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).
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. […]