Feasibility and acceptability of an adapted peer-based walking intervention for adults with moderate-to-severe traumatic brain injury.

PURPOSE: To examine the feasibility and acceptability of a 6-week peer-based walking intervention for adults with moderate-to-severe TBI with telehealth supports. MATERIALS AND METHODS: Pre-post feasibility trial with 18 community-dwelling adults (10 men; 8 women) with moderate-to-severe TBI aged 21-61 years (M = 40.6, SD = 11.3). Feasibility outcomes included participation, attrition, safety across 12 90-minute sessions, and telehealth platform quality. Acceptability outcomes included program satisfaction. Exploratory outcomes included daily step count with activity trackers and pre-post intervention questionnaires (mood, leisure satisfaction, exercise self-efficacy, quality of life) through video conferencing. RESULTS: 15/18 (83%) participants completed ≥ 9 sessions (75%). Three participants were lost to attrition. No major adverse events reported. Minor events included fatigue and muscle soreness. Participants reported high satisfaction (M = 9.2/10, SD = 0.9). Average weekly steps per day rose from 10,011 to 11,177 steps (12%). Three participants' step count data were not included due to tremors or forgetting to wear the device (≥ 9 days). One major and several minor connectivity problems occurred. Wilcoxon Signed Ranks tests identified a significant change in negative affect (p < 0.002). CONCLUSIONS: Findings support the feasibility and acceptability of a 6-week peer-based walking intervention with telehealth supports for our sample.

It was feasible and acceptable for our sample of adults with moderate-to-severe traumatic brain injury (TBI) to engage in a peer-based walking program during unforeseen circumstances.A peer-based walking group program may be a method of promoting health-related outcomes and physical activity for adults with moderate-to-severe TBI.Telehealth supports may be used to adapt a fitness center-based physical activity program for adults with TBI to an outdoor community context.

COVID-19's impact on a community-based physical activity program for adults with moderate-to-severe TBI.

PURPOSE: Physical activity (PA) is proposed for long-term problems after traumatic brain injury (TBI) with mood, quality of life, and participation. However, COVID-19 mitigation strategies resulted in widespread closures of community-based fitness centres, including one housing a peer-assisted PA program (TBI-Health). The purpose of this study was to provide an in-depth exploration of COVID-19's impact on the TBI-Health program for adults with moderate-to-severe TBI and determine how their PA behaviours could be supported in the pandemic. METHODS: Interpretative phenomenological analysis was employed to collect and analyze data from semi-structured Zoom-facilitated interviews with seven female and nine male adults with moderate-to-severe TBI (including program participants and mentors). RESULTS: Three major themes were identified. Need for PA after TBI included specific benefits of PA after TBI and desire for an adapted PA program. Lasting Impacts of the TBI-Health Program identified belonging to the TBI-Health community, benefits, and knowledge transfer from the program. Resilience and Loss through the Pandemic comprised the repercussions of COVID-19, loss of the PA program, adapting PA to the pandemic, and resilience after TBI. CONCLUSION: This study provides insights about impacts of participating in community-based peer-assisted PA programs after moderate-to-severe TBI and ways to support PA in unforeseen circumstances.IMPLICATIONS FOR REHABILITATIONOur community-based peer-assisted physical activity program for adults with moderate-to-severe traumatic brain injury (TBI) promoted a range of daily and social activities.Outdoor group-based physical activity programs provide physical activity and social opportunities for adults with moderate-to-severe TBI when indoor physical activity is restricted.Community-based peer-assisted physical activity programs can assist with posttraumatic growth after moderate-to-severe TBI.

Is parental coping associated with the level of function in children with physical disabilities?

OBJECTIVES: The objectives of this study are: (1) to describe parental coping in a cohort of children with physical disabilities (PDs); (2) to determine whether the child's level of function is associated with parental coping; and (3) to explore whether socio-demographic factors such as child's age, maternal education and family structure are associated with parental coping. METHODS: Parents of 150 children with PDs were interviewed after being referred to community rehabilitation services. They answered the following: the Coping Health Inventory for Parents, the Functional Independence Measure for children (WeeFIM) and a study questionnaire that addressed socio-demographic characteristics. Multiple linear regression models were used to determine the association between level of function and other factors and parental coping. RESULTS: Mean (SD) age of the children was 40.9 (15.2) months and 64.7% were male. Parental coping scores, measured by the Coping Health Inventory for Parents, indicated that the parents in our study found seeking out social support from community resources useful. Parents of children with moderate to severe dysfunction in mobility (WeeFIM) found coping behaviours related to communicating with the healthcare professionals regarding their child's condition useful (beta coefficient, 2.07; 95% CI, 0.37, 3.78). Greater perceived usefulness of maintaining social support through community resources was associated with lower maternal education, working parents and two-parent families. CONCLUSION: These findings underscore the importance of helping parents of children with PDs maintain social support. It is important to help parents understand their child's medical situation, especially those whose children have more severe mobility dysfunction.

