A Randomized Feasibility Trial of a Novel, Integrative, and Intensive Virtual Rehabilitation Program for Service Members Post-Acquired Brain Injury

Abstract

Introduction Acquired Brain Injury, whether resulting from Traumatic brain injury (TBI) or Cerebral Vascular Accident (CVA), represent major health concerns for the Department of Defense and the nation. TBI has been referred to as the “signature” injury of recent U.S. military conflicts in Iraq and Afghanistan – affecting approximately 380,000 service members from 2000 to 2017; whereas CVA has been estimated to effect 795,000 individuals each year in the United States. TBI and CVA often present with similar motor, cognitive, and emotional deficits; therefore the treatment interventions for both often overlap. The Defense Health Agency and Veterans Health Administration would benefit from enhanced rehabilitation solutions to treat deficits resulting from acquired brain injuries (ABI), including both TBI and CVA. The purpose of this study was to evaluate the feasibility of implementing a novel, integrative, and intensive virtual rehabilitation system for treating symptoms of ABI in an outpatient clinic. The secondary aim was to evaluate the system’s clinical effectiveness. Materials and Methods Military healthcare beneficiaries with ABI diagnoses completed a 6-week randomized feasibility study of the BrightBrainer Virtual Rehabilitation (BBVR) system in an outpatient military hospital clinic. Twenty-six candidates were screened, consented and randomized, 21 of whom completed the study. The BBVR system is an experimental adjunct ABI therapy program which utilizes virtual reality and repetitive bilateral upper extremity training. Four self-report questionnaires measured participant and provider acceptance of the system. Seven clinical outcomes included the Fugl-Meyer Assessment of Upper Extremity, Box and Blocks Test, Jebsen-Taylor Hand Function Test, Automated Neuropsychological Assessment Metrics, Neurobehavioral Symptom Inventory, Quick Inventory of Depressive Symptomatology-Self-Report, and Post Traumatic Stress Disorder Checklist- Civilian Version. The statistical analyses used bootstrapping, non-parametric statistics, and multilevel/hierarchical modeling as appropriate. This research was approved by the Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences Institutional Review Boards. Results All of the participants and providers reported moderate to high levels of utility, ease of use and satisfaction with the BBVR system (x̄ = 73–86%). Adjunct therapy with the BBVR system trended towards statistical significance for the measure of cognitive function (ANAM [x̄ = −1.07, 95% CI −2.27 to 0.13, p = 0.074]); however, none of the other effects approached significance. Conclusion This research provides evidence for the feasibility of implementing the BBVR system into an outpatient military setting for treatment of ABI symptoms. It is believed these data justify conducting a larger, randomized trial of the clinical effectiveness of the BBVR system.

Upper Limb Motor Improvement after TBI: Systematic Review of Interventions

“…In another study, Buccellato et al 46 examined the effects of virtual reality gaming on a group of participants with acquired brain injuries (ABIs) including those caused as a result of strokes (n = 4), TBIs (n = 13) or a combination of stroke + TBI (n = 4). These 21 participants were randomized to an early treatment group (n = 11) or a delayed treatment group (began training 3 weeks after study initiation).…”

“…55 At the motor impairment level, the FMA was the most commonly used clinical outcome. 39,40,46,49,51 Goniometry 32,33,47 and torque controlled passive extension 35 helped assess changes in wrist and elbow ranges of motion. In addition, kinematic motor performance outcomes including speed, reaching path straightness and accuracy helped quantify motor impairment in some studies.…”

“…The WMFT was the most commonly used clinical assessment 38-40,54 across the different studies. Dexterity was measured by using the BBT, 44,46,49 Purdue Pegboard Test, 41 TEMPA 35,50 and Jebsen Taylor Hand Function test 46 in different studies. Limitations in ADL performance were also quantified using the FIM, 34,51 the CHART, 34 Frenchay Arm Test 54 and the ARAT.…”

“…62,63 Amongst the papers we reviewed, only two papers 40,48 examined the association between UL motor improvement and cognitive impairment. Few other studies provided information on baseline levels of cognitive functioning, 38,46,51,52 but did not assess the effects of baseline cognitive dysfunction with motor improvement. Only two of the included studies in this review measured the levels of baseline depressive symptomatology, 45,46 which is known to predict motor improvement and satisfaction with life after discharge from rehabilitation in this population.…”

Cognitive rehabilitation of patients with focal brain damage

“…В целом ряде исследований была показана целесообразность совместного проведения двигательной и когнитивной реабилитации. Отмечается эффективность сочетания использования виртуальной реальности и повторяющихся двусторонних тренировок верхних конечностей [50]. Показано положительное влияние роботизированной нейрореабилитации с использованием Lokomat в сочетании с виртуальной реальностью на процессы внимания и исполнительные функции у пациентов с ЧМТ [51].…”