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Each year in America, at least 1.5 million people sustain an injury to the
head. While a majority of those people will receive care from their physician
and return to their regular activities unchanged, 50,000 to 100,000 will
continue to have prolonged problems affecting their daily lives. Young children
and teenagers are particularly susceptible: traumatic brain injury (TBI) is the
number one cause of death and disability in children older than one month of
age. The most common cause of TBI is car crashes, including pedestrian-car and
bicycle-car encounters, while falls, child abuse, violence and sports injuries
are other culprits.
"Younger kids are more likely to have TBI due to falls. And teenagers
have more TBI than any other population -- from motor vehicle crashes,"
explains Barbara Wechsler, M.D., a specialist in pediatric rehabilitation
medicine at The Children’s Hospital at The Cleveland Clinic.
Symptoms can be slow to show
TBI occurs when an external physical force damages the brain. Loss of
consciousness is the hallmark symptom of TBI and the areas of the brain most
often affected by TBI are the frontal and temporal lobes. These areas control
the brain’s "executive functions" such as behavior and intellectual
activities, including problem solving, memory and speech.
One confounding aspect of TBI is that its effects may not show up for years.
"Traumatic brain injury has been called a silent epidemic because many
children recover physically, but their brains are irrevocably altered and don’t
develop correctly. This may not become apparent until they are in the third
grade and try to do multiplication or division or spelling," Dr. Wechsler
points out. Such deficits or learning disabilities are hard to predict.
Unlike other problems in pediatrics, studies suggest that the younger a child
is when severe brain injury occurs, the worse the prognosis is in the long run.
Dr. Wechsler says, "The magnitude of the problem is great, particularly
when discussing mild TBI." She adds, "We are only at the beginning of
our understanding of this disease."
In the New York City area, for instance, authorities go to schools to
identify kids who have had injuries to their brains. They are compiling
information about the injuries, such as when and how they occurred, what, if
any, therapies were provided afterward and what cognitive deficits are surfacing
in children post injury. They are also providing teachers with guidelines for
managing the educational needs of children post TBI.
Recovery from TBI
Children with moderate or severe brain injury face an arduous recovery.
"These are very complicated, sick kids, so it is important to have the
specialized expertise and facilities needed to make sure they get well, and can
grow to be as independent as possible," Dr. Wechsler says.
Children come into the rehabilitation program at The Cleveland Clinic’s
Children’s Hospital for Rehabilitation through the Pediatric Intensive Care
Units when medically stable -- whether they are conscious or not. The
unconscious child, or one who is just waking up from a coma, is kept in a
low-stimulation environment. Parents are encouraged to talk to their child, but
large groups and noise are strongly discouraged. "Patients need to sleep a
lot because the brain heals as it sleeps," Dr. Wechsler explains.
The staff carefully watches over the children, preventing pressure sores and
other complications, ensuring nutrition through feeding tubes, and monitoring
medications and mechanical aids such as ventilators. Intensive evaluations of
the child’s level of awareness and awakening are performed daily. As each
child wakes up, his or her rehabilitation program is gradually intensified.
When the children are able to tolerate three hours a day, six days a week of
intensive therapy, they begin their acute rehabilitation. A team of doctors and
therapists specifically trained in pediatric rehabilitation cares for these
children. Physical therapists work to improve the function of their legs and
their mobility. In the therapeutic swimming pool, kids work on balance and
strength. A psychologist assesses the child’s mental capabilities, while
pulmonologists and respiratory therapists address any breathing issues.
Together, occupational and speech/language therapists focus on swallowing,
hand-eye coordination and fine motor skills, language, thinking and memory
skills. A personalized book describing each child’s activities in words and
pictures enables a child with memory deficits to participate in a daily routine.
"TBI affects a child’s ability to learn," Dr. Wechsler
emphasizes. "It’s crucial to treat these children as early as possible,
because a child’s job or vocation is to attend and learn in school. We try to
get them back to learning as quickly as possible."
To that end, the hospital employs a Cleveland Public School System educator,
and patients attend school as soon as they are responsive. The teacher works
individually with each child and contacts the child’s regular school right
away to get lessons and start planning for the child’s return to school.
To prepare the children for return to their communities, the rehabilitation
unit’s "hospital-like appearance" is minimized as much as possible.
The kids wear street clothes, not hospital gowns or pajamas. They get up and eat
breakfast together too. At a model store, they can pretend they are shopping.
Working with peers they create a newspaper and whenever possible, the kids enjoy
field trips into the community.
The average stay in the rehabilitation program is three to four weeks. When
it’s time, the staff helps the child and family make a smooth transition to
home. "We work with the whole family, teaching them what they need to know,
from changing their child’s tracheostomy tube to working on the child’s
mobility and flexibility," explains Dr. Wechsler. Rehabilitation continues
after discharge with either a day hospital program for children who still
require the intensity of acute rehabilitation or an outpatient program.
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