate Guidelines Network and quality assessed using Grading of Recommendations, Assessment, Development and Evaluations., Data Sources: MEDLINE, Embase, APA PsycInfo, Cochrane Central Register of Controlled Trials, CINAHL Plus and SPORTDiscus. Searches were conducted in October 2019 and updated in March 2022., Eligibility Criteria: Original research articles with sport-related mechanism of injury in >50% of study sample and that evaluated how PA, prescribed exercise, rest, cognitive activity and/or sleep impact recovery following SRC. Reviews, conference proceedings, commentaries, editorials, case series, animal studies and articles published before 1 January 2001 were excluded., Results: 46 studies were included and 34 had acceptable/low ROB. Prescribed exercise was assessed in 21 studies, PA in 15 studies (6 PA/exercise studies also assessed cognitive activity), 2 assessed cognitive activity only and 9 assessed sleep. In a meta-analysis of seven studies, PA and prescribed exercise improved recovery by a mean of -4.64 days (95% CI -6.69, -2.59). After SRC, early return to light PA (initial 2 days), prescribed aerobic exercise treatment (days 2-14) and reduced screen use (initial 2 days) safely facilitate recovery. Early prescribed aerobic exercise also reduces delayed recovery, and sleep disturbance is associated with slower recovery., Conclusion: Early PA, prescribed aerobic exercise and reduced screen time are beneficial following SRC. Strict physical rest until symptom resolution is not effective, and sleep disturbance impairs recovery after SRC., Prospero Registration Number: CRD42020158928., Competing Interests: Competing interests: JJL receives grant/research support from NIH, DoD and AMSSM. He is a member of the Scientific Advisory Boards for Neuronasal, Highmark Innovations and Quadrant Biosciences; has minority stock options in Highmark Innovations and 360 Concussion Care; is an expert consultant to NCAA; consults with NFL and NHL teams on athlete care but does not receive any compensation from these organisations. GAD is an honorary member of the AFL Concussion Scientific Committee and has attended meetings organised by sporting organisations including the NFL, NRL, IIHF and FIFA; however, he has not received any payment, research funding or other monies from these groups other than for travel costs. BW receives grant/research support from NIH, DoD and AMSSM. NDS receives clinical consulting fees from the National Hockey League and Major League Soccer. BGK receives grant support from NIH. IG receives funding from Fonds de la recherche du Québec–Santé; Canadian Institutes of Health Research; Research Institute of the McGill University Health Center; School of Physical and Occupational Therapy, McGill University. CCG receives grant/research support from Hit-IQ (2022–2023); NIH NINDS (R01 NS110757 2019–2024); NINDS (U54 NS121688 2021–2026); UCLA Brain Injury Research Center, UCLA Steve Tisch BrainSPORT Program, Easton Clinic for Brain Health; a clinical consultant (provides clinical care to athletes) for NBA, NFL-Neurological Care Program, NHL/NHLPA, Los Angeles Lakers; a member of the Advisory Boards (non-compensated) for Major League Soccer, National Basketball Association and US Soccer Federation, as well as Advisory Boards (stock shareholder) for Highmark Interactive; other financial or material support: book royalties—Blackwell/Wiley Publishing: prioritised neurological differential diagnosis. KJS is a lead and coinvestigator on grants related to concussion and traumatic brain injury funded by several governments or other organisations (including but not limited to the Canadian Institutes of Health Research, Canadian Academy of Sport and Exercise Medicine, National Football League Scientific Advisory Board, Public Health Agency of Canada/Parachute Canada, Hotchkiss Brain Institute, Wellcome Trust, International Olympic Committee, Highmark Innovations, Mitacs Accelerate, University of Calgary), with funds paid to her institution and not to her personally. She is an associate professor and clinician scientist at the University of Calgary in the Sport Injury Prevention Research Centre and is a physiotherapy consultant, primarily working with patients with concussion and traumatic brain injuries. She is an associate editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is coordinating the writing of the systematic reviews that will inform the 6th International Consensus on Concussion in Sport, for which she has received an educational grant to assist with the administrative costs associated with the writing of the reviews. She is a member of the Scientific Advisory Board for Eye Guide (share options), and member of the AFL Concussion Scientific Committee (unpaid position) and Brain Canada (unpaid position)., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The present study examined the differential effect of the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism on neuropsychological functioning in children with traumatic brain injury (TBI) relative to orthopedic injury (OI)., Methods: Participants were drawn from a prospective, longitudinal study of children who sustained a TBI ( n = 69) or OI ( n = 72) between 3 and 7 years of age. Children completed a battery of neuropsychological measures targeting attention, memory, and executive functions at four timepoints spanning the immediate post-acute period to 18 months post-injury. Children also completed a comparable age-appropriate battery of measures approximately 7 years post-injury. Parents rated children's dysexecutive behaviors at all timepoints., Results: Longitudinal mixed models revealed a significant allele status × injury group interaction with a medium effect size for verbal fluency. Cross-sectional models at 7 years post-injury revealed non-significant but medium effect sizes for the allele status x injury group interaction for fluid reasoning and immediate and delayed verbal memory. Post hoc stratified analyses revealed a consistent pattern of poorer neuropsychological functioning in Met carriers relative to Val/Val homozygotes in the TBI group, with small effect sizes; the opposite trend or no appreciable effect was observed in the OI group., Conclusions: The results suggest a differential effect of the BDNF Val66Met polymorphism on verbal fluency, and possibly fluid reasoning and immediate and delayed verbal memory, in children with early TBI relative to OI. The Met allele-associated with reduced activity-dependent secretion of BDNF-may confer risk for poorer neuropsychological functioning in children with TBI.

