ArticlePDF Available

Yoga after Traumatic Brain Injury: Changes in Emotional Regulation and Health-Related Quality of Life in a Case-Study

Authors:

Abstract

Purpose: The purpose of this study was to analyze changes in emotional regulation and health-related quality of life (HRQOL) following a yoga intervention for three participants with traumatic brain injury (TBI). Yoga was utilized as a modality to improve HRQOL and emotional regulation. Methods: A mixed method design was used to analyze changes in emotional regulation and HRQOL. Participants completed an eight-week yoga intervention and assessments were completed before and after the intervention. Outcome measures included the Difficulty in Emotional Regulation Scale (DERS) and Quality of Life after Brain Injury Scale (QOLIBRI, both are reliable and valid after TBI. The Change in score (percent change) were calculated for data from both assessments. Semi-structured interviews were completed, data were transcribed, and qualitative data were analyzed with a focus on emotional regulation and HRQOL. Results: On average, the three participants had a 16% improvement in DERS scores and 6% improvement in QOLIBRI scores following the yoga intervention. Analysis of the qualitative data indicate that participants identified improvements related to emotional regulation in the mind-body connection, peaceful and calm feelings, concentration and focus, and self-control. In relation to HRQOL participants noted social changes, physical changes leading to life changes, confidence to do things and self-development. Conclusion: Yoga is a potential intervention to address emotional regulation and HRQOL for individuals with chronic TBI. Emotional regulation and HRQOL are two important factors affected post-TBI that through this study were impacted by yoga as a focused mind-body intervention.
Internationa Journal of Complementary & Alternative Medicine
Yoga after Traumatic Brain Injury: Changes in Emotional
Regulation and Health-Related Quality of Life in a Case-
Study
Submit Manuscript | http://medcraveonline.com
Volume 8 Issue 1 - 2017
1Department of Occupational Therapy, Colorado State
University, USA
2Department of Parks, Clemson University, USA
3Department of Physical Therapy, Indiana University School of
Health and Rehabilitation Sciences, USA
4Vera Z. Dwyer College of Health Sciences, Indiana University
South Bend, USA of Health and Rehabilitation Sciences, USA
*Corresponding author: Laura Grimm, 1Colorado
State University, College of Health and Human Sciences,
Department of Occupational Therapy, Fort Collins, CO, Tel:
315-373-9168; Fax: 970-491-6290;
Email:
Received: May 19, 2017 | Published: July 24, 2017
Research Article
Int J Complement Alt Med 2017, 8(1): 00247
Abstract
Purpose: The purpose of this study was to analyze changes in emotional regulation
and health-related quality of life (HRQOL) following a yoga intervention for three
participants with traumatic brain injury (TBI). Yoga was utilized as a modality to
improve HRQOL and emotional regulation.
Methods: A mixed method design was used to analyze changes in emotional regulation
and HRQOL. Participants completed an eight-week yoga intervention and assessments
were completed before and after the intervention. Outcome measures included the
  
Scale (QOLIBRI, both are reliable and valid after TBI. The Change in score (percent
change) were calculated for data from both assessments. Semi-structured interviews
were completed, data were transcribed, and qualitative data were analyzed with a
focus on emotional regulation and HRQOL.
Results: On average, the three participants had a 16% improvement in DERS scores
and 6% improvement in QOLIBRI scores following the yoga intervention. Analysis
         
to emotional regulation in the mind-body connection, peaceful and calm feelings,
concentration and focus, and self-control. In relation to HRQOL participants noted
 
self-development.
Conclusion: Yoga is a potential intervention to address emotional regulation and
HRQOL for individuals with chronic TBI. Emotional regulation and HRQOL are two
important factors affected post-TBI that through this study were impacted by yoga as
a focused mind-body intervention.
Keywords
Emotional Regulation; Health-related Quality of Life; Traumatic Brain Injury; Yoga;
Mind-Body Interventions
Abbreviations: TBI: Traumatic Brain Injury; HRQOL: Health-
Related Quality of Life; MMSE: Mini Mental Status Exam; DERS:
       
Therapist
Introduction
A traumatic brain injury (TBI) is a form of acquired brain
injury, resulting from damage caused by an external force to
the head [1]. The injury can be penetrating or non-penetrating,
creating an open or closed head injury. In 2010, it was estimated
that 2.2 million emergency room visits in the United States
resulted in a TBI diagnosis [2]. Over three million Americans are
living with a residual disability because of a TBI [3,4]. The effects
of TBI permeate the individual’s lifespan, potentially creating low
         

60% had either died or experienced functional decline [6]. Due
to alterations in brain function, a TBI can result in residual
impairments in physical, emotional, cognitive, social, and daily
functioning across the lifespan [7].
The impact of a health condition impairment on an individual’s
perception of function is known as health-related quality of
life (HRQOL) [8]. TBI is associated with multiple long-term
impairments in HRQOL [9], potentially affecting functioning
in physical, emotional, cognitive, and social domains [10].
Individuals with TBI often develop poor coping strategies
following the injury, which also negatively impacts HRQOL [11].
When HRQOL domains and coping are interrupted by a TBI, the
ability to understand limitations and adjust behaviors, known as
emotional regulation, may decline.
This ability to regulate emotions by managing behaviors and
making adaptations in social contexts [12,13] is important to
         
Yoga after Traumatic Brain Injury: Changes in Emotional Regulation and Health-
Related Quality of Life in a Case-Study 2/9
Copyright:
©2017 Laura et al.
Citation: Grimm LA, Van Puymbroeck M, Miller KK, Fisher T, Schmid AA (2017) Yoga after Traumatic Brain Injury: Changes in Emotional Regulation
and Health-Related Quality of Life in a Case-Study. Int J Complement Alt Med 8(1): 00247. DOI: 10.15406/ijcam.2017.08.00247
both psychological (cognitive) and social HRQOL domains,
       
that directly address emotional regulation [14]. Additionally,
emotional regulation can act as a predictor of HRQOL outcomes.
Regarding individuals affected by TBI, Henry et al. [15] found that
        
      
         
function [16]. Emotions, such as hope and optimism, have been
linked to higher scores in HRQOL [17]. In general, the ability to
cultivate positive emotions may be fundamental to well-being
[18], and may be particularly important following a TBI if an
individual’s emotional regulation capabilities are disrupted [13].
Negative changes in post-TBI HRQOL and emotional regulation
indicate a need for interventional research that can address these
important outcomes [13,7]. TBI creates a perceived mind-body
disconnect for many individuals [19]. A study by Fernros and
Furnhoff (2008) analyzed HRQOL changes following one week of
    
subsets of general health perception, and emotional well-being
[20]. Therefore, interventions focused on connecting the mind
and body may improve the emotional domain of HRQOL and
should be further studied for individuals with TBI in conjunction
with emotional regulation. Participants with stroke, another
neuropathology, reported an increased sense of connection
      
and emotional domains following a yoga intervention [21]. As
a mind-body practice focused on physical postures and mental
awareness, yoga can lend itself to a neurological population when
implemented by trained practitioners [22]. Currently, there are a

none targeting emotional regulation. Silverthorne et al, completed
       
improvements in physical functioning and emotional well-being
from baseline to nine months following the intervention [23].
In another related population, researchers evaluated an 8-week
yoga program for acquired brain injury [24]. They found that the

and participants reported high satisfaction ratings indicating that
yoga is potentially feasible for individuals with brain injuries.
Other studies examined the effects of mindfulness-based stress
reduction (MBSR) for individuals after TBI [25,26], and MBSR
programs contain a Hatha yoga element but are not designed
to be yoga interventions [27]. There is however more yoga-
      
       
to yoga interventions have been demonstrated in other clinical
neurological populations [28], such as: multiple sclerosis [29];
Parkinson disease [30-32]; and stroke [33,21]. Yet, there is
      
emotional regulation and HRQOL after yoga for individuals
with TBI. Many studies recommend that future research should
examine the role of yoga, or other non-pharmaceutical treatment,
for individuals with TBI [34,35]. The purpose of this study was
to analyze the participant reported outcomes of emotional
regulation and HRQOL, along with their perceptions of an eight-
week yoga intervention.
Methods
Design
This was a multi-methods case-study including three par-
ticipants and was focused on changes in HRQOL and emotional
regulation following a yoga intervention. Each participant
completed 16 sessions of yoga, twice a week for eight weeks, and
outcome data were collected before and after the eight-week yoga
intervention.
Participants
All participants were adults, 18 years of age or older, and
consented to the study following Institutional Review Board
       
TBI (greater than six months post injury). All participants
received occupational therapy or physical therapy services post-
TBI, but had completed all TBI rehabilitation prior to enrollment
in this study. In order to qualify for the study, individuals had to
score >4/6 on the Short Mini Mental Status Exam (MMSE)[36], be
able to speak, read, and understand English and be able to stand
with or without an assistive device.
Data collection
Demographic data, patient reported outcome data, and
qualitative data were collected by a trained research assistant.
Age, race, gender, marital/partnership status, and education were
all included as demographic data. Date of TBI, years since TBI,
and corresponding hemiparesis were also collected. Quantitative
assessments occurred before and after the yoga intervention
through use of the DERS and QOLIBRI.
    
