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PHTH 551- Neurological Rehabilitation > Control of Mobility Functions > Flashcards

Control of Mobility Functions Flashcards

1
Q

What are common mobility functions to consider?

A

Gait
Transfers
Bed mobility
Stairs/Ramps

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2
Q
  1. Are the postural control demands for walking and stance the same?
  2. What is the goal of walking?
A
  1. No. The postural adaptations differ in standing and walking (see pictures on slide w/ tilt table).

In walking there is a continuum of postural control strategies depending on the phase of the gait cycle to minimize loss of balance and continue forward progression.

  1. Move CoG ahead of BoS to advance.
    - The CNS does play a role in projecting CoG ahead of BoS.
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3
Q

What is harder: Maintaining balance on a tilting platform while standing or walking?

A

-Standing is harder than walking.
Why? B/c the goal of walking is always to stay in motion by projecting CoG ahead of BoS, CNS control keeps this going. So while walking you are already trying to maintain balance w/ a changing CoG. However, in standing reactive postural control is required when the platform tilts. B/c standing is a state of equilibrium followed by a perturbation.

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4
Q

How does the slope incline of a treadmill relate to forward bending of the trunk?

A

Walking: the trunk is always bent forward no matter if the slope is going up or towards b/c the CoG needs to be projected forward.

Standing: trunk is in a stable position even as the treadmill tilts.

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5
Q

What are the essential elements for locomotion?

A
  1. Progression: Basic locomotor pattern that coordinates muscle activation and initiates and terminates locomotion. Moving body forward.
  2. Postural Control: Orientation: Align body segments relative to one another and the environment to achieve requirements of locomotion. Equilibrium: Control CoM relative to BoS.
  3. Adaptation: To different environments or terrains.
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6
Q

What are the phases of the Gait Cycle?

A

1 Cycle is from foot-strike to foot-strike for on one side.

Stance (60%)

  • Weight acceptance:
    1. Initial Contact.
    2. Loading response
  • SLS
    3. Mid Stance
    4. Terminal Stance
  • 5.Preswing

Swing (40%)

  • Limb advancement
    6. Initial Swing
    7. Mid Swing
    8. Terminal Swing
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7
Q

Define the following Temporal Distance Factors used for gait analysis:

  1. Velocity
  2. Step Length
  3. Step Frequency
  4. Stride Length
  5. Step width
A
  1. expressed m/s
  2. AP distance from one foot strike to the foot strike of the other foot.
  3. Number of steps per min
  4. AP distance covered from one heel strike to the next heel strike by the same foot.
  5. Horizontal distance between the centre of heel of the right and left foot.
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8
Q

What is the ambulation speed for normal young adults?
Mean Cadence?
Mean Step Length?

A
  1. 1.46m/s
  2. 1.9steps/sec
  3. 76.3 cm
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9
Q

What are joint kinematics? Why is it important?

A
  • Mvmt of joints and the segments of the body through space.
  • Appropriate ROM at various its (hip, ankle, knee) are necessary for normal gait patterns.
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10
Q

How are joint kinematics related to progression?

How do joint kinematics relate to energy?

A

Complex series of coordinated joint rotations, which when combined as a whole, provide for a smooth forward progression of COM.

Coordinated movement of the joints allows for smooth mechanical transfer of kinetic and gravitation potential energies, reducing the metabolic cost of walking.

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11
Q

What are the goals and what muscle are activated during each phase of stance?

A
  1. Initial contact:
    - Position foot, begin deceleration.
    - Ankle DF, Knee Flex, Hip ext
  2. Loading response:
    - Accept weight, decelerate mass
    - Knee ext, ankle PF
  3. Midstance:
    - Stabilize knee, preserve anterior momentum
    - Knee ext, ankle PF, hip ext
  4. Terminal stance:
    - Accelerate mass, push off
    - Ankle PF
  5. Preswing:
    - Prepare for swing
    - Hip Flex
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12
Q

What are the goals and what muscle are activated during each phase of swing?

A
  1. Initial swing
    - Clear lower limb off the ground
    - Hip flex, Ankle DF
  2. Mid swing
    - Mainly momentum, clear foot
    - Ankle DF
  3. Terminal Swing
    - Decelerate lower limb, position foot, prepare for contact
    - Knee flex, hip ext, knee ext, ankle DF
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13
Q

What are the two goals of locomotion and how does this relate to muscle activation patterns?

