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Handling of the patient. Therapist`s intervention NOTE: Help given by the therapist for walking on the Laufband should be: As little as possible, as much as necessary. In other words, the principle is to have the patient use his (remaining) voluntary activity and merely help to maintain the flow of stepping. Note that patients tend to stop their own walking activity when the limb(s) is (are) moved by the therapist(s) (or mechanical devices, see below). Help basically depends on the defects the patient has and will include one or all joints of a limb. The goal is to achieve rhythmic and symmetric movement of both limbs for training on the LB. For this purpose not only limbs need to be controlled but also the rump. In general the therapist has to avoid brisk grips when holding or moving a limb since this might by itself cause spasticity (as does the harness when not properly mounted, see below "Spasticity") Help at single joints Hip joint: Hip extension and thus upright position are maintained by the rubber bands or by the therapist pulling on the harness or a therapist behind the patient. Hip flexion can be aided by pushing the weight -relieved limb upwards (hand of therapist firmly holding the foot) or simply by moving the distal part of the upper thigh. Spastic patients often pull the pelvis up during attempted swing phase, stop this by pulling the pelvis down (hand on the harness) and encourage movement out of the hip joint. Verbal commands can include: "Try to climb a step" rather than just "Hip flexion". Knee joint: If necessary break extensor spasticity at the end of stance by firmly pushing with one hand into the hollow of the knee with the other hand located at or above the ankle joint. Bring knee joint into full extension during stance, always encourage the patient verbally to try himself; tapping on the quadriceps above the knee might help. If not actively done, bring knee passively into full extension before mid stance and before under full load. Thisway the otherwise occurring "snapping" into full extension which in the long run might jeopardize ligaments is avoided; when muscles at the knee joint are too weak altogether (e.g. in flaccid paralysis like Guillain Barre syndrome) early knee hyperextension is unavoidable and must be done at heel strike. The command: Put strength into your knee sometimes helps (Bringen Sie volle Kraft in das Knie), or: Stand on this limb (Stellen Sie sich auf dieses Bein); after all stabilization needs co-contraction of Quadriceps and Hamstrings. Always work with the patient's sleeves put up (or use shorts) so you can see active contraction of muscles, particularly Quadriceps and control for knee extension/hyperextension Ankle joints: Encourage (verbally) or help/perform passively placement of the foot with attempted heel strike at the beginning of stance. If active knee extension is a problem, though not strictly physiological, the knee joint might already at heel strike be brought into full extension (see above). Correct for too much supination (pronation), but always ask the patient to perform actively or at least demand his help. A useful command to antagonize pronation at ankle joint and at the same time too much adduction at the hip joint is: "Walk on the outer edge of your foot, prepare this attempt already during preceding stance." To counteract supination, demand: "Heel strike and roll over digit I (large toe)". Usually in the beginning only one command at a time can be realized by the patient. Thus a second correction is worked out only after the first goal has been achieved. This principle of goal oriented training on single joints is helpful and necessary for SCI patients, hemiplegics, some brain injuries. Brain damaged patients with severe deficits in perception (Wahrnehmung) might be tried differently (Vreni Jung): Give a specific task, like: "Try to climb an (imaginary) step" (to get more hip flexion). |