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Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach -1 (2020) 1–8
DOI 10.3233/PRM-190636
IOS Press

Case Report

Multidisciplinary rehabilitation of a
post-stroke pediatric patient considering the
ICF perspective

on

Giulia Gilardone1,∗ , Francesca Maria Fumagalli1 , Alessia Monti, Giuseppe Pintavalle,
Isabella Derada Troletti, Marco Gilardone and Massimo Corbo

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Department of Neurorehabilitation Sciences, Casa di Cura del Policlinico, Milan, Italy

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Abstract.
PURPOSE: There is a general lack of evidence on the efficacy of rehabilitation training methods after childhood stroke. The
aim of the current paper is to provide an example of a multidisciplinary assessment and intensive patient-centered rehabilitation
program that was devised following the Clinical Guidelines for Childhood Stroke Diagnosis, Management and Rehabilitation,
based on the International Classification of Functioning, Disability and Health.
METHOD: The case of a 13-year-old teenager with physical, linguistic, cognitive and emotional impairments after acute ischemic
stroke (AIS) in left middle cerebral artery territories is presented and his neurorehabilitation program is described.
RESULTS: After an intensive and comprehensive rehabilitation period, the patient showed significant improvement involving
language abilities, cognitive flexibility, logical reasoning and motor independence. A 6-month post-stroke follow-up evaluation
showed further gains in spontaneous language, improved motivation and collaboration, reduction of impulsiveness and better
general motor stability.
CONCLUSION: This case highlights how an intensive, patient-centered, interdisciplinary rehabilitation approach can lead to
good improvement across different domains, maximizing the spontaneous recovery in children and adolescents after AIS.

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1. Introduction

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Keywords: Pediatric stroke, multidisciplinary rehabilitation, intensive treatment, ICF

Arterial ischemic stroke (AIS) in pediatric patients
is rare yet recognized as a significant cause of acquired
brain injury and life-long morbidity [1]. Its incidence
is progressively increasing and ranges from 1.3 to 13
per 100,000 [2]. Stroke etiology in childhood is broader
than in adulthood and it is often of unknown origin [3].

1 These authors contributed equally to the work.
∗ Corresponding author: Giulia Gilardone, Department of Neurore-

habilitation Sciences, Casa di Cura del Policlinico, Via G. Dezza 48,
Milan, 20144, Italy. Tel.: +39 0248593725; E-mail: g.gilardone@
ccppdezza.it.

Cerebral arterial dissection, which may occur spontaneously or after trauma, can be considered a rare cause
of ischemic stroke in children [4].
Although ischemic stroke in children is generally perceived as having a more favorable outcome compared
to adults, in a significant number of cases it leaves patients with residual impairments and long-term motor,
cognitive, and behavioral consequences [5].
Recovery is a complex process occurring through
a combination of spontaneous and learning-dependent
processes grounded on restitution, substitution and
compensation mechanisms [6]. In order to set up a specific rehabilitation program, neuropsychological and
motor testing are essential to assess the presence of neu-

1874-5393/20/$35.00 c 2020 – IOS Press and the authors. All rights reserved

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2. Case presentation

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A 13-year-old Italian teenager with neither family
history of neurological disease nor previous medical
history except for favism disease is described.
On the day of the AIS, he suddenly mentioned left
orbital and facial pain, fell to the ground and developed
aphasia and right hemiplegia, without losing consciousness. There was no antecedent trauma. In the morning of the onset of symptoms, headache and vomiting
occurred.
Upon the patient’s arrival to the Hospital, he had
aphasia, left head and gaze deviation and right hemiplegia. A first Magnetic Resonance Imaging (MRI) revealed a dissection of the left internal carotid artery
and a homolateral acute ischemic territorial lesion (see
Fig. 2). An attempt of mechanical thrombectomy of
the occluded left Middle Cerebral Artery (MCA) was
performed without success.
In the Intensive Care Unit, the patient was maintained in a medically-induced coma for 5 days, while he

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rocognitive and/or physical impairments. Child-based
rehabilitation promotes and assists neural plasticity, optimizing recovery and outcome [7]. Taking into account
all of the International Classification of Functioning,
Disability and Health (ICF) domains, benefits of intensive and early multidisciplinary treatment are highlighted by the Clinical Guidelines for Childhood Stroke
Diagnosis, Management and Rehabilitation [8]. The use
of the ICF model in clinical practice allows providers
to move from purely medical or social models of disability toward a biopsychosocial framework, focused
on the dynamic interactions between the health condition and the personal and environmental factors at play
(Fig. 1) [9].

