Recovery of ambulation after traumatic brain injury

Community Reintegration After Traumatic Brain Injury

Achieving effective community reintegration is important to maximize recovery in patients with traumatic brain injury, simultaneously limiting caregiver burden and improving satisfaction with quality of life. Certain medical complications that are common after brain injury may impact community reintegration, and should be addressed by the physician in a systematic approach. Additionally certain social and environmental factors such as mobility or return to work or school may arise, and should be addressed proactively by the physician. Inpatient/residential or outpatient programs with case management and a multi-disciplinary team can facilitate community reentry for patients, and should be considered when available.

Safety and efficiency of Wharton's Jelly-derived mesenchymal stem cell administration in patients with traumatic brain injury: First results of a phase I study

BACKGROUND

Traumatic brain injury (TBI) is characterized by a disruption in the normal function of the brain due to an injury following a trauma, which can potentially cause severe physical, cognitive, and emotional impairment. Stem cell transplantation has evolved as a novel treatment modality in the management of TBI, as it has the potential to arrest the degeneration and promote regeneration of new cells in the brain. Wharton's Jelly-derived mesenchymal stem cells (WJ-MSCs) have recently shown beneficial effects in the functional recovery of neurological deficits.

AIM

To evaluate the safety and efficiency of MSC therapy in TBI.

METHODS

We present 6 patients, 4 male and 2 female aged between 21 and 27 years who suffered a TBI. These 6 patients underwent 6 doses of intrathecal, intramuscular (i.m.) and intravenous transplantation of WJ-MSCs at a target dose of 1 × 106/kg for each application route. Spasticity was assessed using the Modified Ashworth scale (MAS), motor function according to the Medical Research Council Muscle Strength Scale, quality of life was assessed by the Functional Independence Measure (FIM) scale and Karnofsky Performance Status scale.

RESULTS

Our patients showed only early, transient complications, such as subfebrile fever, mild headache, and muscle pain due to i.m. injection, which resolved within 24 h. During the one year follow-up, no other safety issues or adverse events were reported. These 6 patients showed improvements in their cognitive abilities, muscle spasticity, muscle strength, performance scores and fine motor skills when compared before and after the intervention. MAS values, which we used to assess spasticity, were observed to statistically significantly decrease for both left and right sides (P < 0.001). The FIM scale includes both motor scores (P < 0.05) and cognitive scores (P < 0.001) and showed a significant increase in pretest posttest analyses. The difference observed in the participants' Karnofsky Performance Scale values pre and post the intervention was statistically significant (P < 0.001).

CONCLUSION

This study showed that cell transplantation has a safe, effective and promising future in the management of TBI.

Safety and efficiency of Wharton’s Jelly-derived mesenchymal stem cell administration in patients with traumatic brain injury: First results of a phase I study

BACKGROUND

Traumatic brain injury (TBI) is characterized by a disruption in the normal function of the brain due to an injury following a trauma, which can potentially cause severe physical, cognitive, and emotional impairment. Stem cell transplantation has evolved as a novel treatment modality in the management of TBI, as it has the potential to arrest the degeneration and promote regeneration of new cells in the brain. Wharton’s Jelly-derived mesenchymal stem cells (WJ-MSCs) have recently shown beneficial effects in the functional recovery of neurological deficits.

AIM

To evaluate the safety and efficiency of MSC therapy in TBI.

METHODS

We present 6 patients, 4 male and 2 female aged between 21 and 27 years who suffered a TBI. These 6 patients underwent 6 doses of intrathecal, intramuscular (i.m.) and intravenous transplantation of WJ-MSCs at a target dose of 1 × 10⁶/kg for each application route. Spasticity was assessed using the Modified Ashworth scale (MAS), motor function according to the Medical Research Council Muscle Strength Scale, quality of life was assessed by the Functional Independence Measure (FIM) scale and Karnofsky Performance Status scale.

RESULTS

Our patients showed only early, transient complications, such as subfebrile fever, mild headache, and muscle pain due to i.m. injection, which resolved within 24 h. During the one year follow-up, no other safety issues or adverse events were reported. These 6 patients showed improvements in their cognitive abilities, muscle spasticity, muscle strength, performance scores and fine motor skills when compared before and after the intervention. MAS values, which we used to assess spasticity, were observed to statistically significantly decrease for both left and right sides (P < 0.001). The FIM scale includes both motor scores (P < 0.05) and cognitive scores (P < 0.001) and showed a significant increase in pretest posttest analyses. The difference observed in the participants’ Karnofsky Performance Scale values pre and post the intervention was statistically significant (P < 0.001).

CONCLUSION

This study showed that cell transplantation has a safe, effective and promising future in the management of TBI.

Exploring the challenges of avoiding collisions with virtual pedestrians using a dual-task paradigm in individuals with chronic moderate to severe traumatic brain injury

BACKGROUND

Individuals with a moderate-to-severe traumatic brain injury (m/sTBI), despite experiencing good locomotor recovery six months post-injury, face challenges in adapting their locomotion to the environment. They also present with altered cognitive functions, which may impact dual-task walking abilities. Whether they present collision avoidance strategies with moving pedestrians that are altered under dual-task conditions, however, remains unclear. This study aimed to compare between individuals with m/sTBI and age-matched control individuals: (1), the locomotor and cognitive costs associated with the concurrent performance of circumventing approaching virtual pedestrians (VRPs) while attending to an auditory-based cognitive task and; (2) gaze behaviour associated with the VRP circumvention task in single and dual-task conditions.

METHODOLOGY

Twelve individuals with m/sTBI (age = 43.3 ± 9.5 yrs; >6 mo. post injury) and 12 healthy controls (CTLs) (age = 41.8 ± 8.3 yrs) were assessed while walking in a virtual subway station viewed in a head-mounted display. They performed a collision avoidance task with VRPs, as well as auditory-based cognitive tasks (pitch discrimination and auditory Stroop), both under single and dual-task conditions. Dual-task cost (DTC) for onset distance of trajectory deviation, minimum distance from the VRP, maximum lateral deviation, walking speed, gaze fixations and cognitive task accuracy were contrasted between groups using generalized estimating equations.

RESULTS

In contrast to CTLs who showed locomotor DTCs only, individuals with m/sTBI displayed both locomotor and cognitive DTCs. While both groups walked slower under dual-task conditions, only individuals with m/sTBI failed to modify their onset distance of trajectory deviation and maintained smaller minimum distances and smaller maximum lateral deviation compared to single-task walking. Both groups showed shorter gaze fixations on the approaching VRP under dual-task conditions, but this reduction was less pronounced in the individuals with m/sTBI. A reduction in cognitive task accuracy under dual-task conditions was found in the m/sTBI group only.

CONCLUSION

Individuals with m/sTBI present altered locomotor and gaze behaviours, as well as altered cognitive performances, when executing a collision avoidance task involving moving pedestrians in dual-task conditions. Potential mechanisms explaining those alterations are discussed. Present findings highlight the compromised complex walking abilities in individuals with m/sTBI who otherwise present a good locomotor recovery.

Diffusion in the corpus callosum predicts persistence of clinical symptoms after mild traumatic brain injury, a multi-scanner study

Background

Mild traumatic brain injuries (mTBIs) comprise 80% of all TBI, but conventional MRI techniques are often insensitive to the subtle changes and injuries produced in a concussion. Diffusion tensor imaging (DTI) is one of the most sensitive MRI techniques for mTBI studies with outcome and symptom associations described. The corpus callosum (CC) is one of the most studied fiber tracts in TBI and mTBI, but the comprehensive post-mTBI symptom relationship has not fully been explored.

