This document discusses neurological gait and gait rehabilitation. It begins by defining normal gait and describing common pathological gaits that can result from neurological conditions, including hemiplegic, spastic diplegic, Parkinsonian, myopathic, and ataxic gaits. Specific characteristics and management approaches are described for each type. Rehabilitation approaches covered include traditional gait training exercises, use of assistive devices, high-tech options like body-weight supported treadmill training and electrical stimulation, as well as strength and balance training. Surgical management is also briefly discussed for some conditions.

1. NEUROLOGICAL GAIT
REHABILITATION
-By Dr. Rima Jani PT (B.P.T., M.P.T.)

2. CONTENTS
• Introduction
• Normal Gait
• Pathological Gait/Gait Deviation
• Types of Neurological Gait
• Gait Rehabilitation

3. INTRODUCTION
• Gait is locomotion achieved through the mobility of limbs.
• It is defined as bipedal, biphasic forward propulsion of the body,
which includes alternate sinuous movements of different
segments of the body with optimum energy expenditure.
• Gait is a person's pattern of walking, it involves balance and
coordination of muscles so that the body is propelled forward in
a rhythm, called the stride.
• There are numerous possibilities that may cause an
abnormal gait.

4. PATHOLOGICAL GAIT
• Problems in the nervous system will show up in the way a
person walks.
• Pathologic gait patterns can be broadly divided into either
neuromuscular or musculoskeletal etiologies.
• Neurological Gait Deviations result from neuromuscular
etiologies, because of underlying pathology associated to CNS or
PNS.

5. TYPES OF NEUROLOGICAL GAIT
Basic pathological gaits that can be attributed to neurological
conditions:
• Hemiplegic,
• Spastic Diplegic,
• Parkinsonian,
• Myopathic,
• Ataxic.

6. HEMIPLEGIC GAIT
• Hemiplegic gait is also known as Circumductory Gait.
• It includes impaired natural swing at the hip and knee with leg
circumduction.
• The pelvis is often tilted upward on the involved side to permit
adequate circumduction.
• With ambulation, the leg moves forward and then swings back
toward the midline in a circular movement.

7. COMPONENTS OF HEMIPLEGIC/CIRCUMDUCTORY
GAIT
• Hip Hike
• Circumduction of the leg
• Reduced hip & knee flexion
• Decreased weight shift towards affected
side
• Foot drop, poor dorsiflexion, toe first or flat
foot placement

8. HEMIPLEGIC GAIT REHABILITATION
Traditional Gait Rehabilitation
High Tech Gait Rehabilitation
Additional Strength Training

9. TRADITIONAL GAIT REHABILITATION :
• Gait Training in parallel bar
• Gait Training exercises
• Balance and core training
• Use of Assistive devices &/or Orthotics
• Task-specific training.
• Treadmill Training

10. GAIT TRAINING IN PARALLEL BAR

11. GAIT TRAINING EXERCISES
• Seated Marching
• Knee Extension Exercises
• Toe Taps
• Braiding Exercises
• Side Stepping
• Ankle Dorsiflexion Exercises
• Assisted Toe Raise
• Heel Raises

12. SEATED MARCHING
• This basic gait training exercise can be
done from any seated position.

13. KNEE EXTENSION EXERCISES

14. TOE TAPS

15. BRAIDING EXERCISE
• Braiding exercise
is performed by
crossing one leg in
front of or behind
the other in a
continuous
manner.

16. SIDE STEPPING EXERCISES

17. ANKLE DORSIFLEXION EXERCISES

18. ASSISTED TOE RAISE

19. HEEL RAISES

20. BALANCE AND CORE TRAINING
• Balance and core training both help improve
gait. But there is lack of significant evidences.
• Walking is a full-body task that requires
coordinated movement from the feet, legs, and
core.
• Reach outs in Standing
• Walking on different surfaces
• Balance Board Exercises
• Weight Shifts on Affected side

21. USE OF ASSISTIVE DEVICES &/OR ORTHOTICS
Ankle Foot Orthosis:
• Solid AFO
• Posterior leaf spring AFO
(PLS)

22. TREADMILL TRAINING
• Initially treadmill speeds are slow (0.23 m/sec)
• Over a period of few weeks it is gradually increased up to (0.98
m/sec)

