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High Intensity Gait Training to Improve Walking and Balance with an Adolescent Post  Hemispherectomy

Madison Oren, SPT, Caroline Buchanan, PT, DPT, Ethan Hood, PT, DPT, GCS, NCS

A Case Report

Introduction

High-intensity Gait Training (HIGT) is strongly recommended based on level I-II evidence for the rehabilitation of patients with chronic neurological conditions, such as stroke.(1) HIGT is defined as locomotor training at aerobic intensities of 60-80% of heart rate reserve, or 70-85% of  maximum heart rate, depending on the patient’s age.(1-2) Implementing HIGT three times a week for 30-50 minutes has shown improvements in patients walking speed and distance in individuals with central nervous system (CNS) pathology.(1) The success seen from utilizing high intensity aerobic exercise is believed to be a result of implementing the principles of neuroplasticity, or the brain's capacity to adapt, reorganize, and form new neural connections following injury.(3,4) Aerobic exercise has been shown to promote release of the neurotransmitter brain derived neurotrophic factor (BDNF) which is a key contributor to neuroplasticity following neurologic injury.(5) Inducing error during training is essential to motor learning following neurological injury.6 This may include weighting a paretic limb or adding unpredictable variability to locomotor training. More recent research is showing this method of treatment to be effective in subacute phases of injury(3,7) and other neurological conditions, such as Multiple Sclerosis and Parkinson's Disease.(8-10) There is limited research on the use of HIGT for the adolescent population, as well as for patients following cerebral hemispherectomy.

 

Cerebral hemispherectomies are performed to treat drug-resistant seizures due to epilepsy or injury causing hemispheric damage, especially in children.(11-13) Epidemiologic statistics are lacking for the prevalence of cerebral hemispherectomies and recent trends are poorly defined, since the etiologies resulting in hemispherectomy are rare.(13-14) Because of the strong evidence supporting high intensity training as a therapeutic intervention for adults following subacute to chronic neurologic injury, this form of aerobic exercise is beginning to be utilized in adolescents with neurologic injury as well.(15-16) Patients typically present similarly to a patient following stroke, with hemiparesis involving the contralateral upper and lower extremity resulting in coordination and balance deficits.(11) Minimal research is available discussing best interventions for patients following cerebral hemispherectomy, especially in the pediatric population, due to the rarity of these central nervous system pathologies.(17) With minimal evidence available for rehabilitation of adolescents following hemispherectomy, it is crucial for clinicians to determine the best rehabilitation approach for optimizing functional mobility and returning to activities of daily living (ADLs) following surgery.

Background / Case Description

A 14-year-old female presented to physical therapy following a left arteriovenous malformation (AVM) rupture at seven years old followed by a left frontal lobe hemispherectomy and shunt removal seven years later, secondary to seizures. The patient was discharged home eight days following surgery with her first physical therapy evaluation in the outpatient neurologic setting nine days after returning home. She presented with right side hemiparesis, with decreased balance and endurance in addition to cognitive deficits including impaired short-term memory and attention. The patient required use of a hemi walker and a right ankle-foot orthosis at supervision level but continued to have difficulties with her ambulation and stair negotiation without assistance from her parents. These impairments and functional limitations impacted her ability to independently access her family’s multilevel home in addition to her performance as a full-time student with extracurricular activities. She received physical therapy, occupational therapy, and speech therapy for her deficits. Her goals included walking independently to tolerate a full day of school, and return to track and field and marching band. She initially attended physical therapy three times a week for four weeks to improve her functional mobility in the community and at school. At the start of her school year, sessions were then reduced to one to two times per week for 12 weeks to accommodate her personal schedule.

Figure 1. Utilization of ICF Model for a 14 year old female following left cerebral hemispherectomy.

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Initial Examination 

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Upon observation, the patient presented with gait abnormalities including uncompensated Trendelenburg, decreased right lower extremity stance time, and excessive right knee flexion throughout the gait cycle when ambulating with hemiwalker. Ambulation with single point cane and no assistive device were trialed, however the patient required contact guard to minimal assistance of one to prevent loss of balance. Outcome measures utilized included the 10 Meter Walk Test (10MWT) for gait speed, 6 Minute Walk Test (6MWT) for walking or cardiovascular endurance, and the Functional Gait Assessment (FGA) and Berg Balance Scale (BBS) for balance. Findings and assistive devices utilized during examination are demonstrated in Table 1.

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Based upon the normative values for adults, an individual must achieve a gait speed of at least 0.8 m/s to be a safe community ambulator, and a speed of at least 1.2 m/s to cross a busy street.(18) The patient’s gait speeds recorded at evaluation suggest that she is a limited community ambulator and at an increased risk for falls. The average healthy female between 11-14 years old ambulates a total of 1788.06 ft on the 6MWT.(19) A cut off of 997 ft was used to determine walking independence and endurance in patients following stroke.(20) The patient’s total distance walked on 6MWT indicates decreased functional capacity and aerobic endurance. Lastly, an FGA score of <22/30 for an adult indicates an increased fall risk due to decreased dynamic balance.(21)Specific normative values for gait speed, 6MWT, and FGA are not available for adolescents following neurologic injury.

