Comparisons between Locomat and Walkbot robotic gait training regarding balance and lower extremity function among non-ambulatory chronic acquired brain injury survivors.

ABSTRACT: Lower limb rehabilitation exoskeleton robots connect with the human body in a wearable way and control the movement of joints in the gait rehabilitation process. Among treadmill-based lower limb rehabilitation exoskeleton robots, Lokomat (Hocoma AG, Volketswil, Switzerland) has 4 actuated joints for bilateral hips and knees whereas Walkbot (P&S Mechanics, Seoul, Korea) has 6 bilateral actuated joints for bilateral hips, knees, and ankles. Lokomat and Walkbot robotic gait training systems have not been directly compared previously. The present study aimed to directly compare Lokomat and Walkbot robots in non-ambulatory chronic patients with acquired brain injury (ABI).The authors conducted a single-center, retrospective, cross-sectional study of 62 subjects with ABI who were admitted to the rehabilitation hospital. Patients were divided into 2 groups: Lokomat (n = 28) and Walkbot (n = 34). Patients were subjected to robot-assisted gait training (RAGT) combined with conventional physical therapy for a total of 14 (8-36) median (interquartile range) sessions. Baseline characteristics, including age, sex, lag time post-injury, ABI type, paralysis type, intervention sessions, lower extremity strength, spasticity, and cognitive function were assessed. Functional ambulation category (FAC) and Berg balance scale (BBS) were used for outcome measures.There were no significant differences in baseline characteristics between the groups. Baseline FAC score was 1 (0-2) in Lokomat and 1 (0-1) in Walkbot group. After the intervention, FAC scores improved significantly to 2 (1-3) in both groups (P < .05). Lokomat and Walkbot groups showed significantly enhanced BBS from 5 (2.75-24.25) and 15 (4-26.5) to 15 (4-26.5) and 22 (12-40), respectively (P < .05). Degree of improvements in both group were not significantly different with regard to balance (P = .56) and ambulatory ability (P = .74).This study indicates that both Locomat and Walkbot robotic gait training combined with conventional gait-oriented physiotherapy are promising intervention for gait rehabilitation in patients with chronic stage of ABI who are not able to walk independently.

An Unusual Case of Posttraumatic Visual Agnosia Posing Challenges to Rehabilitation.

ABSTRACT: Acquired focal visuoperceptual deficits are rarely reported, and rehabilitation strategies are not well established. This is a report on visuoperceptual deficit after traumatic brain injury that initially went unnoticed. Missing visual agnosia is not unusual especially when perceptual deficits present with visual field defects, impaired insight, and inattention. This case is made more interesting because of the rarity of visual agnosia with predominant ventral pathway involvement, affecting object and face recognition. This report provides a brief discussion on visual agnosia spectrum deficits and rehabilitation measures.

Ethical Considerations in Chronic Brain Injury.

A growing number of individuals are living with chronic traumatic brain injury. As these individuals and their families attempt to reintegrate into their communities, several ethical questions arise for clinicians and researchers. These include issues around alignment of perspectives and priorities, as well as responsibilities for ongoing treatment, education, community outreach, and research. An action plan for addressing these questions is outlined.

Setting and achieving individualized social communication goals for people with acquired brain injury (ABI) within a group treatment.

BACKGROUND: Cognitive-communication disorders are common following an acquired brain injury (ABI). Remediation should involve individualized goal-setting, yet few reports describe the effectiveness of setting communication goals in a group setting. AIMS: To describe a process for setting and achieving goals for people with ABI. METHODS & PROCEDURES: A total of 21 participants with ABI participated in a group treatment (triads and dyads) over 6 weeks (20 h in total). Specific social communication goals were set using goal attainment scaling (GAS) with the participant and their communication partner. Goals targeted strategy use that accounted for existing cognitive abilities. The participant and their communication partner evaluated the goals post-treatment and 6-8 weeks later. Data were analysed using Friedman's test to identify the achievement of GAS goals. OUTCOMES & RESULTS: A total of 20 participants recalled goals independently post-treatment. Significant improvement post-treatment on GAS goals was rated by both the participant (p < 0.001) and their communication partner (p < 0.001). This improvement was maintained at follow-up. No significant differences in ratings were found between participants and their communication partners at either time point. CONCLUSIONS & IMPLICATIONS: Individualized social communication goals can be set and achieved for people with ABI in group treatment, even when participants are several years post-injury. GAS offers a method for structuring and quantifying goal progress. Involving communication partners and cognitive strategies were effective in improving communication.

