Brain Injury Rehabilitation Research Articles

Developing an understanding of the Frontal Lobe Paradox through clinical group discussions

This discussion paper presents reflections from a group of clinical, forensic and neuropsychologists on their clinical caseloads in brain injury rehabilitation services at Cygnet Healthcare. These services specialise in working with people with coexisting mental health or behavioural difficulties where the work involves frequent staff discussions on interpreting an individual’s behaviour, considering its functions and whether it is part of an involuntary neuro-psychological disorder related to their brain injury, specifically the Frontal Lobe Paradox. Through consideration of six patients, the cognitive mechanisms that may relate to, or underlie apparent Frontal Lobe Paradox were highlighted. Several additional reasons were found to explain why people might show this paradox, including testing conditions, slowed processing, reduced attention, disinhibition, self-monitoring problems, and premorbid difficulties. The authors also discuss interventions, which could be used to support these individuals, with the aim of broadening clinical understanding and discussion surrounding the causes of, and treatment approaches for individuals presenting with potential Frontal Lobe Paradox.

Enhancing management of agitation after traumatic brain injury: Psychiatric perspectives and quantitative assessments.

Post-traumatic agitation is a common and problematic complication after traumatic brain injury. It may present with features consistent with psychiatric disorders, which may provide clues as to management. This is a narrative review of pertinent literature and a description of a collaborative clinical approach utilizing psychiatric and brain injury rehabilitation strategies to optimize outcomes in the management of post-traumatic agitation. Describe and provide evidence for a transdisciplinary clinical approach supported by existing literature and clinical experience. Given the heterogeneity of the problem and limitations in the current literature there is no standardized approach to manage post-traumatic agitation; nevertheless, a strategy is proposed that clinicians may utilize to guide treatment and assess efficacy of the chosen intervention(s). A clinical approach that uses quantitative assessment of targeted behavior to objectively evaluate pharmacological interventions that are generated by a collaborative approach may yield improved outcomes for managing post-traumatic agitation.

The Measure of an Outcome: Comparing Norming and Stacking to Benchmark the Effectiveness of Brain Injury Rehabilitation Services.

Practitioners have a clinical, ethical, academic, and economic responsibility to dispassionately consider how effective their services are. Approaches to measure how "good" or "bad" healthcare is include clinical audit, satisfaction surveys, and routine outcome measurement. However, the process of comparing the clinical outcomes of a specific service against the 'best' services in the same specialism, also known as benchmarking, remains challenging, and it is unclear how it affects quality improvement. This paper piloted and compared two different approaches to benchmarking to assess clinical outcomes in neurorehabilitation. Norming involved comparing routine measures of clinical outcome with external validators. Stacking involved pooling and comparing internal data across several years. The analyses of routine clinical outcome data from 167 patients revealed significant differences in the patient characteristics of those admitted to the same service provider over time, but no differences in outcomes achieved when comparing with historical data or with external reference data. These findings illustrate the potential advantages and limitations of using stacking and norming to benchmark clinical outcomes, and how the results from each approach might be used to evaluate service effectiveness and inform quality improvement within the field of brain injury rehabilitation.

Validation of the work-ability support scale in individuals seeking to return to work after severe acquired brain injury

Purpose To assess the reliability and validity of the work-ability support scale (WSS) in a severe traumatic/acquired brain injury (TBI/ABI) population seeking to return to work (RTW). Materials and methods One hundred forty-four clients were enrolled in a vocational rehabilitation (VR) intervention trial through the Brain Injury Rehabilitation Program in New South Wales, Australia. Each client’s primary brain injury clinician and VR provider completed the WSS pre- and post-intervention. Validating measures assessing dysexecutive behavior, disability, participation, and work instability were completed. Several aspects of reliability and validity were evaluated. Results Internal consistency was excellent for Part A (Cronbach’s αs > 0.9) but unacceptably low to questionable for Part B (αs < 0.6). Inter-rater reliability between clinicians and VR providers was generally fair to moderate for Part A (κw < 0.6) and worse for Part B (κw < 0.5), with both slightly improving at post-intervention. Strong support was found for predictive and convergent validity, but not divergent validity. Confirmatory factor analysis indicated a poor fit for Part A, whereas most Part B fit indices met criteria. Conclusions The WSS can play a useful role in assessing return to work (RTW) potential, planning and evaluation after severe TBI/ABI. Training could improve consistency of administration among staff working across health and VR service sectors.

