High Intensity Gait Training Flashcards
3 Important principles of neuroplasticity that apply to gait training
Specificity, Repetition Matters, Intensity Matters
Specificity
- Weight-bearing, stepping, efficiency and balance are retrained SIMULTANEOUSLY during locomotor training
- Walking is a continuous task, whole practice should be provided
- If the goal is walking, practice walking!
What is intensity
- workload as estimated by HR or perceived exertion
- Active ingredient to precipitate change in walking function
What hormone is important for intensity
brain derived neurotrophic factor
flowchart of intensity
higher intensity training –> improved cardiovascular and neurologic function –> improved walking outcomes
High intensity gait training with Parkinson’s disease
- Moderate to high intensity aerobic exercises in Parkinson disease reduces motor
disease severity in early-stage PD - Moderate to high intensity aerobic exercises in Parkinson disease improve functional outcomes and quality of life in individuals with mild to moderate PD
High intensity gait training with multiple sclerosis
High intensity interval training safe and effective in improving fitness in lower levels of
disability
Little evidence on effects on biomarkers, need to ensure incorporating adequate rest and
avoid overheating
Monitoring intensity during high intensity gait training
- determine Max HR (208 - 0.7age)
- Target: 70-85% of HRmax
- Equivalent to 15-17 on borg
Safety considerations
- Determine if patients are medically appropriate for high intensity training
- Monitor patient response
- Ongoing communication with physician/medical team
Leap frog hypothesis
earlier and more aggressive therapies associated with better outcomes
reverse transfer
complex task practice translates to improvements in lower-level tasks without same amount of practice
Other considerations
- cognition/language
- other medical issues
- Anticipated discharge plan –> focus on what they need to be as independent as possible
goals of gait training
Improve gait independence
Improve gait capacity (cardiovascular endurance)
Improve gait speed
Improve safety with gait (balance)
Variability
- need kinematic, task, and environment variability
- kinematic: body’s exploration of a movement in space (letting them start to fall but catch)
How many consecutive errors should you allow for?
- no more than 3-5
Error is critical for motor learning
Too much error can result in less practice/repetition & patient disengagement
is the ultimate goal learning or performance?
learning
- performance may go down when you increase the challenge but it will promote more learning
successful task completion
stepping in an intended direction with a positive step length while maintaining upright
biomechanical components of gait
Propulsion – ability to move COM in specific direction
Limb advancement – foot clearance & positive step length
Postural stability – maintaining upright
Stance control – absence of limb/trunk collapse
Common movement problems in stance control
- knee buckling
- severe knee hyperextension thrust
- sagittal plane hip collapse
- uncontrolled ankle equinovarus
is stance time asymmetry a primary focus?
no
common movement problems in limb advancement
- inability/difficult to initiate swing
- insufficient toe/foot clearance
- negative step length
is the limb advancement strategy (steppage, circumduction, etc) the patient chooses a primary focus?
no
common movement problems in propulsion
- slow walking speed
- negative step length
what is the most efficient way to elevate HR into target zone?
challenging propulsion
ways to challenge propulsion
- increase treadmill speed
- overground timed challenges
- inclines
-banded posterior-directed resistance at pelvis - pushing or pulling heavy loads
common movement problems for postural stability
inability to remain upright without UE use or other physical assistance
focusing on balance may cause what to occur?
- decrease in HR intensity
- may benefit from alternating between propulsion demanding tasks and balance challenges within a session
is treadmill or overground training better?
- one is not necessarily better than the other
- overground is more meaningful day to day
Robotic exoskeleton
- tool not an intervention
- evidence is inconclusive
- does show the critical active ingredients of our gait interventions include specificity, repetition, intensity, motor learning (variability and errors)
Does evidence support practice of optimal kinematics during gait?
- nope
- emphasize kinematics only related to successful task completion (limb advancement, prevention of trunk/limb collapse, sagittal and frontal plane stability)
Clinicians SHOULD perform:
- walking training at moderate to high aerobic intensities
- walking training with virtual reality
clinicians MAY consider:
- strength training at > 70% 1 RM
- circuit training, cycling or recumbent stepping at 75-85% HR
- balance training with virtual reality
Clinicians SHOULD NOT perform:
- static or dynamic balance activities including pre-gait
- BWSTT with emphasis on kinematics
- robot assisted gait training
evidence does NOT support what?
- body weight supported treadmill training in chronic, ambulatory post-stroke population
- applicable to subacute neurologic populations
- may not apply to non ambulatory individuals or those who require BWS or assistance to ambulate
Check out the example strategies to assist with subcomponents of gait
