http://physical-therapy.advanceweb.com/Archives/Article-Archives/Walking-Tall.aspx
Gait Rehabilitation
My job as an inpatient rehab manager at Sheltering Arms Hospital in Richmond, VA, is to facilitate my team's ability to help patients realize this important but often difficult goal. Since I am also a clinician, I understand how challenging it can be to learn to walk again and also how crucial this skill is to quality of life.
Recently, I worked with a patient who had not walked in several weeks. She had a long hospital course with several surgical procedures, resulting in pain and dysfunction. When I asked this patient what her goals for physical therapy were, her answer was simple but familiar: "I just want to walk."
Although she was severely debilitated, I was determined to help her attain her goal. A rehab technician and I attempted to help her stand with a walker and move her legs, but after only a few steps we were all totally exhausted. If you are a PT in inpatient rehabilitation, this frustrating situation is probably one you know well.
Principles of motor learning and neuroplasticity tell us that repetition is essential for recovery.1,2 Yet how can a patient possibly learn and recover if he or she is only able to walk a few steps at a time? How can physical therapists help patients meet the goal to resume walking and recover faster using evidence-based practice?
The Role of a Rehab Manager
Although most of us take it for granted, the ability to walk independently is required for most daily activities. The majority of patients need to be able to walk fast enough to function in the community in order to return to prior level of mobility.
The unfortunate fact is that studies have shown only 7 percent of patients discharged from rehabilitation meet the criteria for community walking, which includes the ability to cross a road safely, and they continue to demonstrate gait patterns that deviate from the norm.3,4 This tells the therapy community that we, as caregivers and rehabilitation experts, could do better.
Part of my responsibility as an inpatient rehab manager is providing the finest tools and resources that enable therapists to deliver the best possible care to each patient. Yet there are hundreds of different devices on the market, and it can be difficult to determine which technology is the best fit for a clinic or specific patient populations.
Any new technology must be appropriate for the patient and be designed based on the most recent evidence in motor learning. The technology must also be easy to use; if a piece of equipment takes too long to set up or is difficult to operate, therapists simply will not use it. They want to use their time-and the patient's time-wisely.
Stepping Forward with Technology
At Sheltering Arms we are fortunate to have the resources to acquire new technologies to supplement physical therapy expertise. Our iWALK Recovery Center program includes inpatient and outpatient services built upon the latest research in assessment and intervention.
The center was created to provide the most advanced technologies available to help patients walk again. Our goal is to have a variety of equipment and technology to meet the needs of patients with a range of diagnoses and functional abilities, all in one place. Patients who have reached a plateau with other therapies or who have been living with debilitating conditions for years finally have a resource to make progress.
The iWALK therapy team is also trained in neurorecovery-without highly trained experts to effectively use and operate the technology, devices and equipment cannot deliver on their promise.
After all, these are just tools; without the clinical judgment and expertise of a therapist, they would be useless. The therapist determines the right tool for the right patient at the right time.
Choosing Your Tools
New technologies are designed based on principles of motor learning and the relatively new concept of neuroplasticity; it has not always been known that the brain is capable of modification after injury.
In the case of my patient mentioned above, this is the point where technology came into play for her rehabilitation. After the frustrating effort to help her take a few steps with a walker, we fit her with a harness and hooked it into a dynamic over-ground body weight support system.
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The over-ground body weight support system is just one example of technology that can be used to capitalize on the theories of neurorecovery while keeping patients safe and engaged in therapy.
Because it is a dynamic system and can be used over ground or over a treadmill, patients experience walking in a real-world environment and are safe from falling. Patients are even able to experience loss of balance by being able to fall up to six inches before the system "catches" them.
As recent research indicates, it is important for patients to experience error in order to promote learning in the neural pathways. Coupled with a split-belt treadmill, which uses the principle of motor adaptation to improve asymmetric gait patterns, many patients are able to recover much faster than previously possible.5
In addition, advances in functional electrical stimulation (FES) have resulted in the ability to cue and facilitate muscle activity during functional activities. For example, we frequently use a cuff that fits on the patient's lower leg and has three components that communicate with each other through wireless technology to stimulate the muscles used to lift the foot while walking. It is especially useful because it allows for real-time adjustments and adaptations according to the patient's gait pattern.
Recently, we started using a new expansion on the technology that was cleared by the FDA earlier this year. This includes a thigh cuff that works along with the lower leg cuff to stimulate the quad or hamstring muscles used during walking and allows for even greater facilitation of gait kinematics.
Although the technology was just commercially released and is new in our facility, patients are already seeing results from working with the new thigh cuff. Our therapists use these technologies frequently because they are easy to use and can be set up in less than 15 minutes and patients are motivated and engaged by their use.
While the ultimate resource is the expertise and judgment of the therapist, these kinds of advances in the rehabilitation tool kit enable patients to practice walking with appropriate kinematics earlier in their rehabilitation course and promote recovery of the central nervous system.6
Early rehabilitation has been associated with improved functional outcomes and quality of life following a stroke.7 Therapists need to have the right tools and expertise to help patients improve more quickly and ultimately attain a higher level of recovery.
At Sheltering Arms, our patients benefit from our ability to provide walking retraining earlier in their recovery process. When considering how to best approach patients hoping to walk again, it is important to consider the exciting advances in our constantly evolving field, and how to best marry technological power with clinical expertise.
Before even doing anything an objective assessment like this would be good.
Computerized gait analysis helps patients with brain injuries
Or:
Automatic identification of gait events using an instrumented sock
The article covers these types of technology:
Lite Gait except the harness connects to ceiling rails.
http://www.litegait.com/litegait.html
The picture is the Lokomat which I used and thought was wonderful, my doctor thought it was a waste of time, shows you what he doesn't know.
http://www.hocoma.com/en/products/lokomat/
The FES stuff referred to is something like the Bioness or Walkaide.
Split-belt treadmill here:
http://www.treadmilltalk.com/split-belt-treadmills.html
Other technology for walking that wasn't mentioned:
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