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Fig. 1. Biopsychosocial model of the International Classification of
Functioning, Disability and Health – Children and Youth version
(ICF-CY).

was treated with anticoagulant, antibiotic and infusion
therapy. A central venous catheter and a nasogastric
tube were positioned. Vital signs were within the normal range, routine blood examination and ECG were
normal, and EEG showed no epileptiform discharges.
Five days after the onset of symptoms, another MRI
confirmed a left hemisphere ischemic lesion, and a CT
Angiography study showed a lack of visualization of
the supraclinoid tract of the left MCA (see Fig. 3). After
40 days, the anticoagulant was switched to antiplatelet
therapy.
Tests for vasculitis, prothrombotic states, and viral
neurotropic antibodies, as well as genetic analysis for
Fabry disease, assessments of plasma amino acids concentration and oropharyngeal swab were all negative.
Transesophageal and transthoracic echocardiography
were normal.
The patient was transferred to our Neurorehabilitation Center where he was on antiplatelet therapy. A
multidisciplinary team cooperated in order to obtain a
global view of his difficulties. An intensive (4–5 hours
per day for 106 days) neurological rehabilitation training was designed according to his specific needs and
focused on speech therapy, cognitive function training, motor and occupational therapy and psychological
support.
2.1. First assessment

For each area of intervention, the patient underwent
an initial assessment aimed at identifying a specific
rehabilitation pathway.
A standardized clinical evaluation of his communicative behavior revealed the presence of motor speech
disorders and severe aphasia. The patient’s speech was
dysarthric, almost unintelligible. Also, his spontaneous
language was not fluent, characterized by word-finding
impairment and by several phonemic and semantic paraphasic errors. The absence of function words and inflections revealed the presence of agrammatism. Repetition
and naming impairments were detected. Comprehension was relatively good, with some difficulties in understanding grammatical contrasts. Since the patient’s
motor deficits prevented him from manipulating writing
instruments, the agraphia could not be assessed.
A comprehensive neuropsychological examination
highlighted the presence of several difficulties in
problem solving, planning, cognitive flexibility, selfmonitoring and cognitive inhibition. Mild deficits were
found in the nonverbal intelligence domain. No impairments of perception, memory or attention were observed.

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Fig. 2. Brain magnetic resonance imaging showing the acute left ischemic lesion on FLAIR axial scans.

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consistent anxiety-related behaviors, psychological distress and poor motivation, and refused complex exercises in order to avoid frustrating experiences. In addition, he showed poor self-reflection ability, attempting
to escape from negative thoughts and feelings.

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2.2. Intervention

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Fig. 3. Brain CT angiography revealing left internal carotid artery
occlusion.

The patient presented with severe right hemiplegia
with right upper limb hypotonia. He was only partially
autonomous in postural changes. Thus, he was completely dependent in basic (BADL) and instrumental
(IADL) activities of daily living, needing physical assistance. Motor tests showed a good performance in
static sitting balance and more difficulties in dynamic
sitting balance and coordination.
Specific linguistic, cognitive and motor tests with
raw scores and percentages of accuracy are reported in
Table 1.
With respect to behavioral and psychological response, the patient struggled to establish a good working alliance with all of the specialists, showing avoidance signals and emotional unavailability. He presented

After the initial speech evaluation, a twice daily rehabilitation program was focused on articulation, verbal
production and auditory and reading comprehension.
For specific tasks, see Table 2.
Compensatory approaches for aphasia intervention in
adult patients, such as the Promoting Aphasics’ Communicative Effectiveness (PACE) [19] and the application of Semantic Feature Analysis (SFA) [20], were
adapted to the patient’s needs. Moreover, a smartphone
and tablet were used to facilitate communication.
A specific daily neuropsychological rehabilitation
program was designed with paper and pencil exercises
and computerized tasks using the rehabilitation software “ERICA” [21]. Cognitive training was focused
mainly on executive functions, while sustained, selective and divided attention tasks were aimed at reducing impulsivity (see Table 2). The complexity of each
exercise was progressively increased to match the patient’s improvement in accuracy and processing speed
and decrease of impulsiveness.
The motor impairment was treated with physiotherapy sessions twice daily. Exercises were aimed at
strengthening muscles, decreasing spasticity, improving transferring abilities and postural changes, increas-

