Hemiplegic Gait Rehabilitation OCSI Hemiplegic Gait Clinical Solution Sport Rehabilitator Knee With Elite AFO Rehabilitator John Kenney, BOCO

Hemiplegic Gait Described Hip hike Circumduction of the leg Reduced hip and knee flexion Decreased weight shift towards affected side Foot drop, poor dorsiflexion, toe first or flat foot placement

Hemiplegic Gait Description Broader base of support Increased double stance time Shorter step and stride length Slower gait speed Decreased walking efficiency Poor endurance

Hemiplegic Gait Impairments Loss of proprioception Quadriceps weakness Hamstring weakness Decreased plantarflexion activity at push off Decreased afferent input (periphery to CNS) Knee instability; poor balance Decreased truck and motor control Disrupted muscle memory firing patterns (ankle, knee and hip; both sides)

Biomechanical Factors in Hemiplegic Gait Instability of the ankle and knee joint Muscle weakness in ankle and / or knee Decreased neuromuscular control Pathological gait changes (muscle memory) Loss of proprioception (balance / motor control) Decreased afferent input (decreased ability to re-learn) Weakness of the ankle and knee musculature Achilles tendon and extensor weakness / stiffness; quad weakness and reduced dynamic support of the ankle and knee

Chronic Hemiplegic Gait Pattern Initially dispensed orthotics may hinder gait improvements six months to 1 year out. After discharge from post stroke rehabilitation, many patients develop a learned compensatory gait pattern (Hemiplegic Gait) Many researchers suggest that the brain is not at optimal readiness for re-learning until 6 months to 1 year post stroke (Taub, Levine and Page, etc.) Appropriate orthotic therapy with Hemiplegic gait rehabilitation can improve gait in many patients who are poor ambulators.

Long Tern Rehab Therapy Findings 59 patients who were unable to walk 3 months after stroke were enrolled in study Patients received therapy 3X / week for up to 2 years 79% regained capacity to walk without assistance after therapy Predicting the outcome of individual patients who will benefit is difficult * The effects of long-term rehabilitation on poststroke hemiplegic patients. Tonin, et al, Department of Neurology, University of Padua, Italy

Neurological Overview Disruption of descending signals from the brain Decreased afferent input Loss of corticospinal influence to the lower gamma loop Lower gamma motor loop is intact in most Hemiplegic patients Since LMN is intact, massed practice re-learning is possible in spite of Stroke

Benefit of Intact Gamma Motor Loop Re-learning can be stimulated using the intact Gamma Motor Loop Decreased afferent (peripheral) input can be stimulated with sensorimotor excitation at the limb (facilitate re-learning) Central Program Generators (CPG’s) are in the spinal cord; re-write muscle memory with massed practice of improved steps over time

Corticospinal Connectivity Clinical research on Hemiplegic Gait suggests that the neurophysiology of lower-limb motor control requires corticospinal connectivity to improve ambulatory performance. Peripheral sensory information and descending inputs from the motor cortex are important in shaping CPG function.

Corticospinal Connectivity Supraspinal control is needed to provide both the drive for locomotion as well as the coordination for ambulation.* Spinal cord generates human walking; cerebral cortex makes a significant contribution to voluntary changes in gait pattern.* *Rehabilitation of gait after stroke: a review towards a top-down approach, Belda-Lois, et al., Journal of Neuroengineering and Rehabilitation, Dec. 2011.

Clinical Research Review on Gait Neuro-rehabilitation

Perturbation Therapy Clinical studies using balance perturbation (balance tilt modification) demonstrates that hemiplegic patients improve volitional muscle activation and statistically improved balance over time. Perturbation is believed to stimulate reflexive corticospinal muscle firing. If timed correctly, the perturbation training leads to improved balance in stroke patients. * Sensory Stimulation Promotes Normalization of Postural Control After Stroke, Magnusson, et. al., Stroke, 1994.

Perturbation Therapy w/ Simultaneous Sensory Stimulation Improvements in perturbation muscle re-education training are significantly more effective when combined with simultaneous sensory stimulation. Sensory stimulation therapy includes electrical stimulation, kinesiotaping, dynamic movement Lycra compression garment therapy and various manual therapies (PNF). * Sensory Stimulation Promotes Normalization of Postural Control After Stroke, Magnusson, et. al., Stroke, 1994.

