UCSF patient significantly improves gait 13 years post-stroke

Lindsay Palmer is a 30-year-old occupational therapist employed by Greenbrae Care Center, a 55-bed inpatient transitional care center that is part of the Kindred Healthcare network. She had a major stroke 13 years ago while visiting relatives in Florida, resulting in profound right-sided hemiparesis, which physicians at the time predicted she was unlikely to reverse.

View KCRA News’ coverage of Lindsay Palmer and the Tibion Bionic Leg.

After about two weeks in local hospitals, she flew back to her home in Seattle, to begin a month of inpatient and three years of outpatient physical, occupational and speech therapy. Her arm and hand function came back faster than gait. During this time, she had multiple surgeries on her right leg and ankle due to repetitive ankle sprains, decreased balance, decreased strength, and decreased motor control.

Her experience as a patient inspired her to pursue a degree in occupational therapy from Dominican University of California. Upon graduation, she joined Greenbrae Care Center.

Today, she is a patient of Nancy Byl, PT, PhD, FAPTA, at the University of California at San Francisco’s PhysFit Physical Therapy Health and Wellness Center. Dr. Byl is professor and chair of the Physical Therapy and Rehabilitation Science department at UCSF School of Medicine.

How did you learn about Dr. Byl and her Bionic Leg program here at UCLA?

Lindsay: Our speech therapist showed me an article about it in the San Francisco Chronicle. I had been thinking about going back to physical therapy again because I noticed that I was tripping and limping more. I knew I wasn’t as strong but didn’t just know where to go for more than conventional therapy.  I emailed Tibion and they suggested I contact UCSF.

The first time you put it on the Bionic Leg – what was your reaction to putting it on and taking it off?

Lindsay: It seemed too good to be true.  Almost immediately I could walk without my AFO without tripping. I could see improvement from the very first session.

How long was that first session? Did you see any carry-over?

Lindsay: My first session was long – an hour and a half.  There was a lot of repetition and I was exhausted. But afterwards, I did see a little carryover for 15-20 minutes. And the more I’ve used the leg, the longer carryover lasts.  At this point, I have used the Bionic Leg for about 16 sessions, twice a week for eight weeks.

Dr. Byl, can you describe your impressions of Lindsay’s gait when you first evaluated her?

Dr. Byl: My impression was that Lindsay’s gait could be a lot better. Lindsay has a lot of muscle wasting in her right leg, much more noticeable in her right leg than her right arm. This recovery pattern is somewhat unusual for a post-stroke patient. Part of this could be explained by her work as an OT and her greater awareness of how to rehabilitate her arm. On the other hand, the location of the ischemia is important. Her arm was spared a little more than her leg.

If Lindsay was sitting in a chair using her arms and talking to you, you would never know she had a stroke. But as soon as she gets up to walk, she has a very typical circumducted gait with a drag of her toes. Her gait was very asymmetric. When she would complete the circumduction, her leg was so far out to the side there was no way she could possibly shift her weight over her center of support over the right leg. That meant she could not achieve any push off. Because she couldn’t really push off with her right foot, and she was off balance, she would take a quick step with her left leg.

Also, she didn’t dorsiflex her foot at all. She was wearing a static AFO when she was walking. This would keep her ankle in neutral dorsiflexion to try to minimize tripping. Because she didn’t bring her foot up into dorsiflexion, had minimal knee flexion and weak hip flexion, it made it very hard for her to go up and down stairs reciprocally. She reported great frustration at having to go one step at a time. She works as a busy professional under a tight schedule and needs to be able to move quickly.

As both a therapist and a patient, how do you evaluate the results of the first 16 Bionic Leg sessions?

Lindsay: I have more endurance and a more efficient and effective gait pattern. I can walk faster and straighter. I do not turn my foot out as much as I did and I can push off my right leg to facilitate knee flexion, hip flexion and dorsiflexion. I am able to clear my toes when walking and also when going up and down stairs, reciprocally.

Dr. Byl: She gained more flexibility in her gait. She restored a normal arm swing. She now can walk sideways; she can walk and kick a ball as if she was playing soccer. She’s improved the symmetry of her gait and she swings the right leg through more in the sagittal plane. She has been able to decrease circumduction, which potentially was largely learned. Circumduction is somewhat protective because when her leg is out to the side, the ankle is pronated, not supinated. Thus, she doesn’t turn her ankle as much.

Lindsay, it sounds like some day, if you keep up this kind if progress, you might get rid of the AFO.

Lindsay: That’s what I’m hoping, something I never thought would be possible. I had come to the conclusion that I would need the AFO for life.

Dr. Byl, what impact has the Bionic Leg had on Lindsay’s gait speed? Just seeing her walking in your clinic is very impressive. Is she likely to ever be able to run?

Dr. Byl: I think it’s possible. We’ve kept her speed down because our goal has been to improve quality of gait and integrate sagittal plane movement to the swing phase instead of circumduction. When you push people to the limit of their speed, they tend to return to their bad habits. So particularly with the Bionic Leg, I try to keep their speed under control to maximize gait symmetry and quality.  Now that Lindsay is walking with a better pattern, we have her walking on a treadmill and trying to increase speed.  She has been up to 3.0 mph with good quality.

Patients with motor control problems and hypertonicity must concentrate 100% on walking. If they’re walking and talking and trip over a crack in the sidewalk, they don’t have the quick reaction time to protect themselves. Gait is a reflex in normal individuals and requires minimal attention.  Lindsay always has to think about walking to walk correctly. If she is not thinking about it, she returns to her bad habits.

Lindsay is clearly a community ambulatory (>1.0 mph). Our functional objective is to help her become a better, safer, more integrated community ambulatory.  She works very hard, but she has to think about it. With every step, she’s got to say, okay, where’s my balance? Where’s my weight? We want to integrate quality of gait without attention.

Lindsay: That’s especially true when I’m going down stairs, stepping off curbs, and looking out for uneven sidewalks. I’m always looking down. Thinking about every step is just natural now. It’s something that becomes just a habit for safety. I can never stop thinking about my walking. I am hoping that one day walking will be more spontaneous.

Dr. Byl: The gait pattern she demonstrated when she walked into our clinic the first day was partly compensatory and partly learned. When she uses the Bionic Leg, it is helping her to replace the abnormal learned gait pattern with a better one.

Lindsay, you’ve commented that your gait is better since you started Bionic Leg therapy. Have you seen your toe clearance improved with the Bionic Leg?

Lindsay: I can see improved toe clearance since I started therapy with the Bionic Leg. In fact, if I’m not wearing shoes, since starting Bionic Leg therapy, I am able to clear my toe on my own, without wearing the AFO.

Dr. Byl: Right before Christmas, I noted that her carryover was pretty spectacular; even her mom and dad commented about it.

Lindsay remains critical of her own achievements and she would like to be even better. However, the fact she is walking faster, she’s walking better, she is tripping less and now she only wears her AFO to work speaks to her progress. She’s a very dedicated patient, and I’m optimistic she’ll achieve the high goals she has set for herself, or at least come awfully close. I wish all patients had Lindsay’s commitment and motivation.