Archive for category Gait Rehabilitation – Foot Drop

[Abstract + References] Gait rehabilitation after stroke: review of the evidence of predictors, clinical outcomes and timing for interventions

Abstract

The recovery of walking capacity is one of the main aims in stroke rehabilitation. Being able to predict if and when a patient is going to walk after stroke is of major interest in terms of management of the patients and their family’s expectations and in terms of discharge destination and timing previsions. This article reviews the recent literature regarding the predictive factors for gait recovery and the best recommendations in terms of gait rehabilitation in stroke patients. Trunk control and lower limb motor control (e.g. hip extensor muscle force) seem to be the best predictors of gait recovery as shown by the TWIST algorithm, which is a simple tool that can be applied in clinical practice at 1 week post-stroke. In terms of walking performance, the 6-min walking test is the best predictor of community ambulation. Various techniques are available for gait rehabilitation, including treadmill training with or without body weight support, robotic-assisted therapy, virtual reality, circuit class training and self-rehabilitation programmes. These techniques should be applied at specific timing during post-stroke rehabilitation, according to patient’s functional status.

References

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[WEB SITE] New technology is helping patients to get moving again – News

A ground-breaking ’bicycle’ which simulates muscle movements is helping a range of patients with long-term mobility problems caused by head or spinal injuries, stroke or MS. Julie Blackburn watched a demonstration.

One morning in April last year Jason Moffatt from Peel woke up with a headache.

And not just any normal headache, as he recalls: ’I don’t usually do headaches and this one was the worst: it felt like my head was about to explode out of the top.’

He put up with it for a while then decided it ’might be worth popping into the A&E’. It was lucky he did because an examination and subsequent scan revealed dried blood on his brain. He had suffered a bleed.

Jason was flown off the island to Walton Hospital in Liverpool for an operation but during surgery he suffered a stroke which left him paralysed down the left side of his body.

’I then spent three months in Liverpool, learning to walk again and do everyday tasks,’ he says.

While there, Jason realised that strokes do not just happen to older people, but to plenty of younger ones too.

Back on the island his rehabilitation programme has included sessions on a Functional Electrical Stimulation (FES) bicycle.

FES is a technique that uses low energy electrical pulses and has been found to be effective in restoring voluntary functions.

These pulses artificially generate body movements in specific muscle groups through electrodes placed on the patient’s body.

Jason’s physiotherapist is Christine Wright, from the Community Adult Therapy Services team. She specialises in helping patients with long-term neurological conditions and she demonstrated how the machine works.

Once the electrodes are positioned on the muscle groups which Jason needs to get working, he sits in a chair which is attached to the machine with his legs strapped onto the ’pedals’.

His session starts with a warm-up of around one and a half minutes before the resistance increases and he is working hard, concentrating on putting in more effort on his left leg.

Having started his treatments with around 10 to 15 minutes on the bike, Jason has now built up to 30 minutes in each session.

’I’ll be sweating at the end of this,’ he says.

As she keeps an eye on his progress, Christine explains: ’Although it’s a bike, the pattern of movement is simulating walking: each turn of the bike gives Jason a step.

’Numbers of repetitions lead to changes in the brain and the development of new neural pathways.

’The bike also strengthens the muscles so that, when those connections in the brain reform, those muscles are there, ready to be used.’

It has probably served Jason well that he was a keen cyclist before he became ill, having done the End2End mountain bike race, as well as the Parish Walk to Peel and the End to End walk.

He knows that he is also fortunate to have the use of the FES bicycle. When he was doing rehab in Liverpool, at a large, dedicated 30-bed rehab centre there, they didn’t have one: ’It was basically just a gym,’ he recalls. This is true of most rehab units where FES simulators are not part of the standard kit.

’We’re incredibly lucky to have this,’ Christine says.

This machine was purchased for the Community Physiotherapy Department two years ago with £11,695 provided by the Henry Bloom Noble Healthcare Trust.

The Trust’s main remit is to provide equipment over and above what the DHSC in the island would be able to buy.

It has been a great success for Christine and the other physiotherapists, Graihagh Betteridge and Rosie Callow, who are also trained to use the machine.

As well as working on patients’ lower limbs, the simulator can be detached from the bicycle element and used as a portable machine.

It can then be taken to people’s homes and used to help them regain shoulder and arm movement.

At the moment the department has to ration the machine’s use.

They take around 25 to 30 patients at a time, usually for a six-eight week course, with a session once a week on the bike.

They have a waiting list, both with new patients and patients who have had a course already and need further treatment. Because of this the Henry Bloom Noble Healthcare Trust has agreed to purchase a second bicycle so more patients will have the chance to use one.

Chairman of the Trust, Terry Groves, said: ’Jason’s story, and many others, have shown the value of this FES bicycle in managing differing conditions and rehabilitation.

’Recognising the continuing donations made to our Healthcare Trust we are delighted to fund the acquisition of this second FES bicycle from our funds so that continuing strides in this important area of aftercare can be made.’

Jason himself is delighted with the progress he has made using the bicycle: ’I can see an improvement. I can walk further and with a better balance,’ he says.

His aim now is to get back on his (real) bike.

