Neuromuscular 2 Unit 9 Balance and Gait Interventions Flashcards
Category 1
What are the 3 Control Strategies for Balance?
- Steady State (static) Postural Control
- Anticipatory Postural Control
- Reactive Postural Control
Category 1: Control Strategies for Balance
What is Steady State Postural Control?
The ability to control the location of the body’s COM within the area defined by the BOS under predictable, quasi-static conditions.
- This includes the ability to adapt motor behavior to meet the demands of different task and environmental conditions
Category 1: Control Strategies for Balance
What is Anticipatory Postural Control?
The ability to generate postural adjustments prior to the onset of and during voluntary movement for the purpose of either countering an upcoming postural disturbance due to voluntary movement or realigning the body’s COM prior to changing the BOS.
- This includes the ability to adapt motor behavior to meet the demands of different task and enviornmental conditions
Category 1: Control Strategies for Balance
What is Reactive Postural Control?
The ability to respond to sensory input that signals a need for a response to ensure successful maintenace of postural control. The need for response is unanticipated but may be generated externally (pertubation originating external to body) or secondary to an internally generated movement.
- This includes the ability to adapt motor behavior to meet the demands of different task and environmental conditions
Category 1: Control Strategies for Balance
What are the Deficits in Steady State Postural Control (SSPC)?
- Postural Movement Strategies: Primarily related to abnormal postural movement strategies
- Sensory Processing: Primarily related to abnormal sensory integrity/processing
- Balance confidence: Primarily related to fear of falling/reduced self-efficacy
- Verticality: Primarily related to impaired orientation with respect to gravity
Category 1: Control Strategies for Balance
What are the Deficits in Anticipatory Postural Control (APC)?
- Postural Movement Strategies: Primarily related to abnormal postural movement strategies
- Sensory Processing: Primarily related to abnormal sensory integrity/processing
- Balance confidence: Primarily related to fear of falling/reduced self-efficacy
- Executive Function/Multi-task Ability: Primarily related to impaired dual-task ability
Category 1: Control Strategies for Balance
What are the Deficits in Reactive Postural Control (RPC)?
- Postural Movement Strategies: Primarily related to abnormal postural movement strategies
- Sensory Processing: Primarily related to abnormal sensory integrity/processing
With the Sitting Core Task, what balance type is used?
- Steady State
- Anticipatory: Dynamic Task Variation
- Reactive: Spontaneous LOB or pertubated
With Sit to Stand Core Task, what balance type is used?
Anticipatory
With the Standing Core Task, what balance type is used?
- Steady State
- Anticipatory: Dynamic Task Variation
- Reactive: Spontaneous LOB or pertubated
With the Walk and Turn Core Task, what balance type is used?
Anticipatory
With the Step Up Step Down Core Task, what balance type is used?
Anticipatory
With the Reach and Grasp Core Task, what balance type is used?
Anticipatory
Category 2
What are the Underlying Determinants of Balance?
- MSK: ROM, Flexibility, Muscle performance, alignment/posture
- Neuromuscular: Coordination, postural movement strategies, sensory integrity, sensory processing, perceptual function including verticality
- Cognitive/Metal Function: Arousal, attention, exclusive function, multi-task ability
- Behavioral Factors: Balance confidence, falls self-efficacy, fear of falling, past experience
What are the Focus of Interventions for Steady State Postural Control: Postural Movement Strategies?
Develop initial conditions appropriate for tasks and increase efficiency for organiziation and timing of motor responses generated to allow for sitting and standing under various task and environmental conditions
What are the Suggested Intervention strategies for Test Specific Training for Steady State Postural Control: Postural Movement Strategies?
- Practice aligning body during various tasks while using augmented sensory feedback (visual, manual, verbal auditory, vibrotactile) to assist in finding a vertical posture that maintains line of gravity within individual’s stability limits
- Practice maintaining alignment and stability in sitting and standing during various base of support conditions
What are the Focus of Interventions for Steady State Postural Control: Sensory Processing?
Improve organization and selection of appropriate sensory information for postural control under various task and environmental conditions
What are the Suggested Intervention strategies for Test Specific Training for Steady State Postural Control: Sensory Processing?
Practice maintaining sitting or standing under predictable and unpredictable sensory and BOS conditions while systematically varying availability and accuracy of 1 or more senses for orientation (Vestibular, visual, somatosensation)
What are the Focus of Interventions for Steady State Postural Control: Verticality?
Improve internal reference for vertical position for postural control under various task and environmental conditions
What are the Suggested Intervention strategies for Test Specific Training for Steady State Postural Control: Verticality?
Practice achieving midline in sitting and standing using environmental vertical cues (mirror, doorway, wall) to augment individual’s perception of vertical
What are the Focus of Interventions for Steady State Postural Control: Balance Confidence?
Improve balance confidence and self-efficacy so individual’s perceived balance abilities more closely align with actual balance abilites under various task and environmental conditions
What are the Suggested Intervention strategies for Test Specific Training for Steady State Postural Control: Balance Confidence?
