ELECTRONIC ASSISTIVE TECHNOLOGY 151 access the device should be the fastest, most energy-effi- KEY POINTS cient and reliable. This can sometimes mean a compro- mise in terms of positioning when undertaking a specific Basic characteristics to consider in the choice of activity. This also means that therapeutic targets may not mechanical switch: be paramount when thinking about access options for a child. For example, placing a switch centrally on a tray to ● Force encourage the child to move hands towards midline is ● Shape/size not a fast or energy-efficient way of accessing equipment ● Travel (movement to activate) in comparison with placing the switch to one side where ● Feedback the child can easily reach. KEY POINTS As well as the array of mechanical switches available there is also a range of devices which can pick up body move- Access methods used should be: ments that activate a switch, e.g. eyeblink switches, move- ment (twitch) switches, sip and puff, sound and, more ● Fastest recently, eye gaze movements (Figure 10.9). These options ● Most energy-efficient for the child tend to require a power supply in order to operate, e.g. a ● Reliable battery, and in some cases require more detailed set-up by a carer prior to each use. Alternative access options It should be noted that not all methods are appropri- There are many forms of switches commercially available, ate for all activities; however the availability of this spec- each being suitable for a particular client group. When trum of solutions offers potential independence in an undertaking the assessment there is a need to have know- activity for even the most physically challenged child. ledge of the different types of switches and controllers that exist, what inputs different equipment accept, how the Posture options can be displayed on different devices and the user needs in order to match their abilities (Cook & Hussey A fundamental part of any assessment for EAT is consid- 1995). The simplest types are mechanical switches (Figure eration of the child’s posture. Research shows that appro- 10.8). They have a number of characteristics which vary priate posture aids a child’s ability to concentrate on a task on different models to meet the physical needs of the (Sents & Marks 1989). This is particularly important child. These characteristics include size (larger switches for with children with complex disability as posture affects poor targeting skills), force required to activate the switch, the child’s ability to control the movements of the trunk, feedback and amount of movement required to operate arms, hands and head (Cowan 2005). The first part of the switch. this chapter elaborates on the ideal posture for a child, Figure 10.8 Selection of commercially available simple Figure 10.9 Sound-operated switch and infrared beam mechanical switches. switch.
152 10 ASSISTIVE TECHNOLOGY and in general this is true for establishing a good starting base for activities involving switches and EAT. However each child needs to be seen as an individual to determine appropriate posture for a given activity. For some children consideration of accessing toys while lying down in a support may be appropriate or perhaps in a standing support wherever most effective use of their hands/arms or head is possible. Young children learn through play and therefore introducing this technology in a play setting, e.g. switch- adapted toys, playing chase in a powered chair, has huge benefits. Sullivan & Lewis (2000) reported on the positive impact switch-activated AT has in developing a child’s understanding that the environment is responsive and controllable. Smith (1994) reported on the important role communication aids play in a child’s total communication system. Besio (2003) reported on the benefits of AT used in play to enhance social and cognitive development. KEY POINT ● Consideration of posture is an important part of the assessment of a child for any type of EAT Powered mobility Figure 10.10 Child using powered wheelchair with seat riser. (Courtesy of Whizz Kidz Charity.) Powered mobility offers children the opportunity to explore their environment independently. There is now Access options for powered mobility are also now a wide range of powered chairs available with differing very flexible. As well as the traditional joystick, a wide capabilities. As well as controlling the movement of the array (and number) of switches can be used to operate chair, positioning of the seat can be altered such as recline a chair. and tilt and also raising and lowering the height of the seat, which allows interaction with peer group when standing In order to be able to operate a powered chair there is a or sitting on the floor (see Figure 10.10). For older children need for the child to develop an array of skills which then and young adults, when moving and handling become have to be integrated to achieve what we call ‘driving’ a more challenging, chairs that allow the user to transfer to powered chair. A child with no experience of independ- a standing position are also available. ent movement therefore has an enormous learning curve to climb when faced with operating a powered chair. Specialist features are available commercially and There is a need for the team to introduce this activity just include options such as collision avoidance systems or as one would other learning experiences. The activity SMART wheelchairs which offer track-following facil- needs to be graded appropriately for the child’s skills, both ities or avoidance of obstacles (Figure 10.11). These physical and cognitive. For some children introducing can be used to offer additional support when some chil- powered mobility is straightforward and on being pre- dren are learning to operate a powered chair (Nisbet sented with a joystick they quickly gain an understanding 2002). of space, route-finding and problem-solving in order to drive from A to B. For others this can take several years As stated in the mechanical AT section, within the UK and it is only by observing and presenting the child with National Health Service wheelchair services are the main opportunities to practise and gain experience and skills providers of mobility equipment and this includes pow- that powered mobility can be achieved. ered mobility, although due to limited resources options are sometimes limited. Eligibility criteria can mean that in some services very young children are not provided with powered mobility (Durkin 2002, Staincliffe 2003). If a more elaborate chair is required, discussion with the child’s local service can bring different funding and maintenance options.
ENVIRONMENTAL CONTROL SYSTEMS 153 TV controls, audio equipment, toys, an alarm to call for help and for young adults control access through the front door and answer the telephone. Figure 10.11 Smart wheelchair with bumper to detect KEY POINTS when impact has been made and also track-following capability. (Courtesy of Call Centre, Edinburgh.) Environmental control can enable control of function in the following areas Communication ● Simple voice output capabilities ● Access to a telephone ● Intercom systems ● Calling or paging for assistance Comfort ● User can control operation of heating and cooling devices such as fans and heaters ● Operation of main overhead lighting and lamps ● Curtains ● Control of profiling beds and seats Leisure ● Access to a computer ● Page-turners ● Television and music systems Figure 10.12 Environmental control systems. The devices can be similar in size to standard TV remote controls and they operate equipment using infrared ENVIRONMENTAL CONTROL SYSTEMS or radiofrequency signals. The child controls which device to operate by scanning through a menu of options. ECS allow children to control aspects of their home/ school environment that they would normally be unable To access a system offering all the above functions to control (Figure 10.12). requires a range of physical and cognitive skills. For example, a single-switch user would need to have timing For example, children who have only one reliable skills in order to access more than one option. The options voluntary movement, such as voluntary eyeblink or are arranged in menu structures and therefore there needs movement of one finger, can access a switch controlling to be an understanding of this structure. There needs to be a scanning array of options which allow them to operate an ability to anticipate and recall the location of options on different pages of the menu. For example, the volume-up option is on the TV page of commands. Environmental control can be introduced at an early age by using simple items of equipment, for example, to turn on and off the mixer in the kitchen, or operate a set of Christmas tree lights (Figure 10.13). This more basic equipment is often funded in the early years by educa- tion for school purposes or sometimes provided by child development centres on a loan basis, or alternatively pri- vate/charity funding is sought. Again, early introduction of environmental control is important as children learn that they can affect their own environment. From an
154 10 ASSISTIVE TECHNOLOGY Figure 10.14 Simple voice output communication aid (Courtesy of Inclusive Technology) Figure 10.13 Child using simple environmental control be displayed. The device chosen will therefore depend to operate mains-operated light globe. (Courtesy of on a number of factors, including sensory needs and Inclusive Technology.) likely expansion of the system over time. early age typically developing children learn how to con- Consideration of where the main controller should be trol their environment (e.g. television, opening and clos- mounted is important as often operation of equipment ing doors, switching on lights) and this equipment offers while in bed is required as well as when in a wheelchair. this opportunity to children with physical disability. Use This may require additional consideration of different of this equipment, like all AT, should be incorporated switch access in different rooms as the child’s physical skills into all areas of the child’s life. Some children are more in and out of postural control equipment may vary greatly. motivated to access this type of technology than others as Again, the activity needs to be graded to meet the child’s it offers an immediate and functional output. learning needs Therefore the size and the number of options in any menu have to be considered as well as posi- National Health Service environmental control ser- tion within the menu, i.e. all frequently used options near vices are in place around the country. Some operate at a the top. regional and others at a local level. Referral is generally through an occupational therapist. Once installed, training is required for both child and carers, with regular review to ensure the equipment con- The more complex systems which are more generally tinues to meet the child’s needs. available through services can cover a variety of options and can be extended as the child’s needs expand. Thus COMMUNICATION AIDS children could begin with a basic system which allows them control of the television. Then as their scanning and Around the UK, communication aid assessment centres access skills increase, control of other remote controlled offer assessment for different types of voice output com- equipment could be added. Room set-ups can then be munication aids (VOCAs: Figure 10.14). Some offer developed. With the system mounted on the child’s additional assessment expertise, advising on access to the wheelchair, for example, they can scan through menus curriculum (e.g. ACE centres) Often a ‘library loan’ sys- offering them the control options for different rooms. tem is in place which allows the child to trial a device before the local team and family seek funding. Consideration of all aspects mentioned in the earlier assessment section is required. The devices have differing VOCAs operate in a variety of ways and can offer sizes and offer different access options. For example, a simple recorded message output through to complex text child with visual impairment may require auditory scan- to speech output. ning of the options or a screen where large symbols can The simplest system (e.g. BigMack) outputs a single short recorded phrase. This is often used as an introduction to VOCAS and enables the child to take part in simple story-telling activities and games during the school day. Others can offer a larger number of prerecorded digitized
COMMUNICATION AIDS 155 speech phrases which the child can access using one or Figure 10.15 Example of alternative keyboard. more switches. The phrases can be recorded over depend- (Courtesy of Inclusive Technology.) ing on the child’s needs. Figure 10.16 Examples of a trackball and switch Like ECS, more sophisticated devices have dynamic alternative to a mouse. (Courtesy of Inclusive screens, i.e. using switches children can navigate their way Technology.) through pages of menus filled with words or symbols to build up sentences as required. These systems tend to use young children there are simple cause-and-effect type synthesized speech as output rather than the digitized programs which are readily operated using one or two prerecorded option. switches. Support for both family and the child in the use of Having full access to the mouse can be a more challeng- these systems has been identified as crucial to ensure suc- ing proposition. This entails being able to move around the cess and extended use. screen, dragging, single- and double-click and scrolling. Different types of mouse are available with different shapes The devices are available in a range of sizes and have and sizes to accommodate some difficulties; also trackball- different display and access options to meet a wide range type devices can be used. These require the user to move a of needs. For ambulant users small devices can be pur- ball on top of the device instead of gliding the mouse over chased; these are accessed using a keyboard on a Personal a surface. A joystick can also be used in place of a standard digital assistant (PDA) type device or for non-ambulant mouse. Other devices replace switches with each direc- users they can be mounted on a wheelchair. In this case tional movement of the mouse, e.g. four switches allow care needs to be taken to ensure that the stability of the movement in four directions (Figure 10.16). chair is not compromised and that users have a clear view of where they are going when driving their powered chair. For children with visual impairments, screen readers and magnifiers are available which allow access to stand- Assessment is usually undertaken by a specialist speech ard software packages and the internet. and language therapist and requires assessment of the child’s basic communication skills. Device choice is based Again assessment is crucial and individual for each child. on a complex consideration of the child’s current abilities and requirements, environments in which the system is Multifunctional devices to be used, access skills and sensory ability. Increasingly, devices are being produced which are multi- Computer access functional (Figure 10.17). For example, communication aids have ECS capabilities; ECS have communication aid For clients who cannot access a keyboard or mouse there is capability and also computer access options. This use of now a range of commercially available products which can enable access to all computer activities. For children of school age this aspect of access is generally addressed by the education provider. Keyboards of different shapes and lay- outs are available to assist those for whom the standard lay- out is not effective (Figure 10.15). Also key guards can be employed to provide access for those who have difficulty lifting their hand or fingers off the keys between strokes, thus preventing errors when using the keyboard. Standard operating systems such as Microsoft Windows also have accessibility options which can be set to accommodate some basic needs. For example, for those who accidentally hit the keys twice due to tremor, timeframes can be set up so that a given time has to elapse between keystrokes. Also for those who cannot manipulate a mouse, keys can be set to produce cursor movement around the screen. For those who cannot access a keyboard at all, i.e. a one- or two-switch user, keyboard emulators are available (Figure 10.16). This is software which produces a key- board (whose layout, size shape and colour can be adapted to meet the individual needs of the child) on the screen. Using a switch or switches, the child then scans through the keyboard to the letter required and continues generat- ing a sentence in this way. Altering scanning patterns can dramatically speed up the access time for this method. For
156 10 ASSISTIVE TECHNOLOGY multifunctional equipment has led to an increased need for teams and services to work more closely to ensure Figure 10.17 Multifunctional device incorporating that resources are effectively used. For example, ECS communication and environmental control. services need to be informed if the child has a communi- cation aid which has an ECS integrated within it as this could then be used as a main controller within the home and school. As well as integrated devices, integrated control systems exist (Figure 10.18). These allow children who may only have one reliable voluntary movement to have real inde- pendence when operating a number of pieces of EAT, for example, a powered chair, communication aid and an ECS. With each piece of equipment comes a switch or access method. Therefore children using three types of equipment are left with three switches on their tray. With limited movement they then need someone to position each switch as it is required. The integrated control system allows the child independently to change the device the switch is operating. Guerette & Sumi (1994) and Nisbet (1996) have discussed these systems and developed criteria to determine when integrated control systems should be considered. KEY POINT ● Children who have only one reliable access method or single voluntary movement which can be used to access a switch may benefit from using an integrated control system to enable full independent use of EAT Figure 10.18 Integrated access scanner offering control of wheelchair and other devices using single-access method. (Courtesy of Novomed.)
CASE STUDY 10.1 157 CASE STUDY 10.1 Table 10.1 Chailey level of ability for F at age 1 3 (case study 10.1) 3 F is 6 years old. He has a diagnosis of quadriplegic 3 cerebral palsy and he takes medication to control his Supine 2 seizures. He has used assistive technology since the Prone age of 1. Floor sitting Standing Age 1 Table 10.2 Chailey level of ability for F at age 6 Following an assessment at a posture clinic (Table (case study 10.1) 10.1), F was issued with postural management equipment, including a lying support, supportive Prone 6 seating system and standing support. Supine 6 Floor sitting 7 Although F was able to lie in a symmetrical posture, Box sitting 7 a supine lying support was prescribed. This was because Standing 8 he lay with hips widely abducted and externally rotated. There was also concern for his breathing as he extended Age 4 his head and neck. In the lying support F’s hips were neutral for abduction/adduction and internal/external F continued to use the standing support as he could rotation. His head was supported with his chin tucked by not free his hands to use them in standing. the use of the head and shoulder girdle support. F was able to walk short distances inside without F was prescribed with a Minicaps seat on a assistance. He continued to use DAFOs to correct his mobile base. He was able to sit on the floor with wide foot position. abduction and external rotation of his hips but he was not able to move and tended to fall backwards. The F was issued with a Blade self-propelling supportive seat enabled F to use his arms and practise wheelchair with a cushion that he was able to propel control of his trunk within his base. outside over level ground. F was prescribed with a standing support that F was provided with a potty chair to assist him emulates the posture of a typically developing child. with toilet training. When assessed, F required full support under his axilla in order to stand. Within the standing support F F used his Minicaps supportive seating system on was able to begin to take weight through his feet and to occasions at home. experience a typically developing standing posture. F was introduced to switches in order to operate Age 2 switch toys. He used a one- or two-switch system. F was able to roll from supine to prone and move Age 5 about from a lying position. The lying support was limiting his activity, therefore it was withdrawn. F was able to walk short distances outside and used a soft hat for outside play. F was issued with a tricycle with adaptations to provide postural support. This enabled him to explore F continued to use his potty chair for toileting and his environment. was now able to get on and off independently. F continued to use the Minicaps on the mobile The supportive seating system was no longer base and the standing support. required and was withdrawn. Age 3 Age 6 F’s ability was constantly improving and he continued F walks using DAFOs and, although much more to use his supportive seating system at school .The confident, he continues to have difficulties with steps, anterior and lateral supports on the standing support slopes and uneven ground (Table 10.2). were removed as F had developed good trunk control in this position. continued F was beginning to be able to stand unaided, although he stood with a poor posture with a very wide gait and with his pelvis posteriorly tilted. He was supplied with dynamic ankle–foot orthoses (DAFOs). F was beginning to communicate more formally using Signalong and Makaton signs. He was issued with a Chailey Communication System (CCS) book.
158 10 ASSISTIVE TECHNOLOGY He continues to use his wheelchair for longer F is using the computer at school. He is able to distances outside. access it using two switches, a joystick or using the touchscreen facility. F is assessed for a school chair to enable him to stabilize his pelvis while working at school. He The standing support is no longer required and is requires a seat at the correct height, with the correct withdrawn. seat depth, a conforming top surface and a lap strap. CASE STUDY 10.2 Powered chair progressed to using two directions (i.e. left and right) to keep the task simple and Electronic Assistive Technology achievable but still enabling her to take part in chase games and games such as knocking over boxes. S also S has cerebral palsy affecting all four limbs and used the powered chair on a track system to seizures controlled by medication. She has no verbal manoeuvre around the school environment. communication. She is gastrostomy-fed and relies on others for all aspects of daily living. Age 8–11 Currently used mechanical assistive technology: S continued with all activities. S stopped using her hands to operate switches but still found accessing chin switches ● Manual wheelchair with seating system difficult. The head switch was used more reliably, ● Lying support although movements were still ungraded, but timing ● Standing support skills were emerging. S used a head switch mounted on ● Adapted trike a headrest to access the computer using a single switch ● Hoists at home and school and so could begin to access a menu of options using ● Supportive armchair at home autoscanning (software scans through options rather ● Adjustable-height bed than the user having to move through options using ● Adapted toilet/shower seat. switch presses). S used switches to control racing cars and games on a computer. Voice output communication She lives in an adapted house with her parents. aids (VOCA) were introduced: access was slow in comparison with other communication methods but Age 1–3 speed improved with increased timing skills. VOCA had environmental control integrated within the device so S used wedge-shaped hand switches to activate toys that it could be used for both communication and control and later on a tape player to listen to stories and songs. of other devices. S used this at home to operate a simple Although successful to some extent, with only gross TV control menu and a couple of mains sockets for movements of her arms S found it difficult to control devices such as a fan, a lamp and kitchen equipment. movement and maintain pressure on switches regardless of positioning. During this period S’s control of her rotational head movement from midline to right improved and Communication progressed with development of she could control the extent of movement and force. S reliable yes/no responses and use of communication could also achieve midline to left rotation but without book. S used a single switch in a power chair during play. any timing skills or grading of force within movement. S quickly progressed to using this method on her Age 3–8 communication aid. S used this in class and at home along with yes/no responses and a communication S persisted with hand switches for a short period, as book. S accessed powered mobility using a scanner family and S indicated they were not ready to give up. mounted on her chair and a single switch. S no longer She moved on to trail chin and head switches as an needed the track system. option. These offered more choices to meet her cognitive ability but she found it difficult to access these Extending the environmental control system to as extension and flexion of neck were difficult to initiate allow her to use equipment when in lying support and without great effort. A single head switch could be armchair was considered. However it was problematic accessed but produced large movement and S could to use the system when not in the seating system as S not grade the force with which she accessed the head has less control of head movement. switch. S used switches at home and school for different activities. continued Access to computer was introduced using switches. S still found it difficult to target and slow to make choices but given time she was able to.
