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This is to certify that the
thesis entitled

THE EFFECTS OF RHYTHMIC AUDITORY STIMULATION
(RAS) ON GAIT TRAINING FOR PERSONS WITH
TRAUMATIC BRAIN INJURY

presented by

Jody L. Wilfong

has been accepted towards fulfillment
of the requirements for the

MM. degree in Music Therapy

 

 

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THE EFFECTS OF RHYTHMIC AUDITORY STIMULATION (RAS)
ON GAIT TRAINING
FOR PERSONS WITH TRAUMATIC BRAIN INJURY
By

Jody L. Wilfong

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER of MUSIC
Music Therapy

2009

THE EFFECTS OF RHYTHMIC AUDITORY STIMULATION (RAS)
ON GAIT TRAINING FOR PERSONS WITH TRAUMATIC BRAIN INJURY

By
Jody L. Wilfong
ABSTRACT
Persons suffering from the debilitating effects of Traumatic Brain Injury (TBI) often
require gross motor rehabilitation after injury. Previous research has Shown positive
relationships between motor functioning with rhythmic pulses, brain functioning, and
temporal motor management in physical rehabilitation with persons suffering with
neurologic diseases. The purpose of this study was to examine the effect of rhythmic
auditory stimulation on gait rehabilitation for adults with TBI. Rhythmic Auditory
Stimulation (RAS) is a specific neurologic music therapy technique that uses the
physiological responses to rhythm, to assist in controlled movement within the body’s
motor system (Thaut, 2005). Gait exercises were observed and tested during auditory
stimulation to collect data in the following components of gait: Cadence, Velocity, and
Stride Length. Seven subjects from two long term care day treatment centers in
southeastern Michigan were referred to rhythmic auditory stimulation testing by the
physical therapy department from each treatment center. Data were collected using a
stride analyzer before and after treatment and analyzed accordingly. Testing revealed a
Significant difference towards normal between baseline and posttest results using a pair
t-test (Cadence: t(6) = —3.017, p = .023; Velocity: t(6) = -3.518, p= .013; Stride Length:
((6) = -2.454, p=.050). This study suggests that the use of rhythmic auditory stimulation
in gait training assists in overall gait proficiency for persons suffering with debilitating

gross motor deficiencies due to TBI.

ACKNOWLEDGEMENTS

This thesis is dedicated to my family Kayla, Tye, and Jeremy Wilfong who remind me
everyday how blessed my life is. To my parents Diana and Gerald Priestley and my Aunt
Annette who all helped me achieve my dreams of continuing my education. To my good
friend Christopher Showerman who continues to remind me that ALL THINGS are really
possible. To the memory of my grandmother Adelaide Cook. To .Dr.Ted Tims who taught
me more about myself as a therapist and engrained a solid sense of confidence in the
skills required to be a good music therapist. To Dr. Cynthia Taggart who provided
endless guidance and encouragement from the first day of graduate school. To Roger
Smeltekop who has remained a constant source of knowledge and support in my
professional endeavors, and to the clients of Willowbrook rehabilitation who continue to

serve as a source of inspiration in researching the field of neurologic rehabilitation

TABLE OF CONTENTS

LIST OF TABLES .................................................................................. vi.
CHAPTER I ........................................................................................... 1
INTRODUCTION ........................................................................... 1
Characteristics of T BI Patients ............................................................. 1
Overview of the Brain ....................................................................... 3
Impairments associated with T BI ......................................................... 4
Neurologic Music Therapy ................................................................. 6
Research Predictions ............................................................................................... 7
CHAPTER II .......................................................................................... 9
REVIEW OF LITERATURE .............................................................. 9
CHAPTER III ....................................................................................... 17
METHOD ................................................................................... 17
Participants ................................................................................. 17
Inclusion Criteria ........................................................................... 19
Apparatus and Materials ............................ . ...................................... 19
Procedure .................................................................................... 20
CHAPTER IV ........................................................................................ 24
RESULTS ................................................................................... 24

- Quantitative Results ........................................................................ 25
CHAPTER V ........................................................................................ 30
DISCUSSION ............................................................................... 30

Future Implications ........................................................................ 31
Conclusions ................................................................................. 32
APPENDIX A. Glasgow Coma Scale (GSC) ................................................. 34
APPENDIX B. Ranchos Los Amigos Gait Performance Test ............................. 37
APPENDIX C. Normative Data for Stride Parameters ..................................... 39
APPENDIX D. Stride Analyzer Footswitch Graphic Sample .............................. 42
APPENDIX E. Assent Form ........................................................................ 44

iv

APPENDIX F. RAS Testing Consent Form .................................................. 50

APPENDIX G. HIPAA Consent form ........................................................ 54
APPENDIX H. Sample data collection of Stride Analyzer report ........................ 57
APPENDIX 1. Individual Data Analysis ...................................................... 59
APPENDIX J. Individual Raw Data used in Statistical Analysis ......................... 67

LIST OF TABLES

Table 1. Types of Traumatic Brain Inj ury ......................................................... 3
Table 2. Description ofPartrcrpantsl8
Table 3. Means, Standard Deviations for Cadence .............................................. 26
Table 4. Results of Paired t-test for Cadence .................................................... 26
Table 5. Means, Standard Deviations for Velocrty27
Table 6. Results of Paired t-test for Velocity ..................................................... 27
Table 7. Means, Standard Deviations for Stride Length ......... l ............................... 28

Table 8. Results ofPaired t-test for Stride Length29

vi

CHAPTER ONE

INTRODUCTION

Music therapy techniques and methods vary among clinical settings and
populations served, including those for persons with tramnatic brain injuries (TBI). Head
injuries disable more people than any other type of neurological damage and are the
second leading cause of death in men under the age of 35 (Merck Manual, 1997). In
2006, The National Center for Injury Prevention and Control reported 1.4 million cases
of TBI in America alone, among which were 50,000 reported deaths and over 235,000
people hospitalizations. Over one million received emergency medical treatment directly
related to TBI complications (N CIPC website, 2007). The Center for Disease Control
(CDC) identified the following causes of traumatic brain injuries in 2006: 28% occurred
because of a fall, 20% occurred during motor-vehicle crashes, 19% were caused due to a
collision with or against a moving or non-moving object, and 11% were a result of an
assault (CDC, 2007).

Characteristics of TBI Patients

Traumatic brain injuries ofien cause varying degrees of permanent disabilities,
depending on the location in the brain where the damage occurs. The National Institute of
Neurological Disorders identifies the following disabilities resulting from TBI:
“Cognitive impairments (thinking, memory, and reasoning), sensory processing (sight,

hearing, touch, taste, and smell), communication limitations (expression and

understanding), and behavior or mental health problems (depression, anxiety, aggression,
and social inappropriateness)” (National Institute of Neurological Disorders on-line
publication, retrieved Nov. 15, 2005 at http://www.ninds.nih.gov/disorders/tbi/tbi.htm).
Presently, there is a small amount of research specifically designed to study the physical
and neuro-motor impairments associated with traumatic brain injuries. The majority of
the research in this field has focused primarily on the behavioral and cognitive areas
causing a need for future inquiry within the neuro-motor domain (Walker & Pickett,
2007).They identify the common neuro-motor impairments including: paresis, ataxia and
postural instability associated with severe traumatic brain injuries.

