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Jacobs Journal of Physical Rehabilitation Medicine

Comprehensive Treatment of Complex Postural Needs (CPN) in Spastic-dystonic Tetraplegia Secondary to Traumatic Brain Injury (TBI): A Pilot Case StudyMaurizio Falso1*, MD, Francesco Rossetti2, MD, Tiziano Bacchini3, MD, Angela Di Lorenzo1, Pth, Katia Prandini1, Pth, Milena Beschi1, Pth, Chiara Vanzani1, Nurs, Eleonora Cattaneo1, Psy, Franco Zucchini4, Orth, Marco Zucchini4, Orth, Massimiliano Paoletti4, Orth, Gianni Ferrari5, Orth, Andrea Malvicini1, MD¹Section of Neurological Rehabilitation, Clinical Institute Città di Brescia, Brescia, Italy

²Section of Orthopaedic and Traumatology, Clinical Institute Città di Brescia, Italy

³Section of Anaestesiology, Clinical Institute Città di Brescia, Italy4Il Podologo Srl, Brescia, Italy,5Otto Bock Italia Us, Budrio, Italy

*Corresponding author: Dr. Maurizio Falso (MD), Physical Medicine and Rehabilitation Specialist, Section of Neurological Rehabilitation

- Clinical Institute Città di Brescia – via Gualla 15, 25128, Brescia, Italy, Tel: 349.4971729; Email: falsomaurizio@libero.it

Received: 07-12-2018

Accepted: 07-19-2018

Published: 07-21-2018

Copyright: © 2018 Maurizio Falso

A Pilot Case Study

Cite this article: Maurizio Falso. Comprehensive Treatment of Complex Postural Needs (CPN) in Spastic-dystonic Tetraplegia Secondary to Traumatic Brain Injury (TBI): A Pilot Case Study. J J Physical Rehab Med. 2018, 4(2): 026.

Abstract

Objective: Aim of this interventional evaluation study was to assess the modification and amelioration of complex postural attitudes in a patient with functional disorders, related to a spastic-dystonic muscle pattern of trunk and limbs secondary of traumatic brain injury (TBI), by using a comprehensive treatment approach.

Methods and Main outcomes: A male, 37 years old, affected by TBI with a complex spastic-dystonic muscle pattern of trunk and limbs implicating a whole of disfuctional postural attitudes never treated before and conditioning the quality of life and care-giver approach, was recovered in our Section from April to June 2013.

Step 1. Baseline evaluation. After recovery in our Section of Neurological Rehabilitation, patient underwent to a clinical and functional evaluation in a resting bed position and in a noiseless milieu.

Step 2. Rehabilitative approach. Our patient underwent physiotherapy during the recovery and observational period, 6 days a week, in 2-hour session, in line with the GCS National Consensus Coference about the treatment protocol of patients affected by severe brain injury.

Step 3. Botulinum neurotoxin treatment. In line with our internal treatment protocol, BoNTX-A (Xeomin®) was injected after 15 days and 49 days of hospitalization to reduce muscle overactivity and the pathological schema observed. Ultrasound guide to optimize the treatment tecnique was used for the multisegmental botulinum toxin treatment of the neck, of the right shoulder and of the right lower limb.

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Step 4. Functional orthopaedic approach. To realize a surgical correction of the unstable left ankle, completely intrarotated and in varus dislocated, a comprehensive bone and joint stabilization was made 35 days after hospitalization.

Step 5. Assistive postural device approach. To optimize patient’s postural attitude and to increase his ergonomic sitting and standing outbed positioning, an innovative disability-assistive postural chair and an orthostatic aid device were used at the end of this mutlidisciplinary approach.

