High-level Mobility Assessment Tool Research Articles

Relation Between Cognitive Assessment and Clinical Physical Performance Measures After Mild Traumatic Brain Injury

ObjectivesTo investigate the relation between cognitive and motor performance in individuals with mild traumatic brain injury (mTBI) and examine differences in both cognitive and motor performance between adults after mTBI and healthy controls. DesignMulti-center, cross-sectional study. SettingThree institutional sites (Courage Kenny Research Center, Minneapolis, MN, Oregon Health & Science University, Portland, OR, and University of Utah, Salt Lake City, UT). ParticipantsData were collected from 110 participants (N=110), including those with mTBI and healthy controls, who completed cognitive and physical performance assessments. InterventionsNot applicable. Outcome MeasuresCognitive assessments involved the Automated Neuropsychological Assessment Metrics to evaluate domains of attention, memory, reaction time, processing speed, and executive function. Physical performance was evaluated through clinical performance assessments, such as the 1-min walk test, the modified Illinois Agility Test, the Functional Gait Assessment Tool, the High-Level Mobility Assessment Tool, a complex turning course, and a 4-Item Hybrid Assessment of Mobility for mTBI. Participants also completed additional trials of the 1-min walk test, modified Illinois Agility Test, and complex turning course with a simultaneous cognitive task. ResultsIndividuals with mTBI performed worse on cognitive assessments, as well as several of the physical performance assessments compared with healthy controls. Complex tasks were more strongly related to cognitive assessments compared with simple walking tasks. ConclusionsCombining complex motor tasks with cognitive demands may better demonstrate functional performance in individuals recovering from mTBI. By understanding the relation between cognitive and physical performance in individuals recovering from mTBI, clinicians may be able to improve clinical care and assist in return to activity decision-making.

Dizziness-Related Disability One Year after a Mild-to-Moderate TBI-A Follow-Up Study.

Persisting dizziness and balance problems after mild-to-moderate traumatic brain injury (mmTBI) may result in considerable disability. The primary aim of this study was to explore the factors associated with dizziness-related disability one year post-injury. Data from 64 participants (mean age 39.4 [SD 13.0] years; 45 [70.3%] women) with mmTBI from a previous randomised controlled trial were analysed using simple and multiple regression analyses (Clinical Trials Registry #NCT01695577). The Dizziness Handicap Inventory one year (12.1, [SD1.6] months) post-injury was the dependent variable. Demographic and injury-related variables, clinical findings, and measures of post-injury symptoms and functioning (Rivermead Post-Concussion Symptoms Questionnaire, RPQ; Vertigo Symptom Scale-short form, VSS-SF; Hospital Anxiety and Depression Scale; Balance Error Scoring System; and High-Level Mobility Assessment Tool, HiMAT) at baseline (3.5 [SD 2.1] months post-injury) were the independent variables. Dizziness-related disability at one year was associated with pre-injury comorbidity, neck pain, higher RPQ, higher VSS-SF, and lower HiMAT scores (adjusted R2 = 0.370, F = 6.52 p < 0.001). In conclusion, the factors associated with dizziness-related disability one year post-injury, such as pre-injury comorbidity, neck pain, increased post-concussion symptom burden, increased dizziness symptom severity, and reduced balance and mobility, should be addressed early in the rehabilitation process to reduce patient burden.

Construct Validity of the Revised High-Level Mobility Assessment Tool for Children Who Are Developing Typically.