More serious injuries to the brain can result in coma, vegetative state, or persistent
vegetative state. The Glasgow Coma Scale (GSC) assists medical personnel in assessing
the Severity of the neurological condition. The GSC (See Appendix A) is comprised of
three tests including eye, verbal and motor responses. Each category, including eye
opening, verbal and motor responses are scored from Three being the lowest (no response

to stimulus), to 15 as the highest (full response to stimulus).

 

Table 1.

Types of Traumatic Brain Injury (GCS)

 

 

Mild Brain Injury 13-15 points
Moderate Brain Iniury 9-12 goints
Severe Brain InimI > 9 points

 

(Public Safety on-line publication, retrieved August 1, 2008 at

http://publicsafety.com/article/photos/ l 1 54448509235_71_5 .j pg.

 

Overview of the Brain

Neuroscience has identified various regions in the brain that are responsible for
different functioning aspects in humans and notes that injury to different regions can
cause debilitating effects in human fimctioning. The brain contains three main structures,
the cerebrum, cerebellum and brainstem. The cerebrum contains the left and right
hemisphere; each hemisphere contains the frontal, temporal, occipital and parietal located
within the brain. The frontal lobe involves movement, planning, reasoning, speech,
problem solving, and emotions. The parietal lobe involves movement, recognition,

orientation and perception. The occipital lobe involves visual processing, and the

temporal lobe involves recognition of auditory stimuli, speech, memory and perception
(Baker and Tamplin, 2007). The cerebellum is located above the brain stem and is
responsible for the coordination of balance, muscle activity and movement. It assists in
the coordination of incoming sensory stimulus from the inner ear to provide the
appropriate movement for body control (Baker and Tamplin, 2007). The brainstem is
comprised of the medulla oblongata, pons and spinal cord. It assists in the control of
attention, alertness and awareness. It controls the body’s vital living functions such as

blood pressure, heart rate, respiration and digestion (Baker and Tamplin, 2007).

Impairments Associated with TBI

In TBI patients, varying degrees of brain injury can cause physical manifestations
that are dependent upon the location of injury sustained. For example, sustained injury in
the cerebrum can cause the following impairments: Adiadochokinesia, Aphasia,
Asynergia, Ataxic dysarthria, Gait ataxia. Adiadochokinesia or the inability to alternate
physical movements, Aphasia or the ability to express language, Asynergia or slow,
uncoordinated movements, Ataxic dysarthria or slurred speech, disrupted gait patterns
(gait ataxia).

Many TBI patients suffer from disabilities related to long and short term memory
recall (National Institute of Neurological Disorders, 2005). Due to the various injuries
sustained after a TBI, deficits can also be found within the body’s motor and sensory
systems directly affecting balance and posture, causing gait disturbances (Hurt, Rice,
McIntosh & Thaut, 1998).

In working with the TBI population, I have found that one must identify the

varying functioning levels of long and short-term memory recall processes, as well as

sustained physical injuries for each individual. As a result, TBI patients often require
longer periods of time to acclimate to their surroundings, which may require several
repetitive sessions before therapeutic techniques are successful. This results in the need
for longer periods of time during testing before significant improvements can be detected
(Falkner, 2007). Individuals suffering with the debilitating effects associated with a TBI
often find themselves with newly acquired physical limitations affecting many areas of
their lives, including: leisure activities and simple tasks needed for vocational skills
(Gallahue, 1982). Gallahue identified a relationship between the degree of physical
activity, and the patient’s view of self-worth throughout the rehabilitation process.

The synthesis of existing research identifies successful rehabilitation processes,
including treatment for gross motor impairments, as well as effective therapy including
music-based treatment that specifically addresses the physical, emotional, and behavioral
needs of traumatic brain-inj ured patients. Researchers alsohave articulated the
importance of assisting all TBI patients in adapting to their newly acquired physical
limitations, identifying appropriate coping skills, compensating for dysfimctions, and
strengthening their overall capabilities in the rehabilitation setting.

Widespread impairments in several physical firnctions, as well as cognitive
impairments can occur after traumatic brain injuries (Falkner, 2007). However, music
therapy has effectively assisted patients with cognitive impairments, communication
deficits, and socio-emotional barriers due to neurologic disorders (Lucia, 1987).
According to Claeys, Miller, Dalloul-Rampersad, and Kollar (1989), music therapy
assisted in motivating subjects engaged in physical and occupational therapy. The

researchers suggested that applied music selections provide the structured rhythm,

duration, and repetition needed to assist in optimizing the subjects overall physical
workout, thus maximizing results of the prescribed rehabilitative exercise routines.
Similar studies in physical and occupational therapy also yielded significant results when
music-based treatment assisted the overall level of motor functioning (Thaut, McIntosh,
Prassas & Rice, 1992; Kwak, 2007; Mauritz, 2002; Morris, Suteerawahananon, Etnyre,
Jankovic, & Protas, 2004). Music therapy research that is focused on neurological
disorders, such as traumatic brain injuries, suggests the music stimulus assists in the
overall brain functioning. Music stimulation can help integrate movement in patients with
physical disabilities by providing structure and motivation in treatment. Music and
rhythm have been used as an accompaniment to movement by acting as a natural
pacemaker in muscle movement timing (Thaut, McIntosh, & Rice, 1997; Nelson, & ,
Rothman, 2002; Hummelshein, 1999).

Davis, Gfeller, and Thaut (1999), identify three advantages of using music as
therapeutic aid in the following areas: The natural organization of rhythm found in music
(such‘as accented rhythms) provides predictable cues that can assist in organized

patterned movement. Music is a natural auditory stimulus, noted as one of the earliest

senses developed. The central nervous system is naturally activated when sounds are
perceived. “When we hear a sound, neurons in the motor system are excited, and our
muscles are set into a state of readiness” (Davis, Gfeller, and Thaut 1999, p.267). This
allows muscles to synchronize with rhythm, plan the sequences of motions and
coordinate the use of muscles needed to move smoothly without interruption. This

process is known as muscular entrainment through rhythmic auditory stimulation (Thaut,

2005)

Neurologic Music Therapy

“Neurologic Music Therapy (N MT) is defined as the therapeutic application of
music to cognitive, sensory, and motor dysfunctions due to neurological disease of the
human nervous system” (Thaut, 2005, p.126). NMT implements specific, goal-oriented
treatment objectives that facilitate functional rehabilitation in persons with neurological
disorders. Techniques include standardized Therapeutic Music Interventions (TMI),
which are adapted to each individual’s specific need. For example: A neurologic music
therapist can implement rhythmic auditory stimulation (RAS) as a Therapeutic Music
Intervention for a TBI patient with severe gait ataxia. Rhythmic auditory stimulation
(RAS), which is a specific neurologic music therapy intervention, is defined as a
“neurological technique using the physiological effects of auditory rhythm in the motor
system to improve the control of movement in rehabilitation and therapy” (Thaut, 2005,
p.139). Primarily used in gait therapy, RAS assists in the recovery of walking patterns in
patients with Parkinson’s disease, as well as those suffering from the effects of aging,
stroke, or other neurological impairments. Neurologic Music Therapists receive .
specialized training in the areas of neuroanatomy, physiology, brain pathologies, medical

terminology, as well as rehabilitation of cognitive and motor functions (Training Manual
for Neurologic Music Therapy). The purpose of this study is to determine if the use of
rhythmic auditory stimulation (RAS) assists in the overall functioning in gait training for

adult TBI patients.

Research Predictions

Following are three research predictions for the study: (1) RAS-enhanced gait
training will improve cadence of subjects tested, (2) RAS-enhanced gait training will
improve velocity of subjects tested, and (3) RAS-enhanced gait training will improve

stride-length of subjects tested.

