Dynamic Gait Training: Stepping Over Cones and Leveling Up

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult faculty member Julie Brauer emphasizes the importance of executing obstacle courses in a specific, dynamic, objective, and progressive manner. The purpose of these obstacle courses is to prepare patients for the chaos of their daily lives and help them confidently overcome these challenges.

To make obstacle courses specific, Julie suggests replicating the functional demands of the patient's specific goals. This means creating exercises and challenges that directly mimic the movements and tasks the patient needs to perform in their daily life. By doing so, the patient can develop the skills and confidence necessary to navigate these challenges effectively.

In addition to being specific, obstacle courses should also be dynamic. This involves incorporating a combination of exercises and layering dynamic challenges. By introducing variability and unpredictability into the obstacle course, patients can improve their ability to adapt and respond to different situations. This dynamic nature of the obstacle course helps simulate real-life scenarios and prepares patients for the unexpected.

Objectivity is another crucial aspect of executing obstacle courses effectively. Julie suggests leveraging subjective and objective outcome measures to make the obstacle course objective. This means using measurable criteria to assess the patient's progress and performance. By having clear and measurable goals, both the therapist and the patient can track improvement and make necessary adjustments to the obstacle course.

Lastly, obstacle courses should be progressive. This involves gradually increasing the difficulty and complexity of the challenges as the patient improves. Progression ensures that patients are continually challenged and can continue to develop their skills and abilities. It also helps to keep the obstacle course engaging and motivating for the patient.

Overall, executing obstacle courses in a specific, dynamic, objective, and progressive way is essential for helping patients develop the confidence and competence to effectively navigate the challenges in their daily lives.

Take a listen to learn how to better serve this population of patients & athletes.