The aim of this project was to evaluate the construct validity of the high-level mobility assessment tool (HiMAT) for children who are developing typically with no underlying condition that may affect mobility. The HiMAT is a revised 8-item measure of high-level mobility. Rasch analysis was used to assess fit to the Rasch model indicating unidimensionality, person separation index local dependency, targeting of items, and differential item functioning. Children with typical development aged 5 to 12years (n = 1091; 554 girls and 537 boys) were recruited from 8 schools. The mean HiMAT score was 22.4/32 (range, 8-32). Data fit the Rasch model, indicating that the HiMAT was a unidimensional scale assessing a single construct (high-level mobility). The person separation index was .86, indicating good reliability. The skip item exhibited differential item functioning by sex. Although items were well targeted, the fit residual mean for persons was 2.40, indicating most found the tasks easy to complete. Unlike in adult populations, 2 items (walk and walk over obstacle) exhibited local dependency >0.2. The HiMAT is a unidimensional targeted performance measure of high-level mobility for children with typical development aged 5 to 12years. Further examination of the relationship between the test items "walk" and "walk over an obstacle" may be required to ensure that scores on these items are truly independent of one another.

Exploring Vestibular Ocular Motor Screening in Adults With Persistent Complaints After Mild Traumatic Brain Injury.

The purpose of this study was to (1) explore differences in vestibular ocular motor screening (VOMS) symptoms between healthy adults and adults with persistent symptoms after mild traumatic brain injury (mTBI), and (2) explore the relationships between VOMS symptoms and other measures (self-reported vestibular symptoms, clinical measures of balance and gait, and higher-level motor ability tasks). Research laboratory setting. Fifty-three persons with persistent symptoms (>3 weeks) following mTBI and 57 healthy controls were recruited. Eligibility for participation included being 18 to 50 years of age and free of medical conditions that may affect balance, with the exception of recent mTBI for the mTBI group. Cross-sectional. The primary outcomes were the VOMS symptom scores and near point of convergence (NPC) distance. Secondary outcomes included the Dizziness Handicap Inventory (DHI) total and subdomain scores, sway area, Functional Gait Analysis total score, gait speed, and modified Illinois Agility Task completion time, and Revised High-Level Mobility Assessment Tool total score. The mTBI group reported more VOMS symptoms ( z range, -7.28 to -7.89) and a further NPC ( t = -4.16) than healthy controls (all P s < .001). DHI self-reported symptoms (total and all subdomain scores) were strongly associated with the VOMS symptom scores (rho range, 0.53-0.68; all P s < .001). No significant relationships existed between VOMS symptoms and other measures. Significant group differences support the relevance of the VOMS for mTBI in an age-diverse sample with persistent symptoms. Furthermore, strong association with DHI symptoms supports the ability of the VOMS to capture vestibular complaints in this population.

Can adults with cerebral palsy perform and benefit from ballistic strength training to improve walking outcomes? A mixed methods feasibility study

BackgroundPower bursts of hips and ankle plantar flexors are prerequisites to walking propulsion. However, these power bursts are reduced during gait for persons with cerebral palsy (CP) and mainly in the ankle plantar flexors. Hence, task specific training, such as ballistic strength training, is suggested to increase muscle power in walking but not investigated in adults with CP. Therefore, the aim was to investigate if adults with CP could perform and benefit from ballistic strength training to improve walking, evaluated through physical measures and self-reported measures and interviews.MethodsIn this mixed methods feasibility study, eight ambulatory adults (aged 24–56) with spastic CP conducted ballistic strength training on a glideboard targeting the ankle plantarflexors two times a week for eight weeks. The feasibility of the training was assessed through objectives described by Orsmond and Cohn. Before and after the intervention, physical measures (6-Minute Walk Test and the eight-item High-level Mobility Assessment Tool) and self-reported measures (Patient Global Impression of Change, Numeric Pain Rating Scale, Fatigue Impact and Severity Self-Assessment, and Walk-12) were collected. After the intervention, semi-structured interviews explored experiences of this training.ResultsThe participants experienced training the ankle plantar flexor as relevant but reported it took about four weeks to coordinate the exercises successfully. Although we observed no changes in the physical performance measures, most participants reported improvements; some felt steadier when standing, walking, and hopping.ConclusionThis study demonstrated that ballistic strength training was feasible and suitable in adults with CP. However, guidance and a long (4 weeks) familiarization time were reported necessary to master the exercises. Most participants reported self-experienced improvements, although no physical performance measures improved. Thus, prolonged intervention may be required for perceived physical improvements to emerge. Also, other outcome measures sensitive to power output remains to be investigated.

