Gait Training

An observational report of intensive robotic and manual gait training in sub-acute stroke

Date: 2012; 9: 13.

Authors: Lucas Conesa, Ursula Costa, Eva Morales, Dyland J Edwards, Mar Cortes, Daniel Leon, Montserrat Bernabeu, & Josep Medina

Publication: Neuroengineering Rehabil.

PubMed ID: 22329866

Abstract

Background

The use of automated electromechanical devices for gait training in neurological patients is increasing, yet the functional outcomes of well-defined training programs using these devices and the characteristics of patients that would most benefit are seldom reported in the literature. In an observational study of functional outcomes, we aimed to provide a benchmark for expected change in gait function in early stroke patients, from an intensive inpatient rehabilitation program including both robotic and manual gait training.

Methods

We followed 103 sub-acute stroke patients who met the clinical inclusion criteria for Body Weight Supported Robotic Gait Training (BWSRGT). Patients completed an intensive 8-week gait-training program comprising robotic gait training (weeks 0-4) followed by manual gait training (weeks 4-8). A change in clinical function was determined by the following assessments taken at 0, 4 and 8 weeks (baseline, mid-point and end-point respectively): Functional Ambulatory Categories (FAC), 10 m Walking Test (10 MWT), and Tinetti Gait and Balance Scales.

Results

Over half of the patients made a clinically meaningful improvement on the Tinetti Gait Scale (> 3 points) and Tinetti Balance Scale (> 5 points), while over 80% of the patients increased at least 1 point on the FAC scale (0-5) and improved walking speed by more than 0.2 m/s. Patients responded positively in gait function regardless of variables gender, age, aetiology (hemorrhagic/ischemic), and affected hemisphere. The most robust and significant change was observed for patients in the FAC categories two and three. The therapy was well tolerated and no patients withdrew for factors related to the type or intensity of training.

Conclusions

Eight-weeks of intensive rehabilitation including robotic and manual gait training was well tolerated by early stroke patients, and was associated with significant gains in function. Patients with mid-level gait dysfunction showed the most robust improvement following robotic training.

Repetitive locomotor training and physiotherapy improve walking and basic activities of daily living after stroke: a single-blind, randomized multicenter trial

Date: 2007 Jan;21(1):17-27.

Authors: Pohi M, Werner C, Holzgraefe M, Kroczeck G, Mehrholz J, Wingendorf I, Hoolig G, & Koch R, Hesse S.

Publication: Clin Rehabil.

PubMed ID: 17213237

Abstract

OBJECTIVE

To evaluate the effect of repetitive locomotor training on an electromechanical gait trainer plus physiotherapy in subacute stroke patients.

DESIGN

Randomized controlled trial.

SETTING

Four German neurological rehabilitation centres.

SUBJECTS

One hundred and fifty-five non-ambulatory patients (first-time stroke <60 days).

INTERVENTION

Group A received 20 min locomotor training and 25 min physiotherapy; group B had 45 min physiotherapy every week day for four weeks.

MAIN OUTCOME MEASURES

Primary variables were gait ability (Functional Ambulation Category, 0-5) and the Barthel Index (0-100), blindly assessed at study onset, end, and six months later for follow-up. Responders to the therapy had to become ambulatory (Functional Ambulation Category 4 or 5) or reach a Barthel Index of > or = 75. Secondary variables were walking velocity, endurance, mobility and leg power.

RESULTS

The intention-to-treat analysis revealed that significantly greater number of patients in group A could walk independently: 41 of 77 versus 17 of 78 in group B (P B < 0.0001) at treatment end. Also, significantly more group A patients had reached a Barthel Index > or = 75: 44 of 77 versus 21 of 78 (P B < 0.0001). At six-month follow-up, the superior gait ability in group A persisted (54 of 77 versus 28 of 78, P B < 0.0001), while the Barthel Index responder rate did not differ. For all secondary variables, group A patients had improved significantly more (P B < 0.0001) during the treatment period, but not during follow-up.

CONCLUSIONS

Intensive locomotor training plus physiotherapy resulted in a significantly better gait ability and daily living competence in subacute stroke patients compared with physiotherapy alone.

Training to achieve over ground walking after spinal cord injury: A review of who, what, when, and how

Date: 2012 Sep; 35(5):293-304.

Authors: Jaynie F. Yang & Kristen E. Musselman

Publication: Spinal Cord Med.

PubMed ID: 23031166

Abstract

Objectives

(1) To provide clinicians with the best evidence for effective retraining of walking after spinal cord injury (SCI) to achieve over ground walking. (2) To identify gaps in our knowledge to guide future research.

Methods

Articles that addressed the retraining of walking in adults with SCI and reported outcome measures of over ground walking ability were identified through a non-systematic search of the PubMed, Scopus, and CINAHL databases. No restriction was applied to the method of training. Selected articles were appraised using the Physiotherapy Evidence Database scale. Information was synthesized to answer who best responds to what type of treatment, how that treatment should be delivered, and at what stage after injury.

Results

Individuals with motor incomplete SCI (American Spinal Injury Association (ASIA) Impairment scale (AIS) C and D) are most likely to regain walking over ground. The effective methods of training all involved a substantial component of walking in the training, and if assistance was provided, partial assistance was more effective than total assistance. Walking training resulted in a change in over ground walking speed of 0.06–0.77 m/s, and 6 minute walk distance of 24–357 m. The effective training schedules ranged from 10 to 130 sessions, with a density of sessions ranging from 2 per week to 5 per week. Earlier training led to superior results both in the subacute (<6 months) and chronic phases (>6 months) after injury, but even individuals with chronic injuries of long duration can improve.

Conclusions

Frequent, early treatment for individuals with motor incomplete SCI using walking as the active ingredient whether on the treadmill or over ground, generally leads to improved walking over ground. Much work remains for the future, including better quantification of treatment intensity, better outcome measures to quantify a broader range of walking skills, and better ways to retrain individuals with more severe lesions (AIS A and B).