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Virtual Reality-Based Interventions to Improve Balance in Patients with Traumatic Brain Injury: A Scoping Review

Hernan, Gabriel; Ingale, Neha; Somayaji, Sujith; Veerubhotla, Akhila
INTRODUCTION/BACKGROUND:Virtual reality (VR)-based interventions to improve balance and mobility are gaining increasing traction across patient populations. VR-based interventions are believed to be more enjoyable and engaging for patients with traumatic brain injury. This scoping review aims to summarize existing studies from the literature that used VR to improve balance and mobility and determine the gap in VR-based balance literature specific to individuals with traumatic brain injury. METHODS:Two authors independently searched the literature using the search terms "Virtual Reality Traumatic Brain Injury Lower Limb", "Virtual Reality Traumatic Brain Injury Balance", and "Virtual Reality Traumatic Brain Injury Gait". RESULTS:A total of seventeen studies, specifically, three randomized controlled trials, one one-arm experimental study, two retrospective studies, two case studies, one feasibility/usability study, one cohort study, and seven diagnostic (validation) studies, met the inclusion criteria for this review. The methodological quality of the studies evaluated using the PEDro scale was fair. DISCUSSION/CONCLUSIONS:Future studies should focus on large-scale clinical trials using validated technology to determine its effectiveness and dose-response characteristics. Additionally, standard assessment tools need to be selected and utilized across interventional studies aimed at improving balance and mobility to help compare results between studies.
PMCID:11119161
PMID: 38790408
ISSN: 2076-3425
CID: 5655212

Implementing Remote Patient Monitoring of Physical Activity in Clinical Practice

McCarthy, Margaret; Jevotovsky, David; Mann, Devin; Veerubhotla, Akhila; Muise, Eleanor; Whiteson, Jonathan; Rizzo, John Ross
PURPOSE/OBJECTIVE:Remote patient monitoring (RPM) is a tool for patients to share data collected outside of office visits. RPM uses technology and the digital transmission of data to inform clinician decision-making in patient care. Using RPM to track routine physical activity is feasible to operationalize, given contemporary consumer-grade devices that can sync to the electronic health record. Objective monitoring through RPM can be more reliable than patient self-reporting for physical activity. DESIGN AND METHODS/METHODS:This article reports on four pilot studies that highlight the utility and practicality of RPM for physical activity monitoring in outpatient clinical care. Settings include endocrinology, cardiology, neurology, and pulmonology settings. RESULTS:The four pilot use cases discussed demonstrate how RPM is utilized to monitor physical activity, a shift that has broad implications for prediction, prevention, diagnosis, and management of chronic disease and rehabilitation progress. CLINICAL RELEVANCE/CONCLUSIONS:If RPM for physical activity is to be expanded, it will be important to consider that certain populations may face challenges when accessing digital health services. CONCLUSION/CONCLUSIONS:RPM technology provides an opportunity for clinicians to obtain objective feedback for monitoring progress of patients in rehabilitation settings. Nurses working in rehabilitation settings may need to provide additional patient education and support to improve uptake.
PMID: 37723623
ISSN: 2048-7940
CID: 5591172

Implementing Remote Patient Monitoring of Physical Activity in Clinical Practice

Mccarthy, Margaret; Jevotovsky, David; Mann, Devin; Veerubhotla, Akhila; Muise, Eleanor; Whiteson, Jonathan; Rizzo, John Ross
ISI:001100769700008
ISSN: 0278-4807
CID: 5591122

Wearable devices for tracking physical activity in the community after an acquired brain injury: A systematic review

Veerubhotla, Akhila; Krantz, Amanda; Ibironke, Oluwaseun; Pilkar, Rakesh
OBJECTIVE:The application of wearable devices in individuals with acquired brain injury (ABI) resulting from stroke or traumatic brain injury (TBI) for monitoring physical activity (PA) has been relatively recent. The current systematic review aims to provide insights into the adaption of these devices, the outcome metrics, and their transition from the laboratory to the community for PA monitoring of individuals with ABI. LITERATURE SURVEY/UNASSIGNED:The PubMed and Google Scholar databases were systematically reviewed using appropriate search terms. A total of 20 articles were reviewed from the last 15 years. METHODOLOGY/METHODS:Articles were classified into three categories: PA measurement studies, PA classification studies, and validation studies. The quality of studies was assessed using a quality appraisal checklist. SYNTHESIS/RESULTS:It was found that the transition of wearable devices from in-lab to community-based studies in individuals with stroke has started but is not widespread. The transition of wearable devices in the community has not yet started for individuals with TBI. Accelerometer-based devices were more frequently chosen than pedometers and inertial measurement units. No consensus on a preferred wearable device (make or model) or wear location could be identified, although step count was the most common outcome metric. The accuracy and validity of most outcome metrics used in the community were not reported for many studies. CONCLUSIONS:To facilitate future studies using wearable devices for PA measurement in the community, we recommend that researchers provide details on the accuracy and validity of the outcome metrics specific to the study environment. Once the accuracy and validity are established for a specific population, wearable devices and their derived outcomes can provide objective information on mobility impairment as well as the effect of rehabilitation in the community.
PMID: 34689426
ISSN: 1934-1563
CID: 5134082