Christine smiles when he says this. ’You will do it,’ she assures him.

via New technology is helping patients to get moving again | News |

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[WEB SITE] Staying One Step Ahead – Rehab Managment

Staying One Step Ahead

photo caption: Patient walks with an AFO which supports his ankle. While the loss of muscles in his lower leg will be permanent, the orthosis will stabilize the foot and aid in walking.

by Polly Swingle, PT, GCS, CEEAA, and Brian Paulson, CPO

Foot drop is a potentially painful—and even disabling—condition where an individual has difficulty raising (or a complete inability to raise) the front of the foot. Foot drop—also referred to as dropped foot or drop foot—is caused by a damage or impairment to the muscles and nerves responsible for lifting the foot. The resulting weakness or paralysis leads to characteristic symptoms that most obviously manifest in an altered gait. Because individuals suffering from foot drop cannot properly lift their foot, they may drag their toes on the ground while walking. To avoid this potentially painful and dangerous impairment (which can damage the foot and increase the risk of falling), foot drop patients may utilize a “steppage gait,” a common compensation tactic where they lift their knee(s) higher in a marching-style walk or swing their leg(s) outward.

Causes of Foot Drop

It is important to understand foot drop is not a disease; it is a symptom. There are several types of damage or diseases that can weaken nerves and/or muscles and lead to foot drop, but the three most common are an injury to the peroneal nerve that controls the muscles responsible for lifting the foot; muscular compromise due to a disorder such as amyotrophic lateral sclerosis (ALS) or muscular dystrophy; and neurological conditions such as multiple sclerosis (MS) or stroke.

Patient has a diagnosis of Cauda Equina injury due to a lumbar discectomy that had complications, and resulted in loss of his distal muscles controlling the ankle. The intervention for this injury is physical therapy for strengthening the intact muscle above the ankle, as well as balance activities and a solid AFO.

Treatment Options

There are four basic categories of treatment options for foot drop. Because successfully treating foot drop almost always depends on addressing/correcting the underlying cause of the condition, the best course of treatment and therapeutic care can vary significantly from one patient to the next.

Treatment options include the following:

Surgical intervention

Surgical treatment options can be effective for foot drop patients whose condition has been caused by physical damage to nerves or muscles. A herniated disc, tumor, or other spinal condition that has damaged or pinched a nerve can often be addressed surgically. Damaged muscles or tendons in the leg or foot can also be repaired in surgery. Patients suffering from persistent or chronic foot drop that is resistant to treatment may benefit from surgical intervention that fuses the bones of the ankle or foot, or even surgery that transplants and/or reconfigures tendon and muscle.

Functional electrical stimulation (FES)

In cases where peroneal nerve damage or impairment is causing foot drop, functional electrical stimulation (FES) can be an effective form of treatment. Therapeutic FES treatment in conjunction with physical therapy can help stimulate damaged nerves and muscles and promote motor recovery.

FES treatment uses sophisticated equipment to deliver targeted pulses of electrical current that evoke muscle contraction and activity. This can improve muscle functionality, enhance blood flow and range of motion, reverse muscle atrophy, and—in some cases—help foot drop sufferers regain some or all of their ability to lift their foot/feet and walk normally. Portable FES devices designed specifically for foot drop patients are also available. These systems deliver low-level FES impulses targeting the peroneal nerve, allowing wearers to achieve improved foot dorsiflexion and walk more naturally—with improved speed, stability, and confidence. These two-part systems use a specialized sensor to monitor the motion and position of the leg, in conjunction with a stimulator that delivers the electrical impulse and stimulates the peroneal nerve.

Physical therapy

Physical therapy is an important and often effective treatment option for foot drop that can be used alone or in conjunction with another treatment. The overall goal of any therapeutic or rehabilitation program for foot drop is to strengthen the muscles in the foot, ankle, and lower leg, enhance joint function and range of motion, prevent stiffness, minimize the chances of re-injury, improve balance and stability, and ultimately achieve improved mobility and regain a normal gait.

While the specific details of a therapy program for foot drop symptoms may vary from patient to patient, strength and balance training, stretching, and range of motion exercises are standard. Exercises include stretching with towels or exercise bands, seated or standing lifts, ankle dorsiflexion and plantar flexion exercises (pulling the foot toward you and pushing it away from you) with resistance from exercise bands, and even picking up small objects with your toes.

Foot drop patients should participate in a personalized therapeutic program under the guidance of a physical therapist with demonstrated experience working with foot drop patients. While in-office visits and therapy sessions are critical, most programs also include a home component with a series of exercises that the patient can perform independently.

External support and bracing

After determining the root cause for the foot drop and beginning a therapy program that incorporates the many facets of therapeutic care, including strength training, range-of-motion stretches, balance training, etc, the next step involves orthotic treatment to improve function and safety while reducing the risk of joint damage until the patient has fully recovered. An ankle-foot orthosis (AFO) can help to stabilize the affected foot and help foot drop patients maintain a normal foot position.

It is highly advisable that doctors and therapists who frequently see patients with foot drop take the time to establish a good working relationship with an orthotist. That relationship is the key to ensuring a collaborative, multidisciplinary approach where the patient, the therapist, and the orthotist are all on the same page.