A
  1. Progression: Propulsive force to keep the body in motion
    - COM anterior to supporting foot
    - Activation of extensor ms during stance
    - Concentric PF push off
    - Assist from hip flex
  2. Postural Stability: Impact absorption and maintain stability.
    - Eccentric activation of quads (to control knee extension during terminal swing as the foot comes down) and ankle DF to control the foot as it is lowered to the ground.
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14
Q

What are joint kinetics?

What is the difference w/ kinetics compared to Kinematics

A
  • Determining the forces generated during the step cycle.

- There is more variability in terms of active and passive muscle force for kinetics compared to kinematics.

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15
Q

What is the main goal and net forces during the:

  1. Stance
  2. Swing
A
  1. Stance: Stabilize the limb and generate propulsive force.
    - Net ext moment: a variety of combinations of ms can be used to prevent collapse.
    - Balance during gait: Ms activation required at hips to control HAT segment.
    - At slower walking speed , med-lat COM displacement increases.
  2. Swing: Reposition Limb
    - Hip Flexion
    - Momentum
    - Knee moment to contrain motion (i.e. early swing ext moment slows knee flex and late swing flex moment slows knee ext)
    - Ankle-joint forces are the greatest of all moments, showing that PF main contributor to acceleration of the limb into swing.
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16
Q

What are the mechanism controlling gait?

A
  • At the level of the spinal cord the central pattern generator creates alternating flexor and extensor activity.
  • There is also evidence that descending influence from the cerebellum, brainstem and motor cortex influence gait pattern generated by CPG.
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17
Q

What research supports CPG?

A
  1. In neonates the descending pathways are not yet developed, yet the show a stepping response (so CPG).
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18
Q

What to deafferentation studies show?

What do decerebrate studies show?

A
  1. Transect spinal cord of a cat. Apply an external stimulus and a similar gait pattern is elected. Even when higher levels are cut cats can still walk b/c of CPG, although pattern is not as refined. With only lumbar spine CPG, cats can walk.
  2. Mesencephalic locomotion region is important midbrain structure for gait. Decerebrate cats do not walk normally on a treadmill. When MLR region is stimulated they walk normally. MLR activates the MRF then the spinal locomotor system.
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19
Q

How does the somatosensory systems contribute to gait?

A
  1. Step Frequency: when their is no somatosensory information the step cycle is longer.
  2. Muscle spindle afferents contribute the transition between the stance and swing phase (by exciting flexors and inhibiting extensors)
  3. GTO: afferents serve to excite their own muscle during gait.
  4. Stretch reflexes also play a role in modulating gait, but are phase dependent so change throughout the stages of gait.
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20
Q

How to vision and the vestibular system contribute to gait?

A

Vision:

  1. Optic Flow: Visual flow cues helps in determining gait speed.
  2. Vision influences alignment of the body w/ reference to the environment (visual vertical)
  3. Used extensively in anticipatory gait modification.

Vestibular System:

  1. Vestibuloccular reflex plays an important role in head stabilization.
  2. Postural control takes a top down approach starting w/ gaze/head control from the vestibular system.
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21
Q

What are sensory motor integration aspects of gait?

How does attentional demand play a role in gait?

A

Steering mechanisms, speed control, obstacle avoidance, anticipatory control and dual task.

Attention is a limited resources. When dual tasking, a task that has increased attentional demand will have a greater impact on gait. There is a hierarchy in terms of which mobility functions require the greatest attentional demands: sit or stand (lowest), stand in tandem, obstacle, external perturbation (higher).

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22
Q

How do we initiate gait?

When is steady state reached?

A

Initiation: Relaxation of postural control ms (like gastroc) cause forward movement.

1-The COP shifts posteriorly and lateral towards the swing limb.

2-COP shifts towards stance limb and forward.

Steady state is reached w/ in 1-3 steps.

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23
Q

Walk to run transition:
1. Does energy cost affect gait speed?
2. What happens to GRF during transition?
3 What are 2 critical components of the transition?
4. How does body size play a role?

