BackgroundOne of the key factors for enhancing outcomes in neurorehabilitation of patients with congenital or acquired brain injury is optimal sensory function and identification of possible visual dysfunctions. Awareness of visual dysfunctions including cerebral visual impairment (CVI) is therefore of utmost importance in the rehabilitation process. The purpose was to investigate the frequency and nature of vision disorders in children admitted to a rehabilitation centre over a 5-year period.MethodsThis is a retrospective analysis of patients at the Swiss Children's Rehab who received an ophthalmological consultation between January 2019 and December 2024. Electronic chart review was performed in patients with consent for the study.Analysed DataReferral diagnoses leading to admission to the rehabilitation centre, corresponding ophthalmological findings, therapeutic interventions and demographics. The study was approved by the local ethics committee.ResultsA total of 229 consultations from 163 patients were reviewed. The two most common causes for admission were traumatic (41/163) and inflammatory (36/163) conditions. Congenital disease was present in 30 patients. Most of the children had an acquired disorder (133/163). Pathological ophthalmological findings were present in 101/163 (62%) children examined. The most common findings were reduced vision (26/163) followed by CVI (22/163) and refractive errors (20/163). Traumatic causes were most often associated with oculomotor disorders (10/41) or CVI (6/41). CVI was prevalent in 22% of the pathological findings in this study.ConclusionsOphthalmological assessment is recommended for all children with suspected visual dysfunction as part of the rehabilitation process.

STUDY AIMS: SwissPedNet aims to improve the quality of multicentre research through standardised documentation of routine healthcare data. Therefore, SwissPedData was developed as a set of defined common data elements to be documented in each electronic patient file in a standardised format. This study evaluates the preparedness of the ten SwissPedNet hospitals for SwissPedData before its nationwide implementation, focusing on: (a) whether the defined common data elements are effectively documented and can be retrieved for children presenting with traumatic brain injuries to paediatric emergency departments, and (b) analysis of the content of these common data elements to assess how children with traumatic brain injuries are treated in paediatric emergency departments across Switzerland. METHODS: This multicentre point-prevalence study, conducted in June 2023, included all children up to 16 years presenting with traumatic brain injuries to ten SwissPedNet paediatric emergency departments over one calendar week. To assess the documentation of common data elements, a questionnaire was developed, consisting of 21 common data elements defined by SwissPedData, covering patient demographics, accident details, symptoms, paediatric emergency department course, and if applicable, inpatient course. Each hub retrospectively collected data from the electronic health records of all traumatic brain injury patients during the specified week. The primary objective was to assess the rate of successful data retrieval, defined as the presence of documented information for specific common data elements. Data were classified as missing if no information regarding a specific common data element was found in the electronic health record. The retrieval rate of each common data element was evaluated, and the average time investment per patient was recorded to estimate the associated workload. The secondary objectives focused on the content of the compiled common data element information, assessing causes and symptoms of traumatic brain injuries and injury severity and comparing management procedures for traumatic brain injury patients across Switzerland. Logistic regression was used to assess associations between specific patient characteristics (e.g. symptoms), the probability of having computed tomography (CT) scans in paediatric emergency departments, and the rate of hospitalisations. RESULTS: During the study period, a total of 349 children with traumatic brain injury were treated; the median age was 4.0 years (interquartile range [IQR] 2.0–7.5 years). Data retrieval rates exceeded 90% for each common data element; specifically, common data elements with numeric information were extracted in 98.3% to 100% of cases, while those with standardised options or free-text entries had a retrieval rate of 91.7% to 100%. However, data on written discharge information were available for only 51.2% of outpatients and 53.3% of inpatients, with significant variability among hospitals. Data collection efforts varied among the ten participating hubs, with an average time investment per patient ranging from 0.5 to 2 hours and limited involvement of information technology (IT) departments. The prevalence of traumatic brain injury patients at the paediatric emergency departments was 6% (range: 3% to 11.5%), with most traumatic brain injuries occurring at home (48%) or on playgrounds (18.9%). The primary trauma mechanism was a fall (56.5%), usually from a height of less than 1 metre. Most patients (99.1%) had a normal Glasgow Coma Scale (GCS). CT scans were performed in ten cases in the paediatric emergency departments, revealing pathologies in four cases, and resulting in neurosurgical intervention in one case. Factors associated with undergoing a CT scan or being hospitalised included lower triage category numbers and loss of consciousness. CONCLUSIONS: Common data elements are conscientiously documented within clinical information systems for patients with traumatic brain injuries in paediatric emergency departments, but data extraction requires considerable time and effort, underscoring the need for additional technical support. Although traumatic brain injuries are a common reason for paediatric emergency department visits, they are generally mild in severity. Although Switzerland has no national guidelines for treating children with traumatic brain injuries, management practices, particularly the low rate of CT scans in children with traumatic brain injury and normal GCS, appear to be fairly consistent across hospitals.

