Motor Rehabilitation for Children Following Brain Injury

Motor capacity is another aspect of functioning that is often impaired following an ABI. Improvements in motor function have been reported in children after sustaining an ABI, however persistent differences in gait velocity, stride length, and hand function may remain in the long term (Kuhtz-Buschbeck et al. 2003). Therefore, despite improvements in overall function, residual impairments are common. Baque et al. (2016) report from a systematic review on motor rehabilitation that both physiotherapy and virtual reality result in favourable outcomes in the pediatric population. Other therapies that have had success within the adult ABI population for remediation of motor abilities are bracing, botulin toxin, constraint induce movement therapy (CIMT), virtual reality, and robot-assisted therapy. However, there is lack of high-quality research investigating the aforementioned motor rehabilitation post-ABI in the pediatric population. 

Bracing

In the growing child, bracing is often utilized to prevent contracture formation by providing regular stretch or to improve functional gait and upper extremity use. There is animal model data supporting lack of growth in muscles due to spasticity and highlighting the need for stretch of muscles to promote growth (Ziv et al. 1984). This information is often quoted in support of bracing children with spasticity. Data analyzing the impact of bracing children with traumatic brain injury is limited. 

Individual Study

Table: Bracing Children with ABI

Discussion

Corn et al. (2003), have studied the impact of utilizing second skin lycra splinting on the quality of upper limb movement in children. Low numbers (only 2 of 4 subjects being diagnosed with traumatic brain injury) and single subject design result in inability to generalize this data to the general traumatic brain injury population. Lack of improvement in one child and significant improvement in another, as documented with the Melbourne Assessment of Upper Limb Function, highlights the need for goal focused use and careful measurement of outcome when requesting a child and their family to undertake a bracing protocol which may be time consuming and uncomfortable.

Conclusion

There is Level 5 evidence that upper limb lycra splints improve the quality of movement in some individuals with traumatic brain injury.

 

Upper limb lycra splints improve the quality of movement in some children with traumatic brain injury.

 

Pharmaceutical Agents in the Treatment of Spasticity

Spasticity has been defined as: “a velocity-dependent increase in tonic stretch reflexes and is one component of the upper motor neuron syndrome” (O'Brien 2002 pg S182). For some individuals who sustain an ABI, spasticity post-injury presents as mild to severe muscle contracture, repetitive spasms and/or pain. The treatment of spasticity ranges from physiotherapy (to stretch muscles) to the administration of various medications.  Amongst these are dantrolene, tizadine, baclofen and benzodiazepams (O'Brien 2002). Here we will review the administration and effectiveness of intrathecal baclofen and botulinum toxin in children post-ABI. 

Individual Studies

Table: Effectiveness of Pharmaceutical Agents for Spasticity in Children post ABI

Discussion

Two studies evaluated the effectiveness of botulinum toxin type A (BTX-A) for the management of spasticity in children with an ABI. Overall, BTX-A improved spasticity and range of motion in children and adolescents that sustained an ABI (Guettard et al. 2009; van Rhijn et al. 2005). When BTX-A for both upper and lower extremities was paired with other therapies (physical, occupational and exercise therapy) there was also an improvement in voluntary motor control, in addition to the improvements seen in spasticity and range of motion. However, due to the lack of comparison group, conclusive statements cannot be made; it is difficult to determine if the effects were due to the combination of therapy, BTX-A alone, or the standard therapy. Future research should differentiate these groups to compare effectiveness (Guettard et al. 2009). Importantly, BTX-A treatment did not cause any adverse side effects for injection doses under 10U/kg of botulinum toxin (Guettard et al. 2009; van Rhijn et al. 2005). Intra-muscular BTX-A injections may be considered an effective treatment for severely brain-injured children, especially in combination with orthotic devices and specific functional exercise programs. A review of the literature on botulinum toxin suggests that injections are effective for lower limb functional improvements, however future research is needed to determine the effects for the upper limb (Gordon & Di Maggio 2012).

