Individuals with chronic traumatic brain injury improve walking speed and mobility with intensive mobility training

Estimating highest capacity propulsion performance using backward-directed force during walking evaluation for individuals with acquired brain injury

There are over 5.3 million Americans who face acquired brain injury (ABI)-related disability as well as almost 800,000 who suffer from stroke each year. To improve mobility and quality of life, rehabilitation professionals often focus on walking recovery soon after hospital discharge for ABI. Reduced propulsion capacity (force output of the lower limbs to counteract ground reaction forces) negatively impacts walking ability and complicates recovery during rehabilitation for brain injured people. We describe a method, using backward-directed resistance (BDR) in a robotic-based treadmill device, to allow measurement of maximum walking propulsion force (MWPF) that is not otherwise possible during overground walking assessment. Our objective was to test the construct validity of a maximum walking propulsion force (MWPF) measure that reflects a person's propulsive strength against applied BDR, while walking on a robotic treadmill-based device for participants with acquired brain injury (ABI). Our study enrolled 14 participants with ABI at an in inpatient rehabilitation in Galveston, TX from 8/1/21 - 4/31/22. The range of weight-adjusted MWPF was 2.6-27.1% body weight (%BW), mean 16.5 ± 8.4%BW, reflecting a wide range of propulsive force capability. The strongest correlation with overground tests was between the 6-minute walk test (6-MWT) distance and the MWPF values (r = 0.83, p < 0.001) with moderate correlations between the 10-meter walk tests at comfortable (CWS) and fast speeds (FWS). The Five Times Sit-to-Stand (used as a standard clinical measure of functional lower extremity strength) and MWPF tests were poorly correlated (r = 0.26, p = 0.4). Forward model selection included 6-MWT distance, age, and overground CWS as significant partial predictors of MWPF. We conclude that this novel MWPF measure is a valid representation of maximum propulsive force effort during walking for people post-ABI. Additional research could help determine the impact of interventions designed to increase propulsive force generation during rehabilitation training to improve overground walking performance.

Physical Activity Interventions That Address Motor and Balance Impairments and Skills for Adults With Traumatic Brain Injury (TBI) (2012-2021)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. The systematic review is on interventions to address motor and balance impairments to improve occupational performance for adults with traumatic brain injury.

Feasibility of virtual reality and treadmill training in traumatic brain injury: a randomized controlled pilot trial

OBJECTIVE

To evaluate the safety and efficacy of treadmill training with virtual reality compared to treadmill training alone and standard of care balance and mobility treatment in chronic traumatic brain injury (TBI).

PARTICIPANTS AND DESIGN

Thirty-one individuals with chronic TBI with self-reported and objective balance deficits participated in a 4-week 12 session intervention of treadmill training with virtual reality, treadmill training alone, or standard of care overground therapy.

OUTCOME MEASURES

Primary measures included recruitment and enrollment rates, retention, tolerance to intervention, completeness of outcome measures, and adverse events. Secondary measures included the Community Balance and Mobility Scale, 10 Meter Walk Test, 6 Minute Walk Test, and Timed Up and Go.

RESULTS

No serious adverse events were reported. All participants completed all training sessions and assessments at all time points. Recruitment, enrollment, and retention rates were high. All groups showed a trend toward improvement in all balance and mobility measures following treatment.

CONCLUSION

Virtual reality and treadmill training are safe and feasibile for individuals with TBI. Participants show improvements on balance and mobility measures following a 4-week intervention. Future research is needed to evaluate the efficacy of this intervention compared to other modes of balance and mobility training.

Wearable devices for tracking physical activity in the community after an acquired brain injury: A systematic review

OBJECTIVE

The application of wearable devices in individuals with acquired brain injury (ABI) resulting from stroke or traumatic brain injury (TBI) for monitoring physical activity (PA) has been relatively recent. The current systematic review aims to provide insights into the adaption of these devices, outcome metrics, and their transition from the laboratory to the community for PA monitoring of individuals with ABI.

