Chapter 11: Locomotor Training

The recovery or improvement of walking ability is a primary goal for people with many different health conditions who seek the services of a physical therapist.^1,2,3 Initially, approximately two-thirds of people who experience a stroke cannot ambulate or require assistance to walk.⁴ Three months later, one-third of those with a stroke still require some level of assistance to walk.⁴ Approximately 70% of people with a spinal cord injury (SCI) cannot walk 1 year after their injury.⁵ People with Parkinson's disease (PD) often have impaired postural control and limited walking ability.⁶ Individuals with low back pain, lower extremity (LE) amputations, multiple sclerosis (MS), and a host of other health conditions all may present with impaired locomotion. The Guide to Physical Therapist Practice includes elements of gait and locomotor training (LT) as an intervention category within each of the four preferred practice patterns.⁷

The recovery of walking ability is such an important goal because people who can walk independently are more likely to be able to participate in expected social roles and desired recreational activities, have a higher quality of life, and have improved health status.^2,3,6,8,9

The major requirements for successful walking include the following:

• Support of body mass by the LEs

• Production of locomotor rhythm

• Dynamic postural control of the moving body

• Propulsion of the body in the intended direction

• Adaptability of the locomotor response to changing environmental and task demands

These requirements should be performed in an energy-efficient manner so as to minimize stress on the individual.

Recent advances in basic science research using animal models of different neurological health conditions provide a strong foundation for physical therapy interventions designed to improve locomotor capability in different patient populations. Research using an SCI cat model has found that spinalized cats trained by suspension in a harness over a treadmill (TM) and provided with manual assistance to step can learn to walk/step on the TM without supraspinal input.^10,11,12 Studies incorporating an animal model of stroke indicate that skilled, repetitive, task-oriented training can lead to beneficial neural plastic changes that are associated with improved mobility and reaching.^{13,14,15,16,17} Exercise in animal models of PD have also demonstrated beneficial effects.^18,19,20

Taken together these findings from basic science research provide important insight and guidance for physical therapists. Clinical researchers have used these findings to develop physical therapy interventions designed to improve locomotor ability in a variety of patient populations. Locomotor training using a body weight support (BWS) and a TM system,^21,22,23,24 task-oriented circuit training,^{24,28,29,30,31,32,33} TM training and task-specific strengthening exercises^24,30,31 are some of the interventions developed based on translating findings from basic science research to clinical practice. Although the specific interventions strategies vary, they share common principles.⁷⁵ These LT principles guide selection of interventions that are:

• Task oriented to the specific task of walking.

• Goal directed and meaningful to the patient.

• Shaped and progressed to maximally challenge the patient's capabilities.

• Performed multiple times (high number of repetitions).

The application of these principles to the specific LT interventions will vary depending on a variety of factors, including patient health condition, prognosis, patient goals, body structure/function impairments, and weight-bearing status. Evaluation of gait analysis data (see Chapter 7, Examination of Gait) can assist the therapist in developing an appropriate, task-oriented, goal-directed plan of care (POC) to address the limitations in walking ability. The LT interventions and principles can be implemented in and progressed through different environments: parallel bars, BWS and TM system, overground with and without a BWS system, and in the community. Interventions that target improved strength, transferring from sitting to/from standing, and standing balance are complementary activities often performed in conjunction with LT because these activities are functionally related to the task of walking.

Box 11.1 provides an overview of complementary interventions to LT and specific LT strategies. It should be noted that the interventions in their entirety are likely not indicated for each patient. Depending on individual patient need, multiple interventions may be accomplished concurrently, a more rapid progression may be used, or portions may be completely omitted. While performing LT within the different environments (e.g., parallel bars, indoor, community), principles of motor learning (see Chapter 10, Strategies to Improve Motor Function), strength training, and aerobic conditioning should be incorporated to facilitate learning and maximize walking ability.

The selection of interventions complementary to LT is based on examination findings (e.g., identified impairments and activity limitations) and typically includes strategies to improve the following:

• Strength

• Sit to/from stand transfers

• Standing balance

Strength

A key strategy for improving strength is to combine strength training with task-specific practice. This requires repetitive practice of tasks that are specific to the outcome (i.e., locomotion) and meaningful to the patient in terms of function. Although muscle-specific strengthening (e.g., progressive resistance, isokinetic equipment) may also be indicated and complementary to LT, using task-specific practice provides optimum transfer of strength gains to functional skills.

Inherent to task-specific strength training is resistance provided by body weight or limb segment weight; this weight may be augmented by the addition of external resistance (e.g., resistive bands, pool activities, cuff weights). Task selection is based on elements of the whole task, including the body segments involved; the required type, speed, and magnitude of contractions; and the degrees of freedom needed for the desired outcome. The goal is progression to whole task training. Activities typically begin with individual joints or body segments with progression to whole body movements.

For example, strengthening of LE extensor muscles is often a complementary activity to LT for some patient groups (e.g., stroke, Parkinson's disease). Task-specific functional activities that focus on extensor control might include partial wall squats, step-ups and step-downs, sit-to-stand transfers, and first bilateral, then single-limb heel rises to strengthen ankle plantarflexors. Another example is strengthening of hip abductors and adductors using side-stepping, cross-stepping, and braiding (manual contact or resistive bands can be used for resistance). Task-specific strengthening is important because it requires interplay of contraction types similar to the demands of walking.

Sit to/From Stand Transfers

Practice to improve transfers focuses initially on sitting with symmetrical weight-bearing, an erect posture on anterior portion of chair with neutral or slight anterior tilt of pelvis, and feet behind knees (allows dorsiflexors to assist forward rotation of legs over feet); emphasis is also placed on coordinated muscle responses and on appropriate timing. The reader is referred to the work of Fulk²⁵ for a thorough discussion of interventions to improve transfers.

To accomplish a sit-to-stand transfer, the patient must first actively flex the trunk and hips and may use momentum to shift the body mass forward. The patient's arms may be folded across chest, held forward with hands clasped, or hands placed on the chair armrests. (Note: Using the hands on a support surface should not be substituted for effective forward translation of body weight.) A higher, firm, seating surface (e.g., high-low treatment table) may be used initially for patients with weakness, and the height gradually reduced. Asking the patient to focus on a visual target can promote upper trunk extension during forward weight shift and enhance postural alignment and vertical orientation. As the patient moves toward the extension phase of the transfer, greater demands are placed on the hip and knee extensors to come to vertical. Tactile and proprioceptive cues can be used to promote contraction of extensor muscles.

To return to the seated position from standing, the motion is similar to that used for sit-to-stand transitions, but executed in reverse order. However, the timing and types of contractions are different. The focus of practice is on eccentric control as the body mass moves downward and backward. Eccentric contractions of the LE extensor muscles control lowering as the hips, knees, and ankles flex.

Initially, transfers may be performed slowly. With repetitive practice, focus can be placed on increasing speed of movement and performance of sit-to-stand and reverse without pausing. Practice should also include a variety of seating surfaces and heights, performance in open environments, and a gradual reduction in verbal cues.

Standing Balance

Adequate standing balance and control are integral components of locomotion. As continuous postural adjustments are needed during locomotion, intervention strategies to improve balance should be selected that impose similar demands. Locomotion requires static postural control (stability) to maintain standing and dynamic postural control (controlled mobility) to control movements within standing (e.g., weight shifting, LE stepping). Examples of interventions to improve balance follow; balance interventions are also discussed in Chapter 10, Strategies to Improve Motor Function, and in the work of O'Sullivan.²⁶

Initial standing activities may require touch-down support of the hands and can be performed in the parallel bars, between two treatment tables, or next to a wall or corner of a room (corner standing). The patient is first directed to stand tall and hold steady in the posture. Techniques such as quick stretch or approximation can be used to enhance postural stabilizing muscle contractions. Enhanced postural awareness can be achieved with limits of stability (LOS) training during weight shifting and in response to anticipated and reactive perturbations. Active exercise to improve standing may include heel-rises, toe-offs, back-kicks and sidekicks, hip and knee flexion, hip flexion with knee extension, partial wall squats, and marching in place. These exercises can also be performed in a pool. Adding ankle cuff weights, altering the base of support (BOS) (feet apart, together, tandem stance), upper extremity (UE) position (e.g., arms overhead, reaching), and support surface (e.g., inflated disc, wobble board) can all impose greater challenge.

Engagement of ankle and hip strategies can be promoted using incremental shifts in center of mass (COM) alignment and postural sway movements. Challenges can be enhanced using a foam cushion (eyes open to closed), split foam rollers (flat side down to flat side up), and wobble boards. Large COM shifts in all directions beyond the LOS will promote stepping strategies. Balance control can be further enhanced using manual perturbations, resistive band around pelvis during stepping (forward, backward, sideward), and using mobile and compliant surfaces with alterations in BOS (feet together, tandem standing, and single-limb stance).

The discussion of locomotion training strategies is divided into the following environments in which LT can be performed: (1) parallel bars, (2) overground indoors, (3) overground community, (4) BWS and TM, (5) BWS overground, and (6) other.

