Unlocking Potential: A Q&A on High-Intensity Gait Training (HIGT) with a PT Expert
High-Intensity Gait Training (HIGT) or HIT is gaining traction in the world of neurologic physical therapy. To shed light on this approach, we sat down with CariAnn German, PT, DPT, a Board Certified in Neurologic Physical Therapist with expertise in HIT. She generously answered some of the most common questions surrounding this exciting area of rehabilitation.
1. How long did it take you to get comfortable using HIGT as an intervention?
CariAnn: About 6 months. Like anything new, it can feel uncomfortable at first. But using heart rate monitoring and seeing tangible improvements in my patients made it easier to adjust to these newer strategies.
2. Why do you think more clinicians are not yet implementing HIGT? What barriers do you see?
CariAnn: Not everyone has access to adequate training and mentoring in the concepts of HIGT. There are some core principles, such as understanding the subcomponents of gait, heart rate monitoring, and error augmentation, that are essential to help clinicians feel comfortable and effective in implementation.
"Also, I think there is a bit of concern about achieving the "high intensity" aspect (i.e., elevating heart rate). More traditionally, as neuro physical therapists, we were taught to avoid over-exertion. But many of our patients are safe to push to these levels and honestly require it for progress"
Resources:
- Free tools: Academy of Neurologic Physical Therapy (ANPT) website: https://www.neuropt.org/practice-resources/anpt-clinical-practice-guidelines/locomotor
- Comprehensive Course: "Walk the Walk: High Intensity Gait Training in Rehabilitation" offered by the Knowledge Translation Institute.
3. What are "ideal" patients that you use HIGT for? Any patient presentations you will not use HIGT for?
CariAnn: Ideal candidates are individuals with chronic (more than 6 months post-injury) CNS injuries including stroke, brain injury, and spinal cord injury. I tend to observe greater benefit in younger individuals, but I don't limit HIGT application based on age.
Caution: Per the "CPG to Improve Locomotor Function," I would be more cautious with patients who have comorbidities including uncontrolled cardiovascular or metabolic disease, musculoskeletal injuries, or severe neurological deficits. In these cases, physician clearance and potentially graded exercise testing with electrocardiographic assessments are recommended.
Not Ideal for: HIGT is not for every patient. Some individuals may need to focus on safety for household mobility or gradually improve endurance before tolerating higher intensities. Others with a completely flaccid lower extremity may require different approaches. In these cases, I use more traditional physical therapy interventions and transition to HIGT if appropriate.
4. How do you monitor cardiovascular demand/intensity? Any recommendations for clinicians? Do you always keep it to 70-85% HR Max?
CariAnn: I use a heart rate monitor that straps onto the arm and syncs via Bluetooth with the Polar Beat app on my phone. You enter the patient's max heart rate into the app, and it tracks the heart rate max zones for you. Many affordable heart rate monitors are available online (brands like PowrLabs, Wahoo, Polar, and Moofit).
If medications or other medical diagnoses limit heart rate response to exercise, I use the Borg Rate of Perceived Exertion (RPE) 6-20 Scale with a target of 13-16/20.
Target Zone:
In a 60-minute session, I aim for at least 15 minutes in the 70-85% HR Max zone, but more is often better. The "CPG to Improve Motor Function" recommends 20-60 minutes per session. Typically, the total time is achieved through interval training, with 5-10 minutes at a time in the 70-85% HR Max zone.
5. What are some of your favorite ways to manipulate the "subcomponents" when implementing HIGT? Any cool tips for propulsion, limb advancement, etc.?
CariAnn: I'm a big fan of interventions that target multiple subcomponents at a time. I love using obstacles (foam noodles, vinyl dots, hurdles) on the treadmill and overground. This works on stance control on one side while simultaneously working on limb advancement on the other. I also regularly use ankle weights to challenge limb advancement, often combined with an incline on the treadmill to work on propulsion. Reciprocal stairs with ankle weights or a weighted vest and minimal upper extremity support can target all four subcomponents at the same time!
