I hope to let you all know more about Rehabilitation, sort of information as to why and what really.

14th November 2009
I am back doing Hydrotherapy at the moment to try and improve my stamina and position of my leg. I love working in the pool and hope to get stronger that I may be able to walk better.

23rd October 2009
So I am still doing Physio, yup I will need to see what i can achieve. Swimming is again on the list to try and build my strength. I love swimming. I have to have another splint for my leg as I keep outgrowing this one and as my dad says at least I am growing. I am stronger now though still need support as my balance is not all that great. More physio and then more physio will help alot.

23rd April 2009

I received this email from a special trainee nurse, I thank her for her care and attention during my time at the Hospital, as I THANK all in my ward and at Physio:

I am now doing some HYDRO THERAPY, this involves water:

Using Hydrotherapy to Heal a Physical Injury

Hydrotherapy uses water to heal the body. Hydrotherapy is most commonly used to treat musculoskeletal problems such as muscle strains or tears, repetitive stress injury (RSI), spinal cord injuries, and bone injuries. It can also be beneficial for non-injury problems such as cystic fibrosis, eczema, bursitis, rheumatoid arthritis, stress, prostatitis, burns, sore throat, cold, stroke, or paralysis.

Temperature
Water temperature is one aspect of hydrotherapy that controls inflammation and circulation. Exposing a new injury to cold water can reduce swelling. Cold water also stimulates the body and is invigorating. For general aches and pains, such as tense muscles or stiff joints, warm water relaxes muscles and encourages blood circulation. Warm water assists with removing waste from body tissues. The best water temperature is determined by the nature of the injury. For example, one should not apply warm or hot water when there is still swelling.

Motion
Motion is another aspect of hydrotherapy that can involve one’s passive or active participation. For example, resting in a Jacuzzi or whirlpool requires no action from the patient. However, the motion of the water jets provides a therapeutic massage. Conversely, water aerobics requires active participation from the patient. The buoyancy properties of water prevent a patient from performing any high-impact moves that could be harmful or painful. Exercising in water is effective in building strength because water provides resistance, requiring greater effort. For example, walking in the water is more difficult than walking on land.

I am now at home so having PHYSIO in WORCESTER and HYDRO THERAPY IN MALVERN. It is really cool and do this 3 times a week. I do rolling,kneeling and some games to try and improve my motor skills. I am also doing some standing to get me to try and walk. This is hard as my RIGHT LEG seems to have a mind of its own. I have no power in that leg.

I still have my splint on that leg and this helps to stop my foot from dropping, I cant control my RIGHT leg and cant seem to move my toes at the moment. I hope to have it looked at soon to see why.

At Hospital

I am currently having Physio and Occupational Therapy (OT). I get to go down to the gym 3 times a week and do new stuff, they place me on a table that can stand me up, they try and get me to sit on my own (not doing that yet) they get me to try and roll over and turn my head from side to side. It is hard work.

I will need some bigger shoes, as the splints on my legs (To stop my feet from deforming to non use) are much bigger than my feet. It will also help me try to stand and look a bit normal too. I also get the Speech and Language Therapists comming round. They are trying to get me to swallow yogart at the moment (I can do about 10 teaspoons)............mmmmmmmmm I love yogurt.

All these people are looking after me and trying to get me better. Even the student nurses are trying to get me to do things all the time. As they say " Every little bit helps!". Even my friends that are visiting me are so cool about it and I THANK THEM ALL.

Introduction

The estimated incidence of traumatic brain injury (TBI) doubles between the ages of 5 and 14 years and peaks for both males and females during adolescence and early adulthood to approximately 250 per 100,000. Children and adolescents are more likely than adults to survive following TBI.

Because the lives of most survivors of moderate to severe TBI involve chronic, life-long disabilities with varying degrees of dependence, the cost in individual suffering, family burden, and financial burden to society is greater for those who have more years to live.

Limitations in bathing, dressing, and walking are observed in between 50 percent and 90 percent of children with TBI with multiple functional deficits, depending upon and directly proportional to the number of functional deficits. For children with four or more functional deficits, there are impairments in self-feeding, cognition, and behavior (75 percent); there also may be impairments in speech (67 percent), vision (29 percent), and hearing (16 percent).

In the 18th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act, the number of children receiving services because of TBI for the 1994 to 1995 school year was 7,188 students aged 6 to 21 years. The gap between this number and reports of incidence of TBI among children and adolescents suggests that many children with TBI may be misidentified or unidentified. The concern is that the problems of these children may go unrecognized, or they may be treated with methods that were developed for other pathologies but are inappropriate to the special needs of children with TBI.

Although many children with TBI may move on to inpatient rehabilitation and some to long-term care facilities, the goal, when possible, is school. Laws requiring schools to provide for the special education needs of students define schools as the best place for ongoing rehabilitation of most children with TBI. Ideally, a child identified with TBI would be evaluated for special needs and provided with an individual education program (IEP) designed to meet those needs. However, the content and quality of the program would depend on the resources available in the school and varies across States and regions.