Repetitive TMS does not improve cognition in patients with TBI: A randomized double-blind trial.

OBJECTIVE: To determine whether high-frequency repetitive transcranial magnetic stimulation (rTMS) improves cognition in patients with severe traumatic brain injury. METHODS: A single-center, randomized, double-blind, placebo-controlled study of rTMS was conducted in patients aged 18-60 years with chronic (>12 months postinjury) diffuse axonal injury (DAI). Patients were randomized to either a sham or real group in a 1:1 ratio. A 10-session rTMS protocol was used with 10-Hz stimulation over the left dorsolateral prefrontal cortex (DLPFC). Neuropsychological assessments were performed at 3 time points: at baseline, after the 10th rTMS session, and 90 days after intervention. The primary outcome was change in executive function evaluated using the Trail Making Test Part B. RESULTS: Thirty patients with chronic DAI met the study criteria. Between-group comparisons of performance on TMT Part B at baseline and after the 10th rTMS session did not differ between groups (p = 0.680 and p = 0.341, respectively). No significant differences were observed on other neuropsychological tests. No differences in adverse events between treatment groups were observed. CONCLUSIONS: Cognitive function in individuals with chronic DAI is not improved by high-frequency rTMS over the left DLPFC, though it appears safe and well-tolerated in this population. CLINICALTRIALSGOV IDENTIFIER: NCT02167971. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for individuals with chronic DAI, high-frequency rTMS over the left DLPFC does not significantly improve cognition.

Developing a Therapeutic Approach Toward Active Engagement for Veterans With Mild Traumatic Brain Injury.

BACKGROUND: Treatment of chronic mild traumatic brain injury (mTBI) or postdeployment syndrome can be challenging to frontline providers who care for our nation's war heroes. There is ample guidance available for symptom-based interventions, but relatively little information regarding the structure and language of the clinical encounter. Dynamic patient education centered upon relatable language, accessible analogies, and brain health can move the visit beyond historical diagnostics into a shared understanding of postdeployment barriers to reintegration. OBJECTIVE: We aim to describe a practical, education-based clinical approach for chronic mTBI or postdeployment syndrome (mTBI/PDS). The foundation of this method is gathering the veteran's narrative, validating and normalizing his or her experience, highlighting neurobehavioral changes from combat that may represent barriers to full community reintegration, and transitioning to an emphasis on overall brain health. CONCLUSION: The chronic mTBI or PDS clinical encounter can be enhanced by empowering the patient with relatable terms and concepts to describe his or her reintegration challenges and emphasizing factors of brain health. This approach can provide the patient with a base of understanding regarding his or her current symptoms, promote focus on factors for cognitive health, and orient the clinical encounter toward improved community reintegration and long-term cognitive wellness.

Treatments and rehabilitation in the acute and chronic state of traumatic brain injury.

Traumatic brain injury (TBI) is a major cause of acquired disability globally, and effective treatment methods are scarce. Lately, there has been increasing recognition of the devastating impact of TBI resulting from sports and other recreational activities, ranging from primarily sport-related concussions (SRC) but also more severe brain injuries requiring hospitalization. There are currently no established treatments for the underlying pathophysiology in TBI and while neuro-rehabilitation efforts are promising, there are currently is a lack of consensus regarding rehabilitation following TBI of any severity. In this narrative review, we highlight short- and long-term consequences of SRCs, and how the sideline management of these patients should be performed. We also cover the basic concepts of neuro-critical care management for more severely brain-injured patients with a focus on brain oedema and the necessity of improving intracranial conditions in terms of substrate delivery in order to facilitate recovery and improve outcome. Further, following the acute phase, promising new approaches to rehabilitation are covered for both patients with severe TBI and athletes suffering from SRC. These highlight the need for co-ordinated interdisciplinary rehabilitation, with a special focus on cognition, in order to promote recovery after TBI.