A
  1. Not a primary factor in gs.
  2. Increase.
  3. Peak ankle angular velocity and acceleration.
  4. Different heights have different accelerations.
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24
Q

How do the 3 requirements for gait apply to stair walking?

A
  1. Progression: Concentric contraction to go up stairs and eccentric downstairs.
  2. Stability: Control CoM constantly changing BoS
  3. Adaptation: Accomodate changes in stair environment.
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25
Q

What are the phases of stair ascent? Descent

A 
Ascent: Concentric contraction RF, VL, soleus and gastroc. 
Stance (64%): 
-Weight acceptance
-Pull-up
-Forward continuance

Swing (36%):

  • Foot clearance
  • Foot placement
Descent: Eccentric contraction of muscles above. 
Stance: 
-Weight acceptance
-Forward continuance
-Controlled lowering 
Swing: 
-Leg pull-through
-Preparation for foot placement
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26
Q

What three requirements do all mobility tasks share?

A
  1. Motion in desired direction (progression)
  2. Postural control (stability and orientation)
  3. Ability to adapt to changing tasks and environmental conditions (adaptation)
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27
Q

What do we know a lot about in terms of transfers and where is information lacking?

A

Biomechanics: Typical mvmt strategies used to perform transfer tasks- well researched.

Perceptual strategies and strategy modifications are less well understood.

28
Q
  1. How do the 3 requirements of mobility ability to sit to stand?
  2. What are the phases of a sit to stand?
A
  1. Progression: generate sufficient joint torque to rise.

Stability: Ensure stability by moving COM from one BOS (chair) to a different based BOS (feet)

Adaptation: Modify movement strategies depending on environmental constraints (like chair height)

  1. Weigh shift/flexion moment, transfer of momentum causing body to lift, extension to vertical, then stabilization.
29
Q

Supine to Standing:
Movement strategy?
Components of movement?

A

There is not one universal movement pattern for supine to standing. There are 3 different strategies described in the slides. The most common is symmetrical movement of the trunk and extremities.

The three components of movement include: UE, LE and axial.

30
Q

Rising from a bed: How do the three fundamental mobility concepts apply?

A

Progression: Generate momentum to move the body vertical.

Stability: Control COM as it moves from horizontal body to buttocks and feet then to solely the feet.

Adaptation: To different characteristics of the environment, like different bed heights.

31
Q

What is the common movement pattern for rolling?

A
  • Lift and reach arm pattern: Where the shoulder girdle initiates motion of the head and trunk.
  • Unilateral leg lift.
32
Q

Is mobility dysfunction due to aging or pathology?

What is the difference between primary and secondary age-related changes.

A
  1. Pathology is not a primary part of the aging process, yet research does not do a good job of distinguishing pathology from normal aging so it is hard to differentiate the causes of mobility dysfunction in terms of these to factors.
    That being said, their is some research to indicate that their are distinctive change in gait in healthier older adults.
  2. Primary: genetics, hormones, predisposition to disease.
    Secondary: experiential, exercise nutrition, stress level and acquired pathologies.
33
Q

What are the changes in gait among older adults in terms of:

  1. Temporal and distance factors
  2. Kinematic changes
  3. Muscle activation patterns
  4. Kinetic Changes
A
  1. Decrease: velocity, step length, stride length, step rate or cadence, swing phase.
    Increase: Stride width, stance phase, double support time.
    * Women show greater decrease in velocity and step length.
    * Overall increase in gait variability.
  2. Decreased vertical movement of the COG, arm swing, hip/ankle/knee flexion.
    Flatter foot on heel strike.
    Decrease ability to vary hip/knee movement, decreased dynamic stability in stance (Difficulty controlling HAT while simultaneous maintaining extensor moment)
  3. Increased coactivation
  4. Decreased power generation at push-off and power absorption at heel strike.
    - More use of hip and knee extensors, less PF at push off.

Guarded gait: slower walking speeds do to less balance control.

34
Q

How does balance control change with age and how does this relate to falls.

A

Falls increase as we age and many falls happen while walking (slips, trips)

W/ age there is altered proactive adaptive strategies (preventative responses) and reactive adaptive strategies (in response to loss of balance).
As well as other balance impairments du to sensory changes.

35
Q

How are proactive adaptations influenced by age?

