Physiotherapy Rehabilitation in a Pediatric Outpatient with Diffuse Axonal Injury Using the WHO PIR Guideline: A Case Report

1. Introduction

Among pediatric traumatic brain injuries, few conditions are as elusive yet devastating as diffuse axonal injury (DAI). Unlike focal lesions that present with clear radiological signatures, DAI often unfolds silently, driven by widespread shearing forces that disrupt axonal integrity and impair functional connectivity across the brain [1]. This invisible pathology has earned DAI the reputation of being a “hidden disruptor,” capable of producing profound cognitive, motor, and behavioral deficits despite minimal structural changes on conventional imaging. In children, the impact of DAI is even more alarming. The immature brain, while plastic and adaptive, is also highly vulnerable to shearing stresses during high-velocity trauma such as road traffic accidents and falls. Consequently, pediatric patients frequently present with fluctuating levels of consciousness, motor incoordination, and cognitive decline that extend far beyond the acute recovery phase [2,3]. Long-term sequelae often include impaired balance, reduced functional independence, and social reintegration challenges that compromise both quality of life and family well-being [4]. While acute management focuses on stabilization, mounting evidence underscores the critical role of rehabilitation in shaping long-term outcomes. Reports increasingly highlight that early, structured physiotherapy can bridge the gap between survival and functional independence, providing targeted interventions that promote neuroplasticity, restore motor performance, and improve quality of life [5,6]. Yet, despite its significance, physiotherapy in pediatric DAI remains under-documented, particularly within outpatient care settings where continuity and intensity of rehabilitation are often fragmented. This case report contributes to the growing body of knowledge by detailing the physiotherapy rehabilitation of a pediatric outpatient with DAI.

2. Case Presentation

2.1. Demographics

The patient is a 12-year-old male. He is the last child in a family of four and resides with his parents in a bungalow setting. His mother is a businesswoman, and the family identifies as Sabbatean. At the time of first outpatient assessment (July 11, 2024), he was enrolled in Primary 5 and reported enjoying interaction with animals. His demographic and social background reflects a supportive family environment but with financial constraints that delayed continuity of post-discharge rehabilitation.

2.2. Case Background

The patient sustained his injury in February 2024 following a fall from a one-story building, which resulted in immediate loss of consciousness. He was admitted through the emergency unit and subsequently transferred to the intensive care unit, where he remained unconscious for approximately one month. Neuroimaging confirmed the diagnosis of diffuse axonal injury (DAI) revealing tiny hyperdense foci consistent with hemorrhagic shearing injuries, particularly at the corpus callosum and subcortical white matter regions. The magnetic resonance imaging (MRI) revealed microhemorrhages, axonal swellings, and signal abnormalities in the corpus callosum, internal capsule, and brainstem lesions. Clinically, his course was marked by prolonged coma, gradual regaining of consciousness, with quadriparesis which later resolved to right-sided hemiparesis. Based on this presentation, the case is most consistent with severe DAI (Adams Grade III), which is typically defined by coma lasting longer than 24 hours and the presence of lasting neurological impairments [1,12].

2.3. Assessment

The child presented to the outpatient clinic with residual impairments consistent with diffuse axonal injury and is represented in the ICF qualifier table (Fig 1). Patient and caregiver consent were obtained prior to assessment, with full explanation of the rehabilitation process and expected outcomes. The child was referred to physiotherapy with a diagnosis of Diffuse Axonal Injury (DAI) following a fall from height. On subjective assessment, the caregiver reported persistent difficulties with balance, gait, and coordination, as well as challenges in school participation. General observation revealed reduced precision control, cautious mobility, and fatigue during prolonged walking. From a patient-centered perspective, both the child and caregiver expressed concerns about safety during mobility and the child’s ability to return to regular play and school activities. Their main expectation was to regain independence in walking and improve participation in age-appropriate activities. At baseline, the child’s highest functional activity level was limited to short-distance household ambulation with supervision, reflecting significant restrictions in community and school participation (Table 1). Overall, the child’s primary problems were categorized under motor function and mobility, activities of daily living, cognitive-emotional regulation, and participation restrictions, with underlying causes traced to axonal disconnection and subsequent neuromotor and cognitive dysfunction (Table 2). Indicators such as the Pediatric Balance Scale [13], Gross Motor Function Measure (GMFM-88) [14], 10-meter Walk Test [15], WeeFIM [16], and Pediatric Quality of Life Inventory [17] were employed to monitor progress and outcomes in alignment with WHO PIR domains.

