AGait Analysis in C.P .

[salo_spain]

Introduction

?Gait patterns in spastic motor disorders have been described by a number of authors, but only two classifications are widely used.

?Winters et al. described four gait patterns in spastic hemiplegia and Sutherland and Davids described four patterns of knee motion in spastic diplegia (Winters et al., 1987; Sutherland and Davids, 1993).

?Management recommendations are made on the basis of the classification.

?Management options are for convenience grouped as `spasticity management' or `contracture management.

?Spasticity: is a reversible type of muscle stiffness and sometimes referred to as dynamic contracture

?Contracture: is a more fixed type of stiffness referred to as fixed or myostatic contracture

?Management strategies are complex and, almost invariably, more than one method is required to achieve optimal outcomes.


Postural and gait patterns

?Although gait and posture are variable in children who have cerebral palsy, there are certain patterns that can be identified and recognized by clinicians using a variety of tools.

?In general, spastic motor patterns are reasonably consistent from stride to stride and from day to day (Gage, 1991).

?over the longer term, there are often changes with age and as the result of intervention.

?The most common change with age is from a pattern of `toe walking' (because the gastrocnemius is dominant) to a pattern of increasing hip and knee flexion and eventually, `crouch gait' with hip and knee flexion and ankle dorsiflexion (Rab, 1991).

?The transition from equinus gait to crouch gait is seen in many children with severe spastic diplegia or spastic quadriplegia as a normal progression.

?It may be accelerated by an injudicious isolated lengthening of the heel cord (Sutherland and Cooper, 1978; Borton et al., 2001).

?Although there are at least four types of gait patterns seen in hemiplegia, in general, there is more involvement distally and therefore true equinus is the basis of the most common patterns (Winters et al., 1987).

?In diplegia and quadriplegia, more proximal involvement is typical and therefore apparent equinus and crouch gait are frequently seen.

?These common patterns are more accurately referred to as postural patterns rather than gait patterns.

?Although the pattern will vary according to the precise part of the gait cycle, the postural patterns referred to here are usually most clearly seen during the middle and end of the stance phase of gait.

?Given that the focus of this classification are postural patterns caused by spasticity or contracture of the principal sagittal plane motors.


Common postural/gait patterns spastic hemiplegia

?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.

?Given that spasticity in hemiplegia is unilateral, management with SDR and ITB is not appropriate, but BTX-A is very useful for spasticity, and orthopedic surgery for fixed deformity.


? 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.

This gait pattern is rare, unless there has already been a calf lengthening procedure.

Management summary:
- Spasticity management: Not applicable.
- Contracture management: Not applicable.
- Orthotic management: Leaf spring or hinged AFO.


? Type 2 Hemiplegia:

It is by far the most common type in clinical practice.

It has two subtypes:
- 2a Equinus plus neutral knee and extended hip.
- 2b Equinus plus recurvatum knee and extended hip.

Management summary
- Spasticity management: BTX-A
- Contracture management: Strayer calf lengthening, if the contracture is confined to the gastrocnemius.
- Orthotic management: Hinged AFO or leaf spring AFO.


? Type 3 Hemiplegia

It 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 summary
- Spasticity management: BTX-A injections to the calf and hamstrings.
- Contracture management: Strayer calf lengthening combined with lengthening of the medial hamstrings and transfer of the rectus femoris to the gracilis or semitendinosus.
- Orthotic management: solid or hinged AFO, according to the pre and post intervention integrity of the plantar-flexion, knee-extension (PF±KE) couple.


? Type 4 Hemiplegia

There is much more marked proximal involvement and the pattern is similar to that seen in spastic diplegia.

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 summary
- Spasticity management: multilevel injections of BTX-A, including the calf and hamstrings, sometimes the hip adductors and hip flexors.
- Contracture/deformity management: lengthening of the calf, medial hamstrings (with rectus femoris transfer when indicated), hip adductors and iliopsoas. External rotation osteotomy of the femur;
- Orthotic management: ground reaction AFO, solid AFO or hinged AFO, according to the integrity of the PF±KE couple.


Common postural/gait patterns spastic diplegia/quadriplegia

?The patterns of knee involvement in spastic diplegia described by Sutherland and Davids are an excellent basis for classifying postural and gait patterns in spastic diplegia (Sutherland and Davids, 1993).

?Torsional deformities of the long bones and foot deformities are frequently found in association with musculo-tendinous contractures.


?1. True Equinus
When the younger child with diplegia 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.

True equinus may be hidden by the development of recurvatum at the knee. The patient can stand with the foot flat and the knee in recurvatum (Miller et al., 1995).

Management summary
- Spasticity management: BTX-A injections to the calf.
- Contracture management: lengthening of the gastrocnemius.
- Orthotic management: solid or hinged AFO, according to the integrity of the PF-KE couple.


?2. Jump gait (with or without stiff knee)
It is very commonly seen in children with diplegia, who have more proximal involvement, with spasticity of the hamstrings and hip flexors and an anterior pelvic tilt and an increased lumbar lordosis, in addition to calf spasticity

There is often a stiff knee because of rectus femoris activity in the swing phase of gait.

