PediatricNeurorehabilitation

Donna L. Nimec, M.D., M.S.

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston MA;

Disclosures

I have nothing to disclose.

▪ Reviewbasicconceptsinthefieldofrehabilitationmedicineandexploreoptionsfordeliveryofservices.

▪ Gainagreaterappreciationofdifferenttherapeuticoptionsandinterventionsforrecoveryoffunctioninpatientswithneurologicinjuries.

▪ Reviewafewstrategiesandtechnologiesthathelpfacilitaterecovery.

§ Understandthatneurorehabilitationisanongoingprocessinresponsetoaninjuryordevelopmentalanamoly.

§ Appreciatetheroleofcaregiversintherecoveryprocess.

Objectives

Neurorehabilitation:Rehabilitation istheprocessrestorationfollowinginjuryordisease,withthegoalofmaximizingindividualsabilitytofunction.

Neurorehabilitation isamedicalsubspecialtythatisaimedatthetreatmentofpatientswithdisabling(andoftenchronic)diseasesofthecentralorperipheralnervoussystem.[Selzer,1992]

- Theactiveprocessdesignedtoreducetheeffectsofaprimaryneurologicalconditionperformanceofactivitiesindailylife.

- Therapeuticmodalitiesimplementedtoovercomeorimproveneurologicimpairmentinterferingwithdailylife.

Definition

InternationalClassificationofFunctioning,Disability,andHealth- CY• Bodyfunctions

– physiologicandpsychologic• Bodystructures• Impairments

– problemsinstructureorfunction

• Activity(taskoriented)• Participationinlife

situations• Activitylimitations• Participationrestrictionsin

lifesituations

• ICFdescribesthesituationofanindividualinthecontextofenvironmentalandpersonalfactors

Diagnoses:

TraumaticandacquiredbraininjurySpinalcordinjuryInfectionsofthebrain(encephalitis)StrokeSeizuredisorderPediatriccancerinlateeffectsofcancertreatmentOtherproblemsthataffectthebrainorcentralmotorsystem

PatientPopulations

Howcanarehabilitationprogramworkbest?

▪ Acute inpatient rehabilitation

▪ Acute outpatient rehabilitation

▪ Home therapy program

▪ School therapy program

PotentialRehabSettings

▪ Howintenseshouldthetherapyprogrambeatthispointintherecoveryprocess?- Howquicklyarethechild’sabilitieschanging?

▪ Whatisthechildabletotolerate?

▪ Howstableasthechildmedically?

▪ Howmuchdoesthefamilyneedtolearntoreturnhomesafelywiththeabilitytomeetthechild’sneeds?

RationaleforAppropriatenessofSettingChoice– FromAcuteInpatient

TherapeuticActivities

PhysicalTherapyandRelatedActivities

▪ Neurodevelopmental Therapy (NDT), Proprioceptive NeuromuscularFacilitation, Feldenkrais, etc

▪ Aquatic Therapy, Hippotherapy, Pilates, Yoga

▪ Robotic Therapy, Virtual Reality

§ Motion Analysis

▪ Bracing (orthoses)

TheGaitCycle

Gait:NormalMuscleActivity

Gaitgraphs

TherapiesandRelatedActivities

▪ Neurodevelopmental therapies

§ Sensory Motor Integration

▪ ConstraintInducedMovementTherapy

▪ Academicallyorientedtasks

▪ Bracing(orthoses)

OccupationalTherapy

OccupationalTherapy:UpperExtremityManagement

• Stretchingandstrengthening

• Increasebodyawarenessinspace

• Increasemotorplanning

• Brachialplexusinjuriescanalsooccur,knownassocalled“traction”neuropathy

• Electricalstimulation

UpperExtremityFunction:TreatmentOptions

• Equipment• Orthoses forfunctionandROM

• Targetedinjections(botulinumtoxin)– Improveselectivemotorcontrol

• Serialcasting

• Therapy– Stretchtightmuscles– Strengthenweakmuscles– Improveselectivemotorcontrol

