Gait Abnormalities in Functional Problems of the Lower Extremities and in Neurological Diseases

Home , Scissor gait, Spastic gait, Steppage gait, Trendelenburg gait

48 Review articles

GAIT ABNORMALITIES IN FUNCTIONAL PROBLEMS OF THE LOWER EXTREMITIES AND IN NEUROLOGICAL DISEASES

M. Becheva, PhD

Medical University- Plovdiv, Medical College, Bulgaria, 120Buxton Bros. 4004 Plovdiv Abstract: Gait is a complex, automated and stereotyped motor activity that allows for movement of the body in an upright position. The investigation of gait is an integral part of the pathokinesiological study of the functional problems in any of the segments of the lower limbs. As the stereotype of walking changes at departure, stopping, turning, walking alongside another one, gait should be examined in different situations. In functional problems of the lower limbs and in some neurological diseases, the follow- ing abnormal gaits are detected: arthrogenic gait in extensional contractures of the hip or knee, walking in flexion contractures, "Gluteus maximus" gait, "Gluteus medius"gait, ataxic gait, hemiparetic (hemiplegic) gait, gait in parkinsonism, gait in paresis of plantar flexor, lameness in spasm of m. psoas major, gait in insufficiency of m. quadriceps femoris, gait in shortening of a lower limb, steppage gait and scissor gait. Adjusting abnormal gait is especially important to improve the functional condition of the patients in view of procuring a better quality of life.

Keywords: abnormal gait, functional problems, neurological diseases.

Introduction ground and allows the body to move forward. Gait is a complex stereotyped and auto- Gait is a conscious and volitional motor activity mated motor activity, which allows for move- [3]. ment of the body in an upright position. It 3. A complex coordination action during consists of several components: body movements, to maintain the center of grav- 1. Keeping the body upright. It is imple- ity by adjusting muscle tone of the extensors and mented by antigravity reflexes that keep body flexors. Vestibular-cerebral reflexes, proprio and head upright and limbs in extension [1]. receptive reflexes and neocerebral activities are These reflexes depend on proprioreception, important for the realization of a normal gait [4]. which gives information about the position of 4. Auxiliary motor actions (synkinesis). the limbs, a sense of stepping down and so on. These are reflex motor acts which are not direct- Anti-gravity reflexes may be increased patho- ly related, but only assist motor activity for its logically in the so called decerebration - better coordination, stability and keeping the increased muscle tone of the body and limbs body balance. The visual function is also import- extensors. It occurs when the brainstem is ant to gait [5]. blocked at the level of the mesencephalon and bulbar nucleus [2]. Types of abnormal gaits 2. Stereotypical, automated sequential The investigation of gait is an integral motor acts related to the movement of the body. part of the pathokinesiological study of the func- This is a complex reflex activity that is activated tional problems in any of the segments of the by the consistent contact of the foot with the lower limbs. Gait abnormalities in functional problems... PHARMACIA, vol. 64, No. 1/2017 49

