Ambulation Training With and Without Partial Weightbearing After Traumatic Brain Injury

Comparative Efficacy of High-Intensity Training Versus Conventional Training in Individuals With Chronic Traumatic Brain Injury: A Pilot Randomized Controlled Study

Numerous studies have evaluated the efficacy of interventions to improve locomotion after acute-onset brain injury, although most focus on patients with stroke, with less attention toward traumatic brain injury (TBI). For example, a number of studies in patients post-stroke have evaluated the effects of high-intensity training (HIT) attempting to maximize stepping practice, while no studies have attempted this intervention in patients with TBI. The purpose of this blinded-assessor randomized trial was to evaluate the effects of HIT focused on stepping practice versus conventional training on walking and secondary outcomes in individuals with TBI. Using a crossover design, ambulatory participants with TBI >6-months duration performed HIT focused on stepping in variable contexts (overground, treadmill, stairs) or conventional training for up to 15 sessions over five weeks, with interventions alternated >4 weeks later. HIT focused on maximizing stepping practice while trying to achieve higher cardiovascular intensities (>70% heart rate reserve), while conventional training focused on impairment-based and functional exercises with no restrictions on intensities achieved. Greater increases in 6-min walk test and peak treadmill speed during graded exercise testing were observed after HIT versus conventional training, with moderate associations between differences in stepping practice and outcomes. Greater gains were also observed in estimates of aerobic capacity and efficiency after HIT, with additional improvements in selected cognitive assessments. The present study suggests that the amount and intensity of stepping practice may be important determinants of improved locomotor outcomes in patients with chronic TBI, with possible secondary benefits on aerobic capacity/efficiency and cognition. Clinical Trial Registration-URL: https://clinicaltrials.gov/; Unique Identifier: NCT04503473.

Differences in muscle activity during squat exercises according to the knee angle and standing angle of a sliding tilt table: A comparative study

BACKGROUND AND PURPOSE

Weight-bearing exercises can help improve physical function; however, they may be difficult to perform in patients with neurological issues or lower limb fractures. The purpose of this study was to evaluate the activity of the leg muscles during squatting when using a new exercise aid designed to help patients with difficulty in performing squats, termed the sliding tilt table, at different knee angles and to estimate the squat level for each angle.

METHODS

This study was a cross-sectional, observational study performed in the general community. Participants comprised 30 healthy adult men. Squats were performed by setting the knee joints at 30, 60, and 90° and the tilt table angles to 15, 30, and 45°. The muscle activity of the vastus medialis, tibialis anterior, and gastrocnemius was measured using surface electromyography.

RESULTS

As the tilt table and knee joint angle increased, the %maximal voluntary isometric contraction increased. Similar patterns were found in both legs.

CONCLUSIONS

Weight-bearing exercises, such as squats, are important exercise elements in patients who require lower limb rehabilitation. Therefore, it is necessary to provide efficient lower limb rehabilitation exercises by adjusting the squat level according to the patient's ability, which can be achieved using a sliding tilt table.

The effect of physical activity on health outcomes in people with moderate-to-severe traumatic brain injury: a rapid systematic review with meta-analysis

BACKGROUND

In 2020, the World Health Organization (WHO) released the first global physical activity and sedentary behaviour guidelines for children and adults living with disability. The evidence informing the guidelines though is not specific to people living with traumatic brain injury (TBI), but rather comes from other disabling conditions such as Parkinson's disease, and stroke. There remains a clear lack of direct evidence of the effects of physical activity for people living with TBI. The objective of this rapid review was to identify direct evidence of the effect of physical activity on health outcomes in people with moderate-to-severe TBI to inform adaptation of the WHO physical activity guidelines into clinical practice guidelines.

METHODS

We conducted a rapid systematic review with meta-analysis of randomised controlled trials, including people of any age with moderate-to-severe TBI, investigating physical activity interventions compared to either usual care, a physical activity intervention with different parameters, or a non-physical activity intervention. Four databases (CENTRAL, SPORTDiscus, PEDro, Ovid MEDLINE) were searched from inception to October 8, 2021. The primary outcomes were physical function, cognition, and quality of life.

