Rehabilitation of Ambulatory

Limitations
a b,
Lara A. Pilutti, PhD , Audrey L. Hicks, PhD *

KEYWORDS
 Ambulation  Rehabilitation  Walking

KEY POINTS
 A variety of tools and techniques are available for the rehabilitation of ambulatory impair-
ments in adults with central neurologic disorders.
 These strategies can be described as traditional and nontraditional.
 Each strategy has particular advantages and disadvantages with respect to feasibility,
cost effectiveness, accessibility, and training specificity.
 The various rehabilitation strategies should be considered complementary rather than
exclusive.
 Rehabilitation strategies should be selected using an individualized approach.

INTRODUCTION

Rehabilitation has been defined by the World Health Organization as “a proactive and
goal-oriented activity to restore function and/or to maximize remaining function to
bring about the highest possible level of independence, physically, psychologically,
socially and economically.”1 The rehabilitation process ideally involves a multidisci-
plinary team of professionals to promote recovery in physical, psychological, and
social domains.1 Rehabilitation represents a particularly important strategy for the
treatment of ambulatory limitations in adults who have central neurologic disorders.
For certain neurologic populations, rehabilitation strategies may be the only effective
mode of therapy to improve or maintain functional abilities. Deficits contributing to
ambulatory limitations in adults with central neurologic disorders commonly include
impaired walking speed and spatial and temporal parameters of gait, balance, lower
extremity strength, and tone (spasticity)2–8; consequently, these targets are often
the focus of ambulatory rehabilitation strategies. Individuals with neurologic diseases

Disclosure statement: The authors declare no conflicts of interest.

a
Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign,
906 South Goodwin Avenue, Urbana, IL 61801, USA; b Department of Kinesiology, McMaster
University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
* Corresponding author.
E-mail address: [email protected]

Phys Med Rehabil Clin N Am 24 (2013) 277–290

http://dx.doi.org/10.1016/j.pmr.2012.11.008 pmr.theclinics.com
1047-9651/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
278 Pilutti & Hicks

have unique clinical presentations and courses, and, as such, rehabilitation strategies
should be prescribed based on the specific needs and deficits experienced by each
patient.
Despite the importance of ambulatory rehabilitation for individuals with central
neurologic disorders, there are several limitations of the current literature in this field.
Common limitations include small sample sizes, lack of appropriate controls, substan-
tial patient heterogeneity, lack of long-term interventions and follow-up, and inconsis-
tent or insufficient outcomes for evaluating ambulation in individuals with neurologic
impairment. The assessment of ambulatory rehabilitation strategies has typically
included outcomes of walking velocity, walking endurance, spatial and temporal
gait parameters, or clinical examination.3 Importantly, the inclusion of real-life
measures of ambulation (ie, pedometers and accelerometers) and patient-reported
experiences of walking impairment have been increasingly included as outcomes in
the evaluation of ambulatory limitations.3
Several strategies are currently available for the rehabilitation of ambulatory limita-
tions in adults with central neurologic disorders that can be described as traditional or
nontraditional rehabilitation. In general, traditional rehabilitation strategies are those
that involve passive or active movements or exercises, whereas nontraditional thera-
pies involve the use of advanced therapeutic technologies or devices. This article
describes and evaluates the most common traditional and nontraditional therapies
available for ambulatory rehabilitation in adults with central nervous system (CNS)
disorders such as stroke, spinal cord injury (SCI), multiple sclerosis (MS), and Parkin-
son’s disease (PD). Traditional rehabilitation strategies that will be explored include
exercise training and conventional gait training. Nontraditional rehabilitation strategies
that will be explored include functional electrical stimulation (FES), recumbent stepper
training, body weight–supported treadmill training (BWSTT), and the ZeroG over-
ground gait and balance training system. The advantages, disadvantages, and appli-
cations of each of these rehabilitation modalities are discussed. Rehabilitation is also
often used in conjunction with other interventions for ambulation (eg, fitting and
training to the use of an assistive device or orthosis, medical or surgical treatments
for spasticity). Such an approach is often considered standard of care or best practice,
and, as a consequence, there is little evidence showing the specific benefits of reha-
bilitation strategies in terms of the overall efficacy, safety, and acceptability of other
interventions. We will, therefore, mostly focus our review on the effects of rehabilitation
techniques when used alone.

