The guideline for the subacute management of childhood stroke. has been developed with,Endorsed by, Suggested citation Victorian Subacute Childhood Stroke Advisory Committee Guideline for the subacute management. of childhood stroke 2019, Copyright information The cover image of the child may not be used or reproduced in any manner without the express. written consent of the Murdoch Children s Research Institute. Disclaimer This document has been produced by the Murdoch Children s Research Institute for use by health. professionals The statements and recommendations are evidence based unless labelled as consensus based. Recommendations are not to replace clinical judgement Interpretation of this document by those without appropriate. medical and or clinical training is not recommended unless in consultation with a relevant health professional. Despite the utmost care taken in developing this document the Murdoch Children s Research Institute cannot accept. any liability including loss or damage resulting from use of content or for its accuracy currency and completeness. Victorian Subacute Childhood Stroke Guidelines 2,1 Quick reference guide 6. 2 Introduction 7,3 Methodology 8,4 Framework for providing rehabilitation 10. 5 Motor function 13,6 Sensory function 14,7 Pain management 15. 8 Dysphagia and nutrition 16,9 Communication speech and language function 17. 10 Cognition 18, 11 Psychosocial emotional and behavioral function 20. 12 Activities of daily living 21,13 Participation in recreation and leisure 22. 14 Education learning and vocation 23,15 Family function 25. 16 Future research directions 26,17 References 27,Victorian Subacute Childhood Stroke Guidelines 3. ACKNOWLEDGEMENTS, The Victorian Subacute Childhood Stroke Advisory Dr Ali Crichton. Committee gratefully acknowledges the generous Clinical Neuropsychologist. contributions of the Victorian Stroke Clinical Network Monash Children s. The Department of Health and Human Services,Ms Anne Fulton. Victorian State Government and the Murdoch Children s. Speech Pathologist,Research Institute,Goulburn Valley Health. Ms Jane Galvin, Victorian Subacute Childhood Occupational Therapist. Stroke Advisory Committee The Royal Children s Hospital Melbourne. Dr Sue Greaves, Sincere thanks to all members of the steering committee Occupational Therapist. clinical advisory group and expert Delphi panelists for their The Royal Children s Hospital Melbourne. invaluable input to the development of this guideline. Dr Lyndal Hickey,Social Worker, Steering Committee The Royal Children s Hospital Melbourne. A Prof Mark Mackay Chair MBBS PhD Dr Brian Hoare,Occupational Therapist. Dr Sarah Knight PhD Monash Children s, A Prof Adam Scheinberg MBBS MMed Dr Emily Incledon. Prof Vicki Anderson PhD Clinical Psychologist,The Royal Children s Hospital Melbourne. A Prof Michael Fahey MBBS PhD,Prof Angela Morgan,Dr Jillian Rodda PhD Speech Pathologist. Murdoch Children s Research Institute,Project Coordinator Mrs Kathryn Newton. Occupational Therapist,Dr Mardee Greenham PhD Eastern Health. Ms Chloe Noble,Clinical Advisory Group Occupational Therapist. The Royal Children s Hospital Melbourne,Dr Kathleen Bakker. Clinical Neuropsychologist,Miss Clare O Donnell,Physiotherapist. The Royal Children s Hospital Melbourne,The Royal Children s Hospital Melbourne. Ms Janeen Bower,Music Therapist,Ms Jillian Steadall. Speech Therapist,The Royal Children s Hospital Melbourne. The Royal Children s Hospital Melbourne,Ms Kim Cartwright. Education Consultant,Dr Jayasri Srinivasan, Paediatric Rehabilitation Consultant and Paediatric Neurologist. The Royal Children s Hospital Melbourne,The Royal Children s Hospital Melbourne. Ms Catherine Clancy,Physiotherapist,Ms Renata Winkler. Speech Therapist,Monash Children s,Eastern Health,Dr Therese Clark. Clinical Neuropsychologist,Barwon Health,Victorian Subacute Childhood Stroke Guidelines 4. Delphi panelists Abbreviations, Vicki Anderson Kath Bakker Ella Barry Sally Bletcher AIS Arterial ischaemic stroke. Sanjay Bhate Janeen Bower Sarah Burney Frances Burns. CBR Consensus based recommendation, Jo Butchart Michelle Buttler Di Cameron Kim Cartwright. Rachael Cavanagh Catherine Clancy Therese Clark EBR Evidence based recommendation. Ali Crichton Alana Cummins Mahek Dudhwala,GDC Guideline Development Committee. Suzanne Edelmaier Adrienne Epps Michael Fahey, Allesha Fecondo Michelle Fisher Rob Forsyth mCIMT Modified constraint induced movement therapy. Adrienne Fosang Anne Fulton Jane Galvin, NHMRC National Health and Medical Research Council. Vigeya Ganesan Karen Garthwaite Anne Gordon, Sue Greaves Fay Guyatt Chatwell Hababa PSD Program for Students with Disabilities. Monika Hasnat Michele Hervatin Lyndal Hickey, Brian Hoare Deb Houston Kate Hunter Emily Incledon PNF Proprioceptive Neuromuscular Facilitation. Jacqueline Irlam Helen Jeges Renee Jenkins rTMS Repetitive transcranial magnetic stimulation. Sonia McCall White Angela Morgan Tamara Moritz, Angie Morrow Melissa Murphy Emma Naughtin SCD Sickle cell disease. Kathryn