Neurorehabilitation and acquired brain injury: Viva

Branch 1: Framing the rehabilitation and the recovery curve

The candidate should frame the rehabilitation on the World Health Organization International Classification of Functioning, separating the body structure and function impairment from the activity limitation and the participation restriction. A strong candidate states that the goals are set at the activity and the participation level with the girl and the family, using the Goal Attainment Scaling, and that the plan is multidisciplinary, goal-directed, and family-centred. [2]

If the examiner presses on the recovery curve, the candidate should state that the recovery rests on the neuroplasticity, the capacity of the surviving brain to reorganise, and that the gains are fastest in the first three to six months and continue more slowly through the first year. The candidate should add that the therapy is dosed to the curve, with the greatest intensity in this early high-plasticity window, and that the principle is use-dependent: the connections that are used are strengthened and the unused are pruned, which is why the therapy is repetitive, intense, task-specific, and salient. [8]

Branch 2: The upper limb therapy and the spasticity ladder

If asked to choose the upper limb therapy, the candidate should state that the right 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, which found the two approaches both effective and of a similar magnitude. The constraint-induced therapy restrains the unaffected arm and intensively trains the affected, and the bimanual therapy trains the two hands together on the meaningful tasks, and the choice turns on the child and the goal rather than on a hierarchy of efficacy. [1][2]

For the spasticity, the candidate should run the ladder. The physiotherapy, the stretching, the orthoses, and the serial casting keep the range and the alignment. The focal overactivity in the gastrocnemius and the biceps is treated with the botulinum toxin-A 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, paired with the casting and the therapy. A strong candidate adds that the over-treatment of the tone at the expense of the strength and the function is a recognised pitfall, and that the intrathecal baclofen and the selective dorsal rhizotomy are reserved for the severe, generalised spasticity that has not responded to the focal and the oral measures. [5]

Branch 3: The cognitive, the fatigue, and the return to school

If the examiner moves to the cognition, the candidate should state that the slowed processing speed is the early sign of the cognitive deficit, and that the cognitive rehabilitation uses the attention process training, the compensatory strategies, and the metacognitive training, supported by the systematic reviews of Laatsch. The candidate should add that the cognitive and the behavioural deficits are the dominant long-term determinants, and that the executive deficit emerges late at the school transitions, so the cognition is re-assessed at the return to school and the move to the secondary school. [7][8]

For the fatigue, the candidate should state that the post-injury fatigue is common, persistent, and disabling, and that the midday fatigue is managed with the graded return, the reduced timetable, the rest breaks, and the assistive technology. 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. [8]

Branch 4: Appraising the evidence

If asked to appraise the evidence, the candidate should state that the motor rehabilitation is anchored by the Cochrane review of the constraint-induced movement therapy by Hoare, which found the improvement in the upper limb function in the unilateral cerebral palsy, and the meta-analysis by Sakzewski which found the constraint-induced and bimanual approaches both effective and of a similar magnitude, with the consensus guidelines by Eliasson setting the research direction. The candidate should note the caveat that the trials are in the cerebral palsy and the translation to the acquired brain injury relies on the shared motor learning principles. [1][2][3]

The candidate should appraise the cognitive rehabilitation on the two systematic reviews of Laatsch, which support the cognitive, the emotional, and the family interventions, with the caveat that the field is hampered by the small sample sizes, the heterogeneous outcomes, and the variable methodological rigour. A strong candidate closes by stating that the dominant message of the topic is that the rehabilitation must be early, intense, repetitive, task-specific, and goal-directed, that the cognitive and the behavioural deficits are the long-term determinants, and that the family-centred home programme is the engine of the recovery. [7]