Gait Training and Functional Movement

Walking is the most fundamental functional movement for older adults. The ability to walk safely and efficiently affects independence, quality of life, and health outcomes. Gait speed is now considered a "vital sign" for older adults, predicting disability, hospitalization, and mortality. This lesson covers assessment and training approaches to maintain and improve walking ability and functional movement patterns.

Why Gait Matters

Gait Speed as a Vital Sign

Research has established gait speed as a powerful predictor of:

Future disability
Hospitalization risk
Nursing home admission
Cognitive decline
Fall risk
Mortality

Cut-points for gait speed:

Greater than 1.0 m/s: Generally good health and function
0.8-1.0 m/s: Moderate function
Less than 0.8 m/s: Poor function, increased risk
Less than 0.6 m/s: Severe limitation, high risk

Functional Implications of Gait

Walking ability determines:

Community mobility (shopping, appointments)
Social participation
Physical activity capacity
Ability to cross streets safely
Access to multi-story buildings
Emergency evacuation capability

Age-Related Gait Changes

Normal Aging Changes

As we age, typical gait changes include:

Spatial parameters:

Shorter stride length
Wider base of support
Reduced toe clearance
Less arm swing

Temporal parameters:

Slower walking speed
Longer time in double support (both feet on ground)
Shorter single support phase

Qualitative changes:

More cautious pattern
Reduced push-off power
Flatter foot contact
More variable gait pattern

Contributors to Gait Changes

Musculoskeletal factors:

Decreased ankle plantarflexion strength (push-off)
Hip flexor weakness
Reduced hip extension range
Ankle dorsiflexion limitations (toe clearance)

Neurological factors:

Slowed reaction time
Reduced proprioception
Impaired balance responses
Cognitive-motor interference

Sensory factors:

Visual decline
Vestibular changes
Peripheral neuropathy

Gait Assessment

Observational Gait Analysis

Observe the client walking and note:

Overall impression:

Speed (slow, normal, fast)
Smoothness and rhythm
Symmetry
Use of assistive device
Safety concerns

Head and trunk:

Forward lean
Lateral sway
Trunk rotation

Arms:

Swing present and symmetric?
Reciprocal with legs?
Held stiffly?

Pelvis:

Level or dropping on swing side?
Adequate rotation?

Lower extremities:

Step length symmetric?
Adequate hip flexion and extension?
Knee flexion and extension appropriate?
Adequate toe clearance?
Foot contact pattern (heel-toe)?

Quantitative Gait Measures

Gait speed:

4-meter walk at usual pace
10-meter walk (more reliable)
Calculate: distance ÷ time = m/s

Cadence:

Steps per minute
Normal: 100-115 steps/minute

Step/stride length:

Step: heel to heel, one side to other
Stride: heel to heel, same foot
Can measure with tape or footprint walkway

Functional Gait Assessment

Dynamic Gait Index:

Walking with head turns
Walking and stopping on command
Walking over obstacles
Walking up stairs
Pivoting while walking

Functional Gait Assessment (FGA):

Expanded version of Dynamic Gait Index
10 tasks scored 0-3 each
Score less than 22 indicates fall risk

Gait Training Principles

Target the Limiting Factors

Address the specific deficits identified:

If push-off is weak → calf strengthening
If toe clearance is poor → hip flexor and dorsiflexor work
If step length is short → hip flexor stretching, hip extension strength
If balance is limiting → balance training

Practice Walking

Gait improves with practice:

Specificity principle applies
Practice different types of walking
Challenge but don't overwhelm
Quality repetitions matter

Integrate Components

Gait requires integration of:

Strength
Balance
Flexibility
Cardiovascular endurance
Coordination
Cognitive function

Gait Training Exercises

Preparatory Exercises

Before gait training, address prerequisite abilities:

Ankle strength and mobility:

Seated calf raises
Standing calf raises (with support)
Ankle circles
Toe taps and heel raises

Hip flexor strength:

Marching in place
Seated hip flexion
Standing hip flexion (with support)
Stair stepping

Hip extension mobility and strength:

Hip flexor stretches
Glute bridges
Standing hip extension (with support)

Trunk stability:

Core activation exercises
Marching with arm swings
Rotational exercises

Basic Gait Exercises

Heel-toe walking:

Exaggerate heel strike
Roll through foot to push off toes
Focus on each phase of gait

Large step walking:

Take deliberately larger steps
Focus on reaching forward with leg
Maintain upright posture

Fast walking intervals:

Walk faster for short distances
Return to normal pace
Progress duration of fast walking

Arm swing practice:

Walk with exaggerated arm swing
Opposite arm forward with leg
Promotes rotation and balance

