Each year at least 1.7 million traumatic brain injuries (TBIs) occur in the United States, which cost an estimated $76.5 billion.1 In addition, 43% of persons discharged home after hospitalization develop long-term disability.1 The sequelae of a TBI can include motor, cognitive, behavioral, and emotional dysfunctions.2 The resulting motor impairments can impact a person's independence and participation in his or her life roles.3
Independent gait is a common therapy goal for most individuals post–brain injury. In one study, 73.3% of persons achieved independent gait by 5 months postinjury.4 It is interesting that gait recovery occurred early, suggesting that recovery of independent gait more than 3 to 4 months after injury is much less likely.4 Impairments of gait after TBI are common, including decreased velocity, step length, altered stance and swing times, and varied kinematics.5 The inability of a person post-TBI to traverse his environment using upright mobility can limit performance of basic care skills. One study estimated that approximately 33% of individuals post-TBI required assistance with at least 2 activities of daily living (ADLs).6 This high level of dependence places an extraordinary burden on caregivers.7
There is not a consensus on best practice for gait recovery after TBI.8 Although it is generally understood that early intervention creates the best environment for promoting neuroplasticity,9 addressing gait recovery after TBI is often complicated and delayed by musculoskeletal and internal injuries and by altered levels of consciousness.4,10 There is limited and conflicting literature to support the use of locomotor treadmill training (LTT) as a gait training method. There have been 2 randomized controlled trials comparing LTT with conventional gait training and neither found LTT to be superior.11,12 A third study compared manually assisted LTT with robotic-assisted LTT and found gait improvements in persons with chronic TBI with both interventions.13 In addition to these 3 research articles, there have been 3 case series/studies, Seif-Naraghi and Herman14 reported on 2 individuals in which LTT improved ambulatory independence. Likewise, Wilson and Swaboda15 found improvements in gait using LTT with 2 individuals. Scherer16 used LTT with an individual 7 months post-TBI and saw improvements in gait.
Beyond LTT, there is limited evidence to support the use of other interventions for improving gait in persons with TBI. One study found functional electrical stimulation (FES) to be successful for gait recovery with a patient with a chronic TBI when many other interventions had failed.17 There is, however, stronger evidence for the use of FES in other populations. A systematic review found a modest benefit of FES for strengthening in persons with stroke.18 Functional electrical stimulation–assisted gait has been studied in the spinal cord injury population with good outcomes.19–21
Considering the prevalence of TBI and the associated costs, it is critical to explore viable treatment options for recovery of function, especially gait. It is particularly critical to consider treatment options for the growing number of individuals with chronic TBI, many of whom have poor gait prognosis.4 Despite the limited TBI-specific evidence available to guide treatment planning, there is a substantial body of motor learning research available to guide the development of effective treatment plans.9,22–26 Critical to these plans are elements such as salience, intensity, repetition, and task specificity. This case study details a comprehensive outpatient treatment program, which included LTT and FES, as well as other interventions, for a 26-year-old man with a severe chronic TBI after a motor vehicle accident.
The client (S.R.) was a previously healthy 26-year-old college student who was involved in a motor vehicle accident 4 years prior to the initial examination. The Institutional Review Board of the UT Southwestern Medical Center does not require consent for participation in a study for a single subject design. At the time of the motor vehicle accident, he sustained multiple injuries in addition to a TBI, including fractures of the right humerus, right femur and pelvis, bilateral pneumothoraces, splenic and liver lacerations, respiratory failure, and extra- and intraperitoneal bladder ruptures. S.R. required extensive surgical intervention including chest tube placement, external fixation of his pelvis, open reduction and internal fixation of his right femoral neck and humerus, inferior left vena cava filter placement, percutaneous gastrostomy tube placement, tracheostomy placement, intracranial pressure monitor placement, and suprapubic tube placement. Early brain imaging revealed subarachnoid and intraventricular bleeding with shear hemorrhage in the left internal capsule, as well as restricted diffusion in the centrum semiovale, corona radiata, splenium of the corpus callosum, medial parietal and occipital lobes, and the left parahippocampal gyrus. There was evidence of edema in the cerebellar vermis and a right cerebellar contusion. See Figure 1 for additional details of recovery and therapy course.
