Treating the patient with a dual diagnosis of a spinal cord injury (SCI) and traumatic brain injury (TBI) is a challenge faced by many neurologic physical therapists. Within the SCI population, early rehabilitation primarily focuses on functional mobility, activities of daily living, psychosocial adaptation, and family training.1 In patients with concomitant TBI, early interventions to address their cognitive and behavioral impairments may shift the treatment focus away from the movement system impairments and activity limitations posed by the SCI-related deficits.1 Early rehabilitation reduces secondary complications and enhances neurologic function in individuals with traumatic SCI, highlighting the need to address both SCI and TBI intensively.1,2
The reported incidence of co-occurring SCI and TBIs varies between 16% and 70%, depending on the method used to determine cognitive deficits.1,3–5 Previous studies reported that individuals with a dual SCI/TBI diagnosis had poorer outcomes than those with SCI alone, including greater personal and family adjustment difficulties, lower performance on cognitive, neuropsychological, and motor tests, and a significantly greater level of medical resources required.5–7 More recently, Nott et al8 matched individuals with dual diagnoses to single diagnosis patients with SCI of similar level. Although they found that individuals with dual diagnoses had poorer motor performance outcomes than those with TBI alone, they had similar motor performance to those with SCI alone.8 These recent findings8 showed higher functional outcomes in this complex population than in previous studies,5–7 indicating improved outcomes.
Although the diagnosis and functional outcomes for individuals with SCI/TBI are improving, the literature is unclear regarding whether these individuals will benefit to the same extent from interventions that have established effectiveness in the single diagnoses. Individuals with dual SCI/TBI diagnoses often have impaired cognition, showing deficits in attention, problem solving, memory, processing, reasoning, initiation, and executive function.1 Explicit learning systems are commonly disrupted, impairing the ability to learn new skills through traditional motor learning.9 In contrast, studies reported that individuals with severe TBI often demonstrate preserved skill acquisition through implicit learning.10,11
Errorless learning (ELL) is a cognitive therapy technique used for individuals with severe memory deficits.12,13 During the learning process, errors are hypothesized to be stored in memory through implicit learning and corrected by explicit memory processes.14,15 If explicit memory is impaired, errors may not be corrected.14 Traditional motor learning, a process that is inclusive of multiple theories, relies on error identification and feedback to facilitate and reinforce the correct performance of movements.9 Individuals with impairments to the explicit learning systems may have difficulty identifying errors and, therefore, their motor skill acquisition may be hindered. Errorless learning, in contrast, aims to prevent errors from occurring, relying on verbal cues, modeling, hand-over-hand assistance (therapist's hand over the patient's hand to guide/assist movement), forward and backward chaining (learning tasks in forward or reverse order in which they are performed), discouragement of guessing, and gradual fading of prompts.14,16–18 The task being learned is broken down into small discrete steps with immediate correction if an error does occur.12
Several studies have reported that individuals with dementia or amnesia with impaired explicit learning, but intact implicit learning, acquired new semantic and procedural knowledge following the application of ELL approaches.12–15 Individuals with severe cognitive impairments from brain injuries had improved performance on everyday tasks, increased functional independence, improved cognitive performance, and fewer inappropriate social behaviors after use of ELL.15,19,20 However, ELL was primarily used in these studies to teach the patients familiar tasks rather than develop novel skills.21
In SCI rehabilitation, learning novel skills never before performed (ie, slide board transfers, wheelchair propulsion) is crucial for independent mobility. Individuals with a dual SCI/TBI diagnosis often have explicit learning deficits but may retain the capacity for implicit learning. Hypothetically, using an ELL strategy for these individuals would engage the intact implicit learning processes and enable novel task acquisition.14,15 Thus, the purpose of this case study was to (1) describe the application of an ELL strategy in the rehabilitation of an individual with a dual diagnosis of severe SCI/TBI and (2) assess the outcomes of this strategy on the individual's ability to learn novel motor tasks including bed mobility, slide board transfers, and wheelchair propulsion.