Alterations to locomotor navigation in a complex environment at 7 and 30 days following a concussion in an elite athlete.

PRIMARY OBJECTIVE: To compare the locomotor capacity during (1) unobstructed walking and (2) the circumvention of fixed obstacles with and without a simultaneous visual task in an elite athlete before and after a sports-related concussion. RESEARCH DESIGN: Case report. METHODS AND PROCEDURES: Gait analysis and clinical neuropsychological measures were taken pre- and at 7 and 30 days post-injury in an 18 year old male junior hockey player. The task consisted of walking along an unobstructed or obstructed path with or without a visual interference task. Measurements included dual tasks costs, response errors, maximal gait speed and minimal clearance with the obstacle. MAIN OUTCOME AND RESULTS: Although the athlete was symptom-free and neuropsychological test results returned to baseline relatively quickly, he showed continued errors in the interference task, abnormally small obstacle clearance distances and decreased maximal gait speed up to 30 days after the concussion. CONCLUSIONS: Concussion can result in persistent planning and attention deficits in ecologically valid, complex environments. This report suggests that functional assessment within an ecological context could be an innovative way to evaluate concussed athletes before sending them back to play, even in the absence of medically related symptoms or abnormal neuropsychological test results.

The experiences of individuals with a traumatic brain injury, families, physicians and health professionals regarding care provided throughout the continuum.

PRIMARY OBJECTIVE: To investigate the experiences of individuals who had sustained a traumatic brain injury, their families and the physicians and health professionals involved, from the critical care episodes and subsequent rehabilitation. RESEARCH DESIGN: Semi-structured interviews were conducted with individuals who had sustained a TBI (n =8) and their families (n = 8) as well as with the health professionals (or service providers) (n = 22) and physicians (n = 9) who provided them care. MAIN OUTCOMES AND RESULTS: Results revealed the difficulties encountered by the different people involved, from the standpoint of the readjustment of the individual with the TBI and their family, the relationships among the various actors and the continuity of care. CONCLUSIONS: This study brings to light the importance of including the family and the person with a TBI in the care process by calling for their participation and by setting up suitable structures that prioritize a meaningful partnership among the key individuals.

Concordance between childhood injury diagnoses from two sources: an injury surveillance system and a physician billing claims database.

OBJECTIVES: (1) To determine the concordance between injury diagnoses (head injury (HI), probable HI, or orthopedic injury) for children visiting an emergency department for an injury using two DATA SOURCES: an injury surveillance system (Canadian Hospitals Injury Research and Prevention Program, CHIRPP) and a physician billing claims database (Regie de l'assurance maladie de Quebec, RAMQ), and (2) to determine the sensitivity and specificity of diagnostic and procedure codes in billing claims for identifying HI and orthopedic injury among children. DESIGN: In this cross sectional cohort, data for 3049 children who sought care for an injury (2000-01) were obtained from both sources and linked using the child's personal health insurance number. METHODS: The physician recorded diagnostic codes from CHIRPP were used to categorize the children into three groups (HI, probable HI, and orthopedic), while an algorithm, using ICD-9-CM diagnostic and procedures codes from the RAMQ, was used to classify children into the same three groups. RESULTS: Concordance between the data sources was "substantial" (weighted Kappa 0.66; 95% CI 0.63 to 0.69). The sensitivity of diagnostic and procedure codes in the RAMQ database for identifying HI and for orthopedic injury were 0.61 (95% CI 0.57 to 0.64) and 0.97 (95% CI 0.96 to 0.98), respectively. The specificity for identifying HI and for orthopedic injury were 0.97 (95% CI 0.96 to 0.98) and 0.58 (95% CI 0.56 to 0.63), respectively. CONCLUSION: Combining diagnostic and procedures codes in a physician billing claims database (the RAMQ database) may be a valid method of estimating injury occurrence among children.

