THERAPY-Magazin
Increasing intensity during electromechanical gait training
Jakob Tiebel
Business Owner, N+ Digital Health Agency
In everyday clinical practice, therapists are constantly confronted with the question of which load and level of intensity is adequate during electromechanical gait training. This article makes some basic recommendations.
In electromechanical gait training, as in other exercise and exertion situations, the training intensity is also described as a function of frequency (number of exercise intervals, e.g. per week), duration (time) and number of repetitions. The aspects of effort and difficulty are also considered.
If the aspects mentioned above are applied to the specific training situation, the result is a structure for shaping with the following basic recommendations for targeted gait training:
- With regard to frequency, international guidelines usually recommend five training sessions per week, i.e. one session per day for a five-day therapy week. However, in order to significantly increase the chances of regaining walking ability, training should take place at least three days a week.
- The number of repetitions depends on the mobility of the patient. One step is usually considered one repetition. Patients who are not able to walk should achieve 500 to 1,000 steps per exercise unit; patients who are beginning to regain walking ability should achieve at least 3,000 steps. The fitter the patient, the more the recommendations are based on the World Health Organisation (WHO) data for healthy people (10,000 steps per day). Depending on the level of performance, the recommendations cannot always be followed. If the patient is the limiting factor, the rule of thumb is x+1, i.e. one more step should be taken every day. This ensures progression. In most cases, the patient makes much faster progress. Counting the steps and setting individual goals can increase motivation and willingness to perform.
If the aspects mentioned above are applied to the specific training situation, the result is a structure for shaping with the following basic recommendations for targeted gait training:
- With regard to frequency, international guidelines usually recommend five training sessions per week, i.e. one session per day for a five-day therapy week. However, in order to significantly increase the chances of regaining walking ability, training should take place at least three days a week.
- The number of repetitions depends on the mobility of the patient. One step is usually considered one repetition. Patients who are not able to walk should achieve 500 to 1,000 steps per exercise unit; patients who are beginning to regain walking ability should achieve at least 3,000 steps. The fitter the patient, the more the recommendations are based on the World Health Organisation (WHO) data for healthy people (10,000 steps per day). Depending on the level of performance, the recommendations cannot always be followed. If the patient is the limiting factor, the rule of thumb is x+1, i.e. one more step should be taken every day. This ensures progression. In most cases, the patient makes much faster progress. Counting the steps and setting individual goals can increase motivation and willingness to perform.
Counting the steps and setting individual goals can increase motivation and willingness to perform.
- As a rule, a gait training session is planned for 30 to 45 minutes. 10 minutes are required for set-up, so that the net exercise time is between 20 and 35 minutes. This makes it clear that achieving the necessary number of repetitions within a limited therapy duration can only be achieved by increasing the walking speed. In general, a speed should be selected that is tolerable for the patient. Faster walking is often easier, even for severely affected patients, because they are not forced to stand on the affected leg for an unnaturally long time. In addition, high speeds activate the Central Pattern Generators (CPG) in the spinal cord. Slow walking is only suitable for targeted improvement of the supporting leg phase, balance and equilibrium.
- The level of exertion required by the patient determines how strenuous the exercise feels. Partial relief of body weight plays a decisive role here. Patients who are unable to walk should be dynamically relieved of about 40% of their body weight at the beginning. Relief should be consistently decreased by 5% as functional recovery increases.
How do you find the optimal “challenge point” between all parameters? Unfortunately there is no “one size fits all” solution for this. Although this might be a good thing. Every patient reacts differently to electromechanical gait training.
In order to select the optimal individual parameters, the expertise of the therapist is required – preferably in partnership with the patient. A simple and effective way to measure exertion is by using the Borg scale, for example. Patients can determine for themselves how strenuous they find the training. As a therapist, it is important to remember that the optimal level of difficulty is not when the patient performs best. The performance limit is reached when performance visibly and noticeably decreases. This point must be found carefully and then shifted progressively towards increasing performance.
- The level of exertion required by the patient determines how strenuous the exercise feels. Partial relief of body weight plays a decisive role here. Patients who are unable to walk should be dynamically relieved of about 40% of their body weight at the beginning. Relief should be consistently decreased by 5% as functional recovery increases.
How do you find the optimal “challenge point” between all parameters? Unfortunately there is no “one size fits all” solution for this. Although this might be a good thing. Every patient reacts differently to electromechanical gait training.
In order to select the optimal individual parameters, the expertise of the therapist is required – preferably in partnership with the patient. A simple and effective way to measure exertion is by using the Borg scale, for example. Patients can determine for themselves how strenuous they find the training. As a therapist, it is important to remember that the optimal level of difficulty is not when the patient performs best. The performance limit is reached when performance visibly and noticeably decreases. This point must be found carefully and then shifted progressively towards increasing performance.
Summary
Training should begin with up to 40% partial body weight relief in order to make effective use of the full therapy duration. Active takes precedence over passive, however, so the weight relief should be gradually phased out as soon as possible. In general, a higher walking speed should be set rather than a lower speed. However, it must be tolerable for the patient and should not be increased at the expense of endurance, particularly in patients who are unable to walk. As walking must be practised repetitively, the number of repetitions is crucial. Counting the steps can be an incentive and can help to set goals: take at least one step more every day! Progression is the name of the game. The Borg Scale provides a simple way to determine the patient’s perceived level of exertion. Once the patient reaches their limit, their performance drops visibly. The key is to neither overexert nor to underchallenge the patient.
Training should begin with up to 40% partial body weight relief in order to make effective use of the full therapy duration. Active takes precedence over passive, however, so the weight relief should be gradually phased out as soon as possible. In general, a higher walking speed should be set rather than a lower speed. However, it must be tolerable for the patient and should not be increased at the expense of endurance, particularly in patients who are unable to walk. As walking must be practised repetitively, the number of repetitions is crucial. Counting the steps can be an incentive and can help to set goals: take at least one step more every day! Progression is the name of the game. The Borg Scale provides a simple way to determine the patient’s perceived level of exertion. Once the patient reaches their limit, their performance drops visibly. The key is to neither overexert nor to underchallenge the patient.
Ambulante Rehabilitation
Fachkreise
Gait
lyra
Produkte
Therapy & Practice
THERAPY 2020-II
THERAPY Magazine
Jakob Tiebel
Business Owner, N+ Digital Health Agency
Jakob Tiebel studied applied psychology with a focus on health economics. He has clinical expertise from his previous therapeutic work in neurorehabilitation. He conducts research and publishes on the theory-practice transfer in neurorehabilitation and is the owner of Native.Health, an agency for digital health marketing.
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