What are the Indications and Contraindications for ValedoMotion Therapy?
What are the Indications and Contraindications for Andago Therapy?
What Must be Considered During the Armeo Therapy Session of Patients with Shoulder Subluxation*?
Do some of the patients you treat suffer from shoulder pain and subluxation*? Are you interested in some clinical tips on how to train these patients with the Armeo? Read this Q&A to find out more!
Armeo therapy in patients with shoulder subluxation is possible and successfully applied in a number of clinics. However, special care from therapist’s side is required in order to ensure a safe therapy session. A few important points should be considered before and during training:
- Fixing or limiting the range of motion of the shoulder joints g. gleno humeral joint to focus on specific muscle training in order to reduce the risk of subluxation. (ArmeoPower: within the software– Fig1; ArmeoSpring manual adjustments – Fig2)
- Adjusting the arm weight support in order to ensure a correct shoulder alignment and to avoid overstretching of the soft tissues by the effects of gravity2,3. E.g. If the shoulder is distracted caudally due to the arm’s weight, you can increase the arm weight support to reduce the space between the head of the humerus and the glenoid cavity.
- Approximation (coaptation) of the gleno humeral joint to stimulate proprioception and a better joint alignment. This can be obtained by slightly shortening the length of the upper arm.
- Carefully adjusting the workspace with AROM and AMOVE keeping in mind that excessive ranges of motion (>90°) in flexion and abduction of the shoulder can be harmful2 g. During AMOVE limit the painting on the ceiling and on the wall to the side of the impaired arm.
- Choosing specific exercises in accordance with the patient’s abilities e.g consider choosing exercises without challenge aspects related to the shoulder.
*Subluxation grades 1-2 according to Langenberghe and Hogan1
Van Langenberghe HVK, Hogan BM. Degree and grade of subluxation in the painful hemiplegic shoulder. Scand J Rehabil Med. 1988;20:161–166.
Gresham, G. E., Duncan, P. W., & Staston, W. B. (1995). Post-Stroke Rehabilitation Guideline Panel. Post Stroke Rehabilitation. Clinical Practice Guideline No. 16 CAHCPR Publication No. 95-0662). Rockville, MD: U.S. Department of Health an Human Services, Public Health Service, Agency for Health Care Policy and Research.
Cailliet R. The shoulder in the hemiplegic patient. In: Shoulder Pain. 3rd ed. FA Davis; 1991:193-226
Is it Possible to Train Patients with Cognitive Deficits?
Severe cognitive deficits are listed as contraindications for Armeo training. However, depending on the severity of the deficit, training may be possible if the following criteria are met:
- The patient is able to interact with the software and perform the exercises.
- The patient is able to understand the instructions of the therapist.
Below we have outlined a number of risks associated with limited cognitive abilities, and possible adjustments in order to ensure safe and effective therapy session with the ArmeoSpring.
Possible Training Adjustments for Possible Risks or Challenges
- If there is a risk that the patient could stand up while he is strapped into the Armeo, stay close to the patient in order to intervene if needed.
- If the patient forgets how to perform the exercise, select a simple training plan. Start with only one exercise and choose the easiest one for the patient.
- If the patient gets frustrated, dismayed or if he exhibits negativity, select a difficulty level where the patient is challenged but not overstrained.
- If the patient easily gets distracted, assess risk related to the patient’s lack of concentration. Divide training sessions into short sequences with breaks in between the exercises.
Please note that it is the clinicians’ responsibility to evaluate the possible risks and benefits for patients with impaired cognition and decide whether Armeo therapy is suitable.
In Which Units and Patient Groups can I Use the Erigo?
The Erigo has been designed with the aim to provide rehabilitation therapy to severely impaired, bed-ridden, neurological patients as early as possible after the incident, even in acute care. The aim of therapy at this early stage is to make use of the increased plastic potential of the neurological system but also to enhance functional recovery and to avoid degeneration and negative effects of long term immobility. This means that any neurological patient free of any contraindication and being stable enough to be mobilized and verticalized can potentially benefit from Erigo assisted training.
Thus, the continuum of rehabilitation with the Erigo reaches from admission to intensive care unit through high dependency unit and general care ward to rehab hospital recovery and the treatment of chronic functional deficits in bedridden patients.
According to the feedback received from experienced Erigo users, the patient groups that most frequently train on the Erigo are patients that suffered from stroke, traumatic brain injury and spinal cord injury. In the hospital, the device is mainly used for bedridden patients to reach the capacity needed for independency in transfer, standing and gait.