Methods

This is a retrospective observational study of how quantitative DTI data of the CC and its sub-regions may relate to clinical presentation of symptoms and timing of resolution of symptoms in patients diagnosed with uncomplicated mTBI. DTI and clinical data were obtained retrospectively from 446 (mean age 42 years, range 13-82) civilian patients. From patient medical charts, presentation of the following common post-concussive symptoms was noted: headache, balance issues, cognitive deficits, fatigue, anxiety, depression, and emotional lability. Also recorded was the time between injury and a visit to the physician when improvement or resolution of a particular symptom was reported. FA values from the total CC and 3 subregions of the CC (genu or anterior, mid body, and splenium or posterior) were obtained from hand tracing on the Olea Sphere v3.0 SP12 free-standing workstation. DTI data was obtained from 8 different 3T MRI scanners and harmonized via ComBat harmonization. The statistical models used to explore the association between regional Fractional Anisotropy (FA) values and symptom presentation and time to symptom resolution were logistic regression and interval-censored semi-parametric Cox proportional hazard models, respectively. Subgroups related to age and timing of first scan were also analyzed.

Results

Patients with the highest FA in the total CC (p = 0.01), anterior CC (p < 0.01), and mid-body CC (p = 0.03), but not the posterior CC (p = 0.91) recovered faster from post-concussive cognitive deficits. Patients with the highest FA in the posterior CC recovered faster from depression (p = 0.04) and emotional lability (p = 0.01). There was no evidence that FA in the CC or any of its sub-regions was associated with symptom presentation or with time to resolution of headache, balance issues, fatigue, or anxiety. Patients with mTBI under 40 had higher FA in the CC and the anterior and mid-body subregions (but not the posterior subregion: p = 1.00) compared to patients 40 or over (p ≤ 0.01). There was no evidence for differences in symptom presentation based on loss of consciousness (LOC) or sex (p ≥ 0.18).

Conclusion

This study suggests that FA of the CC has diagnostic and prognostic value for clinical assessment of mTBI in a large diverse civilian population, particularly in patients with cognitive symptoms.

Utilization of overground exoskeleton gait training during inpatient rehabilitation: a descriptive analysis

BACKGROUND

Overground exoskeleton gait training (OEGT) after neurological injury is safe, feasible, and may yield positive outcomes. However, no recommendations exist for initiation, progression, or termination of OEGT. This retrospective study highlights the clinical use and decision-making of OEGT within the physical therapy plan of care for patients after neurological injury during inpatient rehabilitation.

METHODS

The records of patients admitted to inpatient rehabilitation after stroke, spinal cord injury, or traumatic brain injury who participated in at least one OEGT session were retrospectively reviewed. Session details were analyzed to illustrate progress and included: "up" time, "walk" time, step count, device assistance required for limb swing, and therapist-determined settings. Surveys were completed by therapists responsible for OEGT sessions to illuminate clinical decision-making.

RESULTS

On average, patients demonstrated progressive tolerance for OEGT over successive sessions as shown by increasing time upright and walking, step count, and decreased assistance required by the exoskeleton. Therapists place preference on using OEGT with patients with more functional dependency and assess feedback from the patient and device to determine when to change settings. OEGT is terminated when other gait methods yield higher step repetitions or intensities, or to prepare for discharge.

CONCLUSION

Our descriptive retrospective data suggests that patients after neurological injury may benefit from OEGT during inpatient rehabilitation. As no guidelines exist, therapists' clinical decisions are currently based on a combination of knowledge of motor recovery and experience. Future efforts should aim to develop evidence-based recommendations to facilitate functional recovery after neurological injury by leveraging OEGT.

Mild traumatic brain injury and sports-related concussion

Mild traumatic brain injury (mTBI) and concussion are equivalent terms for the sequela of injury to the head that disrupts brain functioning. Various forces may be causative from seemingly innocuous bumps to the head resulting from sports-related injuries to more severe blows to the head. However, the postconcussive motor, cognitive, emotional, and psychosocial sequelae can be just as devastating and long lasting, leading to loss of independent function and safe performance of activities. Taken together, they pose a significant challenge to recovery, requiring a multifaceted dynamic rehabilitative strategy. The current systems of health care pose challenges to suboptimal management of sports-related concussion (SRC) that goes beyond the acute injury, and into the school setting, failing to be identified by school staff, and inconsistencies in communicating medical information regarding school modifications, follow-up health services, or concussion-related educational services. Children who sustain SRC at different ages face different challenges. Young children face increased vulnerability due to SRC that coincides with periods of brain motor maturation and development.

Improvement in postural alignment is associated with recovery of mobility after complex acquired brain injury: An observational study

PURPOSE

Determine how mobility changes over 6 months in people unable to walk at 8-weeks post-Acquired Brain Injury (ABI); if there is an association over time between postural alignment and mobility post-ABI; and if alignment after ABI becomes closer to healthy alignment over time.

METHODS

Fourteen adults with ABI, evaluated over 6 months, and a reference sample of 30 healthy adults were studied. The primary measure for changes in mobility was the Clinical Outcome Variables Scale (COVS). Secondary measures were sit-to-stand, timed standing holding rails, independent walking speed and number of testing conditions achieved. The Functional Independence Measure (FIM) was scored at rehabilitation admission and discharge. To analyze postural alignment, participants were recorded in sitting and standing, each repeated holding rails, and walking if able. Three-dimensional kinematic data were used to quantify whole-body postural alignment, equal to mean segment displacements from the base of support in the transverse plane. Associations between three-dimensional kinematic alignment scores and COVS scores were calculated using Linear Mixed-Effects Models.

RESULTS

Participants made significant improvements in COVS scores, most secondary mobility scores, and FIM scores over time (p ≤ .001). Relationships between increasing COVS scores and decreasing sitting and standing mal-alignment scores were statistically significant. Visual analysis of graphed segment positions indicated that sitting and standing alignment became more similar to healthy alignment over time; this was not clear for walking.

CONCLUSION

Improvement in postural alignment may be a factor for improving mobility in people with severe impairments after ABI.

Improving physical mobility is critical for wellbeing in people with severe impairment after an acquired brain injury: a qualitative study

OBJECTIVES

1) Understand the experience, and personal significance, of mobility skills for people with severe mobility impairment after brain injury 2) Determine how these evolve over time.

DESIGN

Longitudinal qualitative study.

PARTICIPANTS

Ten adults, unable to walk at 8 weeks post-injury.

METHODS

Participants were interviewed up to three times, at three-month intervals. Semi-structured interviews were transcribed and coded independently by two researchers, then themes developed. Codes were then reviewed longitudinally.

RESULTS

Initial analysis derived six themes: I lost everything overnight; It feels frustrating; Walking is absolutely the most important; I need help; I'm making progress; I can start doing things that I used to be able to do. Participants described overwhelming losses, with loss of mobility affecting many aspects of life. All participants described progress other than walking that was critical for their wellbeing, including assisted standing and transfers without a lifter. Themes from longitudinal analyses: My losses softened by progress; Walking means freedom; Control helps adjustment happen; Challenges keep coming. Over time, participants valued greater control within their lives and progress with mobility was key.

CONCLUSION

Participants saw mobility as crucial to recovering control of life. Mobility achievements other than independent walking matter to individuals after brain injury.

