Institute for Knowledge Translation

How do you know if you are providing too much assistance to create worse outcome for the patient?

How do you know a patient is ready to increase the challenge?

When initiating treadmill training, how do you decide what speed to try?

When adding leg weights/weighted vests, do you usually start with specific weight (e.g., 5, 10, 15 lb)?

How do the biomechanical deficits apply to jogging? For instance, if the patient is clipping their toes multiple times in a row and unable to correct, should I be reducing speed to fast walking vs keep practicing jogging, but with BWS or ankle support?

Is there a specific subcomponent of gait that should be addressed first/prioritized?

At what point do you introduce obstacles or stair training?

Would you ever use ankle weights on a person who has adequate limb advancement for the sole purpose of increasing the intensity of the intervention?

When a patient is very impaired in most or all of the biomechanical subcomponents, how do you decide which one(s) to target first?

Do you have any tips to prevent sitting in a harness during treadmill training?

Do you have a list of treatment ideas for the biomechanical subcomponents?

If compensations are observed for limb advancement (e.g., hip hiking, vaulting, decreased foot clearance or toe catching) but the patient is still consistently achieving a positive step length, is error augmentation appropriate?

Can you clarify the difference between the criteria for successful stepping and a patient’s biomechanical deficits?

How does stair training primarily focus on swing and stance control? Don’t all functional tasks require all four biomechanical subcomponents in some regard?

For a patient who requires total assistance for limb advancement, how do I balance the need to provide assistance while being mindful of the principle of laziness?

Does a weighted vest challenge propulsion in addition to stance stability?

I’ve noticed that adding variability/error augmentation to one biomechanical subcomponent could also have a negative effect on another biomechanical subcomponent. How do I manage this?

What is the difference between assistance and guidance?

Can you clarify use of the cords/straps to aid in in limb swing limb on the TM? Initially, it was shown that doing so decreased muscle activity in a healthy individual, while later it was shown as a treatment for a patient following neurologic injury.

When would it be appropriate to begin trial & error with a degree of skill acquisition?

Would you say propulsion is more focused on in outpatient therapy? It doesn't seem to be a heavy hitter in IPR since the other 3 components usually provide more of an obstacle.

Please explain how to decide whether to increase treadmill speed vs treadmill elevation to get patients into their target heart zone.

When challenging lateral stability and propulsion, does an assistive device counts as assistance and guidance? Is it inappropriate to introduce challenge/error until patient can successfully complete without the AD?

How long does a patient need to participate in HIT to make a lasting difference on their function? If they stop HIT after leaving inpatient rehab, is there regression of skill?

In patients undergoing rehabilitation within the first 6 months following a stroke, what type gains should I expect and in what time frame?

Do infarcts in different areas of the brain respond differently to HIT?

With the understanding that circuit training is a “may consider” recommendation from the locomotor CPG, what are some examples of exercises to include if this be deemed an appropriate treatment for a particular patient?

Is there a role for functional e-stim/neuromuscular e-stim during HIT? Would it feed into the principle of laziness or be useful "guidance" early on?

With participation in HIT are you seeing an increase in falls during therapy sessions or at other times of day?

Do you recommend any VR or biofeedback programs during BWSTT?

Is it best to combine HIT with VR for optimal effects on walking and overall function?

What is the evidence that supports high intensity gait training in subacute and chronic stroke?

Do any of the recommendations from the locomotor CPG change for inpatient rehab given we are much more acute than the studied >6 months?

Has research looked directly at the relationship of high-intensity gait training to participation-level or quality of life measures?

Are there newer studies available? I may have overlooked it, but the most recent study seemed to be from 2014.

Have there been any studies looking at how increased number of steps per day relates to improved quality of life beyond the SF-36?

Has there been any research showing that HIT helps promote spontaneous recovery?

Aside from some of the studies using control groups consisting of interventions that are not reasonable alternatives, what are some of the biggest limitations of the CPG?