The following section addresses the parallel bar progression. Parallel bars have a time-honored tradition in conventional LT. They provide a reasonably safe and stable environment to become acclimated to upright standing, and they allow early walking practice on a relatively normal indoor floor surface for short distances. They also permit the UEs to assist in maintaining an erect posture and static/dynamic balance control, and to partially or fully unweight an LE. Because a high level of stability is provided by UE support, there is less demand imposed for balance control and the highly coordinated movements required of normal locomotor rhythm. However, prolonged parallel bar training promotes compensatory practice and learning of skills that often transfer poorly to independent overground walking and use of an assistive device. Owing to the increased weight borne by the UEs, a forward head and flexed trunk posture (limiting hip extension range of motion [ROM] and loading) is imposed and practiced. Locomotor speed, symmetry, and rhythm (timing) are typically diminished and appropriate dynamic balance mechanisms cannot be effectively promoted. In addition, the amount of body weight relief cannot be easily monitored.

In recent years, the availability of partial BWS training devices has diminished the routine use of parallel bars in many facilities. Training using a BWS system can be used in conjunction with a TM or used on overground surfaces and involves the patient donning a harness attached to an overhead frame that supports him or her in an upright vertical posture. Treadmill training using BWS is addressed later in this chapter.

Parallel Bars

Before standing, two important preliminary activities are fitting the patient with a guarding belt and adjusting the parallel bars. The initial adjustment of the parallel bars is an estimate based on the patient's height. Ideally the bars should be adjusted to allow 20 to 30 degrees of elbow flexion and come to about the level of the greater trochanter. Considering individual variations in body proportions and arm length, the elbow measurement is usually most accurate. Once the patient is standing, the height of the bars can be checked. If adjustments are required, the patient should be returned to a sitting position.

Before beginning LT in the parallel bars, wheelchair positioning and use of a guarding belt are important considerations. The patient's wheelchair should be positioned at the end of the parallel bars. The brakes should be locked, the footrests placed in an upright position, and the patient's feet on the floor well under the seating surface (COM over the BOS). The guarding belt should be fastened securely around the patient's waist. Guarding belts provide several critical functions. They increase the therapist's effectiveness in controlling or preventing potential loss of balance; they improve patient safety; they facilitate the therapist's use of proper body mechanics in untoward circumstances; and they are an important consideration regarding issues of liability. The safety implications of the guarding belt should be explained to the patient carefully.

Locomotor training in the parallel bars is initiated with patient instruction and demonstration. First, the entire progression should be presented before breaking it into sequential component parts. This will include instruction and demonstration in how to assume a standing position in the parallel bars, guarding techniques to be used by the therapist, the components of initial standing balance activities, gait pattern to be used, how to turn in the parallel bars, and how to return to a sitting position. Demonstrating these activities by assuming the role of the patient during verbal explanations will facilitate learning. Each component of the parallel bar progression should then be reviewed before the patient's actual performance of the activity. A sequence of activities for use in the parallel bars follows.

Assuming the Standing Position

To prepare for standing, the patient should be instructed to move forward in the chair. The therapist is positioned directly in front of the patient. A method of guarding should be selected that does not interfere with the patient's use of the UEs while moving to standing. Having moved forward in the chair with the supporting foot or feet on the floor well under the seating surface, the patient should be instructed to come to a standing position by leaning or rocking forward and pushing down on the armrests of the wheelchair with verbal cueing from the therapist ("rock your shoulders forward, continue rocking and on the count of three push down on the armrests, and come to standing, one, two, three"). The patient should not be allowed to stand by pulling up on the parallel bars because this approach has little functional carryover. As the patient nears an erect posture, the hands should be released from the armrests one at a time and placed on the parallel bars. The patient's COM should be guided over the BOS to promote a stable standing posture.

Standing Activities

During initial parallel bar activities, the therapist typically stands inside the bars facing the patient or outside the bars on the patient's weaker side. In guarding the patient from inside the bars, one hand should grasp the guarding belt anteriorly, and the opposite hand should be in front of, but not touching, the patient's shoulder. (Note: An underhand grip is always used when grasping a guarding belt.) From outside the bars one hand should grasp the belt posteriorly with the opposite hand in front of, but not touching, the patient's shoulder. This method of guarding provides effective hand placement for an immediate response should the patient lose his or her balance. It also eliminates the patient's feeling of being "held back" or "pushed forward," which may occur with manual contacts at the shoulders. The following initial activities in the parallel bars can be modified relative to the patient's weight-bearing status and specific requirements (e.g., use of a prosthesis or orthosis). The therapist maintains guarding techniques during these activities.

1. Standing, holding, acclimation to upright position; feet in symmetrical stance position, equal weight on both LEs; hands supported on parallel bars.

2. Limits of stability training (weight shifts with feet in stance position; alteration in hand placement on parallel bars).

   1. Lateral weight shift from side-to-side without altering the BOS; hand placement on the parallel bars is not altered.

   2. Anterior–posterior weight shifting forward and backward without altering the BOS; hand placement on the parallel bars is not altered.

   3. Anterior–posterior hand placement and weight shift; patient lifts and moves hands forward on bars and shifts weight anteriorly; alternated with posterior hand placement, and weight is shifted backward.

   4. Single-hand support; patient balances with support from only one hand on the parallel bars; hands are alternated. A progression of this activity involves gradual changes in position of the freed hand and UE. For example, move the freed hand several inches above the bar and gradually progress to alternate positions such as shoulder flexion, abduction, crossing the midline, and so forth. A progression can be made to balancing with both hands freed from the bars.

3. Stepping forward and backward. Patient steps forward with one LE, anterior weight shift, and then returns foot to starting position (normal BOS); alternated with stepping backward with one LE, posterior weight shift, with return of foot to starting position.

4. Side-stepping and cross-stepping. Patient turns 90° from a forward-facing position and places both hands on one parallel bar; weight is then shifted over support limb and dynamic limb abducts and side-steps. Progression made to cross-stepping; weight shifted over support limb and dynamic limb moves up and over the stance limb.

5. Forward progression. Ambulation in the parallel bars using selected gait pattern and appropriate weight-bearing (e.g., partial, full).

6. Turning. Once the desired distance in the parallel bars has been reached, the patient should be instructed to turn toward the stronger side. For example, with a non–weight-bearing left LE, the turn should be toward the right. The patient should be instructed to turn by stepping in a small circle and not to pivot on a single extremity. This technique will carry over to ambulation outside the bars, when pivoting will always be discouraged because of the potential loss of balance by movement on a small BOS. Guarding can be accomplished two ways. The therapist can remain in front of the patient, maintain the same hand positions, and turn with the patient. This will keep the therapist positioned in front of the patient. A second method is not to turn with the patient but, rather, to guard from behind on the return trip. In this method hand placements will change during the turn. Hand placement is changed gradually by first placing both hands on the guarding belt as the patient initiates the turn. One hand then remains on the posterior aspect of the belt and the freed hand is placed anterior to, but not touching, the shoulder on the patient's weaker side for the return trip toward the chair. Although both techniques are acceptable, the latter is probably more practical, considering the limited space available in the parallel bars.

7. Return to seated position. When reaching the chair the patient should again turn as described above. Once completely turned, patients are typically instructed to continue backing up until they feel the seat of the chair on the back of their legs (this will require substitution with visual or auditory clues for patients with impaired sensation). At this point the patient releases the stronger hand from the parallel bar and reaches back for the wheelchair armrest. Once this hand has securely grasped the armrest, the patient should be instructed to bend forward slightly, release the opposite hand from the parallel bar, and place it on the other armrest. Keeping the head and trunk forward, the patient gently returns to a seated position.

Overground Indoors

Activities for the indoor overground progression typically include walking forward and backward, resisted progression, side-stepping and cross-stepping, and stair climbing. Manual contacts can be used to guide and assist control of pelvic movement if necessary. Verbal cueing can be used to promote normal timing and locomotor rhythm. Upper extremity support may initially be required (e.g., hands resting lightly on therapist's shoulders; or therapist may be positioned in front of patient with elbows flexed and forearms supinated and patient uses therapist's hands for touch-down support as needed). Manual contacts, verbal cueing, and UE support are progressively decreased and then eliminated.

1. Walking forward and backward. This activity can begin with standing; stepping in place with emphasis on diagonal weight shifts forward and backward onto stance limb; and pelvic rotation in combination with advancing the swing limb.

2. Resistance with forward and backward walking is applied using a resistive band around the pelvis and held from behind as the patient moves forward or held in front facing the patient as he or she moves backward. In standing, wooden dowels held horizontally by both the patient and therapist can be used to promote reciprocal UE movements and trunk rotation moving both forward and backward.

3. Side-stepping and cross-stepping. Side-stepping involves abduction of the leading dynamic limb with foot placement followed by movement of the remaining limb to a parallel position with the first (symmetrical stance). Emphasis should be placed on keeping the pelvis level. Cross-stepping involves side-stepping and then crossing the remaining limb up and over the other limb.