At the time of the initial evaluation at our facility, S.R. used a power wheelchair for all functional mobility. S.R. had received extensive physical therapy prior to the initiation of services in our clinic. Much of that therapy had been focused on recovery of gait. Therapeutic activities included LTT with and without body weight support (BWS), hippotherapy, overground walking with partial BWS and with a bilateral platform walker, as well as aquatic therapy. He had been able to walk short distances in therapy with the assistance of 2 people but had not walked outside the clinic. S.R. was taking serotonin at night to help him sleep and had a baclofen pump (dosage was 548 μg/d dispensed continuously) to control spasticity. His mother was his sole caregiver and was extremely supportive; she assisted him with all ADLs.
Assessments were performed by a physical therapist with 17 years of experience treating patients with neurologic injuries (K.M.). S.R. presented with bilateral motor control limitations. His movements were very slow and he had more control on the left. S.R. was not able to use his right upper extremity (UE) for ADLs. Manual muscle testing grades at the time of initial and discharge examination are detailed in Table 1.
S.R. had poor trunk control in sitting and standing, with a fixed pelvic obliquity and posterior pelvic tilt and corresponding thoracolumbar scoliosis (left side of pelvis higher). His trunk was flexed with marked neck flexion and dropped head. He was able to hold his head up for 10 s. Range of motion in his lower extremities (LEs) was within normal limits with the exception of decreased hamstring range bilaterally, lacking 35° (knee extension method). It was not possible to accurately assess sensation due to communication issues, but S.R. appeared to have moderate sensory deficits in the LEs (proprioception, light touch), with greater deficits on the right. There was no evidence of spasticity in the LEs as measured by the modified Ashworth Scale. S.R. demonstrated a leg length discrepancy in supine, left 1 cm shorter.
S.R. was dependent with basic ADLs (dressing, bathing, grooming, and eating) and required moderate assistance for basic transfers and bed mobility. He required moderate assistance to stand with UE support. He was able to activate most of the muscles in his LEs on command, despite being much weaker on the right. He had difficulty isolating movements bilaterally, as well as difficulty with grading and timing movements. Movements on his left side were smoother and more reliable but atypical with respect to timing or grading. He was able to walk up to 15 ft on level surfaces with hand-held assistance of 2 people. His steps were short, with frequent hip adduction during swing bilaterally resulting in widely variable foot placement. He had foot drag on the right during swing as well as knee hyperextension bilaterally during stance. S.R.'s primary goal for therapy was to regain the ability to walk, preferably independently.
S.R. was treated in the Gait Disorders Clinic in the School of Health Professions at the University of Texas Southwestern Medical Center for a total of 79 visits (not including the initial evaluation and discharge visit) over a period of 62 weeks. Treatments were provided by the author (K.M.) with the frequent assistance of a physical therapy technician and occasional assistance of another physical therapist. Each therapy session was approximately 45 to 60 minutes in duration. The interventions and functional changes related to the current course of care are detailed in Table 2. Therapy was initiated at a frequency of twice per week. During the 62-week period, services were provided during 47 of those weeks. For 34 weeks, S.R. received twice-weekly visits and for 13 weeks, he received 1 visit per week. He missed 1 week secondary to a cholecystectomy and the other 14 weeks without therapy were due to absences related to travel with his mother.
Locomotor Treadmill Training
A total of 32 treadmill treatments were performed over the first 14 months of the intervention period described in this report. The initial training was performed with 50 lb (30%) of BWS and bilateral UE support, large rubber straps around his hips to stabilize his pelvis, and maximum assist of 2 therapists for limb advancement, at a training speed of 0.3 m/s (0.7 mph). The initial session was 6 minutes in duration. On occasion, another physical therapist assisted by providing cues at S.R.'s trunk to promote upright posture. With this assistance, he was able to train without UE support. By the conclusion of LTT, S.R. was walking up to speeds of 2.0 mph with no BWS and no assistance for LE advancement, utilizing bilateral UE support and pelvic stabilization straps. At these upper limits of speed, he was able to walk in 2- to 3-minute bouts. Videographic examples of S.R.'s progression during treadmill training are available online (see Video, Supplemental Digital Content 2, available at: http://links.lww.com/JNPT/A176).
Locomotor treadmill training was chosen as a primary intervention based on evidence that it can enhance gait recovery by means of activation of central pattern generators and facilitation of spinal plasticity.11,27 Given the fact that S.R. had experienced very limited gait recovery at 4 years postinjury, LTT was chosen to provide optimum sensory input while also providing the opportunity for maximum repetitions. Initial BWS was based on recommendations in the literature for initial training parameters for LTT.28,29 As his gait improved, the BWS was reduced and eventually eliminated. Likewise, as his skills improved, the speed was increased and assistance decreased. Locomotor treadmill training was discontinued regularly in the clinic when S.R. was walking consistently at home and in the community with his gait trainer.
