Page 20 - Mobility Management, October/November 2020
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Pediatric Series
Invisible Injuries
One enduring mystery of brain injuries is the unique paths that recovery can take.
“The toughest part about a head injury is not knowing what the end is going to be,” Laurence said. “They can have changes years after. People can gain skills years later.”
Kiger remembered another client, a teenager we’ll call Sophia: “She was directly out of her injury, an automobile accident at
14 or 15. She had a pretty significant brain injury, and I was trying to figure out ‘Where will she be at the end of this?’ We discharged the wheelchair and she continued out-patient therapy. She was ambulatory, and she had some gait issues.
“She sat down in my office about two years after her accident. I was just chatting with her; I wanted to know what had changed. She was doing almost everything she’d done before. I said, ‘What are your friends saying about this Sophia that is different from the Sophia before, prior to the injury?’ She said, ‘They’re saying my personality is different and my memory is different.’ But other than that, she had rehabbed really well. Depending on the injury, with a lot of therapy and a lot of consistency, they can continue
to get better. Research tells us you can continue to improve from a brain injury years down the line.”
Since every brain injury follows its own recovery path — one inevitably made more complex as the child grows — what are the points to remember when working with this population?
Laurence described a call from a mother of a toddler recently seated in his first power wheelchair. “She said, ‘We got a problem: I took him grocery shopping, and he took off. I found him in the cookie aisle.’”
Laurence was ecstatic that this newly independently mobile 3-year-old was behaving... like a 3-year-old.
“They’re a child first, and their disability is secondary,” she noted. “Treat them as a child first and foremost. It’s devastating for a child to have a disability, but don’t disable them further by protecting them from the world. I think that’s one of the hardest things about working with kids with disabilities, particularly head injuries or something that’s hereditary. There’s a lot of parental guilt in there. You’d better be looking at equipment that meets that client’s needs and enables them instead of creating a new disability.” m
For the child with a brain injury, optimally fitted seating and wheeled mobility can facilitate so many critical activities, from reaching to playing and exploring.
One Child, Multiple
Everyday Environments
“Appropriate seating is essential for motor function, cognition, feeding and commu- nication,” said Kristen Wagner, PT, DPT, Certified Brain Injury Specialist and Team Lead at Children’s Healthcare of Atlanta — Scottish Rite. “We know that motor function and cognitive skill acquisition are linked, so as a PT, it is so important that my patients have a way to access and explore their environment.”
That includes, Wagner added, the many environments a child can experience each day: “We have to consider seating systems to assist with transportation (personal vehi- cles and school bus), feeding, communica- tion, weight bearing/upright standing, and access in their home, daycare, or school. Children with brain injury require seating systems that are adaptable to their growing skeletal system, and help to prevent further deformity. Hip instability and scoliosis are
common in patients with high tone and with poor postural control, so we really rely on a good seating system to decrease or minimize the occurrence. Seating and posi- tioning systems are really the key for a child to participate in age-appropriate activities, keep up with their peers, and engage with their environment.”
Seating That Also Repositions
Ryan Rhodes, OTR/L, ATP/SMS, Pediatric Sales Specialist for Sunrise Medical, noted that children with brain injuries often inad- vertently move out of position, then can’t reposition themselves. Dynamic seating components can help in those situations.
“Two of the biggest focuses are keeping the child safe and not letting them injure themselves, and also maintaining the integrity of the equipment that they’re using,” Rhodes pointed out. “So some- times we’ll put a dynamic backrest on, which is available on our activity chairs as well as our Zippie line. We have dynamic headrests and dynamic legrests. Those two factors, protecting the equipment and the patient, are the primary focuses.
“But even if they aren’t injuring
themselves or damaging their equipment, [spasticity and extension] can still move them out of the appropriate seated posi- tion. Extension tone is a huge, common activity that we see as a result of a brain injury or spasticity: It causes them to bridge across their chair, or if they’re sliding their behind forward, it can result in a posterior pelvic tilt or even shearing of the seating surface interface. If they’re reliant on lateral supports inside their chairs to sit upright, now they’re in a lower position.”
That puts the child in a much less func- tional position that can also raise the risk for other complications. Adding dynamic components to the seating system can help to return the child to an optimal and functional position once the extension episode has passed.
“There’s a number of ways these kiddos can move themselves out of their seated position, and more often than not, they’re unable to reposition themselves inde- pendently,” Rhodes said. “So without a very avid caregiver, we could start to see postural deformities if they’re sitting inappropriately for 12 hours through a school day, despite all of our efforts at custom seating.” m

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