LITERATURE SURVEY

The PubMed and Google Scholar databases were systematically reviewed using appropriate search terms. A total of 20 articles were reviewed from the past 15 years.

METHODOLOGY

Articles were classified into three categories - PA measurement studies, PA classification studies, and validation studies. The quality of studies was assessed using a quality appraisal checklist.

SYNTHESIS

It was found that the transition of wearable devices from in-lab to community-based studies in individuals with stroke has started but is not widespread. The transition of wearable devices in the community has not yet started for individuals with TBI. Accelerometer-based devices were more frequently chosen than pedometers and inertial measurement units. No consensus on a preferred wearable device (make or model) or wear location could be identified, though step count was the most common outcome metric. The accuracy and validity of most outcome metrics used in the community were not reported for many studies.

CONCLUSIONS

To facilitate future studies use wearable devices for PA measurement in the community, we recommend that researchers provide details on the accuracy and validity of the outcome metrics specific to the study environment. Once the accuracy and validity are established for a specific population, wearable devices and their derived outcomes can provide objective information on mobility impairment as well as the effect of rehabilitation in the community. This article is protected by copyright. All rights reserved.

Enhancing sensory acuity and balance function using near-sensory biofeedback-based perturbation intervention for individuals with traumatic brain injury

BACGROUND

Interventions addressing balance dysfunction after traumatic brain injury (TBI) only target compensatory aspects and do not investigate perceptual mechanisms such as sensory acuity.

OBJECTIVE

To evaluate the efficacy of a novel intervention that integrates sensory acuity with a perturbation-based approach for improving the perception and functional balance after TBI.

METHODS

A two-group design was implemented to evaluate the effect of a novel, perturbation-based balance intervention. The intervention group (n = 5) performed the intervention with the sinusoidal (0.33, 0.5, and 1 Hz) perturbations to the base of support with amplitudes derived using our novel outcome of sensory acuity - perturbation perception threshold (PPT). The efficacy is evaluated using changes in PPT and functional outcomes (Berg Balance Scale (BBS), Timed-up and Go (TUG), 5-meter walk test (5MWT), and 10-meter walk test (10MWT)).

RESULTS

There was a significant post-intervention change in PPT for 0.33 Hz (p = 0.021). Additionally, clinically and statistically significant improvements in TUG (p = 0.03), 5MWT (p = 0.05), and 10MWT (p = 0.04) were observed.

CONCLUSIONS

This study provides preliminary efficacy of a novel, near-sensory balance intervention for individuals with TBI. The use of PPT is suggested for a comprehensive understanding and treatment of balance dysfunction. The promising results support the investigation in a larger cohort.

Effects of physical therapy interventions on balance ability in people with traumatic brain injury: A systematic review

BACKGROUND

Balance deficits are common impairments in individuals with post-traumatic brain injury (TBI). Balance deficits can restrict the activities of daily living and productive participation in social life. To date, no systematic reviews have examined the impact of physical therapy intervention on balance post-TBI.

OBJECTIVE

To examine the effects of physical therapy interventions on balance impairments in individuals with TBI.

METHODS

We systematically searched in PubMed, EMBASE, Scopus, PEDro, MEDLINE, REHABDATA, and Web of Science for randomized controlled trials (RCTs), clinical control trials, and pilot studies that examined the effects of physical therapy interventions on balance deficits in individuals post-TBI. The methodological quality was estimated using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Eight studies published from 2003 to 2019 were included in this study. A total of 259 TBI participants post-TBI were included in this review, 71 (27.41%) of which were females. The methodological quality of the selected studies ranged from low to high. There were no significant differences between experimental interventions, virtual reality (VR), vestibular rehabilitation therapy (VRT), control group interventions, and other traditional physical therapy interventions.

CONCLUSIONS

The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited. Further randomized controlled trials are strongly warranted to understand the role of physical therapy in patients with TBI who complain about balance deficits.

