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Hernan G, Ingale N, Somayaji S, Veerubhotla A. Virtual Reality-Based Interventions to Improve Balance in Patients with Traumatic Brain Injury: A Scoping Review. Brain Sci 2024; 14:429. [PMID: 38790408 PMCID: PMC11119161 DOI: 10.3390/brainsci14050429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
INTRODUCTION Virtual reality (VR)-based interventions to improve balance and mobility are gaining increasing traction across patient populations. VR-based interventions are believed to be more enjoyable and engaging for patients with traumatic brain injury. This scoping review aims to summarize existing studies from the literature that used VR to improve balance and mobility and determine the gap in VR-based balance literature specific to individuals with traumatic brain injury. METHODS Two authors independently searched the literature using the search terms "Virtual Reality Traumatic Brain Injury Lower Limb", "Virtual Reality Traumatic Brain Injury Balance", and "Virtual Reality Traumatic Brain Injury Gait". RESULTS A total of seventeen studies, specifically, three randomized controlled trials, one one-arm experimental study, two retrospective studies, two case studies, one feasibility/usability study, one cohort study, and seven diagnostic (validation) studies, met the inclusion criteria for this review. The methodological quality of the studies evaluated using the PEDro scale was fair. DISCUSSION Future studies should focus on large-scale clinical trials using validated technology to determine its effectiveness and dose-response characteristics. Additionally, standard assessment tools need to be selected and utilized across interventional studies aimed at improving balance and mobility to help compare results between studies.
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Affiliation(s)
| | | | | | - Akhila Veerubhotla
- Department of Rehabilitation Medicine, Grossman School of Medicine, New York University, New York, NY 10016, USA; (G.H.); (N.I.); (S.S.)
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Tendolkar P, Ibironke O, Marchesi G, De Luca A, Squeri V, Nolan KJ, Pilkar R, Karunakaran KK. Relationship between Timed Up and Go performance and quantitative biomechanical measures of balance. FRONTIERS IN REHABILITATION SCIENCES 2024; 5:1220427. [PMID: 38566622 PMCID: PMC10985617 DOI: 10.3389/fresc.2024.1220427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 02/01/2024] [Indexed: 04/04/2024]
Abstract
Traumatic brain injury (TBI) impairs sensory-motor functions, with debilitating consequences on postural control and balance, which persist during the chronic stages of recovery. The Timed Up and Go (TUG) test is a reliable, safe, time-efficient, and one of the most widely used clinical measures to assess gait, balance, and fall risk in TBI patients and is extensively used in inpatient and outpatient settings. Although the TUG test has been used extensively due to its ease of performance and excellent reliability, limited research has been published that investigates the relationship between TUG performance and quantitative biomechanical measures of balance. The objective of this paper was to quantify the relationship between biomechanical variables of balance and the TUG scores in individuals with chronic TBI. Regression models were constructed using six biomechanical variables to predict TUG scores. The model that conservatively removed gait speed (i.e., TUG-1/GS) gave the best results, achieving a root-mean-square error of ∼±2 s and explaining over 69% of the variability.
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Affiliation(s)
- Prasad Tendolkar
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, United States
| | - Oluwaseun Ibironke
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, United States
| | | | | | | | - Karen J. Nolan
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, United States
- Department of Physical Medicine and Rehabilitation, Rutgers—New Jersey Medical School, Newark, NJ, United States
| | - Rakesh Pilkar
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, United States
- ActiGraph, LLC, Pensacola, FL, United States
| | - Kiran K. Karunakaran
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, United States
- Department of Physical Medicine and Rehabilitation, Rutgers—New Jersey Medical School, Newark, NJ, United States
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Tedla JS, Sangadala DR, Reddy RS, Gular K, Kakaraparthi VN, Dixit S, Alamri AM, Nayak A, Nambi G, Ponneru BR. Oblique, forward, and lateral directions reach test distances in young adults, and concurrent validity of these tests with the center of pressure excursion in assessing the limits of stability. Heliyon 2024; 10:e24591. [PMID: 38312626 PMCID: PMC10835236 DOI: 10.1016/j.heliyon.2024.e24591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/06/2024] Open
Abstract
Limits of stability is required to perform functional activities and other advanced tasks of life without losing balance, and assessment of limits of stability is essential in clinical practice. Forward, Lateral, and Oblique direction reach tests are clinical balance tests that assess limits of stability, and these reach distances in various directions may be symmetrical or asymmetrical. The aim was to establish the symmetry between various reach distances on three reach tests and to establish the concurrent validity of oblique, forward, and lateral direction reach test distances with limits of stability measured by the Iso Free machine of TecnoBody company. METHODS The measurements of oblique, forward, and lateral reach tests and limits of stability excursions of center of pressure were taken in eight directions on Iso Free machine of Techno Body in fifty typical college-going young adults who were recruited through convenience sampling. Pearson correlation test was used to find the relationship between forward, lateral, and oblique direction reaches and limits of stability in forward, lateral, and oblique directions. Regression analysis was used to find the factors influencing the forward, lateral, and oblique reach tests. RESULTS The reach distances were symmetrical, and out of the three tests, the lateral and oblique direction reach tests have a moderate positive correlation with limits of stability test in lateral and oblique directions with an r-value of 0.569 (p < 0.001) and 0.50 (p < 0.001) respectively. A Significant standardized beta value of 0.49 (p < 0.05) for the oblique direction reach test with total stability limits. CONCLUSIONS The oblique and lateral direction reach tests are correlated with their respective center of pressure excursion. However, the oblique direction reach test moderately correlated with the total limits of stability scores. Forward reach distances were more in number followed by oblique and lateral reach distances among young Saudi adults.