Are there improvements seen with other outcome measures even when not specifically addressing those deficits (PASS or TIS for instance)?

What does the evidence reveal about combining HIT with dual tasking in an individual's s/p CVA? Does the divided attention take away from therapy outcomes?

How is spatiotemporal symmetry and temporal symmetry tested?

Is there research on performing HIT with other equipment including Bioness Vector and LiteGait overground?

When will there be CPG for locomotion for under 6 months post?

Is there evidence to suggest HIT decreaes length of stay (i.e., decreases cost to health care system)?

Literature also supports High-intensity interval training (HIIT) with the stroke population. How does high-intensity training compare?

Is there evidence for high-intensity gait training to help increase the function of the affected upper extremity? Or is it not task-specific enough to have an effect?

Why was 3-5 consecutive errors selected as the threshold for changing an activity?

The course indicated that HIT has been observed to improve transfers, 5xSTS, BERG, but has it been shown to improve bed mobility too?

Since the CPG targets chronic stroke, is there published research that looks at efficacy/safety using these methods in acute CVA? Is it safe to apply the chronic CPG to subacute patients?

In the research for SCI patients, is anyone studying HIT with motor complete spinal cord injuries? Does HIT carry over with improvements in other mobility, ADLs, etc?

Is there a goal for the total amount of time patients should be working at the target intensity per session?

We have had a difficult time getting patients on beta-blockers into the target HR range. If we increase the weights or decrease BWS they get too tired and start refusing to do HIT. Is there a time where you switch and more heavily rely on RPE?

What are the differences between HR Reserve and % HR max? If a patient’s resting HR varies throughout the day, what do you use?

If patient is reaching/reporting desired RPE 14-18/20 range but HR is not reaching the desired range, is this still intense enough?

What target heart rate calculation do you use?

When using HRR, what do you document for resting heart rate?

Have you had any success downloading raw heart rate data from polar or other smart watches that can be imported into excel to create graphs?

If a patient spends more time walking, but achieves a lower target heart rate, is it better to do shorter bouts of HIT (interval training)?

I find it hard to keep the intensity up for a longer period on time when training on the stairs. Any good advice?

Do you ever re-calculate a HR max again if you are using the heart rate reserve method or just stick with the one that you calculated on day one?

Sometimes I notice a variation in the resting heart rate from visit to visit. Is the age-based calculation preferred because of this variation?

Do you often find a conditioning effect where it becomes more difficult to meet the target intensity just because the patient becomes more acclimated to the activities despite adding more weight and resistance and error augmentation tasks?

Are there recommendations for the 1-10 RPE scale vs. 6 – 20? Are there namebadges with the 1-10 scale? Do you ever use word descriptors for RPE?

Why do some patients seem unresponsive to HIT? I've had a few patients that getting even 60-70% HRmax is seemingly not possible.

Should I consider doing lower extremity therapeutic exercise or sit to stands to increase heart rate prior to gait training?

If a generally healthy patient is getting above 80% heart rate target without symptoms, is it okay to continue at this intensity or should we be insisting they take a break?

How frequently should heart rate be monitored during high intensity gait training?

What happens physiologically at training >85% HRmax and is that detrimental?

If a patient is on beta blockers or HR altering meds, do you use Borg consistently?

If a patient is not medically cleared for HIT (i.e. cardiac concerns), is there benefit from low intensity gait training? If not, what interventions are recommended for patients who cannot participate in HIT?

Should we adjust the target HR range if the individual is on an ACE inhibitor?

Is there an alternative way to assess/document RPE if patient has profound aphasia?

I have a patient who was running marathons prior to his stroke. His heart rate is low with activity. Other than a RPE scale what would you do to make sure he is exercising at the target intensity?

If you have limited polar monitors in your clinic and you cannot continuously measure HR, how do you best monitor intensity? Do you use a pulse oximeter, BORG scale..?

How common is it to not achieve a high heart rate for an individual with subacute stroke undergoing inpatient rehabilitation?