The Ohio State University Institutional Review Board waived the need for approval for this study. S.M. was a 44-year-old Somali man admitted to a level 1 trauma center following a motor vehicle accident. Upon arrival, S.M. had a Glasgow Coma Scale score of 4/15. This score indicated that the patient was nonresponsive to verbal and painful stimuli. Neuroimaging showed diffuse subarachnoid hemorrhaging, a small right frontal lobe subdural hematoma, and multiple spinal fractures at the levels of C1, C2, C6, and T4-T6. The cervical spinal cord was uninjured; however, severe stenosis with cord compression was present at the T4 level. S.M. received a thoracic laminectomy and fusion, tracheostomy, and feeding tube. He spent 6 weeks in the acute hospital, where the physical therapist (PT) initiated bed mobility training; following this, the patient was transferred to an inpatient rehabilitation facility (IRF).
On day 1 after IRF admission, a multidisciplinary team (PT, occupational therapist [OT], and speech-language pathologist [SLP]) evaluated S.M. Based on findings of confusion, disorientation, poor personal awareness, and absent short term memory, his cognition was classified as level IV on the Ranchos Los Amigos Scale (RLAS).22 Individuals classified as RLAS IV exhibit confusion, agitation, nonpurposeful or inappropriate behaviors, and impaired memory and attention.22 Although S.M. was competent in English prior to his accident, he was unable to understand English afterward, requiring a Somali language interpreter for communication. Because of the cognitive and translator inaccessibility barriers, an American Spinal Injury Association Impairment Scale (AIS) assessment could not be performed; however, the patient's presentation was consistent with a T4 AIS A classification.23 Per physician prescription, the patient wore a cervical thoracic orthosis during all out-of-bed activities and a cervical collar (Miami J) 24 hours a day.
After communicating with the patient's family through an interpreter during the first week, the PT determined that S.M. lived with his wife and 2 young sons in a second floor apartment, with no elevator. He worked full time as a construction contractor and was the sole financial provider for his family. S.M.'s family had immigrated to the United States from Somalia 5 years before the accident and had varying levels of English competency. He had no significant medical history prior to the accident and was self-insured.
Initial Clinical Examination
S.M. was mildly agitated and had abdominal swelling and discomfort with emesis due to a progressive ileus. He was disoriented, presenting with severe posttraumatic and retrograde amnesia. He scored a 9/30 on The Orientation Log (O-Log), indicating severe cognitive deficits.24 He could not recall any life event since moving to the United States and was unaware of his current physical impairments. S.M. exhibited anosognosia, reporting that he walked around the hospital all morning. When assessed on the Functional Independence Measure (FIM) System25 cognitive items, S.M. scored 1 on comprehension, expression, social interaction, and memory items (Table 1). The therapist did not administer the Montreal Cognitive Assessment because of the language barrier and no Somali-specific test version.26
Examination of the patient's musculoskeletal and neuromotor systems revealed multiple impairments. S.M. demonstrated no volitional muscle contractions or movement below the level of the midthoracic region. Mild hypertonicity was present in each hamstring, measuring 1 on the Modified Ashworth Scale.27 The therapist noted strength deficits in his left arm; manual muscle test grades of 3+/5 were given to his left wrist flexors, extensors, and long finger flexors. S.M.'s sensation was not formally tested because of his cognitive deficits. Excluding surgical incisions, S.M.'s integumentary system was intact. His passive range of motion in all extremities was within normal limits, and his right upper extremity (UE) strength was 5/5 for all muscles.
S.M's overall mobility and balance were assessed using the FIM, Function in Sitting Test (FIST), Wheelchair Skills Test, and timed static sitting assessments.25,28,29 On the FIM, he received a score of 1/7 on the Transfers: Bed/Chair/Wheelchair item, requiring maximal assistance of 2 to complete a slide board transfer into the wheelchair. He scored a 1/7 on the Locomotion: Wheelchair item, propelling the chair 25 ft with minimal assistance and poor motor control of his right UE (Table 1).25 After maximal assistance to assume sitting, S.M. was able to maintain unsupported static sitting for 30 seconds on a firm surface. He scored a 9/56 on the FIST, with an inability to shift his body weight outside of his base of support or reposition his UEs.28 Because of his difficulty propelling a wheelchair, S.M. was unable to perform the Wheelchair Skills Test.29
S.M.'s initial examination revealed severe cognitive impairments (ie, agitation, disorientation, RLAS level IV) and a language barrier complicated by retrograde and posttraumatic amnesia and anosognosia. Physically, S.M. demonstrated complete T4 paraplegia with impaired bilateral UE coordination during functional tasks. These impairments affected his functional balance, mobility, and level of independence. Language barriers and health literacy disparities also complicated S.M.'s care, as S.M.'s wife expected S.M. to walk before his discharge. Based on these findings, the PT determined that he was a candidate for skills training involving balance retraining, neuromuscular facilitation, cognitive rehabilitation, functional mobility training, and caregiver education. Traditional motor-learning strategies were initially implemented to utilize whatever explicit and implicit learning abilities he had for maximizing his functional independence.
