Locomotion-Assessment and Intervention In Persons w/Brain Injury Flashcards
what are the typical structures impaired in pw stroke?
SMA, pre-motor cortex
M1 motor cortex (+/-BS)
sensory cortex
frontal lobe
when the pre-motor cortex is impaired in pw stroke, what is the impairment?
they can’t figure out how to set their posture to take a step
what structure is responsible for the motor plan of gait?
SMA and pre-motor cortex
what structure is responsible for the motor output for gait?
the M1 motor cortex
what system functions are typically impaired in pw stroke?
motor fxn
sensory fxn
postural alignment
gait patterns impairment
what motor fxn impairments are typical in pw stroke?
dec active, fractionated (isolated) motor control
abnormal tone, typically hypertonicity and clinical hypertonicity
chronic learned non-use and secondary MSK impairments, weakness
what sensory fxn impairments are typical in pw stroke?
hemisensory deficits
proprioception and kinesthesia in a % if the primary somatosensory cortex is affected
what postural alignment impairment is typical in pw stroke?
asymmetrical WB in standing
what gait patterns impairments are typical in pw stroke?
typical “classic” stroke gait deviations
increased clinical hypertonicity
t/f: bc the MCA is the most commonly affected artery in stroke, gait tends to look very similar in pw stroke in the acute phase
true
t/f: walking is mediated by complex neural systems both automatic and voluntary
true
t/f: damage to all BS descending pathways and corticospinal tracts decrease fractionated mov’t
true
what is the postural alignment of the limbs in pw stroke?
assymetrical WB bw limbs
involved limb in relative ER and adduction w outtoeing
what is often the cause of relative ER and adduction w outtoeing in the acute phase in pw stroke?
often from retraction
what is often the cause of relative ER and adduction w outtoeing in chronic phase in pw stroke?
often from ROM deficits
what is the postural alignment of the trunk on the involved side in pw stroke?
trunk shortening
scap depression and Retraction
pelvic retraction
what is often the only active muscle control in pw stroke?
adductors
t/f: pw stroke will often use the adductors to advance the limb forward in gait
true
in the acute phase, what are postural alignment impairments likely due to?
lack of activation
in the chronic phase, what are postural alignment impairments likely due to?
likely due to sitting a lot and getting stuck like that
what muscles are often the strongest in pw stroke?
extensor synergy muscles
t/f: in pw stroke, the trunk leans towards the involved side w/scap and pelvic retraction
true
what is the problem with unilateral ADs in pw stroke?
it promotes even more lean to the uninvolved side
what is the locomotor central pattern generator (CPG)?
a complex network of spinal interneurons to generate rhythmic, alternating activities of flexion and extension at the hips and knees
what are the 2 inputs to the CPG?
afferent input from stretch receptors
jt loading at IC
the afferent input stretch receptors facilitates what?
flexion
t/f: stretch of the hip flexors in gait facilitates hip flexion
true
jt loading at IC drives what?
extension
step length on the ____ side is key in facilitating hip flexion
uninvolved
what are 3 steps in activating the CPGs in pw stroke?
alignment of the foot facing forward
taking a big step with the uninvolved leg to get a good stretch of the hip flexors
make sure to get good heel strike and repeat
what can we work on in pregait to get a good swing phase on the involved side?
work on getting a good big step w/the uninvolved leg
why do we care about the CPG?
bc we set up our pts to use automatic gait patterns generators to our advantage to make interventions easier
what are the 2 most important phases in gait for facilitating gait recovery in stroke?
heel strike/initial contact
terminal hip ext/terminal stance phase on the trailing limb
what is the importance of effective heel strike/IC?
maximizing IC at the ankle maximizes sensory input and facilitates LE extension to stance
what is the importance of terminal hip ext/terminal stance phase?
the trailing limb in good hip extension maximizes sensory input through stretch of the hip flexors to facilitate hip flexion for swing
why are CPGs so important in interventions?
lots of our interventions will be focused on terminal limb ext
we can try to regain ROM in chronic pw stroke
if we want to intervene on gait with less degrees of freedom (DOF), what can we do?
have the pt in kneeling on the involved limb and lunging into it to get the stretch of the hip flexors
when we see clinical hypertonicity come into play, what might this tell us?
what we are doing doesn’t have enough stability or is too difficult for the pt
t/f: there is a typical set of gait deviations and resultant biomechanical adaptations that we can expect in pw stroke
true
what are the typical kinematic deviations at initial contact (heel/foot contact and loading)?
