PEDIATRIC

PHYSIOTHERAPY
MAMOONA ANWAR
SHS.510.Lec.18
 Today’s Lecture
• Traumatic Brain Injury
 Introduction

• Head injuries are injuries to the scalp, skull or brain caused by trauma.
• Brain injury is damage to the brain that results in impairments in
physical, cognitive, speech/language and behavioral functioning.

• The universal term used to describe brain injury as a result of head injury
is Traumatic Brain Injury.
 Traumatic Brain Injury

• An alteration in brain function or other evidence of

brain pathology caused by an external force
COMMON MOTOR DEFICITS
 BALANCE
• Balance problems are common after a traumatic brain injury (TBI).
Symptoms of dizziness, unsteadiness, or imbalance have been most
frequently attributed to sensory organization problems involving the use
of visual, proprioceptive, and/or vestibular information for postural
control.
 TREMOR
• More pronounced proximally

• Increases with effort and movement

 TONE ABNORMALITIES
• Spasticity

• Dystonia

• Rigidity
 SPASTICITY
• Spasticity results from an upper motor neuron injury and is manifested by
increased deep tendon reflexes.
 DYSTONIA
• Dystonia is defined as a disorder in which involuntary sustained
or intermittent muscle contractions cause twitching and
repetitive movements, abnormal postures, or both.
 RIGIDITY
• Rigidity is the resistance to an externally imposed joint movement, with
an immediate resistance to reversal of the direction of the movement, and
the limb therefore does not tend to return to a particularly fixed posture
 Deficits
• Sensory Deficits
• Olfactory
• Hearing
• visual
• Common Cognitive Impairments
• Memory
• Attention and arousal
• Behavioral
• Communication
• Social functioning
MANAGEMENT
 SENSORY STIMULATION
• Even before a child is following commands, rehabilitation may be
initiated.
• Focus on positioning, including specialized equipment, and activities.
• Head and trunk control are facilitated.
• Localized responses are channeled into more purposeful activity using
hand-over-hand techniques.
 INTERVENTIONS BASED ON THE COGNITIVE LEVEL

• As children become more responsive and interactive, therapy can become

more cognitively based.
• An eclectic therapeutic approach should be used .
• Classic neurorehabilitative therapy approaches adaptive equipment, the
use of technology, and environmental modification all have the ultimate
goal of increasing the child’s independence and ability to function, and
continuing to facilitate ongoing development and acquisition of skills.
 INTERVENTIONS BASED ON THE COGNITIVE LEVEL

• Cognitively based rehabilitation should continue even after discharge

from the inpatient rehabilitation setting, as improvement in this area has
been noted as far as 2 years postinjury .
• Speech can also be impaired after a TBI. Children therefore should be
assessed by a speech pathologist who can provide them with directed
therapy or communication aids as appropriate (217).
 PSYCHOSOCIAL SERVICES
• Supportive services are essential not only for the injured child, but also for the entire
family.

• It is also important to assess preinjury family functioning.

• The injured child participates in supportive counseling in addition to cognitive

rehabilitation activities.

• Counseling is imperative to assist in preparing for community reentry.

PHYSIOTHERAPY
MANAGEMENT
 ACUTE STAGE
• The physiotherapist works along with the medical and nursing team in and
out of ICU in the acute stage, with the following aims:
a. Positioning and turning of the patient to maintain soft tissue length, and
prevent pressure ulcer formation.
b. Regular passive movements to maintain joint range of motion.
 ACUTE STAGE

c. Breathing techniques and postural drainage without head tilt, without

or with suction to remove secretions.

d. To assist the Physician/Surgeon to judge prognosis and plan further

management.
 CHRONIC STAGE
The aim of Physiotherapy in the chronic stage include:
a. To normalize muscle tone.
b. To improve strength, endurance.
c. To improve posture and balance.
d. Restore function.
e. Assist in the Rehabilitation .
• The following pictures demonstrate some therapeutic exercises applied to
the patients of TBI.
• The aim of rehabilitation is to improve /restore mobility with or without
Orthotics and walking aids and enable to achieve ADL/IADL with or
without adaptive technology.

• After discharge from the inpatient rehabilitation treatment unit, care may
be given on an outpatient basis.
• Community-based rehabilitation will be required for a high proportion of
patients, including vocational rehabilitation; this supportive employment
matches job demands to the worker's abilities.
Rancho Los Amigos Level of Cognitive Functioning

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 Acute Phase

Prevent complications:
• Pressure sores
• Contractures
• DVT
• respiratory problems
• postural hypotension

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 Chronic Phase

• Acquiring or re-learning motor skills → PT program is built around the

cognitive level

• Owing to cognitive impairments, pts. may experience mental as well as

physical fatigue during treatment sessions.

