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Mark Hirsch -> Re: Treatment ideas for adult ataxia (December 12, 2001 11:03:00 PM)
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Hi Drew and Diane, good discussion going on. I hope the following post can spark some good discussion on the use of the treadmill with PBWS, associated reactions and mass synnergies, NDT-Bobath.
Drew, I havent read the article and I'm not knowledgeable about Hippotherapy so I can't comment on its efficacy. This was a case study with two subjects right? Have there been studies with more N? My fax in Germany is: 49-211-8116281....please make it out to Prof. Dr. Mark A. Hirsch, Ganglabor, Department of Orthopedics, University of Düsseldorf. Thanks
"Seems logical to me that we would want to replicate natural development of "normal" motor control by helping a patient control trunk balance/coordination first, then get them working up on their pins after"
Diane you said something about the beauty and logic of the hierarchical proximal to distal development and how that relates to physiotherapy practice. What would you do with a , say, 7 year old spastic diplegic CP child who is not ambulatory, has poor trunk control (can crawl and sit, not walk, cannot ambulate with walker), and good head, arm, hand control?
In my opinion our goal in PT should not be to "normalise" movement. Diane, I'm glad you put normal in "". It's a subtle point but I picked up on it. To me normalization is not whats so important. Important is that the patient, in the case of ambulation, can move from point A to point B, as quickly (or slowly, if they want) as possible, without long and short term injury to self or others. Many therapists, especially NDT and Bobath trained therapists, but also therapists without Babath training, will say that patients should not be allowed to practice repetitive stepping or grasping movements if they display associated reactions, mass synnergies or increased tone, spasticity during the practice of the task, at least that has been my experience talking with roughly 100 Bobath therapist -- so I know its just my opinion and I'm sure there are plenty of progressive NDT-Bobath trained therapists among our Rehabedge readers. I would love to see a topic started on "why we need to worry about associated movements in neurological rehabilitation"? To my knowledge no study has looked at if associated movements interfere with motor learning or if they are correlated with long term injury etc. Might associated movements actually HELP motor learning? I don't know. Havent thought long enough about it if pathological movement patterns can be used to teach the CNS system something usefull or how to design a study to test this hypothesis. Do patients who display associated movements during therapy, learn faster or slower -- do they learn more or less, is their quality of movement at the end of therapy different if we allow Associated movements during therapy sessions than if we try to inhibit them when they occur?
I'd also like to know if there is any scientific evidence showing that pathological gait patterns are a long term risk factor for joint pathology or other disease processes. I overhear the argument therapists and physicians(!) make towqard patients: "it's bad for you to walk that way" all the time. I know its not "pretty" to walk with associated reactions and it certainly isn't "normal" to walk with spasticity. If spasticity intereferes with my rehabilitative goal then I need to address the spasticity or the goal or both. Normal is not the only desirable endpoint, in my opinion, although normal or "physiological" gait might be less energy cost efficient to the patient and that would be an important point to consider. But efficiency of movement isn't the only important factor to consider. Maybe it's normal to strive for normality, from the perspective of the therapist. I'd be interested to hear from other therapist how important realization of "normality" is to them.
Now, I allow patients to practice walking on the treadmill even if the movement pattern is a-physiological or they display mass synergies or associated movements (as many of my stroke patients will do initially during the first training sessions).
Anyway, getting back to gaittraining in CP, I put these children on the treadmill with partial body weight support and don't wait for self-initiated standing trunk control prior to gait training. We have custom harnesses which are made for extremely small patients (very expensive but its crucial that harness fits snugly and does not chaff skin or irritate pressure sores). We have a ramp leading up to the actual treadmill (Woodway, by the way), and a special handlebar for children. Very little is done in the way of facilitating movement while the child walks on the treadmill. There are different techniques which can be used, ranging from placing the foot very carefully and ensuring heel to toe movement during stance, facilitating the hip, quads etc, to just pushing the heel forward in swing phase and not worrying so much about "physiological" gait movement patterns...but there are no standardized protocols on what works better and what works less in terms of patient handling while on the treadmill. Perhaps its important that in stance, the patients foot contacts the ground and the patient puts weight on the foot. Of course these children still receive the standard training, where we concentrate more on quality of movement but thats secondary on the treadmill where quality is also considered on a patient to patient basis but repetition and intensity of therapy are more important...patients practice roughly 1000 steps in 30 minutes of treadmill training and roughly 50-100 steps during level-ground therapy.
