Gait Treatment Flashcards
there is no evidence to support what?
achievement of a more normal pattern of movement may decrease metabolic or mechanical costs or reduce balance problems for disabled individuals or ultimately facilitate functional outcomes
why cant a typical gait pattern be the standard?
there are real changes in the pathways, processes, and structures necessary for ambulation
what should you judge instead of gait pattern?
efficacy of your patients movement strategies by asking “are they meeting the demands of the task in the face of these impairments”
treatment of walking function
- knowledge of the control of walking
- normal movement may not be the goal
knowledge of the control of walking
- the movement system is more likely organized around task-level requirements of walking vs. movement patterns
- ask daniela to clarify rest of this
normal movement may not be the goal
need functional movement that meets as many (and/or an optimal combination) of the requirements
Goal of Gait Training
assist the patient in developing skilled walking that meets the requirements of progression, stability adaptability, long term viability, and long distance travel
skilled walking implies that the rehabilitation of walking function include:
- ambulation indoors within a relatively stable environment
- ambulation in the real world
- outdoors, community, neighborhood, work, school, playground (but not all patients will be community ambulators)
what should you do if the goal is to improve gait?
practice gait
warning about treating impairments
In a task-oriented approach, the PT helps the patient resolve specific impairments constraining walking (requirements).
Early intervention
- achieve upright and ambulate as early as possible
- Tilt tables in acute care; sit to stand; stand with assist
Partial task v. whole task training
- what works/ what doesn’t?
- Whole practice (with high repetition of steps) works to improve gait speed and distance
- Circuit-like training (strengthening, cardio, balance (part) training) may also be considered
Part practice aka pre gait activities
- Postural alignment in standing: Trunk control (‘look up’, assistive devices, manual cues).
- Stability in standing: Extensor moment of LE; extensor activity to prevent collapse.
- Weight shifting in standing
- Stepping forward and back in standing
what should you encourage when seeking successful solutions
- flexibility
- how many ways can you get up the stairs?
Dual - Task locomotor training
- Gait speed (and other s-t parameters) are affected by attention to additional motor or cognitive tasks
- Apply attention (motor or cognitive task) to environments of increasing challenge
Clinicians SHOULD perform: (chronic)
- Walking training at moderate to high aerobic intensities (aerobic priming and massed practice)
- Walking training with virtual reality
clinicians may consider: (chronic)
- Strength training at ≥70% 1 rep max
- Circuit training, cycling, or recumbent stepping at 75-85% HRmax
- Balance training with virtual reality
clinicians SHOULD NOT perform:
- Static or dynamic standing balance activities including pre-gait
- BWSTT with emphasis on kinematics
- Robot-assisted gait training
big 3 neuro learning principles for gait?
specificity, repetition, intensity
to improve walking function in ambulatory patients with stroke, incomplete spinal cord injury and brain injury, should therapists focus on normalizing kinematics?
no
what type of training addresses specificity, repetition, and intensity?
high intensity gait training
typical gait pattern of a person with hemiparesis
- slow (potential >50% slower than normal, increased double support time)
- step length asymmetry -> some larger, some shorter
- increased weight bearing on the unaffected leg with decreased stance time on the affected leg
swing in a person with hemiparesis
- decreased affected hip and knee flexion
- Sometimes circumduction and/or hip hiking
stance in a person with hemiparesis
- Lack of controlled knee flexion with knee hyperextension
- Pelvic drop on unaffected side
- Lack of hip extension and ankle dorsiflexion
about how many people with hemiparetic gait can become independent by 6 mo?
65-85%
large variability in steps per day
major impairment with hemiparetic gait
- weakness
- Decreased paretic positive work is a major feature of hemiparetic gait and is associated with increased metabolic cost
hemiparetic gait - balance/coordination
- Standing postural control is correlated but not strongly correlated with gait function
- But BBS is mod-highly correlated to walking endurance (6MWT)
hemiparetic gait - selectivity/fractionation
- decreased access to dorsolateral systems
- Learned disuse
hemiparetic gait - tone
- decreased reciprocal inhibition
- mechanical factors –joint/soft tissue mobility
when to treat asymmetry:
- initial conditions
- early in rehab when amount of damage or prognosis remains unclear –> Can focus a bit more on essential elements too
you can make a person post-stroke walk more symmetrically BUT…
- possibly with diminished paretic limb work
- correlates with increased metabolic cost, decreased speed, and increased asymmetry in limb mechanics
- mechanics used to restore symmetry must be considered
problems of progression look like:
- slow (maybe related to instability)
- profound asymmetry
- stop-start (maybe instability or AD)
- lack of knee flexion during swing
lack of knee flexion during swing
- Speed-related
- Tone
- Synergy
- Inter-limb Coordination
- Weakness of other muscles besides hamstrings
Acute Gait Training
- when the patient is first starting to walk
low function acute gait training
- Provide maximum stability via mat table or assistive device
- If mat table, provide a push up block to use as handle of device
- Support provided at hemiplegic lower extremity
- Have cane at end of mat table or chair for sitting or an aide follow with wc
advantages of treadmill with/without body weight support
rhythm, speed, endurance, hip pull off, may not force increased conscious control
disadvantages of treadmill with/without boy weight support
externally driven instead of internally generated; different joint kinematic and temporal measures (e.g., leg pulled backward instead of trunk gliding forward over leg); may not be better than over-ground training.