BACKGROUND:Paediatric acquired brain injury is a life-long condition which impacts on all facets of the individual's lived experience. The existing evidence base continues to expand and new fields of enquiry are established as clinicians and researchers uncover the extent of these impacts.PRIMARY OBJECTIVE:To add to recommendations described in the International Paediatric Brain Injury Society's 2016 paper on post-acute care for children with acquired brain injury and highlight new areas of enquiry.REVIEW OF INFORMATION:Recommendations were made based on the opinions of a group of experienced international clinicians and researchers who are current or past members of the board of directors of the International Paediatric Brain Injury Society. The importance of each recommendation was agreed upon by means of group consensus.OUTCOMES:This update gives new consideration to areas of study including injuries which occur in pre-school children, young people in the military, medical referral, young offenders and the use of technology in rehabilitation.

IntroductionCasting is an essential treatment for neuro-orthopedic conditions in children with cognitive, sensory, and communicational disabilities. However, a main side-effect is the development of pressure injuries resulting in additional (wound) therapies and prolongation of the hospital stay. The primary aim of our study was to investigate the potential of objective pressure measurements in casts to assess the risk for pressure injury development.MethodsFive pediatric healthy participants were included in this study. We measured the global and the local compression force at body sites prone to pressure injury development for different body positions and the transfer in-between in a cast equipped with pressure sensors. These conditions resulted in partial or full body weight loading.Results and discussionThe global maximum compression force was affected significantly by body postures with partial and full loading of the cast and during transfer. The local compression force significantly correlated with the global compression force at the heel and instep area. In conclusion, the integration of sensing technologies into casts bears a high potential for early recognition of critical conditions inside the cast and inducing preventive measures in the at-risk population.

Aim Investigation of the perspectives of paediatric health care professionals (PHCPs) in Switzerland regarding factors that influence participation in physical activity programs for children and adolescents with disabilities or chronic conditions (CADCCs). Evaluation of self-reported exercise counselling behavior of those professionals.Method A cross-sectional survey was used to collect the opinions of 171 PHCPs working with CADCCs using a structured questionnaire. The information obtained was evaluated by performing a combined quantitative and qualitative statistical analysis.Results PHCPs in Switzerland think that CADCC do not get enough physical activity and see the underlying reasons in lacking information/knowledge and organizational factors. We found that the level of knowledge about disability sports opportunities among PHCPs has a positive influence on their exercise counselling behaviour.Conclusions We propose three approaches to increase the level of physical activity in CADCC: Establishing personalized exercise counseling, intensifying information about disability sports programmes towards PHCPs, and improving inclusion and integration in PE lessons or regular sports clubs.

Background: Equinus deformity with or without concomitant drop foot is a common finding in children with unilateral spastic cerebral palsy and spastic hemiplegia of other causes. Hypothetically, these deformities may lead to pelvic retraction and hip internal rotation during gait. Orthoses are used to reduce pes equinus during gait and to restore hindfoot first contact. Objective: We aimed to investigate whether the use of orthotic equinus correction reduces rotational hip and pelvic asymmetries. Methods: In a retrospective study, 34 children with unilateral spastic cerebral palsy or spastic hemiplegia of other causes underwent standardized instrumented 3D gait analysis with and without orthotic equinus management. We analyzed the differences in the torsional profile during barefoot walking and while wearing orthoses, as well as investigated the influence of ankle dorsiflexion and femoral anteversion on pelvic and hip kinematics and hip kinetics. Results: Wearing orthoses corrected pes equinus and pelvic internal rotation at the end of the stance phase and in the swing phase compared to barefoot walking. Hip rotation and the rotational moment did not significantly change with orthoses. Orthotic management or femoral anteversion did not correlate to pelvic and hip asymmetry. Conclusion: The findings indicate that the correction of the equinus by using orthoses had a variable effect on the asymmetry of the hip and pelvis and internal rotation; both appear to have a multifactorial cause that is not primarily driven by the equinus component.