Regulation Scale (DERS)
The DERS is a 36-item questionnaire, consisting of options 1
almost never” to 5 “almost always” [37]. Six subscales are included:
lack of emotional awareness; lack of emotional clarity; non-
acceptance of negative emotions; lack of strategy building; lack
of control of impulsive behaviors; and inability to behave during
goal-directed emotions while experiencing negative emotions.
There are no established cut-off scores for TBI participants
when using the DERS. In this study, items were reverse scored
which made a higher total DERS score indicate higher emotional
regulation abilities.
Quantitative data collection-Quality of Life after Brain
Injury (QOLIBRI)
The QOLIBRI is a 37-item questionnaire that includes a 5-point
Likert scale with scoring from 1 “not at all   very
       
cognition, feelings and emotions, autonomy and daily life, and
social relationships. Part two focuses on impact, in regard to
negative feelings and restrictions. The total score 0-100 acts as a
HRQOL measurement for individuals following TBI, with higher
scores indicating better HRQOL [39].
Yoga after Traumatic Brain Injury: Changes in Emotional Regulation and Health-
Related Quality of Life in a Case-Study 3/9
Copyright:
©2017 Laura et al.
Citation: Grimm LA, Van Puymbroeck M, Miller KK, Fisher T, Schmid AA (2017) Yoga after Traumatic Brain Injury: Changes in Emotional Regulation
and Health-Related Quality of Life in a Case-Study. Int J Complement Alt Med 8(1): 00247. DOI: 10.15406/ijcam.2017.08.00247
Qualitative data collection
Qualitative data were collected post intervention using an
18 question face-to-face semi-structured interview format. All
interviews were audio recorded for verbatim transcription.
Primary questions included, “What has been your overall
experience in the therapy program?” and “What did you expect the
yoga program to be like before it started?” Further questions were
developed as the interview progressed, and when appropriate
participants were probed for further information with phrases
like, “expand on that thought.
Intervention
The intervention consisted of one-hour yoga sessions,
provided by a registered yoga therapist (RYT), bi-weekly for
eight weeks. Yoga was delivered in a 1:1 fashion and a research
assistant was available if needed to assist with postures or
         
advancing from seated, to standing, then supine, or quadruped on

and safety needs. Sessions began with breathing techniques to
enable awareness. Adjustments throughout the session included

support and ideal biomechanical alignment. Sessions ended with
ten minutes of progressive muscle relaxation alongside guided
meditation, with the RYT providing eye pillows while participants
were supine on their yoga mats. See Table 1 for a full description
of yoga postures and progression. Additionally, information on the
protocol has been previously published focusing on the physical
and balance outcomes [40].
Table 1: Yoga intervention.
Position (Week
Estimate) Description Yoga Practice:
Select Examples
Seated (Weeks 1-8)
Opening breathing
Breathing Practices:
i. Breath with sound
ii. Natural rate breathing
iii. Prolonged exhale breathing
iv. Alternate nostril breathing
Eye Movements, eyes opened or closed:
i. Diagonal
ii. Horizontal
iii. Circles
iv. Hourglass
Cervical Movements:
i. Rotations
ii. 
Head Movements:
i. 
Shoulder Movements:
i. Shoulder shrugs
ii. Shoulder forward rolls
iii. Shoulder backward rolls
iv. Rotations with shoulders in abducted position
v. Scapular protraction and retraction
Torso Movements:
i. 
ii. Rotation
Breathing:
a. Ujjayi
b. Pranayama
c. Nadi Shodhana
Eye Movements:
a. Drishti Bheda
b. Pralokita, Saachi, Alokita
Head/Neck/Torso Movements:
i. Adapted Ardha Chandrasana
ii. Adapted Simhasana
iii. Ardha Matsyendrasana
Standing
(Weeks 3-8)
Using the wall or chair for support:
i. Calf stretch/hip extension
ii. Supported Toe Balancing
iii. Supported One leg balance
Standing Movements:
i. Tadasana
ii. Virasan
iii. Utkatasana
iv. Vrksasana
Yoga after Traumatic Brain Injury: Changes in Emotional Regulation and Health-
Related Quality of Life in a Case-Study 4/9
Copyright:
©2017 Laura et al.
Citation: Grimm LA, Van Puymbroeck M, Miller KK, Fisher T, Schmid AA (2017) Yoga after Traumatic Brain Injury: Changes in Emotional Regulation
and Health-Related Quality of Life in a Case-Study. Int J Complement Alt Med 8(1): 00247. DOI: 10.15406/ijcam.2017.08.00247
Floor
(Weeks 3-8)
Quadruped:
i. 
ii. Opposing hip and shoulder extension
Prone:
i. Thoracic extension
ii. Tricep extension
iii. Hip extension
a. Full body extension
Supine
a. Holding knees to chest
b. 
c. Pelvic tilts and holds with guided isometric
contractions
Relaxation
a. Guided relaxation
b. Targeting certain muscles and areas with breath
Movements on all Fours:
i. Purvottanasana
ii. Marjaryasana
iii. Bitilasana
iv. Ardha Pincha Mayurasana
Movements on Stomach:
i. Chakravakasana
ii. Bhujangasana
iii. Salambhasana
Movements on Back:
a. Pawanmuktasana
b. Ananda Balasana
c. Setu Bandha Sarvangasana
d. Savasana
Relaxation:
a. Samadhi
Data Analysis
Quantitative data
Quantitative data were analyzed using SPSS 20.0 (Chicago, IL).
Demographic data were described using descriptive statistics:
means and standard deviations or frequencies and proportions.
Pre and posttest means and standard deviations are included for
the DERS and QOLIBRI scores. With the case study format of three
participants, researchers calculated a percent change for each
outcome measure (Posttest—Pretest/Pretest x100).
Qualitative data
Transcripts were transcribed verbatim by a trained research
assistant into a word processing document and then were
imported into NVivo for analyses (NVivo 10 QSR International,
Victoria, Australia). Transcripts for qualitative data were
analyzed and coded by two trained researchers. Two primary
          
analyses and therefore focused on the variables of interest:
HRQOL and emotional regulation. Secondary themes then
evolved with multiple researchers through an iterative consensus
building process. Through this process, researchers agreed upon
reoccurring subthemes which emerged during analysis of semi-
structured interviews (Figure 1). Researchers then used NVivo
        
and comparison. Qualitative comments that best illustrate each
code or theme are included in the results.
Figure 1: Primary and Secondary Themes derived from Participant Interviews.
Results
Demographics
Three individuals enrolled and completed the yoga
intervention. Two were female, two were more than ten years post
TBI, and one was married. See Table 2 for additional demographic
and TBI characteristics.
Yoga after Traumatic Brain Injury: Changes in Emotional Regulation and Health-
Related Quality of Life in a Case-Study 5/9
Copyright:
©2017 Laura et al.
Citation: Grimm LA, Van Puymbroeck M, Miller KK, Fisher T, Schmid AA (2017) Yoga after Traumatic Brain Injury: Changes in Emotional Regulation
and Health-Related Quality of Life in a Case-Study. Int J Complement Alt Med 8(1): 00247. DOI: 10.15406/ijcam.2017.08.00247
Table 2: Demographic Information.
Variable Participant One Participant Two Participant Three Mean
n=3
Age 42 48 43 44.33±3.22
Gender Female Female Male Two female (67%)
Race White ‘Other’ White Two white (67%)
Years since TBI 21 28 9 19.33±9.6
Corresponding hemiparesis Yes Yes Yes Hemiparetic (100%)
Age at time of injury (years) 22 21 35 26±7.81
Medication for anxiety (current) No No Yes No
Medication for depression
(current) Yes No Ye s Ye s
Partner Single Widowed Married
Education (any college) Post-graduate Some college Some college Some college (100%)
Quantitative data
DERS scores indicated overall improvements, the mean DERS
score improved from 94.67 to 109.67, a 16% improvement. Two
out of three participants presented higher scores indicating
improved emotional regulation capabilities (Table 3). Participant
three showed the largest change, with an increase of 36%
following the yoga intervention.
QOLIBRI scores improved for all three participants following
the intervention (Table 3). Individually, scores increased from
between 5% and 8%, showing an improved perceived HRQOL.
The overall mean score increased from 108.33 to 115.33, which
is a 6% positive change. Further analysis was then obtained using
semi-structured interviews.
Table 3: Emotional Regulation and Health-Related Quality of Life Changes.
Outcome Measure n=3 Baseline
Score
8 weeks
Score % Change