Characteristics and Functional Impact of Unplanned Acute Care Unit Readmissions during Inpatient Traumatic Brain Injury Rehabilitation: A Retrospective Cohort Study.

This study investigated the incidence, characteristics and functional outcomes associated with unplanned Acute Care Unit Readmissions (ACUR) during inpatient traumatic brain injury (TBI) rehabilitation in an Asian cohort. A retrospective review of electronic medical records from a single rehabilitation unit was conducted from 1 January 2012 to 31 December 2014. Inclusion criteria were first TBI, aged >18 years, admitted <6 months of TBI. ACUR were characterized into neurological, medical or neurosurgical subtypes. The main outcome measure was discharge and Functional Independence Measure (FIM™). Secondary outcomes included rehabilitation length of stay (RLOS). Of 121 eligible TBI records, the incidence of ACUR was 14% (n = 17), comprising neurologic (76.5%) and medical (23.5%) subtypes occurring at median of 13 days (IQR 6, 28.5) after rehabilitation admission. Patients without ACUR had a significantly higher admission mean (SD) FIM score compared to those with ACUR (FIM ACUR-negative 63.4 (21.1) vs. FIM ACUR-positive 50.53(25.4), p = 0.026). Significantly lower discharge FIM was noted in those with ACUR compared to those without. (FIM ACUR-positive 65.8(31.4) vs. FIM ACUR-negative 85.4 (21.1), p = 0.023) Furthermore, a significant near-doubling of RLOS was noted in ACUR patients compared to non-ACUR counterparts (ACUR-positive median 55 days (IQR 34.50, 87.50) vs. ACUR-negative median 28 days (IQR 16.25, 40.00), p = 0.002). This study highlights the significant negative functional impact and lengthening of rehabilitation duration of ACUR on inpatient rehabilitation outcome for TBI.

Return to work following traumatic brain injury: An exploration of using the Brannagan Executive Functions Assessment to increase self-awareness in practice

Aim and Background: The Brannagan Executive Functions Assessment is an occupation-based approach for increasing self-awareness. This study explores the application of the Brannagan Executive Functions Assessment in traumatic brain injury return to work intervention. It describes changes in self-awareness, goal achievement and perspectives of occupational therapy and people with brain injury. Methods: Case study design using a mixed-methods approach: with pre-post evaluation of outcomes and semi-structured interviews. Participants with traumatic brain injury completed the assessment with two occupational tasks related to return to work. Primary outcomes were self-awareness (Self-awareness Deficits Interview and Awareness Questionnaire) and Goal performance/satisfaction using the Canadian Occupational Performance Measure. Mood was a secondary outcome. Analysis was descriptive for quantitative data, thematic for qualitative data. Results: Two participants with brain injury, two support people and one occupational therapist were recruited. One participant with brain injury had an increase in self-awareness scores. Brain injury participants and the occupational therapist identified benefits including an increased awareness of needing to incorporate planning to meet goals. Conclusion: The Brannagan Executive Functions Assessment offers benefits to practice in brain injury rehabilitation, facilitating a structured occupational approach to self-awareness and participation in meaningful return to work tasks.

Virtual Reality Game Selection for Traumatic Brain Injury Rehabilitation: A Therapist's Wish List for Game Developers.

This project explored the selection process of commercially available virtual reality (VR) games for traumatic brain injury rehabilitation. Occupational therapy practitioners (OTPs) developed a classification framework that they used to evaluate VR games. The classification framework focused on movements required to effectively play the game, cognitive demand, position for game play, ease in menu navigation, and perceived therapeutic applications. OTPs used the ratings to aid in game selection and identified relevant game examples that allowed customizable settings and basic navigation with a game focus on functional activities. The OTPs and the research team identified the need for further work on accessibility and adaptability of game features (e.g., difficulty and limb usage) allowing for more individualization to optimize outcomes of VR-enhanced rehabilitation. The classification framework was useful in evaluating the potential therapeutic benefit of commercially available VR games. However, trial of the game by clinicians prior to use was still warranted.

Psychosocial Factors Associated with Prolonged Length of Stay in Acquired Brain Injury Rehabilitation: A Retrospective Cohort Study.

