44.8.3. Gait Training

Individuals with a neurological lesion may lack selective motor control, which prevents them from controlling the timing and intensity of muscle action (Perry, 1994). As a result, they exhibit an abnormal gait. The goal of gait training is to retrain movement patterns to achieve normal gait. Similar to balance training, a trainer uses verbal and tactile cues to correct abnormal patterns as the patient walks while using the PoNS device.

Gait training is more easily performed on the treadmill, eventually transferring to overground walking. As in balance, it is important to determine an appropriate starting point. This is relative to the individual’s baseline performance. Variables for gait training on the treadmill include speed, grade, and use of handrails (Table 44.4).

Table 44.4

Variables That Affect Treadmill Training

To find the starting point, the trainer has the individual walk on the treadmill (no incline) at a comfortable pace and observes their gait pattern to identify areas that need work. Training typically begins at a pace slower than normal. This allows the subject to work on the areas identified by the trainer.

Gait training sessions are 20 minutes and performed with the PoNS device. Working on the treadmill, the first 5 minutes are done at a slow pace. For the second 5 minutes, the speed should be increased 0.1–0.2 mph. In the third 5 minutes, speed should increase again and should be the most challenging. The last 5 minutes, the individual should work at a comfortable speed that he/she can maintain while exhibiting good walking posture. At each level, the individual is working to adjust their movement pattern as instructed. Change in grade and use of handrails can be used to vary the difficulty. If the individual’s performance starts to break down, the challenge is too hard.

• Speed: Generally the individual walks at the highest speed that they are able until the observed quality of performance breaks down. The optimal speed is just below this point.

• Grade: An incline increases effort and affects the work of ankle dorsiflexors, knee, and hip flexors.

• Handrails: Using the handrails allows greater stability. Without using handrails allows work on arm swing.

It is important for the trainer to cue proper walking posture, focusing on areas identified as abnormal. Cues may be needed to equalize step length, decrease foot drag, emphasize heel strike, straighten a knee, relax the shoulders, or to modify arm swing. Additional activities can be incorporated into gait training, such as backwards walking or use of a metronome. Backwards walking can improve upright posture and foot clearance. A metronome can help with pacing. The trainer’s observations and expertise should guide the treatment.

After treadmill training, individuals practice walking on the ground, incorporating the cues practiced on the treadmill. In addition, the individual can practice walking on a straight line, or staying in between two lines that are 12 inches apart. The goal is to eventually exhibit normal gait when walking without the PoNS device.