Walking is such a routine activity that unless you have difficulty with it, you really do not even think of it. The Greek philosophers from Aristotle to Socrates viewed walking as a central tenant of the essence of man. The ability to walk is so natural to what we are, it is analogous to breathing. From ancient times to the present day, walking is what a child most desires to master and what an old man most loathes to give up. That is why it is so “crushing” to lose this ability though matter the reason.
As a physical therapist, I have felt the despair of many patients over the years as they engage in the struggle to restore this ability. Many battles. Many outcomes. A great deal of attention on the topic by many people including myself has been on the subject of walking. Everything from its health effects to exactly what it is in terms of the mechanics continues in earnest.
I hope though that instead of “lecturing”, that I can merely “walk you” (pun intended) through my experience, how I exactly came to my understanding of the act, and how to best restore it when lost.
In the 1980’s, gait analysis as described by the late Dr Jacqueline Perry, MD, PT. was all the rage and for good reason. She and her colleagues at Rancho Los Amigos National Rehabilitation Center did at the time, the most comprehensive study of the mechanics of gait, both normal and abnormal. It put that organization on the map. Her work was the standard of gait analysis and training. I have read her textbook and studied it extensively over the years. My professional understanding of gait is largely due to the work of Dr Perry.
Her work though is very research oriented and comprehensive. It does not readily lend itself to the on the ground, day to day clinical “grind”. So, the reality is that key markers of her analysis are synthesized when working with patients. This is purely practical. Obvious metrics are selected such as symmetry of the steps, foot clearance during swing, "step to" pattern and so forth.
An attempt to comprehensively describe gait when assessing and even when treating using Perry’s method would be impossible. Using key metrics of normal walking though is vital. Knowing the details Perry describes is therefore important. The problem though is that there is not a uniform methodology. At best there is a loose consensus on the description of gait. Even less uniformity in terms of gait restoration. The approach can vary quite a bit as can the outcomes.
When a patient has an intact nervous system and the gait impairment(s) is mild, the restoration is straight forward, and with a degree of diligence even severe problems can resolve with fairly good outcomes. In neurology, the entire process can radically break down as the body readily compensates and manifestation of abnormal postures, perceptions and responses occur. Even when the therapist and patient are both aware and trying to resolve the problems, they persist and may evolve into more severe and long standing disability. These compensations are perceived by the therapist and sometimes by the patient as inability to position properly, weight shift adequately, or to control body parts accurately. Over time if the normal movement is not restored, the compensated patterns are reintegrated as normal from the point of view of the patient’s nervous system.
I cannot tell you how frustrating it is for the therapist, patient, and family to work hours, weeks, months, or even years and though matter how good a session was, it seemed to be in vain. The patient walked out reverting and reinforcing the compensated pattern. That led me to just wanting a portable scale in a shoe to at least give the patient and myself an indication of when all the weight was on the foot. This simple “want” turned into a career altering experience. The discussions with therapists in the field had been going on about this since I started practice and doing something about it started in 2012.
In 2017, the first prototypes were created and tested. Simple, but promising. By 2020, the feedback was rich and understanding the gait cycle for me radically evolved. It was no longer for me the traditional or Perry descriptions.
It changed to an image. An image which is comprised of four(4) distinct vectors of a person’s center of mass or predominant weight. Something that could now be seen, monitored, and used to guide therapists, patients, and caregivers to normal parameters. Not only “simple”, but also universal. The foundation of the analysis and treatment was upon the body’s predominant weight (referred to in mechanics as Center of Mass) as it tracks over the feet and field of balance.
Of the many discoveries, the best was that in short order a patient and caregivers could understand and see the problem as they worked to restore the gait pattern. For the acute and subacute, this is profound. It has the potential to prevent chronic and severe gait and balance dysfunction from developing, even in the more involved cases. Furthermore, it gives opportunity for the chronically impaired to exact meaningful change or improvement, not just maintenance and conditioning.
The complexity of walking could in fact be distilled down into its simple essence. The signal above can only be produced if the walking is normal. So, train the patient to produce this signal and you have trained them to walk normally. This includes all the aspects of walking including posture, swing, and control. In order for that signal to be produced, the individual must work in a normal fashion.
These vectors are produced in the following manner (see figures 4 – 7):
The clinical implications are revolutionary. Using real time feedback, the therapist has a tool to guide the patient’s walking in a highly objective and scientific way back to normal. It was a slow start, but this eventually is what happened. We learned to utilize the technology to guide the therapist, patient, and caregivers in restoration of normal walking.
The walking training exercises below are universal to each patient. They represent the foundation to restore the 4 vectors of walking within the patient’s balance field. See figure 8: A montage of the feedback exercise the patient and therapist observe during training.
These screens have evolved over time, but the concept is unchanged. Restore the patient’s ability to control the predominant body weight or center of mass in these vectors and you can restore the ability to walk.
Utilizing this concept, a severe TBI, stroke or other severely impaired patient has a chance of going from a chronic impaired pattern with limited gait to a normal independent community pattern (figure 10).
Even in cases of severe trauma in which the prognosis is poor, guided therapy using this technology has the potential to yield remarkable results ( Figure 11)
The initial results of this novel method using real time feedback to assess, train and restore the ability to walk in acute and chronic patients alike are compelling. The technology is in the early stages and there is so much more to learn. The Envision System technology of today is the equivalent of an entire lab in the 1980s plus additional capabilities not even thinkable at that time. It is an exciting time in the realm of technology assisted rehabilitation. I am grateful to have been able to play a role in this advancement.
Warm Regards
Dr Michael J. Malawey, PT
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