INTRODUCTION The Gait Coordination Protocol (GCP) was successful in producing clinically and statistically significant gains in impairment, function, and life-role participation for those in the chronic phase after stroke who had exhibited persistent moderate to severe gait deficits [1-3]. The GCP was initially developed to test response to functional electrical stimulation (FES); notably, the GCP produced enhanced coordinated gait regardless of whether FES was used [1]. (The Video shows gait recovery in response to the GCP for a participant from the No-FES group.) In response to national and state presentations, there was a strong call for description of the details of the GCP and its clinical implementation. Therefore, the purpose here is to detail the implementation of this treatment protocol. We constructed the GCP based on the phenomenon of brain plasticity and associated motor learning principles that included task-specific practice (practice as close-to-normal movement as possible [4-7] with continual progression toward normal), high repetition of the desired movement pattern [8-10], focused attention on the part of the learner [11], training specificity [9,12-14], and awareness and feedback [15]. The GCP, described subsequently, was provided 1.5 h/d, 4 d/wk, and for at least 48 visits (12 weeks) [1-2]. Before treatment, the initial assessment included muscle strength, coordination, muscle tone, balance, gait coordination, gait speed, function, and quality of life. Critical aspects of the assessment included the ability to generate normal movement at the hip, knee, and ankle for the motor tasks listed in Figure 1: A-J. For those movements that were impaired, assessment included not only the ability to volitionally generate each of these movements, but also the ability to move in conjunction with an array of assistive movement devices (body-weight support [BWS], bodyweight supported treadmill training [BWSTT], FES) and gait support devices (parallel bars, walker, cane). Each motor task (Figure 1) was assessed for the following characteristics: * Percentage of the normal range of movement that could be executed, volitionally and independently. * Percentage of the motor task that could be executed with the support of verbal or tactile facilitation. * Percentage of the normal range of movement that could be executed along with an assistive movement device. * Normality of effort level during the task (e.g., holding breath, abnormal co-contraction of muscles distant from the targeted task joints or antagonist muscle contractions). * Compensatory strategies employed during execution of the motor task. * Percentage of the task for which compensatory strategies were employed. * Number of repetitions of the motor task that could be performed with only a beat between repetitions before the motor task was performed in an abnormal fashion. In this manner, the assessment was used to identify the initial training level in the hierarchy schema of difficulty (Figure 1). For those motor tasks that could not be volitionally performed, an array of motor learning tools were employed (Figure 2). The GCP utilized an array of tools to optimally apply the principles of motor learning. These tools included selective body positioning (Figure 2: B.1-B.1.1), awareness training (Figure 2: B.2), and practice-assist devices (Figure 2: B.3). The position for motor task practice was selected to satisfy practice of both the most normal movement possible and also the most challenging body position, both of which are required for motor skill acquisition [16-19] (Figure 2: B.1). Practice included the standing position (Figure 2: B.1.1) and dynamic walking, of course, to satisfy the learning principle of task specificity (Figure 2: B.1.2). [FIGURE 2 OMITTED] Awareness training (Figure 2: B.2) consisted of learning to identify and differentiate between normal coordinated movement and the abnormal movement, learning to monitor oneself during practice, assessing how close one's movement was to the normal movement pattern, and assessing the frequency of execution of the more normal movement pattern during a series of practice trials [15]. …
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Jun 1, 2012
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