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Stepping Forward With Gait Rehabilitation

People receiving rehabilitation often say that walking is their most important goal for recovery.^1,2 With this in mind, it's not surprising that physical therapists spend much time and effort assessing and retraining walking with their patients.³ Walking ability has major implications for health: poor walking performance is a predictor for heart disease,⁴ discharge to nursing homes,⁵ and osteoporosis⁶ and increases probability of death in older adults.⁴ Many health-related quality-of-life measures have a component of walking.

We are delighted to showcase gait rehabilitation in this PTJ special issue. Gait assessment and treatment are a core competency for every physical therapist professional education program. This issue is dedicated to Dr Jacquelin Perry for her pioneering work in the field of gait analysis and gait rehabilitation, which has influenced the research and practice of so many physical therapists (see Dr Craik's tribute to Dr Perry on page 142). The issue covers gait for several populations, including older adults and people with stroke, incomplete spinal cord injury, Parkinson disease, and cerebral palsy. All 12 articles highlight new advances and future directions in gait assessment and rehabilitation.

We begin with a thought-provoking paper by Kuo and Donelan.⁷ They provide data that refute gait theories that have stood for more than 50 years—theories that many of us learned in school. The authors introduce us to the concept of dynamic gait models and the step-to-step transition cost of human walking. The testing and refining of these theories will serve to develop and advance the field of gait research and the clinical applications of that research.

During the past decade, we have witnessed an explosive growth in health care technology. Mulroy et al⁸ demonstrate that a task-specific, lower-extremity training program that includes body-weight–supported treadmill training can improve walking speed and that these changes in walking speed are related to improvements in gait biomechanics. The data of Burnfield et al⁹ suggest that an elliptical trainer—technology that is available in your local community—might be a valid modality for training gait. Namdari et al¹⁰ use advanced surgical procedures involving a muscle transfer to improve stiff knee gait due to brain injury. They emphasize that appropriate surgical interventions rely on a comprehensive understanding of knee kinematics and kinetics during walking.

Some technological advances in gait may seem futuristic, but, indeed, they are here today:

• Imagine watching a child with cerebral palsy walk and then using a computer simulation to determine which intervention would improve the child's walking. After inputting the data of a child with crouch gait, Damiano et al¹¹ use a computer simulation to help explain how a strengthening program can improve walking by altering the gait dynamics. Musculoskeletal models and simulations of walking show potential in identifying which changes in impairment are critical for walking.
  
• Imagine walking on a treadmill where the right and left legs move at different speeds. Reisman et al¹² use split-belt treadmill technology to understand the extent to which the injured nervous system is capable of producing normal movement patterns.
  
• Imagine walking down a shopping aisle with a grocery cart, all within a typical rehabilitation clinic. This is what Kizony et al¹³ accomplish with their virtual reality task that allows them to assess the ability of individuals with stroke to complete a complex, practical task in a realistic setting.
  

As with Kizony et al,¹³ there is a growing interest in developing gait outcomes and treatment paradigms that are realistic and meaningful for our patients. Tilson et al¹⁴ assess how much improvement in gait speed is necessary for patients with stroke to realize a change that is meaningful to them. Among individuals with incomplete spinal cord injury, Saraf et al¹⁵ assess the amount of daily stepping activity that reflects participation in the actual community environment. Walking in any realistic environment involves the motor system interacting with the cognitive system. Both Yogev-Seligmann et al¹⁶ and Kizony et al¹³ examine dual-task protocols that challenge walking and a cognitive task. Morris et al¹⁷ discuss how the visualization of walking can be helpful for improving gait in people with Parkinson disease. In their highly instructive article, Malouin and Richards¹⁸ address the specifics of prescribing mental practice to improve walking.

This special issue highlights several new advances in gait assessment and treatment, with physical therapists playing a central role in many of these innovations. We urge you to "step forward" into this new decade and use this information to help you better assess and improve the walking ability of your patients.

	Manuscript Reviewers for PTJ's Perry Issue on Gait Rehabilitation

 
Dr Rebecca Craik, Editor in Chief, and Dr Janice Eng and Dr Sara Mulroy, Guest Editors, gratefully acknowledge the manuscript reviewers who contributed their time, expertise, and constructive comments to this special issue:

Gordon Alderink, PT, PhD

Rosa Angulo-Barroso, PhD

M.J. Blaschak, PT, PhD, MSEE

Jennifer Brach, PT, PhD, GCS

Jack Crosbie, PT, PhD

Vanina Dal Bello-Haas, PT, PhD

Janis Daly, PhD

Judith Deutsch, PT, PhD

Nancy Devine, PT, DPT

Carol Giuliani, PT, PhD

Diana Glendinning, PT, PhD

Gammon Earhart, PT, PhD

Terry Ellis, PT, PhD

Steven Hanna, PhD

Chris Hass, PhD

T. George Hornby, PhD

Therese Johnston, PT, PhD, MBA

Valerie Kelly, PT, PhD

Teresa Liu-Ambrose, PT, PhD

Trish Manns, PT, PhD

Karen McCulloch, PT, PhD

Jennifer McGinley, PT, PhD

Jan Mehrholz, PhD

Patricia Pohl, PT, PhD

Sandy Ross, MHS

Ann Spungen, EdD

Mary Thigpen, PT, MHS, NCS

A. Joseph Threlkeld, PT, PhD

Carole Tucker, PT, PhD, PCS

Hidde van der Ploeg, PhD

Jaynie Yang, PT, PhD

Footnotes
Listen to the podcast of the "Stepping Forward With Gait Rehabilitation" Symposium recorded at APTA Combined Sections Meeting, San Diego.