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 Chronic Phase

• Signs of mental fatigue may include:

• increased irritability
• decreased attention and concentration
• deterioration in performance of physical skills and delayed initiation.
• Treatment sessions should include sufficient rest periods to minimize both
physical and mental fatigue and maximize motor relearning

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 Rancho Los Amigos I-III (no response -
inconsistent response)
• Goal: Prevent secondary complications
 Passive movement (full range all joints) -
 Rancho Los Amigos I-III
Positioning
• To Prevent complications (pressure sores, DVT, improve pulmonary
hygiene and circulation)
• In bed, pt. head should be kept neutral
• Hips and knees should be slightly flexed
• Splints may be used to assist in positioning; special boots can be used to
prevent foot drop and skin breakdown on the heel.
 Click icon to add picture

Rancho Los Amigos I-III

Multi podus Boot for foot drop
 Rancho Los Amigos
I-III
Pts. should be repositioned in bed
every 2hrs
Use of specialized air mattresses

Serial casting to maintain or

improve ROM
 Rancho Los Amigos I-III
Maintain respiratory status:
• postural drainage, percussion,
• Vibration
• suctioning to keep airway clear and prevent pulmonary complications.
Rancho Los Amigos I-III
 Rancho Los Amigos I-III

Promote early return of mobility

• upright positioning for improved arousal ( as soon as medically stable, pt.

should be transferred to sitting and out of bed to wheelchair)
• -Proper body alignment
 Rancho Los Amigos I-III
• Goal: Increase the interaction with environment.

 Sensory stimulation (Stimulate all sensory modalities)

• Auditory: talk to the patient, intermittent use of radio or T.V
• Visual: people, pictures, stimulate all areas of visual fields.
• Olfactory: use patient’s favorite smells.
 Rancho Los Amigos I-III
• Goal: Increase the interaction with environment.

 Sensory stimulation (Stimulate all sensory modalities)

• Gustatory: apply cotton swab with flavored solution to the lips &
gums.
• Tactile: use different texture.
• Vestibular: head movement (angular or rotational).
 RANCHO LOS AMIGOS IV (confused agitated)

-Eliminate any stimuli which agitate the patient.

-Give simple tasks with structured instruction.

-Give a lot of orientation. Patient has a memory problem

-Use what the patient likes, avoid sudden introduction of a new task. Be calm!

-If patient is not responding, you have to be creative.

Work in endurance rather than new tasks.

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 Rancho Los Amigos IV
Get patient out of bed: focus on
*ROM exercises

*Mat exercises (rolling, lying to sitting to

standing).

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 Rancho Los Amigos IV

*Transfer activities

*Gait training or wheelchair training.

•Patients having adequate muscle strength, postural alignment,

ROM and Sufficient cardiovascular endurance are candidates for
ambulation

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 Rancho Los Amigos IV

Patients whose trunk muscles (abdominals and erector spinae) are

in fair or better grade can be considered as functional ambulators

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 RANCHO LOS AMIGOS V/VI (Confused
inappropriate- confused appropriate)

-Patient can follow structured simple tasks.

-Clear short instructions.
Provide verbal or physical assistance.
-Control rate of instruction; provide frequent orientation to time, place, your
name and task.

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 RANCHO LOS AMIGOS V/VI (Confused
inappropriate- confused appropriate)

-Goals:
Patient is more involved in the program
Increase endurance
Address specific problems

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 RANCHO LOS AMIGOS VII and VIII
(Automatic appropriate purposeful appropriate)
- Patient is in control.
- Patient is usually discharged at this stage.
- Patient may still have memory and judgment impairment.
- Promote independence in functional tasks: ADLs, in real life
environments.
 RANCHO LOS AMIGOS VII and VIII
(Automatic appropriate purposeful appropriate)
- Specific program for any residual problems
- Prepare for community reentry, give honest feedback.
- Develop realistic fitness program
 SUMMARY
• A TBI is a devastating and life changing event for the individual
and his or her family.
• The PT must adapt physical therapy interventions to the unique motor
function, cognitive and behavioral challenges presented.
• The resulting impairments make working with the patient extremely
challenging and exhausting. However, the rewards of assisting a
patient with severe brain injury to return home or school vastly
outweigh the challenges of rehabilitation.
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