Transcript Hemiplegic Gait Described

Hemiplegic Gait
Rehabilitation
OCSI Hemiplegic Gait Clinical Solution
Sport Rehabilitator Knee
With
Elite AFO Rehabilitator
John Kenney, BOCO
Hemiplegic Gait Described





Hip hike
Circumduction of the leg
Reduced hip and knee flexion
Decreased weight shift towards
affected side
Foot drop, poor dorsiflexion, toe
first or flat foot placement
Hemiplegic Gait Description






Broader base of support
Increased double stance
time
Shorter step and stride
length
Slower gait speed
Decreased walking
efficiency
Poor endurance
Hemiplegic Gait Impairments








Loss of proprioception
Quadriceps weakness
Hamstring weakness
Decreased plantarflexion activity at push off
Decreased afferent input (periphery to CNS)
Knee instability; poor balance
Decreased truck and motor control
Disrupted muscle memory firing patterns (ankle,
knee and hip; both sides)
Biomechanical Factors in
Hemiplegic Gait



Instability of the ankle and knee joint
– Muscle weakness in ankle and / or knee
Decreased neuromuscular control
– Pathological gait changes (muscle memory)
– Loss of proprioception (balance / motor control)
– Decreased afferent input (decreased ability to
re-learn)
Weakness of the ankle and knee musculature
– Achilles tendon and extensor weakness /
stiffness; quad weakness and reduced dynamic
support of the ankle and knee
Chronic Hemiplegic Gait
Pattern




Initially dispensed orthotics may hinder gait
improvements six months to 1 year out.
After discharge from post stroke rehabilitation,
many patients develop a learned compensatory gait
pattern (Hemiplegic Gait)
Many researchers suggest that the brain is not at
optimal readiness for re-learning until 6 months to
1 year post stroke (Taub, Levine and Page, etc.)
Appropriate orthotic therapy with Hemiplegic gait
rehabilitation can improve gait in many patients
who are poor ambulators.
Long Tern Rehab Therapy
Findings




59 patients who were unable to walk 3 months
after stroke were enrolled in study
Patients received therapy 3X / week for up to 2
years
79% regained capacity to walk without assistance
after therapy
Predicting the outcome of individual patients who
will benefit is difficult
* The effects of long-term rehabilitation on poststroke hemiplegic patients. Tonin, et al,
Department of Neurology, University of Padua, Italy
Neurological Overview





Disruption of descending signals
from the brain
Decreased afferent input
Loss of corticospinal influence
to the lower gamma loop
Lower gamma motor loop is
intact in most Hemiplegic
patients
Since LMN is intact, massed
practice re-learning is possible
in spite of Stroke
Benefit of Intact Gamma Motor
Loop



Re-learning can be stimulated using the intact
Gamma Motor Loop
Decreased afferent (peripheral) input can be
stimulated with sensorimotor excitation at the limb
(facilitate re-learning)
Central Program Generators (CPG’s) are in the
spinal cord; re-write muscle memory with massed
practice of improved steps over time
Corticospinal Connectivity


Clinical research on Hemiplegic
Gait suggests that the
neurophysiology of lower-limb
motor control requires
corticospinal connectivity to
improve ambulatory
performance.
Peripheral sensory information
and descending inputs from
the motor cortex are important
in shaping CPG function.
Corticospinal Connectivity


Supraspinal control is needed to provide both the
drive for locomotion as well as the coordination for
ambulation.*
Spinal cord generates human walking; cerebral
cortex makes a significant contribution to voluntary
changes in gait pattern.*
*Rehabilitation of gait after stroke: a review towards a top-down approach, Belda-Lois, et al.,
Journal of Neuroengineering and Rehabilitation, Dec. 2011.
Clinical Research Review on
Gait Neuro-rehabilitation
Perturbation Therapy


Clinical studies using balance perturbation (balance
tilt modification) demonstrates that hemiplegic
patients improve volitional muscle activation and
statistically improved balance over time.
Perturbation is believed to stimulate reflexive
corticospinal muscle firing. If timed correctly, the
perturbation training leads to improved balance in
stroke patients.
* Sensory Stimulation Promotes Normalization of Postural Control After Stroke, Magnusson,
et. al., Stroke, 1994.
Perturbation Therapy w/
Simultaneous Sensory Stimulation


Improvements in perturbation muscle re-education
training are significantly more effective when
combined with simultaneous sensory stimulation.
Sensory stimulation therapy includes electrical
stimulation, kinesiotaping, dynamic movement
Lycra compression garment therapy and various
manual therapies (PNF).
* Sensory Stimulation Promotes Normalization of Postural Control After Stroke, Magnusson,
et. al., Stroke, 1994.
Massed Practice Therapy


