Leanne Hassett

Test–re-test reliability of walking speed, step length and step width measurement after traumatic brain injury: a pilot study

Primary objective: Assess the test–re-test reliability of walking speed, step length and step width measurement in people with traumatic brain injury (TBI). Research design: Repeated measures (two test occasions). Methods: Thirteen people with TBI completed four comfortable and four fast-paced walking trials of the 10 m walk test and two trials of the 6-minute walk test (6MWT). Walking speed, step length and step width were measured during the 10 m walk test and walking distance and average speed were measured during the 6MWT. The tests were repeated 1-week later. Main results: Walking speed and distance showed excellent test–re-test reliability, with an intra-class correlation coefficient (ICC) of 0.95–0.96. Reliability was also high for step length and width measurement (ICC 0.91–0.98). Conclusions: This test–re-test reliability means that walking speed and distance and step length and width can be used by physiotherapists to monitor improvements in walking after TBI.

Ecological validity of walking speed assessment after traumatic brain injury: a pilot study

Objective:To assess the ecological validity of walking speed measurement after traumatic brain injury (TBI). Participants:Ten people with TBI who could walk independently and were participating in a rehabilitation program. Design:Walking speed on 3 clinical gait tests (comfortable and fast pace over a 10-m distance and a 6-minute walk test) in 3 “natural” environments (a corridor in a brain injury rehabilitation unit, a car park of a metropolitan shopping center, and inside a metropolitan shopping center). Normative data were collected for 275 able-bodied pedestrians as they walked in the 3 natural environments. Results:For subjects with TBI, agreement between the speeds used in the clinical gait tests and the natural environments was poor (intraclass correlation coefficient [ICC] values ranged from −0.24 to 0.63). The closest speed match was the comfortable paced 10-m walk test and walking in a corridor of a brain injury rehabilitation unit (ICC 0.63). Able-bodied pedestrians walked at significantly faster speeds than did subjects with TBI in all 3 natural environments. Conclusions:Comfortable walking speed appears to have the highest ecological validity of the clinical gait tests investigated. Practice in natural and more complex environments should be incorporated into walking rehabilitation programs for people with TBI.

Inter-rater reliability and concurrent validity of walking speed measurement after traumatic brain injury

Objective: To assess the inter-rater reliability and concurrent validity of walking speed measurement after traumatic brain injury. Design: Twelve subjects each completed five comfortably paced and five fast-paced walking trials. Walking speed was measured simultaneously by five observers using a stopwatch (clinical procedure) and by infrared timing gates (gold standard). Setting: Brain injury rehabilitation unit. Subjects: People with traumatic brain injury who could walk independently and were participating in a rehabilitation programme. Main outcome measures: Walking speed over a 10-metre distance. Results: The inter-rater reliability of walking speed measured using a stopwatch was very high, with an intraclass correlation coefficient of at least 0.998 for both comfortable and fast-paced tests. Concurrent validity was excellent for comfortable and fast tests, with perfect correlations between the stopwatch and infrared timing gate measurement procedures. Conclusions: Physiotherapists can use a stopwatch as a reliable and valid measurement tool to quantify walking speed over a short distance at both comfortable and fast paces in people who have sustained traumatic brain injuries.

Validity of the Fitbit activity tracker for measuring steps in community-dwelling older adults

Background Commercially available activity monitors, such as the Fitbit, may encourage physical activity. However, the accuracy of the Fitbit in older adults remains unknown. This study aimed to determine (1) the criterion validity of Fitbit step counts compared to visual count and ActiGraph accelerometer step counts and (2) the accuracy of ActiGraph step counts compared to visual count in community-dwelling older people. Methods Thirty-two community-dwelling adults aged over 60 wore Fitbit and ActiGraph devices simultaneously during a 2 min walk test (2MWT) and then during waking hours over a 7-day period. A physiotherapist counted the steps taken during the 2MWT. Results There was excellent agreement between Fitbit and visually counted steps (intraclass correlation coefficient (ICC2,1)=0.88, 95% CI 0.76 to 0.94) from the 2MWT, and good agreement between Fitbit and ActiGraph (ICC2,1=0.66, 95% CI 0.41 to 0.82), and between ActiGraph and visually counted steps (ICC2,1=0.60, 95% CI 0.33 to 0.79). There was excellent agreement between the Fitbit and ActiGraph in average steps/day over 7 days (ICC2,1=0.94, 95% CI 0.88 to 0.97). Percentage agreement was closest for Fitbit steps compared to visual count (mean 0%, SD 4%) and least for Fitbit average steps/day compared to the ActiGraph (mean 13%, SD 25%). Conclusions The Fitbit accurately tracked steps during the 2MWT, but the ActiGraph appeared to underestimate steps. There was strong agreement between Fitbit and ActiGraph counted steps. The Fitbit tracker is sufficiently accurate to be used among community-dwelling older adults to monitor and give feedback on step counts.