4. Braiding. This activity involves a cross-step and sidestep progression with one limb advancing alternately anteriorly and posteriorly across the other while the second limb side-steps. It incorporates lower trunk rotation, as well as crossing the midline. This is a challenging activity and may require support from the therapist standing in front of the patient (forearms supinated, patient's hands lightly touching therapist's hands) or by use of a modified plantigrade position with UEs lightly supported on the treatment table.

5. Step-ups. To practice stepping up, a portable step can be placed directly in front of the patient. The patient weight shifts laterally toward the support limb and places the dynamic limb on the step. The limb is then returned to the original stance position. Verbal cues and manual guidance are provided as needed. The height of the step can be varied to increase or decrease the difficulty of the activity. For example, a 4-in (10-cm) step can be used initially with a gradual progression to a standard 7-in (17.5-cm) step. A progression is made to a step-over-step pattern on stairs. Early activities may require support from a railing. An erect trunk posture should be maintained and "pulling" on the railing should be avoided.

Indoor overground practice activities should also include strategies to vary locomotor task demands such as the following:

• Walking with head turns on verbal command such as look right, look left, look up, or look down.

• Increasing speed and rhythm of gait by using pacing cues to vary speed such as walk slow and walk fast.

• Use of a metronome or personal listening device (e.g., marching music) to increase speed and improve rhythm.

• Progress to longer distances with decreased number of rest intervals to improve walking endurance.

• Practice dual-task walking (e.g., walk and talk; walk and catch/throw a ball; tapping a balloon back and forth; bouncing a ball; carrying a tray that holds a glass of water, walk and perform a cognitive task).

• Practice walking on varied indoor surfaces such as tile, wood flooring, and carpeting.

• Practice walking through doorways including opening and closing door.

• Progress from a closed to an open environment.

Box 11.2 presents an overview of strategies for varying locomotor task demands. It provides suggested practice activities for enhancing specific (missing) components of gait that can be incorporated into the indoor overground progression.²⁷

Circuit Training

These (see Box 11.2) and other activities can be incorporated into a task-oriented circuit-training program. Circuit training generally consists of different stations at which patients participate in different specific, task-oriented activities designed to improve walking ability.^{24,28,29,30,31,32,33} For example, there may be six to eight stations at which patients participate in the activity for 5 to 10 minutes. Specific training stations may have activities such as standing and reaching, standing on different surfaces, walking through an obstacle course, transitioning from supine to sitting to standing, walking and carrying objects, walking and picking up objects from the floor, stepping up and down, walking at varying speeds and over varying surfaces, and standing and kicking a ball. As patients' performance improves, the specific tasks are progressed by increasing the complexity and difficulty. For example, to progress a patient in an obstacle course the patient can be required to do it more quickly, carry an object while walking through it, or step over higher objects.

A dual cognitive task can be added to the activity to increase the difficulty as well. Progressive resistive strength training targeting key muscles can also be incorporated.³¹ Box 11.3 Evidence Summary presents research examining the effectiveness of circuit training for improving locomotor ability.^{24,28,29,30,31,32}

Body Weight Support/Treadmill

Locomotor training using a BWS and TM system involves suspending a patient over a TM and using the BWS system to partially unweight the patient. The ability to partially unweight the patient allows patients with LE or trunk weakness to stand and take steps in a more symmetrical, natural manner without the need for excessive UE weight-bearing or compensatory movement patterns. Using this system also allows physical therapists and other rehabilitation professionals to manually assist the patient while stepping on the TM (see Fig. 20.37 in Chapter 20, Traumatic Spinal Cord Injury).

Locomotor training using a BWS and treadmill system was first used in patients with SCI. The rationale for its use is supported by animal studies of cats with thoracic spinal cord lesions that regained hind limb stepping patterns when supported by a harness over a moving treadmill.^10,11,12 These findings suggest that the spinal cord is capable of reciprocal locomotor patterns produced by central pattern generators (CPGs) at the spinal cord level in the absence of supraspinal input. Central pattern generators are also influenced by sensory input, allowing motor output modification based on environmental demands.

Behrman et al²¹ and Behrman and Harkema³⁴ have proposed the following guiding principles for LT:

• Maximally load the LEs for weight-bearing, while minimizing weight-bearing on the UEs (e.g., the BWS system sustains sufficient body weight so that the patient can stand and step with minimal or no UE support).

• Provide sensory cues that are consistent with normal walking (e.g., manual facilitation to the extensors and flexors during stance and swing, respectively).

• Promote trunk, limb, and pelvic kinematics associated with normal walking.

• Promote balance and upright control consistent with normal walking.

• Maximize the recovery and use of normal movement patterns and minimize compensatory movement patterns.

The overarching principle is to train like you walk. A key element of LT using BWS and a TM is facilitation of automatic walking movements within the context of intensive, task-specific training (whole-task practice). With body weight supported, the TM speed provides a rhythmic input. Manually guided movements are used to enhance the rhythmicity of the gait pattern. The BWS and TM system provides an environment in which these LT strategies can be accomplished.

Sensory input such as appropriately timed manually assisted limb movements can promote function-induced recovery.^28,31 Within a task-specific and safe patient environment, LT using BWS and a TM allows the therapist access to trunk, pelvis, and LEs to manually assist, guide, or adjust locomotor rhythm, limb placement, weight shifts, and stepping symmetry. Movements are coordinated to simulate normal gait; upright posture and balance are maintained, and speed of walking is controlled. Kosak and Reding³⁵ emphasize the role of sensory input during LT using BWS and a TM by stating, "Stride and cadence vary with treadmill speed, indicating local sensory feedback to a lumbosacral gait pattern-generator. The intensity and timing of sensory feedback from pressure receptors in the sole of the foot and joint proprioceptors from the ankle, knee, and hip are thought to provide facilitory and inhibitory effects on flexor-extensor motor neuron pools in the spinal cord at appropriate time during the gait cycle."^{35, p. 14}

Some of the advantages of LT using BWS and a TM include the following:³⁴

• Interlimb and intralimb timing can be practiced before limbs are capable of fully supporting body weight.

• Gait training can be initiated earlier within an episode of care.

• Specific elements of the gait cycle (e.g., midstance limb loading; swing phase unweighting and stepping) can be promoted within a dynamic task-specific strategy.

• Limb loading can be varied based on ability to support weight.

• Owing to forced stepping movements, "learned nonuse" may be prevented by focusing attention on both involved and uninvolved limbs.

• Opportunity to practice walking is provided without undue fear of falling.

• Dynamic balance can be enhanced by decreasing BWS and increasing TM speed.

• Compensatory strategies (e.g., UE support) to compensate for LE impairment are reduced.

• Constant speed of the TM provides rhythmic input that may reinforce a coordinated reciprocal gait pattern.

• Hip extension is facilitated.

Locomotor training using a BWS and TM system can be progressed by increasing TM speed, decreasing the amount of BWS and manual guidance, and increasing the time of stepping on the TM. For example, training may be initiated at very low speeds (e.g., 0.3 m/sec) with limited LE weight-bearing (30% to 40% of BWS), constant manual guidance at both LEs and the trunk/pelvis, and a stepping session of only 1 to 3 minutes. With continued training and patient improvement, this can be progressed to normal, age-appropriate walking speeds of 1.2 to 1.4 m/sec (4 to 4.5 ft/sec), full weight-bearing through the LEs, no manual guidance for stepping, and a stepping session of 30 minutes without rest.

Locomotor training using a BWS and TM system has also been successfully combined with robotic interventions; a robotic device instead of a physical therapist moves the LEs.^36,37,38,39 Although the effectiveness of LT using a BWS and TM system has been examined in a variety of patient populations, including those with spinal cord injury^{39,40,41,42,43} (see Evidence Summary Box 20.8), stroke^35,44,45 (see Evidence Summary Box 15.9), Parkinson's disease,^46,47,48 and multiple sclerosis,^49,50 it is not clear that it is more effective than other intervention approaches and what specific patients it is best suited for.

Overground Community

Locomotor training overground in the community is integral to returning the patient to a former environment and lifestyle. Overground community training activities must be specifically examined to determine their appropriateness for an individual patient.

1. Curbs. A useful lead-up activity to curb climbing is provided by training using a series of interlocking portable steps arranged in increments of height. For additional security they can be placed next to a treatment table, wall, or other support surface. A progression can be made from a 3- or 4-in (7.62-or 10.16-cm) increment to a 7-in (17.78-cm) curb height.

2. Ramps and slopes. Ramps and other sloping surfaces can be negotiated in several ways. If the incline is very gradual, it may be sufficient simply to instruct the patient to use smaller steps. For steeper inclines the patient should be instructed to use smaller steps and to traverse the ramp (use a diagonal, zigzag pattern) for both ascending and descending. Practice should include inclines of varying height. Walking up an inclined surface is associated with decreased speed, cadence, and step length.

3. Terrain variations. Community walking presents a variety of terrains that require adaptation of locomotor skills. Practice should include uneven surfaces such as sidewalks, grassy surfaces, parking lots, and so forth.

