BACKGROUND AND PURPOSE
Each year 70,000 to 90,000 individuals sustain a traumatic brain injury (TBI) severe enough to result in long-term functional limitations, making TBI the leading cause of long-term disability in young adults.1 Traditionally, rehabilitation after TBI has emphasized assessment and treatment of impairments and functional limitations.2 Once someone demonstrates independence in daily functional activities, they are often discharged without the chance to work on higher level tasks like those involved in sporting and recreational activities. Rinne et al3 found that 79% of physically well-recovered men diagnosed with a TBI changed their sporting activities, 13% quit former sporting activities, 27% did not exercise weekly, and 58% did not participate in leisure activities more than once per week. When asked what obstacles prevented them from returning to sporting activities, 25% reported that it was due to difficulties running.
Running comprises of a stance, swing, and float phase. The stance phase is further subdivided into absorption and propulsion. During absorption, the lateral heel (or in some people the midfoot) strikes the ground at initial contact and the foot rapidly pronates as the hip, knee, and ankle all flex to decrease the forces at impact. At this point, the leg is also storing elastic energy to be used for more powerful propulsion. During propulsion, the hip, knee, and ankle all extend and the foot supinates until there is maximal extension at toe-off. The swing phase is subdivided into initial and terminal swing. At the beginning and end of swing, there are two periods of float in which both feet are airborne.4,5 The upper extremity and trunk provide reciprocal movement to produce torque and force as well as provide an equal center of gravity and balance when in the multiple stages of running.6
The act of running requires greater range of motion, strength, balance, and motor control than walking.4,5,7 The response of the body to increased speed is to lower its center of gravity, which requires greater hip, knee, and ankle range of motion as well as greater eccentric muscle contraction.4,5 Running includes a longer stride length, a narrower base of support, no period of double support, and a float phase so adequate balance and motor control is important.7
Persons with TBI often demonstrate impairments in tone, sensation, proprioception, strength, coordination, balance, and cognition.8 These impairments can interfere with the ability to run and may place the person at higher risk of falls and musculoskeletal injury. Physical therapists have the responsibility to maintain the well-being and safety of patients.2 Rehabilitation programs designed to teach someone to run again should address strengthening to promote performance, as well as decrease the risk of musculoskeletal injuries, and safety to prevent falls.
The effects of strength training on running in those with neurological diagnoses were unknown, although outcomes with untrained or moderately trained people without disabilities are positive. Aerobic endurance performance during running is dependent on maximum oxygen consumption, lactate threshold, and running economy.9 Resistance training programs have been found to improve all three of these factors.10 It is also hypothesized that strength training may prevent musculoskeletal injuries because stronger tissue tends to sustain less damage11 and because balanced strength in the core and lower extremities promotes symmetrical running, which can decrease biomechanical stressors.12
It is often not feasible to retrain someone with a TBI to run overground due to the risk of injury. One specific method of training that can address running safely is body weight–supported treadmill training (BWSTT). BWSTT uses a harness together with a calibrated lift mechanism to support a portion of a person's body weight while running on the treadmill. It requires lower levels of muscle force because the person is unweighted, and the harness provides posture and balance control. Individuals can run in a safe environment where running would otherwise be difficult or even impossible without such a system. Use of BWSTT reinforces a reciprocal pattern by naturally increasing single limb support time on the weaker side and decreasing muscle activity of weight-bearing muscles allowing locomotion to become more efficient and limiting the development of asymmetries.13,14
Use of BWSTT is consistent with the principles of motor learning15 and neuroplasticity16 as it allows for an increased number of repetitions of a functional task.17 Use of BWSTT has been shown to require less energy expenditure than conventional gait training,18 and subjects are able to walk longer and perform a larger number of repetitions of completed cycles. Although the results of studies using BWSTT for gait training in those with TBI are inconsistent,19–23 the preliminary findings in those with cerebral vascular accident and spinal cord injury are promising. Research has shown that subjects demonstrate a greater ability to ambulate,24,25 with increased gait speed,24,26 increased stride length,24 and greater endurance26 compared with control conditions.
