#10 Functional Activity Interventions for Upright Mobility

What is gait?

Rhythmical, repetitive movement pattern involving multiple body segments, weight shifts in multiple planes for limb advancement and limb stability

What are factors contributing to functional upright mobility?

1. Individual variables

2. Mobility tasks

3. Regulatory features

4. Environmental variables

What individual variables contribute to functional upright mobility?

1. Age

2. Prior experience

3. Motor abilities

4. Diagnosis

5. Motivation

6. Primary impairments

7. Secondary impairments

What mobility tasks contribute to functional upright mobility?

1. Walking

2. Stair climbing

3. Inclines

4. Curbs

5. Obstacle negotiation

6. Single or dual task

What regulatory features contribute to functional upright mobility?

1. Surface conditions

2. Object characteristics

3. Changes in regulatory conditions between attempts

What environmental variables contribute to functional upright mobility?

1. Moving or stationary environment

2. Changes in regulatory conditions between attempts

How should PT interventions be designed when looking at functional upright mobility?

Intervention designed to promote the best possible match between resources and requirements

What are motor control considerations for gait?

1. Gait initiation and termination

2. Relative phase relationship

3. Arm swing

4. Stability - mobility - stability

5. CPG

What is the motor control framework?

1. Descriptive: what's happening?

2. Diagnostic: why is it happening?

3. Predictive: what's likely to happen?

4. Prescriptive: what do I need to do now?

Accurate diagnosis can lead to focused interventions (Lori Quinn)

What are the observable movement constructs for gait?

1. Speed

2. Symmetry

3. Amplitude

4. Alignment

5. Postural stability/verticality

6. Stability

7. Smoothness of movement (rhythmicity/continual fashion)

8. Sequencing

9. Timing

10. Accuracy

11. Symptom provocation

What are tasks changes (progressions/regressions) for gait?

1. Base of support

2. Speed

3. Perturbations

4. Cognitive demand

What are environmental changes (progressions/regressions) for gait?

1. Surface type

2. Cueing

3. Physical assistance

4. External support

5. Environmental inputs

What are the different movement phases for the movement analysis check list?

1. Initial conditions

2. Preparation phase

3. Initiation phase

4. Execution phase

5. Termination phase

6. Whole tasks analysis

What should you observe during the initial conditions phase?

1. Observe starting conditions

What should you observe during the preparation phase?

1. Did the person understand the instructions?

2. Can the person perform baseline tasks without modification?

What should you observe during the initiation phase?

1. Does movement begin with appropriate timing and in sequence in the appropriate direction?

What should you observe during the execution phase?

1. Do the body segments achieve and maintain an adequate position during SLS?

2. Is an appropriate BOS maintained during DLS?

3. is the swing limb advanced part the stance limb with a smooth, efficient trajectory with adequate step length on each side (amplitude, symmetry, smoothness)?

4. Do limbs consistently move in symmetrical, alternating pattern?

5. Does the body progress forward to achieve trailing limb position?

6. Does swing limb consistently achieve adequate clearance?

What should you observe during the termination phase?

1. Does the person maintain COM over BOS without excessive sway?

What should you observe during whole task analysis?

1. Is the overall speed appropriate?

2. Is the whole task smooth, continuous, and efficient?

3. Are there associate symptoms with this task?

4. Is the performance consistent if task is repeated?

5. Is the overall path straight to the intended destination?

What are new perspectives for locomotion assessment?

3 new frameworks for clinicians:

1. Locomotor requirements checklist

2. Standardized walking assessment (SWA)

3. Biomechanical assessment of walking for clinicians

What is the locomotor requirements framework?

1. Initiation

2. Termination

3. Coordination of rhythmical stepping and arm swing

4. Stance stability

5. Progression during stance

6. Swing limb advancement

7. Anticipatory dynamic balance

8. Reactive dynamic balance

9. Adaptability

10. Navigation to unseen locations (pathfinding)

11. Multi-task capacity

12. Walking confidence

13. Purposefulness

14. Metabolic energy expenditure

15. Long-term MSK integrity

What is the standardized walking assessment?

1. Has 4 key "aspects of walking"

2. Assessments DURING walking

3. Score sheet (1-5 for each aspect of walking)

4. Hierarchy to correct deficits: 1) verbal cues, 2) tactile cues, 3) physical assistance

With the standardized walking assessment, what are the 4 key "aspects of walking"?