limited ankle DF
lack of knee flexion (knee hyperextension)
in the acute phase, what is the cause of limited ankle DF at IC?
decreased activation of ant tib muscles
contractile block of advancement (hypertonicity of calf muscles)
in the chronic phase, what is the cause of limited ankle DF at IC?
consider jt immobility/PROM, contracture, contractile block
what are the causes of lack of knee flexion (knee hyperextension) at IC?
contracture of soleus paired w/limited control of quads at 0-15 deg
contracture a/or hypertonicity of calf muscles w/premature activation
what are the typical kinematic deviations at midstance?
knee hyperextension
lack of knee extension (knee remains flexed 10-15 deg w/excessive ankle DF)
excessive lateral pelvic shift
what are the mechanical causes of knee hyperextension at midstance?
failure to progress body mass forward over the foot due to limited tibial advancement (DF) and terminal hip extension
in the acute phase, what are the mechanical causes of knee hyperextension at midstance?
decreased activation of ant tib muscles
contractile block of advancement-contracture and/or hypertonicity of calf muscles
mechanical block of advancement created by an orthosis
in the chronic phase, what are the mechanical causes of knee hyperextension at midstance?
contractures, jt immobility, and PROM
what is the behavioral cause of knee hyperextension in midstance?
fear of limb collapse due to weakness of muscles controlling the knee as an adaptation
t/f: normally the tibia advances over the foot going forward w/a little knee flexion
true
what are the causes of lack of knee ext in midstance?
synergistic activation of the LE musculature (flexor synergy or co-contraction)
what are the causes of excessive lateral pelvic shift in midstance?
decreased ability to activate stance hip abductors and control hip and knee extensors
what are the typical kinematic deviations in late stance (pre-swing)?
excessive pelvic retraction and lack of terminal hip ext
lack of knee flexion and ankle PF
what are the causes of excessive pelvic retraction and lack of terminal hip extension in late stance?
no stretch of the hip flexors
no “driver” for the LE flexor arm of SPG/CPG to initiate swing phase
what are the causes of lack of knee flexion and ankle DF in late stance?
weakness of calf muscles (GS)
inadequate PROPULSION
even though we have tone of the calf muscles, there is a lack of activation
t/f: even though we have tone of the calf muscles, there is a lack of activation of the muscles in late stance that limit knee flexion and ankle PF
true
in early and mid swing phase, the dominant muscle activity in the LE is…
extensor tone
when the extensor tone is dominant in the LE in early and mid swing phase, what muscles are weak?
hip flexor activity is weak
what are the typical kinematic deviations in early and mid swing phase?
limited hip flexion
limited knee flexion
when hip flexion is limited during early and mid swing, what do we often see pts doing?
hip hiking or circumducting
OR
advancing the limb with hip adductors (limb ER and outward toe angle)
when the adductors are used to advance the limb in early and mid swing, what is the position of the limb?
ER and outward toe angle
what are the causes of limited hip flexion in early and mid swing phase?
decreased activation of flexor muscles, often with hypertonicity of extensor muscles/extensor synergy dominance
what causes limited knee flexion in early and mid swing?
decreased activation of HS often with hypertonicity of rectus fem
reciprocal inhibition of the HS w/lots of quad activation
the ____ needs to be facilitated out of synergy early on
HS
what can we do to decrease reciprocal inhibition to the HS?
calm the rectus fem and facilitate active HS
get into hooklying for low stress HS activation
what are the typical kinematic deviations in late swing?
limited knee extension and ankle DF for IC
decreased loading response
what are the causes of limited knee ext and ankle DF for IC at late swing?
contracted/hypertonic calf muscles
decreased DF activity
what are the causes of decreased loading response at late swing?
inadequate heel strike and no jt loading “driver” to activate the LE extensor arm of the SPG/CPG
what is the secondary impairment of spatiotemporal adaptations?
decreased ROM
what are the composite impairments of spatiotemporal adaptations?
increased “learned non-use”
clinical hypertonicity
what are the spatiotemporal gait adaptations?
decreased walking speed
short and/or uneven step and stride length
increased stride width
increased double limb support phase
dependence on support through the hands
how do we measure gait velocity?
the a forward 10m WT (2m ramp up, 6m walk, 2m deceleration)
why do we do the 10mWT with max speed too?
bc we want to see what happens when pts change speed for things like going to the bathroom, getting the phone, or getting the door
what is the range for normal walking speeds?
1.2-1/4 m/s
what is an important gait velocity threshold for community ambulation and independence in ADLs?