An intrathecal baclofen injection pump improved spasticity in three young children (Walter et al. 2015). However, unlike botulinum toxin, baclofen side effects were more common. Two of the three patients had complications and five of the complications were related to the device. Two of these complications were due to skin protrusions. The pumps must be implanted in the skin and one child experienced problems with epifascial implantation. However these effects were minimized with subfascial implantation, which has become the sole technique for intrathecal baclofen pump implantations for children (Walter et al. 2015). Other complications were due to wound infection, cerebrospinal fluid leakage, and intractable spasticity. All complications were reversed with treatment or relocation of the pump.

Conclusions

There is Level 2 evidence that botulinum toxin type A is an effective treatment for children and adolescents with upper and lower limb spasticity.

There is Level 4 evidence that intrathecal baclofen pumps are effective at reducing spasticity in the upper and lower limbs for children with hypoxia. 

 

 

Botulinum toxin type A effectively improves both upper and lower limb spasticity in children and adolescents following brain injury.

Intrathecal baclofen pumps reduce upper and lower limb spasticity in children with hypoxia.

 

Constraint-induced Movement Therapy

Constraint induced movement therapy (CIMT) has received increased attention in the literature as a possible treatment for cerebral palsy in children and stroke in the adult populations. This treatment has two key components. First the limb that is least impaired or not at all impaired is constrained. Following this a therapist creates intensive, repetitive daily motor movements that are performed with the affected limb (Cimolin et al. 2012). The mechanism underpinning this approach involves the learning of using the impaired limb to promote neuroplasticity and cortical reorganization (Gordon & Di Maggio 2012). This type of treatment has been shown to be effected with adults who have suffered a stroke, a TBI or focal hand dystonia; however, to date little research has been conducted with children.

Individual Study

Table: Constraint Induced Movement Therapy in Children with ABI

Discussion
In a recent case control study looking at the effectiveness of CIMT with children post TBI, Cimolin et al. (2012) found that motor function improved post intervention in the hemiparetic limb of each child who had sustained a TBI. Prior to treatment, movements with the affected arm were slower and took longer. Post intervention, improvement was noted in the arm’s overall range of motion and the execution of movement. Gross motor function also improved significantly following CIMT therapy, compared to baseline. However the authors suggest that such improvement may be attributed to spontaneous recovery over time. Despites findings from Cimolin et al. (2012), there are concerns for CIMT in the pediatric population, such as tolerability of such intense treatment, inability to deal with psychological effects from frustration, and difficulties with bimanual movements (Cimolin et al. 2012). Therefore, future research is warranted to determine if the benefits outweigh the risks within the pediatric population.

Conclusion

There is Level 2 evidence to suggest that constraint induced movement therapy improves motor function of the hemiparetic limb compared to no care, in children following a TBI. 

 

Constraint induced movement therapy improves upper limb function in children post TBI; however future research is warranted.

 

Virtual Reality and Videogame-Based Therapy

Alternative methods for motor therapy has focused on the use of modern-day technology to remediation motor deficits post-ABI. The use of the Nintendo Wii videogame console has been found to be a cost-effective and highly-motivating alternative to physical and cognitive treatment with both limb movement and social interactions promoted at the same time (Loureiro et al. 2010). The interaction between player movements and on-screen challenges allows for an interactive approach while maintaining the player’s attention and competitiveness. The use of the Nintendo Wii and Wii-Fit software has also been found to be successful amongst adult populations for balance (Gil-Gómez et al. 2011) and moderately successful for walking (McClanachan et al. 2013). Other systems have been used including virtual reality simulators (Bart et al. 2011) to recreate a real-world environment.