REFERENCES 159 Age 12 control system. S accessed the computer at home via the integrated control system and could contact her S required help when she wanted to change from friends via the internet. operating her chair to operating her communication aid. She was provided with an integrated control Age 13 system. She used her reliable centre-to-right head movement as the main control and would change S continues to use her system. She has requested an mode (or device to be operated by the main switch) by alternative communication aid as the current one accessing a second switch placed on the left-hand side obscures her vision when driving. of the headrest. S chooses when she wants to use her technology. Her environmental control system was extended Sometimes she chooses to have someone operate her so that she could control more aspects of her home, chair and communicate using her communication including the curtains in her room, doors around the book and at others times she uses the equipment house, TV (including Sky options), music system and herself exclusively. She is aware of what the system mains sockets when seated in her wheelchair. Her can do and directs what she wants to control next. integrated control system also had infrared input/output and so family could add codes to the S’s parents feel she has the opportunity to device each time a new remote-control toy was bought express her personality, be naughty and be left alone or additional devices such as TVs were added around to play. the home. S operated these as part of her integrated The addition of the integrated system has improved interaction with her peer group and socially generally. REFERENCES Demers L, Weiss-Lambrou R, Ska B 2002 The Quebec User Evaluation of Satisfaction with assistive Technology Audit Commission 2000 Fully Equipped. London: Audit (QUEST 2.0): an overview and recent progress. Technology Commission. and Disability 14: 101–105. Beresford B 1995 Expert Opinions: A National Survey of Durkin J 2002 The need for the development of a child led Parent Caring for a Severely Disabled Child. The Policy assessment tool for powered mobility users. Technology and Press: Bristol Disability 14: 163–171. Beresford B 2003 The Community Equipment Needs of Engstrom B 2002 Ergonomic Seating. A True Challange. Disabled Children and their Families. Research works 2003-01. Wheelchair Seating and Mobility Principles. Germany: York: Social Policy Research Unit, University of York. Posturalis Books. Besio S 2003 They play and learn to play. First results of the Goodacre L, Turner G 2005 An investigation of the Italian research project on play and children with motor effectiveness of the Quebec User Evaluation of Satisfaction impairment. Proceedings of AAATE 2003 AT. Shaping the with assistive technology via a postal survey. British Journal future, pp. 221–226. 105 Amsterdam Eds Buhler C, Krops H of Occupational Therapy 68: 93–96. Brubaker CE 1986 Wheelchair prescription: an analysis of Green EM, Mulcahy CM, Pountney TE et al 1993 The factors that affect mobility and performance. Journal of Chailey standing support for children and young adults Rehabilitation, Research and Development 23: 19–26. with motor impairment: a developmental approach. British Journal of Occupational Therapy 56: 13–18. Cartwright RD 1984 Effect of sleep position on sleep apnea severity. Sleep 7: 110–114. Guerette P, Sumi EI 1994 Integrating control of multiple assistive devices: a retrospective review. Assistive Technology Caulton JM, Ward KA, Aisop CW et al 2004 A 6: 67–76. randomised controlled trial of standing programme on bone mineral density in non-ambulant children with Ham R, Aldersea P, Porter D et al 1998 Wheelchair Users and cerebral palsy. Archives of Disease in Childhood 89: 131–135. Postural Seating. A Clinical Approach. Singapore: Churchill Livingstone. Cook A, Hussey S 1995 Control interfaces for assistive technologies. In: Assistive Technologies: Principles and Practice. Jutai J, Day H 2002 Psychosocial Impact of Assistive Mosby: Philadelphia pp. 311–373. Devices Scale (PIADS). Technology and Disability 14: 107–111. Cowan D, Khan Y 2005 Assistive technology for children with complex disabilities. Current Paediatrics 15: 207–212. Kelsall AD, Houghton RH, Cochrane GM et al 1993 Wheelchairs. Oxford: The Disability Information Trust. Demers L, Weiss-Lambrou R, Ska B 1996 Development of the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). Assistive Technology 8: 3–13.
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11 Acquired brain injury: acute management Lesley Nutton CHAPTER CONTENTS who are surviving severe ABI who have major residual problems. Introduction 163 The aim of this chapter is to emphasize the impor- What is acquired brain injury? 163 tance of early physiotherapy intervention in respiratory, Incidence 163 musculoskeletal and neurological care, highlighting the Causes 164 background knowledge, especially with emphasis on pae- Developmental considerations 164 diatric/developmental considerations, required to enable Classification of head injury 165 the physiotherapist to help optimize outcome for each Intracranial dynamics and autoregulation 169 child. Secondary brain damage 170 Primary management and interventions for acquired brain injury 171 WHAT IS ACQUIRED BRAIN INJURY? Different stages of recovery 172 The physiotherapist’s role for children 174 ABI is a non-degenerative injury to the brain that has with acquired brain injury occurred since birth, and can be classified into two groups: Useful adjuncts to physiotherapy 177 The multidisciplinary team approach for 177 1. Non-traumatic – strokes, other vascular accidents, the child with acquired brain injury tumours, infectious disease, hypoxia, metabolic dis- Preparation for discharge from hospital Outcome following acquired brain injury 178 orders and toxic product inhalation/ingestion 179 (www.headway.org.uk) Case study 11.1 179 2. Traumatic brain injury (to be referred to as ABI References 181 throughout this chapter) is the commonest cause of Websites 184 acquired disability in childhood (Crouchman et al Appendix 11.1: Cranial nerve damage 184 2001) and will be the main topic of this chapter, but acute rehabilitation pathways are similar. INTRODUCTION INCIDENCE In children head injuries are very common: some are of a A recent study (Parslow et al 2005) found that: serious nature with consequences which will remain with them for the rest of their lives. In 2002 acquired brain ● The prevalence rate for children (0–14 years) admitted injury (ABI) caused 2% of all deaths in those aged 0–14 to intensive care with ABI was 5.6 per 100 000 per year years in England and Wales (Parslow et al 2005). ● ABI was commonest in low socioeconomic class Although children have better survival rates compared (overcrowding, decreased supervision, less secure play with adults with ABI, the long-term sequelae and conse- areas) quences are often more devastating in children due to their age and developmental potential. The costs involved in the ● In 65% of admissions ABI was an isolated injury care of a child with severe ABI, extended over a lifetime, ● There was a significant summer peak in admissions in are significant (Mazzola & Adelson 2002). children under 10 years Although advances in emergency resuscitative treat- ● Time of injury peaked late afternoon and early ment, improved neurosurgical facilities and diagnostic procedures (computed tomography (CT) scans, magnetic evening, a pattern that remained constant across the resonance imaging) have resulted in a reduction in mortal- days of the week ity, there has been an increase in the number of children ● Prevalence of ABI is higher in males than females in all age groups, with a 2.5:1 male-to-female ratio (Felice 2005) 163
164 11 ACQUIRED BRAIN INJURY: ACUTE MANAGEMENT Figure 11.1 Change in body proportions from before birth to adulthood. ● Children with premorbid problems displayed a higher DEVELOPMENTAL CONSIDERATIONS risk of ABI – behavioural (11%), learning (18%), both of these (42%) and neither (29%) (Rutter 1981) A fundamental knowledge of age-related differences in cerebrovascular physiology and anatomy is essential in the ● Children with existing behavioural problems are application of adult-based head trauma protocols in paedi- three times as likely to sustain ABI as compared to atric patients. Anatomical differences in the skull, cervical those without behavioural problems (Michaud et al spine, brain and chemistry render the child’s brain more 1993). susceptible to injury than the adult. The outcome for chil- dren suffering ABI is far worse than the outcome for an CAUSES equally injured adult (Anderson & Moore 1995). Causes of ABI vary considerably with the age of the Head-to-torso proportions child. Parslow et al (2005) also found that: The brain has achieved 25% of its adult size at birth, 50% ● The commonest mechanism of injury was a pedes- by the end of 1 year, 90% by the end of the fifth year and trian accident (36%), most often occurring in children 98% by age 15 (Wong 1995) (Figure 11.1). over 10 Height of child ● Injuries involving motor vehicles have the high- est mortality rates (23% of vehicle occupants, 12% The toddler’s head is at the level of the motor vehicle front, of pedestrians) compared with cyclists (8%) and and isolated severe head injury is subsequently common. falls (3%) Skull ● Infants fall from windows, furniture and down stairs, whereas older children fall from trees, roofs and play- Children’s skulls are only one-eighth as strong as adults and ground equipment therefore more vulnerable to injury through deformation and fracture of the skull, leading to brain injury. Infants ● Cycling injuries account for 20% of all ABI in children and young children tolerate increased intracranial pressure (Powell 2005) (ICP) better because open fontanelles and cranial sutures lead to a compliant intracranial space. The mass effect of, ● Non-accidental injury is most common in infants for example, a haemorrhage, is often masked by a compen- (Billmire & Myers 1985). satory increase in intracranial volume through fontanelles The above causes and statistics give clear targets for injury prevention. Primarily accidents can be prevented by traf- fic calming. Airbags, soft playground surfaces, use of infant restraint harnesses and removal of pull bars have reduced ABI incidence and cycle-related ABI has been reduced by 85% since the promotion of cycle helmet use (Powell 2005).
CLASSIFICATION OF HEAD INJURY 165 and sutures. Therefore increased ICP signs and symptoms Table 11.1 Cerebral blood flow in normal present when the pathology is advanced. Mature suture unanaesthetized children (Zwienenburg & Muizelaar closure occurs by 12 years but completion of fusion con- 1999) tinues until the third decade (Ommaya et al 2002). Age Cerebral blood flow Brain growth and development rates 0–6 months (ml/100 g per min) 3–4 years (approximate) There are vast differences in the organization of the brain 9 years onwards in different ages of childhood/adolescence. During the 40 normal maturation of the brain plasticity and potential are most diverse and extensive remodelling will occur in devel- 108 oping children, thereby increasing their ability to learn. This has led many to expect a greater degree of recovery in 71 younger children. However, babies and young children have very few matured functional pathways to tap into and CLASSIFICATION OF HEAD INJURY this may well put the child at a disadvantage when com- pared to an older child who will have existing pathways Injuries can be divided into primary and secondary for functional movement. Skills that are emerging or devel- injuries. oping may be affected differently by brain injury than skills that are already established (Wedel-Sellars & Hill-Vegter ● Primary injury is due to direct mechanical damage 1997). inflicted at the time of injury. Except for preventive measures, little can be done to alter primary brain Some neurological deficits may not manifest for years damage which is irreversible (Palmer 2000). If pri- after a head injury, e.g. frontal lobes develop relatively mary damage is not extensive, outcome becomes late in a child’s growth, so that injury to frontal lobes may dependent upon the management of the secondary not become apparent until the child reaches adolescence damage as higher-level reasoning develops and social interaction and interpersonal skills are required (Tranel & Eslinger ● Secondary injury is represented by systemic and intra- 2000). cranial events that occur in response to primary injury and further contribute to neuronal damage and cell Brain water content death. The child’s brain has a higher water content (88%) than Recovery from any type of brain injury depends on the the adult brain (77%), meaning that the brain is softer extent of the initial injury and the secondary damage and more prone to acceleration–deceleration injury. (Arbour 1998). Blood supply Injuries are also classified by mechanism (closed versus open), morphology (fractures, focal intracranial injury Cerebral blood flow (CBF) is the amount of blood in and diffuse axonal injury) and severity (mild, moderate transit through the brain at a given point in time. A child or severe). has a larger percentage of cardiac output directed to the brain, as the head accounts for a larger percentage Mechanisms of injury of body surface area and blood volume (Table 11.1). This can make maintenance of cerebrovascular stability ● Open – also referred to as penetrating injuries; difficult. these occur when both the skin and the dura are pen- etrated by a foreign object (e.g. bullet) or a bone frag- Pituitary gland ment of a fractured skull. The most common (and most severe) type of injury to the brain is the diffuse The pituitary gland can be damaged in moderate to severe injury ABI. If production of growth hormone is affected, hor- mone therapy may be needed to prevent the long-term ill ● Closed – are the most common type; the skin remains effects of low pituitary output, which may affect the intact and there is no penetration of the dura. Closed heart, the psychiatric state of the child and produce sex- ABI falls into two categories: focal and diffuse. ual dysfunction (Bondanelli et al 2005). The severity of these injuries varies according to the velocity of impact and the vector (linear versus rotational) of forces applied. History of the accident is utilized to determine the velocity of the injury.
166 11 ACQUIRED BRAIN INJURY: ACUTE MANAGEMENT Low-velocity injuries include a child falling a short dis- The first and second points give rise to contusions or tance, an accidental blow to the head, e.g. with a bat, or an haematomas on the surface of the brain. aggressive tackle in a football game. Injuries are usually mild and only require observation. There are often two contusion sites. One occurs at the impact site – coup injury (frontal and temporal lobes are High-velocity injuries include a fall from an upper- commonly involved). The other arises where the brain storey window and a pedestrian being struck by a moving bounces off the skull when it has been moved away from car. Even in the absence of neurological dysfunction chil- the site of the original blow – contrecoup injury (Figure dren are usually observed in hospital. 11.2b). Some bleeding may also arise at the suture points where the dura mater, which serves to suspend the brain Crushing injuries may also occur where the head might within the skull, is torn away from the inside of the skull. be caught between two hard objects (e.g. the wheel of a car Contusions are usually multiple and may occur bilaterally. and the road). This is the least common type of injury, and Multiple contusions do not in themselves contribute to often damages the base of the skull and nerves of the brain- depression of conscious level, but this may arise when stem rather than the brain itself (Duhaime et al 1995). bleeding into the contusions produces a space–occupying haematoma. Morphology of injury The third point, susceptibility of the brain to shearing Skull fractures may be in the cranial vault or skull base forces, plays a role primarily in injuries that involve rapid and may be linear or stellate, depressed or non-depressed. and forceful movements of the head, e.g. motor vehicle The main significance of finding a fracture is that it is accidents, shaken-baby syndrome. Rotational forces, associ- an indication of the force of the injury. Depressed skull ated with rapid acceleration–deceleration of the head, are fractures are invariably associated with high-velocity injury smallest at the point of the rotation of the brain near the and may result in brain injury. A CT scan is mandatory. lower end of the brainstem and successively increase at Basal skull fractures may involve the floor increasing distances from this point The resultant shearing of the skull’s brain cavity and are occasionally associated forces cause different levels in the brain to move relative to with cerebrospinal fluid (CSF) rhinorrhoea or otorrhoea one another. This movement produces stretching and tear- (leakage of spinal fluid into the nose and ears). Bruising ing of the axons (diffuse axonal injury; Figure 11.2a) and around the eyes, ears and back of neck may also be the insulating myelin sheath, injuries which are the major present. cause of loss of consciousness in a head trauma. Small blood vessels are also damaged, causing bleeding deep in the brain. Brain injuries arise from three characteristics of the brain/skull anatomy: Collectively these injuries can result in swelling of the brain. If swelling continues the brain will gradually be 1. Rigidity and internal contours of the skull pushed down through the foramen magnum (coning). 2. Incompressibility of the brain tissue Brainstem nuclei controlling breathing and cardiac function 3. Susceptibility of the brain to shearing forces. will eventually be compressed, resulting in death (Lindsay et al 1986, Wong 1995, Waugh & Grant 2005). Forward and backward movements of the brain within the skull Stretching and tearing of nerve fibre pathways Rotational movement of the brain within the skull Figure 11.2 (a) Diffuse axonal injury and (b) coup/contrecoup.
CLASSIFICATION OF HEAD INJURY 167 To summarize, the brain may be injured in a specific Severity of head injury location or the injury may be diffused to many different parts of the brain. The indefinite nature of brain injury The Glasgow Coma Scale (GCS) is the most widely makes treatment unique for each child. It is important to accepted tool to determine severity of head injury. It is a understand that the brain functions as a whole by interre- simple scale developed in 1974 to assess conscious levels lating its component parts and its implications for rehabil- and has a relatively high degree of interobserver reliability itation. The injury may only disrupt a particular step of (Rowley & Fielding 1991, Gill et al 2004). It serves as an an activity that occurs in a specific part of the brain. The immediate prognostic guide and provides a useful baseline interruption of that activity at any particular step, or out with which future examinations can be compared. The of sequence, can reveal the problems associated with the scale has been adapted for infants and young children – the injury (Table 11.2). Paediatric Coma Scale (Reilly et al 1988). Table 11.2 Specific functions of different brain areas and problems associated with injury Area of brain Functions Problems if damaged Frontal ● Motor cortex ● Monoplegia/hemiplegia is dependent on Parietal ● Contralateral movement of face, arm, extent of damage Occipital leg, trunk ● Paralysis of head and eye movements to the ● Contralateral head- and eye-turning opposite side ● Expressive centre for speech ● Personality and initiative, and emotional ● Inability to sequence a complex task, difficulty with problem-solving response ● Cortical inhibition of bladder and bowel ● Persistence of a single thought (perseveration) voiding ● Changes in personality with antisocial ● Appreciation of posture, touch and passive behaviour and loss of inhibitions movements ● Loss of initiative and becomes ● Receptive speech area where language is uninterested and unconcerned understood ● Emotionally labile ● Visual attention ● Expressive language problems ● Manipulation of objects ● Incontinence of urine and faeces ● Concept of body image and awareness ● Postural and passive movement sensation of external environment disturbed ● Mathematical skills ● Receptive dysphasia ● Perception of vision ● Lack of awareness of certain body parts or surrounding space ● Difficulty distinguishing left from right ● Difficulty with mathematics ● Hand-eye incoordination ● Difficulty reading, naming and drawing objects, locating words for writing ● Can only attend to one object at a time ● Cortical blindness ● Visual field cuts ● Difficulty identifying colours ● Hallucinations ● Visual illusions ● Difficulty recognizing words and drawn objects ● Reading and writing problems ● Cannot put name to familiar face continued
168 11 ACQUIRED BRAIN INJURY: ACUTE MANAGEMENT Table 11.2 continued Area of brain Functions Problems if damaged Temporal ● Hearing of language, sounds, rhythm, music ● Cortical deafness ● Learning and memory ● Difficulty in hearing spoken words, ● Some visual perceptions ● Emotional/affective behaviour appreciation of rhythm/music ● Short- and long-term memory ● Inability to establish new memory ● Aggressive and antisocial behaviour ● Persistent talking (right lobe) ● Difficulty recognizing faces and objects Brainstem ● Breathing ● Decreased vital capacity for ● Heart rate breathing, important for speech ● Swallowing ● Reflexes to seeing and hearing (startle ● Swallowing ● Difficulty with organization/ response) ● Controls seating, blood pressure, digestion, perception of the environment ● Problems with balance and temperature (autonomic nervous system) movement ● Affects level of alertness ● Dizziness and nausea ● Ability to sleep ● Sleep difficulties ● Sense of balance (vestibular function) Cerebellum ● Maintenance of gait ● Unsteady gait ● Maintenance of postural tone and coordination ● Tremor of voluntary movement ● Unable to perform rapid movements ● Maintenance of balance and equilibrium ● Impaired fine–movement coordination ● Dizziness ● Slurred speech Modified from Lindsay et al (1986), Wong (1995) and Waugh & Grant (2005). The GCS is scored between 3 and 15, 3 being the Table 11.3 Grading of acquired brain injury (ABI) worst and 15 the best (Table 11.3). It is composed of three using the Glasgow Coma Scale (GCS) score parameters: best eye response, best verbal response and best motor response: Grade of ABI GCS score Mild 13–15 Best eye response (E) Moderate 9–12 Severe 3–8 1. No eye-opening 2. Eyes opening to pain Motor response (M) 3. Eye-opening to verbal command 4. Eyes open spontaneously. 1. No motor response 2. Extension to pain (decerebrate posturing) Best verbal response (V) 3. Flexion to pain (decorticate posturing) 4. Withdrawal from pain 1. No vocal response 5. Localizing to pain 2. Incomprehensible sounds 6. Obeys commands. 3. Inappropriate words 4. Confused 5. Oriented.