Practice sitting or standing postures unde conditions that do not necessitate use of balance recovery strategies. Focus is on slef0efficacy coaching while altering degree of postural control challenge (e.g., reducing UE support, changing BOS)
What are the Focus of Interventions for Anticipatory Postural Control: Postural Movement Strategies?
Improve organization and timing of motor responses generated prior to and concomitant with voluntary movement use to control COM under various task and environmental conditions
What are the Suggested Interventions Strategies for Task-Specific Training for Anticipatory Postural Control: Postural Movement Strategies?
Practice tasks that require predictable dynamic control of COM
What are the Focus of Interventions for Anticipatory Postural Control: Sensory Processing?
Improve organization and selection of appropriate sensory information for postural control under various task and environmental conditions
What are the Suggested Interventions Strategies for Task-Specific Training for Anticipatory Postural Control: Sensory Processing?
Practice whole body or limb while sytematically varying availability and accuracy of 1 or more senses for orientation (Vestibular, visual, somatosensation)
What are the Focus of Interventions for Anticipatory Postural Control: Balance Confidence?
Improve balance confidence and self-efficacy so patient’s perceived balance abilities more closely align with actual balance abilites under various task and environmental conditions
What are the Suggested Interventions Strategies for Task-Specific Training for Anticipatory Postural Control: Balance Confidence?
Practice self-limiting destabilizing tasks that do not necessitate use of balance recovery strategies. Focus is on self-efficacy coaching and incrementally increasing postural control challenge
What are the Focus of Interventions for Anticipatory Postural Control: Executive Function/Multi-Task Ability?
Build skill in ability to maintain balance during various tasks (that use APAs) aand environmental conditions under dual-task conditions (ie, while performing a secondary cognitive or manual task)
What are the Suggested Interventions Strategies for Task-Specific Training for Anticipatory Postural Control: Executive Function/Multi-Task Ability?
Practice single condition balance-challenging tasks followed by performance of same task under dual task conditions
What are the Focus of Interventions for Reactive Postural Control: Postural Movement Strategies?
Improve organization and timing of multi joint motor responses (Including both in place and changes in support strategies) effective in recovery stability after an unexpected loss of balance under various task and environmental conditions
What are the Suggested Interventions Strategies for Task-Specific Training for Reactive Postural Control: Postural Movement Strategies?
Practice tasks requiring recovery of balance after unexpected pertubations (self-limited or external)
What are the Focus of Interventions for Reactive Postural Control: Sensory Processing?
Improve organization and selection of appropriate sensory information for recovering stability after an unexpected loss of balance under various task and environmental condition
What are the Suggested Interventions Strategies for Task-Specific Training for Reactive Postural Control: Sensory Processing?
Practice tasks requiring balance recovery after unexpected perturbations (self initiated or external) while systematically varying availability and accuracy of 1 or more senses for orientation
What should education regarding Fall Prevention include?
- Maintaining physical activity
- Correct use of any AD
- Potential medication side effects - referral to physician
- Annaul vision check-ups
- Home safety - remove tripping hazards, remove or secure small rugs, improve lighting, install grab bars or handrails as needed
- Wear well-fitted shoes
What should education regarding Compensations for Balance include?
- Widen BOS with challenging standing or walking activities
- Lower COM when greater balance is needed
- Use an AD if needed, train patient on correct use
- Rely on intact senses as possible
- Minimize head movements during more difficult balance tasks
- Focus vision on a stationary target if possible
- Avoid uneven surfaces and/or poorly lit environments
What are the Major Requirements for Successful walking?
- Support of body mass by the LE
- Production of locomotor rhythm
- Dynamic postural control of the moving body
- Propulsion of the body in the intended direction
- Adaptability of the locomotor response to changing environment and task demands
- Energy efficent
What are consistent principles of Locomotor Training?
Stategies must be Specificity, repetition, intensity, and variability
With the Principles of Locomotor training, Interventions should be…
- Specific and task oriented to the task of walking
- Shaped and progressed to maximally challenge the patients capabilites (intensity)
- Performed multiple times with a high number of repetitions
- Performed with variation to meet task and environmental demands and drive errors
- Meaningful and goal directed to the individual patient
What are different locomotor training environments/equipments?
- Parallel bars
- Overground indoors
- Overground community
- Body weight support/treadmill
- Body weight support/overground
- VR
- ADs
What are some different types of locomotor training strategies that can be implemented with patients?
- Assisted walking and gait training using neurofacilitation (NDT, PNF)
- High Intensity gait training
- Activity based locomotor training
- Resisted walking
- Circuit training
What are some interventions that are complementary to Locomotor training?
- Strengthening activities
- Sit to Stand (STS) training
- Standing balance activities
- Pre-gait activities
What are some ADs used for Locomotor Training?
- Overground or over treadmill harness
- Walkers
- Canes
- Hiking poles
- Shopping carts
- Bedside tables
- Specialized UE slings
- AFO
- FES
- Knee bracing
With Clinical Descision making, what are some factors we must consider with gait training/interventions?
We must determine if we are using Restorative or Compensatory approach
- We must also have patient specific considerations in mind
What are Clinical Practice Guidelines?
