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‘HyperMED NeuroRecovery is committed to expanding the therapeutic window promoting worthwhile functional outcomes - gone are days of simply living and coping with disability!' Dr Mal Hooper _ HyperMED NeuroRecovery Australia
The Facts on Central Nervous System Disorders (Spinal Cord and Brain) There are an estimated 50 million Americans affected by diseases or disorders of the spinal cord and brain. The list of disorders includes: spinal cord injury, memory loss, addiction, schizophrenia, learning disability, depression, violence, stroke, brain injury, dementia, suicide and many others. More than 90% of the both the Australian and American population has experienced or will experience the effects of a brain-related, mental, emotional or behavioral, disease, disorder or injury at some point in their lives. Spinal cord injuries affect 250,000 Americans, costing more than $10 billion yearly. Head injuries have disabled two million individuals, costing the country $25 billion annually. Strokes affect 500,000 new people every year, costing the national economy $25 billion yearly. Spinal cord and brain disorders impact the American economy in excess of $400 billion a year, on direct health care costs and additional indirect lifetime costs. Individual suffering and loss to society, however, are almost impossible to quantify. Sources: American Paralysis Association for Brain Initiatives 2007.
Traumatic Brain Injury (TBI) and Stroke Rehabilitation TBI and Stroke are among the leading causes of acute and chronic disability in Western countries. TBI occurs in more than 500,000 individuals in the United States every year and may result from such causes as motor vehicle accidents, falls, bicycle accidents, and other traumatic injuries. Stroke is among the leading causes of death in both Australia and the United States for women and men, with an incidence of just more than 500,000 individuals each year (USA). Stroke accounts for nearly one-half of all those hospitalized for acute neurological conditions annually. Although the majority of individuals who sustain a stroke survive, a significant proportion of survivors require rehabilitation, and nearly one-third have some type of permanent disability. Among those who survive stroke, 50 percent are alive more than five years after the event, which means that rehabilitation needs continue well after the initial event. The rehabilitation needs and goals of individuals with stroke vary considerably. For some, the goal may be to return to full independence and resumption of all previous life activities. For others, the goal may be to return home with family assistance. Source: Stroke Foundation. HyperMED NeuroRecovery going ‘Beyond Therapy’ Beyond Therapy goes beyond the conservative therapy program a person would normally receive as an ‘in-patient’ or even attending an out-patients program where the focus is on adapting to disability. Traditional rehabilitation programs are typically designed to get patients as independent as possible and trained on how to take care of them selves after discharge. In contrast HyperMED NeuroRecovery Beyond Therapy focuses on the full extent and capacity to re-train and re-learn function. Most patients in the chronic phase of their condition become stagnant in their recovery and virtually all aspects of recovery and motivation fade. HyperMED NeuroRecovery Beyond Therapy is like a ‘rigorous boot-camp’; patients attend between 4-6 hours on each day and receive combination therapies designed to challenge immune and physiological responses and facilitate change. HyperMED NeuroRecovery Beyond Therapy is best accomplished with a boot camp like situation and may extend for several weeks and in complex cases several months. Patients require an initial intensive saturation or start up program followed by periodic short blocks of intensive therapies designed to promote neuroplasticity salvage. Bottom line: ‘YOU have got to WORK!’ Lokomat (Robotic Gait Assisted Walking) Gait Training
Lokomat is NOT passive involvement. The Lokomat is constantly adjusted to best assist the functional responses of the patient. Patients commence with passive assistance however as the patient compliancy builds the Lokomat settings and various programs are tailored to the patient performance and capabilities. Some patients have high level spasticity and others a complete loss of tone. Each patient's presentation is different - Lokomat provides excellent opportunity to 'best-fit' the patients specific capabilities and capacity to re-train function. And this is replicable on every separate training session! In addition the support harness treadmill system are utilized independent of the Lokomat to promote functional changes. Functional changes being driven by 'man and machine' are then put to the test with the patient then able to implement strategies being focused on during each Lokomat session. This combination effect is both unique and significant towards each neurologic patient developing a sense of supportive assistance whilst focusing on improving functional independence. Walking requires a 'fluid like connection between spinal reflex generators and higher brain centers'. The combined approach is invaluable to promote functional changes - neuroplasticity (the ability to salvage back what has been damaged).