The examiner, however, should be aware shortened (the support phase of the affected foot that the irregularities in the posture of the head, is shortened) [12]. neck, chest and lumbar spine can also lead to pathological changes in the gait without affect- Gait in flexion contractures. ing the lower limbs [6]. Such contractures develop most often We need to investigate the movement of from prolonged immobilization, prolonged each motor segment of the trunk and lower mode and improperly conducted conservative extremities and report any deviation from the treatment. normal stereotype of walking [7]. Arthrogenic gait in extensor contracture First, a comprehensive view of the in the left knee or hip. posture of asymmetries need to be made and then A) increased plantar flexion during the support gait should be analyzed taking into account the phase of the unaffected limb. length and frequency of steps, duration of indi- B) circumduction in the swinging motion of the vidual phases of the servomotor cycle, the speed affected leg of movement [8]. Flexion contracture in the hip is mostly A normal walking stereotype in a patient offset by increased lumbar lordosis (increased is usually established after the third step. inclination of the pelvis) and extension of the After the overall view, the study is direct- body, combined with flexion in the knee with a ed to separate motor moments of the kinetic view to achieve foot contact with the floor [13]. chain. Because the stereotype of walking chang- In flexion contracture in the knee, the es at departure, stopping, turning, walking patient compensates by increased dorsal flexion alongside another one, the gait should be exam- in the ultimate swing phase and in meeting the ined in different situations. We need to seek support with the unaffected limb, as in the early ways to make the patient walk, not realizing that phase of the push with the affected limb [11]. they are being observed- be sent to a device, Plantar-flexion contracture in the knees bring some object, etc. During walking the offset by hyperextension in the knee in the patient should be viewed from all sides [9, 10] monosupportphase of the affected limb and flexion of the corpse forward in the hip in the second Arthrogenic gait in extensional contractures part of the same phase. Lifting the heel at the end in the hip or knee. of the support phase of the affected limb occurrs Arthrogenic gait, caused by contracture earlier [14]. or deformity, may be or may be not accompanied by pain. If until recently the knee was in immo- "Gluteus maximus" gait bilization and can be folded to the extent neces- Such a gait is manifested in weakness of sary to carry out normal swing, the pelvis will be m.gluteus maximus, which is considered the compensatorily raised through increased plantar main extensor hip. The offset is achieved with a flexion of the opposite leg over his/her support rear swing of the corpse in the phase of meeting phase [4]. On the other hand, the affected leg the support with the injured limb to keep the will not be moved ahead in a straight trajectory, extension in hip joint [4]. but will strikean outer trajectory (mowing or circumduction)[11]. "Gluteus medius" (Trendelenburg) gait The pelvis on the affected part will carry Such a gait occurs in weakness in the hip out compensatory elevation. Irrespective of the abductor (m. gluteus medius and minimus). This joint (s) where the contracture is, in general there violates the stabilization of the pelvis in the will be a different length of the steps between the monosupport phase and it lowers in the direction affected and unaffected leg. of swing foot – the Trendelenburg symptom. In a Usually, the step of the unaffected leg is more pronounced deficit the patient tilts 50 PHARMACIA, vol. 64, No. 1/2017 M. Becheva, PhD the shoulder belt in the direction of the injured lack of dissociation of the belly muscles. When leg to shorten the arm of the Support Center of walking the patient leans forward and walks Gravityaction and thus alleviate the hip abductor faster, unable to stop propulsio [16]. (symptom of Duchenne). This type of gait is called by some Duchenne – Trendelenburg[12]. Gait in paresis of plantar flexor If the insufficiency of the abductor in the In plantar flex dysfunction the stabiliza- hip is bilaterally pronounced, the gait is associat- tion of the knee and TBS is significantly affected with a significant deviation in the frontal ed. The insufficiency of plantar flexors leads to plane (duck walking). This type of gait is most loss of the thrust. frequently found in patients with bilateral The support phase with the affected limb congenital dislocation of hip joint [9]. is shortened, respectively the final swing is shortened (ie, length of step) with the unaffected Ataxic gait. leg [17, 18]. If the patient has impaired proprioreception or impaired muscle control, there is a Lameness in spasm of m. psoas major. tendency of disturbing the balance and diver- This type of claudication occurs in gence of legs. The feet are dragged on the floor diseases and damage to the hip joint (eg. in because of the impaired sensation. The patient Prethes). The patient has difficulties with looks at his feet while walking. In patients with performing the swing and limps, while manifest- cerebellar ataxia, the gait characterized by stag- ing compensatory increased mobility of the gering and rolling, shredded, interrupted, while pelvis and trunk. The limping can be caused by the movements are irregular [14, 15]. weakness or painful inhibition of m. psoas major [18]. Hemiparetic (hemiplegic) gait. In the classic version of expression the Patients with hemiparesis and hemiparal- affected hip is in external rotation, flexion and ysis move the affected foot with a swinging adduction. The patient increases the amplitude motion (mowing gait), while simultaneously of motion of the trunk and pelvis so that to cause folding more hip joint and the knee to separate flexion moment in the during the swing [6]. the fingers of the sagging in plantar flexion foot from the floor. The affected upper limb is close Gait in insufficiency of m. quadriceps femoris to the body [16]. In quadriceps insufficiency the patient At expressed hemiparesis and hemiparal- includes proximal and distal compensatory ysis, the pelvis is rotated forward on the affected mechanisms. Most often in the support phase, part. Thus the unaffected lower limb is located the knee is locked in hyperextension. In meeting further back. In walking, the passing in opposite the support, the body leans forward and while direction of either leg becomes almost impossi- the ankle is flexed inaplantar fashion. If the body ble. There is no back support with the affected flexors, hip joint and the foot can not implement leg and front support with the unaffected leg [14, this compensatory mechanism, the patient 16]. extends the knee with a hand [15].

