Targeted rehabilitation reduces visual dependency and improves balance in severe traumatic brain injury: a case study

Abstract

Purpose: To further understand the mechanisms underlying gait impairment following traumatic brain injury. Case report: A 58-year-old man presented with marked unsteadiness and motion sensitivity following a severe traumatic brain injury. He underwent a 6-week inpatient rehabilitation program focused on reweighting and subsequently re-integrating ascending interoceptive information, by gradual reduction of maladaptive visual fixation techniques. We report clinical neurological outcomes and measures of functional outcome, as well as an objective assessment of visual dependency (the rod and disk test) at baseline and after the rehabilitation. Results: Clinically, the patient had gait unsteadiness exacerbated by visual motion. A significant reduction in visual dependency occurred with tailored multi-disciplinary rehabilitation via gradual removal of visual fixation strategies that the patient had developed to maintain balance (t-test; p < 0.01), as well as clinical improvements in gait, balance, and functional outcome. Conclusions: We highlight the importance of visual dependency in the generation of maladaptive gait strategies following brain injury. Our data suggest assessing and treating visual dependency to be an important component of gait rehabilitation after traumatic brain injury. ä IMPLICATIONS FOR REHABILITATIONWhilst gait disturbance in TBI is multifactorial, abnormal visual dependency may be important but under-recognised component of the disorder. Visual dependency can be easily and objectively assessed by the bedside in patients using a dynamic rod and disc test. Tailored rehabilitation with gradual reduction of maladaptive visual fixation can reduce visual dependency and contribute to improved gait and balance following TBI. ARTICLE HISTORY

Post-Traumatic Craniocervical Disorders From a Postural Control Perspective: A Narrative Review

“…Visual dependency is a condition in which patients rely preferentially on visual inputs to ensure balance. This condition may be responsible for inappropriate gait and balance strategies following TBI [ 83 84 ].…”

Vestibular rehabilitation in multiple sclerosis: study protocol for a randomised controlled trial and cost-effectiveness analysis comparing customised with booklet based vestibular rehabilitation for vestibulopathy and a 12 month observational cohort study of the symptom reduction and recurrence rate following treatment for benign paroxysmal positional vertigo

“…Functional ambulation using the Dynamic Gait Index [68,[73][74][75] Static and dynamic visual acuity assessed using an Early Treatment Diabetic Retinopathy Study (EDTR S) chart with and without passive head motion (40 0 yaw rotation at 1.5 Hz) [76,77] Visual dependency assessed using the Rod and Disc test [78,79] Cognitive impairment and processing speed assessed using the Symbol Digit Modalities Test (SDMT) [80] Impact of MS on walking assessed using the 12 item self-report walking scale (MSWS-12) Version 2.0 [81] Perceived confidence in performing activities of daily living assessed using the self-report Activities-Specific Balance Confidence Scale [82] Self-reported symptoms of poor balance and increased anxiety and arousal assessed using the Vertigo Symptom Scale-Short Form [59,83] Symptoms of visually induced dizziness symptoms assessed using the self-report Situational Characteristic Questionnaire [52] Fatigue as assessed using the self-report Fatigue Scale for Motor and Cognitive functions (FSMC) [84] Symptoms of depression and anxiety assessed using the self-report Hospital Anxiety and Depression Scale (HADS) [85] Health-related quality of life using the 29-item Multiple Sclerosis Impact Scale (MSIS-29) Version 2.0 [86], a disease specific patient-reported outcome measure [87] QALYs assessed by the Multiple Sclerosis Impact Scaleeight dimensions (MSIS-8D) and the Multiple Sclerosis Impact Scale -Eight Dimensions Patient version (MSIS-8D-P) [88,89]. Both measures are based on responses to the MSIS-29, and will be used in sensitivity analyses Retrospective diary of falls over the past month for baseline measure and prospective daily falls diary over 12 weeks for assessment 2 (T14) and follow up (T26) Treatment adherence as determined by the use of patient reported diaries and reported as the percentage of completed prescribed exercises and attendance at face to face sessions User experience of the intervention will be explored through brief semi-structured face to face individual exit interviews based on an interview schedule.…”