Neurological Gait Deviations

Original Editor - Stacy Schiurring based on the course by Damien Howell

Top Contributors - Stacy Schiurring and Jess Bell

Introduction[edit | edit source]

Gait deviation is often synonymous with compensational movement.[1] The human body will find a way to make mobility happen, but this sometimes results in less than optional movement patterns. It is the role of the rehabilitation professional to guide patients through a plan of care to improve and or correct movement dysfunction. The ultimate goal is to achieve an ideal movement for each unique individual.

There are often two schools of thought in physiotherapy: neurological and musculoskeletal clinical paradigms. A 2014 article published in Manual Therapy looks at applying the concepts of neuroplasticity and motor learning to musculoskeletal physiotherapy practice. They found that integrating some of these concepts into traditional musculoskeletal physiotherapy treatments improved participants' outcomes with earlier and greater movement gains.[2]

"The authors compare and contrast neurological and musculoskeletal physiotherapy clinical paradigms in the context of the motor learning principles of experience-dependent plasticity: part and whole practice, repetition, task-specificity and feedback that induces an external focus of attention in the learner. It is proposed that increased collaboration between neurological and musculoskeletal physiotherapists and researchers will facilitate new discoveries on the neurophysiological mechanisms underpinning sensorimotor changes in patients with musculoskeletal dysfunction."[2]

The management of neurological gait deviations can differ from that of painful musculoskeletal syndromes in the following ways:[1]

  1. Cognitive impairments can limit the use of explicit motor learning principles and require more implicit mechanisms of motor learning.
  2. Organic degenerative processes that occur with some neurological diagnoses can limit the capacity to alter observed gait deviations.
  3. Gait training for those with neurological gait deviations tends to focus on deviations in the swing phase and double support phase of gait. For musculoskeletal gait deviations, gait training tends to focus primarily on the stance phase of gait.
  4. Gait deviations can be an early sign of some neurodegenerative diseases. The observed gait deviation may be the best available movement pattern for that individual to remain ambulatory and independent. For these patients, the rehabilitation professional needs to be more proactive in terms of potential side effects or unintended consequences when attempting to alter a gait deviation.


The management of neurological gait deviations are similar to that of painful musculoskeletal syndrome in the following ways:[1]

  1. The motor learning mechanisms and considerations of good verbal cueing are applicable to both painful musculoskeletal syndromes and neurological gait deviations.
  2. The motor learning principles of (1) external focus of attention, (2) using the patient's preferred sensory system preference, (3) using positive language, and (4) visual imagery are applicable to both painful musculoskeletal syndromes and neurological gait deviations.
  3. The clinical reasoning process of symptom modification procedures and clinical reasoning of a working hypothesis is still applicable for gait deviations associated with both painful musculoskeletal syndromes and neurological gait deviations.

Neurological Gait Deviations[edit | edit source]

Pirker and Katzenschlager[3] provided a classification of 14 gait disorders associated with neurological conditions. This classification provides a broad description of different gait deviations. There is a need to provide more detail and sub-classification of deviations which occur during gait.[3]

[1][3]
Gait Disorder Characteristics/description
Hemispastic gait Unilateral extension and circumduction
Paraspastic gait
  • Bilateral extension and adduction
  • "Stiff"
Ataxic gait
  • Broad base
  • Lack of coordination
Sensory ataxic gait
  • Cautious
  • Worsening without visual input
Freezing gait
  • Blockage
  • Stopping on turning and or stepping
Propulsive gait
  • Centre of gravity in front of the body
  • Festination
Astasia gait Primary impairment of stance balance
Dystonic gait Abnormal posture of foot and or leg
Choreatic gait
  • Irregular
  • Dance-like
  • Broad-based
Steppage gait Weakness of foot extensors
Waddling gait
  • Broad-based
  • Swaying
  • Drop of swinging leg
Antalgic gait Shortened stance phase on the affected side
Vertiginous gait
  • Insecure
  • Tendency to fall to one side
Psychogenic gait
  • Bizarre
  • Rarely falls

The following is a list of common signs of neuromuscular conditions movement system classification, which is based on the work of Scheets et al.[4] with additions by Dr Damien Howell.[1] A few of the more common neuromuscular conditions with potential clinical interventions will be outlined in more detail in the chart below.

