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My son's right side is not active yet after 6 months of TBI. What should we do to activate his right side?

My son is five years old and had a diffuse axonal injury.

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Senior physical therapist

Answer transcribed from Brightway's interview with Dr. Cristen Gordon (pt.1):

Diffuse axonal injury is a tricky one. There's a lot that has been impaired but particularly because he's young, there's a lot of room for neuroplasticity. Nerve regeneration does not happen quickly, so part of it is being patient, staying diligent, and continuing to work on it. That said, there are some companies that create electric stimulation machines that recreate the way the brain activates muscles. I'm not saying it's a cure-all, but it can definitely aid in building on the function that is there as well as initiating function if you can get the correct stimulation set up. That has to be in conjunction with challenging the brain, challenging the arm, and trying to incorporate into functional tasks. I know that can be the frustrating part of doing therapy, the diligence, and the patience. Nerves regenerate at something like one-eighth of an inch per year, so if you think about a diffuse axonal injury, there's a lot of nerves that have been impaired after that injury. There are a lot of nerves that have to heal themselves and a lot of neuroplasticity that has to happen. A lot of the other brain cells have to get in gear in order to regain function. 


The other thing to not be afraid of is bracing and splinting. I've had plenty of patients say they don't want to use a splint or brace because they don't want to be dependent on it. Oftentimes, the way recovery happens is it goes from proximally, which is the part of the body that's closest to the body, to approximately, so from the shoulder to the hand. You'll get more function in the shoulder first, and then the hand will come later. We can use bracing and splinting to protect the hand or to even offset the weight of the hand so that the shoulder can function, and then you can regain function going that way as well.


In the therapy world, we call it electric stimulation or neuromuscular re-education, for which there are different versions. You can use electric stimulation for pain management or to coordinate muscles. You will see some advertisements of some of the companies that make these machines saying if you use our machine, you're going to go from zero strength to 100 strength. The research is not there to show that that's how it works, but I will say that just from treating patients over the years, I have seen where patients who have had some a little bit of function, maybe not enough to use their arm, rebuild coordination between the muscles to help improve strength. In other words, I can use the electro electric stimulation to tell the muscle when to turn on, add a specific exercise with that, and suddenly we've got way more function than we started with. Then we can build on that and eventually, the goal is to take away the electric stimulation. That being said, there are also companies that make electric stimulation that is used for function. There is a company called Bioness that makes both an arm and a leg device that you can use when you're walking or when you're trying to pick up things like a glass of water from the table. The electric stimulation kicks in and tells your muscles when to turn on. It turns them on for you and then allows you to pick up the glass and put it down when you need to. What happens is there are electrodes, which are these sticky gel electrodes that we put on the muscles that we are trying to activate. Then there are specific electric stimulation frequencies and patterns that we can use to get the muscles to turn on at the right times. 


There are other techniques like mirror therapy, where you can basically use your hand that's not impaired to trick your brain into thinking the impaired hand is moving. What you do is you'll have a patient sit perpendicular to a mirror. You want the mirror facing the good hand and you want your impaired hand to be on the opposite side of the mirror so you can't see your impaired hand. What you do is you may do an exercise, and by the way, you can do this with the legs as well, but you do an exercise with your unimpaired or uninjured arm. Maybe it’s just making a fist and looking into the mirror. I’d see that my left hand in this case is making the fist, but because it's a mirror, it tricks my brain into thinking it's the right hand that's doing it. At the same time, I can be using and trying to make the fist with my right hand as best as I can, and I can also use electric stimulation in conjunction with that to try to train the brain that this is what it's supposed to look and feel like. You can literally trick your brain. Even though I don't have an injured right hand, I have done this exercise and it throws you off because you're like wait, am I doing it or am I not doing it. It's very effective and there's some good research that shows that it works pretty well in helping to regain those pathways from the brain to the muscles.