Gait training
Nicole L. Evanosky
Defining the problem
Gait training is one of the most frequently prescribed rehabilitation techniques for the older adult because gait is the most common of all human movements and, as such, any pathology that affects it requires immediate attention. Normal gait includes a complex sequence of limb motions that propel the body in a manner that is energy conserving, stable and shock absorbing. Rehabilitation therapists must be aware that gait in the healthy older adult includes a wide variety of ‘normal’, yet disruptions in the sequence of actions are easily identified (see Table 68.1). Typical changes in gait parameters with older adults include reduced gait speed, decreased stride length and increased double support time (Perry & Burnfield, 2010). In addition, executive function and visual deficits impact gait variability and fall risk in this population (van Iersel et al., 2008; Bock & Beurskens, 2011).
Table 68.1
Normal versus pathological gait in elderly persons
| Parameter | Normal Aging Gait | Pathological Gait |
| Speed | Decreased self-selected and fast speed, although ability remains to voluntarily increase speed from self-selected to fast speed | Significant decrease in free velocity (<0.85 m/s) with loss of ability to voluntarily increase speed from self-selected gait speed |
| Step/stride lengths | Smaller step and stride lengths but symmetrical | Significant decrease in step and stride length and/or nonsymmetrical steps |
| Step width | Averages 1 to 4 inches (2.5–10 cm) | Step width is greater than 4 inches (10 cm) or less than 1 inch; or too much or too little step width variability |
| Toe clearance | Small toe clearance | Either large toe clearance or tripping or both |
| Ankle–foot | Mild decrease in force at push-off and/or slight decreases in plantar flexion and dorsiflexion range of motion | Large toe clearance or tripping or both; forefoot or foot-flat contact during initial contact; excess plantarflexion or dorsiflexion |
| Knee | Range of motion from 5° of flexion during weight acceptance to 60° of flexion during swing limb advancement | Limited or excessive flexion, wobbling; extension thrust |
| Hip | 15–20° of flexion during weight acceptance and 15–20° of apparent hyperextension at terminal stance | Limited flexion or extension; ‘past retract’ meaning a visible forward and then backward movement of the thigh during terminal swing; excessive abduction or adduction; excessive or limited internal or external rotation |
| Pelvis | 5° of forward rotation during weight acceptance; and 5° of backward rotation at terminal stance and pre-swing; iliac crest on reference limb is higher or equal to the iliac crest on the opposite side during midstance | Limited or excess rotation forward or backward; pelvic drop; pelvic hiking |
| Trunk | Erect | Forward, backwards or sideways lean |
Gait changes due to aging, disease or disability become problematic when the individual suffers pain, has difficulty maintaining balance, lacks sufficient endurance, or has insufficient ability to ambulate to meet his/her activities of daily living (ADLs). Gait disorders are associated with falls in older adults. This is clinically relevant because falling is one of the leading causes of injury-related deaths among elderly people. For many older adults, the inability to ambulate safely results in loss of independence and frequently results in the need for institutional assistance (Quadri et al., 2005; Stevens, 2006).
Gait assessment
Gait analysis must be conducted in order to determine what gait deviations and/or problems are present. Gait is assessed in a variety of ways ranging from observation, to optical-motion analysis in a specialized gait lab. The ‘gold standard’ method for measurement parameters of human gait is considered to be the force-place and/or optical motion capture systems (Cliodhna et al., 2011). Other gait assessment methods utilize measure of distance, stability and time (see Table 68.2). There are many valid and reliable gait assessment tools which are appropriate for use with the older adult. Observational gait analysis is routinely performed by clinicians and refers to the use of qualitative methods to assess gait deviations (Ranchos Los Amigos National Rehabilitation Center, 2001; McGinley et al., 2003). This analysis is portable and inexpensive, unlike some of the gait analysis systems which utilize force plates, gyroscopes, accelerometers and pressure sensitive insoles. In addition, the assessment of gait speed is important as it has been shown to be the single best predictor of disability and frailty among older adults (Studenski et al., 2011).
Table 68.2
Gait assessment and outcome measures
