As the most common cause for falls and subsequent decline in older adults, physical therapists are vigilant in their recognition and treatment of gait dysfunction.
At Rehabilitation Associates of Central Virginia's Clifton Street practice, a large percentage of the patient population has gait dysfunction because of a history of falls, said physical therapist Abbey J. McClanahan, PT, DPT. Others experience changes in their normal walking pattern because of diabetes, Parkinson's, stroke, or other degenerative diseases.
Whether physical therapy on its own will help patients regain their previous walking pattern or a device is needed is not a decision made lightly. Some practices have expensive evaluation equipment, but McClanahan's had the most success using the visual tools she learned in graduate school.
"I look for cycles of gait pattern, heel contact, push off, and essentially make sure the portion of the limb, hip, knee and ankles are doing what they're supposed to," she said.
Any treatment is based on the gait evaluation. There are no accepted national standards for determining normal gait in an older adult, but McClanahan provided some parameters. If the patient is experiencing foot drop, lapsing, can't keep their toe pointed to their nose, drags toes or, in the case of hip issue, can't pick up their leg, the problem may be complex. McClanahan works on weakness issues with the patient and, after a couple weeks, completes a full evaluation and consults with orthotists.
At New England Rehabilitation Hospital, Heidi Fullerton, MSPT, feels fortunate to have access to technology to help her patients with neurological diagnoses strengthen and re-educate their muscle. If she feels they'll respond to a mechanical intervention, she tries electrical stimulation or auto-ambulator devices.
"With the electrical stimulation machines, we can strap it to the patient's leg and electrical impulses get the muscles to work. We can use it on the patients' legs while they're walking," Fullerton explained. "There are two ways we use the robotic auto-ambulator devices. We can secure their legs into the robot and the machine does the work so the patients learn the correct gait pattern. Alternatively, we use treadmill training with bodyweight support, essentially lifting the patient to take the weight away. It's very effective and we follow up by having them walk on the ground so muscles get a chance to relearn the correct sequence."
If patients don't respond to the machines within a couple weeks, Fullerton talks to the doctor about extra support with an orthotic device.
While there are no nationally accepted parameters for "normal" gait, therapists look for key indicators of dysfunction, such as foot drop, lapsing, inability to keep the toe pointed to the nose, dragging of toes or, in the case of a hip issue, the inability to pick up one's leg.
McClanahan has an established relationship with a local orthotics office and said the representatives usually agree with her assessment. The decision to fit a patient with an orthotics device is one not entered into lightly, as it's usually worn for life.
"We can always work on strengthening but, if the patient has a diagnosis where the nerves aren't transmitting signals correctly, there's nothing I can do," she said. "Often, the muscles aren't working properly and probably won't again, because of their medical history."
If McClanahan feels the patient can't regain 100% of their ankle strength, she recommends a carbon-fiber ankle-foot orthosis. Though some patients resist anything that looks therapeutic, most are willing to wear the device once they learn how it will help them continue in their activities of daily living.
"I show the picture of the ankle-foot orthoses and ask if they're okay with it," she said. "If they oppose the idea because they wear shorts, I tell them we'll try and modify something else. Let's not get it if they're not going to use it."
The vast majority of patients are on board once they learn how the products will help them maintain normalcy. McClanahan said the goal is community ambulation, which is defined as 500 feet. But she likes to delve a little deeper into the patient's routine and refine their objectives.
"I talk to my patients about keeping up with those around them, going to the grocery store and walking in a mall," she explained. "Their goals really depend on their life. If the church parking lot requires a 50-foot walk, we'll start there."
Safety is a top priority, so McClanahan likes to have the patient fitted with the orthotic device during the course of their therapy so she can teach them how to use it properly.
"People have reported pain with orthotic device," said McClanahan. "The carbon-fiber ankle-foot orthosis is light and thin. Any time you don't use the appropriate gait pattern, another body part is forced to work harder. We want the most efficient gait pattern so patients can expend less energy and walk further."
The same theory holds true for patients with a walker or cane. "It's typical for people to use a slower walking speed or feel off-balance with walkers and canes," she said. "If the walker's too short and the patient leans forward, back pain will result. If it's too high, you can't use your hands so don't achieve good balance. We want our patients to have overall good health. If they are having back pain, they won't want to walk."
Embracing Leg Lifts
McClanahan estimated treating 10 patients a day with gait dysfunction; however, when the problem is foot-related, she refers to Jacqui Gooden, PT, DPT, at Rehabilitation Associates of Central Virginia's Timberlake office, for a biomechanical full foot analysis.
Though she sees patients ages 8 and up, the majority are in the 40-70 age range. "In their 40s and 50s, people usually have issues with leg length inequality and just can't take it anymore," Gooden shared. "Patients with gait dysfunction and no leg length issues are usually 65 to 90 and start to fear falling, or say they're not as steady."
With structural leg length inequality, there's no standard way to measure the issue. While the X-ray is the standard assessment, it's not 100% accurate.
"I determine if the problem is structural, like the limb being physically too short," explained Gooden. "I check if it's functional from pelvis rotation. Once we confirm the issue is structural and the leg length inequality is 5 mm or more, the person is a candidate for a leg lift."
Almost universally, Gooden's patients are pleased to learn there's relief in sight for their discomfort, even if it means wearing a leg lift for life. She proceeds to measure landmarks on the pelvis and the ankle to determine the appropriate amount of length to begin with, which is typically 70% of the inequality.
The only necessary patient education, said Gooden, is teaching patients to choose shoes with removable liners. "An athletic shoe is typically best and they can't wear ballet flats. But the shoe industry has changed so much that even dress shoes or sandals are now designed to accept orthotics."
The one-month follow-up appointments are critical, as patient feedback is the only way to know whether the leg lift is fitting correctly.
"Leg lifts can give someone too much or too little correction," said Gooden. "Patients report how they feel. We listen, make adjustments and their pain goes away. If you're not measuring their legs, that would be wrong. You need data to get a good fit."
As not all insurance covers orthotic devices, Gooden has recommended $25 over-the-counter leg lifts frequently. Otherwise, patients buy the customized $170 version and return to her office after a few years when the materials have compressed and symptoms return.
But the leg lifts and other orthotic devices allow patients to resume their activities of daily living without fear.
"When it comes down to it, planning is the art and the science of physical therapy," summarized McClanahan. "We're planning for discharge from the first visit onward and plan for them to return to their normal activities."
Robin Hocevar is on staff at ADVANCE. Contact: firstname.lastname@example.org.