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Affiliation(s)
- Jaya Shanker Tedla
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Alfara, Abha, Kingdom of Saudi Arabia
| | - Devika Rani Sangadala
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Alfara, Abha, Kingdom of Saudi Arabia
| | - Ravi Shankar Reddy
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Alfara, Abha, Kingdom of Saudi Arabia
| | - Kumar Gular
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Alfara, Abha, Kingdom of Saudi Arabia
| | - Venkata Nagaraj Kakaraparthi
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Alfara, Abha, Kingdom of Saudi Arabia
| | - Snehil Dixit
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Alfara, Abha, Kingdom of Saudi Arabia
| | - Ahlam Mohammed Alamri
- Department of Rehabilitation Health Services, Armed Forces Hospital Southern Region, Khamis Mushayat, Kingdom of Saudi Arabia
| | - Akshatha Nayak
- Department of Physiotherapy, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Gopal Nambi
- Department of Health and Rehabilitation Sciences, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, Al-Kharj, Kingdom of Saudi Arabia
| | - Bhaskar Reddy Ponneru
- Department of Physical Therapy, King Khalid Hospital, Najaran, Kingdom of Saudi Arabia
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Modi AD, Parekh A, Patel ZH. Methods for evaluating gait associated dynamic balance and coordination in rodents. Behav Brain Res 2024; 456:114695. [PMID: 37783346 DOI: 10.1016/j.bbr.2023.114695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 10/04/2023]
Abstract
Balance is the dynamic and unconscious control of the body's centre of mass to maintain postural equilibrium. Regulated by the vestibular system, head movement and acceleration are processed by the brain to adjust joints. Several conditions result in a loss of balance, including Alzheimer's Disease, Parkinson's Disease, Menière's Disease and cervical spondylosis, all of which are caused by damage to certain parts of the vestibular pathways. Studies about the impairment of the vestibular system are challenging to carry out in human trials due to smaller study sizes limiting applications of the results and a lacking understanding of the human balance control mechanism. In contrast, more controlled research can be performed in animal studies which have fewer confounding factors than human models and allow specific conditions that affect balance to be replicated. Balance control can be studied using rodent balance-related behavioural tests after spinal or brain lesions, such as the Basso, Beattie and Bresnahan (BBB) Locomotor Scale, Foot Fault Scoring System, Ledged Beam Test, Beam Walking Test, and Ladder Beam Test, which are discussed in this review article along with their advantages and disadvantages. These tests can be performed in preclinical rodent models of femoral nerve injury, stroke, spinal cord injury and neurodegenerative diseases.
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Affiliation(s)
- Akshat D Modi
- Department of Biological Sciences, University of Toronto, Scarborough, Ontario M1C 1A4, Canada; Department of Genetics and Development, Krembil Research Institute, Toronto, Ontario M5T 0S8, Canada.
| | - Anavi Parekh
- Department of Neuroscience, University of Toronto, Toronto, Ontario M5S 1A1, Canada
| | - Zeenal H Patel
- Department of Biological Sciences, University of Toronto, Scarborough, Ontario M1C 1A4, Canada; Department of Biochemistry, University of Toronto, Scarborough, Ontario M1C 1A4, Canada
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Zampieri C, Leary JB, Shahim P, Damiano D, Ho PS, Pham DL, Chan L. Associations between white matter integrity and postural control in adults with traumatic brain injury. PLoS One 2023; 18:e0288727. [PMID: 38011096 PMCID: PMC10681193 DOI: 10.1371/journal.pone.0288727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/03/2023] [Indexed: 11/29/2023] Open
Abstract
Abnormalities of postural sway have been extensively reported in traumatic brain injury (TBI). However, the underlying neural correlates of balance disturbances in TBI remain to be elucidated. Studies in children with TBI have reported associations between the Sensory Organization Test (SOT) and measures of white matter (WM) integrity with diffusion tensor imaging (DTI) in brain areas responsible for multisensory integration. This study seeks to replicate those associations in adults as well as explore relationships between DTI and the Limits of Stability (LOS) Test. Fifty-six participants (43±17 years old) with a history of TBI were tested 30 days to 5 years post-TBI. This study confirmed results in children for associations between the SOT and the medial lemniscus as well as middle cerebellar peduncle, and revealed additional associations with the posterior thalamic radiation. Additionally, this study found significant correlations between abnormal LOS scores and impaired WM integrity in the cingulum, corpus callosum, corticopontine and corticospinal tracts, fronto-occipital fasciculi, longitudinal fasciculi, medial lemniscus, optic tracts and thalamic radiations. Our findings indicate the involvement of a broad range of WM tracts in the control of posture, and demonstrate the impact of TBI on balance via disruptions to WM integrity.
