Initiation of physical, occupational, and speech therapy in children with traumatic brain injury

Objectives: (1) To determine factors associated with physical therapy (PT) or occupational therapy (OT) evaluation and speech or swallow therapy evaluation in hospitalized children with traumatic brain injury (TBI); (2) to describe when during the hospital stay the initial therapy evaluations typically occur; and (3) to quantify any between-hospital variation in therapy evaluation.

Design: Retrospective cohort study.

Setting: Children's hospitals participating in the Pediatric Health Information System database (January 2001-June 2011).

Participants: Children (age <18y) with TBI (N=21,399) who were admitted to the intensive care unit and survived to hospital discharge.

Interventions: Not applicable.

Main outcome measures: PT or OT evaluation and speech or swallow therapy evaluation. A propensity score was calculated to allow comparison of expected with observed rates of therapy evaluations by the hospital.

Results: The median hospital length of stay was 5 days (interquartile range, 3-10d). Overall, 8748 (41%) of 21,399 children received either a PT or OT evaluation, and 5490 (26%) out of 21,399 children received either a speech or swallow evaluation. Older children and those with higher energy injury mechanisms, more severe injuries, extremity fractures, more treatment with neuromuscular blocking agents or pentobarbital, and admission to a hospital with an American College of Surgeons Level I pediatric trauma designation were more likely to receive therapy evaluations. The median time until the first therapy evaluation was 5 (PT or OT) and 7 days (speech or swallow). Expected hospital evaluation rates were 25% to 54% (PT or OT) and 16% to 35% (speech or swallow), while observed hospital evaluation rates were 11% to 74% (PT or OT) and 4% to 55% (speech or swallow).

Conclusions: There is wide between-hospital variation in provision of rehabilitation therapies for children with TBI. Evidence-based criteria for initiation of routine therapy evaluations after TBI are needed.