Specific literature on rehabilitation programs in those with neurological diagnoses whose goal is to run is limited to use of BWSTT as the sole means of intervention and no articles were found that address running in those with TBI. Gardner et al27 completed a single-subject design to determine the effect of gait training using BWSTT on gait and running speed in a 28-year-old man diagnosed with incomplete quadriplegia. Both gait speed and running speed improved with the largest gains noted in running.
In a single-subject design completed by Miller et al,28 a 38-year-old man diagnosed with a cerebral vascular accident was trained to run using BWSTT as a task-specific intervention. The subject received therapy three times per week for eight weeks. Each session consisted of three periods of running up to a maximum of 10 minutes. From initial evaluation to six-month follow-up, his sprint speed improved significantly from 3.4 to 4.1 m/sec, timed standing on one leg improved significantly from 3.4 to 7.1 seconds, step width decreased significantly from 9.2 to 4.4 cm, and no changes were noted in step length ratio. Six of the eight lower extremity muscles tested improved in a range from 18% to 167% and clinically important changes were noted on the Stroke Impact Scale. The subject was able to run two miles several times per week with his wife after the intervention.
The purpose of this case study is to document outcomes after a rehabilitation program in an adolescent male with post-TBI whose goal was to run one mile (1.6 km). We hypothesized that he would be able to meet this goal.
The subject of this prospective case study was a 17-year-old boy who sustained a TBI as a 14-year old when he fell while skiing. He was in a coma for six days, and medical imaging results indicated damage affecting the basal ganglia. His initial prognosis was poor, and he was not expected to walk again. After 4.5 months of subacute rehabilitation, he was able to walk household distances independently with a crutch and used a wheelchair when out in the community. Medical history was unremarkable except for asthma. His diagnosis falls into Preferred Practice Pattern 5D: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the CNS-Acquired in Adolescence or Adulthood in The Guide to Physical Therapist Practice.2 His parents gave written informed consent, and he assented to participate in the project. Human subject's approval was obtained from The Sage College's Institutional Review Board.
The current initial physical therapy evaluation was completed 3.5 years after his initial injury. He was functioning at level VIII on the original Ranchos Los Amigos Level of Cognitive Functioning Scale.29 He was able to learn new tasks but showed some limitations with judgment in stressful or unusual situations. Passive range of motion was within normal limits throughout except for left ankle dorsiflexion, which measured 0 to 5 degrees. He presented with impaired strength of the left lower extremity and normal strength of the right. His left upper extremity was nonfunctional.
A slight increase in tone at end range was noted in the left lower extremity extensors, whereas right lower extremity tone was normal. Light touch and pain/temperature testing of bilateral lower extremities were intact as was position sense and kinesthetic testing. A moderate impairment in coordination was evident in the left lower extremity in that his movements were slow, awkward, and unsteady. He was able to stand for 10 seconds on his right leg but only two seconds on his left. He denied any pain.
The subject ambulated community distances without a device wearing a plastic hinged ankle-foot orthosis (AFO) with a plantarflexion stop on the left. He was able to run 10 m on even surfaces. Initially he required supervision due to concerns for falls because he presented with left ankle instability and occasionally stubbed his toe even while wearing the AFO. He was independent in all activities of daily living and instrumental activities of daily living. He attended high school and drove with adaptive equipment.
The outcome measures chosen for this study were bounding forward onto a single leg,30 toe walking,30 backward step ups,30 timed standing on one leg,30 muscle strength of the lower extremities, running distance, running speed, and running quality. The subject was reevaluated at two-week intervals throughout the intervention period by the treating physical therapist who had 19 years experience working with this population. Measurements were taken at two-week intervals because it was expected that he would make gains quickly, and these data were necessary to make clinical decisions about how to progress with his exercises. At six-month follow-up, the subject was attending college so follow-up measurements were taken on campus. Due to limited time and space, only measurements for strength testing and running quality were completed.
Bounding forward onto a single leg, toe walking, backward step up, and timed standing on one leg are all associated with the ability to run in those diagnosed with TBI.30 For this reason, they were chosen as outcome measures for this case study. The exact procedures as outlined by Williams and Goldie30 were followed for all tasks except bounding and toe walking. Our subject was unable to maintain single limb stance on his left leg long enough to complete the bounding task. It was modified for him to start in partial tandem stance with the left leg forward. Each of the four tasks was performed twice and the scores were averaged. All four measures have been shown to have excellent test retest reliability (r = 0.92–0.97), demonstrate construct validity in those with TBI, and are associated with the ability to run.30 The subject did not wear his AFO when completing any of these measures which were tested over ground. See Table 1 for operational definitions of these outcome variables.
