Comparative Study of Two Systems for the Assessment of Static Balance in Veterans with Mild Traumatic Brain Injury.

BACKGROUND: Traditionally, the diagnosis of postural instability relies on the clinical examination of static balance. In recent years, computerized technologies have provided a new approach for the accurate detection of positional changes during functional balance. AIM: The aim of this study was to investigate the similarities and differences between two electronic systems, NeuroCom and BioSensics, and their application in the clinical assessment of impaired balance in American veterans. MATERIALS AND METHODS: We examined the sway around the center of mass during static balance conditions in 25 veterans with mild traumatic brain injury, using the two electronic systems. These patients met the inclusion criteria and were assessed for their impaired balance at the District of Columbia Veterans Affair Medical Center, Washington, DC, USA. RESULTS: There were six static balance tests conducted on either NeuroCom or BioSensics system in triplicate. Of the data for 36 sets of statistical data analyses, there were significant correlations among those for eight data sets (22.2%) between the two systems. The strongest positive correlation between the data from the two systems was found during the baseline test, when inputs from visual, vestibular and sensorymotor sources were uninterrupted. The data from the remaining experimental conditions did not correlate significantly with one another. CONCLUSIONS: Both NeuroCom and BioSensics provided comparable data in eight out of 36 experimental conditions in the assessment of static balance in patients with mild traumatic brain injury. The findings clarified the ambiguities in the application of NeuroCom versus BioSensics, provided new knowledge for the field of physical medicine and rehabilitation, and improved the clinical assessment of static balance in patients with mTBI.

The Role of Dual Tasking in the Assessment of Gait, Cognition and Community Reintegration of Veterans with Mild Traumatic Brain Injury.

BACKGROUND: This study focussed on the effect of dual versus single tasking on balance, gait and cognition in veterans with mild traumatic brain injury (mTBI). We examined the correlation between these parameters, with responses to questions on community reintegration activities. METHOD: 22 male and female veterans (aged 19-65) walked along a narrow and 6.1-meter long path, both at their self-selected and fastest but safe pace under single and dual tasking conditions. For dual tasking, participants were required to recall and vocalize a 5-digit number at the end of the path. The outcome measures were the accuracy, velocity, cadence, stride length, and number of steps off the path. We calculated the reliability and correlation coefficient values for the walking time compared with the stride length, velocity, and percentage of swing and stance. RESULTS: Under dual task, the participants demonstrated slower gait, recalled shorter digit span and stepped off the path 12.6% more often than under single task. The stride length decreased by about 20% and the stride velocity increased by over 2% in dual compared with single tasking. CONCLUSIONS: Dual tasking slows down the gait and reduces the attention span in patients with mTBI, which can negatively impact their community reintegration, at least early after their hospital discharge, hence the need for exercising caution with their community reintegration activities. Dual tasking may have the potential to improve balance, gait and attention span of the patients in the long-term, thus leading to safer community integration, if incorporated in the rehabilitation plans.

Affective and Cognitive Conditions are Stronger Predictors of Success with Community Reintegration than Gait and Balance Performance in Veterans with Mild Traumatic Brain Injury.

INTRODUCTION: Optimal community reintegration is an integral part of the clinical management of patients with mild traumatic brain injury. BACKGROUND/OBJECTIVE: We sought the contribution and inter-relation of such variables as balance, executive function, and affective regulation to the community reintegration of veterans with mTBI. METHODS: We examined the statistical relationship among the above variables by conducting a series of objective evaluations to assess the balance, gait, executive function, affective regulation, and scores representing the patients' issues with community reintegration. The data were statistically analyzed for correlation and regression. RESULTS: High correlation was found among scores for balance and gait, executive function and affective regulation. The first and second best predictors of success with patient's community reintegration were data representing affective regulation and cognitive impairments, respectively. However, the data for dynamic balance correlated weakly and insignificantly with scores for the three subsets of community reintegration. CONCLUSIONS: We revealed varying degrees of correlation among balance, executive function and affective regulation, and as they related to the community reintegration success of patients with mTBI. The strongest, intermediate and weakest predictors for these patients' success with community reintegration represented those for affective regulation, executive function, and dynamic balance and gait performance, respectively.