23. TASK-SPECIFIC TRAINING.
• This simply refers to walking.
• Walking in different environments.
• Hurdle walking
• Climbing small slope

24. HIGH TECH GAIT REHAB :
• Partial Body Weight Supported Treadmill Training
• Functional Electrical Stimulation
• Virtual Gait Training

25. BODY WEIGHT SUPPORTED TREADMILL TRAINING
(BWSTT)

26. • An overhead harness is used to support a portion of the patient’s
body weight.
• The harness controls the upright position of the patient in the
absence of good postural stability & reduces fear of falling.
• The use of harness also eliminates the need for adaptive UE
support to compensate for LE weakness.
BODY WEIGHT SUPPORTED TREADMILL TRAINING
(BWSTT)

27. FUNCTIONAL ELECTRICAL STIMULATION.
• Adding electrical stimulation to the affected muscles during gait
training exercises can help boost results, according to studies.
• NMES improves dorsiflexion and prevents foot drop
• Significant improvement in gait is proven with use of FES.

28. VIRTUAL REALITY GAIT TRAINING

29. ADDITIONAL STRENGTH TRAINING
• Some muscle atrophy is common after a stroke.
• Therefore, adding some strength training can help improve
overall health and gait.
• Keep in mind that this addresses the secondary complication of
muscle atrophy, while rehab exercise addresses the primary
concern

30. BENEFITS OF GAIT TRAINING AFTER STROKE
• Gait training exercises can help prevent falling after stroke,
because strong legs can help with stabilization if patient loses
balance.
• Ultimately, a consistent rehab exercise program can help patient
get back onto their feet and back to the activities that they
enjoy.
• Focus on high repetition of exercises to help rewire the brain.
• Be sure to target core and feet along with legs to improve
overall coordination and balance.

31. SPASTIC HEMIPLEGIA DIPLEGIA: GAIT

32. DROP FOOT GAIT
• A `drop foot' which is noted most clearly in the
swing phase of gait due to the inability to
selectively control the ankle dorsiflexors during
this part of the gait cycle.
• No calf contracture and therefore during
stance phase, ankle dorsiflexion is relatively
normal.

33. DROP FOOT GAIT
• This gait pattern is rare, unless there has
already been a calf lengthening
procedure.
• The only management maybe needed is
a leaf spring or hinged ankle foot
orthosis (AFO).

34. SPASTIC DIPLEGIC GAIT
• Torsional deformities of the long bones and foot
deformities are frequently found in spastic Diplegic CP.
• Musculo tendinous contractures are also present
• These are collectively referred to as `lever arm disease‘.
• The most common bony problems are medial femoral
torsion, lateral tibial torsion, midfoot breaching, with foot
valgus and abduction.

35. ROTATIONAL DEFORMITIES
• Child with rotational deformities present with
either an in-toed or out-toed gait
• This in-toeing and out-toeing must be
evaluated properly
• It is due to position and pressure in the uterus
during pregnancy

36. • Internal tibial torsion: causing toe in
• External tibial torsion: causing toe
out
• Internal femoral torsion: causes toe
in
• External femoral torsion: causes toe
out

37. CROUCH GAIT PATTERN
• This shows the features of `lever
arm disease'. There is an out-toed
stance and gait pattern because of
midfoot breaching and lateral
tibial torsion.
• The right image is a sagittal view
demonstrating a crouch gait
pattern.

38. CROUCH GAIT PATTERN
• When the bony lever (the foot)
is bent and is abnormally
directed.
• Weakness of gastro-soleus is
unable to control the
progression of the tibia over the
planted foot and a crouch gait
results.

