Paediatric Brain Injury Where are we now?

Dr Mary-Clare Waugh

Kids Rehab

BIA Sydney

10-11 November 2014

ABI• Myths

• Evidenced based practice in Paediatric BI rehabilitation – deals with the myths!

• Inflicted head trauma follow up essentials

• What treatments are effective?

Where are we now?

• Australia 22.6 m– NSW 7.3 m

• Sydney 4.6 m

– 1.84 m children 0-18 years

• Children’s Hospital at Westmead– 29,000 admissions /yr

– 13,000 day stays /yr

– 500 TBI kids admitted/yr

Kids Rehab

• 3,500 children and adolescents with physical or cognitive disability

• 350 new referrals/year

• 1/3 new Brain injury

Kids Rehab model of care

• Family centred – Parent advisory group

• Multi- & interdisciplinary • Goal-directed• Co-ordinated care• Transition• Outreach including Telemedicine• From diagnosis to school leaving age• Based on the ICF framework

ICF Framework WHO

ABI Incidence

• Traumatic TBI

– MVA, falls, inflicted injury, sport injury

• Non-Traumatic BI

– Haemorrhage eg AVM

– Stroke

– Infections

– Demyelinating conditions

Severity of TBI

• Mild Brain Injury coma scale 14-15

– >80% have a good outcome

• Moderate BI coma scale 9-13

• Severe BI coma scale 8 or less

– >60% have long term problems

Paediatric Coma Scales

Severity of Brain Injury

• Post Traumatic Amnesia – State of confusion

– Continuous new memory

< 5 mins Very mild

5-60 mins Mild

1-23 hours Moderate

1-7 days Severe

1-4 weeks Very severe

>4 weeks Extremely severe

Rancho Los Amigos Scales

Physical Challenges• Headaches

• Cognitive Fatigue

• Physical Fatigue

• Seizures

• Medications

• Vision neglect reduced acuity

• Tinnitis

• Ataxia

• Motor difficulties

ABI and Learning challenges

• Brain injury sequelae– Attention

– Motivation

– Initiation

– Processing speed

– Abstract thinking

– Exp and rec language

– Memory

– Reasoning

– Strategic thinking

– Self monitoring

High School demands

• HS pre-requisites– Attention

– Motivation

– Initiation

– Processing speed

– Abstract thinking

– Exp and rec language

– Memory

– Reasoning

– Strategic thinking

– Self monitoring

Social challenges

• Social skills difficulties

• Frustrations

• Disinhibition

• Aggression

• Labile mood

• Family functioning

Sequelae of Paediatric ABI

• Learning/Cognitive

• Social /Emotional

• Behavioural

NETWORKS

• Working memory

• Attention

• Inhibitory control

• Sequencing

• Speed of processing

Switch efficiency

controls

TBI

Caeyenberghs K et al 2014

Paediatric Rehab challenges

• Heterogeneity of injuries

• Injury to a developing brain

– Interplay of age at injury and developmental level, ongoing development and mechanisms of recovery

• Functional and neuropsycholologicaloutcome measures for children

ABI• Myths

• Evidenced based practice in Paediatric BI rehabilitation – deals with the myths!

• Inflicted head trauma follow up essentials

• What treatments are effective?

Myths for Paediatric BI

Better to have a brain injury when you are young.

Fact about Paed BI

Good evidence that the earlier you have a brain injury the worse outcome especially cognitive and behavioural outcomes

Long term cohort studies IQ and executive

function

– Mckinlay A 2010+

– Anderson V 1997 2001 2006 2008 2009 … 2014

– Lidzba K 2009

– Webb C 1996

– Yeates KO 1997 2010 2012

– Jaffe KM 1993+

– Taylor HG 1995 +

– Many more

Myths for Paediatric BI

A student is in the average IQ range can learn new material well.

Myths for Paediatric BI

Children don’t have strokes.

Fact about Paediatric BI

Children do have strokes.

– 7 per 100,000 children,

– Gomes et al 2014 review 16 articles• ADHD symptomatology most common

• Emotional dysregulation, anxiety, and mood instability

• Location of lesion vs networks to determine outcomes

Myths for Paediatric BI

Recovery will take about a year.

