Effects of An Intensive Exercise Program on Fitness and Function for People with Long Term Brain Injury

Ann L. Charrette PT DPT MS PCS NCSLaura S. Lorenz, PhD, MEd, CBISJeffrey Fong, PharmD, BCPSKaren S. Lamson, MLS Therese O’Neil-Pirozzi, ScD, CCC-SLPMichelle Demore-Taber, ScD, LRC, CBIS

Effects of An Intensive Exercise Program on Fitness and Function for People with Long Term Brain Injury

oWhy Exercise MattersoChronic Brain Injury and Exerciseo Supportive Living Inc, SLI Context:

Peter Noonano Study Methods o Intervention AccesSportAmerica:

Ross LilleyoResultsoDiscussion/ Conclusions

o Exercise Participant Peter CoNext StepsoQ and A

Why EXERCISE Matters!

• Exercise is good for you!

• Exercise as medicine

https://www.youtube.com/watch?v=aUaInS6HIGo

Healthy People 2020 Overarching Goals

1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.

2. Achieve health equity, eliminate disparities, and improve the health of all groups.

3. Create social and physical environments that promote good health for all.

4. Promote quality of life, healthy development, and healthy behaviors across all life stages.

Exercise with Individuals with chronic brain injury

• Exercise has been proven to be good for individuals with disabilities but the TBI population has not been studied extensively• Adults with chronic brain injury living in a

community setting have not been studied

Wise EK, Hoffman JM, Powell JM, BombardierCH, Bell KR. Benefits of exercise maintenance after traumatic brain injury. Arch Phys Med Rehabil. 2012;93(8):1319-1323.

Wise study CONCLUSION:Exercise may contribute to improvement in mood and quality of life for people with TBI and should be considered as part of the approach to depression treatment.

Fogelman D, Zafonte R. Exercise to enhance neurocognitive function after traumatic brain injury. PM and R. 2012;4(11):908-913.

Fogelman study CONCLUSION:

“Clinical trials that evaluate exercise as an intervention after severe and moderate TBI are needed in the subacute and chronic periods after injury.”

Our Research Question

What changes will we observe for persons who are long term survivors of brain injury and living in a community setting, after intensive exercise?

PETER NOONANExecutive Director of SLI

https://www.youtube.com/channel/UCDE5sWF2qgLNgPm4ky6vVaA?feature=watch

Sample

14 Individuals who reside in SLI residential settings and who meet the inclusion criteria: • can stand independently or with only

minimal assistance • can walk with or without ambulation

device and/ or bracing• have an interest in exercise• available for 1½ hours on Mon, Wed and

Fri for 6 weeks

AGE Years since ABI

gender specific brain injury extremities involved functional status

42 16 M TBI X 2 Right sided weakness assisted ambulatory, WC user

48 30 M TBI BUE and BLE assisted ambulatory with rolling walker, WC user

46 44 M TBI Right side weakness assisted ambulatory with quad cane, WC user

27 17 M multiple CVA Bilateral weakness ambulates with walker short distance, WC user

55 24 M CVA X 2 Left side ambulatory with quad cane, WC user

56 15 F TBI and substantial ortho injuries

Bilat. LE’s ambulatory short distance with walker, WC user

53 8 M TBI LUE and LLE ambulates with quad cane, WC user

45 24 M anoxic encephalopathy Bilateral weakness ambulatory with ataxic gait

50 31 M brain tumor Kyphotic posture ambulatory with rolling walker

37 5 M TBI BLE/ RUE ambulatory

30 8 M CVA Left side neglect ambulatory

51 34 F TBI LLE ambulatory

46 13 M TBI - ambulatory

41 19 M TBI - community ambulatory

Measures

6MWT- Six Minute Walk Test• measure of endurance

Gait speed• speed of walking

HiMAT- High Level Mobility Assessment Tool• advanced motor skills

POPS- Participation Objective, Participation Subjective• Participation in Life Activities

Self-Efficacy Scale

Research DesignProspective, non-randomized, unblinded interventional trial • Utilizing a before and after intervention

comparison

Statistical analysis: •Wilcoxon signed ranks test • SPSS 21.0

Pre- TestINTERVENTIO

N Post-testAt 6 weeks

At 12 weeks

6MWT 6MWT 6MWTGait speed Gait Speed Gait SpeedHiMAT HiMAT HiMAT

POPS POPS POPSSelf-efficacy scale

Self-efficacy scale Self-efficacy scale

Description of the intervention

Ross LilleyExecutive Director and Founder

http://accessportamerica.org/

“The biggest human temptation is to settle for too little.” Thomas Merton

Results

Baseline(n=14)

After(n=14)

6 weeks follow up (n=14)

6MWT (feet) median (IQR)

431 (87, 1294)

1016*

(298, 1876)712*

(281, 1566)Gait Speed (m/sec)

median (IQR)

0.59(0.25, 1.50)

1.11*

(0.53, 1.96)1.10*

(0.46, 1.77)

HiMAT median (IQR)

3.5 (1, 27)

9*

(3.75, 33)8*

(2.75, 29)

6MWT= 6 minute walk test, HiMAT=High Level Mobility Assessment Tool. IQR= interquartile range, *= denotes statistical significant comparison against baseline p<0.05

Comparison of measures over 6 week study period

Clinically Significance in Change in 6MWT

Eng et al, 2004, Chronic Stroke, MDC = 112.76 feetOur data:

Chronic Stroke: (Eng et al, 2004) MDC = 112.76 feet

Baseline(n=14)

After(n=14)

6 weeks follow up

(n=14)