Graded recommendations on best practice for a specific condition based on the systematic review and evaluation of the quality of the scientific literature. These documents are defined by stringent methodology and formal process for development
What is the Inclusion criteria for Locomotor Training CPGs?
- These evaluate available evidence of the efficacy of various physical interventions to improve walking function of patients with a Hx of acute onset stroke, motor incomplete SCI, or TBI of > 6 months duration
- Individuals who could walk
MS, PD are not included also those with stroke, motor incomplete SCI LESS than 6 months are not included
What are the target outcomes for Locomotor Training CPGs?
- Walking Speed (10 MWT)
- Timed Distance ( 6 Min walk Test, 2 Min walk Test, 12 Min walk Test)
With the CPG to Improve Locomotor Function, what SHOULD clinicians perform, following CHRONIC stroke, incomplete SCI, and brain injury > 6 months? (Green Light)
- Walking training at Moderate to High Aerobic Intensities (up to 85% HR Max)
- Walking training with VR
To improve walking speed and distance in individuals greater than 6 months following acute onset CNS injury as compared with alternate interventions
With the CPG to Improve Locomotor Function, what MAY clinicians performfollowing, CHRONIC stroke, incomplete SCI, and brain injury > 6 months? (Yellow Light)
- Strength training at ≥ 70% 1RM
- Circute training, cycling, or recumbent stepping (up to 85% HR Max)
- Balance training with VR
With the CPG to Improve Locomotor Function, what SHOULD NOT clinicians perform, following CHRONIC stroke, incomplete SCI, and brain injury > 6 months? (Red Light)
- Static or dynamic balance activities including pre-gait
- Body-weight support treadmill training with emphasis on kinematics
- Robot-assisted gait training
If the clinician is working with an ambulatory patient, the research does not support spending time on pre-gait;
If a patient is not yet ambulaotry or just barely ambulatory, pre-game weight shifts may be an acceptable activity to get the person to the level of being ambulatory before worrying about gait speed or distance
What are our Active Ingredients as PTs?
The principles of exercise physiology and motor learning, including specificity, repetition and intensity
What is considered our Inactive Ingredients?
Therap equipment such as balance beam, harness, therapist handling, HR monitor, treadmills, etc
Why do we use Active and Inactive Ingredients together?
To facilitate neuromuscular or cardiovascular alterations to improve motor performance
How do we apply Specificity to Locomotor Training?
Walk
- If you want to improve on walking, you need to walk
How do we apply Repetition to Locomotor Training?
Do it a lot
- If you want to improve walking, you have practice walking a lot
How do we apply Intensity to Locomotor Training?
HARD
- This is a piece that is most likely missing in many clincial setting
- We need them to be 70-80% HRR OR 85% HR Max; according to CPGs
With this we need to continuously monitor the patient when we increase intensity for the safety of the patient via HR with pulse before, during and after training; HR with monitor or Pulse Ox.
What is the Key Element of Locomotor training?
Cardiovascular Intensity
Intensity Matters
With Functional Gait Training, what are the principles to Intensity?
- Obstacle courses
- Circuit training
- Dual-tasking
- Multi-directional walking
- Different surfaces
With Locomotion Training, what are barriers to you using CPGs?
- Time to develop a program based off CPG recommendations
- Time to read
- Institutional support
- Lack of access to CPG
- Lack of understanding the recommended practice
Clinical Descision Making
What is the criteria needed for the patient to begin Treadmill training?
- They need to medically stable
- Able to sit at the edge of bed with Independence
The patient does NOT need to have current capacity to stand
What are the Advantages of VR in Rehabilitation?
- The PT can manipulate sensory information to affect patient motor performance
- The PT can measure and analyze motor performance and control feedback
- The patient can train in simulated real-world environments in a safe and controlled manner
- The patient can practice using activities that are motivating and engaging
What are the Limitations of VR in rehabilitation?
- Cost and access to technology
- Some patient experience motion sickness or sensitivity
- Systems not designed for rehabilitation may be too fast or too complex for some patients
- Fast-pace technology changes may require updating or replacement
- Most research is done using expensive custom environments
What are the Pros of Immersive VR systems?
- Cameras allow tracking capability
- Very immersive
What are the Cons of Immersive VR systems?
- Requires a large defined space with cameras
- Expensive
What are the Pros of Portable immersive VR systems?
- Affordable
- Portable
- No PC needed
What are the Cons of Portable immersive VR systems?
- No Clinical view
- Limited tracking and data collection abilites
What are the Pros of Non-immersive or Partially Immersive VR systems?
- Affordable
- Easy availability
- Easy to use
What are the Cons of Non-immersive or Partially Immersive VR systems?
- Less immersive
- Limited tracking and data collection abilites
With Locomotion CPG, what is Action Statement 2?
Individuals post-stroke and no evidence for individuals with Incomplete SCI or TBI, clinicians should use VR training interventions coupled with walking practice for improving walking speed and distance in individuals greater than 6 months following acute-onset CNS injury as compared with altenative intervention