CHAPTER TWO

REVIEW OF LITERATURE

The majority of RAS studies are with patients suffering from the debilitating
effects of Parkinson’s disease. There are undoubtedly many similar characteristics that
exist between the traumatic brain injured patients and persons with Parkinson’s disease,
as well as other neurological disorders. Currently, there is one published article from the
Center for Biomedical Research in Music, in which research specifically addresses the
effects of NMT with TBI patients. Hurt, Rice, McIntosh &‘ Thaut (1998) explore the use
of RAS in gait training with those suffering with TBI. Results of this study suggest a
relationship between sensory motor functions, gross motor movement, and rhythmic
motor entrainment when RAS is used in gait training. The investigators of this study
tested the effects of RAS within an entrainment design, and a specific gait training
method to help assist in each participant’s gait rehabilitation. 8 participants were tested in
the entrainment design, where all three gait parameters (Cadence, Velocity, and Stride
Length) were tested. Once a baseline Cadence was established for each participant,
cadences were then matched to RAS for gait exercises. Participant’s were asked to walk
at the fastest pace possible, and then requested to walk to the matched rhythmic cadences

(5% faster than the initial baseline cadence).

Five participants in the training design experiment were later asked to conduct
prescribed daily gait exercises to RAS musical tapes independently. Prescribed tempos
were initially set at the participants normal Cadence, then set at a faster tempo after each
week of training. The music therapist reassessed each participant at the end of each week
for endurance levels and vital statistics for precautionary measures. RAS sessions were
then increased by one minute per week. Foot switches recorded strides to ensure accurate
calculations of the gait parameters tested during the pretest and posttest, and compared.
Results of the first experiment were all found to be statistically nonsignificant, although
increases in velocity during the normal and fast walk phases were recorded. Increased
cadences in both normal and fast walking condition were also recorded, when RAS was
present. Results also suggest an overall increase in stride length throughout normal and
fast walking trials, again when RAS was present. Aspects of gait symmetry were also
increased during walking phases with RAS. Investigators analyzed scores between pretest
and posttest data after the 5 week independent RAS experiment. Results indicate
significant changes in all three gait parameters, with an overall 50% increase in Velocity,
16% increase in Cadence, and a 29% increase of Stride Length. Analysis of symmetry did
not yield a statistical significant increase, although overall mean percentages increased by
12%.

Participants in the entrainment design model were only allowed enough time to
measure each individual’s ability to entrain to a given tempo during time of testing. The
individualized RAS treatment designs were tested; endurance levels were reassessed and
increased by one minute at the end of each week of training. There were no music

therapists or physical therapists present on a daily basis to administer stride analysis

10

throughout these independent gait exercises. The results of this study suggest that
participants in the independent study improved in all three gait parameters after daily
exercises for 5 weeks. A daily systemic analysis of gait during these exercises could have
possibly assisted the participants in achieving even more improvements. This study was
the first of its kind, and investigates important issues concerning the Specific needs of
TBI patients suffering with gait deficits, and identifies RAS as an effective therapeutic
technique used in gait rehabilitation.

Fernandez del Olmo, Arias, F urio, Pozo, & Cudeiro (2006) evaluated the effects
of rhythmic movement by using an auditory stimulation with Parkinson’s patients in fine
and gross motor movement exercises. Through careful study of timed variability in
finger-tapping and gait training, results indicate a decline in the overall variability of
movements in subjects tested. Nine participants were tested in fine and gross motor
movement exercises, as well as a control group consisting of five patients with no history
of neurological pathologies. Subject’s attended treatment sessions for one hour per day,
five days per week for a four week period. Assessments of fine and gross motor
movement abilities were recorded before and after assigned exercises including the
special temporal patterns of footsteps, velocity, step length, cadence and variation
coefficients found between each footstep. Fine motor testing consisted of finger-tapping
exercises, repetitive extension and flexion movements for a 30 second time period.
Tapping exercises were performed with the index finger on the side of the body most
affected by Parkinson’s disease. Tapping frequencies were recorded in Hz and coefficient
variation of intervals recorded between consecutive taps. PET scans were performed

before and after movement exercises resulting in a statistical significance found within

11

variable movements upon completion of assigned exercises, consistent timing regularity
was also detected in both fine and gross motor movement exercises. Results suggest
auditory stimulation enhances both fine and gross motor tasks over a 30 day period by
improving the regularity of temporal motor movements in participants tested in this
study.

Pacchetti, Mancini, Aglieri, F undaro, Martignoni, and Nappi, (2000) observed
that music activities consisting of rhythmic free body movements, choral singing, and
voice exercises, combined with physical therapy, produced a positive, significant overall
effect on patients with Parkinson’s disease. In this study, the combination of rhythmic
movement and auditory stimulation through different pathways of the brain resulted in an
enhancement of motor skills, affect, and behavioral functioning. Hamburg and Clair
(2003) suggest that rehabilitation should include more than the physical workout; it
should focus attention on attitudes, motivation, endurance, and emotional components
that music has been known to affect directly. In this study, music was used to enhance
movements in physical exercises that contribute to an increase of motor control and
balance in patients with neurological disorders. Research also suggests that the rhythm in
music can improve different types of physical movements, including range of motion and
speed, while concurrently reinforcing dynamics, duration, and timing of movements in
the elderly (Hamburg and Clair, 2003).

As demonstrated in a 1993 study by Georgiou, Iansek, and Bradshaw, music and
rhythm are effective cues for fine motor responses. The subjects in their study had
Parkinson’s disease, and the researchers tested fine motor functioning by assessing each

individual’s ability to press spatially sequential keys located on a board. Treatment

12

yielded improvements in fine motor movement as demonstrated by the participant’s
abilities to press keys with temporal cuing. The rhythmic pulses assisted in a natural
temporal pace of finger movement. This reinforces the assumption that rhythm can be
used as a support for rhythmic timing in the brain.

Humans regularly perform intrinsic rhythmic movement daily while walking
(Roth &Wisser, 2004).The effects of music and rhythm on walking abilities also suggest
increases of gait efficiency through the use of rhythmic auditory stimulation. Rhythmic
auditory stimulation has been the focus of clinical studies with several populations, and
the results of these studies suggest a significant relationship between rhythm and physical
movement (Kwak, 2007; Prassas, Thaut, McIntosh, & Rice, 1997; Thaut, McIntosh, Rice,
Miller, Rathbun, & Brault, 1996).

Staum (1983) investigated rehabilitative rhythmic control of gait. Twenty-five
patients with gait disorders listened to preferred music and rhythmic percussion '
selections, while attempting to synchronize footsteps to the stimulus. Observations of
patients while the loudness of auditory stimuli faded indicated a significant gain in
rhythmic control and accuracy throughout gait training exercise.

McIntosh, Brown, Rice, & Thaut (1997) tested gait patterns of Parkinson’s
patients for which a musical tempo was set. Each patient’s heel strike was recorded on
strong rhythmic pulses. Treatment yielded a significant increase in velocity, cadence, and
stride symmetry found within each participant’s gait pattern suggesting a positive
relationship between musical tempo and gait.

Molinari, Leggio, Demartin, Cerasa, & Thaut (2003) studied neurobiology of

rhythmic motor entrainment with Parkinson’s patients. These researchers found a

13

relationship between movement and rhythm by identifying how rhythm is intrinsically
perceived and reproduced, while patients synchronized finger tapping to a rhythmic
stimulus. Results of motor responses throughout the tapping exercises were tracked
through neuroimaging of the brain, suggesting that differing levels of timing in the brain
are processed both consciously and unconsciously. Treatment yielded a positive
relationship between unconscious temporal movement and rhythmic auditory stimulation.