INTRACRANIAL DYNAMICS AND AUTOREGULATION 169 To be useful the ‘GCS of 12’ needs to be broken down Table 11.4 Clinical signs of increased intracranial into its components, e.g. E4V3M5 ϭ GCS 12 (Teasdale & pressure in infants and children (Wong 1995) Jennett 1974). Infants Children The GCS has limitations in the assessment of some children, including those who are intubated, dysphasic, ● Tense, bulging ● Headache have periorbital haematomas and facial swelling and fontanelle ● Nausea immobilized broken limbs. ● Vomiting ● Separated cranial ● Diplopia, blurred vision INTRACRANIAL DYNAMICS AND sutures ● Seizures AUTOREGULATION ● Changes in behaviour ● ‘Cracked-pot’ sound on In order to plan appropriate intervention, it is essential for skull percussion and personality the physiotherapist to understand the importance of moni- toring the patient’s intracranial status. At present ICP and ● Irritability Late signs (all ages) cerebral perfusion pressure (CPP) monitoring remain the ● High-pitched cry ● Decreased most commonly used clinical parameters for assessing ● Increased occipitofrontal intracranial dynamics. By continuous observation and consciousness regulation of the ICP and mean arterial pressure (MAP), circumference ● Decreased motor and CPP can be maintained. ● Distended scalp veins ● Changes in feeding sensory responses What is intracranial pressure? ● Cries when held or ● Alteration in pupil size It is the pressure exerted by the volume of the three rocked and reactivity (pupillary intracranial components inside the skull: ● ‘Setting-sun’ sign response changes*) ● Decerebrate and 1. Brain tissue: 80% (impaired upward gaze) cortical posturing 2. Blood: 10% ● Change in respiration 3. CSF: 10% (Andrus 1991). pattern ● Papilloedema† Under normal conditions ICP ranges between 0 and 10 mmHg, although it will rise transiently with coughing *Pupillary response changes: the light reflex tests oculumotor or straining (Chudley 1994), with no significant pressure (III) nerve function and is a crucial indicator of an expanding gradient between the two cerebral hemispheres or intracranial lesion. The pupil dilates on the side of the expanding between supratentorial and infratentorial compartments lesion and is an important localizing sign (Lindsay et al 1986). (Dixon & Vyas 1999). Following trauma, this situation †Papilloedema: swelling of the optic disc when intracranial pres- may change. sure is raised. When the volume of any of the intracranial components 15 mmHg or higher (Johnson 1999). Treatment is nor- increases, the volume of one or both of the others must mally required Ͼ20 mmHg and can be measured by vari- decrease or the ICP will rise (Arbour 1998). Normally the ous monitoring devices. brain has the ability to autoregulate its blood flow by dila- tion and constriction of blood vessels. This ensures a con- Monitoring of ICP is important and this is closely stant blood flow to all areas of the brain. Autoregulation is linked to the maintenance of an adequate CPP and the apparently preserved in the majority of head-injured chil- importance of normovolaemia. dren (Sharples et al 1995a). Clinical effects of increased intracranial Compensatory mechanisms for increased pressure intracranial pressure A raised ICP will produce signs and symptoms but does The brain may try to compensate for the increase in one of not cause neuronal damage provided CBF is maintained the intracranial components by shunting CSF to the spinal (Table 11.4). Damage results from brain shift. subarachnoid space, increasing CSF absorption or decreas- ing CSF production or shunting venous blood out of the What is cerebral perfusion pressure? skull. However, cerebral trauma may disrupt autoregula- tory mechanisms and cause a sustained increase of ICP to CPP is the pressure at which the brain tissue is perfused with blood and is a measure of the adequacy of the cerebral circulation. It is maintained by supporting MAP and/or reducing ICP. When autoregulation is impaired, the CBF fluctuates with changes in systemic blood pressure e.g. during
170 11 ACQUIRED BRAIN INJURY: ACUTE MANAGEMENT suctioning, coughing, causing a rise in blood pressure ● Brain shift and resultant increased ICP. An acutely injured brain has ● Ischaemia a higher metabolic rate and therefore requires a higher ● Infection. CPP (Sharples et al 1995b). Haematoma Normal CPP in paediatric patients is variable and dependent upon the age-related MAP. Monitoring of ICP Intracranial bleeding may occur outside (extradural) or as a means of calculating CPP is widely used, aiming for a within the dura (intradural) (Figure 11.3): CPP of Ͼ50 mmHg in infants under 1 year and 60 mmHg in children above that age (Table 11.5: Dixon & Vyas ● Extradural – a skull fracture may cause tearing of the 1999, Hackbarth et al 2002). middle meningeal vessels, causing a bleed into the extradural space. There may be a lucid interval after SECONDARY BRAIN DAMAGE the injury, then increasing headache (the dura is pain- sensitive) and a subsequent clinical deterioration as Critical care management is focused on minimizing sec- the mass lesion increases in size. ondary brain injury caused by a cascade of cellular events that occur after the primary insult. Initial vascular and ● Intradural – which may evolve into a life-threatening parenchymal disruption leads to ongoing neuronal degen- mass as bleeding from the torn veins continues, con- eration, resulting in neuronal ischaemia and cell death sisting of a mixture of both subdural and intracerebral (Bayir et al 2003). haematomas. Bridging veins may be ruptured follow- ing impact, producing a subdural haematoma. It is Secondary brain damage is caused by several factors, usually associated with high-velocity injury with including increased ICP and decreased CPP, which may immediate severe neurological dysfunction. follow: Brain swelling ● Haematoma ● Brain swelling This results from either vascular engorgement or an increase in extra- or intracellular fluid. A haematoma may Table 11.5 Minimum cerebral perfusion pressure or may not be present. (CPP) to strive for (Chambers et al 2005) Brain shift Age band (years) CPP (mmHg) 2–6 53 A progressive rise in ICP due to a supratentorial 7–10 63 haematoma at first produces midline shift followed by a 11–16 66 series of herniations, causing progressive midbrain and lower brainstem compression (Figure 11.4). (a) Subdural haematoma (b) Subarachnoid haemorrhage (c) Intracerebral haemorrhage Figure 11.3 Effects of different types of expanding lesion. (a) Subdural haematoma; (b) subarachnoid haemorrhage; (c) intracerebral haemorrhage.
PRIMARY MANAGEMENT AND INTERVENTIONS FOR ACQUIRED BRAIN INJURY 171 Subfalcine herniation with unfavourable outcome underlies the importance of immediate action with airway protection, adequate ven- Mid-line shift tilation and intravenous access and fluid replacement. Lateral tentorial Hypotension has been shown to increase mortality herniation rates significantly in children with ABI but isolated ABI rarely leads to hypotension. Blunt abdominal trauma and Central tentorial long-bone fractures frequently occur in association with herniation ABI and may be a major source of blood loss. A child’s blood volume should be restored with crystalloid solutions Tonsillar and/or blood products. These children should undergo herniation aggressive fluid therapy resuscitation with isotonic fluids until appropriate fluid balance is achieved (Felice 2005). Figure 11.4 Supratentorial haematoma producing midline shift and herniation. Children who suffer multisystem trauma typically pre- sent with head injury, followed in decreasing frequency Ischaemia by limb fracture and trauma to the torso (Moulton 2000). Fracture management follows once medical stability is This is caused by either hypoxia or impaired cerebral per- optimized. fusion and may result in a drop in cerebral perfusion since autoregulation results in cerebral vasodilation. Children suspected of head injury require an assess- ment of: Infection ● GCS Skull fractures may result in dural tearing which leaves the ● A neurological examination, including pupillary brain susceptible to a potential route for infection. Basal skull fractures may cause leakage of CSF from the nose responses (rhinorrhoea) or ear (otorrhoea) which requires immediate ● An examination of the head and neck for signs of antibiotic therapy to prevent infection, leading to meningi- tis or cerebral abscesses. bruising, lacerations and open fractures – bruising associated with basal skull fractures often takes several PRIMARY MANAGEMENT AND hours to develop. INTERVENTIONS FOR ACQUIRED BRAIN INJURY Following initial assessment, repeated neurological obser- vations are required to detect deterioration. Children in a The first 24–72 hours is the vital period in management coma (GCS < 8) require urgent intubation. Endotracheal of ABI (Johnson 1999). Adequate oxygen delivery and intubation allows for airway protection and better control haemodynamic stability in the child at the earliest moment of oxygenation and ventilation. Oral (for base-of-skull remain the most important aspects of the management plan fractures) or nasal intubation tubes should be taped and (Lam & MacKersie 1999). not tied in place to avoid jugular compression. Confused or agitated patients may also require controlled sedation, Most patients who survive the first few hours after intubation and ventilation before CT scanning. severe ABI require several days of intensive care, and ICP is usually measured during this time (Segal et al 2001). The detection of a skull fracture in combination with an impaired level of consciousness greatly increases the risk of The recognition that the combination of hypoxia intracranial haematoma formation. A fracture demon- (oxygen saturation Ͻ 90%) and hypotension (systolic strated on a skull X-ray is now a definite indication for a blood pressure Ͻ 90 mmHg) is universally associated CT scan. Hypoxia and hypercapnia are both potent vasodila- tors, resulting in increased CBF and increased ICP. Therefore mechanical ventilation should ideally keep the following levels: SaO2 92–100% PaO2 10–14 kPa PaCO2 4–4.5 kPa After issues involving oxygenation, ventilation and hypotension are addressed, focus is shifted towards other strategies that minimize intracranial oedema, limit intracra- nial hypertension, maintain adequate CPP and prevent sec- ondary damage (Table 11.6). Most of the management will occur simultaneously, but it is important to assess each child’s response to each intervention (Palmer 2000).
172 11 ACQUIRED BRAIN INJURY: ACUTE MANAGEMENT Table 11.6 Interventions to reduce intracranial pressure (ICP) and increase cerebral perfusion pressure (CPP) Intervention Details Head midline Prevents kinking of the jugular veins (Johnson 1999) Cervical collars and endotracheal tube ties not too tight as may impair cerebral venous drainage (Arbour 1998) Nurse head elevated 15–30° of head elevation is optimal Ͼ30° elevation reduces CPP (Dixon & Vyas 1999) Inotropes May be indicated to maintain the MAP and CPP Induced hypothermia Fever (Ͼ38°C) can arise due to hypothalamic dysfunction or infection and decreases seizure threshold (Chambers 1999) Using cooling devices (32–34°C) decreases inflammatory responses, excitoticity, metabolic demands and oxidative stress (Marion et al 1993, Chambers 1999, Johnson 1999) Increases risk of bleeding and infection, arrhythmias and exacerbation of chest infection (Schubert 1995) Sedation Barbiturates (heavy sedation) cause a ‘barbiturate coma’ Decrease cerebral metabolic rate and ICP (Arbour 1998) Anticonvulsants Seizures impose major metabolic burden on the brain and increase ICP Used if seizure activity is identified clinically or on EEG (Dixon & Vyas 1999) Hyperosmolar therapy Reduces elevated ICP by creating an osmotic gradient that draws cerebral oedema fluid from brain tissue into the circulation Mannitol widely used Hypertonic saline solutions may also be used (Knapp 2005) Hyperventilation Decreases PCO2 to between 4 and 4.5 kPa, producing a reflex cerebral vasoconstriction, therefore decreasing CBF and ICP (Arbour 1998) Effects noted less than 30 seconds from onset, and the peak effect is noted at approximately 8 minutes (Oh 1997) Positive end-expiratory Used to maintain airway patency, but PEEP above 10 cmH2O mmHg may cause pressure pressure (PEEP) decreased intracranial compliance (Dixon & Vyas 1999) Paralysing agents Can be given continuously or in intermittent boluses as required Disadvantages of use include masking of seizure activity (Dixon & Vyas 1999), prevention of coughing and decrease in effective secretion clearance (Felice 2005) and development of muscle weakness which may prolong ventilation (Dixon & Vyas 1999) Analgesia Reduction of painful stimuli (e.g. tracheal suction, intravenous cannulation) Craniotomy Removal of a section of the skull (bone flap) to access the traumatized brain underneath and then it is replaced (Lindsay et al 1986) Burrhole A small opening is made and minimally invasive procedures used, e.g. to drain a blood clot (Lindsay et al 1986) MAP, mean arterial pressure; EEG, electroencephalogram; CBF, cerebral blood flow; PEEP, positive end-expiratory pressure. DIFFERENT STAGES OF RECOVERY pattern of recovery after severe ABI. The brain may be injured within a specific location or diffused to many As children progress out of their coma and wean from parts of the brain. The indefinite nature of brain injury is sedation/paralysing medication, most follow a general unique for each child and follows the stages of recovery
DIFFERENT STAGES OF RECOVERY 173 in a different way; the amount of time spent in each stage Observation of spontaneous activity, resting posture varies and recovery may stop at any stage. and response to painful stimuli provides clues to the location and extent of the neurological damage, for The Wessex Head Injury Matrix (WHIM) is a use- example: ful behavioural scale to assess and monitor recovery in children after severe ABI. It can be used from the earliest ● Damage above the brainstem results in flaccidity of stages of coma recovery onwards and can demonstrate sub- muscle tone, is asymmetrical and may be valuable in tle signs of recovery that enable realistic goal-setting (Shiel the localization of structural damage (Bateman 2001). et al 2000). Flaccidity can occur before spasticity appears but may persist indefinitely A general understanding of the brain and its functions paves the way for the knowledge required to facilitate the ● Limb weakness with decreased level of consciousness physiotherapist to adapt assessment, treatment and goal- can be determined by comparing the response in each planning around these different phases (Appendix 11.1). limb to painful stimuli Recovery from ABI can be grouped into the following ● Hemiparesis usually occurs in the limbs contralateral to main stages: the side of the injury but may also occur in the ipsilat- eral limbs. This is due to indentation of the contralat- 1. Unresponsive/coma stage eral cerebral peduncle by the edge of the tentorium 2. Early responses stage cerebelli 3. Agitated/confused stage 4. Higher-level responses stage. ● If eyes and head are deviated to the side opposite hemiparesis, this implies a hemisphere lesion, whereas Unresponsive/coma stage deviation to the side of hemiparesis is indicative of a pontine lesion Coma is a state of unawareness of self or environment, and the inability to sense or respond to bodily or envi- ● Using the GCS, if pain produces an asymmetrical motor ronmental needs, caused by injury to the arousal centre response, the limb weakness is present on the side with in the brainstem. Coma is caused by brainstem damage the lower score, e.g. right-side weakness if right side and severe injury to both sides of the cortex. The brain- extends, left side flexes or right side flexes, left side stem is highly interconnected with other parts of the localizes (Lindsay et al 1986). brain; therefore, when it is injured other parts of the brain are affected as well. The child’s eyes remain closed, he or A child may start to appear to be ‘more wakeful’, with she is unable to communicate, fails to move in a purpose- cycles of eye-opening and closing, but reveals no sign of ful manner or respond in a consistent or appropriate man- awareness or wakefulness. This stage is sometimes referred ner and a normal sleeping pattern is not re-established to as the ‘vegetative state’, when the child is breathing spon- (Bateman 2001). taneously and has a stable circulation. The shorter the period of coma/vegetative state, the better the prognosis for The auditory sense is often present in a state of coma, recovery (Jennett 2002). therefore discussion about the child’s condition and thoughtless or derogatory remarks should be discouraged The use of coma arousal therapy, also known as sensory (Wong 1995). stimulation, is the subject of much debate. It is intended to promote awakening and enhance rehabilitative potential by Random movements of the arms and legs may occur for using an intensive programme of visual, auditory, olfac- no specific reason. Families can become very fixated on any tory, gustatory, cutaneous and kinaesthetic sensory input. and very varied movements that the child starts to exhibit. Sensory stimulation can start as soon as the child’s medical The following stereotyped postures may also occur: condition is stable but there are conflicting views on its efficacy. There is limited reliable evidence to support its ● Decerebrate posture – bilateral upper- and lower-limb use (Lombardi et al 2002) and constant stimulation may extensor posture, usually the consequence of bilateral even be detrimental (Wood 1991). midbrain or pontine lesions. Opisthotonos, a severe muscle spasm of the neck and back, may accompany Early responses stage decerebrate posture in severe cases Children will now be keeping their eyes open for longer ● Decorticate posture – bilateral flexion of the upper and need less vigorous stimulation to wake them up, e.g. limbs and extension of the lower limbs, usually the initially arouse only to painful stimuli, then touch, then consequence of an upper-brainstem lesion. Although sound. Children start to respond to the environment and a serious sign, it is usually more favourable than responses will be more appropriate but may be inconsis- decerebrate posture and may progress to a decerebrate tent or slow. Localized responses, e.g. turn towards a posture, or the two may alternate sound, pull away from something uncomfortable, follow with eyes. ● Unilateral decerebrate or decorticate postures can be seen and are an indication of a unilateral lesion. This asymmetry has some localizing value (Bateman 2001).