Muscle strength of the hip extensors, hip abductors, knee flexors, knee extensors, ankle dorsiflexors, and ankle plantarflexors was measured using a Nicholas hand-held dynamometer using the protocol recommended by Bohannon.31 Dynamometry testing using the Nicholas dynamometer has been shown to have good intratester reliability (intraclass correlation coefficients [ICCs] = 0.74–0.94)32 and high concurrent validity with isokinetic testing (ICC = 0.80–0.97)33 but is dependent on tester strength34 and varies among muscle groups.33,34 Because all measures completed above were performed twice in each reevaluation session, it was possible to compute ICC values using data from all sessions to provide an estimate of reliability. ICC values for test-retest reliability were >0.70 for bounding, hip abductor strength, knee flexor strength, ankle dorsiflexor strength, ankle plantar flexor strength, and toe walking suggesting more than satisfactory reliability for these measures. Reliability was less than satisfactory for one-legged stance, knee extensor strength, and hip extensor strength because ICC values for test-retest reliability were <0.70.35
Maximum running distance was measured using a GO walking pedometer by Sportline. Testing using pedometers has been shown to have excellent reliability (ICC = 0.93).36 Running speed was computed after he was timed running a marked distance of 10 m. On initial evaluation, the subject could run ∼10 m, which is why running speed was based on a timed 10-m sprint and not the longer distances as noted in previous research.37–39 Two trials of timed running were averaged, and speed was determined by dividing distance by time. Timed walking speed has been shown to have excellent test-retest reliability when applied to individuals with neurologic impairments (r = 0.95–0.98),40 but no data were found regarding timed running tests using a stopwatch.
The subject was filmed while running, and 10-m clips showing angles from the front, back, and side were analyzed by three physical therapists who have been practicing for a combined total of 58 years. The evaluators viewed each video clip in order from initial evaluation to six-month follow-up and were not blinded to the order. Each evaluator was given a running analysis form to assist them in evaluating any running deviations. The form included a brief description of the phases of running and the critical events that occur in each phase. The three evaluators were instructed to complete a list of all biomechanical deviations and then note any changes from initial evaluation to discharge and from discharge to the six-month follow-up. A change in running quality was noted when two of the three evaluators documented the same differences. All running tests were completed indoors at the local Young Men's Christian Association while the subject was wearing his AFO.
Impairments in muscle strength combined with the decreased ability to stand on his left leg resulted in an asymmetrical running pattern and prevented adequate forward propulsion while running. Because of severe impairments in left ankle strength, he wore a plastic AFO with a plantarflexion stop that prevented natural push-off while running. He often supported his left upper extremity with his right upper extremity thus inhibiting natural upper extremity swing and trunk rotation. We assumed that running endurance was at least partially limited by cardiovascular deconditioning because he had not been physically active since his injury. Mossberg et al41,42 found that persons who sustained a TBI were significantly more deconditioned than their nondisabled sedentary counterparts. In addition, locomotor deviations increase energy expenditure43 making his running less efficient. These limitations had to be addressed for him to regain the ability to run one mile.
We determined that he had good potential to meet his goal. He was able to perform two of the four tasks, which were found by Williams and Goldie30 to be associated with the ability to run in those with TBI. He had adequate gross motor skills to participate in the rehabilitation program and was able to run 10 m with supervision. He had sufficient cognitive skills to follow commands and make decisions about his treatment within guidelines set up by the physical therapist. He also demonstrated normal strength in his right lower extremity, had intact sensation and proprioception bilaterally, was motivated to improve his performance, and had a strong family support system. One concern was his exercise-induced asthma, which most likely played a role in his limited endurance. As a preventive measure, he was instructed to use his inhaler 15 to 20 minutes before the scheduled appointment and always had his inhaler with him during therapy.