Lokomat (Robotic Gait Assisted Walking) Gait Training For the past 15-years bodyweight supported treadmill training (BWSTT) has become a prominent gait rehabilitation method in leading rehabilitation centers throughout the world. Experiments conducted on spinalized cats demonstrate that spinal circuitry (reflex generators) below the level of injury remains active and functional neuronal properties can respond to peripheral input from below the level of injury. Treadmill cats can be ‘trained to sit, stand and walk’ Lack of appropriate stimulation induces functional incapacity called the ‘learning non-use’. Simply stated if you teach the remaining active spinal circuits to sit they will sit! Motor cortex centers in the brain re-allocate functional capacity lost through spinal cord injury – it is imperative to keep this ‘window open’. Body Weight Support Treadmill Training (BWSTT) and more recent studies on Lokomat (Robotic Gait Assisted Walking) demonstrate the potential of functional neuroplasticity - the ability to re-learn and re-organize function. This type of locomotor training has many functional benefits but the labor costs are considerable. To reduce therapist effort, Robotically Gait Assisted BWSTT (Lokomat) has been shown to be more accurate and financially feasible, compared to the other BWSTT modalities. Currently 45+ Lokomat systems are in use in large Neurorehabilitation hospitals in the USA and approximately 150 Lokomat systems found in 31 Countries. Internationally Lokomat (Robotic Gait Assisted Walking) and Body Weight Support Treadmill Training programs are payable under Third Party Insurance for spinal cord injury and a range of neurodegenerative and neurodevelopment gait disorders. Basis of Locomotor Training Neural plasticity refers to the natural ability of the neurons in the nervous system to generate and develop new connections aimed at repairing the neuronal damages. In the other word, they can learn new tasks. Based on this fact, locomotor training focuses on retraining the nervous system through simulating and repetition of walking gait, in order to regain their function and/or enhance their existing potentials. By repetitively stimulating the muscles and nerves in the lower body Lokomat Gait Assisted Training works to awaken dormant neural pathways controlling standing, stepping and balance. Experiments conducted on spinalized cats demonstrate that treadmill walk was possible suggesting evidence of a central gait pattern generator which remain active; these spinal generators drive the ability to re-learn function. When these generators are not activated the spinal circuits remain dormant; this inability to realize a movement combined with the neuroplasticity of the central nervous system may induce a secondary functional incapacity called “learning non use” – the ability to sit! Locomotor Gait Assisted Training refers to an intervention for retraining patients to walk after neurologic injury providing repetitive, intensive and task specific training that induces neuronal plasticity and subsequently cortical reorganization after brain and spinal cord damage. The goals of locomotor training are to capitalize on the intrinsic mechanisms of the CNS that respond to sensory input associated with walking to generate a stepping response and the ability of the CNS to learn through intensive, task-specific repetition and practice. Task specific training such as gait assisted walking enables repair and reorganization of processes in the central nervous system. In order to walk or regain functional capacity the injured patient must ‘re-learn to walk’. Activity based rehabilitation after neurological injury relies on three principles of motor learning. Practice is the first principle. All other things being equal, more functional learning will occur with more accurate practice. Specificity is the second principle. The best way to improve performance of a motor task is to execute that specific motor task repeated many times. Effort is the third principle. Individuals need to maintain a high degree of focus, participation and involvement to facilitate motor learning. These three principles are critical to promoting activity-dependent plasticity (i.e. altering the efficacy and excitation patterns of neural pathways by activating those pathways). With regards to neurological rehabilitation, it is important to emphasize that plasticity occurs in neural pathways that are active. Over the past decades, extensive research studies have assessed and evaluated the use and benefits of body weight-supported locomotor training. These studies reveal that BWSTT can effectively improve walking parameters such as speed, limb coordination, distance, and level of independence. It has also been shown that BWSTT in incomplete SCI patients can also lead some positive neurological alterations namely stepping ability, corticospinal tract function, and increased electromyography activity. Manually assisted treadmill training has been used for more than 15-years as a regular training for patients with spinal cord injury and stroke. The most extensive study published to date found that 80% of wheelchair bound patients with chronic incomplete spinal cord injury gained functional walking ability after functional training Spinal Cord Inj Rehabil 2005. Unfortunately BWSTT has not found prominence in Australian hospitals or private rehabilitation clinics. Long term benefits of Lokomat Gait Training? Patients with spinal cord injuries who have been wheelchair bound for many years are still potentially able to ambulate. Improving a patient to the point that he/she no longer needs a wheelchair to move would definitely lead to reducing the yearly costs of his/her neurological disease as well as the financial burden of wheelchair-associated complications such as; pressure ulcers, circulatory disorders, osteoporosis and attendant care. Lokomat Gait Training also records improved cardiovascular performance and reductions in spasticity, bone loss and bladder/bowel complications. The Lokomat has been suggested to be predestined for patients with complex neurologic disability who are too weak to walk over-ground without external support and thus require the assistance of several therapists to perform body-weight- supported treadmill training. Our experience (HyperMED NeuroRecovery) is that Lokomat Gait Training is highly adaptable for all patients with disability. Lokomat Gait Training can provide numerous accurate repetitions necessary to restore activity especially walking function with neurologic patients. Lokomat Gait Training kinetic settings can be varied and specifically adjusted throughout the training session intensifying functional outcomes. Patients with incomplete spinal lesions and with stroke undertaking Lokomat Gait Training have measurable functional changes; reflex stiffness and spasticity are significantly reduced; range of motion, peak velocity and acceleration of voluntary movements are increased with patients with incomplete spinal lesions and stroke. Therefore the walking ability improves as well as functional independence. Additionally, it has been revealed that Lokomat Gait Training can lead to functional improvements in patients with different neurological diseases such as; Multiple Sclerosis, Chronic Stroke, Parkinson’s Diseases, Cerebral Palsy (CP), as well as the other various types of idiopathic and secondary muscular dystrophies and neurological disorders in adult and children. In stroke hemiparetic patients BWSTT has been shown to improve balance, lower limb motor recovery, walking speed, endurance, and other important gait characteristics such as symmetry, stride length and double stance time. Moreover, a number of research studies have shown that Lokomat Gait Training can not only improve the gait in neurological patients but also positively affect cardiovascular and general health regulations. For this reason, to keep a level of maintenance treadmill training after the initial period of intense training is highly recommended.
Lokomat - Robotic Assistance - Learning to Walk The central nervous system develops function through interaction. Activities that we take for granted shape our nervous system developing healthy skills and mental function that ensures a healthy functioning nervous system. When the brain and spinal cord suffer ‘hypoxic injury’ the normal functioning skills become replaced by abnormal signals leading to disabilities the brain recognizes as ‘normal’. Abnormal signals need to be corrected through functional re-organization. Lokomat treadmill training is a task-specific rehabilitation strategy that enhances neurologic re-organization impacting cognitive function and development. The Lokomat produces a constraint-induced movement therapy of a specific task - the gait training enables pattern of muscle activation as physiologic as possible. The alternating ‘stance and swing phase’ of the Lokomat generates afferent inputs which stimulate the spinal gait generator inducing a motor reorganization and acquisition of forgotten skills or the learning of new ones. The partial body weight support allows patients to stand even with very weak muscles. It is common practice in physical therapy to move a patient’s limbs and joints through natural motion in order to improve function. Gait ability is a complex motor activation pattern organized hierarchically with the upper most level (initiation of the movement) mediated through the primary cortex and the lowest levels (organization and execution of the movement) mediated through the spinal motor neurons. The deficit induced by a central nervous system lesion depends on which group of cells is damaged: lesions of the upper motor neuron let some muscle contractions even with an altered highest cortical control. Lesions of the lower motor neuron result in flaccid paresis without the ability to recover some movements. Therefore central