Pediatric Series

Why We Love Gait Training

Gait Training Benefits Extend Far Beyond the Potential of Functional Ambulation

Gait Training

Rouzes/ Heart: samxmeg/

The name itself can be a little misleading, at least for some clients. To the uninitiated, gait training sounds like the act of teaching someone — often a younger child, in the complex rehab realm — to walk. And for some gait-training clients, that’s exactly what happens.

But what about clients who never learn to functionally ambulate? What if the only steps they take come with the support of a gait trainer? Is gait training still a worthwhile exercise for them? Is there more to gait training than functional ambulation?

Early-Intervention Gains

Gilbert Thomson, a PT who work for Rifton, said that besides the obvious potential benefit of gait training — that the participating client might eventually be able to walk without using the gait trainer — the other benefits can be significant.

“In addition to the obvious goal of ‘learning to walk,’ there are so many potential benefits of gait training that our goals could easily include these other factors as well,” Thomson said. “The many health benefits of an upright position and physical activity are well documented, and people with physical disabilities often have fewer opportunities to be physically active!”

So when compiling the possible clinical benefits of gait training, you can do a quick cross reference with the benefits gained by being upright in a standing frame. According to many research studies, those can include improved respiration gained by opening up the chest cavity; improved digestion; improved bowel and bladder functions; and weight shifting and pressure relief (gained from a change in position from sitting or lying down to standing).

Gait training can also yield developmental benefits, Thomson said.

“We also cannot forget the cognitive, emotional, and social benefits of interacting with our world in an upright position,” he noted. “Look at how a typically developing child actively explores their environment. A developing child learns about their world by exploring and interacting with it. There is a big difference between actively moving yourself around your environment vs. being moved passively.”

Gait training can have an especially significant impact in very young children says Denise Swenson, PT, DPT.

“Gait trainers allow children as young as 10 to 12 months to experience interaction with their peers at eye-level in standing,” Swensen said. “Children have the opportunity to bear weight on their legs, and weight shift from side to side and back and forth — all pre-ambulation skills. Seeing other children move and explore can be very motivating for children with disabilities, and they may quickly learn that they can move, too.”

While early-intervention independent mobility discussion predominantly centers on pediatric wheelchairs, gait trainers can help young children enjoy similar benefits.

“The research literature supports the use of early mobility using adaptive equipment in order to provide very young children the ability to explore, reach, interact with their peers and problem solve within the social and cultural contexts of their everyday experiences,” Swensen said. “Cognition, language, social interaction and self-help skills are all interrelated and develop within the context of motor learning.”

Gait Training Indications & Contraindications

The range of mobility clients who might benefit from gait training is encouragingly robust, and not confined to young children or children with congenital mobility conditions.

“Many clients who lack the ability to ambulate independently can benefit from gait training,” Thomson said. “This is not limited to children and adults with developmental disabilities, but also includes those with acquired injuries, stroke or older individuals with a loss of functional ambulation due to immobility and deconditioning.”

Gait training can also be started at a very young age for your littlest clients — thereby mimicking the independent mobility that a typically developing child would experience.

“By 10 to 12 months, typically developing babies are standing and getting ready to take their first steps,” Swensen said. “Babies who have developmental delays or severe physical motor impairments have little opportunity to explore, interact and reach in the way that typical babies do. They are unable to move due to motor impairments, poor postural control or visual perceptual problems. This has the effect of delaying not only their motor skills, but also skills in all other areas of development. They do not have the same real-life experiences that their typical peers have to play, process and problem solve.”

Gait training can help to fill that gap, Swensen added.

“By providing supported mobility devices, we can give mobility to babies and toddlers so they can begin to experience what their peers are able to do on their own. If a child is not able to sit and explore by 6 or 8 months of age, physical therapists (PT) need to provide the intervention strategies and suggest equipment to help them do what they cannot. It is not too early for supported standing and moving by 10 to 12 months of age.

“Gait trainers can be adjusted so children may bear partial or full weight on their legs. The PT, in consultation with other medical professionals, can determine the best support and protocols for differing medical conditions.”

As with any mobility intervention, gait training is not suitable for every mobility client.

