Hemiplegic Gait

Related terms:

Spasticity, Neurostimulation, Orthosis, Lesion, Walking Speed, Hemiplegia

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Case studies in orthopaedics

Anne-Marie Hassenkamp, ... Kaye Walls, in Clinical Case Studies in Physiotherapy,
2009

Case Study 10
1. Right-sided hemiplegia (now recognised as having a prenatal origin) means a
typical hemiplegic gait with the weight on the left side only, retraction in the
right hip and shoulder, curled toes of her right foot and a fisted hand on the
same side. She will be ‘toe’ walking on the right side (Rodda & Graham 2001).
The possible underlying factors for this are muscle weakness and imbalance,
uncoordinated co-contraction, spasticity and disuse atrophy. She may also
have a lack of recognition of her right side as well as a sensory deficit on that
side (Neville & Goodman 2001).
2. Explain that it is very common for the umbilical cord to be found in this
position due to the cramped quarters of the uterus. Furthermore, umbilical
cords have mechanisms in place to help them keep functioning even when
stretched. It is important, however, to remain sensitive to their concerns and
possible mistrust of health care professionals (Nelson & Grether 1998).
3. Gait patterns can be identified and categorised by the use of instrumented
motion analysis. Motion analysis provides a comprehensive gait evaluation.
They quantify the nature and severity of neuromuscular and musculoskeletal
abnormalities.The patient would be videoed while walking and an observa-
tional analysis produced. Reflective markers would have been placed on her
limbs, pelvis and trunk to provide a 3-dimensional picture of joint motion
(kinematics).Kinetic data are measures of the forces that cross the joints and
the moments that cause the motion.An EMG analysis may be done which
can provide a measure of muscles activity differentiating the action of each 4.
muscle which is correlated with the stance and swing phases of gait.Finally,
joint kinematic and kinetic measurements can be analyzed with the EMG data
to provide a comprehensive picture of the contributing factors to the patient's
gait disorder (Coutts 2005b).
During this period the parents should be taught to encourage the patient to 5.
exercise the dorsiflexors (particularly tibialis anterior) and plantarflexors of her
right leg in addition to her hip extensors. This will be carried out through the
medium of play (Department of Health 2003 – refer to Perthes case study).
This could be achievedwith ball play, all climbing activities (climbing frame,
steps to a slide) walking on her toes, water play and swimming for example.
•Provide parents with clear messages regarding the goals of treatment and 6.
allow them to take part in the planning and decision making thus respecting
their role as the patient's main carers (Litchfield & MacDougall 2002).•Don't
overburden parents, fit exercises into their day-to-day activities.•Plan a weekly
activity sheet with them and record any difficulties they have with the
exercises.
•Sit out of the bed – suggestions: sit alongside patient to read a story. Get her to7.
throw/catch a ball while sitting on the edge of the bed, ‘post’ a ball through the
hoop in sitting.•Stand up with the plaster – suggestions: in standing play with
a puzzle, tea set, thread beads, draw/paint.•Walk at least 10 m independently
– prepare a fun course, kick/fetch a ball, push a pram along.•Go up and
down stairs – a play slide or fetch a toy.•Be confident with the home exercise
programme – prepare with her an exercise programme, draw pictures, paint it,
etc. Prepare an exercise diary with smiley faces and stars. (For age-appropriate
play refer to Chase 1994.)
A review of 11 studies looking at strengthening in cerebral palsy found evi-
dence to suggest that, ‘training can increase and may improve motor activity
in people with cerebral palsy without adverse effects’ (Dodd et al 2002).

