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

Neurologic gait deviations are a little different than the gait deviations we've been talking about that are associated with painful musculoskeletal syndromes in the following ways. There can be more cognitive impairments limiting our use of explicit motor learning principles and requiring that we use more implicit mechanisms of motor learning and control in the environment. The capacity to alter observed gait deviations may be more limited because of the organic degenerative processes that occur with some of the neurological diagnoses. And it requires more time to alter the observed gait deviations and the swing phase and the double support phase of gait require more attention. When we were talking about the painful musculoskeletal gait deviations, we focused primarily on stance phase. Gait deviations are sensitive for the early diagnosis of neurodegenerative diseases. They're not specific, but they can be an early sign of some of the neurodegenerative diseases. And the observed gait deviations may be the best compensation that that individual has the capacity for. Again, a gait deviation is often synonymous with a compensation. So if we're trying to alter the observed gait deviations, we're gonna need to be a little more proactive in terms of potential side effects or unintended consequences when we try to alter a gait deviation with a neurologic diagnosis.

So however, neurologic gait deviations are similar to the gait deviations we've been talking about with musculoskeletal pain syndromes in that the motor learning mechanisms and considerations of good verbal cueing that we applied for painful musculoskeletal syndromes are applicable. The same motor learning principles of external focus of attention tends to be what we should be choosing first, using the sensory preference of the client, using positive language and visual imagery as our starting points. And the clinical reasoning process of symptom modification procedures, see something do something, is still applicable and the clinical reasoning of a working hypothesis is still applicable for gait deviations associated with neurological problems.

Neurologic Gait Deviations

So I'm gonna take a moment and define or describe some of the potential neurologic gait deviations that are unique for this class. Walter Pirker et al. in 2017 provided a classification of 14 gait disorders associated with neurologic conditions. He describes a hemispastic, which is a unilateral circumduction; a paraspastic, which is bilateral extension and adduction, a stiff gait; ataxic gait, which is broad based, lacks coordination; sensory ataxic, which is cautious, worsening when you take away visual input; the freezing gait, we're gonna talk about that; the propulsive gait, or what some would describe as a festinating gait where the centre of gravity gets in front of the body or the base of support; the astasia gait, which is a primary impairment of stance and balance; dystonia gait, abnormal posturing of the leg and the foot; the choreatic gait, which is irregular dance-like, broad base of support; steppage gait, which refers to a weakness of foot dorsiflexion; the waddling gait, a broad-based, swinging or dropping of the swinging leg; the antalgic gait, which is basically a limp; the vertiginous gait, which is an insecure and a tendency to fall to one side; and then the psychogenic gait, or some people call it a functional gait. So these classifications are broad and they're a good starting point, but I think we need to get to greater detail and greater clarity before we can begin our clinical reasoning process of seeing something and doing something with a working hypothesis.

So I like the work of Patricia Scheets et al. in 2014 and in a subsequent publication in 2017, movement system classification or signs of neuromuscular conditions. So I'm gonna use those as a starting point and I added a few. She talks about an increased base of support, kind of going with the waddling gait. This is common across many neurologic conditions, and it's more than likely a gait deviation that is a good compensation that rarely do I try to alter to bring in so it's not so wide-based. It's a safe gait. However, you can have the opposite of an increased base of support, which is a decreased base of support. Tends to be more prevalent in our Parkinson's neurodegenerative disease. You can have a lateral shift of centre of mass towards the stance limb. You can have knee hyperextension in stance, genu recurvatum, a sustained hip and knee flexion in stance, weak leg, a vaulting gait, toe walking, especially prevalent with autistic clients. You can have the limp, which is an unequal step length and decreased time on the involved limb. You can have the decreased step length, increased cadence, which is festination. You have a freezing or difficulty initiating gait, variable foot placement is a gait deviation, a pelvic contralateral elevation goes with the listing of centre of mass to the stance phase, circumduction, scissoring gait, decreased hip and knee during swing phase, and then foot drop.

limp

So let's talk about the limp. Good verbal cueing, not necessarily because of positive language, but sometimes it works, do you see that you're limping? Don't do that. That's a kind of a default that I'll go to when I'm struggling for an external focus with a visual image. But if I say, imagine or visualise you're walking with smooth rhythmic steps. Take long, even steps. Spend less time on your good leg, spend more time on your weak leg. If you have a sensory preference where they're good at auditory learning, provide a metronome or a rhythm or a song, and then sometimes just swinging the arms will get more symmetry.