In a climate of rising healthcare costs and increasing pressure to reduce inpatient length of stay, hospitals must balance their role as care providers with that as resource stewards. There is a need to understand what factors are associated with patients staying beyond rehabilitation length of stay targets. The aim of this study was to determine psychosocial patient factors that are identifiable on admission that influence length of stay targets in acquired brain injury rehabilitation. A retrospective case series of 167 inpatients with acquired brain injury was conducted at an urban, academic rehabilitation hospital. A total of 29 factors were used for data analysis. Logistic and multiple linear regression analysis was utilized to determine if any patient factors were associated with patients exceeding their length of stay targets. Premorbid communal living status (e.g. group home) was associated with an odds ratio of 14.67 of exceeding length of stay target. Patients who did not drive prior to their admission had an odds ratio of 2.63 of exceeding their length of stay target. Premorbid communal living and premorbid non-driving status are predictors of patients with acquired brain injuries exceeding target rehabilitation length of stay. These findings may help acquired brain injury rehabilitation programmes plan for the needs of and advocate for patients.

Head Control Contributes to Prediction of Emergence From the Minimally Conscious State in Children Admitted to Inpatient Rehabilitation

ObjectiveTo examine the utility of head and trunk control, assessed using the Physical Abilities and Mobility Scale, for predicting emergence from a minimally conscious state (eMCS) among children with acquired brain injury admitted to inpatient rehabilitation in a disorder of consciousness (DoC). DesignRetrospective study. SettingPediatric inpatient rehabilitation hospital. ParticipantsForty patients (2-21 years-old) directly admitted from acute care to pediatric inpatient brain injury rehabilitation in a DoC (average length of stay=85 days; N=40). InterventionsNot applicable. Main Outcome MeasuresState of consciousness (eMCS vs not) at discharge from inpatient rehabilitation. ResultsForty-five percent of patients emerged from a minimally conscious state during inpatient rehabilitation. Admission state of consciousness and head control (but not trunk control) were significantly associated with eMCS and provided complementary prognostic information. Admission state of consciousness (ie, admitting in a vegetative state/unresponsive wakefulness syndrome) afforded the greatest negative predictive value (93.8%), whereas admission head control ability afforded the greatest positive predictive value (81.8% for any independent head control; 100% for maintaining head-up position for >30 seconds). Fifty percent of patients who emerged during the inpatient stay did not have independent head control at admission, highlighting the importance of exploring head control as a prognostic marker in conjunction with indicators with greater sensitivity (eg, state of consciousness at admission). ConclusionsA brief measure of head control at admission may contribute to identification of a subgroup of patients who are likely to emerge.

Changes in skeletal muscle mass index and fat mass index during rehabilitation for traumatic brain injury and stroke measured by bioelectrical impedance analysis.

Although malnutrition may negatively impact the outcomes of rehabilitation and increase the cost of care, there are still no valid nutritional assessment methods appropriate for specific groups of patients undergoing rehabilitation. This study aimed to determine if a multifrequency bioelectrical impedance is suitable for monitoring the changes in body composition of brain-injured patients for whom individualized nutritional goals were set during rehabilitation. Fat mass index (FMI) and skeletal muscle mass index (SMMI) were examined by Seca mBCA515 or portable Seca mBCA525 device within 48 h of admission and before discharge in 11 traumatic brain injury (TBI) and 11 stroke patients with admission Nutritional Risk Screening 2002 scores ≥2. The changes in outcomes and plausible interactions were examined between the admission values and the values estimated for the 18th day (minimum length of stay in the sample) using a repeated measure mixed-sample analysis of covariance. In patients with low FMI at admission (mainly younger, TBI patients, with longer ICU stay), there was no change over time whereas, in those with high admission FMI (older, stroke patients, with shorter ICU stay), a decrease was observed (significant interaction F(1,19) = 9.224 P = 0.007 Part. η² = 0.327). The SMMI significantly increased over time (F(1,19) = 5.202 P = 0.034 Part. η² = 0.215) independently of gender, age, days spent in ICU and cause of brain injury. Our results suggest that bioelectrical impedance analysis is feasible and informative for monitoring the changes in body composition during rehabilitation, which also requires consideration of demographic and pre-rehabilitation characteristics.