Participant 1 82 80 -2%
Participant 2 118 135 14%
Participant 3 84 114 36%
Mean (SD) 94.67 ± 20.23 109.67 ± 27.75 16%
Quality of Life After Brain Injury
Participant 1 133 144 8%
Participant 2 84 89 6%
Participant 3 108 113 5%
Mean (SD) 108.33 ± 24.50 115.33 ± 27.57 6%
Emotional regulation qualitative data
Driven by the research questions, two primary themes were
       
       
examination and analysis of the semi-structured interviews.
Secondary themes within emotional regulation included: Mind-
Body Connection; Peaceful & Calm; Concentration & Focus; and
Self-Control (Figure 1). The data showed an improvement in
overall self-perceived ability to regulate or manage emotions.
Certain quotes from the data have been previously published in
a manuscript on the physical effects of yoga for chronic TBI [40].
A few of these quotes bear repeating due to the powerful nature

questions.
Mind-body connection
Two participants acknowledged how yoga practice facilitated a
stronger relationship between the mind and body. Participant One

TBI, he stated “I mean mine’s what? 19 years, 20 years after, and
I’m noticing different things that…are improving. I mean I think
that it would be incredibly valuable to someone with [a] brain
injury that was just because of the connection.” Participant Two
Yoga after Traumatic Brain Injury: Changes in Emotional Regulation and Health-
Related Quality of Life in a Case-Study 6/9
Copyright:
©2017 Laura et al.
Citation: Grimm LA, Van Puymbroeck M, Miller KK, Fisher T, Schmid AA (2017) Yoga after Traumatic Brain Injury: Changes in Emotional Regulation
and Health-Related Quality of Life in a Case-Study. Int J Complement Alt Med 8(1): 00247. DOI: 10.15406/ijcam.2017.08.00247
also noted the connection and simply stated, “I am more mindful”.
       
others with chronic TBI, an increased connection between mind
and body surfaced from the interviews.
Peaceful & calm

to emotional regulation. One participant commented on how
increased peacefulness during or after yoga had led to calmer
feelings throughout daily activities, “It’s more real now…I feel
          
participant stated, “it was very peaceful.” Another participant
noted his control in the way of revving up or relaxing: “The
breathing techniques were huge… [In] how to calm myself down
or how to ram [rev] myself up.” Attention to breath had provided
an opportunity to elicit a peaceful awareness.
Concentration & focus
Cognition may be impacted post-TBI, in this study concentration
and focus emerged as a noted improvement from yoga by two of the
participants. For example, Participant Three compared previous

addressed the ability to “now be able to concentrate,” in a way that
he had not previously seen improvements, despite specialized TBI
interventions. Expanding on the concentration piece, he noted
that his attention was more focused on his kids at tee ball and he
did “not constantly scan the crowds or you know all the people
around it’s just there’s so many things that just made my life
better.” Contextually, his statement was in regard to not needing to
scan the crowds for terrorists or harm, given he is a veteran with a
brain injury, post-traumatic stress, and multiple physical injuries.
Self-control
Another theme which emerged under emotional regulation was
self-control. Participant Two did not experience an improvement
in DERS scores but described her overall improvement in self-
control, stating that for her the yoga intervention was “more
mental” with a focus on “getting more self-control.” Participant
Three, the veteran, discussed using the breathing techniques
and eye movements learned in the program as a method of self-
control “to ground you in the here and now,” and as an escape
from continuing to perceive the threats of Iraq in his home,
while driving, and elsewhere in his day to day life. He discussed
these improvements through daily activities, as well as within an
overarching sense of self-control that he received from the yoga
intervention.
Health-related quality of life qualitative data
HRQOL was a qualitative primary theme and included the
following secondary themes: Social Changes; Physical Changes
         
Development (Figure 1).
Social changes
Relating to HRQOL, all participants described an increase in
social engagement as the result of this yoga intervention. One
    
impacted in the form of “wanting to go out more and to have that

and engagement due to the yoga intervention emerged as a theme
from all three participants.
Physical changes leading to life changes
      
from yoga practice became a vehicle to complete their chosen
meaningful activities. Participant One expressed that halfway
through the intervention he was engaging in an occupation he
had been missing, “I started playing golf…last September - and
            
this year. It was only the second time I’d ever played a full-size
course [since my injury].” Participant Two similarly discussed the
impact of physical improvements and stated: “I learned…that I
could make my body move and accomplish feats that I didn’t think
were possible.” Due to the yoga intervention Participant Three
highlighted the daily improvements related to strength, “I’ve got
more strength in my legs and I’ve got more stamina now…to be
able to go out.”

People who have experienced TBI often report dissatisfaction
        
performance in life [41]. Two out of three participants indicated
          
       
yoga intervention. This improvement allowed them to complete
more desired activities. For example, one participant noted the

go back to school and start and complete my degree.
Self-development
The semi-structured interview revealed statements from all
three participants regarding personal growth. One participant
noted yoga as a form of self-development, and indicated “I used it
more…to…develop myself, that’s what I appreciate more, the self-
development.” While another participant stated, “I’m not quite as
hard on myself,” in response to how life was different following
the program.
Interaction of multiple HRQOL themes
     
relationship in HRQOL: “I mean it’s rocked my world. It’s changed
my life. I mean all the different aspects.” For him, all the HRQOL
changes culminated in perceived new capability in his role as a
father: “this has changed my world and given me a new life back,
because I’ve got a new opportunity now with my two youngest
sons to be the Dad that I couldn’t be, in my eyes, to my older kids.
He further commented on several HRQOL domains “physically,
emotionally, mentally…it’s given me, you know, my life back. It’s
opened up so many doors for me.
Discussion
These data indicated that an eight-week yoga intervention for
Yoga after Traumatic Brain Injury: Changes in Emotional Regulation and Health-
Related Quality of Life in a Case-Study 7/9
Copyright:
©2017 Laura et al.
Citation: Grimm LA, Van Puymbroeck M, Miller KK, Fisher T, Schmid AA (2017) Yoga after Traumatic Brain Injury: Changes in Emotional Regulation
and Health-Related Quality of Life in a Case-Study. Int J Complement Alt Med 8(1): 00247. DOI: 10.15406/ijcam.2017.08.00247
people with TBI is potentially an impactful modality to address
HRQOL and emotional regulation. The three individuals included
in this multi-methods study showed an overall improvement in
QOLIBRI and DERS scores, as well as perceived improvements
as evidenced by the semi-structured interviews. The QOLIBRI
provided a foundation for HRQOL domain analysis, and the
data from the DERS elaborated on the “emotions” domain
      
the QOLIBRI assesses emotions, but also includes the additional
domains: cognition, general “self”, daily life and autonomy, social
relationships, and physical problems [14]. Emotion was then
further explored with the DERS through six subsets assessing
emotional regulation: “(a) lack of awareness of emotional
responses; (b) lack of clarity of emotional responses; (c) non-
acceptance of emotional responses, (d) limited access to emotion
      
controlling impulses when experiencing negative emotions,
       
experiencing negative emotions” [37]. This three-person format
then allowed for in-depth discussion and understanding of
each domain through analyses of semi-structured interviews.
Researchers focused on the participants’ perspectives and
       