1. Knee stance stability

2. Trunk upright

3. Swing limb advancement

4. Dynamic balance

What is the purpose of the biomechanical framework?

1. Address neuromuscular impairments in context of stepping practice

2. 4 biomechanical sub-components for stepping practice

According to the biomechanical framework, what are the 4 biomechanical sub-components for stepping practice?

1. Propulsion

2. Swing

3. Stance

4. Postural stability (upper body on lower body/verticality)

According to the biomechanical framework, what are common compensations and challenges during propulsion?

1. Patients compensate with hip/knee extensors (non-paretic limb)

2. Challenges: higher speeds/inclines

According to the biomechanical framework, what are common compensations and challenges during swing?

1. Patients compensate with reduced speed/cadence

2. Challenges: obstacle avoidance, foot clearance, stairs

According to the biomechanical framework, what are common compensations and challenges during stance?

1. Patient compensate with limited stance time, hyperextension

2. Challenges: uneven, compliant surfaces, stairs

According to the biomechanical framework, what are common compensations and challenges during postural stability (upper body on lower body?

1. Patient compensate with decreased gait speed and require AD

2. Challenges: community mobility

What are the primary impairments affecting upright mobility?

1. Perceptual deficits

2. Cognitive deficits

3. Sensory loss

4. Motor problems: muscle weakness, abnormal muscle tone, ROM issues

5. Balance problems

6. MC problems: poor selective control (fractionated movements), multi-joint coordination problems

7. Psychosocial issues

What are commonly used tests to assess fall risks?

1. Activities Confidence Balance Scale

2. Berg Balance Scale

3. Bestest

4. DGI

5. FGA

6. Falls Efficacy Scale

7. Multidirectional Reach Test

8. MCTSIB

9. POMA-Tinneti

10. TUG

What are the possible effects that movement coordination deficits can have on gait?

1. Variable foot placement

2. Slow, small steps

3. May need assistance

What are the possible effects that force production deficits can have on gait?

1. Severe gait deviations: crouched gait, knee buckling, not able to ambulate)

2. May need assistance or AD

What are the possible effects that sensory detection deficits can have on gait?

1. Variable foot placement

2. Gait may improve with vision

3. May require assistance

What are the possible effects that sensory selction/weighting deficits can have on gait?

1. Deviation from straight path

2. Difficulty with changes in sensory environment

What are the possible effects that perceptual deficits can have on gait?

1. Variable gait pattern

2. Asymmetric posture

What are the possible effects that fractionated movement deficits can have on gait?

1. Slow, stiff movements

2. Marked gait deviations

3. May need assistance

What are the possible effects that hypermetria can have on gait?

1. Variable foot placement

2. May need assistance

What are the possible effects that hypokinesia can have on gait?

1. Difficulty initiating gait

2. Variable step length

3. May need assistance

What are general considerations for functional interventions for upright mobility?

1. SAFETY!

2. General approaches

3. Therapeutic approaches

What safety considerations should be taken into account for functional interventions for upright mobility?

1. Intrinsic and extrinsic risk factors for falls (Table 37-2)

2. Age related changes in balance

What general approaches should be taken into account for functional interventions for upright mobility?

1. Neuroplasticity principles: must be engaged in the intense, repetitive, task-specific practice of meaningful activities

2. Incorporate entire body -- all body segments

3. Incorporate balance and dual tasking

What therapeutic approaches should be taken into account for functional interventions for upright mobility?

1. BWSTT

2. Exoskeletal assisted gait training

3. VR assisted gait training

4. Complex walking activities

What questions should you ask as you develop a gait training session?

1. What type of exercises -- closed/open chain, eccentric/concentric?

2. What intensity -- degree of intensity, for how long?

3. In what specific position -- BOS, COM, stability vs mobility vs controlled mobility?

4. How should I progress exercises/activities to place optimal demand on the system for optimal improvement -- Challenge Point Framework?

5. Am I working on specific phrases or constructs or requirements of gait?

What are the evidence based practices for functional interventions for upright mobility?

Combination of strategies associated with remediation and compensation models to help patients attain functional mobility is successful (combination approach!)

What are therapeutic activities to improve upright position?

1. STS

2. Standing

3. Postural control

What are therapeutic activities to improve stability in upright position?

1. Environmental changes

2. Tasks challenges

3. Strengthening and balance exercises

What are therapeutic activities to improve mobility in upright position?

1. Treadmill vs overground walking

2. Functional gait training

3. Attention and dual task control

4. Gait endurance training