Side Effects of Verbal Cueing and Interventions to Alter Gait Deviations

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

Top Contributors - Stacy Schiurring, Kim Jackson, Jess Bell and Lucinda hampton

Introduction[edit | edit source]

Verhagen et al.[1] discuss the use of physical activity as a medicine to help decrease the burden of chronic and lifestyle-related diseases on the general public. While the benefits of physical activity are well known and shared with patients, the unwanted side effects or unintended consequences are often ignored or neglected as part of patient education.[1]

Horvath et al.[2] performed a systematic literature review and found that the nocebo effect can influence an individual's motor performance and can be evoked by negative verbal cues. In certain circumstances, the nocebo effect can be more robust than the placebo effect.[2]

The risk of adverse effects when prescribing rehabilitation interventions such as physical activity, exercise, or gait training is low, but they are not nonexistent. Clinicians should be proactive in sharing potential side effects with patients[3] as part of the informed consent process.

Side Effects of Altering a Gait Deviation[edit | edit source]


A side effect is typically an undesirable or unintended consequence of an intervention.[3]

A nocebo effect occurs when a patient's negative expectations of treatment cause the treatment to have a more negative outcome than it otherwise would have.[4]

A placebo effect is the tendency of a medication or treatment, even an inert or ineffective one, to exhibit results simply because the recipient believes that it will work.[5]

Possible clinical outcomes of sharing potential side effects:[3]

  1. Increasing the level of engagement with patients
  2. Can facilitate timely adjustments for chosen interventions
  3. May itself induce unintended or adverse effects through the nocebo effects

A rehabilitation professional can use clinical reasoning to create a working hypothesis to try to improve the unintended consequences of therapeutic interventions.[3]

The three common side effects of altering a gait deviation:[3]

  1. Increased energy expenditure; it can be physically taxing to walk and run in a new way
  2. Increased cognitive demand; the brain must work harder to perform the task
  3. Increased muscle fatigue and soreness for utilising muscles in a novel way

Gait Deviation Clinical Examples[edit | edit source]

Gait deviation Related musculoskeletal

pain syndromes

Sensory System Internal focus of attention: Cue, Prompt, Feedback External focus of attention: Cue, Prompt, Feedback Potential side effects
Too long a step or stride length[6]
  • Back pain
  • Anterior hip pain
  • Lateral knee pain
  • IT band syndrome
  • Anterior knee pain
  • Patellofemoral arthralgia
  • Medial tibial stress syndrome
  • Stress fractures
  • Achilles pain
  • Plantar heel pain syndrome
Visual Imagine/visualise walking on hot sand Use laser light target for shorter steps Making step length shorter could result in increased energy expenditure[7]
Auditory "Walk like you are sneaking up on someone" Listen to metronome beat at appropriate cadence beats/minute
Kinaesthetic Tactile Take shorter steps more steps/minute Wearable device with vibratory feedback at appropriate cadence
Late/delayed heel off
  • Anterior hip pain
  • Anterior knee pain
  • Patellofemoral arthralgia
  • Anterior ankle pain
  • Achilles pain (due to stretch weakness)
  • Plantar heel pain syndrome
Visual Imagine/see yourself propel up and forwards Walk towards a mirror and watch the top of your head, laser light target Cognitive overload
Auditory “Spring in your step” Listen to verbal cues provided: “yes”; “dampen it”; “need more effort”
Kinaesthetic Tactile Feel the heel lift off the ground sooner Use of elastic tape
Too much toe out[8]

(more than 15 to 20 degrees of foot progression angle)