39. CROUCH GAIT
• Excessive dorsiflexion or
calcaneus at the ankle in
combination with excessive
flexion at the knee and hip.
• Seen in children with more severe
diplegia and in the majority of
children with spastic quadriplegia

40. CAUSES
Any of the following causes or combination of following causes:
• Spastic hamstrings
• Weak Gastro-soleus.
• Malrotation of femur, tibia and foot.
• Tight Iliopsoas
• Weak Quadriceps
• Poor Balance

41. CAUSES
• Isolated lengthening of the heel cord in the younger child.
• Once the heel cord has been lengthened, if the
spasticity/contracture of the hamstrings and iliopsoas has not
been recognized and is not managed adequately, there will be
a rapid increase in hip and knee flexion.
• The result is an unattractive, energy-expensive gait pattern,
followed by anterior knee pain and patellar pathology in
adolescence

42. SURGICAL MANAGEMENT
• By the time it is recognized, the musculoskeletal
pathology is usually too advanced to respond to
intramuscular BTX-A.
• Surgical management: lengthening of the hamstrings and
iliopsoas, and adequate correction of bony problems such
as medial femoral torsion, lateral tibial torsion and
stabilization of the foot.

43. ORTHOSIS
• A ground reaction AFO
• Orthotic management: long-term use of a ground
reaction AFO until the integrity of the plantar
flexion- knee extension couple is clearly re-
established.

45. PHYSIOTHERAPY MANAGEMENT
• Strengthening of weak muscles : gluteus maximus mainly
• Strengthening the lower extremity muscle extensors can
improve the excessive hip flexion, hip internal rotation,
and knee flexion for an overall improvement ambulation,
function, and quality of life.

46. FUNCTIONAL GAIT TRAINING
• Walking on different surfaces
• Side walking
• Backward walking
With orthosis off course
Robotic Gait Training

47. SCISSORING GAIT
• A scissoring gait is most
common in individuals with
spastic Diplegic cerebral
palsy.
• There are a variety of
abnormal gait patterns that
can result from spastic
cerebral palsy, but a
scissoring gait is the most
prevalent.

48. SCISSORING GAIT
• It is an abnormal walking pattern characterized by the
thighs and knees pressed together or crossing each other.
• This is caused by overactive contractions of the hip
adductors.
• Along with hip adductions, the feet will be pointed
inwards due to internal hip rotation, and knees will be
bent.

49. • This can cause the upper body
to move quite a bit while the
individual is walking and make
it difficult to stay balanced.
• Individuals with cerebral palsy
and scissoring gait typically
walk slowly with limited
mobility.
SCISSORING GAIT

50. COMPLICATIONS IF LEFT UNTREATED:
• develop deformities due to uneven muscle pull
• experience frequent falling due to poor balance
• have limited independence and mobility due to poor
range of motion
• eventually, be unable to walk

51. MANAGEMENT
• Fixing a scissoring gait pattern is two-fold:
1. Spasticity Management.
2. Physiotherapy.

52. SPASTICITY MANAGEMENT
• Muscle relaxants like Baclofen: Help reduce muscle
hyperactivity for temporary spasticity relief.
• Botox Injections: Blocks nerve signals that cause muscles
to contract.
• Orthotics: Wearing an orthosis can help counteract
spastic muscles from tightening even more.

53. SPASTICITY MANAGEMENT
• Surgery: For a scissoring gait, an adductor lengthening
surgery may be recommended. This involves
lengthening the inner thigh muscles and weakening
obturator nerve activity.
• Another surgery that is commonly performed to
reduce spasticity is a selective dorsal rhizotomy.
• This involves cutting overactive sensory nerve fibers.

54. PHYSIOTHERAPY
• Stretching tight muscles : Hip Adductors
• Strengthening underused muscles: Hip Abductors
• Activating neuroplasticity by continuously practicing
walking with correct form : Gait & Balance Training

55. GAIT & BALANCE TRAINING
• Gait reeducation
• Balance & coordination
exercises
• Hydrotherapy
• Mobility Rehabilitation

56. JUMP GAIT
• The jump gait pattern is very
commonly seen in children with
diplegia.
• The ankle is in equinus, the knee and
hip are in flexion, there is an anterior
pelvic tilt and an increased lumbar
lordosis. Also hip adduction and
internal rotation.

