Paeds · neurology-neurodisability-and-neuromuscular
Neurorehabilitation and acquired brain injury
Also known as Acquired brain injury rehabilitation · Paediatric neurorehabilitation · ABI recovery · Post-injury motor and cognitive recovery · Rehabilitation after brain injury
Fellowship guide to neurorehabilitation after acquired brain injury in children. Covers the definition of acquired brain injury as brain damage sustained after a period of normal development from trauma, stroke, infection, anoxia, or tumour, and the World Health Organization International Classification of Functioning framework of body structure, activity, and participation. Explains neuroplasticity and the recovery curve, the multidisciplinary goal-directed approach, the motor interventions of constraint-induced movement therapy and bimanual therapy, the spasticity management ladder from physiotherapy and oral baclofen through botulinum toxin-A and casting to intrathecal baclofen and selective dorsal rhizotomy, and the cognitive rehabilitation and return to school strategies. Reviews the predictors of outcome, the late-emerging executive and behavioural deficits, the Cochrane and meta-analysis evidence for upper limb therapies, and the botulinum and cognitive rehabilitation systematic reviews.
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Red flags
- A child who fails to recover or who regresses after an acquired brain injury may have a treatable complication such as post-traumatic epilepsy, hydrocephalus, or depression rather than a poor natural history
- Executive and behavioural deficits often emerge only as the child reaches the higher school grades, so a clean early assessment does not exclude later difficulty
- Persistent fatigue after childhood brain injury is common, disabling, and frequently mistaken for laziness or poor motivation
- A new or worsening focal deficit weeks after the injury raises a subdural effusion, a post-stroke recurrence, or a tethering complication rather than expected recovery
- Hypopituitarism can present months after a traumatic brain injury with growth failure, fatigue, or amenorrhoea and is easily missed
- Botulinum toxin-A has a total ceiling of 400 units per session or 12 to 16 units per kilogram, whichever is lower, and over-dosing risks generalised weakness
- The family carries the rehabilitation programme between sessions, and family burnout is a leading cause of a stalled recovery
Life stages
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Clinical exam formats
Board mappings
- Defines acquired brain injury as damage to a previously normally developing brain from trauma, stroke, infection, anoxia, or tumour, and distinguishes it from congenital and neurodegenerative disease
- States that recovery is driven by neuroplasticity and that rehabilitation is most effective when it is early, intense, repetitive, task-specific, and goal-directed
- Names the World Health Organization International Classification of Functioning levels of body structure and function, activity, and participation as the framework for setting goals
- Explains the recovery curve of rapid early gains then a plateau, the concept of critical and sensitive periods, and the double vulnerability of the very young brain to early focal injury
- Runs the spasticity management ladder from physiotherapy, orthoses, and casting through oral baclofen and botulinum toxin-A to intrathecal baclofen and selective dorsal rhizotomy
- Appraises the evidence for constraint-induced movement therapy and bimanual therapy and the systematic reviews of cognitive rehabilitation in children with acquired brain injury
- The International Classification of Functioning levels and the goal-directed, multidisciplinary, family-centred model of rehabilitation
- The spasticity ladder with the botulinum toxin-A dosing ceiling of 400 units per session or 12 to 16 units per kilogram, whichever is lower
- The late-emerging executive and behavioural deficits and the predictors of outcome after acquired brain injury
- Builds a goal-directed multidisciplinary rehabilitation plan across motor, cognitive, communication, and participation domains
- Escalates the spasticity ladder and chooses between constraint-induced and bimanual therapy for a hemiparetic child
- Counsels the family on the recovery curve, the late-emerging deficits, the return to school, and the transition to adult services
- Level 1: Recognition that acquired brain injury recovery depends on early, intense, task-specific, goal-directed multidisciplinary rehabilitation
- Level 2: Application of the International Classification of Functioning framework and the spasticity and upper limb therapy ladders with correct doses
- Level 3: Coordination of complex inpatient and community rehabilitation, the management of late-emerging deficits, and the transition to adult care
- Definition and causes of acquired brain injury and the distinction from congenital and neurodegenerative disease
- Neuroplasticity, the recovery curve, and the International Classification of Functioning framework of body structure, activity, and participation
- Evidence from the Cochrane review of constraint-induced movement therapy, the upper limb meta-analysis, and the cognitive rehabilitation systematic reviews
- Structured assessment of a child with acquired brain injury across motor, cognitive, communication, and participation domains using the International Classification of Functioning
