Cerebral Palsy Gait Therapy

GAIT DISORDERS AND THERAPY

FOR CEREBRAL PALSY

1. What is a gait disorder in cerebral palsy?   

Gait is a pattern of walking. Walking involves balance and coordination of muscles so that the body is moved forward in a rhythm, called the stride. There are many possibilities that may cause an abnormal gait. Some common causes in children with cerebral palsy are:

• Due to lower limb spasticity results in tightness anD contracture of muscles can cause the knees to flex at the hip knee and ankle which can cause difficulty in walking

• Anatomic shortening of muscle-tendon of lower limbs

• Scissoring pattern of leg due to tightness of adductor muscles of lower limb

• Hip joint subluxations/dislocations 

• Club foot

2. What are the gait disorders in cerebral palsy?    

A gait disorder in cerebral palsy is due to: 

• Imbalance during walking 

• Shuffling gait- in which the child drags feet while walking

• frequent falls- An unsteady gait that is caused by diseases of or damage to the legs and feet (including the bones, joints, blood vessels, muscles, and other soft tissues) or to the nervous system that controls the movements necessary for walking

• Staggering gait - when walking is uncoordinated and appears to be 'not ordered'.

• Freezing gait – it is the brief, episodic absence or marked reduction of forward progression of the feet despite the intention to walk.

• Gait disorders are very common in the children with cerebral palsy due to tightness of lower limbs muscles, reduced range of motion of joints, weakness of muscles, and loss of balance and lack coordination, neurological or non-neurological cause.

3. The common causes of gait disorders in cerebral palsy include:    

a. Spastic gait - here the children affected with spastic cerebral palsy have involvement on both sides with tightness of muscles  in lower extremities worse than upper extremities. The child walks with an abnormally narrow base, dragging both legs and scraping the toes. This gait is seen in bilateral periventricular lesions in brain, such as those seen in cerebral palsy. There is also characteristic extreme tightness of hip adductors which can cause legs to cross the midline referred to as a scissoring gait. Children with cerebral palsy may have hip adductor release surgery to minimize scissoring.

b. Ataxic gait - due to lack of coordination and can include staggering gait as well as uncoordinated arm movements, speech and eye movements. It is seen in children with Ataxic cerebral palsy in which the gait is clumsy, staggering and wide based. While standing these children tends to swagger back and forth and from side to side, known as Titubation. In this the child will not be able to walk from heel to toe or in a straight line. 

c. Hemiplegic Gait - here the children stands with unilateral weakness on the affected side. While walking, the Leg on the affected side is in extension with plantar flexion of the foot and toes. When walking, the patient will hold his or her arm to one side and drags his or her affected leg in a semicircle (circumduction) due to weakness of distal muscles (foot drop) and extensor hypertonia in lower limb. This is most commonly seen in stroke. With mild hemiparesis, loss of normal arm swing and slight circumduction may be the only abnormalities.

d. Choreiform Gait (Hyperkinetic Gait) - This gait is seen with certain basal ganglia disorders including forms of chorea, athetosis or dystonia. Here the child with cerebral palsy will display irregular, jerky, involuntary movements in all extremities. 

e. Scissors gait - This type of gait gets its name because the both the thighs cross in a scissors-like pattern when walking. The legs, hips, and pelvis become flexed, making the person appear as though he or she is crouching. The steps are slow and small. This type of gait occurs often in children with spastic cerebral palsy.

f. Waddling gait - Movement of the trunk is exaggerated to produce a waddling, duck-like walk. Progressive muscular dystrophy or hip dislocation present from birth can produce a waddling gait.

g. Sensory Gait - it is due to loss of this propioreceptive input as child fails to locate the feet with the ground position. This gait is also sometimes referred to as a stomping gait since patients may lift their legs very high to hit the ground hard as it is difficult for the child to maintain the balance of tight muscles to coordinate during walking

4. Therapy Care and Treatment:     

What can be done to improve a gait disorder?

a. Physiotherapy and Occupational therapy intervention plays a vital role in developing gait patterns in the children with cerebral palsy through positioning, stretching of tight muscles, strengthening of weak muscles, developing balance and coordination of limbs, use various support modalities like orthosis, callipers, braces, that are the most appropriate way to improve proper foot alignment, balance, strength and flexibility. 

b. Stretching and strengthening muscles of lower limbs to improve gait patterns include:

• Hip Adductor Muscles - The hip adductors are the muscles of your inner thigh, which support balance and alignment. These stabilizing muscles are used to engage the hips and thighs or move them toward the midline of your body. Their primary action is to bring and join the thighs together; they also aid in rotation and flexion of the thigh.