AppReminders – a pilot feasibility randomized controlled trial of a memory aid app for people with acquired brain injury

ABSTRACT Mobile phone reminding apps can be used by people with acquired brain injury (ABI) to compensate for memory impairments. This pilot feasibility trial aimed to establish the feasibility of a randomized controlled trial comparing reminder apps in an ABI community treatment setting. Adults with ABI and memory difficulty who completed the three-week baseline were randomized (n = 29) and allocated to Google Calendar or ApplTree app. Those who attended an intervention session (n = 21) watched a 30-minute video tutorial of the app then completed reminder setting assignments to ensure they could use the app. Guidance was given if needed from a clinician or researcher. Those who passed the app assignments (n = 19) completed a three-week follow up. Recruitment was lower than target (n = 50), retention rate was 65.5%, adherence rate was 73.7%. Qualitative feedback highlighted issues that may impact usability of reminding apps introduced within community brain injury rehabilitation. Feasibility results indicate a full trial would require 72 participants to demonstrate the minimally clinically important efficacy difference between apps, should a difference exist. Most participants (19 of 21) given an app could learn to use it with the short tutorial. Design features implemented in ApplTree have potential to improve the uptake and utility of reminding apps.

A service evaluation measuring the effectiveness of ABC training on staff confidence in reporting ABCs and their understanding of the framework rationale

The Antecedent-Behaviour-Consequence (ABC) model is commonly used to document and analyse challenging behaviours within brain injury rehabilitation services. Data from these recordings can be utilised to implement Positive Behavioural Support (PBS) plans and inform effective support strategies to manage challenging behaviour. Therefore, it is pivotal that staff within these settings are adequately trained in recognising and reporting challenging behaviours and feel confident in their ability to do so. Currently, there is no existing literature that evidences the effect of ABC framework training on staff confidence in recognising and reporting challenging behaviours. In this service improvement project, nineteen staff members from a neurorehabilitation service completed one training session focusing on challenging behaviours and the ABC framework. Participants completed an eight item Likert scale questionnaire pre-training (immediately before training), post-training (immediately after training) and at a four-week follow-up to assess their self-perceived confidence in their knowledge around the ABC model, the rationale behind this framework and their ability to effectively complete an ABC report. Descriptive statistics and a repeated measures ANOVA were conducted to examine whether training had an effect on self-reported confidence scores. Findings revealed a significant effect of training on staff confidence, Wilks Lambda = 0.35, F (1,18) = 1252.42, p = .000, with an effect size of np2 = .98, with an increase in confidence post-training. This effect was also maintained at follow-up indicating that staff confidence was retained after a 4-week period.

Impact of depression and post-traumatic stress on manual and oculomotor performance in service members with a history of mild TBI

ABSTRACT Objective To determine the impact of depression and post-traumatic stress on an automated oculomotor and manual measure of visual attention, compared to conventional neuropsychological assessment. Setting: Military traumatic brain injury (TBI) rehabilitation program. Participants 188 Active Duty Service Members (ADSM) with a history of mild TBI. Design A cross-sectional and correlational study with data obtained through an IRB-approved data registry study. Main measures: Bethesda Eye & Attention Measure (BEAM); brief neuropsychological battery; self-reported symptom surveys including Neurobehavioral Symptom Inventory (NSI), Patient Health Questionnaire-8 (PHQ-8), and PTSD Checklist-5 (PCL-5). Results Small effect sizes were found for partial correlations between both depression and post-traumatic stress and key BEAM metrics. In contrast, small-to-medium effects sizes were found across all traditional neuropsychological test measures. Conclusion This study illustrates the profile of impairments associated with depression and post-traumatic stress on saccadic eye movements and manual responses to BEAM relative to conventional neuropsychological tests. Results demonstrated that among ADSM seen for mTBI, depression and PTS exert a significant negative impact on measures of processing speed, attention, executive function, and memory across saccadic, manual, and conventional neuropsychological tests. However, the unique psychometric features of each of these assessment approaches may assist in distinguishing the effects of psychiatric comorbidities within this population.

Thirty years of research on traumatic brain injury rehabilitation: a bibliometric study.

