ARTICLES Recovery of Ambulation After Traumatic Brain Injury Douglas I. Katz, MD, Daniel K. White, MSPT, Michael P. Alexander, MD, Reva B. Klein, MD ABSTRACT. Katz DI, White DK, Alexander MP, Klein RB. Recovery of ambulation after traumatic brain injury. Arch Phys Med Rehabil 2004;85:865-9. Objectives: To identify variables that are predictive of in- dependent ambulation after traumatic brain injury (TBI) and to define the time course of recovery. Design: Retrospective review of consecutive admissions of patients with severe TBI over a 32-month period. Setting: Brain injury unit in an acute, inpatient rehabilitation hospital. Participants: Of 264 patients screened, 116 met criteria that included the ability to participate in motor and functional evaluation on admission to acute rehabilitation, and the ab- sence of other neurologic disorders or fractures that affect one’s ability to ambulate. Intervention: Inpatient rehabilitation on a specialized TBI unit by an interdisciplinary team. Main Outcome Measures: Recovery of independent ambu- lation and time to recover independent ambulation. Results: Of eligible patients, 73.3% achieved independent ambulation by latest follow-up (up to 5.1mo). Patients who achieved independent ambulation were significantly younger (P.05), had better gait scores on admission (P.05), and tended to be less severely injured— based on duration of post- traumatic amnesia (PTA; P=.058)—than those who did not ambulate independently. There were no differences in recovery based on neuropathologic profile. Mean time to independent ambulation  standard deviation was 5.74.3 weeks; of those achieving independent ambulation, 82.4% did so by 2 months and 94.1% by 3 months. If not independent by 3 months postinjury, patients had a 13.9% chance of recovery. Multivar- iate regression analysis generated prediction models for time to independent ambulation, using admission FIM instrument scores and age (38% of variance); initial gait score, loss of consciousness, and age (40% of variance); or initial gait score and PTA (58% of variance), when restricted to just those patients with diffuse axonal injury. Conclusions: Most patients with severe TBI achieved inde- pendent ambulation; the vast majority did so within 3 months postinjury. Functional measures, injury severity measures, and age can help guide prognosis and expectations for time to recover. Key Words: Brain injuries; Gait disorders, neurologic; Recovery of function; Rehabilitation. © 2004 by the American Congress of Rehabilitation Medi- cine and the American Academy of Physical Medicine and Rehabilitation A LLOCATING REHABILITATION resources, planning appropriate treatment, and establishing plausible goals for patients with severe traumatic brain injury (TBI) requires an evidence-based understanding of the prognosis and time course of recovery for key functional limitations such as cognition, arm function, and ambulation. Most research on recovery from TBI has focused on cognition and behavior. We recently re- ported an analysis of predictors and timing of recovery of arm function after TBI. 1 The best predictors were severity of paresis at admission and overall injury severity; most recoveries oc- curred within the first 2 months postinjury. The predictors and time course of recovery of ambulation after TBI have not been comparably and directly investigated. Patterns of recovery of gait can only be inferred from global measures of disability and handicap after TBI, such as the FIM instrument and the Glas- gow Outcome Scale. 2-5 The absence of data on ambulation after TBI is in striking contrast to the data available on ambulation after stroke. 6-10 The severity of leg paresis and the degree of functional gait disrup- tion at admission are the best predictors of recovery of ambu- lation after stroke. 6 When recovery does occur, it usually does so within 2 to 3 months after onset. 8-10 Our purposes in this study were to define the time to recov- ery of ambulation after severe TBI and to identify the variables that predict recovery. METHODS Participants We retrospectively reviewed records of all patients (N=264) admitted to an inpatient rehabilitation TBI unit over a 32- month period from January 1992 to August 1994. Length of inpatient rehabilitation was longer at that time than it is today, which made it possible to review further into recovery with uniform serial evaluations and treatment intensity. We identi- fied a cohort of 116 patients who met inclusion and exclusion criteria. Patients were included if they were responsive and able to participate in motor and functional evaluations at ad- mission. Patients were excluded if they had any other injury factor that affected their ability to ambulate, such as fractures that affected weight bearing, or lower-extremity peripheral nerve injury. Patient characteristics are described in table 1. Measures Indices of overall severity of injury were the Glasgow Coma Scale (GCS) score at acute hospital admission, duration of unconsciousness (loss of consciousness [LOC]), and posttrau- matic amnesia (PTA). They were recorded for each case ac- cording to a previously published method. 11 Admission FIM score was the measure of overall functional disability. 12 Age and gender were the independent variables. For each patient, we determined on the occurrence of 4 separate neuropathologic From HealthSouth Braintree Rehabilitation Hospital, Braintree, MA (Katz, White); Department of Neurology, Boston University School of Medicine, Boston, MA (Katz, Klein); Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA (White); Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA (Alexander); Youville Lifecare Rehabilita- tion Hospital, Cambridge, MA (Alexander); and Memory Disorders Research Center (Alexander) and Harold Goodglass Aphasia Research Center (Klein), Boston Uni- versity, Boston, MA. Presented in part at the American Physical Therapy Association’s Combined Section Meeting, February 15, 2003, Tampa, FL. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Douglas I. Katz, MD, HealthSouth Braintree Rehabilitation Hospital, 250 Pond St, Braintree, MA 02184, e-mail: dkatz@bu.edu. 0003-9993/04/8506-8645$30.00/0 doi:10.1016/j.apmr.2003.11.020 865 Arch Phys Med Rehabil Vol 85, June 2004