Translingual Neurostimulation for the Treatment of Chronic Symptoms Due to Mild-to-Moderate Traumatic Brain Injury

OBJECTIVE

To compare the efficacy of high- and low-frequency noninvasive translingual neurostimulation (TLNS) plus targeted physical therapy (PT) for treating chronic balance and gait deficits due to mild-to-moderate traumatic brain injury (mmTBI).

DESIGN

Participants were randomized 1:1 in a 26-week double-blind phase 1/2 study (NCT02158494) with 3 consecutive treatment stages: in-clinic, at-home, and no treatment. Arms were high-frequency pulse (HFP) and low-frequency pulse (LFP) TLNS.

SETTING

TLNS plus PT training was initiated in-clinic and then continued at home.

PARTICIPANTS

Participants (N=44; 18-65y) from across the United States were randomized into the HFP and LFP (each plus PT) arms. Forty-three participants (28 women, 15 men) completed at least 1 stage of the study. Enrollment requirements included an mmTBI ≥1 year prior to screening, balance disorder due to mmTBI, a plateau in recovery with current PT, and a Sensory Organization Test (SOT) score ≥16 points below normal.

INTERVENTIONS

Participants received TLNS (HFP or LFP) plus PT for a total of 14 weeks (2 in-clinic and 12 at home), twice daily, followed by 12 weeks without treatment.

MAIN OUTCOME MEASURES

The primary endpoint was change in SOT composite score from baseline to week 14. Secondary variables (eg, Dynamic Gait Index [DGI], 6-minute walk test [6MWT]) were also collected.

RESULTS

Both arms had a significant (P<.0001) improvement in SOT scores from baseline at weeks 2, 5, 14 (primary endpoint), and 26. DGI scores had significant improvement (P<.001-.01) from baseline at the same test points; 6MWT evaluations after 2 weeks were significant. The SOT, DGI, and 6MWT scores did not significantly differ between arms at any test point. There were no treatment-related serious adverse events.

CONCLUSIONS

Both the HFP+PT and LFP+PT groups had significantly improved balance scores, and outcomes were sustained for 12 weeks after discontinuing TLNS treatment. Results between arms did not significantly differ from each other. Whether the 2 dosages are equally effective or whether improvements are because of provision of PT cannot be conclusively established at this time.

Test-retest reliability and minimal detectable change of the computerized dynamic posturography PROPRIO for adults with chronic traumatic brain injury

PURPOSE

Balance deficits after brain injury, including reactive recovery from unexpected perturbations, can persist well after rehabilitation is concluded. While traditional clinical assessments are practical, the anticipatory nature of the tasks may mask perceptible balance control. Computerized dynamic posturography can directly quantify capacity to respond to unexpected, external perturbations. This study examined the reliability of the computerized dynamic posturography assessment with the device PROPRIO^® 4000 in adults with traumatic brain injury and created the minimal detectable change for its standardized test.

METHODS

Ten adults (ages 21-55 years) with chronic (average 10 ± 6 years post-injury) severe (loss of consciousness 2-75 days) brain injury performed three trials of the Propriotest^® on two separate days. The average of three trials and the best scores were used separately for analysis. Test-retest reliability was verified using Intraclass Correlation Coefficients with 95% confidence interval and standard error of measurement in relation to the Intraclass Correlation Coefficients at 95%. The minimal detectable change was calculated at 95% confidence level (minimal detectable change₉₅) and Bland-Altman plots were created to express agreement between measurement days.

RESULTS

The results exhibited excellent reliability for both average (Intraclass Correlation Coefficient of 0.969, standard error of measurement 50.9 points) and best (Intraclass Correlation Coefficient of 0.985, standard error of measurement 31.3 points) scores, with average and best minimal detectable change₉₅ of 141.0 and 86.7 points, respectively.

