Feasibility of gaming console exercise and its effect on endurance, gait and balance in people with an acquired brain injury

The timeframe for safe resumption of high-level mobility following traumatic brain injury is currently unknown: a systematic review

PURPOSE

To examine the safety of high-level mobility (HLM) prescription in the early sub-acute phase of recovery following moderate-to-extremely severe traumatic brain injury (TBI) with specific focus on provocation of concussion-like symptoms.

DESIGN

Systematic review. PROSPERO ID: CRD42017069369.

MAIN MEASURES

Extracted data included study design, brain injury severity, time to commence HLM, type of HLM, physiological and symptom monitoring, and rate of adverse events.

RESULTS

Nineteen studies were included in the review. Fifteen studies included participants who commenced HLM within 6 weeks of injury, with the earliest time to commencement being 3 days. Overall, adverse events and symptom monitoring were poorly reported. A total of six adverse events were reported across three studies. One of the six adverse events was a concussion-like symptom. No falls were reported. No studies monitored concussion-like symptom provocation in direct relation to HLM.

CONCLUSION

A safe timeframe for return to HLM after moderate-to-extremely severe TBI could not be determined due to insufficient reporting of symptom monitoring and adverse events. Further research into the safety of HLM in the early sub-acute rehabilitative stage after moderate-to-extremely severe TBI is required in order to better understand potential sequelae in this population.IMPLICATIONS FOR REHABILITATIONHigh-level mobility assessment and training is commonly reported in the early sub-acute phase of recovery following moderate-to-extremely severe traumatic brain injury.There is no consensus on a safe timeframe to commence high-level mobility assessment or training after moderate-to-extremely severe traumatic brain injury.High-level mobility assessment and training appears to be safe in the early sub-acute phase following moderate-to-extremely severe traumatic brain injury, however, adverse events and symptoms are poorly reported.Clinicians should continue to proceed with caution when assessing and prescribing high-level mobility for patients with moderate-to-extremely severe traumatic brain injury in the early sub-acute phase of recovery and monitor for risks such as falls and exacerbation of concussion-like symptoms.

Effect of Virtual Reality Therapy on Balance and Walking in Children with Cerebral Palsy: A Systematic Review

Aim: To investigate the effect of Virtual Reality Therapy (VRT) on balance and walking in children with cerebral palsy (CP). Method: A systematic search in Pubmed and Embase was performed until the 9th of July 2019. Articles were included if the population consisted of children with CP and data on balance and/or walking were reported. Results were pooled in two meta-analyses. Results: 26 articles were included. For 'balance' 5 and for 'walking' 4 were used for the meta-analyses. The meta-analyses showed a significant result in favor of VRT for balance, SMD 0.89 [95% CI, SD 0.14, 1.63] and for walking, SMD 3.10 [95% Cl, SD 0.78, 5.35]. Interpretation: VRT seems a promising intervention for rehabilitation in children with CP. The meta-analysis confirmed this positive effect. These results must be interpreted with caution due to differences in the interventions used, the lack of randomized-controlled trials, and the relatively small groups.

Play seriously: Effectiveness of serious games and their features in motor rehabilitation. A meta-analysis

BACKGROUND

Evidence for the effectiveness of serious games (SGs) and their various features is inconsistent in the motor rehabilitation field, which makes evidence based development of SGs a rare practice.

OBJECTIVE

To investigate the effectiveness of SGs in motor rehabilitation for upper limb and movement/balance and to test the potential moderating role of SGs features like feedback, activities, characters and background.

METHODS

We ran a meta-analysis including 61 studies reporting randomized controlled trials (RCTs), controlled trials (CTs) or case series designs in which at least one intervention for motor rehabilitation included the use of SGs as standalone or in combination.

RESULTS

There was an overall moderate effect of SGs on motor indices, d = 0.59, [95% CI, 0.48, 0.71], p <  0.001. Regarding the game features, only two out of 17 moderators were statistically different in terms of effect sizes: type of activity (combination of group with individual activities had the highest effects), and realism of the scenario (fantasy scenarios had the highest effects).

CONCLUSIONS

While we showed that SGs are more effective in improving motor upper limb and movement/balance functions compared to conventional rehabilitation, there were no consistent differences between various game features in their contribution to effects. Further research should systematically investigate SGs features that might have added value in improving effectiveness.

Fitness training for cardiorespiratory conditioning after traumatic brain injury

BACKGROUND

Reduced cardiorespiratory fitness (cardiorespiratory deconditioning) is a common consequence of traumatic brain injury (TBI). Fitness training may be implemented to address this impairment.

OBJECTIVES

The primary objective of this updated review was to evaluate whether fitness training improves cardiorespiratory fitness in people who have sustained a TBI. The secondary objectives were to evaluate whether fitness training improves body function and structure (physical and cognitive impairments, psychological responses resulting from the injury), activity limitations and participation restrictions in people who have sustained a TBI as well as to evaluate its safety, acceptance, feasibility and suitability.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Injuries Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Embase; PubMed (MEDLINE); CINAHL; AMED; SPORTDiscus; PsycINFO; PEDro and PsycBITE) and the International Clinical Trials Registry Platform for relevant trials. In addition we screened reference lists from systematic reviews related to the topic that we identified from our search, and from the included studies, and contacted trialists to identify further studies. The search was run in August 2017.

