Backward walking has been found to be a more sensitive measure to identify fallers than forward walking in Parkinson's Disease, but also in older adults, Multiple sclerosis, Stroke, and Traumatic Brain Injury.  It may be used to reveal mobility impairments better than forward walking.  Compared to young adults, backward walking in older adults is characterized by decreased step length, slower speed, and increased gait variability. 

Here are only a few examples of when we walk or step backwards daily.

• Backing up to sit down
• Moving in a crowd, you step back to allow someone to maneuver in a tight space
• With a 2-person furniture lift, you may be the one to walk backwards
• At an art gallery, you may take a few steps back to take in the beautiful painting.
• Step back to open a door

Utilizing multisensory feedback from the Balance Matters System has the potential to improve proprioceptive integration for backward gait. 

Additional sensory information of backward step distance through tactile (foot pads), auditory (heel-toe clickers), enhanced proprioceptive feedback and a visual laser feedback for trunk upright posture, would help to re-code angles of the hip, knee, and ankle during the backward stride and stepping exercises. (Winkler et al, 2022)

Training Backward Walking

Many of the below studies discuss backward walking and stepping on the ground and on the treadmill with significant changes in strength, balance, gait mechanics, and reduction in pain.  

• The meta-analysis (Balasukumaran et al 2019) demonstrated significant differences with conventional physiotherapy treatment for 2-4 weeks to reduce pain, and functional disability and to improve quadriceps strength in patients suffering from knee osteoarthritis.
• The balance and stability in cases of juvenile rheumatoid arthritis, and gait parameters and muscle strength in anterior cruciate ligament injury improved significantly when backward walking was included as an exercise.
• Backward walking training with motor dual tasks could be a more effective interventional approach than forward walking training to improve balance and walking functions of children with spastic hemiplegia. (Choi et al, 2021)
• BWT significantly improved motor functions of stroke patients, including 10MWT, cadence, BBS, paretic step length, and stride length, and BWT should be recommended for patients after stroke. (Wen et al 2022)

How backward walking is different than forward walking.

Sensory systems:

• It involves greater reliance on neuromuscular control to make up for the lack of vision.
• The variation in optic flow as well as the simple novelty of the task leads to alterations in spine and pelvis stabilization to maintain dynamic balance.
• The absence of vision during backward gait requires proprioceptive information for accurate foot placement particularly from the hip.

Musculoskeletal:

• It has been used in orthopedic rehabilitation as it produces less mechanical strain on the knee joint.
• During backward walking, plantar flexion plays only a small role in propulsion and requires significantly lower ankle power. (Soda et al 2013)
• Considered a safe training method for hamstring strain rehabilitation because it involves relatively low eccentric loading on the hamstring muscle group. (Kachanathu et al 2013)
• Physiologic studies have noted that the backward training approach activates key stability muscles such as the trunk, hip, and knee muscles to a greater extent than forward training. (Winter et al 1989)

Neuromuscular Control:

• Backward walking is more challenging for the nervous system.
• May facilitate motor control by alleviating the maladaptive flexor-synergy gait pattern typical after brain injury (Dewolf et al. 2021)
• Age-related modifications on the intersegmental coordination were greater during backward walking. Older subjects take shorter steps and adapt their intersegmental coordination mainly by changing the amplitude and phase of trunk and foot. (Dewolf et al 2021)

 Cerebral Activation and Neuroplasticity

• Compared with forward walking, backward walking is more effective at inducing cerebral activation.
• An increased oxygenated hemoglobin response during backward compared with forward walking in healthy adults, consistent with increased cortical processing, was observed in the supplementary motor area, primary motor cortex, and superior parietal lobule. (Godde et al 2010)
• Given the known role of novelty and task challenge in promoting neuroplasticity, backward walking, a more novel motor skill relative to walking forward, may promote cortical neural plasticity.
• Backward walking induces more sensorimotor cortex activity than forward walking. 