Aim: To predict ambulatory status and Gross Motor Function Classification System (GMFCS) levels in patients with cerebral palsy (CP) by applying natural language processing (NLP) to electronic health record (EHR) clinical notes., Method: Individuals aged 8 to 26 years with a diagnosis of CP in the EHR between January 2009 and November 2020 (~12 years of data) were included in a cross-sectional retrospective cohort of 2483 patients. The cohort was divided into train-test and validation groups. Positive predictive value, sensitivity, specificity, and area under the receiver operating curve (AUC) were calculated for prediction of ambulatory status and GMFCS levels., Results: The median age was 15 years (interquartile range 10-20 years) for the total cohort, with 56% being male and 75% White. The validation group resulted in 70% sensitivity, 88% specificity, 81% positive predictive value, and 0.89 AUC for predicting ambulatory status. NLP applied to the EHR differentiated between GMFCS levels I-II and III (15% sensitivity, 96% specificity, 46% positive predictive value, and 0.71 AUC); and IV and V (81% sensitivity, 51% specificity, 70% positive predictive value, and 0.75 AUC)., Interpretation: NLP applied to the EHR demonstrated excellent differentiation between ambulatory and non-ambulatory status, and good differentiation between GMFCS levels I-II and III, and IV and V. Clinical use of NLP may help to individualize functional characterization and management., What This Paper Adds: Natural language processing (NLP) applied to the electronic health record (EHR) can predict ambulatory status in children with cerebral palsy (CP). NLP provides good prediction of Gross Motor Function Classification System level in children with CP using the EHR. NLP methods described could be integrated in an EHR system to provide real-time information., (© 2022 Mac Keith Press.)

Background: In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes., Methods: Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category., Results: Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions., Conclusion: This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research., Level of Evidence: Diagnostic Tests or Criteria; Level IV., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The objective of this study was to examine the impact of preinjury attention-deficit/hyperactivity disorder (PADHD) and secondary ADHD (SADHD) on outcomes after pediatric traumatic brain injury (TBI)., Methods: Two hundred eighty-four individuals aged 11 to 18 years hospitalized overnight for a moderate-to-severe TBI were included in this study. Parents completed measures of child behavior and functioning and their own functioning. Linear models examined the effect of ADHD status (PADHD vs SADHD vs no ADHD) on the child's executive functioning (EF), social competence, and functional impairment, and parental depression and distress., Results: ADHD status had a significant effect on EF [F(2,269] = 9.19, p = 0.0001), social competence (F[2,263] = 32.28, p < 0.0001), functional impairment (F[2,269] = 16.82, p < 0.0001), parental depression (F[2,263] = 5.53, p = 0.005), and parental distress (F[2,259] = 3.57, p = 0.03). PADHD and SADHD groups had greater EF deficits, poorer social competence, and greater functional impairment than the no ADHD group. The SADHD group had greater levels of parental depression than the no ADHD and PADHD groups, and the SADHD group had higher parental distress than the no ADHD group., Conclusion: The results highlight the importance of early identification and management of ADHD symptoms after injury to mitigate downstream functional problems. Supporting parents managing new-onset ADHD symptoms may also be important., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To explore adolescent and parent perceptions of the impact of a concussion/mild traumatic brain injury (mTBI) on family functioning and activity levels in the first 4 weeks of recovery., Setting: Outpatient research setting., Participants: Twenty-seven adolescents (aged of 13-17 years) within 1 week of a concussion/mTBI and a parent/guardian were enrolled in the study., Design: Prospective ecological study with qualitative, semistructured interviews., Main Measures: Adolescents reported symptoms electronically every 2 days for 28 days via the Post-Concussion Symptom Inventory. Semistructured interviews were completed with each adolescent-parent dyad at the end of the 28-day period. Interview questions focused on perceptions of recovery progress and study procedures., Results: Symptom trajectories were variable across participants. Three main themes emerged from thematic analysis, including: (1) disruption of routines and activities, (2) injury management considerations, and (3) positive and negative influential factors (eg, school and coach support, timing of injury, and recovery expectations). Results highlighted nuances of recovery challenges that families specifically face and help emphasize the potential benefits of shared decision-making and where more guidance would be appreciated such as more specific self-management of symptoms and physical activity reintegration strategies., Conclusions: Study findings support a shared decision-making approach with the identified themes as potential topics to help consider social and environmental influences on recovery. The themes presented in the results could be topics emphasized during intake and follow-up visit processes to help guide plans of care and return-to-activity decisions., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To understand usage patterns of SMART (Self-Monitoring Activity Regulation and Relaxation Treatment) mHealth app among adolescents with acute mild traumatic brain injuries (mTBIs) and to identify individual characteristics that influenced app usage., Setting: Emergency departments of tertiary care children's medical center., Participants: Children aged 11 to 18 years with mTBI in the past 2 weeks, English-speaking, no evidence of severe TBI, and no preexisting neurological impairment., Design: Nested cohort of the intervention arm of a randomized clinical trial (n = 34)., Mhealth App Intervention: SMART was a month-long educational program on mTBI designed to promote self-monitoring and management of recovery. SMART included digital symptom and activity self-monitoring surveys, feedback on symptom changes, and 8 modules providing psychoeducation, strategies for symptom management, and training in active problem solving., Main Measures: App usage time, navigation, and interaction data were automatically collected. Usage involved inputting symptom ratings/activities and reviewing modules. Patterns of symptom/activity reporting and completion of learning modules data were analyzed. Predictors of app utilization, including individual characteristics, resilience (Connor-Davidson Resilience Scale), and coping (Coping Strategies Inventory-Short Form), were analyzed using Spearman correlations., Results: Participants completed symptom monitoring an average of 9 days over the month. Participants completed an average of 1.87 learning modules out of 7. Parent income and education, comorbid attention-deficit/hyperactivity disorder (ADHD), and emotional engagement coping style predicted symptom monitoring. Parental income, comorbid ADHD, and greater reliance on emotional engagement coping predicted module completion., Significant Adverse Events: None., Conclusion: Adolescents of higher socioeconomic status and those who manage their emotions using active engagement spent more time on both components of the SMART program., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The present study examined the differential effect of the brain-derived neurotrophic factor ( BDNF ) Val66Met polymorphism on behavioral adjustment in children with traumatic brain injury (TBI) relative to children with orthopedic injury (OI). Participants were drawn from a prospective, longitudinal study of children who sustained a TBI ( n  = 69) or OI ( n  = 72) between 3 and 7 years of age. Parents completed the Child Behavior Checklist (CBCL) at the immediate post-acute period, 6, 12, and 18 months after injury, and an average of 3.5 and 7 years after injury. Longitudinal mixed models examined the BDNF Val66Met allele status (Met carriers vs. Val/Val homozygotes) × injury group (TBI vs. OI) interaction in association with behavioral adjustment. After adjusting for continental ancestry, socioeconomic status, time post-injury, and pre-injury functioning, the allele status × injury group interaction was statistically significant for Internalizing, Externalizing, and Total Behavior problems. Post hoc within-group analysis suggested a consistent trend of poorer behavioral adjustment in Met carriers relative to Val/Val homozygotes in the TBI group; in contrast, the opposite trend was observed in the OI group. These within-group differences, however, did not reach statistical significance. The results support a differential effect of the BDNF Val66Met polymorphism on behavioral adjustment in children with early TBI relative to OI, and suggest that the Met allele associated with reduced activity-dependent secretion of BDNF may impart risk for poorer long-term behavioral adjustment in children with TBI.