A

-Visual Strategies:
OA monitor terrain for longer time periods when sampling environment.

-Predictive strategies: OA take more time to make gait pattern modifications (i.e. obstacle avoidance, slower approach and crossing speeds)

36
Q

How do Reactive Adaptations Change w/ age?

A

Trips:

  • Key to recovery of balance is quick reactions of hip flex in swing LE and ankle PF of stance LE.
  • W/ age the magnitude and rate of developing ms activity decreases.
  • Rate of development of ms activity in OA is slower.

Slips:

  • Delayed and weaker ms response.
  • Less effective balance response (like backwards extension of the trunk and raise of the arms at the onset of a slip.

Overall OA have reduced ability to recover from unexpected perturbations, contributing to loss of mobility function.

37
Q

How does pathology play a role in locomotion changes in older adults.

A

Subtle pathologies may contribute to changes in locomotor skills, these subtle changes may not be evident in research studies.

Impairments in many systems (motor, sensory and cognitive) or multiple systems may contribute to reduced mobility.

Improving one impairment can reduce the probability of developing other problems and more gait disability.

38
Q

What are some cognitive factors that contribute to changes in locomotion w/ older adults.

A

Attentional resources: W/ age there is a decreased capacity to divide attention btwn task and limited information processing capacity. This leads to decreased performance in one or both of the dual tasks.

If they develop a fear of falling they may change their gait, restrict movement and activity. This leads to a cycle because they avoid moving which makes them weaker and then puts them at a greater risk of falling.

Assess self-efficacy and balance confidence in pt w/ a history of falls, to address fear of falling.

39
Q

What is the main ask change that happens with age?

A

Sarcopenia
Associated decrease in ms strength, especially LE and trunk.

Decrease power push-off

40
Q

What is the COP-COG moment arm?

A

Helps predict an individual’s ability to tolerate dynamic unsteadiness; lower in more disabled elderly.

41
Q

What types of exercise programs have an effect on gait function?

A

HITT: RT, AT

PT

42
Q

What are age-related changes in stair-walking?

A

Distorted visual inputs causes:

  • Slower cadence
  • Larger foot clearance
  • Posterior foot placement
43
Q

What are age-related changes in sit-to-stand?

A
  • Forces used were lower
  • Time take to rise was longer
  • Movement strategies: Increased flexion of the trunk. Higher movement velocity to gain more momentum.
44
Q

What is the difference in rising from a bed w/ age?

A

In younger adults there is a lot of variability in terms of the pattern used to raise from a bed.

Older adults use a more synchronous lifting pattern using both legs simultaneously.

45
Q

What are the basic components of a mobility evaluation?

A
  1. Bed mobility (assistance/time)
  2. Transfers(assistance/arms)
  3. Sit to stand (assistance, time, arms)
  4. Standing balance (assistance, time)
  5. Stairs (assistance/handrails)
  6. Ambulation (time, number steps)
46
Q

What are the categories in the functional ambulation classification scale?

A 
0- Nonambulation 
1- Nonfunctional ambulation 
2- Household ambulation 
3- Neighbourhood ambulation 
4- Independent community ambulation 
5-Normal ambulation
47
Q

What are the three primary frameworks for classifying abnormal gait?

A
  1. Neurological diagnosis (parkinsonian gait)
  2. Level of CNS involvement (middle, high)
  3. Primary pathophysiological mechanism (paresis, spasticity, loss of selective motor output or a non neuronal component)
48
Q

What are the classifications of gait abnormalities based on the level of CNS pathologies?

A

Low Level:
Peripheral msk problem (Arthritic gait)
Peripher sensory problem (sensory ataxia)

Middle:
Hemiplegic, paraplegic, cerebellar ataxia, parkinsonian, choleric, distonic.

Higher:
Cautious gait, subcortical disequilibrium.

49
Q

What are the four pathological mechanisms of gait abnormalities?

A
  1. Paresis: Defective ms activation.
  2. Spasticity: Abnormal velocity-dependent ms recruitment.
  3. Loss of selective motor control and coordination (abnormal synergies)
  4. Abnormal mechanical properties of the non-neural components i.e. tendons, contracture.
50
Q

What is the difference between primary and secondary impairments contributing to gait abnormalities.

