Gait Training Health Article

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.

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."