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Affiliation(s)
- Cris Zampieri
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Jacob B. Leary
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Pashtun Shahim
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Diane Damiano
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Pei-Shu Ho
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Dzung L. Pham
- Center for Neuroscience and Regenerative Medicine, The Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Leighton Chan
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, Maryland, United States of America
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Famili HP, Zalewski CK, Ibrahimy A, Mack J, Cantor F, Heiss JD, Brewer CC. Audiovestibular Findings in a Cohort of Patients with Chiari Malformation Type I and Dizziness. J Clin Med 2023; 12:jcm12082767. [PMID: 37109107 PMCID: PMC10142081 DOI: 10.3390/jcm12082767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Chiari Malformation Type I (CM1) is a neurological condition in which the cerebellar tonsils extend past the foramen magnum. While many studies have reported dizziness symptoms in patients with CM1, the prevalence of peripheral labyrinthine lesions is largely unknown. This study aimed to comprehensively describe the audiovestibular phenotype in a cohort of patients with CM1 expressly referred for dizziness. Twenty-four patients with CM1 and a complaint of dizziness/vertigo were evaluated. Hearing and auditory brainstem tract function were essentially normal. While vestibular abnormalities were most prevalent during rotational testing (33%), abnormal functional balance was the most common finding (40%). Patients with CM1 had a greater likelihood of exhibiting an abnormal sensory organization test (SOT) postural stability score for fixed platform conditions, and for the somatosensory analysis score. While no significant associations were identified between tonsillar ectopia extent and any vestibular/balance outcome measure, a significant negative association was identified between neck pain and the somatosensory sensory analysis score. Abnormal functional balance in the somatosensory domain was remarkable, with poorer scores associated with neck pain. An isolated peripheral vestibulopathy was present in only 8% of patients. Despite the low prevalence of vestibulopathy, vestibular/balance assessment is warranted to identify patients who may benefit from referral to specialized medical disciplines.
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Affiliation(s)
- Hannah P Famili
- Audiology Unit, NIDCD, National Institutes of Health, Bethesda, MD 20892, USA
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | | | - Alaaddin Ibrahimy
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jessica Mack
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - Fredric Cantor
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - John D Heiss
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
| | - Carmen C Brewer
- Audiology Unit, NIDCD, National Institutes of Health, Bethesda, MD 20892, USA
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Lecca D, Hsueh SC, Luo W, Tweedie D, Kim DS, Baig AM, Vargesson N, Kim YK, Hwang I, Kim S, Hoffer BJ, Chiang YH, Greig NH. Novel, thalidomide-like, non-cereblon binding drug tetrafluorobornylphthalimide mitigates inflammation and brain injury. J Biomed Sci 2023; 30:16. [PMID: 36872339 PMCID: PMC9987061 DOI: 10.1186/s12929-023-00907-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/09/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Quelling microglial-induced excessive neuroinflammation is a potential treatment strategy across neurological disorders, including traumatic brain injury (TBI), and can be achieved by thalidomide-like drugs albeit this approved drug class is compromised by potential teratogenicity. Tetrafluorobornylphthalimide (TFBP) and tetrafluoronorbornylphthalimide (TFNBP) were generated to retain the core phthalimide structure of thalidomide immunomodulatory imide drug (IMiD) class. However, the classical glutarimide ring was replaced by a bridged ring structure. TFBP/TFNBP were hence designed to retain beneficial anti-inflammatory properties of IMiDs but, importantly, hinder cereblon binding that underlies the adverse action of thalidomide-like drugs. METHODS TFBP/TFNBP were synthesized and evaluated for cereblon binding and anti-inflammatory actions in human and rodent cell cultures. Teratogenic potential was assessed in chicken embryos, and in vivo anti-inflammatory actions in rodents challenged with either lipopolysaccharide (LPS) or controlled cortical impact (CCI) moderate traumatic brain injury (TBI). Molecular modeling was performed to provide insight into drug/cereblon binding interactions. RESULTS TFBP/TFNBP reduced markers of inflammation in mouse macrophage-like RAW264.7 cell cultures and in rodents challenged with LPS, lowering proinflammatory cytokines. Binding studies demonstrated minimal interaction with cereblon, with no resulting degradation of teratogenicity-associated transcription factor SALL4 or of teratogenicity in chicken embryo assays. To evaluate the biological relevance of its anti-inflammatory actions, two doses of TFBP were administered to mice at 1 and 24 h post-injury following CCI TBI. Compared to vehicle treatment, TFBP reduced TBI lesion size together with TBI-induction of an activated microglial phenotype, as evaluated by immunohistochemistry 2-weeks post-injury. Behavioral evaluations at 1- and 2-weeks post-injury demonstrated TFBP provided more rapid recovery of TBI-induced motor coordination and balance impairments, versus vehicle treated mice. CONCLUSION TFBP and TFNBP represent a new class of thalidomide-like IMiDs that lower proinflammatory cytokine generation but lack binding to cereblon, the main teratogenicity-associated mechanism. This aspect makes TFBP and TFNBP potentially safer than classic IMiDs for clinical use. TFBP provides a strategy to mitigate excessive neuroinflammation associated with moderate severity TBI to, thereby, improve behavioral outcome measures and warrants further investigation in neurological disorders involving a neuroinflammatory component.