The Intensive Cognitive-Communication Rehabilitation Program for Young Adults With Acquired Brain Injury.

Purpose This study investigated the effects of an intensive cognitive-communication rehabilitation (ICCR) program for young individuals with chronic acquired brain injury. Method ICCR included classroom lectures; metacognitive instruction, modeling, and application; technology skills training; and individual cognitive-linguistic therapy. Four individuals participated in the intensive program (6 hr with 1-hr lunch break × 4 days × 12 weeks of treatment): 3 participants completed 3 consecutive semesters, and 1 participant completed 1 semester. Two controls did not receive treatment and completed assessments before and after the 12-week treatment interval only. Results All 4 experimental participants demonstrated significant improvements on at least 1 standardized cognitive-linguistic measure, whereas controls did not. Furthermore, time point significantly predicted participants' scores on 2 of the 4 standardized outcome measures, indicating that as duration in ICCR increased, scores also increased. Participants who completed multiple semesters of ICCR also improved in their therapy and personal goals, classroom behavior, life participation, and quality of life. Conclusion After ICCR, participants showed gains in their cognitive-linguistic functioning, classroom participation, and individual therapy. They also demonstrated improvements outside the classroom and in their overall well-being. There is a gap between the large population of young adults with acquired brain injury who wish to return to higher education and a lack of rehabilitation programs supporting reentry into academic environments; ICCR is a first step in reducing that gap.

Training in Goal-Oriented Attention Self-Regulation Improves Executive Functioning in Veterans with Chronic Traumatic Brain Injury.

Deficits in executive control functions are some of the most common and disabling consequences of both military and civilian brain injury. However, effective interventions are scant. The goal of this study was to assess whether cognitive rehabilitation training that was successfully applied in chronic civilian brain injury would be effective for military veterans with traumatic brain injury (TBI). In a prior study, participants with chronic acquired brain injury significantly improved after training in Goal-Oriented Attentional Self-Regulation (GOALS) on measures of attention/executive function, functional task performance, and goal-directed control over neural processing on functional magnetic resonance imaging. The objective of this study was to assess effects of GOALS training in veterans with chronic TBI. A total of 33 veterans with chronic TBI and executive difficulties in their daily life completed either 5 weeks of manualized GOALS training or Brain-Health Education (BHE) matched by time and intensity. Evaluator-blinded assessments at baseline and post-training included neuropsychological and complex functional task performance and self-report measures of emotional regulation. After GOALS, but not BHE training, participants significantly improved from baseline on primary outcome measures of Overall Complex Attention/Executive Function composite neuropsychological performance score (F = 7.10, p = 0.01; partial η2 = 0.19), and on overall complex functional task performance (Goal Processing Scale Overall Performance; F = 6.92, p = 0.01, partial η2 = 0.20). Additionally, post-GOALS participants indicated significant improvement on emotional regulation self-report measures (Profile of Mood States Confusion Score; F = 6.05, p = 0.02, partialη2 = 0.20). Training in attentional self-regulation applied to participant-defined goals may improve cognitive functioning in veterans with chronic TBI. Attention regulation training may not only impact executive control functioning in real-world complex tasks, but also may improve emotional regulation and functioning. Implications for treatment of veterans with TBI are discussed.

A Clinical Framework for Functional Recovery in a Person With Chronic Traumatic Brain Injury: A Case Study.

