Balanseproblemer etter mild traumatisk hodeskade : en kartlegging av balanseproblemer fire år etter skaden

Studiens bakgrunn og hensikt: Personer med mild traumatisk hodeskade (MTBI) klager ofte over balanseproblemer som en langvarig konsekvens av skaden. Til tross for dette er det gjort få langtidsoppfølginger av balanseproblemer hos personer med mild traumatisk hodeskade. Denne studien følger opp en gruppe personer med MTBI fire år etter skaden. Studiens problemstillinger er å få belyst hvor mange som opplever å ha balanseproblemer fire år etter skaden, og om selvrapporterte balanseproblemer etter ett år kan predikere selvrapporterte balanseproblemer fire år etter skaden. Videre ønskes å få belyst forskjeller mellom forsøkspersonene med og uten selvrapporterte balanseproblemer med hensyn til prestasjonsbaserte tester og sammenhenger mellom selvrapportert balanse og resultater fra prestasjonsbaserte tester fire år etter skaden. I studien belyses også sammenhenger mellom selvrapportert balanse og selvrapportert helsestatus fire år etter skaden. Design og metode: Studien er en tverrsnittstudie og en prospektiv studie. Studiepopulasjonen består av 29 personer (19 menn, 10 kvinner). Populasjonen er delt i to grupper; de med selvrapporterte balanseproblemer, SBP (9), og de med ingen selvrapporterte balanseproblemer, ISBP (20). Metode for datainnsamlingen er strukturert intervju knyttet til selvrapportert balanse og helsestatus (SF-12) i tillegg til prestasjonsbaserte tester. Prestasjonsbaserte tester i studien: balanseplattform (normal stående med øynene åpne og lukket, tandemstående med åpne øyne og dual task), Dynamic Gait Index (8 deltester) og gangtester (normal, maksimal ganghastighet, 6-minutters gåtest). For å se om selvrapportert balanse ved ett år predikerte utfallet av selvrapportert balanse ved fire år, ble sensitivitet, spesifisitet, positiv og negativ prediktiv verdi beregnet. For å analysere forskjeller mellom gruppene ble to utvalgs T-test, Mann-Whitney U Test og Fisher exact test brukt med signifikansnivå på 0,05. Bivariat sammenheng mellom selvrapporterte balanseproblemer og prestasjonsbaserte tester og selvrapporterte balanseproblemer og selvrapportert helsestatus er vurdert ved hjelp av korrelasjonskoeffisienten Spearmans Rho. Resultater: 31 % rapporterer å ha balanseproblemer 4 år etter skaden. Selvrapporterte balanseproblemer ved ett år predikerer selvrapporterte balanseproblemer ved fire år med en positiv prediktiv verdi på 88%, negativ prediktiv verdi på 90%, sensitivitet på 77%, og spesifisitet på 95%. På balanseplattformen hadde SBP-gruppen signifikant større hastighetsmoment på kroppsvaien på testen stillestående med manipulasjon av kognisjon (dual task). Dette tolkes som om at SBP gruppen har dårligere balanse enn ISBP gruppen på denne testen. Det var ingen signifikant forskjell på gruppene på de andre testene på balanseplattformen. På Dynamic Gait Index skårte SBP gruppen signifikant dårligere på tre av åtte deltester. Disse var ”gange med horisontale hodedreininger”, ”gange med vertikale hodedreininger” og ”gange med hurtig vending og stopp”. På gangtestene (normal og maksimal ganghastighet) gikk SBP gruppen signifikant saktere enn ISBP gruppen, og på gangdistanse testen (6-minutters gåtest) gikk de signifikant kortere. Det ble funnet signifikante korrelasjoner mellom selvrapportert balansestatus og de prestasjonsbaserte testene nevnt over hvilket indikerer at selvrapporterte balanseproblemer kan måles med disse testene. Det ble funnet signifikant korrelasjon mellom selvrapporterte balanseproblemer og fysisk dimensjon til helsestatusskjemaet SF-12. Dette indikerer at de med selvrapporterte balanseproblemer opplever å ha dårligere fysisk helsestatus enn de som ikke har selvrapporterte balanseproblemer. Konklusjon: 31% av denne studiepopulasjonen opplevde balanseproblemer som en langtidskonsekvens av skaden. Selvrapportert balansestatus ett år etter skaden, predikerer selvrapportert balansestatus fire år etter skaden. Ved sammenligning av gruppene med og uten selvrapporterte balanseproblemer, hadde gruppen med balanseproblemer signifikant dårligere resultater på følgende tester: Dual task på balanseplattformen, tre deltester i Dynamic Gait Index og alle gangtestene. De samme testene viste signifikant bivariat sammenheng med selvrapporterte balanseproblemer. Disse testene kan derfor være anvendelige til å måle de balanseproblemene personer med mild traumatisk hodeskade rapporterer å ha. Selvrapporterte balanseproblemer viste signifikant sammenheng med lave sumskårer på fysisk helsestatus på SF-12, hvilket indikerer redusert fysisk helsestatus. Jeg vil være forsiktig med å fortolke resultatene fra studien fordi studiepopulasjonen er liten. Nye studier anbefales før en kan trekke gode konklusjoner om vedvarende balanseproblemer hos personer med mild traumatisk hodeskade