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Affiliation(s)
- Daniela Lecca
- Drug Design and Development Section, Translational Gerontology Branch, Intramural Research Program National Institute On Aging, NIH, Baltimore, MD, 21224, USA
| | - Shih-Chang Hsueh
- Drug Design and Development Section, Translational Gerontology Branch, Intramural Research Program National Institute On Aging, NIH, Baltimore, MD, 21224, USA
| | - Weiming Luo
- Drug Design and Development Section, Translational Gerontology Branch, Intramural Research Program National Institute On Aging, NIH, Baltimore, MD, 21224, USA
| | - David Tweedie
- Drug Design and Development Section, Translational Gerontology Branch, Intramural Research Program National Institute On Aging, NIH, Baltimore, MD, 21224, USA
| | - Dong Seok Kim
- Aevisbio Inc., Gaithersburg, MD, 20878, USA
- Aevis Bio Inc., Daejeon, 34141, Republic of Korea
| | - Abdul Mannan Baig
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, 74800, Pakistan
| | - Neil Vargesson
- School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK
| | - Yu Kyung Kim
- Aevis Bio Inc., Daejeon, 34141, Republic of Korea
| | - Inho Hwang
- Aevis Bio Inc., Daejeon, 34141, Republic of Korea
| | - Sun Kim
- Aevis Bio Inc., Daejeon, 34141, Republic of Korea
| | - Barry J Hoffer
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Yung-Hsiao Chiang
- Neuroscience Research Center, Taipei Medical University, Taipei, 110, Taiwan.
- Department of Neurosurgery, Taipei Medical University Hospital, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan.
| | - Nigel H Greig
- Drug Design and Development Section, Translational Gerontology Branch, Intramural Research Program National Institute On Aging, NIH, Baltimore, MD, 21224, USA.
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Wafa T, Zalewski C, Tamaki C, Barac-Cikoja D, Bakke M, Brewer C. A new paradigm for assessing postural stability. Gait Posture 2023; 100:188-192. [PMID: 36571908 PMCID: PMC9975023 DOI: 10.1016/j.gaitpost.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/05/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The sensory organization test (SOT) is an established and effective method for assessing postural stability and determining fall risk. SOT equilibrium scores are derived from the relationship between an individual's peak sway amplitude and a standard, theoretically-derived normal limits of stability (tLOS). Determining an individual's postural stability and fall risk based on this one-size-fits-all tLOS may overestimate functional equilibrium scores and underestimate fall risk when personal stability limits (pLOS) are reduced. RESEARCH QUESTION The purpose of this study is to investigate whether LOS measured from a group of healthy adults is different from the tLOS, and whether SOT equilibrium scores are significantly different when calculated using pLOS versus the standard tLOS. METHODS Sixty healthy volunteers were recruited into three age-groups: young (18-39), middle-aged (40-64), and elderly (65-80), with 10 males and 10 females in each age-group. Outcome measures included SOT and LOS. Additional measures o balance perception and functional mobility were obtained including the Activities Balance Confidence (ABC) scale and the timed-up-and-go test (TUG). The tLOS and pLOS were used to calculate standard (tSOT) and personalized (pSOT) equilibrium scores. RESULTS The mean pLOS from the group of healthy adults was significantly lower than the tLOS. Consequently, the pSOT equilibrium scores were significantly lower than the standard SOT scores derived using the tLOS. SIGNIFICANCE Individual measures of LOS are significantly lower than theoretical estimates of the LOS in healthy adults. This suggests that use of tLOS in the calculation of SOT equilibrium scores often overestimates postural stability and may have implications for the determination of fall risk.
