This case study shows the benefit of long- term physical rehabilitation in reducing activity limitations and enhancing participation levels in an individual with chronic traumatic brain injury-related mobility deficits.

Traumatic brain injury (TBI) is the leading cause of death and disability in children and young adults around the world (Thurman et al 1999), with an incidence ranging from 108 to 392 per 100,000 population (Abelson-Mitchell 2008).

With the majority of accidents occurring in the prime of life, TBI-related disability is an enormous public health problem (Rushworth 2008).

TBI may lead to physical, sensory, cognitive and psychosocial/emotional disabilities, often in combination (Kendall 1991).

Due to multisystem impairments, falls in the TBI population are a significant clinical issue (McKechnie et al 2015) with many identified as high falls risk (McKechnie et al 2015).

Existing evidence indicates that impairments such as spasticity, muscle weakness, reduced motor control and balance deficits are prevalent following TBI (Williams et al 2015) and many of these symptoms are known to cause falls (Krych et al 2013).

Therefore, comprehensive assessments are essential in order to understand how TBI-related impairments contribute to falls and subsequent activity limitations.

Approximately 18–30 per cent of TBI survivors experience spasticity requiring treatment post-accident (Verplancke et al 2005).

To determine the impact of spasticity, careful clinical evaluation is imperative. A comprehensive multidisciplinary team assessment following neurological impairment is essential (Olver et al 2010).

Assessments of passive range of movement, angle of spastic catch or clonus, active movement, and functional ability are required to assist differentiation between muscle and joint contracture, and all components of the upper motor neuron syndrome.

However, improvement in spasticity does not necessarily translate into functional gains. Hence, collaborative goal-setting is paramount to measure the effect of spasticity interventions.

These assessment procedures can support the need for treatment and drive selection of re-assessments at follow-up (Yelnik et al 2010).

In order to describe the complexity of TBI and its impact on a person’s life, a universal framework is needed.

The International Classification of Functioning, Disability and Health (ICF) provides a standard language and framework for the description of health and health-related states (WHO 2001), and can distinguish body structure impairments from activity limitations and participation exclusions (WHO 2001).

The Brief ICF Core Set for TBI can describe the functioning of a person with TBI and is suitable for use in both primary care and research (Bernabeu et al 2009).

Evidence indicates that brain injury is a dynamic condition that changes over time (Corrigan & Hammond 2013).

Almost a third of individuals demonstrate functional decline over a 15-year period following TBI (Dijkers et al 2010).

Rather than being static, brain injury can evolve into a lifelong health condition, chronic brain injury (CBI) (Hammond & Malec 2013).

With health and function variability, some individuals may benefit from periodic therapy to regain or maintain motor function (Corrigan & Hammond 2013).

Case summary

Evidence-based guidelines for the treatment of gait and balance problems following TBI are limited.

As a result, there is great variability in the treatment methods employed for the rehabilitation of people with TBI.

Currently available evidence regarding aerobic fitness, strength training, conventional gait retraining, and intensive, repetitive task practice was fully integrated into clinical reasoning in this complex case.

Treatment modalities reflected clinician expertise and patient preferences, ensuring a client-centred, evidence-based rehabilitation program aimed to reduce falls and improve mobility following chronic TBI. ***

Patient information

A 30-year-old female was referred by her GP for consideration of botulinum toxin (BoNT-A) for right leg pain and stiffness.

The patient survived a TBI when eight years old with right spastic hemiplegia (Table 1). On presentation to the spasticity clinic she reported a six- month history of recurrent tripping, falls, dragging the right leg and intermittent right calf pain and cramping.

Despite monthly reviews by a community physiotherapist for equipment provision, she had not received physiotherapy for several years.

With the benefit gained from BoNT-A injections and physiotherapy in the past, the patient was hopeful that with similar treatment she may regain the ability to walk independently, and learn to run.

Following multidisciplinary team assessment, the patient was referred to outpatient physiotherapy for conservative management and 12-week review.