For those who rely heavily on a walker, have very flexed posture, and are unable to get on a treadmill with a harness, what would be strategies to increase the intensity?

If you have access to treadmill and over-ground training, which is best?

In patients with Trendelenburg who have hip drop when walking without a cane, is it beneficial to take time away from HIT and strengthen the hip separately?

What are your thoughts on other methods of higher intensity training as an avenue for neural priming and/or facilitating central pattern generators prior to high intensity gait (e.g., NuStep)?

Is there a downside to utilizing "too much" treadmill training in comparison to overground gait when client is very resistive to overground increased speed but will keep walking on the treadmill at higher speeds?

How much time within a session should be focused on high intensity gait?

Is there any benefit to practicing pre-gait activities- weight shifting, heel taps forwards/backward, etc., or just get right into walking?

Are there benefits to high intensity even if it's not gait training? (i.e. arm bike)

What about using LE FES for high-intensity cycling since cycling is recommended by the locomotor CPG?

I understand that based on specificity weight shifting has not been shown to translate into walking performance. Can the same be said about marching on the spot?

How do you determine the amount of initial resistance applied during the error augmentation phase?

How often do you check vitals?

Is it possible to detect A-Fib on a polar monitor?

With COVID and patients having to wear masks in the facility, have you seen this change how they present during high intensity gait training?

The stairwell interventions: why not drill them in the II bars for safety?

Do you recommend stair training with patients who require maximum assist?

Do you frequently see patients pass out during training, especially early after injury?

Can you provide an example of a cardiac patient that you had that you utilized moderate intensity gait training?

As a therapist, how do I get more comfortable with higher weights and stressing patients more?

Many of my patients are tachycardiac at rest. Would this preclude them from participating in HIT?

Most of the chronic CVA patients we see don't have exercise stress testing done to officially determine safety of this. Do you recommend asking the physician for clearance?

Do you ask physicians for approval each time you provide HIT?

Are there red flags to look out for when performing HIT with patients, especially ones with comorbid heart conditions?

Aside from not having medical clearance when might you not use this approach (or is that very patient dependent)?

If cardiology does not follow the patient, should I just follow-up with the attending MD to determine safety?

Do you have a sample letter/correspondence that you send to external MD's to obtain clearance for their patients for HIT?

Are patients with pacemakers appropriate for HIT?

How are patients with atrial fibrillation monitored?

Are there patient diagnoses that you would not recommend trying HIT?

Are there studies on the effects of HIT on joint laxity or change in ACL/PCL?

How soon can you initiate HIT following CVA?

Is there evidence of increased risk for stress fractures or increased pain/arthritis with HIT?

If normal kinematics are associated with increased efficiency, why not incorporate kinematic training into high intensity gait training?

When do you decide on emphasizing more compensatory measures rather than maintaining a 100% focus on motor recovery?

Are there long-term studies on possible orthopedic issues resulting from abnormal kinematics such as knee hyperextension?

If a patient is having knee pain that may be related to abnormal gait patterns affecting the knee, is it then appropriate to address specific kinematics to try to address that pain?

What are strategies to decrease knee extensor thrust / hyperextension during stance?

What are strategies for patients with profound forward-flexed posture?

Are there any instances in which you find it appropriate to work on kinematics?

Are you providing any verbal cues for kinematics, like step length, knee extension, etc. or are you allowing the patients to figure it out without verbal coaching?

How many simultaneous cues are recommended for the biomechanical subcomponents?

Over what period of time should we expect to see a patient’s mechanics ‘normalize’ after participating in high intensity gait training / when can we tell if these gait deviations are more permanent?

Is it harder to change a patient’s ‘bad’ mechanics later in their recovery if they are permitted to ambulate with such deviations or variability early on?

It was stated that reduced knee flexion and increased hip circumduction during gait are difficult to alter whether the focus is on kinematics or subcomponents. What is the best way to address these two specific limitations?

