More than 100 000 children and adolescents are hospitalized each year with traumatic brain injury (TBI). Using the Glasgow Coma Scale (GCS) to classify TBI severity, it has been estimated that 5% of such children have a severe TBI (GCS score= 3 to 8), 7% have a moderate TBI (GCS score = 9 to 12), and 88% have a mild TBI (GCS score = 13 to 15). ' This article focuses on the prognosis and rehabilitative management of children who have sustained brain injuries as a result of the acute transfer of mechanical energy to the cranium, excluding children injured from birth trauma (with possible anoxic injury), nonaccidental trauma (with possible chronic or repeated injury), or gunshot wounds (with penetrating injury).
Two recent studies have demonstrated good longterm outcome for children with mild TBI. In a large retrospective study of a subsample of the 1970 British Birth Cohort, Bijur et al2 found that children who had sustained a concussion or a loss of consciousness requiring ambulatory treatment or hospitalization for one night were indistinguishable from uninjured children on all outcome measures of cognition, achievement, and behavior, except for a teacher's rating of hyperactivity. Using a prospective cohort study, Fay et al3 found that children who sustained a mild TBI showed no significant differences from controls at 1 year on measures of intellect, adaptive problem solving, memory, motor skills, independent living, or social skills. Mild TBI and concussion do not appear to cause long-term problems in children.
In contrast, children with moderate or severe TBI may experience a host of physical, cognitive, language, and psychologic sequelae that may improve over time or may be permanent. The optimal time after injury to measure outcome is not yet evident. Many of the first outcome studies in children used global measures of outcome and reported results 6 months to 1 year after injury. Further work using more sophisticated neuropsychological measures and statistical analyses has focussed on 1' to 5 -year outcomes, but questions in the areas of long-term independent living skills and vocational success will require even longer monitoring. Prognosis for moderate and severe TBI will be further described.
Both acute and chronic psychologic and behavioral sequelae can occur. After moderate or severe TBI, children may have a slow emergence from coma. They may look awake but be confused. They may be agitated, displaying emotional outbursts, spitting, restlessness, thrashing, and low tolerance to tactile, auditory, or visual stimulation. Acute confusion usually resolves within days to weeks and the child becomes oriented. Chronic behavior problems such as emotional lability, apathy, impulsiveness, irritability, depression, disinhibition, or impatience can result from injury to the prefrontal regions of the brain. These behaviors may persist for months and sometimes worsen. Unfortunately, most children with such problems also have an organically based lack of insight (anosognosia) regarding their deficits.
Speech, Swallowing, and Language
Motor speech disorders occur commonly after TBI. A small number of children can be transiently mute, unable to say words but able to understand language. Such mutism has a more rapid recovery in cases of demonstrable lesions to the basal ganglia than in cases of diffuse TBI.4 Other motor speech disorders include oral motor apraxias (inability to voluntarily control speech or swallowing functions in the absence of weakness, although some automatic, voluntary movements may be seen), dysarthrias, and difficulties with breath control resulting in a whispering or a monotone voice. After severe TBI, apraxia or dysarthria may persist indefinitely. Dysarthria may be a marker for dysphagia, but significant swallowing disorders with risk of aspiration can also be present after TBI in the alert nondysarthric patient.5
Language problems after TBI differ from both the classic receptive or expressive aphasias resulting from cerebrovascular accidents and developmental language disorders. The most common language problem after TBI is one of word retrieval, where the child is unable to name an object or think of the right word to say. Other common language problems include difficulty writing to dictation, problems with organizing thoughts, difficulty understanding multiple-step commands, and decreased speed of information processing reflected by a delayed response. Language processing can be very concrete, and the child may be unable to use or understand abstract language such as metaphors or inferences. Conversations are often disorganized, tangential, or socially inappropriate. Such problems may not be noticed in the young child who has had a TBI, but may become more apparent as the child matures and needs to use language more fluently for discourse, narration, or exposition. These higher level language problems commonly persist indefinitely in more severely injured patients.
Cognitive sequelae have the greatest impact on social, educational, and vocational prognosis. These problems include lack of attention and concentration, heightened distractibility, short-term memory impairment, difficulty with logical thinking and reasoning, impaired cognitive flexibility or difficulty in switching from one task to another, impaired visual spatial or visual motor skills, and slowed reaction time. These deficits are compounded by a lack of insight into them. They all tend to show some improvement over time, with measurable changes occurring 6 to 18 months after TBI. The greater the initial impairment, the greater the magnitude of both residual deficits and the amount of recovery.6 Whether each of these individual problems may have a different course of improvement is unknown, but the general consensus is that the rate of improvement slows after the first year.
