REHABILITATION

Rehabilitation's goals are to reduce disability and help a child achieve the maximum degree of age-appropriate functional independence in physical, cognitive, social, and emotional areas after having sustained a TBI (205).

Rehabilitation efforts include attempting to restore function or, when that is not possible, to teach adap­tive techniques to compensate for areas of deficit (207).

10.2

Computed Tomography Criteria for the Evaluation of Hydrocephalus

1. Increased size of the lateral ventricles at the anterior horns

2. Increased size of the temporal horns and the 3rd ventricle

3. Increased size of the basilar cisterns and 4th ventricle

4. Sulci appear normal or of decreased size

5. Periventricular hypodensity

Context-sensitive rehabilitation with integration across many domains of functioning and providers should be practiced (208). For example, when a child is returning to school, in addition to appropriate special education, social reintegration, help with activities of daily living, and comfortable positioning should all be addressed.

Early Rehabilitation

Initiating rehabilitation services early shortens the overall hospital and rehabilitation stay (209,210). Rehabilitation efforts, therefore, should begin early while the child is in the intensive care unit (ICU). Early efforts should be aimed at reducing potential com­plications of immobility, including ischemic ulcers, compression neuropathies, and contractures (211).

It is also helpful to have a social worker begin to meet with the family while the child is still in the ICU to begin education about brain injury and the rehabili­tation process, as well as to provide support (87). Early transfer to a rehabilitation setting is indicated as soon as the patient is medically stable (212).

Inpatient Rehabilitation

Inpatient rehabilitation requires the participation of an interdisciplinary, specialized team lead by a rehabili­tation physician to manage the multiple physical, cog­nitive, and social issues with which the child is faced (213,214). Central to this team is the injured child and their family.

Sensory Stimulation

Even before a child is following commands, reha­bilitation may be initiated. In addition to providing structured stimulation and assessing responses on a frequent basis, physical and occupational therapy may work with positioning, including specialized equip­ment, and activities. Head and trunk control are facil­itated. Also, localized responses are channeled into more purposeful activity using hand-over-hand tech­niques. Oral stimulation is started to help with eval­uating oral motor function, and may facilitate more control and begin the process of evaluating for attempt to transition to oral feeding (87).

Computer-assisted rehabilitation can be used at many times in the rehabilitation continuum. Even when a child is not yet consistently following com­mands, computer programs may be useful to elicit auditory or visual attention.

Interventions Based on the Cognitive Level

As children become more responsive and interactive, therapy can become more cognitively based, address­ing specific areas of identified deficits that have been previously noted. An eclectic therapeutic approach should be used (87). Classic neurorehabilitative ther­apy approaches, adaptive equipment, the use of tech­nology, and environmental modification all have the ultimate goal of increasing the child's independence and ability to function, and continue to facilitate ongo­ing development and acquisition of skills. Cognitively based rehabilitation should continue even after dis­charge from the inpatient rehabilitation setting, as improvement in this area has been noted as far as two years post-injury (211).

Speech can also be impaired after a TBI. Children therefore should be assessed by a speech pathologist that can provide them with directed therapy or com­munication aids as appropriate (211).

Psychosocial Services

An acquired brain injury of a child changes the entire family. Roles and responsibilities change, and the degree of disability affects the family's future activi­ties and opportunities (87,216). Supportive services are essential not only for the injured child, but also for the entire family. It is also important to assess preinjury family functioning because this factor has been shown to have an impact on long-term outcome, especially with regard to behavioral problems (217).

Providing supportive counseling and education for the patient's siblings is also important. Medical play can be an effective technique for both injured children and their siblings. Siblings may also benefit from peer support (87).

Counseling and education about TBI and its con­sequences can be helpful to parents. Proper training enables them to become advocates for their children and to help their children deal with the challenges they face because of the injury (217). These counseling and education needs may be long-term because the par­ents initially may be in denial concerning the severity of injury and permanence of impairment (87,218,219). The injury results in the need to negotiate systems with which parents were previously unfamiliar. These include special education, medical and rehabilitation services, and publicly supported programs (217). Also, for families of children with severe injury and those who had difficulties before injury, stressors continue long-term, and families may need additional atten­tion and resources to assist them in coping with the consequences of their child's injuries (220). One of the areas most severely affected after a TBI is social and peer reintegration. The inpatient rehabilitation process should also address this issue (162).

Another issue that requires attention is the poten­tial impact of a child's TBI on family finances. Osberg and colleagues (221) found that parents of children who required transfer to a rehabilitation unit expe­rienced difficulty with work and finances. Proactive planning, contact with employers, and the exploration of alternative funding sources can be of substantial benefit.

Discharge Planning

Rehabilitation has become a continuum of care, being provided at many different sites and intensities of service. It is important to begin discharge planning early in the rehabilitation hospitalization. The costs of caring for children with TBI are significant. The majority of those costs relate to the acute care hospi­talization, but for those with significant injury, up to 47% of the hospital costs are due to inpatient rehabil­itation (199).

Most children are discharged to home after TBI. Determining the appropriate services, assisting the family in obtaining them (depending on their third- party payer and network requirements), and coor­dination with the public school system are essential elements in this planning process. Working closely with the third-party payer case manager can be helpful in obtaining the appropriate services for optimal tran­sition. Family or other caregiver training is imperative in medical or nursing procedures as well as the man­agement of behavioral problems after TBI.

After discharge from the acute care setting, reha­bilitation continues, with reintegration into the com­munity. Coordination of medically and educationally based services and effective communication among providers are essential. Accommodations to facilitate effective reintegration can be physical, environmental, or instructional (207).