Gait Rehabilitation in Patients with Neurological Disorders - Essay Example

Appraisal of treadmill training in gait rehabilitation in patients with neurological disorder and their attainment of community ambulation Introduction Walking difficulties is one of the main features of neurological disease and loss of mobility is the main activity of daily living which is most valued by such patients (Lord and Rochester, 2005). Different neurological pathologies and impairments often result in abnormal or reduced walking. Multiple sclerosis (MS) is an example of neurological disorder where an individual presents with weaknesses and spasticity from pyramidal tract lesions, vestibular and visual dysfunction, pain and cognitive and mood disturbances which may all contribute to difficulties in walking (Brown, Bradberry, Howze, Hickman, Ray, and Peel, 2010). In this case mobility is determined by weaknesses in primary muscle disease although secondary factors such as contractures, weight gain, breathlessness and fatigue may have major impacts on the mobility of the patient (Ada, Dean, Lindley and Lloyd, 2009). In such cases the degree of impairment is not linearly related to the activity and participation. For instance the walking speed is poor correlated to leg strength while various environmental factors and personal factors may influence the impact of similar degrees of loss of walking on mobility. In neurological disorders such as MS, impaired walking could be an indication of both progression of disease and disability (Mayr et al. 2007). The regaining of walking in patients with neurological disorders such as Parkinson’s disease (PD) and MS is a vital outcome measure in their treatment. It has been argued that mobility measurement could have a direct influence on the accessibility to treatment in such disorders (Lord, McPherson, Rochester and Weatherall, 2008). This is exemplified in treatment of MS where maximum walking distance determines whether a patient is eligible to take disease modifying drugs or not (Ada et al. 2009). Gait is regularly observed by clinicians for diagnostic purposes and forming opinions on patients with neurological disorders (Lord and Rochester, 2005). This is usually aided by the patient’s impression as to the effect of walking in the context of disease progression or response to treatment (Herman et al. 2007). Walking is often measured objectively in case of monitoring the state of neurological disorder (Koenig, Omlin, Zimmerli, Sapa, Krewer, Bolliger, Muller, and Riener, 2011). Community ambulation Community ambulation is outdoor locomotion that entails activities which are essential for living independently (Miller, Quinn, and Seddon, 2002). This may include activities such as visiting the bank, supermarkets and pharmacy (Brown et al. 2010). It is the ability of an individual to integrate walking with other activities in a complex environment (Ada et al. 2009). Patients recovering from neurological disorders such as stroke need to have better community ambulation in order for them to be able to enjoy quality life after leaving hospital premises (Banala, 2008). The ability of such patients to regain independent community ambulation is integral to quality of life for such recovering patients and their ability to reintegrate in the society. The International Classification of Functioning, Disability and Health (ICF) provides a description of the existing interaction between physical, social and environmental factors with the health conditions of an individual which produce outcomes which are of interest to the physical therapists. According to ICF activity is the execution of an action or a task by a person which mainly focuses on his rehabilitation efforts (Lord and Rochester, 2005). Therapists are involved in improving the endurance, increasing gait speed and improving an unsteady gait or a person’s poor ability to climb stairs. All these activities are essential for maintaining independence. ICF also encourages participation which encourages individuals to be involved in a social situation (Koenig et al. 2011). Participation has been identified as an essential domain of function which is integral to quality of life led by an individual (Brown et al. 2010). The participation of an individual in society is dependent on the environment in which the individual is found according to ICF (Hallett and Poewe, 2008). ICF argues that the mobility of an individual in a community may be strongly influenced by the environment and that the physical requirements may not be constrained to variables which are associated with terrain, speed and distance (Ada et al. 2009). Thus ICF is related to community ambulation since it enables the patient to integrate into the society and perform various tasks independently. Methods which are currently used to measure community ambulation are a representation of what researchers consider to represent the task (Ada et al. 2009). Such measurements include gait velocity or endurance, the locomotion domain of global function measures, functional mobility scales or self reported levels of activity. Community ambulation is one of the major goals of physical therapist for patients with neurological disorder (Miller, Quinn, and Seddon, 2002). Treadmills have long replaced traditional methods