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Pediatric Stroke Rehabilitation

2016 UPDATE
February 2016

The Canadian Stroke Best Practice Recommendations for Stroke Rehabilitation, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Pediatric Stroke Rehabilitation, and all other sections of the Stroke Rehabilitation recommendations, please click on this URL which will take you to the recommendations online in the IJS: http://journals.sagepub.com/doi/pdf/10.1177/1747493016643553

For the French version of these recommendations, open the appendix at this link :  http://wso.sagepub.com/content/suppl/2016/04/18/1747493016643553.DC1/Stroke_Rehabilitation_2015_IJS_Manuscript_FINAL_FRENCH.pdf

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

Rationale

Pediatric stroke affects >10,000 Canadian children. Stroke in children is a different disease process with different mechanisms, treatments, and outcomes as compared to adults. There are many developmental factors that are involved in the growing and maturing brain. This means that the outcomes of individual strokes in patients cannot simply be determined by location of the damage and the initial physical extent of damage, but also must be evaluated with a developmental lens in mind. The long-term outcomes of individuals who may have had a stroke must be monitored for many years prior as infants and toddlers may not have the full extent of the stroke impact realized until they are adolescents or young adults.

System Implications

To ensure children who have experienced a stroke receive timely stroke rehabilitation assessment and treatments, the acute care, rehabilitation, and community organizations require:

  • An adequate complement of clinicians experienced in pediatric stroke, developmental pediatrics, and stroke rehabilitation.
  • A clear process for referral of patients to rehabilitation professionals and programs throughout childhood.
  • Programs for children with stroke established in each province and partnerships to ensure access across regions. These programs should be appropriately resourced to meet the rehabilitation frequency and intensity needs of children affected by stroke.
  • Standardized, validated, and expert consensus-based screening assessment tools and outcome measures specific to pediatric populations and training for professionals in using these tools.
  • Development or expansion of stroke rehabilitation expertise in children’s hospitals and children’s treatment centres, as needed, and integration of stroke rehabilitation needs into school supports.
  • Mechanisms to periodically re-evaluate children with stroke over their developing years to ensure that they have access to rehabilitation as appropriate, as they develop to ensure emerging or changing rehabilitation needs and goals are met.
  • Coordination and development of strong partnerships in the community, and adequate resources to ensure access to comprehensive stroke rehabilitation. This is especially important in more rural and remote geographic locations where telehealth technologies should be optimized.
  • Employers and education providers should be encouraged to provide school modifications and flexibility to allow patients to return to school.
  • Financial assistance programs for families to ensure the child’s rehabilitation and developmental needs are met after stroke.

Performance Measures

Process and Outcome Performance Measures:

  1. Rate of pediatric stroke cases in Canada diagnosed by year, stroke type, and by age group at onset (PPIS, neonatal stroke, childhood stroke).
  2. Description of stroke functional levels pre and post rehabilitation based on validated measures of stroke functions and outcomes.
  3. Distribution of stroke severity levels for all pediatric stroke patients admitted to inpatient and/or outpatient rehabilitation services following stroke.
  4. Admission destination (facility type, service, location) for pediatric stroke and TIA patients in inpatient rehabilitation facilities.
  5. Number and percentage of paediatric ischemic stroke or transient ischemic attack patients who received antithrombotic therapy prescriptions before or during rehabilitation.
  6. Rates of readmission to acute care for children with stroke.
  7. Number and rate of children with stroke who are admitted to inpatient and outpatient rehabilitation programs.
  8. Degree of functional ability of paediatric stroke or transient ischemic attack patients at discharge from acute care and rehabilitation services, using modified Rankin score).
  9. Pediatric Stroke Outcome Measure (PSOM) changes between neurology clinic follow-up visits. –Changes in scores from Recovery Recurrence Questionnaire between neurology clinic follow-up visits.
  10. Discharge destination for pediatric stroke and TIA patients following inpatient rehabilitation stay.
  11. Changes in neuropsychological evaluation outcomes between neurology clinic follow-up visits.

System Performance Measures:

  1. Improved recognition and understanding of stroke-specific issues by rehabilitation professional caring for children.
  2. Stroke-specific rehabilitation procedures and programs at tertiary care pediatric centres in all major Canadian centres.
  3. Increased community-based rehabilitation options and patient participation for children and families affected by stroke.
  4. Integrated neuropsychological testing and educational planning within the school system for children with stroke.
  5. Access to experimental interventional therapies via a national integrated clinical trials network.

Measurement Notes

  • Pediatric data could ideally be obtained from primary chart audit.
  • Data may also be accessible from the Canadian Pediatric Ischemic Stroke Registry (CPISR) managed through the hospital for Sick Children in Toronto, and/or the International Pediatric Stroke Study registry, accessed through https://app3.ccb.sickkids.ca/cstrokestudy/.
  • CIHI databases do contain information on children with stroke admitted to acute care facilities. This data is documented retrospectively and without validation studies so may be an underestimate of the total admissions for stroke in infants and children.

Implementation Resources and Knowledge Transfer Tools

Health Care Provider Information  

Patient Information

Summary of the Evidence

Evidence Table 12: Pediatric Stroke Rehabilitation

In general, there is a dearth of studies that evaluate rehabilitation interventions among the pediatric stroke population. This discussion will focus on the evidence for pediatric stroke specifically. Pediatric specific studies have been conducted in the following areas: functional electrical stimulation (FES), constraint induced movement therapy (CIMT), mirror therapy, botulinum toxin type A, and repetitive transcranial magnetic stimulation (rTMS).