Comparisons between Locomat and Walkbot robotic gait training regarding balance and lower extremity function among non-ambulatory chronic acquired brain injury survivors

ABSTRACT

Lower limb rehabilitation exoskeleton robots connect with the human body in a wearable way and control the movement of joints in the gait rehabilitation process. Among treadmill-based lower limb rehabilitation exoskeleton robots, Lokomat (Hocoma AG, Volketswil, Switzerland) has 4 actuated joints for bilateral hips and knees whereas Walkbot (P&S Mechanics, Seoul, Korea) has 6 bilateral actuated joints for bilateral hips, knees, and ankles. Lokomat and Walkbot robotic gait training systems have not been directly compared previously. The present study aimed to directly compare Lokomat and Walkbot robots in non-ambulatory chronic patients with acquired brain injury (ABI).The authors conducted a single-center, retrospective, cross-sectional study of 62 subjects with ABI who were admitted to the rehabilitation hospital. Patients were divided into 2 groups: Lokomat (n = 28) and Walkbot (n = 34). Patients were subjected to robot-assisted gait training (RAGT) combined with conventional physical therapy for a total of 14 (8-36) median (interquartile range) sessions. Baseline characteristics, including age, sex, lag time post-injury, ABI type, paralysis type, intervention sessions, lower extremity strength, spasticity, and cognitive function were assessed. Functional ambulation category (FAC) and Berg balance scale (BBS) were used for outcome measures.There were no significant differences in baseline characteristics between the groups. Baseline FAC score was 1 (0-2) in Lokomat and 1 (0-1) in Walkbot group. After the intervention, FAC scores improved significantly to 2 (1-3) in both groups (P < .05). Lokomat and Walkbot groups showed significantly enhanced BBS from 5 (2.75-24.25) and 15 (4-26.5) to 15 (4-26.5) and 22 (12-40), respectively (P < .05). Degree of improvements in both group were not significantly different with regard to balance (P = .56) and ambulatory ability (P = .74).This study indicates that both Locomat and Walkbot robotic gait training combined with conventional gait-oriented physiotherapy are promising intervention for gait rehabilitation in patients with chronic stage of ABI who are not able to walk independently.

Interval-censored survival analysis of mild traumatic brain injury with outcome based neuroimaging clinical applications

Objective

The purpose of this study was to assess the relationship between MRI findings and clinical presentation and outcomes in patients following mild traumatic brain injury (mTBI). We hypothesize that imaging findings other than hemorrhages and contusions may be used to predict symptom presentation and longevity following mTBI.

Methods

Patients (n = 250) diagnosed with mTBI and in litigation for brain injury underwent 3T magnetic resonance imaging (MRI). A retrospective chart review was performed to assess symptom presentation and improvement/resolution. To account for variable times of clinical presentation, nonuniform follow-up, and uncertainty in the dates of symptom resolution, a right censored, interval censored statistical analysis was performed. Incidence and resolution of headache, balance, cognitive deficit, fatigue, anxiety, depression, and emotional lability were compared among patients. Image findings analyzed included white matter hyperintensities (WMH), Diffusion Tensor Imaging (DTI) fractional anisotropy (FA) values, MR perfusion, auditory functional MRI (fMRI) activation, hippocampal atrophy (HA) and hippocampal asymmetry as defined by NeuroQuant ® volumetric software.

Results

Patients who reported LOC were significantly more likely to present with balance problems (p < 0.001), cognitive deficits (p = 0.010), fatigue (p = 0.025), depression (p = 0.002), and emotional lability (p = 0.002). Patients with LOC also demonstrated significantly slower recovery of cognitive function than those who did not lose consciousness (p = 0.044). Patients over the age of 40 had significantly higher odds of presenting with balance problems (p = 0.006). Additionally, these older patients were slower to recover cognitive function (p = 0.001) and less likely to experience improvement of headaches (p = 0.007). Abnormal MRI did not correlate significantly with symptom presentation, but was a strong indicator of symptom progression, with slower recovery of balance (p = 0.009) and cognitive deficits (p < 0.001).

Conclusion

This analysis demonstrates the utility of clinical data analysis using interval-censored survival statistical technique in head trauma patients. Strong statistical associations between neuroimaging findings and aggregate clinical outcomes were identified in patients with mTBI.

Absence of Glia Maturation Factor Protects from Axonal Injury and Motor Behavioral Impairments after Traumatic Brain Injury

Traumatic brain injury (TBI) causes disability and death, accelerating the progression towards Alzheimer's disease and Parkinson's disease (PD). TBI causes serious motor and cognitive impairments, as seen in PD that arise during the period of the initial insult. However, this has been understudied relative to TBI induced neuroinflammation, motor and cognitive decline that progress towards PD. Neuronal ubiquitin-C-terminal hydrolase- L1 (UCHL1) is a thiol protease that breaks down ubiquitinated proteins and its level represents the severity of TBI. Previously, we demonstrated the molecular action of glia maturation factor (GMF); a proinflammatory protein in mediating neuroinflammation and neuronal loss. Here, we show that the weight drop method induced TBI neuropathology using behavioral tests, western blotting, and immunofluorescence techniques on sections from wild type (WT) and GMF-deficient (GMF-KO) mice. Results reveal a significant improvement in substantia nigral tyrosine hydroxylase and dopamine transporter expression with motor behavioral performance in GMF-KO mice following TBI. In addition, a significant reduction in neuroinflammation was manifested, as shown by activation of nuclear factor-kB, reduced levels of inducible nitric oxide synthase, and cyclooxygenase- 2 expressions. Likewise, neurotrophins including brain-derived neurotrophic factor and glial-derived neurotrophic factor were significantly improved in GMF-KO mice than WT 72 h post-TBI. Consistently, we found that TBI enhances GFAP and UCHL-1 expression and reduces the number of dopaminergic TH-positive neurons in WT compared to GMF-KO mice 72 h post-TBI. Interestingly, we observed a reduction of THpositive tanycytes in the median eminence of WT than GMF-KO mice. Overall, we found that absence of GMF significantly reversed these neuropathological events and improved behavioral outcome. This study provides evidence that PD-associated pathology progression can be initiated upon induction of TBI.

Long-Term Impact of Mild Traumatic Brain Injuries on Multiple Functional Outcomes and Epigenetics: A Pilot Study with College Students

People who suffer a mild traumatic brain injury (mTBI) have heterogeneous symptoms and disease trajectories, which make it difficult to precisely assess long-term complications. This pilot study assessed and compared deficits in cognitive, psychosocial, visual functions, and balance performance between college students with and without histories of mTBI. Global DNA methylation ratio (5-mC%) in blood was also compared as a peripheral epigenetic marker. Twenty-five volunteers participated, including 14 healthy controls (64.3% females; mean age of 22.0) and 11 mTBI cases (27.3% females; mean age of 28.7 years) who self-reported mTBI history (63.6% multiple; 2.5 ± 1.29 injuries) with 7.1 years on average elapsed following the last injury. Every participant was assessed for cognitive (executive function, memory, and processing speed), psychological (depression, anxiety, and sleep disturbances), and visual function (by King–Devick and binocular accommodative tests); force-plate postural balance performance; and blood 5-mC% levels. Students with mTBI showed poorer episodic memory, severe anxiety, and higher blood 5-mC% ratio, compared to controls (all p’s < 0.05), which were still significant after adjusting for age. No differences were detected in sleep problems (after adjusting for age), visual function, and postural balance. These findings identified changes in multiple functions and peripheral epigenetics long after mTBI.