“Potential contraindications or precautions with gait training mostly relate to tolerating an upright position (circulatory issues), tolerating weight-bearing (osteogenesis imperfecta, severe osteoporosis, joint instability, severe contractures), as well as significant lack of head control,” Thomson said. “Medical screening is important in such cases to assess whether full or partial participation in a gait training program is appropriate.”

If Independent Ambulation Isn’t Likely

Not all clients who participate in gait training learn to walk independently. For those clients, is gait training still a worthwhile activity?

“Absolutely!” Swensen said. “Children [who use gait trainers] are then at eye level with their peers, seeing the world from a vertical rather than horizontal position. Positioning at play tables enables children to participate with their peers in a variety of activities, including feeding and eating, sand and water play, social interaction, turn-taking and finemotor tasks. Moving through space enables them to participate in exploration, problem solving, social interaction and play. Other research articles suggest that the benefits of standing may also include improvements in the gastrointestinal, cardiopulmonary and musculoskeletal systems.”

“There are a few things to consider here,” Thomson said regarding the question of whether gait training is a helpful activity, even if the client is unlikely to learn to walk. “Firstly, it is quite difficult to predict how far someone will go with gait training. But even for those who will never achieve independent functional ambulation, there may be opportunities to make significant gains.

“For example, the increased leg strength and control could allow an individual to perform a stand-pivot transfer with minimal assistance — dramatically lowering the burden on caregivers. Or someone may achieve the ability to take a few steps with assistance, opening up new worlds of opportunity in going out into the community — moving between wheelchair and the car, restaurant seating, toilet, etc.”

Thomson also emphasizes the social gains that are possible while a child is in a gait trainer or otherwise in a standing/upright position.

“For social interactions, I have heard anecdotally from quite a few school settings that when students go from sitting into an upright standing/walking position, the number of interactions with staff, other students, visitors, etc., increases,” he noted. “It seems logical that if you are at eye level with your peers, you can interact more easily.”

Expectations & Goals for Gait-Training Clients

Since not every client using a gait trainer will eventually learn to functionally ambulate, what are realistic goals and expectations to then have?

Swensen pointed out that every client will be different, and that clinicians therefore need to start by selecting the type of gait trainer and components most appropriate for each situation.

“Gait trainers are available in a variety of styles with many options for support, known as prompts,” Swensen said. “Choosing the right gait trainer for a child depends on their diagnosis, muscle tone, presence of contractures, ability to bear weight on the legs, head and trunk control, among other factors. Children who require a lot of support in the upright position may need prompts at the trunk, pelvis, arms, knees and/or ankles. As their skills improve, prompts can be removed from the device to give more freedom of movement.”

She suggested encouraging the client’s family to look for ways to include standing in a child’s daily routine.

“Physical therapists can help the family incorporate standing strategies into everyday activities whether at home or in the daycare setting,” Swensen said. “The ability to explore, reach, interact and problem solve is dependent on the ability of a baby to move through their environment within the social and cultural contexts of their everyday experiences, routines and activities.”

Thomson said he keeps a handful of key points in mind when working on gait training with a client.

“Look for the optimal amount of physical support that allows the best function,” he suggested. “For example, providing more firm support at the trunk and arms initially might help someone begin taking steps.

“For a client who has a lot of difficulty initiating stepping, position them in a slightly forward-leaning position in the gait trainer, which may help facilitate this.”

Be patient, he added, when dialing in a gait trainer’s specifications: “It may take a few sessions until you have the positioning optimal. Be willing to adjust things several times to get it right.”

Thomson also recommended tweaking the overall environment to keep a client new to gait training from getting overly frustrated early in the learning process.

“Initially, control some of the excess ‘degrees of freedom’ so that your client can have success,” he said. “For example, you might need to set the wheels so the gait trainer only goes forward in a straight line at first, because expecting the client to start taking steps and control the direction of the gait trainer may be asking too much.”

As the client begins to make progress, be prepared to help him/her to continue to move forward.

“Have a plan,” Thomson said, “for how to reduce support as the client gains strength and control. Typically, we see progress in two ways: the ability to walk further and faster, and the ability to do the same task with less support.”

Finally, he said, don’t have too many pre-conceived ideas when starting gait training with a new client.

“Be prepared to be surprised,” he said. “When someone is comfortably positioned upright with partial body weight support, they may show abilities you have not seen before.”

This article originally appeared in the April 2016 issue of Mobility Management.

In Support of Upper-Extremity Positioning