Pre-treatment depressive symptoms predict physical performance among pediatric pain program participants

A central concern raised by many patients attending a pediatric chronic pain interdisciplinary clinic is physical functioning decline, fatigue, and diminished endurance. However, most studies examining treatment effects of pain programs on physical outcomes have relied on self- and/or parent-reported measures without confirming the results using objective indices, and predictors of objective indices of physical function in this population have rarely been examined. The purpose of the present study was to evaluate changes in objective physical functioning and to investigate psychosocial predictors of physical functioning over time in a sample of pediatric patients who completed an intensive outpatient pain program (IOP). Participants (N=55; Mage=14.92 years; 12.7% male, 87.3% female; 83.6% White, 5.6% African-American/Black; 9.1% Latinx) completed baseline measures assessing pain levels (Brief Pain Inventory), anxiety/depressive symptoms (Hospital Anxiety and Depression Scale), pain catastrophizing (Coping Strategies Questionnaire), and kinesiophobia (Tampa Scale for Kinesiophobia). Participants completed the FitKids Treadmill Test (FitKids) assessing physical endurance and the high-level mobility assessment tool (HiMAT) assessing physical ability pre- and post-IOP completion. Paired samples t-tests indicated significant improvement in Total Time to Exhaustion (TTE) on FitKids (p .138). Participation in an IOP led to significant improvement in physical endurance and ability. Depressive symptoms were negatively associated with endurance at baseline but not after program completion. Depressive symptoms may influence pre-treatment objective physical endurance and should be assessed in pediatric chronic pain patients beginning rehabilitation.

Application and Implementation of the High-Level Mobility Assessment Tool (HiMAT): An Overview

Levels of mobility that are more advanced or ‘high-level’ that independent walking are required for participation and play in many social, leisure and social activities. These activities are important for quality of life. In recent years there has been a shift towards clinical research and programs that are aimed to improve a person’s capacity for high-level mobility. In order to evaluate the effectiveness of such programs, the High-level Mobility Assessment Tool (HiMAT) was developed. This short commentary discusses the development and application of the HiMAT in children and adults with health conditions that lead to mobility limitations.

High-Level Mobility Assessment Tool Normative Values for Children.

Physical therapists need to be able to evaluate high-level gross motor skills of children to determine their capacity to engage in activities such as running, jumping, hopping, and stair climbing. The High-Level Mobility Assessment Tool (HiMAT) has excellent interrater and retest reliability and is less susceptible to a ceiling effect than existing mobility scales in children who are 6 to 17years old and have traumatic brain injury. The purposes of this study were to develop normative HiMAT score ranges for Australian children and to investigate the relationship between children's HiMAT scores and their age, height, weight, and body mass index (BMI). This study used a cross-sectional design. Children included in this study were 5 to 12years old, had no condition affecting their mobility, could follow 2-stage instructions, and had written informed consent from their parent or guardian. A total 1091 children were assessed at their local school, where their height, weight, and HiMAT score were recorded. The relationships between children's age, height, weight, and BMI were summarized using Spearman rank correlations. Truncated regression models were used to determine the most appropriate predictor variable for developing sex-specific normative ranges. There was a positive correlation between children's HiMAT scores and their age, height, weight, and BMI. Age explained the most variability in HiMAT scores for both boys and girls. The reliability, validity, and responsiveness of the HiMAT have not been tested across a broad range of children with mobility limitations. Normative data reported in this study are for Australian children only. HiMAT scores for children in this study increased with age, height, weight, and BMI. Age was the most appropriate variable for developing a normative dataset of HiMAT scores for children of primary school age.