Minimum Clinically Important Difference of Gross Motor Function and Gait Endurance in Children with Motor Impairment: A Comparison of Distribution-Based Approaches

Objective

The minimum clinically important difference (MCID) is a standard way of measuring clinical relevance. The objective of this work was to establish the MCID for the 6-minute walking test (6minWT) and the Gross Motor Function Measure (GMFM-88) in pediatric gait disorders.

Methods

A cohort, pretest-posttest study was conducted in a hospitalized care setting. A total of 182 patients with acquired brain injury (ABI) or cerebral palsy (CP) performed 20 robot-assisted gait training sessions complemented with 20 sessions of physical therapy over 4 weeks. Separate MCIDs were calculated using 5 distribution-based approaches, complemented with an anonymized survey completed by clinical professionals.

Results

The MCID range for the 6minWT was 20-38 m in the ABI cohort, with subgroup ranges of 20-36 m for GMFCS I-II, 23-46 m for GMFCS III, and 24-46 m for GMFCS IV. MCIDs for the CP population were 6-23 m, with subgroup ranges of 4-28 m for GMFCS I-II, 9-19 m for GMFCS III, and 10-27 m for GMFCS IV. For GMFM-88 total score, MCID values were 1.1%-5.3% for the ABI cohort and 0.1%-3.0% for the CP population. For dimension “D” of the GMFM, MCID ranges were 2.3%-6.5% and 0.8%-5.2% for ABI and CP populations, respectively. For dimension “E,” MCID ranges were 2.8%-6.5% and 0.3%-4.9% for ABI and CP cohorts, respectively. The survey showed a large interquartile range, but the results well mimicked the distribution-based methods.

Conclusions

This study identified for the first time MCID ranges for 6minWT and GMFM-88 in pediatric patients with neurological impairments, offering useful insights for clinicians to evaluate the impact of treatments. Distribution-based methods should be used with caution: methods based on pre-post correlation may underestimate MCID when applied to patients with small improvements over the treatment period. Our results should be complemented with estimates obtained using consensus- and anchor-based approaches.

Surgical Intervention for Spastic Upper Extremity Improves Lower Extremity Kinematics in Spastic Adults: A Collection of Case Studies

BACKGROUND

Spasticity of the upper extremity often occurs after injury to the upper motor neurons (UMN). This condition can greatly interfere with the hand positioning in space and the functional use of the arm, affecting many daily living activities including walking. As gait and balance involve the coordination of all segments of the body, the control of upper limbs movement is necessary for smooth motion and stability. The purpose of this study was to assess the effects of surgical interventions on upper extremity spasticity to gait patterns in three spastic patients, as a way to assess the effect on patient's mobility.

METHODS

Three patients with an anoxic brain injury, upper extremity spasticity, and an altered gait participated in this study. A specific treatment plan based on the patient was tailored by the orthopedic hand surgeon to help release the contractures and spastic muscles. Three-dimensional gait analysis was performed before surgery, 3, 6, and 12 months postoperatively. During each experimental session, the patient walked at a self-selected pace in a straight line across four force plates embedded into the floor (Kistler®). Motion data were acquired using Vicon® Motion Capturing System. Spatiotemporal measurements as well as bilateral kinematics of the hip, knee and ankle were studied. The results from matched non-disabled controls were included as reference.

RESULTS

Overtime, clinical assessment displayed recovery in hand functions and restored sensation in the fingers. Gait analysis results demonstrated overall improvements in spatiotemporal parameters, specifically in cadence and walking speed. Improvements in kinematics of the lower limbs were also evident.

CONCLUSION

The results of this study indicated that, within a timeframe of one year, gait patterns improved in all patients. These observations suggest that, over time, upper limb surgery has the potential to improve the biomechanics of gait in spastic patients.

Physical Performance and Fall Risk in Persons With Traumatic Brain Injury

Injuries sustained from traumatic brain injury (TBI) culminate in both cognitive and neuromuscular deficits. Patients often progress to higher functioning on the Rancho continuum even while mobility deficits persist. Although prior studies have examined physical performance among persons with chronic symptoms of TBI, less is known about the relatively acute phase of TBI as patients prepare for rehabilitation discharge. The aims of this cross-sectional study were to (a) compare balance and gait performance in 20 ambulant persons with moderate to severe TBI who were nearing rehabilitation discharge with their age-matched controls and (b) describe performance with thresholds for fall risk and community navigation. During a designed task circuit, 40 participants (20 persons with TBI and 20 controls) performed the Timed Up and Go (TUG), gait velocity, and Walking and Remembering tests. Balance testing included the Fullerton Advanced Balance Scale (FABS) and instrumented Modified Clinical Test for Sensory Interaction in Balance (MCTSIB). Statistical analyses included analysis of covariance for group comparisons and a multivariate analysis of covariance for MCTSIB sway velocities with anthropometric controls. The TBI group (mean [ M] age = 42, standard deviation [ SD] =19.5 years; 70% males) performed significantly more poorly on all mobility tests ( p < .05) and their scores reflected a potential fall risk. Gait velocity was significantly slower for the TBI versus control group ( M = .96, SD = 2.6 vs. M = 1.5, SD = 2.2 m/s; p < .001), including TUG times ( M = 13.5, SD = 4.9 vs. M = 7.7, SD = 1.4; p < .001). TBI participants also demonstrated significantly greater sway velocity on all MCTSIB conditions ( p < .01) and lower performance on the FABS ( p < .001). Performance indices indicate potential fall risk and community navigation compromise for individuals with moderate to severe TBI. Physical performance scores support the need for continued interventions to optimize functional mobility upon discharge.

Outcomes following a locomotor training protocol on balance, gait, exercise capacity, and community integration in an individual with a traumatic brain injury: a case report

Background and Purpose: The NeuroRecovery Network (NRN) established a locomotor training protocol that has shown promising results for individuals with spinal cord injury, yet research to date has not determined its feasibility in those with traumatic brain injury (TBI). The purpose of this case report was to determine the feasibility of implementing the NRN protocol in an individual with a TBI. Case Description: The participant was a 38-year-old male, 21 years post-TBI. Twenty-four sessions of the therapy portion of the NRN protocol were provided. Outcome measures included the Berg Balance Scale (BBS), spatial temporal parameters of gait, 6-Minute Walk Test and Community Integration Questionnaire (CIQ). Outcomes: His BBS score improved from 37/56 to 43/56. Left step length improved; although gait speed, cadence, stride length and right step length did not. Observable changes were noted in quality of gait. Six-Minute Walk Distance increased by 47.2 m while CIQ score changes did not exceed the minimal detectable change (MDC) value. Discussion: Use of the NRN protocol may be feasible in individuals with TBI, though 24 sessions may not have been enough to achieve the full potential benefit of this intervention in an individual with a chronic TBI.

An Immersive Virtual Reality Platform to Enhance Walking Ability of Children with Acquired Brain Injuries

Background: Acquired brain injury (ABI) may result in lifelong impairment of physical, cognitive, and psychosocial functions. Several rehabilitative treatments are often needed to support walking recovery, thus participants’ engagement becomes a crucial aspect, especially when patients are children. In the last few years, traditional physiotherapy (PT) has been flanked by innovative technologies for rehabilitation in the fields of robotics and Virtual Reality (VR). Preliminary results have shown interesting perspectives in the use of a VR system, the GRAIL (Gait Real-time Analysis Interactive Lab), in improving walking abilities in a small group of children with ABI, although further insights are needed about its use as rehabilitative tool in the pediatric population.