Traumatic brain injury (TBI) is a major public health concern with far-reaching consequences on individuals' lives. Despite the abundance of works published on TBI rehabilitation, few studies have bibliometrically analyzed the published TBI rehabilitation research. This study aims to characterize current international trends and global productivity by analyzing articles on TBI rehabilitation using bibliometric approaches and visualization methods. We conducted a bibliometric analysis of data retrieved and extracted from the Web of Science Core Collection database to examine the evolution and thematic trends in TBI rehabilitation research up until December 31, 2022. The specific characteristics of the research articles on TBI rehabilitation were evaluated, such as publication year, countries/regions, institutions, authors, journals, research fields, references, and keywords. Our analysis identified 5,541 research articles on TBI rehabilitation and observed a progressive increase in publications and citations over the years. The United States (US, 2,833, 51.13%), Australia (727, 13.12%), and Canada (525, 9.47%) were the most prolific countries/regions. The University of Washington (226, 4.08%) and Hammond FM (114, 2.06%) were the most productive institution and author, respectively. The top three productive journals were Brain Injury (862; 15.56%), Archives of Physical Medicine and Rehabilitation (630; 11.37%), and Journal of Head Trauma Rehabilitation (405, 7.31%). The most frequent research fields were Rehabilitation, Neurosciences, and Clinical Neurology. Co-citation references primarily addressed "outcome assessment," "community integration" and "TBI management," and "injury chronicity" and "sequelae" have gained more attention in recent years. "Mild TBI," "outcome," "stroke" and "children" were the commonly used keywords. Additionally, the analysis unveiled emerging research frontiers, including "return to work," "disorder of consciousness," "veterans," "mild TBI," "pediatric," "executive function" and "acquired brain injury." This study provides valuable insights into the current state of TBI rehabilitation research, which has experienced a rapid increase in attention and exponential growth in publications and citations in the last three decades. TBI rehabilitation research is characterized by its multi-disciplinary approach, involving fields such as Rehabilitation, Neurosciences, and Clinical Neurology. The analysis revealed emerging research subjects that could inform future research directions.

Focal vibration in dysphagia: A technological treatment for severe acquired brain injury rehabilitation.

A patient with severe acquired brain injury (sABI) may experience impairment in the physiological swallowing process. Many studies in the rehabilitation field have sought to understand the effects of local vibration therapy at various levels of the central nervous system and the possible benefits in neuro-rehabilitation. There are few studies directed towards the use of vibratory energy for improving swallowing and phonatory function. The purpose of this study is to observe the effects of integrating conventional dysphagia therapy with the focal vibration therapy in patients with sABI. This is a pilot, randomized controlled, parallel-arm, single-blind study. Twenty-eight patients with post-sABI dysphagia were included in the study and randomized to Conventional Group (CG, conventional treatment for dysphagia) or Experimental Group (EG, conventional treatment for dysphagia plus focal vibration therapy). Patients were assessed at baseline (T0), after 4 weeks (T1) and after 8 weeks (T2) using the Dysphagia Outcome Severity Scale (DOSS) and the Bedside Swallow Assessment scale (BSAs). Patients in the experimental group showed a statistically significant change at T1 compared with T0 at DOSS (p = .014), and at BSAS between T1 and T2 (p = .024) and between T0 and T2 (p = .027). Overall, all patients improved significantly at DOSS between T0 and T1 (p < .001) and between T0 and T2 (p < .001). The results obtained from this pilot study are encouraging and demonstrate how the use of focal vibration therapy in add on to conventional treatment for dysphagia may be another useful tool for improving swallowing in patients with sABI.

Poster Boys and the Rehabilitative Dream: Using a Temporal Lens to Explore Severe Brain Injury Rehabilitation

Poster Boys and the Rehabilitative Dream: Using a Temporal Lens to Explore Severe Brain Injury Rehabilitation

Uncovering the social determinants of brain injury rehabilitation.

Social determinants of health (SDH), such as social isolation and loneliness, are often more frequently experienced in brain injury survivors. The paper explores the personal experiences of loneliness among brain injury survivors during lockdown to negate health inequalities and improve rehabilitation for this population in the future. Twenty-four brain injury survivors participated in semi-structured interviews and questionnaires relating to loneliness, resilience and wellbeing. Three themes (the experience of loneliness, loneliness during the pandemic and loneliness after the pandemic) explored survivors' experiences of loneliness generally post-brain injury, but also chronicle how these feelings developed in lockdown and survivors' feelings regarding society returning to 'normal'. Future interventions should focus on reframing survivors' beliefs regarding societal expectations and minimise the pressure they experience to keep up with their peers physically and emotionally. Additionally, we recommend creating accessible peer support options for all brain injury survivors as an important step for alleviating loneliness.

