For me body weight supported treadmill training was worthless. I needed the weight of my body to counteract the spasticity of my legs. And since spasticity never goes away, even now as I'm chronic this would do no good. Overground training is much better in my opinion since it normally gives you perturbations you need to deal with, giving you better balance and preventing falls.
And of course my doctor and therapists DID NOTHING to cure my leg spasticity.
Body-weight support gait training in neurological intensive care: safety, feasibility, and delays before walking with or without suspension
Journal of NeuroEngineering and Rehabilitation volume 20, Article number: 167 (2023)
Abstract
Background
Early Mobilization in Intensive Care Units (ICUs) enhances patients’ evolution, but has been rarely studied in neurological ICUs. The aim of this study was to assess gait training with body-weight support (BWS) in neuroICU, and to report on its safety, feasibility and on delays before walking with and without BWS.
Methods
This study was an observational one-year single-center study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria.
Results
Patients’ conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, and 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, and 33 performed BWS walking. Among non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Among the 45 eligible patients who did not receive BWS training, main reasons were workload and weekends (31%), medical barriers (29%), and early ICU discharge (22%). 78 BWS sessions were performed on the 33 beneficiaries (median sessions per patient 2, max 10). Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small, and recovered spontaneously after the session. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), and battery failure (1). None of these adverse events required medical intervention, patients recovered upon session interruption. Median session duration was 31 min, patients walked on median 17 m. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended.
Conclusions
Verticalization and walking using a suspension device in patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated.
Trial registration: ClinicalTrials database (ID: NCT04300491).
Introduction
The benefits of Early Mobilization (EM) in critical care has been demonstrated on the duration of mechanical ventilation, on lengths of stay, and on functional outcomes [1]. This has made EM a common practice in Intensive Care Units (ICUs) [2]. The basic principle of EM is that patients realize motor exercises of increasing intensities along their clinical evolution—from passive in-bed mobilizations to active out-of-bed motor training. Step-by-step progress of EM is made as early as clinically feasible (eg. bedside sitting, bed-to-chair, bedside standing, walking) [2]. International recommendations [3] and National Guidelines [4] provide guidance for EM.
EM research has mostly been performed in general or surgical ICUs, and primary conditions of patients were respiratory, cardiac or septic failure [5]. These studies included few—if any—patients with primary neurological failure, although EM is presumably beneficial for critical neurological patients also [6]. Data on safety, benefits, and EM strategies for these patients is lacking. In particular, patients with critical brain injuries have clinical specificities which make EM implementation challenging [7]. The need to control the intracranial pressure and the cerebral blood flow prevents the early interruption of sedation. Consciousness and speech disorders limit patient participation. Motor, sensitive and balance deficits reduce active mobilization capacities and increase the risks of falls.
As such, verticalization is challenging in neurological ICUs without specific devices. Previous reports illustrate the use of tilt tables [8], which might integrate robotic stepping devices—the Erigo® system [9]. This passive verticalization could promote arousal for disorders of consciousness [9].
When consciousness levels allow more active training, EM should progress towards bedside standing and walking, but this is likely to be prevented by neurological impairments. Body weigh-support (BWS) systems might at this stage be used. BWS has been greatly tried in chronic stroke sequelae [10]. It may be effective in acute stroke rehabilitation [11], where it tends to result in more rapid access to independent walking [12]. Various devices exist, including suspension systems associated with treadmills, with robotic-assisted gait training, or with exoskeletons, but few of them are mobile enough to be used in an ICU unit.
The present study describes the use of a mobile body-weight support device to allow walking training soon after weaning from ventilation for patients requiring neuroICU care. Its aims were (1) to evaluate the safety of training sessions (changes in clinical parameters, occurrence of adverse events); (2) to specify the feasibility of suspended gait training in neuroICU (characteristics and proportion of eligible patients, caregivers' time and number required, reasons for missed sessions); (3) and to assess whether the use of a suspension device could shorten the delays before gait training initiation, by measuring the time-interval between BWS walking and walking without suspension.
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