by Venerando Lomongo, PT From large hospital-based units, including acute care and subacute facilities, nursing facilities and outpatient physical therapy offices, facilities that provide physical therapy treatment strive to provide optimum outcomes. Those outcomes can be especially critical for individuals affected by a mobility impairment, whose goal may be to restore the ability to walk, or to be able to achieve a higher level of mobility in the community and in activities of daily living. To achieve this, facilities must equip their clinics with gait and balance technologies that will help therapists lead patients to their goals, budgets notwithstanding. The dollars a healthcare facility can provide to its therapy practice are affected by a range of variables. For the recovery of gait and balance, time and effort carry a high value, and the market provides a wide spectrum of technologies that can help therapists make the most of critical recovery periods. Those technologies range from costly computerized systems, to tiltboards and foam pads, with each piece of equipment contributing toward the goal of helping patients achieve the highest level of functional return to activity in their community. Not all clinics have equal buying power, but solutions exist for all, depending on the vision and creative ability of the clinician—whether they are the owner of a small clinic or a manager of a larger hospital-based physical therapy unit.
Gait Recovery Toolbox
There are many computer-assisted devices utilized for obtaining objective measures for patients recovering from diagnoses such as CVA and joint reconstruction. These devices allow the clinician objective data to show patients their progress throughout the rehabilitation process. These devices also provide the physical therapist a training tool to improve balance and proprioceptive awareness. Cable-assisted suspension systems and overhead bodyweight support (BWS) systems are designed to help the patient to improve and restore balance. The nature of the design, which safely suspends a patient into a harness secured to a ceiling-mounted track, stationary frame, or mobile frame, allows the practitioner a safe way to progress patients over a variety of surfaces. This, in turn, enables the patient to practice walking- and balance-related tasks safely, while likewise preparing the patient to return to outdoor activities. This enhanced level of safety while walking helps the therapist to reduce the reliance on other therapists or assistants, and prevents potential falls. Furthermore, this allows the patient to feel a level of security that he or she requires in overcoming a fear of falling. When patients regain confidence during weight-bearing activities, they can progress throughout their rehabilitation process and become less reliant on assistive devices. They can then be challenged on repetitive task training and balance training, allowing their center of gravity to move throughout their base of support while maintaining an upright position and thereby reducing the need for balance strategies. Force plate systems allow the clinician objective data to assess principles of gait, such as stride length, step length and gait speed. Gait mat systems and walkways embedded with electronic sensors are engineered to provide a therapist with objective measures of gait, such as temporal-spatial data and data regarding pressure—all of which can be used to create a detailed analysis of gait. Current functional limitation reporting measures (FLR), such as the TUG and Tinetts tests, provide objectivity to patients’ balance, which allows the clinician a baseline and further testing to document progression or regression during the course of treatment. The current technologies used also provide the clinician valuable and reliable objective measurements for justifying medical necessity in an escalating world of insurance company denials.