such as use of parallel bar to regain walking. Unlike the previous methods which required much support, treadmills offer patients more independence (Lord and Rochester, 2005). Weight supported treadmill training gives patients an opportunity for physical training of lower extremity strength and endurance and repetitive task (Banala, 2008). Treadmill training Gait hypokinesia is one of the main movement disorders in patients suffering from neurological disorders such as PD. It determines the disability and quality of life in such patients. Treadmill training is often used in rehabilitation and has been found to improve gait parameters of patients with Parkinson’s disease (Banala, 2008). Treadmill training has been noted to be one of the most promising ways of increasing walking ability of patients recovering from neurological disorder (Brown et al. 2010). Studies have suggested that supported Treadmill training is effective in improving walking in inpatients that already can walk. Studies have also indicated that unsupported Treadmill training when employed post-discharge is effective when used post discharge as a means of improving community ambulation (Lord and Rochester, 2005). For instance, studies have shown that supported treadmill training are effective in the reduction of fall frequency among patients living in the community who suffer from PD (Ada et al. 2009). Studies on electromechanical devises such as treadmill training have recently shown to be effective in rehabilitating patients with hemiparesis and impaired gait. Various studies have provided evidence for the beneficial effect of treadmill training in patients with different neurological disorders (Koenig et al. 2011). Several recent studies have provided enormous body of evidence on how various treadmill protocols can be used to improve symptom severity with increased limb ambulatory function, dynamic posture and physical function. Treadmill training has for instance shown to improve speed, mobility and to reduce fear of falling and postural instability in patients suffering from PD. These studies have also investigated the influence of variable weight bearing conditions in their treadmill training (Miller, Quinn, and Seddon, 2002). The results of these studies have all been positive. This is an indication that neuromuscular regulation can be facilitated in all patients with PD. The ability to carry out various tasks at a time characterizes effective human function. People suffering from PD have been found to be unable to carry out more than one task at ago. It has been found that when a person focuses on carrying out a single task at the expense of the other, the person often deteriorates in his ability to carry out the other task (Lord and Rochester, 2005). For instance studies have indicated that when PD patients walk and perform a concurrent verbal cognitive task, they often slow down in walking, their strides are shortened and the time they spend in double limb support increase well beyond that of control group (Ada et al. 2009). Another study found that when a PD patient walks and concurrently performs a task using his/her upper limb the walking speeds and stride length decreases significantly. Various studies comparing treadmill training with all other interventions (excluding treadmill training) have shown that treadmill is able to improve gait speed at the end of the intervention phase than all other intervention methods (Corrigan and McBurney, 2008). In addition, a comparison of treadmill training and non treadmill training has also shown in various studies to improve stride length. Research has also indicated that treadmill training improves walking distances as compared to non treadmill training at the end of intervention phase (Miller, Quinn, and Seddon, 2002). However, some studies have indicated that treadmill training does not improve cadence at the end of intervention phase (Koenig et al. 2011). Dropouts from treadmill training have been found to be low in various studies as opposed to that reported in non treadmill training (Scherer, 2007). Contribution of treadmill training towards community ambulation Treadmill training is designed for recovery of walking for individuals with neurological disorders. Patients suffering from spinal cord injuries (SCI), incomplete spinal cord injury (ISCI), stroke, traumatic brain injury, cerebral palsy, multiple sclerosis (MS) Parkinson’s disease (PD) can benefit from treadmill training. Treadmill training employs the scientific principle of neuro-plasticity for generation of new locomotion patterns. Neuro-plasticity entails neurons’ and axons’ ability to develop new pathways around an injury or a lesion through repetitive sensory input. The primary neural retraining activity occurs during step training on a body weight support treadmill (Brown et al. 2010). Sensory information (originating from the limbs and the trunk when the patient walks) is sent repetitively to the spinal cord. The actual stepping produces the sensory input as the therapist manually steps on the patient and from the contact of the foot’s sole and the ground. The therapist helps the patient in ensuring that the standing and walking is optimized (Corrigan and McBurney, 2008). However, the support of the therapist reduces as the patient