Manual Facilitation Techniques for Common Gait Impairments Post Stroke

Manual Facilitation Techniques for Common Gait Impairments Post Stroke

Natalie Stein, SPT

Background:

Stroke is the fifth leading cause of death in the United States and is one of the principle causes of disabilities in all industrialized countries. ^1,2 In fact, almost 60% of individuals still exhibit motor impairments following standard stroke rehabilitation.¹ One of the largest motor impairments that impacts disability following stroke is reduced gait performance.¹ Common gait impairments include decreased gait speed, decreased endurance, reduced weight-bearing on the paretic limb, decreased stance time on the paretic limb, lower limb asymmetry, and limited range of motion, to name a few.^1,3,4 Regardless of setting, a physical therapist will undoubtedly work with patients who have suffered a stroke at some point in their career, whether they are treating them immediately post stroke or observing prevailing disabilities years following a stroke. It is therefore important that all therapists are aware of how to work with these patients and are knowledgeable of different gait training interventions.

 

Project Interest and Statement of Need:

This project originally came to my mind during my third clinical rotation at an outpatient neuro facility. During this clinical we worked with many patients who had suffered a stroke. Along with being one of the most prevalent disabilities, impaired gait was also one of the most difficult and frustrating impairments I worked with because of my lack of intervention ideas. I knew from my neuro class that functional activity was the key to recovery, but I struggled with finding “functional” activities for rehabbing gait other than purely walking with the patient. This was something that the patient could most likely work on at home and I found it difficult to justify billing a patient for my lack of “skilled” intervention.

Luckily, during this rotation my CI taught me some valuable manual facilitation techniques that I was able to use while working on a patient’s gait. These techniques required hands on assistance and facilitation from the therapist in order to make necessary adjustments to improve gait. I observed how well these patients responded to manual facilitation both subjectively and objectively.

When I came back from that third clinical I spoke with other students who had a neuro experience as well. These students also agreed that they felt as if they had a lack of intervention ideas when it came to working on gait with patients post-stroke. These conversations sparked my interest in creating a capstone project that demonstrated the manual facilitation techniques I had learned that summer for the future second year students about to begin their neuro clinicals.

 

Guiding Research:

Unfortunately, the literature and research for manual facilitation is extremely scarce. Most of the research on gait rehab is focused on treadmill training, body weight support training, orthoses, and various electric modalities. However with much reading, research, and guidance from my committee I was able to piece together different literature that helped support and guide my project.

The three intervention approaches I found that most strongly correlated to manual facilitation were Proprioceptive Neuromuscular Facilitation (PNF), Neuro-Development Treatment (NDT), and the Motor Learning approach developed by Carr and Shepherd.^1–3 PNF and NDT both focus on the use of therapeutic handling by the therapist in order to facilitate correct movement patterns. These approaches place emphasis on providing sensory feedback via manual contacts with the goal of increasing the patient’s awareness to areas of muscle weakness, poor activation, or poor proprioception. ^2–7 The Carr and Shepherd approach emphasizes the brain’s plasticity and its ability to recover following a lesion if appropriate feedback is presented.¹ This approach is less focused on manual facilitation; however, it does stress the importance of enhanced sensory feedback from the specific body part and the need to perform specific and functional movement during rehab. ¹These three theories, along with an understanding of the basic gait impairments following stroke, helped guide my project.

 

Project Overview:

My Capstone Project is designed to be a supplemental presentation for second year students in the stroke section of PHYT 784 (Neuromuscular Intervention 1). I spent the first half of the semester completing the research previously described and speaking to different clinicians about their use of manual facilitation in the clinic. I then created videos demonstrating common gait impairments following stroke as well as the manual facilitation techniques to correct them. My final project is an easily accessible presentation that includes an overview of manual facilitation, a description of the common gait impairments seen post stroke, and the videos I created to teach students how to perform this intervention.

