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Background The incidence of positional plagiocephaly has increased significantly over the last two decades, which has caused a service delivery challenge for pediatric neurosurgeons. As a potential solution to the long waitlists for abnormal head shape, a plagiocephaly clinic was established at BC Children's Hospital (BCCH) in Vancouver, Canada. This clinic was supervised by an occupational therapist who had been trained by a neurosurgeon to independently assess and manage patients with a referring diagnosis of positional plagiocephaly. Objectives To determine the efficiency of the BCCH Plagiocephaly Clinic in the management of positional plagiocephaly patients and to investigate the clinic's ability to appropriately identify and refer patients with craniosynostosis to pediatric neurosurgeons for further assessment. Methods A retrospective chart review was conducted to identify patients who were assessed and managed at the BCCH Plagiocephaly Clinic between 2008 and 2014. Data on patient demographics, head shape measurements, and treatment recommendations were collected, and the BC Children's neurosurgical database was cross-referenced to identify craniosynostosis cases missed by the Plagiocephaly Clinic. A descriptive analysis of the clinic's average wait times, severity of the patients' plagiocephaly, and recommended interventions was conducted. In addition, the sensitivity and specificity of the clinic's ability to appropriately refer craniosynostosis patients to pediatric neurosurgery were calculated. Results Of 1752 patients seen in the BC Children's Plagiocephaly Clinic between 2008 and 2014, 66% of patients received counseling about repositioning, 34% were referred for head banding, 19% were referred to physiotherapy for torticollis, and 1.4% were referred to the BC Children's Pediatric Neurosurgery Clinic for suspicion of craniosynostosis. The mean time from referral to first assessment by the Plagiocephaly Clinic was 41 days, and time from referral by the plagiocephaly clinic to diagnosis of craniosynostosis by a pediatric neurosurgeon was 8 days. Pediatric neurosurgeons requested imaging for 6 of the referred patients (25% ). The sensitivity and specificity of the plagiocephaly clinic for referral of craniosynostosis patients to the Pediatric Neurosurgery Clinic were 100 and 99%, respectively. Conclusion The BC Children's Plagiocephaly Clinic is efficient and safe for the initial evaluation and treatment of patients with positional plagiocephaly. The clinic's model decreases wait times, appropriately manages patients with positional plagiocephaly, screens for craniosynostosis with high sensitivity and specificity, and takes pressure off outpatient neurosurgical clinics. This model for assessment of plagiocephaly could be considered in other medical centers.

In children with spastic cerebral palsy, selective dorsal rhizotomy (SDR) is conducted to improve lower limb spasticity. Improvements in upper extremity function have also been noted in early follow-up. The purpose of this study was to determine if upper extremity improvements are sustained in the long term. A retrospective review of prospectively collected data on children who underwent SDR was conducted. Quality of Upper Extremities Skill Test (QUEST) scores for dissociated movement, grasp and total scores were compared using repeated measures ANOVA for individual patients at three time points: preoperatively, early post-operatively (≤ 2 years) and late post-operatively (9+ years). Out of 200+ patients having SDR, 32 had QUEST assessment at all three time points. Significant improvements in QUEST dissociated movement (F = 3.665, p = 0.045), grasp (F = 7.995, p = 0.001) and total scores (F = 9.471, p = 0.001) were found. Pairwise comparisons were significant from pre-operative to early post-operative times for all QUEST scores (p = 0.001, 0.003, 0.001), and this was maintained at late post-operative assessment for grasp and total scores (p = 0.02, p = 0.02). There was no significant change in scores between early and late post-operative assessment time points. Early improvements in upper extremity QUEST total scores are sustained in the long term following SDR.

OBJECTIVES: To investigate the effectiveness and feasibility of early intervention telephone counseling with parents in limiting postconcussion symptoms and impacts on children and youth. SETTING: Recruitment occurred postdischarge from one pediatric emergency department. PARTICIPANTS: Sixty-six parents of children aged 5 to 16 years with a diagnosis of a concussion injury. DESIGN: A pilot, randomized controlled study compared the efficacy of telephone counseling (reviewing symptom management and return to activity with parents at 1 week and 1 month postinjury) with usual care (no formalized follow-up). MAIN MEASURES: The Post-Concussion Symptom Inventory and the Family Burden of Injury Interview administered with parents by a blinded therapist at 3 months postinjury. RESULTS: No significant difference between the groups at 3 months postinjury in postconcussion symptoms (P =.67) and family stress (P =.647). CONCLUSION: The findings suggest that the early counseling intervention strategy trialed herein may not be effective for children and youth who experience significant postconcussion symptoms. Further research is needed to determine whether more intensive and integrated care would better serve children. Language: en

