PHOTO CAPTION: At The Recovery Project, Livonia, Mich, a therapist uses the RTI 600 with a patient to facilitate walking over a treadmill.
By Frank Long, MS, Editorial Director
It is true that there is a window during which stroke patients make their greatest gains toward functional recovery. But, according to recent research, stroke recovery is more of a continuum than a hard stop, and patients who strive for progress over the long haul may achieve functional gains beyond where the initial window of recovery closed. Because of that, it is critical for patients and therapists to work consistently for progress all along the continuum and take advantage of rehabilitation technologies that facilitate improvement. The focus of that improvements for post-stroke patients very often is recovering the ability to walk.
Effective gait analysis can play an important role in helping stroke patients improve their walking function. However, gait analyses performed solely by a therapist’s visual observation can be affected by subjectivity or observer bias. Using objective data gathered by computerized measurements can help lift those analyses to a higher level of accuracy. Two technologies that can provide those data are the GAITRite from CIR Systems Inc, Franklin, NJ, and the Zeno Walkway from ProtoKinetics, Havertown, Pa.
Every therapy clinic is keen to provide superior outcomes and optimum reimbursement. According to CIR Systems Inc, the company’s line of GAITRite walkways and modular systems check both of those boxes. GAITRite is designed to provide a simple means of collecting valid, reliable, and objective temporo-spatial measures of gait. For therapists working with post-stroke cases, the device allows them to record and compare gait health simply by having the patient walk over the surface of a walkway embedded with electronic sensors.
The GAITRite’s ability to capture and compare objective temporo-spatial measurements of gait offers advantages to both the clinical setting and the research setting. Karen J. Nolan, PhD, Senior Research Scientist, Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, explains those differences.
“In research, we have access to comprehensive gait analysis systems to measure mechanistic changes in gait. While this provides robust information about the biomechanics of walking, it is difficult to include in a clinical session,” Nolan says. She adds, “In the clinical setting, measurements of gait typically include walking speed, timed up and go, as well as balance assessments. The GAITRite device can provide insight into changes in walking speed, balance or functional mobility by adding information about the timing of limbs, spatial orientation of the feet, and loading parameters.”
Furthermore, Nolan says, she finds the GAITRite is easy to set up and provides a non-invasive method to quantify gait. “You get information about speed and symmetry, which provides insight about physical therapy progression or the effect of an intervention,” she says.
A Dynamic Solution
The Zeno Walkway from ProtoKinetics, Havertown, Pa, also offers research-grade objective data for clinical practice and scientific study. The Gait Lab at the University of Nevada Las Vegas is home to a Zeno Walkway, which Merrill R. Landers, PT, DPT, PhD, OCS, Department Chair in the Department of Physical Therapy at UNLV, says refined how the lab approached gait analysis.
Landers says he did not feel that introducing a force plate or camera system would fully provide the type of analysis the lab needed. The reason the lab chose the Zeno, he explains, came from a need to study dynamic balance.
“We knew we needed something that would give us some type of data for how a person moves and turns. The Zeno walking mat is 20 feet long and 4 feet wide, so it is big enough to evaluate a turn,” Landers says. That aspect of the Zeno is particularly important in evaluating Parkinson’s disease, Landers explains, because making a turn can stimulate a gait abnormality called freezing of gait.
“If you want to do research and demonstrate subtle changes or improvements, you need more research-grade type of technology and that’s what the Zeno walking mat affords,” Landers says. “A lot of people use this device in the clinic and it provides good clinical data, but it also provides excellent research-grade data for dynamic balance and walking.”
Landers points out that measuring some of the subtle changes that occur in a person’s gait requires a more sophisticated means. He acknowledges that while some therapists are extremely good with their eyes and can observe subtle changes, documenting and assessing those subtle changes is extremely difficult to do without something quantifiable.
“Qualitatively we can assess and say something is wrong, but quantitatively it is really hard to do with only observation,” Landers says. “The Zeno walking mat allows you to have additional information to make inference about a person’s gait. It removes subjectivity and makes your measurements more objective,” he adds.
Landers points out that while therapists will have a degree of bias in their eyes when they use the Zeno for assessing gait, there is no bias in the score the device provides.
“Anytime you can remove the subjective rating of someone’s performance you are improving the assessment. It’s a valuable tool for a researcher, but it is also an important tool to a treating clinician,” Landers says.
Therapists who support patients during standing or ambulating activities may incur wear and tear on their own bodies. These activities may also require the attention of several therapists or other therapy staff to keep a patient stable and prevent falls, which can drain hours of employee labor. Technologies that support a patient’s body weight by suspending the patient from overhead can help eliminate these obstacles. At The Recovery Project, a group of three full-service clinics headquartered in Livonia, Mich, the LiteGait from Mobility Research, Tempe, Ariz, is one such technology used frequently for those purposes.