Characteristics such as social inappropriateness, lack of awareness, and decreased control of attention, memory, and strategic thinking may result in difficulties when a child with TBI is integrated into mainstream educational settings. Some States provide training for public school teachers that is focused on the special needs of children with TBI. Some programs serve both children who live at home and those who require residential treatment in a specialized educational/neurorehabilitative setting.

Choice of model (mainstream vs. separate) may be dictated by the severity of deficits and functional capabilities of the child; it also may be influenced by the availability of resources within the community, family choice, or the local or regional philosophy of inclusive vs. segregated education of students with disabilities.

Background

At the conclusion of the project, AHCPR requested that the OHSU EPC conduct a survey of the literature regarding child and adolescent TBI rehabilitation. Specific objectives for the project were to:

1. Identify studies of all phases of rehabilitation for child/adolescent TBI from a variety of bibliographic databases and compile a data set of studies ranging from acute care through in and outpatient rehabilitation, educational reintegration, and long-term functional status.
2. Document the process of applying search strategies to the literature, including where the strategies failed and succeeded, producing a road map to this body of literature for use in future investigations.
3. Categorize the retrieved studies and produce a bibliography.
4. Working with a panel of technical experts, including a parent of a child with TBI, define key questions regarding child and adolescent TBI rehabilitation and use them to search the database to locate studies with evidence for effectiveness of interventions.
5. Summarize the studies relevant to each key question.
6. Construct a template for evidence tables to address the key questions by specifying important variables to define the columns in the tables.
7. Propose a research agenda for rehabilitation of child and adolescent TBI.

The main goal was to create a template for a comprehensive systematic review of existing literature. A secondary goal was to describe research projects capable of closing information gaps revealed by a survey of the literature.

Conceptual Model for Rehabilitation of TBI in Children and Adolescents

Children are naturally changing and developing both before and after they are injured, including while they are receiving rehabilitative interventions. Therefore, in order to examine the effects of rehabilitation, information is required on normal child development. Longitudinal studies that compare development of injured and uninjured children also are needed. To be useful the studies must assess capabilities of children at different ages and determine individual variation in developmental outcomes of children with different injuries and in different social environments.

The best organizing principle for reviewing the literature on child and adolescent TBI comes from the modern study of human development and, in particular, the metatheoretical approach known as Life-Span Developmental Psychology. Simply stated, any research question about child and adolescent TBI must be oriented to the relevant developmental category and age group. Also, subsets of information within a research question must address developmental phases. For example, when describing the sample of a particular study, age at injury, age at evaluation, and time since injury, as well as the developmental implications of those age-related landmarks, all should be identified.

Key Questions

Two panels of experts, one local and one national, worked with the research team to identify the following key questions in the rehabilitation and survivor phases of recovery from TBI for children and adolescents. For each question, they provided a rationale for asking the question, as well as definitions, target populations, and outcome measures. The questions are:

1. Does the application of early, intensive medical rehabilitation in the acute care hospital improve outcomes for children with TBI?
2. Among children diagnosed with TBI, how many are provided special education that is designed to accommodate the needs of TBI?
3. Do children with TBI who receive special education designed to accommodate the needs of TBI have better outcomes than those who are provided special education that is not so designed and those who do not receive special education?
4. For children who have sustained brain injury, does the early identification of (a) the child's developmental stage at the time of injury, (b) the child's developmental stage at the time of assessment, and (c) the extent to which the injury has arrested the child's normal developmental process increase the ability to predict when the child will exhibit the needs, behaviors, and problems resulting from brain injury?
5. Does the provision of support to families of children with brain injury enhance the family's ability to cope and reduce the burden of illness?

Effectiveness of Early Rehabilitation

There were no randomized controlled trials and no comparative studies that investigated the efficacy of early, intensive rehabilitation for children or adolescents. Inferences about this intervention for children have been drawn from studies with adult samples. One prospective, uncontrolled observational study and two retrospective studies were reviewed for indirect information about the effects of the intervention. Of these, one study suggests that early, thorough physical and occupational therapy evaluations that include bone scans may serve to identify otherwise undetected musculoskeletal trauma and heterotopic ossification, indirectly arguing for early physiatry intervention. Authors suggested that the difficulties in communication unique to TBI warrant special methods for detecting physical trauma in people with TBI.

Use of Special Education for Children Diagnosed with TBI

This question has two parts:

1. How many children with TBI receive special education services?
2. Are the programs and services they receive delivered by people who understand and are able to manage TBI in children?

Only the first part of this question could be addressed, because no studies were found on special education programs delivered by personnel who have been trained in caring for and educating students with TBI.

Three retrospective studies and one cross-sectional State-wide study suggest that between 9 percent and 38 percent of students with identified brain injury receive referral to special education. However, since no evaluation of the students with TBI who did not receive special education was provided, it is not known whether these students needed special services, or how many were functioning well without services. Therefore, it is not possible to determine whether these reported referral rates indicate adequate referral, under-referral, or over-referral. The important question is whether the child with TBI who needs special services receives them. The answer to that question depends on being able to measure independently the need for or potential benefit from special education and then determining the proportion of children who could benefit and are actually referred. These data were not found in the published literature.