Main outcomes and results: Evaluation was made at time T0 (at the beginning of hospitalization), T1 (15 days after hospitalization), time T2 (30 days after hospitalization), time T3 (45 days after hospitalization) and time T4 (60 days after hospitalization) using: a. outcome measures (MAS of upper and lower limb; TCT), b. objective behavioural and cognitive aspects; c. objective postural attitudes in different conditions considered. After our comprehensive treatment approach we observed:

✓ a significant change of all complex postural limb and trunk attitudes and a significant change of multisegmental muscle hypertonous

✓ an amelioration of the individual grade of space and environment exploration

✓ a progressive vertical positioning using an innovative static aid

✓ with the introduction of an innovative postural chair, the maintaining of an optimal and ergonomic sitting position

Conclusions: This interventional case study suggests that a comprehensive clinical-functional and surgical (multidisciplinary) approach is needed for an appropriate and incisive change and amelioration of CPN secondary to TBI.

Keywords: Spasticity; Severe brain injury; Outcome assessment; Wheelchair design; Seating systems

Abbreviations:

CPN: Complex Postural Needs;

TBI: Traumatic Brain Injury;

BoNTX-A: Neurobotulinum Toxin type A;

UMNS: Upper Motoneuron Syndrome;

GCS: Glasgow Coma Scale;

MAS: Modified Ashworth Scale;

TCT: Trunk Control Test;

HSP: Hemiplegic Shoulder Pain;

SBD: Severe Brain Damage;

CP: Cerebral Palsy

Introduction

Motor impairments following severe acquired brain injury (SBI) and collectively termed “upper motor neurone syndrome” (UMNS) are a common problem limiting patient functioning (1,2,3,4). In our knowledgment, components of the UMNS are commonly divided into positive and negative symptoms. Positive features are the most disabling phenomena of patients affected by SBI, characterized by a variety of so called “muscle overactivity patterns, often not easy to modulate and modify. These patterns can be distinguish into “spasticity” (defined as exaggerated tonic and phasic stretch reflexes of skeletal muscle after passive stretch) and into a so called “non-spastic muscle overativity, such as co-contraction of antagonist muscles, flexor and extensor spasm, and dystonia [5-8].

In the daily clinical treatment of patients affected by acquired brain damage, we can use the acronym CPN (Complex Postural Needs) to connect postural ergonomics or comfort perception with their complex spastic-dystonic limb schema, with the purpose to reduce the persistence and evocation of them and to prevent joint and muscle damages, secondary to badly postural attitudes, by using new and innovative seating and standing devices. The most important feature of any seating or mobility system is its ability to provide pelvic stability (for tilt, rotation and obliquity), as this gives the optimum base for trunk and head alignment and upper and lower limb function.

In the literature, we can find several studies which describe the relevant role of a comfortable and adjustable seating system or wheelchair by preventing and optimizing CPN in patients affected by paraplegia, by spinal cord injury, by stroke and by CPI [9-15].

Few studies described the effectivness of an accurate research about seating comfort as prevention of secondary skin and muscle damages in patients affected by acquired brain damages [16]. With the hypothesis that an individualizing and plurimodulating trunk and hip seat and standing system can affect the ergonomic perception of seating and standing in patients with CPN, this study analyzes the effects of an innovative disability-assistive postural chair and orthostatic stander on patient’s pathological seating and standing attitudes combined to an integrated neurobotulinum toxin and mutliprofessional treatment approach.

Methods

Subject

Male, 37 years old, affected by TBI with a complex spastic-

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✓ a shear strain injury

✓ a diffused axonal brain damage

✓ a damage focus on the left frontal brain area (Figure 1c)

✓ an indirect evidence of a right dystonic laterocollis (Figure 1d)

Figure 1a,b,c,d. Patient’s cerebral post-traumatic RMI images.

Instrumentation

For the aim of this study we used 2 innovative disabilitative-assistitve devices:

✓ Horizon Stander by Leckey (Ottbock®)

The Horizon Stander by Leckey (see figure 2) is a robust, durable 3-in-1 stander which can be positioned in prone, supine or upright. This innovative device is ideal for patients affected by complex postural attitudes who have not benefitted from standing therapy for some time and represents for a rehabilitative equipè a safe and easy transfer device using either mobile or tracking hoists. For optimizing and personalizing

dystonic muscle pattern of trunk and limbs implicating a whole of disfuctional postural attitudes never treated before and conditioning the quality of life and care-giver approach, was recovered in our Section of Neurological Rehabilitation from April to June 2013.