The purpose of this study is to evaluate long-term outcomes after selective dorsal rhizotomy (SDR) for children with spastic cerebral palsy. This is a retrospective review of a prospective database of patients who underwent SDR at British Columbia Children’s Hospital. Hip adductor spasticity, hip range of motion (ROM), quadriceps strength, and motor function were assessed pre-operatively, at 6 months to 5 years and more than 10 years postoperatively. Patients were stratified by Gross Motor Function Classification System (GMFCS) level into group 1 (GMFCS II and III) and group 2 (GMFCS IV and V). Forty-four patients, with mean age at SDR of 4.5 years (range 2.9–7.7), were followed for a mean 14.4 years. Spasticity (Modified Ashworth Scale) decreased 1.5 (p

The perceived need for electrophysiological guidance (EPG) during selective dorsal rhizotomy (SDR) has limited the frequency with which SDR is performed. The need for EPG during SDR has been questioned. At our institution, of200 children with SDR for spastic cerebral palsy, 22 children underwent SDR without EPG using clinical guidance (no EPG group). Electrophysiological stimulation was used to distinguish dorsal from ventral roots. The remainder had SDR with EPG. The purpose of this study was to compare outcomes between the groups having SDR with and without EPG.The 22 patients in the no EPG group were matched with 22 controls in whom EPG was used, with respect to Gross Motor Function Classification System score (GMFCS) and age. The 12-month outcomes with respect to motor function score, hip adductor spasticity (Ashworth), hip abduction range of motion (ROM), quadriceps power [Medical Research Council (MRC)], WeeFIM, Quality of Upper Extremities Skills Test (QUEST), and incidence of complications were compared.There were no statistically significant differences preoperatively with respect to GMFCS, age, gross motor function, Ashworth or MRC scores, joint ROM, WeeFIM, or QUEST. At 1 year after SDR, there were no differences between the groups in the incidence of complications or outcome measures. Percentage of dorsal roots cut was similar, but the duration of surgery was significantly shorter in the no EPG group.There was no advantage of doing SDR with EPG compared to no EPG. SDR can reasonably be done in centers where EPG is not available, but electrophysiological stimulation to distinguish dorsal from ventral roots may be useful in avoiding complications.

Many controversies exist regarding the practicality, the theoretical premises, and the supporting evidence for the use of casts in the management of joint hypomobility and hypertonia (ie, increase in joint resistance to passive movement resulting from hyperactivity of the stretch reflex and/or changes in the muscles and connective tissues). The purpose of this review was to determine current best practice for the use of casting in the rehabilitation of adults with brain injury. A systematic review was undertaken to find studies that quantified the effectiveness of casting in adults with brain injury. Thirteen articles that presented experimental or case report evidence on casting were analyzed using Sackett's levels of evidence and were examined for scientific rigor. A grade B recommendation is given for the use of casting to increase passive range of motion or to prevent its loss, and implications for further research are provided.

As the incidence of deformational plagiocephaly (DP) has risen, so has the demand on clinicians to make appropriate treatment recommendations. While knowledge of risk factors and natural history continue to evolve, there is uncertainty and controversy regarding intervention approaches. The purpose of this report is to review current treatment approaches for DP, in particular the use of orthotic helmets. A narrative literature review was conducted to summarize current evidence supporting preventative measures and re-positional and orthotic interventions. When started early at under 2 months of age, positional efforts and ‘tummy time’ can be effective in preventing and improving DP, but these strategies need to be better promoted to caregivers. The timing, severity and parental concerns as indicators for orthotic treatment are reviewed. Limitations discussed include high cost, lower level of evidence and poor understanding of long-term outcomes and caregiving implications. For optimal outcome, current evidence supports use of repositioning in young infants and start of orthotic helmet treatment for infants with significant DP at 4–6 months. Further research is needed to better understand the parameters for use (stratified by age and severity), long-term outcomes and natural history and the impact on caregiving, as well as the cultural significance of head shape.

The treatment of positional plagiocephaly is controversial. A confounding factor is the lack of a proven clinically viable measure to quantify severity and change in plagiocephaly. The use of anthropometric measurements is one proposed method. In this study, the reliability and validity for this method of measurement were investigated. Two clinicians independently recorded caliper measurements of cranial vault asymmetry (CVA) for infants referred for plagiocephaly or torticollis, and an unbiased observer recorded visual analysis scores during the same visit. CVA scores were assigned into three predetermined severity categories (normal CVA3 mm, mild/moderate CVAor= 12 mm, moderate/severe CVA12 mm). CVA measurements and visual analysis scores were recorded for 71 and 54 infants, respectively. Intrarater reliability was established (kappa = 0.98, kappa = 0.99), but inter-rater reliability was not (kappa = 0.42). In addition, the inter-rater reliability for the severity categories based upon these measures was poor (kappa = 0.28) and failed to correlate to the visual analysis (kappa = 0.31). Development of a stable and meaningful measurement system for the extent of plagiocephaly is needed to allow scientific studies of the natural history of plagiocephaly and effectiveness of interventions.