Before you start with the training, we recommend to always weigh possible benefits of Erigo therapy (e.g. mobilization, training of cardiovascular system, decrease spasticity) against possible risks for the patient (e.g. too high intensity, pain, syncope) to decide whether Erigo therapy is suitable for each individual patient.
How can we Handle Patients with Infusions, Feeding Tubes, Catheters, Urine Bags or Venous Accesses?
There is no contraindication for conducting Erigo therapy with patients with infusions, feeding tubes, catheters, urine bags nor venous accesses. Nevertheless, we recommend you to consider the following aspects:
- Avoid pressure of any hard plastic parts on the patient to prevent injuries. Check in particular if the belts or the cuffs are fixed too tightly over these parts.
- Ensure that the tubes are not compressed and that the fluid is able to flow.
- Infusions: whenever possible, remove the infusions during the session to facilitate patient handling. We recommend to clarify with the responsible doctor if the infusion can be removed. If this is not possible, ensure that the infusions are hanging higher than the patient and that both the vein and the tube are not compressed.
- Feeding tubes: ensure that the feeding tube is closed and that it is not compressed by any belt.
- Catheters and urinal bags: flexible tubes need to be adjusted in a way, that there is no tension on the tubes (e.g. you can make a curve at the hips’ height). Don’t compress the tube in a way that the urine stops to flow. Use the catheter hook provided to safely attach urinal bags to the Erigo.
To ensure safety during the therapy session, we recommend to evaluate all possible interfaces between the Erigo and any other devices or equipment that the patient needs.
Please note that the recommendations provided above are based on feedback we received from experienced Erigo users. However, the decision whether the patient is suitable for Erigo therapy and how to handle the patient’s individual condition, lies within the clinician’s responsibility.
Is it Possible to Train Children on the Erigo?
Erigo training is not limited due to age but to the size of the patient. As long as it is possible to appropriately adjust the device to the patient it is possible to use the Erigo with patients of all ages.
The patient size for Erigo training is defined by:
- A maximum weight of 135 kg (297 lb)
- Leg length (measured from the foot sole to the greater trochanter) less than 75 cm (29 in.) or greater than 100 cm (39 in.)
How Frequently Should I Train Patients on the Erigo?
The simple answer is: the more often the better.
Especially in the early stage of rehabilitation, training the cardiovascular system and increasing the patient’s tolerance to the upright position are very important therapy goals. A minimum of 5 times a week is desirable to activate severely impaired patients. You can even train them twice a day on the Erigo (for example in the morning and in the afternoon).
Criteria for Increasing/Decreasing Frequency
- Increasing the training frequency/maintaining a high training frequency is recommended when improvements (e.g. muscle tone regulation, cardiovascular stability) during or after the therapy session are visible.
- Criteria for reducing the training frequency are: signs of fatigue, skin irritations (especially in the areas of the groin or thighs) or other negative effects which could result from the therapy itself.
Is the Lokomat Suitable for Patients with Spasticity?
Yes, it is possible to use the Lokomat with patients with spasticity. Most clinics even use the Lokomat as a tool to reduce spasticity. However, patients with high levels of spasticity require special attention while training on the Lokomat.
Aspects to Consider when Training Spastic Patients
With patients with high spasticity, please pay special attention to the following points. If any of these three points is the case, then Lokomat therapy is not suitable for the patient.
- The patient presents a contraindication resulting from maintained spasticity. For example, severe fixed contractures due to joint retraction.
- The level of spasticity is so severe and resistance constantly exceeds the safety threshold of the orthosis despite the adjustments to handle it, causing the Lokomat to stop. If this happens too often it may frustrate patients and make them feel “not good enough” for Lokomat training. Hence, this can affect their overall treatment motivation.
- The patient presents discomfort and pain during walking even when trained at a very slow speed and with the recommended adjustments.
Tips for Regulating the Spastic Response
- Air walking at slower speeds: Start the session with walking in the air at a slow speed (≤ 1 km/h) for a brief period of time before lowering the patient to come into contact with the treadmill. The spastic response is velocity dependent and is normally higher during the first movements; after a few repetitions the response usually regulates.
- Hip ROM and hip extension: Start with a reduced hip ROM. A greater ROM, particularly hip extension will more likely provoke a spastic response. If the patient’s spasticity response is still causing the device to stop even with reduced hip ROM, you can limit the hip extension either by increasing the hip offset value or by bringing the pelvic cushion backwards.