regulation for the three participants.
Emotional regulation
Emotional regulation can be viewed as the constant situational
adaptation of behaviors to meet social expectations. This study
separated four subsets of emotional regulation that emerged in
qualitative interviews: mind-body connection, peaceful & calm,
concentration & focus, and self-control. Yoga interventions
frequently include attention to mindfulness, or moment-to-
moment awareness through the development of adaptive
          
emotional regulation. Azulay and Mott (2016) implemented
      
improvements in DERS scores for individuals with mixed brain
injuries [43]. Mindfulness programs may target the disconnect
between the mind and body, which is a common theme for
individuals with neurological impairments [44,19]. The current
study presented qualitative data which described an increased
mind-body connection for three participants following a yoga
intervention.
Further, previous research indicates that yoga can trigger the
ability to implement a relaxation response [45,46], this supports
the presented qualitative results regarding increased peaceful
and calm feelings. A study done with individuals diagnosed with
multiple sclerosis assessed emotional regulation and found that
higher emotional regulation correlated to improved scores in
psychological and environmental QOL domains [47]. Participants
in the current study highlighted HRQOL domains that were affected
in conjunction with emotional regulation changes. In a different
study, researchers used the DERS measure and found that, in 50
participants with TBI, global distress strongly related to lower
DERS scores [48]. High negative correlation between emotional
       
addressing emotional regulation. Furthermore, continuous
emotional regulation can lead to higher life satisfaction [49],
reasoning that emotional regulation and quality of life cannot
be disentangled, and measurement together is cornerstone to
future treatment planning for individuals with neurological
impairments. Collectively, these data represent preliminary
case study evidence for an individualized yoga intervention and
support further exploration of yoga as a treatment intervention
post-TBI.
Health-related quality of life

to decreased ability to sustain meaningful relationships, which
leads to a reduction in overall quality of life [15]. This study
divided HRQOL into four subsets that emerged during qualitative
analysis of the interviews: social change, physical changes leading
        

by Hawthorne, Gruen, & Kaye (2009) found that lower HRQOL is
associated with decreased social interactions [50]. Individuals with
TBI generally report lower HRQOL [50]. All three participants in
this study discussed their increased social participation following
the yoga intervention, which was supported by increased HRQOL
         
yoga study for healthy older adults; those who participated in
       
than the control or exercise groups [51]. Improvements in social
engagement may potentially be related to increase varying
     
following a yoga intervention.
Regular yoga practice has been connected to increased
        
       
they had avoided since their TBI. In a mindfulness study for
a population with mixed (ex. anoxic, traumatic) brain injury,

  
and well-being through mindfulness [43]. Another part of

self-reported physical improvements, which allowed for a return
to participation. The relationship between physical changes,
       
eight-week yoga intervention study, which revealed increased
   
with chronic stroke [53]. The results can be interpreted to show
a relationship between the physical component of balance, the
       
improvements. All three participants in this current study
discussed how physical changes had promoted increased life
involvement. Participant One, for example, returned to his

the yoga intervention. Silverthorne et al. (2012) implemented
breath-focused yoga, for individuals with severe TBI, and found
      
being, and overall health [23]. Tying together the important
factors included in emotional regulation helps to perhaps explain
some of the improvements seen throughout HRQOL in this study.
Yoga after Traumatic Brain Injury: Changes in Emotional Regulation and Health-
Related Quality of Life in a Case-Study 8/9
Copyright:
©2017 Laura et al.
Citation: Grimm LA, Van Puymbroeck M, Miller KK, Fisher T, Schmid AA (2017) Yoga after Traumatic Brain Injury: Changes in Emotional Regulation
and Health-Related Quality of Life in a Case-Study. Int J Complement Alt Med 8(1): 00247. DOI: 10.15406/ijcam.2017.08.00247
Limitations
Limitations in this study include that there was no control
group and a small sample size, which is common in emerging
mind-body intervention research and continues to be a limitation
especially in neurological populations [22]. The size makes it


this line of research. In addition, severity of impairment (mild,
moderate, severe) and the location of the injury were not included
in the demographic data. Therefore, researchers analyzing these
data cannot discuss changes following yoga as they relate to

Strengths and implications for future research
     
        

for yoga interventions. This study highlights an intervention
strategy that improved emotional regulation and HRQOL scores
for individuals with TBI. To generalize the results and prove

          
important to consider the strengths of a small yoga group. In this
study, participants were provided individualized adaptations and
adjustments throughout yoga sessions, tailoring each session to
meet the participants’ needs. Hands-on adaptation and attention
to each participant could have been a reason for the positive
results seen in HRQOL and emotional regulation. However, a
group yoga intervention for people with TBI should be tested to
meet social and economic needs.
Conclusion
This study provides preliminary evidence that an eight-week
        
emotional regulation and HRQOL for individuals with chronic
TBI. Improvements were seen with this sample, and this study
highlights the importance of assessing emotional regulation
along with HRQOL for individuals with TBI. However, further
research is warranted because this study was not large enough to
be generalizable.
Acknowledgments
Dr. Schmid and this study were supported by a Veterans
Administration Career Development Award (VA RR&D CDA
D6174W). We thank Nancy Schalk, a yoga therapist, for
developing and teaching the yoga intervention to each of the study
participants. We also thank the Indiana University Occupational
Therapy students involved with this research: Erin Debaun-
Sprague, MS OTR; Elizabeth Short, MS OTR; Jenna Mitchell, MS
OTR; Laura Montgomery, MS OTR; and Tiffani Davis, MS OTR.
References
1. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-
Education/Hope-Through-Research/Traumatic-Brain-Injury-Hope-
Through
2. http://www.cdc.gov/traumaticbraininjury/get_the_facts.html
3. Zaloshnja E, Miller T, Langlois JA, Selassie AW (2008) Prevalence
of Long-Term Disability From Traumatic Brain Injin the Civilian
Population of the United States, 2005. J Head Trauma Rehabil 23(6):
394-400.
4. Corrigan JD, Selassie AW, Orman JA (2010) The epidemiology of
traumatic brain injury. J Head Trauma Rehabil 25(2): 72-80.
5. Whiteneck GG, Cuthbert JP, Corrigan JD, Bogner JA (2016) Prevalence
of self-reported lifetime history of traumatic Brain Injand associated
disability: a statewide population-based survey. The J Head Trauma
Rehabil 31(1): E55-E62.
6. Corrigan JD, Cuthbert JP, Harrison-Felix C, Whiteneck GG, Bell JM, et
al. (2014) US population estimates of health and social outcomes
5 years after rehabilitation for traumatic brain injury. The J Head
Trauma Rehabil 29(6): E1-E9.
7. von Steinbuechel N, Richter S, Morawetz C, Riemsma R (2005)
Assessment of subjective health and health-related quality of life
in persons with acquired or degenerative brain injury. Curr Opin
Neurol 18(6): 681-691.
8. Annemieke Scholten (2016) Outcome after Traumatic Brain Injury:
Epidemiology, impact and assessment. Erasmus Medical Center.
9. McCarthy ML1, MacKenzie EJ, Durbin DR, Aitken ME, Jaffe KM, et
          
