Handling of the patient.
LB-Speed:
Again: Speed is adjusted according
to the patients status and needs ("Most comfortable speed").
Apart from that, according to current experience, two speed ranges
may be used with each patient even in one and the same session:
Low speed (0.2- 1.0 km/h): Gives patient enough
time to use his voluntary activity and walk with as little as possible
help by therapists. Forces/allows the patient: to have a long stance
phase to properly load the limb, learn to carry weight and balance
the whole body (particularly important and effective with hemiplegics).
With low speed, single features can be focused on, like knee extension
or active abduction in case of too high adductor tone, better placing
of the foot etc.. You will be surprised how much is possible; however,
only one feature can be trained at a time and previously learned
ones need to be rehearsed. Even with severe paralysis on both limbs,
training at this speed can be done with a single (well trained)
therapist sitting at the side and controlling both limbs. This speed
range resembles speed the patient might initially be capable of
performing over ground. With improvement both, stepping on the treadmill
and walking over-ground will be increased in speed.
High speed (up to some 3 km/h): Experience
has it that limb setting is easier and also the patients feel that
they have to put less effort into stepping with high speed. The
reasons for this apparent facilitation are certainly complex, one
being that the swinging limb gains a higher centrifugal force at
high speed. Also, stance phase is shorter and the need for balancing
the whole body eased. If one limb is already performing some independent
stepping, a single therapist may handle the patient also at high
speed. If both limbs are not capable of stepping, passive limb setting
by two therapists - one at each limb - has to be performed. Rarely
and not as a rule, a third therapist may - standing behind the patient
- rotate the patient`s rump / shoulder / pelvis. Periods of training
at high speed during a session will be maintained especially when
there are obvious benefits, e.g. reduced spasticity, better rhythm
of walking etc
There is a group in USA led by Susan Harkema, which
mainly and immediately goes on even higher speeds (ultra high
speed, 4.5 km/h) with SCI patients; as a consequence they regularly
have to employ three therapists which makes the therapy unnecessarily
expensive and handling much more tedious. There are not many institutions
who will be able to afford this. Moreover, purely passive movement
at such speeds is likely to involve forces which might harm the
limbs of patients especially with flaccid paralysis and osteoporotic
bones. Finally, the ultra high speed version will yet have to prove
that it is similarly effective as compared to the less consuming
regimen we and others have been employing. In fact, only if it
proofs largely superior in achieving overground ambulation,
the significantly higher effort might be warranted.
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