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Case

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Kumar

Kumar is a 20-year-old who was in good health until he was involved in a motorcycle accident that required a transfemoral amputation of his right leg. He has progressed in rehabilitation and is now ready to initiate gait activities. Kumar has never used an assistive gait device.

How would you initially approach this situation?

How would you determine which assistive device to use?

How would your plan differ if Kumar did or did not have a prosthesis?

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Introduction

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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 independence in 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, ambulation 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 the desired direction.

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Assistance for ambulation comes in the form of 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 Image not available. the broader context of the individual patient’s mobility goals and environmental demands.

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Although “gait” and “ambulation” are both terms for walking, they are often used differently to distinguish skilled therapy from maintenance activities. 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.

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Several instruments are available to quantify gait performance, most of which focus on measures of gait distance, speed, dynamic balance during gait, endurance, and coordination as well as on the patient’s ability to maintain postural control during ambulation. Some frequently used assessments include:

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  • Gait Velocity Assessment1

  • Dynamic Gait Index (DGI)2

  • Timed Up and Go (TUG)3

  • Performance-Oriented Mobility Assessment (POMA) 4

  • Six-Minute Walk Test5

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Standardized tests paired with qualitative assessments and expert observation can provide therapists with valuable information for designing effective rehabilitation programs to help patients achieve their functional goals (see Appendix 14-A: Parameters for the Community Ambulator).

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Weight-Bearing Restrictions

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Obviously, bearing weight on the LEs is a key component ...

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