While working with persons suffering from neurological disorders, the therapist
must take into account direct effects of medication, especially the use of dopaminergic
drugs, which are known to affect the basal ganglia functioning in the brain. The basal
ganglia are associated with timing functions of motor control and postural coordination.
For example, when the brain initiates an action, such as finger movement, nerve cells in
the basal ganglia process. the signals for movements, helping to smooth the movements,
and the coordination of posture. These signals are processed in the basal ganglia by
neurotransmitters, primarily dopamine (Thaut, 2006). Researchers must also take into
account the effects of dopaminirgic medicine on the basal ganglia, when testing patient’s
suffering from neurologic impairments and motor movement, to ensure accurate data
collection.

Elliot, McCoy, Joyce, and Kohl (2002) observed significant changes in gait cycles
of subjects with Parkinson’s disease. Participants walked to accentuated rhythm with
metronome pulses. A significant increase in walking velocity was observed, but was
limited to only stride length of the left leg and increases in range of motion in the left
shoulder. These were most likely caused by the use of drugs used to suppress the

debilitating effects of Parkinson’s disease, including tremors, muscle rigidity, and

14

sluggish initiation of movements. A similar study, also with Parkinson’s patients, tested
subjects without medication for a forty-eight hour period. Results indicate that the
deficient basal ganglia functioning did not alter rhythmic entrainment (Rao, Mayer, &
Harrington, 2001).

Throughout the related research, the use of RAS has been shown to have a
positive effect on gross motor movement in gait rehabilitation for persons with
debilitating neurological disorders. These studies are important in identifying rhythm as
an asset in physical rehabilitation and potentially define the temporal motor and timing
functions of the brain. Therefore, rhythmic auditory stimulation may be an appropriate
form of treatment in neurological rehabilitation including gait training with TBI patients.

Kwak, (2007) observed significant changes in gait performances of children with
spastic cerebral palsy after a three-week treatment period using RAS. Twenty five
participants, in need of gait stabilization and coordination due to the debilitating affects
of spastic cerebral palsy were randomly divided into three groups: self guided training,
therapist guided training and control group. The control group received gait training with
a physical therapist, without RAS. The therapist—guided training group received gait
training with physical therapists, music therapist and RAS gait exercises. The self-guided
training group received gait training with physical therapists and self guided RAS
training. All three groups were tested in stride-length, velocity, cadence and gait
symmetry. Data were collected using a stride analyzer and compared pre-test/post-test
results. Results between groups suggest RAS enhanced gait therapy assists in the overall

gait performances of participants.

15

Rhythmic Auditory Simulation in Gait Training for Patients with Traumatic Brain
Injury (Hurt, Rice, McIntosh & Thaut, 1998) is the only published article that specifically
addresses RAS with TBI patients. Research that investigates the use of gait rehabilitation
techniques for TBI patients is important in assisting those suffering with gait deficits.
Research that systematically records the immediate effects of RAS in gait rehabilitation
(through daily gait and observational analysis) will assist in a better understanding of the
relationship between rhythm and gross motor movement in gait rehabilitation.

The following study was conducted to assist in determining if there is an effect of
tempo on cadence synchronization, by measuring Cadence, Velocity, and Stride Length

with RAS as an auditory cue.

16

CHAPTER THREE

METHOD

Participants

Seven adults with TBI who had previously been diagnosed at an in-patient
rehabilitation center, comprised the participants in the study. Two rehabilitation sites
were chosen, both located in Michigan. Four participants from one site and three from
another site were identified through referrals by each facility’s head physical therapist.
Participants had lived in a long term care in-patient rehabilitation program for a minimum
of six months post-injury to ensure safety while participating in rehabilitative gait
therapy.

Demographics for the participants can be seen in Table 2.

17

Table 2.

Demograrirics of Participants

ID Sex A e Balance difficult Gross Motor function
Al F 26 YES Below 50%
BZ F 34 YES Below 50%
C3 M 28 NO Below 50%
D4 F 29 YES Below 50%
F6 M 19 YES Below 50%
G7 M 53 YES Below 50%
H8 M 54 YES Below 50%

*Observational Gross Motor scores were recorded in each participant’s chart, based on

professional observations by the physical therapist before the treatment.

18

Referrals by the physical therapist were based on the following criteria:
1. Interest in music.
2. Uneven or labored gait patterns.
3. Lack of motivation in physical gait exercises.
Rhythmic auditory training was administered for a three-week period to allow
participants the time to establish a familiar routine during gait training. Participants were
tested three times per week in fifteen-minute sessions. One original participant did not
meet the selection criteria, and was, therefore, omitted form the data analysis. One
participant was unable to meet three times per week due to scheduling conflicts; his data
were analyzed and included for the 7 days in which he participated.
Inclusion Criteria

(1) Participants were free of hearing deficits as determined by on-site speech and

language pathologists prior to treatment to assure that the participants could

hear instructions and auditory stimuli.

(2) Participants adequately understood and spoke English to assure that each
participant understood instructions.

(3) Participants had enough physical stamina to complete a fifteen-minute gait
exercise session as determined by the on-site physical therapy departments.

(4) Participants presented a baseline motor proficiency score of 50% or lower, as

determined by the physical therapist, using Ranchos Los Amigos Gait
Assessment test (see Appendix B.).

Apparatus and Materials

0 The Ranchos Los Amigos Gait Proficiency test (see Appendix B) was used to
identify gross motor abilities, including speed and agility, balance, bilateral
coordination, and strength. The observational test was created in 1992 specifically

for the Ranchos Los Amigos Neurological Rehabilitation Center in California. The

19

Ranchos Los Amigos has been used in similar studies of RAS and gait training
(Kwak, 2007) and is a prevalent observational test currently used in physical
therapy. There were no studies found by the author regarding the reliability and
validity of the observational Ranchos Los Amigos Gait Proficiency Scale.

A timed metronome within a CASIO CTX-501 keyboard provided rhythmic
auditory stimulation.

A Stride Analyzer (Model SA-IV), developed by B & L Engineering, Inc. is a
microprocessor designed for recording foot to floor contact. F ootswitches have
pressure sensitive points for the purpose of recording foot to floor contact. The
stride analyzer calculates data from the footswitches and compares results to normal
gait parameters according to gender and age (see Appendix C). Foot contact
patterns (see Appendix D) display walking patterns of each participant’s heel, great
toe, fifth and first metatarsals. Walking pattern data Was collected through recorded
data from the footswitch pressure points. This analyzer was used to accurately
calculate cadence, velocity and stride length of participants in this study.

