This article is a case study, which to me, although they aren’t the highest level of evidence, provide the most poignant physical therapy stories that make you want to laugh and cry and jump up and down. This is evidence that neurologic physical therapy works when you do it right.
The case is a 26 year old man 4 years post a severe brain injury in a car accident. At the time of initiation of this episode of treatment, he was using a power wheelchair for all mobility and was dependent upon his mother for activities of daily living (ADL) like dressing and showering. To put it lightly, he was an invalid. His goal was to regain walking ability. He had already had the typical course of physical therapy treatment (and then some in my opinion) including treadmill training with and without body weight support, hippotherapy (therapeutic horseback riding), aquatic therapy, and over ground walking training with a walker that had 2 platforms. He had not walked outside the clinical setting since his accident.
The investigators provided the following types of treatment over 79 visits in 62 weeks in 45-60 minute sessions.
— Locomotor treadmill training— beginning with body weight support, physical assistance to advance his legs, arm support and several straps to no body weight support, no physical assistance, no arm support, reduction in the number of straps.
— Orthoses— a custom double action joint AFO on each ankle
— Functional neuromuscular e-stim— to trigger a stepping pattern for swing during early treadmill sessions
— Functional mobility training— including standing balance, sit-to-stands, car transfer, strengthening, stair climbing
— Intensive home program— early on practicing standing for up to 2 hours a day, then once he could manage the gait trainer on his own, he would practice walking for 1-3 HOURS most days. Rode recumbent stepper at home on most days.
After all that, this person became independently ambulatory with the gait trainer in the community for upwards of 3,000 feet at a time or needing only minimal assistance from his mother with the rocker crutch for 350 feet at a time.
The authors acted surprised at his outcomes. I’m not really. This fellow was young; therefore, his brain was more easily moldable. AND look at that intensity! He and his mom worked hard for HOURS EVERYDAY at home on this. Not only that, they obviously had some money to put into his goal, as no insurance company would pay for that many physical therapy visits nor would they pay for one of those awesome gait trainers or a NuStep to have at home, sad to say.
I, personally, have never gait trained with one of those StrongArm canes, although I did have a patient that was being seen for something else come to the clinic with one once. I’ve also never gait trained with a rocker bottom crutch. Does anyone in the great world wide web know the benefits of these devices vs. the typical straight cane and regular rubber tipped crutch? I HAVE gait trained with a Pacer walker and I will say they are wonderfully adaptive devices that are super expensive, but worth the investment for those that need that trunk support in my opinion.
Also, I am salivating over the wheelchair ramp attached to the treadmill. Getting the treadmill set up is part of the reason I deign to use it, as setting it up is difficult and tiresome for clinician and patient. Although I do have a client at the moment I may put up there.
Anyway, neurologic physical therapy DOES work wonders with the right treatment strategy, right intensity, supportive family and a motivated patient.