The effects of vestibular rehabilitation on dizziness and balance problems in patients after traumatic brain injury: a randomized controlled trial

Objective: To investigate the effects of group-based vestibular rehabilitation in patients with traumatic brain injury. Design: A single-blind randomized controlled trial. Setting: University Hospital (recruitment and baseline assessments) and Metropolitan University (experimental intervention). Subjects: A total of 65 patients (45 women) with mild-to-moderate traumatic brain injury (mean age 39.4 ± 13.0 years) were randomly assigned to intervention (n = 33) or control group (n = 32). Intervention: Group-based vestibular rehabilitation for eight weeks. Participants were tested at baseline (3.5 ± 2.1 months after injury) and at two post-intervention follow-ups (2.7 ± 0.8 and 4.4 ± 1.0 months after baseline testing). Main measures: Primary outcome: Dizziness Handicap Inventory. Secondary outcome: High-Level Mobility Assessment Tool. Other outcomes: Vertigo Symptom Scale; Rivermead Post-concussion Symptoms Questionnaire; Hospital Anxiety and Depression Scale; and Balance Error Scoring System. Between-group differences were analyzed with a linear mixed-model analysis for repeated measurements. Results: At baseline, no group differences were revealed (personal factors, clinical characteristics and outcome measures). At the first follow-up, statistically significant mean differences in favor of the intervention were found in the primary (−8.7, 95% confidence interval (CI): −16.6 to −0.9) and secondary outcomes (3.7 points, 95% CI: 1.4–6.0). At the second follow-up, no significant between-group differences were found. No significant between-group differences in the other outcomes were found at the two follow-ups. Conclusion: The intervention appeared to speed up recovery for patients with dizziness and balance problems after traumatic brain injury. However, the benefits had dissipated two months after the end of the intervention.

HiMAT: High-Level Mobility Assessment Tool

HiMAT: High-Level Mobility Assessment Tool

White matter alterations and their associations with motor function in young adults born preterm with very low birth weight.

Very low birth weight (VLBW: ≤ 1500 g) individuals have an increased risk of white matter alterations and neurodevelopmental problems, including fine and gross motor problems. In this hospital-based follow-up study, the main aim was to examine white matter microstructure and its relationship to fine and gross motor function in 31 VLBW young adults without cerebral palsy compared with 31 term-born controls, at mean age 22.6 ± 0.7 years. The participants were examined with tests of fine and gross motor function (Trail Making Test-5: TMT-5, Grooved Pegboard, Triangle from Movement Assessment Battery for Children-2: MABC-2 and High-level Mobility Assessment Tool: HiMAT) and diffusion tensor imaging (DTI). Probabilistic tractography of motor pathways of the corticospinal tract (CST) and corpus callosum (CC) was performed. Fractional anisotropy (FA) was calculated in non-crossing (capsula interna in CST, body of CC) and crossing (centrum semiovale) fibre regions along the tracts and examined for group differences. Associations between motor test scores and FA in the CST and CC were investigated with linear regression. Tract-based spatial statistics (TBSS) was used to examine group differences in DTI metrics in all major white matter tracts. The VLBW group had lower scores on all motor tests compared with controls, however, only statistically significant for TMT-5. Based on tractography, FA in the VLBW group was lower in non-crossing fibre regions and higher in crossing fibre regions of the CST compared with controls. Within the VLBW group, poorer fine motor function was associated with higher FA in crossing fibre regions of the CST, and poorer bimanual coordination was additionally associated with lower FA in crossing fibre regions of the CC. Poorer gross motor function was associated with lower FA in crossing fibre regions of the CST and CC. There were no associations between motor function and FA in non-crossing fibre regions of the CST and CC within the VLBW group. In the TBSS analysis, the VLBW group had lower FA and higher mean diffusivity compared with controls in all major white matter tracts. The findings in this study may indicate that the associations between motor function and FA are caused by other tracts crossing the CST and CC, and/or by alterations in the periventricular white matter in the centrum semiovale. Some of the associations were in the opposite direction than hypothesized, thus higher FA does not always indicate better function. Furthermore, widespread white matter alterations in VLBW individuals persist into young adulthood.