57. JUMP KNEE
• It is characterized by gastroc-soleus
spasticity or contracture
• Impaired ankle dorsiflexion in swing
• Flexed stiff knee gait as a result of
hamstring/quadriceps co contraction.
• There is often a stiff knee because of rectus
femoris activity in the swing phase of gait.

58. MANAGEMENT
• Single event multi level surgery :
• Mainly muscle tendon lengthening
for gastroc-soleus contracture
• Orthosis: Hinged Dynamic AFO
• Physiotherapy

59. PHYSIOTHERAPY
• Stretching tight muscles : Mainly Gastroc-soleus
• Strengthening underused muscles: Anterior tibial group
of muscles
• Activating neuroplasticity by continuously practicing
walking with correct form : Gait & Balance Training

60. GAIT & BALANCE TRAINING
• Gait reeducation
• Balance & coordination
exercises
• Hydrotherapy
• Mobility Rehabilitation

61. PARKINSONIAN GAIT
• It is characterized by small shuffling steps and a general
slowness of movement (hypokinesia), or even the total
loss of movement (akinesia) in the extreme cases.
• Freezing can occur.

62. PARKINSONIAN GAIT

63. PARKINSONIAN GAIT
• Their steps become shorter. It is more common in
someone suffering with later stages of Parkinson’s disease.
• They may have problems stopping, starting and turning
around during walking.
• They may appear to be falling forward or in a forward
flexed posture.

64. FESTINATING GAIT
• It is one in which the patient involuntarily moves with
short, accelerating steps, often on tiptoe, with the trunk
flexed forward and the legs flexed stiffly at the hips and
knees. It is seen in Parkinson's disease and other
neurologic conditions that affect the basal ganglia.
• Also called festination.

65. SHUFFLING V/S FESTINATING
• Steps may also be shorter in stride in a shuffling gait.
The shuffling gait is also seen with the reduced arm
movement during walking.
• Festinating gait or festination – A quickening and
shortening of normal strides characterize festinating gait.

66. MANAGEMENT
• Medication : Levodopa (L-
dopa), Carbidopa
• Deep brain stimulation (DBS)
• Physiotherapy : exercises &
walking strategies

67. PHYSIOTHERAPY
• Improving flexibility and range of
motion: improves balance & gait, as
well as reduces rigidity.
• Sit in a chair twist to your right and
left.
• Get on all fours and turn your upper
body to the right and left. Lift your
arm on the side you’re turning to as
you turn.

68. PHYSIOTHERAPY: STRENGTH TRAINING
• Leg exercises: Q drills.
• Mini Squats with support in
front.
• Stationary exercise bike.
• Repeatedly sit in and rise out
of a chair.
• Kitchen sink exercises.

70. PHYSIOTHERAPY
Metronome or music cues
• Walking to the beat of a metronome or music may
reduce shuffling, improve walking speed, and reduce
freezing of gait. Try it for half an hour at a time, a few
times a week.

71. WALKING VISUALIZATION
• Ask patient that before you start walking, visualize
yourself taking long strides and “rehearse” walking in
your head. This can help you focus your attention on
walking. It also activates parts of your brain besides the
basal ganglia, which some studies show can help you
compensate for low levels of dopamine.

72. TAI CHI
• This set of exercises helps align posture and increase
stability and coordination.

73. MYOPATHIC GAIT
• Myopathic gait (or waddling gait) is a type of gait
abnormality in which the affected person walks like a duck.
The "waddling" is due to the weakness of the proximal
muscles of the bilateral pelvic girdle.
• Also known as Trendelenburg Gait because of presence of
Trendelenburg sign.
• Weakness: Hip Abductors Bilateral weakness
Waddling gait.