6MWT (feet) median (IQR)

431 (87, 1294)

1016*

(298, 1876)712*

(281, 1566)

*= denotes statistical significant comparison against baseline p<0.05

Clinically Significant Change in Gait Speed

Baseline(n=14)

After(n=14)

6 weeks follow up

(n=14)Gait Speed (m/sec)

median (IQR)

0.59(0.25, 1.50)

1.11*

(0.53, 1.96)1.10*

(0.46, 1.77)

*= denotes statistical significant comparison against baseline p<0.05

TBI: (Watson et al, 2002) Change in performance of > 0.05 seconds is greater than rater error

Clinically Significant Changes in HiMAT, High Level Activity Measure

Baseline(n=14)

After(n=14)

6 weeks follow up

(n=14)HiMAT

median (IQR)3.5

(1, 27)9*

(3.75, 33)8*

(2.75, 29)

*= denotes statistical significant comparison against baseline p<0.05

Chronic TBI: (Williams et al, 2006)MDC = increase of 4 points or decrease of 2 points on the total score of the HiMAT

Discussion

Individuals living with chronic brain injury can significantly improve:• Endurance• Home ambulator to community ambulator• Ability to do advanced gait

with 6 weeks of exercise!

Discussion

Individuals living with chronic brain injury at a range of levels can significantly improve with 6 weeks of exercise!

Peter C’s data

BASELINE POST INTERVENTION

6 WEEKS AFTER INTERVENTION

6MWT 243 feet 393 feet 385 feet

GAIT SPEED .29 m/sec .5 m/sec .42 m/sec

HiMAT 1 4 4

Our conclusions

Exercise improves function even when the individual is in a chronic state.

• Can payers be motivated to cover this type of therapeutic intervention?• How do we sustain these programs if they are not

covered by health care payers?

More Questions

Does the way the exercise was delivered influence the results?• AccesSportAmerica

What are some ways that physical therapists could incorporate intense fitness in their work?

How can we foster collaboration between Physical Training, Recreation Specialists and Physical Therapy?

What if any impact do fitness changes have on the residents daily lives?

Next steps

• Analyze POPS and self-efficacy data

• Qualitative study investigating impact of fitness improvements and supports and barriers to continued exercise among the participants

• Can we observe similar types of changes in a new population- individuals living with chronic brain injury who are currently not ambulating?

• Study to investigate the impacts on health and healthcare utilization, or exercise as medicine;

SLI’s wellness approach

References• Brown M, Dijkers M, Gordon W, Ashman T, Charatz H, Cheng Z. Participation objective, participation subjective: a measure of

participation combining outsider and insider perspectives. J Head Trauma Rehabil. 2004;19(6):459-481.• Chen G, Gully SM, Eden D. Validation of a new general self-efficacy scale. Organizational Res Methods. 2001;4(1):62-83. • Durstine J, Moore G, Painter P, Roberts S. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. 3rd Ed.

Champaign, IL: Human Kinetics; 2009.• Eng JJ, Dawson AS, Chu KS. Submaximal exercise in persons with stroke: test-retest reliability and concurrent validity with maximal

oxygen consumption. Arch Phys Med Rehabil. 2004;85(1):113-118.• Fogelman D, Zafonte R. Exercise to enhance neurocognitive function after traumatic brain injury. PM and R. 2012;4(11):908-913.• Hassett L,Moseley AM, Tate R, Harmer AR. Fitness training for cardiorespiratory conditioning after traumatic brain injury. Cochrane

Database Sys Rev. 2008;(2):CD006123. doi:10.1002/14651858.CD006123.pub2.• Hassett LM, Moseley AM, Whiteside B, Barry S, Jones T. Circuit class therapy can provide a fitness training stimulus for adults with

severe traumatic brain injury: a randomised trial within an observational study. J Physiother. 2012;58(2):105–112.• Hellweg S, Johannes S. Physiotherapy after traumatic brain injury: a systematic review of the literature. Brain Inj. 2008;22(5):365–

373.• Mossberg K, Amonette W, Masel B. Endurance training and cardiorespiratory conditioning after traumatic brain injury. J Head

Trauma Rehabil. 2010;25( 3):173–183.• Mossberg K, Ayala D, Baker T, Heard J, Masel B. Aerobic capacity after traumatic brain injury: comparison with a nondisabled cohort.

Arch Phys Med Rehabil. 2007;88(3):315-320.• Mossberg K , Fortini E. Responsiveness and validity of the six-minute walk test in individuals with traumatic brain injury. Phys Ther.

2012; 92(5):726-733.• van Loo MA, Mosleley AM, Bosman JM, de Bie RA, Hassett L. Inter-rater reliability and concurrent validity of walking speed

measurement after traumatic brain injury. Clin Rehabil. 2003;17(7):775-779.• Watson MJ. Refining the ten-metre walking test for use with neurologically imparied people. Physiotherapy. 2002;88(7):386-397.• Williams G, Robertson V, Greenwood K. Measuring high-level mobility after traumatic brain injury. Am J Phys Med Rehabil.

2004;83(12):910–920. • Williams GP, Greenwood KM, Robertson VJ, Goldie PA, Morris ME. High-Level Mobility Assessment Tool (HiMAT): interrater

reliability, retest reliability, and internal consistency. Phys Ther. 2006;86(3):395-400.• Wise EK, Hoffman JM, Powell JM, Bombardier CH, Bell KR. Benefits of exercise maintenance after traumatic brain injury. Arch Phys

Med Rehabil. 2012;93(8):1319-1323.

Q and A