Therapeutic Gait Training: What Prosthetists Need to Know

Of the estimated 1.6 million people in the United States living with limb loss, approximately 1.3 million (86 percent) have a lower-limb amputation. 1-2 When these individuals fail to achieve prosthesis-assisted ambulation, they are at an increased risk for physical deterioration, a number of comorbid health conditions, and compromised overall health. 3 In addition, those who are able to ambulate with a prosthesis often do so with characteristic gait asymmetries including altered limb loading patterns and movement strategies. 4 These adaptive gait strategies are frequently less metabolically efficient, increasing the metabolic costs of walking, especially for individuals with more proximal amputation levels or bilateral amputations. As a result, they may reduce their self-selected walking speed to reduce their energy consumption.

While some gait adaptations enable sustainable, stable ambulation, others may be maladaptive, potentially leading to long-term complications such as low back pain and osteoarthritis, and their associated impacts on global function and quality of life. 4 Thus, post-amputation gait training is a key consideration to well-being after lower-limb amputation.

While the current strength of evidence regarding different gait training methods for individuals with lower-limb amputations is limited, recent systematic reviews of the literature support the position that multiple gait training modalities are effective in improving overall gait quality for people with lower-limb amputations. 4-6 These reviews were recently used to develop a clinical practice guideline (CPG) on the topic of physical therapy following lower-limb amputation, presented at the 2018 American Congress of Rehabilitation Medicine. 7

Integral to these guidelines is the concept of therapeutic gait training, discrete from the less nuanced modality of supervised ambulation. This article describes the tenets and observed benefits associated with therapeutic gait training.

Therapy Modalities in Post-amputation Gait Training

A number of physical therapy modalities have been described to assist new lower-limb prosthesis users develop the skills necessary to ambulate in a safe and efficient manner. These are described as follows and summarized in Table 1.

Supervised ambulation represents a minimalist intervention in which a physical therapist or physical therapist assistant supervises new lower-limb prosthesis users to ensure relative safety during prosthetic ambulation. Ideally, this occurs after they have learned basic gait skills, and its objective is to increase the distance walked and improve physical capacity. The absence of such basic skills may lead to the establishment of gait deficits.

Therapeutic gait training extends beyond supervised ambulation, as a physical therapist or physical therapist assistant uses tactile, verbal, and visual cues to provide real-time, performance-based feedback to assist new prosthesis users to improve the quality and efficiency of their gait. In contrast to supervised ambulation, where the objective is often limited to increasing physical capacity and the distance a new prosthesis user is able to walk, therapeutic gait training anticipates and mitigates the longitudinal risks of secondary overuse symptoms including osteoarthritis of the contralateral lower extremity and low back pain. By training new users toward a symmetrical, smooth gait pattern with appropriate kinematics at the shoulders, trunk, pelvis, and joints of the lower limb, therapeutic gait training also seeks to reduce overall metabolic inefficiencies.

In addition to tactile, verbal, and visual cuing, components of therapeutic gait training may include the following:

Pre-gait activities are directed toward acquiring those prerequisite skills that will ultimately facilitate prosthetic ambulation. These may include donning and doffing the prosthesis, performing sit-to-stand transfers, and creating confidence in static standing balance and dynamic weight shifting.

Part-to-whole gait training consists of practicing the individual components of gait prior to the practice of the whole task. This practice provides the treating clinician the opportunity to identify those elements of gait where an individual may be experiencing the most deficiencies and prioritize training and improvement in these areas.

Treadmill training is one popular means of enabling new prosthesis users to increase their walking stamina in a safe, controlled environment where hand rails or therapeutic assistance is readily available. The use of a treadmill provides a consistent, level walking surface free from environmental obstacles. In addition, the stationary nature of treadmill training facilitates treating therapists' ability to focus on gait mechanics and provide both verbal and tactile cues.

Bodyweight-supported treadmill training (BWSTT) is a variant of treadmill training. BWSTT may use mechanisms such as an overhead harness or an externally created hydrostatic environment to unload a desired percentage of a subject's bodyweight. Where available, BWSTT allows individuals to learn and reinforce proper gait mechanics under reduced physiological loads that can be progressively increased as patients develop confidence and skill.

Psychological awareness training encourages a mindful recognition of certain gait variables of interest as identified by the treating therapist. Such variables might include step and stride lengths, pelvic rota tion, side-to-side movement symmetry, and overall postural/dynamic balance elements. This training can be coupled with treadmill training, BWSTT, and supervised ambulation as patients consciously monitor their performance with respect to the targeted gait elements.

Resisted gait training is a manual exercise in which the therapist resists certain motions to cue correct movement patterns. The resistance is modulated throughout the range of motion to provide proprioceptive feedback and facilitate neuromuscular engagement.

