Childhood injuries impose an enormous burden on our health-care system and societal resources. Such injuries account annually for an estimated 600 000 pediatrie hospitalizations, almost 16 million pediatrie emergency department visits, and costs that are thought to exceed $7.5 billion.1 But these staggering figures tell only part of the story.
Improvements in emergency medical services and acute care have increasingly enabled children to survive severe central nervous system injury, multiple injuries of the musculoskeletal system, and burns. Despite optimal early care, more than 30 000 children each year are left with permanent or long-term disabilities because of the irreversible or slowly reversible nature of the pathology that originates from their primary and secondary insults.1 Almost all areas of functioning can be compromised including mobility, self-care and other activities of daily living, speech and language, cognition, social adjustment and competence, and educational performance.
This article was written to help pediatricians understand the importance of comprehensive and coordinated rehabilitation services for children who have sustained serious traumatic brain, spinal cord, and burn injury.
THE CASE FOR REHABILITATION
Seriously injured children may not achieve their full recovery potential if the medical team responsible for their early management does not appreciate the possibility of ensuing disability. Many of these disabilities are preventable.2 Others can be eradicated or mitigated. Seriously injured children can enjoy improved function, independence, and quality of life if there is early integration and provision of rehabilitation services within the acute care setting.
When severe injury decreases a child's functional capacity to the point of total dependence (Figure), acute medical and surgical care alone may ensure survival (curve A), but a chronic state of partial or total dependence may persist.3 The addition of limited rehabilitative care can aid in the restoration of a higher level of function, but this may not be sustained (curve B). An ideal comprehensive rehabilitation program and plan should include sufficient training, education, and long-term monitoring to enable the child not only to attain self-sufficiency, but also to maintain an optimal level of function throughout life (curve C). Enabling a child to move along the continuum of function (Figure) from total dependence (requiring custodial care) to partial dependence, partial independence, and finally, total self-sufficiency reduces total lifetime expenses.4 Unfortunately, only a small percentage of injured children receive such care. A recent analysis of 4870 cases of head injury from the National Pediatrie Trauma Registry showed that 58% of children with four or more impairments in the areas of vision, hearing, speech, self-feeding, bathing, dressing, walking, cognition, and behavior were discharged from acute care without rehabilitation management.5
Rehabilitation following injury differs from the provision of acute care because of its focus on how the associated physical, neurological, and psychological impairments result in disability. Rehabilitation employs the following goal-oriented treatment strategies to lessen or eradicate disability: 1) prevention or correction of additional impairment or disability, 2) enhancement of systems unaffected by the pathological process, 3) enhancement of the functional capacity of affected systems, 4) use of adaptive equipment and aids to promote function, 5) modification of the social, educational, and vocational environment, and 6) psychological techniques to enhance patient performance.6 For children, these strategies occur in the context of continuing growth and development, with goals and objectives influenced by premorbid development and level of functioning. Placing parents of disabled children in touch with parent groups whose members have experienced the same problems can provide strong support for and contribute immeasurably to the adjustment of the entire family.
Because the residual disabling effects of injury can be so far-reaching, even the intensive care unit setting can serve as the beginning of a comprehensive management scheme for the provision of rehabilitation services. The earliest goal of treatment is to prevent secondary complications. If the child's condition permits, a program to prevent muscle contracture and joint capsular tightness is implemented. This includes proper positioning, passive range-of-motion exercises, and splinting. Frequent turning and regular inspection of the skin will help prevent the development of decubitus ulcers. Obviously, such efforts are subordinated to acute care demands.
Children may develop feeding and swallowing disturbances that predispose to aspiration following traumatic brain injury. Oral-motor skills and swallowing should be evaluated by a feeding ream (speech therapist, occupational therapist, and dietitian) for recommendations covering methods of food delivery (oral versus tube); food consistency, texture, and temperature; positioning requirements; and oral feeding techniques. Other issues include the management of early agitation and reorientation of the child awakening from coma.7
Figure. Human performance following disability as a reflection of rehabilitation. Reprinted with permission from Kottke JF, Lehmann JF, Stillwell GK. Krusen's Handbook of Physical Medicine and Rehabilitation. Copyright © 1 990, WB Saunders Co.