• Hamstring muscles – The hamstring muscles are included in the back muscle groups of the thigh. The hamstring muscles are responsible for the movement of your hip and knee, which helps in walking, sitting, flexing the knees and flexing the hip.

• Quadriceps Muscles - The quadriceps are a group of four muscles located on the front of your thigh. These four muscles work together to help you stand, walk, run and move around with ease. They also keep your knee cap (patella bone) stable.

• The calf muscles - the calf muscles in the back of the legs are responsible for plantar movement of the foot and ankle. During walking, running or jumping, the calf muscle pulls the heel up to allow forward movement.

c. Basic therapeutic exercises to improve gait patters are:

i. Stretching exercises for tight muscles of the thigh and leg

• Calf Muscles (Achilles Tendon) Stretching Exercises

• Hamstring muscles Stretching Exercises

• Quadriceps stretching exercise

• Adductor stretching exercise

• Gluteus muscle stretching exercise

ii. Exercises for stiffness of the Lower limbs 

• Bilateral hip and knee exercises

• Hip rotation exercise

• Kneeling

• Half Kneeling

iii. Bolster Therapy

• Kneel with Bolster

• Bolster squat sit

iv. Ball Therapy

• Supine to sit on ball as it strengthens the core muscles

• Lying on the ball on the tummy and encouraging the baby to raise the head

v. Mat Activities Exercises

• Bridging - Teach back Raise

vi. Parallel bar walking

d. Surgical options

• Surgery can help reduce muscle stiffness, increase flexibility, and function in children with cerebral palsy. However, it is important to note that surgery is not a suitable option for every child with cerebral palsy, and it also comes with risks. After surgery, most children should be able to participate in post-operative physical therapy and rehabilitation. Sometimes, this is not an option for some children.

• There are many types of surgeries performed for children with cerebral palsy. These include procedures on the feet, ankles, feet, hips, wrists, arms or shoulders, as well as the spine and joints.

• Each child's situation is unique, and treatment will be individualized to his or her needs. Surgery will be recommended if the benefits outweigh the risks that come with it.

e. Basic Accessories Required During Cerebral Palsy Therapy to improve gait patters are - 

• Gaiters – The gaiter is like a cricket pad that is wrapped around the foot from the mid-thigh to the ankle joint. The main function is to reduce the tightness around the knee joint and bring the leg to a straight position. By wearing these gaiters, the child gets support to sit and can stand against the wall. It stabilizes the foot and helps to break the tightness of the leg muscles. It is ideal for foot positioning.

• Ankle-foot orthosis (AFO) - Ankle-foot orthosis (AFO) is the most commonly used type in children with cerebral palsy. AFOs are designed to improve ankle joint function and prevent or treat muscle contractions. This is a brace to control the position and motion of the ankle, reduce muscle weakness, or correct deformity."AFO" can be used to position a limb with stiff muscles to overcome weak limbs or in a more general case.

• Knee Ankle Foot Orthosis (KAFO) - KAFOs extend from under the middle hip to the toes and stabilize the ankle joint as well as the knee. It reduces the stiffness around the knee joint. It reduces deformity around the knee and ankle joint. It helps in improving the efficiency of the gait.

• Calipers - Calipers are a very important aid in the care of a child with cerebral palsy. It can prevent contractions. Calipers are also used to reduce pain and prevent deformities of the foot and ankle. Calipers can improve range of motion of joints and reduce muscle stiffness. 

5. Conclusion:    

Cerebral Palsy is a diverse group characterized by delayed body function, disorders and neurological that are non-progressive. Although the clinical picture may change as the brain matures. There is a need to know the associated signs and symptoms. Diagnosis and thorough testing is needed to know the exact problem in a child affected by cerebral palsy.

Cerebral palsy children require a complex health care team to care for development of gait patterns and follow-up with these children gives them the best quality of life they can have.

Early physiotherapy and occupational therapy interventions provide an opportunity for the child to practice functional activities, body positions and gait. By practicing meaningful and effective skills in a variety of environments, the child will have the opportunity to acquire skills that encourage them to be more independent with the activity of daily living and to increase their level of participation in society.