Interventions

The patient attended a total of 28 physical therapy sessions to address gait and balance dysfunction following left hemispherectomy with HIGT initiated at the third session. Sessions included varied methods of HIGT, including treadmill training with overhead harness, overground training, stair training, and ambulation on uneven surfaces. Additional methods to increase task intensity and induce error included reducing upper extremity support, weighting the right lower extremity, wearing a weighted vest, pelvic resistance, faster stepping speed, and changing ambulation direction. The patient performed HIGT for at least 25 to 30 minutes each session, with maximum heart rate and RPE achieved displayed in Graph 1.

Vital signs including heart rate (HR), blood pressure (BP), and pulse-ox were taken pre and post treatment. The original Borg Rating of Perceived Exertion (RPE) scale of 6-20 was utilized to determine the patients perceived level of exertion. Heart rate was monitored throughout each treatment session using either a Fitbit©, iWatch©, pulse oximeter, or a Polar© heart rate monitor. The patient’s target HR range was calculated based on the percentage of heart rate reserve to determine target HR zone dependent upon age and resting HR. Based on a resting HR at the initial evaluation of 98 beats per minute (bpm), the Karvonen method was utilized to determine a target HR of 173-189 bpm. This target range differed slightly depending on the patient’s HR at rest beginning each session.

Graph 1. Maximum HR in bpm and RPE achieved during each treatment session.

Outcomes

 The patient demonstrated improved gait speed and functional endurance as indicated by statistically significant improvements in the 10MWT and the 6MWT. Statistically significant improvement was also noted in the FGA, indicating improved dynamic balance and a decreased risk for falls. With improved balance, endurance, and overall self-reported confidence, the patient no longer required an assistive device for ambulation. The patient additionally met goals of walking independently and stair negotiation without an assistive device and was able to return to a full day of school. She returned to participating in track and field in less than three months from the time of her surgery.  

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Discussion

This case study observed the efficacy and safety of implementing HIGT with an adolescent following cerebral hemispherectomy. The patient experienced no adverse reactions or injuries. There is little to no research available discussing the implementation of HIGT in adolescents following acute neurologic injury. Evidence is especially limited for locomotor training rehabilitation following cerebral hemispherectomy. Current literature focuses on rehabilitation for adult individuals following neurologic injury, such as stroke, incomplete spinal cord injury, and traumatic brain injury.(1,2,5,7)

Aerobic exercise at moderate-high intensities promotes neurotransmitter release in the brain, specifically the release of BDNF.(3) The release of BDNF promotes the development of new synaptic connections around necrotic tissue, which is extremely effective in helping the brain recover and adapt following neurologic injury. The adolescent brain is resilient in its ability to respond to internal and external changes.(22) Therefore, this patient may have been able to adapt to the alteration in neuronal connections following surgical intervention with the help of neurotransmitters released during aerobic activity. Brain development continues through childhood and becomes fully developed in an individual’s early 20s.(23) This patient was only 14 years old with no other significant comorbidities. With her young age and the acuity of her procedure, early initiation of HIGT may have accompanied the brain in creating synaptic connections around the affected tissue.

It is crucial to focus interventions during adolescence toward promoting neuronal connections and synaptogenesis, which occurs through neuroplasticity biomarkers released during high intensity aerobic exercise.(3-5) Initiating HIGT in the subacute stage of her injury could allow for major gains to be made early on in balance and functional mobility. Early mobility with variability in training to induce error helped the patient in motor learning following surgery. In addition to typical neuronal pruning and new connections seen during brain development, the release of neurotransmitters during high intensity aerobic exercise further contribute to the brain’s ability to adapt following injury.

Limitations of this case study include the variability in documentation of target heart rate zone, as well as the variability in the device utilized at each session to monitor the patient’s heart rate. There was variation in the physical therapist working with the patient among sessions and potential discrepancies in knowledge of HIGT. Additionally, the patient only attended 28 sessions over the course of 16 weeks. It is possible that progression at a faster rate would have been made if weekly frequency was maintained for the full 16 weeks. Over the course of treatment, the patient was occasionally underdosed, as a minimum of 30 minutes in the target heart rate zone per session is a requirement for HIGT. Total steps covered at each session was not measured, which may be another effective measure to monitor HIGT.

Implementation of HIGT during physical therapy sessions is increasing in patients with neurological conditions to improve locomotion. Clinicians must first evaluate the patient’s vital signs at baseline to determine a safe target HR zone to achieve during HIGT sessions. Vitals as well as RPE and patient presentation should be monitored during session for a safe and appropriate progression of treatment. Variability in training type is important for motor learning to occur. With proper dosing and monitoring, HIGT is a safe and effective rehabilitation treatment to utilize in an ambulatory adolescent following cerebral hemispherectomy.

     Table 1. Outcome measu scoring and type of assistive device ut

References

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