Massed Practice Therapy Massed practice locomotor training evokes functional improvement in gait.* Massed practice locomotion training with sensory stimulation significantly improves outcomes compared to massed practice alone.* Significant sensory stimulation of the lower extremity increases corticospinal excitation and accelerates volitional control of the affected limb. * Exercise-mediated locomotor recovery and lower-limb neuroplasticity after stroke, Forester, et al., Journal of Rehabilitation Research and Development, 2008.

Functional Electrical Stimulation w/ EMG Control FES controlled by biological signals (EMG) results in improvements in Hemiplegic gait, faster rehabilitation process, and enhancement of patient endurance.* EMG facilitated FES reinstates appropriate proprioceptive feedback because the feedback is directly triggered by voluntary movement (re-learning requirement).* EMG w/ FES includes Walk Aid, Bioness 300, Bioness H200, and NeuroMove technologies. FES may be contraindicated if FES exaggerates spasticity.

Ambulation is Learned The precise sequence of muscle firing correlated to ambulation is stored in the CPG (Central Program Generator) in the spinal cord. Disruption of sensory input from the cordicospinal tract leads to abnormal compensatory muscle memory walking patterns (Hemiplegic Gait Pattern). The ideal therapy for re-learning ambulation initiates premotor cortex (PMC) and sensory motor cortex (SMC) activation techniques.* *Rehabilitation of gait after stroke: a review towards a top-down approach, Belda-Lois, et al., Journal of Neuroengineering and Rehabilitation, Dec. 2011.

Mechanical Assistance and Facilitated Assistance Gait Therapy Patients assessed with fNIRS (Functional Near Infrared Spectroscopy) demonstrated premotor cortex and sensory motor cortex activation with mechanical assisted and physical therapist assisted (facilitated) gait therapy with enhanced extension swinging of the affected leg.* “Locomotor recovery after stroke seems to be associated with improvement of asymmetry in SMC activation and enhanced PMC activation in the affected limb.”* *Rehabilitation of gait after stroke: a review towards a top-down approach, Belda-Lois, et al., Journal of Neuroengineering and Rehabilitation, Dec. 2011.

Knee Braces Activate Brain “Functional Magnetic Resonance Imaging research demonstrates the affect of lower extremity proprioceptive stimulation on brain activity and confirms that the effect of a knee brace is associated with significantly higher level of brain activity then when no device was applied.”* Movement w/ a knee brace providing somatosensory stimulation activates the primary sensorimotor cortex of the brain. The “tight” knee brace was associated with the highest levels of brain activity.* *Knee braces activate brain, Foster, Jordana, LER, January 2011

Leg Strengthening A flat foot landing in Hemiplegic Gait results in significant loss of quadriceps activation during gait. Over time, quad strength and muscle mass is lost due to gait alterations. Clinical research demonstrates that by correcting foot placement to establish more normal biomechanics in heel to toe – mid line placement of the ankle / foot with gait will reactivate quad firing leading to increased quad strength and muscle mass.* Gait and Clinical Improvements with a Novel Knee Brace for Knee OA, Johnson, et. al., Knee Surgery, Dec 2012.

Muscle Learning after Stroke Can be Recovered at Any Time Significant clinical research on Constraint Induced Therapy, Modified Constraint Induced Therapy, and Robot Assisted Therapy demonstrate significant functional recovery when massed practice therapy is completed years after a stroke (1 to 15 years post stroke). Movement patterns post stroke are compensatory abnormal movement patterns that are learned. Dynamically assisted orthotic therapy simultaneously providing sensorimotor stimulation can lead to significant recovery of a more normal gait in Hemiplegic patients.

Clinical Findings Summary Orthotic therapy that creates a safe perturbation during gait can significantly improve gait rehabilitation over time by stimulating balance re-learning and gait muscle timing activation (muscle memory rehabilitation). Orthotic sensorimotor stimulation during gait accelerates gait recovery by activating the motor control centers of the brain (recruit adjacent grey matter to provide reorganized control). Mechanical assisted orthotic therapy extension during swing phase facilitates locomotor relearning.

Clinical Findings Summary Orthotic therapy that improves heel to toe biomechanics leads to quad strengthening. Knee bracing can increase brain activity and lead to improvements in Hemiplegic gait. Gait recovery can be achieved if the patient has any volitional intact sensorimotor control in the affected limb. Sensorimotor / proprioceptive stimulation may have to address entire leg depending on level of dysfunction to excite the corticospinal receptors.

