Effects of physical therapy interventions on balance ability in people with traumatic brain injury: A systematic review

Alashram AR, Annino G, Raju M, Padua E. Effects of physical therapy interventions on balance ability in people with traumatic brain injury: A systematic review. NeuroRehabilitation. 2020;46(4):455-466. doi:10.3233/nre-203047

Link to Original Article: https://content.iospress.com/articles/neurorehabilitation/nre203047

Key Points

- Balance deficits are common impairments in individuals with post-traumatic brain injury (TBI) and can restrict daily activities and social participation.

- This systematic review examined the effects of physical therapy interventions on balance impairments post-TBI.

- Eight studies were included in the review and the methodological quality ranged from low to high.

- The results showed no significant differences between experimental interventions (such as virtual reality and vestibular rehabilitation therapy) and control group interventions (such as traditional physical therapy interventions) in improving balance post-TBI.

- The evidence about the effects of physical therapy interventions on balance ability post-TBI was limited.

- Further randomized controlled trials are needed to understand the role of physical therapy in improving balance in individuals with TBI.

Introduction

Balance deficits and postural instability are common in individuals with traumatic brain injury (TBI), affecting 39-62% of patients. These deficits are associated with negative outcomes, including longer hospital stays, increased risk of falling, delayed recoveries, and gait abnormalities. Balance impairments can also restrict daily activities and social participation. Despite some improvement in balance within the first six months after TBI, they remain a chronic impairment for many individuals. Balance is defined as the ability to maintain the gravity line within the base of support with minimal postural sway, relying on the integration of visual, vestibular, and somatosensory inputs to the central nervous system. Various factors contribute to impaired balance, including biomechanics, sensorimotor control, cardiopulmonary dysregulation, and cognition. Different rehabilitation therapies have been used for balance rehabilitation in neurological disorders, including TBI. These therapies include rhythmic auditory stimulation, whole-body vibration, virtual reality, exercise, mirror therapy, traditional Chinese medicine, and traditional Chinese exercise. In the context of post-TBI rehabilitation, traditional physical therapy focused on motor learning principles has shown promise in improving postural and coordination deficits. While some studies have investigated the effects of virtual reality and vestibular rehabilitation therapy on TBI patients, no systematic reviews have examined the role of physical therapy interventions in balance rehabilitation post-TBI. Therefore, this review aims to fill this gap by examining the influence of physical therapy interventions on balance ability in individuals with TBI.

Methods

The methods section of the research paper describes the criteria used for study inclusion and exclusion. The PICOS approach was utilized to determine the inclusion criteria, which included randomized controlled trials, clinical control trials, and pilot studies focusing on participants with confirmed diagnoses of traumatic brain injury (TBI). Exclusion criteria consisted of studies involving animal models, pharmacological interventions as the main intervention, and descriptive or case series study designs.

Two independent authors screened the titles and abstracts of potential studies for relevance, and disagreements were resolved through discussion with a third author. After reviewing the selected studies, a meta-analysis was deemed inappropriate due to varying outcomes and significant heterogeneity among the studies. Data extraction was carried out by two authors, independently assessing study design, participants, treatment session details, experimental intervention, and control group intervention.

The methodological quality of the selected studies was evaluated by two reviewers using the PEDro scale, which consists of 11 items assessing external validity, internal validity, and interpretability. The PEDro scale is a reliable and valid measure of methodological quality. Studies with higher PEDro scores were given more attention, and any disagreements were resolved through discussion.

The selected studies in this systematic review were classified as level I and II evidence according to the provided level of evidence classification. The review followed PRISMA guidelines and reported essential information accordingly.

Results

The research paper conducted a systematic review of studies on balance deficits in individuals with traumatic brain injury (TBI). A total of 1042 studies were initially identified, and after screening and exclusion criteria, eight studies were included in the review. These studies included a total of 259 post-TBI patients. Three studies utilized virtual reality (VR) training interventions, which involved balance exercises using the Wii Fit and Wii games, and showed some improvements in balance ability. Two studies explored the use of vestibular rehabilitation therapy, which included exercises for motion sensitivity, gaze-stabilization, and balance improvement, and showed varying degrees of improvement in balance ability. One study used video game therapy and showed improvements in postural balance and mobility-related tasks. Another study used an elliptical trainer device and reported some improvements in gait training, balance exercises, and range of motion. Various scales were used to assess balance ability, including the Berg Balance Scale, Dynamic Gait Analysis, and the Unified Balance Scale. The included studies generally had a low risk of bias and did not report any adverse effects or complications. Overall, the interventions showed modest improvements in balance ability, but the differences between experimental and control groups were not always statistically significant. Further research is needed to determine the most effective rehabilitation therapies for balance deficits in post-TBI patients.

Discussion

This paper is the first review to examine the effects of physical therapy interventions on balance ability in individuals with traumatic brain injury (TBI). The preliminary results showed no superior effects of virtual reality (VR), virtual reality training (VRT), video game therapy, elliptical training, and mobility training on balance ability compared to other traditional rehabilitation interventions. The evidence for the effectiveness of VR and VRT post mTBI/concussion is limited. VR offers augmented feedback and increases attention and motivation, which are crucial for learning motor skills. Traditional rehabilitation interventions based on motor learning principles have shown improvements in balance and body stability in patients with mild-to-moderate TBI. However, the selected studies had various limitations and biases, including small sample sizes, lack of randomization, concealed allocation, blinding, and intention-to-treat analysis. Therefore, the reported effects cannot be considered clinically meaningful. Balance deficits in TBI can be caused by various factors, including medications, postural hypotension, vision impairments, vestibular impairments, sensory impairments, brainstem injury, perilymph fistula, and mental health issues. Maintaining balance is essential for daily activities, and different causes require different treatments. The somatosensory and vestibular systems play a significant role in postural control, and interventions that stimulate visual, vestibular, and somatosensory systems simultaneously may enhance balance ability in individuals with TBI. However, this review has limitations, including language bias and inadequate data for calculating effect sizes. Future high-quality randomized controlled trials with larger sample sizes are needed to explore the relationship between TBI characteristics, therapy dosage, and balance rehabilitation outcomes.

Conclusion

This research paper highlights the limited understanding of the effects of physical therapy interventions on balance impairments in individuals with traumatic brain injury (TBI). The current literature lacks studies exploring this topic, indicating a paucity of research in this area. Preliminary findings suggest that physical therapy has a limited impact on balance ability in TBI patients. The choice of physical therapy intervention should be based on the underlying cause of the balance deficits. The authors propose a multi-system stimulation approach to potentially enhance neuroplasticity in individuals with balance impairments. However, further randomized controlled trials with a larger sample size are essential to better understand the role of physical therapy in individuals with TBI and balance deficits and to validate the proposed hypothesis.

Opportunities for Future Research

1. Conduct randomized controlled trials to assess the effectiveness of virtual reality (VR) interventions on improving balance in individuals with traumatic brain injury (TBI).

2. Explore the effects of vestibular rehabilitation therapy (VRT) on balance impairments in individuals with TBI using larger sample sizes and longer intervention durations.

3. Investigate the potential benefits of video game therapy and other innovative interventions, such as elliptical training and mobility training, on balance improvement in TBI patients.

4. Compare the effectiveness of different physical therapy interventions, such as VR, VRT, video game therapy, and traditional balance training, in improving balance ability in individuals with TBI.

5. Examine the impact of other physical therapy interventions, such as whole-body vibration, mirror therapy, and traditional Chinese exercise, on balance deficits in individuals with TBI.

6. Determine the optimal duration, frequency, and intensity of physical therapy interventions for balance rehabilitation in patients with TBI.