Neurological Gait Deviations

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

Top Contributors - Stacy Schiurring, Jess Bell, Kim Jackson, Lucinda hampton and Tarina van der Stockt

Introduction

Gait deviation is often synonymous with a compensation. The human body will find a way to make mobility happen, sometimes resulting in less than optional movement patterns. It is the roll of the rehabilitation professional to guide patients through a plan of care to improve and or correct movement dysfunction with the ultimate result being ideal movement for that 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 concepts of neuroplasticity and motor learning to musculoskeletal physiotherapy practice. They found that integrating some of these concepts into traditional musculoskeletal physiotherapy treatments improved participant's outcomes with earlier and greater movement gains.

"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."

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

1. Cognitive impairments can limit the use of explicit motor learning principles and requiring 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 tend to focus on deviation in the swing phase and double support phase of gait. Musculoskeletal gait deviations, tend to focus primarily on stance phase gait deviations.
4. Gait deviations can be an early sign of some of neurodegenerative diseases. The observed gait deviation may be the best available movement pattern for that individual for 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. 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 are still applicable for gait deviations associated with both painful musculoskeletal syndromes and neurological gait deviations.

Neurological Gait Deviations

Walter Pirker et al 2017 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.

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	Center of gravity in front of 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 Swayin 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 off the the work of Patricia Scheets et al 2014 with additions by Dr Damien Howell. 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

Gait deviation	Examples of intervention with possible cue/prompt/feedback
Limp	“See that, don’t do that” Imagine visualize 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	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	Imagine visualise a scaaffold 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 or elastic tape, Swedish knee cage
Sustained hip and knee flexion in stance	Stay nice & tall Push foot into the ground Use cane in the contralateral hand
Vaulting	Leave heel on the ground longer Imaging 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 Gait squeaker shoe adaptation Trial of a shoe lift with nonaffected limb
Toe walking	Let heel down touch ground Imagine visualise leaving an imprint of your heel in wet sand Take long steps Walk/goose-step/march Backwards walking Gait spot squeaker shoe adaptation
Freezing	Mental imagery: visualize coming to the threshold in a doorway & boldly stepping thru into the room. Self talk, say out loud: “stop, stand tall, shake off, shift weight, Step” Laser light pointer line target Kinesthetic specific self-prompting tricks Trial of assistive devices
Festination	Mental imagery Laser light pointer or line target Metronome music Backwards walking
Circumduction	“ See that don’t do that” Therapist touches the front of the patient's hip and cues "lift from your hip" Imagine visualise walking in deep snow or shallow water Walk close to wall do ,not strike wallthe do ,not lean away from wallthe Trial of a shoe lift with nonaffected limb
Foot drop	Visualize a firm heel strike Trial of a temporary AFO with nonelastic tape or an elastic therapy band Shoe lift nonaffected leg Gait spot shoe squeakers

Resources

Optional Recommended Reading:

• Pirker W, Katzenschlager R. Gait disorders in adults and the elderly : A clinical guide. Wien Klin Wochenschr. 2017 Feb;129(3-4):81-95.
• 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.