OCSI Hemiplegic Gait Clinical Solution Dynamic carbon fiber AFO (Elite) with unique footplate flexibility to initiate vertical lift perturbation at toe off, to facilitate knee flexion and hip flexion movements, and correct ankle / foot biomechanics. Dynamic knee brace (Sport) with mechanical gait correcting extension swing assist and sensorimotor stimulation from air bladder condyles and elastic strapping. Knee brace is applied over the AFO to create a dynamic KAFO. AFO and knee can be used independently as patient improves functional control of the affected joint(s).

Rehabilitative Orthotic Therapy Objectives Provide joint stability Increase sensorimotor / proprioceptive input Initiate quadriceps firing to improve leg strength Kinetically assist more normal limb movement Improve gait muscle memory w/ massed practice Improve UNBRACED gait over time. Significantly improve independent patient mobility and quality of life.

Elite AFO Rehabilitator Corrects foot drop Improves dorsiflexion Increases muscle force at push off Facilitates knee flexion Reduces hip circumduction Normalizes gait pattern over time which carries over w/o brace use in many patients

Orthotic Clinical Research Carbon fiber dynamic AFO’s provide the following benefits: Faster walking speeds Longer stride length Improved gait pattern Increased walking efficiency

Why the Elite AFO? The Elite AFO is a carbon fiber dynamic ground reaction force AFO The unique flexibility in the footplate initiates a vertical movement at toe off to provide a perturbation stimulus to facilitate volitional firing of the muscles in the ankle / foot, knee and hip. The Elite AFO is the only carbon fiber AFO known to intentionally initiate a perturbation stimulus. Perturbation stimulus is clinically proven to facilitate muscle re-education.

Elite Gait Facilitation Vertical perturbation (upwards bounce of approx. ½ to 1 inch) facilitates: Dorsiflexion of ankle / foot Knee flexion Forward hip flexion to break circumduction Lower leg extension (loaded strut in swing phase)

Orthotic Clinical Research KAFO’s with dynamic assist resulted in: Faster walking speed Longer step length Decreased double stance time Lower energy expenditure with gait

Sport Rehabilitator Knee Provides adjustable sensorimotor / proprioceptive input to facilitate improved patient control and enhance muscle re-education in the affected leg. Provides increased stability to improve balance and patient confidence. Dynamic swing assist facilitates heel first foot placement to initiate quad firing. Strengthen quads over time with routine use. Helps to normalize (improve) gait pattern

Knee Brace ROM Hinge Use extension stop to assist in managing extensor tone Use flexion stop to control knee buckling due to weak quads. Increase flexion movement as quads are strengthened.

Rehabilitator KO / Elite AFO Combo Designed to accelerate gait recovery after stroke; effective for chronic poor ambulators. Assists in normalizing gait kinetics w/ massed practice in real world environment. Facilitates quadriceps firing and leg strengthening. Many patients show significant improvement in gait after several months of brace use when NOT using braces!

Expected Outcomes Significant gait improvement braced and unbraced Longer step length Improved gait symmetry (assists in unaffected leg step length w/ improved support) Improved leg strength Less energy expenditure Greater endurance and distance capabilities

Realistic Expectations Clinical solution will minimally improve extensor pattern of spasticity. Although patient can progress from a room to room ambulator to a community ambulator, gait biomechanics will likely still be impaired. Majority of patients must use braces once a week after gait recovery to maintain gains (like retainer for teeth).

Sport KO / Elite AFO Combo Case Studies Lauren Michele

Patient Selection Patients should be able to walk w or w/o assistance a minimum of 100 ft. Patient should have good rehab potential Patient should want to walk Patient should be on a therapy plan of care including gait training

Contraindications Poor rehab potential Significant genu recurvatum Must be have good cognitive function (learning) Must be motivated to walk Must have ability to slightly move toes and ankle Must walk 100 ft. with or without assistance Significant genu recurvatum Uncorrectable inversion / rotation of the ankle/foot Significant ankle instabilities (unsafe)

Initial trial Combo KO/AFO takes approximately 100 steps for patient to adapt to braces Some improvement in gait should be evident after 100 steps (i.e., improved dorsiflexion, increased step length, reduced double stance time)

Patient Outcomes The Sport Knee and Elite AFO are “Gait Rehabilitators” Patient improvement is dependent on daily training and product use. Measurable improvements in gait speed, efficiency, distance, etc. as well as muscle strength should be evident in 3 - 6 months. Patients rehabilitate their gait by simply walking with the products.

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