Interventions for retraining gait

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Strategies for retraining gait start with interventions to improve control of the head and trunk when necessary, then proceed to sitting and standing balance (Chapter 8 of Volume II). Practice paradigms ought to include a clear schedule and form of reinforcement (Chapter 7 of Volume II). Rehabilitation approaches for walking are listed in Table 3.1. Locomotor interventions are limited only by the imagination of the rehabilitation team. An eclectic problem-solving approach is taken by most therapists. Walkers, canes, ankle-foot orthoses, and on occasion, knee-ankle-foot braces are used to improve balance, lessen the need for full lower extremity weight support, and aid foot clearance and knee control. A trial-and-error approach for fitting and employing these aids and a reassessment over the time of improved motor control is usually needed. For step-training per se, as well as confounders such as hemi-inattention, lateral pulsion (pusher syndrome), truncal ataxia, gait apraxia, and extrapyramidal features, no particular style of care has been shown to be better than another, but few comparisons have been made. Anti-spasticity agents and intramuscular botulinum toxin may improve aspects of the gait cycle, primarily in patients with excessive plantar flexion/inversion.

Several of the approaches in Table 3.1 are being tested in randomized clinical trials (RCTs).

Task-oriented training

Body weight-supported treadmill training (BWSTT) is partially derived from treadmill training experiments on spinal transected animals and CPGs (Barbeau, 2003). It also provides task-oriented, massed practice under more optimal conditions for managing weight bearing and walking speed (Dobkin, 1999; Sullivan

Table 3.1. General approaches for retraining walking.

• Bobath, NDT, et al. to improve head and trunk control, balance, stance

• Progression from parallel bars; correct qualitative gait deviations

• Massed practice of walking

• Braces and assistive devices

• Increase muscle strength (Moreland et al., 2003)

• Increase walking speed and distance

• Reverse deconditioning (Teixeira-Salmela et al., 1999; MacKay-Lyons and Makrides, 2002)

• Task-specific shaping of more selective movements (Taub et al., 2002)

• Treadmill training ± body weight support

• Functional electrical stimulation for reflexive flexion or to fire a critical muscle group during the step cycle (Daly and Ruff, 2000; Loeb and Richmond, 2001; Herman et al., 2002)

• Robotic and electromechanical assists for stepping (Hesse et al., 2003)

• Pharmacological adjuncts for learning or neuromodulation

Biofeedback - kinematic or EMG ± induced muscle stimulation (Moreland et al., 1998; Sinkjaer et al., 2000)

• Practice in virtual environments

• Imagery (Lafleur et al., 2002; Malouin et al., 2004)

• Increase cortical excitation during practice (Dobkin, 2003b) - peripheral nerve, transcranial magnetic or direct motor cortex stimulation et al., 2002). Forms of BWSTT have been employed after SCI, stroke, cerebral palsy (Schindl et al., 2000), multiple sclerosis (Lord et al., 1998), and Parkinson's disease (Miyai et al., 2002).

Reviews and some initial reports of BWSTT after SCI often suggest that the beneficial effect of locomotor training in incomplete SCI patients is "well established" and that "even chronic SCI patients who underwent locomotor training had greater mobility compared with a control group with conventional rehabilitation" (Dietz and Harkema, 2004). The studies that are usually quoted have not, however, included control subjects at all (Field-Fote, 2001; Barbeau, 2003) or they employed "historical" controls (Wernig et al., 1995). Only one trial with clinically meaningful outcome measures obtained by blinded

Table 3.2. Six-month outcomes for a clinical trial of BWSTT versus conventional mobility training for 60 ASIA C and D subjects randomized within 8 weeks of SCI, graded at time of admission for rehabilitation.

BWSTT CONV

Table 3.2. Six-month outcomes for a clinical trial of BWSTT versus conventional mobility training for 60 ASIA C and D subjects randomized within 8 weeks of SCI, graded at time of admission for rehabilitation.

BWSTT CONV

FIM walking score (0-7)

5.8 ±

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