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Physical therapy for correcting postural and coordination deficits in patients

with mild-to-moderate traumatic brain injury

Article  in  Physiotherapy Theory and Practice · August 2014

DOI: 10.3109/09593985.2014.945674 · Source: PubMed

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Physiother Theory Pract, Early Online: 1–7

! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2014.945674

QUALITATIVE RESEARCH REPORT

Physical therapy for correcting postural and coordination deficits in

patients with mild-to-moderate traumatic brain injury
Ksenia I. Ustinova, PT, PhD1, Ludmila A. Chernikova, MD, PhD2, Ann Dull, PT, DPT3, and Jan Perkins, PT, PhD1
1
Doctoral Program in Physical Therapy, Central Michigan University, Mount Pleasant, MI, USA, 2Research Center of Neurology, Russian Academy of
Medical Science, Moscow, Russia, and 3MidMichigan Health, Midland, MI, USA
Physiother Theory Pract Downloaded from informahealthcare.com by Central Michigan University on 08/01/14

Abstract Keywords
The purpose of this study was to test the effects of a conventional exercise program designed Ataxia, gait, motor recovery,
for correcting postural and coordination abnormalities in patients with mild-to-moderate neurorehabilitation, postural instability,
traumatic brain injury (TBI). Using principles of motor learning applied to functional exercise therapeutic exercises, traumatic brain
training, exercises were performed while lying, sitting, standing and walking, with the goal of injury
improving intra- and inter-limb coordination in the upper and lower extremities, postural
stability and gait pattern. Twenty-two participants with TBI-related deficits received therapy in a History
supervised outpatient clinic. Therapy included 20 sessions, each approximately 55 to 60 min in
duration, scheduled four to five times a week over four consecutive weeks. Each participant was Received 11 November 2013
evaluated with a battery of clinical tests at baseline and immediately after therapy. Upon Revised 25 March 2014
completion of the therapy, participants improved static and dynamic postural stability and gait, Accepted 24 May 2014
evaluated with the Berg Balance Scale (from 45.2 ± 5.9 to 49.2 ± 4.2 points) and the Functional Published online 1 August 2014
For personal use only.

Gait Assessment (from 22.8 ± 4.1 to 26.9 ± 3.4 points). They also reduced truncal, upper and
lower extremity ataxia, evaluated with the Ataxia Scale (from 7.3 ± 4.5 to 5.9 ± 4.2 points).
Results will be used to refine the current version of the exercise therapy, which focused on
whole body coordination and balance, and to design a large-scale clinical trial establishing
effectiveness of this intervention and for comparison with other forms of therapy.

Introduction been a primary target for evidence-based research, probably due

to the complexity of injury-related impairments and difficulties in
Impairments of postural control and motor coordination are
forming a relatively homogeneous experimental group. For
common and devastating consequences of traumatic brain injury
example, resulted from damage to the cerebellum, postural and
(TBI) (Arce, Katz, and Sugarman, 2004; Caeyenberghs et al,
coordination deficits may vary from person to person, and present
2010; Hoffer, Balough, and Gottshall, 2007; Perry, Woollard,
in different combinations. A series of studies in individuals with
Little, and Shroyer, 2014; Sartor-Glittenberg and Brickner, 2014)
cerebellar disorders by Morton and Bastian (2003, 2007) suggest
that may result in instability while standing and walking,
that limb ataxia and postural instability are the two distinct factors
abnormal gait pattern, disrupted arm–postural interaction during
that may either present concurrently or separately, thereby
reaching and grasping, lack of bilateral arm/leg coupling, poor
affecting their movement differently. Consequently, not many
manual precision or dexterity, reduced agility, difficulties with
evidence-based therapeutic concepts for physical rehabilitation
coordinating eye–head movement, and problems with visual
after brain injury exist.
tracking or focusing on a target (Dault and Dugas, 2002;
The treatment of postural and coordination abnormalities in
Kuhtz-Buschbeck, Stolze, Gölge, and Ritz, 2003; Sosnoff,
patients with TBI does not follow a single model. Mostly based on
Broglio, Shin, and Ferrara, 2011). If not treated, all these
the principles of task-dependency of human movements (Carr and
problems affect the quality of life in individuals with TBI by
Shepherd, 1998), traditional treatment programs incorporate
limiting their ability to work and participate in social and family
various ways of analyzing movement, identifying key impair-
activities, resulting in the high costs incurred with long-term
ments, and employing task-specific training and motor learning
disability (Thornhill et al, 2000). Thus, the treatment of post-
principles within the context of the patient’s goals, environmental
traumatic postural and coordination deficits warrants special
constraints and task requirements (Schenkman, Deutsch, and
consideration.
Gill-Body, 2006). In other words, a therapist has the flexibility to
Despite the importance of posture and motor coordination,
determine the overall approach to intervention as well as specific
individuals may not receive suitable therapy due to a lack of
outcomes, based on a patient’s unique presentation. Advantages of
understanding what types of interventions are most suited to
this integrated framework for decision making are not always
patients with TBI (Fulk, 2007). The TBI population has never
utilized to a full extent. For example, physical therapy interven-
tions may ignore the variability and complexity of whole-body
movements, and instead focus on the separate restoration of: gait
Address correspondence to Ksenia I. Ustinova, PhD, Doctoral Program in (Brown et al, 2005; Esquenazi, Lee, Packel, and Braitman, 2013);
Physical Therapy, Central Michigan University, Mount Pleasant, balance (Yan, 2008); and arm function (Page and Levine, 2003).
MI, USA. E-mail: ustin1k@cmich.edu Ultimately, such approaches may limit functional improvement in
 2 K. I. Ustinova et al. Physiother Theory Pract, Early Online: 1–7