Regular supportive contact between rehabilitation personnel and family can ensure continuity between acute care and comprehensive rehabilitation. Early tracking by a rehabilitation consultation team can also facilitate timely admission into an intensive inpatient or outpatient rehabilitation program. Letters of justification for services by rehabilitationists and precertification by insurance carriers are usually required. With traumatic brain injury, spinal cord injury, and burns, early provision of rehabilitation can improve functional outcome, reduce hospital costs, and prevent secondary medical complications.
A coordinated, interdisciplinary, team approach is the most effective way to provide care and ensure maximal restoration and maintenance of function, especially for seriously injured children with multiple system involvement.8 Although this article only addresses traumatic brain injury, spinal cord injury, and burns, children with traumatic amputations and complex skeletal trauma also should have an assessment of their need for rehabilitation. A typical inpatient rehabilitation program usually involves a minimum of 30 to 90 minutes per day each of occupational, physical, and speech therapy. Additional services include rehabilitative nursing, academic and neuropsychological assessments, psychological and social work counseling, educational remediation, recreational therapy and dietary/ nutritional monitoring. Orthotic and prosthetic serv' ices also may be necessary. Leadership and coordination of these team efforts are the responsibility of a pediatrie physiatrist - a physician specializing in pediatrie rehabilitation medicine. Depending on the severity and nature of the injury, the site of service provision, the time along the course of recovery, and the composition and expertise of the team, other team members as well as representatives from other medical or surgical disciplines may take on this leadership and coordination role.
Primary Brain Injury
TRAUMATIC BRAIN INJURY
Traumatic brain injury is the most common diagnosis among seriously injured children. Children have increased survival and increased likelihood of achieving independence in motor function and self-care than adults with similar brain injury severity.9 Unfortunately, this has led to the widespread misconception that children are spared the seriously disabling effects of traumatic brain injury. Consequently, they tend to be underserved by the health-care and educational systems.
Traumatic brain injury can either be produced by blunt trauma or less commonly by penetrating objects. The damage originating from the immediate impact is referred to as primary injury and can be characterized as either diffuse axonal injury, focal injury, or mixed injury (Table 1). Secondary brain damage can be due to hypoxemia, ischemia, cerebral edema, compressive hemorrhage or herniation, and is potentially preventable by neurosurgical and neurointensive care.
Injuries Associated With Traumatic Brain Injury
High velocity impact and acceleration-deceleration forces produce a high occurrence of extracranial injuries in children with moderate and severe traumatic brain injury.5 These include fractures and dislocations; maxillofkcial trauma; thoracic, intraabdominal and pelvic visceral injuries; traumatic neuropathy and plexopathy; and spinal cord injury.
In one series of patients with severe traumatic brain injury, 16% of the medical problems found on admission to a rehabilitation center were already present but had not been identified in the acute care setting.10 This both illustrates the difficulty in making diagnoses in the unconscious, injured child and stresses the importance of maintaining a high index of suspicion for occult injuries and medical complications.
Severity of Traumatic Brain Injury and Outcome
Severity of traumatic brain injury can be defined on the basis of 1 ) initial depth of coma determined by the highest Glasgow Coma Scale (GCS) score during the first 8 hours after the injury (Table 2), 2) duration of coma, or 3) duration of posttraumatic amnesia. Outcome following traumatic brain injury depends on a number of factors including severity of brain injury, age, and presence of extracranial injuries (particularly cardiac, chest wall, and intra-abdominal injuries). The lower the GCS score and longer the duration of coma, the greater the risk of permanent neurologic and cognitive impairment. Favorable prognostic indicators include absence of early hypoxemia, absence of prolonged elevation of intracranial pressure, Glasgow Motor Scale (GMS) score of 4 to 6 at 72 hours (a favorable GMS score 5* 4),n coma for less than 24 hours,12 and posttraumatic amnesia for less than 2 weeks.13 Contrary to popular belief there may be increased vulnerability in children younger than age 5 years to residual brain dysfunction.14 Children with mild traumatic brain injury account for more than 80% of all pediatrie head injuries,15 but they generally have no significant residual neurobehavioral deficits that compromise educational functioning.16'17
Sequelae of moderate and severe traumatic brain injury may be grouped into the following categories: 1 ) neurologic (cranial nerve, motor, sensory, cerebellar, and vestibular dysfunction), 2) cognitive, 3) communicative, 4) psychiatric (personality, emotional, and behavioral disturbances), and 5) psychosocial. The majority of children who survive severe traumatic brain injury and emerge from prolonged coma are capable of independent ambulation and self-care with rehabilitative intervention,18 but they frequently have residual disabilities.