Objectives: To evaluate the efficacy of a rehabilitation treatment on a GRAIL system for the improvement of walking abilities, in a group of children suffering from ABI.

Methods: 12 children with ABI (study group – SG; mean age = 12.1 ± 3.8 years old) underwent a 10-session treatment with the GRAIL, an instrumented multi-sensor platform based on immersive VR for gait training and rehabilitation in engaging VR environments. Before (T0) and at the end of the treatment (T1), the participants were assessed by means of functional scales (Gross Motor Function Measure (GMFM), Functional Assessment Questionnaire (FAQ), 6-Minute Walk Test (6minWT) and the 3D-Gait Analysis, over ground (OGA) and on GRAIL (GGA).

Results: All the participants completed the rehabilitative treatment. The functional evaluations showed an improvement in Gross Motor abilities (GMFM-88, p = 0.008), especially in standing (GMFM-D, p = 0.007) and walking (GMFM-E, p = 0.005), an increase of the endurance (6minWT, p = 0.002), and enhanced autonomy in daily life activities (FAQ, p = 0.025). OGA identified a significant decrease of the Gillette Gait Index for the impaired side and a general increase of symmetry. GGA showed improvements in spatiotemporal parameters and joints range of motion that moved towards normality and symmetry recovery.

Conclusions: A 10-session treatment with GRAIL on children with ABI led to improvements in their walking abilities and enhanced their engagement during the training. This is desirable when long life impairments are faced and children’s motor functions have to be regained and it supports the leading role that VR might have in the rehabilitation field.

Proof-of-Concept Testing of a Real-Time mHealth Measure to Estimate Postural Control During Walking: A Potential Application for Mild Traumatic Brain Injuries

Background: Most individuals with mild traumatic brain injury (mTBI) experience post-injury deficits in postural control. Currently available measures of postural control are lab-based or supervised, which may hinder timely symptom assessment for individuals with mTBI, including Asian populations, who do not seek initial screening post-injury. In this proof-of-concept testing study, we introduce a real-time mobile health (mHealth) system to measure postural control during walking. The proposed mHealth system can be used for home-based symptom assessment and management of mTBI.

Methods: In our proposed mHealth system, a smartwatch, a smartphone, and a cloud server communicate to measure, collect, and store body balance data in real time. Specifically, we focus on the rotation vector data that have been reported to be the most effective in terms of differentiating balance control during walking across different participants.

Results: Constant motion change in four participants (two females and two males; three healthy participants, and one individual with reduced physical mobility) was collected and analyzed. The results of our data analysis show that, compared to healthy participants, the individual was reduced physical mobility had a wider range of motion between right and left, up and down, and forward and backward while walking. We also found that female participants had narrower ranges of right-to-left and up-and-down motions than their male counterparts.

Conclusions: Our results highlight the potential of the proposed real-time mHealth system for home-based symptom assessment and management of mTBI, which may benefit Asian and other nonwhite racial minority groups that appear to be more reluctant to access post-acute rehabilitation services.

A Clinical Framework for Functional Recovery in a Person With Chronic Traumatic Brain Injury: A Case Study

BACKGROUND AND PURPOSE

This case study describes a task-specific training program for gait walking and functional recovery in a young man with severe chronic traumatic brain injury.

CASE DESCRIPTION

The individual was a 26-year-old man 4 years post-traumatic brain injury with severe motor impairments who had not walked outside of therapy since his injury. He had received extensive gait training prior to initiation of services. His goal was to recover the ability to walk.

INTERVENTION

The primary focus of the interventions was the restoration of walking. A variety of interventions were used, including locomotor treadmill training, electrical stimulation, orthoses, and specialized assistive devices. A total of 79 treatments were delivered over a period of 62 weeks.

OUTCOMES

At the conclusion of therapy, the client was able to walk independently with a gait trainer for approximately 1km (over 3000 ft) and walked in the community with the assistance of his mother using a rocker bottom crutch for distances of 100m (330 ft).

DISCUSSION

Specific interventions were intentionally selected in the development of the treatment plan. The program emphasized structured practice of the salient task, that is, walking, with adequate intensity and frequency. Given the chronicity of this individual's injury, the magnitude of his functional improvements was unexpected.Video Abstract available for additional insights from the Authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A175).

SIRT1 plays a neuroprotective role in traumatic brain injury in rats via inhibiting the p38 MAPK pathway

Traumatic brain injury (TBI) is a major cause of disability and death in patients who experience a traumatic injury. Mitochondrial dysfunction is one of the main factors contributing to secondary injury in TBI-associated brain damage. Evidence of compromised mitochondrial function after TBI has been, but the molecular mechanisms underlying the pathogenesis of TBI are not well understood. Silent information regulator family protein 1 (SIRT1), a member of the NAD⁺-dependent protein deacetylases, has been shown to exhibit neuroprotective activities in animal models of various pathologies, including ischemic brain injury, subarachnoid hemorrhage and several neurodegenerative diseases. In this study, we investigated whether SIRT1 also exert neuroprotective effect post-TBI, and further explored the possible regulatory mechanisms involved in TBI pathogenesis. A lateral fluid-percussion (LFP) brain injury model was established in rats to mimic the insults of TBI. The expression levels of SIRT1, p-p38, cleaved caspase-9 and cleaved caspase-3 were all markedly increased and reached a maximum at 12 h post-TBI. In addition, mitochondrial function was impaired, evidenced by the presence of swollen and irregularly shaped mitochondria with disrupted and poorly defined cristae, a relative increase of the percentage of neurons with low ΔΨm, the opening of mPTP, and a decrease in neuronal ATP content, especially at 12 h post-TBI. Pretreatment with the SIRT1 inhibitor sirtinol (10 mg/kg, ip) induced p-p38 activation, exacerbated mitochondrial damage, and promoted the activation of the mitochondrial apoptosis pathway. In contrast, pretreatment with the p38 inhibitor SB203580 (200 μg/kg, ip) significantly attenuated post-TBI-induced expression of both cleaved caspase-9 and cleaved caspase-3 and mitochondrial damage, whereas it had no effects on SIRT1 expression. Together, these results reveal that the 12 h after TBI may be a crucial time at which secondary damage occurs; the activation of SIRT1 expression and inhibition of the p38 MAPK pathway may play a neuroprotective role in preventing secondary damage post-TBI. For this reason, both SIRT1 and p38 are likely to be important targets to prevent secondary damage post-TBI.

Comparison of functional outcomes in elderly who have sustained a minor trauma with or without head injury: a prospective multicenter cohort study

OBJECTIVES

The consequences of minor trauma involving a head injury (MT-HI) in independent older adults are largely unknown. This study assessed the impact of a head injury on the functional outcomes six months post-injury in older adults who sustained a minor trauma.

METHODS

This multicenter prospective cohort study in eight sites included patients who were aged 65 years or older, previously independent, presenting to the emergency department (ED) for a minor trauma, and discharged within 48 hours. To assess the functional decline, we used a validated test: the Older Americans' Resources and Services Scale. The cognitive function of study patients was also evaluated. Finally, we explored the influence of a concomitant injury on the functional decline in the MT-HI group.

RESULTS

All 926 eligible patients were included in the analyses: 344 MT-HI patients and 582 minor trauma without head injury. After six months, the functional decline was similar in both groups: 10.8% and 11.9%, respectively (RR=0.79 [95% CI: 0.55-1.14]). The proportion of patients with mild cognitive disabilities was also similar: 21.7% and 22.8%, respectively (RR=0.91 [95% CI: 0.71-1.18]). Furthermore, for the group of patients with a MT-HI, the functional outcome was not statistically different with or without the presence of a co-injury (RR=1.35 [95% CI: 0.71-2.59]).

