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WebKeeper
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Posted: Tue Aug 12th, 2008 05:34 am |
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I like you setting up a test and seems that at least the change was not from 80 to 20 (25%) but 50 to 25 (or 50%). It suggest you made a difference with technique. I do think your next test of supporting 100 pounds and then reducing it to 50 is going to further help the Constancy. Additionally, I will be happy to arrange for you to test out the FlexAble yoke in order to eliminate the sudden changes in the amount of support which cause harness movement.
I was not asking to ignore or dismiss research findings regarding weight bearing initial weight bearing status or the progression of it. Quite to the contrary, I do not believe research methodology supports the findings. Most initial researchers had an instrumented rope with connected to the patient and somehow exerted a known amount of force to the patient body. That is where the weight bearing support percentage came from. However, these early spinal cord patients were hanging on to parallel bar like UE supports and routinely supported more of their body weight on their UE. They also were assisted by therapists' hands which also supported unknown amount of weight. What I have tried to point out that indeed the constancy of the force during the gait cycle or the therapy session is a misrepresentation which unfortunately has clouded the real issue. The patient needs to be kept upright so good afferent input could be generated in order to stimulate CPG. These techniques should be called supported gait training no ref to the weight bearing status. I add my weigh to the hip of a hip-hiking patient to prevent them from the doing so. That is certainly not de-weighting but it is manipulating the environment to achieve improve patterns.
I still think Tim is right in wanting to control the environment and progress the patient through the therapy. I will ask if anyone can comment on how to do that.
Last edited on Tue Aug 12th, 2008 05:35 am by WebKeeper
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tpazier
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Posted: Tue Aug 12th, 2008 12:43 am |
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Thank you for your thoughtful replies to my inquiry into proper unweighting and the BiSym scale. In an attempt to understand the issue at hand, I had one of our clinic aides (trained in LiteGait protocol) set me up in the system. I had him follow the 2- handed technique described with the greater trochanter between the bottom two straps (per Paul Hansen instruction) to capture the pelvis. Those straps were very tight, and the aide was unable to slip two fingers between the straps. The groin strap was also very tight. After 2 minutes at 1 mph and unweighted at 50#, the final BiSym reading was 25#. I could feel that the harness had moved, but I'm not sure what else I could have done to ensure proper fit. Again, there was no wiggle room to speak of at the beginning. I guess what Amir noted in his response would be a better approach - that is unweight more than what you think to allow for the harness to settle in and then start from there. At some point the harness will cease migrating upward ( ), but loss of the pelvis within the system needs to be avoided for optimal facilitation.
With respect to Amir's question about whether it's all about weightbearing status, I believe it's one of many variables, but an important one. If we are to use the research in clinical practice, is it not prudent to follow protocol? If the research states that initial unweighting should be no more than 40%, then how do I know that I've exceeded the recommendations? Or how do I progress appropriately? I absolutely believe looking at kinematics, symmetry, decreasing UE assistance, and physiological status as vital (and ultimately more important) to dosing, but if we strive for consistency in clinical practice, emphasis on unweighting needs to be looked at as well.
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amirseif
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Posted: Fri Aug 8th, 2008 12:37 am |
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Why would a well placed and tight harness wrap with tight groin pieces ride up? As Kayli says below the harness wrap should not move relative to skin/body it is grabbing. However, the soft fatty tissue the harness is pushing on will compress different amount - more with more loads on the unit. So someone is not being supported while the harness is on real tight; I raise the yoke and increase the support to 80 pounds; the tissue is compressed upwards under the specific load level. Then the patient unable to support the remainder of his/her body weight in single limb stance, increases the loads on the harness further indenting upward the harness. This means gaps between the fatty tissue previously not reached by the harness are now holding the harness/groin piece straps. When the patient switches to the opposite side for weight bearing - doing better meaning the system will do less, however, the harness remains within the fatty tissue lowering the effective support - BiSym will just measure this change and displays it.
How does one avoid this? Regardless of how tight the harness is - harness tightness increases the quality of support and patient comfort and results in a more even distribution of the load - you make sure the unit gives a more constant amount of static support from start to finish of a treatment session. If you wish to support someone 60 pounds, produce the static condition Kayli talks about, support the patient 100 pounds (more than 60 !) and then lower the support until it gets to the desired 60 pounds. Supporting the patient more than you intend to at first, you mimic what happens to the harness position when the patient needs more support during treatment. When you lower the device, hence lower level of support to get to the desired level, you get a position of the harness less prone to moving up into the tissue. So to go to 40% go to 60% then come down to 40% you have a better chance of seeing 40% regardless of the dynamics of the treatment.