Aim: To characterize the patterns of care of children with cerebral palsy (CP) in a tertiary healthcare system., Method: Electronic health record data from 2009 to 2019 were extracted for children with CP. Machine learning hierarchical clustering was used to identify clusters of care. The ratio of in-person to care coordination visits was calculated for each specialty., Results: The sample included 6369 children with CP (55.7% males, 44.3% females, 76.2% white, 94.7% non-Hispanic; with a mean age of 8y 2mo [SD 5y 10mo; range 0-21y; median 7y 1mo]) at the time of diagnosis. A total of 3.7 million in-person visits and care coordination notes were identified across 34 specialties. The duration of care averaged 5 years 5 months with five specialty interactions and 21.8 in-person visits per year per child. Seven clusters of care were identified, including: musculoskeletal and function; neurological; high-frequency/urgent care services; procedures; comorbid diagnoses; development and behavioral; and primary care. Network analysis showed shared membership among several clusters., Interpretation: Coordination of care is a central element for children with CP. Medical informatics, machine learning, and big data approaches provide unique insights into care delivery to inform approaches to improve outcomes for children with CP. What this paper adds Seven primary clusters of care were identified: musculoskeletal and function; neurological; high-frequency/urgent care services; procedures; comorbid diagnoses; development and behavioral; and primary care. The in-person to care coordination visit ratio was 1:5 overall for healthcare encounters. Most interactions with care teams occur outside of in-person visits. The ratio of in-person to care coordination activities differ by specialty., (© 2021 Mac Keith Press.)

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 ( n  = 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, p  < 0.01) and complete cisternal effacement (β = -19.4, p  < 0.05) were associated with lower motor DFQ, and intraventricular hemorrhage was associated with lower motor (β = -3.7, p  < 0.05) and cognitive DFQ (β = -4.9, p  < 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.

Objectives: 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)., Design: Retrospective observational, multicenter study., Setting: Eight acute pediatric inpatient rehabilitation facilities in the United States with specialized programs for treating patients with TBI., Participants: Children and young adults (0-21 years) with TBI (n = 234) receiving inpatient rehabilitation., Interventions: Not applicable., Main Outcome Measures: Admission and discharge status assessed by the WeeFIM Cognitive Developmental Functional Quotient (DFQ) and Cognitive and Linguistic Scale (CALS)., Results: 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., Conclusions: 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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To characterize by evidence grades and examine variation in type of physical therapy intervention delivered in routine clinical care in individuals with cerebral palsy (CP)., Methods: Retrospective data collection from the electronic record over 1 year at a tertiary care pediatric outpatient therapy division., Results: Four hundred sixty-five individuals with CP received 28 344 interventions during 4335 treatment visits. Sixty-six percent of interventions were evidence-based interventions (EBIs). Significant variation was demonstrated across Gross Motor Function Classification System levels, with children classified as level V receiving the least and level III the most. The most frequent EBIs delivered were caregiver education, motor control, functional strengthening, ankle-foot orthoses, treadmill training, and fit of adaptive equipment., Conclusions: Further work is needed to determine whether amount of EBI is related to better outcomes. Combining this information with other aspects of dose (intensity, time, and frequency) may elucidate the contribution of each with outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.)

Given sparse literature examining receipt of behavioral health service in children and caregivers following traumatic brain injury (TBI), we sought to identify predictors of unmet need. We performed an individual participant data meta-analysis using generalized linear mixed-effect models to examine predictors of behavioral health service use and unmet need. We included 572 children, ages 3 to 18, who were hospitalized overnight following complicated mild to severe TBI between 2002 and 2015. Caregivers completed ratings of depression and distress, child behavior problems, family functioning, and behavioral health service utilization. For children, unmet behavioral health service need was defined as an elevation on one or more child behavior problem scales without receipt of behavioral health services. For caregivers, unmet need was defined as an elevation on either a depression or distress scale without behavioral health service utilization. Among those with behavioral health needs, rates of unmet need were high for both children (77.8%) and caregivers (71.4%). Poorer family functioning was related to more unmet need in children (F(1, 497) = 6.57, p = 0.01; OR = 1.8) and caregivers (F(1, 492) = 17.54, p < 0.001; OR = 2.7). Children with unmarried caregivers also had more unmet behavioral health service need than those with married caregivers (F(1, 497) = 12.14, p < 0.001; OR = 2.2). In conclusion, unmet needs are common after pediatric TBI and relate to family factors. The findings underscore the importance of monitoring service needs following pediatric TBI and point to disparities in service use.

