Q&A with Our HIT Experts: Balancing Energy Efficiency and Effectiveness in High Intensity Gait Training

At the Institute for Knowledge Translation (iKT), our mission is to advance evidence-based rehabilitation and support clinicians in implementing best practices that improve patient outcomes. A recent question from one of our course participants highlights a foundational concept in gait training:

“Does emphasizing energy efficiency always result in effective gait? Specifically, we are asking about these concepts as they relate to the definitions below. 

Energy efficiency in gait refers to achieving movement with the least possible energy expenditure. 

Effectiveness in gait, on the other hand, is about how well the movement fulfills its intended purpose.

In clinical practice, we’ve encountered patients who are unable to sufficiently shorten their leg during swing due to spasticity or issues with the ankle. In such cases, these patients might compensate by intentionally activating their knee flexors to achieve effective toe clearance. While this strategy promotes effectiveness, it introduces additional energy expenditure due to the intentional use of the knee flexors, making it less energy-efficient”

High-intensity gait training (HIT) protocols, as taught in our Walk the Walk course, address this balance by focusing on both the biomechanical subcomponents of gait, including propulsion, stance, swing, and postural stability, and the energy demands of each phase. HIT encourages therapists to analyze why patients walk the way they do, target interventions to improve both efficiency and effectiveness, and use clinical reasoning to optimize outcomes for each individual. It is important to note that we’re thinking about the definition of effectiveness a little differently.  We think of “effectiveness” of getting from one place to another in the home and community.  That definition means they can walk faster and further and in different terrains/environments they must negotiate in the community.

With these definitions in mind, let’s dive into a Q&A with our HIT experts to explore this important topic further.

Q: How does HIT address this balance efficiency and effectiveness?

A: HIT gait training is designed to improve gait speed, walking endurance, and adaptability which all essential for functional independence. To achieve these goals, HIT challenges patients to walk faster and farther, encouraging them to adopt strategies that are both effective and, over time, more energy efficient. Research demonstrates that HIT improves gait patterns and optimizes functional mobility, supporting better patient outcomes.

Q: Should therapists focus on helping patients achieve “normal” gait patterns?

A: Focusing solely on “normal” gait mechanics is not always realistic or beneficial, especially for patients with significant neurologic or orthopedic impairments. Evidence shows that traditional approaches aimed at normalizing gait don’t always lead to improved outcomes. Instead, interventions like HIT prioritize outcomes that impact functional independence and community reintegration, including walking speed, endurance, and balance.

Q: What role does clinical reasoning play in gait training?

A: Clinical reasoning is essential in gait training. Therapists must consider each patient’s unique impairments, functional goals, and real-world environments to deliver a personalized, effective HIT program. HIT provides a structured framework for addressing impairments in biomechanical subcomponents while integrating intensity (>75% of age predicted heart rate), task-specificity, and motor learning principles. It’s not a one-size-fits-all solution, and successful implementation of this evidence-based practice relies on skilled clinical judgment and individualized care.

In Summary

Effective gait training focuses on outcomes that enhance a patient’s functional mobility and independence. High-intensity gait training is an evidence-based approach that helps clinicians achieve both energy efficiency and effectiveness and is grounded in strong clinical reasoning and science.

If you’re a clinician looking to master high-intensity gait training, our flagship Walk the Walk course is built for you. This comprehensive program empowers physical therapists to implement HIT, improve patient outcomes, and join a vibrant community of evidence-driven practitioners.

Learn more about Walk the Walk and enroll today!