Empowering Patients With Therapeutic Gait Training

The most difficult patient Sheila Clemens ever treated was a man in his 20s who came to her after a crash that resulted in a transfemoral amputation, caused a stroke, and left him blind. Clemens, PT, MPT, PhD, professor at the University of Kentucky and a research scientist at the Lexington, Kentucky, VA Medical Center, was not sure if her patient would ever be able to wear a prosthesis, let alone walk with one. Yet after a year and a half of intensive therapeutic gait training, he is now walking with a cane, living independently, and regularly going to the gym and out with family. “I’m so impressed how far he’s come from where he started,” Clemens says. “He was able to get back to a fulfilling life.” Physical therapists who specialize in gait training have all seen success stories such as this. They say the training has a dramatic impact on patients with lower-limb amputations, helping them become more active and have increased confidence and an overall better quality of life. These patients are also less likely to have long-term injuries associated with a poor gait such as knee or lower back injuries. While there is still more research to be done, existing research shows that patients who receive high-quality gait training are benefitting from it. “What we do know is that it helps, but there isn’t a lot of research that tells us exactly what we should be doing and how much,” says Clemens. Often, she says, physical therapists who specialize in gait training learn from a combination of the available research, from talking and learning from one another, and from their own experience in the field. Clemens says that the best results come from targeted training that makes improvements in symmetry. “Hence, the better quality gait training is, the better quality gait mechanics can be,” she says. Defining Therapeutic Gait Training Therapeutic gait training is highly individualized to patients and their prostheses, personal goals, comorbidities, and overall strength and fitness levels. With that in mind, gait training usually includes the following: Teaching patients how to use their prostheses to the best of the devices’ and their own capabilities Helping patients improve their gait biomechanics Improving patients’ walking symmetry and step length Teaching patients how to negotiate obstacles they will encounter in their day-to-day lives Helping patients gain strength, grow in endurance, and learn to trust their prosthesis to support them What gait training is not, is simply helping patients to get up and move with their devices. [caption id="attachment_240741" align="alignright" width="300"] Lawrence, who says he helps patients get their legs underneath them, works with Mary on therapeutic gait training at The Gait Center. Photographs courtesy of Mission Gait.[/caption] “Not all training is created equal, and in fact some types of therapy can be to the detriment of the patient,” says Phil Stevens, MEd, CPO, FAAOP, director, Clinical and Scientific Affairs, Hanger Clinic, headquartered in Austin, Texas. “There is a big difference between supervised ambulation and therapeutic gait training. Supervised ambulation can be a useful tool to build walking endurance but can also engrain some bad habits if it occurs in place of more intentional therapeutic gait training. There’s not a lot of value in practicing bad walking habits. The challenge there is that you may have to then unlearn some things before you learn correctly.” Stevens says that researchers have not agreed on a single approach to therapeutic gait training, but his team aggregated the observations of several systematic reviews to generate a set of clinical practice guidelines that were subsequently presented at the American Congress of Rehabilitation Medicine. They found that there are several approaches therapists can take when teaching someone to walk with a prosthesis. The lowest level of training is supervised ambulation, which may have a place if the patient is an experienced walker and is trying to increase his or her walking distance in a safe environment. “But supervised ambulation doesn’t really teach you to walk with a prosthesis,” Stevens says. “The literature says that there are a number of therapeutic gait training modalities that are more effective than supervised ambulation.” Stevens says that the best physical therapists will tie the gait training to the needs and priorities of their patients. One of his favorite instances of this was when he had a patient who wanted to walk her dog but was worried that the tug on the leash might make her trip or fall. Her therapist asked her to bring a leash to a couple of sessions and played the part of her dog, tugging on the leash at random intervals while another therapist kept her stabilized with a gait belt as she learned to manage the tugs. “It worked,” Stevens says. “She got to where she could walk the dog every day.” Teaching patients the correct gait takes time, says David Lawrence, MSPT, ATC, founder and CEO of Mission Gait Foundation, and owner of The Gait Center, headquartered in Richmond, Virginia. His patients receive one-on-one training as they learn to walk with their protheses. One of the keys, he says, is for the patients to learn how to position their prosthetic