15/02/2016

Acquired Brain Injury (ABI)

in Children
Physiotherapy and Rehabilitation
Jan Hancock
Senior Physiotherapist
Brain Injury Service
Kids Rehab
The Childrens Hospital at Westmead
February 2016

Outline of presentation
Background information on ABI
Acute management
Long term sequelae of ABI
Long term management
Implications for Physiotherapy
Case studies

can occur early in life (after birth)

BRAIN INJURY
congenital brain injury
prebirth

during birth

acquired brain injury

after birth

(Blosser & DePompei, 1994)

15/02/2016

strokes, cardiac malformations

infections: meningitis

Acquired Brain Injury - ABI

Traumatic Brain Injury
MVA & MBA
pedestrian
passenger
Falls
Bicycle, skateboard accidents
Non accidental injury
(inflicted injury)
other

Non Traumatic Brain

Injury
Vascular: CVA, AVM, ICH
Infections
Diseases
Oxygen reduction (hypoxia
&/or hypoperfusion)
CNS tumour
other

Traumatic Brain Injury

applies to open or closed head injury

generally results in a diffuse axonal injury widespread damage within the cortex
Particular vulnerability of frontal cortex
Impairment generally in one or more areas:
cognition
language
sensory, perceptual & motor abilities
psychosocial behaviour
Primary mechanisms of injury: Coup contre-coup
Secondary mechanisms of injury

2/3 case load will be TBI

closed - no communication of the brain with the external
environment
diffuse axonal - frontal lobe vulnerable

Cerebral oedema
Hypoxia
Haemorrhage/haematoma
Seizures

Traumatic Brain Injury

Severity of injury is the most important factor
influencing outcome
Rivara et al, 1996; OFlaherty, 2000

glasgow coma scale - motor & sensory responses

post traumatic amnesia - confused child, can not remember
memories
PTA up to 6 weeks

15/02/2016

Children with ABI

Children are not little adults
respiratory system
musculoskeletal system
neurological system (plasticity)
developmental (physical and cognitive milestones)

left side hemiplegia, hip dysplasia

angle of neck of femur, smooth acetabulums, articulation of
femoral head in acetabulum

hallux valgus

15/02/2016

significant weakness in dorsiflexors

contractures - unclear about what is the best treatment?

Neuroplasticity
Plasticity = to form, ability to be moulded

greater number of synapses in younger age - greater

opportunity to organise & adapt when younger

15/02/2016

Neuroplasticity
Repetition
Intensity

Neuroplastic
Change

Timing
Difficulty
Specificity
Salience

3000 reps of a task to acquire a skill

intensity - better short term & long term outcomes in
terms of function
timing - optimal time to work on interventions
difficulty - easy/too difficult - will not drive change
specificity - practice makes perfect

salience - how motivated is the activity for the individual,

need to know what motivates the child & encourages the child
to do the activity - will improve outcomes
includes all aspects of child's care - speech, cognition etc..

peers have had ongoing development - therefore a gap exists

when brain injury has occured

A= Adult recovery
B= Child recovery with added developmental trajectory

ongoing issues with speech, language, executive function

C= Recovery trajectory schematic of injury at 5yo

Forsyth RJ 2010

15/02/2016

Complications in Acute Setting

Respiratory
- dysfunction of autonomic nervous
Dysautonomia
system
Post traumatic epilepsy
Other MS injury
Heterotopic ossification
Complex Regional Pain Syndrome

trying to prevent contractures

spasticity issues - hips, elbows, shoulders etc.. - areas prone to
contracture development
tilt tables - weight bearing
PTA rehab - getting them up, active

msk injuries - pelvic fractures, limb fractures

spinal injuries, complete & incomplete spinal
cord injuries

Outcomes of TBI
Cognitive disability more frequent and pervasive outcome of
brain injury than motor disability (Eiben et al, 1984 Jaffe et al, 1995)
Increased physical disability following severe TBI than mild TBI
(Jaffe et al, 1992; Fay et al,1994)

Children with severe TBI (and non TBI) who have limited recovery
of physical skills at 12 months post injury have significant chance
of non recovery of these skills in the long term (Hancock et al 2011)
Motor dysfunction affects integration into home and school
(Hayley et al, 1990)

15/02/2016

Health Condition

activity limitations:
what is this child need to be able to do?

Body Functions
and Structures

Activity

Environmental
Factors

Physical

Participation

Personal
Factors

Brain Injury sequelae

balance difficulties
ataxia
impaired coordination
impaired motor planning
muscle weakness
spasticity
dystonia
tremor
dyspraxia

function - play - giving them the capacity to play & opportunity

to play
family centered practice - therapist prescription needs to fit in
with family's goals
participation - with friends
social development, fitness
TBI - kids are predisposed to obesity/weight issues due to the
injury

cognitive fatigue

Fatigue physical, cognitive

vestibular dysfunction
sensory impairment - vision,
hearing
other injuries eg. #s, soft
tissue injuries, cervical injuries
deconditioning: impaired
strength & CVS fitness
short & long term
musculoskeletal sequelae

structuring of therapy sessions

Brain Injury sequelae

Cognitive

organisational skills/planning
problem solving

inflexibility of thinking

self monitoring
social reasoning

insight

reduced attention and

concentration

slow speed of processing

language problems
new learning and memory
difficulties
difficulties with multiple
tracking & mental flexibility

cognitive fatigue

15/02/2016

Brain Injury sequelae

Behavioural
disinhibition, impulsivity, aggression

need to set up environment prior to treatment

facilitation of community participation

personality changes
poor behavioural control
egocentricity
social problems
emotional difficulties

Implications for Physiotherapy

What is the impact of cognitive and behavioural sequelae?
on childs motor performance?

impulsivity
poor judgement and anticipation of consequences of actions
impaired memory
difficulty with multi tasking

on your assessment?
what are you actually assessing?

on your intervention:

instructions: simple & repeated

history taking eg musculoskeletal Hx

therapy strategies
manageable home programs

Long Term Physio Mx in ABI Whats the Evidence?