Plan of Care
The intervention was divided into three phases. Phases I and III consisted of a strengthening program and phase II consisted of BWSTT. All three phases took place at his home where he was treated by a physical therapist once a week for 1.5-hour sessions. He participated in many school activities and could not schedule physical therapy more than that. He was initially given a home exercise program but did not adhere to it.
Phase I lasted 17 weeks and was designed to increase the strength of his core and lower extremities, so that he could safely meet the demands of running. Most of the exercises were closed chain activities, which allowed him to use his body weight as resistance while training the stabilizing muscles to maintain joint stability.44,45 Two weeks into the intervention period, the subject fractured his left wrist while camping, which required modification of his plan of care during phase I to avoid use of his left upper extremity.
Four weeks into the intervention program, no improvements in left ankle dorsiflexor strength were noted. At this time, mental practice exercises46 were added to the plan of care. He was instructed to picture himself moving his foot and toes toward his head without actually moving them and to do so several times during the day while sitting in class. Mental practice has been shown to increase the neural adaptation process by recruiting motor neurons to a given muscle group.47 These exercises can repetitively activate cerebral and cerebellar sensorimotor structures damaged by brain injury, potentially increasing the quality of the signal output to the muscle and promote motor rehabilitation. Cortical reorganization has also has been documented as a result of mental practice drills.48
At week 12, the subject's strength and motor control progressed to the point where a more challenging exercise protocol was warranted. Simple plyometric and agility exercises were introduced.49,50 These drills can improve agility by reinforcing motor programming through neuromuscular conditioning and neural adaptation as well as improve explosive power while running.51 See Table 2 for the exercises completed throughout phase I.
A Thera-Band taping technique was developed for use during therapy as an alternative method of limiting footdrop and providing medial/lateral stability without the bulkiness and restrictiveness of an AFO. This technique was carried through to all phases of training because the elasticity of the Thera-Band facilitated ankle dorsiflexion, yet did not restrict plantar flexion during toe-off as does an AFO. See Figure 1 for pictures of this technique. Although this taping technique worked well during phases I and III, it did not provide enough dorsiflexor assist while running on the treadmill. The Walk Easy Dynamic Dropped Foot Assistor was applied over the Thera-Band taping technique while running on the treadmill.
At the completion of phase I, the subject's limitations improved to the point where he could safely begin running for extended periods of time with minimal risk of musculoskeletal injuries. At this point, he still required supervision to run due to a risk of falls, and BWSTT provided a safe environment in which he could practice running. Use of BWSTT also allowed him to practice running further than he could overground. He was only able to run 0.22 miles overground at the end of phase I but was able to double that distance by running 0.5 miles on the treadmill on the first day of phase II.
Training was provided using the Lite Gait System I 250 and lasted 15 weeks. Initially, groin straps were applied to prevent the harness from sliding superiorly, but they proved to be uncomfortable. Mid thigh leg straps were substituted for the groin straps, which he found much more comfortable.
The subject self-selected the speed, overall time, and amount of unweighting at which he ran under the supervision of the physical therapist. We allowed him to make these decisions because active involvement has been shown to be associated with better treatment outcomes.52 He was also encouraged to run without use of the handle bars. During the first session of BWSTT, the subject was comfortable being unweighted 30% of his body weight, but after the first month, he preferred 0% unweighting and used the harness mainly as a safety measure. See Table 3 for progression of maximum velocity and overall time on the treadmill throughout phase II. Heart rate, blood pressure, and oxygen saturation were monitored according to American College of Sports Medicine guidelines for stroke.53 Exercise would have been terminated if his systolic blood pressure exceeded 200 mm Hg or decreased 10 mm Hg from rest, his diastolic blood pressure exceeded 110 mm Hg, heart rate exceeded 200 bpm or decreased 15 bpm, or his oxygen saturation decreased to less than 90%. His vital signs stayed well within these parameters, and he used his inhaler three times during therapy over the course of the intervention.