Templated Interdisciplinary Rehabilitation Care Plan Documentation for Veterans With Traumatic Brain Injury.

PURPOSE OF STUDY: Individualized interdisciplinary care is the hallmark for rehabilitation following traumatic brain injury (TBI). Veterans Health Administration (VHA) utilizes an electronic note template to document Interdisciplinary Rehabilitation and Community Reintegration (IRCR) care plans for Veterans with TBI requiring rehabilitation. All Veterans with a TBI diagnosis, receiving skilled therapy for TBI-related issues, and followed by a case manager must receive a care plan. The purpose of this study was to determine the level of compliance with the IRCR care plan requirements used to identify Veterans with TBI in need of the care plan and to evaluate the reasons for inconsistent compliance. In addition, the study sought to provide a more objective assessment of Veterans with TBI requiring an IRCR to assist in establishing a target metric. PRIMARY PRACTICE SETTING: TBI outpatient clinics. METHODOLOGY AND SAMPLE: Investigators conducted a retrospective medical record review of 546 Veterans with a TBI diagnosis seen at the Washington, DC VA Medical Center's outpatient polytrauma clinics in 2013. Cases were initially reviewed for referral or engagement with skilled therapy. Charts where Veterans were referred or engaged with skilled therapy were forwarded to 2 polytrauma clinicians to determine whether therapy was requested to treat a TBI-related condition. Finally, charts were reviewed for case management and analyzed for algorithm compliance. Analysis focused first on compliance with IRCR algorithm requirements and secondarily with identifying potential reasons for noncompliance. RESULTS: In 2013, 42% of the TBI cohort met the criteria for an IRCR. The vast majority of cases with a TBI diagnosis complied with IRCR algorithm criteria; however, 14% of all reviewed cases required an IRCR but did not receive one. Provision of case management outside of the TBI/polytrauma clinic characterized a majority of noncompliant cases. IMPLICATIONS FOR CASE MANAGEMENT: Interdisciplinary care can be challenging, particularly in the outpatient setting, due to patient availability and access to care. Improved documentation in the electronic health record may assist case managers and other clinicians in coordinating rehabilitation care for Veterans with TBI. Case managers in the VA and other settings may find templates and trackable health factors helpful to identify patients in need of care plans.

Progressive Resistance Exercise with Eccentric Loading for the Management of Knee Osteoarthritis.

INTRODUCTION: The patient was a 58-year-old African-American male with radiographic evidence of bilateral knee osteoarthritis (OA). He participated in a standardized 12-week eccentric strengthening program within a Veterans Affairs (VA) medical center. BACKGROUND: The use of an eccentric training paradigm may prove to be beneficial for older adults with knee OA since eccentric muscle actions are involved in the energy absorption at the knee joint during gait and controlled movement during stair descent. Furthermore, in comparison to standard muscle actions, eccentric muscle actions result in higher torque generation and a lower rate of oxygen consumption at a given level of perceived exertion. Therefore, this mode of progressive resistance exercise may be ideal for older adults. DISCUSSION: The patient completed an eccentric strengthening regimen for the knee flexors and extensors twice per week without an exacerbation of knee pain. Muscle morphology measures of the rectus femoris were measured using diagnostic ultrasound. Isokinetic measures of muscle peak torque were obtained at 60°/s and 180°/s. Functional performance was assessed using a physical performance battery and stair-step performance was assessed from the linear displacement of the center of gravity trajectories obtained with a force plate. Visual analog scale pain ratings and self-reported global disease status were also documented. Post-exercise assessments revealed improvements in sonographic muscle size and tissue composition estimates, peak knee extensor torque (ranging from 60 to 253%), functional performance, and global disease status. CONCLUDING REMARKS: The patient exhibited improvements in muscle morphology, muscle strength, functional performance, pain, and global disease status after 12 weeks of an eccentric strengthening regimen. The intervention and outcomes featured in this case were feasible to implement within a VA medical center and merit further investigation.