Objective: The aim of this review was to examine biopsychosocial factors associated with an increased risk of attention problems after a traumatic brain injury in children., Design: A systematic review of the literature was conducted using data sources of MEDLINE, PsycINFO, and CINAHL up to August 30, 2020. Literature primarily examined pediatric patients with traumatic brain injury and attention problems. Risk factors for attention problems posttraumatic brain injury examined in all articles were identified and grouped into broad categories of biological, psychological, and social factors. Methodological quality of each study was assessed using the modified Downs and Black checklist. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines from 2009 were used in completing this review., Results: Forty articles met inclusion criteria for this study. Overall findings were mixed but suggested that younger age at injury, presence of preinjury attention-deficit/hyperactivity disorder, poorer preinjury adaptive functioning, lower socioeconomic status, and poorer family functioning were associated with increased risk of developing attention problems posttraumatic brain injury., Conclusions: Development of attention problems after pediatric traumatic brain injury is complex and influenced by an array of biologic, environmental/social, injury-related, and host factors. Evidence is mixed, and further study is needed to better understand the relationships between these factors and how they influence attention after traumatic brain injury. Nonetheless, screening for attention problems in children with risk factors may allow for earlier identification and intervention, minimizing negative impacts of attention problems after traumatic brain injury in children. Limitations of this study included heterogeneity of studies and overall low to moderate methodological quality of studies included as measured by the modified Downs and Black checklist., To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME., Cme Objectives: Upon completion of this article, the reader should be able to: (1) Describe the importance of recognizing and identifying attention problems after traumatic brain injury in children; (2) Identify risk factors for development of attention problems after pediatric traumatic brain injury; and (3) Recognize gaps in existing literature regarding predictors of attention problems after pediatric traumatic brain injury., Level: Advanced., Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Mild Traumatic Brain Injury (mTBI) is a significant cause of morbidity for adolescents. Currently, there is a lack of evidence-based interventions to address common sequelae of mTBI. To address this gap, we designed a program to promote recovery for adolescents following mTBI. Preliminary testing of the Self-Monitoring Activity Regulation and Relaxation Treatment (SMART) program demonstrated good usability but indicated a need for modifications to the program. The SMART application was redesigned with the addition of more interactive and gamified components. Content was also reframed to specifically target and engage adolescents with mTBI. We describe the usability evaluation of the updated SMART application. Children aged 11-18 years diagnosed with mTBI who were 1 to 6 months post mTBI were recruited to participate in a 1-2-hour usability session in which they thought aloud and responded to targeted usability-related questions during their interaction with the SMART program. After completing the session, participants rated their usability experience using the System Usability Scale (SUS) and rated the overall user-friendliness of the program. Participants' responses during the session were qualitatively coded and analyzed. Six adolescents participated in a usability session (average age = 13.7 years). On the SUS, participants rated the program as highly usable (M = 85.6, SD = 3.24). They also had overwhelmingly positive feedback regarding the content, design and structure of the program. Overall, findings suggest that the redesigned SMART program was usable, acceptable, and relevant to adolescents with mTBI. Based on adolescents' feedback, additional modifications were made before the program undergoes efficacy testing., Competing Interests: Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Objective: To examine the frequency of behavioral problems after childhood traumatic brain injury (TBI) and their associations with injury severity, sex, and social environmental factors., Setting: Children's hospitals in the Midwestern/Western United States., Participants: 381 boys and 210 girls with moderate (n = 359) and severe (n = 227) TBI, with an average age at injury of 11.7 years (range 0.3-18) who were injured ≤3 years ago., Design: Secondary data analysis of a multistudy cohort., Main Measures: Child Behavior Checklist (CBCL) administered pretreatment., Results: Thirty-seven percent had borderline/clinical elevations on the CBCL Total Problem Scale, with comparable rates of Internalizing and Externalizing problems (33% and 31%, respectively). Less parental education was associated with higher rates of internalizing, externalizing, and total problems. Time since injury had a linear association with internalizing symptoms, with greater symptoms at longer postinjury intervals. Younger boys had significantly higher levels of oppositional defiant symptoms than girls, whereas older girls had significantly greater attention-deficit hyperactivity disorder symptoms than boys., Conclusions: Pediatric TBI is associated with high rates of behavior problems, with lower socioeconomic status predicting substantially elevated risk. Associations of higher levels of internalizing symptoms with greater time since injury highlight the importance of tracking children over time.

Objective: The objective of the current study was to examine the driving performance of young drivers with a history of moderate to severe traumatic brain injury (TBI) compared with an uninjured control group. The impact of cell phone related distraction (conversation and texting) and executive functioning (EF) were also explored., Method: Individuals aged 16-25 years with ( n = 19) and without ( n = 19) a history of TBI engaged in a simulated drive under 3 distraction conditions (no distraction, cell phone conversation, and texting). Mean speed, maximum speed, standard deviation of speed, standard deviation of lane position, and crash rates were used as outcomes. The Global Executive Composite (GEC) from the Behavior Rating Inventory of Executive Functioning (BRIEF) was used to measure EF., Results: Significant Injury × Distraction × GEC interaction effects were noted on max speed and speed variability, with a trending Distraction × GEC interaction noted for lane position variability. The effect of distraction was most notable among individuals with greater GEC scores, across both injury groups., Conclusions: A history of pediatric TBI did not specifically impact driving performance independent of EF, with EF playing a central role in functioning across domains of driving performance. Consistent effect of EF suggests that deficits in driving performance may be associated with EF specifically, with individuals with EF difficulties following TBI at greater risk for poor driving performance. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The addition of genetic factors to prognostic models of neurobehavioral recovery following pediatric traumatic brain injury (TBI) may account for unexplained heterogeneity in outcomes. The present study examined the cumulative influence of candidate genes involved in the inflammatory response on long-term neurobehavioral recovery in children with early childhood TBI relative to children with orthopedic injuries (OI). Participants were drawn from a prospective, longitudinal study evaluating outcomes of children who sustained TBI ( n  = 67) or OI ( n  = 68) between the ages of 3 and 7 years. Parents completed ratings of child executive function and behavior at an average of 6.8 years after injury. Exploratory unweighted and weighted polygenic risk scores (PRS) were constructed from single nucleotide polymorphisms (SNPs) across candidate inflammatory response genes (i.e., angiotensin converting enzyme [ACE], brain-derived neurotrophic factor [BDNF], interleukin-1 receptor antagonist [IL1RN], and 5'-ectonucleotidase [NT5E]) that showed nominal ( p  ≤ 0.20) associations with outcomes in the TBI group. Linear regression models tested the PRS × injury group (TBI vs. OI) interaction term and post-hoc analyses examined the effect of PRS within each injury group. Higher inflammatory response PRS were associated with more executive dysfunction and behavior problems in children with TBI but not in children with OI. The cumulative influence of inflammatory response genes as measured by PRS explained additional variance in long-term neurobehavioral outcomes, over and above well-established predictors and single candidate SNPs tested individually. The results suggest that some of the unexplained heterogeneity in long-term neurobehavioral outcomes following pediatric TBI may be attributable to a child's genetic predisposition to a greater or lesser inflammatory response to TBI.

Objective: This study examined whether carrying dopamine-related "risk" genes-either the dopamine transporter (DAT1) 10-repeat allele or dopamine receptor-4 (DRD4) 7-repeat allele-moderated the association of family environment and executive function (EF) following traumatic brain injury (TBI) in early childhood., Methods: Caregivers of children with TBI or orthopedic injury (OI) completed the Behavior Rating Inventory of Executive Function (BRIEF) at postinjury visits. General linear models examined gene by environment interactions as moderators of the effects of TBI on EF at 12 months and 7 years postinjury., Results: At 12 months, we did not find any significant gene by environment interactions. At 7 years, we found a significant 3-way interaction among combined carrier status, level of permissive parenting, and injury type. For children exposed to more optimal parenting, carriers of DAT1 and/or DRD4 risk alleles with TBI showed significantly worse parent-reported EF than carriers with OI. In those with less optimal parenting, carriers and noncarriers with TBI, as well as carriers with OI, showed significantly worse parent-reported EF than noncarriers with OI, with medium to large effect sizes., Conclusions: The findings highlight the importance of considering polygenetic and environmental factors in future studies of recovery following TBI and other injuries in childhood.