References

1. Harris JE, Eng JJ. Goal priorities identified by individuals with chronic stroke: implications for rehabilitation professionals. Physiother Can. 2004;56:171–176.[CrossRef]
2. Williams V, Bruton A, Ellis-Hill C, McPherson K. What really matters to patients living with chronic obstructive pulmonary disease? An exploratory study. Chron Respir Dis. 2007;4(2):77–85.[CrossRef][Medline]
3. Latham NK, Jette DU, Slavin M, et al. Physical therapy during stroke rehabilitation for people with different walking abilities. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S41–S50.[Web of Science][Medline]
4. Newman AB, Simonsick EM, Naydeck BL, et al. Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability. JAMA. 2006;295(17):2018–2026.[Abstract/Free Full Text]
5. Foley S, Quinn S, Jones G. Pedometer determined ambulatory activity and bone mass: a population-based longitudinal study in older adults. Osteoporos Int. 2009 Dec 9. [Epub ahead of print]
6. Mahoney JE, Sager MA, Jalaluddin M. New walking dependence associated with hospitalization for acute medical illness: incidence and significance. J Gerontol A Biol Sci Med Sci. 1998;53(4):M307–M312.[Web of Science][Medline]
7. Kuo AD, Donelan JM. Dynamic principles of gait and their clinical implications. Phys Ther. 2010;90:157–174.[Abstract/Free Full Text]
8. Mulroy SJ, Klassen T, Gronley JK, et al. Gait parameters associated with responsiveness to treadmill training with body-weight support after stroke: an exploratory study. Phys Ther. 2010;90:209–223.[Abstract/Free Full Text]
9. Burnfield JM, Shu Y, Buster T, Taylor A. Similarity of joint kinematics and muscle demands between elliptical training and walking: implications for practice. Phys Ther. 2010;90:289–305.[Abstract/Free Full Text]
10. Namdari S, Pill SG, Makani A, Keenan MA. Rectus femoris to gracilis muscle transfer with fractional lengthening of the vastus muscles: a treatment for adults with stiff knee gait. Phys Ther. 2010;90:261–268.[Abstract/Free Full Text]
11. Damiano DL, Arnold AS, Steele KM, Delp SL. Can strength training predictably improve gait kinematics? A pilot study on the effects of hip and knee extensor strengthening on lower-extremity alignment in cerebral palsy. Phys Ther. 2010;90:269–279.[Abstract/Free Full Text]
12. Reisman DS, Bastian AJ, Morton SM. Neurophysiologic and rehabilitation insights from the split-belt and other locomotor adaptation paradigms. Phys Ther. 2010;90:187–195.[Abstract/Free Full Text]
13. Kizony R, Levin MF, Hughey L, et al. Cognitive load and dual-task performance during locomotion poststroke: a feasibility study using a functional virtual environment. Phys Ther. 2010;90:252–260.[Abstract/Free Full Text]
14. Tilson JK, Sullivan KJ, Cen SY, et al; Locomotor Experience Applied Post Stroke (LEAPS) Investigative Team. Meaningful gait speed improvement during the first 60 days poststroke: minimal clinically important difference. Phys Ther. 2010;90:196–208.[Abstract/Free Full Text]
15. Saraf P, Rafferty MR, Moore JL, et al. Daily stepping in individuals with motor incomplete spinal cord injury. Phys Ther. 2010;90:224–235.[Abstract/Free Full Text]
16. Yogev-Seligmann G, Rotem-Galili Y, Mirelman A, et al. How does explicit prioritization alter walking during dual-task performance? Effects of age and sex on gait speed and variability. Phys Ther. 2010;90:177–186.[Abstract/Free Full Text]
17. Morris ME, Martin CL, Schenkman ML. Striding out with Parkinson disease: evidence-based physical therapy for gait disorders. Phys Ther. 2010;90:280–288.[Abstract/Free Full Text]
18. Malouin F, Richards CL. Mental practice for relearning locomotor skills. Phys Ther. 2010;90:240–251.[Abstract/Free Full Text]

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This Article Extract Full Text (PDF) Symposium Podcast (Coming Soon!) Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Google Scholar Articles by Eng, J. J. Articles by Mulroy, S. J. PubMed PubMed Citation Articles by Eng, J. J. Articles by Mulroy, S. J. Related Collections Gait and Locomotion Training Kinesiology/Biomechanics Rebecca Craik Social Bookmarking                      What's this?