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Praxis
Kenneth M. Heilman, ... Leslie J. Gonzalez Rothi, in Textbook of Clinical Neurology
(Third Edition), 2007

MOTOR/REFLEXES/CEREBELLAR/GAIT
Patients with frontal lobe lesions associated with apraxia may have contralateral
hemiparesis due to involvement of the motor cortex (Video 11, Hemiplegic Gait).
Crural weakness without involvement of the arm and face suggests involvement
of the medial frontal lobe; when acute, this suggests infarction in the territory
of the anterior cerebral artery. These patients may also show evidence of callosal
disconnection (see later discussion). Brachial facial weakness suggests involvement
of the distribution of the middle cerebral artery. Evaluation of tone and evaluation for
the presence of abnormalities of movement is also important. Patients with apraxia
as part of corticobasal degeneration may have rigidity, bradykinesia, and tremor or
myoclonus and alien hand (Video 39, Alien Hand Syndrome).

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Muscular Tone and Gait Disturbances

Kenneth F. Swaiman, John Phillips, in Swaiman's Pediatric Neurology (Sixth Edition),
2017

Spastic Hemiplegic Gait

Hemiplegia typically results from disruption of the corticospinal tract above the
medulla. Tone is often increased, and posture is characterized by leg extension or
slight knee flexion. Hemiplegic gait 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. The heel-walking exercise is
impaired as the patient scuffs the lateral sole and the toe of the shoe while dragging
the foot.

The affected leg bears weight for less time than the normal leg during ambulation.
The expected rhythmic reciprocal swing of the arm with the stance phase of the
opposite leg is absent. Dystonia rather than spasticity should be considered if the
arm is held behind the plane of the body on a routine basis.

The etiology of hemiplegic gait cannot always be determined, but one should look
for focal brain lesions such as porencephalic cysts, subdural hematomas, cerebral
masses, and cerebrovascular accidents.

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Cranial Nerves IX (Glossopharyngeal)

and X (Vagus)
Neal Hermanowicz, in Textbook of Clinical Neurology (Third Edition), 2007

MOTOR/REFLEXES/CEREBELLAR/GAIT
Changes in muscle tone can be indicative of neurological disease involving cranial
nerves IX and X. Cerebral lesions causing pseudobulbar palsy with alteration of
speech and dysphagia may be associated with limb spasticity due to corticospinal
tract injury (Video 11, Hemiplegic Gait). Parkinsonism caused by various etiolo-
gies is frequently associated with difficulties in speech and swallowing (Video
49, Hypophonia). No specific lesions exist of the cranial nerves but, rather, the
subcortical control is affected bilaterally. Patients with progressive supranuclear
palsy particularly have prominent difficulty with speech and dysphagia (Video
206, Postural Instability). In patients with suspected cranial nerve IX or X lesions,
the presence of abnormal reflexes, such as an extensor plantar response, or the
emergence of rudimentary reflexes such as the suck or snout are indicators of
CNS pathology. Disorders of the neuromuscular junction also produce dysarthria
and dysphagia. Repetitive testing of ocular or limb muscle power may produce an
inordinate amount of fatigue and weakness pointing to a diagnosis of myasthenia
(Video 225, Myasthenia Gravis).

A brain stem lesion producing impairment of speech and swallow may also include
ataxia of ipsilateral limbs and gait by injury to the inferior cerebellar peduncle that
lies adjacent to the nuclei of nerves IX and X (Video 95, Brain Stem Infarction).

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Gait analysis
Leon Chaitow ND DO, Judith DeLany LMT, in Clinical Application of Neuromuscular
Techniques, Volume 2 (Second Edition), 2011

• Antalgic gait: a characteristic gait resulting from pain on weight bearing in

which the stance phase is shortened on the affected side
• Ataxic gait: wide-based gait characterized by staggering, lateral veering, un-
steadiness and irregularity of steps, often with a tendency to fall forward,
backward or to one side
• Calcaneal gait: characterized by walking on heel, due to paralysis of the calf
muscles (poliomyelitis, neurologic diseases)
• Cerebellar gait: same as ataxic gait, due to cerebellar disease