Objective: To examine the comparative effectiveness of 3 modes of family problem-solving therapy (F-PST): therapist-guided online, self-guided online, and face-to-face., Setting: Four children's hospitals and a general hospital with pediatric commitment., Participants: A total of 150 adolescents aged 14 to 18 years, previously hospitalized with traumatic brain injury (TBI), and evidence of behavior problems at enrollment., Design: Multicenter, randomized clinical trial., Main Measures: Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC), Behavior Regulation Index, and Metacognition Index, and Strengths and Difficulties Questionnaire (SDQ) Total at baseline and 6 and 9 months later., Results: Mixed-model intention-to-treat analyses of comparative effectiveness failed to reveal statistically significant differences among treatment groups. At 6 months, parent BRIEF-GEC improved for the therapist-guided and self-guided, online groups. Effects remained significant and increased in magnitude at 9 months for the self-guided online group. Scores for the Self-guided online group significantly improved from baseline to 9 months on the SDQ Total., Conclusions: This comparative effectiveness study supports the utility of both self- and therapist-guided online F-PST in improving executive function behaviors in adolescents following TBI. Further work regarding clinical implementation and how best to integrate telehealth with ongoing rehabilitation care is warranted.

Objective: The Ohio Head Injury Outcomes study was a 12-year longitudinal study of early childhood traumatic brain injury (TBI). This article reviewed the findings pertaining to caregiver and family functioning and child cognition, behavior, social competence, emotional functioning, and academics. We further considered individual and social-environmental influences on recovery and interventions., Setting: Recruitment was completed at 3 children's hospitals and 1 general hospital., Participants: Children aged 3 to 7 years at the time of injury with complicated mild to moderate and severe TBI or orthopedic injury requiring hospitalization were included., Design: A concurrent cohort/prospective research design was used. A baseline assessment was completed shortly after the injury. Follow-up assessments were completed at 6, 12, and 18 months and at an average of 38 and 82 months postinjury., Main Measures: At baseline, parents/guardians completed retrospective ratings of their child's behavioral, emotional, and social functioning preinjury. At the subsequent assessments, ratings reflected current functioning. Information about current family and caregiver functioning was collected at each time point and cognitive testing was completed at selected time points., Results and Conclusions: Recovery after TBI is complex, varies over time, and involves injury-related and premorbid influences, cognition, genetics, and caregiver and family functioning. A sizable number of children with TBI have persisting unmet clinical needs.

Objective: To examine the impact of secondary attention-deficit/hyperactivity disorder (SADHD) on long-term global and executive functioning in adolescents after traumatic brain injury (TBI)., Setting: Three tertiary cared children's hospitals and 1 general hospital., Participants: One hundred twenty children (TBI: n = 54; orthopedic injury: n = 66) without preinjury ADHD evaluated approximately 6.8 years postinjury., Design: Cross-sectional data analysis from a prospective, longitudinal study., Main Measures: Outcomes included functional impairment (Child and Adolescent Functional Assessment Scale) and executive functioning (Behavior Rating Inventory of Executive Function [BRIEF])., Results: SADHD moderated the association of injury type with the BRIEF-Behavioral Regulation Index (F1,113 = 4.42, P = .04) and the Child and Adolescent Functional Assessment Scale (F1,112 = 8.95, P = .003). TBI was only associated with poorer outcomes in the context of SADHD. SADHD was also associated with poorer outcomes on the BRIEF-Global Executive Composite (F1,113 = 52.92, P < .0001) and BRIEF-Metacognitive Index scores (F1,113 = 48.64, P < .0001) across groups. Adolescents with TBI had greater BRIEF-Global Executive Composite scores than those with orthopedic injury (F1,113 = 5.00, P = .03)., Conclusions: Although SADHD was associated with poorer functioning across groups, its adverse effects on behavioral regulation and overall functioning were amplified following TBI. TBI + SADHD may confer an elevated risk for significant impairments in early adolescence.

Objective: To examine changes in depression and distress in parents of adolescents receiving family-problem-solving therapy (F-PST) following traumatic brain injury., Method: Families of adolescents hospitalized for moderate to severe traumatic brain injury were randomized to face-to-face F-PST (34), therapist-guided online F-PST (56), or self-guided online F-PST (60). Outcomes were assessed pretreatment and 6 and 9 months later. Parents rated depression and distress on the Center for Epidemiological Studies Depression Scale and the Brief Symptom Inventory, respectively. Mixed modeling was used to examine changes over time and treatment moderators., Results: The therapist-guided online group had significant reductions in parental depression over time. Analyses of slopes of recovery revealed differential improvement on the Center for Epidemiological Studies Depression Scale between the 2 online groups, with no significant change in depressive symptoms following self-guided F-PST. On the Brief Symptom Inventory Global Severity Index, the therapist-guided online group reported significant improvement from baseline to 6 months that was maintained at 9 months. The face-to-face and self-guided online groups reported significant reductions in distress between 6 and 9 months with corresponding large effect sizes. Differences on the Center for Epidemiological Studies Depression Scale between therapist-guided and self-guided online groups at the 9-month follow-up were more pronounced in families of lower socioeconomic status, t103 = -2.87; P = .005., Conclusions: Findings provide further support for the utility of therapist-guided online F-PST in reducing parental depression and distress following pediatric traumatic brain injury and offer limited evidence of the efficacy of self-guided online treatment for these outcomes. Families of lower socioeconomic status may benefit more from therapist involvement.

