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Neuro Rehab Lecture 11: Interventions to Improve Walking in Neurologically Impaired
Terms in this set (62)
Stroke: common deficits
-decreased walking speed and efficiency
-postural instability & asymmetry
Stroke: body structure/body function impairments
-language deficits: expressive (Broca's) / receptive (Wernicke's)
-Motor control deficits
Stroke: walking deficits
-Decreased walking speed
-decreased walking distance and walking endurance
Stroke: possible movement system diagnoses
-If it has to do with timing and sequencing of activation, might be movement pattern coordination deficit
-if it has to do with Selective joint control: might be fractionated movement deficit
-If it has to do with weakness would be force production deficit
Normal gait speed of healthy adult
1.3 m/s or higher
Household ambulation gait speed
0.2 - 0.4 m/s
Limited community ambulation gait speed
0.4 - 0.6 m/s
Full community ambulation gait speed
> 0.8 m/s
functional ambulation category 0
Patient unable to walk or requires help from 2 or more people
Functional ambulation category 1
Patient requires continuous help from 1 person helping with carrying weight and balance
Functional ambulation category 2
Patient requires continuous or intermittent support of 1 person to help with balance and coordination
Functional ambulation category 3
Patient needs only verbal supervision or standby help from 1 person without physical contact!
Functional ambulation category 4
Patient requires help on stairs and uneven surfaces
Functional ambulation category 5
Patient walks independently in the community!
3 phases o f gait rehabilitation
1) Early mobilization out of bed and into wheelchair
--getting them OOB to another surface. might include getting them standing and then working on balance
2) Restoration of independence of walking in varied settings, with/without bracing or an AD
3) Improvement of gait quality and function to meet needs of every day living.
Mechanisms for motor recovery: spontaneous recovery
-occurs hours, weeks post stroke
-due to decreased inflammation/edema, and increased healing/ reperfusion
Mechanisms for motor recovery: late brain reorganization
-occurs months, years post stroke
-due to active learning which results in increased synapses, increased dendrites, and unmasking of latent neural networks.
Refers to improvements in the strength, speed or accuracy of arm and leg movements
-improvements are a result of natural recovery and rehabilitation
Improvements in performance (i.e., ADL's, ambulation)
-improvements are determined by:
---type, severity and resolution of motor deficits
---ability of pts to learn and implement new strategies (including compensation)
---characteristics of rehab program (i.e., timing, frequency)
Factors affecting cortical reorganization
-Task specificity (specificity matters)
-Repetition (repetition matters)
-Emotional impact of the activity
-Use of augmented feedback (tactile and visual)
----> feedback schedule is important!
-Varying the task within and between exercise sessions
----> practice schedule is important!
----> necessary for learning and memory consolidation to occur
Expanded Disability Status Scale (EDSS)
Best-known and most widely used scale for quantifying MS disability.
-A score of 6.0 indicates the need for walking assistance (person, cane, crutch, or brace) to walk 100 meters
-Scores of 7.0 or above = wheelchair bound
-4.0-7.0 is probably who we will see with walking disabilities
MS: BS/BF impairments
-slowed processing: pay attn to this, they might have trouble processing cues. Don't give them 2 things at once.
-decreased sensation (numbness, tingling)
-visual impairment (diplopia)
MS: Walking deficits
-walking speed affected
-Foot drop (these pts tend to have toe drag/ trouble clearing floor. DFs?)
-decreased hip and knee flexion or extension
-to compensate, might find longer DLS on one leg.
Body Weight Supported (BWS) Locomotor Training
-Involves unloading the lower extremities by supporting a percentage of body weight.
-Allows WB load to be manipulated (adaptive training - you can alter the amount of WBing, so it is adaptive training because you are adapting the task)
-permits gait training to begin earlier in rehab process
-discourages compensatory strategies
---pt "feels" safe from falling
---allows pt to learn to walk w an upright posture!
-Leads to a better recovery of ambulation
-allows for trunk rotation and arm swing! (ADs do not)
neurophysiologic rationale for BWS
-Central pattern generator (CPG)
---> Neural networks that produce rhythmic patterned outputs (synchronous pattern of taking steps) (i.e., walking)
--->hip extension activates CPG's!!!
-CPG located in brainstem.
-hip, knee and ankle are set to work in a set pattern of activation
-CPG mediated steps that was not cortically driven!
-CPG Can be modulated to adapt to the organism's needs and surrounding through sensory feedback/input.
Neural plasticity/cortical reorganization
-BWS is practicing a pattern, so actually getting cortical reorganization
-primate studies: picking up pellets, showed areas adjacent to lesion took over function of area that had been lesioned...so cortical reorganization took place.
-In pts with strokes, don't stop too early! even if they plateau, continue; they are often able to activate other areas of the brain and cause them to take over areas that were damaged. Want to give person appropriate dose and might see changes at the brain level, not just functional change.
So, BWS is based on all of these neurophysiological rationales:
-Drives neural plasticity/cortical reorganization.
BWS Motor Learning Rationale
-Early intervention: minimizes the delay in which gait training can be initiated -> prevents learned non-use
-Task-specificity: provides a dynamic and task-specific approach that integrates 3 essential components of gait: (1) weight bearing, (2) stepping, (3) balance.
