Paediatric Acquired Brain Injury

Transcription

1 Paediatric Acquired Brain Injury 12 th November 2016 Sue Mobbs and Gemma Kelly

2 Key messages of this talk To explore the consequences of ABI and evidence for rehabilita9on To consider the ques9on- does age ma=er? To discuss implica9ons for long term physiotherapy management 2

3 ABI Brain injury sustained aaer a period of typical development (Forsyth and Kirkham 2012) 40,000 children year in the UK 4,000 severe (NHS England, 2013) 1,300 will have ongoing major neurological difficul9es- approx the same as incidence of CP of all severity in a year (Forsyth and Kirkham 2012) Heterogenous mechanisms of injury eg. Trauma, infec9ons, stroke and tumours. 3

4 Physical changes in the residential rehabilitation setting Referrals for medically stable children with severe ABI Residen9al placement typically 4 months On site parent accommoda9on Individual tailored MDT programme Team outcome measures UK Rehabilita9on Outcomes Collabora9on (NHS England) FIM/FAM, GAS, SFA, PEDI. Physio outcomes GMFM, PAMS, Melbourne UL, FMS, QFM, Bruinincks- Oseretsky. GMFCS 4

5 Changes in physical skills during rehabilitation n=14 n=26 Mayston (2013) 5

6 Changes in function Change in number of GMFCS levels TBI (n=14 ) ABI (n=26 ) ANX (n=7) /14 (50%) 10/25 (40%) 7 (100 %) 4/14 (29%) 8/25 (32%) Mayston (2013) 6/25 (24%) 3/14 (21%) 2/25 (8%) 6

7 Similar injuries, very different outcomes 7

8 Lucy Disorder of Consciousness (Persistent) Vegeta9ve State v Minimally Conscious State defini9on from Na9onal Clinical Guidelines (Royal College of Physicians, 2013) MDT assessment BADS, ROM WHIM, SMART, PAMS Therapy programme 4 sessions daily and regular rest breaks. Stretches or not! 8

9 Lucy GAS parents require assistance Postural management Hips Physio- joint with OT or SLT Parental involvement Post discharge progressed to MCS 9

10 Charlie MCS at 9me of referral assessment MDT assessment following simple commands inconsistently, assis9ng in rolling. Mix of dystonia and spas9city lots of an9 spas9city medica9on Botulinum Toxin Injec9ons to upper limbs + serial cas9ng contractures star9ng to develop Postural management CAPS II standing frame, AFOs 10

11 Charlie Quickly progressing in all areas GMFMs 0,7,40,80,89 and 95%. GMFCS changed from V- IV- III- II. Standing and gait work (Bobath principles) treadmill training, Cheryl Cole! Football at weekends home Good motor recovery Irish CP football team(!), football coach Speech now giving mo9va9onal speeches Cogni9on is now 18 years old, cogni9on s9ll developing. Long term outlook unknown. 11

12 Current evidence base Very limited evidence for physiotherapy with children post ABI (Baque et al. 2016) Stroke in childhood guidelines (Paediatric Stroke Working Group, 2004) Other evidence sources: Adult ABI- Evidence based review of moderate to severe TBI (2014) Adult stroke- Na9onal Stroke Guidelines (2016) Children with CP (Novak et al. 2013) 12

13 Common themes MDT rehabilita9on 24 hour approach Goals based rehabilita9on Specific physiotherapy Splin9ng/posi9oning: func9on or maintain/increase ROM Balance/coordina9on exercises Repe99ve task training, high intensity Gait re- educa9on- sufficient intensity and level of challenge Help to re- integrate into physical ac9vity in the community 13

14 Family needs Physical based goals on admission Goal selng process challenging (Laver et al. 2010) Compe9ng emo9ons- grateful for child to be alive and grief over child they have lost (Collins 2008) Addi9onal needs Hope is essen9al (Draaistra, Ireland and Harper 2012)) Tailored informa9on at 9mes and rate they want (Kuipers et al. 2014) 14