Facts about Paediatric BI

Recovery takes many years

– Stability only reached at brain maturity

Limond et al 2014

Myths for Paediatric BI

Brain cells don’t regenerate

Stems cells are proven to work in acquired brain injury

Fact about Paediatric BI

Neurons do regenerate

Not all regenerated cells are fully restored

Stem cells are effective for a small number of brain conditions

More research is needed www.hli.ualberta.ca

Myths for Paediatric BI

• A brain scan will always diagnose the injury

Specific areas lead to specific problems

• Networks now much more prevalent

• Language is not just Broca and Wernicke areas but a network

Tractography

• 12 yr boy TBI

Myths for Paediatric BI

• Neuroplasticity does not exist

Neuroplasticity

• Brain at birth 25% of adult size

• By 2 years 75% and adult size at 10 yr

• Motor and sensory areas develop first

• Frontotemporal development – 0-6 years

– 17-25 years

Neuroplasticity

• Neglect and stress shape brain development– ABI can knock out key areas and influence later networks

• Brain changes thru life – Synaptic pruning ↓ grey matter and myelination↑ white

matter

ABI• Myths

• Evidenced based practice in Paediatric BI rehabilitation – deals with the myths!

• Inflicted head trauma follow up essentials

• What treatments are effective?

TBI severity in an infant• Difficult lack of coma

scores that are easily done

• MRI brain assists– Diffuse axonal injury

• Infants behaviour – Irritability

– Play and interaction

– Time to return to “normal”

Outcome after Shaken baby syndrome• Predictors of severity of

outcome

– retinal haemorrhages

– intracranial lesions

– early neurological signs

– deceleration of head circumference or brain growth

Non Accidental Head Injury

• Lack of clear history of the injury type and time

• Difficulties with follow up

• Connecting with the family

• Moving homes in out of home care

• Early follow up can look “ok”

• Fall off the radar

• Lost to follow up

• Morbidity 59-100%

Barlow et al 2004

NAHI essentials

• Earlier recognition

• Long term follow up

• Networks

• Centralised registers

• Standardised data collection

• Tracking

Kelly P et al 2009

ABI• Myths

• Evidenced based practice in Paediatric BI rehabilitation – deals with the myths!

• Inflicted head trauma follow up essentials

• What treatments are effective?

Treatments• Many ………… • Constraint induced movement therapy

• Bimanual training • Strengthening, • Electrical Stimulation• Treadmill training• Virtual reality• Transcranial magnetic stimulation • Motor imagery• Mirror therapy• Cognitive rehabilitation +++• Pharmacotherapy• Adjunctive therapies • Computer based brain training

ICF Framework WHO

ICF Framework WHO

Brain injury

ICF Framework WHO

Brain injury

Diffuse axonal injury

ICF Framework WHO

Brain injury

Diffuse axonal injury

Walking Talking

Thinking ADLs

Writing

ICF Framework WHO

Brain injury

Diffuse axonal injury

Home School

Community Groups

Walking Talking

Thinking ADLs

Writing

What matters?

• Intensity matters

• Timing of intervention matters

• Type of intervention also matters

• Measurement matters

– What tool and when

Intensity of programs

• Adult stroke units

• Dedicated Brain injury units

• Animal studies

• CP studies

• Magic Camps

Brain Training $8b industry

• Practice

• Rest

• Sleep

• CVS fitness /exercise

• Nutrition

• Reduced multitasking

• ? transferability

Animal and human studies • Exercise

– Helps academic cognitive function in children (Hillman 2010) and elderly (Colcombe and Kramer 2003, Erikson 2011)

• Computer based training– Evidence emerging

• Compensatory mechanisms– ?best for the severely

injured brain

Training the brain

• Neuroplasticity of child’s brain

– To what extent

– Which techniques work

– Laboratory or community based

– Which skill to target first

– Is there any risk of harm?

Bryck RL and Fisher PA 2012

Treatment of ABI• Start early • Enriched environment• Maximise intensity

• Ensure it is the right treatment for the family and the developmental level of the child.

• Constraint induced movement therapy

• Bimanual training • Strengthening, ES• Treadmill training• Virtual reality• Transcranial magnetic

stimulation • Motor imagery• Mirror therapy• Cognitive rehabilitation • Pharmacotherapy• Adjunctive therapies

Cognitive Rehabilitation Therapy

• Relearning cognitive skills lost or altered through ABI

– Education about weaknesses and strengths.

– Process Training, retraining or practicing

– Strategy Training or compensatory strategies

– Functional Activities Training in real life.

Neurocognitive Interventions • Behavioural support

• Specific skills training egerrorless learning and rehearsal for a secure base

• Maximise core skills like working memory and inhibitory control

• Cognitive function training –flexibility and metacognition

• Independence training to use above skills

D. Indep.

C. Cognitive training

B. Remediation

A. Compensatory strategies

Psychosocial systemic foundations

Limond et al 2014

Recovery post ABI

Limond et al 2014

Ensuring best practice

• Data data data– Severity of injury: Coma scales PTA

– Outcome measures: weeFIM, Neruopsych, functional outcomes,

• Research

• Measure

• Review

Thank you