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EPISODE TRANSCRIPTION

00:00 - JULIE BRAUER

Welcome to the Geri on Ice segment of the PT on Ice daily show. My name is Julie Brauer. I am a member of the Older Adult Division, and we are going to be talking this morning about obstacle courses and leveling up our dynamic gait training. So I've been really passionate about creating meaningful obstacle courses for a really long time, and I've become even more excited about this topic since our live course has gotten this massive revamp where we spend an entire lab focusing on dynamic gait challenges and how to layer. So I'm so excited to dive into this today because obstacle courses can be a really challenging, fun, creative way to implement dynamic gait training into our plans of care. With the purpose of preparing our patients for the chaos that is their daily lives, right? We want them to be able to move confidently through the chaos of their lives. And if we really think about it, What better exercise could we give our patients than a combination of exercises, a combination and layering of dynamic challenges that exactly replicate the functional demands of their specific goal, right? However, I think we many times really missed the mark here on executing this in an effective way. And when I say executing in an effective way, I mean in a way that is specific and dynamic, objective and progressive. So when I reflect back on the past eight years of my practice, 02:37 OBSTACLE COURSE LIMITATIONS When I think about all the obstacle courses that I have seen throughout various settings, most of them are variations of stepping over cones, or stepping over hurdles, or many times it's stepping over canes. Many times it's one rep, the patient goes through that obstacle course forwards, and then the next time they go through it sideways. Many times it's weaving around cones as well as stepping over them or maybe stepping in and out of an agility ladder. And when we think about that, we have to realize it's pretty unidimensional, right? It doesn't exactly look like real life. Most of these patients are not on a clock. We aren't often capturing our PE while the patient is going through the obstacle course, right? Like I could go on and on about a list of things that are wrong with our typical obstacle courses that we see in our clinics, in our profession. And while stepping over cones and navigating around them is a really solid place to start, we really have to start thinking about moving beyond that, right? I consider stepping over cones and navigating around cones very similarly to our other underdosed exercise. I will go as far as to say that I think that cone stepping is the ankle pump of dynamic gait training. Stepping over cones is the ankle pump of dynamic gait training. And so why? So let's unpack that. Because many of you would probably say, like, what do you mean stepping over cones is challenging for my patients? And I'm going to respond with, well, yeah, I mean, tandem standing is challenging for a lot of my patients, but I'm sure as hell not going to waste multiple weeks of a plan of care with my patient in tandem stance, right? The question becomes, is it the right challenge? Is it the right challenge? Similarly to tandem stance, Do the demands of stepping over cones match the entirety of the chaos and the dynamic demands that comprise our patients' lives? We have to realize that stepping over cones only hits one aspect of dynamic gait and balance, right? It only hits on anticipatory balance. And we know that balance can break down in multiple different areas. And there's so many other components of balance and dynamic gait that we want to pay attention to. we have to realize that stepping over cones is not super specific, right? It doesn't look like real life. Our older adults are not moving around in an environment where these very bright orange cones are sticking out to alert them they need to step over that thing, right? And then also, you know, just thinking about If I am able to get my patient really competent and confident in stepping over cones or weaving around cones, does that actually translate to our patients feeling incredibly confident to take on the adventures in their world? 06:08 ROOM TO GROW WITH OBSTACLE COURSES So we have to first reflect on why there's just a lot of room to grow when it comes to our typical obstacle courses, all right? So now that we've set that framework, let's talk about how to level up our dynamic gait training from assessment to implementation and creating in dialed in workouts, focusing on how to make these obstacle courses specific, objective, dynamic, and progressive. All right. And we're going to put this in the framework of focusing on two different types of goals. And these were goals and dynamic eight challenges that students who were part of our MMOA live course a couple weeks ago in Oklahoma came up with. absolutely stellar students who came up with really awesome dynamic challenges. So I'm going to share some of these with you. So these two goals that we'll be talking about back and forth, um, that many of you can relate to with your patients are the goals of one, being able to independently navigate through the airport and board an airplane independently to be able to go on vacation. And then two, to be able to independently tend to a garden. All right. So two goals that are very common among older adults. And we'll talk about how to make it specific, dynamic, objective and progressive. All right. 