Healthy body, healthy mind: A mixed methods study of outcomes, barriers and supports for exercise by people who have chronic moderate-to-severe acquired brain injury

BackgroundFew people with chronic moderate-to-severe brain injury are following recommended physical activity guidelines. ObjectiveInvestigate effects of planned, systematic physical activity while cultivating social and emotional well-being of people with chronic moderate-to-severe brain injury. HypothesisModerate-to-intensive physical activity would be associated with improvements in impairment and activity limitation measures (endurance, mobility, gait speed) immediately post-intervention and six weeks later (study week 12). MethodsThe intervention was a single group pre-/post-intervention study with 14 people with chronic moderate-to-severe brain injury who live in brain injury group homes and exercised 60–90 min, 3 days per week for 6 weeks at a maximum heart rate of 50–80%. Pre-post measures (administered weeks 0, 6 and 12) were the 6 Minute Walk Test, High-level Mobility Assessment Tool and 10 Meter Walk Test. The qualitative component used a brief survey and semi-structured interview guide with participants, family members, and staff. ResultsFollowing program completion, post-intervention group changes were noted on all outcome measures and greater than minimal detectable change for people with brain injury. Three transitioned from low to high ambulatory status and maintained this change at 12 weeks. During interviews, participants agreed the program was stimulating. More than eighty percent liked working out in a group and felt better being active. ConclusionsProgram impact included physical, cognitive and social/emotional aspects. Social aspects (group format, trainers) were highly motivating and supported by residents, family, and staff. Investments in transportation and recruiting and training interns to assist participants are critical to program sustainability and expansion.

The effect of a running intervention on running ability and participation in children with cerebral palsy: a randomized controlled trial

Purpose: The purpose of this study is to evaluate effects of a running intervention on running ability and participation in children with cerebral palsy.Materials and method: Children with cerebral palsy (9–18 years) with Gross Motor Function Classification System levels I-III were randomly assigned to a 12-week running intervention or usual care. Primary outcomes included improvement in running ability (assessed by Goal Attainment Scaling, high level mobility (assessed by the High-Level Mobility Assessment Tool) and participation (assessed by the Participation and Environment Measure for Children and Youth). Secondary outcomes were aerobic and anaerobic fitness and agility. Blinded assessments took place at baseline and 12 weeks. Regression analysis adjusting for baseline differences was used to determine between group differences.Results: Forty-two participants (mean age 12.5 years, SD 2.8 years; 15 female) completed the study. Statistically significant group differences at 12-weeks were found for improvements in running ability (86% treatment group versus 0% control group achieved or exceeded their running goals, p < 0.001), and participation in the school environment (Participation and Environment Measure mean difference 1.18: 95%CI 1.00–1.39, p = 0.045).Conclusion: A 12-week individualized running training skills intervention results in achievement of running ability goals and participation in the school environment in children with cerebral palsy.Implications for RehabilitationChildren with cerebral palsy who can walk unaided demonstrate impairments in higher level mobility such as running.Running is a motor skill that can be trained in children with cerebral palsy.Individually tailored running skills intervention, delivered in a group context can improve goal-identified running ability and translate into a higher frequency of participation in school activities.

Characteristics associated with physical activity capacity and performance in children and adolescents with an acquired brain injury