TRADITIONAL REHABILITATION IN ADULTS WITH CENTRAL NEUROLOGIC CONDITIONS

Exercise Training
Exercise training has been widely administered as a rehabilitation strategy in adults
with CNS disorders including stroke, SCI, MS, and PD.9–17 The forms of exercise
training that have been most commonly prescribed and that will be considered in
this article include aerobic training and progressive resistance training, either alone
or in combination. Traditional aerobic exercise training modalities used for individuals
with neurologic diseases include treadmill walking, leg cycling ergometry, arm ergo-
metry, and aquatic exercise. Resistance training regimes typically include weight
machines, free weights, body weight exercises, cable pulleys, or elastic bands.
Both of these exercise forms have been used successfully in the MS population to
improve ambulatory outcomes. For example, 8 weeks of leg cycling ergometry
(60 minutes, 3 sessions per week) at a moderate-to-strong intensity resulted in signif-
icant improvements in aerobic capacity, walking speed, and walking endurance in
 Rehabilitation of Ambulatory Limitations 279

adults with MS.18 Similarly, 12 weeks of lower extremity progressive resistance

training resulted in lower limb strength gains and improved walking speed, endurance,
and functional task performance in patients with MS.19
Traditional aerobic and resistance exercise can also be combined or enhanced with
other techniques, such as biofeedback. For instance, biofeedback cycling provides
patients with visual information regarding input from each individual leg allowing for
the monitoring and correction of cycling asymmetries during training.20,21 Correcting
cycling asymmetries during exercise may translate into improvements in ambulation.
Using this type of intervention, 6 sessions of leg pedaling exercise with biofeedback
resulted in improved cycling asymmetry and improvement in walking speed and gait
asymmetry in a case series of 3 chronic stroke patients.20
Physiologic deconditioning, or the loss of aerobic capacity and muscular strength, is
common among adults with neurologic diseases.22–27 This loss of physical fitness
may, in turn, limit ambulatory capacity. Correctly prescribed exercise training is
expected to improve aerobic endurance and muscular strength. As described in the
aforementioned training studies,18,19 the training-induced improvements in aerobic
and muscular performance may also translate into meaningful benefits on ambulation.
There are several advantages to exercise training as a rehabilitation strategy. Exer-
cise training is cost effective compared with many other modalities and generally
available in most community settings. A combined program of aerobic and resistance
training may also result in several health and fitness benefits, such as improved bone
health, body composition, and comorbid disease risk profile.28 The disadvantage of
this modality is that it is generally not task specific to ambulation, with the exception
of treadmill walking. Exercise training, however, may be used in combination with
other task-specific rehabilitation techniques to improve cardiovascular endurance
and muscular capacity, which may act synergistically to improve ambulation. Finally,
for individuals with severe mobility limitations, traditional aerobic and resistance
training equipment is often not physically accessible.

Conventional Gait Training

Conventional gait training is one of the most commonly used forms of rehabilitation for
adults with CNS disorders and may include techniques such as overground walking
and movement training; balance, coordination, and range of motion exercises; and
active and passive stretching. The variety of techniques used in conventional gait
training results in a targeted rehabilitation approach that can be specific to the gait
impairments of each patient. Conventional gait training strategies are typically deliv-
ered by trained personnel, such as physical therapists, occupational therapists, or
exercise professionals. With practice, some strategies may be undertaken outside
of the clinical setting, particularly for patients who are capable of independent ambu-
lation. Conventional gait training strategies have been used in patients with stroke,
SCI, MS, and PD.29–34 For example, a 6-week (3 sessions/week) physical or occupa-
tional therapist-supervised program involved practice of 10 walking-related tasks (ie,
forward and backward walking, stepping, kicking, balancing, and sitting-to-standing
transitions) in patients with chronic stroke.31 Patients were further encouraged to
practice at-home walking. This training program resulted in improvements in walking
speed and distance compared with participants who were involved in seated upper
extremity functional task training.
Conventional gait training techniques may also be supplemented with adjunct ther-
apies, such as rhythmic auditory stimulation (RAS). RAS is described as a neurologic
music therapy technique that targets gait dysfunction through the use of rhythmic
timing cues.35 RAS has been used in patients with several neurologic diseases and
280 Pilutti & Hicks

often in addition to conventional gait-training techniques.35–37 For instance, patients