Initial physiotherapy assessment revealed the patient was falling approximately four times a week and tripping multiple times per day.

Self-nominated reasons provided were right leg heaviness, rushing and fatigue. She was also aware that residual cognitive deficits, reduced attention and planning (not formally measured) exacerbated the problem.

For walking safety and speed she used a right spring-leaf ankle foot orthosis (AFO) and trolley to walk outdoors. Indoors, the patient would manage without the AFO,  and furniture walk.

There was no pain at rest; however, right foot pain and cramping occurred when walking more than 20 minutes with the AFO. Pain and stiffness also impacted her ability to dance.

Selection of outcome measures

An ICF documentation template was adapted to illustrate functional physical examination findings. 

Body function tests

The Visual Analogue Scale (VAS) is a rating scale ranging from 0 (no pain) to 10 (extreme pain) and was used to measure pain (Huskisson 1974).

Manual muscle testing (MMT) using Kendall et al’s (1993) approach was performed to assess muscle power function.

The MMT was supplemented with functional strength assessments (eg, bridging, single leg squat) to more accurately assess Grade 4 to 5 musculature (Knepler & Bohanno 1998).

Muscle tone was assessed using the Modified Tardieu Scale (MTS) (Boyd & Graham 1999) as it can differentiate spasticity from soft tissue hypertonia (Williams et al 2015).

The MTS scores spasticity (X) from 0 to 4, with higher scores representing greater spasticity severity.

Joint mobility was assessed to determine the impact of contracture using handheld goniometry (Nussbaumer et al 2010).

Activity and participation tests

Strong evidence supports the use of the 10 metre walk test (10MWT) to measure gait speed and 6 minute walk test (6MWT) to assess walking distance (Moore et al 2018).

Specific to the patient- stated goal ‘to walk better’, these tests were utilised.

However, walking speed is susceptible to a ceiling effect.

As the patient progressed, the High Level Mobility Test (HiMAT) (Williams et al 2005) was also selected because of its responsiveness and less susceptibility to ceiling effects for independent walkers (Williams et al 2013).

Furthermore, this test incorporated the patient’s long- term goal of running.

As static tests of balance are weak predictors of mobility performance after TBI (Williams et al 2013), static balance measures were not performed and instead, self-reported retrospective falls rate was measured to encompass the patient- stated goal of reducing falls.

Initial physical examination

On initial examination impairment tests of muscle power functions revealed significant right lower limb weakness, primarily of the hip (flex 3/5, abd 3–/5 and ext 3/5), ankle (DF 2/5), and foot (toe ext 1/5).

She also had severe spasticity in the right rectus femoris (spasticity angle (SA)=80 degrees, muscle reaction scoring (X)=3) and right soleus (SA=15 degrees, X=3).

Control of voluntary movement was poor, demonstrated by an inability to perform all right single limb activities. Observational gait analysis

showed that she was able to walk without aids; however, there was an absent first rocker and reduced right knee flexion in swing.

She could negotiate stairs with a rail, non-reciprocally, but was unable to bound right to left or run.

Gait speed (self-selected=1.09m/s; fast=1.45m/s) and walking endurance (6MWT=427m) were below age-matched normative values. Due to a history of depression and anxiety, personal factors of relevance were considered to be mood and motivation; however, these were initially deemed not to be impacting performance.

Evaluation

The primary impairments contributing to the patient’s mobility limitations and participation restrictions were reduced strength, reduced motor control and spasticity.

Considering the patient had not attended formal physiotherapy for a number of years, a conservative treatment regime was designed.

If reduced falls and improved mobility were not achieved with physiotherapy alone, it was considered that BoNT-A injections may be required to treat spasticity.

Orthotist referral to review the right AFO was initiated immediately, as right foot pain was associated with AFO use.

Following TBI, it has been shown that people tend to compensate proximally in the presence of distal weakness (Williams et al 2013).

As a result, it was thought right hip pain was partly related to overuse of hip flexor muscles in the presence of a drop foot. Pain associated with spasticity was also considered.

