Background

The WHO cites low back pain as the leading cause of years lived with disability and recommends physical and psychological therapies rather than pain medication and surgery.1 Walking programmes for those with chronic low back pain (CLBP) have demonstrated decreased pain, improved function and increased physical activity2 and may be more cost-effective than usual physiotherapy.3 Similarly, the use of walking poles (WPs), an alternative ambulation assistive device, is associated with increased aerobic capacity, strength, balance and quality of life in older adults.4 The use of WPs by people with chronic disease is associated with benefits including improved oxygen uptake without an increase in dyspnoea or perceived exertion for persons with chronic obstructive pulmonary disease,5 improved distance before claudication pain in persons with peripheral arterial disease,6 improved postural stability and gait pattern in persons with Parkinson’s disease7 and for persons participating in conventional cardiovascular rehabilitation, the additional use of WPs resulted in increased exercise capacity. Quantitative studies exploring the use of WPs to address musculoskeletal issues such as CLBP have shown mixed results.8–10 Of note, previous studies reported no variation from the standard WP gait method that was instructed to participants. According to Sackett et al, clinical decision-making is informed by three domains: research evidence, expertise of the practitioner and patient preference.11 Research protocols in past WP studies have instructed participants to use the traditional, two-point gait pattern of Nordic walking, during which the foot and the contralateral pole tip contact the ground simultaneously.12 In contrast, the principal investigator in this case study made an a priori determination to respect participant preference if they devised an alternate gait pattern that was deemed safe and functional. Following the CAse REports guidelines, we present a participant with CLBP and grade 1 lumbar spondylolisthesis and degenerative disc disease who devised a novel, self-selected WP gait pattern that achieved short-term and long-term relief of low back and right lower extremity radicular symptoms. We believe that this is the first case examining changes in CLBP symptoms when respecting patient preference by permitting a self-selected WP gait pattern.

Case presentation

The participant was a 65-year-old woman, who had been diagnosed with lumbar spondylolisthesis at age 33. At age 51, she was injured in a motor vehicle crash that left her unable to ambulate in the community without exacerbation of her CLBP and right lower extremity radicular symptoms. The participant had previously undertaken pain interventions such as physical therapy, chiropractic and prolotherapy, but as these interventions did not provide long-term pain relief, she discontinued them. However, on a weekly basis, she received therapeutic massage and participated in Tai Chi classes. The participant also consumed an over-the-counter, non-steroidal anti-inflammatory drug as needed. The participant did not use any prescription analgesics.

Investigations

At age 52, radiographs confirmed that she had grade 1 spondylolisthesis of the lumbar vertebrae (L) four on L5 and degenerative disc disease.

Treatment

The community-based WP course in which the participant enrolled was advertised in a municipal Parks and Recreation department’s quarterly schedule of classes for older adults, with course instruction and supervision provided by three physical therapists and assisted by four physical therapy students. All personnel were trained by the principal investigator in the Nordic walking method. It was decided in advance that if a participant self-initiated a safe and functional gait pattern that deviated from the Nordic walking method, the instructors would be permissive regarding the technique and respect the participant’s preference.

The WP course lasted 1 week, with three 60 min sessions of instruction and practice in using WPs. The first class was taught indoors, walking around an auditorium. The second class was taught outdoors on a large asphalt parking lot, with one section on an incline. Participants were also encouraged to walk on the surrounding flat, grassy area. The third class took place at a local recreational nature trail that was flat and covered with chat gravel.

Although the participant in this case report had initially been instructed in the Nordic walking pattern, she reported that it felt ‘awkward and unnatural’. Therefore, early in the WP course, she adopted an atypical, modified, two-point pole/heel strike pattern and reported that it ‘felt comfortable’. After termination of the WP course, the principal investigator obtained the participant’s consent to conduct institutional review board (IRB)-approved assessments (IRB project number 2003152), including follow-up visits at 6-month and 12-month post-termination of the course.

Data gathered included the participant’s perception of the functional ability of her legs using the Lower Extremity Functional Scale13 (LEFS), which subjectively assesses the level of difficulty (5-point Likert scale, from no difficulty (4) to extreme difficulty or unable to perform (0)) regarding daily self-care, work or leisure activities such as walking, stair climbing, running, squatting and lifting (table 1).

Additionally, the participant reported her exercise walking activity distance (kilometres), duration (min), frequency (times per week), level of physical effort using the Borg’s Rating of Perceived Exertion14 (RPE). The worst level of pain experienced while walking was reported using the Numeric Rating Scale15 (NRS). Of note, the outdoor circular concrete walking track the participant used had signage with subkilometre markers, which improved the accuracy of distance reporting.

Outcome and follow-up

Prior to starting the WPs course, the participant reported she walked (without WPs) 1 km in 15 min, one or two times per week, with an RPE of 17/20 (‘very hard’), a low back pain NRS of 10/10 (‘worst pain imaginable’) and a reported score on the LEFS of 50/80 (table 2). At the conclusion of the WPcourse (table 2), the participant doubled her distance (2 km) and duration (30 min) and increased the frequency of her walking to four or five times per week using WPs. Her RPE improved to 11/20 (‘fairly light’), and her low back pain NRS while walking using WPs was reduced to 0/10. She reported that WPs had provided ‘immediate’ relief of her CLBP symptoms during gait. Notably, the client reported an 8-point increase on the LEFS from baseline (minimally clinical important difference is 9 points).13 Following continued use of the WPs at 6 months postcourse (table 2), the participant maintained her improvements in walking distance, duration and RPE, though her walking frequency decreased slightly to three or four times per week coupled with a 3–4/10 on the NRS and 54/80 on the LEFS. The participant attributed this slight decrease in overall WP performance to a flare up of knee pain she experienced while not using WPs when walking a distance of five miles. She received two corticosteroid injections to her knee after this occurred. At the 12-month follow-up (table 2), initial improvements in walking distance, duration and RPE were maintained, with the participant reporting that winter weather had caused her to reduce the frequency of engaging in the outdoor WP routine. Furthermore, at the 12-month follow-up, the participant reported improved scores in pain on the NRS (0-3/10) and LEFS (58/80) as compared with 6 months prior, while maintaining progress similar to what was experienced at the conclusion of the WPcourse in distance, duration and RPE.

Video Gait Analysis (Video 1): the 6-month follow-up visit was conducted at the participant’s customary paved walking path. An investigator recorded her preferred WP gait pattern using an iPhone 6 (Apple, Cupertino, California) at 120 frames per second to video. The investigator recorded video from the side, front and behind and determined that the gait pattern was most clearly evident in the view from behind. Two investigators later reviewed all video clips, confirmed the consistency of the self-selected WP gait pattern and chose a short video clip that best showed both the pole and heel strikes. Editing was done with Final Cut Pro X (Apple, Cupertino, California) to slow the footage and add color-coded overlays to demonstrate the synchrony of the pole and foot strikes.

Specifically, the participant exhibited pole striking in a regular temporal pattern; however, pole strikes were at half the frequency of heel strikes (figure 1). Likewise, a consistently biased pole strike on both the right and left sides was synchronised to occur only during the heel strike for the right heel (of the symptomatic lower extremity). Coincidentally, the participant had previously reported a history of right lower extremity radicular pain during ambulation activities.

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Figure 1

Novel, self-selected, modified two-point walking pole gait pattern.