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REVIEW OF AMPUTEE GAIT TRAINING 105

Internal and External Validity in two major categories: traditional overground and
Threats to internal validity included lack of inter- treadmill-based training. Beyond this, the evidence
vention blinding, inadequate reporting of eligibility supports general themes with regard to benefits of
criteria, and failure to include statistical analyses (i.e., therapeutic gait training.
expert opinions, editorials) (Table 4). Ten studies had Funding, Subjects, and Outcomes
low, six had moderate, and two had high internal
validity. Conversely, sixteen studies had high and A high number of these studies were unfunded.
two had moderate external validity according to the This is not surprising, as it is less common for com-
mercial parties to have an interest in sponsoring the
AAOP rating tool (Table 5).
development or study of new gait therapies. This
Evidence Statements is likely because gait training therapies commonly
Eight EESs were synthesized from the results represent services rather than products. Therefore,
within the two topical areas previously identified packaging gait training services for a profit is difficult.
(Table 6). One of the statements was supported by The highest amount of funding in this review was
a single study, resulting in an insufficient level of from local government, which may likely be con-
confidence. Four statements had two to four studies nected to academia by way of investigators’ academic
supporting their synthesis, resulting in low confi- affiliations. This is especially surprising given that fed-
dence. One statement was supported by four studies, eral sponsors, such as the U.S. National Institutes of
yielding moderate confidence, and two statements Health, have a mission to apply knowledge to enhance
were supported by sufficient evidence to provide high health, lengthen life, and reduce disability. This body
confidence. Four statements address overground gait of work demonstrates that gait training reduces dis-
training exclusively, one statement addresses tread- ability. Clearly, more federal funding is needed to
mill gait training exclusively, and three statements further enhance this body of gait training research
address both overground and treadmill gait training. in lower limb amputees.
Subjects in the included studies tended to be
DISCUSSION community ambulators of approximately 48 years
The purpose of this study was to systemati- of age who had lost their limbs to either trauma or
cally review the literature to determine the current vascular disease. Additionally, the cohort had a higher
strength of evidence regarding different gait training presence of transfemoral limb loss than other levels.
methods for lower limb amputees and to formulate These characteristics are a bit different than com-
evidence statements to guide current practice and monly cited epidemiologic studies, which describe
future research related to gait training for persons most U.S. amputees as considerably older than 40
with lower limb amputation. This search revealed years and having lost their limbs to vascular disease,
limited literature on the subject, which is consis- most likely at the transtibial level (1,38). These dif-
tent with a recently published systematic review that ferences are not surprising given that transfemoral
identified eight studies investigating the effectiveness amputees may have greater impairment than more
of exercise programs to improve gait performance distal levels of amputation thus justifying heightened
in lower limb amputees (37). The difference in the interest in gait training. Further, given that most sub-
number of studies may be due to the other review jects were community ambulators, it is feasible that
(37) limiting included articles to one-group cohort, the age and etiology would shift lower and toward
pre- to post-test studies, two-group case-control trials, trauma, respectively.
and control trials, whereas this review included all In terms of outcome measures, spatiotemporal,
publications, including expert opinions. Though pub- biomechanical, and bioenergetic measures are com-
lications are limited, our literature review supported mon and logical assessments to determine objectively
our hypothesis that multiple gait training modalities if gait is improving following therapy. Problematically,
are effective to improve overall gait quality in lower these tend to be more research laboratory tools and
limb amputees. Generally, gait training was described less clinically oriented. Therefore, inclusion of obser-