Figure 1. International Classification of Functioning, Disability and Health Qualifier.

Figure 1. International Classification of Functioning, Disability and Health Qualifier.

2.4. Rehabilitation Goals (Based on WHO PIR and ICF Framework)

The physiotherapy program was structured in accordance with the World Health Organization’s Pediatric Rehabilitation (PIR) framework and guided by the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) domains [18]. Therapy sessions were conducted once weekly over a seven-month period, with a strong emphasis on therapeutic play to facilitate engagement, motivation, and skill acquisition appropriate for the child’s developmental stage.

At baseline, intervention targeted motor recovery and postural control through interactive play tasks such as ball-catching, block stacking, and bubble-reaching exercises, designed to encourage right upper-limb activation and weight-bearing symmetry during early gait retraining. Play-based activities were integrated with task-specific exercises to promote muscle strength, coordination, and selective motor control. By the 7th week, the program advanced to dynamic balance games, obstacle play, and bilateral coordination tasks to enhance proprioception and gait rhythm. As progress continued to the 14th week, treatment emphasized functional play simulations including obstacle navigation, hopscotch, and toy-cleanup routines to reinforce daily activities and community participation. The final rehabilitation phase which started in the 21st week, focused on independent functional play, dual-task coordination, and peer interaction, promoting self-confidence and social reintegration (Table 3).

Throughout the rehabilitation process, the caregiver was actively involved through structured home-based play programs, designed to extend therapy beyond the clinic. Periodic reassessments were conducted every seven weeks using standardized pediatric outcome measures such as the Pediatric Balance Scale [13], Gross Motor Function Measure (GMFM-88) [14], and WeeFIM [16]. The program demonstrated that integrating play-based physiotherapy with WHO PIR principles can foster functional independence and meaningful participation in a pediatric outpatient recovering from Diffuse Axonal Injury.

2.5. Functional Outcomes and Progress Across Rehabilitation Phases

Over 28 weeks of physiotherapy guided by the WHO Pediatric Rehabilitation (PIR) framework, the patient exhibited consistent functional recovery. The most notable improvements were in motor coordination, right-sided gait mechanics, and fine motor dexterity, supported by progressive balance and cognitive gains. By week 28, the child achieved independent, age-appropriate physical function and full social participation, with strong caregiver engagement ensuring continuity of home-based therapy (Table 4). These progressive outcomes underscore the effectiveness of structured, goal-oriented pediatric rehabilitation guided by WHO PIR principles in facilitating recovery from diffuse axonal injury.

2.6. Prognosis

Baseline Prognosis: At initial assessment, the prognosis was said to be fair, given the diagnosis of diffuse axonal injury (DAI) and the presence of mild right-sided hemiparesis, coordination deficits during fine motor tasks, and reduced stride length. Although cognitive and communication functions were largely preserved, early limitations in motor control and endurance posed challenges to independent mobility and participation in age-appropriate play and academic activities. Nevertheless, the child’s young age, intact comprehension, and supportive family environment were strong positive predictors for recovery under a structured, multidisciplinary rehabilitation plan.

Follow-up Prognosis: After seven months of weekly physiotherapy guided by the WHO Pediatric Rehabilitation (PIR) framework, the prognosis improved to good, with progressive gains in coordination, balance, gait, and self-care performance. The integration of play-based functional exercises, task-specific training, and caregiver-led home routines enhanced neuroplastic adaptation and participation outcomes. The patient now demonstrates near age-appropriate mobility and functional independence, with only mild fine-motor limitations in the right upper limb. Continued engagement in school and community activities, alongside periodic physiotherapy review, is expected to sustain functional gains and optimize long-term outcomes.

3. Discussion

This case underscores the integral role of physiotherapy, structured within the WHO Package of Interventions for Rehabilitation (PIR) framework, in promoting functional recovery in pediatric patients with Diffuse Axonal Injury. The rehabilitation process described here aligns with a biopsychosocial understanding of recovery, emphasizing the dynamic interplay between neural repair, functional adaptation, and environmental support.