[Content validity of an information system used for head injury rehabilitation based on an analysis of medical records]. / Validation par les dossiers médicaux d'un système d'informationdédié à la clientèle victime d'un traumatisme crânien.

OBJECTIVE: This study examines the content validity of the TCC-Québec Information System based on an analysis of rehabilitation medical records. The goal was to determine the agreement between the variables of the TCC-Québec Information System identified by experts and based on an extensive literature review and those found in medical records. METHOD: The medical records of 82 adults with a head injury were reviewed. The individuals had been hospitalized from 1997 to 1998 at three different acute care facilities or three rehabilitation centers. The abstractor determined if the information pertaining to a variable (e.g. personal history, impairments, or disabilities relating to sensori-motor function) was present in the record. A standardized and reliable procedure was used to ensure the quality of data extraction. The percentage of variables found in the medical records and the number of records in which each variable was documented were calculated for each clinical setting (acute care or rehabilitation) and for the different geographical regions. RESULTS: The results suggest that a large discrepancy exists between what experts desired to be included in the information system and what is really documented clinically. No discrepancy exists between the different regions. Only 23% of variables were found in more than 70% of records. CONCLUSION: This study provides recommendations about the most relevant variables to be included in an information system based on clinicians'information needs and the clinical reality. As such, these results should facilitate the use and implementation of the information system under study.

Balance findings in a child before and after a mild head injury.

OBJECTIVE: This case study reviews the preinjury and postinjury balance performance of an 11-year-old child who sustained a mild head injury. DESIGN: A prospective design was used to document balance 5 days before injury and 1, 4, and 12 weeks after injury. OUTCOME MEASURES: The assessments used were the balance subtest of the Bruininks-Oseretsky Test of Motor Proficiency, the Pediatric Clinical Test of Sensory Interaction for Balance, and the Postural Stress Test. RESULTS: One week after the trauma, balance deficits were observed in the three tests. The deficits improved 4 weeks after the injury, and performance remained stable over the following 2 months for two of the evaluations except for the Postural Stress Test performance, which failed to improve in the 3-month period after trauma. CONCLUSIONS: The good recovery of balance skills observed over the first month after injury seems to validate the current activity restrictions imposed on children after a mild head injury. However, the persistence of poor performance in the area of reactions to external perturbations indicates that some deficits may persist beyond what is expected with this population.

Activity restrictions as part of the discharge management for children with a traumatic head injury.

This article describes a proactive management strategy that is currently part of the discharge protocol for children seeking care for a head injury (HI) at a pediatric and adolescent trauma center. The strategy consists of setting activity restrictions for children hospitalized and those seen in the emergency department after a HI that may or not have been sports related. It was developed based on extensive clinical experience with families of children with a HI and existing guidelines for returning athletes to sports. Possible merits and pitfalls of the strategy are discussed.

Effectiveness of a head injury program for children: a preliminary investigation.

OBJECTIVE: The purpose of this study was to investigate whether a more coordinated, comprehensive head injury rehabilitation program provided at a children's trauma center yielded better outcomes than a less coordinated, less comprehensive program. DESIGN: Using a quasi-experimental design, 64 children with head injury admitted to the center and who received rehabilitation services in either 1995 or 1993 were evaluated by using the Functional Independence Measure for children (WeeFIM)/The Functional Independence Measure (FIM) (e.g., primary outcome measure). Secondary outcomes included "psychosocial adjustment," "return to regular school," and "current problems related to the head injury." RESULTS: No statistically significant differences were found between the groups with respect to mean WeeFIM/FIM scores after controlling for age and injury severity. The 1993 group had poorer scores on the withdrawal subscale of the psychosocial measure (P = 0.02), yet a smaller proportion of these children were enrolled in a special education class (P = 0.02). CONCLUSIONS: This study serves as a model for a larger, definitive study of the effectiveness of rehabilitation for children with head injury. The trends suggest that more comprehensive care may lead to better outcomes.

Using the measure of processes of care with parents of children hospitalized for head injury.