Patient Safety

The highest priority of orthotic care is patient safety. Safety can be greatly improved by use of an AFO by restricting or reducing plantar flexion during swing phase of gait, and thereby reducing the risk of a fall due to catching the toes on the ground. Without the use of an AFO, many gait deviations are utilized to clear the foot during swing phase, including circumduction, hip hiking, and contralateral vaulting. These deviations increase the energy expenditure of the gait and can create muscle imbalances that often lead to further issues and complications.

Early Intervention

Early orthotic intervention is also beneficial for reducing the risk of joint contractures in patients with increased tone, such as a post-CVA foot drop with resulting equinovarus foot position. The AFO can properly position the foot in the coronal and sagittal plane to help maintain functional joint range of motion.

Innovations and Options

Revolutionary changes have taken place in the orthotic industry in the past 20 years. New lightweight materials have been introduced that are not only supportive, but can also provide energy storage and return to assist with push-off at terminal stance for patients with weak calf muscles.

When determining what kind of orthosis would provide the optimal treatment for a foot drop patient, one concept should always be remembered: joint motion should be permitted in an orthosis when sufficient muscle control and strength are present to move the joint normally through the available range. What this means is that, while support is crucial, “overbracing” a patient can create many negative consequences; some of which include muscular atrophy, dependence on the orthosis, and replacing one gait deviation with another by taking away the essential three rockers of gait. It is essential that when a patient has sufficient strength to control the ankle joint in a certain motion, that the orthotic allows them to do so.

One example of overbracing would be putting a patient with a flaccid foot drop (weak dorsiflexors) but strong plantar flexors into a solid ankle AFO. This AFO solution would prevent them from using their calf musculature at terminal stance for push-off. It also would prevent anterior tibial translation during the second rocker of gait, creating an unsmooth rigid transition through mid-stance. That could subsequently lead to genu recurvatum by restricting dorsiflexion of the ankle. A more appropriate AFO selection may be something with flexibility that has enough plantar flexion resistance to improve clearance of the foot during swing phase, but also lets the patient use their own musculature for other motions that they can control appropriately.

Manufacturers provide plentiful options to the physical therapy market for off-the-shelf and custom AFOs. Rockaway, NJ-headquartered Allard USA offers AFOs designed especially for foot drop that provide mild, moderate, and maximum stability. The company’s ToeOFF is a carbon composite dynamic response floor reaction AFO designed to keep the foot up during swing phase and provide a soft heel strike in addition to stability in stand and good toe-off. The company also offers the ToeOFF and the BlueROCKER as custom AFOs when more specific needs must be met, such as fit issues related to unique leg shapes, alignment issues, or calf atrophy/hypertrophy. Another manufacturer, DJO Global, Dallas, offers a line of AFOs including the lightweight Posterior Leaf Splint AFO, designed to provide utility for mild to moderate foot drop needs. Cascade Dafo Inc, Ferndale, Wash, offers a versatile line of pediatric dynamic AFOs that are available as customized products and feature colors and design elements that will appeal to children.

Ongoing Consultation

As recovery progresses, the orthotist should be consulted on a regular basis so that the AFO can be changed or modified throughout each stage of rehabilitation. As the patient’s condition changes, the therapeutic remedies (from exercises to AFO solutions) should change with them. The ultimate goal is to eventually eliminate the need for the brace entirely, because full function has been regained. In the meantime, the proper orthosis can be very beneficial in improving function and safety until independence is possible without it. RM

Polly Swingle, PT, GCS, CEEAA, is co-founder and lead physical therapist of The Recovery Project, which provides progressive, effective, evidence-based neuro rehab therapies that improve the quality of life and functionality of patients with spinal cord, neurological, and traumatic brain injuries at its three Michigan-based locations.

Brian Paulson, CPO, is a clinical manager for Wright and Filippis, a Michigan-based provider of prosthetics, orthotics, custom mobility products, and accessibility solutions with over 70 years of experience. For more information, contact RehabEditor@medqor.com.

 

via Staying One Step Ahead – Rehab Managment

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[Abstract] Enriched, Task-Specific Therapy in the Chronic Phase After Stroke: An Exploratory Study

Abstract

Background and purpose: There is a need to translate promising basic research about environmental enrichment to clinical stroke settings. The aim of this study was to assess the effectiveness of enriched, task-specific therapy in individuals with chronic stroke.

Methods: This is an exploratory study with a within-subject, repeated-measures design. The intervention was preceded by a baseline period to determine the stability of the outcome measures. Forty-one participants were enrolled at a mean of 36 months poststroke. The 3-week intervention combined physical therapy with social and cognitive stimulation inherent to environmental enrichment. The primary outcome was motor recovery measured by Modified Motor Assessment Scale (M-MAS). Secondary outcomes included balance, walking, distance walked in 6 minutes, grip strength, dexterity, and multiple dimensions of health. Assessments were made at baseline, immediately before and after the intervention, and at 3 and 6 months.

Results: The baseline measures were stable. The 39 participants (95%) who completed the intervention had increases of 2.3 points in the M-MAS UAS and 5 points on the Berg Balance Scale (both P < 0.001; SRM >0.90), an improvement of comfortable and fast gait speed of 0.13 and 0.23 m/s, respectively. (P < 0.001; SRM = 0.88), an increased distance walked over 6 minutes (24.2 m; P < 0.001; SRM = 0.64), and significant improvements in multiple dimensions of health. The improvements were sustained at 6 months.

