A Closer Look At Gait Analysis In Patients With Diabetes

Michael DeBrule, DPM

   Instead of placing so much emphasis on one gait parameter like peak plantar pressures, shouldn’t we try to look at the big picture for multiple parameters? Pressure mats and in-shoe pressure systems may provide valuable information like prolonged lateral forefoot loading, early hallux plantarflexion, timing of heel lift, force versus time curves, force-time integrals, symmetry analysis, center of force trajectories, etc. Considering all of these gait parameters may help identify abnormal gait patterns and assist with treating our patients. Unfortunately, there is no evidence-based best algorithm to follow.

Pertinent Tips On Performing Gait Analysis For Patients With Diabetes

If you do not have a room dedicated to gait analysis at your clinic or hospital, you may have to do the best job you can despite limited space. Treadmills do not take up much space and would be great to use for a marathon runner with diabetes. However, treadmills might be a fearful experience for patients who have severe peripheral neuropathy or use assistive devices like canes or walkers. Treadmills also decrease stride length and increase cadence.24

   Therefore, I prefer to observe patients with diabetic neuropathy free walking down a hallway (or a walkway if you are lucky enough to have one). Personally, I prefer hallways over cramped exam rooms. Consider going out into the hallway to observe your patient walk from the front and back. Then observe the patient from the side (sagittal plane) by standing just inside the exam room door while your patient walks back and forth in the hallway in front of you.

   Your goals for gait analysis will vary from patient to patient. For example, let us say you are thinking about applying a fiberglass total contact cast to offload an ulcer. You might have your patient simply try on a controlled ankle motion (CAM) walker, watch the patient walk and quickly assess walking speed and stability. However, you might choose to spend a lot more time analyzing that same patient’s gait if you were planning surgery or thinking about an AFO prescription. Here are some suggested goals.

• Identify gait dysfunction (limited hip flexion).
• Identify gait asymmetry (lateral trunk lean on left side only).
• Identify timing problems (delayed heel lift).
• Attempt to distinguish between primary pathology and secondary gait compensations (knee osteoarthritis and decreased knee flexion).
• Appreciate new diagnoses that are not evident on history, exam or X-rays.
• Reassess gait to determine effectiveness of interventions.

   Most podiatrists do not have access to a full gait laboratory that has a force platform with video vectors, an electromyography amplifier or a 3D motion analysis system. There are also some expensive new wearable sensors that are beyond the scope of this discussion.

   So what can you do with limited technology and time? I suggest a stepwise approach for gait investigation in order of increasing sophistication depending on what is available to you and how much information you need. Keep in mind that advanced equipment will require more time, money and support staff to maintain and support it.

1. Perform a quick observational gait analysis, simply noting anything that strikes you as abnormal including the use of assistive devices.

2. Ask your patient to change into shorts and a T-shirt to help visualize arm, leg and knee motion.

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