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Affiliation(s)
- Talah Wafa
- Audiology Unit, NIDCD, NIH, Bethesda, MD, USA; Department of Hearing, Speech, and Language Sciences, Gallaudet University, Washington, DC, USA
| | | | - Chizuko Tamaki
- Department of Hearing, Speech, and Language Sciences, Gallaudet University, Washington, DC, USA
| | - Dragana Barac-Cikoja
- Department of Hearing, Speech, and Language Sciences, Gallaudet University, Washington, DC, USA
| | - Matthew Bakke
- Department of Hearing, Speech, and Language Sciences, Gallaudet University, Washington, DC, USA
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Joyce JM, Debert CT, Chevignard M, Sorek G, Katz-Leurer M, Gagnon I, Schneider KJ. Balance impairment in patients with moderate-to-severe traumatic brain injury: Which measures are appropriate for assessment? Front Neurol 2022; 13:906697. [PMID: 35989909 PMCID: PMC9381921 DOI: 10.3389/fneur.2022.906697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/30/2022] [Indexed: 11/21/2022] Open
Abstract
Left untreated, balance impairment following moderate-to-severe traumatic brain injury (TBI) can be highly debilitating and hinder activities of daily life. To detect impairments, clinicians need appropriate assessment tools. The objective of this study was to evaluate the feasibility and utility of a battery of clinical balance assessments in adults with moderate-to-severe TBI within 6-months of injury. Thirty-seven adults with TBI [Glasgow Coma Scale score ≤ 12 (33 M/4 F) age 18–50 years] participated in balance testing. Assessments included the Balance Error Scoring System (BESS), National Institutes of Health Standing Balance Test (NIH-SBT), Functional Gait Assessment (FGA), Advanced Functional Gait Assessment (FGA-A), Tandem Gait Test (TGT), Berg Balance Scale (BBS), and Walking While Talking Test (WWTT). We identified pronounced ceiling effects on the BBS and FGA, two widely used clinical balance assessments. The NIH-SBT, WWTT, and FGA used in conjunction with the FGA-A, offered versatility in their capacity to assess patients across the balance severity spectrum. This study provides evidence to support a stepwise approach to balance assessment that can be adapted to the broad range of balance ability found in moderate-to-severe TBI.
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Affiliation(s)
- Julie M. Joyce
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada
- *Correspondence: Julie M. Joyce
| | - Chantel T. Debert
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mathilde Chevignard
- Laboratoire d'Imagerie Biomédicale, LIB, Inserm, CNRS, Sorbonne Université, Paris, France
- GRC 24 HaMCRe, Handicap Moteur et Cognitif & Réadaptation, Sorbonne Université, Paris, France
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France
| | - Gilad Sorek
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Katz-Leurer
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Isabelle Gagnon
- Montreal Children's Hospital Trauma Center, McGill University Health Center, Montreal, QC, Canada
- Faculty of Medicine and Health Sciences, School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
- Division of Pediatric Emergency Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Kathryn J. Schneider
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Integrated Concussion Research Program, University of Calgary, Calgary, AB, Canada
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- Evidence Sport and Spinal Therapy, Calgary, AB, Canada
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10
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Liang Z, Mo F, Zheng Z, Li Y, Tian Y, Jiang X, Liu T. Quantitative cervical spine injury responses in whiplash loading with a numerical method of natural neural reflex consideration. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 219:106761. [PMID: 35344767 DOI: 10.1016/j.cmpb.2022.106761] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 03/07/2022] [Accepted: 03/15/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Neural reflex is hypothesized as a regulating step in spine stabilizing system. However, neural reflex control is still in its infancy to consider in the previous finite element analysis of head-neck system for various applications. The purpose of this study is to investigate the influences of neural reflex control on neck biomechanical responses, then provide a new way to achieve an accurate biomechanical analysis for head-neck system with a finite element model. METHODS A new FE head-neck model with detailed active muscles and spinal cord modeling was established and globally validated at multi-levels. Then, it was coupled with our previously developed neuromuscular head-neck model to analyze the effects of vestibular and proprioceptive reflexes on biomechanical responses of head-neck system in a typical spinal injury loading condition (whiplash). The obtained effects were further analyzed by comparing a review of epidemiologic data on cervical spine injury situations. RESULT The results showed that the active model (AM) with neural reflex control obviously presented both rational head-neck kinematics and tissue injury risk referring to the previous experimental and epidemiologic studies, when compared with the passive model (PM) without it. Tissue load concentration locations as well as stress/strain levels were both changed due to the muscle activation forces caused by neural reflex control during the whole loading process. For the bony structures, the AM showed a peak stress level accounting for only about 25% of the PM. For the discs, the stress concentrated location was transferred from C2-C6 in the PM to C4-C6 in the AM. For the spinal cord, the strain concentrated locations were transferred from C1 segment to around C4 segment when the effects of neural reflex control were implemented, while the gray matter and white matter peak strains were reduced to 1/3 and 1/2 of the PM, respectively. All these were well correlated with epidemiological studies on clinical cervical spine injuries. CONCLUSION In summary, the present work demonstrated necessity of considering neural reflex in FE analysis of a head-neck system as well as our model biofidelity. Overall results also verified the previous hypothesis and further quantitatively indicated that the muscle activation caused by neural reflex is providing a protection for the neck in impact loading by decreasing the strain level and changing the possible injury to lower spinal cord level to reduce injury severity.