Glasgow Coma Scale (GCS) and Traumatic Brain Injury (TBI) Severity
Severe traumatic brain injury is often associated with persisting neurological deficits. Cranial nerve deficits are not uncommon but the prognosis for spontaneous resolution over time is generally iavorable, especially for extraocular palsies. All children with moderate and severe traumatic brain injury should have ophthalmologic and audiologic screening evaluations. Spastic hemiparesis and ataxia are the most common motor deficits.18 Late posttraumatic seizures (occurring more than 1 week after the injury) are uncommon in children. Anticonvulsants have not been demonstrated to be effective in preventing late posttraumatic seizures, and some medications, such as phenytoin (and likely others), have significant negative cognitive effects.19'20 In general, routine prophylactic treatment to prevent late posttraumatic seizures is not warranted.21
The cognitive and behavioral sequelae of traumatic brain injury are primary contributors to the difficulty in resuming prior social roles and responsibilities, school and vocational reintegration, and recreational pursuits. Long-term behavioral disturbances include attentional deficit disorder, hyperactivity and restlessness, impulsivity, and socially disinhibited behavior (including aggression).7 Affective disorders and lower self-esteem appear to be more common in adolescents.18'22 Performance IQ (reflecting impairments in speeded performance, motor dexterity, and problem solving) is more affected than verbal IQ.23 Memory deficits (shortterm memory in particular) are common after traumatic brain injury, as are problems with visual-motor and visual-spatial skills.7
The prognosis for recovery of functional communication skills is favorable. Frequently encountered problems include dysarthria and difficulties with naming, word retrieval, and the organization of expressive language. Although gross measures of receptive language are infrequently impaired, subtle deficits may be present and can be identified with careful testing.7
Neuropsychologic and behavioral deficits in children with moderate and severe traumatic brain injury interfere with the performance of school-related functions that require attention, concentration, ability to organize work, auditory and reading comprehension, abstract thinking, generalization of information, and judgment. Many children with traumatic brain injury are promptly discharged from the hospital if they do not show obvious and persistent motor, sensory, or language impairments. While such children appear to be normal, they may experience significant neurabehavioral problems that can interfere with their reintegration into school, peer group, and family situations. Targeting this population for support, anticipatory guidance, and careful follow-up can help ensure the provision of appropriate care and services.24
SPINAL CORD INJURY
The incidence of spinal cord injury in children aged 15 and younger is low (5% of all spinal cord injury). Fifty percent of all such injuries occur between the ages of 15 and 24 years.26 Most patients who survive traumatic spinal cord injury can now expect a normal life span with proper rehabilitative medical care. A child's successful early adaptation to the resultant disability has a profound functional impact for decades.
Anatomical differences in the immature spine including ligamentous laxity, shallow angulation of the facet joints, incomplete ossification of the vertebral bodies and disproportion of head size to neck musculature produces a high incidence of upper cervical spinal cord injury in the young child.26 In addition, pediatrie spinal cord injury commonly occurs without radiographie evidence of vertebral disruption,27 making its early diagnosis in the comatose child difficult. Findings that should increase suspicion for spinal cord injury include a dermatomal pattern of sensory loss, absence of deep tendon reflexes or anal wink, urinary retention, ileus, or priapism.28
After spinal cord injury, there is an initial period hours to weeks) of spinal shock with corresponding flaccidity and loss of deep tendon reflexes below the level of lesion. In general, incomplete spinal cord injury and injuries to the cauda equina with flaccid lower motor neuron paralysis have a much better prognosis for recovery. Motor level of injury is defined as the lowest level at which greater than antigravity motor strength is present. The determination of complete spinal cord injury requires absence of motor and/or sensory function below three roots from the last normal level.29 Recent reports have demonstrated that the administration of methylprednisolone (within 8 hours) and GM-I Ganglioside (within 72 hours) may have beneficial effects on the preservation and/or recovery of neurologic function after spinal cord injury. ??<31 The complexity of acute spinal cord injury mandates early referral to a regional trauma center that is experienced in the medical and surgical management of this problem.
