Thursday, December 3, 2015

Hiking After Traumatic Brain Injury

"People with TBI are often physically inactive, leading to reduced fitness levels and secondary health conditions. Regular physical activity can enhance balance and coordination, decrease reliance on assistive devices, and improve ability to perform activities of daily life and, therefore, foster independence. Studies also suggest that exercisers with TBI were less depressed and reported a better quality of life than those who did not exercise. The key is to find which exercises the person with a TBI enjoys and develop an individualized exercise prescription that accommodates each person's needs and abilities."  
- National Center on Health, Physical Activity and Disability.
This fall, I happily designed and facilitated a pilot hiking program for people with traumatic brain injuries in western Massachusetts. Before we'd gotten our small group out on the trail, one of our participant's personal caregiver said to me, "I get more physical therapy with Kevin on the trail than in the clinic. It is so much more meaningful for him to be in nature. I'm limited to where we can hike though, because we can't go beyond a safe distance for emergency services in case anything happens. So mostly we hike on one trail in a local state park."

Other soon-to-be participants also reported not feeling safe about hiking on their own for this reason and also cited that short term memory presented challenges for staying found. All five individuals had been coming to other Universal Access Program activities throughout the year and wanted more opportunities to be outside and exercise. One purpose of our custom hiking program was to offer them a chance to hike with peers and the support of three staff with radios connected to the park system and emergency services.
Of course it was so much more than that -  the opportunity for people to find their own pace on the trail, even hike alone if they preferred, enjoy quiet time in nature, and begin to consider fitness elements as part of the experience. I wanted to see if even in four sessions of weekly hiking, people might begin to feel their fitness level increase or other benefits. It was also my hope to introduce more trail options for people to use on their own.
When I invited people who were ambulatory, interested in hiking and clamoring for more opportunities outdoors, I discovered that they all had a common disability - TBI! And it is interesting how they acquired their TBI - stroke, heart attack, fall in bathroom, hitting head while swimming underwater, and being bitten by a mosquito with EEE. Yikes! A good reminder that we are all vulnerable to TBI!
It turns out that our hiking program satisfied three of four standard exercise components recommended by NCHPAD - cardio training, balance training, and, by adding stretching, flexibility training. Only strength training was formally missing, but could be added, since the weight of the daypack might not meet the requirements of strength training with all muscle groups.
Our first hike was a day forecast for 100% rain and strong winds in early October. I was very tempted to postpone, since I knew it wouldn't be an easy start and I wanted to introduce stretching and hammocking in addition to the route and other typical topics. Some participants were adamant about not cancelling, preferring to hike in the rain if necessary. So, off we went! Hiking in part is about knowing how to take care of yourself in the elements and no one wanted to be denied the experience!
We hiked over a mile that day and despite the forecast the weather was kind to us, only drizzling at times. Tree cover protected us too. Hiking along a pond edge kept us out of high winds and provided a relatively level trail to start. I was looking to get a baseline for how people handled mild terrain. We traveled slowly, adjusting layers of clothing, and resting along the way, enjoying the forest, and let participants determine their turnaround point.
The following week we returned to the same location and completed the pond loop originally intended for our first hike. This time we had a beautiful sunny day and more hikers. We successfully introduced stretching and hammocking and completed 1 1/2 miles. Everyone had a great time and I began to understand that part of this success lies in crafting the hike to match everyone's abilities.
To do this the three of us staff hiked the trails one or two times in advance (usually individually), to get accurate mileage and study the trail conditions and features. As we got to know our hikers better, sometimes we had to recon again so we could make the best choice for the next hike. Staff actually hiked a few more trails than we ended up using, so we had a bank of known possibilities to choose from and knowledge of their current conditions. We set up hiking routes with a couple of key things in place - an indoor place to meet with restrooms, a way for someone to leave the hike early if they weren't feeling up for the whole trip, and a trail extension for those who wanted to hike further than the rest of the group. The other very key component was to chose trails that were likely to provide the right level of challenge. This involved careful attention to the blend of distance, elevation gain, and ease or difficulty of trail walking elements. One thing I learned is that people with TBI can be more prone to fatigue or even exhaustion from the process of placing their feet on trails with even low roots and rocks.
We introduced the use of hammocks as a way for people to rest and enjoy nature, as well as getting their feet off the ground if need be. I find hammocking is more refreshing than standing or even sitting on the ground during a rest break. This turned out to be a distinct hit with several participants and even staff. One individual found tremendous relief in taking this soothing break from sensory stimulation. The hammocks are portable and set up in a minute, making them very convenient for hiking.

For our fitness measurement we relied on pulse taking to begin to raise awareness about heart rate. We quickly learned that taking pulses manually was a highly inconsistent and somewhat invasive process. In some cases we simply couldn't find pulses. The purchase of an oximeter (finger reader) quickly resolved these difficulties, although it doesn't work as well with cold fingers. In the four weeks we were able to establish resting rates and exertion rates for comparison. This technique helped staff monitor how hard each hiker was working, with an eye towards keeping everyone in a comfortable range, based on a percentage of increase over their resting heart rate.

As far as adaptive support for our hikers, in addition to hammocks, we offered other conventional gear. Three of the five hikers with TBI used hiking poles for additional stability and balance support. While they all brought their own hiking gear, we provided maps, extra clothing and emergency snacks if needed - just like any other structured hiking program. One hiker brought her own portable seat on two hikes, but then converted over to using hammocks, which can be used in upright and reclined positions.

Our hikes stayed in the vicinity of 2 miles, each one offering different challenge opportunities. The third hike had more elevation variety with a gain of 265 feet from a trout-filled river to the top of a wooded knoll. Our choice of trail made it easier for everyone with roads and footpaths that were relatively smooth, minimizing the fatigue factor of complicated foot placement. Our last hike took everyone on a gradual climb to remote overlooks with clear views via a more moderate trail with numerous challenge spots  over small rocky knolls.

Our four hikes ended all too soon. Participants were now synchronized as a group and ready to hike each week. They wanted to know their pulse readings and looked forward to hammock time, time in the forest and social connection. It was easy to see that if we continued each week, we could build distance, elevation, trail difficulty and fitness capacity. The pilot program was a initial success and we hope to continue to develop opportunities for peer-based hiking programs for people with disabilities. Small customized group hikes offer greater access to all the benefits of being out in nature and on the trail while providing the support needed for those who need it most.

Marcy Marchello is a statewide coordinator for adaptive recreation in Massachusetts State Parks.


Marcy Marchello said...

Dear Marcy—what a great post—eerily familiar, as you will see in the post I wrote, sharing your article on my website, and Facebook page. Would love to partner more closely with you all in Eastern MA to expand this program.

Marry Davis said...

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