Our patient felt victim to a road accident with a secondary several head trauma (GCS 1+1+1) and multisegmental fractures (left clavicle and hip) on February 2012. During the recovery post-trauma in the Intensive Care Unit of the Public Hospital of Brescia, patient: a. underwent to positioning of tracheotomy and mechanical ventilated; b. was affected by sepsis to an acute breath failure; c. underwent to positioning of PEG and bladder catheter; d. underwent to a surgical reduction of clavicle fracture (Kirschner thread) and of hip instability. Post-trauma brain RMI showed:

✓ a damage focus on the temporal-basal left brain area (Figure 1a)

✓ a damage focus on the left corpus callosum (Figure 1b)

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Figure 1a. Figure 1b.

Figure 1c. Figure 1d.

Figure 1a. Figure 1b.

Figure 1c. Figure 1d.

Figure 1a. Figure 1b.

Figure 1c. Figure 1d.

Figure 1a. Figure 1b.

Figure 1c. Figure 1d.

patient’s best ergonomic postural standing positioning, the Horizon offers a very interesting pelvic stability, a correct and pleasure trunk and head alignment and the best stable leg and foot positioning by using respectively: a. an adjustable derotation pelvic support belt which can held the pelvis in a secure and stable position and give more proprioception and structure under the patient’s bottom; b. an adjustable head and chest support and flexible laterals that provide the trunk support whether prone, supine or upright; c. knee supports ensure and indipendently adjustable footplates that offers the ability to accomodate knees in various degrees of flexion and the feet in the maximum therapeutic position where legs are unequal lenghts due to muscle shortening or surgery or different foot heights and positions.

Figure 2. Horizon Stander by Leckey (Ottbock®).

✓ Kit Seat by Leckey (Ottobock®)

Kit Seat by Leckey is a highly adjustable modular seating

system for teens and adults with complex postural needs (see figure 3). It offers to a therapist or care-giver the ability to accomodate and support patient’s often complex pelvic, trunk and limb challenges using an innovative range of interchangeable modular components. To provide patient’s pelvic stability in a sitting position the system is supplied with the exclusive Plevic Cradle, that can encourage a posteriorly tilted pelvis into neutral alignment and prevents users sliding forward by using a simple flexible adjustment in the back section. To realize an individualized trunk and head alignment, by respecting patient’s own spine postural attitude in a sitting position, a combination of adjustable backrest pads and lateral trunk and head supports can be used in this postural system. To optimize and fix the postural sitting allignment enriched by the correct use of the pelvic cradle and the trunk backrest pads, The system also provide to realize the most individualized leg and foot positioning by using adjustable femoral support and footplates that can be angled individually to maximise foot loading and overall postural stability.

Figure 3. Kit Seat by Leckey (Ottobock®).

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Evaluation procedure and outcome measures

Evaluation was made at time T0 (at the beginning of hospitalization), T1 (15 days after hospitalization), time T2 (30 days after hospitalization), time T3 (45 days after hospitalization), time T4 (60 days after hospitalization) using: a. outcome measures (MAS = Modified Ashworth Scale) of upper and lower limb, (TCT = Trunk Control Test), b. objective behavioural and cognitive aspects; c. objective postural attitudes in different conditions considered (resting bed position, wheelchair sitting position and standing position).

Comprehensive systematic approach

• Step 1. Baseline evaluation

After an accurate clinical, functional evaluation of our patient at his domicile, we decided to recover him in our Section of Neurological Rehabilitation of ICCB from April to June 2013. At time T0 (at the beginning of hospitalization), patient underwent to a clinical and functional evaluation in a resting bed position and in a noiseless mileu, observing a very complex global status as described in table 1 and objectified in figure 4 and 5.

Figure 4. Complex spastic-dystonic patient’s postural attitude during resting bed position.