4. Timing requirements. Several community settings impose precise time restrictions (coincident timing) on movement. Walking should be practiced within these time constraints and can include crossing at a stoplight, stepping on and off a moving walkway or escalator, walking onto an elevator, and walking through a revolving door.

5. Open environment. Walking should be practiced in a variable open community environment such as a shopping mall, community center, grocery store, or other patient-specific location. Because learning is task and environment specific, walking should be practiced in all environments normally used by the patient.

Additional overground community practice activities include the following:

• Exit and entrance through outside doors and thresholds (both residential and commercial structures)

• Outdoor stair climbing (e.g., cement stairs)

• Entering and exiting public or private transportation

• Variations in visual conditions (e.g., full to reduced lighting)

• Scanning the environment

Nordic Walking

Nordic walking (trekking poles) has gained considerable presence in overground LT programs with varied patient populations.^{51,52,53,54,55,56,57,58} It is also used in health promotion and fitness programs.^55,59 The International Nordic Walking Federation (INWA) defines Nordic walking as "a form of physical activity, where to regular natural walking there has been added the active use of a pair of specially designed Nordic Walking poles. However, the characteristics of natural, biomechanically correct walking and appropriate posture are maintained in all aspects."⁶⁰

Nordic walking engages muscles of the UE and trunk and is effective in improving gait and aerobic conditioning.⁶⁰ Ample evidence supports the use of Nordic walking in overground LT. It has been shown to be a safe and effective training method for patients with chronic obstructive pulmonary disease (COPD)⁵¹ and coronary artery disease.⁵⁷ Improvements in postural stability, stride length, gait pattern, and gait variability were found in patients with Parkinson's disease.⁵² Nordic walking has also been found to be an effective intervention for low back pain,⁵³ fibromyalgia,^55,56 intermittent claudication,⁵⁸ and overweight individuals with type 2 diabetes.⁵⁴

General goals of Nordic walking include the following:^60,61

• Increase cardiorespiratory endurance

• Promote correct upright alignment and posture

• Improve balance, agility, and coordination

• Improve gait characteristics and walking speed

• Promote active engagement of multiple muscle groups

• Increase ROM and strength

Nordic walking may progress from overground indoors to overground in the community (see previous section). Other organizations promoting Nordic walking include the American Nordic Walking Association (http://anwa.us/html/index.php) and the International Nordic Fitness Sports Organization (www.nordicfitness.net/).

Body Weight Support/Overground

The task-oriented approach to LT using a BWS system can also be performed overground. Some systems are equipped with casters (Fig 11.1). Moving the BWS system away from the treadmill creates a mobile, safe, and efficient environment for continuing the controlled reduction in BWS to overground surfaces. Although a BWS system can be used overground, very few studies have examined its effectiveness in improving walking ability.⁶²

During initial overground training, verbal cueing and manual guidance are provided as needed. Gait speeds may be slower on overground surfaces as compared to over the TM with elimination of the rhythmic steady-state input provided by the TM. Ambulatory assistive devices such as a cane or a walker can be incorporated into overground training (see Appendix 11.A, Ambulatory Assistive Devices: Types, Gait Patterns, and Locomotor Training). The BWS device is manually moved to keep pace with the patient's forward progression. For use without an assistive device, the patient can move and steer the unit with the UEs (Fig. 11.2) before progressing to an assistive device or hands-free reciprocal arm movements.

Other intervention strategies that can be used to improve locomotor capability include virtual reality–based interventions^63,64,65,66 and mental practice with motor imagery.^67,68,69 Virtual reality–based locomotor interventions are typically paired with a TM or robotic device to move the LEs (Fig. 11.3). A computer-generated virtual environment provides a stimulating, task-oriented environment that engages the patient. Visual, proprioceptive, and auditory feedback through interaction in the virtual environment can be used to enhance motor learning.

Motor imagery is the imagining of a motor task without actually performing it, and mental practice is the repetitive imagining of the motor task with the goal of improving physical performance.⁶⁹ Similar areas of the brain are activated when people imagine walking and actually walk. The medial primary sensorimotor cortices and the supplementary motor area (SMA) are activated during actual and imagined walking.⁶⁹ Optimally, mental practice of gait-related movement should be paired with physical practice.

As discussed above, a variety of different intervention strategies can be used to improve locomotor capability. Although these different rehabilitation interventions have been shown to be effective, research has not shown one particular strategy to be superior to another, what the most effective dosage is, or when in the recovery process a particular intervention strategy should be employed.^{32,70,71,72,73} This challenges intervention selection when developing a specific POC.

A variety of factors should be considered when deciding on what intervention to select. Current theories of motor control and motor learning advocate for a task-oriented, repetitive approach to interventions.⁷⁴ Two basic treatment strategies are a compensatory and a restorative (recovery) approach. The compensatory approach seeks to improve functional skills by compensating for the lost ability. A simple example of this is the use of an assistive device such as a cane to provide postural support while walking. A restorative approach seeks to restore the "normal" movement while walking. Locomotor training using a BWS and TM system can be viewed as a restorative approach as the guiding principles emphasize normal movement strategies and minimizing compensatory movement patterns. In many cases interventions will require a balance between both compensatory and restorative approaches. Below are some factors to consider when selecting specific intervention strategies:

• Injury severity (i.e., degree of sensorimotor impairments, weight-bearing restrictions)

• Chronicity of injury

• Secondary complications

• Co-morbid health conditions

• Cognitive, communication, or behavioral barriers

• Motor learning capability

• Psychosocial and financial support

• Discharge destination

When determining dosage of the intervention, principles of neuroplasticity⁷⁵ (see Chapter 19, Traumatic Brain Injury), strength training, and endurance training should be incorporated.⁷⁶

Recovery of independent locomotion is an extremely important goal for many patients seen in rehabilitation settings. It is a functional skill that directly affects performance of expected roles within the patient's social, cultural, and physical environment. A framework of LT strategies has been presented that can be modified to meet the needs of an individual patient. Through a process of careful examination and communication with the patient, family, and/or caregivers, specific training strategies can be identified and implemented.

Questions for Review

1. Describe the LT principles that guide selection of interventions.

2. As a complementary activity to LT, what is the benefit of approaching strength training using task-specific practice (as compared to muscle-specific strengthening)? How is task selection determined for task-specific practice?

3. Describe the approach for instructing and guiding a patient to assume a standing position in the parallel bars.

4. What activities are typically included in overground indoor LT?

5. Describe strategies for varying task demands for overground indoor LT.

6. Describe the guiding principles for LT using BWS and a TM.

7. What advantages does LT using BWS and a TM provide?

8. Identify the parameters used for progressing LT using a BWS and TM system.

9. Describe practice activities required for locomotion training overground in the community.

10. At times, LT requires a balance between both compensatory and restorative approaches. What factors are considered when selecting specific intervention strategies?

HISTORY

Patient is a 74-year-old male, right-handed, admitted for acute care with progressive right-sided weakness over several hours before admission.

Admission computed tomography (CT) scan was unremarkable; carotid Dopplers were unremarkable without significant stenosis or plaque. Electrocardiogram (ECG) was within normal limits. Chest x-ray showed no active disease. Complete blood count (CBC) was within normal limits.

PHYSICAL EXAMINATION

• Blood pressure (BP): 130/76

• Heart rate (HR): 80

• Respirations (regular): 20

• Temperature: 97.9

• Head, ears, eyes, nose, and throat (HEENT) examination unremarkable

• Chest clear to percussion and auscultation

• Neck supple without carotid bruits

• Abdominal examination: obese without tenderness or organomegaly

• Peripheral pulses intact

• Extremities without deformities

INITIAL NEUROLOGICAL EXAMINATION

Patient is alert and cooperative with mild dysarthria. Speech is fully intelligible. He is able to follow complex commands. There is no neglect or apraxia. Visual fields are full to confrontation. Extraocular movements are full without nystagmus. Pupils are equal and reactive. There is a mild right central facial droop. Sensation is intact over the face. His palate and tongue are midline. Motor examination revealed a spastic right hemiparesis, with right UE (RUE) 3+/5 deltoid, trace triceps, 2+/5 biceps, and 2+/5 finger flexors; on the right LE (RLE) 2/5 iliopsoas, 3/5 quadriceps, 4-/5 gastrocnemius. There is no voluntary dorsiflexion of the foot. Deep tendon reflexes are slightly hyperactive on the right with a right + Babinski. The left side is strong in all muscle groups. Sensation is intact to all modalities.

DIAGNOSIS

Lacunar left cerebrovascular accident (L CVA)

PAST MEDICAL HISTORY

• 7-year history of non–insulin-dependent diabetes

• Patient is obese: 5 ft 7 in tall and weighs 225 lb (102 kg)

• No history of hypertension, heart disease, or prior strokes

• Status post–radical perineal prostatectomy

MEDICATIONS

Aspirin q.d.

Tolinase 250 mg q.d.

Sliding scale insulin for b.i.d. cap sticks

SOCIAL HISTORY

Patient is married, lives with his wife in a two-story home. Patient has been sleeping on the first floor.

There are two steps into the house. He is a retired Merchant Marine.