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G. Gilardone et al. / Multidisciplinary rehabilitation of a post-stroke pediatric patient considering the ICF perspective
Table 1
Linguistic, cognitive and motor scores at admission, discharge and follow-up
2nd assessment
Raw score (% of accuracy)

3rd assessment
Raw score (% of accuracy)

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150
90
120
120

20 (13%)
112 (75%)
na
76 (63%)
108 (90%)

5 (3%)
120 (80%)
na
109 (91%)
110 (92%)

5 (3%)
126 (84%)
77 (86%)
110 (92%)
113 (94%)

20

10 (50%)

14 (70%)

14 (70%)

6
128
128

4 (67%)
18 (14%)
39 (30%)

6 (100%)
8 (6%)
36 (28%)

6 (100%)
13 (10%)
6 (5%)

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–
–
–

31 (86%)
10
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161

32 (89%)
97
113
212

31 (52%)

41 (68%)

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12 (60%)
39 (81%)
55 (69%)
0 (0%)
26 (93%)
7 (35%)
7 (29%)
7 (35%)
153 (54%)

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80
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27 (75%)
36 (100%)

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1st assessment
Raw score (% of accuracy)

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Language
AAT
Token test, errors
Repetition
Written language
Naming
Comprehension
TROG-2
Block passed
Executive functions
WCST
Number of categories achieved
Perseverative responses
Non-perseverative errors
ToL
Correct responses
Initiation time (in seconds)
Execution time (in seconds)
Total time (in seconds)
Nonverbal logic reasoning
SPM
Apraxia
Italian orofacial apraxia test
Total on verbal request
Total on imitation
Dysarthria
Robertson dysarthria profile
Respiration
Phonation
Facial musculature
Diadochokinesis
Reflexes
Articulation
Intelligibility
Prosody
TOT
Motor function
TIS
FAC

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Test

15 (65%)
2 (30%)

29 (80%)
55
117
172

41 (68%)

30 (83%)
36 (100%)

15 (75%)
41 (85%)
67 (84%)
25 (57%)
27 (96%)
12 (60%)
13 (54%)
13 (65%)
213 (75%)

17 (85%)
47 (98%)
80 (100%)
20 (45%)
28 (100%)
14 (70%)
15 (62%)
13 (65%)
234 (82%)

16 (70%)
5 (83%)

17 (74%)
5 (83%)

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na = non administrable. AAT = Aachener Aphasie Test [10]; TROG-2 = Test for Reception of Grammar 2 [11]; WCST = Wisconsin
Card Sorting Test [12]; ToL = Tower of London [13]; SPM = Standard Progressive Matrices [14]; Italian Orofacial Apraxia Test [15];
Robertson Dysarthria Profile [16]; TIS = Trunk Impairment Scale [17]; FAC = Functional Ambulatory Classification [18].
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ing balance and posture control during standing and
walking, walking indoors and outdoors independently
and climbing up and down stairs. See Table 2 for specific tasks. A carbon fiber ankle-foot orthosis (AFO)
and a nighttime brace for the right upper limb were
adopted to maintain a full active range of motion and
prevent contractures. In addition to traditional physical
therapy, electrostimulation, virtual reality activities and
hydrokinetic therapy were performed.
Two occupational therapy sessions per day were
aimed at improving fine upper limb motor skills in order
to enhance the patient’s participation and increase his
independence during ADLs.

Psychological support was provided in twenty sessions and focused on cognitive processing of the patient’s traumatic experience. Imaginative techniques
and metacognitive strategies were taught to decrease
restlessness and support him during his difficult rehabilitation training. The last sessions were dedicated to
the return of the patient into society and school. During the sessions, he established a good therapeutic alliance, with increasing self-disclosure and emotional
openness over time. His use of defense mechanisms
was gradually reduced, which allowed for greater availability and cooperation in working with all of the team’s
specialists.