• Charcot gait: the gait of hereditary ataxia

• Circumduction gait: see hemiplegic gait

• Equine gait: see high-stepping gait

• Festinating gait: gait in which patient walks on toes (as though pushed) with
flexed trunk, legs flexed at the knees and hips (but stiff ) with short and
progressively more rapid steps (seen in Parkinsonism and other neurologic
diseases)
• Gluteus maximus gait: compensatory backward propulsion of trunk to maintain
center of gravity over the supporting lower extremity
• Gluteus medius gait: compensatory leaning of the body to the weak gluteal side,
to place the center of gravity over the supporting lower extremity
• Helicopod gait: a gait in which the feet (or foot) describe half circles with each
step (hysteria and in some conversion reactions)
• Hemiplegic gait (circumduction or spastic gait): gait in which the leg is held
stiffly and abducted with each step and swung around to the ground in front,
forming a semicircle
• High-stepping gait (equine gait): gait characterized by high steps to avoid
catching a drooping foot and brought down suddenly in a flapping manner
(peroneal nerve palsy, tabes)
• Hysterical gait: a variety of bizarre gaits in which the foot is frequently held
dorsiflexed and inverted and is usually dragged or pushed ahead, instead of
lifted (hysteria-conversion reaction)
• Scissor gait: gait in which each leg swings medially as well as forward to cross
during walking (cerebral palsy)
• Spastic gait: see hemiplegic gait

• Steppage gait: because it cannot dorsiflex, the advancing foot is lifted higher
than usual to clear the ground (peroneal neuropathies, dorsiflexion weakness,
peripheral neuritis, diabetes, alcoholism, chronic arsenical poisoning)
• Toppling gait: patient displays uncertain and hesitant steps, totters and some-
times falls (balance disorder, in elderly patients post stroke)
• Trendelenburg gait: pelvis sags on the side opposite the affected side during
single leg stance on the affected side; compensation occurs during gait by
leaning the torso toward the involved side during the affected extremity's
stance phase (congenital dislocation, hip abductor weakness, rheumatic arthri-
tis, osteoarthritis)
• Waddling gait: rolling gait in which the weight-bearing hip is not stabilized
and feet are placed widely apart, while the opposite side of the pelvis drops,
resulting in alternating lateral trunk movements that resemble the waddle of
a duck (gluteus medius muscle weakness, muscular dystrophies, coxa vara)

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Viral Infections
Karen L. Roos, in Textbook of Clinical Neurology (Third Edition), 2007

Acute Encephalitis
As discussed in the preceding section on pathogenesis, HSV encephalitis typical-
ly involves the temporal lobe or lobes, the orbital frontal cortex, and the limbic
structures. The clinical presentation is that of a focal encephalitis characterized
by focal neurological deficits (hemiparesis in approximately one third of patients)
(Video 11, Hemiplegic Gait), focal seizure activity often involving the temporal
lobe, headache, altered behavior, personality changes, fever, and altered levels of
consciousness (Video 248, Complex Partial Seizures with Automatisms). The classic
paper on diseases that mimic herpes simplex encephalitis appeared in the Journal
of the American Medical Association in 1989.115 This study, which included a total
of 432 patients who underwent brain biopsy for presumptive herpes simplex en-
cephalitis, predated the routine use of MRI and the availability of CSF PCR. Today,
the differential diagnosis of acute focal encephalitis with fever, after neuroimaging
and CSF analysis, is that of a focal viral encephalitic process. The causes of a focal
viral encephalitic process are listed in Table 41 4.

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Gait Awareness
Clare C. Bassile, Sheila M. Hayes, in Stroke Rehabilitation (Fourth Edition), 2016

1. What constitutes a gait cycle?

2. What are the phases and subphases of the gait cycle?

3. What are step, stride, and cadence?

4. What tests would you perform to assess gait speed and gait endurance?

5. What type of cerebral infarct is associated with the typical “hemiplegic gait”?

6. What are some of the variables that can cause a deviation from the normal
joint excursions during a gait cycle?
7. In what way does the motor control model differ from the more traditional
theoretical models underlying the different therapeutic techniques?
8. How might ambulation recovery be related to hip osteoporosis?

9. What are some of the manifestations of a posterior inferior cerebellar stroke?

10. What makes treatment of individuals demonstrating contraversive pushing so
challenging?
11. What helps compensate for proprioceptive loss after stroke?