RESULTS

Twenty-three studies were included incorporating 812 participants (36% females, majority working-age adults, time post-TBI in studies ranged from 56 days (median) to 16.6 years (mean)). A range of physical activity interventions were evaluated in rehabilitation (n = 12 studies), community (n = 8) and home (n = 3) settings. We pooled data from the end of the intervention for eight outcomes. Participation in a virtual reality physical activity intervention improved mobility, assessed by the Community Balance and Mobility Scale (range 0 to 96; higher score indicates better mobility) more than standard balance training (two studies, 80 participants, Mean Difference = 2.78, 95% CI 1.40 to 4.16; low certainty evidence). There was uncertainty of effect for the remaining outcomes, limited by small sample sizes, diverse comparators and a wide range of outcome measures.

CONCLUSION

This review consolidates the current evidence base for the prescription of physical activity for people with moderate-to-severe TBI. There remains a pressing need for further rigorous research in order to develop practice guidelines to support clinical decision-making when prescribing physical activity in this population.

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.

Rehabilitation modality and onset differentially influence whisker sensory hypersensitivity after diffuse traumatic brain injury in the rat

BACKGROUND

As rehabilitation strategies advance as therapeutic interventions, the modality and onset of rehabilitation after traumatic brain injury (TBI) are critical to optimize treatment. Our laboratory has detected and characterized a late-onset, long-lasting sensory hypersensitivity to whisker stimulation in diffuse brain-injured rats; a deficit that is comparable to visual or auditory sensory hypersensitivity in humans with an acquired brain injury.

OBJECTIVE

We hypothesize that the modality and onset of rehabilitation therapies will differentially influence sensory hypersensitivity in response to the Whisker Nuisance Task (WNT) as well as WNT-induced corticosterone (CORT) stress response in diffuse brain-injured rats and shams.

METHODS

After midline fluid percussion brain injury (FPI) or sham surgery, rats were assigned to one of four rehabilitative interventions: (1) whisker sensory deprivation during week one or (2) week two or (3) whisker stimulation during week one or (4) week two. At 28 days following FPI and sham procedures, sensory hypersensitivity was assessed using the WNT. Plasma CORT was evaluated immediately following the WNT (aggravated levels) and prior to the pre-determined endpoint 24 hours later (non-aggravated levels).

RESULTS

Deprivation therapy during week two elicited significantly greater sensory hypersensitivity to the WNT compared to week one (p < 0.05), and aggravated CORT levels in FPI rats were significantly lower than sham levels. Stimulation therapy during week one resulted in low levels of sensory hypersensitivity to the WNT, similar to deprivation therapy and naïve controls, however, non-aggravated CORT levels in FPI rats were significantly higher than sham.

CONCLUSION

These data indicate that modality and onset of sensory rehabilitation can differentially influence FPI and sham rats, having a lasting impact on behavioral and stress responses to the WNT, emphasizing the necessity for continued evaluation of modality and onset of rehabilitation after TBI.

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 influence of water depth on kinematic and spatiotemporal gait parameters during aquatic treadmill walking

The purpose of this study was to investigate kinematic and spatiotemporal variables of aquatic treadmill walking at three different water depths. A total of 15 healthy individuals completed three two-minute walking trials at three different water depths. The aquatic treadmill walking was conducted at waist-depth, chest-depth and neck-depth, while a customised 3-D underwater motion analysis system captured their walking. Each participant's self-selected walking speed at the waist level was used as a reference speed, which was applied to the remaining two test conditions. A repeated measures ANOVA showed statistically significant differences among the three walking conditions in stride length, cadence, peak hip extension, hip range of motion (ROM), peak ankle plantar flexion and ankle ROM (All p values < 0.05). The participants walked with increased stride length and decreased cadence during neck level as compared to waist and chest level. They also showed increased ankle ROM and decreased hip ROM as the water depth rose from waist and chest to the neck level. However, our study found no significant difference between waist and chest level water in all variables. Hydrodynamics, such as buoyancy and drag force, in response to changes in water depths, can affect gait patterns during aquatic treadmill walking.

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).

Unintentional injuries after TBI: Potential risk factors, impacts, and prevention

BACKGROUND

The top three causes of fatal unintentional injuries are falls, motor vehicle crashes, and being struck against or struck by objects or persons. These etiologies also happen to be the leading causes of TBI, a serious public health problem, in the US. Reduced cognitive functioning, poor decision making, increased risk taking, disinhibition, diminished safety skills and substance use, place individuals with TBI at an increased risk for subsequent unintentional injuries. The caregiving, psychological, social and financial burden of initial injuries is enormous. Unintentional injuries post-TBI add to that burden significantly. Many unintentional injuries can be prevented with simple education and environment and lifestyle changes. Injury prevention requires collaboration among many.