BACKGROUND AND PURPOSE: This case study describes a task-specific training program for gait walking and functional recovery in a young man with severe chronic traumatic brain injury. CASE DESCRIPTION: The individual was a 26-year-old man 4 years post-traumatic brain injury with severe motor impairments who had not walked outside of therapy since his injury. He had received extensive gait training prior to initiation of services. His goal was to recover the ability to walk. INTERVENTION: The primary focus of the interventions was the restoration of walking. A variety of interventions were used, including locomotor treadmill training, electrical stimulation, orthoses, and specialized assistive devices. A total of 79 treatments were delivered over a period of 62 weeks. OUTCOMES: At the conclusion of therapy, the client was able to walk independently with a gait trainer for approximately 1km (over 3000 ft) and walked in the community with the assistance of his mother using a rocker bottom crutch for distances of 100m (330 ft). DISCUSSION: Specific interventions were intentionally selected in the development of the treatment plan. The program emphasized structured practice of the salient task, that is, walking, with adequate intensity and frequency. Given the chronicity of this individual's injury, the magnitude of his functional improvements was unexpected.Video Abstract available for additional insights from the Authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A175).

[The Brain-Injured Relationship: Neuropsychological Rehabilitation Counselling and Therapy of Couples and Families]. / Die hirnverletzte Beziehung ­ Neurorehabilitationspsychologische Beratung und Therapie von Paaren und Familien.

A brain-injured patient's system of relationships is severely disbalanced, and seeks a new equilibrium very much like a kinetic mobile sculpture responding to an impulse. Thus, it is not only the deficits in the patients and their environment and resources that define the success of participation in the process of rehabilitation. Fundamentally, it relies on stable and adjustable relationships as well as trustful communication in the patients' social systems. Negotiating participation is a concerted, interactive adjustment process for everyone involved in dealing with a disruptive life event. Dysfunction in relationships and communication, which frequently is a direct or indirect consequence of brain injuries, puts at risk the sustainability of progress reached during rehabilitation. In this system of relationships often heavily burdened, neuropsychological rehabilitation counseling is needed to secure the long-term success of rehabilitation.

Initial validation of personal self-advocacy measures for individuals with acquired brain injury.

PURPOSE/OBJECTIVE: The purpose of this study was to evaluate the psychometric properties of 2 novel measures assessing personal advocacy, self-efficacy and personal advocacy activities in individuals with acquired brain injury (ABI). DESIGN: This was an instrument development study using (a) expert panel review with a content validity index, (b) consumer survey, and (c) Rasch analysis. Participants were adults (N = 162) with ABI recruited through a community survey. MAIN OUTCOME MEASURE: Participants completed the Self-Advocacy Scale (SAS) and the Personal Advocacy Activity Scale (PAAS). RESULTS: Using Rasch analysis to inform instrument development, after modification on the basis of item response theory analysis, the SAS, a measure of advocacy self-efficacy, was found to be unidimensional with an eigenvalue of 1.6, exhibited monotonicity, and had an item reliability of 0.97. Similarly, the PAAS, a measure of advocacy activity, was found to exhibit monotonicity, is unidimensional (eigenvalue of 1.7) and had an item reliability of 0.97. Both measures demonstrated concurrent validity, because they were significantly correlated with other established measures of related constructs and with each other. A separation reliability of 0.97 (real not model) for both the SAS and PAAS suggests that items will likely hold their relative positions in a similar sample. CONCLUSIONS: This study supported the PAAS and the SAS as reliable and valid measures of personal advocacy activity and associated self-efficacy in individuals post-ABI. (PsycINFO Database Record

Critical illness acquired brain injury: Neuroimaging and implications for rehabilitation.

OBJECTIVE: The increasing likelihood of surviving critical illness has resulted in a large and growing number of individuals transitioning from medical and surgical intensive care units (ICUs) to their homes. Many ICU survivors develop pervasive morbidities in physical, psychological, and cognitive functioning that adversely impact day-to-day functioning, ability to return to work, and quality-of-life. These individuals have been extensively studied with neuropsychological test batteries, but relatively little research has been conducted using neuroimaging. This paper reviews neuroimaging findings in survivors of critical illness treated in medical or surgical ICUs. METHODS: We assessed the relationships between abnormalities on neuroimaging and cognitive outcomes and discussed the implications for rehabilitation. RESULTS: There are limited imaging studies in ICU survivors. These studies use a wide range of modalities including magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), diffusion tensor imaging (DTI), fluid attenuated inversion recovery (FLAIR), and diffusion weighted imaging. Structural abnormalities in survivors of critical illness include cortical and subcortical lesions, white matter hyperintensities (WMHs), and generalized and focal atrophy. These abnormalities persist months to years after ICU discharge and are associated with cognitive impairments. (PsycINFO Database Record

The effectiveness of social communication partner training for adults with severe chronic TBI and their families using a measure of perceived communication ability.