Discussion and conclusions: Enriched, task-specific therapy may provide durable benefits across a wide spectrum of motor deficits and impairments after stroke. Although the results must be interpreted cautiously, the findings have implications for enriching strategies in stroke rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A304

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[WEB PAGE] Gaining Ground Against Neurological Injury

Gaining Ground Against Neurological Injury

photo caption: Elizabeth Watson, PT, DPT, NCS, works with a client on gait training using a robot-assisted over-treadmill dynamic body weight support system.

by Elizabeth Watson, PT, DPT, NCS

Recovery following a neurological injury is a long, slow process and does not follow a set time frame. Recovery is about more than just walking; it is about regaining function and improving overall quality of life.

This article explores a specialized program at Magee Rehabilitation Hospital-Jefferson Health in Philadelphia called Gaining Ground. The goal of Gaining Ground is to extend Magee’s mission beyond traditional physical and cognitive therapy services and reduce the barriers to continued exercise and wellness. This article also highlights the different technologies used during this program and the impact on the quality of life of the participants.

Increased evidence supports the benefits of exercise and physical activity on the physiologic and psychosocial function of individuals following neurological injuries.1 In addition, physical inactivity following a neurological injury leads to increased vulnerability to secondary health complications, including cardiovascular disease and loss of bone density and muscle mass.1 Evidence-based physical activity guidelines have been established for the general population and those with disabilities. These guidelines highlight the importance of moderate-intensity aerobic exercise and strength training for individuals with spinal cord injuries and stroke survivors.2,3

Making Progress Accessible

Barriers to continued exercise following a neurological injury include lack of accessible fitness facilities, absence of personal assistants knowledgeable about exercise programs appropriate for those with neurological injuries, absence of specialized equipment, and fear of injury. Gaining Ground was developed to reduce these barriers.

Gaining Ground is an individualized exercise program, taking into account the goals and abilities of the client. The intensive, boot camp-style program takes place 3 days a week for 4 weeks. Clients vary in presentation from those at a power wheelchair level to ambulatory patients. Some are more recently injured, just finishing outpatient therapy and looking to be challenged further and establish a wellness program. Other clients have been injured for more than 20 years and are exploring newer technologies and treatment techniques that did not exist when they were first injured. These clients find that the program’s intense nature often encourages a continued wellness program after Gaining Ground ends.

Program Structure

Each day includes 4 hours of exercise. A one-on-one training session with an activity-based therapy specialist focuses on increasing cardiovascular endurance, muscle strength and flexibility, sitting or standing tolerance, and balance. Working with a physical therapist provides the opportunity to continue working toward goals not reached during traditional therapy, as well as a chance to trial different technologies and specialized equipment working toward more neurological recovery. Once a client’s program is established, he or she is set up on specialized equipment such as a locomotor device or FES cycle for an hour of activity-based exercise.

A daily group exercise class helps increase strength, improve cardiovascular endurance, and enhance overall well-being. Exercises emphasize the muscle groups of the upper extremity and core necessary to complete daily functional activities. Group sessions include a circuit using the multi-station wheelchair-accessible weight machine, a wheelchair-accessible upper extremity exerciser, a conventional weight machine, a free weight and therapy band circuit training program, and getting onto the floor to work on whole body exercises. This allows clients the opportunity to practice getting on and off the floor in a safe environment and reduce the negative association of being on the floor related to falls. The group environment fosters interaction with others working toward a common goal.

Cardiorespiratory and strength training presented in a group setting with peers provides not just physical but also emotional improvements.1,4 Depression scores and bodily pain scores decreased after participation in a group exercise program for individuals with spinal cord injuries. Past participants of Gaining Ground have commented on the motivating environment of the group sessions.

Equipment utilized during the program may include functional electrical stimulation systems, gait training devices such as the robot-assisted over-treadmill dynamic body weight support system, mobile robotic over-ground body weight support system, lower extremity robotic exoskeletons, vibration therapy plate, computerized balance system, wheelchair-accessible upper extremity exerciser, multi-station wheelchair accessible weight machine, resistance circuit trainer, rowing ergometer, recumbent trainer, and upper body ergometer. A few of the more advanced technologies are detailed below.

Most Gaining Ground clients utilize the robot-assisted body weight support system two to three times a week.
One-on-one training focuses on cardiovascular endurance, strength and flexibility, sitting or standing tolerance, and balance.

Body Weight Support Training

The robot-assisted over-treadmill dynamic body weight support system utilizes robotic-assisted gait training. A harness suspends the patient over a treadmill while the legs are guided through the walking pattern using a robotic orthosis. Speed, the amount of load through the legs, and the amount of guidance provided by the robotic orthosis, are all variables that can be adjusted to appropriately challenge the client. The robot-assisted over-treadmill body weight support system enables effective and intensive training promoting neuroplasticity and recovery potential.

This system can be used with various augmented performance feedback games. The level of difficulty can be chosen based on the client’s ability and therapy focus. Studies have shown that when using augmented performance feedback, muscle activation and cardiovascular exertion can be considerably increased.5 Most clients in the Gaining Ground Program utilize this device two to three times a week.

