Neurological Gait Deviations
Top Contributors - Stacy Schiurring, Jess Bell, Kim Jackson, Lucinda hampton and Tarina van der Stockt
Introduction[edit | edit source]
Gait deviation is often synonymous with compensational movement.[1] 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.[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]
- Cognitive impairments can limit the use of explicit motor learning principles and requiring more implicit mechanisms of motor learning.
- Organic degenerative processes that occur with some neurological diagnoses can limit the capacity to alter observed gait deviations.
- Gait training for those with neurological gait deviations tend to focus on deviation in the swing phase and double support phase of gait, and for musculoskeletal gait deviations, tend to focus primarily on stance phase of gait.
- 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.
- 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.
- The clinical reasoning process of symptom modification procedures and clinical reasoning of a working hypothesis are still applicable for gait deviations associated to both painful musculoskeletal syndromes and neurological gait deviations.
Neurological Gait Deviations[edit | edit source]
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.[3]
Gait Disorder | Characteristics/description |
---|---|
Hemispastic gait | Unilateral extension and circumduction |
Paraspastic gait |
|
Ataxic gait |
|
Sensory ataxic gait |
|
Freezing gait |
|
Propulsive gait |
|
Astasia gait | Primary impairment of stance balance |
Dystonic gait | Abnormal posture of foot and or leg |
Choreatic gait |
|
Steppage gait | Weakness of foot extensors |
Waddling gait |
|
Antalgic gait | Shortened stance phase on the affected side |
Vertiginous gait |
|
Psychogenic gait |
|
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[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.
- Increased base of support (BOS)
- Decreased BOS
- Lateral shift of centre of mass (COM) toward stance limb
- Knee hyper-extension stance
- Sustained hip knee flexion stance
- Vaulting
- Toe walking
- A limp: unequal step length, decreased time on uninvolved limb
- Festination: decreased step length, increased cadence
- Freezing difficulty initiating gait
- Variable placement of foot
- Pelvic elevation contralateral
- Circumduction
- Scissoring
- Decreased hip knee swing phase
- Foot drop
Gait deviation | Examples of intervention with possible cue/prompt/feedback |
---|---|
Limp[5] |
|
Slow gait velocity[5] |
|
Knee hyperextension |
|
Sustained hip and knee flexion in stance |
|
Vaulting[7] |
|
Toe walking |
|
Freezing[8][9] |
|
Festination |
|
Circumduction[7] |
|
Foot drop |
|
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.
Resources[edit | edit source]
Optional Recommended Physiopedia Pages:
Clinical 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.
- 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.
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Howell, D. Gait Analysis. Neurologic Gait Deviations. Physioplus. 2022.
- ↑ 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.
- ↑ 3.0 3.1 Pirker W, Katzenschlager R. Gait disorders in adults and the elderly : A clinical guide. Wien Klin Wochenschr. 2017 Feb;129(3-4):81-95.
- ↑ 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.
- ↑ 5.0 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.
- ↑ 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.
- ↑ 7.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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]