Each intervention session started with a warm up in which he walked five minutes on the treadmill at a low speed (2.5–4.0 mph). The intervention itself was set up in two to three different running periods per session. Timed trial running and time-to-exhaustion running are commonly used to assess running endurance performance.54 The first period was a timed trial that was designed for speed. He was instructed to run as fast as he could tolerate and to maintain that run with a target time that changed as he progressed. The second running period was a time-to-exhaustion period, which was designed for running distance. The subject was instructed to run as long as possible at a comfortable speed. If able, he completed a third running period the goal of which was also time-to-exhaustion running. After the intervention, a cool down was completed by walking on the treadmill at 3.0 to 4.0 mph for five minutes.
During BWSTT, facilitation and verbal cueing were provided by the physical therapist to prevent pelvic retraction on the left during stance. Pelvic retraction can interfere with normal stride length on the opposite side because hip extension is limited.55 Once the subject demonstrated signs of improper running mechanics or requested a slower speed, the speed was decreased to a comfortable running pace. He was given a five-minute rest period in between running trials where he usually stood or walked around his house slowly.
Phase III was an extended modification of phases I and II, which introduced overground running outdoors. Treadmill running has been stated to be monotonously repetitive with consistent body mechanics whereas overground running requires frequent changes in speed, running surface, and body mechanics.56 The use of a harness during BWSTT also limits normal trunk rotation. For these reasons, the gains in repetitive proper running mechanics noted in phase II needed to be applied to overground running. Phase III lasted six weeks and focused primarily on running mechanics (including reciprocal arm swing), running endurance, plyometric and agility exercises,49 and dynamic stretches.57 See Table 2 for the exercises completed throughout phase III.
On completion of all three phases, improvements in multiple areas were noted. Initially, the subject was not able to complete the bounding task and by discharge, he was able to jump 43 inches. Toe walking improved from 21 inches at initial evaluation to 305 feet at discharge. Backward step up increased from 6 inches at initial evaluation to 10 inches at discharge, and timed standing on one leg did not change from initial evaluation to discharge. Refer to Table 4 for values at initial evaluation and at the end of each phase.
A change in right lower extremity muscle strength ranged from a 3.3-kg reduction in force production of the hip abductors to an 18-kg increase of the knee extensors. A change of left lower extremity muscle strength ranged from a 0.1-kg increase in force production of the hip abductors to a 12-kg increase of the hip extensors. Follow-up testing at six months indicated that the subject maintained 69% to 95% of muscle strength of the left lower extremity and 76% to 88% of muscle strength of the right lower extremity since discharge. Refer to Table 5 for strength values at initial evaluation, at the end of each phase, and at six-month follow-up. Improvements in muscle strength were generally greater on the left side compared with the right.
Running speed improved from 0.45 m/sec at initial evaluation to 3.52 m/sec at discharge with most improvement occurring in the first eight weeks of phase I. Running distance improved from 0.1 km at initial evaluation to 1.2 km at discharge. Refer to Table 4 for values at initial evaluation and at the end of each phase. He reported the ability to independently run 1.6 km (one mile) at school by time of discharge. After this phase, he was able to progress from wearing a plastic AFO to a carbon fiber brace for everyday use and running.
Initial running analysis revealed that the left hip and knee did not properly flex nor did the ankle pronate for proper absorption during the absorption phase, the ankle and hips were not in maximal extension during the propulsion phase, the foot remained plantar flexed without proper knee flexion throughout swing, weight bearing on the left was less as compared with the right, center of gravity displacement was excessive, and he supported his left upper extremity with the right throughout the running cycle. Reported changes from initial evaluation to discharge included improvements in hip and knee flexion and ankle pronation during the absorption phase, greater extension at all joints during toe-off, improved ankle dorsiflexion and knee flexion throughout swing, more appropriate center of gravity displacement, and more symmetrical and fluid movements throughout. Videotape analysis taken at the six-month follow-up showed that the subject's running pattern remained unchanged except for further improvement in toe-off on the left during propulsion.
The purpose of this case study is to document outcomes after a rehabilitation program in an adolescent male three years after TBI whose goal was to run one mile. Our observations support that use of such a program can allow someone to resume running after brain injury.