patients with brain injury. Therefore, there is a need to develop
and test evidence-based physical therapy interventions for treat-
ment of postural and coordination abnormalities due to TBI.
To address this need, we designed the current study to test the
effectiveness of an exercise program for restoring postural
stability and whole body coordination in patients with TBI.
Coordination can be defined as an ability of the central nervous
system to initiate, continue and terminate activity of multiple
muscle groups at appropriate time (Bernstein, 1967). The Frenkel
coordination exercises (Danek, 2004; Edwards, 1996) were
chosen as a base exercise routine for the program. Frenkel’s
exercises were originally designed for the treatment of sensory
ataxia by establishing balance between eccentric and concentric
contractions while performing multi-joint movements of upper
and lower extremities. While performing these exercises, the
patient learns to establish slow, controlled and reciprocal multi-
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therapy began. Participants with TBI were admitted to the
program from local rehabilitation centers. A recruitment letter
was sent to physical therapists for dissemination among potential
participants. The letter explained therapeutic program and eligi-
bility criteria, and asked the potential participant to contact the
investigators if interested in the study. The eligibility criteria
included: a history of TBI sustained over 6 months previously
with a stable clinical status; an ability to stand unsupported for at
least 2 min; full or near-full active ranges of motion in major body
joints; normal or corrected to normal vision; injury-related mild-
to-moderate coordination abnormalities, involving upper and
lower extremities; postural instability; and an ability to follow
simple instructions. The coordination deficits were determined as
hypo or hypermetric extremity movements and lack of precision
during performance of the nose-to-finger or heel-to-shin tests.
Postural instability was determined from excessive body oscilla-

joint movements and stabilization. Frenkel’s exercises were
supplemented with other activities, such as using the Swiss ball
and rocker board. Our exercises emphasized temporal coupling of
multi-limb or multi-segmental motions. Patients were instructed
to perform movements of multiple body segments as simultan-
eously as possible. Exercises addressing postural stability were
accompanied by upper and lower extremity movements. In these
exercises, patients practiced controlling postural displacements
rather than attempting to stabilize static positions by trying to be
as motionless as possible.
The program was reviewed by a group of experienced
clinicians (two physical therapists and one neurologist) specializ-
ing in neurological rehabilitation, who confirmed that the content,
sequencing and amount of activities seemed to be reasonable and
For personal use only.
tions or other abnormal findings such as timing below expected
norms while standing in the Romberg position (i.e. standing with
feet together, arms outstretched forward, and eyes closed).
Screening for eligibility was performed by experienced physical
therapists.
Clinical and demographic data of the participants at admission
to the program are presented in Table 1. Severity of brain injury
was classified according to the modified Glasgow Coma Scale
score (GCS) (Teasdale and Jennet, 1974), taken in the first 24 h
after injury. The scale has been shown to be a valid and reliable
measure of brain injury severity (Fulk, 2007). Of 22 patients,
15 patients had moderate TBIs, with GCS scores ranging from
9 to 13 points, and 4 patients presented with mild TBIs with score
413 points. Three patients’ initial GCS were not included in

