Resident lecture 2012 locomotion threapy
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Locomotion therapy : evidence & important considerations 29 May 2008 lo·co·mo·tion n. 1. The act of moving from place to place. 2. The ability to move from place to place. [Latin loc , from a place, ablative of locus, place + motion.]
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Transcript of Resident lecture 2012 locomotion threapy
Locomotion therapy
: evidence & important
considerations Parit Wongphaet,M.D.
29 May 2008
lo·co·mo·tion n.
1. The act of moving from place to
place.
2. The ability to move from place
to place. [Latin loc , from a place,
ablative of locus, place +
motion.]
Overview
• Historical development
• Neurophysiology of walking
• Essential considerations
• Evidence : what works?
• Practical parts
Historical development
• Rossignol 1980’s
– Spinal cat ambulation training
• Barbeau 1987
– Partial Body Weight Support (PBWS) System developed
• Wernig 1992
– PBWSTT case series (Chronic SCI)
• Hesse 1994
– first case series : chronic non ambulating hemiplegia
Robotic Gait Trainer
• Hesse 1999
– “GT1” gait trainer machine invented
• Colombo 2000
– “Lokomat” machine invented
Gait Trainer
GT1
End
Effector
Control
The facts
The facts
“The Spinal Cat”
Spinal cord can “learn”
De-training effect
De-training effect
De-training effect
De-training effect
De-training effect
De-training effect
De-training effect
Mike “the headless chicken”
Fruitia,
Colorado
USA
1940’s
Lived for
4.5 years
AFTER
“Losing his head”
EMG of Spinal Man
EMG of Spinal Man
EMG of Spinal Man
EMG of Spinal Man
EMG of Spinal Man
Non-ambulating SCI ASIA C&D
Conventional Physio
(intensive standing
& walking) PBWSTT
GT 1 Lokomat
2006 Dobkin MRCT
“similar”
Case series
Hesse 2004
Wirz 2005
“better than
No training”
PBWSTT
In good hands?
“controlled study”
Wernig 1998
“better than
No training”
“7 of 8 chronic patients
incapable of walking overground
even with the help of 2 therapists
(our functional class 0)
learned to walk 50 to 100m or more
(5 even without help).”
CPG Triggering
• “Rules of Spinal Locomotion” (according to
Prof. Wernig)
– Weight bearing during Stance through out
– Hip extension (full)
– Unloading at terminal stance
– As little support as possible
– (not as much as necessary!)
Neural control of human “locomotion”
Central Pattern Generator
“CPG”
Musculo- skeletal
system
Cerebellum
Reticular Formation
(Mid-brain)
Cortical Motor Areas
Proprioceptive
motor program change Phasic activation
Motor learning
• Sub task analysis
• Sub task training
• Complex skill training
• Transfer of skill
What is missing?
Walking
Walking
Walking
Walking
Walking
Walking
Why the difference?
Walking
Walking
Determinants : pelvic rotation
Determinants : pelvic list
Determinants : pelvic shift
Essential sub-task of walking
• Swing
– Foot placing
– Foot trajectory
• Stance
– Weight acceptance
– Balance
– Propulsion
– Weight shifting to opposite leg
• How important is BWS ?
• How important is Speed ?
– Control : PNF & Bobath
– Limited progressive : +5% per week
– Aggressive progressive : bouts of 10 secs at
“best speed”
Essential principles
•The “extended”
Rules of Spinal
Locomotion
Essential principles
• Spinal CPG stimulation
– Weight bearing
– Hip extension
– Unloading at terminal stance
– (BWS ?)
– Speed & Continuity
• Motor learning
– Task specific
– High repetition
• Aerobic Capacity
Non-ambulating SCI ASIA C&D
Conventional Physio
(intensive standing
& walking) PBWSTT
GT 1 Lokomat
2006 Dobkin MRCT
“similar”
Case series
Hesse 2004
Wirz 2005
“better than
No training”
PBWSTT
In good hands?
“controlled study”
Wernig 1998
“better than
No training”
“No significant differences
were found at 6 months
for FIM-L (n 108) or
walking speed and
distance (n 72).”
Non-ambulating SCI ASIA C&D
Conventional Physio
(intensive standing
& walking) PBWSTT
GT 1 Lokomat
2006 Dobkin MRCT
“similar”
Case series
Hesse 2004
Wirz 2005
“better than
No training”
PBWSTT
In good hands?
