Neurorehabilitation and acquired brain injury: Case

This girl is in the subacute phase of recovery from a moderate to severe traumatic brain injury, four months out and still within the high-plasticity window in which the intensive goal-directed therapy pays the greatest dividend. The left spastic hemiparesis with the equinus gait and the disuse of the hand, the cognitive deficits of the slowed processing speed and the poor working memory, the disorganisation and the impulsivity, and the disabling afternoon fatigue are the typical mixture of the motor, the cognitive, and the participation deficits that the multidisciplinary rehabilitation must address together. [8]

Clinical findings and assessment

The key findings are the left spastic hemiparesis, the disuse of the hand, the equinus gait, and the cognitive and the fatigue deficits. The modified Ashworth grade of 2 in the left gastrocnemius and the left biceps is a focal spasticity that limits the function, and the equinus gait and the foot drop are the consequence. The disuse of the left hand is the activity limitation that the upper limb therapy addresses, and the slowed processing speed, the poor working memory, the disorganisation, and the impulsivity are the cognitive and the behavioural deficits that the neuropsychological testing will define. [8]

The assessment is multidisciplinary and structured around the International Classification of Functioning. The motor assessment uses the Gross Motor Function Measure, the Melbourne Assessment of Unilateral Upper Limb Function, and the Assisting Hand Assessment for the activity level, and the modified Ashworth scale and the goniometry for the impairment level. The neuropsychological testing measures the attention, the processing speed, the working memory, and the executive function, and it is repeated at the school transitions because the executive deficit emerges late. The vision and the hearing are screened, and the fatigue and the sleep are assessed with the validated questionnaires. [2]

The rehabilitation plan

The plan is goal-directed, multidisciplinary, and family-centred, with the goals set at the activity and the participation level with the girl and the family using the Goal Attainment Scaling. The therapy is dosed to the recovery curve, with the greatest intensity in this high-plasticity window. [2]

The left hemiparesis with the disuse of the hand is treated with the constraint-induced movement therapy or the bimanual therapy, both supported by the Cochrane review of Hoare and the meta-analysis of Sakzewski. The constraint-induced therapy restrains the unaffected right arm and intensively trains the affected left, and the bimanual therapy trains the two hands together on the meaningful tasks, and the two are often combined. The therapy is repetitive, intense, task-specific, and salient, because the neuroplastic reorganisation is use-dependent. [1][2]

The spasticity ladder

The focal spasticity in the left gastrocnemius and the left biceps is managed up the ladder. The physiotherapy, the stretching, the orthoses, and the serial casting keep the range and the alignment and address the equinus. The focal overactivity is treated with the botulinum toxin-A injected into the gastrocnemius and the biceps at 2 to 6 units per kilogram per large muscle for onabotulinumtoxinA, with a total ceiling of 400 units per session or 12 to 16 units per kilogram, whichever is lower, which for this 32 kg girl means a weight ceiling of about 384 to 512 units, so the 400-unit session cap applies. The injection is paired with the casting and the therapy, because the injection alone does not improve the function, and the over-treatment of the tone at the expense of the strength and the function is a recognised pitfall. [5]

The cognitive, the fatigue, and the return to school

The slowed processing speed, the poor working memory, the disorganisation, and the impulsivity are addressed with the cognitive rehabilitation, the attention process training, and the compensatory strategies, supported by the systematic reviews of Laatsch, delivered in the meaningful and the real settings. The disorganisation and the impulsivity are the early signs of the executive deficit, which will surface more fully as the schoolwork demands more planning and self-regulation, so the cognition is re-assessed at the school transitions. [7][8]

The afternoon fatigue is managed with the graded return to school, the reduced timetable, the rest breaks, and the assistive technology, because the post-injury fatigue is common, persistent, and disabling, as Crichton and colleagues showed. The return to school is a staged plan with the liaison between the rehabilitation team, the school, and the family, and the reintegration is reviewed at each transition. The family-centred home programme is the engine of the long-term recovery, and the family is supported to avoid the burnout that stalls the progress. [10]

Outcome and follow-up

The prognosis is shaped by the severity, the lesion, the white matter disruption, the pre-morbid function, and the family environment, and it is the cognitive and the behavioural outcome rather than the motor that determines the long-term quality of life. The motor outcome is likely to be good with the upper limb therapy and the spasticity management, but the cognitive and the behavioural deficits will persist and compound as the schoolwork gets harder, and the executive deficit will surface at the move to the secondary school. [8]

I would counsel the family honestly at every stage. I would explain that their daughter's brain was hurt and that the part that survived can be trained to take on the work of the part that was lost, because the brain rewires itself with use. I would name the therapy as the practice that teaches the surviving brain the skills, the splint and the botulinum injection as the steps that keep the muscle supple and the movement possible, and the school plan as the bridge back to the learning and the friends. I would be honest that the recovery is a long curve, that the gains come fastest early and then more slowly, and that some difficulties with the planning, the attention, and the fatigue may appear only as the schoolwork gets harder. I would reassure the family that the team will measure the progress, set the goals with them, and re-assess the cognition at the school transitions, and that I will walk the road with them through the months and the years ahead. [8]