 

Project Presentation:

Manual Facilitation Techniques for Common Gait Impairments Post Stroke

 

Evaluation

Since I will be graduating prior to the fall semester when PHYT 784 is held, I am unable to present my project to the second year class as I had originally desired. In order to gather feedback about my presentation I therefore asked students who had previously taken this course to evaluate my presentation and its potential value to future students in the form of an online survey. I also asked for feedback from my committee members and capstone advisor. I received valuable feedback from all participating parties and was able to make necessary changes prior to submitting the final product. The survey I sent students is linked below.

 Capstone Evaluation Survey

 

Self Reflection

Overall, I am very pleased with my final presentation and the work I put into it over the course of the semester. I was very passionate about creating this project because I knew it was something the second year class could benefit from, but I was also very intimidated by the lack of research. Countless times I considered changing my topic due to this. Luckily, my amazing and supportive advisor, Dr. Prudence Plummer, encouraged me to keep my original plan because she too believed my project would be beneficial.

The research I put into this project gave me a deeper understanding into the various approaches used in neurological rehabilitation. Even if the approaches I studied had nothing to do with manual facilitation, I still found them beneficial to other areas of practice. This project also allowed me to use the knowledge and skills that I’ve acquired throughout school in order to clinically reason, evaluate, and treat disabilities despite lack of literature.

In conclusion, I believe that the presentation will be a valuable tool for students in PHYT 784 and especially valuable prior to students about to begin a neuro clinical.

 

Acknowledgements:

First and foremost, I must thank my incredible advisor Dr. Prudence Plummer, PT, PhD. I have no doubt that I would have been unable to complete this project without her. She not only answered my incessant emails immediately, but also taught me some of the very skills I present in my project. Dr. Plummer gave me the confidence to complete this project despite my weariness of available research and was able to meet with me almost every week during my routine panic attacks over the project.

I am also very grateful to my committee members Dr. Vicki Mercer, PT, PhD and Kara Jarboe, PT. Dr. Mercer, one of the professors for PHYT 784, allowed me the opportunity to create this project for her class and Kara Jarboe, my CI during my outpatient neuro clinical, is the person who originally taught me about manual facilitation techniques. Both of these individuals gave me valuable feedback throughout the capstone process and helped make my project what is it today.

Of course, I could not forget my wonderful two classmates who helped me film the videos for this project, Carly Bernadotte and Hailey Guerin. Thank you so much for taking the time out of your crazy schedules to travel with me to Hillsborough and assist in these videos.

Finally, thank you to all of my classmates who evaluated this project in such a timely manner and to University Physical Therapy in Hillsborough for allowing me to film in your clinic.

 

References:

1. Belda-Lois J-M, Mena-del Horno S, Bermejo-Bosch I, et al. Rehabilitation of gait after stroke: a review towards a top-down approach. J Neuroeng Rehabil 2011;8:66. doi:10.1186/1743-0003-8-66.
2. Understand Stroke | Stroke.org. Available at: http://www.stroke.org/understand-stroke. Accessed April 19, 2018.
3. O’Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation. 6th ed. Philadelphia: F.A. Davis Co.
4. Carr JH, Shepherd RB. Neurological Rehabilitation: Optimizing Motor Performance. Oxford: Butterworth-Heinemann
5. Bogey R, Hornby GT. Gait training strategies utilized in poststroke rehabilitation: are we really making a difference? Top Stroke Rehabil 2007;14(6):1-8. doi:10.1310/tsr1406-1.
6. Adler SS, Beckers D, Buck M. PNF in Practice: An Illustrated Guide. 3rd ed. Heidelberg: Springer
7. Eng JJ, Tang P-F. Gait training strategies to optimize walking ability in people with stroke: a synthesis of the evidence. Expert Rev Neurother 2007;7(10):1417-1436. doi:10.1586/14737175.7.10.1417.
8. NDTA^TM: Neuro-Developmental Treatment Association. Available at: http://www.ndta.org/whatisndt.php. Accessed March 27, 2018.

image source: https://musculoskeletalkey.com/fundamentals-of-human-gait/