CONCLUSION

This study did not demonstrate that the occurrence of a MT-HI is associated with a worse functional or cognitive prognosis than other minor injuries without a head injury in an elderly population, six months after injury.

Effects of a rapid-resisted elliptical training program on motor, cognitive and neurobehavioral functioning in adults with chronic traumatic brain injury

This small clinical trial utilized a novel rehabilitation strategy, rapid-resisted elliptical training, in an effort to increase motor, and thereby cognitive, processing speed in ambulatory individuals with traumatic brain injury (TBI). As an initial step, multimodal functional abilities were quantified and compared in 12 ambulatory adults with and 12 without TBI. After the baseline assessment, the group with TBI participated in an intensive 8-week daily exercise program using an elliptical trainer and was reassessed after completion and at an 8-week follow-up. The focus of training was on achieving a fast movement speed, and once the target was reached, resistance to motion was increased in small increments to increase intensity of muscle activation. Primary outcomes were: High-Level Mobility Assessment Tool (HiMAT), instrumented balance tests, dual-task (DT) performance and neurobehavioral questionnaires. The group with TBI had poorer movement excursion during balance tests and poorer dual-task (DT) performance. After training, balance reaction times improved and were correlated with gains in the HiMAT and DT. Sleep quality also improved and was correlated with improved depression and learning. This study illustrates how brain injury can affect multiple linked aspects of functioning and provides preliminary evidence that intensive rapid-resisted training has specific positive effects on dynamic balance and more generalized effects on sleep quality in TBI.

Combined robotic-aided gait training and physical therapy improve functional abilities and hip kinematics during gait in children and adolescents with acquired brain injury

PURPOSE

To evaluate the combined effect of robotic-aided gait training (RAGT) and physical therapy (PT) on functional abilities and gait pattern in children and adolescents exiting acquired brain injury (ABI), through functional clinical scales and 3D-Gait Analysis (GA).

METHODS

A group of 23 patients with ABI underwent 20 sessions of RAGT in addition to traditional manual PT. All the patients were evaluated before and after the training by using the Gross Motor Function Measures (GMFM) and the Functional Assessment Questionnaire. Ambulant children were also evaluated through the 6 Minutes Walk Test (6MinWT) and GA. Finally, results were compared with those obtained from a control group of ABI children who underwent PT only.

RESULTS

After the training, the GMFM showed significant improvement in both dimensions 'D' (standing) and 'E' (walking). In ambulant patients the 6MinWT showed significant improvement after training and GA highlighted a significant increase in cadence, velocity and stride length. Moreover, hip kinematics on the sagittal plane revealed a statistically significant increase in range of motion (ROM) during the whole gait cycle, increased hip extension during terminal stance and increased ROM during the swing phase.

CONCLUSIONS

The data suggest that the combined programme RAGT + PT induces improvements in functional activities and gait pattern in children and adolescents with ABI and demonstrated it to be an elective tool for the maintenance of the patients' full compliance throughout the rehabilitative programme.

Effects of traumatic brain injury on locomotor adaptation

BACKGROUND AND PURPOSE

Locomotor adaptation is a form of short-term learning that enables gait modifications and reduces movement errors when the environment changes. This adaptation is critical for community ambulation for example, when walking on different surfaces. While many individuals with traumatic brain injury (TBI) recover basic ambulation, less is known about recovery of more complex locomotor skills, like adaptation. The purpose of this study was to investigate how TBI affects locomotor adaptation.

METHODS

Fourteen adults with TBI and 11 nondisabled comparison participants walked for 15 minutes on a split-belt treadmill with 1 belt moving at 0.7 m/s, and the other at 1.4 m/s. Subsequently, aftereffects were assessed and de-adapted during 15 minutes of tied-belt walking (both belts at 0.7 m/s).

RESULTS

Participants with TBI showed greater asymmetry in interlimb coordination on split-belts than the comparison group. Those with TBI did not adapt back to baseline symmetry, and some individuals did not store significant aftereffects. Greater asymmetry on split-belts and smaller aftereffects were associated with greater ataxia.

DISCUSSION

Participants with TBI were more perturbed by walking on split-belts and showed some impairment in adaptation. This suggests a reduced ability to learn a new form of coordination to compensate for environmental changes. Multiple interacting factors, including cerebellar damage and impairments in higher-level cognitive processes, may influence adaptation post-TBI.

CONCLUSIONS

Gait adaptation to novel environment demands is impaired in persons with chronic TBI and may be an important skill to target in rehabilitation.

VIDEO ABSTRACT AVAILABLE

(See Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A74) for more insights from the authors.

Rehabilitation after traumatic brain injury

Traumatic brain injury (TBI) is a growing problem in the US, with significant morbidity and economic implications. This diagnosis spans a wide breath of injuries from concussion to severe TBI. Thus, rehabilitation is equally diverse in its treatment strategies targeting those symptoms that are functionally limiting with the ultimate goal of independence and community reintegration. In severe TBI, rehabilitation can be lifelong. Acute care rehabilitation focuses on emergence from coma and prognostication of recovery. Therapeutic modalities and exercise, along with pharmacologic intervention, can target long-term motor and cognitive sequelae. Complications of severe TBI that are functionally limiting and impede therapy include heterotopic ossification, agitation, dysautonomia, and spasticity. In mild TBI, most patients recover quickly but education on repeat exposure is imperative, with the implications of consecutive injuries being potentially devastating. Furthermore, rehabilitation targets lingering symptoms including sleep disturbance, visuospatial deficits, headaches, and cognitive dysfunction. As research on the entire TBI population improves, commonalities in the disease process may emerge, helping rationalize therapeutic interventions and providing more robust targets for treatment.

Remote brain network changes after unilateral cortical impact injury and their modulation by acetylcholinesterase inhibition

We explored whether cerebral cortical impact injury (CCI) effects extend beyond direct lesion sites to affect remote brain networks, and whether acetylcholinesterase (AChE) inhibition elicits discrete changes in functional activation of motor circuits following CCI. Adult male rats underwent unilateral motor-sensory CCI or sham injury. Physostigmine (AChE inhibitor) or saline were administered subcutaneously continuously via implanted minipumps (1.6 micromoles/kg/day) for 3 weeks, followed by cerebral perfusion mapping during treadmill walking using [(14)C]-iodoantipyrine. Quantitative autoradiographs were analyzed by statistical parametric mapping and functional connectivity (FC) analysis. CCI resulted in functional deficits in the ipsilesional basal ganglia, with increased activation contralesionally. Recruitment was also observed, especially contralesionally, of the red nucleus, superior colliculus, pedunculopontine tegmental nucleus, thalamus (ventrolateral n., central medial n.), cerebellum, and sensory cortex. FC decreased significantly within ipsi- and contralesional motor circuits and between hemispheres, but increased between midline cerebellum and select regions of the basal ganglia within each hemisphere. Physostigmine significantly increased functional brain activation in the cerebellar thalamocortical pathway (midline cerebellum→ventrolateral thalamus→motor cortex), subthalamic nucleus/zona incerta, and red nucleus and bilateral sensory cortex. In conclusion, CCI resulted in increased functional recruitment of contralesional motor cortex and bilateral subcortical motor regions, as well as recruitment of the cerebellar-thalamocortical circuit and contralesional sensory cortex. This phenomenon, augmented by physostigmine, may partially compensate motor deficits. FC decreased inter-hemispherically and in negative, but not positive, intra-hemispherical FC, and it was not affected by physostigmine. Circuit-based approaches into functional brain reorganization may inform future behavioral or molecular strategies to augment targeted neurorehabilitation.

