Neurological Gait Patterns

Treatment Modalities Cont.

Foot Drop Patho-mechanics

Treatment Modalities

• Normal: The force of the heel at heel strike exceeds that of the body’s weight
• The direction or vector of that force passes behind the ankle and knee.

• Neuropathy: The force exerted at heel strike is uncontrolled.
• Excessive pronation moment during the mid-stance segment of the gait cycle.

• Painful Parastheisa:
• Medications-> Pregablin, Amitriptylline
• Yomanto et. al (2015), rat model showed Pregablin to provide greater anti-allodynic effects then Amitripylline for neuropathic withdrawal stimuli (p<0.05)
• Sympathetic block
• Lack of evidence on efficacy of nerve blockade for CRPS
• Optimizing glucose levels and Vit B levels

• AFO:
• Control PF during gait
• Diania et. al (2016), Level 3 retrospective study concluded AFO to improve gait indices in 53 children with spastic deplegic paralysis.

• Surgical Options:
• Nerve grafting
• Bridal Procedure-TP attached to 3rd cuniform
• Neurotendinous Transposition-LG transferred to TA with proximal end of deep peroneal nerve.
• Joint fusion

Peripheral Neuropathy Cont.

• Physical Therapy:
• Increase strength
• Robotic gait training
• ROM
• Physiotherapy

Peripheral Neuropathy Cont.

• Sensory neuropathy

• Motor Neuropathy:

• Tolchine et. al (2009)
• Inhibits the muscle stretch reflexes
• Muscle weakness
• Deterioration of the Peroneal nerve
• Compromises the function of the foot and ankle muscles.
• It also creates a void that the Achilles tendon will fill by abnormally pronating the midtarsal joint of the midfoot.
• Equinovarus deformity of hindfoot
• Pronation at forefoot

• Gait characterized by the foot slapping the floor at the beginning and toe dragging at the end of a step.

• Zernich et. al (2008)
• Nerve Compression
• Enzymes in the Schwann cells catalyze sugar into a crystalline alcohol that absorbs water. Water saturation causes the cells to swell, compress and thereby strangle the nerve.
• Compression causes pain in the form of burning, prickling and shock sensation to the feet.
• Neuroischemia
• Loss of blood supply for nerve vitality
• Leads to loss sensation, loss of balance
• Anatomical nerve loss
• Damage to large nerves
• Loss of sensory proprioceptive
• Inability to tell temperature difference causing falls.

References

Neurological Disorders & Associated Gait Abnormalities

Peripheral Neuropathy

• Danino B, Erel S, Kfir M, Khamis S, Batt R, Hemo Y, Wientroub S, Hayek S. Are Gait Indices Sensitive Enough to Reflect the Effect of Ankle Foot Orthosis on Gait Impairment in Cerebral Palsy Diplegic Patients? J Pediatr Orthop. 2016 Apr-May;36(3):294-8. doi: 10.1097/BPO.0000000000000429. PubMed PMID: 25757205.

• Yamamoto S, Kawashiri T, Higuchi H, Tsutsumi K, Ushio S, Kaname T, Shirahama M, Egashira N. Behavioral and pharmacological characteristics of bortezomib-induced peripheral neuropathy in rats. J Pharmacol Sci. 2015 Sep;129(1):43-50. doi: 10.1016/j.jphs.2015.08.006. PubMed PMID: 26362518.

• Zenirch, and Toclhin. "Understanding The Impact Of Diabetic Neuropathy On Gait." Podiatry Today. Podiatry Today, 08. Web. 15 Nov. 2016.

• Types of Peripheral Neuropathy
• Sensory
• Motor
• Autonomic
• Combination

• Etiologies of Peripheral Neuropathy
• Metabolic disorders i.e Diabetes Mellitus
• Idiopathic
• Drug Induced
• Vitamin B deficiency
• Alcoholism
• Syphilles
• Many others

Warda Saarah Shamshad

MetroWest Medical Center 2016

Neuropathic Gait

• Seen in patients with foot drop (weakness of foot dorsiflexion).
• If unilateral, causes include peroneal nerve palsy and L5 radiculopathy.
• If bilateral, causes include amyotrophic lateral sclerosis, Charcot-Marie-Tooth disease and other peripheral neuropathies.

Spastic Diplegic Gait

References

• Cerebral Palsy
• Bilateral lower extremity spascity
• Lesions to bilateral periventrilculars
• Characteristics:
• Abnormal narrow base
• Dragging both legs and scrapping toes
• Hip adductor tightness->legs to cross midlne called scissor gait

• Armstrong DG, Holtz-Neiderer K, Wendel C, Mohler MJ, Kimbriel HR, Lavery LA. Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients. Am J Med 120(12):1042-6, Dec 2007.

• Erika GIANNOTTI 1, 2, Andrea MERLO 1, Paolo ZERBINATI 1, 3, Maria LONGHI 1, Paolo PRATI1, Stefano MASIERO 2, Davide MAZZOLI. Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Rimini, Italy; 2 Department of Orthopaedic Rehabilitation, University of Padova, Padova, Italy; 3 Neuroorthopedic Service, Hand Surgery Unit, MultiMedica Castellanza, Italy

Neurological Gait Abnormalities

Gait Cycle

Hemipelegic Gait

• Initial Contact:
• First contact phase
• Beginning of stance phase
• Heel strike

• Swing Phase:
• No contact with ground
• All portions of foot are in forward motion

• Seen with CVA
• Upper motor neuron disorder
• Characteristics of Gait:
• Arm is flexed, adducted
• Leg is extended.
• Foot and toes are plantar-flexed
• Hold arm to side, circumduction of leg in circles

• Terminal Contact:
• When foot leaves ground
• Beginning of swing phase
• Toe off

• Hemiplegic gait
• Spastic Diplegic
• Neuropathic
• Myopathic
• Parkinsonian
• Choreiform
• Ataxic