Walking. The most foundational and functional movement pattern we do every day. This subconscious movement pattern is often taken for granted however the implications of poor walking metrics is actually a huge predictor of vitality and longevity. In fact a 2009 publication by Fritz et al. referred to gait as the 6th vital sign.
Walking Speed, the Sixth Vital Sign
According to Fritz, the aspect of gait that is the most reflective of function is walking speed.
Walking speed is a reliable, valid, sensitive and specific measure that correlates with functional ability and balance confidence.
In addition, it has the potential to predict future health status and functional decline, as it reflects both functional and physiological changes and aids in prediction of falls and fear of falling.
Regression of walking speed has been linked to changes in quality of life, reduced independence, isolation and cognitive decline – all of which are increasing financial burdens on the health care system.
I agree with Fritz about the importance of walking speed as an assessment measure for vitality, however what is missing from this article is the “then what”.
If a patient or client has demonstrated a dramatic decrease in walking speed, what is the course of action for the physician?
What steps need to be taken to determine “why” the patient has slowed their walking speed?
Not all patients slow their pace for the same reason and I argue that it is necessary to understand the cause of decreased walking speed in order to effectively use this metric as a vital sign.
Determinants of Walking Speed
Gait metrics and the coordination of walking mechanics is quite complex however for the sake of this article we will review three of the main contributors that I look for when addressing slowed walking speed in my patients.
- Balance (Single leg stance)
- Mobility (Joint range of motion)
- Fascial Flexibility (Tissue hydration)
Balance & Walking Speed
Our ability to stand on one leg was one of the most important developments in the evolution of bipedalism. I often say that the single leg stance is the most functional, postural position we can train our clients in as it transfers to walking, running, climbing stairs, almost every closed chain movement.
As we age, one of the first functional changes is a decline in our balance. Medication, peripheral nerve disease, poor vision, loss of hearing, and central neurological conditions, all can contribute to compromised balance.
As a Functional Podiatrist I like to begin my balance assessments by understanding the clients foot function and asking myself the following questions;
- What is their perception of the ground?
- Do they have any neuropathy or impaired sensation?
- What footwear are they wearing?
- What is their foot strength?
Perception or the ability to sense ground is obviously necessary to having great balance. If we cannot perceive subtle shifts in our center of gravity then our reaction time will be slower, medial lateral sway will increase and falls are almost inevitable.
If you have a patient with impaired foot and ankle perception there are a few ways to improve their awareness:
Transitioning an older patient to more minimal shoes may be one of the most important things you can do for them. Many studies including one by Robbins et al demonstrated that footwear with soft midsoles can decrease foot awareness and stability, both of which can contributor to fall risk.
A more minimal or transitional shoe that provides more proprioceptive information can play a very important role in ensuring the patient can feel their feet and the ground. If the patient refuses to switch or cannot switch to minimal shoes due to fat pad atrophy, thin skin or other concerns this is where the Naboso Insoles are great. The Naboso textured insoles bring sensory stimulation into any shod environment which can make the foot in a soft, cushioned shoe more connected to the ground.
Another great benefit of the Naboso insoles is that they can actually strengthen the foot, which is another requirement for optimal balance during gait.
Foot strength, especially intrinsic muscle strength is an important predictor of balance and stability. A 2020 study by Quinlan et al. demonstrated that toe flexor strength contributes to improved postural balance for people over the age of 60. Incorporating weekly foot strengthening exercises into the patients routine can create great returns on their overall balance, stability and walking speed.
My go-toe exercise for building toe flexor strength is of course short foot!
Mobility & Walking Speed
The second most common contributor to impaired walking speed is joint mobility. The mobility required for optimal ambulation is not just that of our foot. We have 4 main regions of mobility for optimal walking speed. This includes: the t-spine, pelvis, ankle and great toe.
Let’s start from the top and work our way down.
The mobility needed in our t-spine and pelvis is in close association with each other and is synergistic. This means that if we lose mobility in one area, we most likely will lose it in the other.
Every time we take a step. our pelvis and t-spine rotate and counter rotate relative to each other and essentially cancel out the rotations that are happening in the body. This may seem counter intuitive but it is necessary for keeping our head and eyes level to the ground.
Imagine taking a step with the right leg forward, your left arm should be swinging forward. This reciprocal arm swing is matched with a counter rotation between the pelvis and t-spine.
