Time and effectiveness in treating stroke patients (Full Version)

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chrisPT -> Time and effectiveness in treating stroke patients (October 6, 2000 3:38:00 AM)

These days i am treating a lot of stroke patients. Since many of them are too weak to maintain good standing dynamic or sitting balance, and i just have too many patients to deal with, so i can't actually perform manual facilitation to all of them.
But very often those frequent-used ex for stroke patients( eg gym ball, standing with arjowalker......) are not effective and efficient enough when without manual facilitation.
so, I wanna listen to you guys opinion concerning effectiveness of ex for stroke patient (esp when u need to treat like 6-10 patients within one hour!)



yankeept -> Re: Time and effectiveness in treating stroke patients (October 6, 2000 5:01:00 AM)

It's pretty difficult to treat 6-10 stroke pt's/hour & be effective. I'm treating 1-2/hour & sometimes feel there's not enough time for them.

The best thing you could do for them is try to try work on their trunk & get them to do some exercises on their own, if possible. See if they are able to roll in bed, primarily using their abdominals & not pulling with string UE and not by pushing with LE(using hip/knee extensors on strong side). Have them try to initaite "crunches" by lifting their UE towards their knees & lift up their head. Even if they can only lift up their head, they'll contract their abs a little.

Good luck.



Andrew M. Ball, MS, PT -> Re: Time and effectiveness in treating stroke patients (October 6, 2000 6:58:00 AM)

Get the Journal. Read it. There are LOTS of articles each month about using PWB-GT in patients with Stroke or SCI.

There are lots of references that I've repeated over and over again. Hesse, Visintin, Dobkins, Shindal are the prime researchers in this area. Do a MEDLINE search for more information, or check out the bibliography at the Mobiliy Research Website at:
[URL=http://www.litegait.com]www.litegait.com[/URL]

If the initial studies are replicated, than you should be able to progress any non-ambulatory patient to either ambulation with verbal cues only or independent ambulation within 6 weeks of PWB-GT therapy.

If you're not achieving this with all of your patients within 6 weeks, then you despirately need to take a look at this research. Read the Hesse 1994 and Hesse 1995 studies first, they are easier reading. Visintin is cool, but a little more technical. Once you understand the clinical science stuff, then you may want to dive into the basic science to understand why combining PWB-GT with traditional therapy is so much more effective than traditional therapy alone.



Bobcat -> Re: Time and effectiveness in treating stroke patients (October 6, 2000 8:01:00 AM)

Gait is nice, but first they have to be able to roll.



Andrew M. Ball, MS, PT -> Re: Time and effectiveness in treating stroke patients (October 6, 2000 8:38:00 AM)

Hey Bobcat, welcome back!

I'd have to respectfully disagree though. Your "they have to roll first" comment is not exactly true Cat, the Visintin studies, these two in particular (the 1994 study in particular strongly suggest that you don't need to be able to stand nor sit in order to enjoy better than tranditional PT alone ambulatory benefits from the technique. Furthermore, (and this is the most important point) using PWB-GT in patients not able to stand, yielded better sitting balance and standing balance effects than those patients who received traditional therapy SPECIFICALLY TARGETING sitting and standing balance.

Visintin M, Barbeau H. The effect of parallel bars, body weight support and speed on the modulation of the locomotor pattern of spastic paretic gait. A preliminary communication. Paraplegia 1994; 32: 540-553.

Visintin M, Barbeau H, Korner-Bitensky N, Mayo NE. A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke 1998; 29: 1122-1128.

Let me know when you've had a chance to review them, and we'll hash this out further in the journal review club okay? Besides, sure is a hell of a lot more evidence-based than the garbage your co-worker is pushing dont'cha think?



Andrew M. Ball, MS, PT -> Re: Time and effectiveness in treating stroke patients (October 6, 2000 8:05:00 PM)

Cat,

Good question. You're gonna hate this answer cause it sounds political, but I honestly wouldn't choose a over b, nor vice versa. I'd work on both, and try to do so equally.

The research I've read recently seems to suggest that one should try b over a . . . but just can't buy into that just yet. I'll wait for a few more replication studies. Good enough?

Drew



yankeept -> Re: Time and effectiveness in treating stroke patients (October 8, 2000 5:46:00 AM)

Drew,

Although the ltierature review section might be a better place for this discussion to take place, here goes..

I recently attended a PWB-lite gait course in NYC. I also have the opportunity to use this device in the clinic when I deem it appropriate. I've read a good majority of the literature out there, including Whelan,Hesse,Visintin, etc. and still had a few unanswered questions.

