Ofer Keren

Female TBI patients recover better than males

The purpose of the present study was to look at possible gender differences in outcome after severe traumatic brain injury. Three hundred and thirty four consecutive patients, 72 females and 262 males, age range 5-65 years, were included in the study. Age range and severity of injury, evaluated by duration of unconsciousness, did not differ between male and female patients. Predicted outcome at the time of discharge from an in-patient rehabilitation programme was evaluated according to work capacity. Female TBI patients had a better predicted outcome (p < 0.015). It is suggested that progesterone, acting as a neuroprotective agent, may explain this difference in outcome.

The influence of early cycling training on balance in stroke patients at the subacute stage. Results of a preliminary trial

Objective: To investigate the effect of early cycling training on balance and motor abilities of stroke patients in their subacute stage. Design: Randomized clinical trial. Setting: Inpatient rehabilitation. Subjects: Twenty-four patients who had had a first stroke were randomly assigned to a cycling training group (n = 10) or to a control (n = 14) group. Intervention: All subjects received their usual rehabilitation programme; the cycling training group received in addition a daily session of leg cycle ergometer, lasting three weeks. Both groups were followed for six weeks. Main outcome measurements: Balance was assessed using the Postural Assessment Scale for Stroke Patients (PASS) and the standing balance test. The motor function of the lower extremity was also assessed by the Fugl-Meyer Assessment (FMA). Results: In the within-group comparison, both the exercise group and the control group had improved significantly (P B=0.01) with time with respect to PASS total (exercise group 18.79=2.8 to 31.19=2.2, control group 18.19=3.2 to 26.49=3.8) and PASS subscores, as well as the FMA score (exercise group 17.29=7.5 to 29.19=5.9, control group 16.69=6.4 to 22.19=6.8). In addition there was a significant group=time interaction effect, with exercise group patients demonstrating better performance in both the total PASS score and PASS subscores and FMA score relative to the control patients (P B=0.01). Conclusions: These preliminary findings suggest that stroke patients in the subacute stage can improve their motor and balance abilities after an early short duration of cycling training.

The effects of a `home-based' task-oriented exercise programme on motor and balance performance in children with spastic cerebral palsy and severe traumatic brain injury

Objectives: To evaluate the feasibility and the ability to recruit and retain children with severe traumatic brain injury or cerebral palsy, and their families, to a simple home-based exercise programme and to assess the immediate and short-term effects of such intervention on reducing impairment and improving function. Study design: Randomized clinical trial. Participants: Twenty children aged 7—13 years, with traumatic brain injury (N = 10) or cerebral palsy (N = 10) who were independent ambulators. Five children from each group were randomly assigned to a control group — regular daily activities, or to an experimental group — regular daily activities plus a home-based task-oriented exercise programme of sit-to-stand and step-up exercise, for six weeks. Outcome measures: Feasibility: The number of participants who completed the programme protocol. Efficacy: Timed Up and Go Test and Functional Reach Test were used as functional balance tests. Maximal isometric strength was assessed by using a hand-held dynamometer; walking performance was assessed by the 10 m walk test, 2-minute walk test and Energy Expenditure Index. Results: Nine children completed all parts of the training programme. At the end of the intervention period an increase of 3—4 cm in the mean Functional Reach Test and a reduction of 1.6 ± 2.1 seconds in the Timed Up and Go Test were noted (P<0.01) in the experimental group while no changes were noted in the control group. In all other outcomes assessed no significant differences were noted between groups. The positive change in balance performance in the experimental group was maintained during a six-week follow-up period. Conclusions: A home-based task-oriented exercise programme can improve balance performance in children with spastic cerebral palsy or severe traumatic brain injury.

Relationship between balance abilities and gait characteristics in children with post-traumatic brain injury.

Objectives: To quantify the differences in gait variability and balance performance between typically developed (TD) children and children with post-traumatic brain injury (TBI) and to determine the association between gait variability and functional balance in both groups. Design: Cross-sectional study. Setting: Physical therapy department of a paediatric and adolescent rehabilitation hospital. Participants: A convenience sample of 24 children post-TBI and 24 TD age and sex matched controls. Intervention: Not applicable. Main outcome measure: Step length, step time and base width variability measured with an electronic walkway; timed up and go (TUG) test and functional reach test (FRT) as a functional balance test. Results: Base width and step time variability showed no significant difference between the groups. However, children post-TBI had significantly greater variability in step length in comparison to healthy controls. The functional balance abilities of children post-TBI were significantly limited compared to TD children. A significant linear inverse correlation was found between balance performance and step length variability only among children with a TBI. Conclusion: Ambulatory children post-severe TBI had decreased balance performance, decreased gait speed and increased step length variability as compared to age-matched healthy controls.

Return to work as an integrative outcome measure following traumatic brain injury

In recent years we have witnessed the growing recognition of the centrality of work involvement in the successful rehabilitation of brain injured patients. Evidence from studies conducted at Loewenstein Rehabilitation Hospital (LRH) and from other studies, points to a strong and consistent positive association between employment and social integration, leisure activities, enhanced self-esteem, and perceived quality of life. Patients surviving severe traumatic brain injury (TBI) often suffer from residual impairments in motor control, communication skills, cognition, and social behaviour. These distinctly hamper their capability to return to work and to continue working for an extended period of time. Comprehensive and integrated rehabilitation programmes, such as those employed in LRH, were proven to be effective in returning patients to stable employment. This was demonstrated in the results of our recent follow-up study of 334 severe TBI patients, which indicated that 55.7% were gainfully employed 8-13 ...