A Sony Digital Handy Cam Model DCR-SR45 was used for videotaping purposes

Procedure

Seven adult TBI patients were seen in two separate rehabilitation centers in

Michigan. Participants were approached and asked if they had an interest in participating

in this study using the assent script (see Appendix E). Consent forms and HIPPA forms

were sent to guardians and individuals interested, and each participant gave informed

consent (see Appendix F &G). The physical therapists administered an observational gait

analysis based on the Ranchos Los Amigos Gait Assessment prior to the onset of this

20

study. This testing allowed the researcher and physical therapist to choose subjects with
similar gross motor functioning levels. Disabilities of the participants included mild
cognitive impairments, sensory processing delays, communication limitations, behavior
or mental health problems, and gait disturbances. Participants were seen in their
respective day-treatment rehabilitation centers for RAS treatment. Rhythmic auditory
stimulation (RAS) is a specific neurologic music therapy technique that uses rhythm to
assist in temporal gross motor movements throughout gait exercises for persons with
neurologic disabilities. Out of respect for each participant’s physical well-being, gait
exercises were no longer than fifteen minutes per RAS session. Participant’s stride
length, speed, and velocity were evaluated during gait exercises. The researcher observed
each participant’s ability to synchronize rhythm in gait patterns. This allowed the
researcher to evaluate each participant’s ability to maintain a steady cadence with an
auditory stimulus. Gross motor functioning levels were measured prior to testing by
administering an Observational Ranchos Los Amigos Gait Assessment. Each
participant’s proficiency score was 50% or lower to reduce the variance in levels of
motor proficiency. The auditory stimuli were specifically designed to match each
participant’s current natural gait cadence throughout all gait exercises.
During training all data were recorded and analyzed by a stride analyzer, and compared
using a paired t-test for statistical analysis.

Every participant was tested on the following stride parameters:

(1) Cadence was measured by counting all heel strikes for sixty seconds.

(2) Velocity was measured by recording meters walked in sixty seconds.

21

(3) Stride Length was measured by recording the distance form one heel strike
to the next heel strike (on the same side).

RAS sessions were scheduled for each participant three times per week in 15
minute sessions, for a total of three weeks. Data were collected on three separate gait
variables: Stride Length, Velocity and Cadence. A 14 meter walkway was marked with
10 meters for testing purposes. Two meters were used before and after the walkway for
acceleration/deceleration purposes throughout gait exercises. Quantitative data were
collected using a stride analyzer. Foot switches were measured using each participant’s
shoe and fit to match the insole of each individual foot. After measuring footswitches to
fit each participant, footswitches were placed over the insoles of each shoe. A waistband
was placed around each participant; the stride analyzer was seemed using Velcro tape on
the back of the waistband. Foot switches were attached to the stride analyzer and each
participant walked 10 meters at a comfortable tempo, while data were collected. A pretest
assisted in identifying each individual’s baseline in cadence, velocity and stride length.
Rhythmic tempo was matched and recorded with a metronome. Rhythmic tempo
established in the pretest was observed and increased or decreased dependent upon each
participant’s percentage of normal calculated by the stride analyzer. Increases were set to
5% the second week of testing and increased by 10% the third and final week of testing.
If the individual was unable to increase the tempo of the gait, the current level was
maintained until the researcher and physical therapist conferred, observed, and agreed
when increases were safe for each individual. This was done for each session. If rhythmic
tempos were decreased, the participant was asked to identify the rhythm and begin

walking at a slower tempo. Participants were instructed to listen to the tempo and count

22

to eight with the metronome before starting each RAS exercise. The participants were
instructed to notify the researcher of any discomfort or fatigue throughout testing. If
exercises ceased due to fatigue, testing continued when the individual was able to resume
exercises. RAS exercises took place in the physical therapy gym of each individual
testing site. To determine whether rhythmic auditory stimulation affected gait
rehabilitation, baseline data were graphed and compared to RAS data for each individual
session (see Appendix I). Paired t-tests were performed, using the SPSS program, version
16.0, to identify improvements in each of the gait parameters. Raw measurement data
were compared to normal before and after treatment (see Appendix J) in Cadence,
Velocity, and Stride Length. This comparison was helpful in identifying if rhythm and
music interventions improved rehabilitative motor functioning with adult traumatic brain

injured patients.

23

CHAPTER F OUR

RESULTS

The purpose of this study was to assist in determining if a causal
relationship exists between melodic tempo and temporal cadence synchronization during
gait training for persons with Traumatic Brain Injuries. Data collected included 2
participant’s Cadence, Velocity, and Stride Length in both pretest and post-test. Data
were recorded and analyzed by a stride analyzer and paired t-tests were run to identify
improvements in each of the gait parameter. This chapter includes quantitative results
presented by the order of each research question. Descriptive data were also presented to
assist in a more complete understanding of each participant’s injury and functioning level
. (see Appendix I). It is of interest to note the differences of recorded data between each
participant. In the case of B2, the participant was extremely cognizant of walking to the
exact rhythmic beat presented, which may have caused the natural gait parameters to
decrease. Participant B2 did increase in the overall Stride length during testing. In one of
the cases, Participant A1 increased both Cadence and Velocity, while Stride Length
decreased. Examining the footswitch data assisted in identifying that participant Al often
walked on her toes. Balance was an issue with this participant and matching the set
rhythmic tempo was a difficult task throughout testing. The Cadence and Velocity of this
participant increased, while the heel to heel contact measured in stride-length decreased,

possibly due to the physical limitations.

24

Similar to A1, participant G7 walked with a weak right ankle, although data
yielded dramatic improvements in all three gait parameters. G7 was required to wear a
flexible AF O (flexible orthotic) throughout gait exercises, which assisted in strengthening
the right ankle throughout testing and normal everyday walking. All three gait parameters
improved (Velocity and Stride Length improved dramatically).This participant easily
identified the increase in tempo and was able to entrain to the RAS immediately. In the
case of H8, baseline data was recorded with a walker. By session number 2, the
participant requested to walk without the walker and was permitted to do so. Data yielded
an overall improvement in all three gait parameters throughout RAS testing without the
use of a walker 5 out of 6 sessions (Participant H8 was tested 7 out of 9 sessions due to
scheduling). Throughout testing, it was apparent that the Participant’s enjoyed gait
exercises when RAS was implemented (as demonstrated by a positive affect and
participation throughout sessions). Many participants requested melodic accompaniment
throughout gait exercises, which was unavailable in RAS treatment.

Quantitative Results

Research Prediction #1: RAS-enhanced gait training will improve Cadence of
subjects tested. Cadence was administered and based on the participant’s ability during
gait exercises and testing. Dependent upon the Participant’s observational gait analysis,
the goal was set to increase cadence in seven Participants. The recorded outcomes were
consistent with projected goals for most of the cases (see Appendix I). Contrary to the
initial set goals, Cadence decreased in one of the seven participants (B2). Cadence

increased overall by 6.64% (Table 3).

25

 

Table 3.

Means. Standard Deviations and Standard Error Mean for Cadence

Mean SD SEM

Group Baseline (N=7) 78.2143 8.19927 3.09903

Group Posttest (N=7) 87.5429 4.06729 1.53729

 

The paired t-test for Cadence indicates a significance difference (p< .05) between

baseline and post-test data (Table 4).

 

Table 4.

Thepaired t-test for Cadence

t(two-tailed) df

“O

-3.017 6 .023

 

Research Prediction #2: RAS-enhanced gait training will improve velocity of
subjects tested. Velocity was measured and recorded as the average speed in meters per

minute. An overall increase was recorded for each participant with the exception of one

26

' participant (BZ) who showed a Slight decrease in Velocity. The overall increase of the
group was consistent with predicted results with an increase of 13.24%. (Table 5 includes

the differences between baseline and post-test data.)

 

Table 5.
Means. Standard Deviations and Standard Error Mean for Velocity
Mean SD SEM
Group Baseline IN=7I 57.0143 19.20672 7.25946

Group Posttest (N=7) 72.2286 10.75712 4.06581

 

The paired t-test for Velocity indicates a highly significance difference between

baseline and post-test data (Table 6).

 

Table 6.

