November 2015

On the move: Gait training improves limited mobility

In the moment: OA

Participant-specific biofeedback during instrumented treadmill gait training. Examples of real-time biofeedback provided during gait training for correction of kinematic pat- terns. (Reprinted with permission from Segal NA, Glass NA, Teran-Yengle P, et al. In- tensive gait training for older adults with symptomatic knee osteoarthritis. Am J Phys Med Rehabil 2015;94[10 Suppl 1]:848-858.)

Participant-specific biofeedback during instrumented treadmill gait training. Examples of real-time biofeedback provided during gait training for correction of kinematic patterns. (Reprinted with permission from Segal NA, Glass NA, Teran-Yengle P, et al. Intensive gait training for older adults with symptomatic knee osteoarthritis. Am J Phys Med Rehabil 2015;94[10 Suppl 1]:848-858.)

By Lori Roniger

Gait training is effective for improving limited mobility in patients with knee osteo­arthritis (OA), according to a recent study, but the immediate benefit is not sustained after training has stopped.

In the study, researchers randomized 56 men and women aged 60 years and older with symptomatic knee OA and mobility limitations to 12 weeks of either usual care or a gait training intervention. The intervention group received twice weekly 45-minute gait training sessions, supervised by a physical therapist, plus a therapist-designed individualized home exercise program to increase range of motion, strength, or both.

At three months, the gait training group experienced significantly greater improvement in Late Life Function and Disability Index Basic Lower Limb Function score and Knee Injury and Osteoarthritis Outcome Score symptoms compared with the control group, but these differences were not maintained at six and 12 months. The findings were published in October by the American Journal of Physical Medicine and Rehabilitation.

The authors recruited knee OA patients with moderate to severe mobility problems because they have the greatest need for mobility improvements, explained lead author Neil A. Segal, MD, MS, professor, faculty physiatrist, director of clinical research, and medical director of musculoskeletal rehabilitation in the Department of Rehabilitation Medicine at the University of Kansas Medical Center in Kansas City. However, the patients’ limitations may have been too severe for them to significantly benefit from the intervention, he said.

Gait training was performed on an instrumented treadmill; force plate data and computerized motion analysis were used to generate real-time visual feedback on a computer screen. As they walked on the treadmill, patients were shown either a skeletal image of their alignment or a graph of specific kinematic patterns with a shaded area representing a target range. The patients were then directed to modify their gait in ways that would correct the feedback images.

During the training, the therapist and patient monitored the reduction of the external knee adduction moment and pelvic control, while the therapist confirmed that moments at other joints were not negatively affected.

Segal said that external knee adduction moment and hip extensor range of motion improved at three months in the gait training group, although the published article did not include these data.

He also said the patients appreciated the gait training program.

“Not only did they seem to like it, ninety percent were compliant six to nine months after they completed it,” he said.

The patients were encouraged through scripted motivational telephone interviews at four, five, eight, and 10 months to continue the program on their own.

“I think booster sessions could be helpful,” Segal said, suggesting that a gait training session every six to 12 weeks after the 12-week program might help sustain the initial gains.

He noted the study was resource intensive, and that it would be helpful to sort out which aspects of the gait training intervention could be removed while maintaining its positive effect.

Michael A. Hunt, PT, PhD, associate professor in the Department of Physical Therapy at the University of British Columbia in Vancouver, said his strategy has been to take a patient’s normal alignment and change an aspect of it, such as foot or trunk position, to offload the knee.

“This is in contrast to other pathologies where the aim is to bring them back to neutral,” Hunt said. “The key difference is that neutral movement is likely related to efficiency and function, while what we are doing is for the sole purpose of redistributing the loads within the knee joint–albeit likely at some cost of efficiency and/or stability. For knee OA, the load distribution is key.”

While a multifaceted approach including gait retraining and increasing strength and range of motion may be helpful for knee OA patients, the effects of each of these areas needs to be tested in isolation, Hunt concurred.

“I think it’s still a bit early to throw all of our eggs in the gait retraining basket,” he said.

Source:

Segal NA, Glass NA, Teran-Yengle P, et al. Intensive gait training for older adults with symptomatic knee osteoarthritis. Am J Phys Med Rehabil 2015;94(10 Suppl 1):848-858.

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