As I understand it in a simplistic way, the idea behind the PWB is that it taps into the central pattern generator. The cpg is some sort of mystical entity that has not yet been exactly anatomically identified, but it helps to provide automatic, rhythmic walking in cats & presumably humans.

Now relating this to the discussion that was started, what's the rationale behind using PWB to improve sitting balance for those low level patients who can't walk yet. If the PWB is trying to tap into the CPG for walking, how does it also help sitting.

I'm not saying that the PWB may not have may beneficial effects, but how does it tie into improve sitting balacne. From a sort-of NDT perspective, when a patient is in the harness, their trunk musculature is certainly not active for the most part: usually the patients are just kind of hanging there, unless you make a conscious effort to really facilitate their trunk(usually you're worried about so many other things that this is not possible).

I certainly don't believe that a patient has to be able to crawl before he/she walks, but without proper trunk control it's pretty hard for theme to sit, never mind walk. I don't have a big problem using PWB as an adjunct to some more of out "traditional" approaches, but I've got to side with Bobcat and believe that with a "low level" stroke patient, giving them the ability to roll would be more useful than placing them in the lite gait.

Just some food for thought.



Andrew M. Ball, MS, PT -> Re: Time and effectiveness in treating stroke patients (October 8, 2000 6:35:00 AM)

I'll try to answer your questions as clinically (as opposed to research/analytically) as possible if you like, but first a quick note on CPG's:

CPG's are not at all mystical, nor are they poorly anatomically defined (perhaps they are to most PT’s because most of us are not true clinical scientists). The CPG system is common fact to any cognitive neuroscientist. They are very clearly modulated by the MLR (aka. medullary locomotor region) of the brainstem - specifically in the reticular formation. This is not speculation, this is neurophysiologic fact.

Okay, let me break it down for ya'll . . .
How does the PWB-GT system improve sitting balance and trunk control better than traditional therapy alone as the Visintin study showed? Well, of that we're not sure. But in this case we have a rare case in PT . . . we have a clear outcome, but no underlying physiologic reason for the effect . . . yet.

The harness is supposed to be fastened about the pelvis, NOT the trunk, so maybe that's part of the problem in your clinic. Anyway, The following is speculation, but based on plausible theory, unlike SCS or CST:

The trunk should be free to begin to make minor adjustments for balance perturbations associated with walking (and this is the key part) while the patient feels safe about exploring fine movements at the trunk. In traditional therapy, it takes a lot for the patient to just loosen up to let some of the lower trunk muscles to do their thing. In the PWB system, the patient cannot fall, and I think that's key.

To recap:
You said, "From a sort-of NDT perspective, when a patient is in the harness, their trunk musculature is certainly not active for the most part: usually the patients are just kind of hanging there, unless you make a conscious effort to really facilitate their trunk(usually you're worried about so many other things that this is not possible)." I reply that if the harness is positioned correctly, the trunk muscles CAN be active. Also, NDT and PNF techniques should be used in combination with PWB-GT. Because the harness holds the patient in a reasonable upright position, it gives you an extra set of hands. It is therefore possible to facilitate a person when in the PWB-GT system, it just takes a little bit (okay a lot) of practice.

I'm not trying to teach walking before rolling, but treating in this manner (re-read the Visintin studies in particular) may yield more efficient results even for the rolling goal.


[This message has been edited by Andrew M. Ball, MS, PT (edited October 08, 2000).]



yankeept -> Re: Time and effectiveness in treating stroke patients (October 9, 2000 4:56:00 PM)

Drew,

I'll have to re-read the Visintin articles & get back to you. I certainly agree with the fact that when a person's fear of falling is taken away, it opens up a world of possibility. I don't have a problem with your specualtion of what may be going on, but we could then provide speculation in numerous other instances. Although much of treatment we provide for the neuro population is based on theory & speculation.

With regards to the trunk being active within the support system: Yes, I agree that the potential is there for a patient to have an active trunk. However, when we position the harness around the pelvis(as we do in our clinic), that leaves the trunk to be free. When our adult stroke patients are in the system, the trunk will usually flop a little bit to one side & be somewhat supported by the straps connecting overhead. Theoretically it would be possible to provide facilitation to the trunk, but we usually have one person advancing the hemiparetic LE and the other person stabilizing the pelvis preventing too much lateral displacement. It would probably be a bit easier with the pediatric population.

During the course, he showed some videos of the classic cat studies, with the surgically induced spinal cord injuries. These cats were able to initiate rhythmic walking on the treadmill(as discussed in the Whelan article).