OBJECTIVE

This literature review will share information regarding potential triggers or causes of unintentional injuries after TBI to identify potential issues. The many impacts of these injuries will be reviewed. Best practices in prevention will be presented.

CONCLUSION

Ultimately, education, discussion, and awareness across multiple stakeholders can aid in preventing unintentional injuries after TBI.

Effectiveness of Interventions Within the Scope of Occupational Therapy Practice to Improve Motor Function of People With Traumatic Brain Injury: A Systematic Review

After traumatic brain injury (TBI), many people experience significant motor function impairments. To help occupational therapy practitioners make informed decisions in choosing treatment strategies to improve clients' motor function, we undertook a systematic review and synthesized applicable findings of intervention studies. Of 2,306 articles identified in the literature search, we reviewed 47 full-text articles, of which 16 met approved criteria. We found moderate evidence that various exercise programs increase motor function and limited evidence that people with TBI can benefit from rehabilitation and computer-based programs. We offer implications for practice, education, and research.

Objective Assessment of Activity in Inpatients with Traumatic Brain Injury: Initial Findings

Purpose:Use accelerometers to examine the physical activity behaviours of individuals following TBI undergoing inpatient rehabilitation.

Method:Twenty-one individuals with Traumatic brain injury (TBI) undergoing inpatient rehabilitation (9 females, 12 males;Mage = 43.8 ± 14.7 years;MGCS = 9.1 ± 4.3;Mtime since injury = 40.8 ± 22.1 days;Mlength of stay (LOS) = 30 ± 14 days) wore accelerometers for an average of 8.4 ± 2.0 consecutive days (1440 minutes/day). Activity counts (AC) were collected at 1 minute epochs and descriptive statistics were calculated to assess intensity of activity and time spent being active and sedentary.

Results:During scheduled therapy, time individuals completed an average of 161.4 ± 65.5 AC/minute, which decreased to 114.5 ± 51.3 during non-therapy time and 22.2 ± 10 when sleeping. Using population level cut points, individuals were on average considered inactive during therapy, inactive or sedentary during non-therapy time, and only one participant spent >1 minute in moderate intensity activity. The mean length of active and sedentary bouts was 9 minutes.

Discussion:Findings indicate that the amount and intensity of activity completed is low amongst individuals completing inpatient rehabilitation after TBI, with the majority considered sedentary or inactive. While the sample is small, it is important to develop and implement safe and effective strategies to increase activity levels during rehabilitation.

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.

Classifying physical activity research following stroke using the behavioral epidemiologic framework

BACKGROUND

Stroke is a significant public health issue in the USA and a need emerges to better understand how to reduce an individual's co-morbidity risk. Physical activity is one approach to improving the health of individuals and comprehensive literature supports increased activity as a means to reduce risk of morbidity and mortality. One approach to examining whether research in a field is addressing a public health issue is through application of the behavioral epidemiological framework.

OBJECTIVE

To classify physical activity research for individuals following stroke into distinct phases so that efforts can be made to systematically address gaps and disseminate evidence-based practice.

METHODS

Specific key words were identified and then searched through EBSCO host, PubMed, and Google Scholar. Physical activity and stroke literature from 2000-2014 was categorized into one of five discrete phases. Research in Phase 1 identified associations between activity and health; Phase 2 established valid measures of activity; Phase 3 examined determinants of behavior; Phase 4 evaluated activity interventions; and Phase 5 disseminated evidence-based practice.

RESULTS

A comprehensive review of literature identified 202 articles with 70% categorized in Phase 1 (n = 141), 11% in Phase 2 (n = 23), 10% in Phase 3 (n = 20), 8% in Phase 4 (n = 15), and 1% in Phase 5 (n = 3).

CONCLUSION

Findings suggest that physical activity research for individuals following stroke is in the early stages of development with less than 10% of research evaluating or disseminating interventions.

