The guidelines of the American College of Sport Medicine and the American Heart Association recommend:

• Training 3 to 5 times/week for 20 to 40 minutes
• Training with 50 to 80 % of the maximum heart rate
• Documentation of the results (10-metre walk test, 6-minute walk test, force test)
• Strength training always with one leg
• 10 to 12 repetitions, 3 series
  each with pause

The training should always be at the limit of the patient's performance and be carried out for at least 4 weeks before success can be measured. Many studies have shown that strength training in stroke patients leads to an improvement in the functions trained, with no increase in spasticity or pain. Even high-intensity strength training leads to an improvement in strength and functional abilities.

The walking speed must be set to as quick as possible. Often only a higher speed makes it possible to find the right gait rhythm, improving symmetry and thus making walking easier for the patient. The training is therefore more relevant to everyday life and walking becomes automatic. Even severely affected patients should reach a speed of around 1 km/h in the first sessions. Of course, this depends on the individual – but faster is easier!

Later on, specific attention must be paid to an increase in speed. The higher the speed, the easier it is to walk. For more experienced patients, the minimum speed can be increased to 2.6 km/h. Even the 4 km/h that the lyra goes up to is slower than we would normally walk, but is entirely sufficient for the patients. In general, the patient should not be assisted in any way, as this disturbs motor learning. Remember: if the focus is on speed, the patient can of course hold on to something for support. The patient may and should also look at their feet, as they can learn more effectively from the visual feedback.


Endurance

In addition to speed, the time for which the patient can walk is also a focus. It is important that the patient walks for as long as possible. They can also be allowed to sit briefly on the lyra to rest. The recommended endurance training is interval training at the fastest possible pace, but most importantly for the longest possible time. The metres walked are noted as the target parameter [7]. Step length can also be considered, but this is less important. The most important aspects of gait training are speed and endurance.

Even balance can be trained in the lyra. In this case, the patient should no longer hold on to anything – or only onto mobile objects such as Thera bands. Focus can now be placed on the patient looking right, left and upwards. This will help them train sensory balance. Of course, motor and cognitive dual-task training can also take place.

Weight relief should be minimal and should take place only when necessary, and should be dynamic so that the relief can adapt to the patient's gait. This enables the patient to support their own weight as far as possible.

The affected hand should always be moved along with the arm, even if it has to be supported or fixed. If the therapist has concerns about the shoulder, a shoulder brace should be used. If the shoulder is painful, exercise should be carried out on a raised seat or while standing up, so that the arm is not flexed more than 60 degrees. If the focus is on strength, appropriate resistance must be used. In this case, instead of taking a hesitant approach, it is important to determine the patient's performance limit. This is the individual reference point for controlling the strength requirement.

Strength training

Yes. We know that strength is also essential in the upper limbs in order to reduce evasive movements and make activities possible. Damage to the upper motor neuron leads to negative symptoms, which can and must be alleviated with strength training. The DGNR guideline for "Motor Therapies for the Upper Limbs in the Treatment of Stroke" classifies arm pareses according to strength values and recommends strength training.

... even with spasticity
That's right – because the positive symptoms are sustainably reduced by activity or strength training. Functionally, the positive symptoms of UMNS are reduced to the extent that activity or strength is improved. Even with severe arm pareses, activity and individually adapted resistance loosen the arm both temporarily and permanently. If the arm gets tired, a temporary increase in the positive symptoms may be observed.

Limits of tigo training for arm motor skills

As therapists who focus on functional ability and everyday activities, we know that distal function is what makes arm activity possible in the first place. The grasping function must be accorded central importance in therapy of the upper limbs. Training with the tigo does not reach this function – however, the proximal musculature can be usefully trained.

Lower limbs

A movement exerciser allows targeted endurance and strength training of the lower limbs. It is up to the therapist to decide whether targeted endurance training is performed with the upper limbs to achieve the above effects or whether activation of the lower limbs is preferable. Since endurance training requires as much resistance as possible, as quickly as possible and – most importantly – for as long as possible, short breaks should be planned and exercises repeated up to three times.

Note: For all parameters, the patient's performance limit should first be determined and the training should then be individually adapted.

Strength training with the movement exerciser

During training with the tigo, the lower limbs as well as the muscles important for walking (dorsal flexors, calf, quadriceps and hip flexors) are activated. For this reason, resistance training with the tigo is a very sensible supplement to gait training for patients who have suffered a moderate to severe stroke. Here too, it is important to train at the patient's performance limit and to make sure that the affected leg is activated.
The tigo movement exerciser can generally be used for targeted endurance and strength training of both the upper and lower limbs.

We know that alertness plays a major role for patients with neglect, so it is better to carry out optical stimulation, gripping exercises or mirror therapy to treat the neglect while the patient is standing up, as they will have a higher degree of alertness than when sitting.
With pusher syndrome, the best approach is to move forwards and backwards with the balo along with visual feedback and games, and then gradually switch from the sagittal to the frontal plane.

Balance training

The patient can practice actively shifting their balance at all levels and thus train proactive balance.
Thanks to the spring resistance, the right side is activated more when moving to the left side and vice versa. If a patient has a hemiparesis on the right side, there should be more movement to the left side. The balance must be actively shifted by the right side. It is also important to work with the spring resistance. If lower spring resistance is set, the balance shifting must be adjusted more finely. This means that the demand on the patient's coordination is higher.

Strength training

And it is thanks to spring resistance that the balo provides an effective and targeted means of training strength.

Generally speaking, step triggering also needs to be trained more frequently during balance training. The balo, when appropriately secured, provides the ideal opportunity for this. Its spring resistance also enables heavier patients to use it for active strength training on a regular basis.