with PD were involved in 6 weeks of stepping training with or without the use of
RAS.36 Compared with stepping practice alone, stepping with RAS resulted in supe-
rior improvements on functional gait and balance outcomes, and the effects were
more long lasting after the intervention period. This highlights the importance of
considering alternative and combined therapies when treating ambulatory
impairments.
There are several important benefits to conventional gait training. Conventional gait
training is task specific in that it allows patients the opportunity to practice walking and
movement-related tasks. Unlike other strategies, training can be tailored to the
specific gait deficits experienced by each patient because of the multifaceted rehabil-
itation approach. Conventional gait training is generally more cost effective than
nontraditional rehabilitation strategies involving specialized equipment. Adjunct ther-
apies such as RAS can also be incorporated to enhance outcomes. Unfortunately,
the feasibility of conventional gait training may be limited for patients with severe
mobility impairment, although likely not to the same extent as exercise training. This
modality also requires expertise from specialized personnel, which may only be avail-
able at clinical rehabilitation centers.

NONTRADITIONAL REHABILITATION IN ADULTS WITH CENTRAL NEUROLOGIC

CONDITIONS
Functional Electrical Stimulation
FES is a technique that delivers brief electrical pulses to muscles or peripheral nerves in
patients with CNS disorders with the goal of improving function. To date, FES has been
used in various populations, particularly in stroke survivors and individuals with SCI, to
facilitate ambulatory function and improve muscle strength.38–40 The earliest uses of
FES in the stroke population was to improve or correct foot drop (through peroneal
nerve stimulation),41 but later studies tended to explore the broader utility of FES to
improve specific aspects of walking performance in stroke survivors, such as gait kine-
matics, muscle spasticity, and muscle strength. There is good evidence that FES is
effective in improving gait speed in individuals after stroke, although it may provide
more of an orthotic as opposed to therapeutic benefit (ie, the improvements may not
necessarily be maintained when the FES is removed).42 The strongest evidence for
a benefit of FES to improve ambulation after stroke is when it is combined with other
gait retraining strategies.40,43 In the SCI population, FES-assisted walking has been
used as both an orthotic aid (for complete or incomplete paraplegics) and as a thera-
peutic modality to improve gait in people with incomplete SCI.38 To date, FES-assisted
walking therapy has not been found to be superior to other ambulatory training inter-
ventions (eg, BWSTT, overground walking training) in people with chronic incomplete
SCI, although greater benefits may be seen with combined approaches.44,45 Further
information about the use of FES after stroke and SCI can be found elsewhere in this
issue.
Potential advantages to FES-assisted walking training include the ability to promote
active movement of limb segments (as opposed to immobilization of joints and limb
segments with traditional orthoses), thereby, decreasing the risk of nonuse muscle
atrophy and range of motion limitations, relative safety and ease of use, and the poten-
tial to promote CNS plasticity through repetitive afferent feedback from the muscle
contraction and limb motion generated by the stimulation. However, limitations of
FES-assisted walking training should also be considered. First, this rehabilitation tech-
nique can only be applied in individuals with intact lower motoneurons and viable
 Rehabilitation of Ambulatory Limitations 281

peripheral nerves (and neuromuscular junctions) to the lower limb musculature.

Second, clinically available systems of FES-assisted walking cannot stimulate the
hip flexors directly; thus, any hip flexion during walking has to be initiated voluntarily
by the patient. Third, the muscles stimulated through FES experience rapid fatigue
because the larger-diameter (and more fatigable) nerve fibers are most easily stimu-
lated by surface electrodes, which significantly limits the length of time that FES-
assisted walking can be performed. Finally, the electrical current excites both motor
and sensory nerves and may be painful to some individuals, especially those with
preserved sensation.38

Recumbent Stepper Training

Recumbent stepper training allows patients to step against graded resistive forces
from a supported seated position (Fig. 1). Coupled arm levers and foot pedals
move in a bilateral reciprocal manner, which results in movement of the lower and
upper extremities. The coupled upper and lower body training system allows for
compensation of upper or lower extremity weakness in a self-driven manner in that
all movement is patient initiated. Additional features of the recumbent stepper can
include adjustable arm levers, rotating seat, large foot pedals with exterior edges,
foot and arm strapping, and leg stabilizers, which make this piece of equipment
accessible and adaptable for persons with varying degrees of disability. To date,
the effects of recumbent stepper training in adults with neurologic diseases have
only been examined by 2 research groups: one in patients with stroke46 and the other
in patients with PD.47 Patients with PD who participated in 10–12 weeks of 3 weekly
sessions (30 minutes per session) of recumbent stepper training experienced
improvements in walking speed and step length, although there was no change in
the severity of disability.47 Further trials in a variety of neurologic disease populations
are necessary to determine the potential of recumbent stepper training as a tool for the
rehabilitation of ambulatory limitations.
Recumbent stepper training may target ambulatory deficits through several different
mechanisms. The full-body aerobic training stimulus may result in improvements in
aerobic and muscular performance, similar to traditional exercise training. In seden-
tary adults, recumbent stepper training has been found to improve peak aerobic
capacity and strength and endurance of both upper and lower extremity muscles.48
Improved aerobic endurance and muscle strength may, in turn, improve ambulatory

