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Gait patterns in spastic hemiplegia in children and young adults

TF Winters, JR Gage and R Hicks J Bone Joint Surg Am. 1987;69:437-441.

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Copyright

987

by The Journal

of Bone

and Joint

Surgery.

Incorporated

Gait

Patterns

in Spastic and Young

JAMES R. GAGE, M.D.1,

Hemiplegia Adults*
AND RAMONA HICKS, M.A., R.P.T.1,

in Children
BY THOMAS F. WINTERS, JR., M.D.t, NEWINGTON
From

CONNECTICUT
Childrens

the

Kinesiologv

Laboratory,

Newingion

Hospital,

Newingion

ABSTRACT:

Four

homogeneous

patterns

ofgait

were

of locomotor

coordination,

and the rates

at which

muscles

defined in forty-six patients who had spastic hemiplegia secondary to cerebral palsy or other neurological disorders by analyzing kinematic data in the sagittal plane and electromyographic tients) the primary swing phase. The data. In Group I (twenty paabnormality was a drop foot in the thirteen patients in Group II had a

are stretched also may influence the findingsmo. The result has been that variable regimens of treatment are prescribed for many patients who, from the clinical standpoint, appear to have similar involvement of the central nervous system. We decided to study whether more pertinent information could be obtained electromyography by use of new laboratory tests: and computerized measurements dynamic of the

tight heel cord in the stance phase as well as a drop foot in the swing phase. The five patients in Group III also had more proximal involvement (that is, restricted motion of the knee) ankle. In Group restricted motion as well as an equinus IV, the eight patients of the hip. deformity of the had, in addition,

rotation

ofjoints. These tests allow the physician to evaluate the function of the muscles and the position of the joints during gait and provide a more extensive and objective assessment of the neural deficit in patients who have spastic
disorders.

In 1977, Bekey et al. classified

The term spastic hemiplegia is used for the neural deficit that may occur in patients who have a neurological disorder such as cerebral palsy, traumatic injury to the brain, or cerebrovascular accident. The word hemiplegia means the neuromuscular disorder that involves one-half of the body in the frontal plane while the other half is normal or near normal. Cerebral palsy is generally taken to mean a non-progressive disorder that begins either in utero or within the first two years of life, with a selective loss of muscle control who
iO

the spastic
electromyographs

gait

of thirty
of the

patients

into

four

categories

using

muscles concluded

that activate

motion

of the foot description

and the ankle. of the various

They patterns

that an accurate

of gait is possible if the patterns of movement of the entire lower extremity also were evaluated. In a follow-up study, Chang and Bekey discussed how they were able to apply recognition

of patterns

to the prediction

of the

changes

in and interpat-

Many cerebral

of the characteristics palsy are similar

that are seen in patients to those in patients accident commonly

empirical.

gait that could be expected postoperatively. Knutsson Richards combined electromyographic studies and mittent light photography and found three predominant

have

who

have injury to the brain or a cerebrovascular which the onset occurs later in life. Surgery, bracing, or both, have who
was

in
used
Static

terns of gait in patients who had spastic hemiplegia that was secondary to cerebrovascular accidents; one pattern was similar to the pattern found in our Group-Il patients and two patterns were similar to that in our and Group-Ill patients.

been

to improve the gait in patients but until recently the treatment muscle tests and which These observation to determine lengthening.

have
entirely

spastic

hemiplegia, Materials Methods gait are done in need of critical inwent

of the patients

Forty-six

patients

who had spastic

analysis

hemiplegia

underChil-

muscles are overactive and tests, however, do not yield

a computerized

of gait at the Newington

formation from patients who have lesions of the brain because manual techniques for testing muscle depend on the patients ability to selectively activate a particular muscle while simultaneously releasing the antagonist, and often

drens Hospital Kinesiology Laboratory. The thirty-three male and thirteen female patients had an average age of 1 1 .2 years (range, 3.4 to 30.5 years). Thirty-eight had cerebral palsy; six, traumatic injury to the brain; and two,

juvenile
latter limit

cerebrovascular
diagnoses

accident.