TouchScreenPlatform

• Fiveinteractivegamesthatencouragerepetitivemotions

• SimilartoiPad touchscreen• Eightsensorsonupperlimbs• Recordjointanglesofshouldersandelbows

• Accelerometerembeddedinvestwornbytheparticipant• Providesposturalandpositionaldata

TherapyandRelatedActivities

▪ SpeechandLanguageTherapy

▪ SwallowandFeedingTeamAssessmentandTherapyProgram

▪ Academic oriented services

▪ Augmentativecommunicationprograms

SpeechTherapy

AugmentativeCommunication

AugmentativeCommunication

OutcomeMeasures

• Uniformdatasystemformedicalrehabilitation

• Usedtoassessprogressinfacilitiesacrossthecountry

• Measuresgainsindifferentdomains

• Toassessfunctionalcapabilitiesandperformance,monitorprogressinfunctionalperformance,andevaluatetherapeuticorrehabilitativeprogress.

• FunctionalIndependenceMeasureforChildren(WeeFim)

• PediatricEvaluationofDisabilityInventory

TheProcess:EstablishingGoalsforTherapy

AcutePhaseofRecoveryPriorities

MedicalconcernsGrossmotorskillsFinemotorskillsOralmotorskillsSpeechandlanguageskills

Sub-acuteandLongTermProgramGoalsTherapeuticgoalscontinueSettlingintoahomeroutineIntegrationintoschoolIntegrationintocommunityactivities

Thelongtermgoalistoenablethechildtoreturnhomeandresumepreviousactivitiesincludingschoolandcommunitybasedprograms.

▪ Prepare a plan for return to school. It maystart with home tutoring, then partial day,before return to full day with support.

▪ Discuss appropriate leisure activities.

▪ Address questions around driving safety andthe need for a driving course.

▪ Review possible support groups for families.

CommunityCollaboration

▪Mechanismsregardingpotentialrecoveryofneurologicfunctionarepoorlyunderstood.

▪ Biologicmodificationinresponsetoinjuryexistwithinthenervoussystem.

▪ Thepotentialmechanismsbywhichthenervoussystemcanrespondtoinjuryarevariedmorethanpreviouslythought.

▪Meaningfulrecoveryoffunctioncontinuesforanextendedperiodoftime.

RecoveryResearch

MaximizingFunction:DeterminingInterestandMotivation

• Increasingparticipationandmobility.– Therapy

• Complimentarytherapy• Aquatictherapy• Hippotherapy• Massagetherapy

– Adaptiveequipment– Homeexerciseprogram

• Stretching• strengthening

– Communityactivities• Sports• Music• Drama

OngoingProcess

• Thetreatmentplanchangeswiththechangesinpresentationasthechildgrows.

• Complianceisafactor.• Familyagreementwiththe

planisessential.• Anticipatoryguidanceisa

usefultoolforunderstandingpossibilitiesfortreatmentinthefuture.

OngoingProcess

• Therapygoalsneedtostayrelevanttolifeevents.

• Findwaystomakeitpossibleforthechildtodothings.

• Asmuchaspossible,supportthefamilyintheirefforts.Behonest.Letthemknowyouwillbethere.

• https://drive.google.com/file/d/0B-Grcm2rHCYDb21oM25sRFViODQ/view

mtwashington2.mp4

CaseStudiesandGoalSetting

• Diagnoses

• SpasticDiplegia:Brooke

• Encephalopathy:Sam

• SevereTraumaticBrainInjury:Aubrey

• TransverseMyelitis:Isabel

• GoalSetting• Goalsarebasedon

improvingfunction• Oftentransdisciplinaryor

interdisciplinary• Strategiescarryoverintoall

settings• Evolvebasedon

developmentalsettingsandindividualneeds

SpasticDiplegia:Brooke

§ Bornat26weeksgestation,twin• Targetedtonemanagement

intermittently• Selectivedorsalrhizotomy• Orthopedicsurgery

– 1.Bilateralproximalfemoralshorteningvarus derotational osteotomies.2.Bilateralopenhipadductorlengthenings.3.Bilateralopenmedialhamstringlengthenings.4.BilateralVulpiusgastrocnemius/soleus fractionallengthening.5.RightAchillespercutaneous Z-lengthening.6.Rightmid-footreleasewithsplittibialisposteriortransfer.

