Posts Tagged TBI

[BLOG POST] How Relationships Can Change After a Brain Injury  

I want you to imagine someone who deeply loves you; how they make you feel when they smile at you and what it felt like to be around them. What if life changed in an instant, and they never looked at you the same way again?

Sadly, this happens to many traumatic brain injury (TBI) survivors, myself included. I have always been outgoing and had many cheerleaders who looked up to me. That look of aspiration turned into the look a wild animal would give after being caught in a trap for hours: frightened, helpless and hopeless. I remember seeing this look on people for a long time. Even when we were having a good time together, that look would be hiding deep in their eyes, waiting for my brain to scare them again. They would hug me as if it was the last hug they would ever give me.

My heart would shatter because in my mind I knew there was a chance they might be right; this might be the last time they hugged me. Even if I lived through the hospital stays and tests and “seizures” no doctor could diagnose, what if I forgot so many memories we shared that they couldn’t relate to me anymore?

When my TBI occurred it slowly began to bury every relationship I had. I have had a couple traumatic experiences in my life, and like a cat cashing in his lives, I have always bounced back. But with this brain injury I was not landing on my feet. That strong, confident, feisty woman turned into a helpless little girl who couldn’t even take a bath without supervision, or recognize family members. How do you relate to someone who has changed so drastically overnight?

Each brain injury is unique. Everyone can experience different symptoms, treatments and recovery times. However, there is one part of brain injury that is universal: the evolution of relationships. When the accident first occurs everyone tends to rally around you and cheer for a speedy recovery. When a limb is broken it heals, you rehabilitate, and life tends to move on. When there is damage to the brain or spine, the word speedy doesn’t come up during your recovery.

I remember being in the ICU when the symptoms of my TBI peaked in 2013. I earned myself a bright yellow “fall risk” bracelet, and my head was wrapped in gauze. I would wake up and have no idea who I was, or where I was. I wasn’t able to move the left side of my body and my head felt like it had been manhandled by a gorilla. My vision would be almost non-existent, and if I was really lucky I what I could see would be in doubles.

I would look around the room, not able to recognize my loved ones, a tear would roll out of my left eye and I would say, “Is my brain broken?” I would see everyone around me, dumbfounded on how to answer that question. My mouth would be so dry I could barely move my tongue to talk. “Was I in a car wreck?” I would utter out next. “No, honey, you weren’t in a wreck,” someone would usually confirm. I didn’t understand how I got there, or why I was in the condition I was in, although, they didn’t either.

I was sent home after five days in the ICU with no tools or explanation of what was happening. I would sleep for 14 or more hours a day. I was so weak and fatigued that I couldn’t sit for too long and my head would droop over as if a weight was tied to my neck. Sometimes my eyes looked like a zombie, just soulless. I couldn’t handle too much noise or light. If I reached my capacity with stimulation I would turn into an irritable T-rex that was seeking vengeance on anything that crossed my path.

I remember one day when my best friend sent me a text and asked if I wanted to hang out. I was overstimulated already when my phone began to buzz. He hadn’t heard the news about my condition yet, and unfortunately he found out through a text message sent straight from the wrath of my brain injury. I went off on the poor guy without realizing or remembering what I had done. He showed up to my house about a week later with a Disney puzzle in hand, and sulking sadness and confusion. I tried to explain what I could, as best as I could, and I saw his eyes tear up. He knew to some degree he lost his best friend Nikki, and she may never come back.

After I learned how I treated him on that text, I was immediately filled with regret, shame, and embarrassment. How could I be so cruel to some who cares about me so much? When he left I remember longing for the day we could go hang out again. I was also terrified — what if I said something worse to him, or said something I would never be able to take back?

I began slowly isolating myself from everyone so I wouldn’t be hateful to them, because I knew I wasn’t in a state to control it. I was also too embarrassed to be around them. Some days my speech was slurred and I would mix up my words. I can’t tell you how many times I called my dog a fridge, instead of Nyah. I felt worthless, like I was a burden to my friends and family. I saw the look on my friends and families faces that they would wear at my funeral. I didn’t have the emotional strength to keep facing that.

Significant time had passed and I was still working harder than ever to slowly get my life back. I had family members who would be critical of me because I hadn’t readapted into what they considered a normal life. “When are you going to get a job?” they would ask. Or my all-time favorite, “Is she just lazy?” I would get deeply offended. At the time I was going to 15 appointments a week to try to get to a stage where I could have some sort of quality of life. It took hours and hours of work just to come as far as I had and yet it still wasn’t good enough for them. They talked to me like a failure and a disappointment because I wasn’t healing at the rate they expected. It was ironic to me that all these people had opinions of how far along I should be, or what I should be doing, and yet not one of them had suffered from a brain injury. How could they project such a high standard at me, when clearly they had no education or experience that could relate to my circumstances? Why couldn’t they accept how I had become beautifully broken?

I knew that loss of relationships was a common after-effect of TBI but I was curious as to how common. I know of at least 37 survivors that have lost friends, family, and spouses as a result of their TBI. People who have vowed to be by your side, for better or worse, disappeared when the situation became “worse.”

Brain injury survivors once were nurses, mechanics, doctors, business owners. A brain injury can happen to anyone. Whether you are on your way home and God forbid get in a car wreck, slip on the ice, or collide while shooting some hoops. What would you do if everyone you loved started trickling away from you? Nothing hurts more than losing relationships with family, friends, and everyday life. While your lives have moved on and you pulled away I was still learning how to get dressed by myself.

If you want to support a loved one who has TBI, drop the expectation of what they are supposed to be. First off, unless you have been there, or have some sort of doctorate in the field, you are not qualified to tell me “how I should be progressing” in order to have you in my life. I have come to peace with my condition. I love every part of myself, even if that’s not good enough for you. I wouldn’t apologize for accidentally breaking my arm and I won’t apologize for accidentally breaking my brain. I am “beautifully broken” and I am proud of how far I have come, even if you don’t understand my journey.

If you ever do find yourself in a predicament like I was in, I hope you are treated with love and respect. That you aren’t abandoned by society because you don’t meet their expectations. I hope friends come by your side, and have patience with you even though you have failed to do so with them. If you find yourself in a situation similar to mine with no one around, know that you can reach out to me. I will be your friend and help you, even if you didn’t treat me with the same respect. Survivors are people that matter, and deserve to be treated as such.

Five Ways I am Different After My Traumatic Brain Injury

1. After my TBI I used to repeat myself often, and here and there I still do. I was OK with people calling me out for it, because it pointed out my much-needed growth. If someone was cold, or made fun of me it would make me feel mad and frustrated with myself. Sometimes it could put me in cycle where I would feel worthless.

I know it can be irritating to hear the same broken record, but it was sad to me that I was that record and couldn’t remember it. I may not have remembered telling the person, but I do remember some people’s reactions and it hurt. Saying things like “That’s right, you had mentioned something about that earlier, thanks for reminding me,” was really helpful. I know there were many times when my mom would pretend it was the first time she had heard something, even if I had already told her 10 times that day. I can’t tell you how grateful I am for her support. She was always kind, gentle, and encouraging; it has allowed me to mostly heal my injury.

2. When my brain would be overstimulated or something wasn’t functioning properly, I would turn into an angry wildebeest. My tongue would lash harsh phrases at people and I wouldn’t have a recollection of everything that I said or did. The brain goes into fight or flight (survival mode). It does what it can to survive.

By yelling and going off on everyone two things tend to happen. The brain produces different hormones and begins to change the chemistry of the brain, and a lot of times people would back away from me which brought down the level of stimulation. Arguing with me would only make the situation worse since my brain would go deeper into survival mode. Even if I was really hateful, I was fortunate enough that my parents understood. Them leaving the room and not arguing was extremely helpful, even if I was arguing something ludicrous like the San Francisco Bay Bridge was in the UK. I would also find a sanctuary in my laundry room. I was so hot (mostly because I was pregnant) and I would lay on the floor in the dark to let everything calm down.

3. Before my TBI I used to travel all the time. It has been a hard thing to not be able to just get on a plane and go. My brain is not able to adjust to altitude or barometric changes. When experiencing these drastic changes my head feels like it’s in a microwave and any minute it’s going to explode like overcooked leftovers. The pain is astronomical and I have cried when it’s too intense. I get extremely nauseous and irritable. I am exhausted by the time I get back to the altitude or barometric pressure I am most acclimated to.

4. I have a tendency to forget to do something easy like mail off a bill or make a phone call. It didn’t help the situation to have someone angry at me for forgetting. It wasn’t intentional and I am still very proud of all the things I do remember. Doing things like getting me sticky notes or organizing a calendar with me were very helpful. I also started relying heavily on my phone to track appointments, phone calls, and any other tasks I needed to do.

5. I have always been very confident and witty. I could crack jokes with the best of them. When my symptoms were really bad I couldn’t even understand a knock-knock joke, never mind tell one. I had a hard time relating to people because they were out doing so many things and I was always in the same routine. Go to appointments, and fight to heal the brain injury. I would eventually be vague with people because I was always telling the same ol’ story and I didn’t want to bore them.

Or I got reluctant to hear questions like “When are you going to be better?” or “When are you going to be back to normal?” I myself couldn’t even answer that question and I felt worthless. I have fought this hard to be where I am and I still didn’t feel good enough for them. Like you will only be by my side if I change back to my old self. And sometimes I would utter rude things to myself like, “Newsflash people, I don’t even remember who I was. How am I supposed to ‘get back to normal’ if I don’t even know what that ‘normal girl’ is anymore?”

I was able to build deeper friendships and relationships with the people that would keep encouraging me. If I disclosed a baby step of progression I would get positive affirmations like “awesome” or “I knew you could do it.” It encouraged me to keep fighting, and I felt some sort of self worth. Like I was finally climbing out of the darkness, into the light.