How about FlexAble yoke? How does flexible support help maintain support? Many LiteGait units are equipped or can be equipped with FlexAble yoke - all E models can have a spring module which allows the clinician to dial in the inches of travel before the yoke becomes rigid. Traditionally, LG models have had a rigid quad support to allow the position of the patient to be maintained regardless of the level of support needed. While many low level patient might require this, as therapy progress you may want to increase hat the patient has to do to maintain position by allowing the center of mass to fall for a certain distance before the rigidity kicks in. So if you support a patient statically while standing 80 pounds, with a rigid yoke setting the patient buckled knees result in an instant increase in the level of support to 110 pounds (or so). With a FlexAble yoke you can let the force slowly increase as the patient is allowed to lower his/her center of mass. This softer support - not appropriate for very involved for good gait patterns - demands more posture from the patient so that the supportive forces do not increase suddenly.
For a patient whom you are supporting 40%, the increase during single limb support to 55% suggest the patient needs your assistance with weight bearing on that side. So as I mentioned below you must help that patient not experience such increase in load by bringing him/her through facilitation of weight bearing on the weak side during each and every step. In fact instead of charting the high reading you and the patient should use it as bio-feedback of something you want to avoid.
Last edited on Sat Aug 9th, 2008 04:41 am by shanna
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kdmpt
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Posted: Thu Aug 7th, 2008 05:46 pm |
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It is true that harness upward migration is not a given. Maybe a slight amount of migration is inevitable but if you are having significant migration which would change your static reading from 80 lbs to 20 lbs, there is a problem with the harness application.
To quickly review, it is important that the harness side straps are snug, so snug in fact that you should NOT be able to slip two fingers between the strap and the body. Remember to use a two handed technique when tightening the side straps and the groin straps by feeding the slack forward toward the buckle and using your free hand to pull out the slack. Also important is the placement of the harness with the bottom side strap at the level of the greater trochanter. The harness placement and adequate tightness are the most crucial elements in getting good harness fit which will eliminate riding up. You will find more postings related to harness application in the FAQ section of this forum.
Is it possible that the patient has experienced improved ability to participate and therefore is standing more upright, taking on more of their own body weight, thus the scale shows a decreased number? I don't know what your patient looks like, but many patients will have increased muscle firing and more dynamic participation after they experience the BWS environment. As for the reading of 110 lbs during SL stance, I would suggest that the patient is experiencing more difficulty during this phase of gait and therefore is placing more demands on the unit than during double limb stance time. It is typical to use the BiSym reading you get when the patient is static with an upright, corrected posture because it is the only static reading you will get.
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amirseif
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Posted: Thu Aug 7th, 2008 06:29 am |
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Tim's question brings up several issues.
1. BiSym Operation - what does it measure and how to use the numbers it measures? Does Tim needs to write down the 110 lb measurement or should he make sure it never happens!?
2. Harness application - Is it given that the harness rides up, lowering the support during treatment?
3. Percentage weight bearing? - What support parameter needs to be controlled for application of PWB/BWS techniques to neurological patients? Is it all about weight bearing status?
4. Be Practical - How can the weight bearing status (let's say for 50% PWB ortho patient) be controlled? Is there anything Tim could have done to not have such large changes in support during treatment?
I will post these questions separately and try to answer them hoping others would share their take on these.
Last edited on Sat Aug 9th, 2008 04:42 am by shanna
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tpazier
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Posted: Fri Aug 1st, 2008 06:03 pm |
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In keeping with current clinical protocols for BWSTT, I have tried to set unweighting at a specific number of lbs. (eg starting a pt at 40% unweighting), and I've used the bisym to assist with this. However, as we all know, the harness will migrate upwards, even with the bottom two straps and groin strap snug, and thus my bisym readings change (usually show decreased lbs.). My question is this: instead of using the initial weight as the indication for unweighting, should I use the lbs reading on the bisym scale during dynamic movement (ie during gait)? For example, I may initially set the unweighting at 80 lbs, but after I stop the treadmill, the scale shows 20 lbs. However, during single leg stance, I noted the scale showing 110 lbs. Common sense tells me I should use the 110 lb reading as the actual amount of unweighting for this bout of ambulation. I know there are many facilities and trainers of the LiteGait system that do not use the bisym, however I see this device as critical for demonstrating pt progress. I also think having a sense of unweighting helps me connect with evidence based practice. Any insights would be helpful.
Tim Pazier, MPT
St. Joseph Medical Center
Tacoma, WA
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