M. Motor Function and Control

Traumatic brain injury (TBI) can result in a wide range of motor/physical limitations including changes in muscle tone, disturbed balance and gait, contractures and reduced aerobic fitness. Moreover, many persons with TBI sustain orthopaedic or musculoskeletal injuries that need to be taken into account when providing interventions to improve motor function. Recommended treatment approaches emphasize balance/gait training, positioning, and exercise training for improved strength and endurance. Treatment approaches should encourage practice and repetition of functional tasks in and outside of formal therapy to optimize motor recovery and function. Positioning and use of medications can be helpful for the treatment of spasticity and contractures.

A trained health care professional with neurological expertise should assess, design, implement and supervise therapy to improve the motor functions of individuals with TBI. The interdisciplinary team should also include professionals with expertise in seating, orthotics and the prescription and fitting of assistive technology and devices as well as equipment to address the range of potential motor impairments/limitations. Persons with TBI should be treated in environments providing them the opportunity to experience upright positions early in their recovery (in the absence of refractory intracranial hypertension).

Indicators exemples

• Proportion of individuals with TBI for whom exercise training is included as an objective in the rehabilitation plan.

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Other Resources:

• Information on Botulinum Toxin injections – Dystonia Canada
• Physiopedia

Motor Function Control. When motor impairment is present post injury, the extent and timing of an individual’s symptoms and injuries should be considered when determining a course of action. Motor impairment can result from the independent effects of prolonged immobilization and bed rest in the acute period. Prolonged immobility affects multiple body systems, although it is the direct effects on the musculoskeletal system and the cardiovascular system that impact motor function the most (Bushbacher, 2000).

For select patients, constraint-induced therapy has been shown to improve upper extremity use but it requires a high level of adherence (Shaw et al., 2005). Constraint-induced therapy has been shown to improve the amount and quality of use of the upper limb (Motor Activity Log), as well as some functional improvements of the upper limb (Page & Levine, 2003; Shaw et al., 2005).

In order to improve fine motor control, there are retraining activities that should be considered after TBI. In a RCT byNeistadt (1994), fine motor coordination was examined in a group of adult men with brain injury using two types of coordination retraining activities: tabletop activities (i.e. peg board activities, puzzles etc.) and functional activities (i.e. meal preparation). Results indicated that functional activities were more effective than table top activities in promoting fine motor coordination.

To increase task specific performance post TBI, a number of repetitive training interventions have been studied. A RCT conducted by Canning et al. (2003) used intensive sit-to-stand training as an intervention, demonstrating increased ability to perform sit-to stand within a defined time frame. In a prospective study looking at balance training, Dault and Dugas (2002) noted a significant improvement in balance and coordination for a group that participated in a more specific balance and coordination training program rather than traditional muscular training. Virtual reality interventions have also been shown to be beneficial in improving balance. Ustinova, Perkins, Leonard, and Hausbeck (2014) had participants complete 15 sessions of virtual reality therapy and found that this intervention targeted the recovery of postural and coordination abnormalities, with significant improvements shown for balance and dynamic stability, as measured by the Berg Balance Scale, Functional Gait Assessment and Functional Reaching Test. Cuthbert et al. (2014) also demonstrated a significant improvement on balance using virtual reality therapy; however, the gains made using this intervention were not significantly different than those made with standard therapy. Finally, during static balance tasks, visual feedback provided using a Wii Balance board helped reduce weight-bearing asymmetry (Foo, Paterson, Williams, & Clark, 2013).

Based on the results of several RCTs, partial body weight supported treadmill training does not provide any added benefit over conventional training (Brown et al., 2005; Esquenazi, Lee, Packel, & Braitman, 2013;Wilson, Powell, Gorham, & Childers, 2006).

For individuals where contracture and deformity are progressive, casts, splints and passive stretching may be beneficial. For the upper extremities, Moseley et al. (2008) found patients receiving elbow serial casting showed a greater reduction in elbow contractures post treatment than individuals who received passive stretching; however, this improvement diminished quickly (mean reduction was 22°, then 11° one day later). Follow up assessments found no significant difference in improvements between the groups (Moseley et al., 2008). Range of motion has also been shown to improve with casting (Hill, 1994; Moseley, 1997; Pohl et al., 2002; Verplancke, Snape, Salisbury, Jones, & Ward, 2005). Preservation of functional range of motion is important to allow for future motor recovery.

Cardiorespiratory fitness should be promoted in the TBI population using exercise training. In a RCT, Hassett et al. (2009) found individuals assigned to exercise programs showed significant improvement in their cardiorespiratory levels regardless of where they worked out (in a gym or at home) or how often (2.4 sessions per week vs 0.5 sessions per week). However, adherence to the program was higher among those attending a fitness center. In a case-series study, when comparing individuals with TBI who exercised to those who did not, the exercisers were less depressed, had less symptoms and better self-reported health status than non-exercising brain injury survivors (Gordon et al., 1998). Furthermore, Bateman et al. (2001) compared cycling training (experimental group) to relaxation training (control group) and found significant improvement in exercise capacity for the experimental group.

Spasticity. A number of pharmacological therapies have been suggested to address the issue of spasticity in TBI. Intiso et al. (2014) examined the effects of Botulinum Neurotoxin-A (BoNT-A) and showed a reduction in spasticity for the upper extremity (elbow, wrist, and hand), as well as ankle joints at one and four months post treatment. These findings were similar to those found by Yablon, Agana, Ivanhoe, and Boake (1996) who reported that BoNT-A injections into the upper extremities improved range of motion and spasticity in 21 patients with ABI.

Meythaler, DeVivo, and Hadley (1996) confirmed the effectiveness of intrathecal baclofen in decreasing upper and lower extremity spasticity in a RCT cross-over trial. In subsequent studies, the same investigators went on to demonstrate the effectiveness of intrathecal baclofen for decreasing spasticity for up to three months (Meythaler, McCary, & Hadley, 1997) and 1 year (Meythaler, Guin-Renfroe, Grabb, & Hadley, 1999). Investigations carried out by other research groups have reported similar findings (Becker, Alberti, & Bauer, 1997; Dario, Di Stefano, Grossi, Casagrande, & Bono, 2002; Francisco, Hu, Boake, & Ivanhoe, 2005; Hoarau, Richer, Dehail, & Cuny, 2012; Posteraro et al., 2013; Stokic, Yablon, & Hayes, 2005). However, a common limitation of these studies is the lack of a control group.

Meythaler et al. (2001) completed a RCT cross-over trial examining tizanidine for the management of spasticity. This study evaluated both stroke (53%) and TBI (47%) survivors. For both upper and lower extremity, there was a significant decrease in the Ashworth scores on the affected side with the active drug compared to placebo. However, significant differences between treatments were not found for upper and lower extremity spasm and reflex scores ((Meythaler et al., 2001). In another mixed population study (brain injury and stroke), Meythaler, Clayton, Davis, Guin-Renfroe, and Brunner (2004) completed a retrospective study evaluating the use of oral baclofen to manage spasticity and found that it improved spasticity in the lower extremity assessed using the Ashworth Rigidity Scale and Spasm Frequency Scale; however, no changes for tone, spasm frequency or reflexes were found for the upper extremity (Meythaler et al., 2004).