Is there a way to alter compensation such as vaulting?

How do you decide when/whether/how to brace in order to maximize stepping and intensity of practice?

When do you choose FES vs AFO vs theraband to assist with limb clearance?

Do you recommend the addition of FES (such as a foot drop stimulator) as an add-on to high intensity gait training?

Is there a preferred time a custom AFO is integrated versus taping or off the shelf support when focusing on high intensity gait training?

When should an AFO be discontinued? I have a patient that can safely walk at low intensities without AFO, but can't at high intensities. Could I use error augmentation to facilitate swing at slower speeds instead of using an AFO?

How soon should you intervene with bracing to aide with protecting joints?

If the pt is having multiple errors (3-5) with DF during swing phase which is becoming a safety concern (ex: increased risk of an ankle sprain) would you include assist with use of an ace wrap or AFO, or continue providing manual assistance?

Is using a FES device (like the Bioness) recommended during high intensity gait training or is it better to use an AFO because it is faster to put on the patient?

What is your experience implement high intensity gait training with patients who require a KAFO?

Thoughts on use of DF assist ACE wrap or AFO's to allow successful stepping to increase steps and intensity? Only remove to focus on limb advancement?

Could FES be used to assist with limb swing or stance control and if so, is this better than physical assist from a therapist?

We’ve had some patients that demonstrate increased upper extremity spasticity while performing high-intensity training. Are there ways to avoid this?

How do you manage tone and spasticity? If spasticity is limiting your ability to meet the appropriate intensity, do you have any suggestions?

How do you accommodate for severe spasticity, thus poor ankle positioning that cannot be supported through bracing, when introducing high-intensity gait training? It feels unsafe to gait train with the ankle in such poor positioning due to tone.

Are there any recommendations for a patient that may have significant myoclonus as a secondary impairment?

Is an Ekso robotic gait training device different from other passive robotic gait training devices since PT assist and effort can be augmented throughout gait cycle?

While the lokomat is often not ideal, do you think the lokomat could be beneficial when using the augmented challenges which increase the patient's heart rate to the target zone?

Is there any place or benefit for robotic assisted gait training?

When patients with decreased activity tolerance report inability to continue high intensity training in session. What would you prioritize next?

How often do you offer rest breaks during a HIT session?

How long should rest breaks be when warranted d/t form decomposition rather than RPE or HR being too high?

How do you determine appropriate length of rest breaks? Is there a specific HR or RPE to get down to prior to starting again? For patients who have the endurance, is it better to drop intensity, but maintain walking instead of sitting or standing?

How frequently should rest breaks be provided? Presumably upon HR and RPE increasing beyond the parameters, but what if a patient has significantly decreased activity tolerance but no other barriers?

Is it optimal to encourage standing rest breaks vs seated while HIT?

What do you do if a patient isn’t up to walking on a scheduled day?

What is the #1 reason patients refuse HIT?

What are some tips for getting manager and clinician buy-in?

How do we help with carryover of the intervention when our patients are seen by other therapists?

How do you get buy-in from physiatrists or cardiologists?

How have you educated and engaged physicians in your HIT implementation projects?

What main 3 articles should be used when trying to convince MDs or other PTs on the importance of HIT?

Do you have any recommendations for managing nausea and vomiting in response to HIT? Should you just be prepared for it in the setup or address it medically by discussing medication options and timing of feeding schedules?

Have you noticed any difficulties using harness systems in patients with paretic shoulder pain? Do you keep the arm in a sling?

For higher level patients (able to partially complete HiMat), should the focus be on walking/running or can tasks be broken into components such as plyometrics, jumping, or bounding at high intensity?

Do you still perform HIT with dense hemiparetic pts with minimal to no return in strength?

What if my patient has severe sensory impairment and/or inattention/neglect?

What if my patient has a tracheostomy?

Could you please suggest literature to review on HIT in CABG, valve replacement, etc?

How do you adjust for the cognitive component in participation for high intensity gait training - is it still appropriate?