Follow this journey on My Traumatic Brain Injury.

We want to hear your story. Become a Mighty contributor here.

Source: How Relationships Can Change After a Brain Injury | The Mighty

, ,

Leave a comment

[WEB SITE] Traumatic Brain Injury Resource Guide – Neuroplasticity

Neuroplasticity

Source: Traumatic Brain Injury Resource Guide – Neuroplasticity

, , ,

Leave a comment

[WEB SITE] How OCD and Traumatic Brain Injury Are Linked

Traumatic brain injuries can cause symptoms of obsessive compulsive disorder

Head bandage

Andrew Simpson / Getty Images

Traumatic brain injury (TBI) caused by motor vehicle accidents, falls or other accidents and firearms can cause a wide variety of cognitive issues. In addition to cognitive problems, if you’ve experienced a brain injury, you may also develop symptoms consistent with one or more forms of mental illness including obsessive-compulsive disorder (OCD).

TBI occurs when the brain is injured or damaged by an outside force such as a blow to the head or a gunshot.

TBIs can occur as a closed head injury in which the skull and brain remain intact, like what is seen among professional athletes such as football players, or as a penetrating head injury in which an object penetrates the skull and brain. TBI is often classified according to the severity of injury—mild, moderate or severe.

Common Changes Caused By TBI

If you have experienced a TBI you may also notice a change in your cognitive functioning. After a TBI, your performance on everyday tasks requiring memory, language, spatial or verbal ability may be negatively affected. This can be either temporarily or permanently.

If the TBI affects motor centers within the brain, mobility may also be impaired, and you may need a mobility device like a wheelchair or help with day to day tasks. TBI can also affect your behavior, causing changes in your personality. It is possible, after a TBI, that a previously calm person may become impulsive or aggressive.

Likewise, an outgoing individual may become shy and withdrawn.

TBI and Symptoms of OCD

In addition to changes in cognitive function, behavior, and mobility, TBI can trigger symptoms of OCD including obsessions and compulsions. OCD following a TBI usually occurs soon, if not immediately, after the event has taken place.

However, there have been reports of TBI-induced OCD being diagnosed months after the initial injury. In each case, localized brain damage may or may not be present when viewing a brain scan.

Research has indicated that OCD following a TBI is usually accompanied by symptoms of major depression. Whether this depression is a result of the TBI, the psychosocial stress caused by the injury, the onset of OCD, or a combination of these factors is unclear.

Treating TBI-Related OCD

If you developed OCD after a traumatic brain injury, your doctor may recommend a selective serotonin reuptake inhibitors such as Prozac (fluoxetine) or a tricyclic antidepressant such as Anafranil (clomipramine).

Psychotherapy for OCD following a TBI may also be helpful. However, since cognitive impairment is common among those with TBI, cognitive-based therapies may not be the best option for everyone and should be evaluated on a case by case basis. If you can, choose a supportive therapy which assists you and helps you cope with both the practical and emotional challenges associated with TBI and OCD.

Sources

  • Coetzer, B.R.“Obsessive-compulsive disorder following brain surgery” International Journal of Psychiatry and Medicine 2004 34: 363-377.
  • Grados, M.A. “Obsessive-compulsive disorder after traumatic brain injury” International Review of Psychiatry 2003 15: 350-358.

Source: How OCD and Traumatic Brain Injury Are Linked

, , ,

Leave a comment

[A Case Study] A Clinical Framework for Functional Recovery in a Person With Chronic Traumatic Brain Injury – Full Text

Abstract

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).

INTRODUCTION

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. […]

Continue —> A Clinical Framework for Functional Recovery in a Person Wit… : Journal of Neurologic Physical Therapy

, , , , , , ,

Leave a comment

[BLOG POST] Brain Injury and Sex: What Happens After a TBI?

By Xavier Figueroa, Ph.D.

http://www.msktc.org/tbi/factsheets/Sexuality-After-Traumatic-Brain-Injury

womens-brainsWhat is the largest sex organ in the body?

The brain, of course! (Followed by the spinal cord ganglia but let’s not judge).

Intimacy, desire, physical contact and pleasure, they are very basic needs in a relationship. Marriages, partnerships and friendships rely on this most basic link. But when a brain injury occurs, changes in desire and drive (hypo- and hyper-sexuality) can become apparent. Energy and mood can also be affected, which can induce a change in libido, interest and desire. Damage to certain portions of the brain may affect your ability to move, reducing spontaneity and self-esteem. Elements of coming to terms with the trauma, such as shock and recovery may take time, as well as recovery from physical rehabilitation. If the injury is chronic, other changes may become apparent, including cognitive and behavioral changes that shift how friends and partner interact with each other.

Much of these changes can occur days, weeks or even months after the injury, even in mild to moderate traumatic brain injuries. Knowing how to identify, adapt and overcome the changes associated with an ABI/TBI is an important part of recovery.

The most important information to take away from this post is the following: you are not alone, you are not abnormal and you will get better. Millions of individuals and couples have gone through the recovery of a brain injury and difficulties with reestablishing a functional sexual relationship. Hang in there.

What the Problem Looks Like

When we talk about sex, we are talking about something that is simple in practice, but complex in execution. Prior to the brain injury, a pattern of behavior between yourself and your partner was established. How you interacted and what you expected prior to and leading to sexual intimacy were established and anticipated. I wouldn’t call it a pattern (that’s not very exciting!), but a role in which you knew which part each one would play.

A brain injury directly affects the biggest and most important sex organ in the human body. It’s no wonder that sexual issues appear in 50-60% of people that suffer a moderate to severe TBI. In a recent article in US News and World Report (Health Day, April 29, 2013; Link) that reported on the study that appeared in NeuroRehabilitation: An International Journal:

‘The study found that 50 percent to 60 percent of people with TBI have sexual difficulties, such as reduced interest in sex, erectile dysfunction, pain during sex, difficulties in vaginal lubrication, difficulties achieving orgasm or staying aroused, and a sense of diminished sex appeal, Moreno said.

The research found that partners of those with TBI experienced personality and emotional changes, and a modification of family roles that can lead to a crisis, Moreno said. “For the spouse, the survivor becomes a different person, a person they do not recognize as the one they fell in love with in the past,” he said. “The spouse becomes a caregiver and this imbalance in the relationship directly affects sexual desire.”’

Even in cases of mild TBI, there are incidences of 25-50% of people experiencing sexual difficulties [1], especially in individuals exposed to bomb-blast injuries. Brain injuries are not mild…they can take a life of their own and totally transform who you are and how you relate to your significant other (spouse, partner or lover). Many of these changes can be divided into 5 major groups:

  • Decreased Desire (Hyposexuality): inability to become interested in sex.
  • Increased Desire (Hypersexuality): inappropriate sexual behavior; constant focus on sex.
  • Decreased Arousal: Difficulty in achieving erection/lubrication.
  • Difficulty or Inability to Reach Orgasm/Climax:
  • Reproductive Changes: Low sperm count; missed periods.

But these are just the changes that occur with sexual interaction (as if that weren’t enough). These are behavioral changes that hide deeper and more profound changes that can occur throughout the body. Changes in sexual desire are like the proverbial canary in the coal mine…it warns you that something is amiss.

That Voodoo That You do…

Damage to the brain can induce a number of changes:

Fatigue/Tiredness

Hormonal Changes

Emotional Changes

Cognitive Changes

Spasticity/Movement Problems

These changes can come from very specific damage to certain areas of the brain, such as your pituitary, the frontal and temporal lobes of the brain. When you get down to it, sex is a very complicated process…neurologically speaking! A number of body systems have to work together to make the engines of desire go vroom…and when one system is not working, then it can cause the engine to misfire and stall.

The Tiny Organ

The pituitary gland is a tiny portion of the brain… but don’t let its size fool you. It is a master regulator of hormones that, when damaged, can diminish your ability to regulate your blood pressure, sleep cycle and hormones.

tiny_organThe function of the pituitary is diverse, as it can affect a number of really important functions:

Hormones secreted from the pituitary gland help control the following body processes:

  • Growth
  • Blood pressure
  • Pregnancy and stimulation of uterine contractions during childbirth
  • Breast milk production
  • Sex organ functions in both males and females
  • Thyroid gland function
  • The conversion of food into energy (metabolism)
  • Water and osmolarity regulation in the body (which affects blood pressure)
  • Water balance via the control of re-absorption of water by the kidneys
  • Temperature regulation
  • Pain relief

If that weren’t enough, this can cascade into disease states that may not seem related to a TBI. One thing that we are seeing with returning veterans is pituitary dysfunction is present and undiagnosed or under diagnosed. Even with hormone or growth factor replacement therapies, a pituitary that is not firing on all cylinders will continue to cause long-term problems. Although changes in sexual interaction are the most visible and can be due to pituitary damage, they warn that the damage is more profound. The Big Organ (the brain) has a lot of functions related to behavior…and when it comes to sex, behavior is key (good or bad).

The Tiny Brain (Hypothalamus)

This portion of the brain, the hypothalamus, is a close neighbor to the pituitary. So close, they are friends with benefits. One of the most important functions of the hypothalamus is to link the nervous system to the endocrine system via the pituitary gland (another name of the pituitary is the hypophysis).

The hypothalamus is more of a region than an actual structure. It is composed of many groups of neurons (called nuclei) that control a wide variety of hormonal secretions and behaviors. In a recent small scale study of severe TBI, it was discovered that ~21% of study subjects suffered from hypothalamic-hypophysial dysfunction. In about 40% of male TBI sufferers, there was a detectable drop in testosterone levels [2], which can affect sexual drive and desire in men. About 15% of all patients with a TBI have some degree of hypopituitarism that can go unrecognized and could be mistakenly ascribed to persistent neurologic injury and cognitive impairment [3].