To those who say that walking on a treadmill is not physiologically equivalent to walking on the level ground, I say that several studies have confirmed that EMG traces taken during level walking and during treadmill walking are virtually identical. Another point of contention is spasticity. Will it increase as a result of training? Several studies have shown, using EMG, that the amplitude of the EMG signal decreases during training and this is meant to infer less pathological tone during gait training on the treadmill...but it has not conclusively been shown if spasticity is reduced following treadmill training. I think it is, but I can't explain how this would occur just yet. My hunch is that initially the tone will increase (cautious PT's might stop therapy at this point thinking -- oh my gosh this therapy is increasing the tone and spasticity!). After 2-6 weeks of training tone will "normalize". At least this is what appears to be happening in studies with patients after stroke who are given treadmill training with PBWS. It is also possible to combine treadmill training with EMG stimulation (Hesse does this in Berlin). There are also treadmills on the market with "smart" motors. One developed in Zürich by Dietz group (called the Locomat) features braces attached to a frame which provides support for the hips during walking. The brace is worn on each leg and features smart motors at the joints (knee, ankle, hip) so that when a patient initiates movement at that joint, the motor at that joint produces less torque for that particular step. So far there have been a few case reports documenting its efficacy but nothing serious yet in terms of hard science. There are other gait machines as well, for example the gait-trainer by Hesses group in Berlin. I think its an excellent gait-training tool and it now has a foot adaption for use with children. Studies using the gait trainer have also shown very impressive improvements in Functional Ambulation Category (FAC) scores when compared to a Bobath approach to gait training....very intriguing work.
Another point is that we use 1-3 "therapists" with the treadmill. With some of my TBI patients you need 1 therapist per leg-foot and its hard work (but worth it)taking just 5-6 steps. But without a treadmill the patient would be have to be mobilized exclusively in bed because working on gait on a level surface with these patients is next-to-impossible. With the Hesse gait-trainer only one therapist is needed because here we have a smart motor which assists leg movement, harness and a gadget to help patients with poor trunk control maintain trunk control during gait training. Works well with TBI patients, but I prefer the treadmill because there is more the patient has to do to self-initiate movement. Some critics say, treadmills will make PT's obsolete. Not so! I put the term in "" because a therapist does not necessarily have to be a PT during treadmill training but, like I said, we could have 2 PT's work the treadmill 8 hours a day if we could afford it. Actually we almost have that right now. Some times, patients are so functional they can train on their own. Liability is a problem in Germany. But compared to the USA this is heaven here. Yes, we worry about patient safety but we are not paranoid about it and people are not a sue-happy here as they are in the States.
We also have a lift-system under the Woodway treadmill which makes it more comfortable for therapists to work with patients. The whole thing weighs roughly 1000 kg. Being 5-6 feet off the ground is not threatening for patients. This has never been a problem.
Right, Drew, I agree with you that children are EXTREMELY motivated to walk on the treadmill. I have one patient ( a little boy with cs) who wakes up every morning and the first thing he says when he sees me is "when can I go on the treadmill today?". Perhaps motivation (an optimal level of CNS arousal) is the key to motor learning and that is why the treadmill "works" so well with children.
There are numerous studies using this approach to neurological rehabilitation and most of them come from CP, stroke and SCI populations. I would be happy to post them here if anyone is interested. I wonder if, someday, in the case of children with CP, this appraoch will be seen as superior to the approach of "facilitating" movement patterns and focusing on hierarchy.
Diane:
are you suggesting that before we work on gait in children with developmental disabilities, we should be working on head and trunk control? i.e. follow a developmental sequence of crawl, sit, stand walk (I may have left out a few). In other words, is it ok, in your opinion, to skip stand -- and go directly from sit to walk in therapy of CP children?
Following a set hierarchical structure sounds like a very NDT-Bobath oriented approach to neurological rehabilitation. Not sure if the hierarchical model is still state-of-the-art thinking about how the CNS is organized and how it learns from experience through neurological rehabilitation.
Sorry to be so long winded. I hope my post generates discussion. Mark Hirsch
[This message has been edited by Mark Hirsch (edited December 13, 2001).]
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