Results of t-test for Velocity

tltwo-tailed) df

I'D

-3.518 6 .013

 

27

Research Prediction #3: RAS-enhanced gait training will improve Stride Length
of subjects tested. Stride length was measured in meters from one heel to the next on the
same side. The measurement comparisons revealed an overall increase of 10.7%. In one
subject (Al), the stride length decreased. Table 7 displays the Means, Standard

Deviations and Standard Errors for baseline and post-test data.

 

Table 7.
Means. Standard Deviations for Stride length
Mean SD SEM
Group Baseline (N=7) 72.4286 ' 21.31570 8.05658

Group Posttest (N=7) 84.8286 10.75743 4.06593

 

The paired t-test on Stride Length indicates a significance difference between

baseline and post-test data in (Table 8).

 

28

Table 8.

The t-test for Stride Length

t(two-tailed) df

“O

-2.454 6 .050

 

Data were collected and analyzed using a paired t-test and percentages. A
significant improvement was found in all three gait parameters tested. The data for each
participant demonstrates the variability in individual participants (see appendix 1). After
RAS training, there were Significant improvements in all three stride parameters:

Cadence, Velocity, and Stride Length.

29

CHAPTER FIVE

DISCUSSION AND CONCLUSIONS

Persons suffering from the effects of Traumatic Brain Injury often require gross
motor rehabilitation after injury (Hurt et. a1, 1995). While in previous research, RAS has
improved results in gait performances of persons with neurologic disorders, this study
found significant improvement in all three gait parameters: Cadence, Velocity, and Stride
Length of participants afier RAS. Set goals were consistent with an overall increase to
normal in all three gait parameters of participants after treatment was administered:
Cadence yielded an overall improvement of 6.64% towards normal, Velocity yielded an
overall improvement of 13.24% towards normal, and Stride Length improved by 10.7%
towards normal.

Kwak (2006) found results similar to this study, although her study was with
children who had cerebral palsy. She observed casual relationships between tempo and
gait in all three gait parameters tested. The present RAS study yielded significant
improvements in all three gait parameters tested with TBI adults, while observational
results yielded trends towards normal in the 2006 study by Kwak. It Should be kept in
mind that any differences may have been that the Kwak study was an intervention with
children with a different neurological disorder.

Similar to the 1998 study by Hurt et. a1, RAS resulted in significant improvement

in all three gait parameters tested. Noted differences between these two studies include

30

the experimental testing of motor entrainment, a five week independent gait training
method, daily data collection via stride analyzer, and daily assessments of gait
performances in the present study. While these two studies had differences, they found
similar results, including overall significant improvements towards normal in all three
gait parameters tested.

The overall results of this study and previous research suggests that the use of
neurologic music therapy and RAS for persons with traumatic brain injuries is a valuable
clinical tool.

Implications for practice

Due to time constraints in the sessions, the researcher identified the need for
additional time for RAS sessions. Many participant’s schedules did not permit the extra
time needed to assemble the equipment necessary for testing, thus causing the tests to run
over the allotted 15 minutes for RAS treatment. Stride analyzer comparisons with the
norms were analyzed and compared. Future analyses should consider the participant’s
stature (weight, build, bone structure), not only the age and gender of participants to
produce thorough individualized comparison of gait parameters. Also, a better
measurement tool needs to be found.

Qualitative measures in future studies may enhance a better understanding of the
participants experiences. These components might ask such questions as how the
participants felt about testing, what they liked or disliked about the process.

Future research with RAS and TBI participants should also consider controlling
for the time elapsed after the initial rehabilitation process of the TBI. Through future

inquiry, music therapy can assist in better understanding and acceptance of RAS in

31

neurologic rehabilitation.
Conclusion

The present data suggest that rhythm and music assists in muscular time
management of gross motor movement exercises when a rhythmic tempo is present, even
with Participants who have suffered cerebellar injuries or TBI. This study suggests that
the use of neurologic music therapy and RAS for persons with traumatic brain injuries

can be a valuable clinical tool when used in gait rehabilitation for TBI patients.

32

Appendix A

(Glasgow Coma Scale)

33

Glasgow Coma Scale

A. Motor Response Scores

6 — responds to commands fully

5 - responds to noxious stimuli

4 - withdraws from noxious stimuli
3 - abnormal flexion

2 - extensor response

1 - No response

B. Verbal Response Scores

5 — Is alert and oriented

4 - Confused, although coherent and is able to speak
3 — Inappropriate jumbled words

2 - Incomprehensible sounds

I - No sounds

C. Eye Opening Scores

4 — opens eyes spontaneously
3 — opens eyes to verbal cuing
2 - opens eyes to pain

1 - No eye opening

34

Final scores are determined by adding A, B and C. Numbers help determine the severity

of injuries sustained. Four levels: Mild (13-15), Moderate (9-12), Severe (3-8),

Vegetative State (>3). Persistent Vegetative State, Brain Death (tbi.COM)

35

Appendix B

(Observational Gait Analysis) .

36

 

 

Relerence Limb

LCl REl

Ranrho L Amigos Medical Center

 

 

Major Dcviuu‘on

Minor Deviation

 

 

 

Tnmk Lean: B/F
Imu'al Lean: R/L

Rotates: B/F

Pelvis Hikes
Till: PIA

Lacks Forward Rotation

Links Backward Rotation
Execs Forward Rotation
Ipsilnrcral Dmp

Cmmlarcnl Drop

Hip Flexion' Limited
Excrss

Inadequate Extension

thhlcs

Hypcrcxrcnd

Exlcnsion Thrusr

VanrstnIgus. Vre’Vl

Excess (‘ontmlalcml Flcx

Knee Flexion I.I1'YIll€d
Excess
Inadequate Exlcnsinn

Wobblcs

Ankle Forefoot Contact
Foot Flat Contact
11ch OIT
No Heel OIT
Drag
Tau: Up. Clawcd. Inad Extcn.

 

 

 

 

 

MS! IS! I PSw ISn' MSW

 

L Gait/Analysis: Full Body 1

IIAAIII

Single Limb Swing Limb
Support Advancement

 

 

 

37

Appendix C

(Normal Gait Parameters)

38

From: Gait Analysis, Normal and Pathological Function Book, by Jacqueline Perry,
SLACK Incorporated, 1992, pg. 432. & Oberg T., Karszania A, Oberg K, Basic gait
parameters: Reference data for normal subjects, 10-79 years of age. Journal of

Rehabilitation Research and Development, Vol. 30, No.2, 1993, pg. 210-223.

VELOCITY
Normal gait Male Normal gait Women
AGE (years) Mean (In/min) AGE (years) Mean (In/min)
10-14 79.4 10-14 65.2
15-19 81.1 15-19 74.3
20-29 73.6 20-29 74.5
30-39 79.0 30-39 77.1
40-49 79.7 40-49 74.8
50-59 75.1 50-59 66.3
60-69 76.6 60-69 69.4
70-79 70.9 70-79 66.8
CADENCE
Normal gait Male Normal gait Women
AGE (years) Mean (steps/min) AGE (years) Mean (steps/min)
10-14 128.4 10-14 118.2
15-19 121.2 15-19 125.4
20-29 1 18.8 20-29 124.8
30-39 120.0 30-39 127.8

39

40-49

50-59

60-69

70-79

120.6

117.6

117.0

114.6

4049

50-59

60-69

70-79

129.6

121.8

123.6

121.8

STRIDE LENGTH
(measurement of length from one heel strike to the next on the same side)
Normal gait Male Normal gait Women

AGE (years) Mean (meters) AGE (years) Mean (meters)

10-14 .615 10-14 .542
15-19 .660 15-19 .593
20-29 .616 20-29 .591
30-39 .649 30-39 .597
40-49 .647 4049 .571
50-59 .635 _ 50-59 , .535
60-69 .650 ' 60-69 .553
70-79 .615 70-79 .542

40

Appendix D

(Foot Switch Patterns)

41

Sea Emé

 

 

ESE mass; 352

Foam.“— EE Eaten

                 

E5562».
:3:
HES—«52L

"Ci—r

 

 

u 01—.