The mobile robotic over-ground body weight support system allows a therapist to work on overground balance and gait training, bridging the gap between treadmill-based activities and free walking. The system can provide body-weight support equally or asymmetrically depending on a client’s impairments. Therapists can steer this device or choose the mode that allows a patient to work on self-directed gait. Therapists can challenge the patient with various balance and functional activities by using a balance board, steps, or varied terrain within the width of the device’s frame.

Exoskeleton Training

Another type of equipment used for upright positioning and gait training are robotic exoskeletons designed for the lower limbs. These wearable bionic suits help patients with lower extremity weakness or paralysis to stand and walk overground using a reciprocal pattern with full weight bearing using a walker, crutches, or cane. Sensors in the device trigger a step once the patient shifts weight in the appropriate manner. Motors in the hip and knee joints power the movement in place of decreased leg function. During the Gaining Ground program, therapists use the exoskeletal devices in two ways. The robotic exoskeleton allows those with motor complete spinal cord injuries the opportunity to be upright and reap the benefits of dynamic weight bearing. These include maintenance of bone mass, improved balance and trunk activation, improved sleep, mental outlook, mood and motivation, improved bowel and bladder function with decreased incidence of UTIs, decreased pain, decreased incidence of pressure ulcers, reduction in fat mass, and increase in lean body mass.

These devices can also be used to retrain weight shifting and gait patterns of clients with incomplete spinal cord injuries, and post stroke or traumatic brain injury. As a client relearns the appropriate gait pattern, the amount of assistance provided by the motors is adjusted at each leg and each joint individually to challenge the client. Improved gait parameters and gait speed have been seen following gait retraining using exoskeletal devices with individuals who have incomplete paralysis.

Functional Electrical Stimulation

Functional electrical stimulation (FES) is used in various forms during the Gaining Ground program. Some clients are set up on the FES cycle or FES seated elliptical. Electrodes are placed on up to 12 muscles of the upper extremity, core, or lower extremities. The therapist can customize the stimulation settings to evoke the desired muscle contraction for each muscle group. The motor of the cycle provides the support necessary to complete the cycling motion in conjunction with the stimulation-producing muscle contractions for either upper extremity or lower extremity cycling.

Many patients with neurological injuries experience decreased mobility and physiological function. This more sedentary lifestyle caused by immobility contributes to secondary health complications and the chance of re-hospitalization. The benefits of the FES systems extend beyond reducing muscle atrophy and improving motor function. Studies have shown a positive therapeutic benefit affecting many health conditions including pneumonia, hypertension, heart disease, spasticity, bone density, pressure wounds, urinary tract infections, sepsis, diabetes, weight gain, depression, and quality of life.6

The task-specific integrated functional electrical stimulation systems are utilized by therapists in the Gaining Ground program to work on coordinated, dynamic movement patterns and functional skills with up to 12 channels of stimulation. Each activity has the correct sequenced stimulation pattern to perform the prescribed activity. Common programs worked on during the Gaining Ground program include seated postural correction, bridging, sit to stands, standing, and UE movement patterns. One client with a diagnosis of C4 AIS B tetraplegia demonstrated improved self-feeding and the ability to access the controls on his power wheelchair joystick versus switch options after using the forward reach and grasp program for two consecutive rounds of Gaining Ground.

A robotic exoskeleton was used to help retrain Nicole’s weight shifting and gait patterns during Gaining Ground therapy sessions.

Case Study

Nicole suffered a T2 AIS B injury on August 18, 2018, after an auto accident. In addition to several broken vertebrae, she also suffered six broken ribs, a collapsed lung, and lacerations to her head, face, and hands. Doctors performed two surgeries on her spine, and she underwent intense respiratory therapy. Nicole attended Gaining Ground about 7 months after her injury. She “loved how it pushed [her] out of her comfort zone.” Nicole recognized the individualized nature of the program and how it could be customized to fit her goals. Nicole’s program incorporated use of the exoskeleton or the task-specific integrated FES system for postural retraining and standing during her therapy hours and the robotic over-treadmill dynamic body weight support system three times a week. The training sessions with the activity-based therapy specialist demonstrated what she could achieve independently to continue to challenge herself after the program. As a personal trainer prior to injury, Nicole found this especially valuable. Nicole demonstrated significant progress in her ability to get up and down off the floor each week and realized how important a skill this is.

Magee’s Gaining Ground Program offers clients the opportunity to improve their functional independence and emotional well-being, while setting goals for future wellness initiatives. The small group setting has proven beneficial in helping individuals achieve these goals and make new friends in the process. RM

Elizabeth Watson, PT, DPT, NCS, is clinical supervisor of the Locomotor Training Clinic at Magee Rehabilitation in Philadelphia. She also serves as adjunct professor for area physical therapy programs. In 2018, Dr Watson received the SCI Spinal Interest Group Award for Excellence. Watson earned her DPT from Temple University and is ABPTS certified in Neurologic Physical Therapy. She has presented nationally and published case studies on locomotor training. For more information, contact RehabEditor@medqor.com.