Objective: To examine changes in quality of life (QoL) in adolescents receiving family problem-solving therapy (F-PST) following traumatic brain injury (TBI)., Method: Adolescents hospitalized for moderate-to-severe TBI were randomized to 1 of 3 ten-session, 6-month long treatments: face-to-face F-PST (n = 34), therapist-guided online F-PST (n = 56), and self-guided online F-PST (n = 60). Participants included 96 boys and 54 girls, of whom 124 were White and 6 were Hispanic. Outcomes were assessed pretreatment and 6 and 9 months later. Adolescents and parents rated adolescent QoL and TBI-related symptoms on the PedsQL and Health and Behavior Inventory (HBI), respectively. We used mixed modeling to examine changes over time and moderators of treatment efficacy., Results: Therapist- and self-guided online groups demonstrated improvements in parent-proxy QoL from baseline to 9 months, Cohen's d = 0.75; p = .004 and Cohen's d = 1.30; p < .001, respectively. The face-to-face group had poorer parent-proxy QoL at 6 months (M = 62, SE = 3.4) than either the therapist- (M = 70.9, SE = 2.8) or self-guided online group (M = 71.1, SE = 2.6). There were no changes or group differences in self-reported QoL over time. Similar findings were observed on the HBI. Differential treatment effects on parent-proxy outcomes were found in boys versus girls and in those from single versus 2-parent households. Improvements in parent-proxy HBI ratings mediated QoL improvements., Conclusions: Both online treatments, but not face-to-face F-PST, were associated with clinical improvements, raising questions about our current delivery paradigm. Individual and family moderators of treatment efficacy underscore the potential of personalized treatment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective: To report secondary neurocognitive and quality of life outcomes for a pilot randomized clinical trial (RCT) of aerobic training for management of prolonged symptoms after a mild traumatic brain injury (mTBI) in adolescents. Setting: Outpatient research setting. Participants: Thirty adolescents between the ages of 12 and 17 years who sustained a mTBI and had between 4 and 16 weeks of persistent post-concussive symptoms. Design: Secondary outcome analysis of a partially masked RCT of sub-symptom exacerbation aerobic training compared with a full-body stretching program highlighting cognitive and quality of life outcomes. Main Measures: The secondary outcomes assessed included neurocognitive changes in fluid and crystallized age-adjusted cognition using the National Institutes of Health (NIH) toolbox and self and parent-reported total quality of life using the Pediatric Quality of Life Inventory. Results: Twenty-two percent of eligible participants enrolled in the trial. General linear models did not reveal statistically significant differences between groups. Within group analyses using paired t -tests demonstrated improvement in age-adjusted fluid cognition [ t (13) = 3.39, p = 0.005, Cohen's d = 0.61] and crystallized cognition [ t (13) = 2.63, p = 0.02, Cohen's d = 0.70] within the aerobic training group but no significant improvement within the stretching group. Paired t -tests demonstrated significant improvement in both self-reported and parent-reported total quality of life measures in the aerobic training group [self-report t (13) = 3.51, p = 0.004, Cohen's d = 0.94; parent-report t (13) = 6.5, p < 0.0001, Cohen's d = 1.80] and the stretching group [self-report t (14) = 4.20, p = 0.0009, Cohen's d = 1.08; parent-report t (14) = 4.06, p = 0.0012, Cohen's d = 1.045]. Conclusion: Quality of life improved significantly in both the aerobic exercise and stretching groups; however, this study suggests that only sub-symptom exacerbation aerobic training was potentially beneficial for neurocognitive recovery, particularly the fluid cognition subset in the NIH Toolbox. Limited sample size and variation in outcomes measures limited ability to detect between group differences. Future research should focus on developing larger studies to determine optimal timing post-injury and intensity of active rehabilitation to facilitate neurocognitive recovery and improve quality of life after mTBI. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02035579., (Copyright © 2019 Gladstone, Narad, Hussain, Quatman-Yates, Hugentobler, Wade, Gubanich and Kurowski.)

Objective: To characterize the indications, timing, barriers, and perceived value of rehabilitation currently provided for individuals with moderate or severe traumatic brain injury (TBI) admitted to the intensive care unit (ICU) based on the perspectives of providers who work in the ICU setting., Participants: Members (n = 66) of the Neurocritical Care Society and the American Congress of Rehabilitation Medicine., Design: An anonymous electronic survey of the timing of rehabilitation for patients with TBI in the ICU., Main Measures: Questions asked about type and timing of rehabilitation in the ICU, extent of family involvement, participation of physiatrists in patient care, and barriers to early rehabilitation., Results: Sixty-six respondents who reported caring for patients with TBI in the ICU completed the survey; 98% recommended rehabilitative care while patients were in the ICU. Common reasons to wait for the initiation of physical therapy and occupational therapy were normalization of intracranial pressure (86% and 89%) and hemodynamic stability (66% and 69%)., Conclusions: The majority of providers caring for patients with TBI in the ICU support rehabilitation efforts, typically after a patient is extubated, intracranial pressure has normalized, and the patient is hemodynamically stable. Our findings describe current practice; future studies can be designed to determine optimal timing, intensity, and patient selection for early rehabilitation.

Objective: To investigate the effects of methylphenidate on long-term executive and neuropsychological functioning in children with attention problems following TBI, as well as the relationship between methylphenidate associated changes in lab-based neuropsychological measures of attentional control, processing speed, and executive functioning and parent- or self-report measures of everyday executive functioning., Method: 26 children aged 6-17 years, who were hospitalized for moderate-to-severe blunt head trauma 6 or more months previously, were recruited from a large children's hospital medical center. Participants were randomized into a double-masked, placebo-controlled cross-over clinical trial. Participants completed a comprehensive neuropsychological battery and parent- and self-report ratings of everyday executive functioning at baseline, and at 4 weeks and 8 weeks following upward titration of medication to an optimal dose or while administered a placebo., Results: Methylphenidate was associated with significant improvements in processing speed, sustained attention, and both lab-based and everyday executive functioning. Significant treatment-by-period interactions were found on a task of sustained attention. Participants who were randomized to the methylphenidate condition for the first treatment period demonstrated random or erratic responding, with slower and more variable response times when given placebo during the second period., Conclusion: Results indicate that methylphenidate treatment is associated with positive outcomes in processing speed, sustained attention, and both lab-based and everyday measures of executive functioning compared to placebo group. Additionally, results suggest sustained attention worsens when discontinuing medication. (JINS, 2019, 25, 740-749).

