Classification of Gait Patterns in Cerebral Palsy

Introduction

This page will look at the different types of gait patterns found in people with cerebral palsy, the use of orthosis and the background of use, and interventions which might be used. 

Gait Patterns 

There are a couple of different common gait patterns found in people with cerebral palsy which will be covered in a little more detail below. This page will focus on:

• Spastic Hemiplegia /  Unilateral CP
• Bilateral Spastic CP

It will them focus on the different types of gait patterns found within these two groups. 

Spastic Hemiplegia / Unilateral CP

The most widely accepted classification of gait in spastic hemiplegia is that reported by Winters et al. (1987). They subdivided hemiplegia into four gait patterns based on sagittal plane kinematics. The classification has direct relevance to understanding the gait pattern and management.

• Type 1 –weak or paralysed/silent dorsiflexors (= dropfoot)
• Type 2 – type 1 + triceps surae contracture
• Type 3 – type 2 + hamstrings and/or Rectus Femoris spasticity
• Type 4 – type 3 + spastic hip flexors and adductors

Type 1 Hemiplegia

In Type 1 hemiplegia there is a `drop foot' which is noted most clearly in the swing phase of gait, due to inability to selectively control the ankle dorsiflexors during this part of the gait cycle. There is no calf contracture and therefore during stance phase, ankle dorsiflexion is relatively normal.  In the experience of the author, 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). Spasticity management and contracture surgery are clearly not required. 

Management:

Orthotic management may include a leaf spring or hinged AFO.

Type 2 hemiplegia

Type 2 hemiplegia is by far the most common type in clinical practice. True equinus is noted in the stance phase of gait because of the spasticity and / or contracture of the gastroc-soleus muscles. There are two sub-catagories to type 2 hemiplegic gait patterns, which are:

• 2a Equinus plus neutral knee and extended hip.
• 2b Equinus plus recurvatum knee and extended hip

There is usually a variable degree of drop foot in swing because of impaired function in tibialis anterior and the ankle dorsiflexors. A pattern of true equinus can be seen, with the ankle in the plantar flexion range through most of the stance phase. The plantar flexion / knee extension couple is over active and the knee may adopt a position of extension or recurvatum.

Management: 

If there is a mild contracture, supplemental casting can be very effective. The majority of children will also require orthotic support, both to control the tendency to `drop foot‘. Once a significant fixed contracture develops, lengthening of the gastrocnemius and soleus may be indicated.  Type 2 hemiplegia with a fixed contracture of the gastroc-soleus constitutes the only indication for isolated lengthening of the tendon achilles. If the knee is fully extended or in recurvatum, then a hinged AFO with an appropriate plantar flexion stop is the most appropriate choice of orthosis. A plantarflexion stop or posterior stop in an AFO is designed to substitute for inadequate strength of the ankle dorsiflexors during swing phase of gait. This stop is effective by limiting the plantarflexion range of motion of the talocrural joint. Older children with progressive valgus deformities are likely to become brace intolerant and require bony surgery. 

Common characteristics of types 2, 3 and 4 are a limb length discrepancy (hemiplegic leg is shorter)

Type 3 Hemiplegia

Type 3 hemiplegia is characterized by gastroc-soleus spasticity or contracture, impaired ankle dorsiflexion in swing and a flexed, `stiff€ knee gait' as the result of hamstring/quadriceps cocontraction.  Management may consist of at a later stage, muscle tendon lengthening for gastroc-soleus contracture.

Management:

A solid or hinged AFO may also be helpful; the choice should be according to the integrity of the `plantar-flexion, knee-extension couple'.

Type 4 Hemiplegia

In Type 4 hemiplegia there is much more marked proximal involvement and the pattern is similar to that seen in spastic diplegia. However, because involvement is unilateral, there will be marked asymmetry, including pelvic retraction. In the sagittal plane there is equinus, a flexed stiff€ knee, a flexed hip and an anterior pelvic tilt. In the coronal plane, there is hip adduction and in the transverse plane, internal rotation.

Management:

Management is similar to Type 2 and Type 3 hemiplegia, in respect of the distal problems. However, there is a high incidence of hip subluxation and careful radiographic examination of the hip is important. The adducted and internally rotated hip will usually require lengthening of the adductors and an external rotation osteotomy of the femur. Failure to address the hip adduction and hip internal rotation will usually mean that any distally focused intervention will fail and the overall outcome will be poor.

Common postural/gait patterns bilateral spastic cerebral palsy

Torsional deformities of the long bones and foot deformities are frequently found in bilateral spastic CP, in association with musculo-tendinous contractures. These are collectively referred to as `lever arm disease‘. The most common bony problems are medial femoral torsion, lateral tibial torsion, mid foot breaching, with foot valgus and abduction. Rotational osteotomies and foot stabilization surgery are often required, in association with the spasticity and contracture management.

This shows the features of `lever arm disease'. There is an out toed stance and gait pattern because of mid foot breaching and lateral tibial torsion), the right image shows the sagittal view shows a crouch gait pattern. When the bony lever (the foot) is both bent and maldirected, the already weakened gastroc-soleus is unable to control the progression of the tibia over the planted foot and a crouch gait results.

Type 1. True Equinus

When the younger child with bilateral cerebral palsy begins to walk with or without assistance, calf spasticity is frequently dominant resulting in a `true equinus' gait with the ankle in plantar flexion throughout stance and the hips and knees extended. The patient can stand with the foot flat and the knee in recurvatum. The equinus is real, but hidden. A few children with bilateral cerebral palsy remain with a true equinus pattern throughout childhood and, if they develop flexed contracture, may eventually benefit from isolated gastrocnemius lengthening. The persistence of this pattern is unusual and seen in only a small minority of children with bilateral CP. Orthotic management: solid or hinged AFO.

Type 2. Jump gait (with or without stiff knee)

The jump gait pattern is very commonly seen in children with diplegia, who have more proximal involvement, with spasticity of the hamstrings and hip flexors in addition to calf spasticity. The ankle is in equinus, the knee and hip are in flexion, there is an anterior pelvic tilt and an increased lumbar lordosis. There is often a sti€ff knee, because of rectus femoris activity in the swing phase of gait.In younger children, this pattern can be managed e€ffectively by botulinum toxin type A injections to the gastrocnemius and hamstrings and the provision of an AFO. In older children musculotendinous lengthening of the gastrocnemius, hamstrings and iliopsoas may be indicated with transfer of the rectus femoris to semi-tendinosus for co-contraction at the knee.

Type 3. Apparent equinus (with or without stiff knee)

As the child gets older and heavier, a number of changes may occur which may render the calf muscle and the plantar flexion – knee extension less competent. Equinus may gradually decrease as hip and knee flexion increase. There is frequently a stage of `apparent equinus' where the child is still noted to be walking on the toes and simple observational gait analysis may mistakenly conclude that the equinus is real, when it is in fact apparent. Sagittal plane kinematics will show that the ankle has a normal range of dorsi-flxion but the hip and knee are in excessive flexion throughout the stance phase of gait.
Management should be focused on the proximal levels, where the hamstrings and iliopsoas may benefit from spasticity treatment or musculotendinous lengthening (Corry et al., 1999). Redirection of the ground reaction vector in front of the knee can best be achieved by the use of a solid or a ground reaction AFO. Orthotic management: ground reaction (Saltiel) AFO, solid AFO or hinged AFO according to the integrity of the plantar flexion – knee extension.