1. Disclaimer Phase 1 - Learn the Reference Beat Phase 2 –
Learn the Guide Sounds
The Gait Mate is now known as IM’s In-Motion trigger system.
The content in this webinar discusses Phases 5 & 6, which are now incorporated into Phase 4. The 4 phases are as follows:
Phase 3 – Develop Basic Timing
Phase 4 – Generalize Timing to Improve Cognitive & Motor Skills
Disclaimer
Techniques/strategies detailed within the presentation can be applied regardless of whether you are using older or newer IM technology.

2. Introduction to the Interactive Metronome & the IM Gait Mate
Tools to Improve Cognitive & Motor Function
Shelley Thomas, MPT, Idaho Elks Rehab

3. What is Interactive Metronome (IM)?
IM is a neuro-motor assessment & treatment tool used to improve motor planning and sequencing.
Planning, sequencing, and coordination are critical to efficient human function.
Promotes neuroplasticity by using neuro-sensory and neuro-motor exercises.

4. Interactive Metronome
Evidence-based
Objective
Flexible
Engaging
According to Merzenich and other scientists who’ve studied neuroplasticity, we MUST be attentive and cognitively engaged in a motor activity to reorganize the brain.

5. Visit www.interactivemetronome.com to view the demo video
IM Features
Reference tone
Guide sounds
Visual guidance
Interactive exercises
Objective millisecond data
The IM program provides a structured, goal-oriented process that challenges the patient to synchronize a range of hand and foot exercises to a precise computer-generated reference tone heard through headphones.
A patented audio and/or visual guidance system provides immediate feedback measured in milliseconds, and a score is provided.
Visit to view the demo video

6. Mental & Interval Timing
IM works with mental and interval timing skills
Mental timing: millisecond timing, occurring primarily through the cerebellum
Interval timing: Mental estimation of time. IM emphasizes interval timing as people must alter rhythm to accurately tap the trigger.
Motor and cognitive tasks require both mental and interval timing.

7. Key Diagnoses Developmental Delay/Disorders Learning Disability
Dyslexia
Nonverbal Learning Disorder
Apraxia
ADD/ADHD
Auditory/Language Processing Disorders
Autism/PDD
Sensory Processing Disorders
Cerebral Palsy
Fetal Alcohol Syndrome
Stroke/Brain Injury
Parkinson’s MS
Limb Amputation
And more…

8. IM Gait Mate The IM Gait Mate is a therapy modality for improving:
Stride Length
Heel Strike
Gait Stamina
Weight Shifting
Quality of Movement
Gait Mate is an extension of the Interactive Metronome to assess and treat motor planning, sequencing, coordination and balance. 

9. IM Gait Mate
The Gait Mate makes IM's formerly static exercises more functional and allows the patient to work on these neurological processes while walking around the gym or up and down the hall.

10. IM Gait Mate: How does it work?
Wireless insole is inserted into the patient's shoe that detects when he performs a heel strike.
The patient hears a beat through wireless headphones or speakers and is asked to match the cadence provided.
The Gait Mate provides the patient with auditory feedback as they walk.

11. IM Gait Mate: How does it work?
Gait Mate engages the patient and gives him constant, real-time feedback about his performance. As the patient adjusts his gait, the Gait Mate continues to reward and instruct him so that he is constantly improving and exercising.
Repetition! Neuroplastic changes requires thousands of repetitions.
Many expensive gait assessment devices provide the therapist with data after the patient has completed a gait exercise. IM Gait Mate provides data throughout the exercise.