ABSTRACTAim: To examine characteristics associated with physical activity capacity and performance in children with acquired brain injury (ABI).Methods: 58 children (32 men; age 11 years 11 months ± 2 years 6 months; Gross motor function classification system [GMFCS] equivalent I = 29, II = 29) >12 months post ABI were recruited. Physical activity capacity measures included: (i) combined score of three 30-second repetition maximum functional strength exercises; (ii) timed up and go; (iii) 6-minute walk test and (iv) high-level mobility assessment tool (HiMAT). Physical activity performance determined time spent in sedentary, light and moderate to vigorous physical activity (MVPA). Full scale intelligence quotient (FSIQ) was assessed using the Wechsler intelligence scale for Children-IV. Regression models were constructed with functional strength score (n = 56), activity counts/minutes and time spent in MVPA and sedentary (n = 37).Results: The HiMAT and FSIQ explained 69% of the variance in functional strength. Age explained 12% of the variance in counts/min and 14% of the variance in time spent sedentary. GMFCS explained 10% of the variance in time spent in MVPA.Conclusions: The ability to perform functional strength exercises is associated with mobility beyond independence and adequate intellectual ability for children with ABI. Age was the most significant factor associated with physical activity performance, and interventions should target adolescents with ABI.

Ankle plantarflexor spasticity is not differentially disabling for those who are weak following traumatic brain injury

Primary objectives: The main aim of this study was to determine whether the presence of distal lower-limb spasticity had a greater impact on mobility for those who had greater levels of muscle paresis following traumatic brain injury (TBI).Research design: This was a cross-sectional cohort study of convenience. Seventy-five people attending physiotherapy for mobility limitations following TBI participated in this study. All participants had sustained a moderate–severe TBI and were grouped according to the presence or absence of ankle plantarflexor spasticity for comparison.Main outcomes and results: The primary outcome measure for mobility was self-selected walking speed and the primary outcome measure for muscle strength was hand-held dynamometry. Secondary outcome measures for mobility and muscle strength were the High-level Mobility Assessment Tool (HiMAT) and ankle power generation (APG) at push-off. Spasticity was quantified with the Modified Tardieu scale. Participants with ankle plantarflexor spasticity (Group 2) had slower self-selected walking speeds. There was no statistically significant effect for Group and plantarflexor strength (p = 0.81).Conclusion: Although participants with ankle plantarflexor spasticity walked significantly slower than those without, the presence of ankle plantarflexor spasticity did not lead to greater mobility limitations for those who were weak.

French translation and psychometric properties of high level mobility assessment tool for people with neurological diseases: Preliminary results

The high-level mobility assessment tool (HiMAT) was developed to quantify balance and mobility problems after traumatic brain injury (TBI). The revised HiMAT is valid for people with neurological diseases. The aim of this cohort study was to translate and investigate the internal consistency, reliability of the French version in people with neurological conditions. The original version of HiMAT was translated into French, cross-culturally adapted and field tested. Patients were recruited from “L’Espoir” Rehabilitation Center. All patients were tested with the HiMAT (range of scores = 0 [worst] to 54 [best]). There was one day between 2 tests to avoid fatigue. Two testers independently rated patients. Testers were an experienced physiotherapist and a young physiotherapist (less than 1 year after graduate). Young physiotherapist was trained by a view of the test and the instructions sheet. Internal consistency was investigated with Cronbach alpha. Intraclass correlation coefficients (ICCs) were used for assessing interrater and intrarater reliability (HiMAT sum score and each HiMAT item). Minimal detectable change (MDC) for the HiMAT was estimated. A Friedman test was used to investigate the presence of a learning effect. Currently, 9 patients were included. Six had a stroke, 1 a Guillain-Barré syndrome, 1 a spinal cord tumor treated by neurosurgery and 1 had an unknown peripheral disease affecting lower limbs. The HiMAT had no floor or ceiling effect. Internal consistency was excellent ( α = . 975). Interrater and intrarater reliability of the HiMAT score was high (interrater ICC = . 99, intrarater ICC = . 99). The MDC was −2 to + 4 points. No learning effect occurred ( P = 0, 845). The French version of the HiMAT seems to be a reliable tool to measure high-level mobility in people with neurological conditions.