My question is have you ever seen this in humans? So far I haven't seen this automatic walking in my limited experience. In my thinking(which may be totally off base), this automatic walking is what we're trying to tap into with our patients. And there will always be some degree of doubt until I see this rhythmic walking with my patients. But this will probably not stop me from using this as an adjunct treatment approach.



Andrew M. Ball, MS, PT -> Re: Time and effectiveness in treating stroke patients (October 9, 2000 5:18:00 PM)

LOL! You didn't like my answer that I didn't know why but the Visintin article was clear on the effect, and you asked for me to speculate! If you ask for me to do so, then don't turn around and attack me for doing so! That makes me laugh. Your point that it's mere specuation is VERY WELL TAKEN. At least we've demontrated an effect with a controlled clinical trail, which is more than CST or SCS has ever done . . .

Anyway, I have seen the stepping reflex in humans . . . from one of the first kids I used it on. He was a little dude with VATER association and hydrocephalus. His parents frequent the site from time to time and may shead some additional insight. The automatic stepping seems to occur more readily in the most severaly invovled of patients because they don't volitionally override the pattern.

This kid would volitionally hyperextend himself on occasion, which made things frustrating to say the least.

Your point about my kids being smaller and easier to handle is well taken too. Paul seems to do wonders with his patients, and he frequents the site too. Perhaps he'll lend more insight as to his thoughts.



chrisPT -> Re: Time and effectiveness in treating stroke patients (October 20, 2000 5:57:00 AM)

the idea of PTB- GT is nice
but to be real practical, our setting doesn't even have a single computerised treadmil in our in-patient department. What we have are 2-3 gym balls, a few bobath plinths, a few reciprocal pulleys.......u can imagine.
So, when u are in such a situation, u don't have many choices, do u ?
or if u have other fantastic ideas, do share here!



DarinPT -> Re: Time and effectiveness in treating stroke patients (October 20, 2000 8:12:00 AM)

Chris,
I do not believe your problem lies within what treatment is most effective for patients with strokes- this would be my second priority.

In my view, there is clearly one problem that you are dealing with--staffing. In the acute setting, I don't believe any therapist could be expected to provide effective treatment when dealing with 6-10 patients with stroke in an hour. I would discuss this problem with a supervisor and try to get more PTs or assistants. Productivity will go up and the patients will get the individualized treatment programs they deserve - a win-win situation.

Once the staffing issue is resolved, then I would look into other options such as PWB-GT therapy. Hope this helps.
Darin



chrisPT -> Re: Time and effectiveness in treating stroke patients (October 21, 2000 7:15:00 PM)

DarinPT
thx for ur opinion
of course this is the first priority
but u know, here in Hongkong, all the funding are reduced. The government just keeps cutting off the budget; if they see that u can still do a good job, they just keeps the low budget going.
you know, it is not uncommon in HK to treat something like 6-8 rehab neuro patients or 8-13 rehab ortho patient per hour.
what a pity.



Andrew M. Ball, MS, PT -> Re: Time and effectiveness in treating stroke patients (October 21, 2000 8:24:00 PM)

We're getting a little off topic here folks.

Chris asked a great question that no one's answered. How can he/she treat most effectively and efficiently in a world of limited resources? Chris' contraints are even more severe than in the United States. He's not given the tools, equipment, nor staffing to be optimally effective, and can't exactly demand more from the Communist government for whom he/she works.

What advice do we have?

Drew



DarinPT -> Re: Time and effectiveness in treating stroke patients (October 22, 2000 9:38:00 AM)

Sorry ChrisPT, I didn't know you were in HK.

I don't have any miracle treatments, but maybe just some helpful advice. I'm sure you are already doing this but I'll just reinforce it. If you don't have the staff for longer treatment sessions, could you provide intensive family training (for those that have supportive families or friends)? I would call in family members for training and provide them with a hand-out with ALL of the information. Not just ROM and exercises, but activities that you would be doing with the patient- bed mobility skills, transfer training, sitting/standing balance activities for trunk control, GT training, possibly facilitation/inhibition techniques described in laymans terms, etc.

Good luck.



DarinPT -> Re: Time and effectiveness in treating stroke patients (October 22, 2000 6:09:00 PM)

I am aware of the economic situation in HK and just realized that it may be difficult to personally train the patient's support group. If the caregivers have jobs, they may not be able to take the time off work for training. One consideration is to videotape treatment techniques with the patient to promote independent mobility. Maybe have a co-worker bring a video-recorder and tape the techniques for the family. Also adding information such as letting the patient do as much as possible before assisting in the activity would be helpful.

