The Ethics of Doing a Gait Analysis

I often enjoy playing the provocateur and can frequently make statements to have that effect. They are not done to be mischevious but are typically done to encourage critical self-reflection, mostly in the context questioning one’s own clinical practice and reflecting on improving that. There is always a context and a purpose. Often those comments can be a bit extremist, but the purpose is to encourage that self-reflection on one’s own views and own practice. However, sometimes some of those comments can be taken out of context and portray a meaning that was not intended.

On Facebook, Kettlebell Physio posted a comment that I have frequently made, this time from one of the PodChatLive interviews that I do with Ian Griffiths. The comment is something I frequently make as part of my clinical biomechanics boot camps. I have no problems with what they posted:

It gives me an opportunity to litigate the issues and provide some context to what I am talking about.

The big picture issue is what is the ethics of doing any clinical test or clinical investigation if the outcome of the test or investigation has no potential to alter the intervention? A typical example would be the use of plain x-rays at the initial consultation for a plantar heel pain that all clinical signs point to one obvious thing. What is the ethics of that x-ray (in the context of the minuscule amount of ionizing radiation exposure and the financial cost to the patient)? What is the potential for the outcome of the x-ray to alter the treatment? Probably none. (I am not talking about the 1 in a million chance of it being a bone tumour; the ethics of PYBM (‘protect your butt medicine‘) is a separate ethics issue). The recent consensus document from ACFAS supported not doing that initial x-ray. That does not mean that you do not do the x-ray (and/or other investigations) down the track if the condition is not responding how it should – but at that stage, the potential of the x-ray to alter the treatment is greater as you reached the stage of ruling out and looking for the ‘zebras'(1).

Hopefully, that principle makes sense with that example: ie what is the potential of the test or investigation to alter the intervention? That then leads to the question of what is the ethics of doing that clinical test if it has no potential to alter the intervention?

So what about a gait analysis? This is widely and commonly done as part of a clinical assessment of many types of patients and conditions, as well as at the retail level for the “prescribing” of running shoes. What is the potential of the gait analysis to alter the intervention? What is the ethics of doing a gait analysis if it has no potential to alter the intervention? (By intervention, I mean different foot orthotic design features; a change to the running technique; or different running shoe; or exercises; etc).

I used to teach gait analysis to the students. I used to use it routinely (visual down the corridor and on a treadmill with and without a video; and in-shoe plantar pressure systems). I used to be a big advocate of it. However, I went through a stage in my own clinical practice where I would assess someone, check them out, consider the history, etc and pretty much make a decision on what I consider needs to be done before doing the gait analysis. I eventually came to the realization that the gait analysis was adding nothing to my clinical decision-making process. I was only doing the gait analysis because that is what you are supposed to do. That troubled me. That raises ethical issues of charging for a service that was not helping me make a clinical decision. That troubled me. It did, however, make it easier for me to convince people to part with money as it looked as I knew more about what I was doing as I had done the gait analysis. That troubled me. (Hence, the quote of mine above that KettleBell Physio made form the PodChatLive discussion).

So you could imagine the critical self-reflection that I went through at the time trying to resolve that cognitive dissonance. Hence, in the courses I teach I do tend to take a bit of an extremist view and ask people to think about their own clinical decision-making process and how much the information that they were getting from the gait analysis (and other tests and interventions) that was actually altering the intervention that they used. A hallmark of any good health professional is those critical self-reflective skills and that is often not easy and can be painful. Its all about moving people outside their comfort zone, hopefully to make better clinicians. This also has to be done in the context of the evidence.

Having said all that, I still do use a gait analysis clinically and still do advocate its use. However, that process I went through has changed my practice (which is what it is supposed to do). The gait analysis is now focused on looking specifically for things that I do know will change my clinical decision-making process if they are present and not wasting time looking at those things that do not have the potential to change the process. It is not about impressing the patient that I know what I am doing (though, yes, I do want to do that), it’s about focusing on what information is needed to make clinical decisions as to the recommended intervention.

There are lots of gait systems that come with all sorts of ‘bells and whistles’ and produce pretty pictures that can really impress people. If another health professional down the road from you has one of those, their patients are probably going to be more impressed than your patients. That is going to put you at a competitive disadvantage and puts them in a position to convince people to more easily part with money for whatever intervention they are recommending. This still comes down to ethics. Was their clinical decision-making process as to the intervention altered by the ‘bell and whistles’? Probably not. I am sure you can see the ethical issue.