Test–re-test reproducibility of activity capacity measures for children with an acquired brain injury

Objective: To determine test–re-test reproducibility of the Timed Up & Go (TUG) test, 30-second repetition maximum (repmax) of functional exercises, 6-Minute Walk Test (6MWT) and High-level Mobility Assessment Tool (HiMAT) in children with Acquired Brain Injury (ABI). Secondarily, to assess the accuracy between hand-timed and video-timed scores for the TUG test and HiMAT.Methods: Thirty children at least 1 year post-ABI (mean age at assessment = 11 years 11 months, SD = 2 years 4 months; 14 males; Gross Motor Function Classification Scale I = 17, II = 13) were assessed twice. Intra-class correlation coefficients (ICC), standard error of measurement and minimum detectable change (MDC) were determined. The Bland-Altman method and 95% limits of agreement (LOA) were used to assess the agreement between hand and video-timed TUG test and HiMAT scores.Results: Test–re-test reproducibility was acceptable for the TUG test (ICC = 0.92; MDC = 1.2s); repmax of functional exercises (ICC = 0.84–0.98; MDC = 4–8 reps); 6MWT (ICC = 0.90; MDC = 69.38 m) and HiMAT (ICC = 0.98; MDC = 6). Comparison of hand and video scores for the TUG test and HiMAT demonstrated a mean difference of 0.23 (LOA = –0.3–0.7) and –0.07 (LOA = –1.99–1.85), respectively.Conclusions Test–re-test reproducibility of lower limb activity capacity measures in children with ABI are acceptable. The MDC scores provide a useful reference to interpret treatment effectiveness. Video timing was more accurate than hand-timing for the TUG test.

Ballistic strength training compared with usual care for improving mobility following traumatic brain injury: protocol for a randomised, controlled trial.

Traumatic brain injury is the leading cause of disability in young adults aged 15 to 45 years. Mobility limitations are prevalent, and range in severity from interfering with basic day-to-day tasks to restricting participation in higher level social, leisure, employment and sporting activities. Despite the prevalence and severity of physical impairments, such as poor balance and spasticity, the main contributor to mobility limitations following traumatic brain injury is low muscle power generation. Strengthening exercises that are performed quickly are termed 'ballistic' as they are aimed at improving the rate of force production and, hence, muscle power. This is compared with conventional strength training, which is performed slowly and aims to improve maximum force production, yet has limited impact on mobility. In people recovering from traumatic brain injury: (1) is a 12-week ballistic strength-training program targeting the three muscle groups critical for walking more effective than usual care at improving mobility, strength and balance; and (2) does improved mobility translate to better health-related quality of life? A prospective, multi-centre, randomised, single-blind trial with concealed allocation will be conducted. Participants will be patients with a neurologically based movement disorder affecting mobility as a result of traumatic brain injury. Patients will be recruited during the acute phase of rehabilitation (n=166), from brain injury units in large metropolitan hospitals in Melbourne and Sydney, Australia. For 12 weeks, participants in the experimental group will have three 60-minute sessions of usual physiotherapy intervention replaced by three 60-minute sessions of strength training (ballistic strength, gait). The three key muscle groups responsible for forward propulsion will be targeted: ankle plantarflexors, hip flexors and the hip extensors. Initial loads will be low, to facilitate high contraction velocities. Progression to higher loads will occur only if participants can perform the exercises ballistically. The control group will have their three 60-minute sessions of usual physiotherapy intervention (balance, strength, stretch, cardiovascular fitness, gait) standardised so that all participants have equivalent therapy time. Both groups will continue to receive usual rehabilitation. The primary outcome will be mobility, measured using the High Level Mobility Assessment Tool. The secondary outcomes will be walking speed, muscle strength, balance and health-related quality of life. Walking speed will be measured using the 10-m walking test. Strength will be measured by a 6 repetition maximum, seated, single leg press test. Balance will be measured as the single limb support time. Health-related quality of life will be measured using the Assessment of Quality of Life. Outcomes will be measured at baseline (0 months), at completion of the intervention phase (3 months), and 3 months after cessation of intervention (6 months). Baseline measures will be completed prior to randomisation. Assessors blinded to group allocation will perform all measures. Baseline characteristics of participants will be determined according to group, using descriptive statistics. The proportion of patients compliant with the intervention will be calculated according to group and compared using Fisher's exact test. Compliance with the intervention will be defined as those who have satisfactorily completed at least 80% of the allocated sessions (29 of 36 sessions). The between-group difference for all outcomes will be estimated using analysis of covariance, adjusting for baseline High Level Mobility Assessment Tool score, age, gender and length of post-traumatic amnesia. Analyses will be conducted on an intention-to-treat basis. Strength training in neurological rehabilitation is highly topical because muscle weakness has been identified as the primary impairment leading to mobility limitations in many neurological populations. This project represents the first international study of ballistic strength training after traumatic brain injury. The novelty of ballistic strength training is that the exercises attempt to replicate how lower limb muscles work, by targeting the high angular velocities attained during walking and higher level activities.

