There was only a slight improvement in Billie's stride length. However, heel striking was more definite due to strengthened tibialis anterior muscles (trained by heel walking). Step initiation was also improved due to a strengthened gastrocnemius (trained with heel lifts). The greatest improvement, however, was in step width. Billie's newfound strength in the hip and pelvis region allowed her to decrease her step width and her upper body sway.

When reminded, Billie will now let her arms swing. Her cadence is improving, and her shoulders are relaxing. The right shoulder is still limited in active range of motion, but is pain free. She also has pain-free full range of motion with passive movement. The best news is that Billie's motivation is increasing because her confidence in real-life functioning is increasing.

Circuit Weight Training
The order of the exercise circuit is changed frequently. Billie began with one set of five to seven repetions and either no weight or minimal weight. For example, she initially performed five leg extensions with 10 rounds.

This list shows her current training program. Weight load and repetitions have been gradually increased to this level. While this number of repetitions provides challenge, it is not an intensity that causes muscle failure. Since the training goal is function, muscle failure is not appropriate at this point in the program. Billie uses a combination of free weights and Keiser machines.

Gait Training
2 sets, 20 yds each set:
Initially Billie held onto to me for support. As function improved, she became self-supporting while I walked alongside.

• Toe walking-walking on the balls of the feet with the heels lifted.
• Heel walking-contacting just the heels without rolling onto the balls of the feet.
• Side walking-stepping to the side, then bringing the feet together.
• Carioca walking-crossing one foot over the other while moving to the side.
• Back walking-walking backwards.
• Line walking-walking along a line on the floor
• Foot patterning (square or diagonal, upon command)-stepping to different portions of a quadrant defined by an X drawn on the floor.

Gregory L. Welch, MS, is an exercise physiologist and the president of SpeciFit An Agency of Wellness, located in Seal Beach, California. Greg lectures nationally, is on the board of advisors of the Lifespan Wellness Center at California State University at Fullerton, and is a member of the faculty of the American Academy of Fitness Professionals.