- Construction of a goal-directed multidisciplinary rehabilitation plan and escalation of the spasticity ladder
- Communication with the family on prognosis, the return to school, and the long-term follow-up
- Acquired brain injury and its causes, the neuroplastic substrate of recovery, and the goal-directed multidisciplinary model
- The spasticity management ladder and the choice between constraint-induced and bimanual therapy for hemiparesis
- Cognitive rehabilitation, the return to school, and the late-emerging executive and behavioural deficits
- Recognition of acquired brain injury and the priority of early, intense, task-specific, goal-directed rehabilitation
- The multidisciplinary team and the spasticity and upper limb therapy ladders
- Family-centred care, the return to school, and the coordination of community and inpatient services
- Canadian approach to paediatric acquired brain injury rehabilitation built on the International Classification of Functioning and a multidisciplinary team
- The spasticity ladder and the evidence for constraint-induced and bimanual therapy
- The predictors of outcome, the late-emerging deficits, and the transition to adult services
Overview & Definition
A child who survives a serious brain injury from a crash, a stroke, a brain infection, or a cardiac arrest faces a long road back to walking, talking, learning, and joining in, and the work of neurorehabilitation is to walk that road with the child and the family. Acquired brain injury is damage sustained by a brain that had been developing normally, and it stands apart from the congenital and neurodegenerative conditions that shape the brain from the start. The causes run from trauma, the commonest, through arterial ischaemic stroke, meningitis and encephalitis, hypoxic ischaemic injury after drowning or arrest, and the effects of brain tumour and its treatment. [6]
The task of rehabilitation is not to undo the dead tissue, which cannot be regrown, but to recruit the surviving brain to take over the lost work, and the engine of that recruitment is neuroplasticity. Rehabilitation is therefore built on the principles of motor learning: the therapy must be repetitive, intense, task-specific, and meaningful to the child, because the brain rewrites itself in response to use. The framework that keeps the team honest about what they are trying to achieve is the World Health Organization International Classification of Functioning, which separates the damaged body structure and function from activity child can perform and participation child can achieve in life. [2]
Three ideas make this topic central to the paediatric exam. The first is that recovery is a curve with a steep early rise and a long tail, so the team that measures the function and sets goals at every stage will outperform the team that waits. The second is that the deficits that matter most for the child's life are often the hidden ones, attention, memory, executive function, and the behaviour, which emerge only as the schoolwork gets harder. The third is that the family carries the programme between therapy sessions, so a rehabilitation plan that fails the family fails the child. The evidence for the upper limb and cognitive interventions is now strong enough to guide practice, and the fellowship candidate who can run the ladders and appraise the trials will answer well. [6][7]
References10ShowHide
- [1]Hoare BJ, Wallen MA, Thorley MN, et al Constraint-induced movement therapy in children with unilateral cerebral palsy. Cochrane Database Syst Rev, 2019.PMID 30932166
- [2]Sakzewski L, Ziviani J, Boyd RN Efficacy of upper limb therapies for unilateral cerebral palsy: a meta-analysis. Pediatrics, 2014.PMID 24366991
- [3]Eliasson AC, Krumlinde-Sundholm L, Gordon AM, et al Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: an expert consensus. Dev Med Child Neurol, 2014.PMID 24266735
- [4]Sakzewski L, Bleyenheuft Y, Boyd RN, et al Protocol for a multisite randomised trial of Hand-Arm Bimanual Intensive Training Including Lower Extremity training for children with bilateral cerebral palsy: HABIT-ILE Australia. BMJ Open, 2019.PMID 31501133
- [5]Graham HK, Aoki KR, Autti-Rämö I, et al. Recommendations for the use of botulinum toxin type A in the management of cerebral palsy. Gait Posture, 2000.PMID 10664488
- [6]Laatsch L, Harrington D, Hotz G, et al An evidence-based review of cognitive and behavioral rehabilitation treatment studies in children with acquired brain injury. J Head Trauma Rehabil, 2007.PMID 17667068
- [7]Laatsch L, Dodd J, Brown T, et al Evidence-based systematic review of cognitive rehabilitation, emotional, and family treatment studies for children with acquired brain injury literature: From 2006 to 2017. Neuropsychol Rehabil, 2020.PMID 31671014
- [8]Moran LM, Babikian T, Del Piero L, et al The UCLA study of Predictors of Cognitive Functioning Following Moderate/Severe Pediatric Traumatic Brain Injury. J Int Neuropsychol Soc, 2016.PMID 27019212
- [9]Dennis EL, Caeyenberghs K, Hoskinson KR, et al White Matter Disruption in Pediatric Traumatic Brain Injury: Results From ENIGMA Pediatric Moderate to Severe Traumatic Brain Injury. Neurology, 2021.PMID 34050006
- [10]Crichton AJ, Babl F, Oakley E, et al Prediction of Multidimensional Fatigue After Childhood Brain Injury. J Head Trauma Rehabil, 2017.PMID 27455435