DDSIG: Bonus Episode-  CSM Poster Award 2025: Analysis of Backward Gait Assessment Performance in Typical Older Adults and Individuals with Parkinson’s Disease – with Lisa Inglis

Summary

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Podcast Summary

4D: Deep Dive into Degenerative Diseases – ANPT

Episode: DDSIG Bonus – CSM Poster Award 2025: Analysis of Backward Gait Assessment Performance in Typical Older Adults and Individuals with Parkinson’s Disease
Host: Karen Padgett
Guest: Dr. Lisa Ingles, Assistant Professor, Daemen University
Date: March 24, 2025

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Main Theme & Purpose

This episode features an in-depth discussion with Dr. Lisa Ingles, winner of the DD SIG Best Poster Award at CSM 2025, about her research comparing backward gait assessment in typical older adults and individuals with Parkinson's Disease (PD). The conversation explores the clinical significance of backward walking as an assessment tool, the details of Dr. Ingles' methodology, results, and the implications for physical therapy practice, especially in early intervention for Parkinson’s.

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Key Discussion Points and Insights

1. Introduction & Motivation for the Study

• Dr. Ingles’ Background:
  • Teaches neuromuscular courses at Daemen University with a focus on stroke, Parkinson’s, and spinal cord injury ([01:52]).
• Origins of the Study:
  • Inspired by clinical observation that backward walking seemed to reflect postural stability and could indicate unsteadiness in Parkinson’s patients.
  • Noted a lack of clinical tools assessing backward gait, despite its potential value ([02:48]).
  • Discussed evidence showing early changes in backward gait may precede changes in forward gait for PD patients, highlighting assessment importance ([03:46]).

2. Study Design

• Backward Gait Assessment:
  • Participants walked 5 meters backward at normal speed between two taped lines while both time and step count were measured ([04:24]).
  • Chose physical counting based on prior research that demonstrated no meaningful difference from instrumented walkways.
  • Included established comparative measures: Mini-BESTest, Timed Up and Go (TUG), and the Activities-specific Balance Confidence (ABC) Scale ([05:48]).
  • Participant Groups:
    • 30 individuals with Parkinson’s (avg. age 68.4), 15 female.
    • 30 age-matched controls (avg. age 66.9), neurologically typical.
    • Groups were closely age-matched ([05:54]).

3. Clinical Relevance of Method

• Why 5 Meters and Manual Count:
  • Prior research validated the non-instrumented method as consistent with instrumented walkways; greater clinical feasibility ([06:38]).
  • Emphasized clinical applicability: “Most of us don't have an instrumented walkway easily at our disposal… We're really hoping to get something that was clinically relevant.” – Dr. Ingles ([07:14]).

4. Results

• Primary Outcomes:
  • PD group took more time and steps to walk backward than controls.
    • Average Time:
      • Parkinson’s: 13.7 seconds
      • Controls: 9.5 seconds
    • Average Steps:
      • Parkinson’s: 20 steps
      • Controls: 14 steps ([08:12]).
  • Other standard measures (Mini-BEST, ABC, TUG) reflected the same statistically significant differences ([09:15]).
• Notable Quote:
  • “On average, the individuals with Parkinson's took about 13.7 seconds... whereas the older adults… about nine and a half seconds.” – Dr. Ingles ([08:12])

5. Falls Risk Analysis and Limitations

• Falls Data:
  • Retrospective self-reported falls over the prior year were collected.
  • Small subgroup sizes (e.g., only eight fallers in the control group), limiting power to establish falls risk cutoffs or analyze predictive value ([09:47]).
  • Neither this test nor the standard measures could significantly differentiate fallers vs. non-fallers in this sample.
• Hoehn & Yahr Distribution:
  • PD group mainly early-stage: 8 (Stage 1), 16 (Stage 2), 5 (Stage 3), 1 (Stage 4) ([11:31]).