References

  1. Crane DA, Hoffman JM, Reyes MR. Benefits of an exercise wellness program after spinal cord injury. J Spinal Cord Med. 2017;40(2):154-158.
  2. Martin Ginis KA, van der Scheer JW, Latimer-Cheung AE, et al. Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Spinal Cord. 2018;45:308-321.
  3. Gordon NF, Gulanick M, Costa F, et al. Physical activity and exercise recommendations for stroke survivors: an American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Stroke. 2004;35(5):1230-1240.
  4. Saunders DH, Greig CA, Mead GE. Physical activity and exercise after stroke, review of multiple meaningful benefits. Stroke. 2014;45: 3742–3747.
  5. Zimmerli L, Jacky M, LÜnenburger L, Reiner R, Bolliger M. Increasing patient engagement during virtual reality-based motor rehabilitation. Arch Phys Med Rehabil. 2013;94(9):1737-1746.
  6. Dolbow DR, Gorgey AS, Ketchum JM, Gater DR. Home-based functional electrical stimulation cycling enhances quality of life in individuals with spinal cord injury. Top Spinal Cord Inj Rehabil. 2013 Fall;19(4):324-329.

via Gaining Ground Against Neurological Injury – Rehab Managment

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[ARTICLE] The exoskeleton expansion: improving walking and running economy – Full Text

Abstract

Since the early 2000s, researchers have been trying to develop lower-limb exoskeletons that augment human mobility by reducing the metabolic cost of walking and running versus without a device. In 2013, researchers finally broke this ‘metabolic cost barrier’. We analyzed the literature through December 2019, and identified 23 studies that demonstrate exoskeleton designs that improved human walking and running economy beyond capable without a device. Here, we reviewed these studies and highlighted key innovations and techniques that enabled these devices to surpass the metabolic cost barrier and steadily improve user walking and running economy from 2013 to nearly 2020. These studies include, physiologically-informed targeting of lower-limb joints; use of off-board actuators to rapidly prototype exoskeleton controllers; mechatronic designs of both active and passive systems; and a renewed focus on human-exoskeleton interface design. Lastly, we highlight emerging trends that we anticipate will further augment wearable-device performance and pose the next grand challenges facing exoskeleton technology for augmenting human mobility.

Background

Exoskeletons to augment human walking and running economy: previous predictions and recent milestones

The day that people move about their communities with the assistance of wearable exoskeletons is fast approaching. A decade ago, Ferris predicted that this day would happen by 2024 [1] and Herr foresaw a future where people using exoskeletons to move on natural terrain would be more common than them driving automobiles on concrete roads [2]. Impressively, Ferris and Herr put forth these visions prior to the field achieving the sought-after goal of developing an exoskeleton that breaks the ‘metabolic cost barrier’. That is, a wearable assistive device that alters user limb-joint dynamics, often with the intention of reducing user metabolic cost during natural level-ground walking and running compared to not using a device. When the goal is to reduce effort, metabolic cost is the gold-standard for assessing lower-limb exoskeleton performance since it is an easily attainable, objective measure of effort, and relates closely to overall performance within a given gait mode [34]. For example, reducing ‘exoskeleton’ mass improves user running economy, and in turn running performance [4]. Further, enhanced walking performance is often related to improved walking economy [3] and quality of life [56]. To augment human walking and running performance, researchers seriously began attempting to break the metabolic cost barrier using exoskeletons in the first decade of this century, shortly after the launch of DARPA’s Exoskeletons for Human Performance Augmentation program [7,8,9,10].

It was not until 2013 that an exoskeleton broke the metabolic cost barrier [11]. In that year, Malcolm and colleagues [11] were the first to break the barrier when they developed a tethered active ankle exoskeleton that reduced their participants’ metabolic cost during walking (improved walking economy) by 6% (Fig. 1). In the following 2 years, both autonomous active [12] and passive [13] ankle exoskeletons emerged that also improved human walking economy (Fig. 1). Shortly after those milestones, Lee and colleagues [14] broke running’s metabolic cost barrier using a tethered active hip exoskeleton that improved participants’ running economy by 5% (Fig. 1). Since then, researchers have also developed autonomous active [1516] and passive [1718] exoskeletons that improve human running economy (Fig. 1).

figure1

Fig, 1 Milestones illustrating the advancement of exoskeleton technology. Tethered (blue) and autonomous (red) exoskeletons assisting at the ankle (circle), knee (triangle), and hip (square) joint to improve healthy, natural walking (left) and running (right) economy versus using no device are shown

[…]

 

Continue —->  The exoskeleton expansion: improving walking and running economy | Journal of NeuroEngineering and Rehabilitation | Full Text

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[ARTICLE] Perspectives on the prospective development of stroke-specific lower extremity wearable monitoring technology: a qualitative focus group study with physical therapists and individuals with stroke – Full Text

Abstract

Background

Wearable activity monitors that track step count can increase the wearer’s physical activity and motivation but are infrequently designed for the slower gait speed and compensatory patterns after stroke. New and available technology may allow for the design of stroke-specific wearable monitoring devices, capable of detecting more than just step counts, which may enhance how rehabilitation is delivered. The objective of this study was to identify important considerations in the development of stroke-specific lower extremity wearable monitoring technology for rehabilitation, from the perspective of physical therapists and individuals with stroke.

Methods

A qualitative research design with focus groups was used to collect data. Five focus groups were conducted, audio recorded, and transcribed verbatim. Data were analyzed using content analysis to generate overarching categories representing the stakeholder considerations for the development of stroke-specific wearable monitor technology for the lower extremity.