Vestibular rehabilitation for dizziness and balance problems after mild-to-moderate traumatic brain injury

The purpose of this thesis was to study dizziness-related disability and to investigate the effect of a modified group-based vestibular rehabilitation intervention (VR) in patients with mild-to-moderate traumatic brain injury (TBI). Dizziness-related disability was significantly predicted by pre-injury comorbidity and was associated with concurrent symptoms of vertigo, reduced performance on balance tests and psychological distress. Hence, dizziness-related disability is a complex phenomenon that includes several aspects seen from a biopsychosocial perspective. An eight-week modified group-based VR intervention improved dizziness-related disability and mobility more than the usual multidisciplinary TBI rehabilitation program at the post-intervention follow up. The intervention did not cause any adverse effects. These results indicate that a modified group-based VR intervention accelerates recovery and should be considered included as a component of multidisciplinary rehabilitation for patients with dizziness and balance problems after mild-to-moderate TBI

Early rehabilitation after severe traumatic brain injury: a case report

Introduction: Studies indicate that early rehabilitation is associated with better outcomes in severely traumatic brain injured patients (TBI). Main part: The case report describes early rehabilitation at The Early Rehabilitation Unit, Oslo University Hospital Ullevaal, of a 35 year old man with severe TBI after a fall accident in autumn 2008. The early rehabilitation started 9 days post-injury while the patient still was ventilator dependent and emerging from coma. The case report focuses on the interventions positioning, range of movement exercises and mobilization. The patient made a good neurological and functional recovery during the 11 days of the early rehabilitation phase, before transferral to a specialist rehabilitation hospital. It is difficult to separate the meaning of spontaneous recovery, intensive- and neurosurgical treatment from specific rehabilitation interventions. Conclusion: The results indicate that positioning, range of movement exercises and mobilization are feasible and safe interventions, and contribute to fewer complications and improved functional recovery. Further research is needed to study the effects of different therapeutic interventions in early rehabilitation of patients with severe TBI

Subsymptomtrening for pasienter med trenings-intoleranse etter lett traumatisk hodeskade- en pilotstudie

Hensikt: Vurdere om Buffalo Concussion Treadmill Test (BCTT) og subsymptomtre- ning trygt kan gjennomføres hos pasienter med lett TBI og vedvarende post-commotio symptomer som ikke er aktive idrettsutøvere. Undersøke om subsymptomtrening basert på BCTT bidrar til økt treningstoleranse, økt fysisk aktivitet, symptomlette og økt helserelatert livskvalitet (HRQL). Metode: Pilotstudie. 29 pasienter (16 kvinner), median alder 35 år (23-54) med treningsintoleranse etter lett TBI ble inkludert. Utfallsmål: BCTT, fysisk aktivitet (aktivitetsindeks), Rivermead Post Concussion symptoms questionnaire (RPQ) og Quality of life after brain injury (QOLIBRI). Subsymptomtreningen varte i 13 uker (IQR 10-15). Resultat: Det ble ikke rapportert skader eller alvorlige reaksjoner på BCTT eller subsymptomtreningen. Tjuetre pasienter ble retestet. Deltakerne hadde en signifikant forbedring på BCTTs parametre (testvarighet p<0.001, hjertefrekvens (HF) p=0.001, opplevd grad av anstrengelse (Borg RPE skala p=0.01, og aktivitetsindeksen (0.002). Det var signifikant bedring i post-commotio symptomer (RPQ) (p=0.01) og HRQL (QOLI- BRI) (p<0.001). Konklusjon: BCTT og subsymptomtrening var trygt å gjennomføre i denne pilotstu- dien. Treningen bidro til økt treningstoleranse, økt fysisk aktivitet, symptomlette (RPQ) og økt HRQL (QOLIBRI) hos pasientgruppen

Patient-specific functioning related to dizziness and balance problems after traumatic brain injury – A cross sectional study using an ICF perspective