The reason for the hypothalamic damage being mistaken for neurologic injury and cognitive impairment are due to the very broad effects that the hypothalamus exerts on metabolism and brain function. If the hypothalamus is misfiring, it takes a very involved physician (or physicians), with training in neurology, endocrinology and/or experience with TBI to identify the problem. A lot of systems can malfunction in a brain injury.

The Frontal Lobe

The frontal lobe (in green).

The frontal lobe (in green) • tumblr

In head injuries, damage to the frontal lobe is thought to occur frequently. Car crashes (especially front end collisions, are thought to cause frontal and occipital lobe damage. Damage to the frontal lobe has been reported to cause individuals to behave inappropriately in response to normal social situations. Loud or overly-boisterous exchanges, inappropriate genital touching (in public) or fixation on one subject or person have been reported outcomes after a TBI. Changes in emotional affect (expression of emotions) that are felt may not be expressed in the face or voice. For example, someone who is feeling happy would not smile, and his or her voice would be devoid of emotion. This can be very disconcerting to a partner and can be experienced a loss of affection or interest. How a partner or loved one that is a caretaker of a TBI victim experiences the injury will have a direct effect on their own sexual desire and interest.

Along the same lines, though, the person may also exhibit excessive, unwarranted displays of emotion or poor control of anger. Poor anger management is associated with some forms of frontal lobe damage. Depression is not an uncommon outcome from a head injury, especially if there is frontal lobe damage. Also common along with depression is a loss of or decrease in motivation. Someone might not want to carry out normal daily activities and would not feel “up to it”. Sex might not seem as interesting or motivating.

Those who are close to the person who has experienced the damage may notice that the person no longer behaves like him or herself. The frontal lobe is the same part of the brain that is responsible for executive functions such as planning for the future, judgment, decision-making skills, attention span, and inhibition. These functions can decrease drastically in someone whose frontal lobe is damaged. A short list of behavioral changes associated with frontal lobe damage is given below:

  • Agitation
  • Explosive anger and irritability
  • Lack of awareness and insight
  • Impulsivity and disinhibition
  • Emotional lability
  • Self-centeredness
  • Apathy and poor motivation
  • Depression
  • Anxiety
  • Inflexibility and obsessionality
  • Sexual problems

Frontal lobe damage is only one part of cerebral cortex, but is the most common type of cortical damage due to a TBI. Other parts may be damaged as well. Frontal lobe damage is common and better associated with impulse and emotional control, making sufferers act completely out of character and unable to control or edit themselves or their responses.

Putting it Together

So, after reading all of this, what does it do for you? How does this help you re-establish the emotional, sexual and intimate relationship you wish with your partner? As a caretaker, or as a sufferer, the TBI is a big elephant in the room. It exists; it takes up space in your life, even though it can’t be seen. The person you knew is not present…they have not come back from their injury and they might not come back. Some do recover, others do not. But you can still create a new bond, a new relationship and a new life. And you can fight to repair the damage to the brain.

There are limited options for therapy in current medical practice. Mostly, it is focused on developing new skills, relearning old ones, developing coping skills or taking medications. That’s just for the TBI sufferer, not the caretaker(s). The complexity and variety of problems that pop-up when dealing with a brain injury are truly staggering and expensive. Fortunately, the majority of mild-to-moderate TBI’s do recover. Patience and persistence in therapy are required in order to make a recovery.

Unfortunately, for a portion of all TBI sufferers, recovery may take years. That is a long-time to wait. Therapies that help to re-build the brain connections (neuroplasticity) or restore blood flow to the brain hold promise for restoring function again. Hyperbaric oxygen therapy (HBOT) is one such therapy that has a good number of clinical studies to support its use for chronic TBI and PCS [4-9]. Near infra-red and infra-red technologies show promise for a TBI therapy, as well [10-13].

Nutritional support, such as Omega-3 fatty acids (DHA and EPA), has shown the ability to reduce the long-term neuroinflammation associated with a TBI [14-16] and help with white matter repair. Other nutritional therapies may exist to help mediate repair in a TBI.

The take home message is that there are potential therapies that are being developed to help treat the neurological damage of a TBI. Take heart that the “new normal” for yourself or your loved one may not need to be permanent.

  1. Wilkinson, C.W., et al., High prevalence of chronic pituitary and target-organ hormone abnormalities after blast-related mild traumatic brain injury. Front Neurol, 2012. 3: p. 11.
  2. Kopczak, A., et al., Screening for hypopituitarism in 509 patients with traumatic brain injury or subarachnoid hemorrhage. J Neurotrauma, 2014. 31(1): p. 99-107.
  3. Pekic, S. and V. Popovic, Chapter 18 – Alternative causes of hypopituitarism: traumatic brain injury, cranial irradiation, and infections, in Handbook of Clinical Neurology, M.K. Eric Fliers and A.R. Johannes, Editors. 2014, Elsevier. p. 271-290.
  4. Boussi-Gross, R., et al., Hyperbaric Oxygen Therapy Can Improve Post Concussion Syndrome Years after Mild Traumatic Brain Injury – Randomized Prospective Trial. PLoS One, 2013. 8(11): p. e79995.
  5. Wolf, G., et al., The effect of hyperbaric oxygen on symptoms after mild traumatic brain injury. J Neurotrauma, 2012. 29(17): p. 2606-12.
  6. Harch, P.G., et al., A phase I study of low-pressure hyperbaric oxygen therapy for blast-induced post-concussion syndrome and post-traumatic stress disorder. J Neurotrauma, 2012. 29(1): p. 168-85.
  7. Lin, J.W., et al., Effect of hyperbaric oxygen on patients with traumatic brain injury. Acta Neurochir Suppl, 2008. 101: p. 145-9.
  8. Shi, X.Y., et al., Evaluation of hyperbaric oxygen treatment of neuropsychiatric disorders following traumatic brain injury. Chin Med J (Engl), 2006. 119(23): p. 1978-82.
  9. Wright, J.K., et al., Case report: Treatment of mild traumatic brain injury with hyperbaric oxygen. Undersea Hyperb Med, 2009. 36(6): p. 391-9.
  10. Grillo, S.L., et al., Non-invasive infra-red therapy (1072 nm) reduces beta-amyloid protein levels in the brain of an Alzheimer’s disease mouse model, TASTPM. J Photochem Photobiol B, 2013. 123: p. 13-22.
  11. Gkotsi, D., et al., Recharging mitochondrial batteries in old eyes. Near infra-red increases ATP. Exp Eye Res, 2014. 122: p. 50-3.
  12. Quirk, B.J., et al., Near-Infrared Photobiomodulation in an Animal Model of Traumatic Brain Injury: Improvements at the Behavioral and Biochemical Levels. Photomedicine and Laser Surgery, 2012. 30(9): p. 7.
  13. Naeser, M.A., et al., Significant Improvements in Cognitive Performance Post-Transcranial, Red/Near-Infrared Light-Emitting Diode Treatments in Chronic, Mild Traumatic Brain Injury: Open-Protocol Study. JOURNAL OF NEUROTRAUMA, 2014. 31: p. 10.
  14. Pu, H., et al., Omega-3 polyunsaturated fatty acid supplementation improves neurologic recovery and attenuates white matter injury after experimental traumatic brain injury. J Cereb Blood Flow Metab, 2013. 33(9): p. 1474-84.
  15. Lewis, M., P. Ghassemi, and J. Hibbeln, Therapeutic use of omega-3 fatty acids in severe head trauma. Am J Emerg Med, 2013. 31(1): p. 273 e5-8.
  16. Hasadsri, L., et al., Omega-3 fatty acids as a putative treatment for traumatic brain injury. J Neurotrauma, 2013. 30(11): p. 897-906.

Disclaimer: I am not a medical doctor. I am not giving medical advice, diagnosis or treatment recommendations. The posts on this blog are my opinion. If you are thinking of following or using any of this information for any health related conditions, I would recommend you talk to your physician and seek guidance and help. I try to be as meticulous as possible in the information I use for these posts. I look for potential therapies that are low-risk/high impact. There are no guarantees, but knowledge is power and self-direction can lead you to uncover and do incredible things.

Source: Brain Injury and Sex: What Happens After a TBI? | Brain Health & Healing Foundation

, , , , ,

Leave a comment

[WEB SITE] 9 1/2 Need-to-Know Facts About Traumatic Brain Injury

9 1/2 Need-to-Know Things About Traumatic Brian InjuryAn estimated 5.3 million Americans — about 2 percent of the U.S. population — currently have a long-term or lifelong need for help with everyday activities due to traumatic brain injury (TBI). (1) Many believe this number to be low as it only takes into account the number of reported injuries to hospital emergency rooms and by health care professionals. We’ve compiled the top 9 1/2 things to know about traumatic brain injury, it would have been 10 but the last 1/2 was left off because memory is often affected by traumatic brain injury.

Multimedia

  1. A traumatic brain injury is a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. You do not need to lose consciousness to sustain a concussion.
  2. 1.7 million people sustain a TBI each year in the United States. By the numbers, every American has more than a 1:300 chance of sustaining a traumatic brain injury each year. (2)

  3. The three groups at highest risk for traumatic brain injury are children (0-4 year olds), teenagers (15-19 year olds), and adults (65 and older). (2)

  4. Estimates peg the number of sports-related traumatic brain injuries as high as 3.8 million per year. (2)

  5. Using a seatbelt and wearing a helmet are the best ways to prevent a TBI.

  6. Males are almost twice as likely as females to sustain a TBI.

  7. A concussion is a mild brain injury. The consequences of multiple concussions can be far more dangerous than those of a first TBI. (3)

  8. The area most often injured are the frontal lobes that control thinking and emotional regulation.

  9. A blow to one part of the brain can cause damage throughout.

9 1/2. Most people do make a good recovery from TBI.

