Chapter 14: Navigating the Challenges of Ambulating

INTRODUCTION

As with every other mobility 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.

Assistance for ambulation comes in the forms of instruction and cuing, physical contact, and use of assistive devices. What may at first seem to be merely technical decisions or matters of personal preference—“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 reasoning, which are best determined in the broader context of the individual patient’s mobility goals and environmental demands.

Although “gait” and “ambulation” are both terms for walking, they are often used differently to distinguish skilled therapy from maintenance activities. Facilitation of ambulation with a patient is typically the process of assisting a patient in 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 skilled analysis of gait deviations and their underlying causes, the development and implementation of strategic interventions, and the evaluation of the effectiveness of interventions.

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

• Gait Velocity Assessment¹

• Functional Gait Assessment (FGA)²

• Timed Up and Go (TUG)³

• Performance-Oriented Mobility Assessment (POMA)⁴

Standardized tests paired with qualitative assessments and expert observation can provide valuable information for designing effective rehabilitation programs to help patients achieve their functional goals (see ^{johanmob3_c14_sec053}).

WEIGHT-BEARING RESTRICTIONS

Bearing weight on the LEs is a key component of walking. Sometimes, however, a person ...