What about video gait analysis at the running shoe retail level? Same principles. Firstly, a running shoe store that does a gait analysis is trusted by runners (see this study), despite some data that you are at increased risk for injury if you got running shoes following a video gait analysis. Secondly, a running shoe store is at a competitive disadvantage if they do not have a gait analysis as runners have come to expect it. The question then is, is the recommendation as to what shoe is better altered as a result of that gait analysis? Think about that. Would the same recommendation be made without the gait analysis if other things were considered to decide on the design features that should be recommended for that runner? I not saying yes or no. I just saying reflect on it.

As always, I go where the evidence takes me until convinced otherwise …. and all the above has to be done in the context of the best available evidence.

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(1) There is an old wise clinical saying that when you hear hoofbeats, think of the obvious when all the signs point to it probably being only one thing – horses. Later you can consider that it might be zebras.

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5 Responses to The Ethics of Doing a Gait Analysis

  1. David Meilak January 14, 2018 at 7:32 am #

    I agree with you totally. I own a pressure mat system. The reason i purchased it was due to the fact that we are getting to a point where people would call for an appointment and specifically ask if we have a pressure mat system or not. There were cases when people would not book an appointment unless we confirmed that we had the system. What’s happening is that people have been duped into believing that a machine can decide a clinical outcome better that an experienced practitioner. While i totally agree with you regarding the ethical side, we are having a problem with losing needed income if we dont keep up with this warped logic.

  2. Emma Cowley January 14, 2018 at 8:36 am #

    It would be really interesting to audit clinical outcomes after orthotic therapy informed by gait analysis vs not. I too have been through a similar reflection and the times it has been invaluable (even 2D treadmill) has been spotting timings of reported pain and movements eg I saw a lady who had ruptured her 1st TMTJ plantar lig after falling down the stairs but it hadn’t been picked up or treated in the ED or orthopaedics. It showed up in late midstance as a subtle second ‘arch dip’ in the distal arch and she’s had a plate fitted since. Also it can be useful as a pink flagging tool: to motivate the patient in rehab. Before and after can be really powerful especially if correlating to changes in comfort or pain. But, like you, I’m looking for nuances that will inform both rehab and orthotic or other mechanical therapies. Ref the ethics… it’s a great way to maximise placebo and if it helps improve outcomes who are we to judge 😉 but yeah, charging the Earth when you know your gait analysis is achieving ONLY that is dodgy mcdodgy. For that reason it’s something I spend time making sure undergraduates are really good at (and have an OSCE exam on) so their analysis is just that: analysis not just watching the heel evert *yawn*. Good to question these things Craig, keep up the good work

  3. David Holland January 14, 2018 at 9:37 am #

    I pretty much agree – and David makes a good point too (above). I rationalised taking pressure map readings on the basis that the patient notes now had a baseline set of data. I think I still stand by that, especially for paediatrics (where its really quite useful to know if the child exhibits early heel lift and/or 1st ray adductus during gait). Of course diurnal variation per reading must be factored into the equation. How accurate is the data you just recorded, and by extension, how valid and how valuable?

  4. Dany Lafontaine January 15, 2018 at 3:22 pm #

    Not being a clinician myself, I find this topic quite interesting. i’m of the opinion that more objectivity is brought into the process through use of technology, obviously when appropriate. There are conflicting priorities for sure, as there,s a need to show the customers that you mean business and that you’re up to snuff on the latest. I agree though that lots of these tools can be bells and whistles and in the wrong hands can become pretty useless. All that to state though, that I think that a second set set of eyes of the technological kind can only help and confirm what the clinician’s assessment was.

  5. Steve January 15, 2018 at 4:39 pm #

    Great article Craig. When I went through my Pedorthic training I was told the gait analysis was for two reasons; 1- to confirm to the clinician what the treatment plan was going to be (which may or may not include custom foot orthotics) and 2 – to show the patient what you may have been describing during the initial assessment/consultation.

    Often times we forget that the average person doesn’t understand what our terminology is, so showing them a video etc can visualize what we have verbalized, and it can help them see why they may be having issues.

    But as you stated, the gait analysis is part of the overall package, not a sales tool!

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