Motor Control: High Intensity Gait Training for Locomotion (7)

what approaches was high intensity gait training designed for?

patients with CVA, TBI, and SCI

what are the traditional approaches?

- Bobath/NDT

- PNF

what was a concept that Bobath believed yet contradicts high intensity gait training?

intense exercise could worsen spasticity

what does the recent evidence say about the influence NDT has on walking patterns?

walking patterns are not "more normal" after NDT treatment

3 multiple choice options

what does the recent evidence say about PNF?

there is poor evidence PNF to improve walking performance post stroke

3 multiple choice options

what are possible impairments responsible for toe clearance issues?

decreased hip, knee, or ankle (D)flexion strength

3 multiple choice options

What are the possible impairments responsible for sit to stand difficulty?

decreased LE strength

what are the possible impairments responsible for asymmetrical weight shifts?

inability to weight shift

what does the research say about the influence of traditional approaches on better walking function?

there is not a substantial impact on walking function

3 multiple choice options

Explain in your own words why traditional approaches in PT lack specificity (why we aren't seeing neuroplastic changes)

the traditional approaches focus on multiple tasks such as transfers, bed mobility, supine <-> sit, etc... we will only get better at those skills. there is no specificity in the interventions. we need to WALK to get better at WALKING!!

Explain in your own words why the "Leap Frog" Phenomenon works?

this is the idea of practicing the more challenging tasks first instead of starting with the easy ones and progressing. if you start with hard tasks, the "easy" skills are embedded in the hard ones. (EX. if you work on gait training, you will get better at the toilet transfers because you are strengthening the same muscles needed. HOWEVER this won't work in reverse)

Explain why the traditional approaches aren't hitting the "repetition matters" principle of neuroplasticity?

the average amount of steps in IPR is 262 but the research says you need 2000 steps per treatment session to see any changes in IPR. When following the traditional approaches, the therapists are getting enough out of their patients

describe the study comparing the in clinic and actual outcomes of patients in OP PT and intensive locomotor training?

- patients in OP PT took less steps in stepping practice in the clinic; increased walking within in the clinic; HOWEVER there was no impact on the amount of walking the patient was doing at home

- patient in intensive locomotor training practiced stepping more; this is increased the amount of total steps taken during a treatment session; AND it significantly increased the amount of steps taken at home

why is the study of intensive locomotor training important to us?

this is important because the reason we are treating patients is to improve their QOL outside of the clinic. without actually increasing their activity and participation outside the clinic, we aren't doing that

why does traditional approaches not meet the principle "intensity matters" for neuroplasicity?

intensity is not determined by minutes per session or sessions per week. it is determined by the actual work the patient is doing the treatment.

what is the role explicit feedback plays with motor learning?

explicit feedback is not as beneficial as letting the patient struggle after being set up correctly

is there a CPG for improving locomotor function following chronic stroke, incomplete SCI, and brain injuries?

yes

what are the components of high intensity gait training (HIGT)?

- maximize stepping

- stepping variability

- high aerobic intensities

what does it mean to maximize stepping for HIGT?

you only practice on stepping (treadmill and overground)

What does it mean to include stepping variability in HIGT?

- forward, backward, sideways, stairs, and obstacles

- the focus is to recruit more expansive neural circuits

- the goal is to improve walking adaptability

what aerobic intensity should you be in during HIGT?

70-85% HR max

what range are you aiming for when using RPE?

15-17

when working with a patient in HIGT, what are you focused on with their kinematics?

- stance control

- limb advancement

- propulsion

- balance

What are we less (but still a little) concerned about the patient's kinematics with HIGT?

normalizing patterns

3 multiple choice options

Why are we less concerned about normalizing the patient's patterns?

many of these patients have learned to adapt to their condition. their patterns are how they maximize their level of function

what is the goal of stance control?

avoid vertical limb or trunk collapse with a steady base

How do we assist with stance control?

- BW support with harnesses

- manual blocking or bracing

- UE usage

How do we challenge the patient in stance control?

- weighted vests

- reduced UE on handrails and AD

what is the goal of limb advancement?

adequate foot clearance and positive step length

How can we assist with limb advancement?

- manual or elastic assistance

- AFO

How can we challenge the patient during limb advancement?

- ankle weights

- posterior directed elastic resistance

- stepping over obstacles

- stairs

what is the goal of propulsion?

ability to move the body forward during the stance phase (this is separate from the limb swinging)

how can we assist the patient in propulsion?

- manual or elastic assistance at the pelvis

How can we challenge the patient in propulsion?

- decrease UE support on treadmill

- increase stepping speeds

- inclined surfaces

- elastic resistance at the pelvis

how can we assist the patient with balance?

- manual assist at the pelvis or the trunk

- stabilizing elastic assistance at the pelvis

- use handrails or assistive device

how can we challenge our patients balance?

- decreased UE support

- progress backwards or side stepping

- stepping over or around obstacles

- uneven, compliant, narrow surfaces

- dual task

what are the principles of HIGT?

- specificity

- repetition

- intensity

- external focus of attention

- variable practice

- assist as needed + error augmentation

what is error augmentation?

including interventions that will disrupt what the patient thinks will happen (this can be external perturbations, uneven ground, varying speed on treadmill, etc.)