Management

Following initial assessment, patient-centred short-term and long- term goals were established.

To ensure compliance, in the presence of cognitive deficits, supervised physiotherapy and hydrotherapy sessions were scheduled: twice per week, one-hour individually tailored exercise program; and once per week, one-hour hydrotherapy.

In order to achieve functional goals and allow sufficient time for motor skill relearning, the initial program was delivered for 12 weeks prior to the first formal re-evaluation.

The program included strength training (lower limbs), stretching (lower limbs), aerobic fitness training, conventional gait retraining, and repetitive task practice.

Follow-up time point 1 (12 weeks)

Management plan

As spasticity was impeding the patient’s improvement in function, pharmacological intervention was deemed appropriate.

The patient was injected with 100 units of BoNT-A into the right soleus and right rectus femoris with a total dose of 200 units.

The previously outlined evidenced-based physiotherapy and hydrotherapy program was continued with the addition of pre-running drills.

Follow-up time point 2 (19 weeks)

Physical re-examination and management plan

Functional mobility assessments and pain demonstrated minor improvements. Of note was a strength reduction in the right knee extensors (MMT= –3/5; 5 degrees quads lag) with corresponding loss of right single leg squat.

Botulinum toxin type-A interferes with neuromuscular synaptic transmission for 12 to 16 weeks following injection (Olver et al 2010).

Therefore, it was decided to review the patient in six weeks’ time when BoNT-A effects had likely worn off.

The physiotherapy program continued and progressions were made. In light of the loss of the right single leg squat, knee control during functional activities and the total gym exercises was a focus.

Follow-up time point 3 (25 weeks)

Physical re-examination and management plan

The long-term primary goal of reducing falls rate to once a month was achieved.

The patient described excruciating right hip pain with walking long distances (VAS=10/10) and reported hip pain reduction as her main goal of treatment.

The patient could no longer actively dorsiflex against the spasticity in the calf to achieve heel contact and had lost the first rocker that was observed for a few steps, six weeks prior.

Fatigue led to increased right knee flexion in stance, exposing residual weakness in the quadriceps (5 degree lag; single leg squat—unable).

The considerable increase in gastrocnemius spasticity and associated decline in barefoot walking performance drove the decision to inject the right gastrocnemius with 100 units of BoNT-A.

The agreed goals of treatment were to reduce hip pain, walk without AFO outdoors with the trolley, and run with Mayfield belt in physiotherapy.

The physiotherapy program remained largely unchanged with some progressions in strength exercises and pre-running drills as performance improved. 

Follow-up time point 4 (40 weeks)

Physical re-examination and management plan

Goal achievement exceeded expectation with regards to walking endurance and running outcomes.

The patient was able to run 10 metres in physiotherapy sessions and had started beach running. This corresponded with a significant increase in HiMAT score (24/54).

Walking tests were performed for the first time without the AFO and walking speed and distance (10MWT SS=1.05m/s, fast=1.65m/s; 6MWT=512m), were comparable to age-matched normative data.

Hip pain had reduced (VAS=3/10) (Figure 2) and spasticity impairment tests were insignificant.

The right lower limb strength was sufficient to enable single limb activities to be performed (single leg (SL) bridge=20; SL squat=5; SL calf raise=10). She could also skip three metres with the Mayfield belt.

Fifty-two of 80 scheduled physiotherapy sessions were attended (65 per cent). Twelve of 30 scheduled hydrotherapy sessions were attended (40 per cent).

The vast improvements recorded in all domains of ICF and parallel goal achievement confirmed the patient was suitable for discharge from formal physiotherapy.

Exercise physiologist referral was completed to establish a community gym program with support worker training and supervision advised.

With appropriate community referrals in place, the patient was also formally discharged from the spasticity clinic.

Discussion

This study’s primary aim was to determine if an individually tailored long-term physiotherapy program could reduce falls in a person with chronic mobility impairment following TBI.

Over the 10-month period, the self-reported falls rate reduced from four per week to once a month.