consistent with the treatment goals of restoring postural and motor
control. We hypothesized that the designed exercise program
would be effective in correcting chronic postural and coordination
abnormalities in patients with mild-to-moderate TBI.
Methods
Subjects
This study included 22 individuals (9 females) who had sustained
brain injury as a result of trauma about 8 to 47 months before
admission chart, because of complicating issues such as a
prolonged medically induced coma due to multiple bone fractures.
All participants had mild-to-moderate impairments of gait,
postural control and upper extremity movements, with clinical
test scores ranging from: (1) 33 to 53 points on the Berg Balance
Scale (BBS) (Berg, Wood-Dauphinée, Williams, and Maki, 1989),
with 545 points indicating an increased fall risk (Newstead,
Hinman, and Tomberlin, 2005); (2) 16 to 27 points on the
Functional Gait Assessment Test (FGA) (Wrisley, Marchetti,
Kuharsky, and Whitney, 2004), with 522 points indicating an

Table 1. Demographic data and pre-treatment clinical scores of patients with TBI.

# Gender, F/M Patient age Time since TBI (months) GCS initial BBS FGA Ataxia FIM
x
S1 F 28 21 13 42 19 17 99
S2x M 26 47 Unknown 33 16 18 56
S3 M 45 39 12 49 26 9 97
S4 F 39 28 9 51 27 3 118
S5 M 21 11 11 43 24 9 75
S6 M 21 9 10 52 28 6 96
S7 F 36 14 15 53 27 2 117
S8 M 25 17 11 51 28 3 102
S9 M 37 18 12 49 23 4 96
S10*x M 36 39 12 43 21 3 102
S11* M 34 11 9 45 18 10 94
S12*x F 18 22 11 37 19 9 69
S13* M 33 13 Unknown 43 20 8 88
S14* F 21 26 14 52 28 5 91
S15*x M 29 41 10 42 23 1 65
S16* M 19 10 10 35 17 12 58
S17*x F 22 37 9 40 19 6 93
S18x M 31 8 Unknown 39 18 11 62
S19 F 44 34 11 51 25 6 114
S20 F 34 27 13 52 27 2 109
S21 F 18 15 11 46 24 9 75
S22 M 25 33 10 48 26 8 83

*Participants had mild paresis and/or spasticity in upper or lower extremities.