Fig. 1. Recumbent stepper training (Nustep, TRS 400, Ann Arbor, MI).
282 Pilutti & Hicks

performance, although this requires further investigation in specific neurologic popu-

lations. The stepping motion of recumbent stepper training has also been shown to
have a similar, although less complex, neuromuscular activation pattern to walking,49
suggesting specificity of this training modality to ambulation; however, the joint kine-
matics of recumbent stepping are different than those involved in walking.
Compared with most nontraditional rehabilitation modalities, recumbent stepper
training is cost effective and simple to operate. This modality could be easily imple-
mented in community and home settings. The accessibility and adapted accessories
available for this piece of equipment make it applicable to individuals with varying
disability levels. The self-driven nature of the modality also allows for all work to be
conducted by the patient rather than requiring substantial assistance from therapists
or devices, likely resulting in greater overall effort by the patient. The main disadvan-
tage of this system is that it is less specific to ambulation than other nontraditional
rehabilitation techniques. The movement is also restricted to stepping and would
not allow participants to practice other ambulatory movements, such as balancing
or transferring tasks.

Body Weight–Supported Treadmill Training

BWSTT consists of a motorized treadmill with an overhead counterbalancing system
attached to a supportive harness (Fig. 2). Using the support harness, patients are sus-
pended over the treadmill with a certain amount of their body weight off-loaded by the
counterbalancing system. This system allows patients with neurologic impairment and
limited mobility to practice walking in an upright position without the risk of falling. The
initial amount of body weight support required is selected to allow patients to maintain
an upright torso and to prevent knee buckling while standing. When necessary, move-
ment of the lower extremities can be facilitated through therapist assistance or robotic
assistance. Typically, therapist-assisted training involves 2 trainers positioned one at
each lower limb to guide the patient through the proper walking kinematics. An addi-
tional therapist can be positioned behind the patient to assist in weight shifting and
stabilization when necessary. Robotic-assisted gait training involves the use of
a motorized orthosis, which is attached to the patients’ lower extremities. The gait
orthosis assists patients in moving their lower limbs through proper gait cycle motions
and is controlled by a computerized system. Studies of BWSTT have been conducted
with patients with SCI, stroke, MS, and PD and have evaluated both therapist-assisted
and robotic-assisted training regimes.50–54 For example, patients with PD participated
in 12 sessions (45 minutes per session) of robotic-assisted gait training or physio-
therapy involving conventional gait training and active joint mobilization.55 Robot-
assisted gait training was superior to conventional physiotherapy on outcomes of
walking speed, walking endurance, and some spatiotemporal gait parameters.
The main advantage of BWSTT is the task-specific nature of the training modality as
a tool for the rehabilitation of ambulation. BWSTT is also an alternative for patients with
severe disability who are unable to participate in traditional training modalities
because of inaccessibility of the equipment. The use of robot assistance may also
place less physical burden on the therapists and provide a more normal and consis-
tent gait pattern.56 Superiority of therapist-assisted or robotic-assisted treadmill
training over traditional gait training, however, has not been established in patients
with neurologic diseases.57–59 Several limitations of this training modality exist.
Although BWSTT may allow for the practice of walking specifically, it does not allow
for the practice of other ambulatory movements that may also be important to activ-
ities of daily living. It has been suggested that restricting and controlling patients’ gait
patterns through therapist or robotic assistance may not allow for the opportunity to
 Rehabilitation of Ambulatory Limitations 283

Fig. 2. Body weight–supported treadmill training (Andago with Woodway S55 treadmill
(Hocoma AG, Switzerland)).

self-correct movement, which may be beneficial to ambulatory rehabilitation.60 The

contribution of therapist or robotic assistance to BWSTT may also be higher than other
nontraditional training modalities, for instance, recumbent stepping, and may conse-
quently result in less active contribution to training by the patient. Further, BWSTT
involves specialized equipment that requires highly trained personnel to operate
and is costly to initiate and maintain. BWSTT is rarely available in community settings,
and when it is available, it is often at a high cost to the user.