limbs so their center of mass isn’t leaning toward the sound side. “No one teaches them how to get the leg underneath them,” Lawrence says. “I never teach prosthetic gait,” he says. “I teach human gait with a prosthetic interface.” Experts say the goal is to teach patients how to walk correctly with their prostheses from the start. Once they learn to walk well, then they can build up their step count and endurance. “You need people to be properly trained so they aren’t walking inappropriately and promoting a limp,” says Mark Hopkins, PT, CPO, MBA, chief executive for Dankmeyer, headquartered in Linthicum, Maryland. “Some people say that practice makes perfect, but with gait training, perfect practice makes perfect.” [caption id="attachment_240740" align="alignright" width="206"] Robert used therapeutic gait training to improve his ability to walk with bilateral prostheses.[/caption] What’s at Risk Without the specialized gait training, patients are likely to walk in a way that can cause injuries over time and expend excessive energy, which can lead to a more sedentary and less fulfilling lifestyle the experts say. “While there are always individual issues, as a group, amputees tend to experience some common things,” says M. Jason Highsmith, PhD, PT, DPT, CP, FAAOP, national program director for Orthotic, Prosthetic and Pedorthic Clinical Services for the US Department of Veterans Affairs. “Patients will commonly have challenges with balance, they tend to fall more, and they will be inefficient with their bioenergy, so walking is often more fatiguing and exhausting relative to non-amputees.” He says that patients who are not comfortable walking with their prostheses are more likely to spend too much time on their sound side when they walk, often developing a limp. As time goes on, pressure and force on the sound limb exponentially compounds. “So the patient becomes more predisposed to degenerative joint conditions, and it causes asymmetry in the spine, so that makes them more likely to have back issues,” says Highsmith. He says that therapists have to work with patients to get their gait as symmetric and normalized as possible. If not, patients can create habits that are detrimental to them. “The development of bad habits is a very real thing,” he says. “There’s a number of gait deviations that are really sort of patient-driven and have origins in bad habits. Some may be more remediable than others. The best hope is to not develop them in the first place and get therapy early.” Lawrence says he can make the most impact when he sees patients right after their amputations. “My favorite patient is one who came straight from the amputee clinic and has no bad habits whatsoever,” he says. “They learn the right mechanics from day one.” Unfortunately, it is rarely the case that patients receive the proper training from the get-go, says Cosi Belloso, MSPT, who specializes in working with patients with amputations and is host of the Florida-based podcast “Cosi Talks” that discusses issues faced by patients with amputations. Most of her patients are those who have sought her out after years of not being able to walk as well as they would like. “They want to get off of the cane or walker or something is hurting or breaking down and they come find me,” she says. “Many times, the pain is related to gait deviations. With physical therapy treatment, we can work on these gait deviations and greatly improve their mobility and pain. There are cases where I might refer a patient to a physical therapist who specializes in back pain to provide a comprehensive treatment approach.” If all goes perfectly, and it rarely does, patients may take anywhere from eight to 48 sessions depending on whether they have transfemoral, transtibial, or bilateral amputations. Most times, the process takes longer since patients will have to return to their prosthetists for a socket change as their residual limb volume fluctuates or perhaps an alignment if Belloso notices that adjustments need to be made. How Difficult Is Therapeutic Gait Training to Access? [caption id="attachment_240742" align="alignright" width="300"] Lawrence provides Robin therapeutic gait training at the parallel bars at The Gait Center.[/caption] Experts in the field of gait training know that it helps; they also know that those with the ability and desire to do it are few and far between. “There’s not a lot of people out there who specialize and that’s where the biggest disconnect in the healthcare of amputees lies,” Belloso says. “You see a lot of prosthetists trying to do gait training because they do not have access to a PT amputee specialist, or the patient is handed off to a physical therapist who has never worked with a patient with an amputation, and they get poor care as a result.” Many times, finding a therapist with expertise is by word of mouth. Belloso says that there is no official directory, so her colleagues are working to make a specialty within the American Physical Therapy Association. She also tries to connect patients and prosthetists through her live talk show. One of the key reasons behind the lack of experts is because of the way that therapists are reimbursed. Reimbursement rates reward physical therapists who are able to see several patients an hour and patients who can