Individual Studies

Table: Virtual Reality and Videogame Therapy for Children with ABI

Discussion

The literature demonstrates that usage of a gaming console such as a Nintendo Wii has made effective contributions to motor therapy. Not only have patients shown levels of improvement in their own physical abilities, but greater understandings of disability have emerged that can further enhance motor therapy interventions in the future. De Kloet et al. (2012) reported that patients demonstrated significant increases in amount and intensity of physical activity, and a greater variety of recreational activities at follow-up. However it was conceded that quality of life was not measured so while motor functions improved, psychosocial issues may not have been addressed (De Kloet et al. 2012). Future pediatric research is required to assess the effectiveness of similar interfaces such as the Xbox Kinect system which operates without a controller and measures the player’s own body movements.

The premise of an interactive approach is not just limited to games consoles. Bart et al. (2011) used a virtual reality simulator that could distinguish between children with and without ABI. The results revealed that virtual reality game scores were correlated with self-care abilities and upper-extremity reaching. Biffi et al. (2015) reported that paediatric patients with an ABI demonstrated significant improvements in multiple aspects of gait and walking ability, particularly in the pelvic region. However, knee flexion did not improve. However, one major limitation was the lack of an age-matched control group (Biffi et al. 2015). The current literature suggests that simulators are a user-friendly, safe and motivating tool that can be used as part of a therapeutic intervention.

Conclusions

There is Level 2 evidence that virtual reality simulators are useful in measuring patients’ self-care and attentional abilities, with a view to using them in motor rehabilitation interventions.

There is Level 4 evidence that use of a Nintendo Wii console can be used to improve the amount and intensity of physical activity, and help patients to achieve motor functioning goals.

 

 

Virtual Reality-based Therapy has been shown to improve motor abilities in children post ABI.

Further research is required to observe the efficacy of VR-based Therapy as part of a rehabilitation program.

 

Robot-assisted training

There is currently a scarcity in the literature concerning robot-assisted training among pediatric patients with an ABI (Fasoli et al. 2012). In a study of patients with an ABI, predominantly cerebral palsy and stroke, Keller et al. (2016) reported that use of the ChARMin exoskeleton for upper limb rehabilitation was feasible for all patients thereby highlighting the promise of this type of intervention. Robot-assisted therapy has facilitated motor recovery within these populations and may be beneficial for children that have sustained an ABI. Two studies have evaluated the use of robotic assistance for motor rehabilitation in the pediatric population (Beretta et al. 2015).

Individual Study

Table: Robot-Assisted Training for Children following ABI

Discussion

Two robotic assisted therapies were examined, one for remediation of lower limb motor function (Beretta et al. 2015) and one for the upper limb (Frascarelli et al. 2009). Beretta et al. (2015) used a body-weight supported treadmill in combination with physiotherapy to re-train gait performance in children following an ABI. There was a global improvement in both motor and functional abilities of the lower limbs in children that received robotic assistance compared to those that received standard physiotherapy. Specifically and perhaps more importantly, standing and walking abilities improved post-treatment (Beretta et al. 2015), which is in line with findings from the adult TBI population (Wilson et al. 2006). Children that were ambulant had increased range of motion of the hip and improved hip extension during terminal stance, which was directly related to increased ability to walk further distances and gait pattern improvements (Beretta et al. 2015). Interestingly, there were no dropouts in the study, none of the children missed their appointments, and all were actively engaged in the sessions.

Frascelli et al. (2009) report that upper limb motor function and spasticity are improved following short term robot mediated therapy on reaching tasks. Authors suggest that recovery in upper limb motor function can be influenced by repetitive training with a robotic arm, without negatively affecting muscle tone (Frascarelli et al. 2009).

Conclusions

There is Level 2 evidence suggesting that body-weight supported treadmill training paired with physiotherapy is efficacious in improving gait and motor function compared to physiotherapy alone.

There is Level 4 evidence that reach training with robot mediation improves upper limb motor function in children that have sustained an ABI. 

 

 

Robotic assisted therapy improves motor function in both upper and lower extremities in children that have sustained an ABI.