Comprehensive outcome, goals and treatment planning were defined after a Family – Equipé briefing. We agree to realize a modification and amelioration of patient’s complex postural attitudes with a comprehensive systematic approach conditioning quality of life, environment contact, realtion faculties and care-giver approach.

• Step 2. Rehabilitative approach

Our patient underwent physiotherapy during the recovery and observational period, 6 days a week, in 2-hour session, in line with the GCS National Consensus Coference about the treatment protocol of patients affected by severe brain injury.

Our daily rehabilitation protocol consisted in:

✓ passive multijoint limb kinesis, 30min per day

✓ daily neurodynamic limb excercises of the upper and lower limb

✓ postural control excercises

✓ side to side positioning, starting from the supine position, every two hour

Figure 5. Complex spastic-dystonic patient’s postural attitude during the sitting position in an inadequate postural wheelchair.

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Figure 4.

Figure 5.

✓ progressive vertical positioning using an innovative static aid (Horizon Stander by Leckey – Ottobock®) with a continous monitoring of cardiovascular parameters (starting from the first month of hospitalization, after a surgical correction of the unstable left ankle, completely intrarotated and in varus dislocated)

✓ progressive conditioning to an ergonomic an appropriate sitting position using an innovative disability-assistive postural chair (Kit Seat by Leckey – Ottobock®)

✓ neurosensorial stimulations to optimize and recover patients’ environment contact, relation faculties and to realize the optimal “milieu” for the comunication recovery

✓ therapeutic excercise: stretching and rehabilitative tecniques to reduce spasticity in line with the Bobath concept.

✓ Rehabilitation protocol also icluded the uso of bed sore aids, positioning of an orthesis on the upper left limb and breathing excercises for bronchial clearance.

• Step 3. Botulinum toxin treatment

In line with our internal treatment protocol, BoNTX-A (Xeomin®) was injected after 15 days of hospitalization to reduce muscle overactivity and the pathological schema observed. Ultrasound guide to optimize the treatment tecnique was used for the multisegmental botulinum toxin treatment of the neck (right scalenus anterior/medius; right splenius capitis; right sternocleidomastoideus; right trapezius), of the right shoulder (pectoralis major) and of the right lower limb (extensor hallucis longus; gastrocnemius medialis; soleus; tibialis posterior; flexor digitorum longus; extensor digitorum longus). A 1% diluition with saline solution was defined for

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Clinical status

GCS 3+4+1

Spontaneous breath

Cardiovascular

condition stable

No neurovegetative

crisis during the resting

bed position

Bladder catheter in situ

Artificial nutrition by

gastrostomy

Cognitive and behavioural status

No communication and

relation attitude

Psychological and

psychiatric profile not

available

Environment contact

expressed by

spontaneous eye and

rignt limb movements if

stimulated

Complex postural attitude during resting bed position Spastic-dystonic right

laterocollis

Flexed- adducted and

intrarotated right shoulder

Dystonic right hand

Right lower limb extension

schema

Right equinovarus foot

Left upper limb hyperextended

Palm-in-tumb left hand

Left lower limb extrarotated and

flexed

Unstable left ankle, completely

intrarotated and in varus

dislocated

Asimmetric trunk postural

attitude with an elevation of the

right hip and spine

rotation/flexion versus right sid

Complex postural attitude during bed sitting positioning An immodificable

asimmetric trunk

attitude and the

necessity of

supporting aids to

keep the position

Complex postural attitude during the sitting position in an inadequate postural wheelchair An immodificable

asimmetric trunk

attitude and the

necessity of

supporting aids to

keep the position

A global trunk-hip-

lower limb extension

schema was

involuntary activated

by trying to keep the

sitting position, with a

related high falling

risk

Table 1. Global patient’s Clinical and functional Status at Time T0.

300 Units of Xeomin with a 1% saline solution diluition (see table 2c).

Table 2b. Right lower limb botulinum neurotoxin treatment plan.

