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110 HIGHSMITH ET AL.

anti-gravity training system, or a virtual reality system General Statements
that provides real-time visual feedback. Two out of Due to the high variability of gait training meth-
the three articles to support this statement were case ods identified in the literature, a clear pattern of the
studies (12,36), making current evidence to support most beneficial method of gait training was not able
this statement low. Also, the finding that treadmill to be identified. Conversely, the literature revealed
training is the superior gait training modality to a high level of evidence to support that any of the
improve bioenergetic efficiency is misleading, as none therapeutic gait training programs administered
of the studies that included traditional overground under skilled supervision that increases time spent
gait training methods measured energy consump- performing ambulatory activities beyond the patient’s
tion or expenditure as a primary outcome measure. current functional daily ambulation was effective at
This is most likely explained by the convenience of improving walking function in lower limb amputees
measuring O2 consumption and gas exchange while (6,11,12,16,17,19,25-36). Most studies assessed spa-
participants are relatively fixed on a treadmill versus tiotemporal, joint kinematics, bioenergetic efficiency,
collecting this data while they ambulate over ground. outcome measures, level of assistance, or a combina-
Even so, it is unable to be determined at this time if tion of these to demonstrate improvements in gait.
improved bioenergetics can also be achieved with Subsequently, evidence statements were able to be
overground training methods or if this finding is lim- formed. It is also important to note that adverse or
ited to treadmill training. Therefore, future research safety issues were not reported in connection with
is recommended. the gait training methods studied.
Lamberg et al. compared the effects of body-
weight support treadmill training versus treadmill Spatiotemporal Gait Parameters
training without body-weight support (35). They Current literature supports a high level of evidence
found that treadmill training with and without body- that therapeutic gait training methods, including
weight support is effective to improve six-minute early ambulation with a walking aid (32); in-shoe
walk test distance and timed up and go test time; auditory feedback devices (6,26); psychological
increase treadmill speed; and improve spatiotem- awareness training (11); or treadmill training with or
poral parameters for lower limb amputees with no without body-weight support (34,35), or as a part of a
significant differences found between groups. This structured home exercise plan, are effective to reduce
study reflects similar findings in patients post-stroke spatiotemporal gait deviations. Lower limb amputees
as published in a recent Cochrane review, which demonstrate impaired spatiotemporal gait parame-
concluded that treadmill training with or without ters, including decreased prosthetic limb stance phase
body weight support is effective to improve walking duration, decreased intact limb step length, decreased
speed and endurance (43). These findings have also cadence, and decreased self-selected walking speed
been demonstrated in patients with Parkinson’s dis- compared to a healthy population (7,47). Changes in
ease (44), traumatic brain injury (45), and in some spatiotemporal gait parameters can lead to reduced
patients following orthopedic surgery (46). All of energy efficiency (42) and increased joint stress of
these studies demonstrated carryover to overground intact limb and trunk. Ephraim et al. reported that
training. Beyond providing activity repetitions, the approximately 63% and 49% of amputees experienced
effectiveness of treadmill training may be partially back pain or pain of their intact limb, respectively
attributed to the patients’ ability to practice walking (48). Also, reduced self-selected walking can make
in a safe environment, especially when utilizing a participation in functional and recreational activities
difficult and lead to reduced safety when ambulating
harness system with or without body-weight support in the community, such as being able to cross the
to minimize risk for falls, which improves the patients’ street in an appropriate amount of time (37). This
confidence when attempting to ambulate at increased reinforces the importance of reducing spatiotemporal
speeds.
gait impairments to improve functional mobility,