I hope to get “push back” on this topic. For 30 years as a physical therapist, I have been witness to the compensated gait training of stroke and brain injured patients. I started out as a newly minted physical therapist trained to use a quad cane or hemi-walker which is a cane with 4 points and fitted for either the left or right side depending upon which side of the body was more affected.
These walking aides are by design meant to do two primary things. First, it markedly slows the cadence or speed of walking down. Not a little, but to a snail’s pace. So slow in fact, that the gait will not be “functional” in the community, and often it is not very functional in the home. The second effect is that it markedly facilitates a shift of the body’s center of mass to the less involved side (of the body) either to the right or left foot instead of the space between the two feet. The patient is then standing primarily on either their right or left leg at all times, the more involved and weaker side acts as a “peg” and the patient further “adapts” or more accurately compensates by using the assistive device as a “third leg”. The weaker leg now has no chance of reintegrating into a normal neurological pattern. This has massive ramifications on every level of the recovery and the quality of life for the patient.
The use of these devices will alter and impede the ability of the patient to balance, transfer and adapt to novel physical environments. In fact, these devices are in large part responsible for the “plateau” or ceiling of recovery.
If this is so, then why are they still used? I do not know. I can tell you that back in the 1980s when I was in training, the attitude of the faculty was “Hey they should be grateful that they are even able to walk at all.” Okay, this was in the 1980s, so I will let that pass. However, this was not very comforting as I watched the patient’s lurch and permanently become walking or even wheelchair “wounded.” The research and my experience in the clinic told an alternate story.
The research indicates that the healing brain (nervous system) will adapt to the primary stimulus, so the more normal the action, the more normal the end result. This adaptation to the primary stimulus is so pervasive that it is easy to illustrate. Think of the body type of a swimmer, body builder or distance runner. These bodies adapt to the primary stimulus of their sport on the one end of the spectrum. Now think of a very impaired and immobile person in a nursing home that spends most of the day in a wheelchair or Geri-chair. Their bodies literally take the shape of the chair, and they struggle to move in general. The nervous system does not “judge” the stimuli. It processes it.
Here is what the condition of a modified forward wheeled walker with use of the more involved arm does for restoration rehabilitation. The forward wheeled walker is modified with a platform of some kind and the more involved extremity is fastened to the walker. The walker is further modified by adding 4 to 20 lbs of weight to increase the perception of stability for the patient. See Figures 1 & 2 below.
Figure 1
Figure 2
The attachment of the arm to the walker via strapping, paddles, platforms, etc. facilitates weight bearing of the extremity. This creates a scenario in which the brain and the somato-sensory system of the arm, peripheral nervous system, and lower portions of the central nervous system all the way up to the damaged neocortex are communicating in the context of “active support.” This means in plain terms that the weak and low (or high) tone extremity has purpose. The arm has something to do and the brain because it is adaptive, starts to adapt. This is called neuroplasticity. Again, no judgment, just processing.
Figures 1 & 2 are an example of an attachment to a modified walker front and side. Blue highlights shoulder effects. Green highlights weightbearing and tonal responses in frontal photo. Orange highlights the push purpose of the paretic side and the blue arrows highlight the added weight used to modify the walker
A number of desirable or therapeutic responses result which include:
1. Normalization of tone. If the tone is too low, it will increase the tone. If the tone is too high, it will diminish. The change in muscle tone is the direct response of the nervous system receiving the weight bearing sensation and the added functional demand of pushing the walker.
2. Subluxation of the shoulder is fairly common especially in low tone situations. This can result in ”stroke shoulder” and complex regional pain syndrome, or for folks of my generation “RSD” (regional pain syndrome). The combination of active support and functional pushing will almost immediately resolve the subluxation and pain while engaged in the activity, and over time help to permanently resolve the problem. Use of the modified walker may prevent the secondary impairments altogether and help drive the stages of recovery of the arm and hand. Just ask any occupational therapist.
3. A modified walker will force the effort of restoration of symmetry between the sides in terms of weight bearing and inhibit the inevitable shift of the body’s center to either the right leg or the left leg. Just like the arm and hand, the leg and foot will have a chance of more weight bearing and ground reaction to normalize tone. The leg will have purpose which is closer to the normal biomechanics of the body.
4. The modified walker set up is an issue of safety and appropriateness. Until there is a Berg balance score of 47 or higher, there arguably should not be the risk of using a quad cane, hemi-walker or otherwise. The likelihood of a fall is too great.
The social perception is that use of a cane or hemi-walker and learning proficient use of it is a great feat. Even though in reality, this locks them into a “plateau”. The body did compensate, but the cost of the compensation is that the symmetry is lost. The gun site is not calibrated and though matter how many times you shoot, you will not hit the target. The patient becomes precise at not hitting the target. The new neurological motor pattern is so highly ineffective and inefficient, that progress is truly not possible. The newly acquired software, or the cumulative effect of the compensated movement and abnormal stimuli will not allow the body to move and work as it was designed.
Does this mean that using a modified walker guarantees restoration of normal walking. No, it does not. There are of course a number of other variables. I personally and professionally have spent 20% of my life working on technology to further enhance and facilitate normalization of biomechanics for stroke and brain injury via the Envision system and to inhibit or minimize the common barriers.
I am compelled though to discuss the topic because of the profoundly negative impact training compensated movement and function has in general. Use of the quad cane and hemi-walker for training walking, transfers, and balance- standing activity has in my experience the single most catastrophic consequence on stroke and brain injury rehabilitation.
So, when a new PT or an experienced PT poses the question, “Why are you using a walker to train a stroke (or brain injured patient with hemi-paresis)? I am admittedly taken aback. I think to myself, “Is the predominate training still compensated recovery?” I then ask myself, “When will the research overtake tradition?” __________________________________________________________________________________
References:
1. Brain Functional Reserve in the Context of Neuroplasticity after Stroke Volume 2019 | Article ID 9708905 | https://doi.org/10.1155/2019/9708905
Jan Dąbrowski,1Anna Czajka,2Justyna Zielińska-Turek,2Janusz Jaroszyński,3Marzena Furtak-Niczyporuk,3Aneta Mela,4Łukasz A. Poniatowski,4,5Bartłomiej Drop,6Małgorzata Dorobek,2Maria Barcikowska-Kotowicz,7and Andrzej Ziemba
2. Effects of activities of daily living-based dual-task training on upper extremity function, cognitive function, and quality of life in stroke patients. 2Osong Public Health Res Perspect. 2021 Oct;12(5):304-313. Epub 2021 Sep 13.
3. Effects of task oriented rehabilitation of upper extremity after stroke: A systematic review: J Pak Med Assoc.: 2022 Jul;72(7):1406-1415. doi: 10.47391/JPMA.3864.
Maira Hussain 1, Arooj Fatima 2, Ashfaq Ahmad 1, Syed Amir Gilani 3
4. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. Pain Med. 2022 May; 23(Suppl 1): S1–S53. Published online 2022 Jun 10. doi: 10.1093/pm/pnac046PMCID: PMC9186375. R Norman Harden, Candida S McCabe, Andreas Goebel, Michael Massey, Tolga Suvar, Sharon Grieve, Stephen Bruehl
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