BACKGROUND: Training for communication partners of people with traumatic brain injury (TBI) is efficacious when using blinded independent ratings of casual conversations measured in the clinic. However, the question remains as to whether participants with TBI and their significant other perceive changes to everyday social communication as a result of training. OBJECTIVE: To determine whether treatment focused on improving the conversational skills of everyday communication partners of people with severe TBI using a program called TBI Express resulted in improvements in perceived communicative ability as measured by the La Trobe Communication Questionnaire (LCQ). METHODS: Non randomized controlled trial comparing treatment of people with TBI together with communication partners (JOINT) with treatment of people with TBI without partner involvement (TBI SOLO) and a waitlist control group (CTRL) with follow-up at 6 months post-treatment. Forty-four outpatients from brain injury units in Sydney with severe chronic acquired brain injuries were recruited. A further 27 eligible outpatients refused to participate or could not be contacted. A total of 41 people completed treatment and 38 completed 6 month follow up assessment. The measure of perceived communication ability is the report of the participant with TBI and their partner on the LCQ. RESULTS: Communication partner training (JOINT) improved conversational performance relative to training the person with TBI alone and a waitlist control group on the LCQ. The TBI SOLO group improved in terms of report on the LCQ relative to the CONTROL group. Results were maintained at six months post-training. CONCLUSION: Training communication partners of people with chronic severe TBI using TBI Express led to perceived improvements in everyday communication ability by both the person with TBI and their family member.

Feasibility and results of a case study of yoga to improve physical functioning in people with chronic traumatic brain injury.

PURPOSE: The purpose of this mixed-methods case study was to investigate whether an 8-week 1:1 yoga program was feasible and beneficial to people with traumatic brain injury (TBI). METHOD: This was a mixed-methods case study of one-to-one yoga for people with TBI included three people. We completed assessments before and after the 8-week yoga intervention and included measures of balance, balance confidence, pain, range of motion, strength and mobility. Qualitative interviews were included at the post-assessment. We include a percent change calculation and salient quotes that represent the perceived impact of the yoga intervention. RESULTS: All participants completed the yoga intervention and all demonstrated improvements in physical outcome measures. For the group, balance increased by 36%, balance confidence by 39%, lower extremity strength by 100% and endurance by 105%. Qualitative data support the use of yoga to improve multiple aspects of physical functioning, one participant stated: "I mean it's rocked my world. It's changed my life. I mean all the different aspects. I mean physically, emotionally, mentally, it's given me you know my life back…". CONCLUSIONS: Yoga, delivered in a one-to-one setting, appears to be feasible and beneficial to people with chronic TBI. IMPLICATIONS FOR REHABILITATION: Chronic traumatic brain injury (TBI) leads to many aspects of physical functioning impairment. Yoga delivered in a one-to-one setting may be feasible and beneficial for people with chronic TBI.

EXTENDING THE ASSESSMENT OF TECHNOLOGY-AIDED PROGRAMS TO SUPPORT LEISURE AND COMMUNICATION IN PEOPLE WITH ACQUIRED BRAIN INJURY AND EXTENSIVE MULTIPLE DISABILITIES.

Intervention programs for people with acquired brain injury and extensive motor and communication impairment need to be diversified according to their characteristics and environment. These two studies assessed two technology-aided programs for supporting leisure (i.e., access to songs and videos) and communication (i.e., expressing needs and feelings and making requests) in six of those people. The three people participating in Study 1 did not possess speech but were able to understand spoken and written sentences. Their program presented leisure and communication options through written phrases appearing on the computer screen. The three people participating in Study 2 did not possess any speech and were unable to understand spoken or written language. Their program presented leisure and communication options through pictorial images. All participants relied on a simple microswitch response to enter the options and activate songs, videos, and communication messages. The data showed that the participants of both studies learned to use the program available to them and to engage in leisure and communication independently. The importance of using programs adapted to the participants and their environment was discussed.