A Novel Core Strengthening Intervention for Improving Trunk Function, Balance and Mobility after Stroke [Case Report]

Pilkar, Rakesh; Veerubhotla, Akhila; Ibironke, Oluwaseun; Ehrenberg, Naphtaly
This paper a novel core-strengthening intervention (CSI) delivered using the AllCore360°, a device that targets trunk muscles through a systematic, high-intensity rotating-plank exercise. Three individuals (age: 61.7 ± 3.2 years; range: 58-64 years) with post-stroke hemiplegia participated in 12-sessions of the CSI. The participants completed up to 142 rotating planks at inclination angles (IAs) that ranged from 40° to 65°, over 12 sessions. The interventional effects on the functional outcomes of trunk performance, balance and mobility were assessed using the Trunk Impairment Scale (TIS), the Berg Balance Scale (BBS), the Timed-Up and Go (TUG) test, the 10-m walk test (10MWT), and the 6-min walk test (6MWT). Postural outcomes were assessed using the center of pressure (CoP) data recorded during quiet standing on a balance platform, and neuromuscular outcomes were assessed using electromyography (EMG) during AllCore360° rotations. All participants completed the CSI (minimum of 120 rotations), demonstrating the feasibility of the CSI in chronic stroke. The CoP data suggested improved lateral control of posture during standing across participants (averaging an over 30% reduction in lateral sway), while the EMG data revealed the ability of the CSI to systematically modulate trunk muscle responses. In summary, the current investigation presents the feasibility of a novel delivery method for core strengthening to maximize rehabilitation outcomes in the chronic phase of stroke.
PMCID:9139817
PMID: 35625054
ISSN: 2076-3425
CID: 5284042

Predicting physical activity intensity using raw accelerometer signals in manual wheelchair users with spinal cord injury

Shwetar, Yousif; Huang, Zijian; Veerubhotla, Akhila; Knezevic, Steven; Hong, EunKyoung; Spungen, Ann M; Ding, Dan
STUDY DESIGN/METHODS:Cross-sectional validation study. OBJECTIVES/OBJECTIVE:The performance of previously published physical activity (PA) intensity cutoff thresholds based on proprietary ActiGraph counts for manual wheelchair users (MWUs) with spinal cord injury (SCI) was initially evaluated using an out-of-sample dataset of 60 individuals with SCI. Two types of PA intensity classification models based on raw accelerometer signals were developed and evaluated. SETTING/METHODS:Research institutions in Pittsburgh PA, Birmingham AL, and Bronx NY. METHODS:Data were collected from 60 MWUs with SCI who followed a structured activity protocol while wearing an ActiGraph activity monitor on their dominant wrist and portable metabolic cart which measured criterion PA intensity. Data was used to assess published models as well as develop and assess custom models using recall, specificity, precision, as well as normalized Mathew's correlation coefficient (nMCC). RESULTS:All the models performed well for predicting sedentary vs non-sedentary activity, yielding an nMCC of 0.87-0.90. However, all models demonstrated inadequate performance for predicting moderate to vigorous PA (MVPA) with an nMCC of 0.76-0.82. CONCLUSIONS:The mean absolute deviation (MAD) cutoff threshold yielded the best performance for predicting sedentary vs non-sedentary PA and may be used for tracking daily sedentary activity. None of the models displayed strong performance for MVPA vs non-MVPA. Future studies should investigate combining physiological measures with accelerometry to yield better prediction accuracies for MVPA.
PMID: 34819608
ISSN: 1476-5624
CID: 5134092

Augmented-reality guided treadmill training as a modality to improve functional mobility post-stroke: A proof-of-concept case series

Enam, Nabela; Veerubhotla, Akhila; Ehrenberg, Naphtaly; Kirshblum, Steven; Nolan, Karen J; Pilkar, Rakesh
PMID: 33342389
ISSN: 1945-5119
CID: 5134062

Balance Control Strategies during Perturbed Standing after a Traumatic Brain Injury: Kinematic Analysis

Ehrenberg, Naphtaly; Veerubhotla, Akhila; Nolan, Karen; Pilkar, Rakesh
The objective of the current investigation was to examine the presence, absence or alteration of fundamental postural control strategies in individuals post traumatic brain injury (TBI) in response to base of support perturbations in the anterior-posterior (AP) direction. Four age-matched healthy controls (age: 46.50 ± 5.45 years) and four individuals diagnosed with TBI (age: 48.50 ± 9.47 years, time since injury: 6.02 ± 4.47 years) performed standing on instrumented balance platform with integrated force plates while 3D motion capture data was collected at 60 Hz. The platform was programmed to move in the AP direction, during a sequence of 5 perturbations delivered in a sinusoidal pattern at a frequency of 1 Hz, with decreasing amplitudes of 10, 8, 6, 4, and 2 mm respectively. The sagittal plane peak-to-peak range and root mean square (RMS) of the hip, knee, and ankle joint angles during the 5 seconds of perturbation were computed from optical motion capture data. The TBI group had a higher mean range (5.17 ± 1.91°) about the ankle compared to the HC group (4.17 ± 0.81°) for the 10mm perturbation, but their mean range was smaller than the HCs for the other 4 conditions. About the hip, the TBI group's mean range was larger than the HC's for all conditions. For both groups, the mean range decreased with perturbation amplitude for all conditions. The TBI group showed larger changes in mean range and RMS values as the amplitude of the perturbation changed, while the HC group showed smaller intertrial changes. The results suggest that the TBI group was substantially more reliant on the hip strategy to maintain balance during the perturbations and this reliance was well linked with perturbation amplitude.Clinical Relevance- Existing information regarding changes in postural control strategies in individuals post TBI is limited. The current work demonstrates lower limb kinematic differences between HC and TBI and some preliminary evidence on increased hip movement in the TBI group.
PMID: 34892296
ISSN: 2694-0604
CID: 5134122