15 Does age at injury matter? Is it be=er to have an ABI at age 5 or 25? 15

16 Conflicting models Early plas9city model Kennard principle Early vulnerability model Late consequences (Anderson et al. 2011) 16

17 Adult trajectory Forsyth (2010) 17

18 Child trajectory Forsyth (2010) 18

19 Does age at time of injury make a difference? Forsyth (2010) 19

20 The recovery continuum Anderson et al. (2011) Extent of injury Location of injury Plasticitygood outcome Vulnerability- Poor outcome Environment and experience Rehabilitation 20

21 What does this mean for community rehabilitation Every child is different, but similari9es in physical needs Children with DOC and their parents need support, integra9on and monitoring Tone oaen changing Ac9ve input required for children on a changing trajectory. Par9cipate in physical ac9vi9es (Katz- Leurer et al. 2010). All children and families, and school staff require support Awareness of impact of ABI on communica9on/ cogni9ve skills through transi9on phases 21

22 Key messages of this talk ü To explore the consequences of ABI and evidence for rehabilita9on * Individual treatment approach based on use of evidence from adult/cp with cau9on ü To consider the ques9on- does age ma=er? * Younger is not be=er ü To discuss implica9ons for long term physiotherapy management * S9ll improving physical skills and help for reintegra9on 22

23 References Anderson, V., Spencer- Smith, M., & Wood, A. (2011). Do children really recover be=er? Neurobehavioural plas9city aaer early brain insult. Brain 134: Baque E., Sakzewski L., Barber L. and Boyd R. (2016) Systema9c review of physiotherapy interven9ons to improve gross motor capacity and performance in children and adolescents with acquired brain injuries Brain Injury, 30(8): Collings, C. (2008) That s not my child anymore! Parental grief aaer acquired brain injury (ABI): Incidence, nature and longevity. Bri9sh journal of social work 38(8), Draaistra, H., Ireland, S., and Harper. T. (2012) "Pa9ents percep9ons of their roles in goal selng in a spinal cord injury regional rehabilita9on program." Canadian Journal of Nursing 34(3), Forsyth, R. J. (2010). Back to the future: rehabilitation of children after brain injury. Archives of disease in childhood, 95(7), Forsyth R. and Kirkham F. (2012) Predic9ng outcome aaer childhood brain injury, CMAJ, 184 (11): Intercollegiate Stroke Working Party (2016) Na9onal clinical guidelines for stroke:5 th edi9on Royal College of Physicans Katz- Leurer, M., Rotem, H., Keren, O., & Meyer, S. (2010). Recrea9onal physical ac9vi9es among children with a history of severe trauma9c brain injury. Brain injury, 24(13-14),

24 Kuipers, P. Doig, E., Kendall, M., Turner, B., Mitchell, M. and Fleming, J. (2014) Hope: a further dimension for engaging family members of people with ABI. Neurorehabilita9on 35(3), Laver, K., Halbert, J., Stewart, M. and Cro=y, M. (2010) Pa9ent readiness and ability to set recovery goals during the first 6 months aaer stroke. Journal of Allied Health 39(4), Mayston, M., Kelly, G. and Mobbs, S. (2013) 'Experience of using the GMFM- 66 and GMFCS during inpa9ent rehabilita9on for children with acquired brain injury' at European Academy of Childhood Disability conference, Newcastle Novak, I., Mcintyre, S., Morgan, C., Campbell, L., Dark, L., Morton, N., Stumbles, E., Wilson, S. and Goldsmith, S. (2013), A systema9c review of interven9ons for children with cerebral palsy: state of the evidence. Developmental Medicine & Child Neurology, 55: Paediatric Stroke Working Group (2004) Stroke in childhood; Clinical guidelines for diagnosis, management and rehabilita<on, London: Royal College of Physicians. Royal College of Physcians (2013) Prolonged disorders of consciousness: Na<onal clinical guidelines Teasell R. Marshall M., Cullen N., Bayley M., Rees L., Weiser M., Welch- West P., Ferri C., Aubut J. (2013) Evidence- Based Review of Moderate to Severe Acquired Brain Injury. Available from hip:// 24