12. What are the main differences between metal and plastic orthotic devices?

13. What orthotic device is used most commonly with stroke survivors?

14. What assistive devices are used most commonly with stroke survivors?

15. What determines the type of gait pattern that will be taught to a stroke
survivor?

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Walking difficulties and clumsiness

Geraint Fuller MA MD FRCP, Mark Manford BSc MBBS MD FRCP, in Neurology
(Third Edition), 2010

Gait analysis
On watching a patient walk, the disturbance can be broadly subdivided into sym-
metrical and asymmetrical gait disturbances (Fig. 1).

Asymmetrical gait disturbances

Non-neurological gait disturbances are usually asymmetrical. Any underlying or-
thopaedic problems, for example fixed hip joint or shortened limbs, are usually
evident on closer inspection. The limp of someone in pain can usually be seen and
corroborated by asking the patient about pain.

The basis of an asymmetrical gait caused by neurological abnormalities can usually

be established by conventional neurological examination. These usually reflect uni-
lateral abnormal tone or weakness. Three common patterns are:

1. Hemi-parkinsonian gait. The arm swing is reduced on one side, the posture is
slightly stiff and the gait can be slightly hesitant.
2. Hemiplegic gait. One leg is stiff and is swung out and around, often catching
the toe.
3. Foot drop. This is a high stepping gait where the heel is brought up high
to avoid catching the toe. This is noisy and there is usually a slap as the
foot is brought down. This usually reflects unilateral lower motor neurone
abnormalities.
Symmetrical gait disturbances
In some patients there may be a symmetrical gait disturbance. These can be broadly
divided into:

▪ broad-based gait, where the feet are widely spaced

▪ normally based gaits, with the feet a normal distance apart

▪ crossing or scissoring gait, where the feet cross. These indicate spasticity in
both legs.

Heel/toe walking can bring out an imbalance. A patient with a broad-based gait will
be unable to walk heel/toe.

Broad-based gait

The feet are separated to try and help balance, hence the inability to walk heel/toe.
This usually reflects:

▪ a loss of proprioception (sensory ataxia)

▪ loss of coordination (ataxia).

Patients with impaired proprioception have a positive Romberg's test.

Ataxia with normal sensation indicates a midline cerebellar disturbance. There may
also be limb incoordination which produces a clumsy ataxic gait with more wide-
spread cerebellar disease.

Narrow-based gaits

Patients with narrow-based gaits usually have abnormalities of either:

▪ stride length

▪ stride pattern

▪ posture

▪ arm swings.

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Stroke
Joel Stein MD, in Essentials of Physical Medicine and Rehabilitation (Fourth Edition),
2020

Physical Examination
A full neurologic examination is appropriate. This includes evaluation of mental
status, cranial nerves, sensation, deep tendon reflexes, abnormal reflexes (e.g.,
Babinski), muscle tone and strength, coordination, and functional mobility (sitting,
transfers, and ambulation). The protean manifestations of stroke can cause many
different combinations of abnormalities in the neurologic examination. Common
findings include hyperreflexia and hemiparesis on the affected side with variable
degrees of sensory loss. Dysarthria may be present, as can aphasia or hemineglect,
depending on the areas affected. Hemiplegic gait is commonly seen, with reduced
stride length, reduced knee flexion (“stiff-legged gait”), ankle plantar flexion and
inversion, and circumduction to allow clearance of the affected leg. Given the
high prevalence of post-stroke depression, an assessment of mood and affect is
important. Some degree of sadness is typically present as a normal grief reaction to
a sudden disabling event and should be distinguished from true major depression
on the basis of how pervasive the symptoms are, their duration, and associated
symptoms such as anhedonia. Emotional lability may also occur, with brief bouts
of crying or laughing on minimal provocation. Range of motion in affected limbs
should be measured; ankle plantar flexion contractures and upper limb contractures
are common in patients with long-standing hemiplegic stroke and interfere with
rehabilitation efforts. Shoulder subluxation may occur in hemiparetic patients and
should be noted and quantified. Skin is examined for any areas of breakdown. Limb
swelling is common and should be noted. The fit and function of leg braces, upper
extremity splints, slings, wheelchairs, and ambulatory aids are assessed as part of
the routine physical examination.

