862: high intensity gait training and postural control intervention

Locomotor CPG recommendations: should be performed

Mod-high intensity walking (70-80% max HR)

VR coupled treadmill training

Locomotor CPG recommendations: may be considered

• strength training >70% 1RM

• Circuit or combined training

• Cycling training at high intensities

• VR coupled standing balance training

Locomotor CPG recommendations should NOT be performed

• sitting/standing balance without augmented visual input

• Robotic assisted walking training

• Body weight supported treadmill training with PT assist

Benefits of HIGT

• increased gait efficiency and decreased O2 cost

• Increased average daily steps

• Improving walking outcomes including gait speed and distance

• Rapidly assist patients to reach significant outcomes on 6MWT and 10MWT

• Decrease resource utilization

• Compared to low intensity, HIGT has greater improvements in:aerobic fitness and motor function, protection from CV events

Who is NOT appropriate for HIGT

• severe LE contractures

• Orthopedic injuries aggravated by gait

• Significant osteoporosis

• CV or metabolic instability

• Cognitive impairments that impact attention or 2 step command following

• Untreated major depression

Implementing HIGT: safety

• upon evaluation determine if pt is a candidate for HIGT

• Contact physician for clearance

• Stress test may be necessary for safety due to the need for 12 lead ECG, will need to be performed at another facility

Implementing HIGT: parameters

Moderate-high intensity = 60-80% HRR or 70-85% HR MAX

Implementing HIGT: outcome measures

6MWT and 10MWT

Implementing HIGT: equipment needed

• treadmill or walking path

• HR monitor

• RPE scale/ ANPT HR guide

• Safety harness

RPE target for HIGT

15-17

Signs to terminate HIGT session

• drop in SBP >10 mmHg with increased workload

• SPB> 250 mmHg or DBP> 115 mmHg

• Chest pain or angina

• Dizziness, near syncope

• Cyanosis or pallor

• Pt desire to stop

• Excessive fatigue, SOB, wheezing, leg cramps, or claudication

Suggestions for Intervention

• 3 min warm up at 30-50% max HR

• 2 min cool down at 30-50% maxHR

• Continuous forward treadmill training

• 30 sec interval training with 30-60 sec rest between

• Attempt to train in HIGT for 10-20 mins during session

Intervention ideas

• weighted vest, 10 lbs

• Ankle weight to paretic limb to increase demands of swing

• Theraband with posterior force to increase forward propulsion demands

• Placing a “safety” band posterior to pt to adjust speed or stop as necessary

Acute injury gait training:safety

• discuss aerobic treadmill training with physician: set parameters for HR and BP

• Use continuous HR monitor if possible

• Use RPE to monitor exertion

• Calculate training HR

  • HRmax = 220-age(0.7)

  • THR = (HRmax-HRrest) x .6+ HR rest

Acute injury gait training: outcome measures

• 6MWT

• 10MWT

• Stroke impact scale

Aerobic training recumbent stepper

• 3x per week up to 30 mins per session

• Exercise group avg improved 10MWT comfortable pace = 0.18 m/s

• Showed improved gait symmetry exercise vs control

Focused stepping practice

• large amounts of continuous stepping practice as opposed to part practice stepping or weight shifting

• Treadmill, OG, stairs and with or without BWS or physical assistance

• Feasible intervention in IRF

• Enhances neuroplasticity with repetition, intensity, use it, and transference

• Showed improved overall mobility at 6 months

Acute/subacute takeaways

• repetition and intensity of gait training matters

• BWSTT is a great tool to decrease PT burden and allow safe stepping and gait training

• Utilize mixture of strategies to maximize pt outcomes

Postural control

The ability to maintain a steady position in a WB, antigravity posture

Intrinsic risk factors for falling

• advanced age

• Female

• Gait and balance impairments

• Acute and chronic illnesses

• Cognitive and functional impairment

• Depression

• Visual deficits

• Muscle weakness

• Polypharmacy

• History of previous falls

Extrinsic risk factors for falling

• inadequate lighting

• Slipper floor surfaces

• Loose rugs

• Uneven steps/surfaces

• Cluttered walkways

• Use of AD

• Ill fitting shoes

Commonly used outcome measures to determine which system is impaired

• modified clinical test of sensory interaction of balance, mCTSIB

• Sensory organization test, SOT

Static sitting activities

• achieve static sitting

• Maintain sitting without UE support

• Move within BOS

Dynamic sitting activities

Move COG outside BOS

• weight shifting, reaching

• Ability to recover from slow and quick perturbations

• Change of sitting surface

Dynamic standing activity

• move outside BOS

• Weight shifting, reaching

• Ability to recovery from slow and quick perturbations

• Change of surface

• Change BOS

Components required to maintain balance

1. Quiet standing: ability to maintain COM within the BOS

2. Self induced perturbations: able to adequately reposition COM within BOS

3. External perturbations: able to achieve adequate stepping responses

Sensory strategies

• sensory organization test

• Visual dependent

• Somatosensory dependent

• Vestibular dependent

Motor strategies

• reactive balance control

• Ankle strategy

• Hip strategy

• Stepping strategy

Self reported measures of balance ability

• actives specific balance confidence scale, ABC

• Falls efficacy scale

Performance based measures of balance

• 5x sit to stand

• Functional gait assessment

• Dynamic gait assessment

Performance based measures of balance

• mCTSIB

• Sensory organization test, SOT

• Berg

• Mini BESTest

• TUG

• Tinetti- POMA

• Functional in sitting test FIST

• Rhomberg

Exercise category to improve postural control

• static standing

• Compliant surface standing

• Weight shifting

• Modified COG

• Gait

• Gaze stabilization or VOR training

Increasing surface difficulty

• solid, firm and level surface

• Uneven surface such as grass

• Compliant surface

• Sloped surfaced