The patients

with the two

after the onset the had had walk

patients

who have the conditions that are under study are unable to coordinate these two muscular functions. Variables such as posture of the limbs, vestibular tone, patterns
*

were tested recovery. before

at least two years None

of the hemiplegia
of neurological surgery orthopaedic

and were believed

the analysis

to have reached
of the patients and all could

No benefits party
were

in any form related

have been received or indirectly

of this study.

or will

be received ofthis

from article.

a commercial
No funds

directly
in support

to the subject 1315 South

received

independently without In the Kinesiology

orthoses or other aids. Laboratory, we used four

systems

t Orlando Regional Suite D, Orlando, Florida

Medical 32806.

Center,

Orange

Avenue,

Kinesiology
ton. Connecticut

Laboratory,
061 1 1 . Please

Newington
address

Childrens
for

Hospital,
reprints

NewingGage.

requests

to Dr.

of measurement that were connected to a supervising cornputer (Digital Equipment Corporation, Maynard, Massachusetts): a three-dimensional motion camera (United
437

VOL.

69-A,

NO.

3. MARCH

1987

438

T.

F.

WINTERS,

JR.,

J.

R.

GAGE,

AND

RAMONA

HICKS

Technologies
a three-channel Jersey), forms

Research
visual

Center,
camera

East Hartford (Panasonic, system with Technology,

Connecticut), Secaucus, New

,

compares

the speed of walking in the sagittal plane of the four gait.

and rotations of the joints groups with the parameters whose Nineinjury

a force (Advanced and system amplified

measurement Mechanical

two force platNewton, MasThe from Lake

of normal

sachusetts), telemetry surface City,

an eight-channel electromyographic (Biosentry, Torrance, California). telemetry electrodes system monitored signals (Motion Control, Salt

Group I consisted of twelve boys and eight girls, average age was 9 S years (range 5 2 to I 5 8 years).
. , . .

teen patients to the brain.

had cerebral

palsy

and one had traumatic

electromyographic

deviations

The patients in this group from normal gait. The average

had the mildest speed of walking

Utah) or implanted fine-wire electrodes, or both45. All patients had an orthopaedic evaluation as part of the analysis in which they walked at self-selected speeds during testing. Two runs of kinematic data were done for each subject and were compared visually. In patients who have spastic hemiplegia the differences in data from run to run are usually gross minor. Any patients whose analysis showed differences In patients closely between runs were eliminated from the who had minor differences, the data that normal were selected. meaof the on is,

was 97.3 centimeters per second; the normal speed for children who are between the ages of eight and fourteen years is 1 16.6 centimeters per second7. The most significant abnormality of gait was a drop foot in the swing phase (Fig. 1), but equally important was the fInding that they had an adequate range of dorsiflexion (average, 12 degrees) (Table I) ofthe ankle during the stance phase ofgait. The maximum amount of dorsiflexion in the stance phase was zero degrees in all of the Group-I patients. Other more than deviations

study.
more

approximated

Although analysis of three-dimensional motion surements was done in all patients, the classification

from normal gait that were recorded in this group included increased flexion of the knee at terminal swing phase, at initial contact, and in loading response; hyperfiexion of the hip during the swing phase; and increased lordosis of the pelvis throughout the gait cycle (Fig. 1). Group II consisted of thirteen patients, nine boys and four girls, whose average age was 10.2 years (range, 4.3 to 15.8 tient, years). traumatic Eleven injury patients had cerebral and one, palsy; one pato the brain; a cerebrovas-

patients

into the recordings

the four groups to be described that were made in the sagittal

was based plane (that

the plane of progression for the three major joints of the lower extremity) Electromyographic data were used to classify patients who could not be grouped by kinematic data
.

alone. Results Four distinct patterns GROUP

LU

cular accident. The average speed in Group II was 90.0 centimeters were identified. GROUP II Table I this group Ill was characterized GROUP IV

of walking for the patients per second. The gait in flexion NORMAL that persisted

of gait I

by plantar

GROUP

z
4

LU Zr

I_____
Gilt

CVC1S

Csat

Ccis

Gilt

CcIs

Ceit
CcLi PLUS PATTERN

c.i. cci.
PLUS

FOOT
IC HIP

DROP KNEE FLEX.1

FLEXION
t

PATTERN I PLUS ST PLANTARFLEX. KNEE HYPEREXT.