-intensity: can allow a lot of intense practice because can get a lot of steps
-"train like you walk": Facilitation of automatic walking movements within the context of intensive, task-specific training (whole-task practice)
----with BWS, the TM speed provides a rhythmic input!
---->can facilitate walking in a context-relevant way
-Manually guided movements can be used to enhance the rhythmicity of the gait pattern
---> hands are tactile cue that provide sensory input - intensity and timing
---pressure receptors - plantar surface
---joint proprioceptors - trunk, hip, knee, and ankle
---stretch to hip flexors can facilitate hip extension
Suggested requirements for participation in BWS programs
-able to sit at EOB independently
-medical stability (cardiac)
-ability to follow 2-step commands
BWS: potential limiting factors
-hx of DVT
-pusher's (can still do it, but put mirror in front of treadmill
-bowel & bladder incontinence (use restroom prior to starting activity)
how much BWS?
-Initially: least amount of BWS that enables pt to be standing upright with proper trunk/limb alignment, and WB symmetrically through both LE's
-LE spasticity: BWS SHOULD NOT EXCEED 30%!!
-Reduce BWS % when pt can support weight on paretic LE without abnormal postures, knee buckling, movements, or sitting in harness.
BWS: treadmill speed
-most significant improvements seen in fast group
-Recommendation is that training in fast speeds will improve overground walking the most significantly
-so patients should be trained in a faster speed than their self-selected walking speed.
-remember, overground walking velocity is an important functional outcome measure for measuring post-stroke locomotor recovery! Average adult walking velocity ~1.3-1.4 m/s (3.1 mph)
-Higher walking velocities correlate with:
--- improved gait pattern
---greater likelihood of being an independent community ambulatory!!
Factors to manipulate/how to progress BWS
-change % of BW that is displaced from the machine
-change (decrease) amount of manual guidance
-dual task (cognitive; motor)
--Walking velocity greater than self-selected overground walking velocity
--BWS should be sufficient for patient to maintain upright trunk and limb alignement and proper WS/WB on involved LE
---> no more than 30% BWS!
-20-30 minutes with up to 5 minute bouts of continuous walking
-Rest (in standing) as needed during training bouts
Must participate in over-ground walking after treadmill training!
benefits of BWS program
-increased gait speed
-increased motor recovery score
-increased cardiovascular fitness
-improved gait symetry
diagnoses appropriate for BWS
-SCI (robotics - improvement is less than that of BWS because movement is pretty passive with the robot)
-Down Syndrome (to help reduce delay in walking onset in children w DS)
Recommended outcome measures for PD
Body structure and function:
-6 min walk
-10 meter walk
-PDQ-8 or PDQ-39
-Freezing of gait questionnaire
-Parkinson's fatigue scale
-ABCS: or fear of falling
PPD: BS/BF Impairments
PD: walking deficits
---decreased step length
-dec arm swing
-dec pelvic rotation
-forward flexed posture
-dec hip and knee flexion
intervention ideas for PD gait
-visual cues, such as tape on floor
-crawling to get dissociation of trunk
-singing while walking
-pnf of pelvis
Rhythmic Auditory Stimulation (RAS)
-An augmented feedback intervention, used in PD
-Utilizes the physiological effects of rhythm on the motor system to increase the efficiency of controlled movement patterns
-The auditory system projects to motor structures in the brain, creating entrainment between the rhythmic signal and the motor response
-physiological entrainment of muscle activation through rhythm perception takes place via reticulospinal pathways -> neurons in the SC become excited as a result of auditory perception!!
-one result of neuronal excitement is the "priming" or "readying" of muscle groups utilized in movement, which has a facilitatory effect on subsequent motor functioning.
-RAS frequencies initially set at a patient's resonant (current/intrinsic) frequency of movement (limit cycle) or lower
---> limit cycle = i.e. current step cadence
-During training, tempo is increased by 5% or more
---pt needs to maintain proper mechanics
---use verbal cues as needed, but keep to minimum because may interfere w rhythm perception.
-RAS frequencies that are more closely aligned with a patient's prior level of function have the strongest effect on overall gait patterns.
Guidelines for RAS
-30 minute sessions
-Varied tempo (RAS frequency):
----2/4 or 4/4 meter w strong beat accents
---flat and uneven surfaces, ramps, hills, steps, empty and crowded rooms, etc.
-An augmented feedback intervention, typically used for PD pts
-External cues and visual cues have resulted in improved gait parameters in individuals w/ PD because non-automatic pathways use the frontal cortex to bypass the BG which needs dopamine they don't have to function properly.
-so idea is that if you give verbal instructional cues "take a longer step", pt will bypass BG circuitry and produce better movement.
-it works in research
-theory is that high instructional cueing intensity may translate declarative knowledge gained in the training session into procedural knowledge
-high repetitions and high # of practice sessions is essential
Rhythmical auditory cueing
-an augmented feedback intervention, typically for PD pts
-auditory cueing improves gait in pts with PD because the external cues help to bypass BG to produce better movement.