Massed practice locomotor training evokes
functional improvement in gait.*
Massed practice locomotion training with sensory
stimulation significantly improves outcomes
compared to massed practice alone.*

Significant sensory stimulation of the lower
extremity increases corticospinal excitation and
accelerates volitional control of the affected limb.
* Exercise-mediated locomotor recovery and lower-limb neuroplasticity after stroke, Forester,
et al., Journal of Rehabilitation Research and Development, 2008.
Functional Electrical
Stimulation w/ EMG Control




FES controlled by biological signals (EMG) results in
improvements in Hemiplegic gait, faster
rehabilitation process, and enhancement of patient
endurance.*
EMG facilitated FES reinstates appropriate
proprioceptive feedback because the feedback is
directly triggered by voluntary movement (relearning requirement).*
EMG w/ FES includes Walk Aid, Bioness 300,
Bioness H200, and NeuroMove technologies.
FES may be contraindicated if FES exaggerates
spasticity.
Ambulation is Learned



The precise sequence of muscle firing correlated to
ambulation is stored in the CPG (Central Program
Generator) in the spinal cord.
Disruption of sensory input from the cordicospinal
tract leads to abnormal compensatory muscle
memory walking patterns (Hemiplegic Gait
Pattern).
The ideal therapy for re-learning ambulation
initiates premotor cortex (PMC) and sensory motor
cortex (SMC) activation techniques.*
*Rehabilitation of gait after stroke: a review towards a top-down approach, Belda-Lois, et al.,
Journal of Neuroengineering and Rehabilitation, Dec. 2011.
Mechanical Assistance and Facilitated
Assistance Gait Therapy


Patients assessed with fNIRS (Functional Near
Infrared Spectroscopy) demonstrated premotor
cortex and sensory motor cortex activation with
mechanical assisted and physical therapist assisted
(facilitated) gait therapy with enhanced extension
swinging of the affected leg.*
“Locomotor recovery after stroke seems to be
associated with improvement of asymmetry in SMC
activation and enhanced PMC activation in the
affected limb.”*
*Rehabilitation of gait after stroke: a review towards a top-down approach, Belda-Lois, et al.,
Journal of Neuroengineering and Rehabilitation, Dec. 2011.
Knee Braces Activate Brain



“Functional Magnetic Resonance Imaging research
demonstrates the affect of lower extremity
proprioceptive stimulation on brain activity and
confirms that the effect of a knee brace is
associated with significantly higher level of brain
activity then when no device was applied.”*
Movement w/ a knee brace providing
somatosensory stimulation activates the primary
sensorimotor cortex of the brain.
The “tight” knee brace was associated with the
highest levels of brain activity.*
*Knee braces activate brain, Foster, Jordana, LER, January 2011
Leg Strengthening




A flat foot landing in Hemiplegic Gait results in
significant loss of quadriceps activation during gait.
Over time, quad strength and muscle mass is lost
due to gait alterations.
Clinical research demonstrates that by correcting
foot placement to establish more normal
biomechanics in heel to toe – mid line placement of
the ankle / foot with gait will reactivate quad firing
leading to increased quad strength and muscle
mass.*
Gait and Clinical Improvements with a Novel Knee Brace for Knee OA, Johnson, et. al.,
Knee Surgery, Dec 2012.
Muscle Learning after Stroke
Can be Recovered at Any Time



Significant clinical research on Constraint Induced
Therapy, Modified Constraint Induced Therapy, and
Robot Assisted Therapy demonstrate significant
functional recovery when massed practice therapy
is completed years after a stroke (1 to 15 years
post stroke).
Movement patterns post stroke are compensatory
abnormal movement patterns that are learned.
Dynamically assisted orthotic therapy
simultaneously providing sensorimotor stimulation
can lead to significant recovery of a more normal
gait in Hemiplegic patients.
Clinical Findings Summary



Orthotic therapy that creates a safe perturbation
during gait can significantly improve gait
rehabilitation over time by stimulating balance relearning and gait muscle timing activation (muscle
memory rehabilitation).
Orthotic sensorimotor stimulation during gait
accelerates gait recovery by activating the motor
control centers of the brain (recruit adjacent grey
matter to provide reorganized control).
Mechanical assisted orthotic therapy extension
during swing phase facilitates locomotor relearning.
Clinical Findings Summary




Orthotic therapy that improves heel to toe
biomechanics leads to quad strengthening.
Knee bracing can increase brain activity and
lead to improvements in Hemiplegic gait.
Gait recovery can be achieved if the patient has any
volitional intact sensorimotor control in the
affected limb.
Sensorimotor / proprioceptive stimulation may have
to address entire leg depending on level of
dysfunction to excite the corticospinal receptors.
OCSI Hemiplegic Gait
Clinical Solution