Improvements in strength of all lower extremity musculature except right hip abductors, right ankle dorsiflexors, and right ankle plantar flexors were noted. Major improvements were noted in bilateral hip extensors, bilateral knee extensors, and left ankle plantar flexors, which are the main muscles that propel the body during running.58 By discharge, the amount of force produced in the extensors of the left side was much closer to the force produced by the extensors on the right. These increases in muscle strength coincide with the exercises that were executed in the intervention period. The force production required to run and perform closed chain exercises is derived mainly from the lower extremity extensor muscles.58 The hip extensors, knee extensors, and ankle plantar flexors were extensively trained over the course of this intervention; therefore, a large gain in muscle strength was expected.
Although left knee flexor strength improved 5 kg, the force produced during testing was still significantly less than on the right side. The type of training executed did not allow the knee flexors to be trained as extensively as the extensors. In addition, the left knee flexors were extremely weak at initial evaluation, and he may have needed more time to gain more strength.
Left ankle dorsiflexor strength improved by 4.9 kg, which was not expected because the closed chain exercisers provided did not emphasize ankle dorsiflexion. These gains may be attributed to the addition of mental practice exercises in phase I. He was not able to produce any force during dynamometry testing until after he started the mental practice exercises. The week after initiation of the exercises, he was able to exert 0.75 kg of muscle force and three weeks post-exercise, he was able to exert 2.6 kg of force. It is possible that the neural adaptation process and cortical reorganization were enhanced by the addition of these exercises.46
Miller et al28 also noted improvements in muscle strength, although the percentage improvement was not as great as with our subject. The greater strength improvements are most likely the result of our strong focus on strength training during phases I and III. Strength training was a necessary component of our program due to his impairments in muscle strength and our concerns for musculoskeletal injury. The subject in the study by Miller et al28 had greater lower extremity strength at initial evaluation, and he did not require use of an ankle brace. Because our subject was weaker at initial evaluation, larger gains in strength were expected.
Test-retest reliability for hand-held dynamometry testing of hip abductors, knee flexors, ankle dorsiflexors, and ankle plantar flexors were satisfactory (ICC > 0.70). However, the ICC values for test-retest reliability for hip and knee extensors were <0.70. The quality of dynamometry measurement is dependent on the subject's position and stability of the dynamometer during the test.13 The position of our subject during testing was consistent with Bohannon's31 recommendations, but it is possible that the evaluator's ability to provide enough counterpressure during the test for hip and knee extension was not sufficient. This is consistent with the literature in that reliability tends to decrease with increasing force measurements.34 Because the strength gains were so large in this case study, the lack of stabilization may not have had a significant effect on the results. In fact, tester strength can affect the magnitude of dynamometry testing,34 so it is possible that he had even greater strength in the hip and knee extensors than what was reported.
The subject demonstrated a decrease in muscle strength at six-month follow-up. He reported that he did not continue to work out on his own nor was he involved in any physical extracurricular activities since graduation from high school one month after discharge. During his last physical therapy session, he was instructed in the proper use of the exercise equipment at the college fitness center but reported that he never went. Even without a structured program, he was able to maintain 69% to 95% of his lower extremity muscle strength, which was enough for him to remain independent in running. Ideally, we would have liked to see him join the Achilles Track club for people with physical challenges, but there is no local chapter in our area.
When observing the changes in the quality of the subject's running, it seems that he recovered the function of running, and compensations decreased from initial evaluation. Recovery has been described as regaining a function that was previously lost, whereas compensation has been described as a behavioral substitution.59 The BWSTT allowed him to train in a biomechanically beneficial capacity for long periods of time where he learned the proper running pattern without compensations. The video analysis provided evidence that he had better mechanics to absorb forces at impact during the absorption phase and improved extension during propulsion at discharge. These changes were maintained six months later, which provides evidence that motor learning occurred. The improvement in quality of running is consistent with the literature on the effect of treadmill training on the quality of gait in those with neurological diagnoses.24,60,61
Improvement in running endurance can be supported by both neuromuscular and cardiopulmonary development. Neuromuscular strength gains have been linked to improved running endurance in athletes.10 During phase I, the main focus was to improve neuromuscular strength and control via body weight resistive exercises. Outcomes support the fact that his strength improved. Then during phase II, the BWSTT provided a safe environment where his cardiovascular conditioning and running deviations could be addressed. Decreasing running deviations allows for a more energy efficient running pattern.7
At the time of the initial evaluation, the subject showed little if no ankle stability and required use of a plastic AFO. After phase III, his strength improved to the point where he was able to upgrade his brace to a carbon fiber spring leaf orthotic, which allowed for more appropriate push off during running improving the overall running quality.