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Table 2
Linguistic (A), cognitive (B), physical (C) and occupational (D) therapy specific tasks

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Occupational therapy (D)
Autonomies: training to improve occupational performance in BADL
(feeding, grooming, bathing, upper
and lower body dressing) and IADL
(using telephone, tablet handwriting) in different contexts of daily
life (home, school), counseling
on environmental adaptations and
daily life aids to facilitate occupational performance and enhance independence
Fine upper limb motor skills: ecological exercises aimed at reaching, gripping, manipulating small
objects, bi-manual activities, hand
and finger coordination tasks, specific exercises to reduce spasticity
and enhance muscles strength
Participation: games, daily living
activities and role playing to
enhance awareness and promote
active participation

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Physical therapy (C)
Lower limb: repetitive movements
(hip flexion and external/internal rotation, knee extension, ankle flexion), muscle contractions,
flexibility exercises, muscles tone
management, supported standing
balance activities, walking on
level and unlevel surfaces, avoiding obstacles, climbing up and
down stairs
Upper limb: arm, wrist and hand
stretch, reaching, grasping,
pitching, gripping and releasing
activities, active and passive
mobilization exercises,
coordination and bi-manual tasks

After discharge, the patient was reintegrated into
home and school life with environmental support (e.g.
orthotic devices for mobility, optimal arrangement of
furniture, digital tablet for communication, daily living
aids). He attended the last months of middle school and
passed his eighth grade finals.

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At discharge, the patient showed general improvement. Advancement was particularly evident in verbal
comprehension and understanding of grammatical contrasts, as well as in naming and articulation abilities.
Due to better speech intelligibility, a significant gain in
spontaneous language was observed, with an increased
communicative intent that included conversations on
topics of everyday life.
A second neuropsychological assessment showed
better nonverbal logical reasoning and an increased
ability to coordinate thoughts and behavior, with more
cognitive flexibility, as well as improved planning and
self-monitoring skills.
Regarding motor skills, the patient reached good autonomy in postural changes and walking ability, requiring supervision only on uneven surfaces. If helped by
supervisors with verbal reminders, he was more independent in BADL and IADL.
Results of the final assessment are summarized in
Table 1.
With respect to the emotional domain, the patient
demonstrated greater reduction of impulsiveness, good
availability and cooperation with all of the team’s specialists, increased emotional availability and reduction
of social withdrawal.

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2.3. Final assessment

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Cognition therapy(B)
Executive functions: verbal and visuospatial problem-solving tasks
(decomposing tasks into subgoals, generating alternative solutions to problems, shifting between ideas and actions, monitoring ongoing performances), rulededuction tasks, shifting games
and training for the inhibition of
automatic behaviors and impulsiveness
Sustained, selective and divided
attention: dual-task exercises,
attention demanding tasks with
moving targets, Go/No-Go tasks
with increasing number of
distractors

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Speech and language therapy (A)
Articulation: reading and repetition of isolated sounds, words of
increasing length and complexity and sentences with increasing numbers of constituents, active
and passive praxis exercises, oralmotor exercises with and without
using mirror, strategies to improve
the speech intelligibility (hyperarticulation and slowing speech
rate)
Verbal production: pictures naming, description tasks, semantic
jokes and riddles, semantic and
phonological fluency exercises,
storytelling
Auditory and reading
comprehension: comprehension
of spoken and written words and
sentences of increasing length and
complexity, reading
comprehension exercises with
multiple choices questions, yes/no
questions, scrambled-sentence
tasks

2.4. Follow-up assessment
A 6-month post-stroke follow-up assessment was
performed after a period of sub-intensive (three days
a week) speech therapy and neuro-motor training in
a different structure. The evaluation showed a general
stability in both linguistic and motor domains, with further mild improvement in all tests. The executive functions, in particular planning and self-monitoring abilities, were the only areas in which the patient showed
a mild decrease in performance compared to his discharge evaluation. Written language assessment highlighted the presence of mild agraphia. For raw scores
and percentages of accuracy, see Table 1.