Neurologic and Physical Outcome
Post-traumatic seizures that occur at impact or within the first week are not as concerning as those that occur later. The risk of late epilepsy is highest in children with severe injuries (around 8%); it probably does not exceed the general population risk in children with mild injuries.7 Administration of anticonvulsants such as phenytoin has been found effective only in preventing "early" seizures.8 Phenytoin may impair cognitive function in patients with very severe injuries, so long-term prophylaxis is not warranted unless epilepsy is diagnosed.9
Cranial nerve findings are frequently seen after severe TBI. Anosmia may occur with injury to the olfactory filaments as they pass through the cribriform plate. Recovery is unpredictable but usually apparent by 3 months.10 Basilar skull fractures can be associated with vertigo, tinnitus, and hearing loss. Hearing loss also can be due to cochlear concussion or auditory nerve damage, resulting in permanent sensory neural loss or middle ear damage. The finding of a conductive hearing loss is most commonly due to the spontaneously resolving problem of hemotympanum. Failure of a conductive deficit to improve, however, warrants further search for the surgically correctable problem of ossicle disruption. The fecial nerve also can be damaged from basilar skull fractures. A delayed onset of facial droop implies a neurapraxic injury caused by a fracture along the longitudinal axis of the nerve, whereas a more permanent loss of function is seen in cases of immediate droop due to fracture across the nerve. Vision loss can include scotoma, blindness, and field cuts and is usually permanent. Extraocular muscle palsies may be readily detectable or only apparent when the child develops a head tilt or squint. They usually resolve over 6 to 12 months.
Common motor problems after TBI include hypertonia, apraxia, ataxia, tremor, and impaired speed. Motor dysfunction can be mild or produce. severe disability. In children with moderate TBI, impaired balance may be the only detectable motor finding.
Hypertonia can include rigidity, as seen in patients with decorticate or decerebrate posturing, or spasticity, with velocity-dependent tone, hyperreflexia, and clonus. Both forms of hypertonia diminish as voluntary movement improves, but can remain indefinitely. Apraxias (loss of ability to execute purposeful movements in the absence of other motor or sensory impairments) can affect buccofoeial, limb, or whole body movements and occasionally are unilateral. Ataxia can affect limbs or trunk and can be very disabling. Neither apraxia or ataxia is particularly responsive to treatment, but may resolve or diminish over time. Action tremors can be incapacitating and persistent after TBI, but some tremors have been found responsive to propranolol.11 Recovery of gross motor skills is usually good and generally more satisfactory than cognitive recovery; fine motor skills and speed may show significant long-term impairments. Gross motor skills also may show noticeable improvement over a longer period of time in very severely injured children. Costeff found that children with very severe TBI made noticeable and meaningful improvement in motor skills 3 tò 5 years after injury, while the same children showed no change in cognitive function after 6 to 18 months.12
Disorders of the hypothalamic-pituitary axis can occur after TBI and produce problems such as hyperphagia with absent satiety, diabetes insipidus, growth failure, or hypothyroidism.13 Diabetes insipidus appears acutely, usually the result of transection of the infundibular stalk. Regeneration of the axons from the hypothalamus results in contact with capillaries of the basal hypothalamus, allowing antidiuretic hormone to enter the blood supply and resolution of the diuresis. Permanent diabetes insipidus usually is the result of destruction of the supraoptic and paraventricular nuclei of the hypothalamus. Growth failure and hypothyroidism often are lare findings requiring screening. In young children, a herniation of the dura through a skull fracture can prevent healing of the fracture, and the skull defect can grow over time. The area of the skull fracture should be palpated periodically.
Injuries resulting in blood in the subarachnoid space can cause hydrocephalus due to impairment of cerebrospinal fluid absorption. This can be difficult to distinguish from hydrocephalus ex vacuo, occurring as a result of loss of brain tissue. Increased pressure hydrocephalus should be considered in children with severe TBI who deteriorate or show an early plateau in improvement.
Urinary incontinence is common after moderate and severe injuries. In children with moderate injuries who have good motor function, the most common cause is frontal lobe injury with loss of inhibition of the brainstem detrusor nucleus. The bladder acts in a reflex manner, and the child experiences frequent small-volume voiding with urgency. This resolves over time and is not responsive to pyrtdium. Anticholinergics, fluid restriction, and timed voiding have variable efficacy. In children with more severe injuries, this problem can be compounded by motor problems and/or expressive language dysfunction, which make it difficult for the child to get to the bathroom or indicate the need to be toileted.
Several indicators of TBI severity are useful to clinicians in predicting outcome. These include the admission GCS,6 the length of coma (commonly defined as the length of time to following commands),14·15 and the duration of post-traumatic amnesia (PTA) (the period during which the child cannot reliably, consistently, or accurately remember events).16,17 The latter measure may be less useful in young children or in children with very severe TBI who are unable to demonstrate orientation due to limited cognitive or language skills.
