INNOVATIONS IN REHABILITATION

RETROGRADE AMBULATION – A NEW DIMENSION IN REHABILITATION

Rehabilitation professionals are always striving to develop and implement innov- ative and effective techniques that can be employed in the treatment of many orthopaedic conditions. One novel and relatively new technique is retrograde ambulation or backward walking. This has been used extensively in the USA for performance training and the rehabilitation of knee injuries, based on the clinical claims that the use of backward walking will recruit and strengthen the lower limb musculature to a much greater extent than using traditional forward walking. Thus backward ambulation has some exciting potential uses in the rehabilitation of injured patients.

By Christian Poole BSc (BASRaT) and Michael Nicol MSc (BASRaT)

This article will serve to explain in practi- cal terms what is involved in this form of rehabilitation/conditioning. Secondly it will review the current literature, which demonstrates some of the effects that retrograde ambulation has on the body, and finally outline the potential implica- tions that this could have to our clinical practice.

WHAT IS RETROGRADE AMBULATION? Retrograde ambulation or backwards walk- ing (BW) simply put is, as the name sug- gests, a reversal of forwards walking (FW). A company that has popularised the use of retrograde ambulation is a USA-based company called Frappier Acceleration. Many of their rehabilitation protocols utilise a super treadmill, which has a specifically designed spotting mechanism and handlebar for backward walking and running. The focus of this form of rehabil- itation is to improve strength, stability and flexibility as well as walking and run- ning mechanics. They propose that back- ward walking is particularly useful for rehabilitation after anterior cruciate

TABLE 1: A TYPICAL RETROGRADE AMBULATION SESSION FOR AN ACL PATIENT 6 WEEKS POST-OP

Speed (mph) 3.0 3.0 3.5 3.5 4.0

20

Incline (%) 5

10 5

10 10

Note: Each set involves 3 reps of 15 seconds activity

Sets 2 2 3 3 2

Rest (secs) 180 180 180 180 180

ligament injury and for patellofemoral conditions. An example of a typical retro- grade session is outlined in Table 1.

CURRENT RESEARCH So is there any direct evidence to support the use of retrograde ambulation in reha- bilitation protocols for knee injuries?

Kinematics The first aspect that one must look at while trying to understand retrograde ambulation is how it compares to forward walking in terms of kinematics. In forward gait the stance phase begins with heel strike and ends at toe-off. Weight bearing usually initiates at the posterolateral heel, proceeds distally along the lateral foot and terminates in the vicinity of the first metotarsophalangeal joint. This progres- sion is reversed during backward walking where the toes contact the ground first and the heel is lifted off the ground at the end of the stance phase (1,2).

Thorstensson (3) looked at the modifica- tions occurring in the movement patterns of the leg when changing from forward to backward walking. He concluded that the movement trajectories of the leg in for- ward and backward walking essentially mirrored each other, even though the movements occurred in the reverse direc- tion. The angular displacements at the hip, knee and ankle joints showed similar overall magnitude and pattern in the two situations. Winter and Pluck (4) agreed with the findings of Thorstensson conclud- ing that backward walking was a near mir- ror image of forward walking.

In contrast, both Vilensky and Kramer (5,6) concluded that backward walking

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