6. Clinical Implications and Future Directions

• Potential Clinical Use:
  • Quick and reliable test that strongly correlates with longer, more involved balance assessments ([13:11]).
  • "We're able to do this test in 14 seconds and get data that really strongly correlates with a measure that takes 15 to 20 minutes to administer. So I think that's the clinical utility of it." – Dr. Ingles ([13:11])
  • Especially promising for early screening in multidisciplinary clinics and early PD intervention.
  • Could empower patients by demonstrating measurable differences early, motivating participation in therapy ([14:21]).
• Therapeutic Value:
  • Backward walking is both diagnostically revealing and an effective treatment focus, highlighting early deficits in proprioception and postural control ([15:32]).
  • “It sort of pulls out those challenges earlier. You can't see where you're going. It's almost like a dual task.” – Dr. Ingles ([15:32]).

7. Methodological Insights

• Single vs. Multiple Trials:
  • The team learned that a single trial is more reliable—multiple trials resulted in participants “trying to beat their time,” skewing results. Now recommend a single trial for consistent assessment ([16:19]).
  • “That for some people... seemed to serve almost as a cue, and that they were going to try to beat their time... So we ended up just changing that and going with the first trial.” – Dr. Ingles ([16:19])

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Notable Quotes & Memorable Moments

• “Backward walking is more of a key potentially to their stability, their postural control, compared to forward walking.” – Dr. Ingles ([02:48])
• “I think that's always really helpful for us as clinicians… to be able to establish is there a particular number of steps... or speed at which you are at a greater risk of falling.” – Dr. Ingles ([13:11])
• “It's a very clinically useful, quick to administer score that could give someone a lot of information.” – Dr. Ingles ([13:11])
• “It sort of pulls out those challenges earlier... You have to rely a little bit more on your proprioceptive information.” – Dr. Ingles ([15:32])

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Key Segment Timestamps

• 01:52: Dr. Ingles' background and clinical focus
• 02:48: Reason for choosing backward gait analysis
• 04:24: Study methodology overview
• 05:54: Participant recruitment and demographics
• 06:38: Rationale for clinical approach over instrumented testing
• 08:12: Main results: performance differences in backward gait
• 09:47: Analysis of falls data and study limitations
• 11:31: Description of PD group’s Hoehn & Yahr stages
• 13:11: Discussion on clinical applications and utility
• 15:32: Value of backward walking as both assessment and intervention
• 16:19: Lessons learned: single vs. multiple trial protocol

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Tone and Atmosphere

• Engaged, collegial, and slightly humorous—filled with practical clinical wisdom, honest reflections on methodology, and enthusiasm for the growing use of backward-walking in neuro PT.

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Recommendations for Clinicians

• Consider incorporating the 5-meter backward gait test into routine assessments for patients with Parkinson’s and older adults.
• Recognize its value as a quick screen to identify postural and balance deficits, especially in early Parkinson’s.
• Note current limitations on establishing falls risk cutoffs—further research is needed.
• Use the test’s results to empower patients and prompt timely intervention.

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Closing

Dr. Ingles shares her love for running and watching her sons’ activities, bringing a personal touch to the discussion. The episode wraps up with gratitude for her research and encouragement to clinicians to consider backward gait assessment in their practice.

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For more information and resources, visit www.neuropt.org.

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Transcript

[A]

Welcome to 4D, a podcast brought to you by the Degenerative Diseases Special Interest Group of the Academy of Neurologic Physical Therapy. A component of apta. This is for informational and educational purposes only. It does not constitute and should not be used as a substitute for medical advice, diagnosis, rehabilitation, or treatment. Patients and other members of the general public should always seek the advice of a quality, qualified healthcare professional regarding personal health and medical conditions. The Academy of Neurologic Physical Therapy and its collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication. The views or opinions expressed are those of the individual creators and do not necessarily represent the position of the Academy of Neurologic Physical therapy. Welcome to 4D Deep Dive into Diseases, gaining insights through casual and amusing clinical conversations. I'm Karen Padgett, a physical therapist in the Outpatient Neuro Clinic at Dartmouth Hitchcock Medical center, and I'm on the podcast committee of the dvcig. I'm excited to be here with Lisa Engel, Assistant professor at Damen University in Amherst, New York, over by Buffalo. And Lisa is here to talk with us about her poster that she just presented at CSM and was awarded our best poster for the DD sig. And so we're very excited to have you here, Lisa. And could you just introduce yourself, tell us a little bit about your position and what you do at Damen University.

