Gait Deficits: Long-Term Effects On Stroke Survivors' Mobility

Gait disturbances are common in stroke patients, with walking dysfunction occurring in more than 80% of survivors. The gait of a stroke patient is characterised by asymmetry, with poor selective motor control, delayed and disrupted equilibrium reactions, and reduced weight bearing on the paretic limb.

The primary spatial feature of hemiplegic gait is the difference in paretic and nonparetic step length. In the temporal features of hemiplegic gait, the paretic step length is generally longer than the nonparetic step length.

The primary kinematic disturbance in hemiplegic gait is a decrease in hip extension in the late stance phase. In the kinetic disturbances, the peak moment and power at the hip, knee, and ankle joints follow profiles similar to those of healthy individuals but with reduced amplitude in both limbs, and smaller amplitude on the affected side.

The main compensatory pattern used to minimize the effect of instability during stance is to decrease the unilateral support time on the affected side.

Gait asymmetry in hemiplegic gait

• Poor body support and walking performance
• Abnormal synergistic activation
• Muscle weakness
• Spasticity
• Foot drop
• Knee hyperextension
• Reduced stride length
• Reduced walking speed
• Increased risk of falls
• Circumduction gait

Temporal features of hemiplegic gait

Hemiplegic gait is a mixture of deviations and compensatory motion dictated by residual functions. Temporal features of hemiplegic gait are often used to identify and document a patient's unique gait pattern.

• Walking speed and cadence are reduced, and gait cycle and double limb support are increased.
• The hemiplegic limb spends more time in swing and stance, while the unaffected limb spends more time in stance and single support.
• The gait velocity and symmetry of the swing/phase improve as the patient recovers.
• The hemiplegic gait is characterised by circumduction of the foot, with the arm on the affected side typically flexed, adducted and internally rotated.
• The hemiplegic gait is also characterised by extensor hypertonia in the lower limb, with distal weakness and foot drop.
• The gait is slower and more asymmetrical in the later phases of post-stroke.
• The stance phase corresponds to the duration between heel strike and toe-off of the same foot, constituting approximately 60% of the gait cycle.
• The swing phase begins with toe-off and ends with heel contact of the same foot and occupies 40% of the cycle.

Spatial features of hemiplegic gait

• Differences in paretic and nonparetic step length, with the paretic step length generally being longer than the nonparetic step length.
• Increased stance time on the good leg and decreased step length of the affected leg.
• Reduced hip extension in the late stance phase.
• Increased hip flexion and ankle dorsiflexion in the swing phase.
• Reduced knee flexion (or knee hyperextension) in the stance phase.
• Increased knee flexion in the stance phase.
• Decreased ankle plantarflexion at toe-off.
• A decrease in hip and knee flexion during the swing phase.
• A decrease in ankle dorsiflexion during the swing phase.

Kinematic disturbances in patients who have had a stroke

• A decrease in hip extension in the late stance phase
• Alterations in the lateral displacement of the pelvis and flexion of the knee
• Decreased plantarflexion of the ankle at toe-off
• A decrease in peak hip and knee flexion during the swing phase
• Reduced knee extension prior to initial contact
• Decreased ankle dorsiflexion during swing

These disturbances are caused by abnormal muscle activation patterns, muscle shortening and/or reduced walking speed. Compensatory walking mechanisms may also lead to abnormal angular motion patterns, such as knee hyperextension to compensate for stable weight support during forward propulsion.

Kinetic disturbances in patients who have had a stroke

Stroke patients may exhibit deficits in muscle strength and muscle tone, mobility, perception and motor-control, sensation, and balance. This leads to significant changes in voluntary movement, thereby affecting gait patterns. Gait deviations in post-stroke patients are divided into primary deviations, defined as those directly due to pathology, and secondary deviations, which are the result of the physical effects of the primary deviations (passive), or a compensatory mechanism (active).

The primary spatial feature of hemiplegic gait is characterised by differences in paretic and nonparetic step length. The nonparetic step length is generally longer than the paretic step length.

Kinematic disturbances in patients who have had a stroke include a decrease in hip extension in the late stance phase, decreased peak lateral pelvic displacement in stance phase, increased peak lateral pelvic displacement in stance phase, decreased knee flexion (or knee hyperextension) in stance phase, increased knee flexion in stance phase, and decreased ankle plantarflexion at toe-off.

When walking with a slow cadence, the hip normally extends from about 15° of flexion at heel strike to 10° of extension during the stance phase. Hip extension is important because it moves the trunk segment forward over the stance foot, contributing to normal contralateral step length; however, a decrease in hip extension is a commonly reported kinematic disturbance in persons with a hemiplegic gait.

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