Results

A total of 17 physical therapists took part in four focus group discussions and three individuals with stroke participated in the fifth focus group. Our analysis identified four main categories for consideration: 1) ‘Variability’ described the heterogeneity of patient presentation, therapy approaches, and therapeutic goals that are taken into account for stroke rehabilitation; 2) ‘Context of use’ described the different settings and purposes for which stakeholders could foresee employing stroke-specific wearable technology; 3) ‘Crucial design features’ identified the measures, functions, and device characteristics that should be considered for incorporation into prospective technology to enhance uptake; and 4) ‘Barriers to adopting technology’ highlighted challenges, including personal attitudes and design flaws, that may limit the integration of current and future wearable monitoring technology into clinical practice.

Conclusions

The findings from this qualitative study suggest that the development of stroke-specific lower extremity wearable monitoring technology is viewed positively by physical therapists and individuals with stroke. While a single, specific device or function may not accommodate all the variable needs of therapists and their clients, it was agreed that wearable monitoring technology could enhance how physical therapists assess and treat their clients. Future wearable devices should be developed in consideration of the highlighted design features and potential barriers for uptake.

Background

Individuals with stroke commonly face mobility limitations, beginning at stroke onset [1] and continuing past discharge into the community [2], and demonstrate a range of gait deviations due to altered motor control and resulting compensatory movement patterns [3]. Improving walking quality and quantity is a major focus of therapy [4], as doing so can improve mobility, fitness, quality of life, and prevent secondary complications [56]. One avenue to target walking for individuals with stroke may be to utilize wearable monitoring technology, as previous research has shown that application of an activity monitor can improve user self-efficacy and physical activity levels in various patient populations including older adults, breast cancer survivors, and those with chronic obstructive pulmonary disease [7,8,9,10,11]. Additionally, wearable monitors have been increasingly utilized by therapists and researchers to assess various outcomes relating to exercise and physical activity, [1213] within therapy and between visits, to ensure exercise targets are met [14].

The majority of currently available wearable monitoring technology has not been developed specifically for stroke-related impairments and movement patterns. For example, consumer activity monitors are often limited by a minimum walking speed or movement amplitude in order to provide accurate and reliable feedback [1516]. Research efforts have attempted to adapt available wearable monitoring technology to meet the needs of individuals with stroke with increasing accuracy, from simple solutions such as wearing hip-situated fitness trackers at the ankle [1718], to developing software algorithms to analyze captured data to recognize movements patterns specific to stroke [19,20,21]. The advances in wearable monitoring have reached a point at which designing stroke-specific wearable monitoring technology is a realistic priority to assess outcome and enhance rehabilitation interventions [22].

Much of the efforts to design stroke-specific wearable monitoring technology has so far focused on the hemiparetic upper limb [23,24,25,26]. This is unsurprising, as many individuals with stroke report long-term upper limb deficits or disability [27], and upper limb recovery has been identified as a top research priority from the perspective of individuals with stroke and their health professionals [28]. Conversely, limited efforts have been made in applying sensing technology to design stroke-specific wearable monitors for the hemiparetic lower limb. Research has shown that accelerometry can be reliable and valid in measuring physical activity after stroke [29], and new technologies to quantify foot pressure, leg motion, and muscle activity are being shown to be applicable to stroke [3031]. Thus, there is a gap in wearable monitoring technology for individuals with stroke, between what can be designed to improve rehabilitation of the lower extremity and what is currently available.

In order to develop devices that fill this niche, it is important to involve end-users in the development process from the onset to ensure initial efforts are relevant to the individuals who will ultimately use them, [3233] which inevitably are individuals with stroke and their physical therapists. This user-centered design approach is optimal for identifying relevant factors and technical aspects that should inform design choices [3233]. Thus, the objective of the current study was to identify important considerations in the future development of stroke-specific lower extremity wearable monitoring technology for rehabilitation, from the perspective of physical therapists and individuals with stroke.[…]

 

Continue —->  Perspectives on the prospective development of stroke-specific lower extremity wearable monitoring technology: a qualitative focus group study with physical therapists and individuals with stroke | Journal of NeuroEngineering and Rehabilitation | Full Text

 

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[WEB PAGE] Go Digital To Aid Standing and Walking in Rehab. Here’s How – Rehab Managment

Go Digital To Aid Standing and Walking in Rehab. Here’s How

 

Virtual reality video games, activity monitors, and handheld computer devices can help people stand as well as walk, according to an Australia-based study published in PLoS Medicine looking at the effects of digital devices in rehabilitation.

The trial took place in Sydney’s Liverpool Hospital, Bankstown-Lidcombe Hospital, and Adelaide’s Repatriation General Hospital, and included 300 participants ranging in age from 18 to 101 years old who were recovering from strokes, brain injuries, falls, and fractures.

Participants used on average four different devices while in hospital and two different devices when at home. Fitbits were the most commonly used digital device, but also tested on people in hospital and at home were a suite of devices like Xbox, Wii and iPads, making the exercises more interactive and enabling remote connection with their physiotherapist.

The digital devices included virtual reality video games, activity monitors, and handheld computer devices aimed at enabling a higher dose of therapy.