Augmented feedback intervention, often used for PD pts
-obstacles (lines on floor, cones, etc.)
External cues and visual cues have resulted in improved gait parameters in individuals w/ PD because non-automatic pathways use the frontal cortex to bypass the BG which needs dopamine they don't have to function properly.
-research shows walking at high cardiovascular intenstities improves walking-related outcomes
-Very big now! critical to incorporate with neurological patients!
-Train at 70-80% HR MAX (APHRM = 220-age)
-Or 60-80% heart rate reserve (HRR = HR max - resting HR)
-if ppt is on a medication that blunts heart rate response (such as beta blocker), monitor via the BORG SCALE!!!! (target of at least 14! --> intensity matters!!!)
techniques to improve motor responses?
-Sensory techniques: tapping, vibration, telescoping (approximation), etc.
-PNF (resisted progression, timing for emphasis, repeated contractions)
Strategies for varying locomotor task demands
-upright postural alignment
-foot placement/toe clearance
-forward progression and push-off
-walking against resistance
-trunk counterrotation and arm swing
-step ups/step downs
-stopping, starting, turning on cue
-practice timed walking, increasing speed and locomotor rhythm
-practice dual-task walking
Strategies for varying locomotor demands: upright postural alignment
-practice walking upright; assist patient in vertical trunk posture using manual and verbal cues ("look up and stand tall")
-trekking poles or BWS harness can be used to promote upright alignment and reduce UE support, forward head, flexed trunk position
-progress UE support provided by assistive device to light touch-down support, then use of a trekking pole or wall for support as needed, and finally to no support
Strategies for varying locomotor demands: foot placement/toe clearance
-heel-toe IC; tactile cues can be provided to dorsal foot by tapping over pretib muscles
-high step marching in place and then high step walking accompanied by marching music
-walking with even steps using foot prints attached to floor
-increasing step length and/or step width using floor grids
-walking w altered BOS; progressing from wide to narrow base to tandem
-step-to walking (i.e., taking a long step with one limb; then bring opposite limb even with the first on next step)
-walking on a 3 in line taped to floor; half-foam roller; low balance beam
Strategies for varying locomotor demands: forward progression and push-off
-push-ups (toe rises) in stance; progress to heel walking
-heel rises in stance; progress to toe walking
-forceful push-off on cue during walking
-alternating btw heel walking and toe walking (i.e., walk a certain number of steps on heels, then same number on toes)
Strategies for varying locomotor demands: walking against resistance
-practice walking against manual resistance using resisted progression
-walking against resistance from resistive band around pelvis
-pool walking (ideal initial supportive environment for pts with ataxia)
Strategies for varying locomotor demands: trunk counterrotation and arm swing
-practice walking with exaggerated arm swings
-practice walking with wooden dowels, hula hoops, ball rotation
Strategies for varying locomotor demands: walking sideward
-walking using lateral side-steps; resisted progression (manual and elastic resistive bands)
-walking using cross-steps
-walking using braiding
Strategies for varying locomotor demands: walking backward
-walking backward (retro-walking)
----> practice appropriate knee flexion in combination with hip extension
Strategies for varying locomotor demands: step ups/step downs
-stepping up and stepping down (vary step height progressing from low -> high)
-lateral step ups
-stepping onto and off of varied surfaces (foam pad, half foam roller, inflatable disc, Bosu)
Strategies for varying locomotor demands: stopping, starting, & turning on cue
-practice abrupt stops and starts on verbal cue
-turns on verbal cue
---progress from quarter turn to half turn to full turn
---progress from wide base turns to narrow base turns
-practice figure-8 turns
Strategies for varying locomotor demands: visual input
-practice walking alternating btw EO and EC
(3 steps EO and then 3 EC)
-reading as you walk
Strategies for varying locomotor demands: head movements
-walking with head turning predetermined number of steps and turn to right/left, up/down
-walking w head movements on verbal cue ("look right" "left", etc)
Strategies for varying locomotor demands: practiced timed walking, increasing speed and locomotor rhythm
-begin walking at a comfortable speed, gradually increase velocity
-use pacing cues to vary speed ("walk slow", "walk fast")
-use metronome or brisk marching music to inc speed, improve locomotor rhythm
-impose short bursts of fast walking (on verbal cue) with walking at a comfortable speed
-practice within time constraints (i.e., crossing at a stoplight, stepping on and off a moving walkway or escalator, walking onto elevator, walking thru revolving door)
Strategies for varying locomotor demands: practice dual-task walking
-walk and talk
-walk and count by 3's, 7's, repeat a sequence (forward/backward), categories
-motor task: walk and bounce/toss a ball, carry a tray/cup of water.
Consider environmental constraints
Curbs, Ramps and slopes.
Pattern to traverse the ramp (use a diagonal, zigzag pattern) for both ascending and descending.
Walking up an inclined surface is associated with decreased speed, cadence, and step length.
Practice should include uneven surfaces such as sidewalks, grassy surfaces, parking lots, and so forth.
Because learning is task and environment specific, walking should be practiced in all environments normally used by the patient
shopping mall, community center, grocery store, or other patient-specific location.
Variations in visual conditions (e.g., full to reduced lighting)
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