More ideas:
- Stance control: Decrease upper extremity support, use a weighted vest, stairs, or stepping over obstacles.
- Limb advancement: Ankle weights, band resistance at the knee/ankle, incline, stairs, stepping over obstacles.
- Propulsion: Increase treadmill speed, incline, band resistance at the pelvis, pushing/pulling a heavy load (sled push, resisted walker push, weights in a sheet tied to a gait belt).
- Postural stability: Decrease upper extremity support, use uneven/compliant surfaces (stepping on/off Airex foam, walking over floor mats with ankle weights or foam noodles underneath, grass), vary direction (side stepping, backward walking, 90-180 degree turns, agility ladder), and incorporate dual tasks (using tools like Blaze Pods, head turns to look at playing cards, ball toss/volley).
Resource: The ANPT has an excellent resource on assisting and challenging each subcomponent: https://www.neuropt.org/docs/default-source/cpgs/locomotor/biomechanical-subcomponents-explained---rg-2022.pdf?sfvrsn=8f535d43_0
6. What equipment do you incorporate into HIGT training? Any external assistance/aids?
CariAnn: I frequently use a treadmill with a safety harness (Biodex), but HIGT is not limited to treadmill training alone. Many of my patients don't initially have the endurance for an effective treadmill session. In those cases, I work overground using assistive devices (walker, cane) with added challenges as needed. Remember that intensity is relative to the individual patient!
Equipment I like:
- Hi-Lo Lift Walker by ARJO: Provides a fall-free environment with a harness and bilateral upper extremity support.
- Bilateral platform walker: Similar benefits, but requires more attention to safety.
- Bracing: AFOs, Swedish knee cage, heel lifts, ankle air casts, ACE wrap assist.
- Functional electrical stimulation: For the affected quadriceps or anterior tibialis, using a switch-operated device.
- Foot slider: Reduces friction and eases step-through when limb advancement is difficult.
- Band assistance: Can aid in pulling the leg forward on the treadmill or with an assistive device.
7. How do you decide when and how often to correct errors or biomechanical impairments during HIGT?
CariAnn: I typically allow 3-5 errors in a row before considering changing the conditions. If errors can be corrected with verbal cuing, I'm more lenient. But if we see a consistent error 5 times in a row despite cuing, I'll reduce the challenge or return to assisting the limb, especially when fatigue is a factor.
8. Do you still utilize external cues/external focus during HIGT? If so, any tips?
CariAnn: Yes, I use a lot of external cues when working on limb advancement. I might place a target at the front of the treadmill (like a physioball or resistance band) to encourage the patient to kick their leg toward it. I also sometimes draw lines on the treadmill belt with chalk. Obstacles can also be considered external cues that require increased hip/knee flexion to step over.
To challenge postural stability, I incorporate dual tasks that require the patient to remove their hands from support or turn their head.
9. Any other words of wisdom for clinicians struggling to implement HIGT or who are unsure if they should adopt it?
CariAnn: Once you understand the core concepts, HIGT is an excellent framework that can truly empower your decision-making. You'll feel more confident in your treatment strategies knowing they are evidence-based and more likely to make a difference in your patients' function. The huge range of interventions that fit into this concept allows for a lot of creativity. I've found that it makes my treatment sessions more engaging for both me and my patients, and engagement or attention to the task is key to neuroplasticity!
**Looking for more from CariAnn? Message info@nextsteprobo.com, and we can connect you!**
References:
- Hornby et al. (2020). Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury. Journal of Neurologic Physical Therapy, 44(1), 49-100.
- MacKay-Lyons et al. (2020). Aerobic Exercise Recommendations to Optimize Best Practices in Care After Stroke: AEROBICS 2019 Update. Physical Therapy, 100(1), 149-156.
- Holleran et al. (2014). Feasibility and potential efficacy of high-intensity stepping training in variable contexts in subacute and chronic stroke. Neurorehabilitation and Neural Repair, 28(7), 643-51.
Q&A with HIGT Expert!