Objectives: To test whether genetic associations with behavioral outcomes after early childhood traumatic brain injury (TBI) are enriched for biologic pathways underpinning neurocognitive and behavioral networks. Design: Cross-sectional evaluation of the association of genetic factors with early (~ 6 months) and long-term (~ 7 years) post-TBI behavioral outcomes. We combined systems biology and genetic association testing methodologies to identify biologic pathways associated with neurocognitive and behavior outcomes after TBI. We then evaluated whether genes/single nucleotide polymorphism (SNPs) associated with these biologic pathways were more likely to demonstrate a relationship (i.e., enrichment) with short and long-term behavioral outcomes after early childhood TBI compared to genes/SNPs not associated with these biologic pathways. Setting: Outpatient research setting. Participants: 140 children, ages 3-6:11 years at time of injury, admitted for a TBI or orthopedic injury (OI). Interventions: Not Applicable. Main Outcome Measures: Child behavior checklist total problems T score. Results: Systems biology methodology identified neuronal systems and neurotransmitter signaling (Glutamate receptor, dopamine, serotonin, and calcium signaling), inflammatory response, cell death, immune systems, and brain development as important biologic pathways to neurocognitive and behavioral outcomes after TBI. At 6 months post injury, the group (TBI versus OI) by polymorphism interaction was significant when the aggregate signal from the highest ranked 40% of case gene associations was compared to the control set of genes. At ~ 7 years post injury, the selected polymorphisms had a significant main effect after controlling for injury type when the aggregate signal from the highest ranked 10% of the case genes were compared to the control set of genes Conclusions: Findings demonstrate the promise of applying a genomics approach, informed by systems biology, to understanding behavioral recovery after pediatric TBI. A mixture of biologic pathways and processes are associated with behavioral recovery, specifically genes associated with cell death, inflammatory response, neurotransmitter signaling, and brain development. These results provide insights into the complex biology of TBI recovery.

Objective: Following traumatic brain injury (TBI), depressive symptoms are common and may influence recovery. We performed a meta-analysis to estimate the benefit of antidepressants following TBI and compare the estimated effects between antidepressants and placebo., Participants: Multiple databases were searched to find prospective pharmacological treatment studies of major depressive disorder (MDD) in adults following TBI., Main Measures: Effect sizes for antidepressant medications in patients with TBI were calculated for within-subjects designs that examined change from baseline after receiving medical treatment and treatment/placebo designs that examined the differences between the antidepressants and placebo groups., Design: A random-effects model was used for both analyses., Results: Of 1028 titles screened, 11 were included. Pooled estimates showed nonsignificant difference in reduction of depression scores between medications and placebo (standardized mean difference of 5 trials = -0.3; 95% CI, -0.6 to 0.0; I = 17%), and a significant reduction in depression scores for individuals after pharmacotherapy (mean change = -11.2; 95% CI, -14.7 to -7.6 on the Hamilton Depression Scale; I = 87%)., Conclusions: This meta-analysis found no significant benefit of antidepressant over placebo in the treatment of MDD following TBI. Pooled estimates showed a high degree of bias and heterogeneity. Prospective studies on the impact of antidepressants in well-defined cohorts of TBI patients are warranted.

Objective: To characterize treatment preferences for delivery of family problem-solving treatment (F-PST) to adolescents with behavioral challenges following traumatic brain injury (TBI) and to examine associations with attrition, adherence, satisfaction, and efficacy., Method: Adolescents who had been hospitalized for moderate to severe TBI were randomized to face-to-face F-PST (n = 34), therapist-guided online F-PST (n = 56), and self-guided online F-PST (n = 60). Adolescents and parents rated treatment convenience and anticipated benefit before group assignment. Sessions completed served as an index of adherence. Satisfaction was rated posttreatment. The Behavior Rating Inventory of Executive Function and Strengths and Difficulties Questionnaire were used to assess parent-reported behavioral concerns., Results: Both parents and adolescents were more likely to agree or strongly agree that they anticipated self-guided online F-PST to be the most convenient relative to either of the therapist-involved approaches. Parents were also less likely to anticipate face-to-face treatment as most beneficial, relative to the two online treatments. Adolescent preferences were significantly related to attrition with 27% versus 13% dropout rates for those assigned to nonpreferred and preferred treatments, respectively. Parent and adolescent preferences before treatment were unrelated to post-intervention satisfaction, adherence, or improvements in parent-reported child behavior problems., Conclusions: Online treatments are perceived favorably among adolescents with TBI and their parents. For adolescents, these pretreatment preferences influenced treatment completion. Poor correspondence between initial preferences and posttreatment satisfaction and benefit suggests that therapeutic experience more strongly influences ultimate satisfaction., (© The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

A series of five randomized controlled clinical trials (RCTs) conducted between 2002 and 2015 support the potential efficacy of online family problem-solving treatment (OFPST) in improving both child and parent/family outcomes after pediatric traumatic brain injury (TBI). However, small sample sizes and heterogeneity across individual studies have precluded examination of potentially important moderators. We jointly analyzed individual participant data (IPD) from these five RCTs, involving 359 children and adolescents between the ages of 5 and 18 years, to confirm the role of previously identified moderators (child's age and pre-treatment symptom levels, parental education) and to examine other potential moderators (race, sex, IQ), using IPD meta-analysis. This reanalysis revealed statistically strong evidence that parental education, child age at baseline, IQ, sex, and parental depression level pre-treatment moderated the effect of OFPST on various outcomes. In particular, children of parents with a less than high school education exhibited fewer internalizing problems and better social competence. Children injured at an older age exhibited fewer externalizing behaviors and less executive dysfunction following OFPST. Child IQ moderated the effect of OFPST on social competence, with significantly better competence for children with lower IQ who received OFPST. Lower levels of parental depression followed OFPST among subgroups with lower IQ, boys, and higher parental depression scores at baseline. Our findings indicate that the optimal application of OFPST is likely to involve older children, those with lower IQ scores, or those from families with lower socioeconomic status (SES).