10:21 SPECIFIC OUTCOME MEASURES So starting out with making our obstacle courses really specific. This is where we need to dig deep. So if you're part of our MMA crew, you hear us talk about our formula, make it meaningful, load it, dose it all the time. So this is that make it meaningful part, right? So we need to dig deep into what that goal actually looks like. I want to peel back all the onion layers. So if my patient is telling me, well, I want to be able to go on vacation. I am having my patient take me through from start to finish. I want to know exactly what that looks like for her or for him to go from getting out of that car into the airport through the airport onto the plane into into their seats right so I am asking question after question after question because I want to visualize what that goal looks like, right? If it's gardening, I want to know exactly what the functional movements are that comprise that goal because there is where I'm starting to create my obstacle course. I am in my head taking mental notes about what are all the pieces and parts that are going to comprise this obstacle course to make it very specific for the patient. Now, sometimes going seven layers deep with our patients is really, really difficult, right? They just, they have a hard time answering these questions or having that conversation with us. This is where we can leverage our outcome measures such as the PSFS or the FES and the ABC, right? Those are going to give us some insight into some components of their daily lives that are really scary or they feel like they're going to lose their balance or fall or components that they're actually really confident in. So you can use those outcome measures when perhaps the conversational part and you're asking a million questions and digging deep, is a little bit difficult for your patient. And then we want to really leverage our objective outcome measures, right? So our mini-best and our DGI, because that's going to give us very, very, very specific information. If our patient is telling us that, yeah, I'm having a difficult time because I'm afraid people are going to knock into me at the airport, well, I'm sure as heck gonna want to look at their reactive balance with their mini best, right? So we wanna use both digging deep, asking the questions, using those subjective outcome measures, and then definitely using those specific objective outcome measures to see where perhaps the balance is breaking down, right? So to give a couple of specific examples, If our patient, maybe in their PSFS, are saying that lifting that suitcase over their head is really the part that is limiting them from feeling confident and being able to go on that trip, maybe it's a strength component that we really want to focus on. So maybe I'm going to look at a press or a push press and see what that looks like in isolation and maybe coach that up, right? But then I know that I'm going to add a push press or a press into my obstacle course, because maybe it's not that the strength component of that push press is the big issue, but more that they are so fatigued after going through the entire airport that they just don't have the energy to get that suitcase up into that overhead bin, right? And so, again, to bring it back to the balance component, if they're telling us, I am so scared of getting bumped by someone at the airport, because I'm afraid it might fall, I want to know, hmm, what does their reactive balance look like? I want to look at forward. I want to look at backwards. I want to look at lateral. And then to put that into the obstacle course, maybe I can do something like our stellar students did a couple of weeks ago, where they use TRX straps. And as the patient's walking, they swing those TRX straps at spontaneous times, to see how the patient reacts to that, right? Or you could do something like as your patient is walking, you offer an external perturbation and see what their stepping strategy is. All right, so that's how to make your obstacle course as you're figuring out what the pieces and parts are very, very specific to what they're telling you and what you're finding throughout your assessments. Next, we have to talk about how to make it dynamic. And what I mean by dynamic is not just the patient is moving, right? Like, you know, I can see a lot of you being like, well, yeah, well, you know, stepping over cones or hurdles like that is dynamic. But we have to think more about just the patient moving, right? Yes, that is dynamic, but we have to remember that we need to mimic a dynamic environment, not just our patient being dynamic and our patient moving, right? And in addition to that, what I mean by dynamic is layering. 14:21 MIMICKING REAL LIFE CHALLENGES We want to combine anticipatory balance, reactive balance, vestibular fitness, strength, power. We want to combine all of those things together in our obstacle course, because that's real life. And that's when balance breaks down, when we were trying to navigate through all these different components. Remember that older adults are not waking up in the morning. And for the first two hours of their day, they're only doing a single task. And then the next two hours of their day, they're doing a dual task in reactive balance, right? Like they are constantly moving in and out of forward gate, sideways gate, making 360 degree turns, reactive balance, anticipatory balance, cognitive tasks, motor dual tasking. All that stuff is happening constantly. So we want to mimic that type of chaotic environment. We want to layer all of those challenges on. So what would that look like? Let's think about our gardening example. So if we're thinking, and our patient is telling us, okay, so I have to pull the hose, right? And I have to pull the hose and walk along the grass. And so you're thinking about this, hmm, how can I mimic that? Could I have my patient pull a rope? Could I also then have them do head turns where they're looking behind their shoulder to make sure that their hose isn't totally annihilating all of their flowers, right? You're making it that specific, but you're layering on challenges. What about for the individual who wants to go on vacation, they're really scared about stepping onto the escalator with their suitcase, right? So how do I replicate that? Can I step onto a variable terrain, like stepping onto a BOSU ball, while I'm lifting a weight or doing a suitcase deadlift, right? So now we have that sensory orientation, we're adding in that vestibular fitness, we're adding in the strength to step on and get stability on a moving object while also having the strength to lift an object. If we think about our gardening example, think about the act of pulling weeds. Maybe we're getting our patient down into a half kneel and we're doing a rowing exercise for strength. Or maybe it's more of the balance component our patient is worried about when they go to pull those weeds. So we do something like utilize squigs or we get a really heavy dumbbell and we tie a TheraBand around it and we have them pull the TheraBand and release. or we put