A Closer Look At Gait Analysis In Patients With Diabetes

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Michael DeBrule, DPM

Observing the gait of patients with diabetes can reveal valuable information that can help avert complications. This author discusses gait abnormalities in patients with diabetes, reviews the influence of ground reactive forces and provides a practical guide to analyzing gait in this patient population.

If one considers observational or advanced gait analysis for podiatry patients with diabetes mellitus, there is no consensus for an approach and evidence-based guidelines are lacking. Therefore, it would not surprise me if a podiatrist casually glanced at a diabetic gentleman’s cane in the corner of an exam room but did not bother to watch him walk. This is a sadly missed opportunity to obtain important information that might help prevent limb loss.

   Let us take a closer look at gait analysis in patients with diabetes by attempting to answer the following questions:

• How do patients with diabetes walk?
• What factors alter the gait of people with diabetes?
• What about ground reactive forces?
• How should physicians perform diabetic gait analysis?

How Do Patients With Diabetes Walk?

Gait analysis studies for patients with diabetes vary on their inclusion criteria, the definition of neuropathy, walking surface, data collection methods and sensor technologies. Results from these studies can be confusing or contradictory. However, two clear trends emerge: decreased walking speed (velocity) and an increased base of gait (step width measured from one heel to the other, perpendicular to the line of progression).1-4 If your patient with diabetes walks with both decreased speed and an increased base of gait, these gait characteristics should serve as red flag warnings for advancing neuropathy and foot ulcer risk.

   Increasing the base of gait may increase stability and balance during ambulation.1 A wide base of gait is also present in children beginning to walk and along with some older adult gait patterns such as caution, cerebellar ataxia, choreic disorders (found in Huntington’s disease) and waddling.5 I have noticed in my patients that an increased base of gait is sometimes accompanied by cautious gait changes like abducted legs and arms, very slow walking, or careful turning. When this pattern occurs, I question the patient about anxiety, fall history, fear of falling and visual impairment.

   Researchers have also reported additional gait parameters in patients with diabetes.1,3,4,6-11 These include decreases in cadence, step length, single limb support time, the maximum vertical component of ground reactive force, plantarflexion moments, step variability, and knee and ankle mobility. Also, there are increases in double limb support time and time to complete the gait cycle. Furthermore, patients with diabetes may walk even slower on irregular surfaces like cobblestones.7 However, one should keep in mind that most of these additional parameters could be secondary to slower walking speeds. Slower walking speeds are associated with decreased ground reactive forces, decreased joint angles, decreased single limb support and increased double limb support time.12

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