  1. Increased base of support (BOS)
  2. Decreased BOS
  3. Lateral shift of centre of mass (COM) toward stance limb
  4. Knee hyper-extension stance
  5. Sustained hip knee flexion stance
  6. Vaulting
  7. Toe walking
  8. A limp: unequal step length, decreased time on uninvolved limb
  9. Festination: decreased step length, increased cadence
  10. Freezing difficulty initiating gait
  11. Variable placement of foot
  12. Pelvic elevation contralateral
  13. Circumduction
  14. Scissoring
  15. Decreased hip knee swing phase
  16. Foot drop
[1]
Gait deviation Examples of intervention with possible cue/prompt/feedback
Limp[5]
  • “See that, don’t do that”
  • Imagine visualise walking with smooth rhythmic steps
  • Take long even steps
  • Spend less time on good leg
  • Spend more time on the weak leg
  • Step to the rhythm beat of the metronome
  • Swing your arms
Slow gait velocity[5]
  • Walk faster
  • Step to the beat of the music at or greater than 120 beats/minute
  • Adjust treadmill speed
  • Walk with spring in your step, peer over the crowd
Knee hyperextension
  • Visualise a scaffold around your knee
  • Push off the floor, propel up and forward
  • Therapist touches patient's calf muscle and cues "use this to control your knee"
  • Orthotic trial: Supportive nonelastic[6] or elastic tape, Swedish knee cage
Sustained hip and knee flexion in stance
  • Stay nice and tall
  • Push foot into the ground
  • Use a cane in the contralateral hand
Vaulting[7]
  • Leave heel on the ground longer
  • Imagine or visualise leaning imprint of heel in wet sand
  • Therapist touches thigh of swing leg and cues “relax the knee”
  • Walk while keeping a book balanced on top of your head
  • Gaitspot squeaker shoe adaptation (see handout in additional resources for details)
  • Trial of a shoe lift with nonaffected limb
Toe walking
  • Let the heel touch the ground
  • Visualise leaving an imprint of your heel in wet sand
  • Take long steps
  • Walk/goose-step/march
  • Backwards walking
  • Gaitspot squeaker shoe adaptation
Freezing[8][9]
  • Mental imagery: visualise coming to the threshold in a doorway and boldly stepping through into the room.
  • Self-talk, say out loud: “stop, stand tall, shake off, shift weight, Step”
  • Laser light pointer line target
  • Kinaesthetic specific self-prompting tricks
  • Trial of assistive devices
Festination
  • Mental imagery
  • Laser light pointer or line target
  • Metronome music
  • Backwards walking
Circumduction[7]
  • “ See that don’t do that”
  • Therapist touches the front of the patient's hip and cues "lift from your hip"
  • Imagine or visualise walking in deep snow or shallow water
  • Walk close to the wall, do not strike the wall, but do not lean away from it either
  • Trial of a shoe lift with nonaffected limb[7]
Foot drop
  • Visualise a firm heel strike
  • Trial of a temporary ankle foot orthosis (AFO) with nonelastic tape or an elastic therapy band. *** please see video below
  • Shoe lift the nonaffected leg
  • Gaitspot squeaker shoe adaptation

Please view this short optional video for a demonstration of two methods to use an elastic therapy band for a soft trial for an AFO.

[10]

Resources[edit | edit source]

Optional Recommended Physiopedia Pages:


Clinical Resources:


Optional Recommended Reading:

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Howell, D. Gait Analysis. Neurologic Gait Deviations. Physioplus. 2022.
  2. 2.0 2.1 Snodgrass SJ, Heneghan NR, Tsao H, Stanwell PT, Rivett DA, Van Vliet PM. Recognising neuroplasticity in musculoskeletal rehabilitation: a basis for greater collaboration between musculoskeletal and neurological physiotherapists. Manual therapy. 2014 Dec 1;19(6):614-7.
  3. 3.0 3.1 3.2 Pirker W, Katzenschlager R. Gait disorders in adults and the elderly : A clinical guide. Wien Klin Wochenschr. 2017 Feb;129(3-4):81-95.
  4. Scheets PL, Bloom NJ, MSOT P, Crowner B, MPPA P, McGee PN, PCS P, Norton BJ, FAPTA PP, Sahrmann SA, Stith JS. Movement System Diagnoses Neuromuscular Conditions.
  5. 5.0 5.1 Chang MC, Lee BJ, Joo NY, Park D. The parameters of gait analysis related to ambulatory and balance functions in hemiplegic stroke patients: A gait analysis study. BMC neurology. 2021 Dec;21(1):1-8.
  6. Wang RY, Lin CY, Chen JL, Lee CS, Chen YJ, Yang YR. Adjunct Non-Elastic Hip Taping Improves Gait Stability in Cane-Assisted Individuals with Chronic Stroke: A Randomized Controlled Trial. Journal of Clinical Medicine. 2022 Mar 11;11(6):1553.
  7. 7.0 7.1 7.2 Fortes CE, Carmo AA, Rosa KY, Lara JP, Mendes FA. Immediate changes in post-stroke gait using a shoe lift on the nonaffected lower limb: A preliminary study. Physiotherapy Theory and Practice. 2022 Apr 3;38(4):528-33.
  8. Nonnekes J, Růžička E, Nieuwboer A, Hallett M, Fasano A, Bloem BR. Compensation strategies for gait impairments in Parkinson disease: a review. JAMA neurology. 2019 Jun 1;76(6):718-25.
  9. Tosserams A, Wit L, Sturkenboom IH, Nijkrake MJ, Bloem BR, Nonnekes J. Perception and use of compensation strategies for gait impairment by persons with Parkinson disease. Neurology. 2021 Oct 5;97(14):e1404-12.
  10. YouTube. Foot Drop Treatment with Resistance Band - For Walking, Gait, and Function | Saebo. Available from: https://www.youtube.com/watch?v=iHBJ0f0C2uo [last accessed 03/08/2022]