x
Participants used assistive device or required supervision during walking.
 DOI: 10.3109/09593985.2014.945674
increased fall risk (Wrisley and Kumar, 2010); and (3) 1 to 18
points on the Klockgether’s Ataxia Scale (Klockgether, Schroth,
and Diener, 1990), with 35 points identifying severe ataxia.
No participant displayed severe cognitive or behavioral impair-
ment sufficient to restrict therapeutic practice with all scoring
420 points on the Mini-Mental State Examination (MMSE)
(Folstein, Folstein, and McHugh, 1975).
Of the 22 participants, 2 participants lived independently,
whereas 20 required supervision or assistance in performance of
activities of daily living. Scores on the Functional Independence
Measure (FIM) (Donaghy and Wass, 1998; Linacre et al, 1994)
ranged from 56 to 117 points. Most participants demonstrated full
or nearly full active upper extremity range of motion.
None had severely increased muscle tone, and all had normal or
corrected-normal visual acuity. Eight participants (#10–17)
had mild hemiparesis and/or spasticity affecting the upper
Physiother Theory Pract Downloaded from informahealthcare.com by Central Michigan University on 08/01/14
and lower extremities. Most participants received concurrent
pharmacological or speech therapy. All participants signed
an informed consent form, prepared in accordance with
the Helsinki Declaration and reviewed by the local ethics
committee.
Exercise program
The exercise program consisted of a series of therapeutic
exercises for retraining whole-body coordination, posture and
gait. Whole-body coordination was considered to be the ability to
initiate, continue and terminate movements of several
body segments simultaneously. A coordination exercise might
involve synchronous movement of both arms or legs, of a
For personal use only.
contralateral arm and leg, or limb and trunk. Exercises were
performed while lying, sitting, standing and walking, with the
contents and goals briefly described in Table 2. Therapy included
eye movements and eye–head coordination exercises, which were
performed initially in a sitting position. Participants first
performed activities while sitting, then while standing and
walking.
Before the exercise therapy program began, an experienced
physical therapist evaluated each patient’s physical capacity to
establish a baseline for the practice length and task difficulty.
Practice during the first several sessions did not exceed
30–40 min. Session length was gradually increased to 55–
60 min, as the patient’s condition permitted. In parallel to the
dosage increase, whenever a participant demonstrated stability of
exercise performance for three consecutive trials, the difficulty
level during the next session was increased by adding another
coordination component (e.g. performing movements with arms
while standing or walking, challenging stability by pushing
forward or reducing base of support while walking, and slowing
down the eccentric–concentric exercises while lying). Stability of
exercise performance was defined as a patient’s ability to
successfully repeat the exercise without physical assistance and
with minimum variability.
A variable practice format was used. During the first several
sessions, all exercises were demonstrated and explained in detail.
The explanations included information on correct initial and final
position of the body or body part, movement amplitude and speed.
Patients were instructed to perform all upper and lower extremity
movements slowly with a large amplitude, and with minimum
deviation from the shortest trajectory between the initial and final
positions. The exercises involving movement or more than one
body part required simultaneous rather than sequential motion of
the parts involved, forcing inter-segmental coordination. During
performance of the exercises in standing and walking, patients
were encouraged to use parallel bars for support as much as
needed at the beginning of the program, with eventual reduction
Postural and coordination deficits in patients with brain injury
of the use of support by the end. During walking, patients were
instructed to use reciprocal arm-leg swinging and to maintain
constant step frequency and amplitude. Arm–leg coordination is
frequently disrupted in patients with acquired brain injuries
(e.g. stroke), and this discoordination increases as gait
speed increases (Bovonsunthonchai et al, 2012). Controlled arm
swing during walking enhances gait stability, improves ability to
resist perturbation and changes muscle activation pattern in
healthy and stroke individuals (Bruijn, Meijer, Beek, and
Van Dieën, 2010; Hu et al, 2012; Stephenson, Lamontagne, and
De Serres, 2009). For this reason, reciprocal arm–leg swinging
was emphasized in our program. Verbal feedback on the exercise
performance, accompanied by demonstration when necessary,
was given to the participants between trials. Once patients
mastered the exercise performance, the frequency of feedback was
faded.
The exercise program was delivered individually during the
first 2–4 sessions to familiarize patients with the approach.
Subsequently, practice was done in a group of three participants,
supervised and assisted as needed by an experienced physical
therapist. During individual and group sessions, participants
performed similar exercises. However, the task difficulty was
increased, while the level of assistance was decreased during
group practice. The program included 20 sessions, 30–40 min
each at the start of rehabilitation, increasing to 55–60 min, as the
patient became familiar with the program and tolerance increased.
These were scheduled four to five times a week over four to five
consecutive weeks. All sessions were carried out in an outpatient
neurological center.
Clinical assessment
Effects of the exercise program on body function and structure,
and activity limitations were evaluated with a battery of clinical
tests. The tests (primary outcomes) included the Ataxia Scale,
BBS, FGA and FIM. Tests were administered three times: twice at
baseline (PRE-TEST0 and PRE-TEST) with approximately
2-week intervals between tests and immediately after therapy
(POST-TEST). The PRE-TEST0 evaluation was conducted before
admission to the outpatient clinic, whereas the PRE-TEST was
performed in the clinic before the exercise program began. Two
evaluations ensured stability of injury-related motor and func-
tional deficits, considering that no control group was included in
the study. All pre- and post-assessments were performed by the
same experienced physical therapist, who was not involved in the
intervention.
Statistical analysis
Normality of data distribution was verified with the
Kolmogorov–Smirnov test (p40.5). Primary and secondary
outcomes recorded during the PRE- and POST-TEST periods
were compared with a paired t test, and effect sizes were
calculated with standard means. The significance level was set at
p50.0125 after Bonferroni correction for multiple comparisons
was applied.
Results
All patients were tested twice before they began the exercise
program. Slight variations were observed in pre-test scores on the
FGA (PRE-TEST0 22.9 ± 4.7 versus PRE-TEST 22.8 ± 4.1), and
on the Ataxia Scale (PRE-TEST0 7.3 ± 6.5 versus PRE-TEST
7.3 ± 4.5). These differences were not significant (p40.05), and
no significant changes were found between the two other baseline
test administrations. All 22 participants completed the exercise
program and the PRE-TEST and POST-TEST assessments.
 4 K. I. Ustinova et al. Physiother Theory Pract, Early Online: 1–7

Table 2. Content of the exercise program.