- Ground contact and loading: While contact with the treadmill can cause a spastic response, the weight loading will most likely contribute to muscle tone regulation. Thus, when you bring the patient down onto the treadmill, try to avoid foot contact without loading. Furthermore, reduce the BWS as much as possible later on in the session; this will contribute to muscle response/activation and at the same time regulate the muscle tone.
- Combination with conventional therapy: Interventions such as stretching exercises or standing and weight-bearing exercises in a standing frame device prior to Lokomat training may prepare the patient’s muscles for walk training.
These recommendations are based on the feedback of experienced Lokomat users.
Can I Treat Amputee Patients on the Lokomat?
Yes. Amputee patients are a target group for the Lokomat since their gait ability can be impaired. Though two Lokomat contraindications (“orthosis cannot be adjusted to fit the body (lower limbs)” and “patients with extremely disproportionate growth of the legs”) are given, in general Lokomat training for amputee patients can be explored. They are not explicitly listed as a contraindication nor indication in the User Manual due to the large variety of amputations and orthopedics used.
Gait training with Augmented Performance Feedback has been shown to benefit amputee patients (Darter and Wilken 2011). We are aware that some centers train amputee patients using the Lokomat and have observed benefits and improvements. We therefore recommend that you evaluate the possible benefits and risks for your patient in order to decide the suitability of Lokomat therapy for your patient.
The Lokomat is a very effective tool for treating walking disabilities, and as such amputee patients can benefit from it. Clinics using the Lokomat with this patient population find it very helpful in the following respects:
- Patients relearn how to walk with the new prosthesis in a safe environment.
- Patients improve their gait pattern.
- The Lokomat aligns the patient’s body thereby “forcing” a symmetric weight distribution that pushes unilateral amputees to relearn physiological movements after the amputation.
- The Lokomat allows the therapist to focus on the patient’s specific impairment due to the amputation while the rest of the body is “under control”. (The orthosis controls lower limb movement and the patient is stabilized through the body weight support system).
Possible Risks and Aspects to Consider
Though the Lokomat can be a suitable tool for gait training for amputee patients, we outline below a few questions and considerations that must be taken into account before training begins:
- Is the amputation the only “pathology” or does the patient have an additional pathology (e.g. diabetes with very bad circulation) that would be a contraindication?
- What is the level of the amputation? Are you able to correctly put the harness on the patient?
- Will the Lokomat orthosis and orthopedic equipment be harmful to the patient? For example, a cuff might exert pressure on a point and cause phantom limb pain.
- Does the patient use an orthosis or prosthesis? Is it external or internal? Will it be affected with the movement of the Lokomat orthosis? Or will the force of the Lokomat orthosis create friction between the prosthesis and the patient’s limb or body?
- For patients with a prosthesis who want to train on the Lokomat, we recommend to contact the manufacturers of the prosthesis to identify possible risks.
Darter BJ, Wilken JM, (2011) Gait training with virtual reality-based real-time feedback: improving gait performance following transfemoral amputation., Phys Ther. 91(9):1385-1394.
Lokomat Training with Children with Cerebral Palsy Following Surgery. Practical Recommendations?
Orthopedic surgery in pediatric patients is often recommended when spasticity, stiffness, contractures or bone deformities are severe enough to make walking or moving difficult or painful. The effectiveness of different types of surgery have been proved by several authors (Rodda et al. 2006, Dreher et al. 2012, Bozinovski et al. 2014).
After surgical intervention, a rehabilitation period is needed to achieve the functional goals. Lokomat therapy can be a rehabilitation tool for intensive gait therapy after surgery, but the parameters needed for successful therapy are not well understood.
In this entry, we summarize the practical recommendations for Lokomat therapy after surgery as published by a group of physical therapists and physicians experts in the management of patients with cerebral palsy.
General Recommendations for Robot Assisted Training (RAT) after Surgery
It is extremely important to define clear therapy goals after surgery. Lokomat therapy should only be carried out in accordance with the therapy goals of the patient. According to the recommendations from the experts, Lokomat therapy is not indicated after strong structural changes. Moreover, this group also recommends seeking out alternative therapies for patients whose goal is not to recover or rehabilitate gait after the surgery (Aurich et al. 2015).
Pain is a common problem after orthopedic surgery (Hoiness et al. 2014). Pain should be avoided during Lokomat therapy (Aurich et al. 2015). There are various factors that may lead to pain during a Lokomat session, and each cause should be considered individually. For example, pay special attention while fitting the harness (use additional padding if required), avoid friction between cuff and leg with proper tightening of the cuff, and adjust the range of motion according to the patient’s limits. These are a few examples of general recommendations on how to control or reduce the incidence of pain during a Lokomat session.
