Postural responses after utilization of a computerized biofeedback based intervention aimed at improving static and dynamic balance in traumatic brain injury: A case study

Abstract

Balance dysfunction is one of the most disabling aspects of Traumatic Brain Injury (TBI). Without rapid transmission and accurate perception of somatosensory inputs, the automatic postural responses required during standing may be delayed or absent after TBI which can lead to instability. Further, the sensitivity level to which environmental perturbations can be detected is also vital, as the central nervous system will only employ balance control strategies when it perceives a change in equilibrium. Such undetectable perturbations, however small they may be, can result in fatal falls, especially after TBI. In this investigation we used a novel computerized biofeedback based (CBB) intervention aimed at improving perception of external perturbations, and static and dynamic balance in a single male participant with severe TBI. We used an adaptive single interval adjustment matrix (SIAM) protocol to determine the perception of perturbation threshold (PPT) at baseline (1 day pre-intervention) and follow up (1 day post-intervention). External perturbations were provided through sinusoidal translations of 0.5 Hz to the base of support in anterior-posterior direction. Outcome measures included PPT, the Berg balance scale (BBS) and bilateral surface electromyography (EMG) of the lower limbs at baseline and follow up. PPT assessment post intervention showed a decrease in PPT, suggesting an improvement in the ability (gain of 0.42 mm) to detect (even smaller) perturbations which were not perceivable prior to the intervention. There was a significant increase in BBS (6 points) at follow up. The participant demonstrated increased muscle activation for the right gastrocnemius, left soleus, right bicep femoris and left vastus lateralis muscles at follow up. This investigation demonstrate the potential use of the CBB intervention for improving interpretation and organization of multisensory information in a task specific environment to improve balance dysfunction post TBI.

Evaluating Sensory Acuity as a Marker of Balance Dysfunction After a Traumatic Brain Injury: A Psychophysical Approach

“…Though these tests provide an objective way to quantify sensory integration, the sensory acuity to external perturbations and its relation to balance function still remains to be studied in individuals with TBI. Further, sensory acuity in terms of detection threshold assessments to the whole-body stimuli have been reported ( Fitzpatrick and McCloskey, 1994 ; Richerson et al, 2003 , 2006 ; Puntkattalee et al, 2016 ), however limited data exists for individuals with TBI ( Pilkar et al, 2016 ; Tanis et al, 2018 ). For the first time, a classical psychophysical approach was used to determine sensory acuity in terms of PPT in a sample of individuals with impaired balance.…”

“…At the end of each trial, the participant was verbally asked if they felt the platform move. Depending on the correctness of their yes or no response (HIT: correctly detected perturbation, MISS: non-detected perturbation, Correct Rejection: correctly reported no perturbation and False Alarm: perturbation reported for a non-perturbation trial), the amplitude of the next trial was adjusted using the Single Interval Adjustment Matrix (SIAM) algorithm with parameter estimation by sequential testing (PEST) ( Taylor, 1967 ; Kaernbach, 1990 ; Pilkar, 2011 ; Pilkar et al, 2016 ). The process is shown in Figure 1 using the numbered sequences from 1 to 6.…”

“…Most of the research on assessing balance deficits after a TBI is restricted to biomechanical [CoM, center of pressure (CoP)] and functional outcome measures ( Lehmann et al, 1990 ; Kaufman et al, 2006 ) and no research has reported psychophysical outcomes such as detection thresholds in individuals with TBI. The detection threshold quantifies the level of the external perturbation (magnitude, frequency, velocity, direction) below which the perception of the perturbation becomes unlikely ( Pilkar, 2011 ; Pilkar et al, 2016 ).…”

The effects of video game therapy on balance and attention in chronic ambulatory traumatic brain injury: an exploratory study

“…Focusing on specific gait therapies, body weight-support training on a treadmill (BWSTT) was not found to be superior to overground walking [5] or different robotic devices [6]. Other approaches that have been explored include the use of a biofeedback device to improve perception of external perturbations [7], vestibular rehabilitation [8] or a combination of cerebellar intermittent theta burst stimulation (iTBS) and physiotherapy [9]. Nevertheless, this state-of-the-art work in balance rehabilitation in TBI cannot be translated into useful evidence-based recommendations, and the use of new interventions such as virtual reality (VR) has been encouraged [10].…”