Randomized controlled trials in adult traumatic brain injury: a review of compliance to CONSORT statement

OBJECTIVE

To describe the extent to which adherence to Consolidated Standards of Reporting Trials (CONSORT) statement in randomized controlled trials (RCTs) in adult traumatic brain injury (TBI) has improved over time.

DATA SOURCES

MEDLINE, PsycINFO, and CINAHL databases were searched from inception to September 2013.

STUDY SELECTION

Primary report of RCTs in adult TBI. The quality of reporting on CONSORT checklist items was examined and compared over time. Study selection was conducted by 2 researchers independently. Any disagreements were solved by discussion.

DATA EXTRACTION

Two reviewers independently conducted data extraction based on a set of structured data extraction forms. Data regarding the publication years, size, locations, participation centers, intervention types, intervention groups, and CONSORT checklist items were extracted from the including trials.

DATA SYNTHESIS

Of 105 trials reviewed, 38.1%, 5.7%, and 32.4% investigated drugs, surgical procedures, and rehabilitations as the intervention of interest, respectively. Among reports published between the 2 periods 2002 and 2010 (n=51) and 2011 and September 2013 (n=16), the median sample sizes were 99 and 118; 39.2% and 37.5% of all reports detailed implementation of the randomization process; 60.8% and 43.8% provided information on the method of allocation concealment; 56.9% and 31.3% stated how blinding was achieved; 15.7% and 43.8% reported information regarding trial registration; and only 2.0% and 6.3% stated where the full trial protocol could be accessed, all respectively.

CONCLUSIONS

Reporting of several important methodological aspects of RCTs conducted in adult TBI populations improved over the years; however, the quality of reporting remains below an acceptable level. The small sample sizes suggest that many RCTs are likely underpowered. Further improvement is recommended in designing and reporting RCTs.

Randomized controlled trials in adult traumatic brain injury

BACKGROUND

To optimize strategies for achieving the effectiveness of interdisciplinary interventions, this study conducted a comprehensive literature review of all Randomized Controlled Trials (RCT) in adults with traumatic brain injury (TBI) over the past 30 years.

METHOD

Three major databases including Medline, PsycINFO and CINAHL were searched, yielding 1176 peer reviewed publications. One hundred RCTs were included, encompassing 55 pharmacologic and non-pharmacologic acute phase trials and 45 rehabilitation and pharmacologic post-acute trials.

RESULTS

The majority of acute phase pharmacologic or non-pharmacologic trials (40/55) showed either no effect or adverse effect on TBI outcomes. Several trials involving early nutritional therapy or pre-hospital rapid intubation demonstrated significant treatment effects. The effect of decompressive craniectomy, therapeutic hypothermia and osmotic therapy remained controversial. The majority of post-acute phase trials (36/45), consisting of cognitive rehabilitation, physical rehabilitation and pharmacotherapy, produced various beneficial treatment effects.

CONCLUSION

The data indicate that several active interventions during the acute phase of TBI are likely to be more effective than pharmacotherapy, whereas a comprehensive rehabilitation approach is preferred in post-acute phase TBI management. Great progress has been made in understanding the heterogeneous injury mechanisms as well as the complexity of medical management and rehabilitation following the recovery course of TBI.

Continued recovery in an adult with cerebellar ataxia

BACKGROUND AND PURPOSE

The authors previously reported on the functional recovery of an adult with chronic, severe ataxia secondary to traumatic brain injury (TBI) after 28 sessions of trunk stabilization and locomotor training (LT). The purpose of this case report is to describe this individual's functional abilities 3.5 years after the intervention.

CASE DESCRIPTION

Thirteen months post-TBI and not expected to be a functional ambulator, an adult male participated in a trunk stabilization and LT intervention. After the intervention, he continued to exercise in a hospital-based fitness program and received additional physical therapy. Evaluation of balance, gait, trunk performance, self-reported function, and quality of life was performed at 6 weeks (baseline), 1 year, and 3.5 years after completing the intervention.

OUTCOMES

Balance, gait, and function improved. Resting left transverse abdominis thickness, measured using ultrasound imaging, increased as did left-side bridge and trunk flexion endurance. He increased community participation and expressed general satisfaction with his overall quality of life.

DISCUSSION AND CONCLUSION

In the 3.5 years after participation in an intervention of trunk stabilization and LT this adult became an independent limited community ambulator. Persons with severe ataxia secondary to TBI may continue to improve many years after injury.