Table 2c. Neck and right shoulder botulinum neurotoxin treatment plan (2nd session)

neck and right shoulder botulinum toxin treatment and a 2% diluition for the lower limb multifocal treatment. In a single treatment session, we used 430 Units (see table 2a) and 380 Units (see table 2b) of Xeomin® as botulinum toxin total dose for the neck and right muscle shoulder on one side and the right lower limb muscle treatment on the other side respectively. By botulinum toxin mutlisegmental (neck, right shoulder and right lower limb) treatment we fixed nine functional goals:

- inhibition of spastic-dystonic muscle overactivity causing laterocollis and flexed-adducted and intrarotated right shoulder

- inhibition of spastic lower limb extension schema

- facilitating rehabilitative approach

- recovery of simmetrical postural attitude of the neck and trunk-hip-lower limb unit

- preventive approach for an HSP (Hemiplegic Shoulder Pain)

- preventive approach for fixed muscle contractions and joint immobility

Table 2a. Neck and right shoulder botulinum neurotoxin treatment plan (1st session).

In line with the need of a progressive orthostatic antigravitary trunk reaction stimulation and the appearance of a dysfunctional increase of dystonic laterocollis, botulinum toxin treatment was repeated 49 days after hospitalization by using

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Target muscle

MAS BoTNXA units

(Xeomin®)

n° injection

sites

Ultrasound guide

M. pectoralis major (R)

3++ 100 2 Yes

M. Subscapularis

(R)

3++ 70 1 Yes

M. Trapezius (R)

3++ 80 2 No

M. Scalenus (R)

4-- 50 1 Yes

M. SCM (R)

4-- 80 2 Yes

M. Splenius capitis (R)

3++ 50 1 Yes

Total dose used

430 Units

Table 2c.

Target muscle

MAS BoTNXA units

(Xeomin®)

n° injection

sites

Ultrasound guide

M. pectoralis major (R)

3(2+) 50(100) 2 Yes

M. Subscapularis

(R)

3(2++) 50(70) 1 Yes

M. Trapezius (R)

3++(2) 50(80) 2 No

M. Scalenus (R)

4—(3--) 30(50) 1 Yes

M. SCM (R)

4—(3-) 70(80) 2 Yes

M. Splenius capitis (R)

3++(2--)

50(50) 1 Yes

Total dose used

300U (430 Units)

Target muscle MAS BoTNXA units (Xeomin®)

n° injection sites

Ultrasound guide

M.extensor hallucis longus (R)

4+ 50 1 Yes

M.Gastrocnemius medialis (R)

4+ 50 1 Yes

M. soleus (R) 4++ 0 2 Yes

M.tibialis posterior (R) 4 100 1 Yes

M.flexor digitorum longus(R)

4++ 50 1 Yes

M.extensor digitorum longus (R)

4++ 50 1 Yes

Total dose used 380 Units

• Step 4. Functional orthopaedic approach

To realize a surgical correction of the unstable left ankle, completely intrarotated and in varus dislocated, and with the purpose to correct the flexed wrist, a comprehensive bone and joint stabilization was made 35 days after hospitalization. For this reason we opted with our orthopaedic for an ankle Arthrodesis on the left lower limb (VALOR® Hindfoot Fusion System by Wright) and for a tenotomy of the palmar gracilis on the left flexed wrist. The VALOR® technique represents the latest and most comprehensive system for achieving arthrodesis of the ankle and hindfoot: after left fibula osteotomy, cartilage removal and bone graft a retrograde ankle nail stabilizing system was set up (see figure 6). The clinical and behavioural complexity of our patient assessed procedural anesthesiological problems that could be solved by using a fast and safe procedure: bi-block plexus anesthesia of the left lower limb electrostimulated and ultrasound guided.

Figure 6. Post-surgical patient’s retrograde ankle nail stabilizing arthrodesis X-ray image.

• Step 5. Assistive postural device approach

After surgical correction (45 days after hospitalization) of the unstable left ankle, completely intrarotated and in varus dislocated, for the first time after patient’s brain trauma, a progressive vertical positioning using an innovative static aid (Horizon Stander by Leckey – Ottobock®) was achieved and maintained.