ZeroG Overground Gait and Balance Training System

The ZeroG (Artech, LLC, Bioness Inc, Valencia, CA)61 overground gait and balance
training system is one of the most recently developed training and rehabilitation tools.
This system uses a supportive harness with body weight off-loading, similar to that
used with BWSTT, although the supportive harness is attached to a motorized trolley
that moves along an overhead ceiling-mounted track (Fig. 3).61 By mounting the
harness to a ceiling track, patients have the opportunity to move over a variety of
284 Pilutti & Hicks

Fig. 3. ZeroG overhead track system (Artech, LLC, Bioness Inc, Valencia, CA).

surfaces and practice several different ambulatory movements (eg, forward and back-
ward walking, turning, sitting-to-standing, balance activities). The ceiling-mounted
track and supportive harness still allows for adjustment of the amount of body weight
support provided, in the same manner as BWSTT, although it does not restrict patients
to treadmill walking alone. The overhead motorized trolley system can be pro-
grammed to move with the patient or set to a stationary position.61 Using this system,
patients can participate safely in a variety of ambulatory or stationary movements,
providing a natural progression from assisted treadmill training. The ZeroG training
system also allows patients to practice ambulatory movements using their own assis-
tive device.
The ZeroG overground gait and balance training system is a new tool to rehabilita-
tion, and at this time there are no published data on its efficacy or clinical applicability.
This system is extremely promising, however, considering the benefits of BWSTT in
advanced neurologic disease populations and the additional applications of this
training system. Specifically, the task-specific nature of this rehabilitation modality
may translate into important improvements in walking and activities of daily living for
adults with neurologic diseases. Although efficacy studies are clearly needed, this
training modality will likely be appropriate for adults with a variety of neurologic
diseases and disability levels because of the high level of customizability of this system.
The ZeroG training system is advantageous in that it is task specific and allows
patients to practice walking and balance as well as specific tasks of daily living without
the risk of falling. The variety of movements and actions possible with this training
system also allows for a highly specialized and individualized training program.61
This system would further be appropriate for patients with a variety of disability levels
because of the supportive harness and body weight off-loading system. Similar to
BWSTT, the most significant limitation is the high cost to purchase and maintain the
system. The need for specialized facilities and personnel may also limit the wide-
spread application of this rehabilitation modality.

TRADITIONAL VERSUS NONTRADITIONAL REHABILITATION STRATEGIES

The advantages and disadvantages of traditional and nontraditional rehabilitation

modalities are summarized in Table 1. When comparing these rehabilitation strategies,
a general tradeoff becomes evident; traditional modalities favor cost effectiveness and
ease of implementation, whereas nontraditional modalities favor task specificity and
 Rehabilitation of Ambulatory Limitations 285

Table 1
Summary of advantages and disadvantages of traditional and nontraditional strategies for
the rehabilitation of ambulatory limitations in adults with central neurologic disorders

Rehabilitation Modality Advantages Disadvantages

Traditional
Exercise training  Cost effective  Not task specific
 Easy to implement  Limited application for
 Can combine with other patients with high
therapies disability level
Conventional gait  Cost effective  Limited application for
training  Easy to implement patients with high
 Task specific disability level
 Multitraining (ie, gait,  Requires specialized
balance, range of motion) personnel (ie, physical or
 Individualized training occupational therapists)
 Can combine with other
therapies
Nontraditional
Functional electrical  Can combine with other  Requires specialized
stimulation therapies equipment and personnel
 Limited to individuals with
intact lower motoneurons
and peripheral nerves
 Limited training time
because of muscle fatigue
 Peripheral nerve
stimulation may cause
pain
Recumbent stepper  Cost effective  Movement restricted to
training  Easy to implement stepping motion
 Applicable for all disability
levels
 Self-driven training system
Body weight–supported  Task specific  Movement restricted to
treadmill training  Applicable for all disability treadmill walking
levels  Costly to setup and
maintain
 Requires specialized
personnel
 Limited availability
ZeroG overground  Task specific  Costly to setup and
walking and balance  Multitraining (ie, gait, maintain
system balance, transfers)  Requires specialized
 Individualized training personnel
 Applicable for all disability  Limited availability
levels

accessibility for those with severe mobility impairment. Some debate exists as to the
advantage and potential benefit of nontraditional or advanced rehabilitation strategies
and devices over traditional rehabilitation modalities. Considering the specialized and
often costly nature of nontraditional rehabilitation, the efficacy of these modalities and
the particular groups of patients for which they may be most appropriate should be
established.
286 Pilutti & Hicks

