Jennifer L. Ryan

Background: Youth with persisting symptoms after concussion (PSaC) can experience ongoing physical, cognitive, and emotional challenges, and their caregivers experience increased stress. There are currently limited interventions that support youth with PSaC or their caregivers. Move&Connect is a virtual group program with 2 parallel interventions: Move&Connect-Youth ( M&C-Y ) and Move&Connect-Caregivers ( M&C-C ). M&C-Y includes concussion education, active rehabilitation, and goal setting. M&C-C uses psychoeducation and practical tools to promote family communication and problem solving. Objective: Within the context of a broader pilot study of M&C-Y and M&C-C , we completed a fidelity and engagement evaluation with the objectives of (1) evaluating intervention fidelity and (2) exploring facilitators and barriers to youth and caregiver engagement. Methods: M&C-Y and M&C-C were delivered virtually using Zoom Healthcare and ran in parallel. Youth with PSaC and caregivers were recruited from a children’s rehabilitation hospital in Ontario, Canada. Intervention fidelity was evaluated according to the 5 principles of fidelity from Bellg et al: design, training, delivery, receipt, and enactment. Intervention delivery, attendance, and engagement ratings were monitored through weekly logs and field notes. Participants completed exit satisfaction surveys, and a subset of youth and caregivers completed semistructured interviews to understand facilitators and barriers to engagement. Descriptive statistics were used to analyze logs and surveys. Directed content analysis, guided by a motivational framework, and inductive coding to identify barriers and facilitators to engagement were applied to qualitative data. Results: A total of 34 youth (age: mean 15.1, SD 2.28 years) and 36 caregivers (age: mean 48.9, SD 5.92 years) participated in 10 M&C-Y and 9 M&C-C groups, respectively. Most youth identified as girls (24/34, 71%), and most caregivers identified as mothers (30/36, 83%). Clinician facilitators adhered to the components of the intervention protocols between 92% and 97% of the time in M&C-Y and 82% and 93% of the time in M&C-C . The majority of youth (22/34, 65%) and caregivers (24/36, 67%) attended 5 or more sessions. In addition, 82% (28/34) of youth and 94% (34/36) of caregivers agreed they would recommend the interventions to others. Qualitative findings revealed youth engagement was supported by motivation, comfort in the virtual setting, interactive intervention components, feelings of trust, and diverse and modifiable exercises. Barriers to youth engagement included ongoing symptoms, discrepancies between exercises and physical abilities, and previous knowledge of education. Caregiver engagement was facilitated by perceived benefits of M&C-C , emotional connection and validation, and comfort and convenience of the virtual setting. Barriers to caregiver engagement included stress, competing scheduling demands, and limited reminders or access to intervention materials. Conclusions: The pilot study of M&C-Y and M&C-C was conducted with high delivery adherence. Exit satisfaction surveys combined with qualitative data revealed high levels of caregiver satisfaction and engagement, whereas youth satisfaction and engagement had some variability, particularly related to the exercise. Findings demonstrate important implications for delivering virtual group interventions for youth with PSaC and their caregivers.

Concussion is a common sport injury with serious health implications [1–3]. Managing the return-to-play (RTP) process after concussion is essential, as premature RTP may lead to repeat injury [4–6]...

Background: To address the cognitive difficulties that pediatric brain tumor survivors (PBTS) experience and the potential for exercise to ameliorate these challenges, we evaluated the feasibility of a hospital-led group exercise program for PBTS. Following promising preliminary cognitive outcomes, we developed a web resource (Fitness to Aid the Brain and Cognitive Skills [Fit ABCS]) that trains community fitness instructors to deliver the same program. This study evaluated the feasibility of a community-led group exercise program for PBTS using Fit ABCS. Methods: Fitness instructors were recruited through Wellspring, a community network of cancer support programs and services with varying levels of experience. They completed the FitABCS Training Module, which taught them about the exercise program content, the ways to modify exercises for PBTS, and how to use the online platform to plan for and document exercise sessions. PBTS (6-17 years old) were recruited through the Neuro-oncology program at the Hospital for Sick Children (Toronto, Canada). Eligible PBTS completed the 12-week exercise program (3 sessions/week) with assessments at baseline, post-intervention, and 3-month follow-up. At least two instructors were present for each exercise session. Prior to the exercise session, the instructors used Fit ABCS to plan the exercises, games, and/or sports that would take place in the session. The instructors also used FitABCS to document attendance and the challenges/successes encountered in each session. Feasibility indicators (participant recruitment, attendance, adherence, instructor adherence [2], acceptability [2]) were evaluated with Bayesian statistics. Results: Ten fitness instructors facilitated 5 program cohorts involving 16 PBTS. Posterior means for participant recruitment (14%), adherence (33%), and attendance (78%) fell below a priori mean targets (20%, 80%, 80%, respectively), and instructor adherence (95%, 97%) and acceptability ratings (81%, 82%) surpassed a priori mean targets (80%). Posterior probabilities fell below our 80% target for all indicators except instructor adherence. Conclusions: Based on instructor feedback and study team observations, we developed recommendations to increase the success of future exercise trials for PBTS: provide consistent, comprehensive instructor training, document and reflect on exercise sessions, conduct multi-site research involving more diagnostic groups, minimize participant burden, and obtain program-specific feedback from instructors and participants.