Outcomes of Special Education

One nonrandomized comparative study, one small case series, one survey, and five case studies provide limited data about the effects of special education programs for children with TBI, with varied results. No significant treatment effect was found in the comparative study; however, the comparison group performed significantly better than the treatment group at pretest on neuropsychological and intelligence tests and on adaptive and behavioral measures, suggesting that they were not as impaired as the treatment group from the beginning. In the case series, there was significant improvement from pre- to posttreatment on one of nine laboratory-based neuropsychological tests. In the five case studies, all patients showed improvement on measures taken during intervention when compared with those taken at pretreatment. However, because these studies are uncontrolled, the effect cannot be generalized to a larger population of children.

Predicting Needs, Behaviors, and Problems Associated with TBI

Sixty-one studies reporting data related to predictability of deficits based on developmental issues in child and adolescent TBI were found; 51 were prospective, 4 were population-based, 13 were multicenter, and 12 studies evaluated patients for 3 or more years. Because of the diversity of topics in this question and the large number of citations found, a system was developed for rating the overall quality of each article on an ordinal scale; the articles with the highest ratings were selected for review. Criteria for rating quality were:

1. Number of developmental categories included in the study.
2. Study length.
3. Design.
4. Setting.
5. Sample selection method.
6. Age range in sample at time of measurement.
7. Span of developmental stages covered in age range.
8. Comparison method.
9. Specification of injury severity.
10. Specification of location of injury.
11. Span of developmental stages covered by range of age at injury.
12. Time from injury to assessment.
13. Followup.
14. Analysis methods.

The seven studies that had the highest methodological scores using this system were reviewed. One cross-sectional/longitudinal evaluation of language acquisition demonstrates a predictable pattern of delays and deficits in language acquisition for children up to the age of 3 years when compared with uninjured children. Two additional cross-sectional studies establish the base rate measures of brain growth at each stage of development that are necessary to detect the developmental effects of injury. Two comparative studies revealed the presence of subtle, hidden deficits in cases of apparently normal performance in pediatric TBI with focal brain damage. Two studies used the analytic method of growth modeling and the use of growth trajectories in their research. By analyzing individual growth curves, researchers were able to control for differences in the ages of the children. They discovered systematic, nonlinear changes in growth that were strongly related to injury variables.

Effects of Providing Support Services to Families

There were no randomized controlled trials that compared the effects of support to families with the effects of no support. One trial using random assignment evaluated the differential effects of two forms of support to families, and two prospective studies contained indirect evidence about the effects of provision of support. Results of the trial suggest that an intervention for parents of children with brain injury may be more effective in reducing the burden of illness if it focuses on the needs of the parents as opposed to the needs of the child.

One prospective observational study found a significant and direct correlation between the presence of social support and measures of family functioning at 3 years postinjury; a second suggested that the presence of case management may serve to reduce parents' financial problems associated with their children's TBI.

The reciprocal effects of family functioning on outcomes for the child with TBI were not addressed. A number of studies have demonstrated a relationship between higher family functioning and better outcomes for the injured child and bolster the argument for provision of support to families as an intervention for the child.

Conclusions and Future Research

In general, studies have not been conducted with designs capable of providing evidence for effectiveness of interventions for children and adolescents with TBI. Because the focus of this project was effectiveness, many studies were excluded because they did not provide experimental evidence that could be used to guide practice. The published literature for this topic is primarily exploratory. It provides descriptions of programs that are widely accepted, including logical approaches to treatment that have not been validated either through experimental design or in carefully controlled observational studies. The clinical experience represented in the published literature that has guided the design of intervention programs should generate important hypotheses for controlled studies.

Investigations of what might work to rehabilitate children with TBI may benefit from the literature in other related fields. Future research could be guided by themes that have emerged across many disability groups. Although TBI has unique features, it shares many characteristics with other disabilities. The task is to identify the shared characteristics, and include what has been learned in other fields when designing interventions. One example is social skills training. Certain models for social skills training and cognitive rehabilitation have been shown to be ineffective with people who have other, similar disabilities, yet these models are being used in TBI rehabilitation. At the very least, the failure of these interventions in other fields should call into question their effectiveness with TBI. Similarly, it is important to pay attention to and systematically test successful approaches in other fields.

Three gaps in the literature about child and adolescent TBI define priorities for future research.

1. There is insufficient evidence about the natural history of TBI in this population. Longitudinal, observational studies with large samples are needed to provide this information. Such studies could help researchers and clinicians understand and define the subsets of severity categories, assessments, and interventions. Without distinct subsets, researchers will continue to pool diverse groups into the same study samples and produce results of questionable value.
2. Interventions must be tested with experimental study designs.
3. Because of the strong influence of development on all aspects of life for this population, both longitudinal and experimental studies must incorporate concepts of child and adolescent development presented in this paper, as well as sophisticated methods of analysis capable of accounting for individual variation.