COGNITION

• Alert, follows simple commands, attention is within functional limits (WFL)

• Oriented to place, time, person, situation

• Memory: demonstrates occasional difficulty with immediate/short-term memory; long-term memory WNL

• Safety: demonstrates use of safety precautions during functional situations

• Problem-solving: demonstrates minimal impairment

• Executive function: occasional difficulty with planning, decision making

• Insight: expresses awareness of current limitations with minimal cues

COMMUNICATION

• Auditory comprehension: WNL

• Reading comprehension: WNL

• Written expression: Right (R) hand dominant, legible with left (L)

• Verbal expression: WNL

• Motor speech: Mild dysarthria

SENSORY

• Hearing: WNL

• Visual: WNL

• Somatosensory: trunk and all extremities: WNL

RANGE OF MOTION

• Left upper extremity (LUE) and left lower extremity (LLE): passive range of motion (PROM): WFL

• Right upper extremity (RUE): PROM: WFL; no contractures at wrist or fingers

• Right lower extremity (RLE): PROM: WFL

• Right shoulder subluxation: 1/2 inch (1 finger width)

TONE

• LUE and LLE: WFL

• RUE: Decreased at shoulder; minimal increase: elbow flexors, pronators, wrist and finger flexors, modified Ashworth Scale (mAS) = 1

• RLE: decreased at hip and knee, minimal increase: ankle plantarflexors (PF) (mAS=2)

STRENGTH/ACTIVE ROM

• LUE and LLE: WFL

• RUE: exhibits minimal active control of shoulder flexion, abduction, external rotation with elbow flexion against gravity (flexion synergy pattern)

• RLE: exhibits flexion and extension synergy patterns, can move limb against gravity

BALANCE

Sitting:

• Good (G) static: able to maintain position without handhold support, minimal sway

• Fair (F) dynamic: able to accept only minimal challenge

Standing:

• Poor plus (P+) static: requires handhold support and moderate assistance

• Poor (P) dynamic: unable to accept challenge or move without loss of balance

POSTURAL CHANGES

• Kyphosis

• Forward head position

GAIT

• Able to ambulate 10 feet in parallel bars with moderate assistance

• Gait deviations: unsteady, requires verbal cues for sequencing; decreased foot clearance on right slides RLE forward or hip hikes on right to advance RLE; will benefit from an ankle-foot orthosis (AFO)

PERCEPTUAL

• Spatial awareness: WNL

SKIN

• Dry

• Intact

PSYCHOLOGICAL FUNCTIONING

• Affect: appropriate, no symptoms of depression, emotional distress

• Adjustment to medical condition: good

• Motivation for rehabilitation: good

FUNCTIONAL: FUNCTIONAL INDEPENDENCE MEASURE (FIM) ADMISSION SCORES

• Eating = 6

• Grooming = 4

• Bathing = 4

• Dressing: upper body = 4; dressing lower body = 4

• Toileting = 5

• Bladder management = 5

• Bowel management = 5

• Transfers: bed, chair, wheelchair = 3

• Transfers: toilet = 2

• Transfers: tub-shower = 2

• Locomotion: walk = 1; wheelchair = 5

• Locomotion: stairs =1

• Comprehension = 7

• Expression = 5

• Social interaction = 7

• Problem solving = 7

• Memory = 5

BED MOBILIT

• Patient requires minimal assist to roll onto the sound side and push up into sitting

PATIENT GOALS

• "I want to walk as before"

1. Identify/categorize this patient's problems affecting locomotion in terms of direct impairments, indirect impairments, and activity limitation.

2. Identify an anticipated goal (within 2 weeks) and expected outcome for LT.

3. Identify three interventions complementary to LT.

4. Identify three LT environments that could be used to improve walking and indicate a training progression.

TYPES AND GAIT PATTERNS

There are three major categories of ambulatory assistive devices: canes, crutches, and walkers. Each has several modifications to the basic design, many of which were developed to meet the needs of a specific patient problem or diagnostic group. Assistive devices are prescribed for a variety of reasons, including problems of balance, pain, fatigue, weakness, joint instability, excessive skeletal loading, and cosmesis. Another primary function of assistive devices is to eliminate weight-bearing fully or partially from a lower extremity (LE). This unloading occurs by transmission of force from the upper extremities (UEs) to the floor by downward pressure on the assistive device. Prescribing an appropriate assistive device requires knowledge of the patient's weight-bearing status. Common clinical descriptors used to identify weight-bearing status are presented in Box 11A.1. Considerations specific to the bariatric population are presented in Box 11A.2.

Canes

Most canes used in clinical practice are constructed of lightweight aluminum. Evidence supports the effectiveness of canes to improve balance^1,2,3 and improve postural stability.^1,4,5,6 Although canes reduce biomechanical load on LE joints,^2,7 they are not intended for use with a restricted weight-bearing status (such as non–weight-bearing [NWB] or partial weight-bearing [PWB]). Patients are typically instructed to hold a cane in the hand opposite the affected extremity. This positioning of the cane most closely approximates a normal reciprocal gait pattern with the opposite arm and leg moving together. It also widens the BOS with less lateral shifting of the center of mass (COM) than when the cane is held on the ipsilateral side.

Several investigations have confirmed that contralateral positioning of the cane reduces hip abductor activity on the side opposite the cane.^4,8,9,10 During normal gait, the hip abductors of the stance extremity contract to counteract the gravitational moment at the pelvis on the contralateral side during swing. This prevents tilting of the pelvis on the contralateral side but results in compressive forces acting at the stance hip. Use of a cane in the UE opposite the affected hip will reduce these forces. The floor (ground) reaction force created by the downward pressure of body weight on the cane counterbalances the gravitational movement at the affected hip.³ Thus, the need for tension in the abductor muscles is reduced, with a subsequent decrease in joint compressive forces.

Several components of floor reaction forces that create joint compression at the hip can be reduced by use of a cane. In an early study by Ely and Smidt,¹¹ contralateral use of a cane was found to decrease the vertical and posterior components of the floor reaction force produced by the affected foot. They noted that the reductions in vertical floor reaction peaks were probably due to a shifting of body weight toward the cane, which was a contributing factor in reducing contact force at the affected hip. In a study of patients with total hip arthroplasty (THA), Neumann⁸ found that contralateral use of a cane reduced average hip abductor electromyography (EMG) activity to 31% below that generated when not using a cane. Cane use contralateral to a THA, with the addition of carrying an ipsilateral load, decreased hip abductor activity by 40% compared to walking without carrying a load or using a cane.¹⁰

Research supports use of a cane as an effective method for reducing forces acting at the hip.^4,8,9,10 This reduction is particularly important for activities such as stair climbing, when the forces generated at the hip are significantly increased. Contralateral cane use has also been found to reduce knee pain in patients with osteoarthritis (OA).^7,12 Clearly, use of a cane has important implications for hip and knee involvement such as joint replacements or degenerative joint disease. Box 11A.3 Evidence Summary presents studies addressing the impact and function of canes.^{1,4,7,12,13,14}

Maguire et al⁴ found that contralateral cane use reduced gluteus medius activity by 21.86% and tensor fascia lata activity by 19.14% in patients with subacute stroke. This finding has important implications for patients with stroke, who often use canes, because strategies to improve postural control and balance reactions may be adversely affected by reduced hip abductor activity.

In addition to altering the forces on the affected extremity, canes are selected on the basis of their ability to improve gait by providing increased dynamic stability and improving balance. This is achieved by the increased base of support (BOS) provided by the additional point(s) of floor contact. The level of stability provided by canes is on a continuum. Broad-based (four-point) canes provide the greatest stability and standard (single-point) canes provide the least. The following section presents several of the more common types of canes in clinical use and identifies their advantages and disadvantages.

Types of Canes

Standard Cane

This assistive device also is referred to as a single-point or straight cane (Fig. 11A.1A). It is made of wood or acrylic and has a half-circle ("crook") or T-shaped handle.

• Advantages. This cane is inexpensive and fits easily on stairs or other surfaces where space is limited.

• Disadvantages. The standard cane is not adjustable and must be cut to fit the patient. With a half-circle handle, the point of support (shaft of cane) is anterior to the hand, not directly beneath it. The T-shaped handle shifts the point of support only slightly closer to hand.

Standard Adjustable Aluminum Cane

This assistive device (Fig. 11A.1B) has the same basic design as the standard cane. It is made of aluminum and has a half-circle handle with a molded plastic covering. The telescoping design of this cane enables the height to be adjusted using a push-button mechanism. Variations in available height range differ slightly with manufacturers. However, they are generally adjustable within the range of approximately 27 to 38.5 in (68 to 98 cm). (Note: Most adjustable aluminum assistive devices [e.g., canes, crutches, walkers] use a push-button mechanism to alter height; many include a reinforcing cuff tightened by a thumbscrew or rotation sleeve.)

• Advantages. This cane is quickly adjustable, facilitating ease of determining appropriate height. It is lightweight and fits easily on stairs.

• Disadvantages. The point of support is anterior to the hand, not directly beneath it. This cane is more costly than a standard wooden cane.