Newton Chloe Noble Jennifer Papoutsis VPRS Victorian Paediatric Rehabilitation Service. Barry Rawicki Jill Rodda Kirrily Rogers Rita Rosa, Maree Ryan Adam Scheinberg Emily Schofield Jen Sharp. Heather Sheridan Suzie Smith Karen Speedy,Tanja Spencer Jayarsi Srinivasan Jill Steadall. Michael Takagi Wendy Taverna Abby Thevarajah, Kelly Thompson Lauren Thompson Glennen Claire Toolis. Rachel Toovey Melanie Tozer Joannah Tozer Sue Tupper. Stephen Wainrib Natalie Weekley Kirsten Wilken, Fiona Wilkinson Teresa Williams Neil Wimalasundera. Renata Winkler Felicity Wood Bianca Worboyes,Meredith Wynter Suzy Young. Only names of those who consented for their names, to be acknowledged in publications are printed here. We would also like to acknowledge the guidance provided. by Tanya Medley in the development of the methodology. for this guideline,Victorian Subacute Childhood Stroke Guidelines 5. 1 QUICK REFERENCE GUIDE, Figure 1 Quick reference guide to key recommendations for the subacute rehabilitation of childhood stroke. Involvement of an interdisciplinary team,Active partnership with family. Frameworrk Criteria for determining appropriate settings for service delivery. rehabilitation Quality evaluation of service delivery. Criteria for transfer Creation of Approach, from acute hospital individualised to therapy Transition to. to subacute care plan and individual adult services. rehabilitation care goal setting and or group, Motor function Section 5 Psychological emotional and. behavioural function Section 11,Sensory function Section 6. Activities of daily living Section 12,Pain management Section 7. Interventions Participation in recreation,Dysphagia and nutrition Section 8. Sections 5 15 and leisure Section 13,Communication speech. Education learning,and language Section 9,and vocation Section 14. Cognition Section 10,Family function Section 15,Victorian Subacute Childhood Stroke Guidelines 6. 2 INTRODUCTION,2 1 Background 2 3 Clinical need for. Stroke is among the top ten causes of death in children this guideline. and more than half of survivors have long term disabilities. There is substantial evidence that coordinated, resulting in a need for high quality specialist sub acute. individualised interdisciplinary approaches to stroke. medical and rehabilitation services Contrary to commonly. rehabilitation improve outcomes in adults but no such. held views children do not recover better than adults1. systems currently exist for childhood stroke1 7 9 Further. While relatively rare estimated incidence 1 2 7 9 per 100. there are currently no available clinical guidelines for the. 0002 4 the economic cost of childhood stroke is, subacute care of childhood stroke in Australia Anecdotal. substantial5 The lifelong individual family and societal. reports from treating clinicians and parent members of the. burden of early stroke is likely to be greater than in adults. StroKidz childhood stroke advocacy support group suggest. because children surviving stroke face many more years. there is currently considerable variation in quality of. living with disability A U S case control study estimated. subacute care The development of clinical care guidelines. an average five year medical cost of 110 921 per child. and the statewide standardisation of referral and service. representing a 15 fold cost increase compared to controls5. delivery pathways across the Victorian Paediatric, Of note this figure does not capture costs of families. Rehabilitation Service VPRS will improve consistency. including loss of income reduced employment,of subacute childhood stroke care. rehabilitation expenses and psychosocial consequences. for child and family Costs are higher for childhood than. for neonatal stroke and higher for haemorrhagic than. ischaemic stroke5 Higher costs correlate with worse. 2 4 Scope and intended users, impairment emphasising the importance of rehabilitation of this guideline. to maximise recovery6, This guideline is aimed at hospital and community based. The key difference between children and adults is that healthcare professionals involved in the rehabilitative. paediatric stroke results in the inability to achieve rather management of children after stroke including. than lose functional independence Therefore the occupational therapists physiotherapists education. functional behavioural and social consequences may not consultants clinical psychologists clinical. be apparent at the time of the stroke event particularly in neuropsychologists speech pathologists social workers. very young children who typically grow into their deficits1 dietitians music therapists doctors and nurses This. guideline is intended to be used by appropriately qualified. health professionals to guide clinical management of. 2 2 Purpose rehabilitative care following childhood stroke Further. details on the guideline scope can be found in Appendix 1. The purpose of this guideline is to improve the care of. children with stroke by providing health professionals with. evidence based and consensus based recommendations. to assist in rehabilitative treatment following diagnosis of. 2 5 Target population, childhood stroke This guideline addresses the subacute management and. care of acute arterial ischaemic stroke and non traumatic. intracranial haemorrhage in children aged 29 days to 18. years or until school completion The scope of this. guideline does not include perinatal aged 28 days or. younger at stroke onset subdural haemorrhage secondary. to trauma spinal stroke syndromes or cerebral venous. thrombosis without infarction,Victorian Subacute Childhood Stroke Guidelines 7. 