Are we obsessed with gait: what about walking?
A guest post from Ralph Hammond
Most physiotherapists, in many parts of the world, will spend some part of their working life helping someone to walk. We often call it gait re-education; sometimes, walking practice. We hand over to ward staff what someone’s “mobility status” is; increasingly, we use technology, such as treadmills or step counters, to support these endeavours. But to what purpose?
“How we walk, where we walk, why we walk, tells the world who and what we are”
Geoff Nicholson 2008 The lost ort of walking Riverhead Books (Penguin), London, England
One weakness of our focus on impairments might be that it becomes overly instrumental. Within many services, this is recognised, even valued: the goal to walk from bed to chair to determine whether a person can go home again is important, especially in our covid19-times; to walk far enough to return to work is a financial imperative for many.
The Critical Physiotherapy Network has been established to help us question what we often take for granted; to challenge us to reimagine ourselves in how and why we do the work we do.
However, if we stop, pause, and reflect: is that our real aim, purpose, and all that we have to offer? Should instrumental gait re-education be the sole focus of our attention or a means towards an end? It is often said that medics save a life, therapists make that life worth living. So, how do we conceive of our efforts, and what language do we use to portray these conceptions? Do we phrase the goal in our physiotherapy jargon; could we better use the words and aims of the people we serve?
What are we doing when we walk? Are we “mobilising”, or are we hiking, strolling, sauntering, roaming, promenading, rushing, ambling, marching, wandering, strutting? Do we focus rehabilitation on supporting someone to return to these types of movement? Could we be laying the groundwork for these sorts of ideas, sowing seeds?
Recent podcasts have got me thinking:
The 30-minute podcast from the BBC Something Understood programme, On Walking, is a beautiful meditation of songs, quotations, and reflections on the meaningfulness of walking https://www.bbc.co.uk/programmes/b00wkp9y
To what purpose do we walk? It might be to get to the toilet, and it might be for “health reasons” or fitness; to meet a friend or join a group; to “get into nature”, improve our mental health, to meditate (a walking meditation anyone?) or for “culture”. We might walk with purpose, to get from A to B, or be aimless, or drunken, or for romance.
The longer 60-minute podcast on Walking from the Overthinkpodcast.com considers why so many philosophers place so much emphasis on the benefits of walking to aid thinking
Episode 43 Walking.
I like the idea of a physiotherapist as a bricoleur, someone who makes use of a range of information and evidence to inform their artistry (Shaw JA, DeForge RT. Physiotherapy as bricolage: theorizing expert practice. Physiother Theory Pract. 2012 Aug;28(6):420-7. doi: 10.3109/09593985.2012.676941. PMID: 22765212.).
Perhaps we can incorporate new sets of ideas, languages, insights from a wider range of disciplines to remind us that we provide gait re-education to support people to live their lives in the world: history studies, sociology, philosophy, anthropology, urban geography, social/urban planning, disability studies.
A special issue in the Journal of Transport & Health is a case in point (Walking and Walkability: A review of the evidence on health https://www.sciencedirect.com/journal/journal-of-transport-and-health/vol/5/suppl/C). This might prompt us to reconsider our role and place in society, for example, what is the need to consider someone’s walking speed after a stroke? What will they use their walking for: if it is to walk in the community, then do we understand what speeds people need to achieve? Do we aim our interventions at increasing a speed that will enable them to cross the road safely? The assumed minimum walking speed at pedestrian crossings is 1.2 metres per second; navigating a kerb is calculated as taking 1.5 seconds.
It’s not just stroke: in a recent study of ambulatory people with COPD, mean walking speed was 0.91 m/s with only 10.7% walking at a speed equal or greater than 1.2 m/s (Nolan CM, Kon SSC, Patel S, et al Gait speed and pedestrian crossings in COPD Thorax 2018;73:191-192).
Should we solely focus our efforts at the patient level – or must we become political and be more publicly engaged? Should we challenge the apparent prioritisation of road use by cars over its use by pedestrians; a prioritisation that leads to traffic signals changing too quickly, increasing the risk of accident or death?
How should we conceive of gait, of walking; what language might we use; what focus could we bring to bear?