3. Discussion
The aim of this paper is to report the multidisciplinary
assessment and the patient-centered rehabilitation pro-

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gram of a 13-year-old AIS patient who subsequently
made significant clinical improvement. As the Clinical Guidelines for Childhood Stroke Diagnosis, Management and Rehabilitation suggest, an early, intensive
and multimodal intervention was developed [8]. Referring to the ICF model, the patient functioning was considered in terms of the dynamic interactions between
his disability and environmental and personal factors
(Fig. 4). The ICF, supporting both medical and social
models of human functioning and disability, provides
a multidimensional framework that can be used to set
up comprehensive and interdisciplinary approaches to
assessment and intervention (Tables 1 and 2 and Fig. 4).
Moreover, it offers a common language for health, social and educational services that can be used across
different settings and disciplines [9].
Because descriptions of post-stroke rehabilitation
training in childhood are rare, we referred to adultstroke literature, adapting the therapeutic environment
to the patient’s specific needs in terms of modality, intensity and location of the intervention.
Since children and adolescents usually show consistent difficulties working in structured settings, which
are required in adult standard training [22], it is im-

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Fig. 4. Modified ICF-CY model considering the patient’s characteristics and his rehabilitation program.

portant to customize the treatment in accordance to the
young patient’s needs [23]. All therapeutic interventions were tailored to the teenager’s specific profile.
Therapists tried to develop a good working alliance
with him by including some enjoyable tasks in each
session. Literature highlights how high levels of patient
engagement seem to be strongly associated with better
rehabilitation outcomes [6]. In agreement with these results, consistent improvements in all rehabilitation tasks
were observed as the patient became more interested,
cooperative and involved in training.
Speech therapy sessions followed scientific recommendations for adult aphasic patients [24] and were
adapted to the teenager’s characteristics. As literature
suggests, familiar technology was incorporated for a
more functional treatment [22]. After the rehabilitation period, the patient’s language improved, even more
clearly at the follow-up evaluation, where he showed
greater communicative intent and a general reduction
of inhibition.
Concerning cognition, substantial evidence supports
the effectiveness of cognitive rehabilitation after acquired brain lesions, highlighting how neuropsychological treatment can help patients learn and compensate

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Conflict of interest

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The authors have no conflict of interest to report.

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References

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The authors would like to thank the patient and his
family, as well as the World Health Organization for
the permission to reproduce their material. All authors
gave their consent to paper submission and approved
the current version of the paper. They agreed to take
public responsibility for all the paper’s content. The
first two authors contributed equally to the work. In
addition, the authors ensured that they have written
entirely original work and appropriately cited or quoted
the considered studies. No financial support for the
research, authorship and/or publication of this article
was received.

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Acknowledgments

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for residual limitations in this area [24]. Cognitive tasks
were mainly assigned to the patient using the software
ERICA [21] and included computerized exercises based
on advanced cognitive rehabilitation models. Problemsolving tasks were administered to improve executive
functions while attention exercises were aimed at reducing impulsivity. The presence of executive functioning deficits is known to moderate and negatively
affect the overall response to treatment [24]. Moreover,
during adolescence, the brain is still changing and the
frontal cortex, classically associated with the control
of executive functions, is partially immature and still
developing in an injured brain. Cognitive tasks require
patients to create new strategies and consequently new
neural circuits that replace damaged ones. During treatment, the complexity of each exercise was progressively
increased as the patient showed better cognitive flexibility and self-monitoring skills. The patient’s profile
showed a partial reappearance of difficulties after a period without any training for cognitive functions. This
is consistent with other case descriptions that indicate
nonsignificant decrements of performance between discharge and follow-up assessments [25]. Hence, we can
infer that intensive treatment is effective and should be
long-term in order to maintain results over time.
Physical and occupational therapies were individualized and exercises followed a task-oriented approach.
Also, traditional physical therapy was utilized. Electrostimulation and hydrokinetic therapy were introduced too. Following recent findings [26], virtual reality activities were added and were well accepted by
the teenager. At discharge, the patient showed general
motor improvements, reaching good autonomy in postural changes, gait and ADLs. His advances remained
largely unchanged at follow-up. Increased emotional
availability and cooperation were observed over time
with all of the team’s specialists.
In conclusion, this case highlights how an early, intensive and comprehensive multidisciplinary rehabilitation program following the Clinical Guidelines for
Childhood Stroke Diagnosis, Management and Rehabilitation can lead to significant improvement in children after AIS. In accordance with the ICF model, the
treatment was tailored to the patient’s specific needs,
environment and personal factors, in order to obtain the
best outcome possible and allow the child and his family to achieve a higher quality of life. Further studies
with a larger number of patients are needed to support
evidence of efficacy of childhood stroke rehabilitation
related to Clinical Guidelines.

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