Neurological disorders such as traumatic brain injuries (TBI) can lead to hand impairments in children, negatively impacting their quality of life. Fully wearable robotic hand orthoses (RHO) have been proposed to actively support children and promote the use of the impaired limb in daily life. Here we report a case study on the feasibility of using the pediatric RHO PEXO for assistance at home in a 13- year-old child with hand impairment after TBI. The size and functionalities of the RHO were first fully tailored to the child's needs. We trained the child and their parent on independently using the RHO before taking it home for a period of two weeks. The use of the RHO improved hand ability. Additionally, the tailoring and training benefited the unimanual capacity (Box and Block Test score +2 after tailoring) and bimanual performance (Assisting Hand Assessment score +4) of the child with PEXO. Further, it increased device acceptance by the child and the parent. The child used PEXO at home for 76 minutes distributed over three days during eating and drinking tasks. Personal and environmental factors caused the moderate use. No adverse events or safety-related issues occurred. This study highlights the value of tailoring an assistive RHO and, for the first time, demonstrates the feasibility of home use of a pediatric RHO by children with neurological hand impairments.

Children affected by hand impairment due to cerebral palsy or stroke experience serious difficulties when performing activities of daily life (ADL), which reduces their quality of life and development. Wearable robots such as hand exoskeletons have been proposed to support people with hand impairment in therapy as well as daily tasks. While numerous actuated wearable robots have been developed, few designs support both fingers and wrist function, despite being mutually relevant for reach-to-grasp tasks. A recent feasibility study investigating the use of PEXO, a lightweight and fully wearable pediatric hand exoskeleton, showed that a wrist fixed in a slightly extended position may limit the user’s ability to reach and grasp during ADL and restrict the user group. These insights and further interactions with clinicians inspired a novel design of PEXO that features an additional degree of freedom in the wrist. In this paper, we present a compliant wrist mechanism extending the existing leaf spring finger mechanism of the device. The novel design provides both wrist motion capability of 60° in flexion and extension and wrist stabilization at the same time while actively supporting finger motion. Preliminary results suggest that the adjustability in the wrist enables a larger variety of grasping gestures. The implemented wrist support has the potential to allow for a more versatile use of PEXO and increase the potential target user group.

BACKGROUND:Cerebral Palsy (CP) is a group of permanent disorders of movement and posture that follow injuries to the developing brain. It results in motor dysfunction and a wide variety of comorbidities like epilepsy; pain; speech, hearing and vision disorders; cognitive dysfunction; and eating and digestive difficulties. Central data collection is essential to the study of the epidemiology, clinical presentations, care, and quality of life of patients affected by CP. CP specialists founded the Swiss Cerebral Palsy Registry (Swiss-CP-Reg) in 2017. This paper describes the design, structure, aims and achievements of Swiss-CP-Reg and presents its first results.METHODS:Swiss-CP-Reg records patients of any age diagnosed with CP who are born, are treated, or live in Switzerland. It collects data from medical records and reports, from questionnaires answered by patients and their families, and from data linkage with routine statistics and other registries. The registry contains information on diagnosis, clinical presentation, comorbidities, therapies, personal information, family history, and quality of life.RESULTS:From August 2017 to August 2021, 546 participants (55% male, mean age at registration 8 years [interquartile range IQR: 5-12]), were enrolled in Swiss-CP-Reg. Most had been born at term (56%), were less than two years old at diagnosis (73%, median 18 months, IQR: 9-25), and were diagnosed with spastic CP (76%). Most (59%) live with a mild motor impairment (Gross Motor Function Classification System [GMFCS] level I or II), 12% with a moderate motor impairment (GMFCS level III), and 29% with a severe motor impairment (GMFCS level IV or V). In a subset of 170 participants, we measured intelligence quotient (IQ) and saw lower IQs with increasing GMFCS level. Swiss-CP-Reg has a strong interest in research, with four nested projects running currently, and many more planned.CONCLUSIONS:Swiss-CP-Reg collects and exchanges national data on people living with CP to answer clinically relevant questions. Its structure enables retrospective and prospective data collection and knowledge exchange between experts to optimise and standardise treatment and to improve the health and quality of life of those diagnosed with CP in Switzerland.

Background: After acquired brain injury (ABI), patients show various neurological impairments and outcome is difficult to predict. Identifying biomarkers of recovery could provide prognostic information about a patient’s neural potential for recovery and improve our understanding of neural reorganization. In healthy subjects, sleep slow wave activity (SWA, EEG spectral power 1–4.5 Hz) has been linked to neuroplastic processes such as learning and brain maturation. Therefore, we suggest that SWA might be a suitable measure to investigate neural reorganization underlying memory recovery. Objectives: In the present study, we used SWA to investigate neural correlates of recovery of function in ten paediatric patients with ABI (age range 7–15 years). Methods: We recorded high-density EEG (128 electrodes) during sleep at the beginning and end of rehabilitation. We used sleep EEG data of 52 typically developing children to calculate age-normalized values for individual patients. In patients, we also assessed every-day life memory impairment at the beginning and end of rehabilitation. Results: In the course of rehabilitation, memory recovery was paralleled by longitudinal changes in SWA over posterior parietal brain areas. SWA over left prefrontal and occipital brain areas at the beginning of rehabilitation predicted memory recovery. Conclusions: We show that longitudinal sleep-EEG measurements are feasible in the clinical setting. While posterior parietal and prefrontal brain areas are known to belong to the memory “core network”, occipital brain areas have never been related to memory. While we have to remain cautious in interpreting preliminary findings, we suggest that SWA is a promising measure to investigate neural reorganization.

