Gait training

Definition

Gait training refers to helping a patient relearn to walk safely and efficiently. Gait training is usually done by rehabilitation specialists who evaluate the abnormalities in the person's gait and employ such treatments as strengthening and balance training to improve stability and body perception as these pertain to the patient's environment. Gait training often incorporates the use of such assistive devices as parallel bars, walkers or canes to promote safe and proficient ambulation. In order to walk again without assistance, the patient will need mental attentiveness and adequate sensation, coordinated with adequate musculoskeletal functioning and motor control.

Purpose

A person's gait is a pattern of stepping or walking that is specific to that individual. Gait training is needed to help a specific patient gain proficient and safe ambulation within and outside the home with or without an assistive device. Patients usually require gait training if there is some lower trunk or lower limb dysfunction. This dysfunction is often associated with neurological or orthopedic impairment. Complications that may require gait training include:

• muscle weakness
• deformity
• spasticity (the presence of abnormal involuntary muscular contractions)
• loss of sensation due to injury or disease that results in inaccurate sensory information and unsafe or inefficient motion
• pain in the weight-bearing joints of the lower extremities, which causes distortion of normal gait

These complications may result from injury to or amputation of the lower extremities; surgery; osteoarthritis or other disorders of the weight-bearing joints; muscular dystrophy ; muscle atrophy due to long periods of inactivity or bed rest; lesions of the brain or spinal cord ; or changes in perception and other body functions that are part of the aging process.

Normal gait

In order to understand gait training, the reader may find a descriptive outline of normal human gait helpful. Human gait is measured from heel strike to heel strike, also known as the gait cycle or "one stride." The gait cycle has two phases, the stance (about 60% of the cycle)

KEY TERMS

Ataxia —Loss of muscular coordination.

Cadence —The rhythm of a person's walk.

Double stance —The point in the gait cycle at which both feet are touching the ground. It is also sometimes called double support time.

Gait —A person's habitual pattern of walking or stepping.

Gait cycle —A unit of measurement used in evaluation of gait abnormalities. The gait cycle consists of two phases, stance and swing, and is measured from heel strike to heel strike (the length of one stride).

Gait velocity —The speed of a person's walk.

Muscular dystrophy —An inherited disease characterized by progressive wasting of the muscles.

Osteoarthritis —A degenerative joint disease that causes inflammation and pain in the peripheral and spinal joints.

Spasticity —A condition marked by sudden abnormal involuntary muscle contractions, with associated hyperactivity of deep tendon reflexes. It may be associated with rigidity.

and the swing (about 40%). The point at which the body's weight is transferred from one foot to the other, when both feet are touching the ground, is called double stance or double support time. The speed of a person's walk is called the gait velocity, and the rhythm of their walk is called the cadence. Cadence is usually related to the length of the person's leg and their overall height; short people typically take smaller steps at a more rapid cadence while taller people take larger steps at a slower cadence.

Deviations in gait

Deviations from normal gait can occur in any portion of the lower extremity. Common abnormalities include:

• Ankle/foot. Deviations of stance include foot slap and foot flat. Deviations of swing include toe drag (foot drop).
• Knee. Abnormalities of stance include hyperextension of the knee. Abnormalities of swing include limited flexion of the knee.
• Hip. Deviations of swing include circumduction and "hip hiking."
• Trunk. Deviations of stance include lateral lean (Trendelenberg gait), backward lean (gluteus maximus gait), and forward lean.
• Other. Ataxia (loss of muscular coordination) and antalgia (limping from pain).

Deviations can occur together as a group of compensations for one impairment. For example, a patient's gait may show foot drop as well as hip hiking.

Precautions

Before gait training the clinician must review all medical records and examine any pathologies or impairments that may affect the patient's ability to walk. Furthermore, through the rehabilitation evaluation, the clinician should have an understanding of the patient's present abilities and prior level of function. Once gait training begins, the clinician must choose the appropriate assistive device that will provide optimal stability and still allow the patient mobility.

The therapist should use a gait belt or similar device to help support the patient if he or she loses balance. Gait training should be done in a safe environment with few visual distractions, and with the patient wearing appropriate footwear. Some rehabilitation specialists have designed mechanical gait trainers with parachute harness systems that allow patients to practice their gait without overstraining the therapist.

Preparation

Patient assessment

In determining the patient's readiness for gait training, the therapist will evaluate the patient's physical abilities (weight-bearing, strength, stability, coordination and balance) and his or her mental and emotional readiness for gait training. Routine evaluation of elderly patients who are begining to develop gait problems may be done by a primary care physician, but assessment of complex disorders usually requires a gait specialist. A simple evaluation of a patient's gait can be performed in a straight hallway without pictures or other objects that may distract the eye. The examiner will need a stopwatch for timing and a T-square to measure the length of the patient's stride. Advanced evaluation of gait kinetics, however, requires a laboratory with computer and video technology.

Assistive devices

Patients with gait problems caused by pain in the lower extremities; decreased ability to bear weight; or loss of strength, balance, endurance, or coordination may use a range of assistive devices as part of their gait training. The physical therapist will take into account the patient's prognosis, home or institutional environment, capacity for standing, and the demands of the device itself in selecting an appropriate assistive device.