12. Visit www.imgaitmate.com to view the demo video
IM Gait Mate Demo
Visit to view the demo video

13. Desired Outcomes Equalize step length
Normalize gait velocity, stride length, and cadence for age
Normalize gait biomechanics
Improve postural control
Trunk control
Head-body dissociation
Improve balance reactions
Increase endurance to perform ADLs

14. Candidates for IM Gait Mate Have These Problems
MOTOR IMPAIRMENTS
Poor balance
Gait disturbance
Poor motor planning & sequencing
Hemiplegia
Dyscoordinated or clumsy
Poor postural control

15. IM (and IM Gait Mate) are Treatment Tools Six Treatment Phases
Learn the Reference Tone
Learn IM
Phase 2
Learn the Guide Sounds
Phase 3
Develop Basic Timing Skills
Phase 4
Generalize Timing Skills
Improve Timing & Rhythm with Gait Mate
Phase 5
Develop Timing & Focus Skills
Phase 6
Develop Sustained Timing & Focus Skills

16. IM Gait Mate Treatment Planning
Use IM assessment to determine course of IM treatment: IM first, then Gait Mate…or move directly to Gait Mate.
If patient demonstrates proficiency with IM ref tone and guide sounds, & demonstrates average to above average timing skills, then proceed directly to Gait Mate.
Orthopedic patients who are cognitively intact and do not have a neurological injury may fall in this category
If patient demonstrates poor initial timing, then begin by teaching the patient the ref tone and guide sounds with Interactive Metronome for Phases 1-3.
Advance to Gait Mate after the patient understands the concept and sounds associated with Interactive Metronome & has developed basic timing skills.

17. IM Gait Mate Treatment Planning
How will you adjust your approach for this patient?
Shorter sessions initially?
Pre and/or post-IM treatment activities?
Sensory moderators?
Hands-on cueing? Verbal cues? Neuromuscular reeducation?
Slower tempo? Faster tempo?
Visual mode? Auditory mode?
Pediatric adaptations?
Positive reinforcement? What type?

18. IM Gait Mate Treatment Planning Phase Four
Goal: Generalize Timing Skills
Set the Gait Mate tempo to match the patient’s typical walking speed
Turn both reference and guide sounds on and set difficulty level appropriate for patient
Generalize areas of good timing to deficit areas
Activities include pre-gait activities, walking on level surfaces in quiet hallways

19. Technique to Change Initial Timing Tendency
Once patient has practiced walking at his typical tempo, instruct him to “counteract” his initial timing tendency”
If he tends to walk too fast (hits triggers too early)….purposely walk at a slightly slower pace.
If he tends to walk too slowly (hits triggers too late)….purposely walk at a slightly faster pace.

20. IM Gait Mate Treatment Planning Phase Five
Goal: Develop Timing & Focus Skills
Try to increase duration (2 – 5 minutes)‏
Gradually increase challenge of IM Gait Mate settings
Initially focus on best Gait Mate tasks for patient (walking vs best pre-gait activity)
Advance to Phase Six (develop sustained timing & focus skills) when patient has achieved best performance with IM Gait Mate settings at maximum challenge.

21. IM Gait Mate Treatment Planning Phase Six
Goal: Develop Sustained Timing & Focus Skills
Try to increase duration (5 – 60 minutes)‏
Gait Mate settings remain at maximum challenge
Focus on best Gait Mate tasks for patient

22. IM Gait Mate Exercises
Pre-gait activities (unilateral stepping, weight-shifting, alternate heel tapping, marching in place, etc.)
Side-stepping
Heel taps
Placing foot on/off 2-3” step (alternate steps or one leg at a time)

23. IM Gait Mate Exercises Walking on level surfaces or treadmill
Walking on unlevel surfaces
Walking on changing surfaces (e.g. level floor onto floor mat)
Walking with horizontal or vertical head turns (can patient maintain rhythm, speed, direction, etc.)

24. IM Gait Mate Exercises
Walking backwards (promotes hip extension, hamstring activation, knee extension)
Walking with changes of direction or negotiating obstacles
Combine Gait Mate with use of partial weight-bearing therapy device (e.g. Lite Gait)

25. Hausdorff, J. M. , Lowenthal, J. , & Herman, T. (2007)
Hausdorff, J. M., Lowenthal, J., & Herman, T. (2007). Rhythmic Auditory Stimulation Modulates Gait Variability in Parkinson's Disease. European Journal of Neuroscience. 26,
Study designed to evaluate the effect of RAS on stride-to-stride variability.
Effect of RAS on stride-time variability, swing-time variability, and spatial-temporal measures examined during 100m walks with RAS beat at 100 and 110% of subject’s normal cadence.