Background: Drowning is the second leading cause of unnatural death in childhood worldwide. More than half of the drowned children, who were in need of cardiopulmonary resuscitation (CPR) at the scene suffered from lifelong neurological sequelae. There are few data about prognostic predictors in the pediatric population of drowning victims. The objective of the study was to assess incident characteristics, prognostic parameters, and long-term outcome of children recovering from a drowning incident. Methods: We carried out a retrospective analysis of data of the cohort of pediatric cases (age 0–18) of drowning victims admitted in the years 2000–2015 to the emergency room/intensive care unit/pediatric ward at the University Children’s Hospital of Zurich, Switzerland. Outcome was classified by the Pediatric Cerebral Performance Category Scale (PCPCS). New subcategories of severity for known prognostic parameters have been defined. A correlation analysis was performed between the subcategories of the prognostic parameters and the PCPCS. Results: A total of 80 patients were included in the analysis. Of these, 64% were male, most of the patients were at the age of 0–5 years. More than 80% of the patients were unattended at a public or private pool when the drowning incident happened. In all, 61% (n = 49) needed cardiopulmonary resuscitation (CPR). Of the resuscitated children, 63% showed good to mildly impaired long-term outcome (PCPCS 1–3). Furthermore, 15% (n = 12) were transferred to rehabilitation. Seven children died during the hospital stay and another four died due to complications in the ten years following the incident. The newly defined subcategories of the parameter submersion time, Glasgow Coma Scale (GCS) at time of admission, body temperature at time of admission, blood pH, blood glucose, and blood lactate level correlated significantly with the PCPCS. Conclusions: Supervision of children, especially boys of the age 0–5 years, next to public or private pools is most important for prevention of drowning incidents in Switzerland. Cardiopulmonary resuscitation done by trained staff leads to a better long-term outcome. Medical decision making in severe cases of drowning should consider submersion time, GCS at time of admission, body temperature at time of admission, blood pH, blood glucose, and blood lactate levels, as these parameters correlate with long-term outcome.

PURPOSE:To investigate the effectiveness of outpatient robot-assisted gait training (RAGT) in ambulatory children with spastic cerebral palsy. METHODS:Children were randomized to two different intervention sequences within a pragmatic crossover design. They performed five weeks of RAGT (3 sessions per week) and five weeks of usual care (UC). Dimension E of the Gross Motor Function Measure-88 (GMFM E) as the primary outcome as well as Dimension D (GMFM D), and timed walking tests were assessed before and after each treatment sequence and after a 5-week follow-up. RESULTS:The trial was stopped early because of recruitment problems. We included 16 children with a mean age of 11.3 years (6.0-15.3 years). GMFM E median (IQR) change scores were -0.7 (-2.8 to 3.5) after RAGT and 0 (-2.4 to 2.4) after UC. Neither GMFM E nor any secondary outcome measure changed significantly after RAGT or UC, nor were any period, follow-up, or carry-over effects observable. CONCLUSIONS:RAGT as a single intervention was not effective in improving walking abilities in the included children. It should be embedded in a holistic treatment approach, as it cannot cover all aspects relevant to gait. Furthermore, children's personalized rehabilitation goals should be carefully monitored with individualized measurement instruments.

Improving Communication Quality Caring for Children with Chronic Conditions: Health, Functioning and Wellbeing Traffic-Light Tool Abstract. Effective patient-doctor communication is a crucial aspect while caring for children with chronic conditions or disabilities. The Health, Functioning and Wellbeing Summary Traffic Light has been developed as a communication tool especially for these patients. In a two-month pilot phase the German version was evaluated by parents and physicians in a rehabilitation out-patient clinic setting. 71 % (n = 35/49) returned the evaluation form. The traffic-light tool was rated positive by 80 % of participants and physicians. It can be recommended as a useful tool for improved communication. The simple language version as well as translations into other languages and the use of a mobile App will facilitate its use. Its use is not limited to paediatrics and could be adapted for other disciplines.