Few studies have compared traditional with nontraditional rehabilitation modalities

using well-designed interventions. Two large randomized, controlled, multicenter trials
have compared traditional rehabilitation with BWSTT in stroke62 and SCI.63 Duncan
and colleagues62 examined the effects of 36 sessions (90 minutes per session) of early
therapist-assisted BWSTT (2 months after stroke), late therapist-assisted BWSTT
(6 months after stroke), or home-based exercise (ie, flexibility, range of motion, upper
and lower extremity strength, coordination, and static and dynamic balance training
focus) in 408 patients. Similar improvements in ambulatory outcomes were observed
regardless of the training intervention. Further, no differences in ambulatory outcomes
were observed when patients were stratified by initial severity of walking impairment.
A 12-week inpatient rehabilitation program compared conventional overground
mobility therapy (ie, stretching, standing, and overground walking) with therapist-
assisted BWSTT and overground walking practice in 146 patients with acute incom-
plete SCI.63 Similar improvements in ambulatory outcomes were observed in both
groups. These large-scale, well-designed interventions suggest similar efficacy of
BWSTT and traditional rehabilitation strategies for improving ambulatory outcomes
in patients with acute stroke and SCI. Other studies, however, have found superiority
of BWSTT over traditional rehabilitation in patients with MS and PD.54,64
Importantly, for individuals with severe mobility impairment, most traditional rehabil-
itation strategies are not accessible. Nontraditional rehabilitation modalities may also
be more effective for those with limited mobility. For instance, robot-assisted BWSTT
with standard physiotherapy was compared with standard physiotherapy alone in
inpatient subacute stroke rehabilitation.65 Standard physiotherapy focused on move-
ment of the paretic limb, upper-limb exercises, balance, standing, sitting, and trans-
ferring. BWSTT with standard physiotherapy was found to be more effective than
standard physiotherapy alone on outcomes of mobility and function for individuals
with severe motor impairment; however, there was no difference between treatments
in those with less motor impairment. This finding suggests that the efficacy of nontra-
ditional rehabilitation strategies may be dependent on the disability level of the patient.
Similarly, improvements in balance and motor impairment were observed after recum-
bent stepper training but not a home-based exercise program involving movements of
the affected lower limb in chronic stroke patients.46 The cost-effective and accessible
features of the recumbent stepper make it a particularly feasible tool for the rehabili-
tation of individuals with severe mobility impairments. Future trials should compare the
effects of recumbent stepper training to BWSTT, as well as traditional rehabilitation, to
determine the potential of this rehabilitation tool.

SUMMARY

The rehabilitation of ambulatory limitations in individuals with CNS disorders requires

an individualized approach, with consideration to the specific deficits and rehabilita-
tion targets for each individual. The level of neurologic impairment may be a primary
determinant of the initial course of rehabilitation. The neurologic course of the disease
itself, for instance stable (ie, chronic stroke) versus progressive (ie, MS), may also
determine the course of rehabilitation strategies. Deficits that may contribute to ambu-
latory limitations such as muscle weakness, spasticity, fatigue, visuospatial deficits,
cognitive impairment, and comorbid disease conditions should be evaluated and
considered when selecting the most appropriate rehabilitation strategies. Social and
environmental factors are also important considerations.
Traditional and nontraditional strategies should be considered complementary,
rather than exclusive therapies, to provide the most effective ambulatory rehabilitation
 Rehabilitation of Ambulatory Limitations 287

program. Different modalities can be used concomitantly or in succession, for

example, a more intensive nontraditional intervention can be used initially (often in
combination with traditional therapy) followed by traditional therapy alone (often in
combination with exercise modalities performed independently by the patient), with
final transition to home or community-based exercise. Further research is needed to
better define the most appropriate strategies for specific patient groups (or specific
levels of disability) and the outcomes of combined therapies.

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