The global picture of outcome after severe TBI was perhaps best painted by Brink, who reported on 344 children under 18 years of age who were in coma for a median duration 5 to 6 weeks.14,18 At 1 year after TBI, 73% of the children were independent in ambulation and self care, with better outcomes occurring in the group with less than 6 weeks of coma, and worse outcomes in the group with more than 12 weeks of coma. In contrast to this favorable motor recovery, less than one third had a normal intelligence quotient (normal does not imply undiminished from premorbid), nearly half had significant behavior problems, and three fourths needed special education services at school.
Common Signs and Symptoms Following Traumatic Brain Injury
It has been difficult to identify any early physiologic markers as predictors of late outcome after severe TBI. While Brink's group found a worse prognosis for children experiencing prolonged hypertension, seizures, or ventricular enlargement,14 a recent report by Kriel et al found no correlation with outcome for dysautonomic signs, seizures, or the initial computed tomography (CT) scan. Minimal cortical atrophy at 2 months after injury was associated with a better outcome.15 Large percentages of children with admission findings including fixed and dilated pupils, absent calorics,19 and flaccidity or decorticate or decerebrate posturing20 have been reported to have good outcomes. The initial GCS and length of time to following commands remain the most useful markers for the clinician. For the latter marker, the time frame of 12 weeks appears to separate good from poor physical outcome,14,15 but for intellectual function, it is around 1.7 weeks.18
Many rehabilitative problems are managed by pediatricians and family practice physicians rather than by rehabilitation medicine professionals exclusively. The post-acute management of the child with mild, moderate, and severe TBI is discussed in this section.
While long-term sequelae are not to be expected after a mild TBI, some children will experience acute signs and symptoms including headache, tinnitus, fatigue, emotional lability, or irritability for days to weeks after the injury. Symptomatic treatment, rest breaks, and reassurance are usually all that is necessary.
The child with a moderate TBI may have been hospitalized for several days to weeks, but may not require inpatient rehabilitation treatment. The patient and family should have early post-discharge follow-up with the pediatrician to determine if further evaluation or treatment is needed and to plan the return to school. The salient features to review from the medical history include the circumstances of the injury including use of alcohol or other drugs, the initial GCS score and the length of time it took to follow commands (ie, severity of TBI), the findings on CT scan, and the extent of other injuries. The review of systems should seek to elicit the common physical signs and symptoms of cognitive, language, and behavioral problems seen after TBI (Table).
The general physical examination should include detailed testing of cranial nerve function (including a screen of visual acuity and hearing), deep tendon reflexes, strength, praxis, balance (including single leg stance and tandem gait), and mental status. Casual conversation with the patient may overestimate his or her cognitive abilities, but glaring problems may be unearthed with an appropriate mental status exam. The mental status exam should include orientation, short-term memory (recall of words or pictures at 5 minutes), attention (digit span forward and backward, spelling a word forward and backward, serial 7s or 3s), naming (confrontational labelling), auditory comprehension (follows commands), abstraction (similarities, figures of speech, proverbs), writing, reading, and copying shapes. Long-term memory ("who is your teacher," "where do you live") is less likely to be impaired than short-term memory.
It can be difficult to separate newly acquired problems from pre-existing learning disabilities, but right-left confusion and letter or number reversals are not common after TBI. If deficits are noted on screening, the child should be referred to a neuropsychologist for more detailed testing. Notification of the school may not be enough, as the types of tests used by schools to qualify students for special education services may not be sensitive to the problems occurring after TBI. Intelligence quotient or achievement tests may look more at previously learned information than at a child's ability to maintain attention and learn and process new information.
If no significant problems are found, the child should start back to school as soon as he or she has the stamina for a part or full day. The parent should notify the school of the TBI and maintain regular contact with the teachers. The school may ask the pediatrician for advice about participation in recess or physical education. The family may want similar guidance about activities at home. Sports should not be unnecessarily restricted as they can be a good physical outlet for the child, but prudence dictates avoiding activities with a high risk of another head injury, the use of proper protective equipment, and supervision. Older teens may wonder about resumption of driving. In most states, physicians are not expected to notify authorities of a potentially unsafe driver, but the driver is expected to report his or her injury. There are no satisfactory office-based screening tests to determine driver safety, but many rehabilitation hospitals offer driver evaluation programs for patients who have had a TBI. If the physician is asked to provide medical clearance for a patient where doubt exists, the safest course is to recommend such an evaluation or a repeat driving test by the state licensing agency.
For patients who have experienced a severe TBI, a longer period of hospital care that might include inpatient rehabilitation can be expected. Rehabilitative management can begin in the intensive care unit to protect skin from pressure ulcers, and to prevent contractures, particularly in ankles, elbows, and fingers. Range of motion exercises, splinting, or use of serial casts are all helpful in maintaining range of motion in patients who have posturing with rigidity.