The effect of physical activity on cognitive function after stroke: a systematic review

BACKGROUND

Research in both humans and animals indicates that physical activity can enhance cognitive activity, but whether this is true in patients with stroke is largely unknown.We aimed to evaluate the relationship between increased physical activity after stroke and cognitive performance.

METHODS

A systematic review was conducted of MEDLINE, EMBASE, PsycINFO and other electronic databases. All randomized controlled trials and controlled clinical studies that evaluated the effect of physical activity or exercise on cognitive function in stroke were included. Study quality was assessed using four criteria concerning sources of bias (use of randomization, allocation concealment, blinding of outcome assessment, whether all patients were accounted for in outcome data).

RESULTS

The literature search (first run in 2008, updated in 2011) yielded 12 studies that satisfied inclusion criteria. Exercise interventions were heterogeneous; some studies compared different intensities of movement rehabilitation, others included a specific exercise program. Cognitive function was rarely the primary outcome measure, and cognitive assessment tools used were generally suboptimal. Nine studies had sufficient data to be included in a meta-analysis, which indicated a significant benefit of intervention over control (SMD = 0.20, 95% CI: 0.04–0.36; z = 2.43, p = 0.015). Studies that met all four quality criteria reported smaller treatment benefit than studies that did not.

CONCLUSIONS

There is some evidence that increased physical activity after stroke enhances cognitive performance. The pool of studies identified, however, was small and methodological shortcomings were widespread.

fMRI of the sensorimotor cortex in patients with traumatic brain injury after intensive rehabilitation

For evaluating the patterns of brain activation in sensorimotor areas following motor rehabilitation, seven male patients diagnosed with TBI underwent an fMRI study before and after being subjected to motor rehabilitation. Six patients showed a reduction in the BOLD signal of their motor cortical areas during the second fMRI evaluation. A decrease in cerebellum activation was also observed in two patients. Newly activated areas, were observed in four patients after treatment. In addition, an increase in the activation of the supplementary motor area (SMA) following rehabilitation was observed in only one test subject. The findings show that motor rehabilitation in TBI patients produces a decrease in the BOLD signal for the sensorimotor areas that were activated prior to treatment. In addition, we observed the recruitment of different brain areas to compensate for functional loss due to TBI in line with the cortical reorganisation mechanism.

Effectiveness of physical therapy for improving gait and balance in individuals with traumatic brain injury: a systematic review

PRIMARY OBJECTIVE

The purpose of this review was to investigate the efficacy or effectiveness of non-aerobic exercise interventions to improve balance and gait in functionally mild-to-moderate individuals with TBI (those who demonstrate the ability or capacity to ambulate) and to provide evidence-based guidelines for clinical practice.

METHODS

The authors searched eight databases for papers including exercise interventions to improve gait and balance post-TBI. Twenty papers fully met inclusion criteria. The quality of studies was determined by the Physiotherapy Evidence Database (PEDro) scale and strength by Sackett's Levels of Evidence.

RESULTS

This study found limited evidence of the positive effects of balance, gait or the combination of both interventions in TBI rehabilitation. Most studies included small sample sizes with heterogeneous groups and the interventions were variable and lacked standardization. The outcome measures were variable and low in quality.

CONCLUSIONS

The state of evidence for gait and balance interventions in patients with mild-to-moderate TBI is surprisingly poor. Greater consideration and conformity in the choice of outcome measures and attention in the design and standardization treatment approaches are essential in future research to advance practice.

The immediate effect of treadmill walking on step variability in boys with a history of severe traumatic brain injury and typically-developed controls

OBJECTIVE

To examine the immediate effect of treadmill walking (i.e. enforced walking at a fixed gait velocity) on gait variability among children post-severe traumatic brain injury (TBI) and typically-developing (TD) age-matched controls.

METHODS

Twelve boys post-severe TBI and 18 TD boys participated in this study. Ages were 7-13 years. Step time and length variability were assessed by an electronic walkway prior to and after treadmill walking for 6 minutes.

RESULTS

Significantly reduced walking velocity and step length, with significantly increased step length variability were noted among children post-TBI compared to the TD subjects when walking on level ground prior to the treadmill. Treadmill walking reduced step length variability in TD children, while there was a slight increase in variability in children post-TBI (p < 0.05).

