9.1. About gait training
By Rebecca Kellogg
Offering powerful health benefits and a chance to progress to greater independence, gait training is an attractive option for many individuals with spinal cord impairments (SCI). This article will look at how gait training works, what it can do for you, and what's new in gait training technology and research.
How Gait Training Works
Gait training therapy helps individuals with SCI stand and walk with mechanical or other, sometimes human, assistance. Many researchers agree gait training should be started as soon after injury as is prudently possible.
According to Eric Harness, cofounder and director of research and development at Project Walk in Carlsbad, California, for an individual with SCI to be a good candidate for gait training, his or her joints need to be stable enough so there is limited risk of hyperextension or other types of joint damage. The individual must also be able to tolerate having a harness around the torso and between the legs.
Body Weight Supported Treadmill Training (BWSTT) uses a support system consisting of a winch mechanism that attaches to a crossbar overhead. The harness is clipped to the crossbar and gives lift and support as an individual uses the treadmill.
"Depending on the client's function, from 1 to 4 specialists or aides may be involved in the motion of the legs, providing pelvic support, and spotting," said Harness. "The specialists on the legs position their hands so that one hand is just below the knee and one is holding the ankle."
Robotic gait training, in which a machine does the work of supporting the trainee, is currently done by such devices as the Lokomat (www.hacoma.com). The upside of robotic training is that it requires fewer therapists working with a trainee—but that is also its downside, according to Harness.
"In my opinion, the problem with the robotic devices currently in use is that they do not allow for errors or discrepancies in a person's gait. The Lokomat is very linear in its gait pattern."
According to experts in the field, there are times when it is advantageous to do BWSTT with human assistants instead of a robot.
"There is no substitute to experienced therapists," said Dr. Bradley A. Marcus, director of San Diego Medical Rehabilitation & Kinematics Lab. "Any facility that has the ability to do robotic BWSTT with the Lokomat will also have the ability to do it manually by taking the robotic legs off when needed."
What Gait Training Can Do for You
When people with SCI participate in standing and gait training exercises, they enjoy a range of health benefits. Gait training, like other forms of exercise, improves cardiovascular and respiratory health, as well as decreases the risk of osteoporosis. People with SCI also enjoy the reduction of secondary conditions, including pressure sores and urinary tract infections.
Individuals with incomplete SCI can also increase their walking speed when they undertake regular gait training, which will contribute to greater independence and efficiency.
"Although an individual may always rely on some form of adaptive equipment support when walking, the opportunity to walk is invaluable for muscle and joint health and cardiovascular endurance, just as active exercise is healthy for every individual," said Lori Potts, a physical therapist with Rifton Equipment, a company that develops new gait training devices.
The Latest Developments
Exciting things are happening in the world of gait training in both research and technology.
On the research front, Spinal Cord Injury Services at Helen Hayes Hospital in West Haverstraw, New York has teamed up with the Wadsworth Institute of New York to study a form of biofeedback therapy they hope will someday regularly help train spinal cord reflexes in people who walk with difficulty due to incomplete SCI.
The research team hopes their form of gait-training therapy, called electrical stimulation (EMG), will help people with SCI need fewer braces and walk with fewer assistive devices.
This therapy trains the dorsi-flexor muscles and tibialis anterior—which allows ankles to bend up to keep toes from the floor.
"We hook participants up to a biofeedback machine," said Program Director Elaine DeFrancesco. "If they contract the muscles correctly, the screen turns green and they get a monetary reward. If it stays red, they haven't gotten the response of the 'H reflex.'"
Over time, the people in the study are able to train their minds and close the loop.
Outcomes of the study are encouraging. Participants in the study increased their walking speed, lessened their need for help, and improved their heart health.
"The hope is to use functional electrical stimulation, locomotor training, and electrical stimulation on reflexes as a combination therapy—a recipe for spinal cord recovery," said DeFrancesco. "Locomotor and functional electrical stimulation are appropriate for any spinal cord injured individual. EMG is currently specifically for incomplete spinal cord injuries, or individuals who have some movement in their legs."
DeFrancesco said that it could be several years before this therapy is widely available, but the group at Helen Hayes is currently accepting new participants with incomplete SCI. Those interested can learn more at www.helenhayeshospital.org.
On the technology front, Rifton Equipment has developed an adaptive walker called the Rifton Pacer XL, which is designed to be part of the continuum of rehab after BWSTT but before more independent walking. The Pacer can accommodate even a larger- sized individual and pass through 32" doorways for indoor use.
The Pacer has adjustable supports for postural positioning and for weight-bearing assist," said Potts. "The hip positioner acts as a sling seat to assist weight- bearing, the chest prompt holds the upper body in position, and the arm prompts act as a further support to share weight-bearing and to maneuver the walker. Other supports guide lower extremity position. Transfer into the Pacer occurs either with manual assistance from sitting to standing within the Pacer frame, securing the hip positioner in place, or by using the Rifton SoloLift, a transfer device designed for use with the Pacer."
The Pacer is designed to be able to offer a customized level of support, helping individuals with SCI improve their overall body strength and ability to walk over time. Learn more at PacerXL.Rifton.com.
Dr. Marcus of the Medical Rehabilitation and Kinematics Lab in San Diego shared three additional up-and-coming gait- training technologies:
Tibion Bionic Knee: A robotic knee that may help patients with weakness in their quadriceps with the ability to extend their legs. The Tibion device has showed promise in improving the mobility of stroke patients. It will soon be tested for patients in a study being done at Medical Rehabilitation and Kinematics Lab for patients with incomplete SCI, multiple sclerosis, and spina bifida. Learn more at www.tibion.com.
Re-Walk: The Re-Walk is currently being tested at Moss Rehabilitation in Philadelphia. Learn more at www.argomedtec.com.
Lokomat PRO with Augmented Feedback: Medical Rehabilitation and Kinematics Lab is one of three facilities in the country that has this machine. It is more sophisticated and offers more options than the standard Lokomat. Learn more at www.hacoma.com.
Before Beginning a Gait Training Program
Be sure that any gait training program you are considering is a good fit and will meet your needs.
Dr. Marcus stresses the importance of individualized care when it comes to gait training.
"When you are talking about gait training, every patient is not the same, so it is important that the gait training program is not cookie cutter," said Dr. Marcus. "Each case needs to be looked at individually. Gait training needs to take into consideration the individual medical history and situation of each patient to avoid further injury."