be helped by lesser trained technicians. Therapeutic gait training requires lots of time and individual attention from a well-trained expert. “What has happened in the field is that therapists have migrated to where they can make a better living,” says Lawrence. “Programs for people with more complicated problems have been cut because they weren’t as cost effective.” Lawrence also says that people seek out his center after trying, and failing, to achieve a good gait on their own or with a less experienced physical therapist in a clinic that doesn’t support the time they need. Lawrence started the Mission Gait Foundation to train others in therapeutic gait training. Therapists can take specialized classes from the foundation and patients and therapists can benefit from the free YouTube videos. Since these experts are so hard to find, prosthetists should help their patients to identify them in their communities, says Stevens. “Clinical prosthetists can help identify the therapists in their community that either have the experience or have the interest in finding that experience,” Stevens says. “Many patients may struggle to find it on their own. It’s a rare expertise, given that most therapists will spend very little time in school on amputee rehabilitation.” He says that prosthetists should keep an eye on their patients to determine if the therapists they have are truly trying to improve their gait. “It’s a delicate balance,” he says. “We don’t want to refer patients away from existing relationships, but when a patient says they are getting therapy, it’s reasonable to ask about the therapy they are getting. You can tell fairly quickly if the person is just being walked around the block or if they are trying to fine-tune their walking.” If there are no therapists in the area that specialize in the training, a therapist who is interested in learning will suffice, Stevens says. “There are resources out there, but you have to find someone who is open to finding them and going to the websites and doing the work.” A Lifetime of Changes While therapeutic gait training is most beneficial right when patients receive their first devices, patients will often need additional training to face life changes. As patients age or change their protheses, they will benefit from additional training to address those changes. “People come to me with a beautiful microprocessor setup and walk like they are using a manual lock knee,” Lawrence says. “Every time there’s a technology change or a socket change, you need additional training. If you are changing the device or the fit, you are changing the baseline of information that the patient must learn how to interpret.” It never hurts to check in to make sure they still have a good gait and are using their devices to their full potential, Hopkins says. “I think everyone who is wearing an artificial limb and using it on a regular basis deserves what we call a tune-up,” he says. “After a while they should go back and have a physical therapist or an expert take a look and see what they can do better.” [caption id="attachment_240739" align="alignright" width="206"] Cor’Rales has excelled in his efforts with therapeutic gait training.[/caption] Since most insurance will only cover a limited amount of therapy appointments, Dankmeyer works with the University of Maryland Rehabilitation and Orthopaedic Institute to host Amputee Walking School four times a year. For the school, patients with limb loss team up with staffers as well as patients who are experienced at walking with their prostheses. “This was born out of a need for training beyond physical therapy,” Hopkins says. “It’s a way to take what was learned in therapy and give the patients a simplified and concentrated program that they can do on their own at home and also create a support group so they can do it as a team with their peers.” He says that the experts are on hand to help the patients, but for the most part, they help mentor one another. Highsmith says that patients with amputations, beyond the myriad problems related to limb loss, also face the same life changes as everyone else. The physical therapy they receive should help them deal with those changes and overcome any obstacles they may present. “Rehabilitation is a journey, not a destination,” he says. One of his patients, for example, was a Vietnam veteran who did well with a mechanical knee for decades, but as he aged, he benefited from the additional help of a microprocessor knee and needed help to learn how to balance with it. Then, when the patient’s son-in-law passed away, he took it upon himself to take his grandson to all of his baseball practices and games. That meant he needed to learn how to navigate new environments and situations, such as climbing bleachers, carrying heavy loads, and walking in crowds and on different terrain. “To someone who says they are rehabilitated, you have to caution them that they are rehabilitated only at that moment,” Highsmith says. Maria St. Louis-Sanchez can be contacted at msantray@yahoo.com . Top photo: deagreez/stock.adobe.com

Empowering Patients With Therapeutic Gait Training

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Patients Benefit From Being Included in Prosthetic Design Process

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