This may be too difficult but it sure would provide an excellent continuum of care, especially if this is the only therapy the patients will receive.



chrisPT -> Re: Time and effectiveness in treating stroke patients (October 24, 2000 1:51:00 AM)

thx for your reply darinPT =)
however, i can tell you the idea of videotaping , though it sounds good, is quite difficult to carry out in a busy hospital. It may be helpful if the patient is already discharged from hospital and stay home all days long with a caregiver.

you know, PT in HK nowadays are really quite in a tough situation that did u ever hear that a single PT in a OPD need to treat around 40-50 patient per day, and worse still, a PT in a medical geri ward need to treat around 40 patients perd day too, but many of them really need percussion / vibration or has comorbid state like CVA.

Anyway, now i just try to spend more times on those flaccid or worse conditioned patients and leave those better patients doing simple active control ex.

we need to fight for the resource



Hirsch -> Re: Time and effectiveness in treating stroke patients (October 24, 2000 11:21:00 PM)

Hi everyone. I am new to this BBS. I have been following the discussion on stroke rehab for a few days. I'd like to share a list of articles on stroke rehab using treadmill with harness.

Danielsson A, Sunnerhagen KS.(2000). Oxygen consumption during treadmill walking with and without body weight support in patients with hemiparesis after stroke and in healthy subjects. Arch Phys Med Rehabil. Jul;81(7):953-7.

Dingwell JB, Ulbrecht JS, Boch J, Becker MB, O'Gorman JT, Cavanagh PR. 1999). Neuropathic gait shows only trends towards increased variability of sagittal plane kinematics during treadmill locomotion. Gait Posture. Sep;10(1):21-9.

Felici F, Bernardi M, Radio A, Marchettoni P, Castellano V, Macaluso A. (1997). Rehabilitation of walking for paraplegic patients by means of a treadmill. Spinal Cord. Jun;35(6):383-5.

Flynn TW, Canavan PK, Cavanagh PR, Chiang JH. (1997). Plantar pressure reduction in an incremental weight-bearing system. Phys Ther. Apr;77(4):410-6.

Gardner MB, Holden MK, Leikauskas JM, Richard RL. (1998). Partial body weight support with treadmill locomotion to improve gait after incomplete spinal cord injury: a single-subject experimental design. Phys Ther. Apr. 78(4):361-74.

Hesse S, Luecke D, Jahnke MT, Mauritz KH. (1996). Gait function in spastic hemiparetic patients walking barefoot, with firm shoes, and with ankle-foot orthosis. Int J Rehabil Res. Jun;19(2):133-41.

Hesse S, Sarkodie-Gyan T, Uhlenbrock D. (1999). Development of an advanced mechanised gait trainer, controlling movement of the centre of mass, for restoring gait in non-ambulant subjects. Biomed Tech (Berl).Jul-Aug;44(7-8):194-201.

Hesse S, Krajnik J, Luecke D, Jahnke MT, Gregoric M, Mauritz KH. (1996). Ankle muscle activity before and after botulinum toxin therapy for lower limb extensor spasticity in chronic hemiparetic patients. Stroke. Mar;27(3):455-60.

Hesse S, Konrad M, Uhlenbrock D. (1999). Treadmill walking with partial body weight support versus floor walking in hemiparetic subjects.Arch Phys Med Rehabil. Apr;80(4):421-7.

Hesse S, Uhlenbrock D, Sarkodie-Gyan T. (1999). Gait pattern of severely disabled hemiparetic subjects on a new controlled gait trainer as compared to assisted treadmill walking with partial body weight support. Clin Rehabil. Oct;13(5):401-10.

Hesse S, Jahnke MT, Schaffrin A, Lucke D, Reiter F, Konrad M. (1998).
Immediate effects of therapeutic facilitation on the gait of hemiparetic patients as compared with walking with and without a cane. Electroencephalogr Clin Neurophysiol. Dec;109(6):515-22.

Hesse S, Bertelt C, Schaffrin A, Malezic M, Mauritz KH. (1994).Restoration of gait in nonambulatory hemiparetic patients by treadmill training with partial body-weight support. Arch Phys Med Rehabil. Oct;75(10):1087-93.

Hesse S, Bertelt C, Jahnke MT, Schaffrin A, Baake P, Malezic M, Mauritz KH. (1995). Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients.
Stroke. Jun;26(6):976-81.

Hesse S, Malezic M, Schaffrin A, Mauritz KH. (1995). Restoration of gait by combined treadmill training and multichannel electrical stimulation in non-ambulatory hemiparetic patients. Scand J Rehabil Med. Dec;27(4):199-204.