Limited
Draw on adult stroke/neuro lit, paediatric CP lit
Strong evidence for early intense task specific rehab program
improved ST and LT function
Evidence of neuroplasticity
Serial casting
Gait training
Balance training
Cardiorespiratory training effect on cognitive function

early task specific interventions important in terms of function

gait training & supported weigh training

15/02/2016

Long Term Physio Mx in ABI

Family centred practice

Stage of recovery - time post injury?
Training Motor Control (ADLs for children)
MS system integrity
Adaptive equipment
Fitness and Leisure
Community and School Integration
Coordination with ongoing rehab and medical Rx

what is the function that the child needs to be able to do

to participate in the activity

GOAL SETTING INTERVENTION PLAN

Implications for Physio

Family centred practice
stage of recovery and priority for intervention
set collaborative GOALS
objective measures
impairment, function, participation
motor learning strategies
impact of cognitive and behavioural sequelae on
motor performance and on your intervention
community participation
need for long term follow-up

15/02/2016

Further Information
Kids Rehab, the Childrens Hospital at Westmead
www.schn.health.nsw.gov.au
Brain Injury Association NSW www.biansw.gov.au
Ministry of Health www.health.nsw.gov.au/birp
Working with people with traumatic brain injury, Liverpool BIRU and NSW
BIRD http://www.tbistafftraining.info
www.physiotherapyexercises.com
www.d-ability.org

jan.hancock@health.nsw.gov.au

References
Ada and Canning (eds) (1990) Physiotherapy Foundations for Practice. Keys issues in Neurological
Physiotherapy. Butterworth-Heinmann Limited.
Anderson et al (2011) Do children recover better? Neurobehavioural plasticity after early brain insult. Brain, 125.
Bland et al (2011) Effectiveness of physical therapy for improving gait and balance in individuals with a
traumatic brain injury: a systematic review. Brain Injury 25(7-8): 664-679.
Campbell S, Vander Linden D and Palisano R (2012) Physical Therapy for Children. 4th ed. W.B.Saunders
Company, Philadelphia
Carr and Shepherd, Ada L (1995) Spasticity: Research findings and implications for intervention.
Physiotherapy, 81, 421-429.
Carr and Shepherd (1998) Neurological Rehabilitation Optimising Motor Performance. ButterworthHeinmann Limited.
Hancock J et al (2011) Balance, Mobility and Community Participation Outcomes in Children and Adolescents
with an Acquired Brain Injury. Waiting publication.

10

15/02/2016

References
Hassett L et al (2012) Circuit class therapy can provide a fitness training stimulus for adults with a sever traumatic
brain injury: a randomised trail with an observational study. Journal of Physiotherapy 58 (2) 105112.Physiotherapy for the Acute Care Management of Traumatic Brain Injury An Information Package.
Publication of Brain injury Rehabilitation unit, Liverpool health Service.
Hassett L (2005) Physiotherapy for the Acute Care Management of Traumatic Brain Injury An Information
Package. Publication of Brain injury Rehabilitation unit, Liverpool health Service.
Hellweg s and Johannes S (2008) Physiotherapy After Traumatic Brain injury: a systematic review of the
literature. Brain injury 22 (5) 365-373
Hellweg S (2012) Effectiveness of physiotherapy and occupational therapy after traumatic brain injury in the
intensive care unit. Critical care research and Practice Apr 5 (768456) Epub
Katz-Leurer M et al (2009) The effects of a home-based task-orientated exercise program on motor and
balance performance in children with spastic cerebral palsy and severe traumatic brain injury. Clinical
rehabilitation 23 (8) 714-724.
Kleim J (2008) Principles of experience-dependent neural plasticity: implications for rehabilitation after brain
damage. Journal of Speech Lang Hear Res. 51(1):S225-39
Marshall S et al (2007) Motor Impairment Rehabilitation Post Acquired Brain Injury. Brain Injury 21 (2) 133-160.

References

OFlaherty S et al (2000) The Westmead Paediatric TBI Multidisciplinary Outcome Study: Use of functional
outcomes data to determine resource prioritisation. Archives of Physical Medicine and Rehabilitation. 81
(6) 723-729.
Patradoon H-P et al (2005) Obesity in Children and Adolescents with Acquired Brain Injury. Paediatric
Rehabilitation 8 (4) 303-308.
Rosenbaum P and Gorter J.W (2011) The F words in childhood disability: I swear this is how we should think!
Child: Care, Health and Development
Shepherd, R (1995) Physiotherapy in Paediatrics. Third Ed. Butterworth-Heinmann Limited.
Teasall R et al (2007) A Systematic Review of the Rehabilitation of Moderate to Severe Acquired Brain Injuries.
Brain injury 2007 21 (2) 107-112
Teplicky et al (2002) The effectiveness of casts, orthoses and splints for children with neurological disorders.
Infant and Young Children, Jul15 (1):42-50.
Zhu et al (2001) Does an intensive Rehabilitation improve the functional outcome of patients with traumatic
brain injury? Interim results of a randomized controlled trial. British Journal of Neurosurgery 15 (6) 464473
Zhu et al (2007) Does Intensive Rehabilitation improve the functional outcome of patients with traumatic brain
injury (TBI)? A randomized controlled trial. Brain Injury 21 (7) 681-690

11