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Affiliation(s)
- Ziyang Liang
- College of Mechanical and Vehicle Engineering, Hunan University, Changsha, Hunan 410082, China; Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, China
| | - Fuhao Mo
- College of Mechanical and Vehicle Engineering, Hunan University, Changsha, Hunan 410082, China.
| | - Zhefen Zheng
- College of Mechanical and Vehicle Engineering, Hunan University, Changsha, Hunan 410082, China
| | - Yuandong Li
- College of Mechanical and Vehicle Engineering, Hunan University, Changsha, Hunan 410082, China
| | - Ye Tian
- College of Mechanical and Vehicle Engineering, Hunan University, Changsha, Hunan 410082, China
| | - Xiaobing Jiang
- Department of Spine Surgery, Guangzhou University of Chinese medicine, Guangzhou, Guangdong 510405, China
| | - Tang Liu
- Department of Orthopedics, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, China
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11
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Wood NI, Hentig J, Hager M, Hill-Pearson C, Hershaw JN, Souvignier AR, Bobula SA. The Non-Concordance of Self-Reported and Performance-Based Measures of Vestibular Dysfunction in Military and Civilian Populations Following TBI. J Clin Med 2022; 11:jcm11112959. [PMID: 35683348 PMCID: PMC9181197 DOI: 10.3390/jcm11112959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 11/23/2022] Open
Abstract
As a predominately young, physically active, and generally healthy population, service members (SMs) with vestibular dysfunction (VD) following a TBI may not be accurately represented by the current civilian reference ranges on assessments of VD. This study enrolled SMs who were referred for vestibular rehabilitation following a mild/moderate TBI. The participants self-reported VD using the Activities-specific Balance Confidence (ABC) scale and the Dizziness Handicap Inventory (DHI) followed by evaluation of vestibular performance using computerized dynamic posturography sensory organizational test (CDP−SOT). Retrospective analysis of these outcomes comparing the study sample of SMs to the reported civilian samples revealed SMs self-reported lower VD with significantly higher balance confidence (ABC: 77.11 ± 14.61, p < 0.05) and lower dizziness (DHI: 37.75 ± 11.74, p < 0.05) than civilians. However, the SMs underperformed in performance-based evaluations compared to civilians with significantly lower CDP−SOT composite and ratio scores (COMP: 68.46 ± 13.46, p < 0.05; VIS: 81.36 ± 14.03, p < 0.01; VEST: 55.63 ± 22.28, p < 0.05; SOM: 90.46 ± 10.17, p < 0.05). Correlational analyses identified significant relationships between the ABC and CDP−SOT composite (r = 0.380, p < 0.01) and ratio scores (VIS: r = 0.266, p < 0.05; VEST: r = 0.352, p < 0.01). These results highlight the importance of recognizing and understanding nuances in assessing VD in SMs to ensure they have access to adequate care and rehabilitation prior to returning to duty.
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Affiliation(s)
- Nicholas I. Wood
- Evans Army Community Hospital, Fort Carson, CO 80913, USA; (N.I.W.); (C.H.-P.); (J.N.H.); (A.R.S.); (S.A.B.)
- Traumatic Brain Injury Center of Excellence, Fort Carson, CO 80913, USA;
- General Dynamics Information Technology, Falls Church, VA 22042, USA
| | - James Hentig
- Evans Army Community Hospital, Fort Carson, CO 80913, USA; (N.I.W.); (C.H.-P.); (J.N.H.); (A.R.S.); (S.A.B.)
- Traumatic Brain Injury Center of Excellence, Fort Carson, CO 80913, USA;
- General Dynamics Information Technology, Falls Church, VA 22042, USA
- Correspondence: ; Tel.: +1-(719)-258-0695
| | - Madison Hager
- Traumatic Brain Injury Center of Excellence, Fort Carson, CO 80913, USA;
| | - Candace Hill-Pearson
- Evans Army Community Hospital, Fort Carson, CO 80913, USA; (N.I.W.); (C.H.-P.); (J.N.H.); (A.R.S.); (S.A.B.)
- Traumatic Brain Injury Center of Excellence, Fort Carson, CO 80913, USA;
- General Dynamics Information Technology, Falls Church, VA 22042, USA
| | - Jamie N. Hershaw
- Evans Army Community Hospital, Fort Carson, CO 80913, USA; (N.I.W.); (C.H.-P.); (J.N.H.); (A.R.S.); (S.A.B.)
- Traumatic Brain Injury Center of Excellence, Fort Carson, CO 80913, USA;
- General Dynamics Information Technology, Falls Church, VA 22042, USA
| | - Alicia R. Souvignier
- Evans Army Community Hospital, Fort Carson, CO 80913, USA; (N.I.W.); (C.H.-P.); (J.N.H.); (A.R.S.); (S.A.B.)
| | - Selena A. Bobula
- Evans Army Community Hospital, Fort Carson, CO 80913, USA; (N.I.W.); (C.H.-P.); (J.N.H.); (A.R.S.); (S.A.B.)
