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 individualisation of a therapy plan of care. The study of the human gait cycle can be a career long endeavor 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, 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. Trial of equipment or modification of available resources can be a method of DME assessment without the cost of new devices.

FROM DAMIEN: https://www.youtube.com/watch?v=RjfqtZqVY1A

Equipment

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

Borade et al 2019 gathered data from patient interviews regarding using AD on a daily basis. They found that limited access and untimely prescription of AD, barriers toward 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 need of AD, (2) availability, accessibility and affordability of appropriate devices will improve rehabilitation, (3) raising awareness and removing stigma about ADs will improve utilization, (4) timely and appropriate use of AD will improve patient quality of life, and (5) upgrading and maintenance of devices should become a part of rehabilitation services.

With this 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 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 2009 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 limb advanced, and increased double limb stance time. These results show that the use of either an ipsilateral or contralateral cane can effectively offload a designated lower limb. Hasbiandra et al 2018 looked at the effects of ipsilateral versus contralateral cane use in adults with knee osteoarthitis (OA). They found that ambulation with cane use in either hand caused significant difference in gait speed, step time, stance phase, swing phase, step length and double support when compared with ambulation without an AD. The study 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 warrented to improve gait dynamics, and opens up treatment options limited only by the rehabilitation professional's creativity.

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. 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 right and (2) right trunk lean.

(Insert street video 1, baseline)

A common intervention for excessive weight shift is to provide a cane in his contralateral hand. Observe how adding this single handed device can decreased his excessive trunk lean to the right.

(Insert street video 2, with cane)

As an alternative intervention, the patient is now carrying a weight in the right, ipsilateral, hand. This has the effect of shifting his COM to the right, which in turn also decreased his excessive trunk lean to the right. This option could be appealing to a patient who does not wish to use a cane or walking stick.

(Insert video 3, carrying weight)

Observe what happens when the patient is provided with both a walking stick and a weight in his right hand: his gait velocity increased and his gait deviation of excessive trunk lean to the right decreased.

(Insert video 4, both cane and weight)

Case study example: lateral trunk lean

Tokuda et al 2018 sought to find an association between lateral trunk lean gait and COM displacement in persons with knee OA. They found that the max external knee adduction moment during gait with lateral trunk lean gait was less than that observed during "normal" gait. They also found that a reduced knee adduction moment occurred with a medially shifted knee joint center, decreased distance from the center of pressure to knee joint center, and shortened distance of the knee–ground reaction force during the stance phase. These findings may have clinical applications for gait modification training for patients with knee OA.

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

Insert image one: This is the patient's baseline gait. Please note the ground reaction force, it illustrates that his knee axis undergoing a high external valgus moment.

Insert image two: 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

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 improved resulting altered gait dynamics. There are many different types of external supports available for clinical use. For example, an ankle foot orthosis (AFO) can provide external support for an individual with a neurologic gait deviation of a foot drop. Before issuing an AFO, a rehabilitation professional can fabricate a temporary AFO using tape. Using tape as a temporary device allows for a soft trial of the device to see if the modification warrants the investment of time and resources of a permanent external support.

Clifford et al 2020 found that both McConnell Patellofemoral Joint Taping (PFJT) and Tibial Internal Rotation Limitation Taping (TIRLT) could provide enough short-term pain relief to allows 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 femur and tibial excessive rotation.

Kinesiology taping is another taping method which can 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

Let's talk for a moment about shoes. So again, we choose a gait deviation, try a temporary shoe modification, assess the results. When the foot hits the ground, the force begins. Shoes are important to have and have a significant influence on gait. And we can do a lot of things to modify shoes, to alter gait. I often tell my patients here's a shoe insert. It's only as good as the shoe that you put it in. So I want to talk about two shoe modifications that I've found very helpful to alter gait deviations.

This was the 80-year-old half marathoner with chronic bilateral heel syndrome, heel pain syndrome. He shows an early heel off, an excessive vertical oscillation of centre of mass. He also is status post polio, has a high arch, rigid foot. Some people would call it equinus foot. What do we do with him? We did two shoe modifications.

But let me explain the mechanics of high arch, rigid foot or a functional forefoot drop. The plantar plane of the calcaneus is offset from the plantar plane of the metatarsal heads. In this picture, the foot is just lying there. But if I take my thumb and dorsiflex the foot and ankle to where I take out all the slack, you'll still see this offset. The forefoot is going to be lower or plantar relative to the hindfoot. And the reason that is, is because of the structure of the midtarsal joint, it's plantarflexed. So in order for him to get his heel down to the ground, he's got to compensate somewhere. So how can I deal with a person with a high arch, rigid foot?