Gait in Parkinsonism. Gait in shortening of one lower limb In patients suffering from parkinsonism, In shortening of one lower limb, the the neck, trunk, hip joint and knees are flex- patient limps, while in the support phase with the ioned. Gait is characterized by small quick steps shorter leg tilts the body towards him/her and the (Japanese gait). pelvis leans towards the same part. The patient The upper limbs are stiff and do not carry may supinate the foot on the truncated side in out normal counterswinging motions – there is a their attempt to extend the limb [19]. Gait abnormalities in functional problems... PHARMACIA, vol. 64, No. 1/2017 51

On the side of the longer limb there can nesis are reduced. The reasons for this are com- be observed increased flexion in the knee and plex and are associated with discrete functional pelvic elevation during the swing phase, to disturbances of the entire central nervous enable the foot to be transferred forward without system, in the wake of degenerative and vascular touching the floor The support phase for both atherosclerotic processes [26]. limbs can be the same. Adjusting the parameters of abnormal By using appropriate orthopedic shoes gaits is especially important to improve the func- with different height (to adjust shortening) a tional status of patients in view of a achieving normal gait can be achieve. This gait is called by higher quality of life. some authors osteogenic painless gait [20, 21]. References. Scissor gait. 1. Bouisset S. Biomécanique et physiolo- Such a gait can be observed in elastic gie du movement. Médecine de rééduca- adductor paralysis in hip joint, wherein knees tion2002; 248-320. adhere to one another and can not be separated. 2. Pérennou D. Contrôle postural, The divergence of the legs when walking in this espace, locomotion, édition Solal, Paris, 2013. case requires great effort. Spastic paraplegia is 3. Paysant J, Beyaert C, Datie A, Marti- the reason for this most often, so some authors net N. Évaluation des capacités et des perfor- call this type of gait spastic gait [22, 23]. mances: contribution des monitorages de la locomotion en situation d'exercice et de vie réelle. Steppage gait Annales de Réadaptation et de Médecine Phy- Such gait occurs in paresis and paralysis sique 2007; 3(50):156–164. of the dorsal flexors of the foot, resulting in the 4. Barbier F. Modélisationbiomécanique foot hanging down when carrying it forward in du corps humain et analyse de la marchenormale swing phase. This causes an extension of the et pathologique- Application à la rééducation. affected leg and therefore compensatorily the Paris 1994:5. knee is raised higher than normal (greater flex- 5. Lacour M. Controle Postural, Espace, ion in TBS and knee). The meeting of the Locomotion. Posture, Equilibre&Mouvement support occurs not with the heel but with the 2013:45-62. foot, which "splashes" in contact because of the 6. Bieuzen F. Influence des lack of control by the dorsal flexors [19, 24]. propriétésmusculaires sur un exercice de locomotion humaine; de l'efficience à la déficience- Conclusion motrice. Edilivre-a Paris Universitaire. 2008. Musculoskeletal pathologies leading to 7. Valerius K.-P. Les muscles: Anato- the development of muscle weakness, pain or miefonctionnelle de l'appareillocomoteur, limited range of motion lead to changes in gait. édition De BoeckUniversité, Paris 2013. Some patients develop effective compensatory 8. Dimitrovа, Popov N. Manual function- and replacement mechanisms allowing them to al diagnosis of musculoskeletal system. Sofia: keep their locomotor abilities. Patients with NSA-Press, 2003. damage to the central motor neuron develop 9. Lacour M. Posture Et Locomotion. adequate compensation and replacement mecha- 16emes JourneesFrancaises De Posturologie nisms harder because they have impaired propri- Clinique Posture, Equilibre&Mouvement oreception, equilibrium abilities and prominent 2011:18-42. muscle spasticity [25]. 10. Pennecot G. Marché pathologique de Human gait changes with age. In adults it l'enfant paralysécérébral. Sauramps Medical gradually becomes slower, steps smaller, the 2006. coordination of gait deteriorates, normal synki- 11. Viton Dr. Pr. J M,.Bensoussan L Dr., 52 PHARMACIA, vol. 64, No. 1/2017 M. Becheva, PhD

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Corresponding author: Maria Vakrilova Becheva Medical College of Medical University- Plovdiv Plovdiv 4004 “Buxton Brh 120” Tel: +359 32641882 E-mail: [email protected]