DAI remains one of the most devastating outcomes of traumatic brain injury in children, characterized by widespread disruption of axonal tracts due to shearing forces following acceleration deceleration impact [1,12]. In this patient, the fall-induced mechanism and subsequent presentation of mild right-sided hemiparesis, gait asymmetry, and fine motor coordination deficits are consistent with a Grade II DAI, typified by corpus callosum and brainstem involvement. While neuroimaging findings are critical for diagnostic confirmation, functional manifestations often dictate the rehabilitation trajectory more than radiological severity [4,7].

The progressive gains observed over the seven-month rehabilitation period reinforce evidence that early, structured, and family-centered physiotherapy plays a pivotal role in pediatric neuro-recovery. Previous authors like Sasun & Qureshi, and Lalwani have reported that timely physiotherapy not only restores mobility but also fosters cortical reorganization through repetitive, task-specific training [2-3]. In the present case, the integration of play-based exercises; a key adaptation from the WHO PIR pediatric module [9,10] enhanced engagement, compliance, and motor learning, resulting in marked improvement in dynamic balance and fine motor coordination. This aligns with de la Rosa-Arredondo, who demonstrated that multidomain rehabilitation, combining physical and cognitive tasks, augments neuroplastic outcomes in children with TBI-associated DAI [5].

The use of the WHO PIR framework provided a structured and holistic approach, guiding intervention planning across domains of body function, activity, and participation. It ensured that rehabilitation extended beyond impairment-level recovery to address contextual and environmental factors influencing participation. The patient’s steady progression from assisted mobility to near-independent ambulation with functional gait symmetry reflects the practical utility of the PIR’s domain-based intervention sequencing [8-10]. Moreover, the inclusion of caregiver-led home programs facilitated continuity of care and adherence to the rehabilitation goals, a principle emphasized in WHO’s Rehabilitation in Health Systems framework [11].

Functionally, the patient’s outcome supports growing consensus that rehabilitation intensity and consistency rather than the mere duration of injury are strong predictors of recovery in pediatric DAI [6]. The improvement in motor control and coordination observed in this case aligns with the findings of Lalwani, who reported that early intervention accelerates functional independence and minimizes secondary complications [3]. Importantly, this case also highlights the adaptability of global rehabilitation frameworks, such as WHO PIR, in low-resource outpatient contexts where access to advanced neurorehabilitation technology may be limited.

From a clinical perspective, the integration of physiotherapy within the WHO PIR framework demonstrated measurable benefits across key domains like motor function, self-care, social participation, and play engagement confirming the framework’s relevance to pediatric neurorehabilitation. This case also contributes to the growing body of evidence advocating for context-specific adaptation of international guidelines in real-world pediatric settings.

In summary, this case supports the notion that pediatric DAI rehabilitation requires an individualized, multidisciplinary approach anchored in structured frameworks like the WHO PIR, emphasizing functional recovery, family involvement, and contextual adaptation. The outcome achieved transitioning from mild hemiparesis to near-independent functional participation reflects not only the neuroplastic potential of the pediatric brain but also the transformative impact of evidence-based physiotherapy. Further work should also focus on developing standardized pediatric outcome metrics within the PIR domains to strengthen global comparability and evidence translation. Ultimately, this case affirms that the intersection of evidence-based physiotherapy and structured rehabilitation frameworks can bridge the gap between international best practice and local clinical realities transforming pediatric rehabilitation from impairment-focused recovery to participation-driven health restoration.

4. Conclusions

The journey of this pediatric outpatient recovering from diffuse axonal injury underscores the transformative potential of structured, compassionate, and evidence-based rehabilitation. Guided by the WHO Package of Interventions for Rehabilitation (PIR) framework, physiotherapy moved beyond symptom management to restoring participation, autonomy, and hope. The child’s gradual transition from guarded mobility and emotional withdrawal to purposeful play and regained functional independence illustrates how early, consistent, and family-centered rehabilitation can reshape the trajectory of pediatric neuro-recovery. This case reinforces that physiotherapy, when anchored in structured global frameworks like the WHO PIR, does not merely rehabilitate function, it restores childhood itself.