Instructions Therapeutic goals

Exercises while lying on a mat (1–2 min each; max 10 min)
1. Bend one leg at the hip and knee, straighten and then repeat with the To improve: (1) multi-segmental coordination; (2) sitting balance; (3)
other leg. body awareness; (4) range of lower extremity movement; (5)
2. Raise one leg up simultaneously with the contralateral arm, bring back movement precision; (6) eye-head and eye-hand coordination and
and then repeat with the other arm and leg. (7) to reduce intention tremor.
3. Bend one leg at the hip and knee, place that heel on the opposite knee
and repeat with the other leg.
4. Bend both legs and straighten them back, while keeping the ankles
together.
5. Make bicycling motions.
Exercises while sitting on a chair with feet flat on the floor (1–2 min each;
max 10 min)
1. Mark time, raising the heel. Progress to alternatively lifting the entire
foot and placing it on the floor on a foot print. Add alternating arm
movements.
Physiother Theory Pract Downloaded from informahealthcare.com by Central Michigan University on 08/01/14

2. Make two cross marks on the floor and alternatively glide the foot over;
forward/backward, left/right.
3. Rise from the chair, and then sit down in coordinated manner.
4. Perform reciprocal flexion-extension of the arms and legs, imitating
walking while sitting.
5. Using a stick or ball for the upper extremities, coordinate movements of
the upper and lower extremities.
6. Follow a moving object with the eyes and head for eye-hand
coordination.
7. Sit on the Swiss ball slowly rocking from side to side, back and forth
8. Bend trunk to the left and right to touch the ground.
9. Sit on the Swiss ball while holding stick at the level of chest, rotate
slowly clockwise and counterclockwise.
10. Sit-stand from the Swiss ball.
Exercises while standing erect with feet apart (2 min each; max 20 min)
For personal use only.

1. Stand still on the floor, with or without support. To improve: (1) static and dynamic balance during double and single
2. Stand still on the rocker board, with or without support. stance, and walking; (2) agility; (3) gait pattern; (4) arm-leg
3. Transfer weight onto the front, back and sides, narrowing the support coordination during walking; (5) gait initiation, termination and
surface. walking with different bases of support
4. Stand in tandem position; add alternating arm movements.
5. Stand on one leg; with and/or without arm movements.
6. Turn to the right, raise the right toe and rotate the right foot outward,
pivot on the heel, raise the left heel and pivot the left leg inward on the
toes, and complete the turn.
Exercises while walking (2 min each; max 15 min)
1. Walk sideways, beginning with half steps to the right, bring the left foot
over and repeat on the other side.
2. Walk forward between two parallel lines 14-inches apart.
3. Walk forward, placing each foot on a footprint traced on the floor
2-inches from a center line.
4. Walk up and down the stairs one step at a time, placing one foot on
each step, with and without a railing.
5. Walk to the side with legs crossing over during each step.
6. Walk backward.
7. Walk by performing a series of short lunges.
8. Walk on the toes or heels.
9. Walk with unexpected pushes to the side, forward or backward.

Not all exercises are presented in the table, and the content of the therapy might vary slightly from patient to patient.

