Locomotor Training for the Traumatic Brain Injury Population

Locomotor Training for the Traumatic Brain Injury Population

http://www.msktc.org/sci/factsheets/Gait-Training-and-SCI

Meredith Haigh

Overview

Traumatic brain injury (TBI) is the leading cause of death and impairment in young adults in America.¹ Injury leading to TBI occurs in 1.5 to 2 million people every year. Fifty thousand of these people die and over 230,000 survive with hospitalization and extensive rehabilitation. Of those that survive, approximately 90,000 will live with lifelong intellectual, behavioral, and/or physical disabilities that will limit their ability for functional independence in their home and community.¹ TBI is difficult to both treat and compare research because of its effects on multiple body systems and the heterogenic presentations between individuals lending itself to a paucity of research regarding clinical practice guidelines.² One of the most visible deficits after TBI is motor impairment and movement dysfunction.³  This is often caused by upper motor neuron syndrome (UMNS) which causes spasticity, decreased reflexes in the lower extremities, loss of dexterity, and weakness. UMNS can have significant effects on one’s ability to perform functional activities. Though presentations are varied, patients commonly demonstrate deficits in force, endurance, coordination and balance.³ These impairments negatively affect one’s ability for ambulation which is directly correlated with decreased independence and quality of life.⁴ The current available research focuses heavily on treatment of behavioral and cognitive deficits, but little research exists regarding strategies for motor improvement including ambulation.

During my time on my third clinical rotation, I had the opportunity to participate in the treatment of a few patients with severe TBI during their stay in an inpatient rehabilitation facility.  During this time, several gait training methods were used such as conventional over-ground walking with handrail and therapist support, partial body-weight supported gait training over ground and treadmill, and aquatic therapy. Clinically significant improvements were noted over time; however, I was curious to know which of these therapeutic activities was most beneficial in producing improved ambulatory outcome. Therefore, the purpose of my Capstone project is to search the current literature for the most valuable gait training techniques for patients with moderate to severe brain injury, synthesize this information into clinically relevant findings, and present them to inpatient rehabilitation facilities in Baltimore, MD. I used the Evidence Based Practice course from the fall semester of my third year of school as a springboard for this project to research the answer to the following PICO question: “For patients with moderate to severe traumatic brain injury under the age of 40 and without previous neurological occurrence, is over-ground manually-assisted gait training and handrail support or a body weight-supported device more beneficial for improving functional abilities as measured by over-ground walking speeds?” My focus during this research was narrow, only addressing two types of locomotor training for patients with TBI. For my Capstone project, I sought to broaden this topic to include a more expansive range of gait training techniques as well as to address the benefits of task-specific practice and the most reliable and valid outcome measures for measuring improvement. My new PICO question to be answered is: “For patients with moderate to severe traumatic brain injury, what is the most beneficial gait training technique for improving ambulatory independence as measured by gait speed?”

Literature Review

My review of the literature explored and compared the use of five methods of locomotor training: conventional over-ground gait training, body-weight supported treadmill training, rhythmic auditory stimulation, aquatic gait training, and robotic-assisted gait training. The results of the 12 studies used to compare these techniques are summarized in this Evidence Table and are explained in further detail in my Research Paper. I created a Prezi presentation and implemented presentation guidance provided by my course website to make the visual more learner friendly. I presented this at two different inpatient rehabilitation facilities in Baltimore, MD: Good Samaritan Hospital and John’s Hopkins Hospital. There were approximately 25 therapists present for these presentations and each individual was given a One Page Summary Sheet outlining the information presented, a List of References used to assimilate the information shared, and an Evaluation Form for the therapists to rate and comment on the relevance and quality of my presentation. I received excellent Feedback from both sites regarding my presentation as well as their opinions regarding translation of these findings into practice.

My intentions at the start of this project were to determine the “best” clinical practice tool to improve quality of gait outcomes while simultaneously decreasing length of stay. If I have learned anything over this period of study, it has been that this intention is naïve. The literature was largely inconclusive in the few studies that focused exclusively on patients post brain injury. Much of my research required branching into similar neurological diagnoses such as stroke and spinal cord injury to find beneficial results. A majority of the results lacked statistical significance or had very small sample sizes and poor quality study design. Additionally, subjects were commonly studied several months post injury, making the results inapplicable for use in the post-acute rehabilitation setting during the window of greatest neuroplasticity.  The inclusion criteria were often narrow and the exclusion criteria were often broad. These factors highly limit translation to practice considering many of the patients referred to rehabilitation would be excluded from participation in these studies. No two patients are the same and no two therapists are the same. There is no one single active ingredient that if present in every treatment plan will end in an ability to walk again (as much as I wanted that to be true). The brain injury population is very heterogeneous in presentation, personal factors, and learning styles. In addition, each rehabilitation center is different in their backgrounds, treatment preferences, and available resources. Of the five different gait training techniques that I presented, both rehabilitation sites lacked access to two of them (a therapeutic pool and a robotic-assisted gait device). Furthermore, feedback from the therapists brought to light many barriers to use of a body weight-supported gait device such as time, staff demand, patient appropriateness, and cost. In this case, the therapists were less likely to use the body weight-supported device even if the literature was conclusive about its positive effects. This taught me that one must develop a plan of care based on a healthy balance of evidence-based findings and realistic accommodations and patient preferences. Referring to the literature for guidance in practice is essential; however, we must be highly critical of the results when the study limitations are large and the population at hand is not adequately represented. Further research in this topic would be highly beneficial to expand the literature in regards to patient response and gait outcomes following different types of gait training in the brain injury population.

Acknowledgements

I would like to first thank my advisor, Karen McCulloch for your advice, guidance, and encouragement throughout this project. Thank you also to my committee members, Lauren Demeyer and Michele Sulwyer, for your prompt feedback and graciousness in helping me along the way! Also, thank you to Amy Ryan from Good Samaritan Hospital and Kelly Daley and Jessalyn Ciampa from Johns Hopkins Hospital for providing me with the opportunity to share my research. I’m so thankful to have met you and the PT staff and hope that your experience was as enriching as mine!

References

1. O’Sullivan SB, Schmitz TJ. Physical Rehabilitation. Philadelphia, PA: F.A. Davis Company; 2007. p. 895-928.
2. Evidence-Based Review of Moderate to Severe Brain Injury. Module 1- Introduction and Methodology-V9. 2013. http://www.abiebr.com. Accessed November 11, 2013.
3. Boake C, Francisco GE, Ivanhoe CB, Kothari S. Brain Injury Rehabilitation. Physical medicine and rehabilitation. Toronto: Saunders Company; 2000. p. 1073-116.
4. Danielsson AJ, Bartonek A, Levey E, McHale K, Sponseller P, Saraste H. Associations Between Orthopaedic Findings, Ambulation and Health- Related Quality of Life in Children with Myelomeningocele. Journal of Child Orthopedics. 2008;2:45-54.