high intensity gait training

how do we select interventions

target the impairments found on the exam

How do we structure a session early on during the acute phase of stroke

get out of bed

walk as much as tolerates

repeat

define success in terms of propulsion

directional advancement of the COM

define success in terms of limb advancement

positive step length or swing leg surpass the stance leg

define success in terms of stance control

absence of limb or trunk collapse while stepping

define success in terms of lateral stability

maintaining upright/balance or not losing balance while stepping

What should we give the pt if they are unsuccessful most of the time

guidance

assist as needed

What should we give the pt if they are successful some of the time

trial and error practice

What should we give the pt if they are successful most of the time

error augmentation

Should my pts practice be perfect

No, we want error to learn (need to redefine failure to pt)

define failure

an inability to meet the minimum criteria for success in each component without pain about half the time-”ish”

How does variability and allowing errors affect learning

can improve long term motor learning in the damaged brain

What is characterized as intensity

HR ranges of 70-85%

How long do we need to spend in the intensity range

to pt tolerance (no specific evidence)

What can we use to measure intensity

pt-report (RPE)

CV response

visual appraisal

What percentage of HHR is driven by propulsion

50-75%

What percentage of HHR is driven by stance control

25%

What percentage of HHR is driven by limb swing

5-10%

What percentage of HHR is driven by lateral stability

5-10%

options for challenging propulsion

• speed

• incline/stairs

• resisted walking

options for challenging stance control

• weighted vests

• lessening ADs

• variable surfaces

options for challenging lateral stability

• decreasing UE support

• side-stepping

• external forces

options for challenging limb swing

• stairs/incline

• ankle weights

• hurdles/objects

• theraband resistance

What are the most common beta blockers

carvedilol (coreg)

metoprolol (betaloc or lopresor)

cardiac considerations that would make HR unreliable for intensity

beta blockers

pacers

Afib

recent cardiac interventions

Ca channel blockers

When should body-weight support be used

if the pt is unable to ambulate without stance support from a therapist

According the the CPG, what SHOULD clinicians perform

• walking training at moderate to high aerobic intensities

• walking training with virtual reality

According the the CPG, what MAY clinicians perform

• strength training at </= 70% 1 rep max

• circuit training, cycling, or recumbent stepping at 75-85% HRmax

• balance training with virtual reality

According the the CPG, what SHOULD NOT clinicians perform

• static or dynamic balance activities including pre-gait

• BWSTT with emphasis on kinematics

• robot-assisted gait training

Who is the CPG applied to

ambulatory and chronic stroke pts

What the aim of treatment for the acute phase

get up and get moving

monitor tolerance and ease in

What the aim of treatment for the early subacute phase

keep moving

thousands of steps

start adding intensity

What the aim of treatment for the late subacute-chronic phase

move A LOT with intensity