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12
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Brian AS, Perkins C, Valet SB, Lieberman LJ. Concussion Protocols for Individuals With Visual Impairments: A Brief Report. JOURNAL OF VISUAL IMPAIRMENT & BLINDNESS 2022. [DOI: 10.1177/0145482x221109595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ali S. Brian
- Department of Physical Education, University of South Carolina, Columbia, SC, USA
| | - Courtney Perkins
- Department of Physical Education, University of South Carolina, Columbia, SC, USA
| | | | - Lauren J. Lieberman
- Department of Physical Education, University of South Carolina, Columbia, SC, USA
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13
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Haran FJ, Zampieri C, Wassermann EM, Polejaeva E, Dell KC, LoPresti ML, Stone JR, Ahlers ST, Carr W. Chronic Effects of Breaching Blast Exposure on Sensory Organization and Postural Limits of Stability. J Occup Environ Med 2021; 63:944-950. [PMID: 33990528 PMCID: PMC8570990 DOI: 10.1097/jom.0000000000002266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The goal of this effort to investigate if experienced breachers, professionals with a career history of exposure to repeated low-level blasts, exhibited postural instability. METHODS Postural data were examined using traditional tests of means and compared to normative data. RESULTS Breachers had significantly lower NeuroCom Sensory Organization Test (SOT) visual scores (within normative limits), prolonged Limits of Stability (LOS) test reaction time (30% of breachers and 7% of controls testing abnormal), and slower LOS movement velocity (21% of breachers and 0% of controls testing abnormal) compared to controls. CONCLUSION Our LOS test findings are like those previously reported for students in the military breacher training course and seem to indicate that while acute effects of blasts on sensory control of balance fade away, effects on postural LOS persist over time.
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Affiliation(s)
- F J Haran
- NeuroTrauma Department, Naval Medical Research Center (Dr Haran and Dr Ahlers); Clinical Center, Rehabilitation Medicine Department, National Institutes of Health (Dr Zampieri); National Institute of Neurological Disorders and Stroke, National Institutes of Health (Dr Wassermann); Clinical & Health Psychology, University of Florida (Ms Polejaeva); Department of Psychology, The Pennsylvania State University (Ms Dell); Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research (Dr LoPresti and Dr Carr); Department of Radiology and Medical Imaging, University of Virginia (Dr Stone)
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14
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Thompson XD, Erdman NK, Walton SR, Broshek DK, Resch JE. Reevaluating clinical assessment outcomes after unrestricted return to play following sport-related concussion. Brain Inj 2021; 35:1577-1584. [PMID: 34543089 DOI: 10.1080/02699052.2021.1975818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PRIMARY OBJECTIVE The objective of this study was to examine neurocognition, postural control, and symptomology at multiple timepoints following concussion. We hypothesized that collegiate athletes would perform similar to or better than their baseline in terms of each outcome at both timepoints. RESEARCH DESIGN This was a retrospective study of 71 collegiate athletes (18.3 ± 0.89 years old; 182.2 ± 10.05 cm; 84.2 ± 20.07 kg) to observe changes in outcomes from a previously established clinical protocol. METHODS AND PROCEDURES Participants were administered ImPACT™, the Sensory Organization Test (SOT), and the revised head injury scale (HIS-r) prior to their seasons (baseline); upon reporting symptom-free following concussion (post-injury); and approximately 8-months after return-to-play to establish a new baseline. MAIN OUTCOMES AND RESULTS There were no changes in ImPACT scores or HIS-r reporting over time. ImPACT total symptom score (TSS) decreased over time (p = .002, ηp2 = 0.08). Significant main effects occurred for the SOT equilibrium score (p < .01, ηp2 = 0.34) and Vestibular sensory ratio (p < .001, ηp2 = 0.22). CONCLUSIONS Our data suggest no decline in neurocognition, balance, or symptom burden approximately eight months post-injury. As clinicians continue to explore "best practices" for concussion management and potential long-term implications of these injuries it is important to monitor outcome measures longitudinally.