The Recovery Project’s CEO and co-owner, Polly A. Swingle, PT, GCS, CEEAA, describes the LiteGait as a device that uses a harness to secure and suspend a patient over a treadmill.
“This allows the therapist to unweight the patient while ambulating,” Swingle says. “In turn, it prevents the patient from falling and allows him or her to work on improving their ability to walk (endurance, distance, and gait speed),” she adds.
With patients who suffer from a CVA the LiteGait oftentimes is used to provide treatment that facilitates neuroplasticity, Swingle says, as when the therapist will assist the weaker leg while ambulating on the treadmill. She explains that the following outcomes all decrease a patient’s fall risk:
1) Improved return of motor and sensory function in the weak leg and trunk;
2) Improved balance while standing and ambulating;
3) Improved gait endurance and speed;
4) Improved ROM of all joints in the lower extremity that are required to walk.
Swingle says the LiteGait’s ability to allow the PT to apply the principles of neuroplasticity for a stroke patient drove the decision to purchase the device. She describes those principles as follows:
• Repetitions: Walking on a treadmill provides more repetitions than walking over ground.
• Intensity: adjustable speed allows therapists to work with a patient at a moderate intensity.
• Specificity: Working on the skill that is impaired.
• Use It or Lose It: Forces the use of the weaker side.
Swingle adds that the LiteGait also helps prevent compensation behaviors seen when post-stroke patients re-learn to walk with a cane.
She says that scientific evidence was key in her decision to purchase the LiteGait for The Recovery Project, and points out that scientific evidence supports that the device promotes neuroplasticity of a central nervous system injury.
Training for the Ups and Downs
Once stroke survivors return home, they will need to negotiate stairs and curbs as part of their activities of daily living. One technology that can facilitate training for this is the Dynamic Stair Trainer (DST) from Clarke Health Care Products, Oakdale, Pa. The DST’s electronically adjustable steps are designed to occupy minimal floor space and replicate stairs and curbs. Ron Selzer, PT, Vice President of Rehabilitation Services at Lifeworks Rehab at Medical Facilities of America, Cave Spring, Va, says the DST allows therapists to initiate stair training earlier in rehab and give patients incremental “wins” as they successfully advance to stairs of greater height.
“It is also beneficial to be able to document these incremental gains for reimbursement and skilled justification purposes,” Selzer adds.
To expand the possibilities for therapy programs the DST has a reversible stairs ramp, additional steps that can convert to a slope, and height-adjustable handrails. Selzer notes that the DST is installed in nearly all of the company’s therapy gyms.
Built for Stability
After discharge some post-stroke patients may still have lower-extremity weakness or impairment related to foot drop. The support of a prosthetic such as an ankle-foot orthosis (AFO) may be helpful to these individuals as they return to their daily activities.
Several companies manufacture AFOs for the PT market for broad use, such as DonJoy/DJO, Lewiston, Texas, and Össur, Foothill Ranch, Calif. Another provider, Allard USA, Rockaway, NJ, manufactures a line of off-the-shelf and custom-made AFOs that can be particularly helpful for individuals affected by foot drop. These include the company’s line of BlueROCKER and ToeOFF AFOs.
Jonathan Kinzinger, DPT, NCS, Professor, University of Utah, notes that Allard’s AFOs help to prevent a common secondary complication of plantar flexor contractures and tightness. When these complications are present, Kinzinger says, they impact normal gait kinematics, notably anterior tibial translation.
“Allard AFOs improve dynamic muscle recovery, functional mobility, and gait characteristics compared to more passive support/assist AFOs,” Kinzinger says. He adds, “This lends to improved long-term outcomes including gait quality, control, and kinematics. As a result, this has helped to decrease fall risk and subsequent injuries.”
Kinzinger says the most desirable features among Allard’s AFOs are the carbon footplate and lateral strut, which allow for loading of potential energy in stance and releasing it into toe-off energy in terminal stance, and into initial swing for improved swing-phase kinematics. “These features aid in energy conservation, allowing for longer, safer gait with a reduction in fall risk,” Kinzinger says.
He adds that the anterior shell design of Allard’s AFOs allows individuals with quadriceps weakness to lean into the brace with slight knee flexion in stance (normal gait kinematics).
Risk and Recovery
Stroke continues to be among the leading causes of disability and the American public demonstrates little inclination to move away from lifestyle habits such as smoking, poor diets, and lack of exercise that increase stroke risk. Thus, faced with an aging and unhealthy population, physical therapy clinics should be prepared to evaluate and treat post-stroke patients in growing numbers. Fortunately, a range of tools from sophisticated to simple leave therapists well-equipped to help these patients work their way back toward functional independence and healthier post-stroke choices. PTP
Frank Long, MS, is Editorial Director of Physical Therapy Products. For more information, contact [email protected]