If you found this useful, please share with family and friends or leave a comment below if you think we’ve left something off.

References:

  1. Centers for Disease Control. http://www.cdc.gov/traumaticbraininjury/pdf/BlueBook_factsheet-a.pdf
  2. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006.
  3. Cifu, David, MD. eMedicine.com. www.emedicine.com/sports/TOPIC113.HTM.

Source: 9 1/2 Need-to-Know Facts About Traumatic Brain Injury

, ,

Leave a comment

[ARTICLE] Diffusion MRI and the detection of alterations following traumatic brain injury – Full Text

Abstract

This article provides a review of brain tissue alterations that may be detectable using diffusion magnetic resonance imaging MRI (dMRI) approaches and an overview and perspective on the modern dMRI toolkits for characterizing alterations that follow traumatic brain injury (TBI). Noninvasive imaging is a cornerstone of clinical treatment of TBI and has become increasingly used for preclinical and basic research studies. In particular, quantitative MRI methods have the potential to distinguish and evaluate the complex collection of neurobiological responses to TBI arising from pathology, neuroprotection, and recovery. dMRI provides unique information about the physical environment in tissue and can be used to probe physiological, architectural, and microstructural features. Although well-established approaches such as diffusion tensor imaging are known to be highly sensitive to changes in the tissue environment, more advanced dMRI techniques have been developed that may offer increased specificity or new information for describing abnormalities. These tools are promising, but incompletely understood in the context of TBI. Furthermore, model dependencies and relative limitations may impact the implementation of these approaches and the interpretation of abnormalities in their metrics. The objective of this paper is to present a basic review and comparison across dMRI methods as they pertain to the detection of the most commonly observed tissue and cellular alterations following TBI.

1 INTRODUCTION

Despite the long history of traumatic brain injury (TBI) as a prevalent cause of death and disability in humans, defining the neurobiological underpinnings of damage and recovery following TBI remains a central challenge. The complex collection of physiological, cellular, and molecular changes that follow TBI can appear to be remarkably heterogeneous, but at the same time they are highly organized into coordinated responses such as neurodegeneration, inflammation, and regeneration. The corpus of histological studies spanning a variety of experimental animal models of TBI have provided crucial insights about the pathomechanisms and cellular alterations that accompany posttraumatic tissue change, but considerable work remains to determine the spatiotemporal evolution of abnormalities, interrelationships among different tissue responses, and their impact on health and behavioral outcomes. Noninvasive imaging in animal models has the potential to build on what is known from histology by providing longitudinal and whole-brain information, but for this approach to be successful it is essential to first improve the understanding of how imaging abnormalities correspond to tissue and cellular changes.

Diffusion magnetic resonance imaging (dMRI) methods are particularly promising for the development of imaging markers of TBI pathology because they are sensitive to microscale water displacement as a proxy for tissue environment geometry and provide a range of quantitative scalar metrics across the whole brain. Furthermore, dMRI may be combined with other conventional or advanced magnetic resonance imaging (MRI) methods such as arterial spin labeling, susceptibility-weighted imaging, or a variety of contrast agent MRI approaches to provide complementary and comprehensive outcome measures. Standard dMRI methods and especially diffusion tensor imaging (DTI) have already demonstrated sensitive detection of abnormalities in a number of experimental models of TBI. In the past decade, multiple advanced dMRI approaches have extended beyond the conventional models with the goals of improving the physical description of water diffusion (e.g., by modeling “non-Gaussian” diffusion) or parameterizing dMRI with respect to the expected biological environment (e.g., by modeling cellular compartments and/or fiber geometry). These new tools will be valuable if they are able to improve the sensitivity or specificity of dMRI following TBI; however, we lack a systematic understanding of how dMRI methods differ from one another for detecting and describing tissue alterations.

A number of excellent reviews exist to describe the current understanding of cellular mechanisms of TBI in general (Bramlett & Dietrich, 2015; Pekna & Pekny, 2012) and within particular areas of neurobiology including neurodegeneration (Johnson, Stewart, & Smith, 2013; Stoica & Faden, 2010), inflammation (Burda, Bernstein, & Sofroniew, 2016; Ziebell & Morganti-Kossmann, 2010), and myelin changes (Armstrong, Mierzwa, Marion, & Sullivan, 2016), among others. As well, several existing reviews have been published regarding MRI and DTI to study human TBI (Brody, Mac Donald, & Shimony, 2015; Duhaime et al., 2010; Hulkower, Poliak, Rosenbaum, Zimmerman, & Lipton, 2013), and recently a pertinent overview and summary of advanced dMRI tools and their relevance to clinical outcomes was published (Douglas et al., 2015). The focus of the present review is to combine what is known from work in experimental models of TBI about tissue and cellular alterations that may affect the physical tissue environment with a comparative description of the major methods for dMRI that may be differentially sensitive to TBI-related tissue change alongside several important caveats for their use and interpretation. The first section provides a categorical summary of cellular response to trauma, emphasizing alterations with microstructural, architectural, or neuroanatomical manifestations that may give rise to detectable dMRI abnormalities, including a review of the existing dMRI studies in experimental TBI models. The second section contains a comparative overview of presently available dMRI methods from standard approaches to advanced techniques. The objective of this article is to provide a reference for the current understanding of these topics as well as a perspective to help guide selection of dMRI tools based on particular aspects of TBI questions.

Continue —> Diffusion MRI and the detection of alterations following traumatic brain injury – Hutchinson – 2017 – Journal of Neuroscience Research – Wiley Online Library

Figure 2. Cross-model comparison of scalar maps in the injured brain. A range of tissue and injury-related contrasts may be visually observed in this collage of 16 representative metrics in the same slice from different dMRI models. This cross-model view of scalar maps demonstrates the potential for nonredundant information about regions of injury that may be gleaned from different models. DTI metrics of fractional anisotropy (FA), trace (TR), axial and radial diffusivity (Dax and Drad), directionally encoded color (DEC) map weighted by lattice index, DEC weighted by Westin linear anisotropy (WL) and DEC weighted by Westin planar anisotropy (WP), DKI metrics of mean kurtosis (MK), axial and radial kurtosis (AK and RK) and kurtosis FA (KFA), MAP-MRI metrics of return to the origin, axis, and plane probabilities (RTOP, RTAP, and RTPP), propagator anisotropy (PA) and non-Gaussianity (NG) and NODDI metrics of compartment volume fractions for isotropic free water (Viso), intracellular water (Vic) and intracellular restricted water (Vir), and orientation dispersion index (ODI). Insets of each map show tissue near the injury site where dMRI values are expected to be abnormal.

, , , , ,

Leave a comment

[BOOK] Chapter 5: Hand Rehabilitation after Chronic Brain Damage: Effectiveness, Usability and Acceptance of Technological Devices: A Pilot Study – Full Text

THE BOOK:  “Physical Disabilities – Therapeutic Implications”, book edited by Uner Tan, ISBN 978-953-51-3248-6, Print ISBN 978-953-51-3247-9, Published: June 14, 2017 under CC BY 3.0 license. © The Author(s).

CHAPTER 5: By Marta Rodríguez-Hernández, Carmen Fernández-Panadero, Olga López-Martín and Begoña Polonio-López

 

Abstract

Purpose: The aim is to present an overview of existing tools for hand rehabilitation after brain injury and a pilot study to test HandTutor® in patients with chronic brain damage (CBD).

Method: Eighteen patients with CBD have been selected to test perception on effectiveness, usability and acceptance of the device. This group is a sample of people belonging to a wider study consisting in a randomized clinical trial (RCT) that compares: (1) experimental group that received a treatment that combines the use of HandTutor® with conventional occupational therapy (COT) and (2) control group that receives only COT.

Results: Although no statistical significance has been analysed, patients report acceptance and satisfaction with the treatment, decrease of muscle tone, increase of mobility and better performance in activities of daily life. Subjective perceptions have been contrasted with objective measures of the range of motion before and after the session. Although no side effects have been observed after intervention, there has been some usability problems during setup related with putting on gloves in patients with spasticity.

Conclusions: This chapter is a step further of evaluating the acceptance of technological devices in chronic patients with CBD, but more research is needed to validate this preliminary results.

1. Introduction

According to the World Health Organization [1], cerebrovascular accidents (stroke) are the second leading cause of death and the third leading cause of disability. The last update of the global Burden of Ischemic and Haemorrhagic Stroke [2] indicates that although age-standardized rates of stroke mortality have decreased worldwide in the past two decades, the absolute numbers of people who have a stroke every year are increasing. In 2013, there were 10.3 million of new strokes, 6.5 million deaths from stroke, almost 25.7 million stroke survivors and 113 million of people with disability-adjusted life years (DALYs) due to stroke.

One of the most frequent problems after stroke is upper limb (UL) impairments such as muscle weakness, contractures, changes in muscle tone, and other problems related to coordination of arms, hands or fingers [3, 4]. These impairments induce disabilities in common movements such as reaching, picking up or holding objects and difficult activities of daily living (ADLs) such as washing, eating or dressing, their participation in society, and their professional activities [5]. Most of people experiencing this upper limb impairment will still have problems chronically several years after the stroke. Impairment in the upper limbs is one of the most prevalent consequences of stroke. For this reason making rehabilitation is an essential step towards clinical recovery, patient empowerment and improvement of their quality of life. [6, 7].

