Initial Evaluation 

JH, 31 year old male military veteran sustained a haemorrhagic bleed in the brain due to an arterio venous malformation (AVM) on 24 August 2017. He underwent embolization followed by an induced coma. At 8 weekshe was discharged from hospital and attended BASIC for an initial assessment.  

At assessment he was independent with mobility but required supervision with activities of daily living due to reduced high level balance skills and remaining visual field issues, multi-tasking was difficult and his mood was low.   

Pre- and post-treatment clinical measures used were: Mayo Portland Adaptability Inventory (MPAI), Dynamic Gait Index (DGI), 6-metre walk (6-MWT)Nottingham Extended Activities of Daily Living (NEADL), including a self-reported evaluation questionnaire. The clinical outcome measures were chosen related to JH’s SMART goals.  


JH underwent 18 sessions on the CAREN in addition to working with neuro-physiotherapists on a preparatory program that included stretches and strengthening exercises. JH also followed a home exercise program.  

His goals were to be able to run again, to reduce hypersensitivity of left arm, to increase his social participation, enhance his wellbeing and be able to return to work. 

Challenging the patient 

For JH the CAREN challenged cognition as well as physical ability simultaneously in a safe environment. We could increase the intensity of the applications e.g. Boat, Traffic Jam to optimise his balance which had been affected at a high level. In addition we were able to build up the training to increase the difficulty, for example with the Rope Bridge, where we could incorporate platform movement as well as the treadmill and finally asking JH to walk without his hands on the bars. His concentration improved so could retain information more which was transferable into real life situations.  

The applications used over 18 sessions were:  

  • Kite flyer (trunk stability & dual tasking) 
  • City ride (medio-lateral weight shifting) 
  • Boat slalom (balance and weight bearing/shifting) 
  • Microbes (gait adaptability) 
  • Rope swing bridge (up & down hill walking & dual tasking) 
  • Traffic Jam (one leg stability) 
  • Magicians Apprentice (dual tasking) 



As shown in the below table, JH was able to reach many of his personal goals. He also stated that the CAREN was motivational, challenging and exciting. 



Pre-treatment 19-10-2017 

Post-treatment  21-12-2017  

Walking ability 

unable to step over obstacles safely 

steps safely over obstacles 

NEADL score 



Leisure & social Participation 



Work ability 

Unable to work 

Now helping out at work 

Sensory function 

Hypersensitivity of left arm 

Still sensory issues, but deals with them better 


Left peripheral visual field loss 

Slight improvement with vision 


High level of fatigue 

Improved fatigue level, better management 


Unable to run 

Now able to run 

6-metre walk test 

4.78 seconds 

3.72 seconds 

6-metre run 

Unable to perform 

2.15 seconds 



CAREN is a rehabilitation tool that enhances further recovery, once patients are discharged from NHS rehabilitation. 

The flexibility of the system allows the appropriate applications to be selected to meet the specific needs.  

Using the CAREN helped JH reach his goals in a short time by combining the cognitive and physical training in a safe environment.