Randomized controlled trial of web-based multimodal therapy for children with acquired brain injury to improve gross motor capacity and performance

Objective: To compare efficacy of a web-based multimodal training programme, ‘Move it to improve it’ (MitiiTM), to usual care on gross motor capacity and performance for children with an acquired brain injury. Design: Randomized waitlist controlled trial. Setting: Home environment. Participants: A total of 60 independently ambulant children (30 in each group), minimum 12 months post-acquired brain injury were recruited and randomly allocated to receive either 20 weeks of MitiiTM training (30 minutes/day, six days/week, total 60 hours) immediately, or waitlisted (usual care control group) for 20 weeks. A total of 58 children completed baseline assessments (32 males; age 11 years 11 months ± 2 years 6 months; Gross Motor Function Classification System equivalent I = 29, II = 29). Intervention: The MitiiTM program comprised of gross motor, upper limb and visual perception/cognitive activities. Main measures: The primary outcome was 30-second, repetition maximum functional strength tests for the lower limb (sit-to-stand, step-ups, half-kneel to stand). Secondary outcomes were the 6-minute walk test, High-level Mobility Assessment Tool, Timed Up and Go Test and habitual physical activity as captured by four-day accelerometry. Results: Groups were equivalent at baseline on demographic and clinical measures. The MitiiTM group demonstrated significantly greater improvements on combined score of functional strength tests (mean difference 10.19 repetitions; 95% confidence interval, 3.26–17.11; p = 0.006) compared with the control group. There were no other between-group differences on secondary outcomes. Conclusion: Although the MitiiTM programme demonstrated statistically significant improvements in the functional strength tests of the lower limb, results did not exceed the minimum detectable change and cannot be considered clinically relevant for children with an acquired brain injury. Clinical Trial Registration: Australian New Zealand Clinical Trials Registration Number, ANZCTR12613000403730.

High-level mobility skills in children and adolescents with traumatic brain injury

Aim: To evaluate the reliability, validity and responsiveness of the High-level Mobility Assessment Tool (HiMAT) in children and adolescents with traumatic brain injury (TBI) and to compare the mobility skills of children with TBI to those of healthy peers.Method: The mobility skills of 52 children with moderate and severe TBI (36 males; mean age = 12 years, range = 6–17) were assessed using the HiMAT and the Pediatric Evaluation of Disability Inventory (PEDI). Inter-rater reliability, re-test reliability and responsiveness of the HiMAT were evaluated in sub-groups by comparing results scored at several time-points. The HiMAT scores of children with TBI were compared with those of a healthy comparative cohort.Results: The HiMAT demonstrated excellent inter-rater reliability (ICC = 0.93), re-test reliability (ICC = 0.98) and responsiveness to change (p = 0.002). The PEDI demonstrated a ceiling effect in mobility assessment of ambulant children with TBI. The HiMAT scores of children with TBI were lower than those of their healthy peers (p < 0.001).Interpretation: The HiMAT is a reliable, valid and sensitive measure of high-level mobility skills following childhood TBI. The high-level mobility skills of children with TBI are less proficient than their peers.