Traditionally, therapies are usually provided to patients during their period of hospitalization by physical and occupational therapists and consist in mechanical exercises conducted by the therapists. However, in the last decades, many changes have been introduced in the rehabilitation of post-stroke patients. On the one hand, increasingly, treatments extend in time beyond the period of hospitalization and extend in the space, beyond the hospital to the patient’s home [8]. On the other hand, new agents are involved in treatments, health professionals (doctors, nurses) and non-health professionals (engineers, exercise professionals, carers and family). Most of these changes have been made possible thanks to the development of technology [9].

2. Technological devices for upper limb rehabilitation

In the last 10 years, there has been increasing interest in the use of different technological devices for upper limb (UL) rehabilitation generally [5, 9], and particularly hand rehabilitation for stroke patients [10]. These studies have approached the problem from different points of view: (1) on the one hand, by analysing the physiological and psychophysical characteristics of different devices [11], (2) on the other analysing the key aspects of design and usability [12] and (3) finally studying its effectiveness in therapy [13, 14]. According to Kuchinke [12], these technical devices can be organized into two big groups: (1) on the one hand, devices based on virtual reality (VR) and (2) on the other robotic glove-like devices (GDs).

One of the main advantage of VRs and serious games [15] is to promote task-oriented and repetitive movement training of motor skill while using a variety of stimulating environments and facilitates adherence to treatment in the long term [16]. These devices can be used at home and in most cases do not require special investment in therapeutic hardware because they can use game consumables existing at home such as Nintendo(R) Wii1 [17, 18], Leapmotion2 [19, 20] or Kinect sensor3 [21, 22]. Although first systematic studies based in VRs indicate that there is insufficient evidence to determine its effectiveness compared to conventional therapies [8], more recent studies [13, 14, 23] offer moderate evidence on the benefits of VR for UL motor improvement. Most researchers agree that VRs work well as coadjuvant to complement more conventional therapies; however, further studies with larger samples are needed to identify most suitable type of VR systems, to determine if VR results are sustained in the long term and to define the most appropriate treatment frequency and intensity using VR systems in post-stroke patients.

On the other hand, robotic systems and glove-like devices that provide extrinsic feedback like kinaesthetic and/or tactile stimulation have stronger evidence in the literature that improve motion ability of post-stroke patients [10, 24, 25]. Most of the evidences about effectiveness of GDs are based in pilot studies with non-commercial prototypes [2630], but nowadays, there are also several commercial glove-like devices that support hand rehabilitation therapies for these patients such as HandTutor® [31, 32], Music Glove [3335], Rapael Smart Glove [36] or CyberTouch [16, 37]. The main disadvantages of GDs are price, availability, because they are not yet widespread, and in some case the difficulty of setup handling and ergonomics.

As far as we know, there is little evidence in the literature supporting commercial glove-like devices for hand rehabilitation. This chapter presents a randomized clinical study (RCS) to test HandTutor® System in patients with chronic brain damage (CBD). There are some promising studies that show positive results by applying the HandTutor® in different groups of patients with stroke and traumatic brain injury (TBI) [31, 32], but samples include only people who are in the acute or subacute disease or injury but do not include chronic patients. This may be due to the added difficulty of obtaining positive results in interventions aimed at this group, in addition to the characteristics of adaptability and usability of the device that it is also harder for this kind of patients. The present work focuses on hand rehabilitation for chronic post-stroke patients.

3. Experimental design

We have conducted a pilot study (PS) to test acceptance, usability and adaptability of HandTutor® device in patients with chronic brain damage (CBD). This work describes setup, study protocol and preliminary results.

3.1. Participants description

Eligible participants met the following inclusion criteria: (1) At least 18-year age, (2) diagnosed with acquired brain injury: stroke or traumatic brain injury (TBI) and (3) chronic brain damage (more than 24 months from injury). In the final sample, 18 participants aged between 30 and 75 years old, 28% of subjects included in the pilot study are diagnosed with TBI and the remaining 72% of stroke; of these, more than half (56%) have left hemiplegia. The time from injury time exceeds 24 months, reaching 61% of cases 5 years of evolution. All the subjects included in the study attend regularly to a direct care acquired brain injury centre.

3.2. Device description

HandTutor® is a task-oriented device consistent on an ergonomic wearable glove and a laptop with rehabilitation software to enable functional training of hand, wrist and fingers. There are different models to fit both hands (left and right) and different sizes. The system allows the realization of an intensive and repetitive training but, at the same time, is flexible and adaptable to different motor abilities of patients after suffering a neurological, traumatological or rheumatological injury. The software allows the therapist to obtain different types of measures and to customize treatments for different patients, adapting the exercises to their physical and cognitive impairments. The HandTutor® provides augmented feedback and allows the participation of the user in different games that require practising their motor skills to achieve the game objective. Game objectives are highly challenging for patients and promote the improvement of deteriorated skills.

3.3. Study protocol

A randomized clinical trial (RCT) has been conducted with an experimental group and a control group. Participants in the experimental group have been treated with HandTutor® technological device, combined with conventional occupational therapy (set of functional tasks aimed at the mobility of the upper limb in ADLs). The control group only received conventional occupational therapy. All participants in the experimental group attend two weekly sessions with HandTutor®. Both groups received a weekly session of conventional therapy. It is a longitudinal study with pre-post intervention assessment, in which each subject is his control.

This chapter describes the first phase of the RCT, consisting of a pilot study (PS) to test the acceptance, usability and adaptability of the device by patients. For the PS, 18 patients of the global group were selected. Each subject completed four sessions using HandTutor® in both hands and a weekly session of COT. Each session includes quantitative and qualitative evaluation. The former one includes pre-intervention, and post-intervention assessment evaluating passive and active joint range of fingers and wrist, the latter include patients’ interviews and therapist’s observations. During the session, participants receive immediate visual and sensory feedback about their performance during exercises.

Each session includes a pre-intervention assessment and a back, wrist and hand. At the beginning of the session, the therapist evaluated the passive and active joint range of all fingers and wrist (flexion and extension). After the session, patient and therapist reviewed the increased joint range achieved during therapy on the joints involved. The software allows analysing and comparing the minimum and maximum levels in each of the movements required by the exercise. Each session lasts 45 minutes and consists of two exercises that focus their activity in flexion and extension of wrist and fingers independently, reaction speed and accuracy of the selected motion to move some elements included in the exercise.

First exercise of the session consisted in score as many balls as possible in the basket situated at the left of the patient. Every ball came to the patient from his right side. The goal of the second exercise of the session was destroying cylindrical rocks that were going from the right side to a planet situated in the left side. In both exercises, none of the elements appeared at the same height. That is why the patient had to adjust the degrees of flexion and extension of wrist, fingers or both. The occupational therapist could modify the speed, number of balls and minimum and maximum of degrees to achieve the accomplishment.

In addition to the quantitative variables described above, the therapist evaluated with qualitative methodology through interviews and observation, the condition of the skin (redness in the contact area with the glove), increased muscle tone, pain, motivation and difficulty understanding the instructions, level of usability, applicability and functionality of the patient. During the intervention, the therapist verbally corrected offsets trunk and lower limbs, annotating associated reactions in the facial muscles.

4. Results and discussion

All the participants of the experimental group completed the pilot study (n = 18). Table 1 shows the passive and active range of motion (ROM) of the preseason evaluation in fingers and wrist, divided by diagnostic (stroke vs. traumatic brain injury). Every data about ROM is shown in millimetres (average score). In the evaluation, it is noted that the hand of the participants with traumatic brain injury showed lower passive and active joints in all of the fingers (active: V: 9, IV: 10, III: 9, II: 8 and I: 10; passive: V and IV: 14, III: 11, II: 17 and I: 16), except in the wrist (stroke: active 8; passive 23 vs. traumatic brain injury: active 18; passive 20).

Stroke (average in mm) Traumatic brain injury (average in mm)
Range of motion (flexo-extension)
Wrist
Little
Ring
Middle
Index
Thumb
Active

8
11
14.3
11
10
8.3
Passive

23
20.3
22.6
22.6
22.6
20.6
Active

18
9
10
9
8
10
Passive

20
14
14
11
17
16
Active flexion deficit
Wrist
Little
Ring
Middle
Index
Thumb

9
5.6
5
4.3
5.6
9

2
0
0
2
0
1
Active extension deficit
Wrist
Little
Ring
Middle
Index
Thumb

6
3.3
3.3
8.4
7
3.3

0
5
4
0
9
5
Treatments sessions log
Reaction speed
Accuracy
Time in seconds (half)
Number of objects
Primary ranger

10
Full
240
1
Full

10
Full
240
1
Full

Table 1.

Hand ROM evaluation pre-session and treatments sessions log.

Participants with stroke show higher deficits in the flexion active of the first, second and fifth fingers (9, 5.6 and 5.6, respectively), while the extension appears more weakened in the second and third fingers (7 and 8.4, respectively). However, the participants with traumatic brain injury show higher deficit of flexion in the third finger and the extension in the second, fourth and fifth fingers.

In every session, exercises were configured with the same reaction speed and the same number of objects, to allow the participants to achieve the maximum number of hits. Some of them showed deficit of attention, which means that the speed and the increase of stimulations could decrease the final scores and the motivation of the intervention. In the case of the participants who show spasticity, this speed allows them to autorelax and control the hand between the stimulations. The length of exercises were modified according to the muscular and attentional fatigue of the participant, starting with 5 minutes and decreasing, in some cases, up to 3 minutes. All the participants reached the accuracy of movement calculated by the system, according to the preseason ROM evaluation. Also, all of them were allowed to work all of the primary movement range calculated in the evaluation.

At the beginning of the session, the occupational therapist explained the exercise to the participant and conducted a 1-minute test to check understanding. Only was necessary to provide additional verbal instruction to improve comprehension in the 11% of the cases.