A

Primary:Neuromuscular spasticity, paresis, coordination, abnormal synergies.

Secondary: Msk
Loss of rom, ms weakness- non use or disuse, contracture, loss of flexibility.

51
Q

What are some observable anomalies in observational gait analysis?

A

Hip hiking
Trendelenburg gait
Foot slap at heel contact
Stiff leg WB

52
Q

How does Mobility fit in the ICF framework?

A

Body structure and function: Abnormal Gait Pattern

AL and PR: Inability to maintain/change body position, walking limitations (distance), Restricted ability to move or walk)

53
Q

How do we take a systems approach to mobility in rehab?

A

Individual: Sensation, strength, endurance…

Task: Walking aid, speed, distance

Environment: Terrain, incline, obstacles.

54
Q

What are the 8 dimensions that should be considered for gait and mobility goals/activities?

A 
Distance (m)
Temporal (m/s)
Ambient- Light 
Terrain- surface
Physical Load- groceries ect. 
Postural Transitions- sit-to-stand
Attentional Demands-Dual tasking
Density and collision avoidance. -obstacles
55
Q

What is the most effective method for mobility and gait training?

A

-No one method has been shown to be most effective, so use a combination of techniques and strategies.

56
Q

What is the first thing to do when treating gait?

A

Set goals:
Observable, measurable, meaningful.

Consider: pt impairments, mobility strategies or gait pattern (safety, ease)

-Take steps towards long-term goal.

57
Q

How can you target treatment in terms of the three mobility requirements?

A

Progression: Generate moment for forward progression (ms strength)

Postural support and stability: HAT, foot placement, extensor torque, abd strength.

Adaptation: Modify movement and sensory strategies in different environments.

58
Q

Are sitting and standing postural control prerequisites for mobility training? What about pre-gait skills for recovery of gait?

What does it mean to take a task oriented approach to mobility training?

A

NO

Task Oriented: Primary focus is on gait and mobility tasks specifically w/ repetitive practice. May also target specific impairment w/ interventions such as ROM.

Task oriented:
Work impairment
Work activity limitations/participation restrictions.

59
Q

What sorts of sensory cues can be used to train mobility?

A

Auditory: metronome or music

Touch: Hand cueing for ms activation or LT for balance control.

Vision: cues on floor.

60
Q

How can a PT intervene at the impairment level to train mobility?

Does changing impairment have an impact on functional gait?

A 
Progression: 
MS activity-strength of the PF
Joint ROM
Stiffness, spasticity
Coordination and power-improve speed, timing and ability to generate force.

Postural Control:
Knee, hip and ankle extensors (anti-gravity control)
HAT segment- work on COM control.

2)Strategies such as HIT, RT, ST do change strength, but do not necessarily correlate to functional gait changes.

61
Q

How can a PT intervene at the activity level?

A
  • Functional Strategies
  • Considered the demands of the task (i.e. do they have to carry something)
  • Specific requirement of gait (type of ms activity)
62
Q

What are the important postural support and stability factors to train?

How can they be trained?

A 
What: 
HAT control 
Extensor support moment 
Assistive Devices
Balance in double and SLS
Foot placement at initial contact

How:
Orthotics
Walking Aids
Physical guidance to facilitate correct mvmts and prevent compensation

63
Q

What are the important parts of progression to train?

A

Energy Generation: Pull up and push off

Advancement of the swing limb: Increase Gait Speed

64
Q

What sorts of interventions can be done to improve locomotor adaptation?

A

Changing tasks and environments:

  • Forward, back, side, NBOS, heels
  • Stop, turn, change speeds, obstacles
  • Surface condition
  • Hand and eye movement
  • Busy environment
  • Complex and challenging conditions
  • Carry objects
65
Q

Does motivation have an impact on walking speed?

A

Yes neurological patients can increase their walking speed above their self-selected walking speed, when motivated to do so.

66
Q

What are some technologies that can be used to train gait?

A

NMES/ESTIm
Body weight support on treadmill
Robotics

67
Q

What is essential to training gait?

A

Intense task-related practice.

  • Change environment
  • Change physical demands
  • Problem solving
  • Random practice
  • Empower pt

PHTH 551- Neurological Rehabilitation (12 decks)

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