Interventions for Gait Deviations

Original Editor - Stacy Schiurring based on the course by Damien Howell

Top Contributors - Stacy Schiurring, Kim Jackson, Jess Bell, Lucinda hampton and Ewa Jaraczewska

Introduction

Gait assessment and training are basic clinical skills for a physiotherapist. The complexity and uniqueness of a person's gait cycle requires the individualisation of a therapy plan of care. The study of the human gait cycle can be a career-long endeavour and calls for creativity on the part of the physiotherapist during treatment interventions.

Sometimes, a person's gait deviations call for specialised equipment to improve gait dynamics. This equipment can include durable medical equipment (DME) such as canes or walkers, Introduction to Orthotics, and or braces. Such DME can be expensive and limited by insurance reimbursement. It is the responsibility of the rehabilitation professional to make appropriate cost-effective DME recommendations. Trialing equipment or modifying available resources can facilitate a DME assessment without the cost of new devices.

Equipment

If needed, please review the following pages on standard assistive devices (AD) such as: walkers, crutches, and canes.

Borade et al. gathered data from patient interviews regarding using AD on a daily basis. They found that limited access and untimely prescription of AD, barriers to the use of AD in the home and in public, and the cost of AD were among the greatest complaints of persons using them for at least 12 months. The implications of this study for rehabilitation professionals include:

1. Early identification of the need for AD
2. Availability, accessibility and affordability of appropriate devices will improve rehabilitation
3. Raising awareness and removing stigma about ADs will improve utilisation
4. Timely and appropriate use of AD will improve patient quality of life
5. Upgrading and maintenance of devices should become a part of rehabilitation services

With these implications in mind, it is important that the rehabilitation professional be mindful and purposeful in AD prescription. Critical thinking and creative intervention techniques call for outside-the-box treatments for the assessment and use of AD.

Reasons for prescribing ambulation assistive devices:

1. Increase stability
2. Provide augmentation of muscle action
3. Allow for a reduction of weight-bearing load

Case study example: single point cane versus carrying a weight

When using a single-handed AD, such as a cane or a walking stick, most people will hold them in the contralateral hand when ambulating. However, Aragaki et al. found that in a young and healthy adult population, both ipsilateral and contralateral cane use caused a reduction in cadence, a reduced mean peak vertical plantar force on the limb advanced, and increased double limb stance time. These results show that using a cane on either the ipsilateral or contralateral side can effectively offload a designated lower limb. Hasbiandra et al. looked at the effects of ipsilateral versus contralateral cane use in adults with knee osteoarthritis (OA). They found that ambulation with a cane in either hand caused a significant difference in gait speed, step time, stance phase, swing phase, step length and double support when compared with ambulation without an AD. Hasbiandra et al. also found no significant difference in gait symmetry when comparing ambulation with contralateral versus ipsilateral cane use in patients with knee OA. This evidence points toward using a single-handed ambulation AD as warranted to improve gait dynamics, and opens up treatment options that are limited only by the rehabilitation professional's creativity.

The video below is an example of how a patient's gait deviations can be addressed in multiple ways using AD. This allows for creativity on the part of the rehabilitation professional to address gait deviations in a manner most agreeable to the patient. In this video, each intervention example is shown twice, once in real time and then, in slow motion.

1. This patient has chronic right hip pain. His baseline ambulation includes the following altered gait dynamics: (1) excessive weight shift of centre of mass (COM) to the left and (2) right trunk lean.
2. A common intervention for excessive weight shift is to provide a cane in his contralateral hand. Observe how adding this single-handed device can decrease his excessive trunk lean to the right.
3. As an alternative intervention, the patient is now carrying weight in the right, ipsilateral, hand. This has the effect of shifting his COM to the right, which also decreased his excessive trunk lean to the right. Carrying a heavy object on the ipsilateral side produces lower reactive forces through the right hip joint because the patient must generate less right-sided abductor force in stance to counteract the gravitational pull toward their left leg while it is in swing phase. By generating less force, the patient will experience less pain in the right hip joint. This option could be appealing to a patient who does not wish to use a cane or walking stick.
4. Observe what happens when the patient is provided with both a walking stick and a weight in his right hand: his gait velocity increases and his gait deviation of excessive trunk lean to the right decreases.

Case study example: lateral trunk lean

Tokuda et al. sought to find an association between lateral trunk lean gait and COM displacement in persons with knee OA. They found that the peak external knee adduction moment during gait with lateral trunk lean was less than that observed during "normal" gait. They also found that a reduced knee adduction moment occurred with (1) a medially shifted knee joint centre, (2) decreased distance from the centre of pressure to the knee joint centre, and (3) shortened distance of the knee–ground reaction force during stance phase. These findings may have clinical applications for gait modification training for patients with knee OA.

The images below show a patient utilising a lateral trunk lean with upper extremity assisted weight shift to alter their COM. This patient presents with bilateral knee pain, his right side is worse than his left. He demonstrates significant valgus thrust during stance phase on the right lower extremity. Below are two images of the same patient, captured at right foot strike.

This is the patient's baseline gait. Please note the ground reaction force. It illustrates his knee axis undergoing a high external valgus moment.