The procedure was made by the therapist and the nurser in 3 steps and had a different duration during each hospitalization day:

a. patient’s transfer from the resting and supine bed position to the stander, fixed in a horizontal position

b. progressive posturation of each body segment on the Stander support by respecting patient’s personal feel of stability and postural ensure; by using an adjustable derotation pelvic support belt we could held the pelvis in a secure and stable position and gave more proprioception and structure under

the patient’s bottom; through an adjustable head and chest support and flexible laterals we fixed the trunk support in the supine position; to obtaine the most ergonomic and therapeutic positioning of patient’s lower limbs we fixed the knees by using knee supports ensure and indipendently adjustable footplates; every day we established various degrees of knee flexion and put feet in the maximum therapeutic position by respecting patient’s individual sense and pleasure of postural attitude.

c. to prevent potential neurovegetative reactions during the assisted verticalization the procedure was performed not more than 15 minutes per day, starting from the supine position and increasing the upright position 5 degree per minute.

After an in-between visit (49 days after hospitalization) and a second task-specific botulinum toxin treatment session, in line with the trunk postural attitude change, our patient was positioned on an innovative disability-assistive postural chair (Kit Seat by Leckey – Ottobock®).

This procedure was made by the therapist with the orthotist technician support and the doctor supervision the first time and repeated each day by the therapist and the nurser help only during the hospitalization period.

The sitting positioning procedure was realized each time by:

a. providing patient’s pelvic stability using the exclusive Plevic Cradle, that encouraged a posteriorly tilted pelvis into neutral alignment and prevents patients’ sliding forward by using a simple flexible adjustment in the back section

b. providing an individualized trunk and head alignment, by respecting patient’s own spine postural attitude in a sitting position, with the multidirection regulation of adjustable backrest pads and lateral trunk and head supports

c. optimizing and fixing the postural sitting allignment enriched by the correct use of the pelvic cradle and the trunk backrest pads, by realizing the most individualized leg and foot positioning with the use of adjustable femoral support and footplates that could be angled individually to maximise foot loading and overall postural stability.

To prevent potential neurovegetative reactions during the assisted sitting position the procedure was performed not more than 2 hours per day (1 hour in the morning and 1 hour in the afternoon).

Data Analyisis

Statistical analysis was performed using SPSS version 17.0. In the analysis N-parametric Wilcoxon signed rank sum test was used,since in the study most variables are considered to be ordinal scales. In the text and tables 3 and 4, mean (M) values ± 1 standard deviation (SD) are given. Time-related differences

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Figure 6

between our clinical variables (MAS for neck-shoulder and for the lower limb and TCT) were analysed using non-parametric statistics, such as Spearman’s rank correlation coefficient test. The significance level was set to p < 0.05.

Results

Multisegmental Muscle Overactivity Modification

A general statistical significant decrease of neck/shoulder muscle hypertonous was observed proceeding from time T0 to time T4 (Z = -2,25; p < 0.05), as defined by the parametric paired t-test and N-parametric Wilcoxon (see Figure 7a).

An analytical evaluation of the time-related trend of neck and shoulder muscle overactivity showed:

- a non-significant modification of the neck/shoulder and right lower limb muscle hypertonous from time T0 to time T1 (only rehabilitative treatment intertime)( Z = 0; p = n.s);

- an intercurrent statistical significant decrease of MAS values from time T1 to time T2 (comprehensive rehabilitative and 1th NoBTX injection session intertime)( Z = -2,33; p < 0.05), a following increase proceeding from time T2 to time T3 (comprehensive rehabilitative and surgical treatment intertime)( Z = -2,23; p < 0.05) and a final significant decrease of neck and shoulder MAS from time T3 to time T4 (Z = -2,26; p < 0.05)(final comprehensive rehabilitative/2th NoBTX reinjection/assistive postural device approach intertime)(see Figure 7a).