0.8 m/s
what is the MCID for gait velocity?
0.1 m/s
t/f: a change in gait velocity of 0.1 m/s is significant for mortality
true
people who fell had significantly slower ____ times
3mBWT
3mBWT times slower than ____ indicated a pt is very likely to fall
4.5s
3mBWT times faster than ____ indicated a pt is unlikely to fall
3s
what is the procedure for the 3mBWT?
align heels w/start tape
walk backwards as quickly and safely as possible without looking back
instructed to stop (timing stops) when they reach the 3m tape mark (no ramp up or deceleration)
documentation of gait should always include what things?
level of assistance, gait velocity, and distance
gait fxnal classifications based upon the velocity
description of gait patterns limitations (OGA)
distances of >____ft will jeopardize qualification (insurance coverage) for PT
100
to avoid distances over 100 ft, what should we do?
keep distances low to increase velocity, control and decrease level of assistance
improve safety and independence w/in reduced distances when you’re setting goals
what is the cutoff gait velocity for household walker?
0.4 m/s
what is the cutoff gait velocity for limited community ambulation?
0.8 m/s
what is the cutoff gait velocity for community ambulation?
bw 1.2-1.4 m/s
who is a physiological walker?
some who walks for exercise only either at home or in parallel bars during PT
no level of independence
what population are frequently physiological walkers?
severe TBI
who is a limited household walker?
someone who relies on walking to some extent for home activities
requires assistance for some walking activities, uses a WC or is unable to perform others
who is an unlimited household walker?
someone able to use walking for all household activities w/o any reliance on a WC
encounters difficulty w/stairs and uneven terrain
may not be able to enter or leave the house independently
who is a most-limited community walker?
someone who can enter and leave the home independently
can ascend and descend a curb independently
can manage stairs to some degree
independent in at least one moderate community activity (ie appointment, restaurant) and needs assistance or is unable in no more than one other low-challenge (ie church, neighborhood, visiting a friend)
a most limited community walker is independent in at least one _____ _____ activity and needs assistance or is unable in no more than one other ___ ___ activity
moderate community, low-challenge
who is a least-limited community walker?
someone who demonstrates independence in stair management
independent in all moderate community activities w/o assistance or use of a WC
independence in either local stores or uncrowded shopping centers
independence in at least 2 other moderate community activities
when going through the Ranchos Los Amgios Gait Analysis form, what is the procedure to go through?
decide your reference limb
decide on your sequence
determine your major problem(s)
characterize major deviations by each phase
examine for minor deviations
generate an assessment
assessment drives the intervention plan
what is the basis for HIGT?
high intensity, variable stepping protocol w/an emphasis on overall fxn and efficiency
what vitals are HIGT based on?
HRmax or HRR
t/f: HIGT is based on phases of gait
false, it is based on biomechanical subcomponents of gait
what are the 4 biomechanical subcomponents of gait?
propulsion
limb swing
postural/lateral stability
stance control
what is propulsion?
forward progression of COM
propulsion can be correlated to ___ ___
gait speed
propulsion accounts for what % of metabolic cost of walking?
50-75%
what is limb swing?
advancing the trailing limb past the stance limb
limb swing accounts for what % of metabolic cost of walking?
5-10%
what is stance control?
maintenance of postural stability and accepting weight
can I advance the limb forward without the limb collapsing under me?
stance control accounts for what % of metabolic cost of walking?
25%
what is postural/lateral stability?
maintenance of lateral move of COM (balance upright)
can I maintain upright? can I keep the COM in the midline?
postural/lateral stability accounts for what % of metabolic cost of walking?
5-10%
what role does neuroplasticity play in locomotor training?
we are trying to change the brain to change gait
will challenging limb swing or challenge propulsion have a greater effect?
challenging propulsion will have more of an effect bc it accounts for a larger % of metabolic cost of walking
what are some “pre-requisites” to gait?
appropriate WB status
postural alignment
ROM
muscle performance
motor fxn
balance
static and dynamic control
when is locomotor training initiated?
once the pt has achieved adequate mobility and stability w the ability to initiate and control the pelvis and LE in the appropriate sequence for swing and stance
t/f: the training principles for gait are impairment based
true
what are the training principles for gait?
impairment based
task oriented to the specific task of walking
goal-directed and meaningful (salient)
progressed to maximally challenge the pt’s capabilities
repetition
gait training is ____ oriented
task
t/f: gait training is progressed to maximally challenge the pt’s capabilities
true
what are the various methods for locomotor training?