In my office, I find two main contributors to a loss of t-spine and pelvis mobility: an increase in sitting or sedentary lifestyle and decreased walking speed due to lifestyle.
Firstly, the more we sit throughout the day the more our hips and pelvis tighten. Hip extension decreases and the pelvis starts to posterior tilt. A loss of hip extension and sagittal pelvic mobility further locks down our t-spine and slows are walking pace.
Secondly, the way we walk today is very different from the way man evolved to walk.
In the wild, with wide open fields and distance to cover we were forced to take long strides with a powerful arm swing. Today we drive everywhere and then walk the short distance from our car to the store, or around our office or home. This type of gait pattern is what I call staccotic – small steps – functionally shortened stride as we don’t have much distance to cover.
Regardless of the cause of restricted pelvic and t-spine mobility, it is needs to be addressed in these patients. One of my favorite mobilization techniques is one I learned from Gary Gray. I’ll have my patients do this every day as part of their mobilization series
The next are of the body that I often see a decrease in mobilty is the ankle.
Again a sedentary lifestyle and cushioned shoes can contribute to limited ankle mobility and a compromised walking speed. When we walk, we need at least 5 decreases of ankle dorsiflexion which doesn’t sound like a lot, however so many people are limited even to get just this 5 degrees.
Often associated with tight plantar foot muscles my go-to for increasing ankle mobility is to actually address the bottom of the foot.
This is my favorite 5 minute foot release which can be done with RAD Rounds or the all-new Neuro Ball
Finally, and potentially the most important, is the great toe mobility.
Often overlooked by most specialists, the great toe is THE limiting factor when taking a long stride. For each foot we try to increase our stride, we need an increasing amount of dorsiflexion in the great toe.
Bunions, arthritis and over-pronation are some of the most common contributors to limited great toe dorsiflexion. A thorough great toe assessment should be done on all patients in which walking speed is being measured as a vital sign.
The topic of assessment and correcting great toe dorsiflexion is quite complex and is beyond the scope of this article however I have a great 3-part blog series I wrote on this topic that I highly encourage you to read. Great Toe Mobility Blog Series
Fascial Flexility & Walking Speed
The final aspect of walking speed that I find often begins to deteriorate with age is fascial or connective tissue health. Age, hydration, injury history, activity, diet, so much can affect the health of our connective tissue.
Made up of primarily water, collagen and elastin our connective tissue is everything to longevity!
From our fascia and tendons to our blood vessels and bones, so much of our body is made up of collagen and collagen proteins.
There are three main aspects of connective tissue health that I like to address with my patients: hydration, collagen crosslinks and inflammation
- Hydration is probably the most obvious of the three. Not only does hydration mean to ensure we are drinking enough water and electrolytes but it refers to movement as a form of hydration. Movement, especially reciprocal patterns, hydrate our fascial tissue by essentially ringing out our fascia like a rag. With every rotation more and more hydration is brought to the tissue. This is where some people will say “motion is lotion” – which is true!
- Crosslinks are the stabilizing backbone of our collagen however not all crosslinks are created equal. There are two forms of crosslinks in the body – enzymatic and non-enzymatic. Or you can say natural ones, and unnatural ones. The unnatural, non-enzymatic cross links are like a kink in a hose and are caused by excess glucose in the body which oxidizes, creating free radicals. I often will tell patients that excess or uncontrolled sugar in the body causes stickiness in the tissue. If we are sticky we cannot move with the same joint mobility.
- Inflammation is another form of stickiness. Inflammation from joint stress, arthritis, tendinitis, free radicals, oxidative stress, psychological stress and diet can all cause increased stickiness in our connective tissue. When inflammation is around a joint this stickiness is can cause capsular contractions which takes away our joint range of motion.
From the above you can see how complex walking speed as a vital sign can be. We want to make sure that we are not just collecting data on our patients and then not giving them a solution to correct and improve their score.
A thorough understanding of the exact “why” is important when using walking speed as a vital sign.
Like all vital signs, I take the approach that preventive medicine is the best medicine. This means to start addressing the above influencers of walking speed now, before any changes in gait occur.
Get in the habit of addressing balance, body awareness, joint mobility and fascial health. It is always easier to pre-act than to react when it comes to medicine.
Dr Emily Splichal, DPM, MS