Objective: To characterize the benefits and optimal dose of long-acting methylphenidate for management of long-term attention problems after childhood traumatic brain injury (TBI)., Design: Phase 2, randomized, double-masked, placebo-controlled, dose-titration, crossover clinical trial., Setting: Outpatient, clinical research., Participants: Twenty-six children aged 6 to 17 years who were at least 6 months post-TBI and met criteria for attention-deficit hyperactivity disorder (ADHD) at the time of enrollment., Outcome Measures: Vanderbilt Rating Scale of attention problems, Pittsburgh Side Effects Rating Scale, and vital signs., Results: Among the 26 participants randomized, 20 completed the trial. The mean ages at injury and enrollment were 6.3 and 11.5 years, respectively. Eight participants had a severe TBI. On an optimal dose of medication, greater reductions were found on the Vanderbilt Parent Rating Scale for the medicated condition than for placebo (P = .022, effect size = 0.59). The mean optimal dose of methylphenidate was 40.5 mg (1.00 mg/kg/day). Preinjury ADHD diagnosis status was not associated with a differential medication response. Methylphenidate was associated with weight loss (∼1 kg), increased systolic blood pressure (∼3- to 6-point increase), and mild reported changes in appetite., Conclusion: Findings support use of long-acting methylphenidate for management of long-term attention problems after pediatric TBI. Larger trials are warranted of stimulant medications, including comparative effectiveness and combination medication and nonmedication interventions.

This study examined whether the ankyrin repeat and kinase domain containing 1 gene (ANKK1) C/T single-nucleotide polymorphism (SNP) rs1800497 moderated the association of family environment with long-term executive function (EF) following traumatic injury in early childhood. Caregivers of children with traumatic brain injury (TBI) and children with orthopedic injury completed the Behavior Rating Inventory of Executive Function (BRIEF) at post-injury visits. DNA was collected to identify the rs1800497 genotype in the ANKK1 gene. General linear models examined gene-environment interactions as moderators of the effects of TBI on EF at two times post-injury (12 months and 7 years). At 12 months post-injury, analyses revealed a significant three-way interaction of genotype with level of permissive parenting and injury type. Post hoc analyses showed genetic effects were more pronounced for children with TBI from more positive family environments, such that children with TBI who were carriers of the risk allele (T-allele) had significantly poorer EF compared with non-carriers only when they were from more advantaged environments. At 7 years post-injury, analyses revealed a significant two-way interaction of genotype with level of authoritarian parenting. Post hoc analyses found that carriers of the risk allele had significantly poorer EF compared with non-carriers only when they were from more advantaged environments. These results suggest a gene-environment interaction involving the ANKK1 gene as a predictor of EF in a pediatric injury population. The findings highlight the importance of considering environmental influences in future genetic studies on recovery following TBI and other traumatic injuries in childhood.

Background and Objectives: To determine whether online family problem-solving treatment (OFPST) is more effective in improving behavioral outcomes after pediatric traumatic brain injury with increasing time since injury., Methods: This was an individual participant data meta-analysis of outcome data from 5 randomized controlled trials of OFPST conducted between 2003 and 2016. We included 359 children ages 5 to 18 years who were hospitalized for moderate-to-severe traumatic brain injury 1 to 24 months earlier. Outcomes, assessed pre- and posttreatment, included parent-reported measures of externalizing, internalizing, and executive function behaviors and social competence., Results: Participants included 231 boys and 128 girls with an average age at injury of 13.6 years. Time since injury and age at injury moderated OFPST efficacy. For earlier ages and short time since injury, control participants demonstrated better externalizing problem scores than those receiving OFPST (Cohen's d = 0.44; P = .008; n = 295), whereas at older ages and longer time since injury, children receiving OFPST had better scores (Cohen's d = -0.60; P = .002). Children receiving OFPST were rated as having better executive functioning relative to control participants at a later age at injury, with greater effects seen at longer (Cohen's d = -0.66; P = .009; n = 298) than shorter (Cohen's d = -0. 28; P = .028) time since injury., Conclusions: OFPST may be more beneficial for older children and when begun after the initial months postinjury. With these findings, we shed light on the optimal application of family problem-solving treatments within the first 2 years after injury., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objective: To describe and synthesize the literature on adult traumatic brain injury (TBI) family caregiver and dyad intervention. TBI is a common injury that has a significant long-term impact, and is sometimes even characterized as a chronic condition. Informal (ie, unpaid) family caregivers of adults with TBI experience high rates of burnout, depression, fatigue, anxiety, lower subjective well-being, and poorer levels of physical health compared to noncaregivers. This study addresses the critical gap in the understanding of interventions designed to address the impact of TBI on adult patients and their family caregivers., Data Sources: PubMed and MEDLINE., Study Selection: Studies selected for review had to be written in English and be quasi-experimental or experimental in design, report on TBI caregivers, survivors with heavy involvement of caregivers, or caregiver dyads, involve moderate and severe TBI, and describe an intervention implemented during some portion of the TBI care continuum., Data Extraction: The search identified 2171 articles, of which 14 met our criteria for inclusion. Of the identified studies, 10 were randomized clinical trials and 4 were nonrandomized quasi-experimental studies. A secondary search to describe studies that included individuals with other forms of acquired brain injury in addition to TBI resulted in 852 additional titles, of which 5 met our inclusion criteria., Data Synthesis: Interventions that targeted the caregiver primarily were more likely to provide benefit than those that targeted caregiver/survivor dyad or the survivor only. Many of the studies were limited by poor fidelity, low sample sizes, and high risk for bias based on randomization techniques., Conclusions: Future studies of TBI caregivers should enroll a more generalizable number of participants and ensure adequate fidelity to properly compare interventions., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Physical therapy (PT) is a management strategy increasingly recognized to facilitate recovery after concussion. The purpose of this study was to investigate the safety and outcomes of multimodal impairment-based PT at varying time points after injury in youth diagnosed with concussion., Methods: Data were extracted retrospectively from medical records for patients who received PT for concussion-related impairments. Patient records were categorized into 3 cohorts on the basis of the timing of PT implementation: 0-20 days following injury (early intervention), 21 to 41 days following injury (middle intervention), and 42 or more days following injury (late intervention). The primary outcome measure was Post-Concussion Symptom Inventory score from the beginning to the end of the PT episode of care. Additional outcome measures included number of PT sessions, duration of PT episode of care (days), and occurrence of unplanned visits to a health care provider., Results: A total of 120 patient records (mean age of 14.77 years) were analyzed. Thirty-three, 39, and 48 individuals were categorized into the early, middle, and late intervention cohorts, respectively. There were no significant differences between intervention cohorts with regard to symptom change on the Post-Concussion Symptom Inventory from the beginning to the end of the PT episode of care, unplanned health care visits, number of PT sessions, or duration of PT episode of care., Discussion and Conclusions: Early initiation of PT may be safe and tolerable. Future prospective studies are needed to explore the efficacy of PT services administered early following injury to help characterize an optimal care plan for youth following concussion.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A210).