To describe patient-specific problems in functioning related to dizziness and balance problems in patients with mild to moderate traumatic brain injury (TBI) in a biopsychosocial context. A cross-sectional study where data from the Patient-Specific Functional Scale (PSFS) was linked to the International Classification of Functioning, Disability and Health (ICF). Data from 60 patients were classified into second-level ICF categories, using the ICF linking rules. The 60 patients included 73% women; mean age, 39 (SD 12.9) years with mild to moderate TBI (mean GCS 14.5, SD 1.3). The patients predominantly reported problems representing the activities and participation components of the ICF; mobility-related problems were most frequently reported by 42%. In addition, vestibulo-ocular and hearing problems, attention functions, domestic activities, recreation, leisure and environmental factors were frequently (≥10%) reported as barriers to functioning. The median severity of problems on the PSFS Numeric Rating Scale (0–10 worst to best) was 3 (IQR 1–5) points. The PSFS provided a unique set of problems in functioning most relevant to each patient resulting in a diversity of functional limitations. The patient-specific problems were all represented in the ICF, supporting a biopsychosocial perspective on problems related to dizziness and balance problems after TBI

Vestibular Rehabilitation After Traumatic Brain Injury: Case series

Background and Purpose There has been an increasing focus on vestibular rehabilitation (VR) after traumatic brain injury (TBI) in recent years. However, detailed descriptions of the content of and patient responses to VR after TBI are limited. The purposes of this case series are (1) to describe a modified, group-based VR intervention and (2) to examine changes in self-reported and performance-based outcome measures. Case Description Two women and 2 men (aged 24–45 years) with mild TBI, dizziness, and balance problems participated in an 8-week intervention consisting of group sessions with guidance, individually modified VR exercises, a home exercise program, and an exercise diary. Self-reported and performance-based outcome measures were applied to assess the impact of dizziness and balance problems on functions related to activity and participation. Outcomes The intervention caused no adverse effects. Three of the 4 patients reported reduced self-perceived disability because of dizziness, diminished frequency and severity of dizziness, improved health-related quality of life, reduced psychological distress, and improved performance-based balance. The change scores exceeded the minimal detectable change, indicating a clinically significant change or improvement in the direction of age-related norms. The fourth patient did not change or improve in most outcome measures. Discussion A modified, group-based VR intervention was safe and appeared to be viable and beneficial when addressing dizziness and balance problems after TBI. However, concurrent physical and psychological symptoms, other neurological deficits, and musculoskeletal problems might influence the course of central nervous system compensation and recovery. The present case series may be useful for tailoring VR interventions to patients with TBI. Future randomized controlled trials are warranted to evaluate the short- and long-term effects of VR after TBI

Effect of vestibular rehabilitation on change in health-related quality of life in patients with dizziness and balance problems after traumatic brain injury: A randomized controlled trial

This paper is the first to present results of a vestibular rehabilitation intervention study on changes in healthrelated quality of life in patients with dizziness and balance problems after mild-to-moderate traumatic brain injury. The intervention group received exercises and guidance aimed at self-efficacy and how to cope with their dizziness and balance problems. In addition, both the intervention and control groups received treatment as usual, comprising multidisciplinary rehabilitation at a university hospital. The main result was measured as change on the Quality of Life after Brain Injury questionnaire. Post-concussion symptoms, vertigo and psychological distress were also measured. The study showed that the group receiving the vestibular rehabilitation intervention underwent more improvement in health-related quality of life than the group receiving usual treatment alone. Other factors that influenced the improvement in quality of life were psychological distress at the start of the study and fewer post-concussion symptoms

Effect of vestibular rehabilitation on change in health-related quality of life in patients with dizziness and balance problems after traumatic brain injury: A randomized controlled trial

Objective: Secondary analysis, testing the effect on change in health-related quality of life of group-based vestibular rehabilitation in patients with mild-moderate traumatic brain injury, dizziness and -balance problems. Design: A single-blind randomized controlled trial. Subjects: A total of 65 patients aged 16–60 years with a Rivermead Post-concussion Symptoms Questionnaire dizziness score ≥2, and Dizziness Handicap Inventory score >15 points. Data collection was performed at baseline 3.5 (standard deviation (SD) 2.1) months post-injury, end of intervention, and 4.4 (SD 1.0) months after baseline. Methods: Quality of Life after Brain Injury was the main outcome. Independent variables were demographic and injury variables, Hospital Anxiety and Depression Scale, changes on the Rivermead Post-concussion Symptoms Questionnaire (RPQ3 physical and RPQ13 psychological/cognitive), and Vertigo Symptom Scale-Short Form. Results: Mean age of participants was 39.4 years (SD 13.0); 70.3% women. Predictors of change in the Quality of Life after Brain Injury were receiving the vestibular rehabilitation (p=0.049), baseline psychological distress (p=0.020), and change in RPQ3 physical (p=0.047) and RPQ13 psychological/cognitive (p=0.047). Adjusted R2 was 0.399, F=6.13, p<0.001. Conclusion: There was an effect in favour of the intervention group in improvement in health-related quality of life. Changes on the Rivermead Post-concussion Symptoms Questionnaire were also associated with change on the Quality of Life after Brain Injury