Hansen: L

 

.31 noon. an.”

 

3556: am i

 

 

 

.835

ff 6%

 

bot—NE ”Err 2.80m 0:0 .6: ,3

2535“ £835 “ooh

42

Appendix E

(Assent script)

43

ASSENT SCRIPT

I am Jody Wilfong and I’m a graduate student at MSU studying Music Therapy.
I’m interested in learning more about how people walk when they hear music. I’m
hoping you might be willing to help me learn more about that through participating in my
research study. If you want to participate, we’ll also talk to your physical therapist and
s/he will be here when we do our activity. These exercises won’t take long
approximately 15 minutes per session. I’ll come back three times a week for the next
three weeks. The family members who work with you will help you decide if you want
to do this. Staff from this facility will help us schedule these exercises at a time that is

convenient for you. Do you think you would like to participate?

44

Appendix F

(RAS testing Consent Form)

45

RHYTHMIC AUDITORY STIMULATION ON GAIT TRAINING.
Dear Parent(s)/Guardian(s):
I am Jody Wilfong, a Graduate student at MSU majoring in music therapy. I am
interested in studying the effects of rhythmic auditory stimulation on gait with traumatic
brain injured adults. I am interested in developing a specific music neurological program
for the TBI patients. This study will focus on rhythmic stimulation and each individual’s
ability to synchronize steps to rhythmic stimulus throughout rehabilitative gait training.

The sessions will be taking place twice a week during a 6-week period at

 

Michigan. Each session will be 15 minutes long. It will be videotaped for analyzing
purposes only.
The following information is provided for you to decide whether you and

wish to participate in the present study. You should be

 

aware that even if you agree to participate, you are free to withdraw at any time without
affecting opportunities for participation in future projects offered by the researcher.
An advisor in the School of Music, Division of Music Education and Music

Therapy at Michigan State University has approved all procedures. I ask for you and

 

’s participation in this study, but it is strictly voluntary. Do
not hesitate to ask any questions about the study before, during, or after the research are

complete. Rest assured that you and will not be associated

 

with the research findings in any way. Names will be replaced with pseudonyms in all

research data. If you prefer, you can choose your pseudonym, otherwise I will select a

46

random pseudonym. Confidentiality will be upheld to the highest extent of the law.

Enclosed is a consent form requiring a signature, which will allow the use of each
Participant’s medical records to record the age and diagnosis. You may choose not to
participate at all or you may refuse to participate in certain procedures or answer certain
questions.

The expected benefits associated with participation in this study are to explore the
relationship between music and movement. This study, as a part of long term study, is
geared toward exploring the effects of rhythm on movement and the development of
neurological music therapy programs for the traumatic brain injured adult. It will enhance
the quality of music therapy service offered in rehabilitation. The discomfort and/or risks
are minimal. Michigan State University requires all studies involving human subjects to
include the folloWing statement in all consent forms: “If you are injured as a result of
your participation in this research project, Michigan State University will assist you in
obtaining emergency care, if necessary, for your research related injuries. If you have
insurance for medical care, your insurance carrier will be billed in the ordinary manner.
As with any medical insurance, any costs that are not covered or are in excess of what are
paid by your insurance, including deductibles, will be your responsibility. The
University’s policy is not to provide financial compensation for lost wages, disability,
pain or discomfort, unless required by law to do so. This does not mean that you are
giving up any legal rights you may have. You may contact Jody Wilfong (810)266-4045
with any questions or to report an injury.”

If you have any questions about this study, please contact: Frederick Tims, PhD,

47

by phone (517- 353-9856), email (tims@msu.edu), or regular mail (201 Music Practice
Building, East Lansing, MI 48 824); or Jody Wilfong by email (J jktwilfong@aol.com), or
regular mail.

If you have any questions or concerns regarding your rights and your
son/daughter/ward’s rights as study participants, or are dissatisfied at any time with any
aspect of this study, you may contact-anonymously, if you wish Peter Vasilenko, PhD,
Chair of the MSU Human Research by phone: (517) 355-2180, fax: (517)432-4503, 6-
mail: irb@msu.edu, or regular mail: 202 Olds Hall, East Lansing, MI 48824-1047.

I appreciate your assistance.

Sincerely,
Jody Wilfong, MT-BC

By signing below, you acknowledge receiving information about the research and that
having a chance to ask questions. You also acknowledge receiving a copy of this form.

I voluntarily agree to permit your son/daughter/ward

 

to participate in this study.
Signature of Guardian

Date

 

I agree to allow videotaping of the (RAS) Gait testing to be used for gait assessment and
evaluation throughout each session.

Signature of Guardian Date

 

 

48

Appendix G

(HIPPA Consent Form)

49

 

PATIENT AUTHORIZATION FOR DISCLOSURE,

 

 

 

Patient

Name:

 

Address:

 

D.O.B.

 

I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION

 

 

 

 

 

 

 

 

FROM:

TO:

Name of hospital or health care system or provider Name of researcher or research group
Address Address
Phone/Fax Number Phone/Fax Number

DESCRIPTION OF INFORMATION TO BE DISCLOSED (select one of the
following):

_ALL information contained in my medical record.

93

50

_ ONLY disclose the following information:

RESEARCH STUDY FOR THIS DISCLOSURE:

Title of
Study:

 

Name of
Research Leader:

 

Affiliation of
Researcher:

 

IRB#

 

Name of IRB

 

EXPIRATION (fill in one of the following):

Your Authorization to disclose the above information expires on
Has no expiration date _; or

Expires at the end of the research study _; or

Expires six months from the date signed—
REVOCATION, REFUSAL, REDISCLOSURE:

You may revoke this Authorization in writing at any time by
contacting

‘;or

(e.g., the healthcare system or provider or hospital named above),but it will not affect any

information already released to the researcher(s).

You may refuse to sign this authorization and your refusal will not affect your ability to obtain treatment,

however, it may affect your ability to participate in this research study.

Your information that is disclosed to the researcher(s) may no longer be protected by Federal privacy
regulations if the researcher(s) is not a health care provider covered by the regulations, however the

researcher(s) agrees to protect your information as required by law.