The most stable assistive device is a set of parallel bars, followed in descending order of stability by walkers, crutches, single crutches, bilateral canes, and single canes. In terms of the demands that assistive devices place on the patient's coordination, parallel bars are the least demanding, followed in ascending order by walkers, single canes, bilateral canes, axillary (under the armpit) crutches, and forearm crutches.

Choosing a device and gait pattern

The therapist must consider not only the type of assistive device most appropriate to the patient's needs, but also the gait pattern (pattern of the patient's movement) that will be most helpful. For example, a walker can be used with either a swinging or a stepping-through-androlling motion. Crutches can be used with either a reciprocating (uses both lower extremities) or nonreciprocating (favors the weight-bearing lower extremity). A so-called four-point gait will be used with a cane or single crutch. In this pattern the crutch or cane advances forward first, followed by the opposite lower extremity, then the other limb, all in a reciprocal pattern. In a three-point gait, one lower extremity is full weight-bearing and the other is non-weight-bearing. An example of a three-point gait would be a patient with bilateral crutches, with one limb lifted and one in contact with the ground. A two-point gait is a pattern in which the patient's assistive device is a cane or single crutch that moves simultaneously with the opposite lower limb. The progression of various gait patterns from use of assistive devices to full independence depends on the type of impairment as well as the patient's mental and physical abilities; it also depends to some extent on the experience of the clinician.

Once selected, the assistive device is fitted to accommodate the patient's height and weight. The cost varies: while a standard cane costs about $25 and a quad cane about $50, crutches cost between $65 and $110, with walkers costing between $80 and $150. Most health insurance policies, however, cover assistive devices.

Patient education

After the assistive device has been selected and fitted to the patient, the therapist demonstrates the appropriate gait pattern, including weight-bearing; shows the patient how to check the assistive device for safety and points of wear; teaches the patient how to move from a sitting to a standing position; helps the patient practice the gait pattern; and shows the patient how to move from a standing to a sitting position.

The next stage in training involves learning the gait pattern on different types of surface. The patient must know how to use the assistive device on uneven surfaces, curbs, and stairs as well as level surfaces. In stair gait training, the patient is taught a basic rule regarding the affected and unaffected sides of his or her body: "Up with the good, down with the bad; the device stays below."

Aftercare

Aftercare for gait training includes helping patients cope with the various disadvantages of assistive devices. Crutches and walkers, for example, are difficult to use in small or crowded areas. In addition, walkers offer little or no protection from backward falls . The use of axillary crutches may place too much pressure on the patient's underarm area. Quad canes are hard to use on stairs and may be unstable on some surfaces, since the patient must have all four cane legs down on the floor or pavement with hand pressure centered over the legs.

Results

The results of gait training vary according to the cause of the patient's gait abnormalities, his or her overall health and mental attitude, and the prognosis. Some patients may be able to walk again without assistive devices, while others may make only limited progress. The importance of encouraging physical activity, however, cannot be overemphasized. Even modest amounts of exercise help to prevent muscle atrophy, benefit the cardiovascular system , and may lessen the pain of osteoarthritis. In addition, most gait training patients find that a greater degree of physical independence is good for their spirits as well as their bodies.

Health care team roles

In addition to the roles of physicians and rehabilitation specialists in patient assessment and gait training, nurses and other allied health professionals should monitor the walking patterns of their patients and any use or misuse of assistive devices. Gerontologists should routinely assess elderly patients for changes in gait velocity, cadence, step length, or other indications of fears of falling. Furthermore, nurses and other allied health professionals should monitor all patients for changes in ambulation in an effort to maximize their safety.

Resources

BOOKS

Bennett, S.E., and J.L. Karnes. Neurological Disabilities, Assessment and Treatment. Philadelphia: Lippincott, 1998.

"Gait Disorders." Chapter 21 in The Merck Manual of Geriatrics, 3rd ed. Whitehouse Station, NJ: Merck Research Laboratories, 1995.

Hertling, D., and R.M. Kessler. Management of Common Musculoskeletal Disorders. Baltimore, MD: Lippincott, Williams & Wilkins, 1996.

Lehmkuhl, L.D., and L. K. Smith. Brunnstrom's Clinical Kinesiology. Philadelphia: F.A. Davis Co., 1996.

Magee, D. J. Orthopedic Physical Assessment. Philadelphia: W.B. Saunders Co., 1997.

Norkin, C.C., and P.K. Levangie. Joint Structure and Function: A Comprehensive Analysis. Philadelphia: F.A. Davis Co., 1992.

Perry, J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ: SLACK Inc., 1992.

Pierson, F.M. Principles and Techniques of Patient Care. Philadelphia: W.B. Saunders Co., 1999.

ORGANIZATIONS

National Rehabilitation Information Center and ABLEDATA (database). 8455 Colesville Road, Suite 935, Silver Spring, MD 20910. (800) 346-2742 or (800) 227-0216.

Mark Damian Rossi, Ph.D., P.T.