The therapist's overall PT goals for S.M. were to independently maintain unsupported static and dynamic sitting balance indefinitely, perform chair/bed transfers with a slide board, and propel his wheelchair for household mobility by the end of his IRF stay. Positive prognostic factors for his recovery were his family support and his need to support his family. Negative prognostic factors were his anosognosia, poor spatial perception, minimal postural reactions, poor problem-solving abilities, and his need to learn novel tasks that he had never performed before.
S.M. spent a total of 69 days in the IRF. During this time, he had 2 short admissions to an acute hospital secondary to complications from a progressive ileus (Figure 1); during those times, he received less intensive PT. While in the IRF, S.M. received 3 hours of therapy (PT, OT, and SLP) a day and sometimes twice daily, 5 days a week. Functional outcome measures (FIM transfer and wheelchair locomotion items, FIST, timed static sit, Wheelchair Skills Test) were assessed at the time of his first (day 1), second (day 18), and third (day 37) admissions to the IRF and at discharge (day 69) (Figure 1). Therapy sessions were conducted with a translator present and varied between an empty, quiet room to prevent agitation and confusion from overstimulation and open gym environments.
Using evidence-supported motor-learning principles, the therapist set up S.M.'s initial sessions in controlled environments promoting trial-and-error strategies and internal problem solving to promote skill acquisition (Table 2).30,31 Motor errors were not corrected except for safety, promoting sensory feedback of errors to facilitate correction. The therapist utilized massed task practice, short simple commands, intrinsic feedback, and tactile cues to promote motor learning. S.M. could not comprehend the need for UE support to maintain balance, continually lifting his arms up and reaching out for the therapist to prevent a fall. Although his endurance and activity tolerance showed mild improvement after 2 weeks of practice, he continued to require maximal assistance for transfers and wheelchair propulsion.
During his first 3 weeks, S.M. emerged to a level V on the RLAS, following simple commands less than 25% of the time.22 He was disoriented and inconsistently aware of his physical deficits. The English-Somali language barrier, as well as health literacy disparities limited S.M.'s progress in therapy. During some sessions, multiple members of S.M.'s family were present, encouraging and directing him through tasks. S.M. became overwhelmed and unable to attend to the therapist's instructions, reacting with verbal outbursts. The therapist provided family education regarding brain and spinal cord injuries and agitation reduction strategies and discussed his prognosis for functional recovery.
On readmission to the IRF after the second acute care hospital episode (day 37 relative to initial IRF admission) reassessment following 19 days of intense PT using traditional motor-learning strategies, the therapist found no meaningful gains in S.M's functional measures (Tables 1 and 3). Any small improvements in sitting balance were short-term; he was unable to learn any task explicitly (eg, self-correct his errors). To facilitate motor learning, the therapist shifted S.M.'s therapy to ELL because of his persistent amnesia and cognitive dysfunction and because learning new mobility skills was essential for his household independence (Table 2). With coordination between PT and SLP, consistent use of discrete steps and forward chaining, external cues (verbal, visual, and tactile), modeling, and visual feedback were the primary tools utilized during his sessions across all rehabilitation team disciplines, with the objective being to prevent all errors before they occurred.