The Influence of Substance Use on Traumatic Brain Injury Recovery and Rehabilitation Outcomes: The Outcome-ABI Study

ObjectiveThis study characterized substance use (alcohol, illicit drugs, amphetamines) in patients with traumatic brain injury (TBI) receiving rehabilitation to determine potential benefit of rehabilitation and whether substance use influenced outcomes in moderate–severe TBI. DesignProspective, longitudinal study of adults with moderate or severe TBI receiving inpatient rehabilitation. SettingSpecialist-staffed acquired brain injury rehabilitation center in Melbourne, Australia. ParticipantsA total of 153 consecutive inpatients with TBI admitted between January 2016 and December 2017 (24 months). InterventionsAll inpatients with TBI (n=153) received specialist-provided brain injury rehabilitation in accordance with evidence-based guideline care at one 42-bed rehabilitation center. Main Outcome MeasuresData were collected at time of TBI, upon rehabilitation admission, and discharge and 12 months’ post-TBI. Recovery was measured by posttraumatic amnesia posttraumatic amnesia length-days and change in Glasgow Coma Scale (admission–discharge). Functional independence was measured on the FIM, Functional Assessment Measure, and Mayo Portland Adaptability Index. Quality of life (QOL) was measured on the EuroQOL-5D-5L and Quality of Life After Brain Injury (QOLIBRI) instruments. ResultsInpatients with history of illicit drug use (n=54) reported lower QOL and adjustment at 12 months’ post-TBI compared with those with no history (QOLIBRI social relationships: ratio of means=0.808, P=.028; Mayo Portland Adaptability Index adjustment: incidence rate ratio, 1.273; P=.032). Amphetamine use at time of injury (n=10) was associated with quicker recovery (posttraumatic amnesia length-days: incidence rate ratio, 0.173; P<.01); however, lower QOL at 12 months post-TBI was noted in those with a history of amphetamine use (n=34) compared with those without (QOLIBRI bothered feelings: ratio of means, 0.489, P=.036). ConclusionsAll participants made improvements with rehabilitation post-TBI; however, a history of substance use was associated with lower reported 12-month QOL. These findings add insight to the associations between substance use and acute recovery, potentially suggestive of a short-term recovery-promoting effect of amphetamines but highlighting the importance of rehabilitation to address long-term sequalae.

Unmet Need for Sexual Rehabilitation after Acquired Brain Injury (ABI): A Cross-Sectional Study Concerning Sexual Activity, Sexual Relationships, and Sexual Rehabilitation after ABI

In relation to brain injury rehabilitation, research has stressed the importance of including sexuality issues due to increased risk for sexual dysfunctions after Acquired Brain Injury (ABI). This study aims to explore experiences after non-stroke ABI concerning individual and relational aspects of sexuality, received information about sexuality at rehabilitation, and gender differences. A postal nationwide survey was conducted in Sweden, 2018–2019. The sample included individuals who had participated in brain injury rehabilitation 2014–2016, response rate 40% (250/624). Among all participants 78% had resumed sexual activity, and there was a significant difference between males (84%, 118/140) and females (69%, 76/110, p = 0.004). Among all participants, 95% reported physical intimacy as important, 80% considered sex as important on an individual level, and 91% stated sexuality as important for the relationship (no gender differences). Significantly more females (52%) than males (22%) reported that they had tried sexual aids (p = 0.000), and more males (29%) than females (16%) reported that professionals addressed sexuality issues during brain injury rehabilitation (p = 0.024). However, only a few participants were offered specific sexual counseling during brain injury rehabilitation, such as individual counseling (3%), couples counseling (2%), and group counseling (3%). To conclude, the vast majority valued both individual and relational aspects of sex and sexuality highly, and more males than females had resumed sexual activity. Few had received information about sexuality after ABI, and even fewer females compared to males reported that the issue was raised during rehabilitation. Clinical implications are discussed in relation to sexual rehabilitation.

Applications of Ultrasonic Brain Imaging and Transcranial Ultrasound Therapy in Brain Injury Rehabilitation

Applications of Ultrasonic Brain Imaging and Transcranial Ultrasound Therapy in Brain Injury Rehabilitation