Evidence-based Strategies for Community Reintegration · Evidence-Based Strategies for Community Reintegration Kayla Covert, PT, DPT,NCS, CSCS Brittany Kennedy, PT, DPT, NCS 6th Annual

Evidence-Based Strategies for Community Reintegration Kayla Covert, PT, DPT,NCS, CSCS Brittany Kennedy, PT, DPT, NCS

6th Annual Current Concepts in Brain Injury Rehabilitation

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Evidence-based Strategies for Community Reintegration


Kayla Covert PT, DPT, NCS, CSCS Neurologic and Vestibular Program UPMC Centers for Rehab Services

Brittany Kennedy PT, DPT, NCS Clement J. Zablocki VA Medical Center

Milwaukee, WI

The presenters do not have any disclosures with any proprietary entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients.



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OBJECTIVES

Course participant will be able to:

1. Identify best practice for facilitating community based reintegration in the outpatient setting.

2. Create a comprehensive plan of care that includes balance and gait activities based upon thorough evaluative strategies.

3. Identify effective strategies for enhancing communication between the interdisciplinary team.

4. Apply knowledge from case presentations to his/her current neurological caseload when applicable.

Case Study

• Introduction to Case – Mr. Z

– Age 31 at time of incident, now 32 years old

– Social History:

• Married with 1 young daughter

• Marine Corps veteran who served from 2003 to 2008, 3 combat deployments to Iraq

• Studying health and human performance with hopes of being a personal trainer



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Case Study

• Past Medical History: – Shoulder pain

– Bilateral inguinal hernias

– Dyslipidemia

– Impaired fasting glucose

– GERD

– Epistaxis

– Depression

– PTSD

Case Study

• September 2014: – Patient was found unresponsive in his bed with

missing benzodiazipenes from his prescription by his wife and EMS was called. Patient was breathing and had a pulse at time of call.

– In ambulance on route to hospital, patient vomited and aspirated, then went into cardiac arrest

– Was pulseless and experienced hypoxic moment for at least 6 minutes until he was revived by CPR

– Admitted to a private sector hospital ICU where he was on ECMO for 4 days and intubated with artificial ventilation for 12 days



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Case Study

• September 2014: – Patient was unresponsive to noxious stimuli for

approximately 10 days. Once he regained consciousness, quickly became alert and oriented

– Was transferred to VA hospital 15 days after incident to acute care then was transferred to Acute Inpatient Rehabilitation floor 2 days after that

– PT, OT, Speech consulted. Psychology and social work following throughout

Case Study

• Initial inpatient PT evaluation: – Admitted as max A x 2 for all mobility – Discharged 10/9/2014 at mod I/Ind level for all mobility

with a 19/30 on the FGA

• Initial inpatient OT evaluation – Dependent for all ADLs – Discharged 10/9/2014 at mod I/Ind level for all ADLs

• Initial inpatient Speech evaluation – Found to dysarthric speech, some deficits in sequencing,

thought organization, mental flexibility, and increased time needed for processing

– Ind for all communication upon discharge



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Case Study

• Outpatient PT evaluation completed 2 weeks after discharge from inpatient rehab

• Goals: – Return to running at least 1 mile

– Be able to play with his young daughter (15 months old)

– Improve his balance

– Hopes to return to school to become a personal trainer

Case Study

• Complications that developed during outpatient PT episode of care:

– Post-hypoxic myoclonus (Lance Adams syndrome) – treated with Keppra

– One episode of seizure like activity while on Keppra, but EEG and neuro work-up negative

– Meniscal tear in R knee

– Spasticity developed in LLE

– Thoracic level disc derangement



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Evaluation

• Outcome Measures Chosen:

– HiMAT

– Community Balance and Mobility Scale

High Level Mobility Assessment

• MDC (Williams et al 2006) – Increase of 4 points or decrease of 2

• MDIC: No values available

• Population tested: acquired and traumatic brain injury

• What it looks at: high level motor performance in TBI patients

• ICF classification: Body function, Activity

• Video



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Community Balance and Mobility