traumatic brain injury. Archives of pediatrics & adolescent medicine
160(3): 252-260.
10. Health-Related Quality of Life and Well-Being (2014).
11. Sasse N, Gibbons H, Wilson L, Martinez R, Sehmisch S, et al. (2014)
Coping strategies in individuals after traumatic brain injury:
associations with health-related quality of life. Disabil Rehabil
36(25): 2152-2160.
12. Koole SL (2009) The psychology of emotion regulation: An integrative
review. Cognition and emotion 23(1): 4-41.
13. Cattran C1, Oddy M, Wood R (2011) The development of a measure
of emotional regulation following acquired brain injury. J Clin Exp
Neuropsychol 33(6): 672-679.
14. von Steinbüchel N, Wilson L, Gibbons H, Hawthorne G, Höfer S, et
al. (2010) Quality of Life after Brain Inj(QOLIBRI): scale validity and
correlates of quality of life. J Neurotrauma 27(7): 1157-1166.
15. Henry JD1, Phillips LH, Crawford JR, Theodorou G, Summers F (2006)
Cognitive and psychosocial correlates of alexithymia following
traumatic brain injury. Neuropsychologia 44(1): 62-72.
16. Kipps CM, Mioshi E, Hodges JR (2009) Emotion, social functioning
and activities of daily living in frontotemporal dementia. Neurocase
15(3): 182-189.
17. Sivan Maoz, Harif I, Magen, H (2016) Relationship Between Positive
Personality Traits and Rehabilitation Outcomes Following Acquired
Brain InjSeveral Years Post-Injury. Archives of Physical Medicine and
Rehabilitation 97(10): e26.
18. Fredrickson B L (2000) Cultivating positive emotions to optimize
health and well-being. Prevention & Treatment 3(1): 1-25.
19. Levack WM, Kayes NM, Fadyl JK (2010) Experience of recovery
and outcome following traumatic brain injury: a metasynthesis of
qualitative research. Disabil Rehabil 32(12): 986-999.
Yoga after Traumatic Brain Injury: Changes in Emotional Regulation and Health-
Related Quality of Life in a Case-Study 9/9
Copyright:
©2017 Laura et al.
Citation: Grimm LA, Van Puymbroeck M, Miller KK, Fisher T, Schmid AA (2017) Yoga after Traumatic Brain Injury: Changes in Emotional Regulation
and Health-Related Quality of Life in a Case-Study. Int J Complement Alt Med 8(1): 00247. DOI: 10.15406/ijcam.2017.08.00247
20. Fernros L, Furhoff AK, Wändell PE (2008) Improving quality of
life using compound mind-body therapies: evaluation of a course
intervention with body movement and breath therapy, guided
imagery, chakra experiencing and mindfulness meditation. Qual Life
Res 17(3): 367-376.
21. Garrett R, Immink MA, Hillier S (2011) Becoming connected: the lived
experience of yoga participation after stroke. [Research Support,
Non-U.S. Gov’t]. Disabil Rehabil 33(25-26): 2404-2415.
22. Wahbeh H, Elsas SM, Oken BS (2008) Mind-body interventions
applications in neurology. Neurology 70(24): 2321-2328.
23. Silverthorne C, Khalsa SB, Gueth R, DeAvilla N, Pansini J (2012)
      
yoga for adults with severe traumatic Brain Inj(TBI): a brief pilot
study report. Int J Yoga Therap 22(1): 47-51.
24. Donnelly KZ, Linnea K, Grant DA, Lichtenstein J (2017) The feasibility
and impact of a yoga pilot programme on the quality-of-life of adults
with acquired brain injury. Brain Inj 31(2): 208-214.
25. Johansson, Bjuhr H, Rönnbäck L (2012) Mindfulness-based stress
reduction (MBSR) improves long-term mental fatigue after stroke or
traumatic brain injury. Brain Inj 26(13-14): 1621-1628.
26. Azulay J, Smart CM, Mott T, Cicerone KD (2013) A pilot study
examining the effect of mindfulness-based stress reduction on
symptoms of chronic mild traumatic brain injury/postconcussive
syndrome. The J Head Trauma Rehabil 28(4): 323-331.
27. Cullen M (2011) Mindfulness-based interventions: An emerging
phenomenon. Mindfulness 2(3): 186-193.
28. Patel NK, Newstead AH, Ferrer RL (2012) The effects of yoga on
physical functioning and health related quality of life in older adults:
a systematic review and meta-analysis. J Altern Complement Med
18(10): 902-917.
29. Ahmadi A, Nikbakh M, Arastoo A, Habibi AH (2010) The effects of
a yoga intervention on balance, speed and endurance of walking,
fatigue and quality of life in people with multiple sclerosis. Journal of
Human Kinetics 23: 71-78.
30. Mendoza EU, Van Puymbroeck M, Walter A, Hawkins BL, Woschkolup
K, et al. (2016) Effectiveness of Yoga in Decreasing Symptoms and
Improving Quality of Life in Parkinson’s Disease. Archives of Physical
Medicine and Rehabilitation 97(10): e63-e64.
31. Sharma NK, Robbins K, Wagner K, Colgrove YM (2015) A randomized
controlled pilot study of the therapeutic effects of yoga in people
with Parkinson’s disease. Int J Yoga 8(1): 74.
32. Van Puymbroeck M, Walter A, Hawkins B, Woschkolup K, Urrea-
Mendoza E, et al. (2016) Functional Improvements in Parkinson’s
Disease Following Therapeutic Yoga. Archives of Physical Medicine
and Rehabilitation 97(10): e5.
33. Schmid AA, Miller KK, Van Puymbroeck M (2015) Yoga After Stroke
Leads to Improvements in Multiple Domains of Quality of Life.
Archives of Physical Medicine and Rehabilitation 10(96): e93.
34. Patil VK, St Andre JR, Crisan E, Smith BM, Evans CT, et al. (2011)
Prevalence and treatment of headaches in veterans with mild
traumatic brain injury. Headache: Headache 51(7): 1112-1121.
35. Hernández TD, Brenner LA, Walter KH, Bormann JE, Johansson B
(2016) Complementary and alternative medicine (CAM) following
traumatic Brain Inj(TBI): Opportunities and challenges. Brain Res
1640: 139-151.
36. Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC (2002)
Six-item screener to identify cognitive impairment among potential
subjects for clinical research. Med Care 40(9): 771-781.
37. Neumann A, van Lier PA, Gratz KL, Koot HM (2004) Multidimensional
assessment of emotion regulation and dysregulation: Development,
    
regulation scale. Assessment 17(1): 138-149.
38. von Steinbüchel N, Wilson L, Gibbons H, Hawthorne G, Höfer S, et al.
(2010) Quality of Life after Brain Inj(QOLIBRI): scale development
and metric properties. J Neurotrauma 27(7): 1167-1185.
39. Truelle JL, Koskinen S, Hawthorne G, Sarajuuri J, Formisano R, et al.
(2010) Quality of life after traumatic brain injury: the clinical use of
     
1272-1291.
40. Schmid AA1, Miller KK, Van Puymbroeck M, Schalk N (2016)
Feasibility and results of a case study of yoga to improve physical
functioning in people with chronic traumatic brain injury. Disabil
Rehabil 38(9): 914-920.
41. Mailhan L, Azouvi P, Dazord A (2005) Life satisfaction and disability
after severe traumatic brain injury. Brain Inj 19(4): 227-238.
42. Nagarathna R, Nagendra H, Monro R (1990) Yoga for common
ailments: Gaia Books Limited.
43. Azulay J, Mott T (2016) Using Mindfulness Attention Meditation
(MAP) with a Mixed Brain Inj Population to Enhance Awareness and
Improve Emotional Regulation. Journal of Psychology and Clinical
Psychiatry 6(5): 00372.
44. Ellis-Hill CS, Payne S, Ward C (2000) Self-body split: issues of identity
in physical recovery following a stroke. Disabil Rehabil 22(16): 725-
733.
45. Arambula P, Peper E, Kawakami M, Gibney KH (2001) The
physiological correlates of Kundalini Yoga meditation: a study of a
yoga master. Appl Psychophysiol Biofeedback 26(2): 147-153.
46. Arora S, Bhattacharjee J (2008) Modulation of immune responses in
stress by Yoga. Int J Yoga 1(2): 45-55.
47. Phillips LH, Saldias A, McCarrey A, Henry JD, Scott C, et al. (2009)
Attentional lapses, emotional regulation and quality of life in
multiple sclerosis. Br J Clin Psychol 48(1): 101-106.
48. Shields C, Ownsworth T, O’Donovan A, Fleming J (2016) A
transdiagnostic investigation of emotional distress after traumatic
brain injury. Neuropsychol Rehabil 26(3): 410-445.
49. Gross JJ, John OP (2003) Individual differences in two emotion
regulation processes: implications for affect, relationships, and well-
being. J Pers Soc Psychol 85(2): 348.
50. Hawthorne G, Gruen RL, Kaye A H (2009) Traumatic Brain Injand
         
