Dr. Christian Dohle
Constant repetition is the most important thing
Which therapies are particularly effective in gait rehabilitation? Dr Christian Dohle explains the current state of knowledge and the most important recommendations in an expert interview.
Interview: Mario Leisle
In order to provide doctors and therapists with professional orientation and to provide patients with optimal care, medical associations develop guidelines for treatment. In autumn 2015, the German Society for Neurorehabilitation published its guideline "Rehabilitation of mobility after a stroke". Dr Christian Dohle is one of the authors. He is Medical Director of the Median Clinic Berlin-Kladow and member of the board of the German Society for Neurorehabilitation.
Mario Leisle spoke to him about the current state of knowledge and the most important recommendations.
Dr Dohle, why is it so difficult for many stroke patients to learn how to walk again?
With a therapist at their side, most patients in rehabilitation are able to get back on their feet very quickly. But often the necessary stability is lacking. I have to keep my balance, I have to be mobile, I have to be able to react to obstacles on the ground and I have to be able to turn my head when someone speaks to me. Walking is a complex process.
If you were to take a key lesson from the guideline, would it be "practice makes perfect"?
Exactly, the constant repetition is the most important thing. I need to keep practising what I'm trying to achieve. The important thing is to define the goal precisely: do I have to learn to walk, or can I already do it and would like to improve walking speed? This results in the optimal therapy.
To improve walking speed, you recommend task-based, progressive endurance training. What does that involve?
Progressive training means that we always adapt to the current performance level. The better the patient gets, the faster I set the treadmill so that they can improve further. Therapists call that "shaping". And, of course, they must have a gait-like movement. The treadmill is a device that combines these two approaches well.
The training should be intensive. Is there such a thing as "too much"?
Yes, there are clear criteria for endurance training in particular. We are guided by the heart rate, among other things. This is the art of therapy, to bring the patients to their performance limits and to keep them there, while not over- or under-straining them.
What can the use of modern technology achieve?
Robot-assisted training has been a domain of gait rehabilitation for quite some time. It is true to say that technology in itself has no value for rehabilitation. But for the therapists and the patients it would be much more expensive to achieve the same result by conventional therapy. The intensity and this high repetition rate would be very difficult to achieve conventionally.
Does this make successful gait rehabilitation a realistic possibility even long after a stroke?
Improvements are also documented in the chronic stage, only the effects are usually smaller. But if there is a certain ability there that can be trained, there will also be improvements. However, the training must then be intensive and high frequency. As an outpatient this will be difficult to achieve due to limited resources.
As a scientist in gait rehabilitation, where do you still see potential for further development?
We have taken an important step with this guideline by evaluating the current procedures. Interestingly, medication seems to be of little help to the lower extremities. We now have to differentiate even better between the methods we use for individual patients. Personally, I also believe that electrostimulation has much more potential. How best to use it will become clear in the coming years.
Can you explain the development of such a guideline to a layman?
It was a lengthy process, we worked on it for several years. We sifted through thousands of works and finally evaluated 188 studies from all over the world. There are meta-analyses for the common methods in which the results of several studies are summarised. The study situation is now quite good, so rehabilitation no longer has to hide behind acute neurology.
Dr. Christian Dohle
Dr Christian Dohle is Medical Director and Chief Physician of the Special Clinic for Neurological Rehabilitation at the Median Clinic Berlin-Kladow and is also a member of the Executive Board of the German Society for Neurorehabilitation.
As a member of the Guidelines Commission of the German Society for Neurorehabilitation, he played a leading role in the development of guidelines for the rehabilitation of the lower extremities after a stroke.