Application of HIT in the Clinic
- Is there a goal for the total amount of time patients should be working at the target intensity per session?
- How much time within a session should be focused on high intensity gait?
- Can you review the ideal parameters for length of treatment for HIT?
- 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?
- Some of the research to support elevating high intensity training used 20-to-30-minute sessions. How long is appropriate for high intensity training sessions? Is there a point of diminishing returns?
- When you discuss total walking time in a session at a vigorous intensity, does that include warm up and cool down? Is it important to incorporate a cool down during HIGT?
- In patients undergoing rehabilitation within the first 6 months following a stroke, what type gains should I expect and in what time frame?
- It seems like the two key components of the protocol are high intensity (75-85% HRmax) and maximizing step counts. If both are not able to be achieved, which focus would be more important?
- Do you measure patient steps in a session?
- Do you have any tips/tricks for the most useful/efficient set-up for sessions for collecting metrics and maximizing time spent on gait?
- How do you know if you are providing too much assistance to create worse outcome for the patient?
- If you have access to treadmill and over-ground training, which is best?
- How is a session structured best in terms of intervals, duration, etc?
- How do you know a patient is ready to increase the challenge?
- When moving towards variable practice and error augmentation should intensity (RPE and HR) still be the focus?
- How do you set specific, realistic, and attainable stepping goals for a patient? Does it come with time and experience you start to see what a good number of steps are?
- 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 typically schedule an aide with you for the entire session to assist with transitions between activities and safety on stairs?
- What additional treatment interventions do you use in combination with high intensity gait training?
- Do you still perform HIT with dense hemiparetic pts with minimal to no return in strength?
- Is is appropriate to use assistive devices such as hemi walkers or quad canes with this intervention?
- When initiating treadmill training, how do you decide what speed to try?
- How do you determine if a client is suitable for HIT?
- 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?
- Would you prioritize forward walking at a higher speed/HRR or multi-directional walking at a lower speed/HRR?
- With participation in HIT are you seeing an increase in falls during therapy sessions or at other times of day?
- Our site has space limitations (i.e., 90 or 180 degree turns are required every 100-150 feet). Do you have recommendations on managing these space constraints?
- When adding leg weights/weighted vests, do you usually start with specific weight (e.g., 5, 10, 15 lb)?
Application During Acute Care
- How is HIT utilized in acute care? If utilized, then do many patients get disqualified by insurance from going to inpatient rehab by getting too many steps in?
Application During Inpatient Rehab
- How much time should we be spending on HIT in an IRF setting?
- How do we incorporate OT and assist with carryover to other disciplines? What should OT be focusing on?
- During inpatient rehab, should gait training be split up between supported gait training in a harness on a treadmill and overground for assistive device training?
- How early can I start HIT with my patients in inpatient stroke rehabilitation?
- For patients requiring maxA for ambulation, is it ok to have high levels of body weight support (~50%) to attain a safe stepping pattern for therapist and patient?
- What interventions are suggested for very low level, non-ambulatory patients?
- As many of my patients are very dependent, I am exhausted and would love to hear any suggestions on how to make this sustainable.
- When completing more intensive training in therapist assisted treadmill training where more than one person is required to assist, do you recommend having more than 1 skilled therapists in assisting or do you use support staff such as technicians?
- How would you recommend doing HIT with patients that are max/total assist in a facility with limited bodyweight support resources?
- With requirements at IPR facility for the patient to get 3 hours/day of therapy, what do you do if HIT fatigues the patient to the point that they cannot complete all of their sessions?
- Is there a guideline for % of time split between overground and treadmill training in patient who are ambulatory early in their rehab stay?
- The average LOS in inpatient for patients post-stroke is 8 days. Would you still recommend performing HIT with patient's with little to no movement in the leg if our LOS is that short?
- Do you recommend providing any specific information related to HIT at team conference in IRF?
- For an IRF, what would be the ideal number of HR monitors, treadmills and overground systems to provide HIT? What would you prioritize if you had limited resources?
Application During Home PT
- How do I do HIT in the home PT setting?
Application During Outpatient PT
- In higher level patients, does running/jogging on the treadmill have the same application to improving walking?
- In an outpatient setting where it is often not possible to see a patient 4x/week, do we adjust the frequency to 2-3x/week? Or, should we continue with 4-5x/week and risk using up their visits very quickly?
- In outpatient, is BWS still recommended instead of overground practice for more impaired ambulators despite the increased setup time?
- In an outpatient setting where you can’t have patients for 1:1 treatments, what are other ways we can still get some high intensity in safely?
- If we only see patients once a week or even once every other week, would HIT still be a valuable intervention to perform?
- 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?
- 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?
- 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?
- 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?
Specificity of Training
- 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)
- 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?
- 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?
Orthotics and Bracing
- 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?
- 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?
- 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?
Robotic Gait Training
- 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?
- 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?
- What do you do if a patient isn’t up to walking on a scheduled day?
- What is the #1 reason patients refuse HIGT?
Peer and Supervisor Buy-In
- 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 are cardiologists?
Application in Specific Clinical Populations
- 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?
Home Exercise Programs
- 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?
Clinical Prediction Rules
- 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?
- 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?
HIT in DPT Curriculum
- What topics related to high-intensity gait training should be included in entry-level education? (2-3 hours of content)
Heart Rate Monitors
- What is the best way to track heart rate? Wrist strap (consistent), pulse ox (intermittent)?
- In using the Polar arm strap HR monitor and app, how do you maintain HIPAA compliance with patient info on the app?
- 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?
- 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?
- 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.
Documentation and Billing
- 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?
Sharing What You've Learned with Others
- What are your policies regarding sharing resources from this course with others?