resident lecture 2012 locomotion threapy
TRANSCRIPT
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Locomotion therapy
: evidence & important
considerations Parit Wongphaet,M.D.
29 May 2008
lo·co·mo·tion n.
1. The act of moving from place to
place.
2. The ability to move from place
to place. [Latin loc , from a place,
ablative of locus, place +
motion.]
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Overview
• Historical development
• Neurophysiology of walking
• Essential considerations
• Evidence : what works?
• Practical parts
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Historical development
• Rossignol 1980’s
– Spinal cat ambulation training
• Barbeau 1987
– Partial Body Weight Support (PBWS) System developed
• Wernig 1992
– PBWSTT case series (Chronic SCI)
• Hesse 1994
– first case series : chronic non ambulating hemiplegia
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Robotic Gait Trainer
• Hesse 1999
– “GT1” gait trainer machine invented
• Colombo 2000
– “Lokomat” machine invented
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Gait Trainer
GT1
End
Effector
Control
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The facts
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The facts
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“The Spinal Cat”
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Spinal cord can “learn”
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De-training effect
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De-training effect
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De-training effect
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De-training effect
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De-training effect
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De-training effect
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De-training effect
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Mike “the headless chicken”
Fruitia,
Colorado
USA
1940’s
Lived for
4.5 years
AFTER
“Losing his head”
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EMG of Spinal Man
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EMG of Spinal Man
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EMG of Spinal Man
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EMG of Spinal Man
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EMG of Spinal Man
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Non-ambulating SCI ASIA C&D
Conventional Physio
(intensive standing
& walking) PBWSTT
GT 1 Lokomat
2006 Dobkin MRCT
“similar”
Case series
Hesse 2004
Wirz 2005
“better than
No training”
PBWSTT
In good hands?
“controlled study”
Wernig 1998
“better than
No training”
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“7 of 8 chronic patients
incapable of walking overground
even with the help of 2 therapists
(our functional class 0)
learned to walk 50 to 100m or more
(5 even without help).”
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CPG Triggering
• “Rules of Spinal Locomotion” (according to
Prof. Wernig)
– Weight bearing during Stance through out
– Hip extension (full)
– Unloading at terminal stance
– As little support as possible
– (not as much as necessary!)
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Neural control of human “locomotion”
Central Pattern Generator
“CPG”
Musculo- skeletal
system
Cerebellum
Reticular Formation
(Mid-brain)
Cortical Motor Areas
Proprioceptive
motor program change Phasic activation
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Motor learning
• Sub task analysis
• Sub task training
• Complex skill training
• Transfer of skill
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What is missing?
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Walking
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Walking
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Walking
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Walking
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Walking
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Walking
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Why the difference?
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Walking
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Walking
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Determinants : pelvic rotation
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Determinants : pelvic list
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Determinants : pelvic shift
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Essential sub-task of walking
• Swing
– Foot placing
– Foot trajectory
• Stance
– Weight acceptance
– Balance
– Propulsion
– Weight shifting to opposite leg
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• How important is BWS ?
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• How important is Speed ?
– Control : PNF & Bobath
– Limited progressive : +5% per week
– Aggressive progressive : bouts of 10 secs at
“best speed”
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Essential principles
•The “extended”
Rules of Spinal
Locomotion
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Essential principles
• Spinal CPG stimulation
– Weight bearing
– Hip extension
– Unloading at terminal stance
– (BWS ?)
– Speed & Continuity
• Motor learning
– Task specific
– High repetition
• Aerobic Capacity
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Non-ambulating SCI ASIA C&D
Conventional Physio
(intensive standing
& walking) PBWSTT
GT 1 Lokomat
2006 Dobkin MRCT
“similar”
Case series
Hesse 2004
Wirz 2005
“better than
No training”
PBWSTT
In good hands?
“controlled study”
Wernig 1998
“better than
No training”
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“No significant differences
were found at 6 months
for FIM-L (n 108) or
walking speed and
distance (n 72).”
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Non-ambulating SCI ASIA C&D
Conventional Physio
(intensive standing
& walking) PBWSTT
GT 1 Lokomat
2006 Dobkin MRCT
“similar”
Case series
Hesse 2004
Wirz 2005
“better than
No training”
PBWSTT
In good hands?