Maximum running velocity improved from 4.0 to 7.0 mph while running on the treadmill during phase II. However, this improvement did not carryover to running overground. This result is inconsistent with the results found by Miller et al28 and Gardner et al,27 who both noted improvement in running speed after BWSTT. One explanation for this discrepancy is that the Thera-Band taping procedure allowed for more normal foot and ankle movement during treadmill training in our study but during reevaluation of overground running the plastic AFO was used. Running velocity is typically dependent on a person's stride length and stride frequency.62 The subject wore an AFO during the overground running reevaluations, which most likely disrupted his natural running mechanics and could be a factor in why his running velocities did not improve during the reevaluations in phase II. At initial evaluation, the subject had to use the AFO during running velocity testing because he did not have the ankle stability to run overground without use of an AFO. For purpose of consistency, reevaluations for running velocity were completed using the AFO throughout the study.
The method used to quantify maximum running speed may have measured the subject's acceleration and not his maximum running speed. The distance used to measure his running velocity was 10 m, which may have been too short for him to reach maximum velocity. Zafeiridis et al63 found when running velocities were measured from 0 to 50 m, maximum running velocities occurred from 20 to 50 m, while running accelerations occurred from 0 to 20 m. This research suggests that what was measured in our subjects' 10-m sprint was his acceleration, not his maximum running speed.
The fact that we may have been measuring acceleration could account for why his performance on the maximum running velocity measure improved the most during the first eight weeks of phase I. Acceleration is the result of generating high forces in the correct direction. He was able to generate higher levels of force during this time due to significant increases in strength. Left hip and knee extensor strength doubled during the first eight weeks and allowed the ability for greater force production during acceleration.
No improvements in timed standing on one leg were noted, which is inconsistent with the study by Miller et al.28 The lack of improvement could be a result of our subject's ankle instability. Even though his ankle stability did improve over the course of the intervention to the point where he was ambulating with a less restrictive ankle brace, it did not improve enough to ambulate consistently without the support of an external device. His reliance on external support could affect the ability to stand on his left leg, which was tested without an external device.
Improvements in quality of life were not explicitly measured in this case study, although anecdotal improvements were noted. After the intervention, he was able to play baseball and run around the track with his peers during physical education class. Before the intervention, he was only able to swing the bat while playing softball, but another student ran the bases, and while the rest of his class ran the mile on the track, he did his own exercises on the sideline. The ability to run now gives our subject the ability to participate in sports with his peers.
His family also observed his enhanced outlook on life. At the completion of the study, his mother stated that “This effort has made a significant impact on his abilities to feel more positive about himself and his capabilities and to be able to move more into living his life.”
This rehabilitation program was designed as a research endeavor and was provided as a pro bono service. Clinically, such a program could be reimbursed through health insurance providers or through the school system by using evidence for cardiopulmonary fitness from the perspective of health and wellness. If running is not considered a covered benefit, scholarship programs are available that provide financial assistance for postrehabilitation exercise for those with disabilities. Another option is for the facility to partner with a national sports/recreation program that may fund people with disabilities in individual and team sports. Last, cash-based services should not be overlooked, especially if there are any remaining funds from a settlement.
On reflecting on our experience, we have several recommendations for clinicians and researchers. The use of the High-Level Mobility Assessment tool64,65 as an outcome measure for higher functioning individuals with TBI should be considered. This tool consists of higher level tasks like the ability to negotiate stairs, run, step, hop, and bound. This tool was not available to the authors at the initiation of data collection and is more inclusive than the outcome measures used in this case study. Other suggestions include the use a standardized quality of life measure, a 20- to 50-m running measure that truly measures maximal running speed, an evaluator who is able to match the strength of the subject during dynamometry testing, high-tech running analysis for a more objective measure of running mechanics, and use of the Thera-Band taping technique instead of an AFO during tests of running quality. In addition, it is strongly recommended that the intervention is performed more than once per week to facilitate motor learning and that more emphasis is placed on adherence to the home exercise program.
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