types of gait
All people with cerebral palsy (who are ambulant) display some unusual aspects of gait. The dyskinetic nature of the cerebral palsy sufferer's gait is due to a combination of factors, including physical deformities, irregular rotation of leg joints, and muscle tone issues, such as hypertonia (tightness of muscles) and hypotonia (lack of muscle tone). In addition to an overall unusual gait, cerebral palsy patients may demonstrate a specific type of gait aberration. For instance, perhaps the most common type of gait abnormality is idiopathic toe-walking (whose name is self-explanatory). Other types of gait, such as 'spastic knee' gait (generally characterized by spastic knee flexor activity) and 'crouch' gait (typified by excessive flexing of leg joints) also appear in cerebral palsy.
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Article Abstract
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1. Gait classification in children with cerebral palsy: A systematic review
This systematic review of the literature evaluates the validity of existing classifications of gait deviations in children with cerebral palsy (CP). Numerous efforts have been made to develop classification systems for gait in CP to assist in diagnosis, clinical decision-making and communication. The internal and external validity of gait classifications in 18 studies were examined, including their sampling methods, content validity, construct validity, reliability and clinical utility. Half of the studies used qualitative pattern recognition to construct the gait classification and the remainder used statistical techniques such as cluster analysis. Few adequately defined their samples or sampling methods. Most classifications were constructed using only sagittal plane gait data. Many did not provide adequate guidelines or evidence of reliability and validity of the classification system. No single classification addressed the full magnitude or range of gait deviations in children with CP. Although gait classification in CP can be useful in clinical and research settings, the methodological limitations of many classifications restrict their clinical and research applicability.
[Dobson, F., Morris, M. E., Baker, R. & Graham, H. K. (2007). Gait classification in children with cerebral palsy: A systematic review. Gait & Posture, 25(1), 140-52.]
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2. The validity of an existing gait classification system when applied to a representative population of children with hemiplegia
This study describes sagittal plane gait patterns in a representative sample of children with hemiplegic cerebral palsy (CP). Ninety-four children were prospectively recruited to the study (age range 5-18 yrs, mean age 10 yrs 7 mo) and valid kinematic data was captured for 91 participants. Data was also captured for 49 children (age range 5-18 yrs, mean age 10 yrs) with no physical impairment. One representative gait cycle from each child was exported to an Excel template and run through an algorithm that facilitated the description of gait, using logical arguments derived from Winters' Classification. Children with hemiplegic CP, regardless of past surgery history, were allocated to the following gait types: Groups IV (n=9; 10%), III (n=7: 8%), II (n=5: 5%), I (n=32: 35%) and not classified (n=38: 42%). For children with no lower limb surgical history (n=61), gait types were: Groups IV (n=7: 12%), III (n=2: 3%), II (n=2: 3%), I (n=20: 33%) and not classified (n=30: 49%). The gait data taken from children with no physical impairment were not classified. The ability of the Winters' classification system to distinguish between children with higher levels of hemiplegic involvement and children with no physical impairment was demonstrated: the majority of children with hemiplegic CP present with relatively minor gait deviations. A more complete definition of sagittal plane ankle joint kinematics may account for those children that were not classified.
[McDowell, B. C., Kerr, C., Kelly, C., Salazar, J. & Cosgrove, A. (2008). The validity of an existing gait classification system when applied to a representative population of children with hemiplegia. Gait & Posture, 28(3), 442-7.]
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3. Muscular contributions to hip and knee extension during the single limb stance phase of normal gait: A framework for investigating the causes of crouch gait
Crouch gait, a troublesome movement abnormality among persons with cerebral palsy, is characterized by excessive flexion of the hips and knees during stance. Treatment of crouch gait is challenging, at present, because the factors that contribute to hip and knee extension during normal gait are not well understood, and because the potential of individual muscles to produce flexion or extension of the joints during stance is unknown. This study analyzed a three-dimensional, muscle-actuated dynamic simulation of walking to quantify the angular accelerations of the hip and knee induced by muscles during normal gait, and to rank the potential of the muscles to alter motions of these joints. Examination of the muscle actions during single limb stance showed that the gluteus maximus, vasti, and soleus make substantial contributions to hip and knee extension during normal gait. Per unit force, the gluteus maximus had greater potential than the vasti to accelerate the knee toward extension. These data suggest that weak hip extensors, knee extensors, or ankle plantar flexors may contribute to crouch gait, and strengthening these muscles--particularly gluteus maximus--may improve hip and knee extension. Abnormal forces generated by the iliopsoas or adductors may also contribute to crouch gait, as our analysis showed that these muscles have the potential to accelerate the hip and knee toward flexion. This work emphasizes the need to consider how muscular forces contribute to multijoint movements when attempting to identify the causes of abnormal gait.
[Arnold, A. S., Anderson, F. C., Pandy, M. G. & Delp, S. L. (2005). Muscular contributions to hip and knee extension during the single limb stance phase of normal gait: A framework for investigating the causes of crouch gait. Journal of Biomechanics, 38(11), 2181-9.]