Brooke:ProgramOverview• Goal:Increaseabilityto

walkwithanefficientgaitpattern

• Inpatienttherapyforamonthtwice– Tonemanagement

• Targetedbotulinum toxinandphenolinjections

– IntensivetherapyincludingtheLokomat

– Ongoingtherapyoutpatientandatschool

BeforeandAfter:Brooke

Spasticity/DystoniaManagement

• Impairsfunction• Causesdiscomfort• Increasesriskofcontractures

• Whentreatingspasticity,haveaspecificgoalguidingplacementoftargetedmeds,specifictasksforatherapyprescriptionorbraceprescription,andawaytoinvolveparents.

NormalMotorFunction

• Requirescoordinationthroughthe– Premotor cortex– Motorcortex– Thalmus/basalganglia– Brainstem– Spinalcord

• Pyramidaltracts/Corticospinal tracts

• Extrapyramidal tracts

MuscleStretchReflex

Spasticity- treatment 34

TreatmentOptions

Patient

IntrathecalBaclofen(ITB™)Therapy

OralMedications

RehabilitationTherapy

OrthopedicSurgery

Neurosurgery

InjectionTherapy

Spasticity- Treatment 35

Medications- oral

• Baclofen (Lioresal)• Benzodiazepines(ValiumandKlonopin)• Dantrolene sodium(Dantrium)• Imidazolines (Clondine andTizanidine)• Gabapentin• Cannabinoids

Medications- Targeted

• Botulinum Toxins– Intramuscularinjections

• PhenolMotorBranchBlocks– Perineural injections

Intrathecal Baclofen Pump

• ImplantedpumpwithtunneledcatheterenteringtheintrathecalspaceatL2.

• Theheightofthecathetercanvary.

• ImportantthattheparentsandchildaretiedincloselytotheITBprogram.

RobotAssistedGaitTraining:Lokomat

• Motorplanning• Increasedcorestability

• Increasedbalance• Every6-12monthprogram

• Doserelatedresponses

Neurostimulation

• Stimulation to a specific nerve or muscle– Walkaide– Bioness

Encephalopathy:Sam

SamisajuniorHistorymajor. Hisposterpresentationisentitled"TheFightForThe3/5Clause". Samwrotea20pagepaperlastyearabouthowcongressionalrepresentationwasdeterminedbycounting100%oftheNorthstates'freewhitepopulationandonlycountedslavesequalto3/5ofapersontowardcongressionalrepresentation.

Samtakes3classesasemesteratFraminghamStateaccompaniedbyPersonalCareAides. HeparticipatesfullywithhisTobii becauseofhisseverespeechimpairment.

Samsays"Ican'tdothingsonmyownandsometimesfeelfrustratedbyfeelinghelplessbecauseofmyphysicallimitationsandspeechlimitations”

TransverseMyelitis:Isabel

• Atage16,developedsuddenonsetburningpainanddecreasedLEsensation.

• NormalSpineMRI• Positivemycoplasmaserology

• Treatedwithhighdosesteroidsanddoxycycline

Isabel:ProgramOverview• Intermittenttherapiesfor

specificgoals• Modificationsofankle

footorthoses• Ongoingmedical

managementofSCI• Considerationfor

targetedtonemanagement

• Beginningdiscussionsontransitiontoadultproviders

• Preparationforcollege• Interestindriving• Feelscomfortablewith

socialinteractions.