PATTERN

II

KNEE

MOTION

HIP TST

III MOTION LORDOSIS

LORDOSIS

FIG. The charts indicate the mean normal values. Features of each and TST terminal stance.
(solid line) and standard deviations (dotted

I
lines) of rotation of the joints in the sagittal

group

are summarized

at the bottom

of the chart

using

the following

abbreviations:

IC

plane initial

for

each

group

contact,

ST

and for stance,

GAIT

PATTERNS

IN

SPASTIC

HEMIPLEGIA

439

TABLE
DATA ON AGE AND PARAMETERS OF GAIT

I
SUBJECTS AND HEMIPLEGIC GR0uPS*

IN NORMAL

Normalt Rotation during Maximum (swing

Maximum (stance extension

Grou p I

Grou p II

Group

III

Group

IV

of the joints gait (degrees) dorsiflexion phase)

dorsiflexion phase) of

of the
of the

ankle
ankle

6 4 4 3

- 1 12 51 44

6 6 8
7

16
-

I1 10 10 6 4 20

21
-

8 12 8 10 12
24

14
-

10

10 56

7 60
46

6 37 46

8 33 29 12
84

14 12 4 6
22

Total flexionthe
knee

Total
Age(vrs.) Speed
*

flexionof the

42 hip

extension of walking

1I

10 4
14 97

10 90

15 80

(cm/sec.)
deviation.

I 17

19

Mean

and standard obtained

t Values

from

Newington

Childrens

Hospital.

throughout also

the gait cycle

(Table

I). The patients

in this group

showed

a progression

of involvement

proximally,

and had

demonstrated knee in the stance

full extension or hyperextension of the phase (Fig. 1) as well as hyperfiexion of throughout patients, the gait whose av-

the hip and increased lumbar lordosis cycle. Group III consisted of five male

more limited flexion of the knee during the swing phase than Group-lI patients. Total flexion-extension of the knee during gait was less than 45 degrees in Group-Ill patients; the value for normal subjects is 56.3 degrees. Group-Ill patients were similar to patients in Groups I and II in that they also had lordosis. Group one female. hyperfiexion IV consisted The average Six patients of the hip and of eight age was had patients, 12.2 years palsy increased seven and lumbar male
3.4

erage age was 14.5 years (range, 4.9 to 30.5 years). Two patients had cerebral palsy; two, traumatic injury to the brain; and in one, this a cerebrovascular was 79.7 group had plantar accident. centimeters flexion The at the average The ankle,

and to trau-

velocity
patients

of walking

per second.

(range, two,

21 .5 years).

cerebral

7(7
NORMAL

/ /LL

NORMAL

NORMAL

TOE OFF
* GAIT CYCLE

FIG.

The stick figures of the lower extremity and the electromyographs are representative of the patients in Group III. Flexion of the knee during the swing phase is limited because of the concomitant activation of the hamstring and rectus femoris muscles. The bar graphs that indicate normal values are based on data that were collected at the Shriners Hospital in San Francisco. California2.

VOL.

69-A,

NO.

3. MARCH

1987

440 matic injury to the logical involvement. 84.4 centimeters motion of the knee ited flexion-extension.

T.

F.

WINTERS,

JR.,

J.

R.

GAGE,

AND

RAMONA

HICKS

brain. This group had The average velocity The ankle was

the most neurofor walking was plantar flexed,

tremity in those

was more in Groups

involved I and

in the patients II. Waters et

in Group believed

III than that the

per second.

was restricted, and the hip showed limTotal flexion-extension of the hip

during gait was less than 35 degrees in Group-IV patients; the value in normal subjects is 42. 1 degrees. Group-IV patients compensated for limited motion of the hip by increasing pelvic (Fig. 2). lordosis during the terminal stance of gait

stiff-legged gait of some hemiplegic patients is a regression to primitive locomotor patterns. These patterns are present in quadrupeds that depend on the extensor reflex for stability in stance and activation ofthe lowerextremity. This extensor reflex occurs during terminal swing phase. There is a strong reflexive tie between contraction of the quadriceps muscles, extension of the hip, and plantar flexion of the ankle; therefore, the equinus position is normal during gait in quadrupeds. In bipeds, the extensor reflex at the ankle has been blocked so that humans do not normally initiate the stance phase with the foot plantar flexed. reflex remained in fact, extensor position. A In the Group-Ill patients the extensor at the hip and knee to resist the flexor thrust; tone is enhanced when one rises