Dynamic carbon fiber AFO (Elite) with
unique footplate flexibility to initiate
vertical lift perturbation at toe off, to
facilitate knee flexion and hip flexion
movements, and correct ankle / foot
biomechanics.
Dynamic knee brace (Sport) with
mechanical gait correcting extension swing
assist and sensorimotor stimulation from
air bladder condyles and elastic strapping.
Knee brace is applied over the AFO to create
a dynamic KAFO. AFO and knee can be used
independently as patient improves functional
control of the affected joint(s).
Rehabilitative Orthotic Therapy
Objectives







Provide joint stability
Increase sensorimotor / proprioceptive input
Initiate quadriceps firing to improve leg strength
Kinetically assist more normal limb movement
Improve gait muscle memory w/ massed practice
Improve UNBRACED gait over time.
Significantly improve independent patient mobility
and quality of life.
Elite AFO Rehabilitator






Corrects foot drop
Improves dorsiflexion
Increases muscle force at push
off
Facilitates knee flexion
Reduces hip circumduction
Normalizes gait pattern over
time which carries over w/o
brace use in many patients
Orthotic Clinical Research

Carbon fiber dynamic AFO’s provide the following
benefits:
– Faster walking speeds
– Longer stride length
– Improved gait pattern
– Increased walking efficiency
Why the Elite AFO?




The Elite AFO is a carbon fiber dynamic ground
reaction force AFO
The unique flexibility in the footplate initiates a
vertical movement at toe off to provide a
perturbation stimulus to facilitate volitional firing
of the muscles in the ankle / foot, knee and hip.
The Elite AFO is the only carbon fiber AFO known to
intentionally initiate a perturbation stimulus.
Perturbation stimulus is clinically proven to facilitate
muscle re-education.
Elite Gait Facilitation

Vertical perturbation (upwards bounce of approx.
½ to 1 inch) facilitates:
– Dorsiflexion of ankle / foot
– Knee flexion
– Forward hip flexion to break circumduction
– Lower leg extension (loaded strut in swing phase)
Orthotic Clinical Research

KAFO’s with dynamic assist resulted in:
– Faster walking speed
– Longer step length
– Decreased double stance time
– Lower energy expenditure with gait
Sport Rehabilitator Knee





Provides adjustable sensorimotor
/ proprioceptive input to
facilitate improved patient control
and enhance muscle re-education in
the affected leg.
Provides increased stability to
improve balance and patient
confidence.
Dynamic swing assist facilitates heel
first foot placement to initiate quad
firing.
Strengthen quads over time with
routine use.
Helps to normalize (improve) gait
pattern
Knee Brace ROM Hinge


Use extension stop to assist in managing extensor
tone
Use flexion stop to control knee buckling due to
weak quads. Increase flexion movement as quads
are strengthened.
Rehabilitator KO / Elite AFO Combo




Designed to accelerate gait recovery after stroke;
effective for chronic poor ambulators.
Assists in normalizing gait kinetics w/ massed
practice in real world environment.
Facilitates quadriceps firing and leg strengthening.
Many patients show significant improvement in gait
after several months of brace use when NOT using
braces!
Expected Outcomes

Significant gait improvement braced and unbraced
– Longer step length
– Improved gait symmetry (assists in unaffected leg step
length w/ improved support)
– Improved leg strength
– Less energy expenditure
– Greater endurance and distance capabilities
Realistic Expectations



Clinical solution will minimally improve extensor
pattern of spasticity.
Although patient can progress from a room to room
ambulator to a community ambulator, gait
biomechanics will likely still be impaired.
Majority of patients must use braces once a week
after gait recovery to maintain gains (like retainer
for teeth).
Sport KO / Elite AFO Combo
Case Studies
Lauren
Michele
Patient Selection

Patients should be able to walk w or w/o assistance
a minimum of 100 ft.

Patient should have good rehab potential

Patient should want to walk

Patient should be on a therapy plan of care
including gait training
Contraindications

Poor rehab potential
–
–
–
–
Must
Must
Must
Must
be have good cognitive function (learning)
be motivated to walk
have ability to slightly move toes and ankle
walk 100 ft. with or without assistance

Significant genu recurvatum

Uncorrectable inversion / rotation of the ankle/foot

Significant ankle instabilities (unsafe)
Initial trial


Combo KO/AFO takes
approximately 100 steps for
patient to adapt to braces
Some improvement in gait
should be evident after 100
steps (i.e., improved
dorsiflexion, increased step
length, reduced double stance
time)
Patient Outcomes




The Sport Knee and Elite AFO are “Gait
Rehabilitators”
Patient improvement is dependent on daily training
and product use.
Measurable improvements in gait speed, efficiency,
distance, etc. as well as muscle strength should be
evident in 3 - 6 months.
Patients rehabilitate their gait by simply walking
with the products.
Questions?