What is your experience with this program in patients with cerebellar ataxia?

What is your experience with this program in patients who demonstrate contraversive pushing?

How much research exists for high intensity gait training with TBI patients?

Has research studied HIT in other populations?

Are there any studies performed/completed to review the HIT program with patients who are in rehabilitation post-COVID or with COVID Long Hauler status?

With patients who have experienced a brain injury, do you ever incorporate cognitive tasks while working on HIT or do you focus only on the HIT?

How do you train a patient with bradycardia that is not induced by medications?

My patient has a 4.5 cm aortic aneurysm, can I still do HIT?

Has high-intensity gait training been studied in Parkinson’s disease?

How would you manage an obese patient with (B)LE sensory deficits?

Any suggestions for a very determined patient that is limited by (B) LE nerve pain (despite medications) from reaching the target heart rate?

Does high-intensity gait training improve upper extremity function?

Do you only use RPE in incomplete quads and high paras?

Is HIT appropriate for someone on dialysis? If so, when is the best time to schedule sessions?

How do you utilize HIT for individuals with complete SCI?

Would a patient with significant inattention be expected to have worse outcomes?

How does high intensity gait training impact upper extremity functioning?

Would you recommend HIT for patients requiring supplemental oxygen?

For iSCI following back surgery with spine precautions and back braces are weighted vests and/or weighted limbs contraindicated?

Is there evidence for improvements in objective outcomes for patients post-stroke with cognitive and/or memory issues?

Are targeted intensities different depending on whether it was a hemorrhagic or ischemic CVA?

Would you change any parameters to provide high-intensity gait training (HIT) in the pediatric population? Are there any studies or guidelines for this population?

What is the best way to provide HIT with someone who has decreased command following or level of alertness/arousal?

Is there evidence to support providing HIT to patients with Guillain-Barre syndrome, including in patients who have trace contractions throughout the legs?

Any contraindications around glioblastoma and HIT?

What about HIT and occupational therapy?

What do you prescribe for a home exercise program during this training program?

To improve balance, I usually give patients a HEP in the corner i.e. a static balance HEP. Does this mean I really should be steering away from this because it's not as effective as a dynamic balance HEP?

In outpatient rehab, the HEP is so important. How do you give patients an effective error-based dynamic HEP without compromising safety?

How do you get patients to challenge themselves at home enough when they are only coming in 1-2x/week in an outpatient PT setting?

What is a good home exercise program for a lower level patient that does not have family support to assist?

In the outpatient world, is there evidence to support incorporating HIT into a patient's HEP, or should it be focused more while in the presence of a PT?

How are strength scores utilized in the subacute stroke CPR for HIT?

Is there a clinical prediction rule for stroke or SCI in the outpatient setting?

How might we use the subacute stroke CPR for HIT within our clinical practice?

Does age or type of stroke factor into the subacute stroke CPR for HIT?

In the subacute stroke CPR for HIT study, what was an average LOS for a patient with BBS = 5 and unable to ambulate without significant assistance?

In the subacute stroke CPR for HIT study, are strength scores MMT or from a seated screening?

Can you provide more education on patients with incomplete SCI, ASIA scoring, and applying the clinical prediction rule to patients to make decisions about delivering HIT?

For the HIT CVA prediction rule, what do you define discharge/length of stay as since length of stays in inpatient rehabilitation are continuing to be shortened?

Have you ever used a prediction tool (like the ones utilized to predict odds of ambulating contact guard of less) and then observed if the outcome meets the prediction?

How well does the Berg Balance Scale predict falls in the inpatient rehabilitation setting?

Are both a self-selected and fast 10MWT recommended?

What are the best measures to use with patients undergoing HIT?

Is it necessary to take outcome measures multiple times during a patient’s stay?

Is it necessary to use multiple outcome measures to assess a patient’s outcomes?

What outcome measures can an acute care therapist collect that will help the inpatient rehabilitation clinicians’ decision-making?