Although CIMT is a widely studied therapeutic intervention in the adult stroke population, studies of its effect among pediatric stroke patients are just emerging. Taub et al. (2011) studied 20 children with congenital hemiparesis to evaluate the effect of early (immediate) versus delayed (at 6 months post stroke) CIMT. Participants were randomized initially, and then crossed over to the other treatment arm at 6 months. The authors reported that compared to the delayed group, individuals who received early CIMT had large increases on the Pediatric Motor Activity Log (p<0.0001), and that at 6-month follow-up they continued to show larger gains on the Pediatric Motor Activity Log, Pediatric Arm Function Test, as well as passive and active range of motion (ROM). These findings are supported by an earlier study by Williw et al. (2002) which also compared early (immediate) versus delayed (6 months) CIMT in a cross-over RCT. Similarly, the authors reported that participants improved in the Peabody Development Motor Scale score one month post CIMT in both groups, but only after CIMT was completed. Previous pre-post studies have also demonstrated significant improvements in amount and quality of use of the affected extremity (Karmman et al. 2003), Pediatric Motor Activity Log-Revised (Rickards et al. 2014; Sterling et al. 2013), as well as the Pediatric Arm Function Test (Rickards et al. 2014). Challenges with CIMT include fatigue and compliance with the protocol.

Functional Electrical Stimulation (FES) is a commonly used therapeutic application for adult rehabilitation patients; there is little evidence for pediatric patients. One recent pre-post study has evaluated the use of 48 hours of FES in just four pediatric stroke participants (Kapadia et al. 2014). The authors reported significant improvement on the object manipulation sub-scale of the Rehabilitation Engineering Laboratory hand Function Test; all other measures revealed no significant improvements.

The effectiveness of mirror therapy in improving upper extremity function has been assessed in a single cross-over RCT (Gygax et al. 2011). Ten children were randomized to receive bimanual training with or without a mirror for three weeks; participants then crossed over to the other arm. Gugax et al. (2011) reported that grasp strength (p=0.033) and upper limb dynamic position (p=0.044) significantly improved with training with the mirror, whereas pinch strength improved without the use of a mirror.

Botulinum toxin type A is regularly used around the world to reduce excessive tone in the spastic affected extremity of individuals post stroke. Extensive evidence exists in the adult stroke population. With the exception of studies assessing a cerebral palsy population, there has not been a studied which has examined the use of botulinum toxin specifically among pediatric stroke patients. Given the low prevalence of pediatric stroke, these patients are often combined with cerebral palsy patients in rehabilitation trials. Thus, the evidence for botulinum toxin for pediatric stroke is limited, despite extensive evidence in other populations (e.g., cerebral palsy, adult stroke).

Repetitive transcranial magnetic stimulation (rTMS) likely improves motor recovery in adult stroke and is now Health Canada approved for treating spasticity and major depression. In the pediatric stroke population, three RCTs have evaluated the effect of rTMS in improving upper extremity function. Gillick et al. (2014) reported a significant improvement among children with perinatal stroke in the rTMS group compared to the sham group on the Assisting Hand Assessment measure; however, no differences between groups were reported on the Canadian Occupational Performance Measure. Kirton et al (2015, in press) performed a factorial trial of rTMS and CIMT in 45 children with perinatal stroke and hemiparesis, demonstrating additive effects lasting 6 months when combined with 2 weeks of intensive motor therapy. Kirton et al. (2008) also examined ten children with childhood stroke receiving either active or sham rTMS with possible modest improvements noted in grip strength and the Melbourne Assessment of Upper Extremity Function measure.

Overall, there has been limited research evaluating the use of specific rehabilitation interventions in the pediatric population, although multiple studies, some with small numbers, are increasingly being added. Studies from adult stroke populations have shown various treatments to be effective in improving outcomes. As a result, many of the therapies used among children have been derived from research study and clinical use in the older population. Future studies should recruit a greater number of pediatric stroke participants and evaluate a wide range of interventions. Adherence to strict methodological protocols would be beneficial in comparing between studies.

Finally, it is worth noting that the psychological well-being of the entire family is an important component of pediatric stroke rehabilitation. Often, the cause of perinatal stroke cannot be identified and, as such, parents, particularly mothers, place blame on themselves or doctors and health care professionals. This is largely the result of receiving a gross amount of medical information (or misinformation) during pregnancy. Important research has begun to be investigated in this area. Bemister et al. (2014) reported that when compared to mothers of children without stroke, those who had a child that suffered a stroke were significantly more depressed. Further, there were significant differences in family functioning, parent health-related quality of life, and marital satisfaction. When specifically comparing mothers and fathers of children with pediatric stroke, mothers were found to have significantly higher anxiety and guilt regarding their child’s condition. In a follow-up study, Bemister et al. (2015) reported that several factors including stroke severity, anxiety, social support, stress levels, marital quality, guilt, and blame significantly predicted a caregiver’s depression. In addition to these variables, cognitive and behavioural impairments also predicted family functioning. These psychological complications among parents add to the overall morbidity incurred by the family. Simple educational interventions are likely very effective at reducing or eliminating this complication; however, there are few studies which have assessed these therapeutic strategies and therefore, would be an important avenue for future research.