Neurotrauma 26(10): 1623-1633.
51. Oken BS, Zajdel D, Kishiyama S, Flegal K, Dehen C, et al. (2006)
Randomized, controlled, six-month trial of yoga in healthy seniors:
effects on cognition and quality of life. Altern Ther Health Med 12(1):
40.
52. Woodyard C (2011) Exploring the therapeutic effects of yoga and its
ability to increase quality of life. Int J Yoga 4(2): 49.
53. Schmid AA, Van Puymbroeck M, Altenburger PA, Schalk NL, Dierks
TA, et al. (2012) Poststroke balance improves with yoga: a pilot
study. Stroke 43(9): 2402-2407.
... It is likely that changes in emotional control led to significant improvements on the BRI. Improvements in behavioral regulation, as seen in our study, align with previous findings from Grimm et al. (2017), who found improvements in emotional regulation for 3 participants with TBI after an 8-wk yoga program. In contrast to our findings on behavioral regulation, Donnelly et al. (2021) found no improvements in emotional and behavioral dysregulation in a mixed-methods, pre-post study on yoga for people with TBI (n 5 705); however, qualitative content analysis in their study revealed better ability to regulate impulsivity, anger, stress, and anxiety. ...
... As mentioned earlier, this study was completed during COVID-19, which affected the planned dose of in-person yoga. The planned dose of yoga for our research trials was typically 16 in-person sessions, delivered twice per week over 8 wk (Grimm et al., 2017;Schmid et al., 2012;Stephens et al., 2020). In our study, in-person classes were only offered once a week to minimize the risk of COVID-19 exposure. ...
Article
Full-text available
Importance: Acquired brain injury (ABI) may result in deficits in executive function (EF), which affects engagement in occupations. Objective: To explore the impact of group yoga on EF in people with ABI. Design: Single-arm pilot study with preyoga assessments and postyoga assessments (after 8 wk of yoga). Setting: Yoga classes and assessments were completed within university buildings on a college campus. Participants: Twelve participants with chronic ABI (>6 mo post-ABI) were recruited through convenience and purposive strategies from the local community. Intervention: An 8-wk adaptive group yoga intervention was provided by an adaptive yoga specialist. Yoga classes were 60 min and occurred once per week. Outcomes and Measures: EF was assessed before and after the yoga intervention using the Behavior Rating Inventory of Executive Function—Adult Version (BRIEF–A) self-report form. Normative data were analyzed with paired sample t tests. Results: Nine participants completed all study procedures. Results from paired sample t tests showed significant improvements on the Behavioral Regulation Index of the BRIEF–A (p = .046). No significant improvements were found on individual EF scales, the Metacognition Index, or the Global Executive Composite (ps > .05). Conclusions and Relevance: Group-based yoga may improve some aspects of EF for adults with chronic ABI; however, further research with larger sample sizes is needed. Plain-Language Summary: Yoga, an intervention increasingly used in occupational therapy practice, may be beneficial in improving behavioral regulation (an executive function) for adults with acquired brain injury.
... Hatha yoga incorporates movements that require balance, can be adapted for individual needs, and does not require physician or insurance authorization. Currently, a few quantitative studies investigating yoga for individuals with brain injury have found evidence of improved balance after yoga [11], and other studies (including qualitative studies) have found yoga-induced improvements in outcomes such as quality of life [12], community integration [13], and overall physical functioning [14] in adults with brain injury. However, the neural underpinnings, or changes in brain structure or function, of functional improvements in specific capacities, such as balance, after yoga are largely unknown. ...
Article
Full-text available
Background: To date, no one has prospectively evaluated yoga intervention-induced changes in brain structure or function in adults with acquired brain injuries (ABI). Thus, this study was conducted to test the feasibility of acquiring neuroimaging data from adults with ABI before and after a yoga intervention. Methods: This was a single-arm intervention feasibility study that included 12 adults with chronic (i.e., greater than 6 months post-injury) ABI and self-reported limitations in balance. Neuroimaging data were acquired before and after yoga. The yoga intervention was completed once per week for eight weeks. Feasibility objectives and benchmarks were established a priori. Results: Most feasibility objectives and benchmarks were achieved. The goal of recruiting 12 participants was successfully achieved, and 75% of participants were retained throughout the study (goal of 80%). All imaging feasibility benchmarks were met; rs-fMRI and fNIRS data were acquired safely, data were of acceptable quality, and data pre-processing procedures were successful. Additionally, improvements were detected in balance after yoga, as group-level balance was significantly better post-yoga compared to pre-yoga, p = 0.043. Conclusions: These findings indicate it is feasible to acquire neuroimaging data from adults with ABI before and after a yoga intervention. Thus, future prospective studies are warranted.
... If this is the case, it is possible to influence symbolic/conceptual level of representation to interpret the highest level of communication acceptable to current societal norms. In other words, by addressing the damaged brain and allowing recovery space to be minimally by relieving symptoms of vertigo, nausea, anxiety, and OCD as among the much studied other health benefits [4]. Skilled soft tissue therapy and understanding of trigger points to relieve stress in regions of the body are essential not only in prediagnosis and symptom relief, but also in the rehabilitation of regaining autonomy of functional independence. ...
Article
Full-text available
Physical manifestations vary from subject to subject as well as genetic risk factors when considering traumatic brain injury (TBI)/chronic traumatic encephalopathy (CTE) and recovery. Clinical and behavioral findings may resemble autism that appear with limited mobility and the physical experience may impact treatment. Ataxia, weakness, hemiplegia, hemiparesis are among them. Novel therapy uncovered physical correlations between subject's presentation and physicality with relief and progress when movement and sound are present and monitored during a case study of an adult male with acute head injury from blunt force trauma reported previously. Namely, the release of soft tissue trigger points relieves stress held in the regions affected through soft tissue trigger points stimuli. The occipital attachments for the extensor muscles and positive responses were noted with the stimulation of these regions with effleurage or cross fiber friction and stripping. Vertigo or nausea affecting equilibrium might present as physical displays of deviations of the ability to control balance. Benign Paroxysmal Positional Vertigo or BPPV, vestibular migraines or Broca’s aphasia, are among other presentations affecting one's balance and need to be considered during treatment. Challenging desensitization or flooding and habituation with compensatory strategies are required to maintain safety and autonomy of daily living ADL while providing relief when other therapies fall short. One must not underestimate the commitment needed during pre-diagnosis or when diagnosing a disability of head injury by evaluating for other risk factors. This may include advanced genetic testing for potential genes that may contribute to brain injury and recovery. Brain imaging may also be required to assess the location and severity that may impact treatment approaches and recovery responses.
... Donnelly et al. found that in individuals with chronic TBI, a twice-weekly, 8-week yoga program improved quality of life (QOL) (33), and a once-weekly, 6-week yoga intervention improved strength, balance, quality of life, resilience, cognition, and positive affect (34,35). Several case studies on individuals with chronic TBI participating in a yoga program have reported improved psychological QOL, well-being, strength, endurance, balance, and reduced depression (36)(37)(38)(39)(40)(41). Combs et al. demonstrated improvements in self-reported physical health and mood after a weekly yoga group attended throughout each participant's post-TBI inpatient rehabilitation stay (42). ...
Article
Full-text available
Background: Mild traumatic brain injury (mTBI) and chronic pain often co-occur and worsen rehabilitation outcomes. There is a need for improved multimodal nonpharmacologic treatments that could improve outcomes for both conditions. Yoga is a promising activity-based intervention for mTBI and chronic pain, and neuromodulation through transcranial magnetic stimulation is a promising noninvasive, nonpharmacological treatment for mTBI and chronic pain. Intermittent theta burst stimulation (iTBS) is a type of patterned, excitatory transcranial magnetic stimulation. iTBS can induce a window of neuroplasticity, making it ideally suited to boost the effects of treatments provided after it. Thus, iTBS may magnify the impacts of subsequently delivered interventions as compared to delivering those interventions alone and accordingly boost their impact on outcomes. Objective: The aim of this study is to (1) develop a combined iTBS+yoga intervention for mTBI and chronic pain, (2) assess the intervention's feasibility and acceptability, and (3) gather preliminary clinical outcome data on quality of life, function, and pain that will guide future studies. Methods: This is a mixed methods, pilot, open-labeled, within-subject intervention study. We will enroll 20 US military veteran participants. The combined iTBS+yoga intervention will be provided in small group settings once a week for 6 weeks. The yoga intervention will follow the LoveYourBrain yoga protocol-specifically developed for individuals with TBI. iTBS will be administered immediately prior to the LoveYourBrain yoga session. We will collect preliminary quantitative outcome data before and after the intervention related to quality of life (TBI-quality of life), function (Mayo-Portland Adaptability Index), and pain (Brief Pain Inventory) to inform larger studies. We will collect qualitative data via semistructured interviews focused on intervention acceptability after completion of the intervention. Results: This study protocol was approved by Edward Hines Jr Veterans Administration Hospital Institutional Review Board (Hines IRB 1573116-4) and was prospectively registered on ClinicalTrials.gov (NCT04517604). This study includes a Food and Drug Administration Investigational Device Exemption (IDE: G200195). A 2-year research plan timeline was developed. As of March 2022, a total of 6 veterans have enrolled in the study. Data collection is ongoing and will be completed by November 2022. We expect the results of this study to be available by October 2024. Conclusions: We will be able to provide preliminary evidence of safety, feasibility, and acceptability of a novel combined iTBS and yoga intervention for mTBI and chronic pain-conditions with unmet treatment needs. Trial registration: ClinicalTrials.gov NCT04517604; https://www.clinicaltrials.gov/ct2/show/NCT04517604. International registered report identifier (irrid): DERR1-10.2196/37836.