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Neck and shoulder MAS Timing T0 T1 T2 T3 T4

Mean value +/- SD 3,8 +/- 0,40 3,8 +/- 0,40 1,6 +/- 0,51 3,3 +/- 0,51 1,3 +/- 0,51

Lower limb MAS

Timing T0 T1 T2 T3 T4 Mean value +/- SD 4 +/- 0.00 4 +/- 0,00 3 +/- 0,00 2,5 +/- 0,50 2 +/- 0,00

Table 3. Mean (M) values ± 1 standard deviation (SD) of time-related MAS score.

Table 4. Mean (M) values ± 1 standard deviation (SD) of time-related TCT score

TCT

Timing T0 T1 T2 T3 T4 Mean value +/- SD 13,3 +/- 4,04 48 +/- 0,00 72,3 +/- 7,50 76,6 +/- 7,50 81 +/- 0,00

Figure 7a. Time-related neck and shoulder MAS score trend.

A general decrease of the right lower limb muscle hypertonous was observed proceeding from time T0 to time T4 with a significant time-related modification between time T1 and T2 (Z = -2,45; p < 0.05)(see Figure 7b)

Trunk Assessment Modification

A general increase of the static trunk control (as documented by the TCT) was observed proceeding from time T0 to time T4, but this time-related trend was not statistical significant (Z = -1,633; p = n.s)(see Figure 7c).

A statistical significant correlation was demonstrated between the neck/shoulder muscle hypertonous decrease and the static trunk control attitude increase at time T3 (final comprehensive rehabilitative/2th NoBTX reinjection/assistive postural device approach intertime)(Ps = 1,000; p < 0.001).

Postural Attitudes Objectivation

• At time T2 (15 days after botulinum neurotoxin injection) and with the contribution of the described rehabilitative approach a significant change of the asimmetric trunk postural attitude, an increase of paraxial muscle recruitment in maintaining sitting position without bed sore aids

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Figure 7b. Time-related right lower limb MAS score trend.

Figure 7c. Time-related TCT score trend.

(as documented by the Trunk Control Test), a complete decrease of the spastic-dystonic laterocollis and right equinovarus foot attitude (as documented by the modified Ashworth Scale) were observed; in line with trunk postural attitude change, an amelioration of the individual grade of space and environment exploration was observed

• After the surgical correction of the unstable left ankle, completely intrarotated and in varus dislocated and an establishment of a stable plantigrade position of the left foot and ankle, for the first time after brain trauma (time T3 = 10 days after surgical approach) a progressive vertical positioning using our electrical innovative static aid was achieved by our patient without neurovegetative clinical reactions; we enriched the most ergonomic and therapeutical vertical position by interpretating each day patient’s personal feel of stability and postural ensure and by performing the verticalization procedure not more than 15 minutes per day, starting from the supine position and increasing the upright position 5 degree per minute (see Figure 8)

Figure 8. Patient’s first progressive vertical positioning by using the Horizont Stander by Leckey.

• 20 days after surgical approach and 6 days after a second botulinum neurotoxin injection session, our patient experimented for the first time an ergonomic and stable postural sitting allignment by using an innovative disability-assistive and modulable postural chair; comparing with the sitting postural attitude, observed at the beginning of his hospitalization, our patient showed (see Figure 9): a) a perfect pelvic stability by using an exclusive pelvic cradle that encouraged a posteriorly tilted pelvis into neutral alignment and prevents patients’ sliding forward; b) with the use of a multidirection regulation of adjustable backrest pads and lateral trunk and head supports our patient enriched and mantained his best and ergonomic individualized trunk and head alignment during the sitting position; c) with the use of adjustable femoral support and footplates we could maximise foot loading and overall postural stability during a rest sitting position.

Figure 9. Patient’s post-comprehensive treatment ergonomic and stable postural sitting allignment by using the Kit Seat System by Leckey.

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Figure 8.

Figure 9.