Figures 1 and 2 show the ROM evaluation of the hand. In Figure 1, the active evaluation of flexion of wrist and extension of fingers is observed. Figure 2 includes the graphic representation of the millimetres of active movements (in red colour) versus the passive ones (in blue colour) of two hands with left hemiplegia (1 and 2) and two hands of participants with traumatic brain injury (tetraparesis and predominance of affectation in the right hemibody).

media/F1.png

Figure 1.

Hand ROM evaluation (active).

media/F2.png

Figure 2.

Hand ROM evaluation HandTutor® (passive and active).

Figures 3 and 4 display the functioning of the HandTutor® during the intervention. Figure 3 shows the glove with the hand in flexo-extension, while Figure 4 shows the assisted movement of the occupational therapist to obtain the higher ranges of flexion in a participant who shows rigidity and attentional issues. Besides, in the contralateral hand, it can be seen the associated reactions in the top member, which is not forming a part of the intervention. The hand replicates the movement that the occupational therapist is trying to get in the most affected member.

media/F3.png

Figure 3.

Flexo-extension hand with HandTutor®.

media/F4.png

Figure 4.

Example of assisted movement with HandTutor®.

Figures 5 and 6 show maximum and minimum scores for diagnostic. In them, it can be observed the heterogeneity of the flexion and extension movement of the participants in the study. Regarding the wrist, it is not observed huge differences by diagnostic, except in the minimum flexo-extension of the stroke group, especially in the extension. Nevertheless, the articular ranges of the fingers differ until they reach a difference of 20 millimetres in the third finger in the case of the group diagnosed with stroke, coinciding with the group diagnosed with traumatic brain injury.

media/F5.png

Figure 5.

Flexo-extension maximum and minimum of fingers in treatments sessions log.

media/F6.png

Figure 6.

Flexo-extension maximum and minimum of wrist in treatments session logs.

Participants referred increasing satisfaction with this new therapy. During the intervention, the software provided quantitative measures and immediate feedback of variations in patient mobility showing that HandTutor® sensors are highly sensitive to small variations in patient movement. In post-intervention interviews, patients reported that the glove decreases muscle tone of the hand and wrist, allowing ending the session with increased mobility.

All sessions evaluated qualitatively, through an interview, the following parameters: skin condition, motivation, difficulty in the understanding of instructions, level of HandTutor® utility, clinic applicability and satisfaction.

During the sessions, no side effects were observed related to the skin or post-intervention pain related with the hand use. Every participant ended the sessions without any visible injury in the skin (absence of redness, marks or changes in the coloration) and without any kind of pain. This was evaluated both at the end of the session and at the beginning of the next. To be able to contrast the information in relation with the skin condition and the pain, the data were triangulated by asking the participant and his/her primary caregiver the following day of every intervention. In both cases, they confirmed our data.

All participants referred high level of motivation and satisfaction at the end of the intervention due to the perceived higher performance of limb segments and joins involved in the exercises in their activities of daily life (ADLs). The subjective perception of the patient was checked by comparing the ROM (active vs. passive) pre-post measurement session. All participants showed and transmitted a great motivation and satisfaction with the HandTutor® intervention, except for one user. This one presents acoustic, visual and tactile hypersensitivity. After the pilot study, this participant transmitted that the glove, the sound and the images of the system induced in him/her nervousness and rejection. This information was contrasted with caregivers and professionals of the centre.

Some difficulties were found at the following of the exercise instructions, the motivation and interest maintenance during the 11% of the cases, as a consequence of the presence of attention and/or memory impairments.

All participants shared the sensation of decreasing the muscular tone, immediately at the end of every session and transmitted that this feeling stayed all day long, allowing them a higher mobility and independence at the ADLs.

During the study, some problems were observed associated with the difficulty in putting on the HandTutor® glove, especially in hands with high degrees of spasticity, mainly in diagnosed cases of traumatic brain injury (27.8%; Figure 7). Participants with lower ROM valued positively that the exercise was adapted to their possibilities, so they can reach and move objects even with their limited mobility. The 20% of the users valued negatively the weight of the system placed in the forearm, especially those with weak musculature. The occupational therapists reduced the gravity effect including a cradle to facility the placement of the forearm.

media/F7.png

Figure 7.

Spastic hand with HandTutor®.

In those patients that showed sweating, there were placed vinyl or latex gloves on their hands to avoid direct contact with the glove.

Therefore, it seems that the HandTutor® is a device with high degrees of acceptance and usability among patients with CBD.

5. Conclusions

This chapter is a step further of evaluating the acceptance of technological devices in chronic patients with CBD. On one hand, in the theoretical part of the study, we have found in the literature strong evidence confirming the effectiveness of glove-like devices in hand rehabilitation after brain injury, but no so solid evidence of VRs effectiveness over traditional treatment. On the other hand, the practical pilot study to test HandTutor points in the expected direction confirming participants’ satisfaction about effectiveness and ergonomics of glove-like devices, but according to Ref. [12], there are still some issues to be solved in the usability of these devices for patients with spasticity.

The grade of usability of the HandTutor® device with chronic patients with CBD is high; we only find difficulties in those who show attention disorders and/or memory issues or sensorial hypersensibility. The degree of spasticity should also be taken into account in the design of the experience, because difficulties may arise in the placement of the device when the degree of spasticity is high or there is rigidity or other associated reactions.

Most of the studies performed with active gloves similar to HandTutor® device have been performed in patients in the acute or subacute phase of brain damage. It is important to emphasize that in this study, unlike the previous ones, the rehabilitation has been done with patients with more than 24 months of evolution since the diagnosis of the damage and therefore with a very high degree of chronicity in the neurological sequelae. This is one of the main contributions of the presented work since the more time has passed since the diagnosis of brain damage; the more difficult it is to achieve significant improvements with rehabilitation.

In our study, the HandTutor® device has performed effectively for the spasticity treatment in patients with CBD, producing improvements in the performance of the ADLs and elevating the motivation and satisfaction grades with his use in rehabilitation processes. However, this trial does not provide significant statistical evidence about HandTutor® effectiveness, and it would be recommendable to replicate the study with more participants to confirm our findings.

6. Acknowledgements

Work partially funded by SYMBHYO-ITC [MCINN PTQ-15-0705], RESET [MCINN TIN2014-53199-C3-1-R], eMadrid [CAM S2013/ICE-2715] and PhyMEL [UC3M 2015/00402/001] projects. Authors would like to thank Maria Pulido for their feedback in VR devices, and we also want to express our gratitude to the patients involved in the pilot study.

References

1 – Johnson, W., Onuma, O., Owolabic, M., & Sachdeva, S. (2016). Stroke: A global response is needed. Bulletin of the World Health Organization 94:634–634A. doi:10.2471/BLT.16.181636

2 – Feigin, V. L., Krishnamurthi, R. V., Parmar, P., Norrving, B., Mensah, G. A., Bennett, D. A., Barker-Collo S., Moran A.E., Sacco R.L., Truelsen T., Davis S., Pandian J.D., Naghavi M., Forouzanfar M.H., Nguyen G., Johnson C.O., Vos T., Meretoja A., Murray C.J.L. & Roth G.A. (2015). Update on the global burden of ischemic and hemorrhagic stroke in 1990–2013: The GBD 2013 study. Neuroepidemiology 45(3): 161–176. doi:10.1159/000441085

3 – Bleyenheuft, Y., & Gordon, A. M. (2014). Precision grip in congenital and acquired hemiparesis: Similarities in impairments and implications for neurorehabilitation. Frontiers in Human Neuroscience 8:459. doi:10.3389/fnhum.2014.00459

4 – Henderson, A., Korner-Bitensky, N., & Levin, M. (2014). Virtual reality in stroke rehabilitation: A systematic review of its effectiveness for upper limb motor recovery. Topics in Stroke Rehabilitation 14(2):52–61. doi:10.1310/tsr1402-52

5 – Hatem, S. M., Saussez, G., della Faille, M., Prist, V., Zhang, X., Dispa, D., & Bleyenheuft, Y. (2016). Rehabilitation of motor function after stroke: A multiple systematic review focused on techniques to stimulate upper extremity recovery. Frontiers in Human Neuroscience 10. doi:10.3389/fnhum.2016.00442

6 – Teasell, R. W., Foley, N. C., Bhogal, S. K., & Speechley, M. R. (2015). An evidence-based review of stroke rehabilitation. Topics in Stroke Rehabilitation 10(1):29–58. doi:10.1310/8YNA-1YHK-YMHB-XTE1

7 – Schneider, E. J., Lannin, N. A., Ada, L., & Schmidt, J. (2016). Increasing the amount of usual rehabilitation improves activity after stroke: A systematic review. Journal of Physiotherapy 62(4):182–187. doi:10.1016/j.jphys.2016.08.006

8 – Coupar, F., Pollock, A., Legg, L. A., Sackley, C., & van Vliet, P. (2012). Home based therapy programmes for upper limb functional recovery following stroke. The Cochrane Database Of Systematic Reviews 16;(5):CD006755. doi:10.1002/14651858. CD006755.pub2/abstract

9 – Pollock, A., Farmer, S. E., Brady, M. C., Langhorne, P., Mead, G. E., Mehrholz, J., & van Wijck, F. (2014). Interventions for improving upper limb function after stroke. The Cochrane Database Of Systematic Reviews 12;(11):CD010820. doi:10.1002/14651858

10 – Merrett, G. V., Metcalf, C. D., Zheng, D., Cunningham, S., Barrow, S., & Demain, S. H. (2011). Design and qualitative evaluation of tactile devices for stroke rehabilitation. In IET Seminar on Assisted Living, (pp. 1–6). IET London. http://eprints.soton.ac.uk/271802/1/merrett.pdf. doi:10.1049/ic.2011.0025

