Sagittal gait patterns in spastic diplegia J. M. Rodda, Classifications of gait patterns in spastic diplegia have been either qualitative, based on H. K. Graham, clinical recognition, or quantitative, based on cluster analysis of kinematic data. Qualitative L. Carson, classifications have been much more widely used but concerns have been raised about the M. P. Galea, validity of classifications, which are not based on quantitative data. R. Wolfe We have carried out a cross-sectional study of 187 children with spastic diplegia who attended our gait laboratory and devised a simple classification of sagittal gait patterns From the Royal based on a combination of pattern recognition and kinematic data. We then studied the Children’s Hospital, evolution of gait patterns in a longitudinal study of 34 children who were followed for more Parkville, Australia than one year and demonstrated the reliability of our classification. Children with spastic diplegia usually walk vatum knee. Although these patterns were independently but most have an easily recog- illustrated by sagittal plane kinematic data, no nised disorder of gait which may include devi- information was given regarding the quantita- ations in the sagittal plane such as toe- tive assessment of the individual patients in the ! J. M. Rodda, BAppSC (PT), walking, flexed-stiff knees, flexed hips and an study and there was no discussion of any devi- Senior Physiotherapist 1 ! L. Carson, BSc (Physio), anteriorly tilted pelvis with lumbar lordosis. ation of gait at other anatomical levels. Since Research Physiotherapist When compared with their peers many also these two landmark studies, Miller et al1 have ! H. K. Graham, MD, FRCS Ed, FRACS, Professor and walk at a reduced speed, with increased further elaborated on the sagittal gait patterns Director of Orthopaedic energy expenditure and impaired functional originally described by Rang et al.7 The five Surgery 2-4 ! Hugh Williamson Gait capability. Instrumented gait analysis gives patterns were described as jump, crouch, equi- Laboratory, Royal Children’s detailed information and quantitative meas- nus, jump plus equinus, and recurvatum plus Hospital, Flemington Road, 9-11 Parkville 3052, Victoria, urements. By a process of clinical interpreta- equinus. A number of authors have taken a Australia. tion this may help the clinician to understand different approach and have used cluster ana- ! M. P. Galea, PhD, Professor the gait pattern and perhaps to plan appropri- lysis techniques to classify gait patterns in cer- of Clinical Physiotherapy ate intervention.5,6 However, experienced cli- ebral palsy on a purely quantitative basis. School of Physiotherapy, University of Melbourne, nicians often describe gait patterns using a While the patterns identified by cluster analysis Parkville 3010, Victoria, combination of clinical examination and clin- appear to have statistical validity, none has Australia. ical observation. In 1986, Rang, Silver and De become widely accepted or is regularly used by ! R. Wolfe, PhD, Co-Director, 7 Biostatistics Consulting La Garza described a number of gait patterns clinicians. Service in spastic diplegia and classified them on a Our aim was to combine pattern recogni- Department of Epidemiology and Preventive Medicine, purely observational basis, related to spastic- tion and quantitative kinematic data in order Central and Eastern Clinical ity or contracture of muscles which work in to devise a clinically useful classification of School, Monash University and the Alfred Hospital, the sagittal plane. They observed associations sagittal gait patterns in spastic diplegia. We Commercial Road, Prahan between contractures of the psoas and lumbar planned to develop a template for describing 3181, Victoria, Australia. lordosis, of the adductors and scissoring, of sagittal gait patterns to evaluate muscle- Correspondence should be the hamstrings and knee flexion, of rectus tendon surgery and orthoses in the manage- sent to Professor H. K. Graham. femoris and stiff knee gait and of gastroc- ment of spastic diplegia. Our study was made soleus and tip-toe gait. By linking these in three inter-related parts. The first was a ©2004 British Editorial Society of Bone and observed patterns to specific shortening of the cross-sectional study of gait patterns in chil- Joint Surgery muscles, the association with management dren with spastic diplegia. We then carried out doi:10.1302/0301-620X.86B2. 