Discussion

The main finding of this case pilot study is that a comprehensive clinical, technical and rehabilitative approach is needed in the treatment of so-called Complex Postural Needs (CPN) in patients affected by pathological body schema secondary to muscle overactivity in Severe Brain Damage (SBD). In the literature, several studies described the relevant role of a comfortable and adjustable seating system or wheelchair by preventing and optimizing CPN in patients affected by paraplegia, by spinal cord injury, by stroke and by CP [9-16]. In the same way, it is well known the systematic use of Neurobotulinum toxin in the multisegmental treatment of adult limb spasticity [17-25].

In this study, by using a very fine step-by-step approach, we demonstrated for the first time that an individualizing and plurimodulating trunk and hip seat and standing system, combined to an integrated neurobotulinum toxin and multiprofessional treatment approach, can affect the ergonomic perception of seating and standing in a young patient affected by TBI and recovered in our Section of Neurological Rehabilitation from April to June 2013. Considering the complex pathological body schema during the first clinical and functional evaluation of our patient, we understood that a simple and non-synercic task and symptom specific approach couldn’t be a successfull treatment attitude alone. For this reason comprehensive outcome, goals and time-related treatment planning were defined after a Family – Unit Equipé briefing, before starting with our comprehensive approach. In line with the successfull objectivation of our clinical and functional results, we defined a statistical significant correlation between the neck/shoulder muscle hypertonous decrease and the static trunk control attitude increase at time T3 (final comprehensive rehabilitative/2th BoNTX-A reinjection/assistive postural device approach intertime), using the Spearman’s coefficient test. It was clear that a preliminary comprehensive symptom specific approach, realized at time T3, has been needed for a functional modification of the complex postural pathological pattern observed in our patient at the beginning of the clinical recovery. By reducing the neck/shoulder muscle hypertonous and increasing patient’s static trunk control attitude, we were able in a second time to introduce an innovative individualizing and plurimodulating trunk and hip seat and standing system for realizing the best ergonomic perception of seating and standing by our patient never experimented before. In the daily clinical treatment of patients affected by acquired brain damage we cannot separate postural ergonomics from comfort perception when the presence of complex spastic-dystonic limb schema is the cause of this. We know that in patients affected by CPN an ergonomic position attitude cannot be considered always the expression of a so called “normal position” but the result of a step by step recovery of an individualized comfortable postural attitude, if possible.

With the purpose to reduce the persistence and evocation of muscle limb and trunk overactivity, to neutralize every postural seating or standing muscle activation trigger and to prevent joint and muscle damages, secondary to badly postural attitudes, we decided to use new and innovative seating and standing devices. In line with a well-known Bobath concept of “core-stability”, we seek from our devices a very important and incomparable feature: the ability to provide pelvic stability (for tilt, rotation and obliquity), as this gives the optimum base for trunk and head alignment and upper and lower limb function. At the end (intertime T3-T4) of the clinical recovery and integrated with our comprehensive clinical and rehabilitative approach, the use of the Kit Seat postural chair offered to our patient a perfect pelvic stability, the best and ergonomic individualized trunk and head alignment during the sitting position and the maximal foot loading and overall postural stability during the rest sitting position. Similarly, the use of the Horizont Stander realized for the first time in his post-accident life the most ergonomic and therapeutical vertical position with a daily interpretation of patient’s personal feel of stability and postural ensure.

Conclusion

This interventional pilot case study suggests that compre--hensive clinical-functional and surgical (multidisciplinary) approach is needed for an appropriate and incisive change and amelioration of CPN secondary to TBI. Conditioning a patient with complex postural attitudes to a progressive vertical positioning using an appropriate static aid and realizing a progressive ergonomic an appropriate sitting position using an inno vative disability-assistive postural chair, we can optimize and recover patients’ environment contact, relation faculties and realize the optimal “milieu” for the comunication recovery and relationship faculties returning at home. Starting from the observations obtained at the end of this case interventional study, our daily clinical activity has going on by considering more clinical cases with different CPN, to understand the real value of different innovative devices capable of being modulated in relation of different complex postural attitudes in patients affected by severe brain damages.

Acknowledgments

We would like to thank all colleagues and technicians who participated in this study.

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