When walking fails

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Difficulty walking is reported by 10% of Americans (Iezzoni, 2003). One-third report major difficulty. They are unable to walk or climb stairs or stand. The most rapid rates of increase occur after ages 54 and 74 years old. Musculoskeletal and joint diseases account for 24% of causes of major difficulty, back pain for 8%, stroke for 5%, and multiple sclerosis for 2%. Falls affect 41% of these people yearly. Eleven percent never leave their homes and only 32% get out of the home daily. By report, 25% receive some physical therapy during the year of major difficulty walking. At this level of difficulty, 48% with stroke use a cane, 28% use a walker, and 44% a wheelchair.

Six months after a traumatic spinal cord injury (SCI), 2% of subjects graded by the American Spinal Injury Association (ASIA) scale as ASIA A (sensorimotor complete) at 24 h after onset are able to walk at least 25 ft, 30% of those graded ASIA B (motor complete), and 94% graded ASIA C (Geisler et al., 2001). Six months after stroke, 85% of patients with a pure motor impairment, 75% with sensorimotor loss, and 35% with sensorimotor and hemianopsia deficits will recover the ability to walk at least 150 ft without physical assistance (Patel et al., 2000). These levels of gains do not necessarily lead to walking well enough to navigate outside of the home. In general, walking speeds greater than 80 cm/s make it more likely that a person can participate in the community (Perry et al., 1995; Lord et al., 2004). Only 40% of patients who recover walking ability after stroke achieve community-walking velocities. Indeed, half of those who are walking do so at less than 50 cm/s (about 1 mph). The push for faster, more functional walking speeds and longer distances walked is an underplayed goal in rehabilitation. Successful approaches to improve these walking outcomes would lead to greater participation. More functional walking may also reduce risk factors for cardiovascular disease, recurrent stroke, and frailty by permitting more opportunity for exercise and fitness (Chapter 21 of Volume II) (Macko et al., 2001; Greenlund et al., 2002; Gill et al., 2002; Kurl et al., 2003).

The rehabilitation of walking poses some common questions about the services provided by clinicians (Dobkin, 2003a). How do we know when our patients have received enough goal-directed therapy for their level of motor control? What measures should we use to rate progress? What do we really mean when we say that a patient has reached a plateau in recovery and will no longer benefit from therapy? Do outside-the-box therapies exist that might augment gains?

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