As a doctor of chiropractic, how you perform your initial evaluation and management on a patient may vary greatly from your peers. Many doctors’ examinations include numerous neurological and orthopedic procedures. Do you rely heavily on visual and palpatory findings, range of motion studies, or maybe totally on radiographic findings? For most of us, it is probably a combination of all of the above, with our final goal being the location of the vertebral subluxation complexes we feel may be creating the patient’s symptomatology, or restricted range of motion or alterations in their gait cycle. Does the patient present with an acute antalgic gait, neurological gait or is it a postural gait that has developed over time, either through poor posture or compensation due to pain?
What about adolescent patients whose primary complaint is a parent’s concern over the turning in or turning out of a foot or leg while he or she is standing, walking or running? We evaluate the patient for some type of subluxation complex that may be causing the foot or leg to turn out or in. Once we have located our subluxation complexes, we begin our treatment plan of Chiropractic Manipulative Therapy (CMT) to help reduce and stabilize the subluxation complexes.
Our treatment plan may also include nutrition, rehabilitative exercise, and an assessment for Spinal Pelvic Stabilizers. Our rehab may include providing patients with instructions on exercises using a rehab band, Thera-Ciser™, or doing isometrics against a wall. We may even teach parents how to do isometric and resistance exercise to counteract the internal or external rotation. We may recommend the use of Spinal Pelvic Stabilizers to stabilize early stages of hyperpronation that result in a common finding of foot flare.
But is that enough? One of the main issues we must address is the patient’s gait cycle. Visually watching a patient via video tape, or just visual observation as he/she walks down your hallway may give you clues to biomechanical alterations and muscle imbalances. To many of us, analyzing and gait retraining may not be considered a form of rehabilitation, but it should. We even have CPT coding for billing purposes. Gait Training 97116: training of the manner or style of walking, including rhythm and speed—each 15-minute intervals. Neuromuscular reeducation 97112: reeducation of movement, balance and/or proprioception for sitting and standing activities.
We must introduce neuromuscular re-education. If the patient does all the exercises we provide, but then goes outside and walks and runs, she will immediately slip back into the pattern that her body has become accustomed to. One way we address this phase of our treatment plan is by providing a regime of gait pattern exercises she can do at home. All that is needed is a hallway, mirror and string.
Ask your patient to use a long hallway or a walkway that is approximately twenty to thirty feet in length. At one end, ask your patient to stand in a normal posture and mark the floor with a piece of tape or sticker to indicate the width of her foot or feet. Make sure you have reviewed this with your patient in your office, in case you feel the clinical need to widen or narrow her stance. Then place two strings from those marked locations to maintain the same width the length of the hallway.
Finally, place a mirror at the end of the hallway. This is for the purpose of visual feedback to make sure she is walking in the desired pattern you have recommended. This may be establishing memory of a correct heel strike, midstance, and exaggerated toe-off. It could be as simple as just making sure the foot is placed directly straight on the line without any internal or external rotation. Again the purpose of the mirror is to allow that patient to walk in as normal an upright posture while looking forward at the mirror to check foot placement. If she looks down at her feet as she does the exercise, then we are introducing an abnormal pattern.
As a point of consideration, once your patient comes to the end of the strings, have her walk backwards, while still maintaining proper foot placement on the strings. Backward walking is an excellent addition to help with balance and unsteadiness. It also helps re-educate the musculature in a reversed pattern.
I recommend three sets of fifteen repetitions (a repetition being down and back as one) twice per day. The speed at which you have the patient go originally is a slow natural walking pattern. The focus here is not how quickly she can do the activity but making sure the feet come down in a heel strike position on the line followed by correct placement of mid-stance, and toe-off of the line in a straight pattern.
Earlier we mentioned gait retraining as a concern for why the patient entered your office in the first place with respect to her child. To help assure compliance with the adolescent, try developing a contract between you and the patient—the ultimate goal being ice cream. We have children sign a contract stating they will do their exercises daily for fourteen days. It has two columns with lines for a parent’s signature as well as the child’s signature. Once the contract is completed, that child is able to bring the signed contract back to the office to receive a coupon for a free small hot fudge sundae or milkshake. It’s a very cheap, yet fun way to help with compliance from your patient. (If you would like a copy of our contract we will be glad to fax it to you. Just fax your request to 517- 629-3805, asking for the "Child rehab contract.")
Often, with our chronic patients, some type of reaggravating condition is usually an underlying factor. This may be from an old, worn-out mattress, poor sitting posture, wearing improperly fitting shoes, or just a poor adaptation to lifestyle. After you have introduced your treatment plan of chiropractic adjustments, rehabilitation, nutrition or any other adjuncts you use, do not forget to evaluate the patient’s gait cycle. It could be the difference between your patient’s being able to return to and enjoy a normal healthy lifestyle.
A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan. He is very active with the Michigan Chiropractic Society serving on the legal and government affairs committees.