• MDC (Howe et al 2006) – 7.5 and 9.6

• MDIC: Not established • Population tested: TBI, Cerebral Palsy, CVA,

Geriatric, Acquired brain injury, Healthy adults • What it looks at: detects high-level

balance/mobility deficits during community-based tasks

• ICF classification: Body structure, Body function • Video

Other Outcome Measures

• Subjective Measures – Patient Specific Functional Scale – ABC Scale – AMPAC

• Subjective EDGE recommendations-TBI: – Community Integration Questionnaire – Global Fatigue Index – Sydney Psychosocial Reintegration Scale – Disability Rating Scale

• Subjective EDGE recommendations-Stroke: – Goal Attainment Scale – Stroke Impact Scale



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Other Outcome Measures

• 6 min walk

• 10 m walk

• Functional Gait Assessment

• Dynamic Gait Index

Research to Support Intervention

• Citation List-Refer to Prezi



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Interventions

• Gait Training – Gait analysis

– Treadmill training

– Body weight support

• Running – Treadmill training

– Overground training

– Propulsive: leaping, bounding, skipping

– Coordination training: lower body disassociation, rapid limb coordination

Interventions

• Balance

– Static: single limb stance, tandem stance, variable surfaces, visual confusion/occlusion

– Dynamic: agility ladder training, walking and turning, quick weight shifts, ambulation with direction changes, VOR and VOR cancellation with walking

– Variable surfaces



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Interventions

• Strengthening – Core stability-abdominals and hips – Ankle stability – Full body: can add in Bosu to increase difficulty

• Dual task training – Cognitive dual task training: lists, every other letter of

alphabet, storytelling – Treadmill: word finding, Sudoku – Outdoor – Scavenger hunts-put in busy environments, different

levels

Importance of the Interdisciplinary Team

• Physical Medicine and Rehabilitation: medical management – Spasticity-medication management

– Orthotics

• Occupational therapy

• Speech therapy

• Neuropsychology

• Social workers/Case managers-referral purposes



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Take Home Points

1. Selecting the best outcome measures based upon impairments and limitations will lead to selection of the most appropriate treatment strategies for community reintegration.

2. Current treatment strategies to enhance function for mild impairment and high level functioning patients include: gait training/running, static/dynamic balance interventions, strengthening, and dual-task activities.

3. The communication between members of the interdisciplinary team facilitates comprehensive management for the whole patient.

References

• Cullen N, Crescini C, Bayley M. Rehabilitation outcomes after anoxic brain injury: A case-controlled comparison with Traumatic Brain Injury. PM&R. 2009; 1:1069-1076.

• Fritz N, Cheek F, Nichols-Larsen D. Motor-cognitive dual-task training in persons with neurologic disorders: A systematic review. JNPT. 2015:; 39: 142-153.

• Goldstein L. Neurotransmitters and motor activity: Effects on functional recovery after brain injury. NeuroRx: The Journal of the American Society for Experimental NeuroTherapeutics. 2006; 3: 451-457.

• Griesbach G, Hovda D, Molteni R, et al. Voluntary exercise following traumatic brain injury: Brain-derived neurotrophic factor upregulation and recovery of function. Neuroscience. 2004; 125: 129-139..

• Kleffelgaard I, Roe C, Sandvik L, et al. Measurement Properties of the High-Level Mobility Assessment Tool for mild traumatic brain injury. Physical Therapy. 2013; 93: 900-910.

• Lei-Rivera L, Sutera J, Galatioto J, et al. Special tools for the assessment of balance and dizziness in individuals with mild traumatic brain injury. NeuroRehabilitation. 2013; 32: 463-472.