... What is most often agreed upon is the effects of priming and framing on individuals without the tools to navigate the complex experience. Sensations uncovered and raw form trauma can produce the best results by keeping the benefits [3]. Skilled soft tissue therapy continues to prove essential not only in pre diagnosis and symptom relief, but also in the rehabilitation of regaining autonomy of functional independence. ...
Article
Full-text available
chronic traumatic encephalopathy (CTE) with clinical/behavioral findings resembling autism that often may appear with limiting mobility and the physical experience that may impact treatment. Ataxia, weakness, hemiplegia, and heleperisis among them. Novel therapy uncovered physical correlations between subjects' presentations and their physicality with releaf and progress when movement and sound are implemented during a case study of an adult male with acute head injury from blunt force trauma. Namely, the release of soft tissue trigger points relieves stress held in the regions affected, through stimuli. The occipital attachments for the extensor muscles (semi spinalis cathetus, splenius pathadis, levator scapulae, upper fibers of trapezius) positive response noted with the stimulation of these regions with effleurage (broad strokes to warm the tissue up, against the muscle grain): cross fiber friction and stripping (manipulation with the grain of the muscle fiber). If vertigo or other nausea are present affecting equilibrium presenting as physical displays of deviations of the ability to control balance. Benign Paroxysmal Positional Vertigo or BPPV, vestibular migraines, Brocca’s aphasia, are among other presentations affecting one's balance. Challenging desensitization or flooding and habituation with compensatory strategies to maintain safety and autonomy of daily living or ADL while providing relief when other therapies fall short in progress. One must not underestimate the commitment needed during pre-diagnosis or when diagnosing a disability of head injury.
... Donnelly et al. found that in individuals with chronic TBI, a twice-weekly, 8-week yoga program improved quality of life (QOL) (33), and a once-weekly, 6-week yoga intervention improved strength, balance, quality of life, resilience, cognition, and positive affect (34,35). Several case studies on individuals with chronic TBI participating in a yoga program have reported improved psychological QOL, well-being, strength, endurance, balance, and reduced depression (36)(37)(38)(39)(40)(41). Combs et al. demonstrated improvements in self-reported physical health and mood after a weekly yoga group attended throughout each participant's post-TBI inpatient rehabilitation stay (42). ...
Article
Objective: To compare the impacts of yoga-based physical therapy versus a seated rest within the context of standard rehabilitation practice on sleep, heart rate variability (HRV), anxiety, and fatigue during acute traumatic brain injury (TBI) rehabilitation. Methods: Eleven individuals participated in this crossover study involving the following interventions in a randomized order: group yoga-based physical therapy (YPT), conventional physical therapy (CPT), and group seated rest in a relaxing environment (SR). HRV and self-reported anxiety and fatigue were measured immediately before and after each group, and sleep after each condition and at baseline. Data was analyzed using generalized linear mixed models with repeated measures. Results: The interaction between time and treatment was statistically significant (p = .0203). For the SR treatment, wake after sleep onset (WASO) rate was reduced from 14.99 to 10.60 (IRR = 0.71; p = .006). Time and treatment were not found to be statistically significantly associated with any of the secondary outcomes. Conclusion: Yoga-based physical therapy is feasible and safe in the inpatient rehabilitation setting following TBI. Sleep quality improved following the addition of a one-hour seated rest in a relaxing environment to a standard rehabilitation daily schedule, suggesting that structured rest time may be beneficial to sleep hygiene during inpatient rehabilitation following TBI. ClinicalTrials.Gov Registration Number: NCT03701594.
... 12,13 The LoveYourBrain Foundation has sought to address the lack of holistic community-based services by offering a free, 6-week yoga and psychoeducation program for groups of people with TBI and caregivers in yoga studios across the United States and Canada. 14 Yoga, which encompasses physical movement (asana), breathing exercises (pranayama), meditation practices, and moral principles, 15,16 has been shown to improve outcomes for people with TBI, including physical functioning, 17 emotional regulation, 18 psychological well-being, 19 and quality of life. 20 Each weekly class in the LoveYourBrain Yoga program is designed to include multiple components: 10 minutes of pranayama to enhance nervous system regulation and attention control; 45 minutes of gentle yoga to improve strength, flexibility, and balance; 15 minutes of guided meditation to enhance attention control, mood, and nervous system regulation; and 20 minutes of facilitated discussion with psychoeducation to build community connection and skills in resilience. ...
Article
Emerging benefits of yoga for traumatic brain injury (TBI) suggest that broader accessibility to community-based yoga programming is important. This cross-sectional, mixed methods study sought to identify best practices for adapting and delivering community-based yoga to people with TBI. An online survey was sent to 175 yoga teachers trained to teach LoveYourBrain Yoga, a community-based, 6-week, manualized program for people with TBI and their caregivers. The survey instrument included open- and closedtext questions assessing teachers' perspectives on the most and least helpful adaptions for asana, meditation, pranayama, and group discussion, and on the LoveYourBrain Yoga training and support. Responses we re analyzed using descriptive statistics and qualitative content analysis. Eighty-six teachers (50%) responded. Best practices for adapting yoga for TBI revealed six themes: (1) simple, slow, and repeated; (2) creating a safe space; (3) position of the head and neck; (4) demonstration; (5) importance of props; and (6) special considerations for yoga studios. Three themes emerged for yoga program delivery: (1) structured yet flexible; (2) acceptability of compensation; and (3) time management. Eighty-nine percent of teachers reported that the program manual was very/extremely helpful, yet nearly half (49%) adapted the manual content often/always. To deliver community-based yoga services for TBI, we recommend an environment with props, low light and noise, and sufficient space, along with the facilitation of consistent instruction with a manual that allows for flexibility. We recommend that yoga teachers have skills in physical modifications for the head and neck; slow, simple, and repeated cueing to facilitate cognitive processing; managing challenging behaviors through redirection techniques; and promoting safety through inclusivity, compassion, and personal agency.
Article
Full-text available
Introduction Approximately 75% of caregivers providing unpaid care to family members or friends experience persistent pain. Simultaneously, individuals who require caregiving commonly experience pain. The inherent complexity of pain is enhanced by relationship dynamics of two closely tied individuals (i.e., caregiving dyad = caregivers and care recipients). Currently there are no proven pain interventions that target the caregiving dyad. Thus, the purpose of this pilot study was to assess the feasibility of a new behavioral multi-modal intervention, the Merging Yoga and self-management to develop Skills (MY-Skills) intervention. Methods Each participant was part of a caregiving dyad and all participants had moderate to severe musculoskeletal pain, a score of ≥4 of 6 on the short mini-mental status exam, were ≥18 years old, sedentary, able to speak English, able to stand, and living at home. Participants were randomized to MY-Skills or the control group. MY-Skills was offered twice a week for eight weeks and each two-hour session included yoga and self-management education developed specifically for caregiving dyads experiencing persistent pain. MY-Skills was group based and developed as an in-person intervention. Due to Covid-19, the intervention was moved online and data are presented for in-person and online cohorts. Benchmarks for feasibility were set a priori , addressing: recruitment, attrition, attendance, safety, acceptability/satisfaction, and study completion. Results Thirteen participants completed the in-person MY-Skills intervention (caregivers n = 7, care-receivers n = 6) and 18 individuals completed the online MY-Skills intervention (9 dyads). Most participants had pain for ≥10 years. Recruitment and attrition benchmarks for the in-person intervention were not met; yet they were met for the online version. In-person and online MY-Skills intervention attendance, safety, acceptability/satisfaction, and completion exceeded benchmark criteria. Discussion The MY-Skills intervention appears feasible and acceptable, however changes to recruitment criteria are necessary. Additional testing and larger sample sizes are required to test efficacy. Trial registration Clinicaltrials.gov , #NCT03440320.
