Complex Intervention for a Complex Condition
Balance in Patients with TBI
By Mike Le Postollec
When most of us picture a simple day-to-day activity such as walking down the grocery store aisle and searching for an item, we see the task as one fluid motion, but PTs know that even the simplest of activities are comprised of several component parts. The visual input from our eyes as they scan the shelves for a box of cereal, the physical sensation of our feet on the tiled floor and the proprioceptive awareness of moving down the corridor are separate but interrelated functions--all coming together like the frames of a film to form a consistent picture of balance.
Many patients with traumatic brain injury (TBI), however, are aware of what can happen when even one of these areas is compromised. Because of the interrelated nature of their functions, the vestibular, proprioceptive and somatosensory systems must all work effectively in order for the patient to have normal balance. And when a highly involved shock to the system like a brain injury takes place, balance often pays the price.
"I'd say the large majority of the time, somewhere in the high 90th percentile, balance will be an issue [for patients with TBI]," explained Vivian Custodio, MS, PT, of McClure Rehabilitation, Oakland, CA. "Even if the injury is not on the part of the cortex that controls balance, it can be on the back of the head where the brain controls vision, and people use visual input to control balance. Or the patient may have injured a part of the brain that controls sensation, and could lose some of the sensation in the feet while walking. There are just so many issues that can affect balance."
Fortunately, therapists have found that a multidisciplinary treatment that focuses on these complete, functional movements can be an effective way to re-educate patients' balance systems. Given managed care's time restraints, treating any highly involved condition can be particularly difficult, but by simulating pre-injury activities from the onset of rehab and educating both the patients and their long-term caregivers, PTs can help patients with TBI reach their highest level of independence.
When a patient with TBI first enters the clinic, any number of functions can be affected by the injury, and determining the level of involvement should be the first step to rehabilitation. The evaluation should be as comprehensive as possible, as the current function of patients with brain injury will vary greatly according to a number of factors. "When patients [with TBI] first come here, we really evaluate them from a functional standpoint," said Mike Yarter, PT, of Winways Rehab, Orange, CA. "We look at their current level of function, their mobility status, any assistive devices they are using, and then assess the quality of movement during functional and testing activities." Specifically, therapists at Winways Rehab check for patterning or significant substitution during movement, evaluate strength during transfers and overall posture, and attempt to determine the patient's limiting factors with regard to movement and functional tasks.
Cherie Brown, MS, PT, also of Winways, added that an interdisciplinary evaluation can be a great way for therapists to get a more complete outlook on the patient's current status. Since brain injury often has a very broad range of involvement, team evaluations are a valuable tool. "We work very closely with OTs and SLPs, and this gives us an entire perspective on the patient. How does this patient best learn? Is he a visual learner? Is his auditory comprehension impaired?" she said. Questions like these, which may fall outside of the PT's area of expertise, are more easily answered by a team of rehab professionals.
"The team approach is very important in patients with brain injury because many systems are affected; it's not like just healing a broken arm," she continued. "This population is so involved that I feel the insight of all of the other disciplines definitely adds to my success."
Evaluations at McClure involve a similar team approach and include assessments of gait, transfers and both static and dynamic balance. While many patients, particularly of the older population, are at a very low level of balance after a brain injury, Custodio said that this is not always the case. "We've also had younger clients who are at a very high level, in which case I might take them out to the basketball court and have them just run or run and dribble a ball at the same time to test their hand/eye coordination and balance at the same time, so it really depends on the client ... because there are extremes," she explained.
Nonetheless, Custodio said that balance will be an issue for nearly all patients with TBI, and the telltale signs should be apparent to therapists. "If the patients are at a very low level when they are sitting, you will often see them grabbing onto something; they're not comfortable sitting [without support], because their proprioceptive awareness is not there," she said. "Also, their sense of safety might be thrown off, so a lot of times they might try a movement that's completely inappropriate for them, and it throws their balance off."
Regardless of the specifics of the patients' symptoms, therapists agree that functionally based treatment is the best approach for patients with TBI. Since balance is very rarely the only area affected by brain injury, working on day-to-day skills that require balance is an effective way to address several needs at once.
"I've recently been prescribing some vestibular-specific exercises, where the patients will complete activities that make them dizzy or unstable," explained Brown. "Initially their symptoms are likely to exacerbate and they're going to feel worse. But they eventually will begin to habituate to those activities and we can progress them to the next level."
Activities such as ascending or descending stairs or walking down a hallway while turning the head from side to side might seem elementary to the able-bodied population, but for patients with TBI, they can be valuable forms of rehab. As Yarter added, "The interrelationship between the various structures involved in the balance system (vestibular, somatosensory, visual) are complex. Simple things like head turning while walking down a hallway can become a very useful tool while trying to achieve functional independence."
As patients progress, components can be added to these kind of activities to make them more challenging for higher level patients. "One very easy thing that we'll do is have the patient stand just on their right or left leg and we'll time it, and work on improving the time," Custodio said. "We might encourage them to slowly walk on a treadmill with one hand on the rail, and then slowly let go with the other hand, so they are gradually walking without holding on. Then, we might have them close their eyes so they're not just relying on their visual input but they're really testing their proprioceptive awareness."
Aside from these more function-oriented treatments, therapists at Winways have also had success with a method of repositioning certain inner ear structures, a technique called canalith or BPPV repositioning. "There are 'crystals' (otoconia) in association with a gelatinous mass deep inside the ear that help to detect one's head position in the presence of gravity. This has influence over one's sense of balance. If these structures are displaced, dizziness and balance disorders are common," Yarter explained. "A very quick, coordinated movement can be used to establish velocity in the ear canal. And through that movement, the associated positioning and gravity should help the crystals gravitate back to their normal anatomical positioning, greatly reducing symptoms within about a week."
While the technique is diagnosis-dependent and not for all patients, Yarter said that patients at both Winways and its affiliated hospital have shown very positive results from the treatment.
Working Toward Independence
While a functionally based PT treatment can improve the condition of many patients with TBI, it's unfortunate that managed care organizations won't pay for what PTs deem as the appropriate level of therapy. Particularly for such a complex injury like TBI, physical function is a difficult thing to quantify in order to convince insurers to reimburse for continued treatment. And while it might appear to insurers that patients have reached their peak from the lack of recent gains made, it is not always the case. "Often, you'll see a patient plateau, and they haven't made any significant gains for a while. But with any condition, there can be a plateau and then they will pick up again," explained Custodio. "So sometimes we have to try to ride them out through that plateau if we honestly believe they have the potential to do better. Other times, insurance will be the last word, and if they say there's no more funding, then we're stuck."
To deal with these restraints, therapists now must move through all stages of rehab as quickly as possible, and promote patient and caregiver education much more than in previous years. For some more involved cases, the highest level of independence may not be much greater than the condition at the onset of rehab, but the hope is that by working toward concrete, realistic goals, PTs can help their patients continue to lead productive lives. "We really take the patients' goals into consideration, and if their deficits are incongruent to those goals and thus unrealistic, we emphasize patient education and try to facilitate insight toward more realistic goals," Yarter concluded. "But what we're striving for is independence, at least within their home--that's really the key with many of the patients with brain injury we treat. Many times, if we can get them safe and independent within their home, then we've done a good job."
Mike Le Postollec is on staff at ADVANCE.