CONCLUSION

Walking on a treadmill at a fixed gait velocity has a different effect on boys post-severe TBI and TD controls.

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.

Motor impairment rehabilitation post acquired brain injury

OBJECTIVE

We sought to investigate the efficacy of treatment strategies used to manage motor impairments following acquired brain injury (ABI) in order to provide guidance for clinical practice based on the best available evidence.

METHODS AND MAIN OUTCOMES

A systematic review of the literature from 1980-2005 was conducted focusing on pharmacological, non-pharmacological, and exercise interventions available for motor impairments post ABI. The efficacy of a given intervention was classified as strong (supported by two or more randomized controlled trials (RCTs)), moderate (supported by a single RCT), or limited (supported by other types of studies in the absence of RCTs).

RESULTS

Thirty-six studies examining a variety of treatment approaches for motor impairments and activity limitations following ABI were evaluated. The majority of interventions are only supported by limited evidence. However, there is strong evidence that serial casting does reduce ankle plantar contractures due to spasticity of cerebral origin, and strong evidence also suggests that partial body weight supported gait training does not provide any added benefit over conventional gait training. There is also moderate evidence to support the use of functional fine motor control retraining to improve motor coordination, tizanidine for upper and lower extremity spasticity, and specific sit-to-stand training to improve functional ability. There is also moderate evidence that casting alone is as effective as casting and Botulinum toxin injections for plantar contractures.

CONCLUSIONS

Although there are a variety of treatment strategies to manage motor impairments and activity limitations following ABI, most are only supported by limited evidence pointing to the need for studies of improved methodological quality in this area.

Physiotherapy after traumatic brain injury: a systematic review of the literature

PRIMARY OBJECTIVES

At present there are no standardized recommendations concerning physiotherapy of individuals with traumatic brain injury (TBI) resulting in a high variability of methods and intensity. The aim of this literature review is to develop recommendations concerning physiotherapy in the post-acute phase after TBI on the basis of scientific evidence.

METHOD

literature review: data bases: PubMed, PEDro, OT-Seeker, Cochrane and Cinahl.

KEYWORDS

brain injury (in PEDro, OT-Seeker, Cochrane), brain injury AND physical therapy (in PubMed and Cinahl).

RESULTS

Fourteen studies met the inclusion criteria and were grouped into sub-groups: sensory stimulation, therapy intensity, casting/splinting, exercise or aerobic training and functional skill training. While for sensory stimulation evidence could not be proven, a strong evidence exists that more intensive rehabilitation programmes lead to earlier functional abilities. The recommendation due to casting for the improvement of passive range of motion is a grade B, while only a C recommendation is appropriate concerning tonus reduction. Strong evidence exists that intensive task-orientated rehabilitation programmes lead to earlier and better functional abilities.

CONCLUSION

Although some recommendations for the effectiveness of physical therapy interventions could be expressed, there are many questions concerning the treatment of humans with TBI which have not been investigated so far. Especially on the level of activity and participation only a few studies exist.

Feasibility of robotic-assisted locomotor training in children with central gait impairment

Intensive, task-specific training enabled by a driven gait orthosis (DGO) may be a cost-effective means of improving walking performance in children. A paediatric DGO has recently been developed. This study was the first paediatric trial aimed to determine the feasibility of robotic-assisted treadmill training in children with central gait impairment (n=26; 11 females, 15 males; mean age 10 y 1 mo [SD 4 y]; range 5 y 2 mo-19 y 5 mo). Diagnoses of the study group included cerebral palsy (n=19; Gross Motor Function Classification System Levels I-IV), traumatic brain injury (n=1), Guillain-Barré syndrome (n=2), incomplete paraplegia (n=2), and haemorrhagic shock (n=1), and encephalopathy (n=1). Sixteen children were in-patients and 10 were outpatients. Twenty-four of the 26 patients completed the training which consisted of a mean of 19 sessions (SD 2.2; range 13-21) in the in-patient group and 12 sessions (SD 1.0; range 10-13) in the outpatient group. Gait speed and 6-Minute Walking Test increased significantly (p<0.01). Functional Ambulation Categories and Standing dimension (in-patient group p<0.01; outpatient group p<0.05) of the Gross Motor Function Measure improved significantly. DGO training was successfully integrated into the rehabilitation programme and findings suggest an improvement of locomotor performance.