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Changes in Sensory Motor Behavior in

Aging
Karen M. Hill, Anthony A. Vandervoort, in Advances in Psychology, 1996

GAIT FOLLOWING STROKE

In addition to the normal aging changes of motor and sensory function, disorders
of the central nervous system, such as hemiplegia following stroke, may cause alter-
ations of motor control and therefore deviations of gait. As noted earlier, hemiplegia
may be characterized by loss of selective movements, abnormal sensory function
of the affected limbs and deficit of postural righting and equilibrium responses
(Bobath, 1978).

The gait pattern of hemiplegic subjects is asymmetrical in appearance due to the

unilateral involvement and a reluctance to transfer and support full body weight on
the affected limb (Bobath, 1978). This asymmetry, with respect to affected versus
unaffected side, has been demonstrated by analysis of temporal and distance para-
meters of hemiplegic gait. The duration of the support phase tends to be decreased
on the affected side and increased on the unaffected side (Wall & Ashburn, 1979;
Wall & Turnbull, 1986). Poor weight transference to the affected limb and prolonged
stance time on the unaffected limb are likely due to impaired balance mechanisms.
Hence, it has been shown that intact balance responses are strong predictors of
successful gait performance in hemiplegic patients (Bohannon, 1987; Keenan, Perry,
& Jordan, 1984).

The duration of swing and support phases account for 40% and 60% of the gait cycle,
respectively, in healthy adult subjects (Murray, 1967). Peat, Dubo, Winter, Quanbury,
Steinke, and Grahame (1976) reported that hemiplegic subjects demonstrated al-
tered swing and support phases of both lower extremities. Mean swing phase on
the affected side was determined to be 33%, and support phase 67%, of the gait
cycle. The unaffected limb spent 20% of the cycle in swing and 80% in support
phase. The increased support time on the unaffected side, plus the very short swing
time, reflects the difficulty hemiplegic subjects have in transferring and supporting
weight on the affected limb.

Voluntary movement of the affected hemiplegic limb may be dominated by syner-

gistic patterns of muscle activity (Bobath, 1978). This loss of selective movement is
demonstrated by EMG analysis of hemiplegic gait. Peat et al. (1976) synchronized
the analysis of lower limb EMG activity with specific temporal components of the
gait cycle. Hemiplegic subjects showed peak activity of all muscle groups during
the midstance phase and low activity of all muscle groups during the swing phase.
Healthy subjects, however, show recruitment of specific muscles of the knee and
ankle at the time they are required for either stability or movement of the limb (Dubo,
Peat, Winter, Quanbury, Hobson, Steinke, & Reimer, 1976).

The location of the lesion, plus the manner in which the subject may have learned to
compensate for the motor loss, will influence the movement pattern. For example, if
abnormal tone is strongest in the extensor or antigravity muscle groups, the subject
may be able to support weight on the affected limb during the stance phase, but will
have difficulty moving the limb forward during the swing phase. The result may
be dragging of the toes, or the subject may learn to compensate by circumducting
 the affected limb at the hip and thereby allowing the extended limb to clear the floor
(Bobath, 1978).

Subjects with residual hemiplegia walk slower than urban pedestrians (Finley &
Cody, 1970) and even slower than healthy elderly subjects (see Table 2). Walking
speed has been shown to be related to isometric strength and the stage of motor
recovery of the affected limb, plus the overall balance ability of hemiplegic subjects
(Bohannon, 1986a, 1986b, 1987; Brandstater, de Bruin, Gowland, & Clark, 1983).
Wall and Ashburn (1979) showed a trend towards an increase in walking speed as
patients recovered during the first 9 months post onset of hemiplegia.

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