The Power of Gait

I evaluated a new patient over the weekend. She had a stroke, and her notes from acute care said she required maximum assistance of two people to get out of bed and into a wheelchair, and that she had limited use of her left side. I was pleasantly surprised that she appeared in person so much better than she did on paper. I could help her to the chair by myself. Her goal? As is so common with all of my patients: To walk again.

Throughout my practice of physical therapy, I’ve discovered how spiritual the most human act of walking can be. It’s something we take for granted, really. I also feel bad for my fellow therapists in other disciplines, as the PT’s are often the stars of the whole rehab show in the eyes of patients, at least initially. I see it as part of my job to sell the importance of all aspects of rehab. But the first goal for most patients? Everyone wants to walk. 

From infancy, we long await the development of this crucial milestone, usually at about one year, give or take a month or two. As parents, we are so proud of our babies in learning how to walk on two feet. It’s something to celebrate, indeed! 

Likewise, as we age, loss of mobility, especially walking, most likely means the loss of your independence. It’s the fear that plagues every adult patient, from post orthopedic surgery to weakness from prolonged hospitalization to having a stroke. It is also a fear of caregivers, as the burden of care is typically significant for someone who cannot ambulate, as are the logistics of getting out of the home for appointments, etc. 

Having a stroke is especially impactful on someone’s life, and it’s one event most associated with long term deficits. It’s also really challenging for those who have suffered a stroke and are still cognitively intact. If I find my patient has adequate trunk control to sit up on the edge of the bed with only minor steadying or better, we walk, even if they have limited use of one side of their body, and even if it’s just a few steps. 

I’ve got lots of skills in my bag of tricks to make this happen. We may start in the hall using the guard rail for support if an arm has limited mobility, too. We may have to wrap the weak foot with an ace wrap to hold the toes up. I may need to move the weak leg for them, hold it, and keep it from buckling. And I definitely have a second person to help. But we walk. And we celebrate those first steps!

Of course, these are “old school” tricks. Nowadays, there are body weight support systems with harnesses that prevent falls and functional electrical stimulation to help re-educate the body in how to ambulate. But I always begin with tried and true, low tech methods. 

My patient over the weekend did walk with me. We did use the guard rail. But she could advance and stabilize her affected leg fairly well, only requiring overall steadying, with a second person to follow with a wheelchair to sit when she fatigued. She walked ten feet. And we indeed celebrated like it was a mile!

Certainly the victory of the first few steps is just as sweet for those who have to work harder to get there. I was so inspired by a recent patient who had been in the ICU for quite some time before coming to rehab. He struggled to even stand in his first week. But by the end of the next, he was walking short distances with a walker. So awesome! 

Patients post surgery are a bit different. I love getting patients up for the first time after back surgery. I usually find the same sequence of events. Patients are cautious at first, taking care to not walk too fast. They are taking inventory of what works, and what doesn’t. I often ask what they are feeling. It’s a great result when they admit that the pain they felt prior to surgery is gone. All they feel is the pain from the incision. This they know will resolve. The other, they weren’t sure. It’s a great sense of relief for them. Once they test out those sea legs, they usually progress well. 

Those with spinal cord injuries have to adjust to a whole new mindset. Can you imagine losing your ability to walk as a teenager? My colleagues and I discussed this last week. So many of us have worked with patients who have become paralyzed from gunshot wounds, car accidents, falls… we seem so invincible, especially as young people, until we’re not. But can you imagine losing your ability to walk because someone shot you over a pair of shoes? The grief. The what-ifs. Overwhelming. This is when you truly want a magic wand to fix it all. 

I recently worked with a patient who is about 20 years post injury. He’s been in a wheelchair since he was 17. He’s had the chance to fully process his life changes. He admitted how angry he was after his injury. He loved rehab the first go round, but once he got home, reality settled in. He said it was his toddler son who brought him out of his funk. But he chose to participate in life, as much of a struggle as he faces. He admitted that he was surprised by how challenging it was to go through rehab again so many years later with a much older body. But he did progress well enough to return home. 

A couple of years ago, I worked with a patient who was about 30 years post injury. He had fallen down several stories to the ground at a construction job. He knew immediately after falling that he was paralyzed. He seemed so well adjusted. But after so many years in a manual chair, his rotator cuffs were spent. It was time for a power chair. I specifically asked him about how he was handling the change emotionally, and he offered no indication that he was struggling. I recommended counseling from our team anyway. I learned that later that year, he died by suicide. I was heartbroken. I think for him, losing the manual chair symbolized his loss of independence. 

My own grandfather became a quadraplegic after surgery. He underwent a laminectomy to correct spinal stenosis back in 1980 when we weren’t doing hundreds of these procedures every day in the US like we do now. For multiple reasons, the surgery failed. He went from walking with a cane to being dependent on a wheelchair for mobility. He managed the best he could. I wasn’t old enough to grasp how emotional this life change was for him. But I do recall lots of lightbulb moments in PT school when we were learning about spinal cord injuries, relating what I remembered about my grandfather’s experiences with life after his injury.

Some of these patients who have suffered spinal cord injuries have been able to walk with the help of exoskeletons. Is this practical? Not really. But is it awesome? Indeed! During the 2016 Marine Corps Marathon, an injured soldier completed the last 10k of the marathon course, starting when the marathoners did, wearing an exoskeleton and with a whole team of support with him. I passed him at about mile 25. Keep in mind that I’m a 5+ hour marathoner. That’s how slow a process it is. But to watch someone use this device in the clinic for the first time is a privilege. The sheer joy of standing upright and walking is palpable, and it will move you to tears.

Why go through so much effort to walk if it’s so challenging? Among many physical benefits, there are mental benefits of feeling proud of taking those first steps. They can call their loved ones and say, “I walked today!” It gives hope. It calms anxiety. It renews faith in yourself. For those with spinal cord injuries, the use of exoskeletons allow for continued mobility in the hopes that stem cell research will eventually be able to restore what was once lost, making sure the body is ready by maintaining the benefits of weight bearing and maintaining range of motion, simply by bypassing the neurological injury. And it sets the path in motion for retraining the body to do this most human activity of walking. 

Just as helping someone return to walking if possible is important, it’s equally important to help my patients who may never be able to return to ambulating adjust to a new normal. We focus on gaining independence with wheelchair mobility and transferring into and out of the chair. But even in long term care settings, those residents who could take a few steps with help had a restorative program to do so. We would train the CNA’s providing this service to help maintain this skill. It was as much to help the residents physically as it was mentally. 

I’m privileged to possess the knowledge and skills to help my patients reclaim their ability to walk when they can’t. It brings me great joy. It’s part science, part art, and part cheerleading. I remember my patients who can’t walk when I run. I never take for granted that I can do so. I don’t have to run. I GET to run. Let’s not take for granted our ability to walk on two feet, a most human trait, indeed. 

All photos featured here were taken as part of a special project when I worked for a continuing care facility with the exception of the photo of my daughter, obviously! These are still on display there.

This is my second post in my Power Of series, focusing on spirituality. Do you feel like walking is a part of what it means to be human? I sincerely believe, after all of my years of practice as a physical therapist, that the ability to walk affects us on a spiritual level. Have you been affected by loss of mobility or by a family member or loved one who has? I’d love to hear about your experiences. As always, I hope you all are safe and healthy.