Altered walking gaze behavior after stroke: more than meets the eye

BACKGROUND: A common clinical impression is that individuals with stroke tend to gaze downward while walking—focusing on the walking surface a short distance ahead for extended periods. However, this impression has not been formally verified, and thus, whether this is a true phenomenon—and, if so, what drives it—remains unknown. METHODS: In this cross-sectional study, we examined the spatial and temporal aspects of walking gaze behavior in individuals with stroke and compared them to those of healthy controls. We also investigated the associations between the observed patterns and measures of postural and gait instability, fear of falling, and the tendency for conscious movement control. RESULTS: Our results indicate that individuals with stroke exhibit a greater tendency to gaze downward while walking compared to healthy controls. While the shorter look-ahead distances observed may be attributed to slower walking speeds, the prolonged duration of downward gazing (DWG) cannot be explained by speed alone. Instead, both the short look-ahead distance and prolonged DWG duration were associated with impaired balance and gait control as well as fear of falling. CONCLUSIONS: Taken together with previous findings, the present results suggest that walking instability and fear of falling may underlie both slower walking speeds and the tendency for DWG. Having established the presence of the DWG phenomenon, we propose further investigation into its potential utility as a novel indicator of deficits in reactive and/or proactive balance and gait control.