So this young lady has a high arch, rigid foot. In the picture on the left, she's standing barefoot. And using a vertical line drawn from the anterior malleolus, which Florence Kendall suggests as your reference point when you're looking at a person's standing posture in a sagittal plane. You can see that two-thirds of her body is in front of that vertical line, one-third is behind. May be described as a bit of a swayback posture. In the picture on the right, she's standing on a casting block. A casting block provides a lift under the heel of an inch and a half and a lift under the forefoot of a half inch. So there's an offset of one-inch difference. That's the only thing we did. And you'd see that we've changed her vertical alignment. That line of gravity now divides her body in half. So this young lady is going to be happier in high-heel sneakers. She's going to be happier in a shoe which is called a high-drop, a heel-to-toe drop that's greater. In fashion shoes, it would be a wedgie, in running shoes, it would be a high-drop shoe. Runners classify a high-drop shoe as the difference being greater than eight millimetres, as opposed to the barefoot running shoe, which has no lift under the heel. So, this is a shoe modification that can provide alteration of gait and symptoms. For that 80-year-old half-marathoner, I put him in a shoe with a high drop.

The next shoe modification I want to talk about is the rocker sole shoe. It's been called the aspirin for chronic foot problems. It solves a lot of problems. Pain syndromes, such as hallux limitus, or first MTPJ joint osteoarthritis, plantar heel pain syndrome, big toe fusion, ankle joint fusion, has some benefit to knee osteoarthritis and can have a benefit for back pain. So what would be the gait deviations that might show up to make you want to consider a rocker sole shoe? Decreased dorsiflexion of the toes, especially the big toe joint. Decreased ankle dorsiflexion or early heel off, early supination. Perhaps they were going to hyperextend at the knee to compensate for that limited dorsiflexion down at the foot and the ankle. And they may show evidence of a weak push off or heel off. So how do I test this before I send the patient to a podorthotist, or an orthotist to have a rocker sole modification, or before they invest in shoes that have a rocker sole?

It's pretty simple to do. These pictures show using Corex, you could use any firm material. I've used layering a cardboard, and you cut it and tape it, duct tape it to the bottom of the shoe. You can change the location of that distal edge, more distal or proximal relative to the ankle joint. So you can kind of test where you want the apex of a rocker to be, and/or the thickness of that cardboard or Corex to determine the radius of the rocker.

So this gentleman had chronic bilateral midtarsal joint osteoarthritis. The picture on the left, he's walking in his normal sandal and I've captured his maximum ankle dorsiflexion. And in the picture on the right, we've changed his kinematics and probably kinetics at the force in that midtarsal joint to decrease his need for a dorsiflexion motion by doing a temporary metatarsal bar or rocker bar taped to the bottom of his sandal. Then I send him to the orthotist to have his sandals modified, telling them where the location of that distal break should be.

Wearable Technology

Part of equipment I want to talk about is wearables. Wearables are exploding, Fitbits, Apple watches. There's a variety of wearables that are available that give us measurements and can give us feedback for interventions. They are called, they can be an IMU, an inertial measurement unit. It can do measurements on two dimensions. They're available for three dimensions as well. These IMUs provide measurements of acceleration of a body segment. They can be a gyroscope, sensing angular displacement. They can involve magnetometers, sensing orientation. Our smartphones have them, these IMUs. They can be applied to different regions of the body. We can have wearables placed in the shoe, giving us shoe forces or when we convert that to clinical application, we talk about the pressure, force per unit area in a particular part of the foot or a particular part of the shoe. There are flexible goniometers that can be worn and bluetooth to give us feedback. Now we have sensing fabrics that can give us whole body of feedback and measurements. Of course we can have EMG feedback and there's electromagnetic tracking systems. All of these systems are becoming more readily available.

So what are some clinically useful measurements for gait? For gait assessment and gait feedback or altering gait? We can get feedback on spatiotemporal factors, putting that all together in terms of quantifying exercise load. So we can get feedback on step length or stride length and cadence, steps per minute. We can get measurements and feedback on kinematics, range of motion, accelerations, decelerations. We can get plantar pressure and distributions within the foot and the shoe. We can get measurements of shock or absorbing or shock attenuation. Getting feedback of acceleration and deceleration. It's a measure of movement that can be a factor in eliciting or causing injuries. And it's a relatively new measurement for us in the clinic. But one that I think we need to start to pay attention to. These wearables, if you have one on each side, you can get feedback and analysis of side-to-side differences or asymmetries. And in the future, I think these wearable devices are going to be giving us information about stuff that we cannot see, which is the forces, the kinetics, the joint moments at a knee versus the hip, right versus left. The future is coming.

So it's new technology, new for me, new for most of us, I'm going to refer back to the article by Johann Windt et al., where he raises the generic questions to use to decide whether we're going to use this new technology and is it applicable to decide whether to use the wearable technology to augment our feedback as we attempt to alter gait to make the gait of walking and running more optimal. So he says, will the new technology be helpful? So will it be helpful? Can it, can this technology augment the feedback that I need for this client or this patient? Can it provide data that I currently cannot see? Acceleration and deceleration. The challenge is to be able to analyse this new information. There's a large body of information being published on acceleration factors, and we need to begin to figure out how to apply that clinically. And can you integrate this new information in your current practice? In terms of altering a person's gait, we already know or believe that if you use the client or the patient's preferred sensory system, that you'll be more effective. So can that augmented feedback be visual or can it be auditory or can we design it so that it is kinaesthetic? Those are some of the questions we're going to need to address.