Despite recommendations that rehabilitation programs adopt family/patient satisfaction as an outcome measure, few studies have addressed satisfaction with services for children with head injury. This report describes our use of the Measure of Processes of Care (MPOC) to document the perceptions of care of parents whose children were hospitalized with a head injury and to compare parental perceptions of care with those of the service providers (n = 16). The MPOC is a self-administered questionnaire consisting of 56 items, each of which is included in one of five care-giving scales: (1) enabling and partnership; (2) providing general information; (3) providing specific information about the child; (4) coordinated and comprehensive care; (5) respectful and supportive care. The MPOC was mailed to parents of children with a head injury who were consecutively admitted to a pediatric trauma center during a 5-mo period. The results, based on the responses of 73 parents (response rate, 59.3%), revealed that the needs of these parents are being met to varying degrees. Mean scores for the five scales ranged from 4.6 to 6.4 and from 5.9 to 6.6 for parents and providers, respectively. Significant differences between the groups were found for two scales: providing general and specific information. Because of the low percentage of valid responses for three of the five scales, the MPOC appears to be an inappropriate tool for use with parents of children with mild head injury (89%) in the acute care setting. The MPOC, however, is applicable for parents of children who are more severely injured (e.g., average hospital stay, 9 days) and is informative for rehabilitation service providers.

Longitudinal profile of early motor recovery following severe traumatic brain injury.

A prospective longitudinal design was employed to describe early (first 6 weeks post-injury) motor function recovery in 16 individuals with severe traumatic brain injury (TBI). Reliable, standardized testing and scoring protocols were used by a physical therapist to evaluate subjects on several different aspects of motor function, including primitive reflexes, equilibrium/protective reactions, and a wide range of motor skills. The findings revealed that subjects demonstrated significant changes (chi 2, p < or = 0.05) between 1 and 6 weeks for the following variables: equilibrium reactions in sitting, rolling prone to side-lying, sitting (supported and unsupported), kneeling, standing (assisted and independently), walking (assisted and independently), stair climbing with the use of the handrail and walking 25 m on even ground. A significant change in ability to sit supported between 1 and 3 weeks post-injury was also observed. In addition, recovery was found to be a heterogeneous process, in that different patterns of recovery were evident for the 26 variables and among individual subjects. The clinical implications for physical therapists involved in the rehabilitation of adults with a severe TBI are discussed.

Reliability of early motor function testing in persons following severe traumatic brain injury.

The purpose of this study was to determine the intra- and inter-rater reliability of selected variables measuring motor function in adults following severe traumatic brain injury (TBI). Twelve adults with a severe TBI participated in the study and were assessed (independently) by two physical therapists with extensive clinical experience. Standardized testing protocols and two- or three-point ordinal rating scales were used to evaluate the following categories of variables: primitive reflexes, equilibrium/protective reactions and several motor skills. Intra-rater reliability was generally high for all variables, with kappa values exceeding 0.65 except for the scoring of equilibrium reactions in sitting and standing. Overall, inter-rater reliability was slightly lower, with kappa values ranging from 0.39 to 1.0, indicating 'fair' to 'almost perfect' agreement. The highest level of agreement was consistently reported for the scoring of motor skills. These results suggest that physical therapists trained in the use of standardized testing and scoring procedures can reliably assess primitive reflexes, equilibrium and protective reactions and a range of motor skills in TBI adults during the acute stage of recovery. Moreover, the results provide important information which will assist in the interpretation of data collected as part of a concurrently conducted longitudinal study of early motor recovery.

Agreement of classification decisions using two measures of motor co-ordination in persons with a traumatic brain injury.

Identification of motor co-ordination deficits in persons with a traumatic brain injury (TBI) is a vital part of both assessment and rehabilitation. The purpose of this study was to investigate the agreement of classification decisions based on clinical (subjective) and instrumented (objective) tests for measuring upper-limb co-ordination in persons with a TBI. Twenty-two subjects with TBI performed the 'finger-to-nose' test and a 'lateral reach tapping test' 12 months post-injury. After reduction to categorical form (deficit/no deficit), the data were interpreted using a generalized kappa statistic, to estimate the agreement between the two tests. The kappa values for the right and left upper extremities were 0.625 and 0.360, respectively, while the combined (right and left) value was 0.500, representing only 'moderate' agreement between the two testing protocols. This indicates that motor co-ordination deficits in persons with TBI can be documented using either clinical or instrumented tests. The choice of test does not appear to be based on the subjective/objective nature (dimension) of each test, but rather on more practical factors such as administration time, cost and level of objectivity desired by the clinician.

Expert opinion in the identification of variables for the measurement of early recovery in adults with traumatic brain injury.

