Functional Mobility

Intensifying functional mobility follows evidence-based practice for high-intensity stepping training (Moore, et al., 2021; Moore et al., 2019; Tapp et al., 2023). Here, walking is broken into four subcomponents: stance control, limb swing, propulsion, and postural/lateral stability. The aim is to support the components that are not being challenged and target a subcomponent on a spectrum for skill acquisition (guidance, assistance as needed, trial and error, and error augmentation). Intensity is measured using 75-85% age-predicted max heart rate and/or Borg rate of perceived exertion (RPE) of 14-17 on a 6-20 scale.       

Stance Control 

Defined as "absence of limb collapse"

Use body weight support (BWS) and unweight patients gradually until they are maintaining the tasks with moderate errors. Use IADLs that involve stepping to provide context to the therapy intervention. Grocery shopping can be done using props or contextual reasoning to increase salience. The aim for functional mobility still targets the respective subcomponent. However, the task is also based on additional occupations when appropriate for the patient's cognitive functioning.    

Limb Swing 

Defined as "a positive step"

Use harness and BWS when needed. Assistance can include manually advancing the limb or using equipment such as bands to help bring the leg forward. Error augmentation might include stepping over objects, ankle weights, or increasing demands on stepping speed. 

Propulsion 

Defined as "moving in any direction" 

Propulsion is a major contributor to speed and power of movement. Ways to assist propulsion might include having the therapist pull the harness/BWS system using a treadmill or manually helping the propel upstairs. Ways to error augment include increasing the grade and speed of the treadmill, using a drag bag attached to the patient's hips, pulling weight, or stepping upstairs. 

Lateral/Postural Stability 

Defined as "not using hands for support" 

Lateral/Postural stability helps individuals maintain balance and posture while stepping. When patients use their hands to help them maintain balance during functional mobility, they demonstrate poor postural stability. Ways to assist might include manually supporting the patient's trunk when stepping or having them use their hands for support. Error augmentation might consist of using a weighted vest or dual task activities (i.e., bouncing a ball) while stepping.      

How does OT make high-intensity stepping training unique to its profession? 

Occupational therapists focus on occupations as the source of rehabilitation. Occupations are meaningful everyday activities that contribute to the habits, roles, routines, and rituals of each person. Occupations are things that people want to do, need to do, have to do, and are expected to do (World Federation of Occupational Therapy, 2012). Occupational therapists can increase the salience of high-intensity functional mobility training by simulating occupations within the stepping protocol, challenging the appropriate subcomponent while including context for occupation and goal-oriented interventions. For example, high-intensity stepping can target any of the subcomponents of walking while tailoring the intervention to match valuable occupations, such as grocery shopping, cleaning, and yard work. Note that many occupations can include functional mobility to perform. The OT should collaborate with the patient when tailoring the high-intensity functional mobility training to simulate such IADLs.