Discussion Group I The pattern of gait in the patients in Group I was best

characterized
phase, The heel

by plantar flexion of the ankle in the swing resulting in an equinus deformity at initial contact. cord was not tight since there was adequate dorin the stance phase. To compensate for the drop

to the upright

siflexion

central lesion in Group-Ill patients released the plantar reflex at the ankle from its inhibitory block2. The result was the stiff gait with short steps that the Group-Ill patients demonstrated.
35 In subjects who have a normal gait, the knee flexes to degrees in the late phase of stance, just before toe-off.

foot, the knee hyperflexed at foot strike, forcing the hip into increased flexion in order to maintain the body in a position centered over the foot and to help clear the swinging limb with the The drop lordosis classic foot. The pattern for of pelvic cycle. patients has been to however, can is not a shortas evidenced these tilt showed increased throughout treatment the gait

Flexion

increases

to 65 degrees

by the middle
muscles
the quadriceps

of the swing In
hamand

lengthen
worsen ening

the heel cord. Such treatment, the gait since the pathological lesion of the gastrocnemius and soleus muscles

after the activity of the quadriceps the Group-Ill patients, however,

has ceased2. contrac-

string

muscles

remained

active.

This

simultaneous

by dorsiflexion of more than zero degrees phase. It is more likely that the problem underactivity of the anterior tibial muscle

during the stance is weakness or

relative to over-

tion of flexor and extensor muscles knee during swing. Electromyography plified activity electrodes of these

limited flexion of the using surface am-

confirmed this by showing the abnormal muscles during the swing phase (Fig. 2). of the quadcause of the the swing of of the Howactivity

activity
Group

of the gastrocnemius II

and

soleus

muscles.

We believe riceps and decreased

that loss of coordinated contraction hamstring muscles is the primary flexion and of the knee Richards phase decreased phase that also and occurs found decreased of their electromyographic during

The

tracture
sulted stance

patients in Group of the gastrocnemius plantar

II had a static and soleus flexion

or dynamic conmuscles that reduring the

phase6.
Knutsson the ever, knee they in the hyperextension flexion patients. stance

in persistent and

of the ankle

plantar
unless

flexion

swing phases. Perry9 stated that 15 degrees of of the ankle places the trunk behind the foot is hyperextended, the hip is flexed, or the

knee in the swing

in one-third

also found

the knee

of two

heel is elevated by external support. When the ankle is in fixed plantar flexion, the tibia and foot function together as a long lever that will not allow the usual rocker motion of the tibia on the foot. This forces the knee into hyperextension in the middle and terminal stages of stance. In addition, advancement of the trunk is curtailed and the length of the opposite step is decreased. To maintain the center of gravity over the foot, flexion of the hip and pelvic lordosis were increased, as in the patients In the study of Knutsson
who

or more muscle groups and believed the hyperextension of the knee compensated for weakness of the muscles rather than was secondary to plantar flexor spasticity. Decreased electromyographic activity was not found in our Group-Ill patients. In one-sixth ofthe patients in their series, Knutsson and Richards found concomitant activation (as shown by electromyography) in four to six muscle swing who groups phase. were in and decreased These findings Group III. JV In Group-IV patients, as in Group-Ill patients, the exflexion of the knee during the were true of all of our patients

and

were in Group II. Richards one-third

of the Group

twenty-six patients who had hemiplegia secondary to a cerebrovascular accident demonstrated a pattern that was similar to that in our Group-Il patients. The main disturbance was plantar flexion of the ankle that resulted in hyperextension of the knee. Group III The musculature in the proximal part of the lower ex-

tensor reflex was implicated because they had decreased motion at the hip and knee and plantar flexion at the ankle. The reduction of motion in the sagittal plane at the hip constituted
IV. Increased

the crucial
activity

difference
of the

between
iliopsoas and

Groups
hip

III and
adductors

prevented

the

hip

from

reaching

full

extension
AND

at terminal
JOINT SURGERY

THE JOURNAL

OF BONE

GAIT

PATTERNS

IN

SPASTIC

HEMIPLEGIA

441 should be specific to the neurological deficit.

stance severely anterior the

phase. The shortened pelvic tilt.

length without

of

the stride would the compensatory

have been increase in

ofthe

condition

For example, patients who have a pattern our Group I do not require a lengthening

of gait similar to of the Achilles

are not

In general, four groups.

there was a progression of involvement in The average speed of walking for Groups

tendon since the gastrocnemius and soleus muscles shortened. A leaf-spring orthosis (a flexible plastic foot orthosis) Patients

ankle-

I and II combined was approximately ninety-five centimeters per second compared with approximately eighty-three centimeters per second for Groups III and IV (p < 0. 1). Patients in Groups I and II appeared to have the least residual damage to the central Groups nervous
.