Sub-symptom threshold aerobic exercise for patients with persisting post-concussion symptoms and exercise intolerance after mild traumatic brain injury – a study protocol with a nested feasibility study for a randomized controlled trial

Abstract Background Persistent post-concussion symptoms (PPCS) affect between 34 and 46% after a mild traumatic brain injury (mTBI). Many also experience exercise intolerance. Sub-symptom threshold aerobic exercise, SSTAE (exercise at an intensity level that does not increase symptoms) is proposed as a treatment to both reduce the symptom burden and increase the exercise tolerance after the injury. It is unclear if this also applies in a more chronic phase after mTBI. Main purpose The main purpose of this study is to evaluate whether SSTAE in addition to ordinary rehabilitation will lead to clinically meaningful improvement of symptom burden, normalize exercise tolerance, increase physical activity, improve health-related quality of life, and reduce patient-specific activity limitations compared to a control group that only receives ordinary rehabilitation. Design Randomized, controlled, single-blind parallel-group study with three measurement times; T0 at baseline, T1 after the intervention and T2 six months after T1. Methods Patients between the ages of 18 and 60 with exercise intolerance and persistent PPCS (> 3 months) will be recruited to the study and randomized to two groups. All patients will receive follow-up at the outpatient TBI clinic. The intervention group will in addition receive SSTAE for 12 weeks with exercise diaries and a retest every 3 weeks for optimal dosage and progression. The Rivermead post-concussion symptoms questionnaire will be the main outcome measure. The secondary outcome measure will be a test of exercise tolerance—the Buffalo Concussion Treadmill Test. Other outcome measures include the patient-specific functional scale that measures patient-specific activity limitations, as well as outcome measures for diagnosis-specific health-related quality of life, anxiety and depression, specific symptoms such as dizziness, headache and fatigue, and physical activity. Discussion This study will add knowledge about the effect of SSTAE and whether it should be implemented in rehabilitation for the adult population with persistent PPCS after mTBI. The nested feasibility trial showed that the SSTAE intervention was safe and that the study procedures and delivery of the intervention overall were feasible. However, minor amendments to the study protocol were made prior to the commencement of the RCT. Trial registration Clinical Trials.gov, NCT05086419. Registered on September 5th, 2021

Community-Based Interventions after Acquired Brain Injury - A Systematic Review of Intervention Types and Their Effectiveness

Objectives: Comprehensive review of existing types and effectiveness of community-based interventions delivered to adults (mean age 18-65 years) with long-lasting (≥6 months) difficulties following acquired brain injury (ABI). Design: Systematic review of controlled intervention studies published until February 2021. Main Measures: Systematic searches in databases (MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects [Cochrane Library], and Cochrane Central Register of Controlled Trials [Cochrane Library]) and inclusion of English peer-reviewed full-text articles; randomized or controlled community-based intervention studies; sample size of 20 or more participants; and 3 or more intervention sessions. Two reviewers independently extracted data for the synthesis and assessed the methodological quality. Data extraction included study characteristics, demographics of participants, content and dose of intervention, outcome measures, and findings. Result: The search returned 7386 publications, of which 49 eligible studies were included, revealing a diverse range of community-based interventions and a myriad of outcome measures applied for assessing functional capacities, participation, and quality of life in the chronic phase of ABI. Intervention types encompassed 14 holistic, 23 physical, and 12 specific interventions. A large heterogeneity regarding intervention frequency and intensity was found. Meta-analyses performed on the holistic, physical, and specific interventions did not indicate any significant pooled effects but showed highly variable effects between individuals, both in persons with traumatic and nontraumatic brain injuries. Conclusions: Because of lack of pooled effects within types of community-based interventions, specific evidence-based recommendations within holistic, physical, and specific interventions designed to mitigate long-lasting ABI problems cannot be made. This review highlights the need for future studies to address methodological issues concerning larger sample size, lack of clear description interventions and comparator, missing reports of effects in change scores, need for consistent use of recommended outcome measures, and investigating the wide variety in intervention responsiveness among participants with ABI. Systematic review registration: PROSPERO (CRD42019124949)