THE aim of this special issue is to showcase developing literature in the area of higher-level mobility for individuals with traumatic brain injury, bringing perspectives not only from the US colleagues but also from Australian colleagues who have been studying in this area. In recent years, new outcome measures have been developed that provide means to describe mobility beyond walking. One aspect of higher-level skill in balance and ambulation is the ability to perform dual-task and accomplish a cognitive task while balancing and walking. While the interaction between cognition and walking has been studied extensively in older adults, study in moderate and severe TBI is more limited. The first article by Karen McCulloch and colleagues examines the associations between measures of attention, balance, and dual-task performance in a sample of individuals with acquired brain injury. In this group with chronic injury, anticipated dual-task performance difficulties were less evident than balance impairments, suggesting the need for further research to understand cognitive and mobility interactions as people recover from injury.
Independent walking has often been a goal of traditional rehabilitation, but commonly used outcome measures such as the FIM require walking distances of only 150 ft to attain the highest score. Individuals who sustain traumatic brain injury often undergo dramatic physical changes during their youth, at times when high-level mobility skills such as running, jumping, playing, and participating in sport or recreation are typical activities. Running, as an example of high-level mobility, is necessary for many sports played for recreation or social interaction. Running may also serve a very functional purpose in circumstances when one is late to a meeting, when attempting to catch a bus or catch up with a friend, or in order to play with one's children.
Gavin P. Williams and Anthony G. Schache from Australia illustrate methods that may be used to improve the ability to run by documenting 2 cases with very different motor profiles. His group employs methods that are in contrast with locomotor training strategies incorporating the use of body-weight-supported treadmill training that are currently being used in the United States. Diversity of intervention methods in a new area of study is beneficial so that the effectiveness of different approaches can be studied.
High-level mobility skills are often an avenue for exercise to maintain fitness, to maintain or lose weight, or to address a secondary health concern such as high blood pressure. The article by Mossberg and colleagues summarizes potential benefits of exercise to improve cardiovascular health and fitness. The ability to "work out" with peers using high-level mobility skills aids in adherence to a regular exercise program that has not only physical benefits but potential social and cognitive benefits as well. Jeanne M. Lojovich reviews the literature in the area, suggesting that there may be cognitive improvements as a result of aerobic exercise, an area where she is doing preliminary work. Long-term adherence is facilitated by activity that not only has clear health benefits but is also enjoyable and sufficiently feasible that it can become routine. High-level activity could take many forms including dance, tai chi, yoga, and other activities that require balance while moving in various positions, and could have social or meditative benefits for a survivor following brain injury.
Balance is closely related to vestibular function. Common vestibular impairments after TBI are described by Michelle Peterson with 2 illustrative cases of service members injured in combat situations. She outlines common tests and measures used to diagnose vestibular function and interventions that are guided by clinical examination. The cases chosen for her article highlight the importance of visual-vestibular interactions during intervention and how higher-level mobility skills can be incorporated into conventional treatment.
Finally, the article by Margaret M. Weightman and colleagues represents an effort undertaken by the Proponency Office of the Surgeon General to begin to describe practice guidance for physical therapists who work with those in military service who have sustained mild traumatic brain injury. This work demonstrates the complexity of impairments that require attention during examination and recommendations for measures that are appropriate for clinical use. Although guidance for intervention in this area is limited by a lack of published evidence, this article provides an important foundation for therapists who serve those with milder injuries, where higher-level mobility skills are often very important and achievable goals.
It is my hope as a guest editor that this issue will stimulate further discussion and additional research in this area so that in the future such a topical issue might include a range of empirical studies. I am grateful to all of the authors who contributed to the issue, in particular Gavin Williams, PhD, PT, who collaborated in crafting these introductory comments. I am also appreciative of Editors John Corrigan and Nathaniel Mayer for their encouragement and openness to considering this topic as a special issue of the Journal of Head Trauma Rehabilitation. It is my intent that the issue may serve to attract more submissions related to motor function, balance, and higher-level mobility and, thereby, expand the interdisciplinary readership of the journal.
-Karen L. McCulloch, PT, PhD, NCS, Issue Editor
-Gavin Williams, PhD, PT