Article
Full-text available
Background and Aim: Emotion dysregulation (ED) after traumatic brain injury (TBI) can exacerbate a wide range of symptoms, including problems in restraining emotions and behaviors, executive function disorders, and diminished emotional awareness and expression. This study aims to systematically review these studies on emotion dysregulation (ED) in people with TBI. Methods and Materials/Patients: PubMed, Web of Science, Scopus, as well as Google Scholar, were systematically searched for required articles published between 1997 and 2023. The eligibility of identified literature was determined by screening the titles and abstracts by two autonomous researchers, denoted as the first author and the second author. Only those studies that reported either emotional regulation or expressive suppression in their findings of TBI adults were included in this review. The abstract and full text of search results were screened by Rayyan QCRI (Qatar Computing Research Institute) intelligent systematic review. Subsequently, the two researchers independently assessed the full-text versions of the residual articles to determine their admissibility. Disputes at each stage were amicably resolved through discourse and consultation. Results: Of the 773 articles identified, 361 studies remained after removing duplicate studies. A final 58 studies were retrieved for full-text screening based on inclusion criteria. So that after the renewed screening, 34 studies were included in this review, which indicated the existence of emotional problems in patients with TBI in all severities. Conclusion: Even though numerous effective factors either physical or psychological aspects made brain injuries more complicated, long-term outcomes associated with post-injury emotional and mental distress and dysregulation have rarely been analyzed in terms of TBI treatment. Hence, by considering medical and clinical psychology care, a more comprehensive approach can be adopted to treat people with TBI and improve their quality of life.
Article
Background and purpose This was a preliminary investigation where participants served as their own controls. Nine participants with chronic brain injury were recruited, and seven (four female) completed the study. Materials and methods Performance measures of balance and mobility and self-reported measures of balance confidence, pain, and occupational performance and satisfaction were used. Data were collected 3 times: baseline (study onset), pre-yoga (after an 8-week no-contact period), and post-yoga (after 8 weeks of yoga). Group yoga was led by a yoga instructor/occupational therapist, and sessions lasted 1 h and occurred twice a week. Results No participants withdrew due to adverse effects from yoga. There were no significant changes between baseline and pre-yoga. Significant improvement was observed post-yoga in balance, p = 0.05, mobility, p = 0.03, and self-reported occupational performance, p = 0.04. Conclusion We observed significant improvements in balance, mobility, and self-reported occupational performance in adults with chronic brain injury.
Article
Social functioning in FTD is profoundly affected, and forms the basis for the clinical diagnosis of the behavioural variant of the disease (bv-FTD). In particular, there are deficits in emotional processing, but the inter-relationship of such deficits to other aspects of social functioning remains unclear. We studied patients with bv-FTD (n = 14) and AD (n = 14), and compared their performance on a test of emotion recognition with their scores on two carer-based assessments: the Disability Assessment for Dementia (DAD) of activities in daily living (ADL), and the Cambridge Behavioural Inventory (CBI). The bv-FTD group had significantly greater impairments in ADLs, and had higher scores on the CBI, compared to the AD group. Despite a deficit in emotion recognition, particularly involving negative emotions, in the FTD group relative to AD and controls, performance on this task did not correlate with ADL ratings which instead, correlated highly with carer-rated apathy levels on the CBI. The study highlights the multifactorial nature of social dysfunction in FTD which is important in the management of these patients and in designing effective behavioural and therapeutic interventions. The relationship of emotional processing to other aspects of social cognition in FTD is reviewed.
Article
Objective: This pilot study measured the feasibility and impact of an 8-week yoga programme on the quality-of-life of adults with acquired brain injury (ABI). Methods: Thirty-one adults with ABI were allocated to yoga (n = 16) or control (n = 15) groups. Participants completed the Quality of Life After Brain Injury (QOLIBRI) measure pre- and post-intervention; individuals in the yoga group also rated programme satisfaction. Mann-Whitney/Wilcoxon and the Wilcoxon Signed Rank tests were used to evaluate between- and within-group differences for the total and sub-scale QOLIBRI scores, respectively. Results: No significant differences emerged between groups on the QOLIBRI pre- or post-intervention. However, there were significant improvements on overall quality-of-life and on Emotions and Feeling sub-scales for the intervention group only. The overall QOLIBRI score improved from 1.93 (SD = 0.27) to 2.15 (SD = 0.34, p = 0.01). The mean Emotions sub-scale increased from 1.69 (SD = 0.40) to 2.01 (SD = 0.52, p = 0.01), and the mean Feeling sub-scale from 2.1 (SD = 0.34) to 2.42 (SD = 0.39, p = 0.01). Conclusion: Adults with ABI experienced improvements in overall quality-of-life following an 8-week yoga programme. Specific improvements in self-perception and negative emotions also emerged. High attendance and satisfaction ratings support the feasibility of this type of intervention for people with brain injury.
Article
Traumatic brain injury (TBI) is highly prevalent and in a variety of populations. Because of the complexity of its sequelae, treatment strategies pose a challenge. Given this complexity, TBI provides a unique target of opportunity for complementary and alternative medicine (CAM) treatments. The present review describes and discusses current opportunitites and challenges associated with CAM research and clinical applications in civilian, veteran and military service populations. In addition to a brief overview of CAM, the translational capacity from basic to clinical research to clinical practice will be described. Finally, a systematic approach to developing an adoptable evidence base, with proof of effectiveness based on the literature will be discussed. Inherent in this discussion will be the methodological and ethical challenges associated with CAM research in those with TBI and associated co-morbidities, specifically in terms of how these challenges relate to practice and policy issues, implementation and dissemination.
Article
The purpose of this mixed-methods case study was to investigate whether an 8-week 1:1 yoga program was feasible and beneficial to people with traumatic brain injury (TBI). This was a mixed-methods case study of one-to-one yoga for people with TBI included three people. We completed assessments before and after the 8-week yoga intervention and included measures of balance, balance confidence, pain, range of motion, strength and mobility. Qualitative interviews were included at the post-assessment. We include a percent change calculation and salient quotes that represent the perceived impact of the yoga intervention. All participants completed the yoga intervention and all demonstrated improvements in physical outcome measures. For the group, balance increased by 36%, balance confidence by 39%, lower extremity strength by 100% and endurance by 105%. Qualitative data support the use of yoga to improve multiple aspects of physical functioning, one participant stated: "I mean it's rocked my world. It's changed my life. I mean all the different aspects. I mean physically, emotionally, mentally, it's given me you know my life back…". Yoga, delivered in a one-to-one setting, appears to be feasible and beneficial to people with chronic TBI. Implications for Rehabilitation Chronic traumatic brain injury (TBI) leads to many aspects of physical functioning impairment. Yoga delivered in a one-to-one setting may be feasible and beneficial for people with chronic TBI.
Article
To investigate the prevalence of all severities of traumatic brain injury (TBI), regardless of treatment setting, and their associated negative outcomes. A total of 2701 adult Coloradoans. A statewide, population-based, random digit-dialed telephone survey. The lifetime history of TBI was assessed by a modification of the Ohio State University TBI Identification Method; activity limitation and life satisfaction were also assessed. The distribution of self-reported lifetime injury was as follows: 19.8%, no injury; 37.7%, injury but no TBI; 36.4%, mild TBI; and 6.0%, moderate-severe TBI. Of those reporting a TBI, 23.1% were hospitalized, 38.5% were treated in an emergency department, 9.8% were treated in a physician's office, and 27.5% did not seek medical care. A clear gradient of activity limitations and low life satisfaction was seen, with the highest proportions of these negative outcomes occurring in people reporting more severe TBI and the lowest proportions in those not reporting a TBI. Approximately twice as many people reported activity limitations and low life satisfaction after nonhospitalized TBI compared with hospitalized TBI. This investigation highlights the seriousness of TBI as a public health problem and the importance of including all severities of TBI, no matter where, or if treated, in estimating the prevalence of disability co-occurring with TBI.