Dual-task training for balance and mobility in a person with severe traumatic brain injury: a case study

BACKGROUND AND PURPOSE

Attentional impairments following severe traumatic brain injury (TBI) are common and can lead to decreased functional mobility and balance, as well as deficits in previously automatic movements such as walking and stair climbing. The purpose of this case study was to determine the feasibility and potential value of incorporating a cognitive-motor dual-task training program into physical therapy for a patient with a severe TBI.

CASE DESCRIPTION

The patient was a 26-year-old woman who sustained a severe TBI during a motor vehicle accident 46 days prior to physical therapy evaluation. On the 8-level Rancho Los Amigos Cognitive Function Scale, her functioning was classified as level IV. She had impairments in attention, functional mobility, and balance, all of which limited her ability to participate in activities of daily living.

INTERVENTION

: Physical therapy was provided over 26 days within the inpatient rehabilitation setting. Interventions included mobility tasks such as walking, balancing, and stair climbing. Mobility training was paired with specific secondary cognitive and motor tasks.

OUTCOMES

Dual-task training may have contributed to improvements on outcome measures designed to test divided attention including the Walking While Talking Test and Trail Making Test and a greater rate of improvement in walking speed and time to descend stairs when compared to the baseline phase.

DISCUSSION

Addition of cognitive-motor dual-task training to standard physical therapy in the inpatient rehabilitation setting appears to be feasible and may have value for improving function in individuals with severe TBI.

VIDEO ABSTRACT AVAILABLE

(see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A41) for more insights from the authors.

A multidimensional physical therapy program for individuals with cerebellar ataxia secondary to traumatic brain injury: a case series

The purpose of this case series is to describe changes in impairments and activity limitations in three individuals with severe cerebellar ataxia from traumatic brain injury (TBI) who participated in a long-term, multidimensional physical therapy program. A secondary purpose is to document use of a climbing wall for these persons. Each of the individuals had a TBI, severe ataxia and was admitted to a transitional neuro-rehabilitation day treatment program. The first person, a 22-year-old, was 6 years post injury and had 127 individual physical therapy sessions over 12 months. The second person, a 16-year-old, was 5½ months post injury and had 187 individual therapy sessions over 19 months. The third person, a 20-year-old, was 6 months post injury and had 89 individual therapy sessions over 23 months. An integrative treatment approach was used, and the individuals participated in activities to minimize ataxia and improve mobility. Each of them made gains in coordination, balance, balance confidence, endurance and mobility. The three individuals with cerebellar ataxia participated in a long-term, individualized, multidimensional physical therapy treatment program, and made improvements in all areas of impairment and activity limitations. This study reinforces the need for long-term, multidimensional physical therapy for individuals with ataxia.

The Relationship between Acute Functional Status and Long-Term Ambulation after Severe Traumatic Brain Injury

Objective. To correlate long-term physical impairments of patients with severe traumatic brain injury (sTBI) based on their functional status in an acute care setting. Methods. 46 patients with sTBI participated in this prospective study. The Extended Glasgow Outcome Scale (GOSE) and the FIM instrument were rated at discharge from the acute care setting and at followup. The Functional Ambulation Classification (FAC), the Five-Meter Gait Speed, a quantified measure of negotiating stairs (Stair Climbing Speed and Rails used), and the functional reach test were rated at followup. Results. The subject with a score of 6 on the GOSE at discharge remained nonfunctional ambulator at followup. None of the subjects with a GOSE score of 5 became independent ambulators. Fifty percent of the subjects with a GOSE score of 4 were dependent ambulators. 100% of the subjects with a GOSE score of 2 or 3 at discharge were independent ambulators. A higher FIM score at discharge was associated with a greater chance of ambulating independently at 2 to 5 years after TBI (χKW22df). Conclusions. These data will allow physical health professionals in acute rehabilitation settings to provide more precise long-term physical outcome information to patients and families.

Measuring Balance and Mobility after Traumatic Brain Injury: Validation of the Community Balance and Mobility Scale (CB&M)

PURPOSE

To further investigate the construct validity of the Community Balance and Mobility Scale (CB&M), developed for ambulatory individuals with traumatic brain injury (TBI).

METHODS

A convenience sample of 35 patients with TBI (13 in-patients, 22 outpatients) was recruited. Analyses included a comparison of CB&M and Berg Balance Scale (BBS) admission and change scores and associations between the CB&M and measures of postural sway, gait, and dynamic stability; the Community Integration Questionnaire (CIQ); and the Activities-specific Balance Confidence (ABC) Scale.

RESULTS

Mean admission scores on the BBS and the CB&M were 53.6/56 (SD=4.3) and 57.8/96 (SD=23.3) respectively. Significant correlations were demonstrated between the CB&M and spatiotemporal measures of gait, including walking velocity, step length, step width, and step time; measures of dynamic stability, including variability in step length and step time; and the ABC (p<0.05). Significant correlations between the CB&M and CIQ were revealed with a larger data set (n=47 outpatients) combined from previous phases of research.

CONCLUSIONS

In patients with TBI, the CB&M is less susceptible to a ceiling effect than the BBS. The construct validity of the CB&M was supported, demonstrating associations with laboratory measures of dynamic stability, measures of community integration, and balance confidence.

Clinical characteristics and pathophysiological mechanisms of focal and diffuse traumatic brain injury

Traumatic brain injury (TBI) is a frequent and clinically highly heterogeneous neurological disorder with large socioeconomic consequences. TBI severity classification, based on the hospital admission Glasgow Coma Scale (GCS) score, ranges from mild (GCS 13-15) and moderate (GCS 9-12) to severe (GCS ≤ 8). The GCS reflects the risk of dying from TBI, which is low after mild (∼1%), intermediate after moderate (up to 15%) and high (up to 40%) after severe TBI. Intracranial damage can be focal, such as epidural and subdural haematomas and parenchymal contusions, or diffuse, for example traumatic axonal injury and diffuse cerebral oedema, although this distinction is somewhat arbitrary. Study of the cellular and molecular post-traumatic processes is essential for the understanding of TBI pathophysiology but even more to find therapeutic targets for the development of neuroprotective drugs to be eventually used in human beings. To date, studies in vitro and in vivo, mainly in animals but also in human beings, are unravelling the pathological TBI mechanisms at high pace. Nevertheless, TBI pathophysiology is all but completely elucidated. Neuroprotective treatment studies in human beings have been disappointing thus far and have not resulted in commonly accepted drugs. This review presents an overview on the clinical aspects and the pathophysiology of focal and diffuse TBI, and it highlights several acknowledged important events that occur on molecular and cellular level after TBI.

Assessment of gait recovery in children after Traumatic Brain Injury

OBJECTIVE

The aims were: (1) to quantify the functional limitation of children at the beginning of recovery of independent ambulation after Traumatic Brain Injury (TBI), using clinical-functional scales; (2) to evaluate the changes in gait pattern during rehabilitation (about 5 months later), using 3D Gait Analysis (GA) in post-acute phase; (3) to investigate the presence of correlation among parameters obtained by 3DGA, clinical assessment and measures connected with the trauma.

