Pediatric Series

Invisible Injuries: The Impact of Brain Injuries in Children Is Complicated

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To demonstrate the challenge of working with a young child with a brain injury, Angie Kiger, M.Ed, CTRS, ATP/SMS, Clinical Strategy & Education Manager at Sunrise Medical, described a former client: “By the time we got him in our rehab hospital, he was 14 months. He was the unrestrained front-seat passenger in an automobile accident, and he went through the windshield. He did have a spinal cord injury, high level; that we knew. But that was all the information we had. He was never diagnosed at the acute [care] facility of having a traumatic brain injury.

“Everybody on the rehab team thought, ‘He went through a windshield; he has to have a brain injury.’ But we didn’t know. As you can imagine, his caregiver was arrested, and we could not get information on where he was [in his development] prior to the injury. Was he just not very interactive because of his age? Did he have words? Because some 14-month-olds do have words; some don’t. We had no idea if he had any underlying delays prior.”

That lack of a baseline is just one of the challenges of working with children who have brain injuries.


“Quite often, an adult and a child can be involved in the same car accident, but they get a different brain injury just because there’s a difference in the head-to-body ratio,” said Stefanie Laurence, BScOT, OT Reg. (Ont.), Clinical Educator, Motion Specialties. “For a child, the head is larger in proportion to the body. There are differences in what a child’s head can buffer because their cranial sutures are not closed. So if they have [brain] swelling, there’s some buffering because the sutures can open to absorb to some degree. You don’t see that in adults: Your skull is solid, so you might see a more severe injury because if there’s brain swelling and you can’t relieve the pressure, your brain is getting squashed in that hard shell.”

“Children’s brains are hard at work forming new pathways, and their brains have a high level of neuroplasticity,” said Kristen Wagner, PT, DPT, Certified Brain Injury Specialist and Team Lead at Children’s Healthcare of Atlanta — Scottish Rite. “The potential for

adaptations and alternate pathways is great — however, many of their motor strategies are not yet hardwired (for example, a newly ambulatory toddler), so it is hard when you can’t rely as much on automatic movements as a precursor for relearning motor control, since they may not be very automatic yet!”

“Oftentimes, especially with infants, if there aren’t obvious signs and symptoms of a brain injury, we don’t have a whole lot [of history] to compare to,” said Ryan Rhodes, OTR/L, ATP/SMS, Pediatric Sales Specialist for Sunrise Medical. “Especially with an infant: They cry, they sleep, they eat. You would have to see something kind of stand out to know it’s a brain injury.”

Laurence compared a visibly fractured ankle to the invisible nature of a brain injury: “You can see the injury, you can see the edema, you can see where I’m missing range,” she said of the ankle fracture. “With a head injury, you can’t see the injury. You can see a bruise on the brain, but you can’t see what the effects are 100 percent. We can see some of it, but do we see all of it?”


“Like adults, there is a wide range of presentation depending on the severity of the injury,” Wagner said. “For more severely impacted children, we definitely see increased muscle tone, spasticity, and dysautonomia. Many kids present with a good bit of irritability (neuroirritability), and they are very difficult to calm, which can be really distressing to the parents. Spasticity is very common with flexor patterns of the upper extremities and extension of lower extremities. Often, patients present with visual deficits/inattention to one side. They also frequently have oral aversion and feeding difficulty.”

“Spasticity and muscle tone are a huge point of focus when fitting a child for Complex Rehab Technology, whether that’s a manual wheelchair, a tilt-in-space or stroller, an activity chair or standing frame,” Rhodes said. “They’re considered to try to improve quality of life and reduce other comorbidities.”

Rhodes added that understandably, the acute care professionals who initially treat a child with a brain injury focus on keeping the child alive. “Spasticity oftentimes isn’t addressed within the first year,” he said. “So by the time we get that child into the clinic, if we weren’t fortunate enough to get an in-patient evaluation for seating equipment, some damage may already be done. In seating, are we going to envelope and accommodate to prevent further deformities? Or are we going to correct those? If tone starts to set in, resulting in contractures, then we are already at the point of accommodation.”