They all reported subjective improvements in their motor and

functional abilities, with individual variation in the extent of
self-reported improvement. Upon completion of the program,
participants demonstrated improved balance and gait, reduced
ataxia symptoms and increased functional independence levels
(Figure 1). Static and dynamic balance improved from 45.2 ± 5.9
to 49.2 ± 4.2 points on the BBS (p ¼ 0.011; effect size ¼ 0.36).
Gait showed improvements from 22.8 ± 4.1 to 26.9 ± 3.4 points
on the FGA (p ¼ 0.009; effect size ¼ 0.47). Ataxia symptoms
decreased from 7.3 ± 4.5 to 5.9 ± 4.2 points on the Ataxia Scale
(p ¼ 0.012; effect size ¼ 0.15). Although not significant, a
tendency to increased functional independence on the FIM scale
was observed in most participants, with the FIM score increasing
from 89 ± 18 to 94 ± 24 points.
Discussion
The results of the current study confirmed the effects of the
exercise program for restoring postural control and coordination
after TBI. As a result of a 20-session physical therapy intervention
focused on whole body coordination exercises and activities, most
of our patients had improved their postural stability, gait, and
upper and lower extremity coordination by 8–19%, with a small-
to-moderate size effect. They also demonstrated a trend towards
improved performance of activities of daily living.
Changes on two of the three primary clinical measures neared
or exceeded minimal detectable changes (MDCs) established for
the tests in patients with traumatic and acquired brain injuries.
Postural stability improved on the BBS test by 4 points, exceeding
 DOI: 10.3109/09593985.2014.945674
Berg Balance Scale (BBS)
56
*
48
40
M±SD points
32
24
16
8 20
0 0
PRE-TEST POST-TEST
Functional Gait Assessment (FGA)
Physiother Theory Pract Downloaded from informahealthcare.com by Central Michigan University on 08/01/14
30 *
25
M±SD points
20
15
10
5 2
0 0
For personal use only.
PRE-TEST POST-TEST
Figure 1. Mean ± standard deviation (SD) of the clinical scale scores on PRE-TEST and POST-TEST evaluations. *Significant difference between
PRE-TEST and POST-TEST scores.
the highest MDC of 3.83 points reported for patients with brain
injury (Newstead, Hinman, and Tomberlin, 2005). Assessed with
the FGA test, gait improved by 4.1 points. The MDC scores for
this scale range from 4.2 points in a stroke population to 8 points
for patients with vestibular disorders (Lin et al, 2010). Patients
demonstrated some positive changes on the Ataxia Scale. These
changes were more difficult to interpret. First, MDC values are
not available for this scale. Second, a possibility of learning effect
cannot be completely eliminated, as in any other study testing
patients with the same scales several times. Our patients might
learn how to control ataxia not necessarily by normal balance of
eccentric and concentric control, but rather by learning to
co-contract agonist and antagonist muscles to stabilize trunk or
extremity. Although useful for postural control, this strategy may
not be helpful during performance of fast alternating bilateral
movements. Overall, the Ataxia Scale score change of 1.4 points
is consistent with our previous studies, which showed a decrease
in ataxia symptoms in patients with chronic TBI after practicing
10–15 sessions of virtual reality game-based therapy (Paavola,
Oliver, and Ustinova, 2013; Ustinova, Perkins, Leonard, and
Ingersoll, 2013). Similar to the primary clinical outcomes,
positive changes were observed in the secondary outcomes
measuring activities of daily living. The positive change of
19 points on the FIM scale did not exceed the clinical MDC of
22 points established for patients with stroke as an acquired brain
injury (Beninato et al, 2006). We acknowledge that application
of MDC values established primarily for patients in the acute
stage of their condition may not be considered as valid with
patients with chronic abnormalities, such as seen in our study
population.
Postural and coordination deficits in patients with brain injury
Functional Independence Measure (FIM)
120
100
80
60
40
PRE-TEST POST-TEST
Ataxia Scale
12
*
10
8
6
4
PRE-TEST POST-TEST
It is important to mention that post-therapy improvements in
our patients were much more modest than therapeutic outcomes
reported in other studies. For example, patients with TBI involved
in a case series by reported Sartor-Glittenberg and Brickner
(2014) improved their postural stability on the BBS test by 17–19
points after receiving individualized multidimensional physical
therapy intervention program. Both studies utilized a similar
therapeutic approach to treat different aspects of coordination
abnormalities. However, multidimensional physical therapy was
much more individualized. Coordination exercises were comple-
mented by the use proprioceptive neuromuscular facilitation for
muscle strengthening and neurodevelopmental techniques, which
includes manual assistance and cuing. The individuals in the
previous study had severe motor impairments, including cerebel-
lar ataxia, and received more therapeutic sessions ranging from
89 to 187. Our patients had mild and moderate TBIs, and motor
impairments associated with these injuries, that positioned them