The patient has now thrown his right upper extremity out to the side, possibly to shift his centre of mass to the right. The ground reaction force is passing through the knee joint, perhaps decreasing his knee pain by assisting to shift his COM to the right.

Shoes and Orthotic Interventions

For an overview of orthotics, please read this article. For a review of ankle foot orthoses (AFO), please read the linked article.

Using tape for a temporary orthosis trial

Many musculoskeletal pain syndromes stem from excessive movement, instability, and weakness. Providing external support under these circumstances can help improve altered gait dynamics. There are many different types of external supports available for clinical use. For example, an AFO can provide external support for an individual with the neurologic gait deviation of a foot drop. Before issuing an AFO, a rehabilitation professional can fabricate a temporary AFO using tape. This allows for a soft trial of the device to see if the modification warrants the investment of time and resources for permanent external support.

• Clifford et al. found that both McConnell Patellofemoral Joint Taping (PFJT) and Tibial Internal Rotation Limitation Taping (TIRLT) could provide enough short-term pain relief to allow for more active forms of rehabilitation in patients with patellofemoral pain syndrome (PFPS). This form of taping can also be used as supportive strapping for a tibial internal rotation syndrome and serve as a soft trial for a derotation brace, which helps control excessive femur and tibial rotation.

• Kinesiology taping can also provide tactile cues to prompt feedback to facilitate altering a gait deviation. To learn more about kinesiology taping, please read this article.

Speciality shoes and shoe modification

The type of shoes a patient wears is important and can have a significant influence on gait. When the foot hits the ground, the ground reaction force begins. We can therefore alter gait by modifying a patient's shoes or suggesting an alternative shoe style. For more information on the anatomy of a running shoe, please read this article.

Changing a patient's heel-to-toe drop

Red lines mark the heel-to-toe drop

Heel-to-toe drop refers to the difference in heel height and forefoot height in a shoe. This distance is measured in millimetres (mm) and typically ranges from 0-11mm in running shoes. Heel-to-toe drop is not to be confused with a shoe's stack height, which is the amount of cushioning between the foot and the ground. For example, a shoe with a heel thickness of 10 mm and a toe thickness of 4 mm would have the same heel-to-toe drop as a shoe with a heel thickness of 15mm and a toe thickness of 9 mm. The heel-to-toe drop would be 6 mm in both cases, even though the second shoe has a greater stack height.

Ranges of heel-to-toe drop:

• 0-5mm is a minimalist heel drop
• 5-10mm is a middle heel drop
• 11-15mm is a maximal heel drop

• Runners classify a high heel-to-toe drop shoe as the difference being greater than 8mm
• Barefoot running shoes have a heel-to-toe drop of zero

Besson et al. state that shoe (heel-to-toe) drop has a significant effect on female running kinematics. This was previously known for male runners. They found that smaller heel-to-toe drops were more suitable for those with knee weakness and or those who are prone to developing knee injuries. Larger heel-to-toe drops may be more suitable for those with stiff Achilles tendons.

Zhang et al. found that regular male runners using shoes with medium to large heel-to-toe drop had significantly increased patellofemoral joint stress than runners who used barefoot style running shoes.

Clinical example: Persons with a high arch and rigid foot, i.e. equinus foot, have a functional forefoot drop. The plantar plane of the calcaneus is offset from the plantar plane of the metatarsal heads. The forefoot is going to be lower or plantar relative to the hindfoot due to the plantarflexed midtarsal joint. This person would benefit from a large heel-to-toe drop to allow their heel to be able to touch the ground.

A soft trial of increasing heel-to-toe drop can be done using a casting block. Please examine the following images for an example of this method.

Image 1: Viewing this patient from the sagittal plane, and using a vertical line drawn from the anterior malleolus, it appears that two-thirds of her body is in front of that vertical line, and one-third is behind.Image 2: After adding the casting block, note the changes in her vertical alignment. The vertical line of gravity now divides her body in half. This patient would also benefit from a larger heel-to-toe drop in her shoes.

Rocker-bottom/rocker sole shoe

This shoe modification has been called "the aspirin for chronic foot problems." Rocker-bottom shoes can be used to address: (1) hallux limitus, (2) first MTPJ joint osteoarthritis, (3) plantar heel pain syndrome, (4) great toe fusion, (5) ankle joint fusion, and can have some benefit to (6) knee osteoarthritis and (7) back pain.

A rocker-bottom shoe could be considered for the following gait deviations:

• Decreased dorsiflexion of the toes, especially the great toe joint
• Decreased ankle dorsiflexion or early heel off
• Early supination
• Knee hyperextension to compensate for limited dorsiflexion of the foot and ankle
• Weak push off or heel off

A soft trial of a rocker-bottom shoe can be done simply by adding and securing layers of a firm material, such as Corex or cardboard, to the bottom of the patient's shoe. Both the apex of the rocker and the thickness of the rocker can be adjusted during this trial. A custom rocker-bottom shoe can then be fabricated by an orthotist.