Cycling to Improve Gait and Balance
While cycling can be a very useful exercise for people of many ages and ability levels, many people who are affected by balance disorders cannot enjoy the benefit of riding a two-wheeled bicycle. For these individuals trikes may provide an alternative solution to continue on a cycling program. However, trikes oftentimes may be large and bulky, and can be difficult to manage in smaller places. Recumbent cycles can be useful indoors, while other products such as adult tricycles give riders the ability to balance and ride outdoors independently. This allows riders the benefit of cycling and the security that enables them to balance while riding. These tricycles allow for maneuverability in small spaces and the ability to transport. Conventional trikes use a crank set and sprocket attached by a chain to the rear axle to propel the rider, as opposed to a tricycle, which uses a front hub and crank set that propels the rider from the front wheel. This design functions similarly to a tricycle or Big Wheel, two modes of transportation often enjoyed by children that provide the freedom of riding and accomplishment of independent function. Adult tricycles allow people of many ages and ability levels to ride once again, or perhaps for the first time. For patients affected by balance and movement disorders, cycling can be a functional exercise, and can likewise provide therapeutic benefits to individuals affected by freezing gait, as associated with Parkinson’s disease. Many people with this disease have difficulty walking, but could ride a bicycle with ease. In a report in the New England Journal of Medicine by Snijders and Bloem about patients they encountered in their National Parkinson’s Foundation Center of Excellence Clinic, Bloem noted that patients could ride a bicycle but not walk.1 In an interview with The New York Times, he noted that he was, “not advocating that Parkinson’s patients hop on a bike and go out on busy roads and that they need help in mounting a bike and need to ride in safe areas.”1 He recommended that patients ride tricycles or use stationary bikes. He also reported that “bicycling offers an opportunity to be symptom free and get real cardiovascular exercise even when their disease is so far advanced that they cannot walk.”1 As we are learning that cycling is useful in patients with Parkinson’s disease, others have begun investigating cycling effects with adolescents with autism spectrum disorder (ASD). A study by Ringenbach et al showed that assisted cycling therapy (ACT) improved participants’ inhibition and cognitive planning.2 ACT participants pedal voluntarily, and pedaling rates are augmented with a motor to ensure the maintenance of 80 RPM. Exercise perception improved after the voluntary cycling (VC). They concluded that ACT appears to benefit cortical structures in adolescents with ASD, but a chronic intervention may be necessary to improve exercise perception and self-efficiency.2 There is a need for future studies involving cycling and movement disorders involving basal ganglion dysfunction, as we are learning that basal ganglion disorders are worsened by stress or anxiety.
Small Footprint, Big Value
Rehab managers sometimes may find themselves tasked with having to identify technologies that fulfill several key criteria for patient use. Among those criteria is that equipment oftentimes must be affordable and cost-effective, with the ability to provide a return on investment while improving the efficiency of the therapists who use it. And, of course, also key among those criteria is the ability of gait and balance equipment to contribute to successful outcomes that uphold insurance requirements for paid claims. Managers must also sometimes deal with space constraints in areas of the clinic where gait and balance therapy is conducted. In dealing with restricted space, naturally, equipment that requires a small footprint and provides ease of transportability will be useful. Among such equipment are certain treatment tables, chairs, or other stable structures that can provide security to patients during balance training. Other gait and balance equipment that can be used in small areas and also are inexpensive are exercise balls and wobble/tiltboards. These tools allow the therapist a way to improve postural stability and balance in the clinic but also have the portability to be used during home visits. Foam pads allow the clinician the ability to improve patients’ balance and proprioceptive awareness, which challenge the patients’ vestibular systems when progressing a patient from an eyes-open to an eyes-closed test. Not all equipment needs to be built around high technology to be effective. Familiar equipment such as parallel bars can provide clinicians the ability to provide balance treatment in a secure environment. Parallel bars can provide patients the confidence to use their upper extremities while also helping them progress through the use of assistive devices—from walker to quad cane to upright cane. Whether therapists practice in a large facility or small facility, there is gait and balance equipment to assist clinicians to manage patient care and provide the best possible outcomes. It is up to the clinician’s creative ability to create treatment strategies to challenge the abilities of balance, gait, and proprioceptive awareness, in an effort to help patients reach their goals and achieve the highest level of functional ability. RM Venerando Lomongo, PT, earned a bachelor of science in physical therapy from Iligan Medical Center College, the Phillippines, in 1992. He is director of the Rehabilitation Department at Verrazano Nursing Home, Staten Island, NY. Among Lomongo’s specialized training, he holds certifications in vestibular and balance assessment, and geriatric rehab. He is also a certified ergonomics assessment specialist. For more information, contact [email protected].
1. Snijders AH, Bloem BR. Images in clinical medicine. Cycling for freezing of gait. N Engl J Med. 2010;362(13):e46. 2. Ringenbach SDR. Assisted cycling therapy (ACT) improves inhibition in adolescents with autism spectrum disorder. J Intellect Disabil Res. 2015;40(4):376-387.