• Lin L, Liou T, Hu C, et al. Balance function and sensory integration after mild traumatic brain injury. Brain Injury. 2015; 29: 41-46. • McCulloch K. Attention and dual-task conditions: Physical therapy implications for individuals with acquired brain injury. JNPT. 2007; 31: 104-118. • McCulloch K, Buxton E, Hackney J, et al. Balance, attention, and dual-task performance during walking after brain injury: associations with falls

history. Journal of Head Trauma Rehabilitation. 2010; 25: 155-163. • Mortello G, Frear M, Seaburg K. The recovery of running ability in an adolescent male after traumatic brain injury: A case study. JNPT. 2009; 33: 111-

120. • Pan T, Liao K, Roenigk K, et al. Static and dynamic stability in veterans with combat-related mild traumatic brain injury. Gait and Posture. 2015.

Found online: http://dx.doi.org/10.1016/j.gaitpost.2015.08.012. • Ustinova K, Chernikova L, Dull A, et al. Physical therapy for correcting postural and coordination deficits in patients with mild to moderate traumatic

brain injury. Physiotherapy theory and practice. 2015; 31: 1-7. • Wielenga-Boiten J, Heijenbrok M, Ribbers G. The relationship of health locus of control and health-related quality of life in the chronic phase after

traumatic brain injury. Journal of Head Trauma Rehabilitation. 2015. • Williams G, Schache A. Evaluation of a conceptual framework for retraining high-level mobility following traumatic brain injury: Two case reports.

Journal of Head Trauma Rehabilitation. 2010; 25: 164-172. • Williams G, Schache A, Morris M. Mobility after traumatic brain injury: Relationships with ankle joint power generation and motor skill level. Journal

of Head Trauma Rehabilitation. 2013; 28: 371-378. • Williams G, Schache A, Morris M. Running abnormalities after traumatic brain injury. Brain injury. 2013: 27: 434-443.



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References

• Clark RA, Williams G, Fini N, Moore L, Bryant AL. Coordination of dynamic balance during gait training in people with acquired brain injury. Arch Phys Med Rehabil 2012; 93: 636-40.

• D’Arcy R, Lindsay S, Song X, Gawryluk JR, Greene D, Mayo C, Ghosh Hajra S, Mndziuk L, Mathieson J, Greene T. Long-term motor recovery after severe traumatic brain injury: beyond established limits. J Head Trauma Rehabil 2015.

• Fritz NE, Basso DM. Dual-task training for balance and mobility in a person with severe traumatic brain injury: a case study. JNPT 2013; 37: 37-43.

• Gordon AL, di Maggio A. Rehabilitation for children after acquired brain injury: current and emerging approaches. Pediatric Neurology 2012; 46: 339-344.

• Kim TW, Kim YW. Treadmill sideways gait training with visual blocking for patients with brain lesions. J Phys Ther Sci 2014; 26: 1415-1418.

• Peters DM, Jain S, Liuzzo DM, Middleton A, Greene J, Blanck E, Sun S, Raman R, Fritz SL. Individuals with chronic traumatic brain injury improve walking speed and mobility with intensive mobility training. Arch Phys Med Rehabil 2014; 95: 1454-60.

• Peterson MD. A case-oriented approach exploring the relationship between visual and vestibular disturbances and problems of higher-level mobility in persons with traumatic brain jury. J Head Trauma Rehabil 2010; 23: 193-205.

• Sandhaug M, Andelic N, Langhammer B, Mygland A. Functional level during the first 2 years after moderate and severe traumatic brain injury. Brain Injury 2015; early online 1-8.

• Williams GP, Schache AG. Evaluation of a conceptual framework for retraining high-level mobility following traumatic brain injury: two case reports. J Head Trauma Rehabil 2010; 25: 164-172.

Documents

Evidence-based Strategies for Community Reintegration · Evidence-Based Strategies for Community Reintegration Kayla Covert, PT, DPT,NCS, CSCS Brittany Kennedy, PT, DPT, NCS 6th Annual