174 11 ACQUIRED BRAIN INJURY: ACUTE MANAGEMENT Figure 11.5 Encouraging eye contact in a child with severe at this stage the child’s behaviour is (on the whole!) not acquired brain injury. intentional. A consistent approach to inappropriate behav- iour is vital from all carers and family, e.g. not laughing at At this stage communication should be encouraged the patient’s behaviour or language. but children often experience fatigue and a short atten- tion span. Tips for improving communication include: As the child becomes more aroused, it is important for all carers and visitors to speak to the child in an age- ● Speaking slowly and clearly appropriate manner. Inappropriate language and actions ● Encouraging eye contact if possible (Figure 11.5) can lead to inappropriate responses from the patient and ● Clarifying names of body parts to help movement may lead to future behavioural problems. requests The goal at this stage is to help the child become more ● Using age-appropriate language oriented and continue to treat the physical needs. The ● Blinking – once for yes, twice for no. Blinking is an child may be moving about randomly in bed and trying to climb out of bed; padded cot sides can be helpful to pre- involuntary action so must be done very definitely vent injury and/or tissue damage. Elbow and knee pads can ● Simple commands, e.g. open and shut eyes also be useful. Children are very vulnerable at this stage, as ● Thumbs up and grip and release of hand once out of bed, they can be disoriented, lack safety aware- ● Awareness of slow processing and be patient for a ness and have decreased balance reactions. At this stage they require constant supervision. A child may become very response frustrated if not allowed to move about and mats on the ● Hand gestures or physical guidance with hands or with floor can be useful where the patient can roll about or crawl. Sometimes the presence of a family member can be verbal cues. enough to calm the patient. At this stage the goal is to increase the consistency of At this stage a child benefits greatly from low noise responses. Recording achievements of recovery, however levels and short periods of activity with hopefully increased small, in a diary is a way for all carers to follow the child’s attention span times. Orientate the child to their sur- progress. Rest periods are essential throughout the day roundings using visual and verbal information. Clocks, with decreased stimulation of the surroundings if pos- calendars and diaries can be useful to write a child’s daily sible. However, within a busy ward setting this can prove schedule of timetable, mealtimes, therapy input, visitors difficult. and special appointments. Methylphenidate appears to be an effective treatment to Sitting a child who is constantly moving may prove improve arousal in the minimally responsive child (Hornyak challenging and cause agitation to the child if repeatedly et al 1997). attempted. It is potentially unsafe unless the child is constantly supervised. Agitated/confused stage Higher-level responses stage Children will be responding more consistently at this stage. However, they will probably be confused and disoriented Routine tasks become easier but help is needed with in time and place, with memory and behaviour difficulty. problem-solving and making judgements and decisions. Many children display disinhibited behaviour and may yell, Children will have become aware of any residual physical bite and swear and will often pull their nasogastric tubes problems and conscious of their body image. The goal at and intravenous lines out. All carers need to be aware that this stage is to decrease the amount of supervision needed and increase their independence (see Ch. 12). THE PHYSIOTHERAPIST’S ROLE FOR CHILDREN WITH ACQUIRED BRAIN INJURY Following ABI, the management of each individual child will vary enormously, depending on the extent of the head injury and any other injuries sustained. The clinical experience and problem-solving ability of the physiother- apist in the context of a knowledge and understanding of current research literature remain the main way to deter- mine realistic goals for each child’s management. Owing to the wide age range, developmental and premorbid
THE PHYSIOTHERAPIST’S ROLE FOR CHILDREN WITH ACQUIRED BRAIN INJURY 175 neurodevelopmental backgrounds, there is little evidence ● Paralysing the child inhibits the cough reflex and to guide on the best assessment approaches. reduces the effective mucociliary function The physiotherapist’s roles include: ● Sputum can often become thick and sticky if fluid restriction is required for ABI management; small air- ● Prevention of secondary respiratory problems, primarily ways may plug off easily in intensive care but also after transfer to the rehabili- tation ward ● Pooling of secretions also occurs in dependent lung areas (in supine posterior upper and lower lobes). ● Prevention of secondary soft-tissue shortening and joint contractures. If a chest infection develops, management of the child becomes much more challenging. Infection causes fever In order to assess accurately, plan appropriately and carry and increases already overstretched metabolic demands. out physiotherapy intervention effectively, it is vital for It is harder to achieve good ventilation, especially if pos- the physiotherapist to understand the effects of ABI on itioning of the patient is limited due to ICP problems or intracranial dynamics and how to interpret the interrela- multitrauma. Extubation and intensive care stay are pro- tionships of vital signs, including ICP, MAP and CPP. longed. Weaning may proceed provided that the child is able to maintain and protect the airway and clear secre- Physiotherapy needs to be combined with nursing tions (Coplin et al 2000), but can be more difficult interventions to ensure minimal disturbance. Sedation because the ICP may increase as the child’s cough returns. management, feeding regimes and effective pain relief all need to be discussed so that respiratory assessment/treat- Children needing prolonged ventilation for the man- ment times can be incorporated (Edwards 2002). agement of intracranial hypertension or for respiratory complications (e.g. excess secretions) require a tra- Irrespective of their conscious state, patients should be cheostomy (Koh et al 1997, Gurkin et al 2002). involved in any activity. Talking to a child and explan- ation of what cares are being carried out can help min- It is vital that the physiotherapist has a sound knowl- imize any rise in ICP (Snyder 1983). edge and understanding of intracranial dynamics to be able to assess accurately and treat effectively (Table 11.7). During the acute management of ABI, physiotherapy intervention is known to raise ICP, therefore: Prevention of secondary soft-tissue shortening and joint contractures ● Short, more frequent and efficient treatments are essential In the acute stages following ABI, the child will be chang- ing rapidly. Objective assessments must be done and out- ● Allow time for acute increased ICP to recover to come measures selected in order to monitor change. acceptable values (15–20 mmHg) both between general Physiotherapists have a leading role in this task, having the procedures, e.g. position change, and in individual knowledge that there are likely to be changes in muscle treatments (Johnson 1999) tone following head injury. ● Monitor the child’s reactions to different procedures Objective assessments may include: and modify or avoid them accordingly. ● Muscle tone (Modified Ashworth Scale) An ICP of more than 20 mmHg for longer than 3 min- ● Orthopaedic assessment (joint range and muscle length) utes requires immediate medical intervention. Elevations ● Changes in functional status (Pediatric Evaluation of that return to baseline within 30 seconds are usually well tolerated (Prasad & Tasker 1990). Disability Inventory: PEDI) (Dumas et al 2002). Prevention of secondary respiratory Any measure of muscle tone may be affected by the child’s problems medical status (e.g. pyrexia, coughing, pain), which may make repeatability of some measures unreliable. Spasticity, Children with ABI who present with a GCS Ͻ8 are likely defined as ‘excessive and inappropriate involuntary mus- to have impaired respiratory function at the time of the cular activity in association with upper neurone damage’ is injury or later on. There may be direct damage to the chest probably the most common physical disorder following wall or fractured ribs, or lung damage in the form of contu- acute ABI and soft-tissue contractures commonly follow sions. The child may have vomited and aspirated at the time in its presence (Watkins 1999). of the injury. Any damage to any part of the respiratory sys- tem may potentially lead to hypoxia and hypercapnia which ABI can produce a number of key deformities, espe- ultimately leads to cerebral oxygenation problems. cially when prolonged abnormal posturing is encountered (Table 11.8). Equinovarus is the most common deformity Once ventilated a number of factors predispose to associated with ABI because it appears in both decerebrate secondary respiratory complications: and decorticate posturing (Conine et al 1990). Some- times, even with the optimal medication management and ● Introduction of the endotracheal tube promotes physiotherapy interventions, there may be some unavoid- colonization of lower-respiratory tract with upper- able loss of joint ranges. These may occur during the early respiratory organisms and increased mucus production (Coplin et al 2000)
176 11 ACQUIRED BRAIN INJURY: ACUTE MANAGEMENT Table 11.7 Physiotherapy interventions and effect on intracranial pressure (ICP) Physiotherapy Details intervention Positioning Although patients with raised ICP are nursed with head elevation of 30°, postural drainage can be performed if needed when strict guidelines are followed (Imle et al 1997) Changing position Changes in head and body positioning can increase ICP (Chudley 1994) Log-rolling maintains head in relation to the body Side–lying may increase ICP with only small changes in CPP (Rising 1993) Hip flexion of Ͼ90° limits venous drainage and increases ICP (Arbour 1998) Manual techniques Percussion performed slowly does not increase ICP and may even lower it Shakes may increase ICP over time, whereas vibrations done in isolation have no effect on ICP (Imle et al 1997) Manual hyperinflation Known to increase ICP (Imle et al 1997) Should be interspersed with short-duration hyperventilation to decrease PCO2 and ICP, prior to or following suction (Kerr et al 1997) Suctioning Causes a progressive rise in ICP with each insertion of the catheter. Elevations in ICP are transient and return to baseline levels within minutes (Kerr et al 1998) Stimulation of the cough due to the direct tracheal stimulation causes a rise in ITP, decreased cerebral venous return, increased CBV and ICP (Kerr et al 1998) Hypoxia can be minimized by use of closed–suction circuits and hyperoxygenation (Johnson 1999) CPP, cerebral perfusion pressure; CBV, cerebral blood volume; ITP, intrathoracic pressure. Table 11.8 Key deformities in acquired brain injury stages of recovery but can often be regained further down the rehabilitation pathway. Joint Most common deformity Shoulder Physiotherapy treatment options include: Elbow Adducted/internally rotated ● Passive stretches/movement Forearm Flexed (decorticate) ● Positioning and postural management Wrist Extended (decerebrate) ● Serial casting. Fingers Thumb Pronated Passive stretches/movement Hip Flexed/ulnar-deviated Passive movements for unconscious/paralysed children Knee and those presenting with hypertonus are required to Flexed maintain muscle and joint range of movement (ROM). Ankles/subtalar Adducted/flexed into palm Changes in hamstring and quadriceps length will Great toe hamper forward pelvic tilt and impact on a child’s ability Adducted/medially rotated to sit. Trunk and neck muscles can also become short- Extended if mass extensor ened if passive elongation is not performed. tone very high, or held flexed Maintenance of nervous system mobility is also essen- Extended if decorticate/ tial. Children who are unable to move or those dominated decerebrate posturing present by hypertonic stereotyped postures are as likely to develop Sometimes flexed shortened neural structures as they are of loss of ROM of the musculoskeletal system (Shacklock 1995). Nerve pain Plantarflexed/inverted may occur later into the rehabilitation process, and can be (equinovarus) treated effectively with gabapentin. Often musculoskeletal pain relief fails to have any effect on this type of pain. Flexed/extended Passive movements are ideally done one to two times per day, especially in the intensive care setting. However, due to time constraints, other strategies must be developed
THE MULTIDISCIPLINARY TEAM APPROACH FOR THE CHILD WITH ACQUIRED BRAIN INJURY 177 for the rest of the day, especially for the child dominated by ● Use of casts over the weekend ensures maintenance of stereotyped patterns which maintain muscles in a short- joint positions in the absence of the physiotherapist ened position, to produce more lasting effect in the control of body posture and movement. ● Advice on cast removal is essential if the cast causes increased agitation, or the child deteriorates, e.g. intra- Positioning and postural management venous access is required. Postural management should extend to all aspects of care Serial casting may enhance the treatment of children and be consistent throughout the 24-hour day (see with ABI by reducing the abnormal sensory input. Chapters 7 and 10). Children can weight-bear while casts are in place and thereby achieve a better postural alignment. Casting has The needs of the child will need reassessing and priori- been shown to be as effective as botulinum toxin A in the tizing on a daily basis. The physiotherapist should use skills short-term treatment of spasticity (Corry et al 1998). and experience to anticipate the changes and carry out effective interventions to minimize the risk of secondary USEFUL ADJUNCTS TO PHYSIOTHERAPY complications. Useful adjuncts include medication and orthotic Choice of position, for both support and movement management. performance, must be considered in respect of tonal changes, influence of gravity, potential structural defor- Medication mity and preservation of tissue viability. The physiotherapist can work in conjunction with the A child will require varying degrees of external sup- paediatric neurologist to assess the efficacy of medication port to stabilize body posture and position relative to the to reduce spasticity. The different medication options supporting surface in lying, sitting and standing. include: Serial casting ● Muscle relaxants, which include baclofen delivered orally or intrathecally when oral medication has not Once paralysis and sedation are reversed, ROM should been effective (Armstrong et al 1997) (see Ch. 12) be closely monitored and active intervention com- menced as soon as ROM is at risk. Elbows and ankles are ● Botulinum toxin A can be used to control increased the most problematic areas due to stereotyped posturing tone by causing temporary paralysis and weakness in the early stages following ABI. (Graham et al 2000, Munchau & Bhatia 2000). It pro- vides the physiotherapist with a window of opportu- ● Casts can be used prophylactically to maintain ROM, nity to make changes in the pattern of movement and prevent development of muscle and tendon shortening, can be used in conjunction with serial casting/orthotics to correct alignment of joints and regain lost muscle (Bottos et al 2003, Mackey et al 2003). length Orthotics ● Removable splints such as ankle resting splints or wrap- around arm gaiters can be beneficial. Carers needs to be In order to facilitate prolonged stretching of muscles, the shown the correct application and routine use of splints physiotherapist can work in conjunction with the ortho- and the risk of pressure sores explained in children with tist using splints (e.g. ankle–foot orthosis) to maintain poor sensation. Splints should not interfere with other optimum positions, especially of distal joints (see Ch. 10). team members’ input, e.g. intravenous access. THE MULTIDISCIPLINARY TEAM Guidelines for use of serial casting: APPROACH FOR THE CHILD WITH ACQUIRED BRAIN INJURY ● Children with increased muscle tone can be at risk of pressure areas. Medical management of tone should As in all paediatric settings, the service to a child is therefore be discussed before considering casting best delivered by a multidisciplinary team (MDT). Each extremes of tone child with ABI displays a unique and often rapidly changing recovery pathway; monitoring progress by the ● Casts may need padding on the outside when children MDT is often described as ‘chasing a moving target’ (see are agitated or prone to hitting or kicking. Agitation Ch. 2). may be too severe to be able to apply any form of cast or orthosis ● Arm casts need to be light-weight to prevent pulling on the shoulder ● Ideally casts should be left on for 5–7 days (Conine et al 1990) and be reapplied once reassessment of joint ranges and stretches to muscles have been done
178 11 ACQUIRED BRAIN INJURY: ACUTE MANAGEMENT Assessment, treatment and goal-planning The family play a vital part in providing an accurate pic- ture of a child’s ability before an ABI (Williams 1992) to Assessment, treatment and goal-planning need to be determine if there were predisposing problems or con- adapted through all phases of recovery in conjunction with cerns which need to be considered in the management of the child and family. It is essential to gather information to a child, e.g. visual impairment. Unfortunately, brain injury develop a care plan consistent with the problems and needs is known to exaggerate pre-accident personality traits and of the child. disability (Vannier et al 2000). It is impossible to gather all information in a single Identification of the child’s problems gives the reha- assessment. Use of standardized and objective assessments bilitation team areas to focus treatment plans. Each prob- can prove difficult in the acute paediatric setting as the lem area affects other areas and in many cases resolving child can change on a daily basis. As a consequence, assess- one problem has a major impact on other problems. ment can remain somewhat unstructured in format and subjective in content, relying on the skill and experience Transfer from intensive care to the ward of the therapist to reassess continually, analysing changes in quality of movement, posture and function. Key issues Once weaned off life support and no longer needing inten- should be clearly documented. sive care, a child is transferred to the paediatric ward for ongoing neurorehabilitation. A range of clinical assess- Support and involvement of the family ments is done by the MDT to provide an overall picture of the child’s functional ability. Relevant information is com- The unconscious phase and early recovery stages can be a municated to health, social and education colleagues in the time of great stress and uncertainty for parents, siblings, child’s home area. other family members and friends. There will be many dif- ferent emotions that the family will naturally go through A rehabilitation programme is developed and tailored throughout the child’s recovery, including panic, fear, shock, flexible to the child’s individual needs, including a range denial, anger, guilt, isolation and hope. The parents are faced of identified functional goals. It also starts to address dis- with the uncertain outcome of the ABI. Intervention with charge planning by looking forward to the child’s antici- parents depends upon the personality of the parents, and the pated needs at home and school. parent–child relationship before the injury (Mercer 1994). The child will be seen by the hospital teacher daily for Involvement and training of family members early in short periods. Therapists can advise on adaptation of the recovery process are critical for successful long-term some activities, e.g. positioning, which will help rein- outcome. Family members are best equipped to ensure force rehabilitation. treatment compliance and follow-through with treat- ment recommendations, in maintaining treatment gains, A daily programme of activities is useful to give children and in generalizing treatment effects beyond the medical structure to their daily routine, which needs to incorporate setting (Beaulieu 2002). periods of activity and rest. Following ABI many healing processes take place, especially if they have suffered other Useful tips to guide the family: trauma. Fatigue sets in quickly and attention spans are short-lived. ● General information leaflets are useful, including the roles of different team members Use of a central communication file (from day 1) is essential to: ● Help the family to put together a file of information about their child’s injury and progress reports and to ● Keep the MDT and family all working towards the keep a diary. This will help the child make more sense same goals of events as he/she recovers ● Maintain consistency of care throughout the 24-hour ● Encourage the family to become actively involved, so period reducing any feeling of helplessness ● Encourage a vital team approach to all aspects of care ● Families can attend the weekly team meeting and should to which everyone involved with a child can refer. be encouraged to express and discuss any concerns and anxieties PREPARATION FOR DISCHARGE FROM HOSPITAL ● Providing photographs or favourite toys or belongings and daytime clothes can make the bed space homely Once the rapidly changing stage of recovery has started to stabilize and short-term goals have been achieved, ● Encourage the family’s role in controlling the envir- plans for discharge home or to a local hospital should onment and the number of visitors to avoid overstim- commence. Preparation for discharge is essential early on ulation (Appleton 1994) in the recovery phase, although it is impossible to predict ● Family members also need ‘time out’ to spend time with the rest of the family rather than keeping a vigil at the bedside.