Management summary
- Spasticity management: in younger/less involved children BTX-A injections to the calf and hamstrings. Multilevel injections of BTX-A may be useful. Selective dorsal rhizotomy may be the optimum choice for small group of children, following previously reported selection criteria.
- Contracture/deformity management: single event multilevel surgery, addressing all contractures and lever arm dysfunction.
- Orthotic management: ground reaction (Saltiel) AFO, solid AFO or hinged AFO according to the integrity of the PF±KE couple.


?3. Crouch gait (with or without stiff knee gait)
Crouch gait is defined as excessiv dorsiflexion or calcaneus at the ankle in combination with excessive flexion at the knee and hip.

This pattern is part of the natural history of the gait disorder in children with more severe diplegia and in the majority of children with spastic quadriplegia.

Regrettably, the commonest cause of crouch gait in children with spastic diplegia is isolated lengthening of the heel cord in the younger child (Sutherland and Cooper, 1978; Borton et al., 2001).

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 (Miller et al., 1995).

The result is an energy expensive gait pattern, followed by anterior knee pain and patellar pathology in adolescence.

Frequent BTX-A injections to the gastroc-soleus, without addressing the hamstrings /iliopsoas or providing adequate orthotic support can also lead to progressive crouch gait.

Crouch gait is always difficult to manage and usually requires lengthening of the hamstrings and iliopsoas, a ground reaction AFO and adequate correction of bony problems such as medial femoral torsion, lateral tibial torsion and stabilization of the foot.

By the time it is recognized, the musculoskeletal pathology is usually too advanced to respond to intramuscular BTX-A.

Management summary
- Spasticity management: in younger/less involved children BTX-A injections to the hamstrings and hip flexors.
- Contracture/deformity management: single event multilevel surgery, addressing all contractures, bony torsional abnormalities and joint instability.
- Orthotic management: long-term use of a ground reaction AFO until the integrity of the PF±KE couple is clearly re-established.


Coronal and transverse plane issues

?The simple classification above concentrates on observation and examination of the sagittal plane motors.However, the majority of children with spastic diplegia have also coronal plane and transverse plane problems.

?In the coronal plane, spasticity or contracture of hip adductors may be evident, as well as such issues as limb length discrepancy and hip subluxation.

?The transverse plane is the most difficult to appreciate on visual inspection and three-dimensional gait analysis is always required for a full evaluation (Gage, 1991).

?In the transverse plane the common problems are pelvic rotation, medial femoral torsion, lateral tibial torsion, and foot deformity.

?Management of sagittal plane problems such as spasticity or contracture will usually fail if there are significant transverse plane problems that are not dealt with.

?The use of twister cables attached to an AFO may help the younger child for a short period of time but these orthoses are neither particularly effective nor well tolerated. The definitive answer to lever arm disease is bony surgery

?With optimal management of spasticity and muscle length in early childhood, the requirement for muscle-tendon surgery is decreasing but the requirement for bony surgery remains unchanged.

?Fortunately, the outcome of bony surgery in cerebral palsy is in general more predictable, more durable and more effective than soft tissue surgery.

Summary and Conclusions

?The postural and gait patterns in this algorithm can be most accurately identified by using a combination of clinical examination, video recording of gait and instrumented gait analysis.

?When instrumented gait analysis is unavailable, pattern recognition may help inform clinicians where to look for associated spasticity or contracture and not to focus on a single problem or anatomic level.

?The orthotic recommendations are necessarily general rather than specific.

?This should not be misconstrued to imply that orthotic prescription is unimportant. Appropriate orthotic use is critical to the magnitude and duration of response to spasticity and contracture management.

?The principal issue is that the degree of orthotic support is predicated on the integrity of the PE±KE couple before intervention.

?The PF±KE couple is invariably altered and is frequently unstable after intervention.

?Thus, orthoses must be regularly evaluated as an integral part of spasticity management in children with cerebral palsy.

?Despite some excellent recent studies, the precise indications for the posterior leaf spring AFO, hinged AFO, solid AFO and ground reaction AFO, have not been fully established (Harrington et al., 1984; Ounpuu et al., 1996; Abel et al., 1998; Buckon et al., 2001).

?Many questions remain unanswered and there is ample scope for more clinical trials with objective outcome measures. Many of the existing studies have small numbers, short-term follow up and the outcome measures are neither comprehensive nor sufficiently objective.

Thank

 

[دكتور مجدى]

مشكوره جدا اختى الغاليه سالو على الموضوع
بس لو عملتيه بالعربى يبقى احسن لكى يستفيد منه جميع الاعضاء

 

[ahmed abady]

السلام عليكم ورحمة الله وبركاته
هو كله انجليزى انجليزى , مافيش عربى
بصراحة لما رايت cp قلت مرضى
لما دخلت لم افهم الا القليل

 

[salo_spain]

دكتور مجدي بارك الله فيك المحاضرة كانت بالانكليزي

 

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اخ احمد مشكور مرة تانيه تكرم

 

[طبيعي]

الشكر لك اختي الكريمه

 

[د رامى]

thanks for concern

 

[salo_spain]

مشكور اخ طبيعي

 

[بنت الحسني]

موضوع رائع جدا
الله يجزاك الخير..

 

[salo_spain]

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