11 – Demain, S., Metcalf, C. D., Merrett, G. V., Zheng, D., & Cunningham, S. (2013). A narrative review on haptic devices: Relating the physiology and psychophysical properties of the hand to devices for rehabilitation in central nervous system disorders. Disability and Rehabilitation: Assistive Technology 8(3): 181–189. http://eprints.soton.ac.uk/339891/3/haptic_devices.pdf. doi:10.3109/17483107.2012.697532

12 – Kuchinke, L. M., & Bender, B. (2016). Technical view on requirements for future development of hand-held rehabilitation devices. In 6th IEEE International Conference on Biomedical Robotics and Biomechatronics (BioRob), (pp. 804–809). IEEE Singapore. doi:10.1109/BIOROB.2016.7523726

13 – Laver, K. E., George, S., Thomas, S., Deutsch, J. E., & Crotty, M. (2015). Virtual reality for stroke rehabilitation. The Cochrane Database Of Systematic Reviews 7;(9):CD008349. doi:10.1161/STROKEAHA.111.642439

14 – Viñas-Diz, S., & Sobrido-Prieto, M. (2016). Virtual reality for therapeutic purposes in stroke: A systematic review. Neurología (English Edition), 31(4): 255–277. doi:10.1016/j.nrleng.2015.06.007

15 – Joo, L. Y., Yin, T. S., Xu, D., Thia, E., Chia, P. F., Kuah, C. W. K., & He, K. K. (2010). A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke. Journal of Rehabilitation Medicine 42(5): 437–441. doi:10.2340/16501977-0528

16 – Dimbwadyo-Terrer, I., Trincado-Alonso, F., de los Reyes-Guzmán, A., Aznar, M. A., Alcubilla, C., Pérez-Nombela, S., Ama-Espinosa, A., Polonio-López, B. & Gil-Agudo, Á. (2015). Upper limb rehabilitation after spinal cord injury: A treatment based on a data glove and an immersive virtual reality environment. Disability and Rehabilitation: Assistive Technology 11(6):462–467. doi:10.3109/17483107.2015.1027293

17 – Matamoros, M., Negrete, M., Haddad, Y., & Leder, R. S. (2010, March). Nintendo WII remote and Nunchuck as a wireless data subsystem for digital acquisition of analog physiologic data relevant to motor rehabilitation after stroke; part II. In 2010 Pan American Health Care Exchanges (pp. 198–200). Lima, Peru. IEEE. doi:10.1109/PAHCE.2010.5474568

18 – Adie, K., Schofield, C., Berrow, M., Wingham, J., Freeman, J., Humfryes, J., & Pritchard, C. (2014). Does the use of Nintendo Wii Sports™ improve arm function and is it acceptable to patients after stroke? Publication of the Protocol of the Trial of Wii™ in Stroke–TWIST. International Journal of General Medicine 7: 475. doi:10.2147/IJGM.S65379

19 – Eldem, C. (2014). Visual Neglect Assessment and Rehabilitation Using the Leap Motion. Saarbrücken: LAMBERT Academic Publishing

20 – Iosa, M. et al. (2015). Leap motion controlled videogame-based therapy for rehabilitation of elderly patients with subacute stroke: A feasibility pilot study. Topics in Stroke Rehabilitation 22(4): 306–316. doi:10.1179/1074935714Z.0000000036

21 – Shires, L., Battersby, S., Lewis, J., Brown, D., Sherkat, N., & Standen, P. (2013). Enhancing the tracking capabilities of the Microsoft Kinect for stroke rehabilitation. In IEEE 2nd International Conference on Serious Games and Applications for Health (SeGAH), (pp. 1–8). IEEE Portugal. doi:10.1109/SeGAH.2013.6665316

22 – Bamrungthai, P., & Pleehachinda, W. (2015, November). Development of a game-based system to support stroke rehabilitation using kinect device. In International Conference on Science and Technology (TICST), (pp. 323–326). IEEE London. doi:10.1109/TICST.2015.7369379

23 – Turolla, A., Dam, M., Ventura, L., Tonin, P., Agostini, M., Zucconi, C., & Piron, L. (2013). Virtual reality for the rehabilitation of the upper limb motor function after stroke: A prospective controlled trial. Journal of Neuroengineering and Rehabilitation 10(1): 1. doi:10.1186/1743-0003-10-85

24 – Lo, A. C., Guarino, P. D., Richards, L. G., Haselkorn, J. K., Wittenberg, G. F., Federman, D. G., Ringer R.J., Wagner T.H., Krebs H.I., Volpe B.T., Bever C.T.Jr., Bravata D.M., Duncan P.W., Corn B.H., Maffucci A.D., Nadeau S.E., Conroy S.S., Powell J.M., Huang G.D., & Peduzzi P. (2010). Robot-assisted therapy for long-term upper-limb impairment after stroke. New England Journal of Medicine 362(19): 1772–1783. doi:10.1056/NEJMoa0911341

25 – Subramanian, S. K., Massie, C. L., Malcolm, M. P., & Levin, M. F. (2010). Does provision of extrinsic feedback result in improved motor learning in the upper limb poststroke? A systematic review of the evidence. Neurorehabilitation and Neural Repair 24(2): 113–124. doi:10.1177/1545968309349941

26 – Huang, M. C., Xu, W., Su, Y., Lange, B., Chang, C. Y., & Sarrafzadeh, M. (2012). Smartglove for upper extremities rehabilitative gaming assessment. In Proceedings of the 5th International Conference on Pervasive Technologies Related to Assistive Environments (p. 20). ACM Heraklion, Crete, Greece. doi:10.1145/2413097.2413122

27 – Hiob, M. (2016). Interactive glove for mobility training and rehabilitation after stroke. Bachelor Thesis. In Certec – Rehabilitation Engineering and DesignCertec – Rehabilitation Engineering and DesignCertec – Rehabilitation Engineering and DesignCertec report TNS820 20161. Lund University Publications Student Papers. Lund, Sweden.

28 – Kang, B. B., Lee, H., In, H., Jeong, U., Chung, J., & Cho, K. J. (2016). Development of a polymer-based tendon-driven wearable robotic hand. In IEEE International Conference on Robotics and Automation (ICRA), 2016 (pp. 3750–3755). IEEE Stockholm. doi:10.1109/ICRA.2016.7487562

29 – Fischer, H. C., Triandafilou, K. M., Thielbar, K. O., Ochoa, J. M., Lazzaro, E. D., Pacholski, K. A., & Kamper, D. G. (2016). Use of a portable assistive glove to facilitate rehabilitation in stroke survivors with severe hand impairment. IEEE Transactions on Neural Systems and Rehabilitation Engineering 24(3): 344–351. doi:10.1109/TNSRE.2015.2513675

30 – Isnin, S. J., Hamid, D. H. T. A. H. & Sunar, S. Design of 3D immersive learning environment to enhanced hand skill after stroke. Man in India 96(6): 1727–1736.

31 – Carmeli, E., Vatine, J. J., Peleg, S., Bartur, G., & Elbo, E. (2009). Upper limb rehabilitation using augmented feedback: Impairment focused augmented feedback with HandTutor®. In 2009 Virtual Rehabilitation International Conference. Haifa, Israel. doi:10.1109/ICVR.2009.5174258

32 – Carmeli, E., Peleg, S., Bartur, G., Elbo, E., & Vatine, J. J. (2011). HandTutor® enhanced hand rehabilitation after stroke—A pilot study. Physiotherapy Research International 16(4): 191–200. doi:10.1002/pri.485

33 – Zondervan, D., Friedman, N. Chang, E., Zhao, X., & Cramer, S. C. (2016). Home-based hand rehabilitation after chronic stroke: Randomized, controlled single-blind trial comparing the MusicGlove with a conventional exercise program. Journal of Rehabilitation Research and Development 53(4): 457. doi:10.1682/JRRD.2015.04.0057

34 – Friedman, N., Chan, V., Zondervan, D., Bachman, M., & Reinkensmeyer, D. J. (2011, August). MusicGlove: Motivating and quantifying hand movement rehabilitation by using functional grips to play music. In 2011 Annual International Conference of the IEEE Engineering in Medicine and Biology Society (pp. 2359–2363). IEEE Boston, Massachusetts, USA doi:10.1109/IEMBS.2011.6090659

35 – Friedman, N., Chan, V., Reinkensmeyer, A. N., Beroukhim, A., Zambrano, G. J., Bachman, M., & Reinkensmeyer, D. J. (2014). Retraining and assessing hand movement after stroke using the MusicGlove: Comparison with conventional hand therapy and isometric grip training. Journal of Neuroengineering and Rehabilitation 11(1): 1. doi:10.1186/1743-0003-11-76

36 – Shin, J. H., Kim, M. Y., Lee, J. Y., Jeon, Y. J., Kim, S., Lee, S., Seo B., & Choi, Y. (2016). Effects of virtual reality-based rehabilitation on distal upper extremity function and health-related quality of life: A single-blinded, randomized controlled trial. Journal of Neuroengineering and Rehabilitation 13(1): 1. doi:10.1186/s12984-016-0125-x

37 – Kayyali, R., Shirmohammadi, S., El Saddik, A., & Lemaire, E. (2007). Daily-life exercises for haptic motor rehabilitation. In 2007 IEEE International Workshop on Haptic, Audio and Visual Environments and Games (pp. 118–123). IEEE Lyon, France.

Source: Hand Rehabilitation after Chronic Brain Damage: Effectiveness, Usability and Acceptance of Technological Devices: A Pilot Study | InTechOpen

, , , , , , , , , , , ,

Leave a comment

[BLOG POST] Brain Injury Medicine – Neuro Landscape

 

Brain Injury Medicine

Individuals who sustain brain injury face a unique challenge with their health professionals. Brain injury is now widely viewed as a disease in the medical field, however patients are not yet granted the benefits and opportunities in treatment as are necessary for disease management. Increasing awareness of brain injury as a disease, and exploring the challenges of brain injury treatment will help us reevaluate our current system.

