Effectiveness Of Yoga-Based Therapy Following Traumatic Brain Injury

Abstract

Traumatic Brain Injury (TBI) is a major cause of death in the United States stemming from sport injuries, falls, abuse and motor vehicle accidents, being the most prevalent reasons. A TBI is caused by a bump, blow, or jolt to the head that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. The severity of a TBI may range from “mild” (i.e., a brief change in mental status or consciousness) to “severe” (i.e., an extended period of unconsciousness or memory loss after the injury). Most TBIs that occur each year are mild, commonly called concussions. People that survive a TBI can have side effects ranging from a few days, months, or possibly the rest of their life. Typical signs and symptoms of a TBI include: confusion, blurry vision, concentration difficulty, light and sound sensitivity, vomiting, dizziness, ringing in the ears, etc. Treatment may include medication, vestibular rehabilitation, surgery, or rest and removal from stimuli such as TV and phone screens have been shown to be effective. The population mainly at risk are ages 0-4, 15-24, and adults older than 65. Men are 1.5 times more likely to receive a TBI than a woman. A TBI is graded as mild, moderate, and severe. Any of these grades given are considered serious and should be treated appropriately. As research has shown performing yoga-based activities have shown improvements with balance, upper and lower extremity strength and flexibility, and reduction of fall risks. Yoga originates from India and has been around for more than centuries. It focuses on mind, body, and soul with use of different breathing techniques such as diaphragmatic and pursed lip breathing. Not only does yoga improve strength, flexibility, and balance but it also aides in relaxation and meditation. This case report describes the effects of yoga with a person recovering from a severe TBI to improve flexibility and balance in order to regain functional mobility.

Case Description

The patient is a 36-year old male status post one-year TBI in a skilled nursing home facility. His past medical history is obesity. Social habits are drinking five to seven beers on the weekend. He denies use of drugs and cigarette smoking. He is currently single with no children. His occupation was a bartender prior to having a TBI. Upon evaluation, he presented with hemiplegia, communicating hydrocephalus, muscle weakness, and muscle spasm. His functional limitations were non-ambulatory, balance was not tested (due to refusal to move from bed), rolling side-to-side was dependent, bed mobility was moderate to max assistance, presented with 2-/5 strength, and dependent for sit to stands. Maximum education was provided to this patient about learning to return to a “new normal” following severe TBI accident; such as not being able to live at home by himself, use of wearing a helmet, and maintaining a medication regiment. There will be a major influence of stress on both the patient and his mom due to new living arrangements and the amount of assistance needed for activities of daily living. The patient will not able to return to the duties of bartending but possibly a monotonous job in order to contribute to society. Yoga is an optimal choice to use as an intervention for this patient. The patient lacks strength, is considered a high fall risk, and has extreme angry outbursts when becoming frustrating. Yoga enhances functional mobility, tissue elasticity, and improves balance similar to the effect of stretching exercises. Due to a consistently refusing to get out of bed and poor bed mobility, efforts to perform modified yoga to restore tissue elasticity and circulation in order to prevent pressure sores or any medical emergency from occurring. The group of allied healthcare professionals involved with this case include; neurologist, nurses, speech therapists, occupational therapists, physical therapists, psychologists, and medical doctor on site. The physical therapist and physical therapist assistant will explain the indication for yoga and begin therapy everyday for six days for 50 minutes. In the event of patient change of status occurs, the physical therapist is notified to reassess.

Intervention

Modified yoga rehabilitation began day after eval following TBI. The patient was considered stable with max amount of frustrated outburst.

