CHAPTER 14: Gait Training

CHAPTER OBJECTIVES

At the completion of this chapter, the reader will be able to:

1. Describe the various gait parameters

2. Describe the characteristics of normal gait

3. Discuss how to use the various pieces of pre-ambulation equipment, including the tilt table and parallel bars

4. Describe the various types of weight-bearing status and the functions of each

5. Describe the various methods to monitor weight-bearing status

6. Make a clinical decision as to which assistive device is the most appropriate for a patient

7. Be able to fit a patient for an assistive device

8. Discuss the importance of patient safety during gait or ambulation activities

9. Provide training to the patient on how to use an assistive device during various transfers

10. Teacher patient how to use an assistive device with varying gait patterns, during stair negotiation, and ambulation in the community

OVERVIEW

The lower kinetic chain has two main functions: to provide a stable base of support (BOS) in standing and to propel the body through space with gait. Whereas the objective in standing is to maintain a static equilibrium of forces, the objective with mobility is to create and control dynamic, unbalanced forces to produce movement.¹ Gait is thus an example of controlled instability. It is not clear whether gait is learned or is preprogrammed at the spinal cord level. However, once mastered, gait allows us to move around our environment in an efficient manner, requiring little in the way of conscious thought, at least in familiar surroundings. Bipedal gait has allowed the arms and hands to be free for exploration of the environment. Although gait appears to be a simple process, it is prone to breakdown. Although individual gait patterns are characterized by significant variation, three essential requirements have been identified for locomotion: progression, postural control and adaptation²:

• Progression. Progression of the head, arms, and trunk is initiated and terminated in the brainstem through a spinal cord central pattern generator (CPG). The locomotor CPG produces self-sustaining patterns of stereotype motor output resulting in gaitlike movements. The fall that occurs at the initiation of gait so that an individual must take the first step is controlled by the central nervous system (CNS).³ The CNS computes in advance the required size and direction of this fall toward the supporting foot. In addition, gait relies on the control of the limb movements by reflexes. Two such reflexes include the stretch reflex and the extensor thrust. The stretch reflex is involved in the extremes of joint motion, whereas the extensor thrust may facilitate the extensor muscles of the lower extremity during weight bearing.⁴ Both the CPG and the reflexes that mediate afferent input to the spinal cord are under the control of the brainstem and are therefore subconscious.⁵ This would tend to indicate that verbal coaching (i.e., feedback that is processed in the cortex) regarding an aberrant gait pattern might ...