 

Signature of Patient or Personal Representative/Date

 

51

Name of Personal Representative and Relationship to Patient (or description of authority to act on behalf of
the patient)

PROVIDE COPY TO PATIENT

52

Appendix H

( Sample Data from Stride Analyzer)

53

Sample Data from Stride Analyzer

Date: 06/ 1 7/08
Diagnosis: tbi

Age: 29 years 12 months
Gender: Male

Conditions:

Strides: 6

Trial Type: Walking Trial
Distance: 6.000meters

 

Stride Characteristics
Actual %Norma1
Velocity (M/MIN): 37.8 46.1
Cadence (STEPS/MIN): 96.6 88.8
Stride Length (M): 0.782 52.0
Gait Cycle (SEC): 1.24 111.5 t
-R- -L-
Single Limb Support
(SEC): 0.395 0.520
(%Normal): 58.2 76.7
(%GC): 31.9 41.6
Swing (%GC): 42.0 31.6
Stance (%GC): 58.0 68.4
Double Support _
Initial (%GC): 10.3 15.8
Terminal (%GC): 15.8 10.4
Total (%GC): 26.1 26.2
Left Foot (stance =68.4% GC)
Heel ----Normal Contact at 0.0% GC (0.0% stance)
Delayed Cessation at 50.2% GC (73.4% stance)
5th Metatarsal ----Delayed Contact at 41.1% cc (60.1% stance)
Delayed Cessation at 63.7% GC (93.1% stance)
1gt Metatarsal ----Delayed Contact at 42.6% GC (62.3% stance)
Delayed Cessation at 64.3% GC (94.0% stance)
Toe ----
(0 strides)
Right Foot (stance = 58.0% GC)
Heel ----Normal Contact at 0.0% GC (0.0% stance)
Delayed Cessation at 44.0% GC (75.9% stance)
5th Metatarsal ----Delayed Contact at 18.8% GC (32.5% stance)
Premature Cessation at 63.7% GC (93.1% stance)
lSt Metatarsal ----
(0 strides)
Toe ----
(0 strides)

54

Appendix I

(Individual results)

55

 

A1

26 year old female sustained traumatic brain due to a pedestrian/motor vehicle accident at

the age of 11. Difficulties due to injury include left cranial lobe damage, ataxic

dysarthria, short term memory loss, dysphasia and gait disturbances.

Baseline Normal

Compared to Normal After RAS Compared to Normal Change towards gormal

 

 

 

 

 

 

 

 

 

 

 

 

    

 

Cadence
86.1 124.8 72.7% 96.7 81.5% +8.8%
Velocity
55.7 74.5 68.9% 60.5 74.8% +5.9%
Stride Length
1.294 .591 94.3% 1.252 91.2% -3.1%

100-

so

so ‘

‘0‘ . IBasellne

. IW-RAS

20 I

oI ? .

Velocity Cadence Stripe

Length

 

56

£2
34 year old female sustained traumatic brain injury due to motor vehicle accident at 16
years of age. Difficulties due to injury include decerebrate posturing, left temporal lobe

and right fi'ontal lobe damage, behavior and gait disturbances

Baseline Normal Compared to Normal After RAS Compared to Normal Change towards nopmal

 

 

 

 

Cadence

108.3 127.8 91.3% 104.8 88.4% -2.9%
Velocity

72.6 77.1 89.8% 71.6 88.6% -l.2%
StrideLength

1.341 .597 97.8% 1.366 99.5% +1.7%

 

 

 

 

 

 

 

 

I Baseline
IW—RAS

 

 

 

    

 

82< ‘ ' 1
Velocity Cadence Stride
Length

 

57

Q3
28 year old male sustained traumatic brain injury due to a pedestrian/motor vehicle
accident at the age of 3. Difficulties due to injury include lefi hemi paresis, sensory

deficits, spasticity, mild hemi paretic gait.

Baseline Norn_ia_l Compared to Normal Afler RAS Compared to Normal Chang; tpwards Normal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cadence
78.5 118.8 72.9% 92.9 86.3% +13.4%
Velocity
26.9 73.6 33.3% 52.7 65.1% +31.8%
Stride Length
10.687 .616 45.7% 1.134 75.5% +29.8%
90.
80
70
so.
50.
40- IBasellne
30‘ IW-RAS
20-
10‘

 

 

0‘
Velocity Cadence Stride
Length

 

58

_Dfi

29 year old female who sustained sub arachnid hemorrhage and front parietal hematoma

from a collision with a school bus, while riding a bicycle at the age of 12. Difficulties due

to injury include poor attention, short and long term memory recall, impulsivity and gait

disturbances.

Baseline Normal Compared to Normal After RAS Compared to Normal Change towards Normal

 

 

 

 

 

 

 

 

      

 

Cadence
79.7 124.8 67.2% 96.1 88.4% +21.2%
Velocity
40.9 74.5 50.6% 57.8 71.4% +20.8%
Stride Length
1.027 .591 74.8% 1.202 87.6% +12.8%

90} _

so

70« _,

g; ‘ - —

40‘ - -£ .3330,“

33‘ - -" Imus

‘3; r -‘i —

Velocity Cadence Stride

Length

 

59

 

F_6

19 year old male who sustained left side hemiplegic and spasticity in left band due to a
motor vehicle accident while a passenger in an infant car seat. Difficulties include left
side spasticity, ataxic dysarthria, long and short term memory, cognitive and gait
disturbances

Baseline Normal Compared to Normal After RAS Compared to Normal Change towards Normal

 

 

 

Cadence

89.3 121.2 82.1% 92.1 84.6% +2.5%
Velocity

40.3 81.1 49.2% 47.3 57.7% +8.5%
Stride Length

0.901 .660 59.9% 1.027 68.2% +8.3%

 

 

 

 

 

 

 

 

I Baseline
I W-RAS

 

 

 

 

 

    

 

 

0« . '
Velocity Cadence Stride
Length

 

60

Q]

53 year old male sustained traumatic brain injuries due to a motor vehicle accident at the
age of 24. Difficulties due to injury include right frontal lobe damage, cognitive, short
term memory recall, attentiveness and gait disturbances.

Baseline Normal Compared to Normal After RAS Compared to Normal Change towards Normal

 

 

Cadence

91.6 117.6 84.2% 96.7 84.7% +0.5%
Velocity

33.7 75.1 41.2% 60.5 70.0% +28.8%
Stride Length

0.736 .635 48.9% 1.252 80.2% +31.3%

 

I Baseline
I W-RAS

 

o .
Velocity Cadence Stride
Length

 

 

61

fl

54 year old male sustained traumatic brain injury including cerebral edema, fractured
maxilla, lacerated spleen at the age of 22. Subject was hit by a truck, while riding a
toboggan pulled by a snowmobile. Difficulties due to injury include extension rigidity
with episodic decorticate posturing, short and long-term memory recall and gait

disturbances.

L7,

Baseline Normal Compared to Normal After RAS Compared to Normal Change towards Normal

 

 

Cadence

88.1 117.6 77.1% 101.6 88.9% +11.8%
Velocity

55.4 75.1 66.1% 68.4 81.6% +15.5%
Stride Length

1.257 .635 85.6% 1.346 91.6% +6.0%

 

 

100~

 

80‘
50.

 

 

I Baseline
Iw-RAS

 

4o- ‘

 

 

 

 

    

201 ‘

 

0t ' ‘
Velocity Cadence Stride
Lengfli

62

 

Appendix J

(Individual raw percentage data used in statistical analysis)

63

 

 

Individual Raw Percentage Data Used In Statistical Analysis

VELOCITY Baseline After RAS

 

 

CADENCE Baseline After RAS
A1 1 72.7 81.5 A1 68.9 74.8
132 91.3 88.4 132 89.8 88.6
C3 72.9 86.3 c3 33.3 61.5
D4 67.2 88.4 D4 50.6 71.4
F6 82.1 94.6 F6 49.2 57.7
G7 84.2 84.7 G7 41.2 70.0
H8 77.1 88.9 H8 66.1 81.6
STRIDE LENGTH Baseline After RAS ,

A1 94.3 91.2

132 97.8 99.5

C3 45.7 75.5

D4 74.8 87.6

186 59.9 68.2

G7 48.9 80.2

H8 85.6 91.6

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