The Blog

Parkinson’s Association of Southwestern Ontario

KAL Orthoses was recently asked to publish an article for the Parkinson’s Association of Southwestern Ontario. Below is the publication, even before it goes to press!

Each and every one of us, at some point in our lives, will experience a life-changing event. Car accidents, athletic injuries, illness and death can all fall into these categories. One’s perception, understanding and support systems all play vital roles in the coping mechanisms we apply as survival. When my father was first diagnosed with Parkinson’s disease(PD) this condition was his life-changing event. Activities of daily living slowly became more challenging, and previously simple tasks required increased time and effort. My mother quickly stepped into the role of caregiver, learning that patience and encouragement are her two strongest tools of emotional support. Together they have learned that their perception of the PD condition can be altered with increased understanding. As knowledge on disease progression and treatment options increased, their grasp and control over the condition equally increased.  Through the eyes of daddy’s little girl I watch a disease altering my dad; however through the eyes of a clinician, I appreciate and find joy in helping him and others. Similar to my parent’s personal growth over the last few years, my increased clinical skills and knowledge in PD has shaped both personal control and clinical individuality. My knowledge in pedorthic care as it applied to PD is a constant working progress, as each new PD patient visits my clinic. The following information provides some clinical information on pedorthic interventions applied to patients with PD.


WHAT IS PEDORTHICS?

The science of pedorthics involves specialized lower limb care. A certified pedorthist is the only foot care practitioner who specializes in the assessment, manufacturing, fitting and modification of foot appliances (orthoses) and footwear. A comprehensive and educational assessment consists of a detailed history taking, static and dynamic weight-bearing evaluations, as well as non-weight-bearing range of motion testing. Based on our findings, we determine the right solution for each patient’s unique qualities and symptoms.

 

PEDORTHICS AND PD

Gait

Shuffling steps, a slow walking speed, small stride length, reduced arm swing and rigid trunk movements are common notable changes in gait with most patients suffering from PD. These changes to motor control result in poor balance, loss of coordination and can consequently result in increased incidents of falls. In the more advanced stages of PD, freezing gait poses an additional challenge.  As pedorthists, we try to alter inefficient gait characteristics enabling a much easier ambulation for the patient. For example, patients with PD often exhibit a slower heel-to-toe response during walking than a patient without PD. Secondly, it has been noted that immediately before the occurrence of a freezing episode, there is a rapid shift in this heel-to-toe response. This rapid shift in the gait cycle is the primary reason for freezing episodes to result in a fall. Furthermore, as this shift occurs at lightning speed, the patient is unable to get their walking aid (i.e. cane, walker) under their center of gravity quick enough to avoid falling.

From a pedorthic treatment perspective, two important questions need answers; WHAT and HOW. The patient is educated on the characteristics of their unique gait cycle. A video-gait analysis is an irreplaceable tool allowing a frame-by-frame view of each individual step.  Based on the patient’s unique gait characteristics, we discuss together how we will achieve a more efficient gait pattern.  Footwear and orthotics are often part of the comprehensive treatment plan.

 

Footwear and Orthotics

Secondary to the notable changes observed in gait, patients with PD commonly experience leg cramping and stiffness. Keep in mind that gait is being altered from what is considered ‘normal’. As a consequence, two things are happening at the level of the lower limb musculature; certain muscles that are inactive become rigid, whereas other muscles are getting overused. In such circumstances, orthotics can promote efficient gait patterns, thus decreasing excessive muscular demands. Orthotics can additionally increase natural shock absorption, and redistribute the pressures across the foot, resulting in an increased base of support and increased balance.  This change in proprioceptive feedback is crucial with patients experiencing unsteady gait and decreased stability from a forward flexion of the trunk when walking.

Keep in mind that an orthotic only works as good as the shoe you put it into! An important note pertaining to over the counter footwear is the individuality of walking/athletic shoes. Athletic footwear is broken down into various categories, from cushioning to motion control… and everything in between! Based on your gait analysis, its important to choose the appropriate category of footwear according to your mechanical profile.

The following are a few additional key considerations when choosing your next pair of shoes:

  1. Keep it light! – A lightweight shoe will allow for an easier ground clearance during the swing phase of walking.
  2. Bottoms Up! – Check the bottom soling ms of your shoe. This material should have a wide base of support from heel right through to the end of the toes. This will increase your balance and control with each step. Additionally, a soling material increasing friction to the ground will be beneficial over a smoother surfaced material.
  3. Flexibility is not your friend! – You should not be able to wring your shoe out like a towel! Torsional stability of footwear is key for maximum support. We want the shoe to control the movement of your foot, and not the other way around.
  4. Pop your collar! – The heel counter of your shoe (the back of the shoe around your heel) should be strong and stable. A quick test of heel collar strength can be done by placing your thumb in the center of the heel counter, and pushing towards the middle of the shoe. The heel counter should not collapse into the center of the shoe. Keep in mind that your heel is the first part of the foot that contacts the ground during walking. This part of your shoe should be snug to the foot, and provide maximal movement control.
  5. Let those toes wiggle! A wide toe box (the area of the shoe wrapping your toes) should be wide enough to let those toes wiggle. In cases of poor balance and proprioception, our toes have a tendency to claw the ground as means of “gripping” and increasing the feeling of support. In some cases, toes may remain clawed or hammered as a result of their constant muscular contraction. A wide toe box allows your toe musculature to function more efficiently, and provides a better fit for them in the shoe.
  6. Adjustability! – A shoe with adjustability (i.e: laces, velcro, buckles) will always provide a better fit to your foot than a slip-on shoe. Consider elastic laces in cases where hand tremors pose difficulties with tying standard laces. Elastic laces will provide the benefits of a slip-on shoe, while providing the support of adjustability.

 

Kelly Levac-Robb

Canadian Certified Pedorthist
KAL Orthoses CEO