Interventions Exam #2 - Staal

Brain-Derived Neurotrophic Factor

Helps neurons heal, promotes synaptic connections

Critical for brain health

Lactate

Shuttle for energy across BBB

VEGF

vascular endothelial growth factor

- promotes angiogenesis

- increase BBB permeability

Insulin-like GF

used to communicate with physiologic environment

GDNF

promotes survival of many neurons

Direct Aerobic Effects

Increase GF production

Increase NTM production

Increase neurogenesis

Indirect Aerobic Effects

Physical fitness

Cerebral blood flow

Systemic inflammation

Light Intensity

< 40% HRR

< 4 PRE

< 12 Borg

Mod Intensity

40-60 HRR

4-5 PRE

12-13 RPE

Vigorous Intensity

> 60 HRR

> 6 PRE

> 14 Borg

Walking Speed

Correlates w/ Participation in those with stroke

Predictor of community mobiltiy and QoL

- Trained bia *short, high intensity bursts 85%* of peak HR

Strongest Predictors of walking speed & quality of amb.

# of steps taken and number of PT gait sessions

Propulsion

Driven by PFers

If limited = reduce speed, diff on stairs, posterior lean

*50-75% of metabolic cost*

Limb Advancement

Driven by Hip flexors

If limited = shorten step length, reduced speed, toe or foot catching, diff on stairs

Stance control

Upright posture in sagittal plane

If limited = body collapses, knee buckling, diff on stairs, unsteadiness

Lateral/Postural Stability

Posture control/balance

Ability to alter foot position to reduce lateral COM movement

If limited: AD use, wide BoS, path deviations, reduce speed, diff turning

*25%* of metabolic cost

Adding Error

Propulsion --> Stance control --> Limb advancement --> Stability & Balance

Eccentric Exercise Evidence

In neuro population = may consider supplementing or replacing with Eccentric Training d/t ability to complete greater volumes of work with lower metabolic demand

Hip vs Ankle Strategy

Ankle = Distal --> Proximal (Gastroc/Tib Ant --> Quad/HS)

Hip = Prox --> Distal (Abs --> Quads/HS)

Desired High Intensity Gait Training Practice Components

Reps

Intensity

Salience

Specificity

Walking Impairments after stroke

Step assymetry

High energy expenditure

Fewer steps and bouts of walking

Limited community Participation

Walking Impairments with MS

Balance dysfunction (50-80%)

Reduced speed

Slow movements, delayed response

Smaller step length and higher cortical activity w/ obstacles

Walking Impairments with PD

Walking speed & turning

Decreased step length, speed, turning, multidirectional stepping, backward walking, FOG.

Other Impairments in PD

Multitasking, Concentration, slow speeds

fatigue

insomina

reduced QoL

Pain (central, dystonic [involuntary movement pain], MSK, neuropathic, and akathisia [restlessness])

agitation

Depression

Anxiety (leads to FOG and lower balance levels)

Orthostatic hypotension

PD exercise recommendations

Close to daily:

Aerobic

Gait

RE Training

Balance

- anticipatory and reactive postural adjustments!!

External cues

- visual-spatial cues (step OVER the line), Auditory, LVST cueing (THINK BIG!)

Task-specific

Community-based group

multidisciplinary

behavior change

PD Exercise Tips

DOn't say walk faster

think BIG

Single attentional focus overrides bradykinesia

*Combine gait with any of the other 9!!*

Walking Impairments in TBI

Impaired Turning, timing, cognitive speed, ability to adapt, adjustments, abnormal muscle activation

Walking Impairments in SCI

Variable step-to-step movmeents

Incoordination

Slower walking

Proprioceptive deficits

Rely on vision more

What to include in obstacle course

Backward walking

Dual task

Multidirectional Stepping

Turns (head or body)

environment challanges

reactive/anticipatory balance

change speeds

Clinical Decision Making

Patient Goals

Impairments

Gait subcomponent

Skill Acquisition phase

Stage of learning

Practice type

Motor learning principles (cues)

Extensor Thrust

abnormal extension in knee following IC

Weak Quads ___

Control knee position in standing

Monster walks with proprioceptive training

Sit to stands, eccentric

- POWER

resisted or include sit to stands

Weak or spastic PF ____

Stretch/strengthen

Closed chain strengthening = reaching forward, pushing

AFOs

do not cause less muscle activation and allows eccentric contraction

Rhythmic Auditory Stimulation

Cueing strategy for gait

- allows for brain to anticipate the time to prepare muscles to move between beats

Syncing entertainment + music engages the brain

- increase step length, cadence

- functional walking ability

Cognitive Process Chain

Input & perception --> Organize & store --> Retrieve --> Reason and Apply

Examples of Cognitive Tasks

Hold = sort time info, recall

Process = backward spelling, calculations

Generate = create lists, relatives' names, ingredients

Recall = recall older info, facts, trivia

Examples of Cognitive Tasks - Ranking of Difficulty

Recall (trivia) --> Generate (types of fruits) --> Process (serial calculations, spelling words backwards)

Dual Tasking relies on

ability to perform motor tasks automatically and the cognitive ability to integrate different demands

Safe/Adaptive Strategy

Motor related cognitive interference

- cognition sacrificed

- Motor intact

Optimal Motor Integration

Mutual Facilitation

Motor related cognitive interference

- cognition Maintained

- Motor intact

Capacity Exceeded

Mutual Interference

- Cognition Sacraficed

- Motor drops

Critical/High fall risk

Cognitive related motor interfence

- cognition maintained

- motor drops

4 Executive breakdowns of divided attention

loss of planning

loss of task-switching

loss of self-monitoring

loss of inhibitory control = critical

Where is dual task on degree of skill acquisition

unassisted --> error augmentation

Task Complexity

Task focused

# of components, attention demands

Environmental changes, quicker movements, holding a glass of water

Task Novelty

person focused

experience an individual has with performance of a task

- walking on icy, stepping, walking after stroke

Dual Task Types

Dual motor-motor

- walking and texting

Dual cognitive-motor

- novelty of cognitive changes

- single leg stance with subtracting numbers

Dual Cognitive-motor

- novelty of motor changes

Dual Task Progression

Introduce 1st motor task (3-5 errors/10 reps) --> introduce 2nd task seperately --> put them together

FOG triggers

doorways, turns 360, dual-tasking

- U-step walker helps

FOG Rescue

1. STOP

2. STAND TALL

3. SHAKE IT OUT (relax)

4. SHIFT WEIGHT (unweight stepping foot)

5. STEP (large amplitude step over imaginary line)

Intervnetions = motor+cog training

Neurogenic Orthostatic Hypotension

affects baroreflex cause imapired vasoconstriction

- common in PD

- > 20 mmhg drop in systolic or 10 diastolic after 3 min