Benign paroxysmal positional vertigo as the cause of dizziness in patients after severe traumatic brain injury: diagnosis and treatment

Objectives: To identify patients with benign paroxysmal positional vertigo (BPPV) among patients with severe traumatic brain injury (TBI) and to evaluate the effectiveness of the Particle Repositioning Maneouvre (PRM). Design and methods: Eighteen months prospective study of 150 consecutive patients with severe TBI referred to an in-patients rehabilitation department. Interventions: A structured interview emphasizing the possible presence of vertigo followed by a detailed neuro-otological examination. Patients diagnosed with BPPV were immediately treated with the PRM. Main outcomes and results: BPPV diagnosis was based on a positive Dix-Hallpike positional test. PRM efficacy was determined by repeating the positional test 1 or 2 weeks after treatment. Twenty out of 150 (13.3%) patients complained about positional vertigo. The diagnosis of BPPV was confirmed in 10 patients. Signs and symptoms were completely relieved in six patients after a single PRM, while the other four patients needed repeated treatment for complete resolution of BPPV. Conclusions: About half of the patients with severe TBI who complain about positional vertigo suffer from BPPV. These patients can be efficiently treated by physical maneouvres improving the rehabilitation outcome.

Balance abilities and gait characteristics in post-traumatic brain injury, cerebral palsy and typically developed children

Objectives: To quantify the differences in gait variability and balance performance between children with cerebral palsy (CP), children with post-traumatic brain injury (TBI) and typically developed (TD) children and to determine the association between gait variability and functional balance in these groups. Design: Cross-sectional study. Setting: Physical therapy department of a paediatric and adolescent rehabilitation hospital. Participants: A convenience sample of 15 children post-TBI, 15 children with CP and 30 TD age- and sex-matched controls. Intervention: Not applicable. Main outcome measure: Step length and step time variability measured by an electronic walkway; timed up and go (TUG) test and functional reach test (FRT) were used as functional balance tests. Results: The functional balance abilities of children post-TBI and children with CP were significantly limited compared to TD children. Children post-TBI had significantly greater variability in step length in comparison to healthy controls. A significant linear inverse correlation between balance performance and step length variability was found only among children with TBI. Conclusion: Brain damage is associated with restricted balance performance and increased step variability. It might be that in a child born with brain damage, as opposed to acquired damage, the developmental process has a restraining effect on gait variability.

Upper limb somatosensory evoked potentials as a predictor of rehabilitation progress in dominant hemisphere stroke patients.

Background and Purpose The aim of this study was to determine the predictive yield of upper limb short latency somatosensory evoked potential (USEP) in patients with first stroke in the dominant hemisphere. Methods Nineteen patients (average age, 58 years) were evaluated twice: on arrival at the rehabilitation center, approximately 3 weeks after the stroke, and again approximately 10 weeks later. The clinical assessment included a quantitative evaluation of motor ability, independence in activities of daily living, and communication ability. USEP was recorded during the week of the initial clinical evaluation. Special attention was paid to the relations between USEP parameters and the dynamics of the clinical condition. Results The seven patients in whom no cortical potential could be detected showed the worst outcomes; however, the existence of cortical potentials in the remaining 12 patients did not provide a precise prediction of their “rehabilitative capacity” (ie, the extent of their progress). A correlation was established between the amplitude of the potentials recorded over both hemispheres and changes in communication ability. Additional findings included an association between shortened central conduction time over the damaged hemisphere during the first month after stroke and improvement in motor ability. Conclusions USEP can serve as an adjuvant tool for predicting the recovery progress of stroke patients.

Functional balance tests for children with traumatic brain injury: within-session reliability.

Purpose: To assess the within-session reliability of the Modified Functional Reach Test (MFRT) and the Timed Up and Go (TUG) test in children with traumatic brain injury (TBI) and children with typical development (TD). Methods: A convenience sample of 24 children with TBI and 24 children with TD matched for age and sex were tested. Following 1 practice trial, 3 trials of the MFRT and TUG were completed and recorded for each child. Results: Within-session reliability for the MFRT was excellent [children with TBI (intraclass correlation coefficient, ICC (1,1) = 0.92–0.97), children with TD (ICC (1,1) = 0.94–0.95)]. Within-session reliability for the TUG test was good [children with TBI (ICC (1,1) = 0.86), children with TD (ICC (1,1) = 0.85)]. The average of the first and second trials showed the least measurement error for the TUG test. Conclusion: Within-session reliability values are excellent for the MFRT and good for the TUG test in children with TBI.

Differential time and related appearance of signs, indicating improvement in the state of consciousness in vegetative state traumatic brain injury (VS-TBI) patients after initiation of dopamine treatment

Objective: The goal of the study was to look for the response of treatment with increasing doses of dopaminergic medication on the recovery of vegetative state patients post-TBI. Design: A prospective study of eight patients aged 25–50 years in vegetative state (VS) of mean duration of 104 days following traumatic brain injury (TBI) was performed by investigating changes of their state of consciousness while they were treated with levodopa/carbidopa. Results: Initial improvement was observed in all patients within a mean of 13 days after onset of treatment. Seven patients recovered consciousness after a mean time of 31 days of treatment. The remaining patient showed only slight improvement to minimally conscious state. The sequence of symptoms leading to recovery was the same in all patients; the first to appear was moving a limb on a request, which appeared at a mean time of 13 days. Gradual increase of dose leads to the appearance of better-organized responses like reacting to more than one command, than opening the mouth and appearance of a reciprocal contact. The only side effect was visual hallucinations in one patient, which disappeared after decreasing the dosage. Conclusions: Clinical awareness to the structured order of responses and to the effect of dosage can help clinicians in early assessment of response to dopaminergic treatment in VS patients.