body weight support
treadmill systems
robotic assistance
dance
virtual reality
exergaming
strengthening
circuit training
mental imagery
what are the principles to promote motor learning and neuroplasticity?
practice
feedback
focus of attention
what is the principle of practice in motor learning?
the amount and repetitions
what are the various types of practice in motor learning?
variable, constant, blocked, and random
what is the principle of feedback in motor learning?
intrinsic feedback through own body systems
extrinsic feedback through the therapist usually to change the intrinsic feedback
intrinsic feedback is through what?
own body systems
extrinsic feedback is through what?
usually the therapist to change the intrinsic feedback
what is the 2 types of focus of attention in motor learning?
external and internal
what is external focus of attention?
attention to result
“pretend like you’re walking in a cave”
what is internal focus of attention?
focus on how the body is performing
“want you to realize that every time you step on the R leg your knee is snapping back, don’t let it”
what is locomotor training with body weight support and treadmill?
suspending a pt over a treadmill w/weight unloading
what are the two ways we can use body weight support?
can remove partial body weight or just prevent falls
what can we use to allow those w/LE and trunk weakness to take more steps w/o need for excessive UE support or compensation?
body weight support and treadmill
t/f: body weight support high volumes allows reciprocal locomotor patterns in absence of supraspinal input
true
what is a key benefit of body weight support and treadmill walking?
it allows for high reps
what is the prime focus of locomotor training with body weight support and treadmill?
normalizing kinematics
key components of locomotor training with body weight support are to promote ___ ____ w/ or w/o manual facilitation into flexion/extension and minimization of compensation
normalized kinematics
what can PTs do to further facilitate normalized kinematics with locomotor training with body weight support?
be on either side of the treadmill and manually facilitate flexion/extension for the entire session
what are additional locomotor training strategies?
treadmill w/o body weight support or fall prevention
virtual reality and exergaming
augmentation of muscles force production
balance and dynamic postural controls during overground walking
circuit training
motor imagery
robotics
what are the benefits of treadmill walking w/o body weight support or fall prevention?
CPG activation
pacemaker assistance
variability in speed and incline
what is the downside of treadmill walking w/o body weight support or fall prevention?
lack of variability in compliance of surfaces
what are the benefits of virtual reality and exergaming?
it is salient, variable, and engaging
what are the benefits of augmentation of muscle force production?
it is task specific to locomotor training w/external resistance
how can we augment muscles force production?
with body weight or limb segment weight
part to whole tasks practice (hip flexion with ankle weights for step ups)
what is the purpose of balance and dynamic postural control during overground walking?
to maintain stance (stability) and dynamic postural control (controlled mobility)
how can we do balance and dynamic postural controls during overground walking?
LOS training
anticipatory and reactive postural control
COM control w/a reduction in BOS
transitions to and from single limb stance
t/f: there is ample evidence in the transfer of static balance activities to dynamic control of gait
false, there is limited evidence of the transfer of static balance activities to dynamic control of gait
t/f: overground walking must be trained w/incorporation of dynamic postural controls
true
how can we incorporate dynamic postural control into overground walking?
walking on compliant surfaces
head movt with gait
visual disturbances with gait
change in speed
what pts would we want to use balance and dynamic postural controls during overground walking?
pts that report difficulty walking on compliant surfaces
what is circuit training?
using a variety of tasks oriented stations
what are the benefits of circuit training?
it produces a lot of variability and randomization FOR THOSE IN THE LATER STAGE OF MOTOR LEARNING
circuit training should be used in what populations?
those in the later stages of motor learning
t/f: we should customize and strategically build stations based on what we want to improve
true
how long should we do motor imagery for?
10-20 minutes
what is motor imagery used for?
to augment and supplement strategies w/mental imagery
what is motor imagery?
visualizing the performance of a movt or the sensory experience of a movt
what is the difference bw visual imagery and kinesthetic imagery?
visual imagery is visualizing the performance of a movt
kinesthetic imagery is imagining the sensory experience of a movt
mental imagery is good for successful gait training in what population?
pts with ataxia
what are robotics designed for?
to improve gait fxn
t/f: some robotics need special certification for use
true
t/f: robotics may reduce motor output to match only what the pt needs
true
how does robotic work?
the motor input will kick in where the pt is lacking
what are the potential downsides of robotics?
the pt may become reliant on it
can become very passive
neuroplastic principle of intensity suffers
is robotics designed for high or low reps
high
what neuroplastic principle may suffer with the use of robotics?
intensity
robotics may be helpful for what pts?