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4. The gait deviation index: A new comprehensive index of gait pathology
This article describes a new multivariate measure of overall gait pathology called the Gait Deviation Index (GDI). The first step in developing the GDI was to use kinematic data from a large number of walking strides to derive a set of mutually independent joint rotation patterns that efficiently describe gait. These patterns are called gait features. Linear combinations of the first 15 gait features produced a 98% faithful reconstruction of both the data from which they were derived and 1000 validation strides not used in the derivation. The GDI was then defined as a scaled distance between the 15 gait feature scores for a subject and the average of the same 15 gait feature scores for a control group of typically developing (TD) children. Concurrent and face validity data for the GDI are presented through comparisons with the Gillette Gait Index (GGI), Gillette Functional Assessment Questionnaire Walking Scale (FAQ), and topographic classifications within the diagnosis of Cerebral Palsy (CP). The GDI and GGI are strongly correlated (r(2)=0.56). The GDI scales with FAQ level, distinguishes levels from one another, and is normally distributed across FAQ levels six to ten and among TD children. The GDI also scales with respect to clinical involvement based on topographic CP classification in Hemiplegia Types I-IV, Diplegia, Triplegia and Quadriplegia. The GDI offers an alternative to the GGI as a comprehensive quantitative gait pathology index, and can be readily computed using the electronic addendum provided with this article.
[Schwartz, M. H. & Rozumalski, A. (2008). The gait deviation index: A new comprehensive index of gait pathology. Gait & Posture, 28(3), 351-7.]
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5. Effect of persistent toe walking on the ankle equinus. Analysis of 60 idiopathic toe walkers
Sixty idiopathic toe walkers (age range 1 to 15 years) were evaluated to determine the natural history of toe-to-toe gait and the relationship between the range of ankle dorsiflexion and increasing age. The majority of toe walkers had a normal birth weight (average 7.06 pounds), walked on time (average 11.14 months), began toe walking immediately (87%), stood plantigrade (90%), were able to demonstrate a heel-toe gait (88%), and toe walked intermittently (68%). Forty-six percent of all toe walkers were found to have 0 degree or less of passive ankle dorsiflexion. Equinus toe walkers (mean dorsiflexion -5.2 degrees) had significantly less dorsiflexion than the remaining toe walkers (mean dorsiflexion 16.9 degrees; p < 0.01). An average of 12 degrees of dorsiflexion was resent in the 1-to 2-year age group, which gradually diminished to -4 degrees in the 6- to 15-year age group. It appears that there may be a relationship between persistent toe walking and the development of ankle equinus in some children and therefore interventions should be considered to inhibit the toe walking progression.
[Sobel, E., Caselli, M. A. & Velez, Z. (1997). Effect of persistent toe walking on the ankle equinus. Analysis of 60 idiopathic toe walkers. Journal of the American Podiatric Medical Association, 87(1), 17-22.]
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6. Spasticity and 'spastic' gait in children with cerebral palsy
The current notion of spasticity as a velocity-dependent increase of muscle response to imposed stretch was mainly derived from studies performed under stationary experimental conditions. To address the issue of a spastic muscle behaviour under dynamic conditions, we conceived a novel approach, aimed at quantitatively assessing motor output over the lengthening periods which take place during unperturbed functional movements. Application to the analysis of overground walking in children with spastic cerebral palsy (CP) revealed that, for representative lower limb muscles, the relationship between EMG levels and estimated muscle lengthening rate displays either increased gain or reduced velocity threshold. Parallel measurement of gait kinetics frequently showed congruent increase of the mechanical resistance to joint rotation. Abnormalities preferentially targeted the lengthening contractions occurring around the ground contact period of the stride. The pathophysiological profile of what is clinically defined as 'spastic' gait in CP children did not only consist of dynamic spasticity, as described above. Most often it resulted from the simultaneous contribution of other factors, including paresis, co-contraction, immature and non-neural components.
[Crenna, P. (1998). Spasticity and 'spastic' gait in children with cerebral palsy. Neuroscience and Biobehavioral Reviews, 22(4), 571-8.]
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7. The kinematic patterns of toe-walkers
Children who toe-walk can pose a diagnostic problem. The differential diagnosis includes mild spastic diplegia and idiopathic toe-walking. Clinical differentiation between these two patient groups can be particularly difficult, and there are no objective diagnostic tests to assist the clinician. We assessed 50 children who toe-walk to define the kinematic patterns of lower-limb joint motion in the sagittal plane. There were 23 children with mild spastic diplegia. 22 idiopathic toe-walkers, and five normal children who were asked to toe-walk. We found characteristic patterns of knee and ankle motion that differentiated spastic diplegia from idiopathic toe-walking. Normal children asked to toe-walk had the same pattern as the idiopathic group. Gait analysis is a diagnostic tool that enables the clinician objectively to differentiate mild spastic diplegia from idiopathic toe-walking.
[Kelly, I. P., Jenkinson, A. Stephens, M. & O'Brien, T. (1997). The kinematic patterns of toe-walkers. Journal of Pediatric Orthopedics, 17(4), 478-80.]
