Shawn Marshall

Experimental Studies of Virtual Reality-Delivered Compared to Conventional Exercise Programs for Rehabilitation

This paper presents preliminary data from two clinical trials currently underway using flat screen virtual reality (VR) technology for physical rehabilitation. In the first study, we are comparing a VR-delivered exercise program to a conventional exercise program for the rehabilitation of shoulder joint range-of-motion in patients with chronic frozen shoulder. In the second study, we are comparing two exercise programs, VR and conventional, for balance retraining in subjects post-traumatic brain injury. Effective VR-based rehabilitation that is easily adapted for individuals to use both in inpatient, outpatient and home-based care could be used as a supplement or alternative to conventional therapy. If this new treatment approach is found to be effective, it could provide a way to encourage exercise and treatment compliance, provide safe and motivating therapy and could lead to the ability to provide exercises to clients in distant locations through telehealth applications of VR treatment. VR is a new technology and the possibilities for rehabilitation are only just beginning to be assessed.

Clinical utility of office-based cognitive predictors of fitness to drive in persons with dementia: A systematic review.

OBJECTIVES: To perform a systematic review of evidence available regarding in‐office cognitive tests that differentiate safe from unsafe drivers with dementia.

Systematic Review of Driving Risk and the Efficacy of Compensatory Strategies in Persons with Dementia

OBJECTIVES: To determine whether persons with dementia are at greater driving risk and, if so, to estimate the magnitude of this risk and determine whether there are efficacious methods to compensate for or accommodate it.

Predictors of Driving Ability Following Stroke: A Systematic Review

Abstract Background and Purpose: The objective of this review is to identify the most consistent predictors of driving ability post stroke. Method: A computerized search of numerous databases from 1966 forward was completed. Measured outcomes included voluntary driving cessation or results of on-road driving evaluation. Studies were evaluated using the Newcastle-Ottawa Quality Assessment Scale. Results: 17 eligible studies were identified. The most useful screening tests were tests assessing cognitive abilities. These included the Trail Making A and B tests, the Rey–Osterreith Complex Figure Design, and the Useful Field of View Test. Conclusion: Cognitive tests that assess multiple cognitive domains relevant to driving appear to have the best reproducibility in predicting fitness to drive in stroke patients.

The Role of Reduced Fitness to Drive Due to Medical Impairments in Explaining Crashes Involving Older Drivers

Background. Medical conditions and associated impairments are known to be more prevalent with aging and can potentially impact the function and crash risk of older drivers. Objectives. To evaluate the impact of specific medical conditions and associated impairments on older driver crash risk. Methods. A search identified reports and peer-reviewed publications evaluating the risk for medical conditions and associated crash risk. Medical conditions associated with older persons were reviewed to determine the associated relative risk of crash. Results. The review identified three recent comprehensive reviews of medical conditions or chronic illnesses and crash risk: Dobbs (2005); Vaa (2003); Charlton et al. (2004). Comparison of the reviews reveals a relatively high agreement where medical conditions considered to be at slightly to moderately increased relative risk of crash include alcohol abuse and dependence, cardiovascular disease, cerebrovascular disease/TBI, depression, dementia, diabetes mellitus, epilepsy, use of certain medications, musculoskeletal disorders, schizophrenia, obstructive sleep apnea, and vision disorders. However, determining fitness to drive at the individual level based on diagnosis has significant limitations related to factors such as multiple medical conditions as well as varying severity of disease and associated functional impairments. Medical conditions that may affect driving can serve as “red flags” to assist health care professionals and driving administrators to identify drivers who may need further evaluation. Conclusions. Medical conditions overall, do impact the fitness to drive of older drivers; however, the crash risk tends to be only slightly to moderately increased. The conditions can serve as potential warnings for reduced fitness to drive, but many persons with these medical conditions would still be considered safe to continue driving.

Benefits of activity and virtual reality based balance exercise programmes for adults with traumatic brain injury: perceptions of participants and their caregivers.

Objective: To explore multi-dimensional benefits of exercise participation perceived by adults with traumatic brain injury (TBI) and their caregivers. Methods: Adults (n = 27, aged 18–66) with moderate or severe TBI 6 months or more earlier participated in focus groups following 6 weeks of an activity-based (ABE) or a virtual reality (VR) delivered balance exercise programme. Family members and care providers participated in separate focus groups. Perceptions related to programme participation as well as balance confidence and lower extremity function were extracted from focus group verbatim and quantitative scales, respectively. Outcomes: Benefits in three domains, psychosocial, physical and programme, were identified from transcription and analyses of focus group verbatim. Improvements were noted in balance confidence and function in both groups. Substantially greater enthusiasm and knowledge was expressed by participants in the VR group and their caregivers. Conclusions: Both exercise programmes offered benefits in addition to improved balance. The VR participants had greater improvements on quantitative measures and provided more comments expressing enjoyment and improved confidence. Applications in terms of community reintegration and quality of life are discussed.