Case series
Wernig 1998
“better than
No training”
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Lokomat works
in ASIA C & D patients
-
BETTER than conventional ?
BETTER than PBWSTT ?
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2 of 20 cases showed improved “functional class”
• (12-15)WISCI : 2 crutches 1 cane
• (19-20)WISCI : 1 cane no aids
• NOT NECESSARILY BETTER THAN
PBWSTT (Wernig,Hicks)
Wernig A, Nanassy A, Müller S. Maintenance of locomotor
abilities following Laufband (treadmill) therapy in para- and tetraplegic
persons: follow-up studies. Spinal Cord 1998;36:744-9
Hicks et al. Long-term body-weight supported treadmill training and
subsequent follow up in persons with chronic SCI
. Spinal Cord 2005; 43: 291–298.
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Non-ambulating SCI ASIA C&D
Conventional Physio
(intensive standing
& walking) PBWSTT
GT 1 Lokomat
2006 Dobkin MRCT
“similar”
Case series
Hesse 2004
Wirz 2005
“better than
No training”
PBWSTT
In good hands?
Case series
Wernig 1998
“better than
No training”
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Evidence : Non-Ambulating Hemiplegia
• PBWSTT
–Chronic Non-ambulatory stroke
–A-B-A study (Hesse 1995)
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Non-ambulating hemiplegic
Conventional Physio
(walk and stand
As possible) PBWSTT
GT 1
Lokomat
2003 cochrane
Meta analysis
“similar”
2007 RCT
Huseman et al
“similar”
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Subacute stroke RCT :
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“no significant difference”
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GT1 better than conventional rehab
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Non-ambulating hemiplegic
Conventional Physio
(walk and stand
As possible) PBWSTT
GT 1
Lokomat
2003 cochrane
Meta analysis
“similar”
2007 RCT
Huseman et al
“similar”
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Summary
• Non Ambulatory
• SCI class C&D
–Intensive ground
walking = PBWSTT
–Automated (robotic) is
o.k. but maybe less effective thant PBWSTT
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Summary
• Non Ambulatory
• Stroke
–Best evidence = GT1
–Lokomat not effective
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•Why ??
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Pitfalls ?? • Too high speed?
– Patient must be able to control gait adequately at the selected speed
• No focus on “learning” of the sub-skill?
– One skill at a time?
• Too much passive assistance
– stepping leg
• Triggering the spinal locomotor (CPG)?
– Hip position
– Weight shifting
• Body weight Support
– Too much
– Too little
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PBWSTT
Control
13.6
(6.57)
2.9
(3.44)
0
2
4
6
8
10
12
14
Step length
improvement
(cms)
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PBWSTT
Control
0.71
(0.33)
0.15
(0.19)
0
0.2
0.4
0.6
0.8
Speed
improvement
(Km/hr)
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Summary • PBWSTT
– is effective in
• Stroke
– Subacute and Chronic
– Especially better for more severely affected
patients
• Chronic Para/Tetraplegia
– Mechanism
• Activation of reflex stepping center
• High repetition, Task specific motor
learning
• Improved gait energy efficiency w/wo
improve in aerobic fitness
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Summary
• PBWSTT
• SCI & Hemiplegia • Is at least as good as Intensive ground amublation
training
• Can still be “better” than “Robotic” training
• If certain practice is rigorously followed
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Suggestion : The Perfect System
• GT1 machine
• PBWSTT
• Portable Gait Analysis system.
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Outcome Measurements
• Functional Ambulation Class – FAC (Hemi)
– Wernig Scale (SCI)
• Timed Walk Test – Short
– Long
• Balance
• Power?
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Inclusion criteria
• Neck & Trunk balance
– Fair with hand support
• Postural BP change
– Tolerate at least 10 mins standing
• Bone density
– Weight bearing of legs
• Footware
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exclusion criteria
• Flexion contracture of knee& hip
>20 deg
• Equino varus ankle deformity
(severe)
• Open wound at belt pressure sites
• Active painful arthritis (Les)
• Deep vein thrombosis
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Equipments
• Treadmills
• BWSS
• Harness
• Robotic systems
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Locomotor training
• Is not new
• Is the next standard
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•Thankyou !