improves. Studies have indicated that treadmill training is essential for incorporating virtual reality in gait training programs (Koenig et al. 2011). This has been found to be beneficial in augmenting the community ambulation of individuals recovering from neurological disorders such as stroke (Miller, Quinn, and Seddon, 2002). Studies have indicated that treadmill training are equally beneficial like home exercise programs in attaining similar gains in motor recovery, walking speed, social participation, balance and quality of life (Ada et al. 2009). This implies that treadmill training is beneficial for community ambulation for patients suffering from neurological disorders. The ultimate goal of gait retraining after a neurological disorder is successful ambulation in the home and community. Body weight supported treadmill training (BWSTT) has been found to be an effective treatment method for retraining walking in patients with neurological problems such as those suffering from incomplete spinal cord injury (Koenig et al. 2011). These studies have indicated that intensive treadmill training results in a greater ability of the patient to walk on the treadmill with reduced assistance, faster walking speeds and better endurance. Additional improvements on the treadmill training have indicated increased gains in over ground walking. Kinematically, treadmill training often results in better symmetry of steps, more normal excursion in lower extremity joints, less stride to stride variability and a toe trajectory that is almost similar to that of a normal person. Continued use of treadmill training has further indicated that patients recovering from neurological disorders regain the ability to walk in the households or community and continue improving on this over years (Brown et al. 2010). BWSTT enables patients recovering from neurological disorders to learn new motor patterns which are essential for community ambulation. Measurement of community ambulation outcome using gait speed Mobility outcomes for patients with neurological disorders have been evaluated with measures which cover activity, impairment, participation and health related quality of life. The World Health Assembly endorsed International Classification of Functioning in 2001 (Corrigan and McBurney, 2008). This turned the spotlight toward the understanding of the multidimensional concepts of functioning and disability which are related to physical features, physiological features, the patient’s life situation and the social role. the patient’s life situation and the social role are influenced by physical environment, physical appliances and aids, societal beliefs and attitudes and social policies (Brown et al. 2010). The ICF acknowledges the role of environmental factors to functioning and the relationship between environment and participation as being important factors in the community ambulation (Scherer, 2007). Thus rehabilitation measures should be aimed at attaining the ICF outcomes of a person being able to function and participate normally in daily life activities. The achievement of independent community ambulation following a neurological disorder such as stroke is essential and challenging rehabilitation objective. People with faster gait speeds are often more likely to attain this goal. Studies have indicated that a task practice approach is capable of improving mobility outcomes, social participation and community integration (Corrigan and McBurney, 2008). The main driving force for rehabilitation of patients with neurological disorders is based on their ability to regain walking (Scherer, 2007). This goal has been identified to be relevant to patients months or even years after the occurrence of the disorder. Varying definitions for community ambulation have been provided in literature and thus very minimal information is available on the dimensions of the task and specified tasks that ought to be accomplished for the patient to be said to have attained a complete community ambulation. From previous studies, the ability of a patient to identify relevant community destinations, carry out independent mobility outside the home are considered to be essential for community ambulation (Brown et al. 2010). Operational community ambulation considers eight environmental dimensions which include ambient conditions, terrain characteristics, external physical load, intentional demands, postural transition, traffic level, time constraints and walking distance. Gait velocity is chosen as an outcome measure because most neurological patients loose motor function that is known to produce severe limitations on the mobility of the patient and self care (Scherer, 2007). Treadmill training enables patients to regain this motor function and thus measurement which is related to motor function is the most crucial methods that can determine community ambulation of patients suffering from neurological disorders (Corrigan and McBurney, 2008). Gait velocity is one of the methods that provide an outcome measure for motor function. Repetition is required for new motor learning in order to improve walking function. This is provided by treadmill training which entails many repetitive action. Gait velocity is employed in the classification of functional ambulation based on the speed of the