Serial casting versus positioning for the treatment of elbow contractures in adults with traumatic brain injury: a randomized controlled trial

Objective: To compare the effects of serial casting with positioning for 1 hour per day for the treatment of elbow flexion contracture in adults with traumatic brain injury. Design: Pragmatic randomized controlled trial with concealed allocation and assessor blinding. Setting: Four brain injury rehabilitation units. Subjects: Twenty-six adults with elbow flexion contracture after traumatic brain injury participating in multidisciplinary inpatient rehabilitation. Interventions: Subjects were randomized to receive either serial casting or positioning for two weeks. In the subsequent four weeks subjects could be positioned for up to 1 hour/day. Main measures: Torque-controlled passive elbow extension was measured at baseline, post-intervention (two weeks), post-intervention plus one day, and at follow-up (four weeks post-intervention). Results: All 26 subjects completed the study. Post-intervention, serial casting reduced contracture by an average of 22 degrees (95% confidence interval (CI) 13 to 31; P <0.001) compared with the positioning group. One day later this effect had decreased to 11 degrees (95% CI 0 to 21 degrees; P= 0.052). The effect had almost completely disappeared at the four-week follow-up (mean 2 degrees, 95% CI -13 to 17; P= 0.782). Conclusions: Serial casting induces transient increases in range of motion. These effects are not maintained.

EFFICACY OF A FITNESS CENTRE-BASED EXERCISE PROGRAMME COMPARED WITH A HOME-BASED EXERCISE PROGRAMME IN TRAUMATIC BRAIN INJURY: A RANDOMIZED CONTROLLED TRIAL

OBJECTIVE To compare the effects of a supervised fitness centre-based exercise programme with an unsupervised home-based exercise programme on cardiorespiratory fitness and psychosocial functioning in people with traumatic brain injury. DESIGN Multi-centre, assessor-blinded, parallel group, randomized controlled trial. PARTICIPANTS Sixty-two participants with severe traumatic brain injuries, who could walk at a speed exceeding 1 m/sec, discharged from 3 brain injury units. INTERVENTIONS The fitness centre group completed a combined fitness and strength training exercise programme supervised by a personal trainer in a local fitness centre 3 times per week for 12 weeks. The home group completed a similar exercise programme unsupervised at home. MAIN OUTCOME MEASURE Cardiorespiratory fitness measured using the modified 20-m shuttle test. RESULTS Both groups improved in fitness: the maximal velocity achieved on the modified 20-m shuttle test increased with intervention and was maintained at follow-up. However, the difference between groups was not significant (mean between-group difference (95% confidence interval) 0 m/sec (-0.6 to 0.6) at the end of intervention). There were also no between-group differences in psychosocial functioning at the end of intervention or at follow-up. CONCLUSION Both interventions were equally effective at improving cardiorespiratory fitness in adults with traumatic brain injuries.

Effect of affordable technology on physical activity levels and mobility outcomes in rehabilitation: a protocol for the Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial

Introduction People with mobility limitations can benefit from rehabilitation programmes that provide a high dose of exercise. However, since providing a high dose of exercise is logistically challenging and resource-intensive, people in rehabilitation spend most of the day inactive. This trial aims to evaluate the effect of the addition of affordable technology to usual care on physical activity and mobility in people with mobility limitations admitted to inpatient aged and neurological rehabilitation units compared to usual care alone. Methods and analysis A pragmatic, assessor blinded, parallel-group randomised trial recruiting 300 consenting rehabilitation patients with reduced mobility will be conducted. Participants will be individually randomised to intervention or control groups. The intervention group will receive technology-based exercise to target mobility and physical activity problems for 6 months. The technology will include the use of video and computer games/exercises and tablet applications as well as activity monitors. The control group will not receive any additional intervention and both groups will receive usual inpatient and outpatient rehabilitation care over the 6-month study period. The coprimary outcomes will be objectively assessed physical activity (proportion of the day spent upright) and mobility (Short Physical Performance Battery) at 6 months after randomisation. Secondary outcomes will include: self-reported and objectively assessed physical activity, mobility, cognition, activity performance and participation, utility-based quality of life, balance confidence, technology self-efficacy, falls and service utilisation. Linear models will assess the effect of group allocation for each continuously scored outcome measure with baseline scores entered as a covariate. Fall rates between groups will be compared using negative binomial regression. Primary analyses will be preplanned, conducted while masked to group allocation and use an intention-to-treat approach. Ethics and dissemination The protocol has been approved by the relevant Human Research Ethics Committees and the results will be disseminated widely through peer-reviewed publication and conference presentations. Trial registration number ACTRN12614000936628. Pre-results.

