Factors Associated with Rehabilitation Service Use after Pediatric Traumatic Brain Injury: A Systematic Review and...

Traumatic brain injury (TBI) is a leading cause of long-term functional impairment in children. Rehabilitation services are critical for recovery, yet their use following pediatric TBI is highly variable, potentially contributing to heterogeneity in outcomes. This systematic review and meta-analysis, guided by the Andersen Behavioral Model of Health Services Use, aimed to characterize variability in rehabilitation service use and identify associated factors. Following a registered protocol, we searched Medline, PsycINFO, and Embase (last update June 2025) for observational studies involving participants ≤18 years with TBI that reported rehabilitation service use in relation to at least one individual or contextual factor. Study screening and data extraction were dually and independently completed. Rehabilitation service use data included inpatient and outpatient functional therapies, behavioral health services, and academic supports. Study risk of bias was assessed using the Newcastle-Ottawa Scale. Twenty-four studies (N_TBI = 89,031) met the inclusion criteria. Meta-analysis of 17 studies revealed a pooled prevalence of any rehabilitation service use of 25.7% (95% confidence interval [CI]: 19.9-32.0%) with high between-study heterogeneity. Outpatient functional therapies were most commonly used (34.4% [95% CI: 26.8-42.3%]), followed by formalized academic supports (24.7% [95% CI: 14.9-36.0%]) and behavioral health services (23.5% [95% CI: 19.2-28.0%]). Qualitative synthesis identified 11 individual-level Andersen Model factors; quantitative meta-analyses were feasible for seven. Greater injury severity, presence of impairment, and prior rehabilitation use showed strong positive associations with greater rehabilitation service use; older age and commercial/fee-for-service insurance showed smaller but significant associations. No studies examined contextual determinants. Findings underscore substantial between-study heterogeneity and highlight the need for standardized measurement of rehabilitation service use, as well as research on contextual factors to promote equitable access and to optimize recovery.