Therapy Session

We have all heard that “intensity matters” and there is several evidence for this fact. However, it is not always easy to provide enough intensity on clinical settings (Spiess M et al 2017). According to a recent study, initial impairment at admission, age and intensity are associated with positive outcome (Boltzmann et al 2017).

Performing hundreds of gait cycles per day contributes to the improvement of gait and lead to a better walking ability. The Lokomat, is a robotic system for gait rehabilitation that proved to be effective for gait therapy and provide high intensity therapy by 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 or amount of unloading can be adjusted during the session. Additionally, goal oriented exercises and automatized training programs can be used to increase patient motivation and participation.

This 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

Frequency is the amount of Lokomat sessions per week that a patient receives. It will be influenced by different factors like age, fatigue level or skin fragility. However, a general recommendation can be done as follows:

• (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, examples of reference centers will be published soon)

Fatigue: patients with increased fatigue (like multiple sclerosis patients) 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 functions.

Age can also condition the frequency of the therapy. It is mainly related to their general physical condition. Ensure they have enough rest between sessions to let the muscles, tendons, skin etc recover properly.

Amount of Sessions

The amount 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 over-ground 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

Adjusting Intensity

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 1000m 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 train facilitate motor learning by providing more repetitions, to elicit physiological muscle activity by reproducing the nor-mal gait pattern and to train activity timing. Change speed in intervals of 0.1km/h. Speed training program can be used to challenge our 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 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 physio-logical gait pattern and 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.

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 this clinical recommendations.