3 METHODOLOGY,3 1 Guideline development 3 2 Clinical questions. committee The GDC identified clinical areas to be covered by the. guideline and the project coordinator formulated these. A multidisciplinary guideline development committee. into structured questions in consultation with the steering. GDC was convened to oversee the development of the. committee The clinical questions were developed based. guideline The GDC consisted of a panel of clinical and. on a framework of Population Intervention Comparison. research experts representing the Victorian Paediatric. and Outcome PICO The clinical questions addressed, Rehabilitation Service tertiary paediatric hospitals and. by this guideline are detailed in Table 2 1, researchers in Victoria Members of the GDC are listed. on page 4 under Steering Committee and Clinical Advisory. Group The GDC developed the purpose scope and clinical. questions of the guideline and carried out critical appraisal. and data extraction of publications All conflicts of interest. were declared by the GDC and are recorded in Appendix 2. A copy of the conflict of interest form can be found in. Appendix 3,Table 2 1 Clinical questions,Clinical question. 1 What is the most appropriate framework for providing rehabilitation to children with stroke. 2 In children with stroke and motor difficulties which interventions improve outcome. 3 In children with stroke and sensory deficits which interventions improve outcome. 4 In children with stroke and pain which interventions improve outcome. 5 In children with stroke and dysphagia or poor nutrition status which interventions improve outcome. In children with stroke and speech language or communication difficulties which interventions. improve outcome, 7 In children with stroke and cognitive difficulties which interventions improve outcome. In children with stroke and psychosocial emotional or behavioural difficulties which interventions. improve outcome, 9 In children with stroke and difficulties with activities of daily living which interventions improve outcome. In children with stroke and reduced participation in recreation or leisure activities which interventions. improve outcome, 11 In children with stroke which interventions improve education learning and vocation outcomes. 12 In children with stroke which interventions improve family function. Victorian Subacute Childhood Stroke Guidelines 8,3 3 Systematic review 3 6 Development of evidence. Systematic reviews were conducted to identify studies based and consensus based. relevant to the clinical questions to be addressed by the recommendations. guideline The search strategies used for the systematic. reviews are detailed in Appendix 4 All literature searches Where sufficient evidence was available evidence based. were conducted on core databases including MEDLINE recommendations were formed by the relevant working. Embase Cochrane Library and PsycInfo Searches were committee and then reviewed by the steering committee. limited to the English language Studies were included Evidence based recommendations were developed using. in the review if they i included children aged between the NHMRC evidence statement form Appendix 7 The. 29 days and 18 years with stroke ii examined the form was used to assess the body of evidence for each. rehabilitative treatment of difficulties after childhood stroke clinical question The body of evidence was evaluated. and iii were published after January 2001 Single case according to the evidence base e g number and quality. reports and case series with less than five participants of studies level of evidence consistency of results clinical. were excluded from analyses impact generalisability and applicability Evidence based. recommendations were assigned an NHMRC grade, Appendix 8 based on the quality of evidence and have. 3 4 Appraisal of the evidence been referenced EBR, Members from the GDC were assigned to working Consensus based recommendations were developed. committees for each clinical question based on their based on the results of the Delphi survey Questions. professional expertise Initial abstract screening of the where at least 75 consensus was reached were used to. electronic search results was completed by two members formulate consensus based recommendations These have. of each working committee independently differing been referenced CBR. selections were resolved by a third reviewer Where. reviewers were uncertain