Aim: Aggressive incidents (AI) are a serious concern in health care and can have negative effects on the physical and emotional well-being staff. This study aimed to determine frequency, characteristics and risk factors for aggressive behavior.Methods: AI were recorded during six months by the staff in a pediatric rehabilitation clinic using the evaluation form for AI (EVA). Patients were divided into the study group (patients who were involved in AI) and controls.Results: 14/105 (13%) of patients were involved in 79 AI. 0.44 AI per day occurred. Most often AI occurred on Mondays and 98% included physical, 22% verbal aggression. Most frequent target (43%) were nurses, followed by therapists (31.6%).Significant risk factors for AI were: previous aggressive behavior (p = .038), lower cognitive and higher mobility sub-scores in the WeeFIM. Conclusion: Findings emphasize the magnitude of AI in pediatric rehabilitation and thus the importance of implement preventive strategies.Abbreviations: ADL: Activity of daily living; AI: Aggressive Incidents; CFCS: Communication Function Classification System; EVA: Recording aggressive incidents (Erfassung von Aggressionsereignissen); GMFCS: Gross Motor Function Classification System; MACS: Manual Ability Classification System; SOAS-R: Staff Observation of Aggression Scale-Revised; WeeFIM: Functional Independence Measure for Children; WPV: Workplace violence.

Children with hand motor impairment due to cerebral palsy, traumatic brain injury, or pediatric stroke are considerably affected in their independence, development, and quality of life. Treatment conventionally includes task-oriented training in occupational therapy. While dose and intensity of hand therapy can be promoted through technology, these approaches are mostly limited to large stationary robotic devices for non-task-oriented training, or passive wearable devices for children with mild impairments. Here we present PEXO, a fully wearable actuated pediatric hand exoskeleton to cover the special needs of children (6 to 12 years of age) with strong impairments in hand function. Through three degrees of freedom, PEXO provides assistance in various grasp types needed for the execution of functional tasks. It is lightweight, water proof, and inherently interacts safely with the user. It meets mechanical requirements such as force, fast closing movement, and battery lifetime derived from literature and discussions with clinicians. Appealing appearance, user-friendly design, and intuitive control with visual feedback of forearm muscle activity should keep the user motivated during training in the clinic or at home. A pilot test with a 6-years old child with stroke showed that PEXO can provide assistance in grasping various objects weighing up to 0.5 kg. These are promising first results on the way to make hand exoskeletons accessible for children with neuromotor disorders.

The original article [1] contains a small mistake concerning the ARTIC Team members mentioned in the Acknowledgements. The team member, Rocco Salvatore Calabrò had their name presented incorrectly. This has now been corrected in the original article.

Walking in daily life is complex entailing various prerequisites such as leg strength, trunk stability or cognitive and motor dual task (DT) activities. Conventional physiotherapy can be complemented with robot-assisted gait therapy (RAGT) and exergames to enhance the number of step repetitions, feedback, motivation, and additional simultaneously performed tasks besides walking (e.g., dual-task (DT) activities). Although DT gait training leads to improvements in daily ambulation in adult patient groups, no study has evaluated RAGT with a DT exergame in children with neurological gait disorders. Therefore, we investigated children’s functional and cognitive prerequisites to walk physiologically during RAGT with a DT exergame and analysed the influence of DT on leg muscle activity.

Background. Acquired brain injuries (ABI) such as traumatic brain injury (TBI) or stroke can result in motor, language, or cognitive impairments. Although a considerable number of studies have investigated functional recovery, underlying brain reorganization remains poorly understood. Accumulating evidence indicates that plastic processes in the brain are linked to changes in electroencephalographic (EEG) slow wave activity (SWA) during deep sleep (EEG spectral power 1-4.5 Hz). Objective. We investigated sleep SWA in children and adolescents with ABI. Methods. We used high-density EEG (128 electrodes) to record sleep in 22 young patients with ABI (age range = 4-16 years). We compared patients to 52 previously measured typically developing children and adolescents (age range = 4-16 years). Results. The pattern of alterations in SWA differed between particular patient groups. In patients with bilateral stroke, SWA was globally reduced across the entire scalp. Patients with unilateral stroke showed a local reduction in SWA over lesion areas and an increase over perilesional and contralateral brain areas. In patients with severe TBI, we found a reduction in SWA over the midline and an increase over lateral brain areas. We found no consistent pattern in patients with mild to moderate TBI. Conclusions. Sleep SWA seems to be a sensitive measure to assess individual alterations in neural activity after ABI. Deviations from age norms might indirectly indicate plastic processes that have occurred since injury. Improving our understanding of neural activity after ABI could optimize clinical prognosis and guide the development of novel therapeutic interventions.