Side Effects of Verbal Cueing and Interventions to Alter Gait Deviations

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

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

Introduction

Evert Verhagen et al 2014 discusses the use of physical activity as a medicine to help decrease the burden of chronic and lifestyle-related diseases on the general public. While the benefits of physical activity are well known and shared with patients, the unwanted side effects or unintended consequences are often ignored or neglected as part of patient education.

Horvath et al 2021 performed a systematic literature review and found that the nocebo effect can influence an individual's motor performance and can be evoked by negative verbal cues. In certain circumstances, the nocebo effect can be more robust than the placebo effect.

The risk of adverse effects when prescribing rehabilitation interventions such as physical activity, exercise, or gait training is low but they are not nonexistent. Clinicians should be proactive in sharing potential side effects with patients as part of treatment informed consistent.

Side Effects of Altering a Gait Deviation

Definitions:

A side effect is typically an undesirable or unintended consequence of an intervention.

A nocebo effect occurs when a patient's negative expectations of treatment cause the treatment to have a more negative outcome than it otherwise would have.

A placebo effect is the tendency of a medication or treatment, even an inert or ineffective one, to exhibit results simply because the recipient believes that it will work.

Possible clinical outcomes of sharing potential side effects:

1. Increasing the level of engagement with patients
2. Can facilitate timely adjustments for chosen interventions
3. May itself induce unintended or adverse effects through the nocebo effects

A rehabilitation professional can use clinical reasoning to create a working hypothesis to try and improve the unintended consequences of therapeutic interventions.

The three common side effects of altering a gait deviation:

1. Increased energy expenditure, it can be physically taxing to walk and run in a new way
2. Increased cognitive demand, the brain must work harder to meet the task
3. Increased muscle fatigue and soreness for utilising muscles in a novel way

Gait Deviation Clinical Examples

Gait deviation	Related musculoskeletal pain syndromes	Sensory System	Internal focus of attention: Cue, Prompt, Feedback	External focus of attention: Cue, Prompt, Feedback	Potential side effects
Too long a step or stride length	Back pain Anterior hip pain Lateral knee pain IT band syndrome Anterior knee pain Patellofemoral arthralgia Medial tibial stress syndrome Stress fractures Achilles pain Plantar heel pain syndrome	Visual	Imaging/visualise walking on hot sand	Use laser light target for shorter steps	Making step length shorter could result in increased energy expenditure
		Auditory	"Walk like you are sneaking up on someone"	Listen to metronome music at appropriate cadence beats/minute
		Kinesthetic Tactile	Take shorter steps more steps/minute	Wearable with vibratory feedback at appropriate cadence
Late/delayed heel off	Anterior hip pain Anterior knee pain Patellofemoral arthralgia Anterior ankle pain Achilles pain (due to stretch weakness) Plantar heel pain syndrome	Visual	Imagine/see yourself propel up and forward	Walk towards mirror watch top of head, laser light target	Cognitive overload
		Auditory	“spring in your step”	Listen to verbal cues provided: “yes”; “dampen it”; “need more effort”
		Kinesthetic Tactile	Feel heel lift off ground sooner	Use of elastic tape
Too much toe out (more than 15 to 20 degrees of the foot progression angle)	Hip osteoarthritis (OA) Knee OA Can continue after a total joint replacement Patellofemoral arthralgia medial tibial stress syndrome Achilles pain Plantar heel pain syndrome pain on the ball of the foot Metatarsalgia hallux limitus Great toe OA Bunions	Visual	Visualise your foot as a front car tire, keep it straight down road	Align foot with tape or line on ground	Potential adverse effect with intention increase of toe-in is a decreased knee adduction moment and an increased knee flexion moment For patients status post total knee replacements with weak quadriceps, may experience knee pain
		Auditory	Listen to verbal cues provided: “yes”; “dampen it”; “need more effort”	Say out loud "turn foot inward"
		Kinesthetic Tactile	Push heel outward or turn toe inward	Touch or tap the muscles on front of hip, "use this muscle"
Lateral pelvic drop, contralateral pelvic drop	Back pain Hip labral problems Gluteal tendinopathy Piriformis syndrome Patellofemoral arthralgia IT band syndrome Medial tibial stress Ankle pain Achilles pain Plantar heel pain syndrome	Visual	Imagine pelvis is bucket of water, don’t let water spill out	Walk towards mirror, watch belt and keep it level Laser light target	Muscle fatigue and soreness
		Auditory	"Image pelvis is bell, quiet the clang of the bell"	Listen for foot strike make sound symmetrical and rhythmic
		Kinesthetic Tactile	Touch hand to gluteal muscles, "engage this muscle"	Hip spica brace Neoprene sleeve Nonelastic or elastic strapping of hip

Side Effects Special Topics

Cognitive overload can occur when a person is being challenged mentally by the therapeutic interventions. They are processing too much information or too many tasks, and it adversely affects their motor learning process. The rehabilitation professional can modify this overload by (1) discontinuing the intervention, (2) continuing the intervention and encouraging the patient through the task, (3) modifying the task from the whole into smaller steps or parts, (4) or modifying the intervention by switching the sensory preference of the verbal cue being provided to the patient.

Increased muscle fatigue and soreness is an expected side effect to exercise. However, it is important to have a discussion and talk about the nature of the pain with each patient to ensure this new pain is not a warning sign of additional injury.

Examples of prognosing which muscles will experience soreness &/or fatigue in response to explicit alteration of gait:

Gait deviation alteration	Potential sources of muscle fatigue and or soreness
Too long step or stride to shorter steps	Thigh and or calf muscle
Lateral pelvic tilt to the more stable pelvis/hip	Gluteal muscle
Prolonged heel contact to the appropriate heel of timing	Soreness in foot and or calf muscles, engagement of gluteal muscles
Excessive out-toeing to appropriate foot progression angle	Stretching sensation of muscles around the hip, fatigue in muscles around the hip

Resources

Clinical Resources:

• Handout for Gait Deviation Intervention Side Effects

Optional Video:

Please view this optional additional video which discusses the nocebo versus placebo effect, and provides additional clinical examples of the nocebo effect.

Optional Additional Reading:

• Horváth Á, Köteles F, Szabo A. Nocebo effects on motor performance: A systematic literature review. Scandinavian journal of psychology. 2021 Oct;62(5):665-74.