about inclusion the full text. article was retrieved 3 7 Targeted consultation, The included studies were appraised for methodological The drafted guideline underwent a period of targeted. quality using critical appraisal checklists developed by the external consultation from June to October 2018 All. Scottish Intercollegiate Guidelines Network SIGN and an comments and suggestions were collated and reviewed. NHMRC level of evidence10 was applied to each study by the GDC with a consensus process used to modify. Appendix 5 Evidence summary tables see Appendix 6 the guideline. for selected literature informed the summary of relevant. literature for each clinical question,3 5 Delphi survey. In the absence of sufficient evidence expert opinion via. a Delphi survey was used to inform the development of. consensus based recommendations An online Delphi, survey consisting of three rounds was used to obtain the. expert views of members of the GDC as well as health. professionals from around Australia and internationally. Additional Delphi panelists were obtained from the VPRS or. identified by GDC members The Delphi survey involved. the participation of 99 healthcare professionals including. physiotherapists occupational therapists speech, pathologists neuropsychologists clinical psychologists. social workers education consultants music therapists. dietitians doctors and nurses Delphi panelists are listed on. page 5 The three rounds of the Delphi survey consisted of. open ended and multiple choice questions The methods. of the Delphi survey are described in Appendix 9,Victorian Subacute Childhood Stroke Guidelines 9. 4 FRAMEWORK FOR,PROVIDING REHABILITATION,4 1 Introduction. Children and adolescents with stroke may be treated in a paediatric setting For adults with stroke the timeliness. range of settings Within Victoria this typically includes and intensity of inpatient rehabilitation interventions as well. initial care on an acute neurology inpatient unit within a as the environment in which they are provided have also. tertiary hospital Referral is generally made to rehabilitation been found to be significant predictors of patient outcomes. for ongoing care following stabilisation of the medical post stroke10. condition Rehabilitation may be provided by i the acute. allied health team ii by a specialised rehabilitation team. providing services within the tertiary hospital or in the 4 2 Evidence summary. ambulatory setting iii by a specialised rehabilitation team. in the community or iv by non specialised community A systematic review was conducted and identified. therapy providers Within the adult stroke literature no original research studies reporting on frameworks. complete stroke care delivery in the early days and weeks for providing rehabilitation to children following stroke. following an acute stroke has been shown to have a Due to the lack of evidence the following. significant positive impact on stroke outcomes11 However recommendations are based on the clinical experience. there is only low level evidence of the benefit of providing and expertise of the Delphi panelists. a similarly specialised rehabilitation program within the. 4 3 Recommendations,Recommendation Type Grade, An interdisciplinary team defined as a group of health professionals from diverse fields who work CBR N A. in a coordinated fashion with the parent and child toward a common goal is the most appropriate. model to achieve optimal outcomes for the child and family after childhood stroke for both. inpatient and outpatient rehabilitation, The following criteria should be considered in determining when a child should be transferred CBR N A. from acute hospital to subacute rehabilitation care following a stroke. a The child is medically stable or any medical instability is able to be managed by the. rehabilitation team, b The child has change in function that could benefit from rehabilitation. c Rehabilitation goals have been identified, The following criteria should be considered in determining when a child should be transferred CBR N A. from subacute rehabilitation to long term community care following a stroke. a Safety of the child in the community and home has been achieved. b Current goals are better addressed in the community or are more community based. e g return to school, c Therapy needs have decreased to a level that they can be confidently met in the. community setting, d The family feels capable and ready to care for the child at home. Victorian Subacute Childhood Stroke Guidelines 10,Recommendation Type Grade. Subacute rehabilitation is best undertaken in a dedicated centralized tertiary care facility when. a Multiple disciplines are involved and high intensity therapy over a short period is required. b Some medical assessment and intervention is required but the child is generally medically. c Therapy cannot be provided in a regional centre as the family is too far from a regional. centre or due to lack of access to i required disciplines ii required intensity of therapy. or iii specialised equipment, Subacute rehabilitation is best undertaken in a regional hospital facility with generalized CBR N A. knowledge of paediatric stroke rehabilitation when. a Fewer disciplines are involved and or less intensity is required. b The child is medically stable, c The family prefers this setting due to social or geographical reasons. d The child s fatigue limits their ability to travel. Subacute rehabilitation is best undertaken in a regional community facility with generalized CBR N A. knowledge of paediatric stroke rehabilitation when. a Fewer disciplines are involved and less intensity is required. b The child is medically stable, c The family prefers this setting due to social or geographical reasons. d The child is less fatigued and able to travel to appointments. e The child s goals are best met in the school or community setting. f The child is at a safe functional level for the family to manage care at home. Group therapy should be considered in addition to standard individualised therapy in the CBR N A. rehabilitation of children following childhood stroke. Individualised therapy only is most appropriate when. a Goals are specific to the child, b There are issues with distractibility cognitive dysfunction and psychological issues and or. over stimulation, c There is a need to frequently modify therapy to address gains. d Privacy is required,Victorian Subacute Childhood Stroke Guidelines 11. Recommendation Type Grade, Group therapy in addition to individualized therapy is most appropriate when. a Goals are broad or generic, b There are sufficient numbers of children working towards similar goals at the same time. c Goals focus on social and communication skills, d Goals focus on common physical skills e g riding a bike running skills. The child s family should be involved at all stages of rehabilitative care. In particular the child s family should be involved in the following aspects of rehabilitation. a Creation of the individual care plan,b Setting goals. c Active involvement in therapy sessions, Clear communication with the family should be facilitated by family meetings and by ensuring CBR N A. all communication includes the child s family, The Canadian Occupation Performance Measure COPM should be used when setting CBR N A. rehabilitation goals with a child with stroke and their family. The following processes should be included in the transition from paediatric to adult services CBR N A. following childhood stroke,a Early discussion regarding transition. b Education to empower the child for autonomy ability to access services advocate for their. own needs and negotiate the system,c A key contact person to assist with transition. d Identify and liaise with the relevant adult service to which transition will occur. e Establish clearly defined referral pathway between paediatric and adult services. f Ensure joint appointments between consultants in the paediatric and adult services. A transition coordinator at rehabilitation sites should be involved in assisting in the transition. between paediatric and adult services following childhood stroke. The quality of rehabilitation services for children with stroke should be actively monitored. This should include service level outcome measures as well as consumer satisfaction surveys. Outcome measures should be benchmarked against similar services and quality improvement. projects should be encouraged,CBR Consensus based recommendation. Victorian Subacute Childhood Stroke Guidelines 12,5 MOTOR FUNCTION. 5 1 Introduction, Long term neurodevelopmental disability occurs in 50 upper limb after childhood stroke However this study is. of childhood strokes12 There is a need for high quality limited by a small sample size n 10. evidence based medical and rehabilitation services for. Gordon and colleagues13 investigated the feasibility. these children and their families Childhood stroke results. tolerability and effect of modified Constraint Induced. in difficulty achieving functional independence Age at. Movement Therapy mCIMT in children with hemiparesis. onset of acute ischemic stroke influences motor outcomes. after AIS This study was a small case series of six children. and rates of recovery 12 Hemiplegia is the most common. but findings show some promise for the use of mCIMT. acute clinical sign of childhood AIS and is present in 72. for improvement in goal attainment No significant, to 90 of cases Estimates of the prevalence of chronic. improvements in sensorimotor function nor quality of upper. hemiplegia vary from 25 to 56 12 Appropriate timely. limb movement were found Children and parents were. interventions targeting motor impairment are crucial at all. positive about mCIMT indicating feasibility and tolerability. stages following childhood stroke to optimise function and. of the intervention,participation in everyday activities. Khalid and colleagues14 provide some data support for. the use of Proprioceptive Neuromuscular Facilitation PNF. 5 2 Evidence summary in the improvement of muscle strength This study has a. larger sample size n 50 than the other two studies. A systematic review was conducted and identified three. however it was poorly described limiting the, studies13 15 which reported on interventions to improve. generalisability of findings, motor function in children with stroke Two papers were. controlled trials14 15 and one was a case series13 The level There is no consistency amongst the three studies. of evidence was classified as level II for one study 15 level III as they are all investigating different aspects of motor. for the second study 14 and level IV for the third study 13 interventions Due to the limited and poor quality of. Further details on each study are provided within the available evidence no EBR could be developed The. evidence tables Appendix 6 following recommendations are based on the clinical. experience and expertise of the Delphi panelists, Kirton and colleagues15 provide preliminary evidence for. repetitive transcranial magnetic stimulation rTMS as a. feasible intervention to improve grip strength of impaired. 5 3 Recommendations,Recommendation Type Grade, Goal directed therapya incorporating motor learning principlesb including task specificc repetitive. and intensive practiced should be considered to improve motor difficulties after childhood stroke. Bimanual therapy approaches should be considered to improve motor difficulties after. childhood stroke,CBR Consensus based recommendation. Goal directed therapy Therapy based on child parent therapist identified meaningful goals16. otor learning principle Includes intensive practice which is meaningful for the child active participation of the child. increased practice to increase learning variable not constant task practice non repetitive practice order 17. Task specific Intervention based on the skills needed for a task so training task and goal are similar 18. Intensive practice Greater than two sessions per week 19. Victorian Subacute Childhood Stroke Guidelines 13,6 SENSORY FUNCTION. 6 1 Introduction 6 2 Evidence summary, Childhood stroke can result in a range of sensory A systematic review was conducted and identified no. impairments including lost or altered sensation of studies reporting on interventions for the treatment of. a limb visual defects and visual or sensory neglect sensory deficits in children following stroke Due to the. in approximately 21 of children20 Such difficulties lack of evidence the following recommendations are. may influence movement performance sensorimotor based on the clinical experience and expertise of the. rehabilitation and body awareness and may also have Delphi panelists. implications for safety in functional daily activities. 6 3 Recommendations,Recommendation Type Grade, Repeated practice or task based practice should be considered to improve sensory difficulties. after childhood stroke, Graded sensory exposure should be considered to improve sensory difficulties after. childhood stroke, Use of vision to provide sensory feedback about limb position should be considered to improve. sensory difficulties after childhood stroke, Environmental modifications should be considered to assist children with sensory difficulties after. childhood stroke,CBR Consensus based recommendation. Victorian Subacute Childhood Stroke Guidelines 14,7 PAIN MANAGEMENT. 7 1 Introduction 7 2 Evidence summary, Pain following stroke has been described in the adult A systematic review was conducted and identified no. population and can have various aetiologies including studies reporting on interventions for the treatment and. neuropathic and musculoskeletal causes Post stroke prevention of pain in children following stroke Due to the. headache related pain has been described in the childhood lack of evidence the following recommendations are. population although its mechanism and management is based on the clinical experience and expertise of the. unclear Similarly little is described in the literature about Delphi panelists. what interventions improve outcomes in pain prevention and. quality of life in the paediatric population following stroke. 7 3 Recommendations,Recommendation Type Grade, Multidisciplinary pain management approaches for ongoing pain and a multifaceted approach. should be considered to manage pain after childhood stroke. Medications should be considered to manage pain after childhood stroke CBR N A. Prevention strategiesa should be considered to manage pain after childhood stroke CBR N A. Psychological approachesb should be considered to manage pain after childhood stroke CBR N A. CBR Consensus based recommendation, revention strategies may include correct alignment protect at risk joints maintain joint range of motion monitor bony. growth over time hip surveillance spinal surveillance. sychological approaches may include Cognitive Behavioural Therapy mindfulness Acceptance and Commitment. Therapy meditation,Victorian Subacute Childhood Stroke Guidelines 15.
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