Dynamic sitting balance deficits greatly limited S.M.'s independence. Balancing using his remaining postinjury motor abilities represented a novel skill for him. He required moderate assistance to transition between anterior and posterior tripod positions (ie, sitting with arms supporting the upper body either in front of or behind the buttocks) due to his inability to weight shift laterally. Following principles of ELL, a task was set up using a mirror and external cues. Through demonstration, the therapist instructed S.M. to look in the mirror and move his shoulder laterally toward a target, promoting the necessary weight shift. S.M. successfully performed the activity after blocked practice and continued verbal, tactile, and visual cueing. He progressed to shifting laterally while tossing a beanbag to a target with only intermittent minimal assistance for trunk stability. The therapist subsequently incorporated the use of an external target for UE placement into the tripod transitions in short and long sitting positions. After 4 weeks of massed practice with consistent external cues, modeling, and prevention of errors, S.M. completed the task without physical assistance of the therapist.
The therapist applied ELL to S.M.'s transfer training due to having had minimal success with previous strategies. Since the transfer represented a novel task for S.M., the transfer was broken down into 4 simple steps with 1-word commands (“forward; rock; push; stop”) associated with each step. The therapist took 4 photographs of the patient and herself during each step of the task to promote environmental consistency. Prior to task practice, the therapist modeled the transfer multiple times, with simultaneous use of photographs and 1-word commands. S.M. then performed the task through completion of each individual step. The therapist provided visual cues along with verbal commands while S.M. completed the individual step, pausing after each step while the therapist presented the next corresponding visual and verbal cue. This process was repeated until S.M. fully completed the task. After a week of blocked practice, S.M. performed a slide board transfer with moderate assistance, initiating the motor components without cues 50% of the time. The task was progressed by removing pauses between the steps and fading the external cues from 4 to 2. Based on his greatest difficulty in coordinating trunk momentum with UE use, the cues provided were “rock” and “push.” Four weeks after the inclusion of the ELL strategies, S.M. completed slide board transfers with minimal assistance. This success indicated his ability for motor learning and carryover of education despite severe cognitive impairments.
With S.M's successes in balance and transfer training, the therapist incorporated ELL into wheelchair mobility, another skill that was novel for this patient. The therapist implemented part-task practice, breaking down wheelchair propulsion into steps. S.M. performed only 1 stroke, or push, of the wheels, releasing his hands and letting the chair glide to a stop. This emphasized symmetrical UE use without adding on a second stroke. Initially, the therapist provided hand-over-hand assistance along with modeling. After blocked practice, the therapist removed tactile cues. S.M. progressed from coordinating both UEs during one stroke to continual propulsion with improved UE symmetry. After 4 weeks using the ELL approaches, S.M. propelled the wheelchair up to 150 ft without physical assist.
During the first 37 days after his initial admission to the IRF (19 days at IRF, 18 in acute hospital), S.M. made minimal progress on any of the PT outcome measures (Figure 1). His progress on outcomes occurred from the time of initiating ELL on day 38 until his discharge 32 days later. S.M. was discharged to a skilled nursing facility because of his inaccessible home environment and his family's inability to provide around-the-clock care. Upon discharge, S.M. successfully performed a slide board transfer with only minimal assistance. This demonstrated a significant improvement from his initial dependency. His cognition had progressed from level IV to level V on the RLAS from the start of his motor-learning treatment to the start of his ELL treatment and from 9/30 to 22/30 on the O-Log from the start to the end of his ELL treatment.22,24 Despite the increase, his score still measured below the normative cutoff score of 25/30, indicating continued cognitive deficits across general domains of attention, executive, motor, and visuospatial performance and specifically in explicit memory.24 He showed improvement in all functional mobility and increased his AIS level to a B22 (Table 3). On the Functional Independence Measure (FIM) scores, S.M. decreased his level of assistance in 11 of the 18 items, including eating, bathing, and dressing (Table 1 and Figure 2). Overall, he achieved a 31-point increase, surpassing the minimally clinically important difference of 22 points.32
S.M. achieved clinically meaningful improvement in his sitting balance, with a change of 9 points (improving from a 9/56 to an 18/56) on the FIST (minimally clinically important difference = 6.5).33 He increased his ability to maintain an unsupported static sit from 30 seconds to an indefinite time period, promoting further independence for daily mobility tasks. He surpassed the 3% minimal detectable change on the Manual Wheelchair Skills Test, improving from 9% to 16% (Table 3).34 These successes in functional outcome measures translated to an overall decreased burden of care on his family with an improved prognosis for independent functional mobility.