CASE STUDY 11.1 179 the level of support a child and family will require once age and developmental achievement at time of injury, out of hospital. It is far better to oversubscribe services, maturation and family involvement and resources impact e.g. equipment loans, and reduce the needs as required the later stages of recovery. than to have prepared insufficient support, which will ultimately delay discharge plans. General ABI awareness Severe ABI has been found to be a source of consider- training/training specific to the needs of the child may able care-giver morbidity when compared with other be required for all carers subsequently involved. traumatic injuries (Wade et al 1998) and psychosocial family functioning deteriorates in a substantial number of There are a variety of options for placements following families (Tomlin et al 2002). discharge, including specialist rehabilitation units, a child’s local hospital or a specialist hospital. There are advantages Therefore raising awareness of the consequences of and disadvantages to these options, such as distance from ABI and providing a dedicated and integrated approach home and the type of rehabilitation packages available in to assessment and provision of care across the domains of the different settings. hospital, education and community are vital to facilitate family adaptation and for successful reintegration of these Arrangements can be made to enable the child to go children back into the community. home for short stays, which can then graduate to longer periods, allowing for slow reintegration at home, aiding KEY POINTS the whole family in preparing for the child’s long-term difficulties. ● Children are not ‘mini-adults’ ● ABI displays an extremely varied spectrum of During the inpatient phase the team needs to liaise closely with a child’s local community, social and health possible lesions and resulting potential services to ensure a smooth transition of care into a suit- disabilities. It is the indefinite nature of the brain ably prepared environment. injury that makes treatment unique for each individual child OUTCOME FOLLOWING ACQUIRED ● Fundamental knowledge of age-related BRAIN INJURY differences in cerebrovascular physiology and anatomy, the child’s premorbid ability and Generally, within 6 months to 1 year after the injury, 90% psychosocial situation is required of the long-term neurological outcome has been achieved. ● An understanding of intracranial dynamics, medical Some consequences are likely to remain as long-term and surgical interventions is essential to make impairments. Many children have problems that appear accurate assessment and carry out appropriate months – sometimes years – later as educational, behav- effective treatment ioural or emotional disturbances (Reynolds 1992). ● Physiotherapy intervention is vital from day 1 to optimize respiratory, musculoskeletal and Although neuronal plasticity provides the potential for ultimately neurological outcomes neuronal reorganization in a child’s brain, it is the behav- ● Family members are an integral part of the MDT ioural demands of the environment that allow the child ● Early communication pathways concerning to take advantage of this potential and to maximize referrals to community care are paramount recovery (Beaulieu 2002). ● An awareness of the consequences of ABI needs to inform the integrated approach to assessment The ultimate long-term impact of ABI sustained in and provision of care across health, education and childhood depends on the child’s ability to achieve devel- community opmental milestones following injury. Although injury- related and treatment-related factors are critical during the early stages of recovery, child-related factors such as CASE STUDY 11.1 ● Fracture to left elbow ● Laceration to right elbow Jamie, an 8-year-old boy, sustained a severe acquired brain injury (ABI) when he was hit by a car travelling at His management included: 30 mph whilst he was riding a pedal bike with no helmet. ● Intubated and ventilated (due to GCS Ͻ 8) His Glasgow Coma Scale (GCS) at the scene was 7/15. ● Right frontal craniotomy and evacuation of traumatic The injuries he sustained were: haematoma ● Fracture to right frontal bone of skull. Computed ● External fixator applied to right tibia (non-weight- tomography scan showed a right frontal intracranial bearing) haemorrhage ● Above-elbow plaster cast left arm (set at 90°) ● Fracture to mid-shaft right tibia continued
180 11 ACQUIRED BRAIN INJURY: ACUTE MANAGEMENT ● Repair to right-elbow laceration subsequent carry-over into other treatment input. ● There was no medical history of note. Tracheostomy removal was delayed due to the Jamie lives in a two-storey house with Mum, Dad and presence of granuloma formation in airways three siblings. The house has a downstairs toilet. His (causing stridor). hobbies include Playstation and football. 5. Repeated coughing caused increased muscle tone/decorticate posturing with subsequent He remained on the paediatric intensive care unit tightness in elbow flexors and resultant equinovarus (PICU) for nearly 2 weeks. Intracranial pressure (ICP) bilaterally. Passive stretches and provision of ankle remained Ͻ25 mmHg postoperatively. A failed splints maintained plantargrade but more intensive extubation at day 10 resulted in a tracheostomy. input was required for the upper limbs. The left arm was already immobilized in a plaster cast with the Physiotherapy input commenced immediately after elbow at 90°; the right arm required serial casting to his neurological status was stabilized on PICU. The main maintain optimal extension. Supine lying was aims were to prevent secondary respiratory avoided where possible. complications, maintain joint ranges and prevent joint 6. As decorticate posturing became less dominant, a contractures through passive stretches, positioning dense right hemiplegia became more apparent. His and splints. left side began to display random purposeless movements in all directions which maintained a On transfer to the rehabilitation ward the reasonable overall left upper-limb joint range, but following problems were noted: his right-sided muscle tone began to increase arm (flexor) greater than leg (extensor) with no active 1. Decreased conscious state movement. Right shoulder girdle mobilizations, 2. Inability to communicate botulinum toxin injections and stretches were used 3. Dysphagia to reduce tone and a hand splint was provided to 4. Impairment of respiratory function, tracheostomy, maintain functional hand position. An ankle-foot orthosis was used on the left leg to prevent clonus excess secretions and help with weight-bearing. 5. Decorticate posturing 7. Side-lying and high sitting were encouraged with 6. Dense right hemiplegia (right-handed child) appropriate support for head and trunk in midline. 7. No head or trunk balance A tilt-in-space chair with full head, trunk and 8. Non-weight-bearing right leg with external pelvic support was chosen so that support and chair angles could be gradually reduced as head fixation in situ and trunk control improved. 9. Immobilized left arm in above-elbow plaster cast. Trunk mobilizations were performed in sitting over the edge of the bed to maintain trunk and During the early stages of rehabilitation, Jamie pelvic mobility, and encourage midline orientation, was totally dependent upon others for all his functional head and trunk activity. needs. Following individual and joint assessments by Movements from lying to sitting and vice versa were members of the multidisciplinary team (MDT), the actively assisted via both sides and transfers into a above problems were addressed: chair were done via the left side with maximal assistance to support head, trunk and non-weight- 1. Wessex Head Injury Matrix assessment was bearing right leg. This support was gradually reduced started to monitor change in conscious state. as activity returned. The hoist was used by carers to Position was regularly changed (lying and sitting) transfer from bed to chair, due to the specialized to encourage increased arousal and sensory handling techniques required at this stage. awareness. A structured timetable to encourage a A supportive wheelchair was provided to allow balance of activity and rest was commenced. The some mobility away from the ward. busy ward made it difficult to maintain a controlled 8. The right lower leg required elevation to prevent environment to avoid overstimulation. swelling which created asymmetry in the sitting position. In discussion with the orthopaedic team 2. A personalized therapy file was issued to provide it was agreed that for short periods it would not be consistent communication input, which initially detrimental to allow the lower leg to rest down. started as blinking, progressing on to yes/no and 9. The immobilized left elbow maintained range of picture cards as eye-tracking/fixing and following movement of the elbow at 90° but on removal of returned. continued 3 and 4. The physiotherapist and speech and language therapist worked together to facilitate swallowing and maintain and restore respiratory function. Excess secretions required regular suctioning and repeated coughing impacted on overall muscle tone and posturing. Joint assessments for suitable seating and moving and handling procedures were also done with the occupational therapist, with
REFERENCES 181 the cast the elbow had a moderate degree of fixed activities were encouraged to promote weight flexion due to underlying tone and prolonged transference to his right side. immobilization limiting active elbow extension. Jamie displayed a good physical recovery and Treatment progression was eventually independently mobile, but still had the following residual problems: Over the next few weeks, intensive rehabilitation ● Impulsiveness continued, consisting of: ● Poor safety awareness of his surroundings, ● Establishment of more advanced communication especially on the stairs (tracheostomy in situ/speaking tube. Tracheostomy ● Reduced proprioception in his right leg, resulting in in situ for 2 months overall) ● Re-established gag and swallow, allowing sitting for poor awareness of lower-limb/foot placement meals ● He continued to favour using his left side for many ● Appropriate family involvement ● A balanced timetable with activity and rest periods activities encouraged ● Communication – problems with word-finding and ● Joint treatment sessions with physiotherapist, occupational therapist, speech and language occasional slurring of speech therapist and teacher ● Reduced attention span and easily distracted ● Increased time spent out of bed to promote activities ● Poor motor planning skills, especially with of daily living ● Active movements encouraged to optimize hand-writing (letter formation). functional movement ● Moving and handling reviewed as return of activity Outcome evolved ● Facilitation of active sitting, transfer and standing Jamie has made a good physical recovery over a 4- work, gradually increasing weight-bearing on the month period, but still requires some ongoing right leg assessment and therapy input. ● Mirror used to provide visual feedback on posture and movements and to maintain attention No major home adaptations were required and ● Weekly MDT meeting including family. phased discharge was beneficial, including visits to school and weekend leave, allowing his family and As active movement returned, Jamie became very community carers to prepare for his physical, agitated, especially by the tracheostomy/coughing. When psychosocial and educational needs appropriately as awake he constantly moved randomly about the bed, follows: requiring padded cot sides to prevent injury (especially to ● Continued supervision from carer, especially on external fixator). He required supervision when sat out as he chose to sit in an asymmetrical manner (premorbid stairs favourite sitting posture) and became agitated if attempts ● A working environment to reduce distractions and were made to reposition him. He resisted passive stretches to encourage elbow extension and splints and maintain attention casts were not tolerated due to his agitation. ● Encouragement to use right side in a variety of Once the external fixator was removed from his activities right leg and full weight-bearing was re-established, ● Gait re-education ● Balance and coordination activities ● General muscle strengthening and return of physical fitness ● Ongoing assessments of perceptual needs and sensory processing ● Motor planning skills, especially hand-writing. REFERENCES Arbour R 1998 Aggressive management of intracranial dynamics. Critical Care Nurse 18: 30–40. Anderson V, Moore C 1995 Age at injury as a predictor of outcome following paediatric head injury. A longitudinal Armstrong RW, Steinhok P, Cochrane DD et al 1997 perspective. Child Neuropsychology 1: 187–202. Intrathecally administered baclofen for treatment of children with spasticity of cerebral origin. Journal of Andrus C 1991 Intracranial pressure: dynamics and nursing Neurosurgery 87: 409–414. management. Journal of Neuroscience Nursing 23: 85–92. Bateman DE 2001 Neurological assessment of coma. Appleton R 1994 Head injury rehabilitation for children. Journal of Neurology, Neurosurgery and Psychiatry 71: 13–17. Nursing Times 90: 29–32.
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184 11 ACQUIRED BRAIN INJURY: ACUTE MANAGEMENT WEBSITES www.headway.org.uk www.includemein.org APPENDIX 11.1: CRANIAL NERVE DAMAGE Basal skull fracture or extracranial injury can result in functional tasks. The patient may have to tip the head in damage to the cranial nerves (CN). Evidence of damage a certain way to minimize the diplopia, e.g. in CN IV (except for CN III lesion) does not usually help immedi- palsy the patient complains of double vision when ate management but must be recorded. Damaged CN may looking downwards when descending stairs or reading. have an impact on functional recovery. It is important for Use of eye patches may be beneficial the physiotherapist to be aware of some of them: ● Damage to CN III may cause ptosis (droopy eyelid) which hinders full vision. ● Damage to CN II may cause visual acuity and field problems Damage to CN IX and X is considered jointly since their actions are seldom individually impaired. Impaired swal- ● Damage to CN III, or IV and VI may cause problems lowing and gag reflexes need to be closely observed due to with coordinated movements of the eyes. Loss of one the risk of aspiration. Head positioning is therefore very parameter of eye movements may lead to double vision important (Lindsay et al 1986). and cause visual disturbance to the patient with true and false images. This may be problematic when doing many
12 Acquired brain injury rehabilitation Patricia Wilcox CHAPTER CONTENTS 185 that the family maintains an active role in their child’s care 185 and rehabilitation. They can be involved in goal-setting, Introduction 185 carrying out exercise programmes and the appropriate use Aims of rehabilitation 194 of postural equipment (Demellweek & O’Leary 1998). Rehabilitation 195 Case study 12.1: Sara’s story AIMS OF REHABILITATION References ● To enable reintegration into the community by provid- INTRODUCTION ing therapy and management for children and young people after their discharge from acute care Following discharge from hospital a rehabilitation place- ment can be appropriate for a child once he or she is med- ● To restore children’s former quality of life or to estab- ically stable. Therefore, a child can enter a rehabilitation lish an alternative life plan that is acceptable to them. unit whilst having high health and nursing needs: the child may have a tracheostomy, a gastrostomy or a nasogastric tube It is important that everyone – children, their families and in situ. Alternatively the patient may be independently the rehabilitation team – acknowledge that, although reha- mobile with, for example, some mild balance problems, bilitation can assist in achieving the above aims, it is unable muscle weakness or altered muscle tone. However the to make the trauma and its effects completely disappear majority of children entering a rehabilitation unit are likely (Mazaux & Richer 1998). to be in a wheelchair, to have some muscle tone and joint range problems and to have emerging movement in their REHABILITATION limbs and emerging sitting balance. Rehabilitation needs to be delivered by a multidisciplinary Although a child who has suffered an acquired brain team who are able to make the process a 24-hour-a-day injury may present with similar problems to a child who experience. The team provides nursing and care, physio- has cerebral palsy, there are some important differences. therapy, speech and language therapy, occupational therapy, Children with an acquired brain injury usually have a his- educational psychology and psychiatry as well as recre- tory of normal development and have experienced nor- ational activities. Educational input can be provided by a mal movement. They are therefore retrieving skills rather dedicated teacher or by teachers provided by the home than learning them for the first time. They are in a chang- tuition service. The team needs to meet regularly to share ing situation so they have greater potential for improve- their knowledge and goals and to enable everyone to have ment, especially in the first years following their injury. a greater understanding of a child. This enables the reha- bilitation process to have continuity and to be effectively Rehabilitation is a much more active process than a delivered over the 24-hour period. child may have experienced in the acute stage. Children need to be able to share the therapist’s goals to enable them There are different settings in which rehabilitation can to work with commitment. As the children’s ability and take place and what is right for one child and family will awareness improve, depending on their age, they may take not necessarily be right for another. There are very few the lead in goal-setting. residential rehabilitation centres in the country that are dedicated to acquired brain injury rehabilitation, so chil- The family may have spent the time since their child’s dren and their families may have to be prepared to have injury at the bedside, totally involved in their child’s care. some distance between themselves and home. These cen- The transition to a rehabilitation setting may necessitate a tres, however, are able to offer a holistic, continuous service. change in the family’s role, as parents return to work and When a rehabilitation centre is not available or appropri- spend more time with siblings. It is important, however, ate, rehabilitation can also take place in the acute hospital 185
186 12 ACQUIRED BRAIN INJURY REHABILITATION setting and once children have been discharged back into and physiotherapists should be involved in the discussion the community. If rehabilitation is taking place in the com- as to which muscles need targeting. munity setting, it is difficult for the team to provide an intensive rehabilitation programme as a child will be based Serial casting (Watkins 1999) is often necessary to regain at home and attending a centre for allotted therapy sessions. a joint’s full range of movement; if this is going to be the case, the sooner it is undertaken, the better the result is likely The rehabilitation process can be broken down into to be. A variety of splints can also be used; fixed polypropy- two stages: an active rehabilitation stage and a reintegra- lene splints made by an orthotist can be used when the sit- tion stage. uation is stable but are expensive to supply if the children’s needs are constantly changing. It is possible, however, to The active rehabilitation stage supply polypropylene splints with a ratchet joint so they can adjust to any changes in joint range. These can work This is the stage when rapid change may occur and physio- well, especially on single-plane joints. Backslabs made from therapy input needs to be at a high level to enable children to fibreglass splinting materials are also useful as they can be make good use of their returning gross motor skills. made quickly and changed frequently. Physiotherapists need to be continually reassessing chil- dren to ascertain what weekly or even daily goals are real- Passive stretching, performed slowly, can assist in istic and achievable. Goal-setting plays an important part reducing muscle tone (Zafonte et al 2004) and allows ther- in acquired brain injury rehabilitation and is often very apists to monitor the situation regularly. Parents can be child-led, with the physiotherapist taking a guiding, taught to carry out a stretching programme: although it supervising role. can have the benefit of giving them an active role in their children’s rehabilitation as well as benefiting children, care Common gross motor problems must be taken that the movements are being performed in such a way as to encourage relaxation. The gross motor problems experienced by children after brain injury can be similar to those of children born with Careful positioning to try to avoid musculoskeletal cerebral palsy. There should, however, be a difference in changes is also important and the appropriate equipment approach and treatment as they are in a situation that is should be used in lying, sitting and standing to reduce changing, possibly rapidly. They have also, depending on abnormal postural reactions (Jackson 2004). their age at the time of their injury, experienced normal movement; although this can be emotionally negative in Surgery may be necessary to correct contractures but that they are aware of what they have lost, it is positive in this is a last resort and should not be carried out until the that some motor patterns may have been retained. children’s high muscle tone has stabilized and non-invasive changes in joint range are no longer possible (Anderson Spasticity 1995). Spasticity is a common occurrence in the acute stage of Cerebellar ataxia acquired brain injury and it is often still present when children are medically stable and therefore ready to move Cerebellar ataxia is the disruption of coordination of move- on to rehabilitation (see Ch. 11). In the more severely ment due to damage to the cerebellum. If there is unilateral affected children, decorticate posturing is commonly damage, the symptoms will appear on the same side as the seen, with the upper limbs adopting a flexed position and lesion (Bastian 1997). It may not be apparent in the early the lower limbs held in extension (Griffith & Mayer stages after a head injury and it may only come to light 1990). Spasticity can quickly result in the loss of joint when a child starts to move; indeed, it often appears to be ranges and will greatly impinge on a child’s ability to getting worse as movement increases. make good functional use of any returning active move- ment. The joints most at risk from contractures are the Cerebellar ataxia is characterized by overshooting or ankles, elbows, wrists and fingers. undershooting of voluntary movement, tremor, hypotonia, disturbances of balance and gait and dysarthria. Children The resolution of spasticity needs to be one of the suffering from cerebellar ataxia may have generalized low primary aims of physiotherapy and, although this is not muscle tone but it is the central low tone that tends to have always possible, the effects of spasticity can hopefully be the greatest effect on their functional gross motor ability. lessened. Treatment should focus on increasing children’s core Systemic muscle relaxants (Gormley 1999) such as stability to enable them to perform functional move- baclofen (Meythaler et al 2004) and dantrolene will have ments without the need to use their arms to provide a been started in the acute stage and the multidisciplinary stable base from which to work. Lycra body suits can be team need to make sure that these are at the optimum dose. a useful tool but children must be motivated and willing Botulinum toxin can be used to target specific muscles to wear the suit on a regular basis (Attard & Rithalia 2004). Wrist weights can be used to damp down the arm tremor and to improve hand function but these appear to have only a temporary effect; there tends to be very little carry-over once the weights are removed. Weighted boots
REHABILITATION 187 are more practical, in that they can be worn for long peri- affected side or leave food on one side of the plate ods of time and they can be effective in improving and untouched. It can result in the affected arm being ignored, retraining gait (Griffith & Mayer 1990). Children with even though it may have adequate movement to be func- cerebellar ataxia are generally willing to push their phys- tionally useful. Children need to be reminded that the ical boundaries and need to be allowed to test their phys- arm exists by being presented with bilateral tasks and by ical abilities and make mistakes whilst being kept safe. the arm being positioned in sight, for instance, on the table rather than under it. Paralysis/weakness Constraint-induced movement therapy, which involves If the motor cortex is damaged, it is unable to carry out its restricting the functioning of the unaffected arm, to encour- role fully in regulating the recruitment and frequency of age use of the affected arm (Karman et al 2003), may be motor neurone firing (Duncan 1990). This can result in a appropriate for older children, who are able to understand wide range of problems, from the paralysis of whole muscle and are willing to persevere. This is only necessary for groups to specific areas of muscle weakness. upper-limb function as weight-bearing and lower-limb function tend to happen more spontaneously, There are many different means of trying to facilitate muscle contraction and, although a child may not be con- Orthopaedic sciously activating the nervous system, it is hoped that, in time, it may lead to a voluntary contraction. The most An appreciable number of children undergoing acquired common means of facilitating a muscle contraction include brain injury rehabilitation will have sustained their injury brushing, tapping and fast passive stretch (Jackson 2004). in a road traffic accident. They may, therefore, have also Electrical stimulation of muscles may be appropriate if a sustained spinal or long-bone fractures and this will affect child is able to tolerate it and is sufficiently aware to be able the way their treatment can be delivered. to focus on and attempt to join in the movement. Scoliosis is another orthopaedic problem which can Physiotherapists need to be aware that if a child has occur over a period of time due to asymmetrical muscle spent time immobilized in bed some muscle weakness is tone in the spine; this needs to be monitored and the spine likely to be present. In this case, if there are no neurolog- may need to be braced while the muscle tone stabilizes. ical signs, a graded muscle-strengthening programme and a gradual return to normal daily activities may be all that Heterotopic ossification is a possible complication after is necessary. brain injury. New bone grows in the soft tissues and can cause pain, inflammation and loss of joint range (Jaffe et al Initiation, planning and sequencing of 1990). Passive movements need to be carried out with movement care to avoid the possibility of stimulating ossification. The extra bone can be removed surgically when the situation A substantial number of children who have suffered an has stabilized and if it is causing problems. acquired brain injury have difficulty initiating, planning or sequencing movement. Difficulty with initiating movement Regaining functional abilities can be demonstrated by children who are unable to turn their heads voluntarily, but can spontaneously shake their On admission to a rehabilitation service, most children and head to give a no response. Physiotherapists can give manual their families will declare their aims to be walking and talk- prompts to assist with initiation difficulties. ing. Most parents are anxious, understandably, to see quick results and will sometimes try to take a child forward too Problems with planning and sequencing movement can quickly or expect physiotherapists to do so as well. It is, result in children who are able to move from sit to stand, however, the role of physiotherapists to guide children for instance, if the movement is spontaneous but find it through the developmental stages at an appropriate rate and very difficult to perform the task if the movement is not to explain to the parents the necessity for this approach. instant or if something happens to interrupt the manoeu- vre. For these children tasks need to be broken down into Physiotherapy intervention is guided by accurate assess- a sequence of movements and the same verbal or manual ments of a child’s deficits. Assessment must be ongoing and prompts need to be given each time the task is practised. part of every treatment session, especially when a child’s As these children improve, the prompts can be gradually physical state is changing rapidly. reduced and withdrawn. Normal patterns of movement have been established in Neglect a child who has suffered an acquired brain injury, unless the trauma occurred at a very early age. It therefore seems Some degree of unilateral neglect is common in a child logical that normal movement is used as a model for therapy whose brain injury has resulted in hemiplegia. It can take with these children. However, physiotherapists need to use a the form of visual neglect when children may ignore writ- range of treatment techniques from neurodevelopmental to ing on one side of the page, walk into objects on the task-specific training (see Ch. 5). The approach will vary depending on the child’s needs at the different stages of reha- bilitation (Lennon 2004).