Brain Injury as a Disease

A brain injury is remarkably complex. Emerging evidence suggests that, like cancer, brain injury may actually be comprised of a number of distinct diseases that vary by the etiology of the injury, the nature of the injury, co-morbid health conditions prior to and since the injury, and factors such as gender, race, age, for example.

When the brain is injured, consequential effects often occur within immune, endocrine, and autonomic nervous systems’ functions. Persons with brain injury can become very sick, very quickly, seemingly only heralded by relatively minor early symptoms. Though we do not fully understand why this heightened period of illness occurs, it is likely a result, in some capacity, of the changes to the body’s systems’ functions.

Challenges of Brain Injury Treatment

Medical professionals working within the confines of our current system are often unable to dedicate sufficient time to a patient with brain injury in order to address the full scope of his or her injury, which includes cognitive, behavioral, communicative, and/or physical disabilities. Furthermore, these medical professionals are rarely able to stay current enough on the case to identify advisable and inadvisable medical practice patterns, thereby increasing the odds of treatment-induced complications.

Patients and their families cannot assume that medical providers are alike in their knowledge and experience. For example, the notion that patients can be best followed by practitioners in their home community is seriously flawed. Locality does not replace the prerequisite for a practitioner with expertise on brain injury. In fact, many of these less experienced practitioners are unaware of the comparative medical fragility associated with brain injury. Many poor medical decisions could have been avoided had the proper brain injury specialist been consulted.

Additional challenges can be found in the person’s inability to fully and competently participate in his or her medical care and decision-making. Cognitive, behavioral, communicative and physical disabilities following brain injury can make it difficult, if not impossible, for a person to recognize changes in his or her health, convey those changes, recognize improvements, or a lack thereof, in health following a medical treatment or intervention, accurately convey medical history or the history of present health problem(s), obtain appointments for procedures or laboratory studies, obtain prescribed medications or otherwise properly adhere to a prescribed treatment regimen. One might conclude that the attendance of an advocate or family member to medical appointments will mitigate such difficulties, and while helpful, such participation often fails to provide improved results.

Reevaluating our Current System

In my career, I have seen many downstream medical decisions result in serious and, sometimes, deadly consequences. These have always been avoidable and unnecessary, and borne out of a lack of knowledge.

A general physician cannot reasonably manage a patient with a complicated cancer, and brain injury is no different in this regard. We need to develop mechanisms that enable a patient with a brain injury all the same benefits as those allowed patients with complicated diseases such as cancer or cardiovascular disease. Simply put, there is no substitute for an individual case being followed closely by an experienced brain injury specialist.

Source: Brain Injury Medicine – Neuro Landscape

, ,

Leave a comment

[ARTICLE] Using Xbox kinect motion capture technology to improve clinical rehabilitation outcomes for balance and cardiovascular health in an individual with chronic TBI – Full Text

Abstract

Background

Motion capture virtual reality-based rehabilitation has become more common. However, therapists face challenges to the implementation of virtual reality (VR) in clinical settings. Use of motion capture technology such as the Xbox Kinect may provide a useful rehabilitation tool for the treatment of postural instability and cardiovascular deconditioning in individuals with chronic severe traumatic brain injury (TBI). The primary purpose of this study was to evaluate the effects of a Kinect-based VR intervention using commercially available motion capture games on balance outcomes for an individual with chronic TBI. The secondary purpose was to assess the feasibility of this intervention for eliciting cardiovascular adaptations.

Methods

A single system experimental design (n = 1) was utilized, which included baseline, intervention, and retention phases. Repeated measures were used to evaluate the effects of an 8-week supervised exercise intervention using two Xbox One Kinect games. Balance was characterized using the dynamic gait index (DGI), functional reach test (FRT), and Limits of Stability (LOS) test on the NeuroCom Balance Master. The LOS assesses end-point excursion (EPE), maximal excursion (MXE), and directional control (DCL) during weight-shifting tasks. Cardiovascular and activity measures were characterized by heart rate at the end of exercise (HRe), total gameplay time (TAT), and time spent in a therapeutic heart rate (TTR) during the Kinect intervention. Chi-square and ANOVA testing were used to analyze the data.

Results

Dynamic balance, characterized by the DGI, increased during the intervention phase χ 2 (1, N = 12) = 12, p = .001. Static balance, characterized by the FRT showed no significant changes. The EPE increased during the intervention phase in the backward direction χ 2 (1, N = 12) = 5.6, p = .02, and notable improvements of DCL were demonstrated in all directions. HRe (F (2,174) = 29.65, p = < .001) and time in a TTR (F (2, 12) = 4.19, p = .04) decreased over the course of the intervention phase.

Conclusions

Use of a supervised Kinect-based program that incorporated commercial games improved dynamic balance for an individual post severe TBI. Additionally, moderate cardiovascular activity was achieved through motion capture gaming. Further studies appear warranted to determine the potential therapeutic utility of commercial VR games in this patient population.

Trial registration

Clinicaltrial.gov ID – NCT02889289

Background

The last two decades demonstrated an exponential trend in the implementation of virtual reality (VR) in clinical settings [1]. Researchers and clinicians alike are enticed by the potential of this technology to enhance neuroplasticity secondary to rehabilitation interventions. Currently, Nintendo Wii, Sony PlayStation, and Microsoft Xbox offer commercially developed semi-immersive VR platforms which are used for rehabilitation [2]. Several studies report positive effects of these commercial technologies for improving balance, coordination and strength [345]. In 2010, Microsoft introduced a novel infrared camera that works on the Xbox platform called Kinect. The Kinect camera replaces hand held remote controls through the use of whole body motion capture technology.

Whole body motion capture VR allows a unique opportunity for individuals to experience a heightened sense of realism during task-specific therapeutic activities. However, clinicians need to be able to match a game’s components to an individual’s functional deficits. Seamon et al. [6] provided a clinical demonstration of how the Kinect platform can be used with Gentiles taxonomy for progressively challenging postural stability and influencing motor learning in a patient with progressive supranuclear palsy. Similarly, Levac et al. [7] developed a clinical framework titled, “Kinecting with Clinicians” (KWiC) to broadly address implementation barriers. The KWiC resource describes mini-games from Kinect Adventures on the Xbox 360 in order to provide a comprehensive document for clinicians to reference. Clinicians can use KWiC to base game selection and play on their client’s goals and the therapist’s plan of care for that individual.

In parallel with knowledge translation research, several studies found postural control improvements in multiple diagnostic groups including individuals with chronic stroke [8910], Friedrich’s Ataxia [11], multiple sclerosis [12], Parkinson’s disease [13], and mild to moderate traumatic brain injury (TBI) [14] when using Kinect based rehabilitation. Additional research shows that exercising with the Kinect system can reach an appropriate intensity for cardiovascular adaptation. For example, Neves et al. [15] and Salonini et al. [16] reported increases in exercise heart rate and blood pressure in healthy individuals and children with cystic fibrosis while playing Kinect games. Similarly, Kafri et al. [17] reported the ability of individuals post-stroke to reach levels of light to moderate intensity using Kinect games.

Individuals with TBI are likely to have a peak aerobic capacity 65–74% to that of healthy control subjects [18]. There is limited research on cardiovascular training after severe TBI [18]. However, Bateman et al. [19] demonstrated that individuals with severe TBI can improve cardiovascular fitness during a 12-week program participants exercised at an intensity equal to 60–80% of their maximum heart rate 3 days per week. Commercial Xbox Kinect games, such as Just Dance 3, have been shown to improve cardiovascular outcomes for individuals with chronic stroke [20]. However, there is a lack of research investigating the efficacy of motion capture VR on cardiovascular health for individuals with chronic severe TBI. Walker et al. [21] makes the recommendation for rehabilitation programs to go beyond independence in basic mobility and to develop treatment strategies to address high-level physical activities. The high rates of sedentary behavior in individuals across all severities of TBI could be attributed the lack of addressing these limitations in activity.

Postural instability is the second most frequent, self-reported limitation, 5 years post injury for individuals with severe TBI [22]. It is unknown whether use of motion capture VR in individuals with severe, chronic TBI can address neuromotor impairments related to high-level activities such as maintaining postural control during walking. Similarly, there is a need to determine if training with VR motion capture can attain necessary intensity levels for inducing cardiovascular adaptation. Due to this knowledge gap and heterogencity of individuals post TBI, feasibility of investigatory interventions should be explored prior to examining effectiveness with randomized control trials. Single system experimental design (SSED) provides a higher level of rigor compared to case studies based on the ability to compare outcomes across phase conditions with the participant acting as their own control. The value of SSED within rehabilitation has been noted by other investigators [2324] making it an attractive design for practitioners aiming to gain insight into novel clinical interventions prior to large scale clinical trials. The purpose of this proof of concept and feasibility study was to evaluate the effectiveness of commercially available Xbox One Kinect games as a treatment modality for the rehabilitation of balance and cardiovascular fitness for a veteran with chronic severe TBI. Additionally, we provide herein a description of the Kinect games to assist providers with clinical implementation. […]

Continue —>  Using Xbox kinect motion capture technology to improve clinical rehabilitation outcomes for balance and cardiovascular health in an individual with chronic TBI | Archives of Physiotherapy | Full Text

 

Fig. 1 Dynamic gait index (DGI) scores across phases with celeration line analyses. Two-standard deviation (2 SD) celeration line was used for chi-square analysis between baseline and intervention phases as no trend present in baseline phase. The celeration line was carried through the retention phase for Chi-square analysis due to presence of upward trend in intervention phase

, , , , , , , ,

Leave a comment

%d bloggers like this: