Robotics and the Neuro Patient – Using the Locomotor Clinical Practice Guidelines to choose When and How
When deciding what components to add to your neuro patient’s treatment plan, intensity is what matters most.
In this post, we help provide a more clear understanding of the recent Locomotor Clinical Practice Guideline (CPG) Action Statements as they relate to robotic treatment modalities, and how to think about incorporating them into your own clinical practice.
Early in 2020, the Academy of Neurologic Physical Therapy (ANPT) in collaboration with the American Physical Therapy Association (APTA) released their Clinical Practice Guidelines (CPG) to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury.
The guideline first and foremost emphasizes the need for intensive task-specific training:
“Strong evidence: Clinicians should use moderate- to high-intensity walking training interventions to improve walking speed and distance in individuals greater than 6 months following acute-onset CNS injury” i
This systematic review of the literature assessed randomized controlled clinical trials written between 1995 and 2016 that focused on these patient populations at least 6 months post-injury, and with outcomes of walking speed and distance.
An excellent resource both for learning about, and integrating into practice the principles of high intensity is the Intensity Matters campaign provided by the ANPT which is “focused on promoting walking training at high cardiovascular intensities to maximize locomotor outcomes for individuals with neurologic diagnoses.”ii
The authors advocate the following for training intensity:
HR Max 70-85% HR Reserve 60-80% Perceived Exertion (Borg) ≥ 14/20
This recommendation for training intensity is so strong, in fact, that it produced an unexpected effect on the recommendations for other interventions, most notably the use of Body Weight Supported Treadmill Training (BWSTT) and Robotic-Assisted Walking Training.
The CPG reports that when working toward locomotor goals in the defined populations, “strong evidence suggests that body weight–supported treadmill training, robotic-assisted training…should not be performed.”
Let’s dig a little deeper.
Importantly, in the studies analyzed all or most participants included were able to ambulate without the use of bodyweight support or robotic assistance and so intervening in such a highly supported manner likely resulted in the patients not training at high enough intensities reduced the overall intensity of these training sessions (although often this data was not even reported on unreported) and so did not achieve the desired outcomes. The CPG authors note,
“This recommendation may therefore not apply to non–ambulatory individuals or those who require robotic assistance to ambulate due to significant impairments or to other comorbid conditions.”
“Furthermore, most studies did not indicate targeted or achieved training intensities, which have been postulated to account for some of the inconsistent and negative findings.”
To compound the issue, the type of robotics utilized in the studies (i.e. Lokomat, Gait trainer) are designed to provide maximal support to patients who are often non–ambulatory. In the years since 2016 new robotics have entered the market that allow for locomotor training in these populations to be provided in such a way that is dynamic, challenging (aka intense!) and leads to proven positive results.
An Implementation Plan was set forth in the CPG:
“Therapists may consider reducing the amount of mechanical assistance if patients can independently perform stepping activities. Increased volitional effort without assistance will increase the neuromuscular and cardiopulmonary demands of stepping training, and documentation of intensity (HR, RPE) may therefore be warranted.”
As we will illustrate next, the ReStore Exo-Suit for patients post-stroke and ReWalk Personal 6.0 Exoskeleton for those with spinal cord injury are examples of devices that fit will within these recommendations for increasing training intensity.
ReStore Exo-Suit for Post-Stroke Gait Training
The ReStore Exo-Suit facilitates intensive locomotor practice post-stroke by providing untethered and dynamic assistance/training for both dorsiflexion and plantarflexion (aka paretic propulsion) at the paretic ankle. Propulsion is a key element not only in promoting a normalized gait pattern but also for demonstrating enhanced long-distance walking function and gait speed.iii,iv
Kristen Hohl, PT, DPT, NCS, clinician, and researcher at Shirley Ryan Ability Lab discussed in a Topics in Neurorehab episode how ReStore can provide an avenue for successfully overcoming the common dichotomy of needing to sacrifice intensity and/or dosage to work on and improve mechanics and impairments. She reflects that with the ReStore,
“...you can integrate the CPG Action Statements of moderate to high intensity gait training while also using the exoskeleton to really facilitate addressing improving movement quality, while also getting high dosage, and also decreasing impairments.”
You can find Kristen’s full episode of Topics in NeuroRehabilitation at this link.
ReWalk Personal 6.0 Exoskeleton for Spinal Cord Injury
ReWalk is a rigid but untethered exoskeleton that allows non-ambulatory patients to incorporate functional weight-bearing exercise as well as participate in life’s big standing moments. A study by Asselin et al out of the VA in 2015 looked at the heart rate and oxygen demand when using a powered exoskeleton such as ReWalk or Indego for people with paraplegia,
“The HR response during walking was significantly greater than that of either sitting or standing.” and “Persons with paraplegia were able to ambulate efficiently using the powered exoskeleton for over ground ambulation, providing the potential for functional gain and improved fitness.”v
To hear more from the author of that paper about working with exoskeletons, check out his episode of Topics in Neurorehabilitation at this link.
For busy clinicians, Clinical Practice Guidelines are an extremely attractive tool for quickly tapping into the state of evidence around a particular topic via the well-vetted recommendations these documents produce. Whenever considering if and how to translate new knowledge into your clinical practice however it’s important first to identify how well the practice setting, patient characteristics, and desired outcomes that are being reported upon align with your own clinical circumstances. When these points are aligned with your current clinical question, it can be extremely beneficial and (fairly pain-free!) to incorporate high-quality knowledge into your practice with improved workflows and patient outcomes sure to follow.
For further information on the ReStore Exo-Suit, visit the product page here.
For further information on the ReWalk Exoskeleton and to hear a patient’s experience, visit our ReWalk videos page.
To schedule a virtual or in-clinic demonstration of ReStore or ReWalk, contact us here.