Rehabilitation of Walking The New Paradigm in NeuroRehab

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)

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

30. 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)

31. 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)

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

38. 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

46. 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)