nervous system lesions produce different symptoms: paresis, somatosensory deficits which induce inactivity and loss of function. This inability to realize a movement combined with the neuroplasticity of the central nervous system may induce a secondary functional incapacity called the “learning non use”. Functional incapacity is challenging for spinal patient, supporting family and therapist. Acquired deformity results in a cascade effect of adaptation and dysfunction notwithstanding psychological effects. Task specific training such as Lokomat Gait Assisted Walking enables repair and reorganization of innate processes in the central nervous system. In order to walk or regain functional capacity the injured patient must re-learn to walk. Re-organization of processes refers to the development of the brain to find alternate pathways sending improved electrical signals. It is possible for the brain to transfer function responsibility to another part of the brain. It has also been demonstrated that strength training in spinal patients can increase strength as well as result in higher gait velocity. Similar to strength training, treadmill training with partial body weight support, as discussed can improve walking speed and endurance of spinal patients who have partial walking ability. Furthermore, it has been found that, in some cases, treadmill training with partial body weight support can achieve completely independent mobility for previously non-ambulatory spinal patients. All the above mentioned improvements would lead to positively changing the quality of life of the affected individuals, boost up their physical capacity, their confidence and increase the valuable time they spent in their community.
What are the advantages of using Robotically Assisted Gait Training (Lokomat) compared to manual bodyweight supported treadmill training (BWSTT)? Because manual assisted bodyweight supported treadmill training has high therapist labor requirements, research groups around the world have developed a host of robotic devices to assist treadmill stepping. In manual BWSTT, at least three to four specially trained therapists are required to move the patient’s legs and body. The purpose of these robotic machines is to replace therapist manual assistance, increasing the amount of stepping practice and accuracy while decreasing therapist effort. Manually assisted treadmill training (BWSTT) has several major limitations. The training is labor-intensive and biomechanically challenging to the active therapist; therefore, training duration is usually limited by personnel shortages and therapist, not patient fatigue. Furthermore, therapists often experience back pain because the training is performed in an ergonomically unfavorable seating posture. Consequently, training sessions are shorter than may be required for an optimal therapeutic outcome. The most compelling argument for Lokomat is that manually assisted treadmill training lacks accurate repeatability and objective measures of patient performance and progress. In contrast, the duration and number of sessions in Lokomat Gait Training can be accurately repeated and increased while reducing the number of therapists required for each patient. Indeed, one therapist may be able to train two or more patients at a time in the future. Lokomat has great advantage providing intensive task specific repetitive training that induces neuronal plasticity and subsequently cortical reorganization after brain and spinal cord damage. Patients with high level spasticity causing compensatory gait dysfunction are better suited on the Lokomat than manual BWSTT. Lokomat parameters can be initially set at very low and controlled setting providing a safe environment for the patient to develop confidence and allow functional reorganization through repetition and patterning. These parameters can then be built on and individually tailored to the specific requirements and functional responses of the individual patient. Lokomat provides task specific accuracy and repetition stimulating innate central pattern reflexes and higher cortical function.
Conclusion Hyperbaric provides the available fuel and acts as a catalyst to the underlying central issue (hypoxia). Lokomat (Robotic Gait Assisted Walking) and other forms of intensive physical therapy are required to ‘drive’ neuroplasticity - the ability of the neurons in the nervous system to develop new connections and ‘learn’ new functions. The rate of neuroplasticity is directly impacted by the levels of continuing hypoxia which blocks recovery! This combined Hyperbaric Lokomat approach ‘awakens’ dormant neural pathways and provides accurate neurological repetition enhancing and re-training connections and pathways in the brain and spinal cord. Patients have the ability to ‘salvage back’ what has been damaged improving brain and spinal cord function - to regain walking ability or learn to walk!
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