Overground walking with S.R. began within a week of starting therapy. The initial efforts were made in the parallel bars or overground with bilateral hand-held assistance. This was done to provide the opportunity to practice the skills that were being learned on the treadmill until S.R. received an appropriate gait training device. On visit 13, S.R. was fitted with a gait trainer (Pacer, Rifton Equipment, Rifton, New York). This device was selected for its stability and adaptability. It can be adjusted to provide each client with the necessary support throughout skill acquisition. Initially S.R. used the arm, trunk, hip, and ankle prompts. He needed assistance to propel the device but over a period of 3 weeks, he was able to advance it independently for up to 5 steps. Videographic examples of S.R.'s early independent gait with the gait trainer are available online (see Video, Supplemental Digital Content 2, available at: http://links.lww.com/JNPT/A176). Once fitted with the gait trainer, he began using it daily at home for walking practice. Throughout the course of therapy, S.R. used the gait trainer at home for extended walking practice. In the clinic, he walked with various devices, including a specialized cane that, in addition to the grasp surface, provided posterior support for the forearm (StrongArm Mobility, Evanston, Illinois), a forearm crutch and a rocker bottom axillary crutch. The crutch was used most often as S.R. was able to stabilize this device on his trunk. Since S.R. was walking extensively at home with the gait trainer, walking in the clinic with the crutch was done to focus on balance and upright stability. Videographic examples of S.R.'s gait in clinic with a rocker bottom crutch are available online (see Video, Supplemental Digital Content 2, available at: http://links.lww.com/JNPT/A176).
At the initiation of therapy, S.R. was not wearing any type of orthoses. He had a pair of well-made custom-fabricated double action joint ankle foot orthoses that he had been fitted with earlier in his care for walking. Given the weakness in his plantar flexors and their role in the gait cycle,30 the orthoses were reintroduced in the beginning of the intervention period described in this report to add stability and facilitate strengthening in the LE. This brace design was deemed ideal because the joint configuration allows for assisted dorsiflexion in swing, plantar flexion at loading response and controlled tibial advancement during stance, thus most closely replicating typical gait mechanics.31 In addition, a shoe lift was added to the left shoe sole to equalize his leg length.
Neuromuscular Electrical Stimulation
Electrical stimulation was used to elicit a flexor reflex response during walking.32 This was helpful during early treadmill sessions to facilitate a stepping response, as S.R. was unable to step rhythmically or consistently on command. The stimulation was set up on each leg and triggered by a hand-held switch during the swing phase of gait. This technique was used for a total of 5 treadmill treatments early in training. The stimulus was used constantly at the start of training and was gradually weaned. The stimulation was also used early during overground training sessions following LTT (4 sessions). It was very effective in producing independent stepping in S.R.
Functional Mobility Training
Other therapeutic activities included standing balance training (17 sessions), sit-to-stand practice (9 sessions), car transfers (1 session), strengthening (4 sessions), and stair climbing (4 sessions). All of these activities were chosen to address problems that S.R. identified as important to his daily function and each was included as part of treatment sessions that also included walking.
Home Training Program
From the start of therapy, S.R. was active at home working on newly learned skills. He started at home practicing standing activities from his wheelchair. After he received the gait trainer, he began using it to walk at home. Early in the course of care, he walked most days from 1 to 3 hours with the trainer, often on the top of the parking garage at his apartment building with his mother. Videographic examples of S.R.'s gait practice at home with gait trainer are available online (see Video, Supplemental Digital Content 2, available at: http://links.lww.com/JNPT/A176). In addition, he began practicing standing activities in the gait trainer, often standing as long at 2 h/d. S.R. also rode a recumbent stepper (NuStep, Inc, Ann Arbor, Michigan) at home on most days to supplement his functional gait training.33
By the conclusion of therapy, S.R. could walk more than 900 m (3000 ft) in the gait trainer independently and up to 100 m (350 ft) with the crutch with minimum assistance. He was walking in the community with minimum assistance from his mother with the crutch and using his wheelchair only for long distances. In addition, he was using the gait trainer with no additional prompts (ie, no ankle, trunk, thigh, or arm prompts). He was able to navigate a flight of stairs with moderate assistance.
The changes in S.R.'s strength from initial to final assessment are outlined in Table 1. Quiet standing balance skills improved markedly from the start of therapy to the conclusion. At the start of therapy, S.R. was able to stand 5 s without UE support before losing his balance. By the end of therapy, he was able to balance in standing without UE support for up to 35 s, which improved his toileting and dressing skills. Sensation was unchanged. S.R. had the baclofen dose serially reduced during the course of treatment from 548 μg/d to 39 μg/d by the conclusion of therapy and 8 months later had the pump removed. In addition, head control improved from being able to hold his head up 10 s to full head control by the end of therapy. There was no change in any of the orthopedic impairments (pelvic obliquity or scoliosis).
