Raul Vivaez, Pavel Loeza, Demetrio Villanueva, Marco Ireta.

Marco Ireta,

Clínica CEREBRO, Distrito Federal, Mexico

We would like to share our clinical experience with an MS patient who was very restricted in her daily life. When entering her rehabilitation program she spent most of the day in bed due to the severity of her illness. The improvement we observed over therapy progression encouraged us to share our experience to support other clinicians working with the same patient group. Please find underneath our case report including a detailed description of evaluation, intervention and therapy progression; also scores  that were applied and videos that were taken.


 

Initial Evaluation

Female patient, 42 years of age diagnosed with multiple sclerosis 14 years ago. The lower-extremity strength (Manual Muscle Testing) before the treatment the global weakness was: left hemibody 3/5, right hemibody 4/5 with generalized pain. Upper – limb dismetria. She required assistance for walking (frame walker), low cadence, during gait the initial contact was plantar and increased the pelvic tilt. Patient received pharmacological treatment, and nutritional cares.

Treatment Intervention: Phase 1

Date

01/08/2011 – 10/10/2011

Goals

  • Improve physical condition
  • Sensitivity
  • reduce stance width
  • improve balance and reactions
  • proprioception
  • coordination and control pain.

Intervention

Therapy 3 times a week. Therapy sessions consist of:

Theratrainer – cycloergometer passive – active movement in upper and lower limbs, patient tolerance for no more than 15 minutes, no resistance and using Borg Scale to prevent excessive fatigue
Balance Trainer – Train Balance, equilibrium, reactions, proprioception patient tolerance using Borg Scale to prevent excessive fatigue
Pro vibe platform – Improve sensitivity and stimulate proprioception 3 minutes on it for one minute rest intensity 20 hz
ArmeoBoom – To improve coordination, proprioception and functionality of upper limbs. 10 sessions 3D activities patient to improve coordination and motor control. Patient tolerance using Borg Scale to prevent excessive fatigue.

Improvements

  • Increase in strength 4/5 in lower limbs, psoas 3/5, quads 4/5, hamstrings 4/4
  • Improvement in gait pattern
  • Strength improvements in upper limb, 4/5, grip 4/3,
  • FIM from 73% to 92%.
  • Berg balance scale 31 pts.

Intervention: Phase 2

Date

3/11/2011 – 30/5/2011
In October 2011 she suffers exacerbation with generalized weakness, fatigue and neuropathic pain 4 – 5 (VAS). The treatment prescribed includes physical reconditioning, strengthen and electrotherapy for pain 3 times per week.
Theratrainer – cycloergometer passive – active movement patient tolerance for 20 minutes upper limbs and 20 minutes lower limbs 1 minute active 1 minute passive, no resistance and using Borg Scale to prevent excessive fatigue
Electro stimulation – Kotz current 10 sec contraction, 30 sec rest per 10 repetitions in quadriceps.
Electrotherapy – interferential current 80 – 150 Hz in sacroiliac articulation to control pain

Improvements

  • Increase in strength 4/5 in lower limbs psoas 4+/5, quads 5/5, hamstrings 4/4, Improvement in gait pattern.
  • Strength improvements in upper limb 4/5, grip 4/3,
  • Berg balance scale 49 pts.

Intervention: Phase 3

Date

1/6/2012 – 24/1/2013
Patient presents evolution gaining strength and balance. We continue with physical reconditioning and strengthen.
Lokomat to improve spatial – temporal components of gait. 2 times per week for a total of 34 sessions.

Evaluation and Patient Progression

Study and motion analysis was performed during functional tasks following to record the progression during gait rehabilitation in Lokomat.
Run separate shoe on a flat surface at self-selected speed.
To record the kinematics was used opto-electronic system Smart-D (BTS, Italy) 6 camcorders infrared range, with capture rate of 140 frames per second (140 Hz). To start recording the spherical markers were placed in July (15 mm diameter) of reflective material on anatomical landmarks according to protocol Short-Brain. For registration of the reaction forces used force plate model 9286BA (Kistler, USA).  Conventional video was recorded at the coronal (anterior and posterior) and sagittal (right lateral view and left side). The data were processed with the Smart-Analyzer (BTS, Italy).

Improvements

  • Berg balance 51 pts. FIM 92%
  • Progression on Lokomat parameters
N° Session
Distance
Time
Speed
BWS
Guidance Force
1
433 m
19 min
1.5 km/h
100 %
100 %
20
903 m
37 min
1.5 km/h
79 %
79 %
30
654 m
26 min
1.7 km/h
70 %
70 %
Manual Training
234 m
11 min
1.0 km/h
0 %
0 %
  • Temporal and spatio-temporal parameters
Previous Study
August 21, 2012
Subsequent Study
January 17, 2013
Right
Left
Right
Left
Reference
Stance (%)
86.5
84.6
63.7
61.2
58 – 62
Swing (%)
13.4
15.4
39.3
38.2
38 – 42
Double Support (%)
34.1
36.7
16.4
8.9
10 – 12
Cadence (steps/min)
58.5
78.2
98 – 138
Stride Length (m)
0.51
0.50
1.23
1.26
1.06 – 1.58
Base Support (m)
0.18
0.13
0.07 – 0.09
Velocity (m/s)
0.18
0.72
0.96 – 1.68

Patient before Lokomat therapy.

Patient after Lokomat therapy.

Conclusion

We know that we face a chronic and degenerative pathology; and that a relapse (sudden worsening) can alter the treatment plan from one day to the other. Hence, we recommend a close communication and collaboration within the interdisciplinary team that works with the patient.
The results obtained show the effectiveness of robotic therapy in combination with conventional therapy, with an individualized and interdisciplinary treatment approach.
We want to highlight the improvements in walking ability observed during the treatment with the Lokomat, as well as the improvements observed in motor control of the upper limb by using the ArmeoBoom. These improvements were apparent in the software of both devices.
This resulted in improved functionality, independence and social integration of the patient, despite her chronic condition. Therefore, we believe that it is important to share our experience and support other clinicians which work with the same patient group.
Today, the patient continues with a preservation treatment. She now faces the relapsing periods better and she’s recovering earlier from them.

Patient exercising on the Lokomat.

Our Rehabilitation Team

We are a team of specialists that includes disciplines such as neurorehabilitation, sports medicine, physiotherapy, biomechanics and nutrition. The type of patients we serve covers pathologies such as: neurological, orthopedic and sports. In CEREBRO We help our patients achieve their highest possible levels of functional independence and quality of live. Cerebro offers both upper and lower extremity rehabilitation robots for clinical programs in order that the patients improve their motor functions through repetitive, controlled motion. CEREBRO has on site a motion analysis lab to assessment the functional status of the patients and measure the functional outcomes.


 

Patient before Lokomat therapy.

Patient after Lokomat therapy.