Recommendations in Accordance with Various Orthopedic Operations
Lokomat therapy is possible after soft tissue surgery such as muscle/tendon transfer or myofasciotomy. The onset of Lokomat therapy is recommended 6-8 weeks after the surgery; although after percutaneous myofasciotomy, it is possible to start 4-6 weeks after surgery if the patient has free range of motion (ROM) without pain (Aurich et al. 2015).
After surgery performed on a bone (pelvis, femur, foot, etc.) there is a general recommendation to wait 8-12 weeks before starting Lokomat therapy. Consolidation of the surgery needs to be sufficient and judged by the orthopedic surgeon as well as documented by x-ray. Free passive ROM (especially in hip and knee flexion) should be documented prior to the start of therapy. The amount of loading should be discussed with the orthopedic surgeon prior to the start of therapy. When the patient has been prescribed and/or fitted with an ankle-foot orthosis after surgery, it is recommended that the patient wear it during Lokomat therapy (Aurich et al. 2015).
Lokomat therapy is contraindicated after hip, knee and ankle arthrodesis.
Musculoskeletal Considerations after Surgery
Musculoskeletal deformities are a common secondary problem in children with cerebral palsy. General considerations apply for mild to moderate deformities. Strong structural abnormalities in the frontal or sagittal plane (e.g. genu varus, genu valgus) are contraindications for Lokomat therapy since the risk for secondary injuries due to possible shear forces is increased.
Hip subluxation and dislocation is not a general contraindication. Training in an abducted hip position (by adjusting the frontal plane settings of the Lokomat) is recommended for such patients (Aurich et al. 2015).
Asymmetrical leg length influences the position of the pelvis and/or the foot contact with the treadmill. Relevant leg length discrepancy should be corrected (e.g. using insole or shoe rise) in order to improve the pelvis position and the ground contact (Aurich et al. 2015).
Scoliosis is not a general contraindication. The position of the patient during therapy should be considered and an upright position of the trunk (Aurich et al. 2015) shall be the goal. As an indication, experts point out that patients with a Cobb angle over 60-70° have a difficult time staying upright. Moreover, a trunk stabilizing orthosis needs to be used with caution to prevent pressure marks or disturbed blood flow in the upper limbs (Aurich et al. 2015).
Lokomat therapy with patients after lumbosacral fixation / fusion must be discussed and agreed upon with the orthopedic surgeon (Aurich et al. 2015).
For children with cerebral palsy and a GMFCS level IV-V (non-ambulatory), consider the bone density and the risk that osteoporosis presents. Significant osteoporosis is a contraindication for Lokomat therapy (Aurich et al. 2015).
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.
Practical Recommendations for Lokomat Therapy in Children with Cerebral Palsy: Patient-Specific Considerations?
The pediatric population has special individual characteristics which make a simple generalization from adults to pediatrics impossible. For that reason, a group of physical therapists and physicians met together and developed some practical recommendations for Lokomat therapy in children with Cerebral Palsy. The complete results are published in the 2015 article titled Neuropediatrics by Aurich et al.
In order to ensure proper setup, the following recommendations were made by a group of experts: (Aurich et al. 2015)
- Body weight must be at least 15 kg
- The minimum femur length must be at least 21 cm
- Always use the Lokomat distal cuff to fasten the exoskeleton better to the patients’ legs
- The patient should be able to sustain a vertical position for at least 20 minutes as assessed by the therapist prior to initiation of therapy.
- Emergency exit strategies during therapy have to be set up in advance and it may be useful to practice these with a healthy volunteer in advance.
- The individual institution’s emergency call procedure must be familiar to all therapists.
Handling of Pain
- The condition of the patient must be monitored continuously during therapy.
- Mild occurring pain during the first therapy sessions (e.g. muscle pain, pain caused by pressure of the cuffs or by the belt system) is frequently observed. Any sort of pain, but most critically pain in bones, joints, or soft tissue during therapy, has to be analyzed immediately.
- Shear forces on the joins must be avoided. Consequently, an individual fitting and adaptation of the exoskeleton must be performed with great care on the current range of motion and the axes of the patient’s legs.
- The correction of existing anatomical abnormalities or deformities should be made only through small, gradual changes within the software setting.
- If complaints persist despite adjustments over the second or third therapy session, the indication of robotically assisted treadmill training as a therapeutic option needs to be critically reconsidered.
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.