Children Benefit From Tutor System After Stroke

Linda Childers writing in PT.com on September 19, 2011 tells this story.
It’s early morning when Teresa Gill, PT, walks into her patient’s room, introduces herself, and explains how they will work together to overcome the gait problems and muscle weakness that her patient sustained due to a recent stroke. Gill’s patient isn’t a spry octogenarian, but rather a 6-year-old girl who wants to know when she will be able to play soccer again. Each year, about 4,000 children in the U.S. experience a bleed or blockage of the blood flow in their brain that characterizes a stroke, according to the American Heart Association. Certain conditions such as congenital heart problems, arteriovenous malformations, hemophilia and sickle cell disease also can cause stroke in children.
While the vast majority of strokes occur in those older than 65, U.S. Centers for Disease Control research presented at the International Stroke Conference in Los Angeles this past February, showed that ischemic strokes are increasing among children and younger adults. Between 1995 and 2008, hospitalizations among those ages 5 to 14 increased 31%, from 3.2 per 10,000 to 4.2 per 10,000. Among those ages 15 to 34, hospitalizations increased 30% from 5 per 10,000 to 6.5 per 10,000, researchers found.
Although this study didn’t explore reasons for the trend, CDC researchers point to increased childhood obesity — which can lead to risk factors including heart disease and diabetes — as well as better diagnoses using MRI as likely factors.
Team push
For physical therapists such as Gill, who works at Children’s Hospital in Oakland, Calif., treating childhood stroke survivors involves serving as part of an interdisciplinary team that works to help children relearn their motor skills. This often means working with infants who have suffered a stroke in utero. “We are fortunate enough to have physical therapists here at Children’s who work with patients in the neonatal intensive care unit and pediatric intensive care unit as soon as they are medically stable,” Gill said.
While infants may not show signs of deficits immediately after a stroke, effects often become apparent as they grow older. Four of five newborns who experience a stroke around the time of birth develop neurologic disorders such as cerebral palsy or epilepsy, according to the American Stroke Association. “Treatment time and the frequency of physical therapy sessions depend upon the severity of a child’s injury,” Gill said. “Recovery can range from acute inpatient physical therapy to acute intensive rehabilitation, and often includes outpatient physical therapy. A typical inpatient course can last between six to eight weeks; outpatient physical therapy may continue for years as the patient continues to make gains.”
Symptoms, severity
While some children recover under a physical therapy regimen after sustaining a stroke, others suffer long-term residual effects. “Because [deficits in] children with strokes can be multifaceted, neurorehabilitation includes many different therapies to help children regain the use of their brain function,” said Richard Gee, PT, of Lucile Packard Children’s Hospital in Palo Alto, Calif. “The therapies focused for pediatric stroke patients are specific for the symptoms that are present secondary to the stroke, and are also age specific to the child.”
Gee said that symptoms he encounters with pediatric stroke survivors include spasticity; decrease in range of motion; weakness; paralysis; speech, language and communication problems; aphasia; hemiparesis; neglect of the affected side; decreased vision; dysphagia; and swallowing difficulties. Because their brains are still developing, children can often recover from strokes with better outcomes and prognoses than adults, he said.
“Therapy can be hospital based, outpatient based, school based or community based,” Gee said. “Home programs can be specific exercises for range or strengthening, but also can be used for setting up daily schedules, daily logs for memory, gait and balance, and activities that include returning to community and school.”
Therapeutic advances
Over the years, those who work with pediatric stroke survivors have seen a number of new developments in the field. “There have been many advances in the areas of knowledge of motor control and learning for children, structure of environment for learning, balance, use of resources of constraint therapy, use of adjunctive devices like the Wii, partial weight-bearing training devices using LiteGait or the AlterG anti-gravity treadmill,” Gee said.
At Texas Children’s Hospital in Houston, Lauri Dalton, PT, NDT-trained, has seen the emergence of a variety of new therapies. “Children who previously wouldn’t have survived a stroke are alive today thanks to advances in medicine,” said Dalton, rehab team leader at Children’s, which sees more than 300 pediatric stroke survivors each year. “As a result, we’re starting to see children with more severe injuries and these patients are exhibiting a greater potential for improvement. This puts a greater demand on PTs to do everything possible to make effective change, including a greater incorporation of cutting-edge technology and evidence-based practice.”
There’s a definite need for more PTs to work in this area, Dalton said. “Treatment of a child who has had a stroke differs from that of a child with a congenital diagnosis, such as Down syndrome or cerebral palsy. There is a slightly different focus or approach when you are trying to regain a normal pattern of movement that previously existed, especially in an older child.”
To work successfully with these patients, Dalton said, PTs need training in child development and normal movement patterns. “NDT addresses the dysfunction in posture and movement that are results of a stroke, and works to re-establish normal/typical posture and movement to improve the child’s functional mobility.”
The LegTutor has been effective in rehabilitating children as well as adults after a stroke or other disabling disease. The LegTutor provides a safe and comfortable leg brace with position and speed sensors that precisely record three dimensional hip and knee extension and flexion. Rehabilitation games allow the patient to exercise Range of Motion(ROM), speed and accuracy of movement. The LegTutor facilitates evaluation and treatment of the lower extremity including isolated and combined hip and knee movements.The rehabilitation system employs the known concept of biofeedback to give occupational and physical therapists access to an affordable user friendly rehabilitation package.The LegTutor together with its sister devices (HandTutor, ArmTutor and 3DTutor) aim to optimize motor, sensory and cognitive performance to allow the patient to better perform everyday functional tasks and improve quality of life. The Tutors are being successfully used in leading U.S. and foreign hospitals and clinics and are suitable for home use through telerehabilitation.