What screening tools could I use to screen for depression?

What are the best ways to communicate measurement results to the patient if they aren't happy with their level of improvement?

Do MDC's and MCID's have specific time frames for relevance?

If a patient requires physical assistance during the 6MWT and 10MWT, is it still appropriate to use the MDC and MCID?

How do you differentiate outcome measure changes attributable to spontaneous neuro recovery vs actual change from skilled therapy?

For tests like the FGA, there aren't specific data for a MCID for stroke (only SEM and MDC) are these appropriate for goal setting?

If MDC/MCID values aren't available for some of the less common diagnoses (e.g., anoxic clients, dual diagnosis), should we just use pre vs post change scores?

Are you allowed to be touching assist at all for the FGA?

Are there resources available for MDC/MCIDs specifically for individuals with iSCI?

During an evaluation of a patient poststroke, do you still follow the conventional objective testing (e.g., MMT, ROM, coordination) or do you focus more on functional abilities and outcome measures?

Considering HIT will be the primary treatment intervention, how do you set goals for the POC? Do you still include MMT or ROM goals versus focusing on functional goals?

Do you have any recommendations for information to include in our treatment notes after reassessment of an outcome measure?

We now use the 6MWT, but we previously used the 10MWT. Is one more accurate?

What specific MCID's do you use for each of the core set of measures for acute/sub-acute vs. chronic?

Are there breakdowns of MCID by age? Are MDC/MCID what you are using to write measurable and meaningful goals? Is the standard to retest once a week and are there studies to support this?

Is HIT still beneficial once a patient has plateaued in therapy?

How should we document or demonstrate functional change when only a MDC and not an MCID is available for a population?

What topics related to high-intensity gait training should be included in entry-level education? (2-3 hours of content)

Is HIT being integrated into DPT curriculums?

What is the best way to track heart rate? Wrist strap (consistent), pulse ox (intermittent)?

Could you please provide some tips for documenting heart rate in the EMR?

How much are your heart rate monitors used on a weekly basis? For example, if you have have 20 monitors for 20 PTs, do you expect that each therapist would use the monitor daily?

Which heart rate monitor is best in terms of accuracy and ability to clean? How well do the earlobe monitors work? Can a wrist worn Fitbit work?

Our IRF is within a hospital and we have strict regulations for infection control. How do you all manage to keep the Polar bands clean and up to standards of Joint Commission or other regulatory bodies?

In using the Polar arm strap HR monitor and app, how do you maintain HIPAA compliance with patient info on the app?

Does the Polar app allow you to have different profiles for different patients?

Do you use Polar Beat or Polar Coach to track your sessions?

How do you go about setting up different accounts in the Polar Beat App for different patients?

I'm not getting a HR reading in the Polar Beat app. What do you recommend?

What features should we look for in a weighted vest? Where can I buy one?

Any recommendations for a weighted vest that is able to be sanitized?

Our treadmill system can ONLY be used with BWS at the lowest setting of 5% to engage the harness to prevent a fall...is that OK?

What do you use in the clinic to help advance the LE during TM? I am finding that using my hands is difficult because the patient is stepping on my hand.

Our facility is very strict about infection control and limits the use of any materials that are porous. What do you use to disinfect your harnesses?

What recommendations can you make for specific brands of walking slings and treadmill models that have worked best for comfort, ease of setup, and safety?

How do you charge for HIT, gait training or neuro- re-education or both?

In the sample documentation, gait training was charged. Would it ever be appropriate to charge ther ex or neuro re-ed?

What are key pieces of information to include when documenting a HIT session?

Has any insurance company ever challenged billing for HIT?

How are you documenting a patient's deficits in biomechanical subcomponents in your assessment?

What are your policies regarding sharing resources from this course with others?

I would like to start a discussion about HIT with my colleagues using research articles. Which articles would you suggest using first? Would you modify this list based on diagnosis (stroke vs. SCI) and time post (acute, subacute, chronic)?