Rhodes added that addressing the many needs of the child is important, right from the start. “I think early intervention is key, and I don’t just mean for the age of the child. If it’s an 8-year-old who had a brain injury, I think it’s important that the team keeps postural deformities in the back of their minds, at least when it comes to getting the child out of bed — not just letting them roll up or ball up. There are so many considerations, obviously: skin integrity — that’s why standing frames are so important. We have studies that show that weight-bearing through the legs can reduce spasticity if contractures are not too bad. Imagine sitting there, kyphotic and folded over — your vital organs being compressed, so there’s a reduction of respiration. Often, we might see a kid on a vent because of it, or a trach. We see impactment of the bowels if they’re not continually moved.

“Seating and the complex rehab aspects are a global focus. We can’t just focus on one thing. We can’t just focus on spasticity. Digestion, respiration, bone density, spasticity management — we have to focus on all of those things.”


While it’s easy to blame the brain injury when a child shows a developmental delay, the answer can be more complex. “Babies and kids do things repetitively,” Laurence said. “They pull themselves up to the coffee table. They stand and do that little shuffle, or they lean from one side to the other before they take that step. And they do it again. A baby that pushes itself up to sit: They rock, again and again and again, until they master it.

“Now we’ve got a child who has a disability. They can get therapy every day. But how many times are they doing that little weight shift? Five times, as opposed to a normally developing child, who does it a thousand times? So is there impact because of the injury or because of the loss of opportunity? The injury itself will have an impact on development; there will be an injury to the brain, and it may be misfiring because it’s been injured. But how much is it a lack of experience?”

The aging process can further complicate the situation.

“We have to consider the acquisition of new motor skills after an injury,” Wagner said. “For example, a 6-month-old is injured and in the hospital for four weeks. Now we are dealing with the impact of the brain injury plus a month of lost time of normal development, and likely slower motor skill acquisition going forward. So much happens so fast during early development!”

Laurence added that as kids grow, presentations can change: “You may have the same [muscle] tone, but now that tone gets overlaid by growth. We see it in kids with CP [cerebral palsy]. They grow, the bone grows faster than the muscles, and the muscles get tight. So you may have the same tone in a child versus an adult, but now the child is still growing.

“Now you have the tone from their injuries, and that tone gets overlaid and affected when they grow. They may have gotten tight just because of the growth.”

“Unfortunately, we may not know the extent of a patient’s impairment until they reach school age and are attempting for the first time higher-level skills,” Wagner said. “Many times as they get older, challenges with social interaction (frontal lobe development), executive functioning, and motor skills become more evident. It is really important for these kids to be followed closely by a medical team and neuropsychology, so they can assess cognitive functioning and make appropriate recommendations for school.”


One enduring mystery of brain injuries is the unique paths that recovery can take.

“The toughest part about a head injury is not knowing what the end is going to be,” Laurence said. “They can have changes years after. People can gain skills years later.”

Kiger remembered another client, a teenager we’ll call Sophia: “She was directly out of her injury, an automobile accident at 14 or 15. She had a pretty significant brain injury, and I was trying to figure out ‘Where will she be at the end of this?’ We discharged the wheelchair and she continued out-patient therapy. She was ambulatory, and she had some gait issues.

“She sat down in my office about two years after her accident. I was just chatting with her; I wanted to know what had changed. She was doing almost everything she’d done before. I said, ‘What are your friends saying about this Sophia that is different from the Sophia before, prior to the injury?’ She said, ‘They’re saying my personality is different and my memory is different.’ But other than that, she had rehabbed really well. Depending on the injury, with a lot of therapy and a lot of consistency, they can continue to get better. Research tells us you can continue to improve from a brain injury years down the line.”

Since every brain injury follows its own recovery path — one inevitably made more complex as the child grows — what are the points to remember when working with this population?

Laurence described a call from a mother of a toddler recently seated in his first power wheelchair. “She said, ‘We got a problem: I took him grocery shopping, and he took off. I found him in the cookie aisle.’”

Laurence was ecstatic that this newly independently mobile 3-year-old was behaving… like a 3-year-old.

“They’re a child first, and their disability is secondary,” she noted. “Treat them as a child first and foremost. It’s devastating for a child to have a disability, but don’t disable them further by protecting them from the world. I think that’s one of the hardest things about working with kids with disabilities, particularly head injuries or something that’s hereditary. There’s a lot of parental guilt in there. You’d better be looking at equipment that meets that client’s needs and enables them instead of creating a new disability.”

This article originally appeared in the Oct/Nov 2020 issue of Mobility Management.

In Support of Upper-Extremity Positioning