Adjustable Aluminum Offset Cane

The proximal component of the shaft of this cane is offset anteriorly, creating a straight offset handle. It is made of aluminum with a plastic or rubber molded grip-shaped handle (Fig. 11A.1C). Using a push-button mechanism, the telescoping design allows the height to be adjusted from approximately 27 to 38.5 in (68 to 98 cm).

• Advantages. The design of this cane allows pressure to be borne over the center of the cane for greater stability. This cane also is quickly adjusted, is lightweight, and fits easily on stairs.

• Disadvantages. This cane is more costly than standard or adjustable aluminum canes.

Note: For standard and offset canes, the diameter of both the distal rubber tips and shaft of the cane is generally at least 1 in (2.54 cm).

Quadruped (Quad) Cane

This assistive device is constructed of aluminum and is available in a variety of designs depending on the manufacturer. Both large-based quad canes (LBQCs) and small-based quad canes (SBQCs) are commercially available (Figs. 11A.2 and 11A.3). The characteristic feature of these canes is that they provide a broad base with four points of floor contact. Each point (leg) is covered with a rubber tip. The legs closest to the patient's body are generally shorter and may be angled to allow foot clearance. On many designs the proximal portion of the cane is offset anteriorly. The hand piece is usually one of a variety of contoured plastic grips. A telescoping design allows for height adjustments. Quad canes are generally adjustable from approximately 28 to 38 in (71 to 91 cm).

• Advantages. This cane provides a broad-based support. Bases are available in several different sizes. This cane is also easily adjustable.

• Disadvantages. Depending on the specific design of the cane, the pressure exerted by the patient's hand may not be centered over the cane and may result in patient complaints of instability. As a result of the broad BOS, some quad canes may not be practical for use on stairs. Another disadvantage of broad-based canes is that they warrant use of a slower gait pattern. If a faster forward progression is used, the cane often "rocks" from rear legs to front legs, which decreases effectiveness of the cane. Patients should be instructed to place all four legs of the cane on the floor simultaneously to obtain maximum stability.

Hemi Cane

The hemi cane also is constructed of aluminum (Fig. 11A.4). It provides a very broad base with four points of floor contact. Each point (leg) is covered with a rubber tip. The legs farther from the patient's body are angled to maintain floor contact and to improve stability. The handgrip is molded plastic around the uppermost segment of aluminum tubing. Hemi canes fold flat and are adjustable in height from approximately 29 to 37 in (73 to 94 cm).

• Advantages. Hemi canes provide very broad-based support and are more stable than a quad cane. These canes also fold flat for travel or storage.

• Disadvantages. As with the quad canes, the specific design of a hemi cane or handgrip placement may not allow pressure to be centered over the cane. Hemi canes cannot be used on most stairs. They require use of a slow forward progression and are generally more costly than quad canes.

Rolling Cane

Constructed of aluminum and aluminum tubing (Fig. 11A.5), this cane provides a wide, wheeled base allowing uninterrupted forward progression. It includes a contoured handgrip, height adjustment from 28 to 37 in (71 to 94 cm), and a pressure-sensitive brake built into the handle engaged using pressure from the base of the hand.

• Advantages. The wheeled base allows weight to be continuously applied as the need to lift and place the cane forward is eliminated. This also provides for a faster forward progression. The second and third handles placed between the uprights can assist in rising to standing (brake engaged).

• Disadvantages. This cane is more costly than standard quadruped canes and requires sufficient UE and grip strength to engage the braking mechanism. This cane is not suitable for patients displaying a propulsive gait pattern (e.g., Parkinson's disease).

Laser Cane

This cane incorporates a bright red laser line projected across the floor designed to assist with overcoming freezing episodes while walking (Fig 11A.6). A walker with a laser is also available (Fig 11A.7). Donovan et al¹⁵ examined 26 patients with Parkinson's disease using either a laser cane or walker (selection based on type of device habitually used). The Freezing of Gait Questionnaire (FOG-Q)^16,17 was used as an outcome measure (lower scores suggest improved function). Subjects were instructed not to look at the visual cue (laser beam) unless experiencing a freezing of gait (FOG) episode, at which time they were instructed to "step over" the light. Findings indicated a small but significant mean reduction in FOG-Q scores of 1.25 (±0.48; p = 0.0152). The mean reduction in fall frequency was 39.5% (±9.3%; p = 0.002). No significant changes in gait speed were noted. Although additional research is warranted, these initial findings suggest that assistive devices incorporating a laser beam may hold potential for addressing FOG episodes common in patients with Parkinson's disease.

Handgrips

A general consideration relevant to all canes is the nature of the handgrip. A variety of styles and sizes are available. The type of handgrip should be judged and selected primarily on the basis of patient comfort and on the grip's ability to provide adequate surface area to allow effective transfer of weight from the UE to the floor. The more common types of handgrips are (1) the crook handle, (2) the straight offset handle, and (3) the T-shaped handle, which conforms to the patient's hand. It is useful to have several handgrip styles available for examination and trial with individual patients.

Measuring Canes

In measuring cane height, the cane (or center of a broad-based cane) is placed approximately 6 in (15.24 cm) from the lateral border of the toes. Two landmarks typically are used during measurement: the greater trochanter and the angle at the elbow. The top of the cane should come to approximately the level of the greater trochanter, and the elbow should be flexed to about 20 to 30 degrees. Because of indivi dual variations in body proportion and limb lengths, the degree of flexion at the elbow is generally consi dered the more important indicator of correct cane height.

The 20 to 30 degrees of elbow flexion serves two important functions. It allows the arm to shorten or to lengthen during different phases of gait, and it provides a shock-absorption mechanism. Finally, as with all assistive devices, the height of the cane should be considered with regard to patient comfort and the cane's effectiveness in accomplishing its intended purpose.

Gait Pattern for Use of Canes

As discussed, the cane should be held in the UE opposite the affected limb. For ambulation overground on level surfaces, the cane and the involved (or more involved) extremity are advanced simultaneously (Fig. 11A.8). The cane should remain relatively close to the body and should not be placed ahead of the toe of the involved extremity. These are important considerations, because placing the cane too far forward or to the side will cause lateral and/or forward bending, with a resultant decrease in dynamic stability.

When bilateral involvement exists, a decision must be made as to which side of the body the cane will be held. This question is most effectively resolved by using a problem-solving strategy with input from both the patient and therapist. Questions to be considered include the following:

• On which side is the cane most comfortable?

• Is one placement superior in terms of improving balance and/or ambulatory endurance?

• If gait deviations exist, is one position more effective in improving the overall gait pattern?

• Is safety influenced by cane placement (e.g., during transfers, stair climbing, or overground in community)?

• Is there a difference in grip strength between hands?

• Are two canes needed for stability?

Consideration of these questions will generally provide sufficient information to determine the most effective cane placement and use when bilateral involvement exists.

For some patients, optimal function is achieved using canes bilaterally (Fig 11A.9). In these situations, a two- or four-point gait pattern is used. For example, with a four-point pattern, the contralateral cane is moved forward and then the ipsilateral LE steps forward. Using a two-point pattern, the contralateral cane and ipsilateral LE are moved forward simultaneously. These gait patterns are described in the following section on crutches.

Crutches

Crutches are used most frequently to improve balance and to relieve weight-bearing either fully or partially on an LE. They are typically used bilaterally and function to increase the BOS, to improve lateral stability, and to allow the UEs to transfer body weight to the floor. This transfer of weight through the UEs permits functional ambulation while maintaining a restricted weight-bearing status. There are two basic designs of crutches in frequent clinical use: axillary and forearm crutches.

Types of Crutches and Attachments

Axillary Crutches

These assistive devices also are also referred to as standard crutches (Fig. 11A.10, left). They are made of lightweight wood or aluminum. Their design includes an axillary bar, a hand piece, and double uprights joined distally by a single leg covered with a rubber suction tip (which should have a diameter of 1.5 to 3 in [1.5 to 3 cm]). The single leg allows for height variations. Height adjustments for wooden crutches are accomplished by altering the placement of screws and wing bolts in predrilled holes. The design of most aluminum crutches incorporates a push-button pin mechanism for height adjustments similar to those found on aluminum canes. Some aluminum crutches also have patient height markers adjacent to the notches to assist in adjustment. The height of the handgrips for wooden and some aluminum crutches is adjusted by placement of screws and wing bolts in predrilled holes. The handgrip height on some aluminum crutches is adjusted using a push-button mechanism with a reinforcing clip-lock (Fig. 11A.11). Both the overall height of the crutch and the height of the handgrip typically adjust in 1-in (2.54-cm) increments. Axillary crutches are generally adjustable in adult sizes from approximately 48 to 60 in (122 to 153 cm), with children's and extra-long sizes available.

• Advantages. Axillary crutches improve balance and lateral stability and provide for functional ambulation with restricted weight-bearing. They are easily adjusted, inexpensive when made of wood, and can be used for stair climbing.