188 12 ACQUIRED BRAIN INJURY REHABILITATION Lying tone and provide a stable base for the acquisition of head control and sitting balance. It also provides an optimum Positioning in lying is important until a child is actively learning position and can encourage hand function. moving around in bed. A good supported symmetrical Ideally a range of chairs would be available to allow for lying position will help to minimize the development of children’s individual needs; however, adaptations may be deformities, reduce muscle tone and promote bilateral hand necessary. It is important to remember that a good sitting function. The amount of support needed will vary depend- position will enhance a child’s abilities but a poor sitting ing on the child; it may be that a T-roll under the knees in position will be detrimental. It is therefore necessary to supine-lying is sufficient or the child may need a full lying avoid sitting until an acceptable position can be achieved support (see Ch. 10). (see Ch. 10). As lying is a totally supported position it is ideal for If a child’s head control is insufficient to maintain an working on a wide variety of gross motor skills. Areas that up-right sitting position, it may be necessary to use a can be worked on in this position include the following: wheelchair with a tilt-in-space facility, a supportive collar or a head rest with a brow band to allow functional activ- Gross motor movements of all four limbs ity. A head rest with brow band can help achieve a good sitting position for eating and drinking and switch use. In supine-lying, assisted and manually resisted exercises can be carried out, encouraging control of flexion and It is important to provide a child with some form of extension of the hips and knees. In prone-lying hip exten- independent mobility as soon as possible, as long as it is sion and knee flexion can be encouraged and in side-lying safe. A self-propelling wheelchair can be provided if there hip abduction can be isolated. It is important to give accu- is sufficient hand function. If a powered wheelchair is a rate verbal feedback to a child without being negative if it is possible solution, this idea needs to be introduced sensi- difficult to access a particular muscle group. tively as this can be seen as a prediction of a child’s future abilities. Play in supine-lying and side-lying can encourage gross motor activity of the upper limbs. Once a child can be placed in a reasonably symmetrical sitting position, manually supported sitting can be used to Head control work on head control, sitting balance and posture. Encour- aging propping on both hands will also stimulate activity In supine-lying head-turning and lifting can be encour- of the muscles around the shoulder girdle. A mirror is use- aged. If the therapist supports a child’s head in his or her ful for a child to check his or her own posture and to cor- hands, assistance can be given when necessary and friction rect it. Initially a child is likely to need verbal and visual can be reduced. It is also a good position in which to facil- feedback to achieve this; these aids can gradually be with- itate activity in the neck extensors. In prone-lying a child drawn as a child learns to self-correct. With older children can be assisted into a forearm prop position or placed over a biofeedback machine can be used with pressure plates a wedge to work on head control: it may be necessary to placed under the buttocks and a visual display showing the use noisy toys to gain a small child’s attention. comparative weight-bearing loads. Rolling to side-lying and to prone Children can be gently moved to bring their trunk forwards, backwards and laterally over their base. Initially A child can be assisted to roll by manually rotating the manual support the length of the trunk may be needed pelvis and encouraging the child to turn the head and and this is best achieved by the therapist high-kneeling shoulders. In the early stages, a child might only be able to behind the child. As sitting balance improves, the level of do this in small movements timed to an intake of breath so support given can be lowered to pelvic level. it is necessary to be patient and be aware of any change in a child’s position. When static independent sitting balance has been achieved the task can be made more challenging by raising Pelvic control and stability the plinth so a child’s feet are not on the floor. Movement in sitting can be introduced by asking a child to reach out- Crook-lying is a good position in which to work on side his or her base in all directions or by introducing an pelvic control. Bridging will encourage hip extension and activity such as throwing and catching a ball. Rhythmical lateral control and can be progressed by introducing sin- stabilizations in sitting can be used to improve core stabil- gle-leg bridging or the use of a physio ball under the feet. ity but care must be taken to ensure that the child feels safe. Seating support can also be reduced, although it is Sitting necessary to be aware a child may fatigue quickly whilst practising a newly acquired skill. A Swiss ball can be used As soon as a child is able to tolerate a sitting position, it is to work on sitting balance, starting with a child’s feet wide important that a good position is achieved. This will help apart to give a good base and the therapist giving some to prevent deformities occurring, reduce increased muscle manual support. The exercise can be progressed by reduc- ing the support and making the child’s base smaller and less stable (Carriere 1998).
REHABILITATION 189 Figure 12.1 Poor posture on a standard dining chair. Figure 12.2 Corrected posture on kneeler chair. Posteriorly tilted pelvis and rounded spinal profile. When a child has achieved stable independent sitting Standing balance, it is still necessary to be aware of posture and a kneeler chair can be a useful tool to gain a more upright Supported standing can be used to encourage activity of the position (Figures 12.1 and 12.2). antigravity muscles. If a child has very little head control a tilt table may need to be used initially. Care should be taken Kneeling that the child feels safe, understands what is happening and is able to participate in the process. When bringing a child The majority of children who suffer a brain injury are of up into standing the first time using a tilt table, it is impor- an age when it is not appropriate for them to be using tant to bring it up a few degrees at a time and to check that crawling as a means of mobility. High-kneeling and four- blood pressure remains within the normal limits. Standing point kneeling are, however, useful positions to work on is a good position for a child to work on head control as pelvic control, balance and weight transference. In it tends to encourage a total extension pattern. Weight- high-kneeling rhythmical stabilizations will work on a bearing will also encourage a plantargrade position in the child’s core stability and balance. Physiotherapists can ankles and help to maintain the length of the plantarflexors. also lift a child’s feet off the surface in high-kneeling to challenge their balance further and develop their saving When a child is able to weight-bear fully through the reactions. feet, the standing position can be used to work on trunk and pelvic control, weight transference, posture and balance. Four-point kneeling can be used to encourage weight- This can be done with the physiotherapist giving manual bearing through the affected arm in a child with hemiple- support and postural correction or with a child holding on gia. Balance can be challenged by a child raising the to wall bars or a plinth at an appropriate height. A mirror opposite or same-side arm and leg off the supporting sur- should be used to enable a child to monitor posture and face and maintaining that position for a few seconds. When learn to self-correct. A feedback machine which gives the a child has secure balance in high-kneeling, knee-walking child accurate information about even weight-bearing and can be introduced, forwards, backwards and sideways. Half- weight transference can be a useful tool. kneeling is a useful position in which to work, as it may enable children to learn to rise from the floor to standing. When a child has achieved independent standing balance, it is necessary to continue to work on weight
190 12 ACQUIRED BRAIN INJURY REHABILITATION transference to achieve single-leg standing balance. As in soon to attempt walking (Weston et al 1998). If these sitting and high-kneeling, rhythmical stabilizations can be deficits are present, the stress of walking is likely to cause used to challenge balance and encourage saving reactions. associated reactions and an excessive increase in postural When a child is secure in standing, balance can be chal- tone (Rinehart 1990). The result of trying to walk at this lenged and hopefully improved by the use of a wobble stage may be a frightened and demoralized child. Early board or trampoline (Figure 12.3). A step machine will walking without control of the movement does not con- encourage weight transference as well as being a muscle- tribute any kind of useful information to a child’s brain strengthening activity. Activities such as kicking a foot- (Lynch & Grisogono 1991). ball will encourage single-leg standing. When the appropriate time has arrived, walking can Independent sitting to standing can be started from a start by encouraging cruising sideways using a high plinth, raised plinth so a child’s feet can be on the floor whilst sit- wall bars or parallel bars. A posture control walker can be ting on the edge of the plinth. As a child’s ability to rise used as long as a child has a good upright position in it, is into standing and balance improves, the plinth can be low- fully weight-bearing and is just using the walker as a bal- ered to make the exercise more challenging. If a child has ance aid. For a child with ataxia, this may be the only way weakness in one leg, the foot of the stronger leg can be to get sufficient practice in an upright position to make placed on a box to encourage the weaker leg to do the unsupported walking a possibility. Manual assistance can majority of the work. be given via a chest strap held from behind, a handling belt round the waist, a pole held from in front or by a child Mobility placing the hands on the physiotherapist’s shoulders. All of these methods can allow walking practice to be carried As mentioned earlier, children and their families are anx- out safely when a child would not be safe walking alone. ious for them to walk again and as soon as possible. It is, however, necessary for physiotherapists to time the start of It may be necessary for children to wear a helmet when walking to give the best possible end result. If a child has mobilizing if they are in danger of falling. A child who has poor balance, poor trunk control or is unable to transfer an incomplete skull due to a craniectomy or a fracture will full weight from one foot to the other, it is probably too need to wear a helmet until it is repaired (see Ch. 11) (Figure 12.4). Figure 12.3 A trampoline can challenge balance and Figure 12.4 A hard helmet may be necessary when be fun. mobilizing to protect an incomplete skull.
REHABILITATION 191 When spasticity is present it will have an effect on a ● The Hawaii Early Learning Profile (HELP) covers all child’s gait. It is important to identify the muscles that are aspects of development in depth: sensory, cognitive, causing the dysfunction and reduce the effects as far as language, gross motor, fine motor, social–emotional possible. Gait laboratory analysis may be helpful at this and self-help (Parks 1999). stage (Esquenazi 2004) (see Ch. 4). Other factors affecting gross motor ability When a child has severe gross motor problems, at some stage during the rehabilitation process physiothera- Information on the following areas will be provided by pists need to assess the likelihood of being able to walk other disciplines within the team: speech and language again independently. If this is not going to be an option, therapists, occupational therapists and psychologists. It is then alternative methods of mobility need to be investi- important that physiotherapists are aware of all aspects of gated. Occupational therapists will be involved in assess- a child’s difficulties. Many of these can affect the way ing a child for a powered or self-propelling wheelchair and in which treatment can be delivered and will alter the physiotherapists may provide a walker that gives a lot of approach that is necessary. Joint sessions carried out with support but allows some mobility in an upright position. other disciplines can greatly enhance the physiotherapist’s understanding of the overall effects of acquired brain injury. Cycling may provide a child with independent mobil- ity in some settings as well as providing a form of exer- Sensory cise. Tricycles can be adapted with a variety of supports to meet a child’s needs. Damage to the sensory cortex can result in a disturbance or loss of sight, hearing, smell, taste or touch. Although KEY POINTS the loss of smell or taste may not affect physiotherapy input, disruption of any of the other three senses needs to Role of physiotherapist in the rehabilitation be taken into account. stage It is fairly common for a child who has had an ● Regaining/maintaining joint ranges acquired brain injury to be hypersensitive to touch but ● Provision of orthoses may be unable to pinpoint the precise area that is painful. ● Facilitation of muscle contraction and muscle- Proprioception is often disrupted and a child needs to be given manual, verbal and visual feedback to help monitor strengthening movement and minimize the effects of this loss (Giles & ● Provision of postural management and other equipment Clark-Wilson 1993). ● Promoting postural ability in lying, sitting and standing ● Promotion of balance in sitting, kneeling and standing Attention ● Encouraging mobility on the floor in sitting and Attention is the ability to focus on verbal and visual infor- walking mation. Problems with attention are common in children who have suffered an acquired brain injury and will affect Measuring and recording physical ability their ability to progress physically (Dennis et al 1995). These children are easily distracted, and have difficulty There are many different assessments which can be used blocking out irrelevant stimuli, concentrating and divid- for recording progress in acquired brain injury rehabilita- ing their attention. A quiet working environment where tion (see Ch. 3). Many of them will give a good overview outside stimuli are reduced to a minimum will help them of how a child is functioning but may not give a suffi- attend to a task. ciently indepth picture of a child’s gross motor skills. The following can give useful information. This problem is clearly demonstrated by children who are able to walk until someone speaks to them, whereupon ● The Movement Assessment Battery for Children is useful they lose their balance or have to stand still to respond. for children who have regained good motor function but may have some gross motor or dexterity problems Memory (Henderson & Sugden 1992) The hippocampus encodes a memory and relays it to dif- ● The Gross Motor Function Measure assesses motor ferent areas of the brain. The left and right temporal lobes function in lying and rolling, sitting, crawling and are responsible for verbal and spatial memory respectively. kneeling, standing and walking, running and jump- The cerebellum is associated with motor skills and the ing, so is appropriate for a wide range of abilities frontal lobes are associated with future events and actions (Russell et al 2002). It is appropriate for children with (Powell 2004). Problems with memory can be significant moderate to severe gross motor function deficits and will impact on a child’s ability to make functional gains (Kerkering & Phillips 1994). Children forget, for instance, ● The Chailey Levels of Ability are observational scales which assess lying, sitting and standing abilities. They are especially useful to chart small changes at lower levels of ability (Pountney et al 2004)
