Kumar is a 20-year-old foreign exchange student who came to the United States 3 mo ago. He was recently involved in a severe motorcycle accident that required a transfemoral amputation of his right leg. Prior to the accident, Kumar was in good health. He has progressed in rehabilitation and is now ready to initiate gait activities. He has never used an assistive gait device. How would you initially approach this situation? How would you determine which assistive device to use?
As with every other activity, the goal of gait training is to provide enough of the right kind of assistance so that patients can achieve the greatest mobility with the least risk of injury. Walking is the process of repeatedly shifting the body weight over the advancing lower extremities (LEs). In biomechanical terms, it is a series of movements in which a person's center of mass (CoM) moves out beyond the base of support (BoS) in a controlled manner, and then the BoS moves forward under the CoM. This sequence is repeated to move the body progressively in a direction.
Assistance for ambulation comes in the form of assessment, instruction, physical contact, and use of assistive devices. What may at first seem to be merely technical decisions—"Do I use a walker or crutches? Which hand should the cane be in? Should the walker have wheels or not?”—are in fact the results of careful problem-solving and clinical judgment, which are best determined in the broader context of the individual patient's mobility goals.
Although “gait” and “ambulation” are both terms for walking, they are often used differently to distinguish skilled therapy from maintenance activities (see Box 9-9 “Thinking It Through: Clinical Questions—Is PROM a Skilled or Unskilled Service?” in Chapter 9). “Ambulating” a patient is typically the process of assisting a patient who is walking but not necessarily providing direct education and intervention to overcome gait deviations. “Gait training,” on the other hand, denotes a therapeutic intervention designed to improve some aspect of the patient's gait. Gait analysis involves the analysis of gait deviations and their underlying causes, the development and implementation of strategic interventions, and the evaluation of the effectiveness of interventions.
Several instruments are available to quantify gait performance, most of which focus on measures of gait distance, speed, dynamic balance during gait, and coordination, as well as on the patient's ability to maintain postural control during ambulation. Some frequently used assessments include:
▪ Gait Velocity Assessment1
▪ Dynamic Gait Index (DGI)2
▪ Timed Up and Go (TUG)3
▪ Performance-Oriented Mobility Assessment (POMA)4
Standardized tests paired with expert observation and qualitative assessments can provide therapists with valuable information for designing effective rehabilitation programs to help patients achieve their functional goals (see “Appendix 14-1: Parameters for the Community Ambulator”).