ambulatory (Scherer, 2007). The assessment of gait velocity is usually performed using a standardized method to measure the speed of a person during functional ambulation in order to detect mobility impairments and prediction of adverse events (Brown et al. 2010). Gait velocity is measured using the 10 meter timed walk. This is employed in both clinical and research situations because it has simple clinical application, it has robust psychometric properties and the ratio of data it yields (Corrigan and McBurney, 2008). This method has been shown to be more responsive than functional scales to changes in mobility in patients recovering from neurological disorders such as stroke (Scherer, 2007). Some authors have described the method as being “almost perfect’ measure. Gait velocity is an indication of function and can be stratified into functional classes such as household ambulation, limited community ambulation and full community ambulation (Scherer, 2007). Measurement of gait velocity is essential for both treatment and discharge planning. As noted earlier, the ability of a person to independently walk is critical for the person’s independent living and quality of life (Dunsky et al. 2008). Gait velocity measurement involve over-ground walking ability which is usually evaluated over a short distance (10m) to asses walking speed and over a longer distance to assist in the assessment of functional walking capacity of the patient. These tests are often carried out prior and after the training (Koenig et al. 2011). This method of community ambulation outcome measure does not however guarantee that increased gait velocity exceeding the bounds of measurement error is a denotation of a meaningful improvement in performance (Lord et al. 2008). This is because it is usually carried out inside, an environment which is predictable, uncluttered and controlled (Corrigan and McBurney, 2008). Thus the skills required to attain the required gait velocity cannot be transferred into the community which often has unpredictable environment (Koenig et al. 2011). Even though gait velocity has been found to be a key parameter in the measurement of the community ambulation, it cannot be used discretely to classify different levels of community ambulation without error (Stokes, 2004). Conclusion Of the many activities of human beings, walking is one of the most important. This enables humans to be both productive and participative members of the society. Walking difficulties is one of the main features of neurological disease and loss of mobility is the main activity of daily living which is most valued by such patients. Different neurological pathologies and impairments often result in abnormal or reduced walking. Treadmill training is one of the most promising ways of increasing walking ability of patients recovering from neurological disorders. The method has been found to help in improving walking capacity of both inpatient and outpatients recovering from neurological disorders such as stroke. The regaining of walking in patients with neurological disorders such as Parkinson’s disease (PD) and MS is a vital outcome measure in their treatment. Patients recovering from neurological disorders such as stroke need to have better community ambulation in order for them to be able to enjoy quality life after leaving hospital premises. The ability of such patients to regain independent community ambulation is integral to quality of life for such recovering patients and their ability to reintegrate in the society. ICF is related to community ambulation since it enables the patient to integrate into the society and perform various tasks independently. Mobility outcomes for patients with neurological disorders have been evaluated with measures which cover activity, impairment, participation and health related quality of life. Gait velocity is chosen as an outcome measure because most neurological patients loose motor function that is known to produce severe limitations on the mobility of the patient and self care. Treadmill training enables patients to regain this motor function and thus measurement which is related to motor function is the most crucial methods that can determine community ambulation of patients suffering from neurological disorders. Gait velocity is one of the methods that provide an outcome measure for motor function. Reference Ada, L., Dean, C., Lindley, R., and Lloyd, G. 2009. Improving community ambulation after stroke: the AMBULATE trial. BMC Neurology, vol. 9, no. 8. Available at http://www.biomedcentral.com/1471-2377/9/8 Banala, S. 2008. Lower extremity exoskeletons for gait rehabilitation of motor-impaired patients. London: ProQuest. Brown, C., Bradberry, C., Howze, S., Hickman, L., Ray, H., and Peel, C. 2010. Defining Community Ambulation From the Perspective of the Older Adult. Journal of Geriatric Physical Therapy, vol. 33, no. 2, pp. 56-63 Corrigan, R., and McBurney, H. 2008. Community ambulation: environmental impacts and assessment inadequacies. Disability Rehabilitation, vol. 30, no. 19, pp. 1411-1419 Dunsky, A., Dickstein, R., Marcovitz, E., Levy, S., and Deutsch, J. 2008. Home-Based Motor Imagery Training for Gait Rehabilitation of People With Chronic Poststroke Hemiparesis. 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