Slow velocity

How about the gait deviation that's prevalent with musculoskeletal pain and neurologic conditions majority of the time is slow velocity. Cue them walk faster, step to the beat of the appropriate cadence, greater than 120 steps per minute, if it's too slow. Adjust, we can do implicit training with forced use by adjusting the treadmill speed to a faster speed, and just verbally cue them, walk with spring in your step, as if you're peering over the crowd, that's going to automatically increase their speed a little bit.

Knee hyperextension or genu recurvatum

Let's talk about some neurologic gait deviations during stance phase, the one of knee hyperextension, or genu recurvatum. Give them the cue to imagine or visualise there's a scaffold around your knee, or push off the floor and propel up and forward to use the gastroc to facilitate knee flexion and avoid knee hyperextension. For the kinaesthetic learner, actually tap the gastroc and say, use this muscle to control the knee, give them that kinaesthetic, tactile feedback. And then you can use non-elastic strapping, McConnell taping, or Kinesiotaping, or a Swedish knee cage, an orthosis.

sustained hip and knee flexion in stance phase

If it's not supporting them. So stay nice and tall. Push the foot into the ground are verbal cues. Or use a cane in the contralateral hand.

Vaulting

There's that excessive ankle plantarflexion from spasticity or limited dorsiflexion. So leave the heel on the ground longer, imagine or visualise you're leaving the imprint of the heel in wet sand, keep that heel down. Or touch the thigh in swing and say, relax that leg. They may be vaulting because of the spasticity and diminished knee flexion during swing phase. An auditory learner, there are gait spot squeakers, little squeakers that you can attach to the sole of the shoe to give them that auditory feedback to get the heel down. And then there's an interesting paper I found recently that was suggesting, on a temporary basis, to apply a shoe lift to the uninvolved side so that they don't have to do that vault to clear the functionally long leg

Toe walking

Toe walking. In some of our paediatric patients, some of our adult patients. So visually, or cue them, let the heel touch the ground, imagine or visualise you're leaving the heel imprint and walking in wet sand. Take long steps, get the image or motor image that you're doing a goose step walk and getting that heel down. Backwards walking is implicit learning to get that heel down. And again, a gait spot squeaker adaptation to give them auditory feedback

difficulty initiating or freezing gait

JD Schaafsma et al. in 2020 came up with, I think, a pretty good definition or clarity of this difficulty initiating or freezing gait. They described it as episodic and involuntary cessation of normal walking involving one or three different characteristics: shuffling, small shuffling steps with minimal forward movement; the trembling, leg trembling, but without effective forward movement; and akinesia or no observable movement. All of that is different components of this difficulty initiating movement.

So what do we do when we have this Parkinson's patients that have difficulty initiating movement, what verbal cues, prompting, or feedback is available to us? And this is basically a swing phase gait deviation. Use mental imagery before they practise, when they're sitting, so you could give them descriptions of, visualise you're coming to the threshold of a doorway and you're boldly stepping through into the room. Practise that, think about it when you're not walking. Using self-talk and they can say this out loud or self-talk without. The verb, the vocabulary is stop, stand tall, shake it off, shift weight side to side, step. Stop, stand tall, shake it off, shift weight side to side, and step. Laser pointer or laser line has been used for Parkinson's patients that need that visual cueing or prompting. There are kinaesthetic tricks that have been used where they'll kick a soccer ball or tap a temple or touch their chest to give them that cue to self-trick so that they can initiate it. Several examples of that on the YouTube.

festination or decreased step length

And so what about this festination or decreased step length? Again, you can use your mental imagery, laser lights, metronome music at the appropriate cadence, and backwards walking.

circumduction

Staying in swing phase, the gait deviation of circumduction. Again, you could say, see that, don't do that, try that. Touch the front of the hip, give them that kinaesthetic cue. Lift from the hip, lift from the hip. Walk close to the wall to give them that external focus of attention. Don't hit the wall, but don't list away from the wall. And again, because it's a function of a functionally long leg, temporarily put a shoe lift in the uninvolved side.

foot drop

Then a frequent gait deviation of swing phase is foot drop. Visualise a firm heel strike, use a visual image, a temporary AFO of a non-elastic ankle-foot orthosis, and on the reference list, there's a YouTube description of using theraband on a temporary basis as an ankle-foot-orthosis. And then again, you could use your shoe lift on the uninvolved side as options.

the decreased step length,

increased cadence, which is festination.

You have a freezing or difficulty initiating gait,

variable foot placement is a gait deviation,

a pelvic contralateral elevation goes with the listing of centre of mass to the stance phase,

circumduction,

scissoring gait,

decreased hip and knee during swing phase,

and then foot drop.

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