Wearable Technology

Wearable technology is a rapidly growing field. Examples include Fitbits, Apple watches, and smartphones. Rehabilitation professionals are starting to integrate wearable technologies into practice to quantify biomechanics and the training loads of patients to help prevent movement related injuries. Wearable technology, which can provide measurements and give feedback for clinical interventions, are called inertial measurement units (IMUs). They can provide data on multiple dimensions, provide measurements of acceleration of a body segment, sense angular displacement, and sense body orientation. IMUs can be applied to different regions of the body, for example in the shoe, and provide data on the force per unit area in a particular part of the foot or a particular part of the shoe.

Examples of clinically useful data on gait collected by wearable technology:

• Feedback on spatiotemporal factors which can help quantify exercise load
• Feedback on step or stride length, cadence
• Feedback on joint kinematics, range of motion, accelerations, and decelerations
• Data on plantar pressure and distributions across the foot and within the shoe
• Measurements of shock and or shock attenuation
• Comparison data of reciprocal gait movement between limbs

Special Topic: what is the difference between these clinical measures?

Step or stride length: "the distance between two successive placements of the same foot. It consists of two step lengths, left and right, each of which is the distance by which the named foot moves forward in front of the other one. In pathological gait, it is perfectly possible for the two step lengths to be different."

Cadence: walking or running rate in steps per minute

Walking speed = stride length x cadence

The challenges of wearable technology and clinical practice are summed up well by Windt et al:

"Technology is here to stay—not just in sport but in virtually every discipline ... External loads can be monitored through global positioning systems (GPS), inertial measurement units (IMUs), optical tracking systems, and so on.  Internal loads may be captured with heart-rate monitors, lactate measurements, and more.  Recovery states may be measured with devices ranging from low-tech wellness surveys to more high-tech solutions, such as heart-rate variability or force-plate testing. Currently, we are seeing new technological solutions with potential sporting applications, such as implantable devices,  markerless motion capture,  breath analysis,  smart garments, biomechanical insoles, and skin sensors.  In this technological age, sports science practitioners must critically appraise the plethora of options available and make informed decisions about evaluating and adopting technology in their specific contexts."

These authors suggest a framework and set of questions to help the rehabilitation professional navigate decisions on investing time and money into new wearable technologies.

Framework questions for wearable technologies:

1. Would the promised information be helpful?
2. Can you trust the information you will be getting?
3. Can you integrate, manage, and analyse the data effectively?
4. Can you implement the technology in your practice?
5. Is the technology worth it?

The decision to implement new wearable technologies into clinical practice is complex and individualised based on each rehabilitation professional's needs. The decision requires a mindful evaluation of evidence related to the technology and the environment in which it will be deployed. Patient comfort and their right to privacy should also be considered.

A simple and accessible example of wearable technology is laser light feedback. Laser light can provide a visible external focus for movement feedback.

The following optional video demonstrates how to add a laser level to a rolling walker. For a more cost-effective version, a laser flashlight cat toy or a laser light hardware level can be used.

Remedial Exercises with Gait Training

More often than not, exercise alone is not enough to alter a person's gait deviation or gait dysfunction. Brach et al. discussed how task-oriented motor learning exercises are essential to a plan of care to improve motor skills. They found that multicomponent impairment-based walking exercises can enhance the skills needed to improve walking (strength, flexibility and endurance capacities), but they do not necessarily result in "better walking." The addition of task-oriented motor learning walking exercises improves gait sequencing and coordination and enhances a person's walking ability. Gait training is an essential part of a therapy care plan and is necessary to alter gait deviations.

Van Dillen et al. compared functional outcomes in patients with chronic low back pain (LBP). Those who received individualised motor skill training in addition to more traditional strengthening and flexibility exercises showed a greater improvement in overall function than the group who received just the exercise interventions. This is similar to the concept of sport-specific training; the patient's practice must include the skill they wish to improve.

Plan of care should include:

• Strengthening and flexibility exercises
• Task-specific training to address the gait deviation
• Break down the task into components and practise each part
• Put gait task back together and practise as a whole
• Provide good cueing and prompting based on the patient's preferred sensory system
• Exercise and task-specific training must be individualised to this patient's unique gait deviations

To review motor learning theory concepts applied to gait training, please see this article.

Resources

Optional Recommended Reading:

• Hasbiandra RA, Tulaar AB, Murdana IN, Wangge G. Effect of contralateral and ipsilateral cane usage on gait symmetry in patients with knee osteoarthritis. InJournal of Physics: Conference Series 2018 Aug 1 (Vol. 1073, No. 6, p. 062046). IOP Publishing.
• Van Dillen LR, Lanier VM, Steger-May K, Wallendorf M, Norton BJ, Civello JM, Czuppon SL, Francois SJ, Roles K, Lang CE. Effect of motor skill training in functional activities vs strength and flexibility exercise on function in people with chronic low back pain: a randomized clinical trial. JAMA neurology. 2021 Apr 1;78(4):385-95.

• Windt J, MacDonald K, Taylor D, Zumbo BD, Sporer BC, Martin DT. “To tech or not to tech?” A critical decision-making framework for implementing technology in sport. Journal of Athletic Training. 2020 Sep;55(9):902-10.