METHODS

Fourteen children with hemiplegia after severe TBI were evaluated at independent gait recovery (S0) and 5.5 months later (S1) by clinical assessment (GOS, DRS, WeeFIM and GMFM) and 3D GA (spatio-temporal parameters, kinematics and kinetics).

RESULTS

At S1 all clinical measures had improved. Regarding spatio-temporal parameters, velocity and step length improved. Significant progress was evident at the ankle joint, while an unchanged condition appeared at pelvis and hip in sagittal plane with a worsening of hip rotation which increased its internal rotation. Significant correlations were found between motor performance, clinical assessment and trauma-related measures.

CONCLUSIONS

Repeated GA and clinical evaluations were useful in quantifying the motor recovery of children with TBI during rehabilitation underpinning the role of GA in quantifying these modifications in an objective and non-invasive way.

N-methyl-D-aspartate preconditioning improves short-term motor deficits outcome after mild traumatic brain injury in mice

Traumatic brain injury (TBI) causes impairment of fine motor functions in humans and nonhuman mammals that often persists for months after the injury occurs. Neuroprotective strategies for prevention of the sequelae of TBI and understanding the molecular mechanisms and cellular pathways are related to the glutamatergic system. It has been suggested that cellular damage subsequent to TBI is mediated by the excitatory neurotransmitters, glutamate and aspartate, through the excessive activation of the N-methyl-D-aspartate (NMDA) receptors. Thus, preconditioning with a low dose of NMDA was used as a strategy for protection against locomotor deficits observed after TBI in mice. Male adult mice CF-1 were preconditioned with NMDA (75 mg/kg) 24 hr before the TBI induction. Under anesthesia with O(2)/N(2)O (33%: 66%) inhalation, the animals were subjected to the experimental model of trauma that occurs by the impact of a 25 g weight on the skull. Sensorimotor gating was evaluated at 1.5, 6, or 24 hr after TBI induction by using footprint and rotarod tests. Cellular damage also was assessed 24 hr after occurrence of cortical trauma. Mice preconditioned with NMDA were protected against all motor deficits revealed by footprint tests, but not those observed in rotarod tasks. Although mice showed motor deficits after TBI, no cellular damage was observed. These data corroborate the hypothesis that glutamatergic excitotoxicity, especially via NMDA receptors, contributes to severity of trauma. They also point to a putative neuroprotective mechanism induced by a sublethal dose of NMDA to improve motor behavioral deficits after TBI.

Abnormal corticospinal excitability in traumatic diffuse axonal brain injury

This study aimed to investigate the cortical motor excitability characteristics in diffuse axonal injury (DAI) due to severe traumatic brain injury (TBI). A variety of excitatory and inhibitory transcranial magnetic stimulation (TMS) paradigms were applied to primary motor cortices of 17 patients and 11 healthy controls. The parameters of testing included resting motor threshold (MT), motor evoked potential (MEP) area under the curve, input-output curves, MEP variability, and silent period (SP) duration. The patient group overall revealed a higher MT, smaller MEP areas, and narrower recruitment curves compared to normal controls (p < 0.05). The alterations in excitability were more pronounced with an increase in DAI severity (p < 0.005) and the presence of motor impairment (p < 0.05), while co-existence of focal lesions did not affect the degree of MEP changes. MEP variability was significantly lower in the group with motor impairment only (p < 0.05). The intracortical inhibition, as revealed by SP duration, did not exhibit any significant differences in any of the patient groups. In conclusion, our findings expand the concept that impairment of the excitatory and inhibitory phenomena in the motor cortex does not proceed in parallel and demonstrate distinct patterns of aberrations in TBI. Furthermore, these data suggest that alterations in the corticospinal excitatory mechanisms are determined predominantly by the severity of DAI, and show a significant relationship with clinical motor dysfunction following severe trauma diffusely affecting the motor cortical connections. In severe TBI, motor and functional recovery might be linked to restitution of normal corticospinal mechanisms, indexed by normalization of the cortical excitability parameters.

Can measures of cognitive function predict locomotor behaviour in complex environments following a traumatic brain injury?

PRIMARY OBJECTIVE

To determine the relationships between clinical measures of executive function and attention, and laboratory measures of anticipatory locomotor adaptations with dual tasks following a TBI.

METHODS AND PROCEDURES

Ten people with moderate or severe TBI were compared to 10 healthy subjects for neuropsychological measures in the clinic, as well as locomotor patterns and reading time in the laboratory for adapted Stroop tasks (Bar and Word) during unobstructed and obstructed walking.

MAIN OUTCOMES AND RESULTS

As previously found 1 (Vallee M, McFadyen BJ, Swaine B, Doyon J, Cantin JF, Dumas D. Effects of environmental demands on locomotion after traumatic brain injury. Archives of Physical Medicine Rehabilitation 2006;87:806--813) during the locomotor activities, subjects with TBI walked slower, had higher clearance margins and took longer to read during the Stroop tasks than healthy subjects. In general, subjects with TBI also showed deficits in executive functions and attention. Significant relationships were specifically observed between scores on Trail Making B and clearance margins for subjects with TBI, but not for healthy subjects. Alternatively, significant relationships between clinical scores on Stroop and dual task Stroop reading times were obtained for healthy subjects but not for subjects with TBI.

CONCLUSIONS

These results suggest that measures of executive functioning and attention may be associated to locomotor behaviour in complex environments following a moderate to severe TBI.

Gait rehabilitation with body weight-supported treadmill training for a blast injury survivor with traumatic brain injury

BACKGROUND AND PURPOSE

Research supports the use of body weight-supported treadmill training (BWSTT) in patients with hemi-paresis and may show promise as a gait training and neuromuscular re-education intervention in the blast-injured, traumatic brain injury (TBI) population. The purpose of this case study is to document the use BWSTT and goal-directed therapy in the improvement of gait quality, gait speed and maximum distance ambulated in a blast injury survivor with TBI.

CASE DESCRIPTION

A 36-year-old male soldier injured by a rocket propelled grenade in Iraq who began physical therapy and gait training incorporating purposeful postural stability and mobility interventions as well as BWSTT.

OUTCOMES

Missouri Assisted Gait scores, six-minute walk distances, and maximum distance ambulated all increased post gait training with BWSTT as a component to PT intervention.

DISCUSSION

Intensive gait training including BWSTT may have some efficacy in managing significant blast trauma patients with TBI however, further research is necessary to establish efficacy and appropriateness in this patient population.

Comparison of the O-Log and GOAT as measures of posttraumatic amnesia

PRIMARY OBJECTIVE

To compare PTA severity and duration assessments made by Orientation Log (O-Log) and the Galveston Orientation and Amnesia Test (GOAT) and the relationship of data yielded by these assessments to rehabilitation outcomes.

RESEARCH DESIGN

Retrospective study.

METHODS AND PROCEDURES

O-Log, GOAT, demographic, length of stay, and Functional Independence Measure (FIM) data among 83 inpatient subjects with recent TBI requiring inpatient care were reviewed.

MAIN OUTCOMES AND RESULTS

PTA severity and duration as assessed by the O-Log and the GOAT are statistically similar and correlate similarly with rehabilitation LOS and discharge total FIM score. Simple linear regression models suggest that O-Log scores better predict rehabilitation outcomes than GOAT scores.

CONCLUSIONS

Although the O-Log and GOAT perform similarly as measures of PTA severity and duration, PTA assessments using the O-Log offers better prediction of rehabilitation outcomes. Further study of the O-Log as an alternate assessment of PTA is warranted.