  • Hip osteoarthritis (OA)
  • Knee OA
  • Can continue after a total joint replacement
  • Patellofemoral arthralgia
  • Medial tibial stress syndrome
  • Achilles pain
  • Plantar heel pain syndrome
  • Pain on the ball of the foot
  • Metatarsalgia
  • Hallux limitus
  • Great toe OA
  • Bunions
Visual Visualise your foot as a front car tyre, keep it straight down the road Align foot with tape or a line on the ground
  • Potential adverse effect with intentional increase of toe-in is a decreased knee adduction moment and an increased knee flexion moment[9]
  • Patients status post-total knee replacements with weak quadriceps may experience knee pain
Auditory Listen to verbal cues provided: “yes”; “dampen it”; “need more effort” Say out loud "turn foot inward"
Kinaesthetic Tactile Push heel outward or turn toe inward Touch or tap the muscles on the front of the hip, "use this muscle"
Lateral pelvic drop, contralateral pelvic drop
  • Back pain
  • Hip labral problems
  • Gluteal tendinopathy
  • Piriformis syndrome
  • Patellofemoral arthralgia
  • IT band syndrome
  • Medial tibial stress
  • Ankle pain
  • Achilles pain
  • Plantar heel pain syndrome
Visual Imagine the pelvis is a bucket of water, don’t let the water spill out
  • Walk towards the mirror, watch your belt and keep it level
  • Laser light target
Muscle fatigue and soreness
Auditory "Imagine your pelvis is a bell, quiet the clang of the bell" Listen for foot strike. Make the sound symmetrical and rhythmic
Kinaesthetic Tactile Touch hand to the gluteal muscles, "engage this muscle"
  • Hip spica brace
  • Neoprene sleeve
  • Nonelastic or elastic strapping of hip

Side Effects Special Topics[edit | edit source]

Cognitive overload can occur when a person is being challenged mentally by the therapeutic interventions. They are processing too much information or too many tasks, and it adversely affects their motor learning.[10] The rehabilitation professional can modify this overload by (1) discontinuing the intervention, (2) continuing the intervention and encouraging the patient through the task, (3) modifying the task from the whole into smaller steps or parts, or (4) modifying the intervention by switching the sensory preference of the verbal cue being provided to the patient.[3]

Increased muscle fatigue and soreness is an expected side effect of exercise. However, it is important to have a discussion and talk about the nature of the pain with each patient to ensure this new pain is not a warning sign of additional injury.

Examples of predicting which muscles will experience soreness and / or fatigue in response to the explicit alteration of gait:

Gait deviation alteration Potential sources of muscle fatigue and / or soreness
Too long a step or stride to shorter steps Thigh and / or calf muscles
Lateral pelvic tilt to a more stable pelvis / hip Gluteal muscles
Prolonged heel contact to the appropriate heel off timing Soreness in foot and or calf muscles, engagement of gluteal muscles
Excessive toe-out to appropriate foot progression angle Stretching sensation of muscles around the hip, fatigue in muscles around the hip

Resources[edit | edit source]

Optional Video:

This optional video discusses the nocebo versus placebo effect, and provides clinical examples of the nocebo effect.


Optional Additional Reading:

References[edit | edit source]

  1. 1.0 1.1 Verhagen, E., Bolling, C., & Finch, C. F. (2015). Caution this drug may cause serious harm! Why we must report adverse effects of physical activity promotion. Br J Sports Med, 49(1), 1-2.
  2. 2.0 2.1 Horváth Á, Köteles F, Szabo A. Nocebo effects on motor performance: A systematic literature review. Scandinavian journal of psychology. 2021 Oct;62(5):665-74.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Howell, D. Gait Analysis. Side Effects of Verbal Cueing & Interventions to Alter Gait Deviations. Plus. 2022.
  4. Wikipedia. Nocebo. Available from: (accessed 06/08/2022).
  5. Wikipedia. Placebo. Available from: (accessed 06/08/2022).
  6. Aali S, Rezazadeh F, Badicu G, Grosz WR. Effect of Heel-First Strike Gait on Knee and Ankle Mechanics. Medicina. 2021 Jun 26;57(7):657.
  7. Doyle E, Doyle TL, Bonacci J, Fuller JT. The effectiveness of gait retraining on running kinematics, kinetics, performance, pain, and injury in distance runners: a systematic review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2022 Apr;52(4):192-A5.
  8. Schelhaas R, Hajibozorgi M, Hortobágyi T, Hijmans JM, Greve C. Conservative interventions to improve foot progression angle and clinical measures in orthopedic and neurological patients–A systematic review and meta-analysis. Journal of biomechanics. 2022 Jan 1;130:110831.
  9. Hunt MA, Charlton JM, Krowchuk NM, Tse CT, Hatfield GL. Clinical and biomechanical changes following a 4-month toe-out gait modification program for people with medial knee osteoarthritis: a randomized controlled trial. Osteoarthritis and Cartilage. 2018 Jul 1;26(7):903-11.
  10. Saddy N. Investigating the effects of cognitive overload in a simulated manufactoring task. 2022.
  11. YouTube. Sticks and Stones…and Words can hurt you: the Nocebo Effect | Jeremy Howick | TEDxBonnSquareSalon. Available from: [last accessed 08/08/2022]