Those who exercised using digital devices in addition to their usual rehabilitation were found to have better mobility (walking, standing up and balance) after 3 weeks and 6 months, according to a media release from University of Sydney.

Patients using the digital devices in rehabilitation reported benefits including variety, fun, feedback about performance, cognitive challenge, enabled additional exercise, and potential to use the devices with others (eg, family, therapists, and other patients), the study’s lead author, Dr Leanne Hassett from the University of Sydney, notes in the release.

“These benefits meant patients were more likely to continue their therapy when and where it suited them, with the assistance of digital health care,” says Hassett, from the university’s Faculty of Medicine and Health.

People were young at heart when it came to devices, she adds.

“Participants loved Fitbits; one woman would demand to put it on in the middle of the night before she went to the toilet, to make sure all her steps were counted,” shares Hassett, who is a Senior Research Fellow in the Institute for Musculoskeletal Health and Senior Lecturer in the Discipline of Physiotherapy.

“This model of rehabilitation therapy proved to be feasible and enjoyable, and demonstrated that it could be used across different care settings, such as post-hospital rehabilitation, with mostly remote support by the physiotherapist.

“The study shows that future physical rehabilitation models should look at including digital devices to improve both inpatient and post-hospital rehabilitation,” she suggests.

The next step will be to trial the approach into clinical practice by incorporating it into the work of physiotherapists; recruitment for this is likely in 12 to 18 months, the release concludes.

[Source(s): University of Sydney, MedicalXPress]

 

via Go Digital To Aid Standing and Walking in Rehab. Here’s How – Rehab Managment

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[Abstract] An investigation into the validity and reliability of mHealth devices for counting steps in chronic stroke survivors

To investigate the validity and test–retest reliability of mHealth devices (Google Fit, Health, STEPZ, Pacer, and Fitbit Ultra) to estimate the number of steps in individuals after chronic stroke and to compare whether the measurement of the number of steps is affected by their location on the body (paretic and non-paretic side).

Observational study with repeated measures.

Fifty-five community-dwelling individuals with chronic stroke.

The number of steps was measured using mHealth devices (Google Fit, Health, STEPZ, Pacer, and Fitbit Ultra), and compared against criterion-standard measure during the Two-Minute Walk Test using habitual speed.

Our sample was 54.5% men, mean age of 62.5 years (SD 14.9) with a chronicity after stroke of 66.8 months (SD 55.9). There was a statistically significant association between the actual number of steps and those estimated by the Google Fit, STEPZ Iphone and Android applications, Pacer iphone and Android, and Fitbit Ultra (0.30 ⩽ r ⩾ 0.80). The Pacer iphone application demonstrated the highest reliability coefficient (ICC(2,1) = 0.80; P < 0.001). There were no statistically significant differences in device measurements that depended on body location.

mHealth devices (Pacer–iphone, Fitbit Ultra, Google Fit, and Pacer–Android) are valid and reliable for step counting in chronic stroke survivors. Body location (paretic or non-paretic side) does not affect validity or reliability of the step count metric.

 

via An investigation into the validity and reliability of mHealth devices for counting steps in chronic stroke survivors – Pollyana Helena Vieira Costa, Thainá Paula Dias de Jesus, Carolee Winstein, Camila Torriani-Pasin, Janaine Cunha Polese, 2020

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[WEB PAGE] Post Acute Medical Expands Exoskeleton Rehab with New EksoNR Devices

Post Acute Medical Expands Exoskeleton Rehab with New EksoNR Devices

 

Post Acute Medical LLC, a system of inpatient rehabilitation hospitals, has acquired three additional EksoNR devices from Ekso Bionics to expand the availability of exoskeleton-assisted rehabilitation to seven of its facilities.

The new EksoNR devices will be placed in Kyle and Clear Lake, Texas and Tulsa, Oklahoma. Exoskeleton-assisted rehabilitation is now available at five PAM locations in Texas. The device is designed to help patients stand and walk during rehabilitation after a stroke or spinal cord injury.

“Using EksoNR exoskeletons to help our stroke and spinal cord injury patients learn to walk again has been transformative,” says Anthony Misitano, PAM’s President and Chief Executive Officer, in a media release.

“The technology has been an integral part of our patients’ recovery and our physical therapists are eager to integrate it into their care of more patients. We are pleased to respond to the needs of our patients and providers with three additional EksoNR devices.”

PAM provides inpatient rehabilitation services in 12 states through 41 inpatient rehabilitation hospitals and long-term acute care hospitals, as well as more than 32 outpatient physical therapy locations, per the release.

“We are excited to see the growth of exoskeleton-assisted rehabilitation in systems like PAM,” Jack Peurach, Chief Executive Officer and President of Ekso Bionics, comments in the release.

“Using our exoskeleton devices in rehabilitation can provide better patient outcomes by helping patients walk farther and faster, and have better balance outside of the device. We are thrilled that PAM is embracing our technology and making it available to more of their patients.”

Developed for neurorehabilitation, EksoNR is an intuitive exoskeleton device that empowers patients recovering from stroke or spinal cord injury to learn to walk again with a more natural gait.

[Source(s): Ekso Bionics Holdings Inc, Globe Newswire]

 

via Post Acute Medical Expands Exoskeleton Rehab with New EksoNR Devices – Rehab Managment

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