• Disadvantages. Because of the tripod stance required to use crutches and the resultant large BOS, crutches are awkward in small areas. For the same reason, the safety of the user may be compromised when ambulating in crowded areas. Another disadvantage is the tendency of some patients to lean on the axillary bar. This causes pressure at the radial groove (spiral groove) of the humerus, creating a situation of potential damage to the radial nerve, as well as to adjacent vascular structures in the axilla.

Platform Attachments

These attachments (Fig. 11A.12) are also referred to as forearm rests or troughs. Although they are described here, they also are used with walkers. Their function is to allow transfer of body weight through the forearm to the assistive device. A platform attachment is used when weight-bearing is contraindicated through the wrist and hand (e.g., arthritis, Colles' fracture). The forearm piece is usually padded, has a dowel or handgrip, and has hook-and-loop straps to maintain the position of the forearm.

Forearm Crutches

These assistive devices are also known as Lofstrand and Canadian crutches (Fig. 11A.10, right). They are constructed of aluminum. Their design includes a single upright, a forearm cuff, and a handgrip. This crutch adjusts both proximally to alter position of the forearm cuff and distally to alter the height of the crutch. Adjustments are made using a push-button mechanism. The available heights of forearm crutches are indicated from handgrip to floor and are generally adjustable in adult sizes from 29 to 35 in (74 to 89 cm), with children's and extra-long sizes available. The distal end of the crutch is covered with a rubber suction tip. The forearm cuffs are available with either a medial or anterior opening. The cuffs are made of metal and can be obtained with a plastic coating.

• Advantages. The forearm cuff allows use of hands without the crutches becoming disengaged. They are easily adjusted and allow functional stair climbing activities. Many patients feel they are more cosmetic and they fit more easily into an automobile owing to the overall decreased height. They are also the most functional type of crutch for stair climbing activities for individuals wearing bilateral knee-ankle-foot orthoses (KAFOs).

• Disadvantages. Forearm crutches provide less lateral support owing to the absence of an axillary bar. The cuffs may be difficult to remove.

Measuring Crutches

Axillary Crutches

Several methods are available for measuring axillary crutches. The most common use a standing or a supine position. Measurement from standing is most accurate and is the preferred approach.

• Standing. From a supported standing position, crutches should be measured from a point approximately 2 in (5.08 cm) below the axilla. The width of two fingers is often used to approximate this distance. During measurement, the distal end of the crutch should be resting at a point 2 in (5.08 cm) lateral and 6 in (15.24 cm) anterior to the foot. A general estimate of crutch height can be obtained before standing by subtracting 16 in (40.64 cm) from the patient's height. With the shoulders relaxed, the hand piece should be adjusted to provide 20 to 30 degrees of elbow flexion.

• Supine. From this position the measurement is taken from the anterior axillary fold to a surface point (mat or treatment table) 6 to 8 in (5.08 to 7.5 cm) from the lateral border of the heel.

Forearm Crutches

Standing is the position of choice for measuring forearm crutches. From a supported standing position, the distal end of the crutch should be positioned at a point 2 in (5.08 cm) lateral and 6 in (15.24 cm) anterior to the foot. With the shoulders relaxed the height should then be adjusted to provide 20 to 30 degrees of elbow flexion. The forearm cuff is adjusted separately. Cuff placement should be on the proximal third of the forearm, approximately 1 to 1.5 in (2.5 to 3.8 cm) below the elbow.

Crutch Gait Patterns

Gait patterns are selected on the basis of the patient's balance, coordination, muscle function (strength, power, endurance), and weight-bearing status. The gait patterns differ significantly in their energy requirements, BOS, and the speed with which they can be executed.

Before initiating instruction in gait patterns, several important points should be emphasized to the patient:

• During axillary crutch use, body weight should always be borne on the hands and not on the axillary bar. This will prevent pressure on both the vascular and nervous structures located in the axillary region.

• Balance will be optimal by always maintaining a wide (tripod) BOS. Even when in a resting stance, the patient should be instructed to keep the crutches at least 4 in (10 cm) to the front and to the side of each foot. The foot should not be allowed to achieve parallel alignment with the crutches. This will jeopardize anterior–posterior stability by decreasing the BOS.

• When using standard crutches, the axillary bars should be held close to the chest wall to provide improved lateral stability.

• The patient should also be cautioned about the importance of holding the head up and maintaining good postural alignment during ambulation.

• Stepping in a small circle rather than pivoting should be used when turning.

Three-Point

In this type of gait three points of support contact the floor (two crutch points and a single LE). It is used when a non–weight-bearing status is required on one LE. Body weight is borne on the hands through the crutches instead of on the affected LE. The sequence of this gait pattern is illustrated in Figure 11A.13.

Partial Weight-Bearing

This gait is a modification of the three-point pattern. During forward progression of the involved extremity, weight is borne partially on both crutches and on the affected extremity (Fig. 11A.14). During instruction in the partial weight-bearing gait, emphasis should be placed on use of a normal heel–toe progression on the affected extremity. Patients may interpret "partial weight-bearing" as meaning that only the toes or ball of the foot should contact the floor. Use of this positioning over a period of days or weeks will lead to heel cord tightness. Limb load monitors are often a useful adjunct to partial weight-bearing gait training and are described in the section, Adjunct Training Devices. These devices provide auditory feedback to the patient regarding the amount of weight borne on an extremity.

Four-Point

This pattern provides a slow, stable gait as three points of floor contact are maintained. Weight is borne on both LEs and typically is used with bilateral involvement due to poor balance, incoordination, or muscle weakness. In this gait pattern one crutch is advanced and then the opposite LE is advanced. For example, the left crutch is moved forward, then the right LE, followed by the right crutch and then the left LE (Fig. 11A.15).

Two-Point

This gait pattern is similar to the four-point gait. However, it is less stable because only two points of floor contact are maintained. Thus, use of this gait requires better balance. The two-point pattern more closely simulates normal gait, inasmuch as the opposite LE and UE move together (Fig. 11A.16).

Two additional, less commonly used crutch gaits are the swing-to and swing-through patterns. These gaits are often used when there is bilateral LE involvement, such as in spinal cord injury (SCI). The swing-to gait involves forward movement of both crutches simultaneously, weight is shifted onto the hands, and the LEs "swing to" the crutches. In the swing-through gait, the crutches are moved forward together, weight is shifted onto the hands, and the LEs are swung beyond the crutches.

Walkers

Walkers are used to improve balance and relieve weight-bearing either fully or partially on an LE. Of the three categories of ambulatory assistive devices, walkers afford the greatest stability. They provide a wide BOS, improve anterior and lateral stability, and allow the UEs to transfer body weight to the floor.

Walkers are typically made of aluminum with molded vinyl handgrips and rubber tips. They are adjustable in adult sizes from approximately 32 to 37 in (81 to 92 cm), with children's, youth, and tall sizes available. Several design variations and modifications to the standard design are available and are described below.

Types of Walkers and Features

Glides

Glides are small, plastic attachments placed on the posterior legs of walkers typically in combination with wheels on the front legs (Fig. 11A.17A). They promote a smooth forward progression without having to lift and place the walker with each step. They are typically made of high-density plastic in an inverted-mushroom shape. Other common glide designs include a 1-in (2.54 cm) diameter "disk" with a central stem that slides into the tubular leg and is tightened into place with a screwdriver, and a fitted cap that is placed directly onto the walker leg (in the same manner the rubber tip is attached). Another style of glide incorporates a tennis ball within a fixed housing (Fig. 11A.18).

Folding Mechanism

Folding walkers are particularly useful for patients who travel. These walkers can be easily collapsed to fit in an automobile or other storage space (see Fig. 11A.17B).

Handgrips (Handles)

Enlarged and molded handgrips are available, and may be useful for some patients with arthritis. Some walkers offer a second set of handles to assist with sit-to-stand transitions (see Fig 11A.17A).

Platform Attachments

This adaptation is used when weight-bearing is contraindicated through the wrist and hand (described in crutch section; see Figure 11A.12).

Wheel Attachments

This adaptation to walkers (often called rolling walkers) includes the addition of wheels (either to the two front wheels only or to all four wheels). The addition of wheels frequently allows functional ambulation for patients who are unable to lift and to move a conventional walker (e.g., frail elderly). Swivel wheels turn freely in a complete circle (Fig. 11A.19). Fixed wheels rotate around a central axis (Fig. 11A.20A). Wheels are generally available in 3-, 5-, and 6-in (7.62-, 12.7-, 15.24-cm) diameters. Eight-inch-diameter (20.32 cm) wheels are also available and can be used to add height for tall users.

Braking Mechanism

A braking system is an essential feature of walkers designed with wheels. Walkers with four wheels frequently include handbrakes that lock the rear wheels (see Fig. 11A.19). Spring-loaded locks can be placed on the rear walker wheels (Fig. 11A.20A). These locks engage when weight is placed on the posterior walker legs through the handgrips. Posterior pressure brakes are effective when wheels are placed only on the front walker legs.