Acute management of acquired brain injury part II: An evidence-based review of pharmacological interventions

Primary objective: To review the literature on non-pharmacological interventions used in acute settings to manage elevated intracranial pressure (ICP) and minimize cerebral damage in patients with acquired brain injury (ABI). Main outcomes: A literature search of multiple databases (CINAHL, EMBASE, MEDLINE and PSYCHINFO) and hand-searched articles covering the years 1980–2008 was performed. Peer reviewed articles were assessed for methodological quality using the PEDro scoring system for randomized controlled trials (RCTs) and the Downs and Black tool for RCTs and non-randomized trials. Levels of evidence were assigned and recommendations made. Results: Five non-invasive interventions for acute ABI management were assessed: adjusting head posture, body rotation (continuous rotational therapy and prone positioning), hyperventilation, hypothermia and hyperbaric oxygen. Two invasive interventions were also reviewed: cerebrospinal fluid (CSF) drainage and decompressive craniectomy (DC). Conclusions: There is a paucity of information regarding non-pharmacological acute management of patients with ABI. Strong levels of evidence were found for only four of the seven interventions (decompressive craniectomy, cerebrospinal fluid drainage, hypothermia and hyperbaric oxygen) and only for specific components of their use. Further research into all interventions is warranted.

Validation of an Electronic Device for Measuring Driving Exposure

Objective. This study sought to evaluate an on-board diagnostic system (CarChip) for collecting driving exposure data in older drivers. Methods. Drivers (N = 20) aged 60 to 86 years from Winnipeg and surrounding communities participated. Information on driving exposure was obtained via the CarChip and global positioning system (GPS) technology on a driving course, and obtained via the CarChip and surveys over a week of driving. Velocities and distances were measured over the road course to validate the accuracy of the CarChip compared to GPS for those parameters. Results. The results show that the CarChip does provide valid distance measurements and slightly lower maximum velocities than GPS measures. From the results obtained in this study, it was determined that retrospective self-reports of weekly driving distances are inaccurate. Conclusions. Therefore, an on-board diagnostic system (OBDII) electronic device like the CarChip can provide valid and detailed information about driving exposure that would be useful for studies of crash rates or driving behavior.

Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms

Abstract Objective: To introduce a set of revised guidelines for the management of mild traumatic brain injury (mTBI) and persistent symptoms following concussive injuries. Quality of evidence: The Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms were made available in March 2011 based on literature and information up to 2008. A search for new clinical practice guidelines addressing mTBI and a systematic review of the literature evaluating treatment of persistent symptoms was conducted. Healthcare professionals representing a range of disciplines from Canada and abroad attended a consensus conference to revise the original guidelines in light of new evidence. Main message: A modified Delphi process was used to create 96 recommendations addressing the diagnosis and management of mTBI and persistent symptoms, including post-traumatic headache, sleep disturbances, mental health disorders, cognitive difficulties, vestibular and vision dysfunction, fatigue and return to activity/work/school. Numerous resources, tools and treatment algorithms were also included to aid implementation of the recommendations. Conclusion: The revised clinical practice guideline reflects the most current evidence and is recommended for use by clinicians who provide care to people who experience PPCS following mTBI.

Hypermetabolism following moderate to severe traumatic acute brain injury: a systematic review.

Elevations of metabolic rate following traumatic brain injury (TBI) have been reported previously, with estimates ranging from 32% to 200% above normal values. The aim of this systematic review was to describe the pattern of energy expenditure during the first 30 days following TBI. We searched six databases for trials that measured the energy expenditure at least once during the first 30 days post-injury and compared that value to one that would be predicted in the non-injured state. We identified 24 studies, three of which were randomized controlled trials (RCTs). The sample sizes of the included studies ranged from 6 to 80 (mean, 24.7), and the mean Glasgow Coma Scale (GCS) score of subjects was 4.8. Mean energy expenditure, expressed as a percentage of a predicted value, ranged from 75% to 200%. The lowest values were reported in patients admitted in brain death. Several factors were found to have modulating effects on energy expenditure. The administration of paralyzing agents, sedatives, or barbiturates reduced metabolic rate by approximately 12-32%. Propranolol and morphine were associated with smaller decreases in energy expenditure. Factors that do not appear to augment the hypermetabolic response included the administration of steroids and method of feeding (enteral vs. parenteral). Based on our results, it was unclear if elevated temperature, the presence of extracranial injury, or the severity of injury further exacerbate hypermetabolism. We conclude that energy expenditure following TBI is highly variable, and the use of standard factors to estimate the energy needs of individual patients are inappropriate and should be discouraged.