August 2016

Out on a limb: Falling in with feedback

1Limb-JordanaBy Jordana Bieze Foster, Editor

One of the interesting things about LER’s multi­disciplinary perspective is being able to follow a new idea as it is examined and embraced by one specialty after another, each with its own therapeutic goals and challenges. The use of visual feedback for gait retraining is a recent example of a therapeutic innovation that seems to be gathering multidisciplinary momentum.

This type of intervention typically involves a patient walking or running on a treadmill while looking at a computer screen that displays a graphic representation of a variable of interest (eg, muscle activation) and a target range for that variable. Graphics are created during gait based on measurements taken by instruments within the treadmill or external to it (eg, an accelerometer). The patient is then instructed to alter his or her gait in ways that will keep the graphics within the target range.

Published studies on visual feedback-based gait interventions started appearing in the medical literature in the 2000s, which probably means they were being used clinically for a few years before that. Early studies involved electromyographic feedback to improve ankle function in stroke patients with hemiparetic gait, peak positive acceleration feedback to reduce loading in runners, and dynamic knee alignment feedback to reduce knee adduction moment in patients with knee osteoarthritis.

Now it seems the visual feedback gait retraining trend has caught the attention of clinicians who treat foot conditions in patients with diabetes. Last month, at the annual meeting of the American Podiatric Medical Association, a poster described preliminary research from Rosalind Franklin University in Chicago using peak tibial acceleration feedback to reduce tibial accelerations and ground reaction forces during walking and jogging. Although the data presented involved healthy volunteers, the goal of the project is to apply the same techniques to reduce loading in patients with diabetes and diabetic neuropathy.

It’s hard to think of a patient population that could benefit more. Exercise has multiple benefits for patients with diabetes—from insulin regulation to weight management to cardiovascular health—but the loads and shear forces involved, especially for overweight patients and those with neuropathy, can put diabetic feet at risk for ulceration. Research suggests that exercise is not contraindicated in patients with diabetes, even those with neuropathy, but experts agree that caution and monitoring are warranted (see “Exercise and neuropathy: Not mutually exclusive,” July 2011, page 22). Any intervention that can provide the benefits of exercise while reducing the risks is one that deserves serious consideration.

One of the most attractive things about visual feedback-based gait retraining is that patients aren’t meant to be attached to instruments forever. Studies have shown patients can retain their new gait patterns even as the feedback is gradually diminished over time, and eventually don’t need the feedback at all. One would think this would be particularly true in patients with diabetes who are losing body mass and gaining fitness throughout the process.

It’s an exciting trend with potential benefits for so many different patient populations. I can’t wait to see where it will pop up next.

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