Case Report: using the CAREN with brain injured patients 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 weeks, he 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. Treatment 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) Outcome 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. Outcome Pre-treatment 19-10-2017 Post-treatment 21-12-2017 Walking ability unable to step over obstacles safely steps safely over obstacles NEADL score 41/88 69/88 Leisure & social Participation Limited Greater Work ability Unable to work Now helping out at work Sensory function Hypersensitivity of left arm Still sensory issues, but deals with them better Vision Left peripheral visual field loss Slight improvement with vision Fatigue High level of fatigue Improved fatigue level, better management Sport 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 Conclusion 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.