SELECTION CRITERIA

Randomised controlled studies with TBI participants were eligible if they compared an exercise programme incorporating cardiorespiratory fitness training to usual care, a non-exercise intervention, or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the search results, extracted data and assessed bias. We contacted all trialists for additional information. We calculated mean difference (MD) or standardised mean difference (SMD) and 95% confidence intervals (CI) for continuous data, and odds ratio with 95% CI for dichotomous data. We pooled data when there were sufficient studies with homogeneity.

MAIN RESULTS

Two new studies incorporating 96 participants were identified in this update and were added to the six previously included studies. A total of eight studies incorporating 399 participants are included in the updated review. The participants were primarily men aged in their mid-thirties who had sustained a severe TBI. No studies included children. The studies were clinically diverse with regard to the interventions, time postinjury and the outcome measures used. At the end of intervention, the mean difference in peak power output was 35.47 watts (W) in favour of fitness training (MD 35.47 W, 95% CI 2.53 to 68.41 W; 3 studies, 67 participants; low-quality evidence). The CIs include both a possible clinically important effect and a possible negligible effect, and there was moderate heterogeneity among the studies.Five of the secondary outcomes had sufficient data at the end of intervention to enable meta-analysis: body composition (SMD 0.29 standard deviations (favouring control), 95% CI -0.22 to 0.79; 2 studies, 61 participants; low-quality evidence), strength (SMD -0.02 (favouring control), 95% CI -0.86 to 0.83; 2 studies, 23 participants; very low-quality evidence), fatigue (SMD -0.32 (favouring fitness training), 95% CI -0.90 to 0.26; 3 studies, 130 participants; very low-quality evidence), depression (SMD -0.43 (favouring fitness training), 95% CI -0.92 to 0.06; 4 studies, 220 participants; very low-quality evidence), and neuromotor function (MD 0.01 m (favouring fitness training), 95% CI -0.25 to 0.27; 2 studies, 109 participants; moderate-quality evidence). It was uncertain whether fitness training was more or less effective at improving these secondary outcomes compared to the control interventions. Quality of life was assessed in three trials, but we did not pool the data because of substantial heterogeneity. Five of the eight included studies had no dropouts from their intervention group and no adverse events were reported in any study.

AUTHORS' CONCLUSIONS

There is low-quality evidence that fitness training is effective at improving cardiorespiratory deconditioning after TBI; there is insufficient evidence to draw any definitive conclusions about the other outcomes. Whilst the intervention appears to be accepted by people with TBI, and there is no evidence of harm, more adequately powered and well-designed studies are required to determine a more precise estimate of the effect on cardiorespiratory fitness, as well as the effects across a range of important outcome measures and in people with different characteristics (e.g. children). In the absence of high quality evidence, clinicians may be guided by pre-exercise screening checklists to ensure the person with traumatic brain injury is safe to exercise, and set training parameters using guidelines established by the American College of Sports Medicine for people who have suffered a brain injury.

The Effect of Aerobic Exercise on Brain-Derived Neurotrophic Factor in People with Neurological Disorders: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine the effect of aerobic exercise on brain-derived neurotrophic factor (BDNF) levels in people with neurological disorders.

DATA SOURCES

Six electronic databases (CINAHL, PubMed, Cochrane, PsycINFO, SportDiscus, and Web of Science) were searched until the end of December 2016.

STUDY SELECTION

Experimental or observational studies of people with neurological disorders who undertook an exercise intervention with BDNF as an outcome measure. The search strategy yielded 984 articles.

DATA EXTRACTION

Study data were independently extracted from each article. Methodological quality of studies was assessed using the Physiotherapy Evidence Database (PEDro) scale. A meta-analysis was planned based on the assessment of predetermined criteria.

DATA SYNTHESIS

Eleven articles were included. Studies employed either a program of aerobic exercise, a single bout of aerobic exercise, or both. A meta-analysis of studies comparing a program of aerobic exercise against usual care/nil therapy showed a large effect (SMD: 0.84, 95% CI 0.47-1.20, p < 0.001) in favour of aerobic exercise to increase levels of BDNF. Findings for a single bout of aerobic exercise were mixed. Quality of studies was low (PEDro average score 4.3/10).

CONCLUSIONS

A program of aerobic exercise may contribute to increased levels of BDNF in neurological populations.

Using Xbox kinect motion capture technology to improve clinical rehabilitation outcomes for balance and cardiovascular health in an individual with chronic TBI

BACKGROUND

Motion capture virtual reality-based rehabilitation has become more common. However, therapists face challenges to the implementation of virtual reality (VR) in clinical settings. Use of motion capture technology such as the Xbox Kinect may provide a useful rehabilitation tool for the treatment of postural instability and cardiovascular deconditioning in individuals with chronic severe traumatic brain injury (TBI). The primary purpose of this study was to evaluate the effects of a Kinect-based VR intervention using commercially available motion capture games on balance outcomes for an individual with chronic TBI. The secondary purpose was to assess the feasibility of this intervention for eliciting cardiovascular adaptations.

