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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.
ANATOMY OF THE YOUNG CHILD
“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?”
HOW BRAIN INJURIES PRESENT IN CHILDREN
“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.”
BRAIN INJURY & DEVELOPMENTAL DELAYS
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.”
A LONGER RECOVERY ROAD
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.”