Hesse S, Bertelt C, Schaffrin A, et al. (1994). Restoration of gait in nonambulatory hemiparetic patients by treadmill training with partial bodyweight. Archives of Pysical Medicine and Rehabilitation, 75, 1083-1097.

Hesse SA, Jahnke MT, Bertelt CM, et al. (1994). Gait outcomes in ambulatory hemiparetic patients after a 4-week comprehensive rehabilitation program and prognostic factors. Stroke. Oct;25(10), 1999-2004.

Macko RF, Katzel LI, Yataco A, Tretter LD, DeSouza CA, Dengel DR, Smith GV,Silver KH. (1997). Low-velocity graded treadmill stress testing in hemiparetic stroke patients. Stroke. May;28(5):988-92.

Macko RF, DeSouza CA, Tretter LD, Silver KH, Smith GV, Anderson PA, Tomoyasu N, Gorman P, Dengel DR. (1997). Treadmill aerobic exercise training reduces the energy expenditure and cardiovascular demands of hemiparetic gait in chronic stroke patients. A preliminary report. Stroke. Feb;28(2):326-30.

Malouin F, Potvin M, Prevost J, Richards CL, Wood-Dauphinee S. (1992). Use of an intensive task-oriented gait training program in a series of patients with acute cerebrovascular accidents. Phys Ther Nov;72(11):781-9; discussion 789-93.

Norman KE, Pepin A, Ladouceur M, Barbeau H. (1995). A treadmill apparatus and harness support for evaluation and rehabilitation of gait. Arch Phys Med Rehabil. Aug;76(8):772-8.

Richards CL, Malounin F, Wood-Dauphine S, et al. (1993). Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Archives of Physical Medicine and Rehabilitation, 74, 612-620.

Suzuki K, Yamada Y, Handa T, Imada G, Iwaya T, Nakamura R. (1999). Relationship between stride length and walking rate in gait training for hemiparetic stroke patients. Am J Phys Med Rehabil. Mar-Apr;78(2):147-52.

Suzuki K, Nakamura R, Yamada Y, Handa T. (1990). Determinants of maximum walking speed in hemiparetic stroke patients. Tohoku J Exp Med. Dec;162(4):337-44.

Waagfjord J, Levangle PK, and Creto CME. (1990). Effects of treadmill training and gait in a hemiparetic patient. Physical Therapy, Sept;70(9), 549-558, discussion 558-60.

Uhlenbrock D, Sarkodie-Gyan T, Reiter F, Konrad M, Hesse S. (1997). Development of a gait trainer with regulated servo-drive for rehabilitation of locomotor disabled patients. Biomed Tech (Berl) 1997 Jul-Aug;42(7-8):196-202.

Visintin M, Barbeau H. (1989). The effects of body weight support on the locomotor pattern of spastic paretic patients. Can J Neurol Sci. Aug;16(3):315-25.

Visintin M, Barbeau H, Korner-Bitensky N, Mayo NE. (1998). A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke 1998 Jun;29(6):1122-8.

If you don't have access to a treadmill, try one of these approaches with your stroke patients:

1. Forced-Use -- upper extremity (Taub)
2. Repetitive training UE and LE(Hummelsheim)
3. Rhythmic Auditory Stimulation UE & LE (Thaut)
4. Mirror training UE & LE (Ramachandran & Altschuler).

I can provide references for these if anyoone is interested.

Mark Hirsch


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chrisPT -> Re: Time and effectiveness in treating stroke patients (October 26, 2000 8:58:00 PM)

Thx so much Mark for your sharing of articles and idea of treating stroke patients. I appreciate those effort.^_^

let me respond to your sugggestions
(1) foreced use : it can't be ordered by us physio in HK, it is the decision of MO; we can suggest, but most probabily they together with the nurse will ban, esp in a situation that 8 nurses need to take care of more than 50 patients. if u tied the patients' hands, the nurse will curse u for sure.
(2) repetitive training of UL & LL
i dont know exactly how it is performed, so can;t make comments. But just can tell you, these days the patients in my hospital are mainly flaccid with no or trace amt of control, quite hard to set up for harsh training
(3) i also don;t know too much about the third method, so can;t comment
(4) i like this method the best. using mirror to retrain Wt- shifting and symmetry.
but i must use manual technique as well. so if there are a lot of patients.. then.. it is notpossible again




[This message has been edited by chrisPT (edited October 27, 2000).]



Hirsch -> Re: Time and effectiveness in treating stroke patients (October 27, 2000 3:22:00 AM)

Hi ChrisPT,

would you like me to email you some literature on forced use, repetitive training, mirror training and rhythmic auditory training? Mark

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