Although falls are common following TBI, no studies have investigated the effects of an exercise intervention on falls reduction in this population.

However, results are consistent with research regarding exercise to reduce falls post-stroke (Marigold et al 2005).

As falls are the most commonly reported unsafe event for community-dwelling individuals with TBI (McKechnie et al 2015), this case is a promising demonstration of the benefits of physiotherapy in chronic TBI management.

Study results indicate that an individually tailored goal-directed rehabilitation program can improve mobility outcomes post-chronic TBI.

However, the initial conservative treatment plan had minimal impact on walking and running goals.

Substantial functional improvements were only observed when provided in conjunction with BoNT-A injections, reinforcing international guidelines to refer for BoNT-A when spasticity impedes functional activity improvement (Olver et al 2010).

By program completion, walking endurance and running were greatly enhanced. This is in contrast to most published data, which have shown no change in functional outcome measures with prescription of BoNT-A injection and concurrent therapy in patients with active goals (Olver et al 2010, Ward et al 2014).

This could be due to either having insufficient follow-up (Mullins et al 2016), or insufficient therapy post-BoNT-A injection (Ward et al 2014).

The therapy intensity provided in the current study far exceeded previously reported amounts (Ward et al 2014) and is in line with American College of Sports Medicine exercise guidelines for people post-brain injury (Palmer-McLean & Harbst 2009).

Overall, results support the theory that BoNT-A injection reduces spasticity to enable a window of opportunity for clinicians to target impairments that may increase disability.

Knee extensor strength was significantly reduced after BoNT-A injection in this case study, without detrimental gait changes.

This finding reiterates Hameau et al’s (2014) investigations into BoNT-A effects on stiff knee gait.

Knee extensor strength reduction is important because gait velocity is correlated to voluntary knee strength (Hsu et al 2003).

Clinicians are therefore often wary of exposing weakness in quadriceps with BoNT-A injection. However, supported by Hameau et al (2014) and current case results, BoNT-A injections into rectus femoris enhances ambulation in those with stiff knee gait.

Antagonist muscle strength, particularly ankle dorsiflexors, increased considerably following BoNT-A calf injection.

This is in accordance with prior research (Tang et al 2012). However, vast improvements weren’t observed in this case until both soleus and gastrocnemius were injected.

Ankle joint power generation at push-off is a strong predictor of mobility outcome in people with a TBI (Williams et al 2013).

The decision to delay BoNT-A injection into gastrocnemius was due to the potential to reduce calf power.

Therefore, soleus was injected independently because of the larger spasticity angle.

However, the patient was not able to overcome the force of the plantar flexors to achieve heel contact in gait, until both soleus and gastrocnemius were injected.

The desire to achieve foot clearance in swing has to be carefully considered with ankle power generation when injecting BoNT-A in independently ambulant people.

Future investigation into the impact of BoNT-A injection on agonist and antagonist muscle strength, particularly around the ankle, is warranted.

There is considerable evidence that low levels of motivation and self-efficacy are barriers to exercise adherence (Jack et al 2010).

Although not formally measured, the patient’s mood fluctuated throughout the study.

Despite these changes, motivation remained high as represented by attendance (65 per cent).

This supports previous findings that clear and revisable goal-setting may positively affect patient motivation (Maclean et al 2000).

Issues with motivation and compliance, often reported in chronic TBI rehabilitation programs, were not demonstrated in this case.

The main limitation of this study is that findings cannot be generalised. Causal inference is not possible from uncontrolled observations, therefore results should be interpreted with caution.

This study, however, provides useful information regarding delivery of an evidence-based physiotherapy program that reduced falls and improved mobility in an individual with spasticity following chronic TBI.

>> Patient consent has been provided for this case to be published. Email inmotion@australian.physio for references.

Elizabeth Moore, MACP, is a registrar undertaking Fellowship of the Australian College of Physiotherapists by Clinical Specialisation in the neurology discipline. Elizabeth is a senior physiotherapist and Spasticity Clinic team leader at Epworth HealthCare.