Page 19 - Mobility Management, October/November 2020
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adaptations and alternate pathways is great — however, many of their motor strategies are not yet hardwired (for example, a newly ambulatory toddler), so it is hard when you can’t rely as much on automatic movements as a precursor for relearning motor control, since they may not be very automatic yet!”
“Oftentimes, especially with infants, if there aren’t obvious signs and symptoms of a brain injury, we don’t have a whole lot [of history] to compare to,” said Ryan Rhodes, OTR/L, ATP/SMS, Pediatric Sales Specialist for Sunrise Medical. “Especially with an infant: They cry, they sleep, they eat. You would have to see something kind of stand out to know it’s a brain injury.”
Laurence compared a visibly fractured ankle to the invisible nature of a brain injury: “You can see the injury, you can see the edema, you can see where I’m missing range,” she said of the ankle fracture. “With a head injury, you can’t see the injury. You can see a bruise on the brain, but you can’t see what the effects are 100 percent. We can see some of it, but do we see all of it?”
“Like adults, there is a wide range of presentation depending
on the severity of the injury,” Wagner said. “For more severely impacted children, we definitely see increased muscle tone, spasticity, and dysautonomia. Many kids present with a good bit of irritability (neuroirritability), and they are very difficult to calm, which can be really distressing to the parents. Spasticity is very common with flexor patterns of the upper extremities and extension of lower extremities. Often, patients present with visual deficits/inattention to one side. They also frequently have oral aversion and feeding difficulty.”
“Spasticity and muscle tone are a huge point of focus when fitting a child for Complex Rehab Technology, whether that’s a manual wheelchair, a tilt-in-space or stroller, an activity chair or standing frame,” Rhodes said. “They’re considered to try to improve quality of life and reduce other comorbidities.”
Rhodes added that understandably, the acute care professionals who initially treat a child with a brain
injury focus on keeping the child alive.
“Spasticity oftentimes isn’t addressed
within the first year,” he said. “So by the
time we get that child into the clinic,
if we weren’t fortunate enough to get
an in-patient evaluation for seating
equipment, some damage may already
be done. In seating, are we going to
envelope and accommodate to prevent
further deformities? Or are we going to correct those? If tone starts to set in, resulting in contractures, then we are already at the point of accommodation.”
Rhodes added that addressing the many needs of the child is important, right from the start. “I think early intervention is key, and I don’t just mean for the age of the child. If it’s an 8-year-old who had a brain injury, I think it’s important that the team keeps postural deformities in the back of their minds, at least when
it comes to getting the child out of bed — not just letting them roll up or ball up. There are so many considerations, obviously:
Pediatric Series
skin integrity — that’s why standing frames are so important.
We have studies that show that weight-bearing through the legs can reduce spasticity if contractures are not too bad. Imagine sitting there, kyphotic and folded over — your vital organs being compressed, so there’s a reduction of respiration. Often, we might see a kid on a vent because of it, or a trach. We see impactment of the bowels if they’re not continually moved.
“Seating and the complex rehab aspects are a global focus. We can’t just focus on one thing. We can’t just focus on spasticity. Digestion, respiration, bone density, spasticity management — we have to focus on all of those things.”
While it’s easy to blame the brain injury when a child shows a developmental delay, the answer can be more complex.
“Babies and kids do things repetitively,” Laurence said. “They pull themselves up to the coffee table. They stand and do that little shuffle, or they lean from one side to the other before they take that step. And they do it again. A baby that pushes itself up to sit: They rock, again and again and again, until they master it.
“Now we’ve got a child who has a disability. They can get therapy every day. But how many times are they doing that little weight shift? Five times, as opposed to a normally developing child, who does it a thousand times? So is there impact because of the injury or because of the loss of opportunity? The injury itself will have an impact on development; there will be an injury to the brain, and it may be misfiring because it’s been injured. But how much is it a lack of experience?”
The aging process can further complicate the situation.
“We have to consider the acquisition of new motor skills after an injury,” Wagner said. “For example, a 6-month-old is injured and in the hospital for four weeks. Now we are dealing with the impact of the brain injury plus a month of lost time of normal development, and likely slower motor skill acquisition going forward. So much happens so fast during early development!”
Laurence added that as kids grow, presentations can change: “You may have the same [muscle] tone, but now that tone gets overlaid by growth. We see it in kids with CP [cerebral palsy]. They grow, the bone grows faster than the muscles, and the muscles get tight. So you may have the same tone in a child versus an adult, but now the child is still growing.
“Now you have the tone from their injuries, and that tone gets overlaid and affected when they grow.
They may have gotten tight just because of the growth.” “Unfortunately, we may not know the extent of a patient’s
impairment until they reach school age and are attempting for the first time higher-level skills,” Wagner said. “Many times as they get older, challenges with social interaction (frontal lobe development), executive functioning, and motor skills become more evident. It is really important for these kids to be followed closely by a medical team and neuropsychology, so they can assess cognitive func- tioning and make appropriate recommendations for school.”
Is there impact because of the injury or because of the loss of opportunity? — Stefanie Laurence

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