A Novel Core-Strengthening Program for Improving Trunk Function, Balance and Mobility after Stroke: a Case Study [Case Report]

Pilkar, Rakesh; Veerubhotla, Akhila; Ehrenberg, Naphtaly; Ibironke, Oluwaseun
The objective of the current investigation was to evaluate the feasibility of a core-strengthening program delivered to a chronic stroke participant using a novel robotic device, AllCore360°, which targets trunk muscles through a systematic, consistent, high-intensity exercise. A 58-year old male with hemiplegia post stroke (time since injury: 18 years) was enrolled and performed 12-sessions of the core-strengthening program on AllCore360°. The participant completed a total of 142 360°-rotating-planks (called as 'spins') at four inclination angles, over 12 sessions. Assessments at baseline and follow up included posturography during quiet standing, electromyography (EMG) during AllCore360° spins, and assessments for trunk function (Trunk Impairment Scale (TIS)), balance (Berg Balance Scale (BBS) and mobility (Timed-Up and Go (TUG), 10-meter Walk test (10MWT), 6-minute Walk Test (6MWT)). Clinically meaningful improvements were observed in the TIS (73%), the BBS (45.2%), and the TUG test (22.7%). Medial-lateral Center of Pressure (MLCoP) data showed reduced RMS and range by 32.3% and 29.2%, respectively. EMG data from left and right rectus abdominis (RAB) muscles showed increased levels of activations for both inclination angles, 65° (LRAB: 74%, RRAB: 48.4%) and 55° (LRAB: 22.3%, RRAB: 28.7%). The participant rated the core-strengthening program 71 (scale: 0-126) on Physical ACtivity Enjoyment Scale at the follow up, showing a high level of satisfaction and engagement toward the training program. The preliminary results suggest that the novel robotic design and enhanced engagement of neuromuscular mechanisms features of AllCore360° core-strengthening program could facilitate improvements in trunk function, balance and mobility post stroke. A study with a large sample and an appropriate control group needs to be performed in the future.Clinical Relevance- The majority of clinical programs include core-stability exercises for improving trunk function. The current investigation presents a novel robotic-device based core-strengthening program that can provide systematic, consistent, and repetitive practice for optimal functional gains.
PMID: 34892271
ISSN: 2694-0604
CID: 5134112

Objective evaluation of the risk of falls in individuals with traumatic brain injury: feasibility and preliminary validation

Pilkar, Rakesh; Veerubhotla, Akhila; Ehrenberg, Naphtaly
Falls are a significant health concern for individuals with traumatic brain injury (TBI). For developing effective preemptive strategies to reduce falls, it is essential to get an accurate and objective assessment of fall-risk. The current investigation evaluates the feasibility of a robotic, posturography-based fall-risk assessment to objectively quantify the risk of falls in individuals with TBI. Five individuals with chronic TBI (age: 56.2 ± 4.7 years, time since injury: 13.09±11.95 years) performed the fall-risk assessment on hunova- a commercial robotic platform for assessing and training balance. The unique assessment considers multifaceted fall-driving components, including static and dynamic balance, sit-to-stand, limits of stability, responses to perturbations, gait speed, and history of previous falls and provides a composite score for risk of falls, called silver index (SI), a number between 0 (no risk) and 100 (high risk) based on a machine learning-based predictive model. The SI score for individuals with TBI was 66±32.1 (min: 32, max: 100) - categorized as medium-to-high risk of falls. The construct validity of SI outcome was performed by evaluating its relationship with clinical outcomes of functional balance and mobility (Berg Balance Scale (BBS), Timed-Up and Go (TUG), and gait speed) as well as posturography outcomes (Center of Pressure (CoP) area and velocity). The bivariate Pearson correlation coefficient, although not statistically significant, suggested the presence of linear relationships (0.52 > r > 0.84) between SI and functional and posturography outcomes, supporting the construct validity of SI. A large sample is needed to further prove the validity of the SI outcome before it is used for meaningful interpretations of the risk of falls in individuals with TBI.Clinical Relevance- Clinical assessments of risk of falls are traditionally based on questionnaires that may lack objectivity, consistency, and accuracy. The current work tests the feasibility of using a robotic platform-based assessment to objectively quantify the risk of falls in individuals with TBI.
PMID: 34892252
ISSN: 2694-0604
CID: 5134102