Background and objective: Upper limb dysfunction can persist years after traumatic brain injury (TBI) and take a toll on quality of life. This study examines the home-based arm and hand exercise (HAHE) protocol. The protocol integrates four key elements, including person-centered outcome measures, high-dosage task-specific visuomotor training, individualized activities, and a reminder system.
Participants: Four individuals (one female) participated. They were 36-61 years of age, and time post injury ranged from 2.6 to 14.1 years. Level of impairment of the affected arm was  at Brunnstrom Stage 3 or 4. All were right-hand dominant prior to injury. None received botulinum toxin injection treatment for spasticity within the past three months before study participation. They were assessed at baseline (T0), after therapy (T1) and one month after therapy (T2) with primary outcome measures including Box and Blocks Test (BBT), Wolf Motor Function Test (WMFT), and personal goals based on the WMFT. 
Methods: The intervention started with therapist-guided daily sessions for a week. The therapist selected activities from a pre-determined catalog that best matched the participant’s functional level. The objective was to prepare the patient to perform at least six activities by themselves in a home-based session. In the last therapist-guided session, the patient was provided with customized activities, a daily log, a motion detector, and materials necessary to carry out the activities at home. Participants were instructed to start the home-based therapy the next day and complete two one-hour sessions daily for 14 consecutive days. During each home-based session, participants were instructed to wear a motion detector on their affected wrist. The detector made a sharp, loud noise if no motion was detected for two minutes. The patient received phone calls and text messages every other day as additional reminders. 
Results: Participants 2 and 4 completed the HAHE protocol, responded to all the reminders, documented activities in the daily log, completed two one-hour sessions every day, and wore the motion detector during each session. Participants 2 and 4  achieved improvement in WMFT and personal goals. Participant 2 improved in grip strength while participant 4 improved on BBT scores. Participant 1 did not complete any home-based session, or assessments at T1 and T2. Participant 3 did not use the daily log and was not responsive to reminders, but did complete assessments at T1 and T2. Participant 3 experienced minimal improvement in grip strength.
Discussion: This case series study demonstrated a great potential of the HAHE protocol in improving upper limb function in persons with chronic TBI. The study results suggests that greater degree of adherence to the HAHE protocol was associated with greater improvement. Integrating effective strategies encouraging therapy adherence may be critical to implementation of home-based self-initiated therapy.

Improving Upper Limb Function after Chronic TBI through a Home-based Self-initiated Therapy