This case study is the first to report the use of ELL to improve novel motor skill acquisition in a patient with dual SCI/TBI diagnoses. During the first 37 days of his IRF stay, the therapist employed traditional motor-learning strategies to help the patient acquire novel functional skills with minimal success. After the therapist began using an ELL approach, the patient started to show progress. After 31 days of receiving the ELL intervention, the patient showed clinically meaningful improvements in sitting unsupported, slide board transfers, and self-propulsion of his wheelchair. Our findings suggest that ELL may be a beneficial intervention for training novel functional tasks in people with concomitant SCI/TBI who have cognitive deficits.
This focus of this case report differs from a previous report published by Sommer and Witkiewicz1 regarding treatment of an individual with SCI/TBI, because we introduced novel mobility training early into S.M.'s plan of care. Sommer and Witkiewicz1 described a multidisciplinary rehabilitation program for an individual with dual SCI/TBI diagnoses; however, they avoided the use of novel tasks until the patient's cognition had emerged to RLAS level VI because of fear that the patient was likely to fail and become agitated. Their patient's rehabilitation was primarily focused on cognitive and behavioral interventions and no mention was made of outcomes regarding his transfer ability. In S.M's case, the therapist initiated novel mobility training immediately. Implementation of error-based learning approaches was initially unsuccessful, perhaps because that approach required too high a level of attention and explicit learning. Once the therapist changed strategies to incorporate ELL approaches, S.M. achieved clinically meaningful improvements in sitting balance, slide board transfers, and wheelchair propulsion despite his cognition remaining at RLAS level V.
This case report is unique from other ELL studies in its focus on the use of ELL for motor task training. Traditionally, ELL has been used for individuals with memory deficits resulting from dementia.12,13 Recently, ELL was applied to individuals with severe memory and executive function impairments from an acquired brain injury, resulting in better everyday task performance, increased independence, improved executive task performance, and reduced frequency of inappropriate social behaviors.12–15,19,20 These studies have largely utilized ELL strategies for enhancing procedural learning and executive function activities.12–15,19–21 Little evidence exists on the use of ELL for motor skills, particularly novel tasks. Our study contributes new knowledge regarding the potential value of ELL for promoting acquisition of novel motor skills in individuals with severe cognitive deficits resulting from dual traumatic spinal cord and brain injuries.
This case report has several limitations. Ileus complications necessitated S.M's multiple transfers to the acute hospital, which may have impeded his early progress using traditional motor-learning strategies. The language and cultural differences created challenges in communication between the therapist and S.M. for optimizing skill performance. Many English words translated to multiple-word phrases in Somali, inhibiting the use of 1-word commands to facilitate comprehension. Since S.M. was discharged to an outside facility after completion of ELL, it was not possible to assess the impact of ELL on S.M's ability to carry over the skills he learned to new living environments or to untrained skills. S.M.'s large improvements on the O-Log orientation score during the therapist's implementation of ELL may have positively affected his function and his ability to learn. Other factors that could have contributed to S.M's improved function include his early exposure to the mobility skills during the period when traditional motor-learning strategies were employed, spontaneous physiological recovery associated with the early post-acute stage of SCI and TBI, and subtle differences between motor learning and ELL approaches such as less verbal feedback and more visual cueing and modeling, making it easier for him to process and understand information.
Our experience with the use of ELL indicates that this approach may have contributed to the development of novel motor skills in an individual with physical and cognitive deficits due to SCI/TBI. However, given the limitations of a case report, no conclusions can be made regarding causality between the ELL intervention and the patient's functional improvements. The authors recommend further research to determine the generalizability of ELL on untrained motor tasks and effects of progression from ELL to error-based learning on skill acquisition for the individual with chronic, severe cognitive dysfunction.
The authors thank the patient for allowing them to publish this case report, Meredith Banhos, PT, DPT, NCS, and Meghan Maclean, PT, DPT, NCS, for their mentorship and assistance in data collection, and all of the providers on the traumatic brain injury service at Dodd Hall Inpatient Rehabilitation Hospital for their support.
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