Exploring caregivers' knowledge of and receptivity toward novel diagnostic tests and treatments for persons with post-traumatic disorders of consciousness.

BACKGROUND: A paucity of information is available regarding how caregivers of persons with post-traumatic disorders of consciousness (DOC) approach medical decision-making. Yet for evidence-based standards of care to be established, the onus is on caregivers' willingness to enroll their family members in clinical trials of novel tests and treatments (NTT). OBJECTIVE: To gather information regarding the beliefs and opinions of caregivers regarding NTT for DOC. METHODS: Exploratory qualitative data via focus groups from N = 17 caregivers of persons in post-traumatic DOC at both the acute (N = 7) and subacute (N = 10) phases of injury recovery. Supplemental survey data about knowledge of DOC. RESULTS: While attitudes toward NTT were generally favorable, two main themes emerged that influenced willingness to pursue NTT: patient and caregiver-specific factors, and the acquisition/use of information to guide decision-making. While survey data suggested a lack of knowledge about NTT, qualitative data revealed that this was better explained by different standards for knowledge, i.e., anecdotal versus empirical information. CONCLUSIONS: Current findings could support discussion between healthcare providers and caregivers regarding medical decision-making as well as suggestions for how to increase the likelihood of caregivers being willing to enroll their family members in clinical trials of NTT.

Assessment and Treatment of Cognition and Communication Skills in Adults With Acquired Brain Injury via Telepractice: A Systematic Review.

PURPOSE: This is a systematic review of assessment and treatment of cognitive and communicative abilities of individuals with acquired brain injury via telepractice versus in person. The a priori clinical questions were informed by previous research that highlights the importance of considering any functional implications of outcomes, determining disorder- and setting-specific concerns, and measuring the potential impact of diagnostic accuracy and treatment efficacy data on interpretation of findings. METHOD: A literature search of multiple databases (e.g., PubMed) was conducted using key words and study inclusion criteria associated with the clinical questions. RESULTS: Ten group studies were accepted that addressed assessment of motor speech, language, and cognitive impairments; assessment of motor speech and language activity limitations/participation restrictions; and treatment of cognitive impairments and activity limitations/participation restrictions. In most cases, equivalence of outcomes was noted across service delivery methods. CONCLUSIONS: Limited findings, lack of diagnostic accuracy and treatment efficacy data, and heterogeneity of assessments and interventions precluded robust evaluation of clinical implications for telepractice equivalence and the broader area of telepractice efficacy. Future research is needed that will build upon current knowledge through replication. In addition, further evaluation at the impairment and activity limitation/participation restriction levels is needed.

Negative neuroplasticity in chronic traumatic brain injury and implications for neurorehabilitation.

Based on growing findings of brain volume loss and deleterious white matter alterations during the chronic stages of injury, researchers posit that moderate-severe traumatic brain injury (TBI) may act to "age" the brain by reducing reserve capacity and inducing neurodegeneration. Evidence that these changes correlate with poorer cognitive and functional outcomes corroborates this progressive characterization of chronic TBI. Borrowing from a framework developed to explain cognitive aging (Mahncke et al., Progress in Brain Research, 157, 81-109, 2006a; Mahncke et al., Proceedings of the National Academy of Sciences of the United States of America, 103(33), 12523-12528, 2006b), we suggest here that environmental factors (specifically environmental impoverishment and cognitive disuse) contribute to a downward spiral of negative neuroplastic change that may modulate the brain changes described above. In this context, we review new literature supporting the original aging framework, and its extrapolation to chronic TBI. We conclude that negative neuroplasticity may be one of the mechanisms underlying cognitive and neural decline in chronic TBI, but that there are a number of points of intervention that would permit mitigation of this decline and better long-term clinical outcomes.