S.R. experienced very profound improvements in functional mobility over the course of therapy such as being able to transfer to/from his wheelchair independently. The changes in functional mobility that were made over the course of the 18-month period are outlined in Table 1.
This case study describes a treatment plan designed to promote gait and functional recovery in a young man with a severe TBI. This case chronicles the recovery of an individual with severe impairments that might not have been expected given the chronicity of his injury. Despite the fact that he had received extensive gait training prior to the course of therapy described in this report, it is possible that the gains observed during this intervention period were related to structuring the interventions to optimize motor learning.9,22–24,26 There have been several published reports of individuals with chronic brain injury who made modest improvements in gait.11,13,15 While the current report also focused on gait as a primary outcome, there are differences compared with previous studies. For example, S.R. was not walking in the home or community prior to the intervention, this was a much longer course of therapy than those previously reported, and S.R. made significant functional gains as well as improvements in gait over the course of therapy.
It is well established that learning is enhanced when the task has meaning (salience) for the learner.9,26 Walking was extremely important to S.R., and it was, therefore, very easy to motivate him to work on activities related to walking outside of the clinic. It was also the reason that walking was included in all 79 treatment sessions. Motor learning is also dependent on specific kinds of experiences.9,22,24,26 For S.R. to relearn how to walk, he needed to walk. In all of his previous therapy attempts, he had very little cumulative walking experience. He did many other things in therapy (biofeedback, hippotherapy, etc), which may not have been task specific for walking. In addition, previous gait attempts were made with a bilateral platform walker. This device was likely too unstable to support meaningful gait efforts for S.R. By contrast, the gait trainer provided a wider base of support and more adaptability to fit his unique needs. Likewise, the addition of a shoe lift, appropriate orthoses, and use of FES may have facilitated better walking practice, resulting in a better task-specific training. Because he had appropriate devices, he was able to engage in adequate practice outside of therapy to impact motor learning. Modest changes in strength of the hip muscles as well as improved motor control may have facilitated the discontinuation of the baclofen pump. It is possible that these gains made it easier for S.R. to move within the constraints of his atypical tone.
Repetition and intensity are both critical for driving plasticity and learning. For S.R. to learn to walk functionally at this chronic time point postinjury, he would undoubtedly require extensive repetition of walking skills. This was considered while structuring the clinic and home practice. He and his mother routinely walked at home between 1 and 3 hours most days early in his treatment, which likely had a role in his excellent outcome. This type of structured practice outside the clinic is essential to optimize outcomes given the current health care environment. In addition to his gains in walking skill, S.R. also made significant gains in functional skill over the course of therapy. As detailed in Table 2, these gains allowed S.R. to be much more independent in his environment and significantly lessened the burden of care. These improvements, though not specifically trained, may likely have been an added benefit of the focused gait training.9 It is notable that there were a total of 79 treatments, which is a significantly greater number than most individuals with similar presentation would typically receive. Fortunately, S.R. was covered by his father's insurance policy until he turned 26 years. He was also able to obtain funding through a state agency and eventually through Medicare. This allowed him to receive the extensive services he did, even into the chronic phase of recovery. In addition, some specialized equipment was required (the gait trainer and the LTT unit) that may not be universally available. Finally, it goes without saying that it was important to document his progress through the use of standardized outcome measures.34
At the time of the writing of this manuscript, S.R. is now navigating independently at home and in the community with a lightweight reverse walker (Nimbo reverse walker with platform attachments [Wenzelite, Drive Medical, Port Washington, New York]). He is able to transfer into and out of it independently and is no longer using his power wheelchair at home or in the community. He is now able to perform all ADLs independently. Videographic examples of S.R.'s gait with lightweight reverse gait trainer are available online (see Video, Supplemental Digital Content 2, available at: http://links.lww.com/JNPT/A176).
This case study details the functional outcomes of a young man with a severe, chronic TBI. The result of the intervention was to transition this young man from a functionally dependent individual to someone who regained a tremendous amount of independence in his environment. It also significantly decreased the caregiver burden on his mother who had cared for him full time for 4 years. While not every individual has this potential for recovery, with optimally designed treatment plans, there may be individuals who could experience meaningful gains even in the chronic phase of recovery.
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