Progressive Gait Training

Walking with direction changes:

Turn 90 degrees on command
Turn 180 degrees
Random direction changes
Progress to tighter turns

Walking with obstacles:

Step over low obstacles
Progress obstacle height
Vary spacing
Add turns

Walking with varied speeds:

Start/stop on command
Speed up/slow down
Maintain quality at different speeds

Walking with cognitive load:

Count backward while walking
Name items in categories
Carry on conversation
Carry objects

Walking on varied surfaces:

Carpet vs. hard floor
Outdoor terrain (when safe)
Uneven surfaces (supervised)

Advanced Gait Exercises

Walking with head movements:

Turn head side to side while walking
Look up and down while walking
Track moving object while walking

Walking with quick direction changes:

React to visual or verbal cues
Agility ladder patterns (if appropriate)
Cone courses

Backward walking:

Start with support available
Progress distance
Add obstacles

Multi-directional walking:

Forward, backward, sideways sequences
Figure-8 patterns
Random patterns

Functional Movement Training

Sit-to-Stand Training

One of the most important functional movements:

Technique elements:

Feet positioned under body
Lean forward ("nose over toes")
Push through heels
Extend hips and knees together
Achieve full standing

Progressions:

High seat with armrest use
Standard height with armrests
Standard height without armrests
Lower seat height
Multiple repetitions
Varied speeds (including quick stands)

Floor Transfers

Ability to get up from floor is important for fall recovery:

Assessment:

Can client get to floor safely?
Can client get up from floor?
If not, what assistance is needed?

Training (if appropriate):

Practice getting down safely
Practice getting to hands and knees
Practice getting up using furniture
Progress to more independent transfers

Note: Not all clients can or should practice floor transfers. Assess individually and refer to PT if needed.

Stair Climbing

Assessment:

Can client climb stairs?
What support is needed?
One foot per step or step-to pattern?

Technique:

Up: stronger leg leads ("up with the good")
Down: weaker leg leads ("down with the bad")
Use handrail for safety
Look at steps, not feet

Progressions:

Single step, both directions
Multiple steps with step-to pattern
Reciprocal pattern (one foot per step)
Reduced support
Carrying objects (if safe)

Reaching and Bending

Forward reaching:

Practice reaching for objects at various heights
Progress reach distance
Add balance challenges

Bending to floor:

Practice safe bending techniques
Hip hinge vs. squat patterns
Golfer's lift for picking up light objects
Progress to lower objects

Carrying and Lifting

Loaded walking:

Farmer's walks with light weights
Progress weight gradually
Practice carrying grocery-type loads

Lifting technique:

Practice safe lifting mechanics
Objects from various heights
Progress weight appropriately

Program Integration

Sample Gait-Focused Session (30 minutes)

Warm-up (5-7 minutes):

Ankle mobility exercises
Hip circles
Marching in place
Arm swings

Preparatory exercises (7-10 minutes):

Calf raises (2 x 10)
Hip flexion marching (2 x 10 each)
Mini squats (2 x 10)
Heel-toe rocks (1 minute)

Gait training (10-12 minutes):

Heel-toe walking (2 laps)
Large step walking (2 laps)
Walking with direction changes (3 minutes)
Walking with obstacles (3 minutes)
Fast walking intervals (2 minutes)

Functional movements (5 minutes):

Sit-to-stand practice (10 reps)
Reaching practice
Step-ups (if appropriate)

Cool-down (3 minutes):

Slow walking
Gentle stretching

Weekly Integration

Balance gait training with other program components:

Monday: Resistance training + brief gait work Tuesday: Cardiovascular + gait training focus Wednesday: Balance + flexibility Thursday: Resistance training + brief gait work Friday: Functional movement focus + gait challenges Weekend: Encourage walking for transportation/recreation

Monitoring Progress

Objective Measures

Gait speed (4m or 10m walk)
Timed Up and Go
6-Minute Walk Test (if appropriate)
Stair climb time
Chair stand performance

Functional Measures

Reported walking distance
Community mobility (where do they walk?)
Confidence in walking
ADL performance

Qualitative Observations

Gait quality improvements
Posture during walking
Arm swing
Step length and symmetry

Key Takeaways

Gait speed is a vital sign—assess and track it regularly
Multiple systems contribute to walking ability—address strength, balance, flexibility, and endurance
Practice walking in varied conditions and with different challenges
Target limiting factors identified through assessment
Functional movements like sit-to-stand and stair climbing are essential
Progress systematically from simple to complex challenges
Dual-task training prepares for real-world walking demands
Quality matters—focus on good gait mechanics, not just speed