192 12 ACQUIRED BRAIN INJURY REHABILITATION to carry out an exercise programme even if they are old believe that they do not have a problem, or that tomorrow enough, able and willing. They may over- or underesti- morning they will wake up and find that it was just a bad mate their motor abilities and therefore put themselves in dream. danger or do not perform at their functional best. Fatigue The rehabilitation team needs to give a child verbal and written prompts throughout the day to help overcome these Fatigue can be a major problem, especially at the begin- difficulties. ning of the rehabilitation stage. Many children are unable to recognize or acknowledge that they are tired; the reha- Language bilitation team need to monitor this and adjust their timetable accordingly to allow for sufficient rest periods The ability to produce speech may be affected and gaining during the day. a consistent yes and no is a priority (Middleton et al 1992). Even when a child can speak intelligibly, severe receptive Seizures and/or expressive language problems may be present. Physiotherapists need a basic understanding of these difficul- Although the majority of children and adults who have a ties to enable them to communicate effectively during ther- head injury do not have seizures, it is the leading cause of apy sessions. epilepsy in young adults (Hudak et al 2004). These can take the form of tonic-clonic seizures or, more frequently, Receptive language deficits may result in an inability to they will present as absences. Physiotherapists need to be follow instructions and these will need to be kept as simple able to monitor a child’s seizure activity and feed back the and as brief as possible. Touching the appropriate limb or information to the rehabilitation medical staff. demonstrating a movement can help to overcome this block to therapy. Reintegration stage Expressive language deficits impair the ability to com- Discharge planning municate with others. Word-finding difficulties frequently occur in children with acquired brain injury (McMahon Discharge planning needs to start as early as possible dur- 1998). This is frustrating for children; reading their body ing the rehabilitation process, although this may be lim- language and good guesswork can help ease the situation. ited as a child’s eventual needs may be difficult to predict. The local medical and therapy team need to be identified Speed of information-processing and involved. The community nurse team and social services are likely to be amongst the first to make contact A slowed speed of information-processing can occur fol- with a child and family as they may be required when a child lowing an acquired brain injury. It will, therefore, take a starts to visit home at weekends. A child’s general practi- child longer to respond to a request. If a lot of information tioner will have been kept informed of that child’s progress is given quickly, some of it will be lost so physiotherapists throughout rehabilitation. The community paediatrician need to give brief instructions and wait for a response will be contacted so that the child’s ongoing care can be before repeating the request or giving hands-on assistance. coordinated. Local therapy input will be provided by the community team or, if a child is not being reintegrated into Emotional and behavioural problems mainstream schooling, it may be accessed at school. There are many emotional and behavioural problems that Representatives of all the local services should be can arise following an acquired brain injury. These include invited to a child’s multidisciplinary reviews. Their atten- disinhibition, irritability, frustration, insensitivity to oth- dance is especially important at the discharge review when ers’ feelings, anxiety, depression, eating disorders and ver- a discharge date can be set and final checks, that the appro- bal or physical aggression (Demellweek et al 1998). priate services are in place, can be made. Physiotherapists need to be aware of these problems and adjust their approach accordingly. Reintegration A child entering the rehabilitation stage may be fear- Reintegration back into home and school is possibly the ful, having probably undergone a considerable number most important part of the role of the rehabilitation team: it of interventions in the acute stage; it is necessary for ther- is the outcome of this process that has the greatest long-term apists to be sensitive to this and work hard to make ther- impact on children and their families. apy sessions a positive experience. A negative experience for a child will almost certainly produce a negative result Home whereas a positive experience may produce a positive gain. Most children will have been visiting home, spending The level of motivation after acquired brain injury can weekends there and making contact with old friends. vary greatly. Some children push themselves to the extreme and it is sometimes necessary to try to limit their activities to avoid fatigue. At the other end of the scale, some children spend a considerable amount of time in denial, appearing to
REHABILITATION 193 Unfortunately, friends often find it hard to adjust to a Although a child can move around and be safe in the changed person and will themselves have changed and quiet, controlled environment of a rehabilitation centre, a moved on in the intervening time. This can be very hard busy school is a very different proposition. Physiotherapists for injured children to understand and accept, and need to advise the school of a child’s physical limitations adjusting to their new situation and making new friends and how to minimize their effects. The following areas can be a lengthy process. need to be considered (Child Brain Injury Trust 2006): Within families, the position of a child may have changed. ● Moving around the school – a child may need extra It is very difficult for teenagers, who have been independent, time to move from one class to another so it may be to accept new limitations to their freedom and the loss of necessary to leave the class early. Help may be needed their future plans. It is equally difficult for parents to come to carry bags and the timetable organized to avoid to terms with the changes in a child and to accept that long journeys their future will be very different from their former expectations. ● Stairs – additional handrails may be necessary. The number of level changes a child undertakes needs to be The physiotherapist’s role in reintegration back to minimized. Stairs need to be avoided or a lift installed home will depend on children’s physical limitations. People can live with a bed in the lounge or a commode ● In class – supportive seating may help to minimize downstairs for a short period of time but decisions need physical effort and allow a child to concentrate on to be made about home adaptations; the physiotherapist academic work. A child can be seated near to the will become involved with assessing for equipment and door to make access easier predicting what will be necessary in the future. ● Break times – close supervision may be necessary to School ensure a child’s safety. At lunchtime, extra time may be needed to get to the dining hall or to eat lunch. Planning for a return to school needs to start as soon as it Help may also be needed to carry a tray is clear what type of school is going to be appropriate. Most children and their families are keen for a return to ● Physical education lessons – activities may need to be the previous school if possible. Care needs to be taken that adapted to allow a child to participate in physical edu- this is a realistic option as a failed reintegration is very dis- cation lessons. Alternatively, these lessons can be used heartening for all concerned. as a catch-up session for classroom work or as an exer- cise programme session. A gradual reintegration into mainstream schooling is more likely to be successful in that it allows a slow adjust- Since a child’s brain is still maturing, the full impact of ment period for a child and school staff and will also help the injury may not become evident for many months or a child to build up stamina. even years. A small number of children will need a lot of extra help at school and will need a statutory assessment of special educational needs for the child (see Ch. 2). Table 12.1 Residual problem areas following acquired brain injury Physical and physiological problems Intellectual, educational and personality problems Mobility Attention and memory Coordination and balance Speech and higher-level language skills Intention tremor Planning and organizing Spasticity Speed of information-processing Hand–eye coordination Impulsivity Sight Loss of initiative Hearing Disinhibition Seizures Lack of insight Bladder control Emotional difficulties Weight increase Social relationships
194 12 ACQUIRED BRAIN INJURY REHABILITATION This document describes a child’s needs and the support that should be avoided are ones that may cause a direct that is required to meet these needs. It is vital for the blow to the head, such as contact sports or heading a school and all other agencies involved to be aware of and football. High-velocity or pressure-shifting activities such recognize the short-term and long-term consequences of as diving, trampolining or rollercoasters should also be a child’s head injury, both visible and invisible. If these con- avoided. Opinions as to how long after the injury these sequences are not properly managed, wide-ranging and activities should be avoided vary between 6 months and a long-term problems may arise. It is also essential to highlight year (Child Development Centre 2006, Toronto any additional problems that may arise during times of major Acquired Brain Injury Network 2006). transition such as moving on to secondary school. KEY POINTS Residual problem areas Role of physiotherapist in the reintegration There are many areas in which children may have long- stage term problems which could affect their successful reinte- gration into school and the community (Table 12.1). ● Advice for home adaptations ● Input to statutory assessment of special educational needs Sport and leisure activities ● Early liaison with home therapy team – school and/or Certain activities should be avoided in the months following community an acquired brain injury as the result of a first injury can be ● Handover meetings/visits to home and school compounded by a second one, even if it is minor. Activities ● Advice to school staff CASE STUDY 12.1 day in a reclined position with her knees drawn up defensively. She had no clear vocalization but could nod Sara’s Story for ‘yes’ and shake her head for ‘no’. At this moment in time Sara wailed continuously; she was angry, frustrated When Sara was 12 years old, she went to school like any and frightened. She was aggressive and uncooperative. other day. In the morning, she had a science test in which, She would scratch, kick, pinch or pull hair to avoid what when it was later marked, she performed very well. At she saw as threatening contact. Sara had full range of lunchtime she had what she later described as the worst movement in all joints apart from her left ankle which headache imaginable. She went to the sick bay where necessitated serial plastering over a period of 3 weeks, she started vomiting. Her mother was called and she took after which plantargrade was achieved. An ankle–foot her to the local Accident and Emergency department, orthosis was supplied to maintain the joint range. Sara where her Glasgow Coma Scale was recorded at 5. She was not keen to wear this; she would remove it and throw was transferred to another local hospital and a computed it across the room but managed a few hours every day. tomography scan was performed; this showed a large collection of blood in the posterior fossa. At this point her Four and a half months posttrauma Sara was intracranial pressure had risen to the extent that her brain prescribed an antidepressant, sertraline. She was also was threatening to push through the foramen magnum. starting to communicate using a word board. Sara was Dexamethasone and mannitol were administered to still frustrated and angry and repeatedly spelt out ‘take reduce her cerebral oedema. She was transferred to a me home, take me home now’. London hospital where the clot was drained and she was intubated and ventilated. Her father, who had been Seven months posttrauma Sara was cooperative following her trail, eventually caught up with her in and very hard-working. She had severe cerebellar ataxia London. A week later she was off the ventilator and being but had independent standing balance of a few seconds fed by nasogastric tube. Sara was making no purposeful when placed. She was able to walk with a Kaye walker movements. One month posttrauma she had a with some assistance to stabilize her at pelvic level. gastrostomy inserted. In the weeks that followed it was Sara’s physiotherapy at this stage concentrated on the noted that as Sara’s level of awareness rose, her level of need to improve the muscle power and tone around her cooperation deteriorated. trunk and pelvis. She was willing to carry out an exercise programme and would work in sitting, high-kneeling, Three and a half months after her trauma, Sara, four-point kneeling and standing. She was, however, was transferred to the Children’s Head Injury Service at very focused on functional goals and would endlessly Chailey Heritage Clinical Services for rehabilitation. Sara practise getting from sitting to standing, trying to find her had some active movement of all four limbs. She was unwilling to sit in an upright position and spent most of the continued
REFERENCES 195 standing balance and, of course, walking. Her central was doubled when working to achieve her goals. When control slowly improved and Sara exchanged her Kaye Sara first returned to school 1 year and 4 months walker for a pair of crutches 10 months after her trauma. posttrauma she was refusing to use a wheelchair and She also started taking some unsupported steps. Sara walked with one crutch and some assistance. would still work for periods on single-leg standing balance and independent position changes: she was still Sara’s physical ability progressed over the years focused on walking and her therapy mainly consisted of and she is now, 7 years after her insult, able to walk very slow walks along a corridor with her physiotherapist without support. She has just finished her first year at giving her verbal feedback and acting as a catcher. The university studying psychology and has a full social life determination that Sara had initially used to avoid therapy and is enjoying herself. Extreme motivation can be challenging but it does get results! REFERENCES Griffith ER, Mayer NH 1990 Hypertonicity and movement disorders. In: Rosenthal M, Griffith E R, Bond M et al (eds) Anderson D 1995 Management of decreased ROM from Rehabilitation of the Adult and Child with Traumatic Brain Injury. overactive musculature or heterotopic ossification. In: Philadelphia, PA: Davis, pp. 127–147. Montgomery J (ed.) Physical Therapy for Traumatic Brain Injury. New York: Churchill Livingstone, pp. 79–97. Henderson SE, Sugden DA 1992 Movement Assessment Battery for Children. London: Psychological Corporation. Attard J, Rithalia S 2004 A review of the use of Lycra pressure orthoses for children with cerebral palsy. Hudak AM, Trivedi K, Harper CR et al 2004 Evaluation International Journal of Therapy and Rehabilitation 11: 120–125. of seizure-like episodes in survivors of moderate and severe brain injury. Journal of Head Trauma Rehabilitation 19: Bastian A 1997 Mechanisms of ataxia. Physical Therapy 77: 290–294. 672–675. Jackson J 2004 Specific treatment techniques. In: Stokes M Carriere B 1998 The Swiss Ball. Berlin: Springer. (ed.) Physical Management in Neurological Rehabilitation. Edinburgh: Elsevier, pp. 393–411. Child Brain Injury Trust 2006 Information for teachers. Available online a: www.cbituk.org. Jaffe KM, Brink JD, Hayes RM et al 1990 Specific problems associated with pediatric head injury. In: Child Development Centre 2006 A guide for families of Rosenthal M, Griffith ER, Bond M et al (eds) children with an acquired brain injury. Available online at: Rehabilitation of the Adult and Child with Traumatic Brain www.hoteldieu.com/cdcabi.pdf. Injury. Philadelphia, PA: Davis, pp. 539–555. Demellweek C, O’Leary A 1998 The impact of brain injury Karman N, Maryles J, Baker RW et al 2003 Constraint- on the family. In: Appleton R, Baldwin T (eds) Management induced movement therapy for hemiplegic children with of Brain-Injured Children. Oxford: Oxford Press, p. 207. acquired brain injuries. Journal of Head Trauma Rehabilitation 18: 259–267. Demellweek C, O’Leary A, Baldwin T 1998 Emotional, behavioural and social difficulties. In: Appleton R, Baldwin T Kerkering GA, Phillips WE 1994 Brain injuries: traumatic (eds) Management of Brain-Injured Children. Oxford: Oxford brain injuries, near-drowning and brain tumors. In: University Press, p. 167. Campbell SK, Vander Linder DW, Palisano RJ (eds) Physical Therapy for Children. Philadelphia, PA:WB Dennis M, Wilkinson M, Koski L et al 1995 Attention Saunders, p. 604. deficits in the long term after childhood head injury. In: Broman SH, Michel ME (eds) Traumatic Head Injury in Lennon S 2004 The theoretical basis of neurological Children. Oxford: Oxford University Press, pp. 165–187. physiotherapy. In: Stokes M (ed.) Physical Management in Neurological Rehabilitation. Edinburgh: Elsevier, pp. Duncan P 1990 Physical therapy assessment. In: Rosenthal M, 367–378. Griffith ER, Bond M et al (eds) Rehabilitation of the Adult and Child with Traumatic Brain Injury. Philadelphia, PA: Lynch M, Grisogono V 1991 Strokes and Head Injuries. Davis, pp. 264–283. London: John Murray, p. 116. Esquenazi A 2004 Evaluation and management of spastic Mazaux JM, Richer E 1998 Rehabilitation after traumatic gait in patients with traumatic brain injury. Journal of Head brain injury in adults. Disability and Rehabilitation 20: Trauma Rehabilitation 19: 109–116. 435–447. Giles GM, Clark-Wilson J 1993 Brain Injury Rehabilitation. McMahon S 1998 Speech and language difficulties. In: London: Chapman and Hall, p. 208. Appleton R, Baldwin T (eds) Management of Brain-Injured Children. Oxford: Oxford University Press, p. 127. Gormley M 1999 Management of spasticity in children. Part 2: oral medications and intrathecal baclofen. Journal of Head Trauma Rehabilitation 14: 207–209.
196 12 ACQUIRED BRAIN INJURY REHABILITATION Meythaler JM, Clayton W, Davis LK et al 2004 Orally et al (eds) Rehabilitation of the Adult and Child with Traumatic delivered baclofen to control spastic hypertonia in acquired Brain Injury. Philadelphia, PA: Davis, pp. 331–348. brain injury. Journal of Head Trauma Rehabilitation 19: 101–108. Russell DJ, Rosenbaum PL, Avery LM et al 2002 Gross Motor Function Measure: User’s Manual. London: MacKeith Middleton J, Jones M, Moffat V et al 1992 Rehabilitation Press. after acute neurological trauma. In: McCarthy GT (ed.) Physical Disability in Childhood. Edinburgh: Churchill Toronto Acquired Brain Injury Network 2006 Facts for Livingstone, pp. 249–268. physicians – mild acquired brain injury in children and youth. Available online at: www.abinetwork.ca. Parks S 1999 Inside HELP and HELP for PreSchoolers. Palo Alto, CA: VORT. Watkins C 1999 Mechanical and neurophysiological changes in spastic muscles. Physiotherapy 85: 603–609. Pountney TE, Mulcahy CM, Clarke SM et al 2004 The Chailey Approach to Postural Management. North Chailey, Weston J, Kinley E, Hughes B et al 1998 Physical (motor East Sussex: Chailey Heritage Clinical Services. and functional) difficulties. In: Appleton R, Baldwin T (eds) Management of Brain-Injured Children. Oxford: Oxford Powell T 2004 Head Injury: A Practical Guide. Bicester: University Press, pp. 71–105. Speechmark, p. 75. Zafonte R, Elovic EP, Lombard L 2004 Acute care Rinehart MA 1990 Strategies for improving motor management of post-TBI spasticity. Journal of Head Trauma performance. In: Rosenthal M, Griffith ER, Bond MR Rehabilitation 19: 89–98.