74. ROLE OF HIP ABDUCTORS IN WADDLING GAIT
• The gluteus medius originates on the
ilium (between ant. and post. gluteal
lines), eventually terminating on the
lateral surface of the greater
trochanter.
• Its contraction pulls the two insertion
sites toward one another, thus
elevating the opposite side of the
pelvis.
• Its weakness causes contralateral
sagging of the pelvis (Trendelenburg
Sign)

75. MYOPATHIC /WADDLING/ TRENDELENBURG GAIT…

76. • During stance phase: weakness of proximal
muscles of hip girdles, will interferes with
the stability of the pelvis during walking.
• During swing phase: failure to stabilize
pelvis, it will produces exaggerated rotation
of the pelvis with each steps.
• Hip are slightly flexed as a result of
weakness of hip extension and there is an
exaggerated lumbar lordosis.
GAIT CHANGES…

77. NOTE…
• One important thing to notice is
lateral trunk shifting on affected
stance leg to align COG and
maintain balance when affected
side is in weight bearing during
gait.
• This is a compensatory strategy to
maintain balance during waddling
gait
Affected
side in
stance/
weight
bearing.
Trunk
shifts on
this side.

78. CAUSES
• Muscular dystrophies e.g. Duchenne’s muscular dystrophy
• GB syndrome
• Spinal muscular atrophy
• Superior gluteal nerve injury
• L5 radiculopathy
• OA of hip
• Avulsion of gluteus medius tendon following hip surgery

79. MANAGEMENT
• Strengthening programs
• Functional balance exercise
• Gait training

80. STRENGTHENING PROGRAMS
• Primarily target the muscles that are responsible for gait, weakness
of muscles can lead to variety of abnormality.
• The muscle to be strength while walking is gluteus maximus
and hamstring for hip extension, quadriceps for knee extension,
soleus & gastrocnemius for ankle plantarflexion and dorsiflexion
to step forward.
• Progressive resisted exercise using weight cuff, Thera band,
resistance tube

81. STRENGTHENING PROGRAMS
• Side lying – Hip abduction

82. STRENGTHENING PROGRAMS
• Clamshell
without & with
Thera band

83. STRENGTHENING PROGRAMS
• Isometric single
leg wall lean

84. STRENGTHENING PROGRAMS
• Resisted Abduction with Thera band

85. FUNCTIONAL BALANCE EXERCISE
 Static exercises:
• Sit to stand
• Tandem standing with or
without support
• Stand with eye open and
close
 Dynamic exercises:
• Straight walking
• Tandem walking
• Side walking

86. FUNCTIONAL BALANCE EXERCISE

87. GAIT TRAINING
• Parallel bar walking by placing a mirror in
front of the patient this will provide a
feedback to the patient to correct the
postures.
• During walk promote heel strike at initial
contact with the floor
• Prevent hip dropping and stabilize the
pelvis

88. ATAXIC GAIT
• Ataxia : Ataxia is typically defined as the presence of
abnormal, uncoordinated movements.
• This describes signs & symptoms without reference
to specific diseases.

89. ATAXIC GAIT
• It is described as clumsy gait with , staggering
movements with wide base of support.
• Patient is not able to walk from heel to toe or
in single line
• Uncoordinated gait appears to be not ordered.
• Also known as drunken gait.

90. CAUSES
•Head injury.
•Cerebral palsy.
•Autoimmune diseases.
•Infections.
•Vitamin E, vitamin B-12 or
thiamine deficiency.
•Thyroid problems.
•Abnormalities in the brain: An
infected area (abscess)
•Toxic reaction: Potential side
effect of certain medications,
especially barbiturates, Alcohol and
drug intoxication.

91. MANAGEMENT
Intensive physical therapy:
• Strength training
• Balance training
• Gait training

92. STRENGTH TRAINING
• Whole body functional strength training in form of treadmill training and
stationary cycling.

93. BALANCE TRAINING
Frenkel exercises :

94. FUNCTIONAL BALANCE EXERCISES
Reach outs:
1. Quadruped weight shifting
2. Siting on Physio ball & lateral
weight shifts
3. Standing lateral weight shifts
4. Standing anterior posterior
weight shifts
Tandem standing
with/without support
 Dynamic exercises:

95. BALANCE TRAINING
Balance-Based Torso Weighting
(BBTW) :
• Small weights were applied to the
torso on a specially constructed vest
like garment that allowed Velcro
application of weights to the front,
back, or sides of the torso between the
shoulders and waist to maintain the
balance of the upright posture.

96. GAIT TRAINING
• Hurdle walking
• Walking on commands of
start & stop
• Straight walking
• Tandem walking
• Side walking