Tripod Rolling Walkers

Three-wheel walkers incorporate a tripod design (Fig 11A.21); some manufacturers refer to these as rollators. A major advantage of this device is ease of maneuverability and turning. Height adjustments are made at the handles; the unit folds for storage and travel.

Storage Attachments

The ability to transport items is an important consideration for many patients and is often essential for those needing frequent access to medications, a cordless or cellular phone, or remote control device. A variety of sizes and styles of attachable baskets and pouches are available (Fig. 11A.22). These storage attachments should be used judiciously and only for essential items. Overuse of the attachment creates an excessive anterior load that may pose a safety hazard and/or alter the patient's gait or ability to effectively use the walker.

Seating Surface

A variety of walker seat designs are available that fold out of the way when not in use. The structural design of many walkers also includes a contoured back support (see Figs 11A.19 and Fig 11A.20A). Seats are an important consideration for individuals with limited endurance (e.g., postpolio syndrome), as well as for community ambulators who require periodic rest intervals. Walker seats should be carefully examined for stability and safety with respect to individual patient needs. Patient practice in use of the walker seat should be provided.

Reciprocal Walkers

These walkers are designed to allow unilateral forward progression of one side of the walker (Fig. 11A.23). A disadvantage of this design is that some inherent stability of the walker is lost. However, they are useful for patients incapable of lifting the walker with both hands and moving it forward (in situations in which a rolling walker might be contraindicated).

• Advantages. Conventional walkers provide four points of floor contact with a wide BOS. They provide a high level of stability. They also provide a sense of security for patients fearful of ambulation. They are relatively lightweight and easily adjusted.

• Disadvantages. Walkers tend to be cumbersome, are awkward in confined areas, and are difficult to maneuver through doorways and into cars. They eliminate normal arm swing and generally cannot be used safely on stairs.

Measuring Walkers

The height of a walker is measured in the same way as that of a cane. The handgrip or handle of the walker should come to approximately the greater trochanter and allow for 20 to 30 degrees of elbow flexion.

Gait Patterns: Conventional Walkers

Before initiating instruction in gait patterns using a conventional walker (four points of floor contact without wheel attachments), several points related to use of the walker should be emphasized with the patient:

• The walker should be picked up and placed down on all four legs simultaneously to achieve maximum stability. Rocking from the back to front legs should be avoided because it decreases the effectiveness and safety of using the assistive device.

• The patient should be encouraged to hold the head up and to maintain good postural alignment; forward flexion of the trunk, neck, and head should be avoided.

• The patient should be cautioned not to step too close to the front crossbar. This will decrease the overall BOS and may result in a fall.

Three types of weight-bearing gait patterns can be accomplished with conventional walkers: full weight-bearing (FWB), partial weight-bearing (PWB), and non–weight-bearing (NWB) gait (rolling devices are generally not recommended for patients with altered weight-bearing status). The sequence for each pattern with a walker follows.

Full Weight-Bearing

• The walker is picked up and moved forward about an arm's length.

• The first LE is moved forward.

• The second LE is moved forward past the first.

• The cycle is repeated.

Partial Weight-Bearing

• The walker is picked up and moved forward about an arm's length.

• The involved PWB limb is moved forward, and body weight is transferred partially onto this limb and partially through the UEs to the walker.

• The uninvolved LE is moved forward past the involved limb.

• The cycle is repeated.

Non–Weight-Bearing

• The walker is picked up and moved forward about an arm's length.

• Weight is then transferred through the UEs to the walker. The involved NWB limb is held anterior to the patient's body but does not make contact with the floor.

• The uninvolved limb is moved forward.

• The cycle is repeated.

Note: Rolling walkers generally allow use of a reciprocal gait pattern because the walker can be rolled forward while walking. As the need to lift the walker forward following each step is eliminated, a smoother forward progression can be achieved.

Overground Indoors

Several important preparatory activities should precede locomotor training (LT) on level surfaces with the assistive device. These activities may be completed in the parallel bars for added security. However, if the width of the bars is not adjustable, the BOS of the assistive device may make movement within the bars difficult and unsafe. An alternative is to move the patient outside but next to the parallel bars (or oval bar) or near a treatment table or wall. These preparatory activities include the following:

1. Instruction in assuming the standing and seated positions with use of the assistive device. These techniques are outlined in Box 11A.4 for each category of assistive device.

2. Standing balance activities with the assistive device (similar to those using the parallel bars, described earlier).

3. Instruction in use of assistive device (with selected gait pattern) for forward progression and turning.

As mentioned, demonstrating these activities by assuming the role of the patient during verbal explanations is an effective teaching approach. Following the demonstration, manual contacts, verbal cueing, and explanations can be used again to guide performance of the activity. Following these preliminary instructions gait training using the assistive device can be begun overground on level surfaces. The following guarding technique (Fig. 11A.24) should be used:

1. The therapist stands posterior and lateral to the patient's weaker side.

2. A wide BOS should be maintained with the therapist's leading LE following the assistive device. The therapist's opposite LE should be externally rotated and follow the patient's weaker LE.

3. One of the therapist's hands is placed posteriorly on the guarding belt and the other anterior to, but not touching, the patient's shoulder on the weaker side.

Should the patient's balance be lost during training, the hand guarding at the shoulder should make contact. Frequently, the support provided by the therapist's hands at the shoulder and on the guarding belt would be enough to allow the patient to regain balance. If the balance loss is severe, the therapist should move in toward the patient so that the therapist's body and guarding hands can be used to provide stabilization. The patient should be allowed to regain balance while "leaning" against the therapist. If balance is not recovered and it is apparent the patient must be moved to the floor, further attempts should not be made to hold the patient up because this is likely to result in injury to the patient and/or the therapist. In this situation, the therapist should continue to brace the patient against his or her body to break the fall and to protect the head and move with the patient to a sitting position on the floor. It is also important to talk to the patient ("Help me lower you to the floor") so that the patient does not continue to struggle to regain balance.

Overground indoor activities on level surfaces should include instruction and practice in passage through doorways, elevators, and over thresholds. When using crutches, doorways are most easily approached from a diagonal. A hand must be freed to open the door and one crutch must be placed in a position to hold it open. The patient then gradually proceeds through the doorway, using the crutch to open the door wider if necessary.

Because many patients using a walker or cane may have balance problems, careful examination will determine the safest methods for passage through doorways. A patient using a conventional walker with sufficient balance may be able to use a technique similar to that described above.

Stair Climbing

Several general guidelines should be relayed to the patient during instruction in stair climbing. First, if a railing is available it should always be used. This is true even if it requires placing an assistive device in the hand in which it is not normally used. For stair climbing with axillary crutches using a railing, both crutches are placed together under one arm. Second, the patient should be cautioned that the stronger LE always leads going up the stairs, and the weaker or involved limb always leads coming down ("up with the good and down with the bad").

Stair climbing techniques are presented in Box 11A.5. The therapist should use the following guarding technique during stair climbing.

Ascending Stairs

1. The therapist is positioned posterior and lateral on the affected side behind the patient (Fig. 11A.25).

2. A wide BOS should be maintained with each foot on a different stair.

3. A step should be taken only when the patient is not moving.

4. One hand is placed posteriorly on the guarding belt and one is anterior to, but not touching, the shoulder on the weaker side.

Descending Stairs

1. The therapist is positioned anterior and lateral on the affected side in front of the patient (Fig. 11A.26).

2. A wide BOS should be maintained with each foot on a different stair.

3. A step should be taken only when the patient is not moving.

4. One hand is placed anteriorly on the guarding belt and one is anterior to, but not touching, the shoulder on the weaker side.

Should the patient's balance be lost during stair climbing, the following procedure should be followed. First, contact should be made with the hand guarding at the shoulder. Next, the therapist should move toward the patient to help brace the patient (the patient should never be pulled toward the therapist on stairs) or leaned toward the wall of the stairwell (if available). Finally, if needed, the therapist can move with the patient to sit the patient down on the stairs. Remember to inform the patient of your intentions ("I'm going to sit you down").

Locomotor training using assistive devices should also include outdoor training and practice with curb climbing, negotiating ramps, and sloped surfaces; even and uneven terrains; walking with imposed time requirements (e.g., crossing street at a stoplight); walking for long distances, dual-task training while walking, walking at various speeds, and negotiating open community environments with distractors, as well as outside doors and thresholds; and transportation vehicles.

Adjunct Training Devices

Limb Load Monitors

A limb load monitor is a form of biofeedback used clinically as an adjunct intervention during gait training. The limb load monitor incorporates a strain gauge attached to the sole or heel of the shoe. When a force or pressure is applied, the strain gauge is deformed and an auditory signal provides feedback to the wearer. As pressure increases, the signal becomes louder or more rapid. This feedback provides information about the amount of weight-bearing on a limb. Limb load monitors can also be used to reinforce the correctness or timing of a movement. For example, an audible noise or buzzer sounding when the heel makes contact with the floor can provide immediate feedback on foot placement. Similar devices can also be attached to a cane (often referred to as a biofeedback cane). The principle of operation is the same and incorporates a strain gauge. Auditory signals provide the patient with information on placement, as well as pressure applied to the cane.