intervention principles

remediation: plan A

recovery of skills and/or reversing impairments

assumes potential for change in system and person

ex. neuroplasticity, muscle hypertrophy, muscle lengthening, etc.

compensation: plan B

alteration of environment or task

when full remediation not possible/when reducing demands of task/activity

ex. walker to incr BOS

prevention: so plan A/B is not needed

management of anticipated problems

preventing primary, secondary, tertiary sequalae

CPG for locomotor training

chronic SCI, TBI, CVA/stroke

should: mod-high intensity walking training, training w/ VR

maybe: strength training (>70% 1RM), circuit training, cycling, recumbent stepping (75-85% HRmax), balance train w/ VR

should not: static/dynamic balance, robot assisted gait training, weight shifting

chronic stroke, TBI, iSCI locomotor training

improve walking as primary/sec outcome

outcomes: short distance (10MWT or =), long distance (6MWT or =)

key FITT components: specificity, amount, intensity

essential biomechanical subcomponents of gait

stance control: avoid collapse, steady base

limb advance: adequate foot clearance, good step length

propulsion: ability to move body forward (aside from limb swing)

balance: staying upright

best training for locomotor outcomes

high intensity gait training—high aerobic intensity, repetitive stepping in variable contexts

dosage for task-oriented fxl training

consider, assess, monitor pt tolerance via graded testing

may need to build up to if deconditioned and fatigued

ex.

F: 3-5 days/wk

I: mod-high intensity (4-8/10 RPE, 40-80% HRR/HRmax)

T: intervals vs continuous training, fatiguability, start w/ 5-10 min/task

T: task specific

VP: 30min/day

HR calculations

HRmax=208-0.7*age

adjust for beta blockers

light intensity

30-40% HRR or VO2R

2-<3 METs

9-11/20 RPE (2-3/10)

slight increases in HR and breathing

moderate intensity

40-60% HRR/VO2R

3-<6 METs, 12-13/20 RPE or 4-5/10

noticeable incr in HR and breathing

vigorous/high intensity

>/=60% HRR or VO2R

>/=65% HRmax

>/=6 METs

>/=14/20 RPE or >/=6/10

substantial incr in HR and breathing

dosage for postural control/balance training

must consider, assess, monitor pt tolerance, abilities, and safety (guard, gait belt, harness)

F: 3-5 days/wk

I: mod-high intensity, create instability, 3-5 mins

T: fatiguability, typically start at 30s/position, 3-5 mins

T: steady state, dynamic, anticipatory, reactive balance—specificity critical for transference

VP: 15-20 min/day

adaption based on improvement

incr challenge (task complexity, load, speed, DT, duration, variability)

adaption based on plateau

modify task, environment, or feedback

adaption based on safety concerns

regress context, not goal

adaption based on regression

if expected: regress goal, add compensations

if unexpected: re-exam

volume of PA per day

structure excs—comprehensive program

lifestyle PA

sedentarism: increases in early and late adulthood

goals of AFOs-KO-KAFO & UE orthoses

for pts with injury or MSK imbalance: support foot/ankle, optimal fxl alignment, limit motion to protect healing

neuromotor dysfunction: sub for inadequate mm fx in gait, optimal align, min risk of deformity, assist in tone mgmt?- depends

determinants of fxl gait

stability in stance

clearance in swing

swing phase prepositioning

adequate step length

energy conservation

foot rockers

1st: heel in LR

2nd: ankle in MSt

3rd: forefoot in TSt

4th: toe—extends forefoot (MTPs) in PSw

^ length of foot in brace can allow or inhibit toe extension, affects gait efficiency

optimal foot orthoses

provide a minimal amount of stability so that mobility is least compromised

proper shoewear critical to ensure optimal orthotic function

phases of reach & grasp

locate target

reach

grasp

manipulate

mobility devices

matched to pt goals, ability level

least support device necessary, but consider function, safety, energy management

common in neuro: canes, walkers (rollators), WC, slide board, more

environment

simple to complex changes

height of surface: STS, reach, stairs

surface variability, firmness: walking, bed mobility

lighting: reach, walking

ramps, elevators

home/environmental eval

need to simulate for task specific training

top 10 common complications in neuro

respiratory

psi injuries

DVT/PE

CV

autonomic dysfunction

orthostatic HoTN

heterotopic ossification

osteoporosis

spasticity

pain

primary prevention

ex: fall prevention to avoid SCI, TBI

preventing devlopment of other diseases (heart, diabetes, cancer)

preventing onset of MS in someone w/ genetic predisposition (smoking abstinence, stress mgmt)

facilitation

appropriate for indivs who demonstrate insufficient recovery and lack voluntary mvmt control

contra in pts w/ sufficient active mvmt control→active excs, task oriented training should be used instead

facilitation techniques

neurodevelopmental tx (NDT/bobath approach)

neuromusc facilitation (PNF)

sensory stimulation techniques (tactile—roods)

biofeedback

estim

contemporary NDT

pt self-initiates mvmt

handling techniques thru key points of control to help establish reference of correctness for desired mvmt

remove hands ASAP

as little hand contact & directed input as possible

considerations for contemporary NDT

can allow incr repetition

can improve motivation

perform w/ fxl tasks—forced use

may advance to assist as needed

caution: providing more assist than needed for longer than needed→dependency

PNF

WB (hand on table): applied manually via body position/gravity facilitates mm contraction & kinesthetic awareness

prolonged stretch: slow maintained stretch at max avail range inhibits mm contract

PNF considerations

can be additive, repetitive

perform w/ fxl tasks

may advance to assist as needed

tactile sensory stimulation techniques (ROOD)

maintained pressure (firm pressure to midline, back, abdomen)*

slow repetitive stroking (paravertebral)

light touch: brisk quick stretch can elicit flexor withdrawal response

ROOD considerations

improve attn and arousal lvls

generalized inhibition of mm contraction/agitation

excess stim produces undesired response

must incorporate fxl tasks

limited current evidence to support use

biofeedback

u know what this is

neuromuscular electrical stimulation (NMES) and fxl electrical stimulation (FES)

stim contraction in weak muscles (FP deficit)

re-ed mm

imrpove ROM

decr edema

treat disuse atrophy

what to consider in decision making

prognosis: degenerative? injury w/ + prog or - prog

goals: recovery, compensation, prevention?

time since injury/diagnosis: acute vs chronic, early vs late stage

practice setting

ability level

assist levels (QI score*)

6: indep

2-5: partial dep

5: set up or clean up assist

4: supervision/touch assist

3: partial/mod assist (<50% help)

2: substantial/max assist (>50% help)

1: complete dependence (100% help)

goal considerations for lower lvls of fx & prognosis

ability to direct assistance needed

modified indep with adaptive equipment

maintain fx

slow loss of fx

prevent sec & ter complications (pain, skin breakdown, falls)

tolerance to position & activity

upright: sitting EOB, tilt table, stander, compression (abdominal binder, compress stockings)

prone & other positions: prone b/c WC users will have tight HFs

activity

assistive technology

eye gaze technology (ALS!)

smart phones

voice activation

head array

sip and puff

standardized assessments for lower levels of fx

trunk impairment scale

FIST

PASS

goal considerations for high lvls of fx & prog

ability to be indep w/ least restrictive device possible

enhance/improve fx

prevent sec & ter complications

linear progression of higher levels of function/better prognosis

flexible progression

perfection of one phase is not required before progression to the next

assist levels for higher function/better prog

harness for safety

gait belt

parallel bars

error augmentation for higher function/better prognosis

increase error and intensity

standardized assessments for higher levels of function

functional gait assessment

6MWT