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Rehabilitation of Walking The New Paradigm in NeuroRehab

Rehabilitation of Walking The New Paradigm in NeuroRehab. NeuroRehab …the New Paradigm. Train your NeuroRehab patients like athletes…. Like Athletes NeuroRehab Patients…. Benefit from task specific training Benefit from intense practice Benefit from both resistance and cardio training

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Rehabilitation of Walking The New Paradigm in NeuroRehab

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  1. Rehabilitationof WalkingThe New Paradigm in NeuroRehab

  2. NeuroRehab…the New Paradigm

  3. Train your NeuroRehabpatients like athletes…

  4. Like Athletes NeuroRehab Patients… • Benefit from task specific training • Benefit from intense practice • Benefit from both resistance and cardio training • Benefit from speed training • Need a great coach…YOU!!!

  5. Rocky video (Jeff to shoot)

  6. Rehabilitation of Walking…the New Paradigm • Earlier the better • Task specific • Outcomes are dosage dependent • Speed is important • Gait training improves overall function • Locomotor adaptation

  7. Rehabilitation of Walking • Earlier the Better… • Earlier PT is started the better the functional outcome (Horn et al, 2005) • Gait training within 1st 3 hours best outcomes (Horn et al, 2005) • ICU Early Mobility

  8. Rehabilitation of Walking • Task specific… • If walking is a primary goal PT should focus on walking • Better functional outcomes when functional tasks are practiced directly(Van Peppen et al, 2010) • Pre-gait activities do not translate into better walking outcomes • Time devoted to gait training correlated to ↑ gait speed(Richards et al, 1993)

  9. Rehabilitation of Walking • Outcomes are dosage dependent… • Stroke survivors d/c’d as they reached “plateau” could demonstrate significant improvements in speed, muscle activation & gait efficiency with intense gait training (Moore et al, 2010) • It’s the # of steps that count

  10. Rehabilitation of Walking • Speed is important… • Gait training at ↑ speed → higher self selected speed (Sullivan et al, 2002) • Walking speed correlated to functional ability, quality of life, risk for falls & potential for rehab (Fritz et al, 2009) • ↑ walking speed → improved symmetry, muscle activation & efficiency (Lamontagne et al, 2010)

  11. Rehabilitation of Walking • Gait training improves overall function… • Stroke survivors who receive gait training within first 3 hours achieve higher FIM scores (ADL activities & toilet transfers) (Horn et al, 2005)

  12. Rehabilitation of Walking • Locomotor adaptation… • Process of adjusting motor patterns to new walking challenges through trial and error practice

  13. Rehabilitation of Walking • Locomotor adaptation… • CNS capable of changing walking pattern based on feedback & feedforward adjustments • Adaptations driven by preservation of symmetry, stability, safety & enhanced efficiency

  14. Rehabilitation of Walking • Locomotor Adaptation • Tapping into Central Pattern Generators (CPG’s): • ↓ tension on gastroc-soleus • Elongation of hip flexors • Weightbearing in midstance • Applied resistance & split-belt treadmill training

  15. Walking Rehabilitation…Tools for Optimal Outcomes • Body weight support and treadmill training (BWSTT) • NMES • Applied resistance and split-belt treadmill training

  16. Tools for Optimal Outcomes:BWSTT ↑walking independence post SCI v. conventional therapy (Wernig et al, 1995) Improved walking speed, balance, motor recovery & balance post CVA (Barbeau et al, 2003) Improved short-step gait in Parkinson’s Disease (Miyai et al, 2002)

  17. Tools for Optimal Outcomes:BWSTT Wernig et al, 1995

  18. Tools for Optimal Outcomes:BWSTT ↑walking independence post SCI v. conventional therapy (Wernig et al, 1995) Improved walking speed, balance, motor recovery & balance post CVA (Barbeau et al, 2003) Improved short-step gait in Parkinson’s Disease (Miyai et al, 2002)

  19. Tools for Optimal Outcomes:BWSTT Visintin et al, 1998

  20. Tools for Optimal Outcomes:BWSTT Hesse et al, 1995

  21. Tools for Optimal Outcomes:BWSTT ↑walking independence post SCI v. conventional therapy (Wernig et al, 1995) Improved walking speed, balance, motor recovery & balance post CVA (Barbeau et al, 2003) Improved short-step gait in Parkinson’s Disease (Miyai et al, 2002)

  22. Why BWSTT? • Allows for early training • Safe for patients • Task specific • Ideal environment for: • Propogation of CPG’s • High dose training • Speed training

  23. Tools for Optimal Outcomes:NMES • ↑ speed, ↓ falls & improved symmetry & function with Ness L300 post CVA or TBI(Hausdorff et al, 2006) • Improved walking symmetry & balance Ness L300 v. AFO post CVA or TBI(Weingarden et al, 2007)

  24. Tools for Optimal Outcomes:NMES • Improved gait velocity & symmetry; continued up to a year; carry-over effect, post CVA with Ness L300(Laufer et al, 2009) • FES for patients post stroke ↓ spasticity, ↑ ankle DF torque; all patients in FES group walked and 85% returned home v. 53% & 46% (Yan et al 2004)

  25. Why NMES? • Promotes muscle activation for task specific function • Allows for high dose training • Can help to ↓ spasticity • Activates neurons in the penumbra

  26. Tools for Optimal Outcomes:Applied Resistance • Gait training in normal subjects with resisted dorsiflexion resulted in ↑ TA activation after resistance removed (Blanchette et al, 2011) • Gait training with resistance to swing resulted in changes in swing phase muscle activation

  27. Tools for Optimal Outcomes:Split-Belt Treadmill • Split-belt treadmill training improved walking symmetry for patients post CVA (Reisman et al, 2007) • Gait adaptations following split-belt treadmill training transferred to over ground walking in both normal subjects and stroke survivors (Reisman et al, 2009)

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