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.