Intensive physical rehabilitation in children with Acquired Brain Injury

This thesis was initiated in 2020 in response to a clinical need to improve physical rehabilitation for children with acquired brain injury (ABI) during inpatient rehabilitation in the subacute phase. Current practice is characterised by a limited evidence base regarding the optimal intensity, frequency and content of physical rehabilitation needed to maximise functional recovery and meaningful outcomes. The REHABILITY research project was therefore established. Part 1: Current approaches and foundations for physical rehabilitation in children with ABI Chapter 2 presents a scoping review of the characteristics (frequency, intensity, time and type) and effects of physical rehabilitation interventions for children with ABI in the subacute phase. Of 3009 screened articles, only nine met the inclusion criteria. Interventions showed wide variation in frequency, duration and type, while none reported intervention intensity. All studies demonstrated positive effects at the level of body functions and activities within the ICF-CY framework. However, small sample sizes, heterogeneity and limited methodological quality restrict generalisability. The review highlights both the potential benefits of physical rehabilitation and the substantial gaps in evidence, particularly concerning intervention dosage. Chapter 3 describes a Delphi study exploring expert perspectives on optimal physical rehabilitation. An international panel of rehabilitation professionals and researchers (n=11) evaluated 139 statements and reached consensus on 116 (83%). Experts emphasised early initiation of meaningful physical activity, promotion of activity throughout the day and active family involvement during subacute rehabilitation. Although the amount of practice was considered critical for recovery, no consensus was reached on specific dose–response relationships, underscoring the importance of individually tailored care. This study provides a conceptual framework to support clinical decision-making. Chapter 4 explores the perspectives of children with ABI and their parents through semi-structured interviews. We identified six themes, including beliefs about rehabilitation, tailored care, contextual influences, communication and transition. Participants consistently highlighted the need for a more intensive rehabilitation approach, a positive and motivating rehabilitation climate, and close collaboration with families. Part 2: Development and outcomes of a high-intensity rehabilitation programme Chapter 5 outlines the development and feasibility study protocol of the REHABILITY programme (REHabilitation in Acquired Brain Injury: neuropLasticity and Intensity of physical Training in Youth). The programme was co-created with key stakeholders, ensuring clinical relevance and feasibility. REHABILITY aims to deliver 3–5 hours of physical rehabilitation per day during inpatient care, supported by systematic assessment of physical and cognitive functioning. Chapter 6 reports a prospective case-series study including 14 children aged 6–20 years. Seventy-five per cent achieved at least 3 hours of physical activity per day, with improvements across physical and cognitive outcomes and no adverse events. The programme was well received by families and professionals. Overall, this thesis advances paediatric neurorehabilitation by integrating scientific evidence, expert consensus and lived experiences. It provides a clear rationale and practical foundation for a high-intensity rehabilitation approach and offers a concrete pathway towards more effective, evidence-informed clinical practice for children with ABI.