Case series
Wernig 1998
“better than
No training”
Lokomat works
in ASIA C & D patients
-
BETTER than conventional ?
BETTER than PBWSTT ?
2 of 20 cases showed improved “functional class”
• (12-15)WISCI : 2 crutches 1 cane
• (19-20)WISCI : 1 cane no aids
• NOT NECESSARILY BETTER THAN
PBWSTT (Wernig,Hicks)
Wernig A, Nanassy A, Müller S. Maintenance of locomotor
abilities following Laufband (treadmill) therapy in para- and tetraplegic
persons: follow-up studies. Spinal Cord 1998;36:744-9
Hicks et al. Long-term body-weight supported treadmill training and
subsequent follow up in persons with chronic SCI
. Spinal Cord 2005; 43: 291–298.
Non-ambulating SCI ASIA C&D
Conventional Physio
(intensive standing
& walking) PBWSTT
GT 1 Lokomat
2006 Dobkin MRCT
“similar”
Case series
Hesse 2004
Wirz 2005
“better than
No training”
PBWSTT
In good hands?
Case series
Wernig 1998
“better than
No training”
Evidence : Non-Ambulating Hemiplegia
• PBWSTT
–Chronic Non-ambulatory stroke
–A-B-A study (Hesse 1995)
Non-ambulating hemiplegic
Conventional Physio
(walk and stand
As possible) PBWSTT
GT 1
Lokomat
2003 cochrane
Meta analysis
“similar”
2007 RCT
Huseman et al
“similar”
Subacute stroke RCT :
“no significant difference”
GT1 better than conventional rehab
Non-ambulating hemiplegic
Conventional Physio
(walk and stand
As possible) PBWSTT
GT 1
Lokomat
2003 cochrane
Meta analysis
“similar”
2007 RCT
Huseman et al
“similar”
Summary
• Non Ambulatory
• SCI class C&D
–Intensive ground
walking = PBWSTT
–Automated (robotic) is
o.k. but maybe less effective thant PBWSTT
Summary
• Non Ambulatory
• Stroke
–Best evidence = GT1
–Lokomat not effective
•Why ??
Pitfalls ?? • Too high speed?
– Patient must be able to control gait adequately at the selected speed
• No focus on “learning” of the sub-skill?
– One skill at a time?
• Too much passive assistance
– stepping leg
• Triggering the spinal locomotor (CPG)?
– Hip position
– Weight shifting
• Body weight Support
– Too much
– Too little
PBWSTT
Control
13.6
(6.57)
2.9
(3.44)
0
2
4
6
8
10
12
14
Step length
improvement
(cms)
PBWSTT
Control
0.71
(0.33)
0.15
(0.19)
0
0.2
0.4
0.6
0.8
Speed
improvement
(Km/hr)
Summary • PBWSTT
– is effective in
• Stroke
– Subacute and Chronic
– Especially better for more severely affected
patients
• Chronic Para/Tetraplegia
– Mechanism
• Activation of reflex stepping center
• High repetition, Task specific motor
learning
• Improved gait energy efficiency w/wo
improve in aerobic fitness
Summary
• PBWSTT
• SCI & Hemiplegia • Is at least as good as Intensive ground amublation
training
• Can still be “better” than “Robotic” training
• If certain practice is rigorously followed
Suggestion : The Perfect System
• GT1 machine
• PBWSTT
• Portable Gait Analysis system.
Outcome Measurements
• Functional Ambulation Class – FAC (Hemi)
– Wernig Scale (SCI)
• Timed Walk Test – Short
– Long
• Balance
• Power?
Inclusion criteria
• Neck & Trunk balance
– Fair with hand support
• Postural BP change
– Tolerate at least 10 mins standing
• Bone density
– Weight bearing of legs
• Footware
exclusion criteria
• Flexion contracture of knee& hip
>20 deg
• Equino varus ankle deformity
(severe)
• Open wound at belt pressure sites
• Active painful arthritis (Les)
• Deep vein thrombosis
Equipments
• Treadmills
• BWSS
• Harness
• Robotic systems
Locomotor training
• Is not new
• Is the next standard
•Thankyou !