METHODS

A single system experimental design (n = 1) was utilized, which included baseline, intervention, and retention phases. Repeated measures were used to evaluate the effects of an 8-week supervised exercise intervention using two Xbox One Kinect games. Balance was characterized using the dynamic gait index (DGI), functional reach test (FRT), and Limits of Stability (LOS) test on the NeuroCom Balance Master. The LOS assesses end-point excursion (EPE), maximal excursion (MXE), and directional control (DCL) during weight-shifting tasks. Cardiovascular and activity measures were characterized by heart rate at the end of exercise (HRe), total gameplay time (TAT), and time spent in a therapeutic heart rate (TTR) during the Kinect intervention. Chi-square and ANOVA testing were used to analyze the data.

RESULTS

Dynamic balance, characterized by the DGI, increased during the intervention phase χ2 (1, N = 12) = 12, p = .001. Static balance, characterized by the FRT showed no significant changes. The EPE increased during the intervention phase in the backward direction χ2 (1, N = 12) = 5.6, p = .02, and notable improvements of DCL were demonstrated in all directions. HRe (F (2,174) = 29.65, p = < .001) and time in a TTR (F (2, 12) = 4.19, p = .04) decreased over the course of the intervention phase.

CONCLUSIONS

Use of a supervised Kinect-based program that incorporated commercial games improved dynamic balance for an individual post severe TBI. Additionally, moderate cardiovascular activity was achieved through motion capture gaming. Further studies appear warranted to determine the potential therapeutic utility of commercial VR games in this patient population.

TRIAL REGISTRATION

Clinicaltrial.gov ID - NCT02889289.

Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review

BACKGROUND

Virtual reality (VR) based applications play an increasing role in motor rehabilitation. They provide an interactive and individualized environment in addition to increased motivation during motor tasks as well as facilitating motor learning through multimodal sensory information. Several previous studies have shown positive effect of VR-based treatments for lower extremity motor rehabilitation in neurological conditions, but the characteristics of these VR applications have not been systematically investigated. The visual information on the user's movement in the virtual environment, also called movement visualisation (MV), is a key element of VR-based rehabilitation interventions. The present review proposes categorization of Movement Visualisations of VR-based rehabilitation therapy for neurological conditions and also summarises current research in lower limb application.

METHODS

A systematic search of literature on VR-based intervention for gait and balance rehabilitation in neurological conditions was performed in the databases namely; MEDLINE (Ovid), AMED, EMBASE, CINAHL, and PsycInfo. Studies using non-virtual environments or applications to improve cognitive function, activities of daily living, or psychotherapy were excluded. The VR interventions of the included studies were analysed on their MV.

RESULTS

In total 43 publications were selected based on the inclusion criteria. Seven distinct MV groups could be differentiated: indirect MV (N = 13), abstract MV (N = 11), augmented reality MV (N = 9), avatar MV (N = 5), tracking MV (N = 4), combined MV (N = 1), and no MV (N = 2). In two included articles the visualisation conditions included different MV groups within the same study. Additionally, differences in motor performance could not be analysed because of the differences in the study design. Three studies investigated different visualisations within the same MV group and hence limited information can be extracted from one study.

CONCLUSIONS

The review demonstrates that individuals' movements during VR-based motor training can be displayed in different ways. Future studies are necessary to fundamentally explore the nature of this VR information and its effect on motor outcome.

Physical Activity in Neurological Populations

The importance of physical activity to promote health is not new. However, the importance of physical activity in people with neurological conditions is increasingly being recognised. With many of the consequences of neurological conditions including difficulties with mobility, balance and strength; it stands to reason that optimising physical activity levels can result in many physical benefits. Physical activity can have many other flow-on effects with benefits seen in reduced mortality, and enhanced community participation and quality of life (Gordon et al., 2004). We are yet to understand the full extent to which physical activity contributes to rehabilitation outcomes; however, there is a growing body of research highlighting that the intensity of activity within rehabilitation environments is often inadequate for therapeutic gains (Kuys, Brauer, & Ada, 2006; McClanachan, Gesch, Wuthapanich, Fleming, & Kuys, 2013; Polese, Scianni, Kuys, Ada, & Teixeira-Salmela, 2014). It is not surprising therefore, that levels of physical activity continue to be poor following reintegration into the community (Morris, MacGillivray, & McFarlane, 2014). It is important that, as health care professionals, we support and encourage physical activity in all our clients. To that end, this special issue of Brain Impairment is devoted to raising the issue of physical activity in people with neurological conditions, and addressing questions such as: Why is physical activity important? How do we measure it? How do we enhance it, and what are the benefits of increased activity? This special issue brings together experts from around the world investigating and promoting physical activity across the continuum of care in various neurological populations including stroke, traumatic brain injury, multiple sclerosis and Parkinson's disease.