SevereTraumaticBrainInjury:Aubrey

• 17yo hitbyacar• Minimallyconsciousstatefor3months.Inpatientrehabilitation– Disordersofconsciousnessprogram

– Acuterehabforseveralmonths

• Dicharged tohomewithacommunityrehabprogram

• 31/2yearsout• Stillintermittentlyinacommunityrehabprogram.

• Walkswithcontactguardassist

• CanbeindependentwithADLs

• Speechisrapid• Depression

▪ Each person has individualized goals.

▪ There are different options for therapy available topatients and families.

▪ More research needs to be done to know how tooptimize therapeutic interventions.

▪ Recovery continues long after the initial injury as thechild grows.

Constants

Resources• SupportGroups

– Parentgroups– Researchgroups– Publications– government

andpersonalstories– Blogs

• Financial– Statefundedprograms– Insuranceresources– Homeloans– Specialloanprograms

throughthetown

Equipmentexchangeprograms

– Beachbuggies/chairs– Usedequipment

refurbishing

TheTransition

▪ Build on new technologies (ie. Mobile legs for gait training)

▪ Ongoing pharmacologic research

▪ Advanced treatments for dystonia and other movement disorders

▪ Continue to develop more accessible environments, modifications tovehicles, augmentative communication tools

FutureDirections

Virtual Reality and Therapy

Developingandtestingaugmented-feedbackstrategiestoimprovegaittrainingoutcomes

▪ Neurorehabilitation canhappeninthecontextofavarietyofsettings.

▪ Itoccursmostofteninamultidisciplinarytherapeuticmilieu.

▪ Itisanongoingprocessthatchangesasthedevelopmentalandfunctionalneedsofthechildchange.

▪ Theoptionsfortherapyarechangingandnewtechnologiesarebeingdeveloped.

Conclusions

References• ChronicHeadacheafterPediatricBrainInjury:Asystematicreview(Nampiaparampil,2011)• CanLokomat therapywithchildrenandadolescentsbeimproved?AnadaptiveclinicalpilottrailcomparingGuidance

force,Ptahcontrol,andFreeD (Aurich-Schuler,etal,2017)• Whatisitliketowalkwiththehelpofarobot?Children’sperspectivesonroboticgaittrainingtechnology(Phelan,et

al,2015)• Combinedrobotic-aidedgaittrainingandphysicaltherapyimprovefunctionalabilitiesandhipkinematicsduringgaitin

childrenandadolescentswithacquiredbraininjury(Beretta,etal,2015)• Increasingpatientengagementduringvirtualreality-basedmotorrehabilitation(Zimmerli,etal,2013)• Adultneuroplasticity:Morethan40yearsofresearch(Fuchs&Flugge,2014)• Hypopituitarisminchildhoodandadolescencefollowingtraumaticbraininjury:thecaseforprospectiveendocrine

investigation(Acerin,etal,2006)• Home-Basedversuslaboratory-basedroboticankletrainingforchildrenwithcerebralpalsy:Apilotrandomized

comparativetrail(Chen,etal,2016)• Lateplasticityforlanguageinachild’snon-dominanthemisphere(Hertz-Pannier,etal,2002)• Clinicalapplicationofaroboticankletrainingprogramforcerebralpalsycomparedtotheresearchlaboratory

application:Doesittranslatetopractice?(Sukai-Moulton,etal,2014)• Neurobehavioralsequelaeoftraumaticbraininjury:evaluationandmanagement(McAllister,2008)• Whatistheroleofbrainmechanismsunderlyingarousalinrecoveryofmotorfunctionafterstructuralbraininjuries?

(Goldfine &Schiff,2011)• TraumaticBrainInjuryRehabilitation(Wa,etal,2006)• Timetorehabilitationadmissionandassociatedoutcomesforpatientswithtraumaticbraininjury(Kunik,etal,2006)• Robot-AidedNeurorehabilitation:Apediatricrobotforanklerehabilitation(Michmizos,etal,2015)

OurSuperheros!

ThankYou!SpauldingRehabilitationHospital300FirstAvenueCarlestown,MA02129