7 13878 $2.00 was implied. a longitudinal study of a subset of patients In 1993, Sutherland and Davids8 described who had had more than one instrumented gait J Bone Joint Surg [Br] 2004;86-B:251-8. four typical abnormalities of gait affecting the analysis. Finally, we investigated the intra- Received 26 September knee in children with spastic diplegia, namely and inter-observer reliability of the classifica- 2002; Accepted after revision 30 June 2003 jump knee, crouch knee, stiff knee and recur- tion. VOL. 86-B, No. 2, MARCH 2004 251 252 J. M. RODDA, H. K. GRAHAM, L. CARSON, M. P. GALEA, R. WOLFE Table I. The definition of the sagittal plane posture at each level in late stance. The total number of patients is 174; 13 patients of the original cohort of 187 had sagittal kinematics which fell within our laboratory normal range and are therefore not included in this table Sagittal kinematics Gait pattern Number Pelvic tilt Hip Fx/Ext Knee Fx/Ext Ankle Df/Pf Group I, true equinus 47 Normal Normal Normal Equinus Anterior Recurvatum Group II, jump gait 38 Normal Normal Flexed Equinus Anterior Flexed Group III, apparent equinus 31 Normal Flexed Flexed Normal Anterior Group IV, crouch gait 28 Anterior Flexed Flexed Calcaneus Normal Posterior Group V, asymmetrical gait 30 Combination of any two of the above patterns Total 174 Patients and Methods Group II, jump gait. The ankle is in equinus, particularly in The classification of gait patterns was based on the position late stance. The knee and hip are excessively flexed in early of the ankle, followed by that of the knee, hip and pelvis stance and then extend to a variable degree in late stance, (Table I, Fig. 1). but never reach full extension. The pelvis is either within Group I, true equinus. The ankle is in equinus. The knee the normal range or tilted anteriorly. extends fully or goes into mild recurvatum. The hip extends Group III, apparent equinus. The ankle has a normal range fully and the pelvis is within the normal range or tilted ante- but the knee and hip are excessively flexed throughout riorly. stance. The pelvis is normal or tilted anteriorly. Sagittal gait patterns: Spastic diplegia Group I Group II Group III Group IV Group V True equinus Jump gait Apparent equinus Grouch gait Asymmetric gait RL α >90º α >90º α = 90º α = 90º For example Gastroc Gastroc (Gastroc) — — Hamstrings/RF Hamstrings/RF Hamstrings/RF Apparent Jump — (Psoas) Psoas Psoas equinus gait Hinged AFO Hinged AFO Solid AFO GRAFO Fig. 1 Diagrams showing each gait pattern, with the dominant muscle groups identified for the management of spasticity and/or contracture and appropriate orthotic prescription. Group V is a combination of groups I to IV, with a different group in the right lower limb compared with the left lower limb. In this example, the right lower limb is group III, apparent equinus, and the left lower limb is group II, jump gait. THE JOURNAL OF BONE AND JOINT SURGERY SAGITTAL GAIT PATTERNS IN SPASTIC DIPLEGIA 253 Sagittal plane kinematic data for gait patterns: Spastic diplegia Group I Group II Group IIII Group IV True equinus Jump gait Apparent equinus Crouch gait 50 50 50 50 Pelvic tilt deg deg deg deg -10 -10 -10 -10 70 70 70 70 Hip deg deg deg deg -20 -20 -20 -20 70 70 70 70 Knee deg deg deg deg -10 -10 -10 -10 30 30 30 30 Ankle deg deg deg deg -30 -30 -30 -30 Fig. 2 The summarised sagittal plane kinematic data for each gait pattern for the study population. The light grey band represented the mean ± 1 SD for the laboratory’s normal database, and the black band the mean ± 1 SD for each gait pattern. The vertical axis repre- sents joint angular displacement and the horizontal axis, 100% of the gait cycle. Group IV, crouch gait. The ankle is excessively dorsiflexed the mild gait pattern the sagittal plane kinematics of the throughout stance and the knee and hip are excessively pelvis, hip, knee and ankle were within the 1 SD band of the flexed. The pelvis is in the normal range or tilted posteri- laboratory normal range.12 These subjects had been orly. referred to the gait laboratory with transverse plane devia- Group V, asymmetric gait. The gait pattern is asymmetrical tions, usually in-toeing. We have chosen to present the to the degree that the subject’s two lower limbs are classi- groups in a sequence of decreasing equinus (Table I, Figs 1 fied as belonging to different groups; e.g. right lower limb and 2). The mild and asymmetrical gait patterns were not group III, apparent equinus and left lower limb group II, analysed further since mild gait did not show a significant jump gait (Fig. 1). deviation in the sagittal plane, and asymmetrical gait was Cross-sectional study. This comprised 187 patients who simply a combination of two of the four basic gait patterns. fulfilled the study criteria. In addition to the five basic Longitudinal study. There were 34 subjects (68 limbs) who groups we found it necessary to add an additional group, fulfilled the criteria with a mean time between first and which we have described as ‘mild gait’. We considered that second analyses of 30.2 months (13 to 65). Given that a true equinus, jump gait, apparent equinus, and crouch gait number of subjects had an asymmetrical gait pattern, we were the four basic patterns and, because terminology has have reported limbs rather than subjects.