pts with VERY low levels of mobility w/no other options for ambulation (ie SCI or physiological walkers)
according to the HIGT 2020 CPG, what conditions is HIGT effective for?
chronic (6 months) stroke, iSCI (incomplete SCI), and TBI
HIGT desires to improve what?
gait EFFICIENCY (walking speed and endurance)
t/f: HIGT is good to make gait look “pretty”
false
t/f: HIGT principles are directly related to neuroplastic principles
true
HIGHT treatment interventions are …
valued by the pt
specific to the task being (re)learned
provided at high dosage
challenging
t/f: treatments in HIGT are likely to be associated w/beneficial neuroplastic changes and improvements in fxn
true
what is the rationale for HIGT?
make the pt look worse initially w/the ultimate goal of it normalizing later
what are the principles of neuroplasticity in HIGT?
intensity
variability and error
specificity
repetition
intensity in HIGT is based on what values?
HRmax or HRR
how do we use the principle of variability and error in HIGT?
introducing error augmentation
how do we increase dosage in HIGT?
increased the volume of steps
what has previous research told us about prescription for walking in PT?
steps taken in PT are generally under dosed
to apply specificity and repetition in HIGT, what do we need to do?
prioritize stepping practice w/a high # of reps
what is a more reliable measure of intensity in HIGT when a pt is on beta blockers or the pt is lower level?
RPE
what are some ways to progress intensity in HIGT?
increased speed, incline, duration, or mass (add weights)
what is the frequency of HIGT (FITT)?
4 days/week
what is the intensity of HIGT (FITT)?
70-80% HFmax
Borg 14-18 (zone 4)
what is the time of HIGHT (FITT)?
as much time in zone 4 >30 minutes
what is the type in HIGT (FITT)?
variable stepping practice (forward walking, backward walking, side stepping, obstacles, etc)
what measure for intensity doesn’t account for autonomic dysregulation, deconditioning, or medication use (beta blockers)?
HRmax
what are the intensity targets for HIGT?
70-85% HRmax
70-80% HRR
14-18 Borg RPE (6-20 scale) or 6-8 Borg RPE (1-10 scale)
how does error augmentation help with gait?
it allows the NS to adapt to work harder
t/f: variability improves performance and improved retention
true
what are the benefits of error augmentation?
kinematic variability
environmental variability
external forces
pt must have what ability to introduce error augmentation in gait training?
ability to learn
what considerations would make error augmentation a bad option for gait training?
sensory or memory deficits
cerebellar lesions
how can we provide assistance to stance control?
body weight support
how can we provide error augmentation for stance control?
weighted vest
how can we provide assistance for propulsion?
pulling the pt forward
how can we provide error augmentation for propulsion?
pulling the pt backward
if a pt has ___ consecutive errors, it is too challenging
5
t/f: error augmentation may induce short term clinical hypertonicity until efficiency is improved
true
what concerns need to be addressed prior to error augmentation?
ortho and medical concerns
as a pt leans more towards the left on the error and assistance curve, should we increase assistance or increase error?
increase assistance
as a pt leans more towards the right on the error and assistance curve, should we increase assistance or increase error?
increase error
as the degree of acquisition of a skill increases, what should we do?
introduce more error augmentation
how can we progress the propulsion phase?
elastic or belt resistance to forward progression (resisted walking/posterior forces)
add mass to body/legs
increase speeds
uphill/incline or stairs
how can we regress the propulsion phase?
anterior directed stabilizing straps at the pelvis
decreased speeds
how can we progress the stance control phase?
adding weight to the trunk (weighted vest)
stair negotiation
how can we regress the stance control phase?
reduce body weight with body weight support
handheld assist
how can we progress the postural/lateral stability phase?
practice on unstable or narrow surfaces (balance beam)
obstacle avoidance
dual physical tasks
uneven surfaces
stair climbing
multidirectional walking (backward, side stepping)
how can we regress the postural/lateral stability phase?
anteriorlateral straps to decrease pelvic translation
handheld assist
ADs
how can we progress the limb swing phase?
add leg weight
apply elastic resistance
step over obstacles
how can we regress the limb swing phase?
manual assistance
elastic assistance
body weight support
if pt is doing really well in one phase of gait but struggling in another, what can we do?
add assistance where the y are struggling and add error augmentation where they are doing well
if a pt makes 3-5 consecutive errors, shift ___ on the error assistance curve
L
if a pt shows limited/no errors, shift ___ on the error assistance curve
R
t/f: there is a leapfrog effect from gait training to transfers
true