The expert opinion of 27 experienced physical therapists was systematically sought using a modified Delphi technique in order to identify the important variables to be included in the neurophysical evaluation of the traumatic brain-injured (TBI) adult during the acute stage of rehabilitation (first 3 months). An initial survey of the therapists generated 63 items which were later regrouped into 23 categories. Each category was then rated using a five-point scale (1 = of no importance to 5 = extremely important) by each therapist as to its importance in the early clinical neurophysical evaluation of the TBI patient. Those variables identified as extremely important by at least 50% of experts include: state of consciousness, voluntary movements, spontaneous movement and transfers. The results of this study highlight, for physical therapists and other health professionals, the important variables to be included in the evaluation of neurophysical deficits in persons with TBI in the acute stage of rehabilitation.

Reliability of the scores for the finger-to-nose test in adults with traumatic brain injury.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the intrarater and interrater reliability of measurements of three clinical features of coordination based on the performance of the "finger-to-nose" test. SUBJECTS: Thirty-seven persons with traumatic brain injury (26 male, 11 female), aged 17 to 64 years (mean = 29.1, SD = 9.9), participated in the study. METHODS: Each subject's performance was videotaped and evaluated for the right and left upper extremities (UEs) (two trials each) with respect to the following variables: time of execution, degree of dysmetria, and degree of tremor (four-point ordinal ratings). One year later, five experienced physical therapists (including the original investigator) independently rated each patient's videotaped performance in the same manner as described above. RESULTS: Intraclass correlation coefficients (ICC[3,1]) for intrarater reliability were .971 and .986 and ICCs for interrater reliability were .920 and .913 for right and left UEs, respectively, for the time of execution. A generalized Kappa statistic of .54 was calculated for the scoring of dysmetria (both UEs), and Kappa statistics calculated for the scoring of tremor were .18 and .31 for right and left UEs, respectively. Interrater reliability was lower for the scoring of these variables and varied from .36 to .40 for dysmetria and from .27 to .26 for tremor (right and left UEs, respectively). CONCLUSION AND DISCUSSION: These results indicate that physical therapists demonstrate low reliability in assessment of the presence of dysmetria and tremor using videotaped performances of the finger-to-nose test. The results suggest, however, that therapists reliably measure the time of execution of this test. If the limitations associated with therapists' capacity for objective measurement of subjective phenomena cannot be overcome (eg, by establishment of more definitive scoring criteria for the measures of dysmetria and tremor), then therapists should seek alternative methods of evaluation of UE coordination.

Relation between clinical and instrumented measures of motor coordination in traumatically brain injured persons.

Right and left upper extremity motor coordination was evaluated in 40 traumatically brain injured subjects using two different measurement techniques--a conventional clinical evaluation and an instrumented evaluation. The relationship between the results from the clinical evaluation (finger to nose test) and the instrumented evaluation (timed visual-arm coordinated lateral reach) was determined using canonical correlation analysis (Rc). Clinical and instrumented test scores were significantly correlated (Rc = .685, p = .002; Rc = .629, p = .008 for the right and left sides, respectively). The scores obtained by the clinical test had little variance; instrumented scores varied greatly among subjects. Significant differences did not exist between the right and left sides for the instrumented variables of average movement speed, accuracy, and index of coordination (paired t-tests, p = .550, p = .548, p = .627, respectively) or for the clinical variables of time of execution (paired t-test, p = .468) and tremor (Wilcoxon matched-pairs, p = .228). Although meaningful correlations were obtained, they do not conclusively indicate that the two tests measure the same concept of coordination. Therefore, it is suggested that the instrumented evaluation be used to complement the traditional clinical evaluation to increase the degree of objectivity in clinical measurement.

Observer variation in assessing neurophysical signs among patients with head injuries.

As an early phase in the development of a valid and reliable measure of the neurophysical sequelae after head injury, we carried out assessments of interrater agreement on representative items. The purpose of this study was to determine the degree of agreement among expert raters who independently measured neurophysical signs on patients undergoing physical rehabilitation after brain injury. Agreement was described using the index of crude agreement, expected agreement and Kappa. Therapists showed a high degree of agreement on those items forming part of a routine neurological assessment: prehension, coordination, voluntary movements and tendon reflexes. Crude agreement ranged from 77.8-100%. There was considerable discordance in assessing muscle tonus, equilibrium and protective reactions, spinal reflexes, tremor and dysmetria (crude agreement ranged from 49.7-97.9%). Although, the number of subjects was small, the information generated from this study will be useful in refining our instrument for the assessment of neurophysical signs.