Early acute management requires careful skin protection and turning, bladder decompression with a Foley catheter, and daily manual evacuation of stool during the period of spinal shock. In order for early mobilization and rehabilitation to progress, the spine often requires stabilization with surgical and/or orthotic management. Practitioners must be aware of and strictly adhere to spine precautions, which include specific range of motion limitations, biomechanical guidelines for active and passive movement, and progressive mobilization protocols. Ventilator dependence is more common in children given the increased incidence of upper cervical lesions. Patients with cervical and high thoracic lesions need aggressive pulmonary toilet.
The degree of functional independence attained by a patient depends primarily on that patient's neurologic level and completeness of the injury, but outcome also has been shown to be strongly influenced by the provision of multidisciplinary inpatient rehabilitation services.32 All children with neurologic deficits from spinal cord injury should be referred to an inpatient rehabilitation program experienced in the management of pediatrie spinal cord injury. Management and outcome are reviewed elsewhere.33
Pediatrie patients with significant burns are best cared for in a tertiary referral burn center experienced in the management of children. Frequently used criteria for admission include: 1) bum covering greater than 10% of total body surface area, 2) any bums to face, hands, feet, or genitalia, 3) all electrical burns to the mouth, and 4) home situations not conducive to optimal care. Assessment includes consideration of the causative agent (thermal, electrical, chemical, or radiation), depth, and extent of bums. Inhalation injury and exposure to products of combustion may produce hypoxic brain injury to which the basal ganglia and cerebellum are particularly susceptible. Knowledge of admission carboxyhemoglobin levels is important to determine the extent of carbon monoxide exposure.
Early rehabilitation management with aggressive physical and occupational therapy is critical for the prevention of functional deformity. Early therapy focuses on positioning, passive range of motion, strengthening, endurance building, and mobilization.34 Fresh hypertrophie scar tissue contains increased numbers of myofibroblasts that produce an abundance of collagen. Scars continue to mature, showing a relentless tendency to contract for 6 to 18 months.35 Progressive loss of joint range of motion from contracted, thickened scar continues during this time. Prevention requires vigorous exercise, splinting, and direct mechanical pressure. Hypertrophie scars also may create cosmetic deformity. After grafts and open wounds are healed, they are treated with mechanical pressure applied through compression garments, conforming splints, or clear semirigid plastic face molds. Uniform pressure application leads to capillary occlusion, altered fibroblast activity, more linear alignment of collagen, and less scarring.35 Patients also are at risk for primary traumatic nerve injury, secondary compression neuropathy, or diffuse polyneuropathy, which can cause further deformity and impairment.36
Educational Planning for Children With Disabilities
Once the skin is essentially healed, many children require management in an inpatient pediatrie rehabilitation program for optimal functional restoration. After discharge, ongoing participation in an outpatient therapy program with careful monitoring by the rehabilitation team must continue for up to 18 months. Failure to adhere to such a program can result in rehospitalization or further surgical procedures, and can lead to permanent disability.
School is the setting where children spend the majority of their waking hours. Children with acquired disabilities caused by injury will require special consideration to ensure their full participation in the educational process upon their return to school. Federal law mandates that they will be provided with a free, appropriate public education that includes an individual education program. The responsibilities of local and state educational agencies in serving all children with disabilities include transportation, special education, and services such as speech, occupational, physical and recreational therapy, counseling, social work, and nursing.3?
Preparation for school re-entry by the rehabilitation team ideally should begin on admission to the rehabilitation program. Liaison with key personnel within local educational agencies is essential. Table 3 provides a model for organizing and addressing the questions and concerns that will help ensure a smooth transition back to school.37 Physicians can assist school officials in the development of an individualized health-care plan by outlining the health maintenance activities required by the child's health impairments and disabilities (Table 4).37
Health Maintenance Activities for Children With Disabilities
Despite improvements in emergency medical services and acute care, each year thousands of children are left with disabilities from traumatic brain injury, spinal cord injury, and burns. Many of these disabilities can be prevented, eradicated, or mitigated with proper and timely rehabilitative care. Such intervention will result in improved function, independence, and quality of Hie for these children. The complexities of these conditions and their rehabilitation requires the efforts of an experienced, interdisciplinary, pediatrie rehabilitation team.
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Primary Brain Injury
Glasgow Coma Scale (GCS) and Traumatic Brain Injury (TBI) Severity
Educational Planning for Children With Disabilities
Health Maintenance Activities for Children With Disabilities