Interventions for Gait Deviations

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

Top Contributors - Stacy Schiurring, Jess Bell, Kim Jackson, 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

AFO, orthotics, taping, shoe, ground reaction forces

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

The type of shoes a patient wears are important and can 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

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 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 2019 states 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 are prone to develop knee injuries, and larger heel-to-toe drops may be more suitable to those with stiff Achilles tendons.

Zhang et al 2022 found that regular male runners using shoes 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, ie 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.

(Insert 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, one-third is behind.

(Insert 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 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.

Insert images of rocker shoes

Wearable Technology

Wearable technology is growing rapidly, examples include: Fitbits, Apple watches, and smart phones. Rehabilitation professionals are starting to integrate wearable technologies into practice to quantify biomechanics and 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 in 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, steps per minute
• 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

The challenges of wearable technology and clinical practice are summed up well by Windt et al 2020:

"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 Analyze 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 professionals needs. The decision requires mindful evaluation of evidence related to the technology and the environment in which it will be deployed. Patient comfort and right to privacy should also be considered.

A simple and accessable example of wearable technology is laser light feedback. Laser light can provide a visible external focus for movement feedback. The example below was built using easily found parts, including a laser flashlight cat toy and a laser light hardware level.

For captions: 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.

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.

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.

• 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.