• Day one: patient educated on pursed lip breathing while performing yoga poses. Patient performed seated spinal twists, large circular arm movements, seated side bend, forward fold, supine spinal twist, and happy baby. All poses were performed with maximum assistance except for happy baby. Happy baby was performed with maximum assistance x 2. Yoga was performed for 50 minutes.
• Day two: patient educated on pursed lip breathing while performing yoga poses. Patient performed seated spinal twists, large circular arm movements, seated side bend, forward fold, supine spinal twist, and happy baby. All poses were performed with maximum assistance except for happy baby. Happy baby was performed with maximum assistance x 2. Yoga was performed for 30 minutes. Frequent emotional outbursts that required several minutes to calm the patient down in attempts to retry the yoga poses. Day three: Patient performed seated spinal twists, large circular arm movements, seated side bend, forward fold, supine spinal twist, fire log pose, prone cobra and happy baby. All poses were performed with maximum assistance except for happy baby. Happy baby was performed with maximum assistance x 2. Yoga was performed for 40 minutes with additional rest breaks given due to increased fatigue.
• Day four: Patient performed seated spinal twists, large circular arm movements, seated side bend, forward fold, supine spinal twist, fire log pose, prone cobra and happy baby. All poses were performed with maximum assistance. Yoga was performed for 30 minutes and combined with occupational therapy to decrease fatigability.
• Day five: Patient was able to tolerate full 50 minutes of modified yoga with rest breaks given to decrease fatigue. Patient performed breathing exercises, seated spinal twists, large circular arm movements, seated side bend, forward fold, supine spinal twist, fire log pose, baby cobra, supine hamstring stretch, knee hugs, modified bridge with tactile cues given to stimulate glutes, and happy baby performed with maximum assistance.
• Day six through 30: patient has made remarkable improvement through the use of yoga-based activities. Bed mobility and tolerance to exercise has improved with moderate assistance consistently in order to perform the exercises as patient became more familiar with yoga poses. Emotional outbursts continue to occur; however, these outbursts are not lasting as long as previous outburst.
• Day 30-90: patient has made significant improvement with all activities of daily living ranging from stand by assistance to minimum assistance with increased tolerance for activity. Patient continues to fatigue but does not require as long of rest breaks in between each pose. Patient’s emotional outbursts have subsided with the occasional aggravation to newly added poses.

Physical therapy was administered six times a week, daily with 50 minutes of rehabilitation. Tissue pliability and improved independence with activities of daily living were the main focus of this type of rehabilitation. It was a major goal to have the patient return to or become discharged with close relatively from previous level of function. Modified yoga poses were introduced early in order to get some circulation through the tissues in order to prevent pressure sores and improved tissue elasticity for improved range of motion.

Outcomes

Upon discharge, the patient presents with remarkable improvement and minimal emotional outbursts. The discharge summary demonstrated modified independence with bed mobility, gait, stairs, sit-to-stand transfers, and floor-to-chair transfers. Education was provided to encourage patient to rid use of AD with use of AD only in crowded areas. The TUG test and Borg test were performed with both tests indicating low fall risk. The TUG test does allow for increased improvement due to the test being performed three times in a row. This type of test allows for the patient to become familiar with the test and improve results. Based on the findings, the patient’s limitations were addressed and improved. The patient was discharged to move back home with his mom in a one-story home with two stairs upon entry and no handrails. The patient continues to ambulate with a straight point cane despite efforts to rid the straight point cane. Patient can still not drive due to poor decision making, lack of awareness of location, and fair short-term memory. He is appropriate to return to work. However, the patient requires a momentous job that is a few days out of the week and for only a few hours in order to contribute to society.

Discussion

For the treatment of traumatic brain injury, the effectiveness of yoga has shown advantageous for recovery. It is noted that all traumatic brain injury patients are all different. Each timeline will be different and different yoga poses will be tolerated diversely among patients. The accomplishment of recovery requires patient education, yoga poses that are modified to the patient’s limitations, and in conjunction with therapeutic exercise for maximal results.

A few limitations have been observed throughout this course of development with the yoga intervention. A major limitation is further research is needed on the effectiveness of yoga with people suffering from a traumatic brain injury. This study was limited to one person for only a short duration. A larger population size for a longer duration would be beneficial to accurately determine the effectiveness of yoga and balance and tissue pliability. Another limitation was the failure to follow up with the patient three months after discharge from the skilled nursing facility to determine the carryover of yoga. Another limitation was the multiple physical therapists and physical therapist assistants that worked with the patient. Each therapist would perform each yoga pose in a different manner than the previous therapist. There were some declines from the patient regarding not wanting to participate in therapy and therefore count as a refusal to therapy. In conclusion, yoga would be an extremely beneficial intervention for people suffering from a traumatic brain injury. Yoga has shown benefits to improve balance, improve mood, aide in breathing techniques, increase tissue elasticity, improve musculature strength, and help decrease fall risks.

References:

1. Finn, M. (2018, Jan 4). Traumatic Brain Injury. Retrieved April 24, 2019, from https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/BrainInjury.html
2. Mickelson, K (2015, June 15) Traumatic Brain Injury Information. Retrieved April 24, 2019, from https://www.ninds.nih.gov/Disorders/All-Disorders/Traumatic-Brain-Injury-Information-Page
3. Nelson, K. (2019, March 28). What Impact Will Moderate or Severe TBI Have on a Person's Life? Retrieved April 24, 2019, from https://www.brainline.org/article/what-impact-will-moderate-or-severe-tbi-have-persons-life