CONCLUSIONS

Clinicians and rehabilitation researchers can use these findings to determine if a Propriotest^® change score represents a true post-treatment effect with adults with chronic brain injury.IMPLICATIONS FOR REHABILITATIONAfter brain injury, balance deficits are common and can persist well after completion of rehabilitation programs.Computerized dynamic posturography allows for objective quantification of one's capacity to respond to external perturbations.The device PROPRIO^® 4000 provides reliable quantification of balance deficits of community dwelling individuals who have experienced a severe traumatic brain injury.The minimal detectable change scores created can assist clinicians and rehabilitation researchers detect whether a change in balance score represents a true effect of an intervention at post-treatment.

A retrospective study on the acceptability, feasibility, and effectiveness of LoveYourBrain Yoga for people with traumatic brain injury and caregivers

PURPOSE

To conduct a mixed methods, pre-post, retrospective study on the feasibility, acceptability, and effectiveness of the LoveYourBrain Yoga program.

MATERIALS AND METHODS

People were eligible if they were a traumatic brain injury survivor or caregiver, age 15-70, ambulatory, and capable of gentle exercise and group discussion. We analyzed attendance, satisfaction, and mean differences in scores on Quality of Life After Brain Injury Overall scale (QOLIBRI-OS) and four TBI-QOL/Neuro-QOL scales. Content analysis explored perceptions of benefits and areas of improvement.

RESULTS

1563 people (82.0%) participated ≥1 class in 156 programs across 18 states and 3 Canadian provinces. Mean satisfaction was 9.3 out of 10 (SD 1.0). Mixed effects linear regression found significant improvements in QOLIBRI-OS (B 9.70, 95% CI: 8.51, 10.90), Resilience (B 1.30, 95% CI: 0.60, 2.06), Positive Affect and Well-being (B 1.49, 95% CI: 1.14, 1.84), and Cognition (B 1.48, 95% CI: 0.78, 2.18) among traumatic brain injury survivors (n = 705). No improvement was found in Emotional and Behavioral Dysregulation, however, content analysis revealed better ability to regulate anxiety, anger, stress, and impulsivity. Caregivers perceived improvements in physical and psychological health.

CONCLUSIONS

LoveYourBrain Yoga is feasible and acceptable and may be an effective mode of community-based rehabilitation.IMPLICATIONS FOR REHABILITATIONPeople with traumatic brain injury and their caregivers often experience poor quality of life and difficulty accessing community-based rehabilitation services.Yoga is a holistic, mind-body therapy with many benefits to quality of life, yet is largely inaccessible to people affected by traumatic brain injury in community settings.Participants in LoveYourBrain Yoga, a six-session, community-based yoga with psychoeducation program in 18 states and 3 Canadian provinces, experienced significant improvements in quality of life, resilience, cognition, and positive affect.LoveYourBrain Yoga is feasible and acceptable when implemented on a large scale and may be an effective mode of, or adjunct to, community-based rehabilitation.

Examining the relationship and clinical management between traumatic brain injury and pain in military and civilian populations

In this review, we discuss the comorbidity of traumatic brain injury (TBI) and pain among civilians and military members, the common causes of pain resulting from TBI, and offer insight about the therapeutic management of TBI symptoms and pain. Traumatic brain injury (TBI) is a debilitating health problem and one of the most common post-TBI symptoms is pain, which can contribute to psychological issues such as Post-traumatic stress disorder (PTSD) and depression. Headache pain appears to be the most common type of pain that results from TBI, yet pain can also be more widespread. Managing TBI symptoms and pain simultaneously is difficult because extensive randomized control and clinical studies assessing the effectiveness of therapeutic approaches are lacking. Pharmacological agents such as antidepressants and Triptans and nonpharmacological therapies such as cognitive rehabilitation and physical therapies are commonly used yet it is unknown how effective these therapies are in the long-term. A combination of pharmacological and non-pharmacological therapies is often more effective for managing TBI symptoms and pain than either treatment alone. However, future research is needed to determine the most therapeutic approaches for managing the comorbidity of pain and TBI symptoms in the long term. This review offers suggestions for such future studies.