[B]

Absolutely. Thanks for having me. So I teach in the neuromuscular courses at Damen University and I'm also Deb Pre Professional Fees co coordinator. So helping to work with our students as they're qualifying with their undergraduates to get into the professional fees and then really focusing my teaching on areas like stroke and Parkinson's disease, spinal cord injury, through the second and third year of the professional phase.

[A]

Great. And so tell us a little bit about your poster and I'm just going to read the title here before we get going. Analysis of Backward Gait Assessment Performance in Typical Older Adults and Individuals with Parkinson Disease. So tell us just a little bit about sort of how this came about. How did you decide to look at backward walking analysis?

[B]

So it came just from clinical experience of watching my patients with Parkinson's walking and seeing that I could often tell just from watching someone take a few steps backwards to sit on a plane, how steady they were, how unsteady they were. And so it seems like a really important thing for us to be assessing is how someone is stepping backwards. But there aren't a lot of clinical tools out there that look at backwards walking, most of them look at walking in the forwards direction. So that was sort of the inspiration of, I thought, you know, maybe for this population, backwards walking is more of a key potentially to their stability, their postural control, compared to forward walking. And as I dove into the literature, it seems like that may be true.

[A]

All right, and so you were sort of thinking like, maybe we could use backward walking as an earlier predictor of a balance issue.

[B]

Yeah, there has been research that has looked at that, and they've seen that in de novo Parkinson's. So really early after diagnosis, they're able to detect the changes in gait in the backwards direction before they can detect them forwards direction. So it seems like an important clinical tool for us to be able to measure. And also more and more therapists are starting to work on backwards walking and focus on that. So we definitely want clinical measures that can show change in that backwards gate, if that's what we're working on.

[A]

Yeah. Right. Okay, so tell us what you did for this study.

[B]

Absolutely. So the backwards gait assessment that we were using was a 5 meter backwards gait assessment. And so you just have two tape lines 5 meters apart on the ground, and they begin with their toes lined up on the line, and when you say go, they walk at their normal speed backwards until you say stop for that 5 meter distance. So you start the stopwatch on go and then you stop the stopwatch when both feet have passed the second line. We also chose to count steps because we weren't sure which one would be more potentially correlated with other measures or predictive of falls. So we chose to measure both of those. And then we also used other standardized measures to compare this to that have good validity reliability behind them. So we also had everyone perform the mini best. We had everyone perform the timed up and go, and then also the activity confident scale. So we recruited 30 patients with Parkinson's to perform these different measures. And then we also recruited an age match control group of older adults who did not have a neuromuscular diagnosis to compare them to, because we wanted to see how this tool compared to other known followers predictors and measures of gait and balance. And we also wanted to see if it was able to detect the true differences between these two populations.

[A]

Okay, so how many individuals did you have in each group?

[B]

So each group had 30. So we had 30 individuals with Parkinson's, the female, 15 female, and then we had 30 age match controls. So the average age for those with Parkinson's was 68.4. And then our typical older adults was a 66.9 unit age. So there is a little bit of variability, but the mean and standard deviations are very close.

[A]

So you have these two groups, 60 people total, which is no joke. I mean, that's a really pretty solid N for sure. So that's great. And then you explained how you did your backwards walking and was it instrumented or did you like actually physically count the steps?

[B]

So we physically counted them. And actually the reason we chose the methodology that we did is we were basing it on the work that was previously done on the multi directional walk test by Bryant et al. And they had done a 5 meter over ground assessment in all directions, forward, backwards. And they had compared an overground assessment to an instrumented walkway and found that there was not a significant difference between them. So that was our rationale for choosing the 5 meter force because it had already been compared to an instrumented walkway.

[A]

Okay. And also just so much more clinically applicable.

[B]

Exactly. So most of us don't have an instrumented walkway easily at our disposal. And even if you do, the analysis, time is sometimes quite involved and more than most clinicians would have in a given session. So we were really hoping to get something that was clinically relevant. Right, right.

[A]

So you brought these folks in and you did all of these tests at one time, Correct. Okay. And did you note or have them in any kind of state in terms of their medication?

[B]

We did inform people that they should pick the time when they expected to be in the on phase of their medication. And so we asked them to select the time that they wanted to commit for their assessment.

[A]

Okay. And then this was a one time assessment because you're just comparing these two groups, correct?

