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 compensational movement. The human body will find a way to make mobility happen, but this sometimes results in less than optimal 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. The authors found that integrating some of these concepts into traditional musculoskeletal physiotherapy treatments improved participants' 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 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. 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

Pirker and Katzenschlager 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.

Please see the video in the Additional Resources section for demonstrations of many of these deviant gait patterns.

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, which is based on the work of Scheets et al. with additions from 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 / 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	Walk faster Step to the beat of the music at / or greater than 120 beats/minute Adjust treadmill speed Walk with a 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 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	Leave heel on the ground longer Imagine / visualise leaving an 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	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 or 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	“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 the wall, do not strike the wall, but do not lean away from it either Trial of a shoe lift for the nonaffected limb
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 for the nonaffected leg Gaitspot squeaker shoe adaptation

Special Topic: Freezing of Gait (FOG)

FOG can be defined as a “brief, episodic absence, or marked reduction of forward progression of the feet despite the intention to walk”. FOG related features can include: (1) shuffling, (2) trembling, and (3) complete akinesia. These features are demonstrated during the brief episode of change in forward progression.

Kondo et al. described three phenotypes of FOG based on leg movements:

1. FOG with very small shuffling steps and minimal forward movement (shuffling)
2. FOG with some leg trembling but no effective forward motion (trembling)
3. No observable forward motion of the legs (complete akinesia)

Clinical Pearls: Gait Analysis and the Power of Words

According to Dr. Damien Howell:

"Optimizing human movement requires clarity of description of movement. To know where you are going you must first know where you are.

To optimize human movement, analysis of human movement is required.

To identify optimal human movement clear qualitative and quantitative descriptions are needed.

When describing human movement confusion occurs when we fail to clearly identify a frame of reference and reference point.

A common description of a gait deviation is the individual is “hip hiking.”  What is “hip hiking”? Is the thigh bone hiking? is the pelvic bone hiking? is the hiking during the stance phase or swing phase? We need a frame of reference and reference points.

A common description of a gait deviation is a “Trendelenburg sign.” This description confuses me. I am thinking is the patient is in an upside-down position that is used during a surgical procedure. Is there something wrong with superficial veins? Does he have a limp? Naming clinical tests and descriptions of movements after an individual is not helpful.

Describing gait deviation by pathology is not specific enough to direct treatment. Describing a person's gait as he/she is walking with a Parkinson's gait is very wide-ranging. Is there freezing; shuffling; festinating, all the above? The description of a “hemiplegic gait” is not very helpful.  Whereas relative to vertical line there is a lateral shift of the sacrum (center of mass) towards the stance leg description of movement can provide direction for intervention.

Describing movement or motion requires using a frame of reference and a reference point. There are different frames of reference that are used to describe motion.

The Polar coordinate system is a 2-dimensional system in which each point on a plane is determined by a distance from a reference point and the angle of the reference point. It describes the movement, navigation, and travel. Interestingly indigenous people of Australia (Guugu Yimidhirr) use the polar coordinate system to describe human movement. They have no words for left and right. Instead, Guugu Yimidhirr speakers give all their descriptions and directions based on the fixed four cardinal points of the compass: north, south, east, and west. If I was providing Physical Therapy to a Guugu Yimidhirr I ask the individual to move your east arm/shoulder to the northeast instead of flexing your right arm/shoulder.

The allocentric frame of reference is describing motion with respect to other objects. For example, the person is moving relative towards or away from the window. The high jumper’s center of mass is passing under the bar and his pelvis passing over the bar.

An egocentric frame of reference motion is describing motion with respect to the individual's body axes of self, left-right, front-back, up-down.

There is consensus when describing human motion to use the coordinate system as a frame of reference. The cartesian coordinate system uses two perpendicular lines. We use it to specify a point in the 3-dimensional space.

Describing and analyzing human walking and running the coordinate system the frame of reference uses three perpendicular lines:

• Vertical line assumed to be a line of gravitational force - The body moves fore/aft or side to side relative to the vertical line.
• Horizontal line – The body moves up-down relative to the line of the horizon
• Line of progression – The body moves inward-outward relative to the line of progression.

Given these 3 lines of orientation then specific boney prominences are used as reference points to clearly describe human motion ... Given the frame of reference using vertical line, horizontal line, and line of progression and reference points of boney prominence the time/distance, the motion of joints, and/or body segments (kinematics) can be clearly described.

Using this process describing movement we can analyze motion or gait and make judgments whether the motion is normal, deviant, and optimal ... Avoiding the use of an individual’s name or the name of pathology to describe movement prevents confusion. Take time to describe movement relative to a frame of reference and reference points facilitating clarity. Using terminology that describes the frame of reference and reference points to describe motion will result in a movement system language, development of movement system diagnostic categories, and facilitating optimal movement."

The above information was used with kind permission of Dr. Damien Howell PT. For more information, please explore Dr. Howell's professional blog.

Resources

Optional Additional Videos:

Please view this optional 15-minute video for demonstrations of deviant gait patterns.

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.

Optional Recommended Physiopedia Pages:

• Gait Training in Stroke
• Gait Re-education in Parkinsons

Clinical Resources:

• Handout for Gaitspot squeaker shoe adaptation

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.
• 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.