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8. Classification of idiopathic toe walking based on gait analysis: Development and application of the ITW severity classification
Idiopathic toe walking (ITW), considered abnormal after the age of 3 years, is a common complaint seen by medical professionals, especially orthopaedic surgeons and physiotherapists. A classification for idiopathic toe walking would be helpful to better understand the condition, delineate true idiopathic toe walkers from patients with other conditions, and allow for assignment of a severity gradation, thereby directing management of ITW. The purpose of this study was to describe idiopathic toe walking and develop a toe walking classification scheme in a large sample of children. Three primary criteria, presence of a first ankle rocker, presence of an early third ankle rocker, and predominant early ankle moment, were used to classify idiopathic toe walking into three severity groups: Type 1 mild; Type 2 moderate; and Type 3 severe. Supporting data, based on ankle range of motion, sagittal joint powers, knee kinematics, and EMG data were also analyzed. Prospectively collected gait analysis data of 133 children (266 feet) with idiopathic toe walking were analyzed. Subjects' age range was from 4.19 to 15.96 years with a mean age of 8.80 years. Pooling right and left foot data, 40 feet were classified as Type 1, 129 were classified as Type 2, and 90 were classified as Type 3. Seven feet were unclassifiable. Statistical analysis of continuous variables comprising the primary criteria showed that the toe walking severity classification was able to differentiate between three levels of toe walking severity. This classification allowed for the quantitative description of the idiopathic toe walking pattern as well as the delineation of three distinct types of ITW patients (mild, moderate, and severe).
[Alvarez, C., De Vera, M., Beauchamp, R., Ward, V. & Black, A. (2007). Classification of idiopathic toe walking based on gait analysis: Development and application of the ITW severity classification. Gait & Posture, 26(3), 428-35.]
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9. Idiopathic toe walking: A kinematic and kinetic profile
PURPOSE: The differential diagnosis in children who walk on their toes includes mild spastic diplegia and idiopathic toe walking (ITW). A diagnosis of ITW is often one of exclusion. To better characterize the diagnosis of ITW, quantitative gait analysis was utilized in a series of patients with an established diagnosis of ITW. STUDY DESIGN: Patients with an established diagnosis of ITW were analyzed by quantitative gait analysis. Data were recorded as each subject walked in a self-selected toe-walking pattern. The subject was then asked to ambulate making every effort to walk in a normal heel-toe reciprocating fashion. Data were collected to determine if this group of idiopathic toe walkers was able to normalize their gait. Datasets were compared with each other and with historical normal controls. RESULTS: Fifty-one neurologically normal children (102 extremities) with ITW were studied in the Motion Analysis Laboratory at a mean age of 9.3 years. In the self-selected trials, significant deviations in both kinematics and kinetics at the level of the ankle were identified. Disruption of all 3 ankle rockers and a plantar flexion bias of the ankle throughout the gait cycle were most commonly seen. When asked to attempt a normal heel-toe gait, 17% of the children were able to normalize both stance and swing variables. In addition, 70% were able to normalize some but not all of the stance and swing variables. CONCLUSION: Quantitative gait analysis is an effective tool for differentiating mild cerebral palsy from ITW. Kinematic and kinetic distinctions between the diagnoses are evident at the knee and ankle. The ability to normalize on demand at least some of the kinematic and kinetic variables associated with toe walking is seen in most children with ITW.
[Westberry, D. E., Davids, J. R., Davis, R. B. & de Morais Filho, M. C. (2008). Idiopathic toe walking: A kinematic and kinetic profile. Journal of Pediatric Orthopedics, 28(3), 352-8.]
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10. Voluntary (normal) versus obligatory (cerebral palsy) toe-walking in children: A kinematic, kinetic, and electromyographic analysis
Surgical management of toe-walking gait in children with cerebral palsy currently favors simultaneous, multilevel soft-tissue and bony interventions. Formulation of such a surgical plan is based on our ability to determine which of the gait deviations present are primary and which are secondary or compensatory. To evaluate this issue further, 32 normal children, walking normally and voluntarily toe-walking, were compared to 15 children with cerebral palsy walking in an obligatory toe-walking gait pattern. Computer-based analysis of gait was performed for each child, including time-distance, kinematic, kinetic, and electromyographic analyses. Significant deviations common to both normal and cerebral palsy toe-walking groups were determined to be due, at least in part, to the biomechanical constraints associated with a toe-walking gait pattern. Deviations unique to the cerebral palsy group were thought to represent primary gait deviations related to the underlying injury to the central nervous system. This study identifies the need to develop more sophisticated techniques of data collection and analysis and supports the inclusion of more varied and demanding functional activities for distinguishing between primary and secondary gait deviations in children with cerebral palsy.
[Davids, J. R., Foti, T., Dabelstein, A. & Bagley, A. (1999). Voluntary (normal) versus obligatory (cerebral palsy) toe-walking in children: A kinematic, kinetic, and electromyographic analysis. Journal of Pediatric Orthopedics, 19(4), 461-9.]
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