Testing backwards walking

The 3-meter backwards walk test or backwards gait speed is now being researched more.  Below are the cutoff scores and minimal detectable change for predicting falls in different populations.

The walk ratio in pathological gait

Although speed is important outcome measure to assess fall risk, should walk ratio, the relationship between step length and step cadence also be considered.   Walking speed is the product of step length (SL) and step cadence (SC).  In the literature, the walk ratio was decreased by 20–50%, in patients with Parkinson’s disease, Multiple Sclerosis, after knee-joint replacement and after stroke, compared with the controls.

If the same speed is achieved through shorter and more frequent steps, at each step the body system is subject to smaller upward and forward accelerations, resulting in less muscular work needed to displace the body system with respect to the ground and an improved stability.

More frequent cyclic movements of the limbs within the body system, however, entail an increased metabolic cost.

In PD, there is a concern when an individual decreases step length and increases cadence as they have a greater risk for falls.

For these reasons, a decrease in walk ratio (SL/step frequency) may be sensitive index of decreased neuromotor control of gait, and an increase in the walk ratio toward normal limits should be taken as representative of an improvement in motor control, whatever the underlying mechanisms.

 

Some resources for backwards gait outcomes. 

Abit Kocaman A, Aydoğan Arslan S, Uğurlu K, Katırcı Kırmacı Zİ, Keskin ED. Validity and Reliability of The 3-Meter Backward Walk Test in Individuals with Stroke. J Stroke Cerebrovasc Dis. 2021 Jan;30(1):105462. doi: 10.1016/j.jstrokecerebrovasdis.2020.105462. Epub 2020 Nov 13. PMID: 33197801.

Awosika OO, Chan D, Sucharew HJ, et al. Backward Locomotor Treadmill Training Differentially Improves Walking Performance across Stroke Walking Impairment Levels. Brain Sci. 2022;12(2):133. Published 2022 Jan 19. doi:10.3390/brainsci12020133

Awosika OO, Chan D, Rizik BA, Sucharew HJ, Boyne P, Bhattacharya A, Dunning K, Kissela BM. Serial Backward Locomotor Treadmill Training Improves Bidirectional Walking Performance in Chronic Stroke. Front Neurol. 2022 Mar 14;13:800757. doi: 10.3389/fneur.2022.800757. PMID: 35359661; PMCID: PMC8963981.

Balasukumaran T, Olivier B, Ntsiea MV. The effectiveness of backward walking as a treatment for people with gait impairments: a systematic review and meta-analysis. Clin Rehabil. 2019 Feb;33(2):171-182. doi: 10.1177/0269215518801430. Epub 2018 Sep 19. PMID: 30229667.

Bilek, Furkan & Demir, Caner. (2022). Validity and Reliability of The 3-Meter Backward Walk Test in Mildly Disabled Persons with Multiple Sclerosis. Multiple Sclerosis and Related Disorders. 58. 103532. 10.1016/j.msard.2022.103532.

Carter, Valerie A. DPT, PT, NCS, GCS; Farley, Becky G. PhD, MS, PT; Wing, Kay DPT, PT, NCS; de Heer, Hendrik “Dirk” PhD, MPH; Jain, Tarang K. PhD, PT Diagnostic Accuracy of the 3-Meter Backward Walk Test in Persons With Parkinson Disease, Topics in Geriatric Rehabilitation: July/September 2020 - Volume 36 - Issue 3 - p 140-145 doi: 10.1097/TGR.0000000000000272

Chen Z, Ye X, Wang Y, Shen Z, Wu J, Chen W, Jiang T, Wu H, Xu X. The Efficacy of Backward Walking on Static Stability, Proprioception, Pain, and Physical Function of Patients with Knee Osteoarthritis: A Randomized Controlled Trial. Evid Based Complement Alternat Med. 2021 Jun 11;2021:5574966. doi: 10.1155/2021/5574966. PMID: 34221078; PMCID: PMC8213492.

