Practical Recommendations for Lokomat Therapy: What is the Optimal Frequency, Duration and Intensity for my Patient?
We have all heard that “intensity matters” and there is several evidence for this fact (Veerbeek et al. 2014, Spiess et al. 2017). However, it is not always easy to provide enough intensity on clinical settings (Spiess et al. 2017).
The Lokomat can provide intensive therapy while supporting the patient with a physiological gait pattern. In order to adjust the patient effort and keep the challenge, parameters like guidance force (amount of robotic support), treadmill speed and amount of body weight support can be adjusted during the session. Additionally, goal-oriented exercises and automatized training programs can be used to increase patient motivation and participation.
These practical recommendations have been created by consensus of a group of experts to support clinicians on the use of the Lokomat to adjust the intensity of the therapy to their patients. They do not intend to be a guideline, but to provide a general basis of knowledge on this topic. In addition, they will provide some helpful tips that expert clinicians use to determine dosage of Lokomat therapy.
Frequency is the amount of Lokomat sessions per week that a patient receives. It is influenced by different factors like age, fatigue level or skin fragility. However, general recommendations are:
- (Sub) Acute patients (as soon as patient is cardiovascularly stable): > 5 sessions per week of 45-60min (at least 30 minutes gait).
- Chronic patients (>6 months): at least 2-3 sessions per week of at least 30 minutes (the more the better)
Fatigue: patients with increased fatigue (like patients with multiple sclerosis) can benefit from reduced frequency of sessions with adjusted intensity. The training should follow the recovery process of the patients and fatigue can guide the training intensity to avoid triggering pathologic reactions.
Age can also condition the frequency of the therapy, as it influences patients’ general physical condition. Ensure they have enough rest between sessions to let the muscles, tendons, skin etc. recover properly.
Number of sessions
The number of sessions or therapy duration very often depends on the general length of the medical treatment. However, general recommendations can be done on when a patient can be discharged from Lokomat therapy and transferred to overground gait training:
- Lokomat therapy is no longer needed (but not contraindicated) when the patient has a symmetrical walking pattern in terms of times of stance and swing (on a chronic phase).
- Lokomat therapy is no longer needed (but no contraindicated) when alternative options for overground training are available to ensure the intensity of the therapy (for instance, Andago)
- Lokomat therapy is no longer needed and contraindicated in case of any worsening of physical condition.
- Lokomat therapy frequency can be reduced when the patient has ability to walk overground to cover all therapy goals
Adjustment of intensity during a therapy session is critical to challenge the patient beyond capabilities while ensuring the patient can participate actively in the session for at least 20 minutes or 1000 m walking distance.
- Body weight support (BWS) can be reduced as much as possible while the patient can maintain knee extension during stance phase. Reduce BWS to increase the amount of weight bearing of your patient and train muscle strength, knee stability and extension, hip stability and extension. Change BWS in intervals of 5% to challenge your patient. BWS training program can be used to challenge the patient with automatic changes on BWS. Use intervals of low BWS (at threshold for the patient) with intervals above threshold for recovery.
- Speed can be increased as much as possible as long as the patient can maintain a physiological gait pattern and ensure active participation. Speed can be increased to provide more repetitions, to reproduce the normal gait pattern and to train activity timing. Change speed in intervals of 0.1 km/h. Speed training program can be used to challenge your patient with random changes of speed. Use intervals of speed at the maximum threshold for the patient with intervals of speed above threshold for recovery. Reduced speed can also be beneficial for some patients, since stance phase time is increased and time for unilateral stance is longer. Reduced speed in combination with reduced BWS can contribute to strength and knee extension training.
- Guidance force (GF) can be reduced as much as possible while the patient can maintain a physiological gait pattern, temporo-spatial parameters are preserved, and symmetric gait pattern is achieved. Guidance force can be reduced to train gait variability, motor control and adaptability of the gait. Reduce GF in intervals of 5-10%. Asymmetric guidance force can be used to increase attention on the affect leg on patients with neglect.
Keep in mind that the treating medical experts who prescribe and carry out Lokomat therapy are responsible for the patient. It is their decision as to what kind of treatment is appropriate for individual patients in their care; this includes whether Lokomat training is appropriate for a given patient. Hocoma can only present items to consider when making the decision; Hocoma cannot make the decision as to whether Lokomat training is appropriate, especially without having any contact with the patients.
Veerbeek, J. M., E. van Wegen, R. van Peppen, P. J. van der Wees, E. Hendriks, M. Rietberg and G. Kwakkel (2014). “What is the evidence for physical therapy poststroke? A systematic review and meta-analysis.” PLoS One 9(2): e87987.
Spiess, M. R. and G. Colombo (2017). “Intensity: What Rehabilitation Technology Can Add to the Subject.” Neurol Rehabil 23(1): 53-56.
Acknowledgement to: Dr Andreas Mayr (Tirolkliniken, AT); Corrado Melegari (Elias Neurorehabilitatione, IT); Debora Campos (AASDAP, BR), Chih-Chao Hsu (Taipei Medical University Hospital, TW), Dr Nicolas Buffagni (Clínica San Andrés, AR) for their clinical input and contributions to these clinical recommendations.