It is an exciting time in the field of rehabilitation. For people who have sustained a neurological injury such as a stroke, incomplete spinal cord injury or traumatic brain injury, there is now hope for regaining the ability to ambulate and sometimes even achieving a full recovery.
In the past, a neurological injury was viewed as irreversible, and rehabilitation was focused on helping patients adapt and compensate, particularly if they showed no functional improvement a few weeks after the injury. Now we know that partial or full recovery is possible and can be achieved even many months following injury, provided that rehabilitation is aggressive and immediate.1
While this requires hours and hours of hard work and intensive active practice by both patient and therapist, this kind of focused rehabilitation is the key to remarkable outcomes that are being seen months or even years after the initial injury.1
Rehabilitation science now strongly emphasizes early intensive and repetitive practice for recovery of function in neurologically impaired individuals.2,3 Neuroscience research shows that the human brain and nervous system are not permanently damaged by injury. Remarkably, the central nervous system can create new neuronal branches to connect with other neurons to build new pathways in the brain.
Intensive and Repetitive Practice
The brain's ability to reorganize by forming new neural connections is known as neuroplasticity. This rewiring of the brain can occur after an injury or trauma if there is active purposeful movement of the affected limbs.4,5
Extended periods of physical inactivity after a neurological injury lead to the deterioration of bone and muscle strength, and negatively affect neural circuits in "learned non-use." Learned non-use occurs when neural circuits shut down, thus blocking the formation of new neuronal pathways and connections, which is the basis of neuroplasticity.6
In contrast, using intense activity-based therapies soon after injury stimulates neural activity and promotes neural regeneration for improved recovery. Clearly, timing is an issue, and the sooner active practice can begin, the better.
In addition, with intensive and repetitive practice, the function of the central pattern generators (CPGs) may be stimulated. CPGs are networks of spinal neurons distributed throughout the lower spinal cord regions. When triggered, these relatively small, autonomous neural networks generate rhythmic stepping motions of the legs without dependency on the entire nervous system and sensory input from the limbs. Providing opportunities for repetitive step-taking after an injury in supported ambulation postures may stimulate the firing of the CPGs to further the recovery of walking.7,8
Because the brain is neuroplastic and responds to repetitive and intensive therapy, we must give the patient sufficient practice opportunities. Often, having the chance to perform thousands of repetitions and practice trials is the key to success. Adding a degree of challenge to the skill is also important for recovery as this demands focused attention and problem-solving skills, which additionally stimulate the brain. Intensity and challenge in gait training can be provided in the following ways:
• Duration: increasing length of practice sessions.
• Speed: increasing stepping pace.
• Balance: allowing opportunities for self-correction of unintended movements (patient loses balance in a safe and controlled situation, and self-corrects to achieve improved gait quality).
• Resistance: adding weight, resistance, or "drag" while gait training.
• Accuracy: challenging stride length and limb placement during step taking (for example, navigating through a cone setup or over obstacles).
How can this intense and repetitive practice be safely incorporated in rehabilitation gait training? Certainly, a patient who has recently undergone injury, trauma or surgery is likely to fatigue quickly secondary to deconditioning, weakness, paralysis, or lack of motor control. Most movements and activities require significant energy and concentration to complete.
So ambulating for recovery can be a physically tiring process for both the therapist and the patient. Typically, the exercise session has to be cut short due to patient and therapist fatigue and to prevent the risk of patient falls or therapist injury. Because of this, utilizing equipment and applying the concept of safe patient handling and movement to the field of rehabilitation can be a significant solution.
In the past few decades, various bodyweight support devices, both over treadmill and over ground, have been designed to support ambulation practice. In a bodyweight support system, the patient's feet are in contact with the ground, yet a percentage of their body weight is supported. With some of the load taken off their limbs, the patient can use their available strength to perform a walking pattern.
Meanwhile, the therapist can focus with the patient on the quality of gait, rather than spending energy maintaining the patient's upright position to prevent a fall. As a result, the patient is able to engage in more repetitions of the gait cycle before fatiguing.
Role of Therapist Safety
Manon LaBreche, PT, is injury prevention coordinator for Tampa General Hospital in Florida. LaBreche advocates the use of equipment for therapist safety. She notes that without supportive equipment, in the years before safe patient handling was an area of focus (the "caveman years," as LaBreche refers to them), gait training dependent patients could involve up to four PTs: two to hold the patient up, and two to move the legs.9
"A PT will do whatever it takes to get a patient out of bed, even if it requires five personnel," LaBreche said. "We need to ask if the patient gains anything functionally through this, particularly if they are unable to participate. Equipment can provide the needed power and support so that patients can be mobilized."
Safe patient handling and mobility as a clinical practice area was originally developed for nurses, but is now impacting other health care personnel, including therapists. Therapists throughout the United States are recognizing both the opportunity and the necessity of using the wide variety of safe patient handling and mobility (SPHM) devices available.10 By using safe patient handling equipment, supported transfer and ambulation can begin earlier during recovery.
Early physical activity improves flexibility, reduces spasticity, and enables a patient to rediscover residual muscle strength, make strength gains, and receive feedback on gait performance. There is also the additional benefit of decreased risk of pressure ulcers and urinary tract infections.
Additionally, being upright provides the opportunity to relearn basic static balance, and then move toward more complex dynamic balance control. Margaret Arnold, PT, safe patient handling coordinator of McLaren Bay Region in Bay City, Mich., relates this early recovery activity to motor learning and error augmentation:
"Motor learning is learning a new motor skill. In the case of brain injury, this may be re-learning a skill that was lost through injury, such as the ability to walk. Adaptive motor learning occurs most successfully through patient activation of muscle activity and error augmentation. The patient makes errors, learns from that, and corrects the movement. Robotic devices have been found to be effective in achieving high repetitions of movements for patients, which is important. However, over-ground devices for gait training can provide an additional advantage, in terms of the opportunity for error augmentation and motor learning. Over-ground devices require the patient to propel themselves forward, unlike on a treadmill where they must simply pick their foot up."
Arnold raises a longstanding question in rehabilitation - what's more effective in recovering ambulatory ability: over-ground gait practice or bodyweight-supported treadmill training? Both can play a significant role in rehabilitation. Over-ground gait training can serve as an important progression after treadmill training, to prepare a patient for community ambulation [see table].
New Standards in Practice
Regardless of whether you are using treadmill training or over-ground practice, you need reliable SPH equipment, both for your safety and your patients'. Sometimes this will mean letting go of our long-standing practice patterns of manual support and rehabilitation techniques, and looking to the direction current evidence is pointing.
"I believe there is a cascade of barriers in knowledge and practices," said Anna K. Steadman, MA, OTR, CHSP, owner of SPHM consultant firm Essential Ergonomics LLC, in Kyle, Texas. "I'm sure that in the future, cutting-edge SPHM practical education and training will be made a requirement at the academic level. In addition, CE and CEU educational entities will begin to mandate SPHM standards for healthcare professionals."
References are available at http://physical-therapy.advanceweb.com/Editorial/Tools/references.aspx under the Toolbox tab.
Lori Potts is a physical therapist at Rifton Inc., an adaptive equipment manufacturer based in Rifton, N.Y. Visit www.rifton.com to read her regular blog posts and articles on adaptive mobility and positioning.