26. Gait Variability in Parkinson’s Disease, cont.
29 patients with idiopathic PD
On stable antiparkinsonian medications
Free of motor response fluctuations
Had mild to moderate disease severity (Hoenhn & Yahr stage II-III)
Able to ambulate independently 100m
26 health age-matched controls.
Cognitive function assessed using Mini-Mental State Exam
Functional mobility evaluated using Timed Up and Go
PD severity evaluated using Unified PD Rating Scale

27. Gait Variability in Parkinson’s Disease, cont.
Walking at comfortable pace without RAS
Walking with RAS matched to baseline cadence (RAS = 100%)
Walking at comfortable pace without RAS to examine immediate carryover effect
RAS = 100% Trial
Walking with RAS = 110% of baseline step
RAS = 110% Trial
Walking at comfortable pace without RAS after a 15-minute rest
Examine Delayed Carryover Effect

28. Results
PD Group
Control Group
RAS = 100% (111 beats per minute on average)
Mean stride time unchanged
Gait speed, stride length, swing time significantly increased (improved)
No effect on stride- and swing-time variability
Mean stride time, gait speed, stride length, swing time unchanged
Increased (worse) stride time variability compared to no RAS condition; no change in swing-time variability.
RAS = 110% % (122 beats per minute on average)
Mean stride time reduced
Gait speed significantly increased
Stride length, swing time significantly increased (improved)
Decrease (improved) in stride- and swing-time variability
Gait speed increased
Stride length, swing time unchanged

29. Results
PD Group
Control Group
Carryover effects with RAS = 100%
Immediate carryover effect for gait speed, stride length, swing time
Small, but significant, increase (worse) in stride-time variability
Carryover effects with RAS = 110%
All improvements noted while walking with RAS were observed both immediately and 15-minutes later.
Only changes that persisted after 15-minutes were reduction in average stride time and increase in average gait speed.

30. Gait Variability in Parkinson’s Disease, cont.
RAS positively effects stride-to-stride variability in patients with PD when tempo is set greater than subject’s usual cadence.
Incorporating the IM Gait Mate into therapy sessions influences the neural circuitry regulating ambulation and will result in a lasting carryover effect.

31. Case Study: Patient with Parkinson’s Disease, Balance Deficit, Fall History
81 year-old male
DX: Parkinson’s Disease in 2001
Referred to physical therapy secondary to c/o increasing difficulty initiating mobility resulting in difficulty transferring, walking, performing ADLs, and hobbies including bowling and golf.
Currently resides at assisted living facility
Has fallen 5 times in the last year
The following case study is an example of how to incorporate IM and Gait Mate into treatment sessions.

32. Case Study: Assessment
Right
Left
Strength
5/5 throughout
Trunk Strength
3/5
Sensation
Intact to light touch bilaterally
Active Range of Motion
Within functional limits except knee extension is -5 degrees degrees, dorsiflexion is 3 degrees.
Within functional limits except knee extension is -12 degrees, dorsiflexion is 2 degrees.
Tone
Normal
Trunk Strength: 3/5

33. Case Study: Assessment
Balance
Romberg Stance with Eyes Open
Modified stance with feet 3” apart; able to hold for 30 seconds.
Romberg Stance with Eyes Closed
Modified stance with feet 3” apart; able to maintain stance for 10 seconds with increased postural sway.
Tandem Stance
Unable to maintain stance.
Single Limb Stance
Unable to maintain on right or left leg.
Tinetti Assessment Tool
15/28
Patients who score less than 19 are at high risk for falls.

34. Case Study: Assessment
Transfers
Able to transfer supine  sit independently if provided extra time.
Sit  stand with SBA for safety and cues for anterior weight shifts.
Mat  chair with SBA for safety. Patient has difficulty initiating the transfer and when first standing takes several shuffling steps to regain his balance.
Ambulation
Ambulates without an assistive device (should use a cane or walker for safety, but chooses not to).
Can ambulate 400 feet. Takes short, shuffling steps when initiating gait. Lacks heel strike on left foot at initial contact of stance phase.
Able to step over obstacles smoothly if already walking but is unable to accomplish task if asked to perform this activity from standing.
Had an episode of catching left toe on obstacle, required moderate assist to correct LOB.
Ambulation on uneven ground requires minimal assistance for balance.
Stairs
Can ascend and descend 5 stairs with rail and SBA for safety.