Here's an example of wearable that we can use now, which is laser light feedback. Laser light can provide an external focus that's visual. So there are commercially available laser lights for clinical use. Most of them are relatively expensive, on the order of 200 US dollars to 600 US dollars. I've been using a relatively inexpensive laser flashlight cat toy, and I strap it to the person's body part. I'm beginning to experiment now with a laser light hardware level that construction people use, it gives you feedback. So this illustration is using the dance step to nowhere to learn to alter excessive medial femoral rotation. The image on the bottom is the laser pointer light, the flashlight cat toy, and he's trying to control it so that the femur does not roll excessively medially. The image on the top has a laser light line, gives him better feedback. Very useful.

Remedial Exercises with Gait Training

Next, I want to talk about exercise. We're all good at this, that's what we do. How do we incorporate that into transitioning to altering a person's gait? I want to touch briefly on often exercise alone is not enough to alter a person's gait deviation or gait dysfunction. Jennifer Brach et al. in 2013 professed that if walking is the problem, then the intervention should be primarily focused on the task of walking, through motor skill-based training, through gait training and not impairment-based exercise intervention alone. Ideally you want to use both or perhaps just the gait training is an alternative in some situations. Irene Davis professes the same sort of thought process. She looked at a review of literature of individuals with patellofemoral arthralgia and concluded, strengthening exercises alone is not enough to alter gait mechanics. You need to do gait training as well. In an extensive study recently published by Linda van Dillen et al. in 2020 I believe it was, looking at chronic low back pain patients who received motor skill training. They showed greater improvement in function than a group that just had strengthening and flexibility exercises. So we need to, it's the concept of sport-specific training. If you want to learn to run faster, you need to run faster. If you want to learn to do the free throw, you got to do the free throw shot in basketball.

So how do we incorporate from remedial exercise from transitioning from strengthening and flexibility exercises to walking and running in a more optimal way? We perform the strengthening and flexibility exercises, I'm going to suggest that interim step can be the dance step to nowhere, followed by walk this way. I want to touch a little bit more on the fact that in my experience, many of the musculoskeletal pain syndromes that I see are associated with length associated muscle weakness. Stretch weakness. Especially with many of the tendon problems, gluteal tendinopathy, Achilles tendinopathy, and I believe plantar heel pain syndrome can be a tendon problem. So if you have a length-associated muscle weakness, and I think in gait, there are often problems with gluteal muscles, ankle plantarflexor muscles can be long and relatively weak and the intrinsic plantarflexor muscles of the foot can be relatively long and weaker. Weaker at the shortest length, stretch weakness. So the progression here is I start with isometric strengthening exercises at the shortest length and then progress the isometric exercise at mid-range and then do it in the dance step to nowhere, followed by walk this way.

So plantar heel pain syndrome, if it's a tendon problem in the intrinsic muscles of the foot, which I believe it often is, we need to perform isometric plantarflexion of the toes at our shortest length. So here's an illustration where the ankle is plantarflexed and the toes are plantarflexed. This position, the muscle's in a position of active insufficiency, challenging the intrinsic plantarflexor muscles of the foot. So you keep the foot on the floor and flex the toes. And progression would be to then do it in mid-range in weight-bearing by performing what's commonly called short foot exercise, some people call it, make an arch exercise. Some people call it the doming exercise. And when you are weight-bearing and you do the short foot exercise, it's important to not curl the toes so that you, again, isolate the intrinsics.

Melinda Smith et al. recently published in 2022 an open-source, excellent description of progression of strengthening exercises for the intrinsic plantarflexors of the foot. But basically you perform the isometric contraction with the muscles at the shortest length, then you do it while sitting, and then standing, then the progression is to dance step to nowhere. While maintaining an isometric contraction in the ipsilateral foot. Then you can increase the duration by performing a single limb stance, stand in a yoga position of the tree stand while maintaining isometric contraction or maintaining the arch of the foot. Then you can progress to walk this way. Provide good cueing, prompting of a visual image of imagine you're walking in sand and you leave an imprint showing that there's an arch, and then you can progress to what Janda has called reverse tandem gait exercise, which is walking backwards. And when you place the foot back behind you, you try to maintain that arch, this progresses the training to an implicit level, because when you walk backwards, you may not habitually let that arch pronate and collapse.

So this is a patient that uses this concept, not for plantar heel pain syndrome, but she has hallux valgus on the right that's becoming painful or what would be commonly called a bunion. And so I'm doing the dance step to nowhere, I'm asking her on this picture to maintain the arch, to straighten out that toe. So she's actively using her abductor hallucis brevis and she has to actively assist it, straighten out her toes. She tries to do the dance step to nowhere, and she loses it. Then she taught me this. She's trying to maintain that toe straight. I sent her home to practise this. Four weeks later, she shows me. Again, the right side is the symptomatic side. Now she's raising her heel, she's able to control that big toe using her abductor hallucis brevis.

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