treatment progression problems - external support
- Partial Weight Support: Usually used with treadmill locomotion but can be used over-ground
- “Simple Support” during overground ambulation: quad canes vs. straight canes
treatment progression problems - increase speed
- Speed: use speed to “force” progression
- While loading of the LE and speed are factors in transitions in the gait cycle (stance to swing) sufficient hip extension is the most potent sensory input to initiate swing phase.
Treatment Progression problems - NMES/FES
- PF activity increases NMES: e.g., PF’s = push-off =? Increased speed
- ANPT Guidelines on AFO/FES
rhythmic auditory stimulation
- A musical rhythm with accentuated beats acts as a peripheral pacing signal to facilitate the locomotion pattern and produces changes in
EMG responses - The tempo of the music is set to the patient’s cadence
- Indirectly treats asymmetry
rhythmic auditory stimulation may be useful IF
you do not observe increased joint motion
asymmetry or increased vertical COM motion when symmetry is achieved
Problems of stability look like:
*Slow
*Stop –start
*Wide BOS
*Inconsistent step length, direction, width
*Need for assistive device
*Postural asymmetry (static or dynamic)
*Poor trunk control
stability - early intervention/ loading using tilt table
- Develop a positive extensor support moment via strengthening hip and knee extensors
stability - need to regain HAT control
- Strength and mobility: Hip extensors/flexors
- Cues for posture/trunk position –> Verbal, visual feedback, tactile/manual
stability - utility in of external support
are they aiding gait or limiting the need for the patient to make postural corrections/develop control on his own?
stability - practice in proactive and reactive modes to challenge balance
- Head turns, different self-selected directions, change step size
- Reactive –change speed of treadmill; walk against elastic tubing and release
stability - progressively increase balance challenge
Eye; head, UE movements; carrying loads; placing objects along the way to force weight shifting
is the approach to abnormal synergy patterns about relearning isolated movement?
no- it is to explore external environmental conditions and change the task allowing movements to emerge (through shaping)
most important need for adaptation:
stairs, ramps, curbs, obstacles, surfaces
what does exploit environmental conditions mean?
- Change surfaces, vary obstacles, practice stairs/curbs.
- Progress from stable-uncluttered to unstable-cluttered.
change the task (gait) through:
vary speed; abrupt starts and stops; changing direction; turning the head; interact with differing loads; change attentional demand
increased workload secondary to:
- selectivity
- posture/balance
- coordination
- tone
- tension generation
- muscle/CT properties issues
long term viability - energy expenditure
- Endurance training (increase time and distance) within cardiac restrictions
- Treat other requirements due to their interactions
long term viability - tissue stress
- treat other requirements due to their interactions
- orthotics
why are AFOs needed?
for knee and ankle stability
- should initially be used only if needed for safety of to protect joints
which AFOs are a little better for allowing ankle movement?
articulated
do AFOs allow PF push off?
nope
long distance travel observations
- unable to independently travel to destinations where endpoint is unseen (despite relatively high level of physical capability)
- Behavioral factors: cognitive dysfunction: attention, memory, judgment, problem solving skills
to increase long distance travel
*Progressively increase travel distance and destination goals
*Keep environment stable at first; start with simple paths
*Make a course and provide relevant sensory cues (landmarks)
*Work with written and/or graphic information to help with planning and problem solving
what do you have to practice for use-dependent learning?
gait
all affected requirements should be addressed:
- Treating impairments alone will probably not improve gait function substantially
- Intense mobility training can be effective
gait -
oriented physical fitness training should be offered to all patients assessed as medically stable and functionally safe to participate, when the goal is to improve functional ambulation