35. Case Study: Goals Patient’s goals: Goals established in PT:
Avoid falling, continue golfing, and “not be so stiff” when he first moves.
Goals established in PT:
Modified independent with transfers, bed mobility, and gait
Initiate gait with 50% fewer shuffling steps
Initial contact will be on heel in stance phase of gait bilaterally
Independent with home exercise program
Bilateral knee extension will improve to 0 degrees on right, -5 degrees on left and SLR will increase to 70 degrees bilaterally.

36. Case Study: Treatment Seen for 12 treatment sessions
Treatment plan consisted of stretching, strengthening, balance retraining, and patient education.
The Interactive Metronome and IM Gait Mate were incorporated to improve coordination, balance, motor control, and timing.

37. Case Study: Treatment Short Form Assessment:
Task #1 (w/o guide sounds) task average:
Task #2 (w/ guide sounds) task average:
Focused on teaching reference tone and guide sounds with hand tasks, then foot tasks with Interactive Metronome. Task average was decreased to ~150 with hands, ~250 with feet.

38. Case Study: Treatment Session #3 – IM Gait Mate introduced
Tempo: 75 bpm (matched patient’s baseline cadence)
Duration: 3-5 minutes each exercise set
Guide sounds on, but guide (buzzer) & right-on (rubber band) volume decreased
Difficulty: 300
Task average: ~230 ms
Variability average: ~150 ms

39. Case Study: Treatment
Worked with IM Gait Mate in sessions 4 & 5, but patient’s task average plateaued. He reported understanding of guide sounds but had difficulty altering timing to walk to the beat.
Went back to using traditional IM with more challenging hand and foot tasks. Able to provide more postural support and verbal cues.

40. IM with stepping forward and back
Patient stepped forward and back with left foot, then switched to right foot. Emphasis on accurately hitting trigger, then shifted to opposite leg while maintaining rhythm. Intermittent verbal cues to improve timing.

41. Pre-gait activities using Gait Mate
Progressed to performing pre-gait exercises with Gait Mate with upper extremity support. Emphasis on accuracy and maintaining proper posture.

42. Case Study: Treatment Progressed to using IM Gait Mate again
Walking
Side stepping
Walking backward
Walking – sitting – standing – walking (emphasis on initiation of movement)
Task average decreased to 120 ms, variability average to 85 ms

43. Walking with the Gait Mate
Progressed to walking with the Gait Mate without assistive device, guide sounds on.
Tempo: bpm Difficulty: 250

44. Case Study: Outcome
Seen for 12 treatment sessions. IM and/or IM Gait Mate were used each session. Patient performed approximately repetitions with IM each session.
Patient reports he feels his walking has significantly improved with less freezing episodes.
Returned to bowling, golfing, and participating in group exercise classes.

45. Case Study: Outcome
Goals were met, except SLR only increased to 50 degrees and knee extension increased to -2 degrees on right, -7 degrees on left
Patient is modified independent with mobility (needs extra time for safety)
Ambulates without an assistive device safely on level and unlevel surfaces

46. Case Study: Outcome Balance: Outcome Romberg Stance with Eyes Open
Hold for 30 seconds.
Romberg Stance with Eyes Closed
Modified stance with feet 3” apart; able to maintain stance for 30 seconds with increased postural sway.
Tandem Stance
Can maintain stance for 12 seconds.
Single Limb Stance
Right LE: 10 seconds
Left LE: 8 seconds
Tinetti Assessment Tool
24/28
Patients who score in the range of indicate that the patient has a risk of falls.

47. Conclusion
Interactive Metronome and Gait Mate are modalities that improve motor planning, sequencing, timing and rhythm.
Very powerful treatment tools – can be integrated into treatment plans to improve motor and cognitive skills used in daily activities.
IM and Gait Mate certification courses are available. For more information, visit