Choi JY, Son SM, Park SH. A Backward Walking Training Program to Improve Balance and Mobility in Children with Cerebral Palsy. Healthcare (Basel). 2021 Sep 9;9(9):1191. doi: 10.3390/healthcare9091191. PMID: 34574964; PMCID: PMC8465093.

Chan WLS, Cheung YT, Lee YW, Teo AM, Wo HK, Wong Y. Reliability, Validity, and Minimal Detectable Change of Backward Walk Test in Older Adults With Dementia. J Geriatr Phys Ther. 2021 Mar 23. doi: 10.1519/JPT.0000000000000306. Epub ahead of print. PMID: 33782361.

Dewolf AH, Sylos-Labini F, Cappellini G, Ivanenko Y, Lacquaniti F. Age-related changes in the neuromuscular control of forward and backward locomotion. PLoS One. 2021 Feb 17;16(2):e0246372. doi: 10.1371/journal.pone.0246372. PMID: 33596223; PMCID: PMC7888655.

Godde B, Voelcker-Rehage C. More automation and less cognitive control of imagined walking movements in high- versus low-fit older adults. Front Aging Neurosci. 2010 Sep 1;2. pii:139. 30. Kurz MJ, Wilson TW, Arpin DJ. Stride-time variability and sensorimotor cortical activation during walking. Neuroimage. 2012;59:1602–1607

Grobbelaar R, Venter R, Welman KE. Backward compared to forward over ground gait retraining have additional benefits for gait in individuals with mild to moderate Parkinson's disease: A randomized controlled trial. Gait Posture. 2017 Oct;58:294-299. doi: 10.1016/j.gaitpost.2017.08.019. Epub 2017 Aug 18. PMID: 28843186.

Kachanathu S.J., Hafez A.R., Zakaria A.R. Efficacy of backward versus forward walking on hamstring strain rehabilitation.  J. Ther. Rehabil. Res. 2013;2:8–14. doi: 10.5455/ijtrr.00000017)

Soda N., Ueki T., Aoki T. Three-dimensional motion analysis of the ankle during backward walking.  Phys. Ther. Sci. 2013;25:747–749. doi: 10.1589/jpts.25.747.

Taulbee L, Yada T, Graham L, O'Halloran A, Saracino D, Freund J, Vallabhajosula S, Balasubramanian CK. Use of Backward Walking Speed to Screen Dynamic Balance and Mobility Deficits in Older Adults Living Independently in the Community. J Geriatr Phys Ther. 2021 Oct-Dec 01;44(4):189-197. doi: 10.1519/JPT.0000000000000290. PMID: 33534335.

Wang J, Xu J, An R. Effectiveness of backward walking training on balance performance: A systematic review and meta-analysis. Gait Posture. 2019 Feb;68:466-475. doi: 10.1016/j.gaitpost.2019.01.002. Epub 2019 Jan 3. PMID: 30616175.

Wen H, Wang M. Backward Walking Training Impacts Positive Effect on Improving Walking Capacity after Stroke: A Meta-Analysis. Int J Environ Res Public Health. 2022 Mar 12;19(6):3370. doi: 10.3390/ijerph19063370. PMID: 35329056; PMCID: PMC8956083.

Winkler P., DeMarch, E., Campbell, H. Smith, M. Use of real-time multimodal sensory feedback home program improved backward stride and retention for people with Parkinson Disease: A pilot study,Clinical Parkinsonism & Related Disorders,Volume 6,2022,100132, ISSN 2590-1125,

Winter D.A. Biomechanics of normal and pathological gait: Implications for understanding human locomotor control.  Mot. Behav. 1989;21:337–355. doi: 10.1080/00222895.1989.10735488) 

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101: Why the 3 Meter Backward Walking Test Should Be Essential in Your Evaluations and Exactly How To Use It with Valerie Carter