Injury severity, age and pre-injury exercise history predict adherence to a home-based exercise programme in adults with traumatic brain injury

Purpose: To explore factors that may influence exercise adherence in adults with traumatic brain injury (TBI) within the International Classification of Functioning, Disability and Health (ICF) theoretical model. Participants: Thirty participants with TBI who had been randomized to a home-based exercise programme in a recently conducted randomized controlled trial. Methods: Impairments in body functions, environmental factors and personal factors were explored as predictors for exercise adherence. Significant variables were entered into binary logistic regression analyses to determine their combined power to predict exercise adherence. Results: Greater injury severity, older age and a pre-injury exercise history of walking or jogging positively influenced exercise adherence. As a combined set the three predictor variables accurately classified 82% of participants as adherent or non-adherent and were able to explain 49% of the variance (sensitivity = 67%; specificity = 89%). Conclusion: These results demonstrate people with severe injuries are able to exercise independently and suggest that in order to maximize adherence to an exercise programme, clinicians need to consider exercise history when prescribing the type of exercise. The results also provide factors within the ICF theoretical model to investigate in a large-scale study of exercise adherence after TBI.

Validity of Different Activity Monitors to Count Steps in an Inpatient Rehabilitation Setting

Background Commonly used activity monitors have been shown to be accurate in counting steps in active people; however, further validation is needed in slower walking populations. Objectives To determine the validity of activity monitors for measuring step counts in rehabilitation inpatients compared with visually observed step counts. To explore the influence of gait parameters, activity monitor position, and use of walkers on activity monitor accuracy. Methods One hundred and sixty-six inpatients admitted to a rehabilitation unit with an average walking speed of 0.4 m/s (SD 0.2) wore 16 activity monitors (7 different devices in different positions) simultaneously during 6-minute and 6-m walks. The number of steps taken during the tests was also counted by a physical therapist. Gait parameters were assessed using the GAITRite system. To analyze the influence of different gait parameters, the percentage accuracy for each monitor was graphed against various gait parameters for each activity monitor. Results The StepWatch, Fitbit One worn on the ankle and the ActivPAL showed excellent agreement with observed step count (ICC 2,1 0.98; 0.92; 0.78 respectively). Other devices (Fitbit Charge, Fitbit One worn on hip, G-Sensor, Garmin Vivofit, Actigraph) showed poor agreement with the observed step count (ICC 2,1 0.12-0.40). Percentage agreement with observed step count was highest for the StepWatch (mean 98%). The StepWatch and the Fitbit One worn on the ankle maintained accuracy in individuals who walked more slowly and with shorter strides but other devices were less accurate in these individuals. Limitations There were small numbers of participants for some gait parameters. Conclusions The StepWatch showed the highest accuracy and closest agreement with observed step count. This device can be confidently used by researchers for accurate measurement of step counts in inpatient rehabilitation in individuals who walk slowly. If immediate feedback is desired, the Fitbit One when worn on the ankle would be the best choice for this population.

Circuit class therapy can provide a fitness training stimulus for adults with severe traumatic brain injury: a randomised trial within an observational study

QUESTIONS Can circuit class therapy provide sufficient exercise dosage (at least 20 minutes at ≥ 50% heart rate reserve or total caloric expenditure ≥ 300 kilocalories) to induce a cardiorespiratory fitness effect in adults with traumatic brain injury? Can feedback from heart rate monitors influence exercise intensity? DESIGN Randomised controlled trial within an observational study. PARTICIPANTS Fifty-three people with severe traumatic brain injury, of whom 40 progressed into the trial. INTERVENTION All participants undertook circuit class therapy. Participants allocated to the experimental group received exercise intensity feedback from a heart rate monitor and the control group received no feedback. OUTCOME MEASURES Proportion of participants exercising at ≥ 50% heart rate reserve for at least 20 minutes or expending ≥ 300 kilocalories during circuit class therapy. The primary outcome measure for the trial was the time spent in the heart rate training zone (ie, at ≥ 50% heart rate reserve) during the intervention and re-assessment periods. RESULTS Circuit class therapy provided sufficient cardiorespiratory exercise dosage for 28% (95% CI 18 to 42) of the cohort according to the heart rate reserve criteria and 62% (95% CI 49 to 74) according to the caloric criteria. Feedback did not increase the time in the training zone during the intervention (mean difference 4.8 minutes, 95% CI -1.4 to 10.9) or re-assessment (1.9 minutes, -4.4 to 8.3) periods. CONCLUSION The low intensity, long duration structure of circuit class therapy can provide sufficient exercise dosage for a fitness training effect for 62% of people with traumatic brain injury. Feedback from heart rate monitors does not necessarily influence exercise intensity. TRIAL REGISTRATION ACTRN12607000522415.