BACKGROUND Youth with persisting symptoms after concussion (PSaC) can experience ongoing physical, cognitive, and emotional challenges, and their caregivers experience increased stress. There are currently limited interventions that support youth with PSaC or their caregivers. Move&Connect is a virtual group program with two parallel interventions: Move&Connect-Youth (M&C-Y) and Move&Connect-Caregivers (M&C-C). M&C-Y includes concussion education, active rehabilitation, and goal setting. M&C-C uses psychoeducation and practical tools to promote family communication and problem solving. OBJECTIVE We will examine a pilot study of M&C-Y and M&C-C with the objectives of: (1) evaluating intervention fidelity and (2) exploring facilitators and barriers to youth and caregiver engagement. METHODS M&C-Y and M&C-C were delivered virtually using Zoom Healthcare and ran in parallel. Youth with PSaC and caregivers were recruited from a children’s rehabilitation hospital in Ontario, Canada. Intervention fidelity was evaluated according to Bellg’s five principles of fidelity: design, training, delivery, receipt, and enactment. Intervention delivery, attendance and engagement ratings were monitored through weekly logs and fieldnotes. Participants completed exit satisfaction surveys and a subset of youth and caregivers completed semi-structured interviews to understand facilitators and barriers to engagement. Descriptive statistics were used to analyze logs and surveys. Directed content analysis, guided by a motivational framework, and inductive coding to identify barriers and facilitators to engagement was applied to qualitative data. RESULTS A total of 34 youth (M=15.1 years; SD=2.28) and 36 caregivers (M=48.9 years; SD=5.92) completed ten M&C-Y and nine M&C-C groups. Most youth identified as girls (n=24; 71%) and caregivers as mothers (n=30; 83%). Clinician facilitators adhered to the components of the intervention protocols between 97-92% of the time in M&C-Y and 93-82% in M&C-C. The majority of youth (n=22; 65%) and caregivers (n=24; 67%) attended 5 or more sessions. Youth satisfaction was more variable than caregivers’, with 82% of youth and 94% of caregivers agreeing they would recommend the interventions to others. Qualitative findings revealed examples of cognitive, affective, and behavioral engagement. Youth engagement was supported by motivation, comfort in the virtual setting, interactive intervention components, feelings of trust, and diverse and modifiable exercises. Barriers to youth engagement included ongoing symptoms, discrepancies between exercises and physical abilities, and previous knowledge of education. Caregiver engagement was facilitated by perceived benefits of M&C-C, emotional connection and validation, and comfort and convenience of the virtual setting. Barriers to caregiver engagement included high stress, competing scheduling demands, and a lack of reminders or access to intervention materials. CONCLUSIONS The pilot study of M&C-Y and M&C-C was delivered with high fidelity. Exit satisfaction surveys combined with qualitative data revealed high levels of participant satisfaction and engagement with the interventions. Findings demonstrate important implications for delivering virtual group interventions for youth with PSaC and their caregivers. CLINICALTRIAL Trial Registration: NCT05631301

Background: While exercise training and metformin treatment have demonstrated preliminary cognitive improvements in pediatric brain tumor (PBT) survivors, the neuronal mechanisms underlying their cognitive improvements are unclear. Diffusion‐weighted metrics (e.g., fractional anisotropy [FA]) are commonly used to evaluate remyelination, but magnetization transfer imaging is thought to be more sensitive to myelin plasticity.Methods: We compared white matter changes after exercise and metformin interventions by evaluating magnetization transfer ratio (MTR) and FA changes in irradiated PBT survivors who completed either an exercise (NCT01944761) or metformin pilot trial (NCT02040376) (30 participants: exercise n = 11, metformin n = 12, and control n = 7). Then, we explored correlations between MTR and cognitive outcomes.Results: There were significant MTR changes in three brain regions (right forceps minor in both interventions, right inferior and superior longitudinal fasciculi in the exercise group), but no significant FA changes. MTR increases occurred in the right forceps minor in the exercise and metformin groups compared with the control group (p < 0.033), and in the superior longitudinal fasciculus in the exercise group compared with the control group (p = 0.016). Preliminary correlations between MTR and cognitive changes were not significant after correcting for multiple comparisons.Conclusions: Our results suggest that 12 weeks of exercise or metformin intervention may promote remyelination in PBT survivors in brain regions involved in memory and executive function, and there may be differences in the brain regions affected by each intervention. This work sets the stage for larger clinical trials to identify definitive differences in MTR and validate their association with cognition.

Purpose: Evaluate the feasibility of transcranial direct current stimulation (tDCS) as an adjunct to inpatient physiotherapy for children and youth with acquired brain injury (ABI). Method: This randomized feasibility trial allocated children (5–18 years of age with moderate to severe ABI) to receive either active or sham anodal tDCS immediately prior to 16 of their existing inpatient physiotherapy sessions. Participants, physiotherapists, assessors, and primary investigators were blinded to treatment allocation. Eligibility, recruitment, retention, tolerance, and preliminary treatment outcomes were evaluated against a priori feasibility targets. Results: Of 232 children admitted over 21 months, six were eligible (2.6%) and four were recruited (66.7%). One participant completed the entire study protocol, two were withdrawn for unrelated changes in medical stability, and one could not commence the study due to COVID-19 restrictions. Participants completed all tDCS sessions that were started with the primary transient side effect being sub-electrode itchiness. Conclusions: While the study was infeasible from eligibility and retention perspectives, study procedures (e.g., assessment, treatment, side effect tracking, physiotherapy documentation) were viable and should be applied to future paediatric tDCS studies.

Motor evoked potential amplitude (MEP_amp) is frequently measured in transcranial direct current stimulation (tDCS) studies that target the primary motor cortex (M1), and a subset of these studies involve motor behavior. This systematic review explored the role of MEP_amp as an indicator of neural change in M1-targeted tDCS studies involving motor behavior (i.e., motor practice and/or evaluation of motor performance) in healthy individuals, and examined the association between changes in motor performance and MEP_amp. We executed our search strategy across four bibliographic databases. Twenty-two manuscripts met eligibility criteria. While anodal tDCS combined with motor practice frequently increased MEP_amp, MEP_amp outcomes did not necessarily align with changes in motor performance. Thus, MEP_amp may not be the most appropriate indicator of neural change in tDCS studies that aim to improve motor performance.

Describe how transcranial direct current stimulation (tDCS) was incorporated into an inpatient physiotherapy program for an adolescent with severe traumatic brain injury (TBI), detail the motor lea...

Aim: To estimate gross motor change in inpatient school‐aged children with subacute acquired brain injury (ABI), identify factors associated with gross motor change, and describe inpatient physiotherapy focus.Method: This retrospective chart review involved inpatient children (5–18 years) with subacute ABI who had either two Gross Motor Function Measure (GMFM‐88) assessments or one GMFM‐88 with another pre/post gross motor outcome measure. Outcome change scores and Goal Attainment Scaling (GAS) T scores were calculated. Regression analyses examined factors predicting gross motor change. GAS goal areas were analysed to determine physiotherapy focus.Results: Of the 546 charts screened, 266 (118 female) met study criteria. The GMFM‐88 was generally administered first, followed by other measures. GMFM‐88 (n = 202), Community Balance and Mobility Scale (n = 89), and Six‐Minute Walk Test (6MWT) (n = 98) mean change scores were 18.03% (SD 19.34), 17.85% (SD 10.77), and 142.3 m (SD 101.8) respectively. The mean GAS T score was 55.06 (SD 11.50). Lower baseline scores and increased time between assessments were most predictive of greater GMFM‐88 change (r ≥ 0.40). Twenty‐five percent of GAS goals were ambulation‐based.Interpretation: Appropriate outcome measure selection is integral to detecting gross motor change in pediatric inpatient ABI rehabilitation. Mean change score estimates can be used to compare standard inpatient rehabilitation with new treatment approaches.

Purpose: Documenting the use of motor learning strategies (MLS) in physiotherapy is a foundational step in understanding the effectiveness of motor skills–based treatments in paediatric acquired brain injury (ABI). The purpose of this study was to estimate the inter- and intrarater reliability of the revised Motor Learning Strategies Rating Instrument (MLSRI–22) in physiotherapy for children and youth with ABI when administered by trained student physiotherapists. The MLSRI–22 was then used to describe the MLS content of traditional and robotic treadmill training physiotherapy sessions for children with ABI to demonstrate its application. Method: Thirty videos of children with ABI receiving Lokomat or traditional physiotherapy were rated using the MLSRI–22. Inter- and intrarater reliability were estimated using intra-class correlation coefficients (ICCs). Mean MLSRI–22 item scores described the MLS session content. Results: MLSRI–22 total score inter- and intrarater ICCs were 0.81 (95% CI: 0.61, 0.91) and 0.95 (95% CI: 0.90, 0.98), respectively. There were similarities and differences in MLS content between treatment approaches. Conclusions: Trained assessors can reliably administer the MLSRI–22 in physiotherapy for children with ABI. Research using MLSRI–22 scores to explore and systematically compare MLS across treatment approaches may provide insight into their effectiveness and contribute to MLS practice guidelines for children with ABI.