[B]

That's correct.

[A]

All right. And so what did you find?

[B]

So we compare the scores in terms of the time it took to complete the backwards gait assessment and the number of steps between those with Parkinson's and typical older adults. And we found a statistical difference between them that was significant for both of those characteristics. So on average, the individuals with Parkinson's took about 13.7 seconds to walk this 5 meter backwards forth, whereas the older adults were typically able to complete it in about nine and a half seconds. And then the individual with Parkinson's took about 20 steps to complete it, whereas the typical older adults only took about 14 steps. So there was a difference. And then we also ran the statistical difference between the other known gate and balance measures. So the mini best, the ABC and the tug, and that confirmed that there was that same statistical difference on Those as well. So we were detecting a difference between the groups and that that was a true difference that existed on other measures of postural control.

[A]

Yeah. So really fairly consistent in these two groups of like age matched, you know, people with Parkinson's and more typical aging.

[B]

Yes. That really confirmed our hypothesis. That's what we were expecting and hoping that this measure would do would be to find that patients with Parkinson's took more steps and longer to travel a backwards distance.

[A]

Okay, and then did you do any other analysis?

[B]

We did, so we probably got a little ambitious. We had also collected data from them about retrospective falls for the last year, which there's some recall issues with that methodology. And then as we tried to analyze between followers and non followers between the two groups, our groups got very small. So we only had, because our older adults remember their mean age was about 67, and so they were somewhat young. So our followers in the older adults group, we only had eight of them. So we were trying to see, you know, could this discriminate between followers and non followers. And the group with Parkinson's did what we thought they would do and that the fallers took longer and took more steps in the backwards direction. But it wasn't significant, probably because of sample size. We would need to, I think, continue this research to have the power to really look at a falls risk cutoff. The typical older adults. For some reason, our followers actually work quicker. It took fewer steps, which was not what we were expecting. So, you know, this analysis, we were not able to make any conclusions really about the ability of this tool to detect falls. But interestingly enough, even the mini Best, the ABC and the Tug, were not able to differentiate between the Fowlers and the non Fowlers in a statistically significant way in our population. So I think it was either sampling bias or just not having a large enough sample size to be able to really, truly run that analysis properly.

[A]

Yeah. So let's just talk briefly about your H and Y distribution. What was that for this group?

[B]

For our Hoenn and Yar, we had eight individuals who were in a stage one, 16 in a stage two, five would be a stage three, and only one was a stage four.

[A]

Yeah.

[B]

So definitely more in the earlier stages of Parkinson's. But we did have a range up to page four.

[A]

Right. Then I think sometimes too, like, I assume you're recruiting in Buffalo.

[B]

Yeah, yeah.

[A]

Right. So like, you know, I think it gets tricky sometimes when you ask about falls in the last year because if there's any kind of snow, ice, whatever, you know, people are Going to fall and then I think frequency of falls also, you know, what, what really is a faller, I think is a. Interesting thing to ask. And, and you know, maybe this study wasn't really set up to kind of go that deep.

[B]

No, our initial purpose was really to just look at, you know, the difference between those with Parkinson's and older adults. And we kind of got excited and wanted to just see, you know, if we. If we could detect that. But it wasn't really set up with the power to be able to determine a fall address cut off. So we would definitely need a lot more subjects to be able to do that.

[A]

Yeah. All right, so if we're just looking. So let's just go back to the data with the individuals with PD versus the typical older adults. I guess. Like, as a clinician, would you suggest a way to use. Use this? If I were to time backward walking.

[B]

I think that's why we were eager to look at a fall risk cutoff. Right. So to be able to establish is there a particular number of steps in the backward direction or a particular speed at which you are at a greater risk of falling. And I think that's always really helpful for us as clinicians. We're not able to say what that is at this point in time because we would need to get more subjects and be able to run different analyses to be able to be confident about what that cutoff score would be. I think there's potential for that. The benefit of this is that it really is finding that difference. And we've done a previous study with this where we were looking at the correlation between the backwards gait and the mini vest and the abc and it was very strong. So we're able to do this test in 14 seconds and get data that really strongly correlates with a measure that takes 15 to 20 minutes to administer. So I think that's the clinical utility of it. If we can get more data looking at what is the ideal score for this, what is the ideal number of steps. It's a very clinically useful, quick to administer school that could give someone a lot of information.