Specific exercises can be used to supplement the therapeutic gait training strategies identified above. These exercises might target the constructs of strength, balance, range of motion, or endurance. Functional activities training goes beyond typical gait training to introduce and refine activities of daily living beyond level-ground ambulation, such as stair and ramp negotiation, walking on uneven surfaces, and dual-task, divided-attention activities. For example, surveying items on grocery store shelves requires head turning while walking in a busy environment and attending to the activity in addition to maintaining safe ambulation. Supportive Evidence

Effective prosthetic gait training often employs a range of modalities. As such, the individual components of therapeutic gait training are rarely used in isolation and their individual efficacy is difficult to determine. Rather, current evidence has suggested potential benefits associated with clusters of therapeutic gait training approaches. This position is epitomized in one of the evidence statements identified in the systematic review of Highsmith et al. on gait training interventions: Therapeutic gait training programs under skilled supervision, that maximize time spent performing ambulatory activities beyond current functional daily walking, are safe and effective at improving walking function in lower-limb amputees. 4 In their 2016 systematic review on gait training interventions for people with lower-limb amputations, Highsmith et al. identify a number of additional, more discrete evidence statements related to a range of therapeutic gait training approaches: Part-to-whole gait training, coupled with verbal and tactile cues, has been found to be an effective strategy in improving both overground ambulation and the functional activity of stair negotiation. 4 Treadmill training, augmented by either reduced loading, real-time visual feedback, or a structured home-based program, has been found effective in improving bioenergetic efficiencies. 4 Similarly, both treadmill training and therapeutic overground training under skilled supervision has been found to be effective in the improvement of spatiotemporal gait parameters. 4 BWSTT, when coupled with the verbal and tactile cues of therapeutic gait training has been identified as effective in increasing ambulatory distances with reduced assistance. 4 Psychological awareness training, when integrated with typical gait training, has been found effective at improving frontal and sagittal plane joint kinematics in unilateral transfemoral amputees. 4 The evidence statements of Highsmith et al. are supplemented by the observations of Wong et al. in their review of exercise programs to improve gait performance in individuals with lower-limb amputations. 5 As with the prior review, Wong et al. conclude, "the combined evidence suggests that a variety of different types of exercise can improve self-selected gait speed" with "all exercise programs leading to increased gait speed…." 5 However, using the Cochrane Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system, Wong et al. report a B grade recommendation in support of using specific resisted part-to-whole or functional exercise gait training programs in place of unresisted gait training or supervised walking. 7 With respect to targeted exercises, Wong et al. observe that "all exercise types appeared effective in improving within-group gait speed, whether emphasizing supervised walking, specific muscle strengthening, balance training, part-to-whole gait training, or functional gait/activity training. 7 However, low-to-moderate level evidence was found to support the use of more demanding and functional exercise programs to improve gait speed. 7 While less direct than the systematic reviews already discussed, van Velzen et al., in their review on physical capacity and walking ability after lower-limb amputation, found strong evidence of a relationship between balance and walking ability. 6 While the evidence of a relationship between physical capacity and walking ability was less pronounced, van Velzen et al. observe that physical capacity training such as aerobic capacity, muscle strength, endurance, and functional walking tasks should not be discouraged as part of post-amputation rehabilitation as these elements are generally reduced following amputation. 6 Resultant Recommendations Based on the efficacy associated with the various tenets of therapeutic gait training, it is reasonable to conclude that such training programs should be an integral part of post-prosthetic rehabilitation. These programs should extend beyond supervised ambulation to include tactile, verbal, and visual feedback, as well as psychological awareness training, all of which can occur during both overground gait training and BWSTT. In addition, these programs may include part-to-whole gait training, emphasis on pre-gait activities, resisted gait interventions, and where appropriate, expansion to include functional gait activities. Such therapeutic gait training approaches may be complemented by functional exercise programs that include targeted muscle strengthening, balance training, and endurance activities to enhance aerobic capacity. 7

Shelly Coull, PT, is a clinic manager for Hanger Clinic, Portland, Maine. John Tawfik, PT, DPT, is a board-certified clinical specialist in geriatric physical therapy and certified exercise expert for aging adults. He is currently the clinical compliance & regulatory manager for Accelerated Care Plus. Phil Stevens, MEd, CPO, FAAOP, is in clinical practice with Hanger Clinic, Salt Lake City. He can be contacted at philmstevens@hotmail.com . References 1. Dillingham, T., L. Pezzin, and E. J. MacKenzie. 2002. Limb amputation and limb deficiency: Epidemiology and recent trends in the United States. Southern Medical Journal 95:875-83.

2. Ziegler-Graham, K., E. J. MacKenzie, P. L. Epharim, T. G. Travison, and R. Brookmeyer. 2008. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Archives of Physical Medicine and Rehabilitation 89(3):422-9.

3. Kahle, J. T., M. J. Highsmith, and H. Schaepper, et al. 2016. Predicting walking ability following lower limb amputation: An updated systematic literature review. Technology and Innovation 18:125-37.

4. Highsmith, M. J., C. R. Andrews, and C. Millman, et al. 2016. Gait training interventions for lower extremity amputees: A systematic literature review. Technology and Innovation 18:99-113.

5. Wong, C., J. E. Ehrlich, and J. C. Ersing, et al. 2016. Exercise programs to improve gait performance in people with lower limb amputation: A systematic review. Prosthetics and Orthotics International 40:8-17.

6. Van Velzen, J. M., C. A. van Bennekom, and W. Polomski, et al. 2006. Physical capacity and walking ability after lower limb amputation: A systematic review. Clinical Rehabilitation 20:999-1016

7. Stevens, P., S. Coull, and J. Tawfik. 2018. Lower extremity prosthetic gait training: A clinical practice guideline. Archives of Physical Medicine and Rehabilitation 99:e111.

Therapeutic Gait Training: What Prosthetists Need to Know

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