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Affiliation(s)
- Xavier D Thompson
- UVA Department of Kinesiology, The University of Virginia, Charlottesville, Virginia, USA
| | - Nicholas K Erdman
- Postdoctoral Research Fellow, George Mason University Sports Medicine, Research and Testing Lab, Fairfax, Virginia, USA
| | - Samuel R Walton
- Postdoctoral Research Associate, UNC Center for the Study of Retired Athletes & Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Chapel Hill, North Carolina, USA
| | - Donna K Broshek
- UVA Department of Psychiatry and Neurobehavioral Sciences, UVA Health, Charlottesville, Virginia, USA
| | - Jacob E Resch
- UVA Department of Kinesiology, The University of Virginia, Charlottesville, Virginia, USA
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15
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Joseph ALC, Lippa SM, Moore B, Bagri M, Row J, Chan L, Zampieri C. Relating Self-Reported Balance Problems to Sensory Organization and Dual-Tasking in Chronic Traumatic Brain Injury. PM R 2021; 13:870-879. [PMID: 32844594 PMCID: PMC10440855 DOI: 10.1002/pmrj.12478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Individuals who have experienced a traumatic brain injury (TBI) often have residual balance problems. It remains unclear whether these balance problems are driven by vestibular dysfunction or gait automaticity deficits, particularly in the chronic stages of TBI recovery, because most studies include only acute/subacute cases. OBJECTIVES Compare performance on the Sensory Organization Test vestibular score and Dual-Task test in individuals with and without subjective balance problems at least 1 year after a TBI. Investigate the ability of each test to predict perceived balance problems. DESIGN Prospective cohort study. SETTING Rehabilitation department within a single institution. PARTICIPANTS Fifty adults (21-71 years) with a history of mild, moderate, or severe TBI 1 to 5 years following nonpenetrating TBI. INTERVENTIONS N/A. METHODS Measures included the Dual-Task test, Sensory Organization Test, Neurobehavioral Symptom Inventory, Dizziness Handicap Inventory, and assessments of four cognitive domains and depression. Participants who endorsed "feeling dizzy" and "loss of balance" on the Neurobehavioral Symptom Inventory were classified as symptomatic (n = 26) and others as asymptomatic (n = 24). T-tests, chi-square, and regression analyses predicting the Dizziness Handicap Inventory total score were performed. RESULTS Dual-task gait cost was negatively associated with the Dizziness Handicap Inventory (P = .044), controlling for depression and gender, whereas vestibular scores failed to predict balance-related disability. Symptomatic individuals endorsed more balance problems (P < .001) and depression symptoms (P = .007), had poorer dual-task cognitive output (P = .036), and slower dual-task gait velocity (P = .036) than asymptomatic participants. Groups did not differ on Sensory Organization Test scores. CONCLUSIONS The nature of balance problems in chronic TBI may be related to automaticity of gait. These findings suggest that patients in the chronic stages of TBI may benefit from dual-task assessments and interventions. Balance rehabilitation should be tailored to patient needs and assess cognition and affect.
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Affiliation(s)
- Annie-Lori C Joseph
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Sara M Lippa
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Brian Moore
- Center for Neuroscience and Regenerative Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Manjot Bagri
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Jessica Row
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Leighton Chan
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
- Center for Neuroscience and Regenerative Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Cris Zampieri
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
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16
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D'Silva LJ, Chalise P, Obaidat S, Rippee M, Devos H. Oculomotor Deficits and Symptom Severity Are Associated With Poorer Dynamic Mobility in Chronic Mild Traumatic Brain Injury. Front Neurol 2021; 12:642457. [PMID: 34381408 PMCID: PMC8350131 DOI: 10.3389/fneur.2021.642457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 06/25/2021] [Indexed: 12/02/2022] Open
Abstract
Oculomotor deficits, vestibular impairments, and persistent symptoms are common after a mild traumatic brain injury (mTBI); however, the relationship between visual-vestibular deficits, symptom severity, and dynamic mobility tasks is unclear. Twenty-three individuals (mean age 55.7 ± 9.3 years) with persistent symptoms after mTBI, who were between 3 months to 2 years post-injury were compared with 23 age and sex-matched controls. Oculomotor deficits [depth perception, near-point convergence, baseline visual acuity (BLVA), perception time], vestibular deficits (dynamic visual acuity in the pitch and yaw planes), dynamic mobility measured by the Functional Gait Assessment (FGA), and symptoms measured by the Post-Concussion Symptom Scale (PCSS) and Dizziness Handicap Inventory (DHI) were compared between groups. Participants with mTBI had poorer performance on the FGA (p < 0.001), higher symptom severity on the PCSS (p < 0.001), and higher DHI scores (p < 0.001) compared to controls. Significant differences were seen on specific items of the FGA between individuals with mTBI and controls during walking with horizontal head turns (p = 0.002), walking with vertical head tilts (p < 0.001), walking with eyes closed (p = 0.003), and stair climbing (p = 0.001). FGA performance was correlated with weeks since concussion (r = −0.67, p < 0.001), depth perception (r = −0.5348, p < 0.001), near point convergence (r = −0.4717, p = 0.001), baseline visual acuity (r = −0.4435, p = 0.002); as well as with symptoms on the PCSS (r = −0.668, p < 0.001), and DHI (r = −0.811, p < 0.001). Dynamic balance deficits persist in chronic mTBI and may be addressed using multifaceted rehabilitation strategies to address oculomotor dysfunction, post-concussion symptoms, and perception of handicap due to dizziness.
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Affiliation(s)
- Linda J D'Silva
- Department of Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas City, MO, United States
| | - Prabhakar Chalise
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, MO, United States
| | - Sakher Obaidat
- Department of Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas City, MO, United States
| | - Michael Rippee
- Department of Neurology, University of Kansas Health System, Kansas City, MO, United States
| | - Hannes Devos
- Department of Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas City, MO, United States
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17
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Dizziness and Balance Disorders in a Traumatic Brain Injury Population: Current Clinical Approaches. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2021. [DOI: 10.1007/s40141-021-00308-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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