a resistance band around them in half kneeling, and we go ahead and give them perturbations. So we layer on all different types of challenges, anticipatory, reactive, vestibular fitness, strength, power. That is how we layer. And we want to layer and layer and layer because that is what real life is like. Next, we have to find a way to make this objective, right? We have to dose it appropriately. We have to find a way to progress our obstacle courses. So we got to think about our goal, right? If we think about gardening or the airport example, if the goal is to be able to continuously move through, let's say 20 minutes, because let's say it takes 20 minutes to get through the airport. Gardening usually takes 20 minutes of time to do all those tasks. Okay, that's our long-term goal. So maybe we start out by, we want to see how many rounds you can get through when you continuously move for six minutes. That's more of the short-term goal. And we're recording how many rounds did they get through? How many breaks were required? Or if you have someone who, for example, gets to the airport really, really, really last minute, which just, like, my anxiety goes up even thinking about it, and you know they're going to be racing through the airport, maybe you want to design the workout so that that intensity is really, really high. And maybe you're doing something like three rounds of that obstacle course for time. We also want to be tracking our PE and using that to progress our goal. So if our patients, you know, capacity is really struggling, for example, you know, within three minutes of the obstacle course, it feels like an RPE of seven or eight, then maybe one of our goals is that it takes eight minutes of doing that obstacle course until that RPE of seven to eight come up. If we're focusing on balance capacity, are we using something like the balance stability scale to ensure that the variable terrain that you have mimicked, right, by perhaps having them walk on foam is enough? Or do we need to progress that by maybe underneath the foam, putting in some ankle weights or some other objects or having stepping stones to increase that balance challenge. So it actually elicits a step reaction, which maybe we saw in our mini best that we want to improve. If our patient more has a strength deficit, right? So that push press to get that suitcase in the overhead bin or the deadlift, maybe to get that mulch up from the ground or like a clean up from the ground to the shoulder and up overhead. Are we looking at our patient's estimated one rep max and making sure that we're working them at least 60% of that so that we can elicit positive strength adaptations? We have to make sure that we are dosing appropriately and that we have ways to progress this. Putting a patient on a clock is the easiest, easiest way to do it. Getting that RPE, really making what you're measuring be specific to what their goal is. And then the last part here is we can really utilize part practice of this big obstacle course to even more specifically dial in where our patient is having trouble, right? And it allows us to be very efficient because to create a big obstacle course can take a lot of space and a lot of time. So what we can do is as we're assessing and looking at this patient going through an obstacle course, we can see the pieces and parts that they have the most difficulty with. We can be asking them again from our questions and our subjective measures, like where are they having the most difficulty or where do they feel the most confident? And then we can pick out those pieces that we see and that they tell us and create like an EMOM or an AMRA. right? Making it very, very, very dialed in. So this is where I would take like three to four functional movements that comprise the goal, that comprise that entire obstacle course. So if we look at our gardening example, minute one, we, for an EMOM, we could do a sled push, or that could be a walker or resistance band, right? And we could be trying to mimic pulling that hose. Minute two, we could have our patient do some quadruped rows. So thinking about being down on the ground and doing some weed pulling or picking up different gardening tools. Minute three, we could be doing some external perturbations while they are in half kneeling. That could be mimicking pulling that weed and having to really catch themselves as they move backwards. Minute four, we could do something like a clean and press that could mimic trying to get that heavy bag of mulch from the ground up to the shoulder or up overhead. So that's how you can take your entire big obstacle course, pick out the important parts and create a workout that is much more succinct and easier to set up and doesn't require a whole bunch of space. Okay. That is what I got for you all today to come back around and wrap that up. When it comes to our dynamic gait training and creating obstacle courses, think about how you have to dig really, really deep. Leverage your subjective and objective outcome measures to focus on making your obstacle course specific, objective, dynamic, progressive, and then utilize EMOMs and AMRAPs to dial in the components that they are specifically having difficulty with. Now, talking about all this obstacle course stuff, I know it's getting some of you excited to think about dynamic gait training and all the different things you can do. You've got to come see us on the road to one of our live courses and check out our new revamp where, like I said, we spend an entire lab just on dynamic gait training and showing you all how to add in a lot of these layers. So on the road, there are tons of opportunities in October. My gosh, yes, it's October already. We will be in Virginia, California, and New Jersey. And then in November, we are in Maryland, South Carolina, New York, and Illinois. Plenty of options across the country to catch us out on the road and check out that super cool fun lab. On the flip side, our online courses, both Essential Foundations and Advanced Concepts are starting, gosh, next week. So October 11th and October 12th. Head to ptinice.com, message any of us. We'll be happy to answer any questions for you. We hope to see you on the road or online next week. Have a good day, guys.

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