13 Orthopaedic conditions Jeanne Hartley CHAPTER CONTENTS 199 age and it is this understanding that is important in devel- 199 oping reasoning when counselling families seeking opin- Introduction 200 ion regarding their concerns for their child and also to Growth 202 help us offer physiotherapy interventions appropriately. Assessment 206 Feet 207 This chapter will cover a variety of common paediatric Knees 207 orthopaedic conditions that may be referred to the phys- Hips iotherapist for opinion and management, including club Limb-length discrepancy 210 foot, flat foot, obstetrical brachial plexus injuries, Perthes Obstetrical brachial plexus 214 disease, limb-length discrepancies, knee pain, torticollis 215 and plagiocephaly. Also included is the orthopaedic assess- palsy (OBPP) 216 ment of infants and children. Normal variations in skeletal Torticollis 216 growth will also be discussed. Scoliosis has not been Positional plagiocephaly 216 included in this chapter as the effectiveness of physio- Case study 13.1 217 therapy is unproven. The orthopaedic physiotherapist’s Case study 13.2 217 role in the management of children with neurological con- Case study 13.3 217 ditions such as cerebral palsy has also not been included Case study 13.4 as local protocols and opinions vary (see Ch. 7). Case study 13.5 References GROWTH INTRODUCTION Skeletal growth occurs by adding tissue to its outer surface: The term ‘orthopaedic’ originated with Nicolas André, a French physician who used the combination of two Greek ● by intramembranous ossification on the surface of the words orthos (straight) and paidi (child). In 1741 his book, cortex, as in the scapula and skull, or to increase cir- entitled Orthopaedia: Or the Art of Correcting and Preventing cumference of long bones Deformities in Children: By such Means, as may easily be put in Practice by Parents themselves, and all such as are Employed ● by enchondral ossification at the growth plates situated in Educating Children, was published. At that time surgery at either end of each long bone, increasing length. was still primitive and limited to the correction of defor- mities by the use of crude apparatus, the reduction of In the first 18 months of life a baby undergoes the most fractures and dislocations by traction, and the amputation rapid period of growth and development. At the age of of limbs. Fortunately for us, orthopaedics evolved into a 1 year, sitting height is 63% of a child’s total height. The more ‘scientific’ speciality, concerned with the preserva- limbs are short in proportion. This disproportion in sit- tion and restoration of the musculoskeletal system, using ting height gradually reduces to 52% in males and 53% in sophisticated diagnostic, surgical and therapeutic aids. females at skeletal maturity. From birth to cessation of growth at maturity, sitting height increases by 67%, An understanding of growth, both normal and abnor- whereas the legs increase in length by 145%. In infancy a mal, in a child is vital to our understanding of the paedi- child’s spine lacks the normal adult curve. A long atric orthopaedic problems. Bennet (2002) stated that C-curve is replaced by the appearance of cervical lordo- over half the children seen in his orthopaedic clinic, sis at 3 months of age as the child develops head control referred by family practitioners, were within normal lim- and lumbar lordosis as the child develops sitting balance. its. Appreciation of what is ‘normal’ may also vary with Skeletal growth is very rapid in infancy, slows down during childhood and increases again during the adoles- cent pubertal growth spurt. At the age of 2 years a child is approximately half adult height and three-quarters 199
200 13 ORTHOPAEDIC CONDITIONS adult height by the age of 9. The ability to predict height have been there previously and the injury may have been at skeletal maturity is an important factor in the decision- the catalyst for the consultation. making process for the orthopaedic management of some conditions such as congenital limb-length inequality. Assessment of a baby (under 24 months There are a variety of methods available to predict adult of age) height, from percentile charts to the use of X-ray assess- ment of bone age to determine growth potential. The All babies should have a full and thorough assessment, affects of underlying systemic, endocrine, nutritional and including the following: metabolic disorders, which may impact on skeletal growth, also need to be considered. Transverse growth arrest lines ● Past history is essential and should include antenatal in a long bone (Harris lines) are often seen on X-ray fol- and birth history, family history and, if the baby is old lowing systemic illness. Hormones exert a powerful influ- enough, developmental history. Although all babies ence on growth plates. Growth hormone deficiency can born in the UK are routinely screened for hip dysplasia cause premature closure of growth plates, resulting in in the neonatal period by medical staff, it is not uncom- short stature, whereas hypersecretion of the hormone mon in some tertiary referral centres to see older babies, results in widening of the growth plates and gigantism. toddlers and sometimes even older children with hip problems not noted in the neonatal checks. The growth of a single bone or several bones can be altered if damage has occurred to a growth plate from ● Undress the baby, even if the referral is for advice and trauma, infection (neonatal sepsis, meningococcal menin- management of a foot problem. Count the number of gitis) or iatrogenic causes (drip extravasation injury, irra- toes on each foot; check movement at the ankles, diation). knees and hips. If the baby is very young (under 3 months), remember that physiological neonatal flex- During the final adolescent growth spurt, extending ion contractures will be present in the hips and knees from puberty to skeletal maturity, certain orthopaedic and there may be excessive dorsiflexion. Look for problems may become apparent (such as scoliosis, slipped asymmetry in joint range of movement, limb lengths upper femoral epiphysis) or existing ones become more and girth as well as asymmetry of active movement. pressing as body image and psychosocial issues become more important for the young person. The thin calf and ● Turn the baby over and look at the spine. A baby’s smaller foot resulting from a club foot become less toler- spine should be straight with a single curve. Scoliosis able when a teenage boy is facing a beach holiday with and sharp angulations require investigation. Look for his friends. Accepting that working out in the gym will skin changes such as birth marks, café-au-lait patches not build up the bulk in the calf can be very difficult to and skin dimples over the spine – these can be an accept at this stage. indication of underlying spinal problems such as spina bifida occulta, spinal dysraphism or neurofibromatosis. However, for most people, skeletal growth occurs Look for plagiocephaly (flattened appearance of the without problems, ceasing at around 14 years in girls and back or side of the skull) and asymmetry of neck range 16 years in boys, on average. Growth plates close at dif- of movement. fering times and also grow at differing rates. For exam- ple, 65% of all growth in the leg occurs at the knee, with ● Examination of the upper limbs – look for asymmetry 39% taking place at the lower femoral growth plate and of active movement and joint ranges. 26% at the proximal tibial growth plate. Proportionally less growth takes place at the upper femoral and lower ● Be aware that any baby with asymmetries due to tibial growth plate. Information such as this can be impor- intrauterine moulding, especially at the neck or feet, tant in calculating anticipated leg-length difference at has an increased risk of hip dysplasia – as well as those skeletal maturity in a child with a congenital bone where there is a family history of hip problems. dysplasia. Assessment of a child (over the age of ASSESSMENT 2 years) For physiotherapists the initial assessment of a child is the The assessment should include some or all of the following: most essential step to plan appropriate management. A good understanding of child development is also valu- ● Birth history, including antenatal history able. Many children will experience pain and altered func- ● History of presenting condition tion due to trauma at some stage in their childhood. It is ● Developmental milestones: did the child sit and walk important to be mindful that a recent fall from a scooter or tumble in the garden may have been the reason the par- at the right time? ents sought advice, but careful history-taking may uncover ● Family history of similar bone or joint problems: a sur- further information that indicates that the problem may prising number of orthopaedic problems run in families ● Child/carer’s concerns: listen to the mother if the child is young – her intuition is often very accurate. An older
ASSESSMENT 201 child may be less concerned about leg-length discrep- Paediatric Pain Profile is an important adjunct to our ancy than their parents understanding of the child and in planning interventions. ● Joint range of movement (active and passive as appropriate) Assessment of children and babies with congenital ● Muscle power: grading systems such as the Oxford orthopaedic conditions, which affect their functional rating scale potential or abilities, can be very challenging. It is impor- ● Muscle length: such as the popliteal angle to assess tant to include the family and child in all discussions at hamstring length and Silfverskiold test to differentiate every stage so that aims of treatment and plans of man- muscle tightness between gastrocnemius and soleus agement and everyone’s expectations are realistic, achiev- ● Bony rotational profiles (if appropriate) such as the able, pragmatic and, as far as possible, evidence-based. thigh/foot angle to determine the presence of tibial torsion Normal variants ● Deformity, e.g. scoliosis, club foot ● Limb lengths: traditionally measured from the anterior Jones & Hill (2000) described the difficulty in coun- superior iliac spine (ASIS) to the medial malleolus. selling parents whose children’s problems were due to For congenital limb-length discrepancies, measure- normal variants of skeletal growth, such as bow leg, knock ment may be from the ASIS to the base of the heel knee, in-toeing and flat feet. ‘The five Ss’ can be a help- ● Limb girth: use a bony landmark and measure down ful way of explaining to parents that treatment from a from it to ensure consistency between assessment of surgeon or a physiotherapist is unnecessary in some cases, girth of each limb, e.g. 7 cm below the tibial tubercle whereas other cases may require intervention. to measure calf girth ● Joint stability: such as the Ortolani and Barlow tests for The five Ss hip instability; anterior draw test for knee joint stability ● Pain profile: see below 1. Symmetry: Does the problem under consideration ● Functional abilities. affect both limbs equally? For example, if both lower limbs in a 3-year-old child are bowed, this is likely to Pain be due to normal physiological bowing and it is safe to watch and wait. However, severe bowing, asym- The way a child perceives and expresses pain is age- metric bowing or bowing in only one lower limb is dependent: not normal and warrants further investigation. ● An infant may fuss or cry or avoid moving the painful 2. Symptoms: Does the child have symptoms? If a child part. If the pain is severe, continuous crying is usual is running around happily and not complaining of pain or functional difficulties, then ‘treatment’ is not ● Children in pain may avoid using the affected part required, despite what the parent or the shoeshop or will show altered function such as limping. They assistant may say! may also be able to voice their discomfort, although the description of the pain will be non-specific, e.g. 3. Stiffness: Is there a full range of movement in all a ‘I have a headache in my leg’ child’s joints? Joint stiffness in a growing child is not normal and should be investigated further. ● Most adolescents have language and perception to describe their pain. An athletic boy may underreport 4. Systemic: Is the child well? It is important to his pain if there is a sporting event he is keen to take remember that inflammatory conditions and meta- part in; conversely, a boy who hates sport may be bolic problems can have an impact on skeletal exaggerating the problem. growth. Conditions such as rickets can cause skeletal changes such as bow legs. Previous pain experiences and a family history of painful conditions should also be considered. 5. Skeletal dysplasia: Is a child of normal stature and proportion? Does the child have an unusual face? A parent’s intuition needs to be given serious consid- eration. A diagnosis of pain of non-organic origin should Using this guidance a child who has marked but equal only be entertained after all other possible causes have bowing of both lower limbs, with no pain or stiffness, and been discounted. has no evidence of systemic disease or skeletal dysplasia, is normal. Using this guidance parents can be reassured that it Consider using one of the many pain assessment tools is the passage of time that will be the best treatment and that are appropriate to the age of the child to provide a that shoe modifications and braces are ineffective, could baseline and outcome measure for your intervention make the child uncomfortable and self-conscious and (see Ch. 3). impede play. Likewise physiotherapy exercises are unneces- sary, time-consuming and ineffective. Time spent in careful Children with severe physical and cognitive disability explanation will be time well spent, along with the offer of need careful consideration and the use of tools such as the further review if the parents have concerns in the future.
202 13 ORTHOPAEDIC CONDITIONS Conversely, a child with bowing of one lower limb has activities limited, as well as it being a negative experience asymmetry and therefore warrants further investigation. during their childhood years. Furthermore, as adults they showed lower self-esteem than the control group. The FEET study concluded that prescribed devices and corrective shoes do not alter physical conditions and are not a harm- Children’s shoes less placebo. Allowing childhood developmental varia- tions to follow their natural courses is free, effective and Physiotherapists are frequently asked to give opinion and harmless treatment (Driano et al 1998). advice regarding suitable shoe wear for a child. Children’s shoes are expensive and some companies recommend that Flat foot (pes planus) a child’s feet should be measured at 3-monthly intervals and new shoes provided (Bennet 2002). It has been sug- Flat foot simply means a foot with a large plantar contact gested that if this is the case, children’s shoes do not have area. Often the longitudinal arch is not visible and there to be expensive or long-lasting. There is little evidence may be some valgus of the heel. Flat foot can be flexible to suggest that expensive ‘good’ shoes are in any way (physiological) or rigid (pathological). superior to a cheap pair of trainers. Although most chil- dren have straight feet, shoes are often shaped to fit a Physiological flat foot varus forefoot. Pressure and pain may ensue if the match in shape between the shoe and foot is markedly different. Physiological flat feet are very common, flexible, benign and a normal variant. Flexible flat foot can be divided into Staheli (1991) stated that optimum foot development two types: developmental and static. Parents are often con- occurs in a barefoot environment and that the primary cerned that as their child starts to walk the feet appear to role of shoes is to protect the foot from injury and infec- roll over. Until the age of 3–5 years, most children do not tion and that the provision of corrective (stiff and com- show a longitudinal arch when weight-bearing. Develop- pressive) footwear may cause deformity, weakness and mental flat foot is apparent when the child starts to walk loss of mobility. and disappears spontaneously at around the age of 3–5 years. Asking the child to stand on tiptoe or using the A prospective study to determine whether children great-toe extension test (Rose et al 1986) will demon- with flexible flat feet needed treatment with orthotics or strate restoration of the medial arch to anxious parents. corrective ‘orthopaedic’ shoes was carried out with chil- dren randomly allocated to one of four groups, including Static flat feet are associated with generalized laxity a control group; the children underwent a minimum of 3 and often other family members have flat feet. years’ treatment. Final analysis demonstrated significant improvement in all groups, including the controls, with Some children with ligamentous laxity due to condi- no significant difference between the controls and the tions such as Down’s syndrome or Marfan’s syndrome intervention group. It was concluded that wearing cor- may need orthotic support or high-top trainers to help rective shoes or inserts does not influence the course of them achieve stability for weight-bearing activity. flexible flat foot in children (Wenger et al 1989). Flexible flat feet require no treatment. Advice regard- Many high-street stores now carry an extensive range of ing choice of shoe wear may be needed (high-top train- children’s shoes and are able to provide shoes with narrow ers, integral medial arch support, shock absorbence soles) to extra-wide fittings, high-top trainers and boots and and only occasionally is orthotic support indicated. The many will even offer a service to provide shoes of differing tendency for overtreatment of physiological flat feet by sizes. The provision of prescription footwear is now prima- exercises, orthotics and special shoe wear is still observed, rily reserved for those children whose feet are particularly resulting in high-cost, ineffective treatment. Printed infor- difficult to shoe or if there are considerations such as insen- mation can be very useful for the family to take home to sitivity or the need to maintain a corrected position after share with anxious grandparents (Staheli 1998). surgery. Orthotic supports such as ankle–foot orthoses do not need ‘special footwear’ in most circ*mstances and suit- Pathological flat foot able shoe wear can be found in local high-street stores. Pathological flat foot shows some degree of stiffness, such An important study reported on the effects of correc- as loss of subtalar movement or tightness of the Achilles tive shoe wear on the self-esteem and self-image of 46 tendon (less than 10° dorsiflexion). The deformities can adults who had been provided with corrective shoe wear be due to: as children. It suggested that common orthopaedic prob- lems for which parents seek resolution, such as flat feet or ● Intrauterine crowding (talipes calcaneovalgus) in-toeing, may subject a child to unnecessary treatment ● Abnormal alignment of the tarsal bones (congenital and may have consequences in adulthood. In subjective reports participants in the study group vividly recalled vertical talus (CVT), tarsal coalition) being teased about their shoe wear and having their ● A combination of Achilles tendon contracture with hypermobility.
FEET 203 Talipes calcaneovalgus which may cause discomfort and in the long term lead to pain and arthritis. Contracture of the heel cord is apparent Talipes calcaneovalgus will resolve spontaneously but on assessment. Flat foot is present on standing but the demonstration of passive stretches into plantarflexion and medial arch is restored when standing on tiptoe. Dorsi- inversion, to be carried out regularly with nappy changes, flexion is usually absent beyond neutral. may be helpful in supporting the parents. It is also important to look at the whole patient. A programme of weight-bearing stretching exercises may help in cases of mild contracture. However, applica- Congenital vertical talus tion of below-knee plasters to maintain a sustained stretch is probably more beneficial. If pain recurs after plaster CVT is a severe foot deformity in which the head of the removal, surgery should be considered. Physiotherapy talus can be felt in the sole of the foot. Viewed from the may be indicated if there are mobility problems follow- side, the foot will have a rocker-bottom appearance with ing removal of plaster. fixed equinus of the hindfoot and calcaneus and valgus of the forefoot. Surgical management is necessary to realign Neurogenic causes the talus. Flat foot associated with neurological conditions, such as Physiotherapy, although not necessary for the foot cerebral palsy and myelomingocele, results from valgus of deformity, may be indicated as CVT is associated with the foot secondary to heel cord contractures. Management neuromuscular problems and various syndromes as well options will depend on the severity of the underlying as neural defects and spinal anomalies. Physiotherapy may condition and functional level. Serial casting and splin- help a child achieve developmental milestones as well as tage may be successful in the management of mild manage other joint and soft-tissue deformities that would contractures. Consideration may be given to the use of be amenable to serial splintage, passive stretches, posi- pharmacological agents to help decrease muscle spasm to tioning advice, provision of aids and equipment. facilitate treatment goals. Surgical lengthening of the Achilles tendon may be needed in extreme contracture Tarsal coalitions with provision of appropriate supportive splintage to maintain position, particularly if there is imbalance of Tarsal coalitions, also known as peroneal spastic flat foot, muscle power around the foot and ankle. Any splints can be unilateral or bilateral. There may be a family his- provided, particularly for children with reduced skin sen- tory. The commonest sites are between the calcaneus and sation in their lower limb, should be closely monitored the navicular or the talus and calcaneus. The usual initial to prevent pressure sores. presentation is after a simple twist or sprain of the foot or ankle in a child over the age of 10 years. An abnormal Congenital talipes equinovarus fibrous band, present from birth, between the bones begins to ossify at around this age, causing stiffness and Congenital talipes equinovarus (CTEV), commonly pain. At this stage a child may be referred for physiother- known as club foot, is a common deformity in which the apy, as there may be difficulties in walking and running, foot is pointing downwards and inwards. Its cause as well as pain. However if the symptoms persist a child remains unknown and its treatment empirical (Catterall may be viewed as exaggerating the symptoms, if peroneal 2002). spasm is not recognized. At this stage the foot will be held in valgus and passive inversion causes pain, usually Club foot can be broadly categorized into four types: over the lateral border of the foot. The medial arch is not restored when the child attempts to stand on tiptoe. 1. Positional – this is a normal foot, which was held in Immobilization of the foot and ankle in a plaster cast will an abnormal position in utero. The bony anatomy of relieve symptoms, which commonly relapse when the the foot is normal and the foot will usually correct cast is removed. Surgical resection of the bar can be suc- spontaneously or with appropriate passive stretches cessful in relieving symptoms. carried out regularly by the carer Physiotherapy may be needed to restore range of move- 2. Teratogenic – this is club foot associated with neu- ment and re-educate gait after the postoperative plaster has rological conditions such as spina bifida or sacral been removed. agenesis Hypermobile flat foot with a tight Achilles 3. Syndromic – syndromic club foot is associated with tendon conditions such as arthrogryposis, Freeman–Sheldon syndrome and congenital myopathy This combination will alter foot mechanics as well as producing obligatory heel valgus (valgus ab equinus), 4. Congenital – there is abnormal bony anatomy which is not associated with a neuromuscular cause or syndrome.
204 13 ORTHOPAEDIC CONDITIONS Aetiology severe deformities. Fixed deformity will also be present in the talonavicular and calcaneocuboid joints with pos- The prevalence of CTEV is said to be 1–3 per 1000 live sible subluxations. There will be cavus deformity at the births in the UK. Worldwide there are marked variations tarsometatarsal joints caused by shortening of the plantar in incidence, suggesting racial and genetic factors. In fascia and long and short plantar ligaments. China and Japan the rate is 0.5/1000 whereas the inci- dence in the Pacific islands and the Maori race is of the Muscle changes order of 6–7/1000 live births. Some of this variation may be explained by the inclusion (or exclusion) of positional The most obvious change is calf muscle wasting. The club foot and syndromic club foot in the reporting. amount of wasting appears to be directly related to the Increasingly, club foot is being diagnosed antenatally by severity and stiffness of the foot deformity. Individual mus- ultrasound (Tillet et al 2000). cle fibre size is decreased but not decreased in amount, par- ticularly in the peronei. There are more type 1 fibres and Club foot is commoner in boys than girls, with an inci- increased fibrosis in the muscles themselves, especially in dence of 2.5:1. Seasonal variations in incidence have also the calf muscles and tibialis posterior, and less so in the been reported (Pryor et al 1991, Barker & Macnicol 2002). long-toe flexors. Muscle imbalance is particularly noticed Effects of intrauterine moulding and environmental fac- between the peronei, elongated and weaker because of the tors such as first pregnancy, oligohydraminos and twin foot position, and tibialis anterior, which is tight and appar- pregnancy may be contributory factors to the deformity ently stronger because of reduced excursion of the foot. but do not explain the marked calf muscle wasting. Effects of growth The high incidence of familial club foot suggests an inherited abnormality, which could be of neurological or The foot doubles in size in the first year of life. As the vascular origin. A number of studies have established that soft tissues must grow at the same rate, the underlying the foot in utero develops in an equinovarus position, abnormal changes inherent in these structure, as well as moving into a calcaneovalgus position as the pregnancy disturbances in bony and cartilaginous growth, explain progresses. It has been postulated that an incident at the recurrence of deformity at times of rapid growth. around the 10–13-week gestational stage prevents the foot position from progressing. It has also been observed Dynamic concept of the foot that the blood supply to the limb is changing from pri- mordial to secondary at this stage. Failure of this change The bones making up the medial and lateral rays of the has been linked to cessation of growth of the foot and foot are linked together by interosseous ligaments and development of the deformity (Hootnick et al 1982). various plantar ligaments. Movement of the foot at the Underlying neurological causes such as spinal dysraphism ankle and subtalar joint is restricted by the elasticity of these may explain the muscle imbalance, calf wasting and small tethers as well as joint capsules, ligaments and the insertion foot and are now considered to be a major factor in the of tibialis anterior. In club foot deformity the movement is high recurrence rate of the deformity with growth in some further restricted by abnormalities in the composition of cases. Differences in muscle fibre type have been identi- these structures (Figure 13.1). fied with a high proportion of type 1 fibres, increased fibrosis and reduced excursion in the lower-limb muscles Management of club foot, as well as changes in the structure of liga- ments, particularly on the medial side of the foot com- The aim of club foot management should be to correct pared to the norm (Handelsman & Badalamente 1981, the foot position carefully, without injuring the soft carti- Zimny et al 1985, Macnicol et al 1992). laginous structures of the foot, and retain mobility. The foot should be plantargrade, have a normal load-bearing Pathology area and fit into normal shoes. Surgical division of inelastic structures should be looked on as a protective incident Bony changes during continuing therapy. Flattening of the dome of the talus as well as damage to the lower tibial growth plate As well as fixed joint deformities throughout the foot have been attributed to aggressive conservative treatments, and ankle, many bones in the foot are of abnormal shape such as forced dorsiflexion of the hindfoot before correc- and size. Disturbances in the growth of the bones of the tion of the forefoot deformity using, for example, adhesive whole affected limb may become apparent later, resulting strapping (Lloyd-Roberts 1964, Dobbs et al 2004). in a limb-length discrepancy, which is more common in girls with club foot than boys. It is generally accepted that initial treatment for club foot should be some form of serial splintage, traditionally Joint deformities carried out under the supervision of a physiotherapist, and started soon after birth. There are varied opinions In the ankle joint the head of the talus points downwards regarding the method of conservative management use. and medially and there may be anterior subluxation in