II usually

should adequately control the drop foot. who have a gait similar to our patients in Group will require lengthening of the plantar flexors of

system

as compared

with

patients in Groups

in

III and IV

It is of interest

that the patients

the involved ankle as well as a leaf-spring orthosis. In order to develop the patients ability to walk to the maximum, treatment will probably have to extend to the knee for patients who have a gait similar to our Group-Ill to the knee and the hip for those who have to our Group-IV
Noit:
Hospital. for her
editorial

I and II combined were significantly younger than those in Groups III and IV combined (approximately ten and thirteen years, respectively, p
<

patients and a gait similar

0.05).

patients.
Nelson. Research Coordinator at Ncwington Chtldrcn.. assistance.

Since spastic hemiplegia in young patients encompasses a spectrum of deficits, it follows logically that treatment

The authors thank Marianna

References
1.
2. 3. J.; and HOFFER, M. M.: Pattern-Recognition of Multiple EMG Signals Applied to Description of Human Gait. Eng. , 65: 674-681 , 1977. BLECK, E. E. : Orthopaedic Management of Cerebral Palsy, p. 62. Philadelphia, W. B. Saunders, 1979. CHANG, C. W. . and BEKEY, G. A. : Pattern Recognition Applied to the Prediction of Post-Operative Gait in Man. In Proceedings of the Ninth Conference on Decision and Control, Including the I 7th Symposium on Adaptive Processes. Institute of Electrical and Electronic Engineers Control Systems Society, pp. 674-681 . Piscataway, Institute of Electrical and Electronic Engineers, 1979. GAGE, J. R.: Gait Analysis for Decision-Making in Cerebral Palsy. Bull. Hosp. Joint Dis., 43: 147-163, 1983. GAGE, J. R.; FABIAN, DAvID; HICKS, RAMONA; and TASHMAN, SCOTT: Pre- and Postoperative Gait Analysis in Patients with Spastic Diplegia. A Preliminary Report. J. Pediat. Orthop. , 4: 715-725. 1984. GAGE. J. R. ; PERRY. J. ; HICKS, R. ; Koop. S. ; and WERNTZ. J. : Rectus Femoris Transfer as a Means of Improving Knee Function in Cerebral Palsy. Devel. Med. and Child Neurol. . in press. HICKS, R.; TASHMAN, S.; CARY. J. M.; ALTMAN. R. F.; and GAGE, J. R.: Swing Phase Control with Knee Friction in Juvenile Amputees. J. Orthop. Res., 3: 198-201, 1985. KNUTSSON. EVF.RT, and RICHARDS, CAROL: Different Types of Disturbed Motor Control in Gait of Hemiparetic Patients. Brain. 102: 405-430. 1979. PERRY, JACQUELIN: Kinesiology of Lower Extremity Bracing. Clin. Orthop., 102: 18-31, 1974. PERRY, JACQUELIN: GI0vAN, PETER; HARRIS, L. J. ; MONTGOMERY, JACQUELINE; and AZARIA, MORRIS: The Determinants of Muscle Action in the Hemiparetic Lower Extremity (and Their Effect on the Examination Procedure). Clin. Orthop. , 131: 71-89, 1978. WATERS. R. L.; PERRY, J.; and GARLAND, DOUGLAS: Surgical Correction of Gait Abnormalities following Stroke. Clin. Orthop.. 131: 54-63. 1978. WATERS. R. L.; GARLAND, D. E.; PERRY. JACQUELIN: HABIG, TERRY; and SLABAUGH. PETER: Stiff-Legged Gait in Hemiplegia: Surgical Correction. J. Bone and Joint Surg. , 61-A: 927-933. Sept. 1979.
BEKEY,

G. Proc.

A.; CHANG, C. W.; PERRY, Instit. Electr. and Electron.

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