As the child emerges from coma, attention may turn to managing agitation and nutrition. Decreasing external stimuli such as lights and noise, allowing familiar adults to remain at the bedside, and allowing the child freedom of movement by padding the bed or moving the child in a wheelchair are simple measures that can reduce agitation. In more severe cases, the child's safety should be ensured by using soft restraints, maintaining close supervision whenever the child is out of bed, especially when using a toilet or commode, and by using pharmacologic sedation. Small doses of lorazepam give fest, reliable, and short-acting relief The majority of cases of agitation resolve within 1 week.21 During this same phase, when the child is alert and calm, the child or family may want to initiate oral feeding. The level of alertness and the presence or absence of dysarthria are not completely reliable in predicting who will have gross or silent aspiration, so a clinical swallowing evaluation should be done by a trained therapist. Until this occurs, a nasogastric feeding tube can be placed for enteral feedings.
When the child with a severe TBI is awake for several hours at a time and able to follow commands, it is appropriate to admit that child to inpatient rehabilitation. In such a program, impairments and functional deficits in the areas of mobility, self-care, communication, cognition, and leisure skills are identified, and goals are set toward improving function and independence. The treatment program is interdisciplinary with input from a physiatrist, rehabilitation nurses, occupational, physical, speech, and recreational therapists, teachers, social workers, and clinical and neuropsychologists.
While direct retraining has some use in motor disorders, no routines, drills, or computer programs are efficacious in cognitive retraining. Instead, therapists help patients learn compensatory strategies in the areas of communication and cognitive deficits. The child may learn to "talk around" a word in order to successfully retrieve it. He may record information in a memory book, diary, or daily calendar. He may use a task guide to compensate for organizational problems. To be effective, each of these strategies should be adopted with a specific function in mind, as patients with TBI have difficulty generalizing schemes from one task to another. In addition, these strategies should be tested in "real life" settings, such as on community outings and in classrooms, to establish their practical use.
Family members need support and education during the rehabilitation process, and the entire family unit must be considered when discharge planning is initiated. Resources for respite care should be investigated. Some children with very severe disabilities may not be able to be cared for at home, and alternative placement may be needed.
The physician has an important role in assisting with the child's return to school. Physicians must certify the need for special education services and should provide the school with appropriate medical information including the status of the child's vision and hearing and an update of the child's medical status. If medications or enteral feedings are needed at school, they must be prescribed by the physician. In most states, physicians must provide prescriptions for school occupational and physical therapy and sometimes for speech therapy. As described for children with moderate TBI, the physician may be asked to provide guidance regarding the length of the school day and appropriateness of participation in recess or physical education.
Guidance to the patient and family should cover recreational activities, driving, avoidance of drugs and alcohol, and the need for supervision. It is difficult for parents to provide constant supervision for teenagers, and it may be helpful to educate some of the patient's peers (with patient and family consent) about brain injury, safety implications, and the need to avoid alcohol or drugs. Recommendations previously mentioned for those with moderate TBI for recreation and resumption of driving apply here as well. If the teen was never licensed to drive and has motor or cognitive sequelae after brain injury, a school or commercial driving program can be attempted if there are no obvious restrictions to driving, such as severe disability or active seizure disorder.
On return visits to the physician, medical, social, and educational needs should be monitored. Medical monitoring should include screening of growth, development of secondary sexual characteristics, and screening for scoliosis as well as for previously noted deficit areas. It is easy to focus only on the physical problems, but a mental status exam should be included. The behavior, language, and cognitive problems ensuing after severe TBI can create a situation of poor self-image, social withdrawal, loss of peer approval, and isolation. This should be closely monitored with early referral for treatment if problems arise. Due to the child's lack of insight into his or her deficits, psychodynamic therapy may be less useful than a cognitive behavioral approach that emphasizes social skills and includes family counseling and training.
If the child has been receiving special education services, the physician can review the child's Individual Education Program (IEP) to see if there is a realistic match between deficits and IEP goals. If the child has a stable motor deficit, such as a hemiparesis of 5 years duration, it may not be worthwhile to take that child out of the classroom for physical therapy for gait training each week. Updated prescriptions for occupational and physical therapy should be provided annually, and the physician should be sure the school initiates transition and vocational planning as the child enters secondary school. Finally, physicians should make themselves aware of local resources and support groups for families and survivors of TBI.
Traumatic brain injury is a common childhood condition. Whereas persistent problems are not to be expected after mild TBI, children with moderate and severe TBI usually experience a host of enduring and frequently permanent physical, cognitive, language, and behavioral sequelae. Improved understanding of these sequelae and their rehabilitative management will enable the pediatrician to better meet the needs of these children.
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Common Signs and Symptoms Following Traumatic Brain Injury