closer to the ceiling scores thereby leaving much smaller room for
improvements. These factors may explain inconsistency of our
results with this other reports.
Sixteen of 22 patients in our study had brain injury onset more
than 12 months. A longitudinal multicenter study by Walker and
Pickett (2007) showed that motor recovery after injury usually
slows after the first 6 months and plateaus by 12 months. Thus,
post-therapy improvements in our patients and especially in those
more than 1-year after injury onsets may be attributed to
functional and/or structural changes in the brain associated with
motor learning. During the 4-week practice period, patients
learned several very important skills. Specifically, they learned to
perform slow, controlled and reciprocal multi-joint movements of
 6 K. I. Ustinova et al.
the upper and lower extremities. This learning likely helped to
reduce limb ataxia by establishing balance between eccentric and
concentric contractions, thereby reducing limb inertia and
stabilizing the extremity during the motion. Postural stability
was practiced in sitting and standing by perturbing balance
internally or externally. Internal perturbation included: transfer-
ring weight to the front, back and sides; narrowing the base of
support; and standing in a tandem position or single-leg stance
and performing functional arm movements. External perturb-
ations were applied by the therapist, by pulling and pushing the
patient in different directions. Dynamic stability was also trained
during walking. Patients walked on two narrow lines, in a tandem
or backward gait, slowed or sped up their gait, stopped or turned
in response to sudden directions, and performed flexion, exten-
sion, and left-right rotations of the head.
In two-thirds of our participants, postural dysfunctions were
Physiother Theory Pract Downloaded from informahealthcare.com by Central Michigan University on 08/01/14
accompanied by dizziness. Repetitive and progressively more
difficult coordination movements of the eyes and head were
applied to reduce head motion sensitivity and to facilitate
sensory adaptation and/or substitution (Dix, 1979). These
movements, known as gaze stabilization movements or
Cawthorne and Cooksey exercises, are used to treat vestibular
or vestibulocerebellar dysfunctions in various patient populations
(Corna et al, 2003; Jáuregui-Renaud, Villanueva Padrón, and
Cruz Gómez, 2007).
Skill acquisition was facilitated during the practice by applying
major principles of motor learning (Sullivan and McCulloch,
2013). Motor learning principles included: eventual progression
from easy exercises performed during sitting to more difficult
exercises while standing and walking; variable practice; and the
For personal use only.
use of feedback incorporating both knowledge of results and
knowledge of performance, with feedback frequency tapered off
towards the end of practice. These approaches reportedly induce
relatively permanent changes in motor behavior, recognized as
learning (Schmidt and Lee, 2011). For example, the above-
mentioned gaze stabilization exercises were performed by our
patients first during sitting, and then made more challenging with
performance in standing as patients progressed. Skills learned
during practice were successfully transferred to the performance
of the motor and functional tasks included in the test measures.
This finding is indirect evidence that the mechanisms of motor
learning remain intact after brain injury affecting multiple brain
structures.
Limitations
Along with our positive results, the study has some acknowledged
limitations. The subject pool was represented by a small and
relatively heterogeneous group of patients with chronic condi-
tions, each with unique sensorimotor and cognitive deficits. As we
deliberately chose to study persons with a history of TBI, this
aspect is an unavoidable feature of the population from which our
sample was drawn. There was a wide range of time since injury
onset of our participants which limits conclusions on whether
post-therapy improvements were attributable to spontaneous
recovery or motor learning. Another limitation is the lack of a
control group in this baseline study. Further large-scale controlled
clinical trials are required to establish effectiveness of the exercise
program, designed for correcting postural and coordination
abnormalities in patients with mild-to-moderate TBI.
Conclusion
The participants in this study were patients with post-TBI mild-
to-moderate coordination, balance and gait impairments and
activity limitation. Upon completion of 20 sessions of the
specially designed exercise therapy, participants improved static
Physiother Theory Pract, Early Online: 1–7
and dynamic postural stability and gait, and reduced truncal,
upper and lower extremity ataxia. Results will be used to refine
the current version of the therapy and to design a large-scale
clinical trial to validate this conventional therapeutic technique so
that it can be used as a reference measure of therapeutic
effectiveness when compared with other rehabilitation
approaches.
Declaration of interest
The authors report no conflicts of interest.
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