[A]

Yeah, yeah, I can see how it might be really good in like, for screening, like if you were in a multidisciplinary clinic, might be a good way to screen for like, you know, you should come in and get some one on one PT or without having to do a whole test. You know, I think that in those early newly diagnosed people, sometimes, not that we want to necessarily like find something that they're bad at, but I think, like, showing that they're below, you know, a norm or other people their age for an activity kind of helps people to realize, like, okay, there really is, like, something going on here. I can't just gloss this over, and I need to start addressing it. So I think that, like, that's another place where, if it is something that comes to light earlier in the disease process, it might just help people to realize it and to give them a goal like, okay, I can work on this and get it better and be more like other people my age.

[B]

I think that is one of the values of the backwards walking, both as an assessment and as a treatment. It sort of pulls out those challenges earlier. You can't see where you're going. It's almost like a dual path. You have to rely a little bit more on your appropriate sets of information. And I think that's why it's able to draw out the early challenges that people are having. And we know with Parkinson's, it's a degenerative condition, so the sooner you can start working on things that are problems, the better your outcomes potentially could be in the long term.

[A]

Right? For sure. Was there anything else that came to light that you wanted to make sure that we touched on?

[B]

I will say we initially planned to do two trials and average them, and we did learn this would be our blooper. I guess, through our experience, that it works better to just do a single trial for this. Some of the patients seem to get wise on the first trial, that we were looking at the number of steps they were taking and that we were timing them. And we found that. That for some people, that seemed to serve almost as a cue, and that they were going to try to beat their time and they were going to try to change their performance on that second trial. So we ended up just changing that and going with the first trial because it seems to be most consistent with typical performance for everyone across the study.

[A]

That's interesting. When I do gait speed, I always do two trials. And, like, with the tug, I do feel like people always get a little bit faster second try. Well, Lisa, this is very exciting. We're bands of backward walking. It's definitely, you know, interesting when you. At the beginning, when you said people are using it more clinically, I mean, I think that's totally true. And so we want to thank you for, you know, the effort of putting this study out there and presenting it at csm and congratulations on winning the DD SIG Award for that. And then we have a tradition here at 4D we like to ask people what they enjoy doing when they're not working, so we would love for you to share that.

[B]

Excellent. I love to run. I'm not very good at it, but I like to run as a hobby, and then I kind of reach the age where I am the number one spectator for a lot of team age boys and their bands and athletic performances. So that takes up a lot of my free time.

[A]

Yes. It's all good stuff, though. Yeah, there's a lot of running talk around here, too. All right, well, thank you so much for being here. We really enjoyed meeting you and talking and learning about your study and, you know, keep in touch with us if you have other things related to backward walking. We totally love it. So let us know.

[B]

Excellent. Thank you so much.

[A]

This podcast was produced and edited by the ANPT Degenerative Diseases Special Interest Group Podcast. For more information on this SIG and ANPT, visit www.neuropt.org. our podcast team includes Sarah Zoller, Christina Burke, Ken Binocco, Jeff Schmidt, Shannon Brown, Skyler Ross, and I'm K. Paget. Thanks to Jimmy McKay for providing music. Please share this episode with a colleague. Today there's plenty of o. I love your chair, and I feel like I'm watching Star Trek. Okay, so I'm here. Oh, and how do I. Is it English? How do I say your name?

[B]

Ingles.

[A]

Ingles.

[B]

Yeah. Like Little House in the Prairie.

[A]

I'm excited to be here with Laura Ingles.

[B]

Go.

[A]

Was 56.66.96. Okay.

[B]

They were. They were pretty close.

[A]

It's like, parm. You are so strict. I don't know what you want here. I was like, wait a minute. Yes. Okay. Those are very similar. Okay. Okay.

[B]

Thank you. That was the best we could from our recruitment.

[A]

What should I sign up for? This is a grilling. Listen to the bloopers. Because that's where you, like, throw someone under the bus without realizing it. And then you're like, oops, we probably shouldn't put that out there.

[B]

We'll cut it. We'll cut it.

[A]

Don't worry.