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.

The effects of video game therapy on balance and attention in chronic ambulatory traumatic brain injury: an exploratory study

Background

Patients with traumatic brain injury often have balance and attentive disorders. Video game therapy (VGT) has been proposed as a new intervention to improve mobility and attention through a reward-learning approach. In this pilot randomized, controlled trial, we tested the effects of VGT, compared with a balance platform therapy (BPT), on balance, mobility and selective attention in chronic traumatic brain injury patients.

Methods

We enrolled chronic traumatic brain injury patients (n = 21) that randomly received VGT or BPT for 3 sessions per week for 6 weeks. The clinical outcome measures included: i) the Community Balance & Mobility Scale (CB&M); ii) the Unified Balance Scale (UBS); iii) the Timed Up and Go test (TUG); iv) static balance and v) selective visual attention evaluation (Go/Nogo task).

Results

Both groups improved in CB&M scores, but only the VGT group increased on the UBS and TUG with a between-group significance (p < 0.05). Selective attention improved significantly in the VGT group (p < 0.01).

Conclusions

Video game therapy is an option for the management of chronic traumatic brain injury patients to ameliorate balance and attention deficits.

Trial registration

NCT01883830, April 5 2013.

A Comparison of Locomotor Therapy Interventions: Partial-Body Weight-Supported Treadmill, Lokomat, and G-EO Training in People With Traumatic Brain Injury

BACKGROUND

Literature in the application of gait training techniques in persons with traumatic brain injury (TBI) is limited. Current techniques require multiple staff and are physically demanding. The use of a robotic locomotor training may provide improved training capacity for this population.

OBJECTIVE

To examine the impact of 3 different modes of locomotor therapy on gait velocity and spatiotemporal symmetry using an end effector robot (G-EO); a robotic exoskeleton (Lokomat), and manual assisted partial-body weight-supported treadmill training (PBWSTT) in participants with traumatic brain injury.

DESIGN

Randomized, prospective study.

SETTING

Tertiary rehabilitation hospital.

PARTICIPANTS

A total of 22 individuals with ≥12 months chronic TBI with hemiparetic pattern able to walk overground without assistance at velocities between 0.2 and 0.6 m/s.

INTERVENTION

Eighteen sessions of 45 minutes of assigned locomotor training.

OUTCOME MEASURES

Overground walking self-selected velocity (SSV), maximal velocity (MV), spatiotemporal asymmetry ratio, 6-Minute Walk Test (6MWT), and mobility domain of Stroke Impact Scale (MSIS).

RESULTS

Severity in walking dysfunction was similar across groups as determined by walking velocity data. At baseline, participants in the Lokomat group had a baseline velocity that was slightly slower compared with the other groups. Training elicited a statistically significant median increase in SSV for all groups compared with pretraining (Lokomat, P = .04; G-EO, P = .03; and PBWSTT, P = .02) and MV excluding the G-EO group (Lokomat, P = .04; PBWSTT, P = .03 and G-EO, P = .15). There were no pre-post significant differences in swing time, stance time, and step length asymmetry ratios at SSV or MV for any of the interventions. Mean rank in the change of SSV and MV was not statistically significantly different between groups. Participants in the G-EO and PBWSTT groups significantly improved their 6MWT posttraining (P = .04 and .03, respectively). The MSIS significantly improved only for the Lokomat group (P = .04 and .03). The data did not elicit between-groups significant differences for 6MWT and MSIS. There was less use of staff for Lokomat than G-EO.

CONCLUSIONS

Locomotor therapy using G-EO, Lokomat, or PBWSTT in individuals with chronic TBI increased SSV and MV without significant changes in gait symmetry. Staffing needed for therapy provision was the least for the Lokomat. A larger study may further elucidate changes in gait symmetry and other training parameters.

LEVEL OF EVIDENCE

II.

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.