What is childhood spastic gait?

Childhood Spastic Gait

Childhood spastic gait is a motor disorder characterized by velocity-dependent increase in muscle tone with exaggerated deep tendon reflexes, resulting in abnormal movement patterns during walking, primarily seen in children with cerebral palsy or other upper motor neuron disorders. 1, 2

Definition and Pathophysiology

• Spastic gait results from hyperreflexia (increased muscle response to stretch), which is velocity-dependent and causes abnormal muscle activation during movement 3, 4
• It is most commonly associated with cerebral palsy (CP), which affects 2.1 per 1000 children in high-income countries 1, 2
• The pathophysiology involves damage to upper motor neurons in the brain, leading to reduced inhibitory signals to the spinal cord and resulting in hyperactive stretch reflexes 1, 4

Clinical Presentation

Characteristic Features

• Increased muscle tone (spasticity) that worsens with rapid movement 1
• Abnormal plantar reflex with upgoing toes (Babinski sign) 1
• Increased deep tendon reflexes 1
• Persistence of primitive reflexes beyond appropriate developmental age 1

Common Gait Patterns

• Pattern 1: Increased knee flexion during stance and swing phases due to hamstrings and rectus femoris hyperreflexia 3, 5
• Pattern 2: Increased ankle plantar flexion (equinus or toe-walking) due to gastrocnemius hyperreflexia 3, 6
• Pattern 3: Combination of increased knee flexion and ankle plantar flexion due to gastrocnemius, soleus, and hamstrings hyperreflexia 3, 7

Diagnostic Evaluation

Clinical Assessment

• Observe quality and quantity of movement, including antigravity movement and sequential transition from sitting to walking 1
• Assess for Gower maneuver (using arms to push up from floor) which suggests muscle weakness 1
• Evaluate muscle tone by documenting scarf sign in infants and popliteal angles after the first year 1
• Check for persistence of primitive reflexes and asymmetry of protective reflexes 1

Neuroimaging

• MRI is the most sensitive tool (86-89% sensitivity) for identifying brain abnormalities associated with spastic gait 1, 2
• Common MRI findings include white matter injury (56%), cortical and deep gray matter lesions (18%), and brain maldevelopments (9%) 2

Standardized Assessments

• Hammersmith Infant Neurological Examination (90% sensitivity) 1, 2
• Prechtl Qualitative Assessment of General Movements (98% sensitivity) in infants 1, 2
• Gross Motor Function Classification System (GMFCS) to determine severity in children 2 years or older 1

Differential Diagnosis

• Hereditary spastic paraparesis - distinguished by family history and progressive nature 5
• Duchenne muscular dystrophy - characterized by weakness, calf hypertrophy, and elevated creatine phosphokinase (CK) 1
• Ataxia - characterized by incoordination rather than spasticity 1
• Developmental coordination disorder - motor coordination below age norms without definable medical condition 1

Red Flags Requiring Prompt Referral

• Loss of previously acquired motor milestones (suggests neurodegenerative process) 1, 2
• Respiratory insufficiency with generalized weakness 1
• Abnormalities on brain MRI requiring neurosurgical consultation 1
• Motor delays present during minor acute illness (may suggest mitochondrial myopathies) 1
• Elevated CK to greater than 3× normal values 1

Prognosis

• In high-income countries, 2 in 3 individuals with cerebral palsy will walk 1, 2
• 3 in 4 will develop speech 1, 2
• 1 in 2 will have normal intelligence 1, 2
• Common comorbidities include chronic pain (75%), epilepsy (35%), intellectual disability (49%), musculoskeletal problems (28%), behavioral disorders (26%), sleep disorders (23%), visual impairment (11%), and hearing impairment (4%) 1, 2

Clinical Pearls

• Spasticity may not be evident in early infancy and can emerge after 1 year of age; therefore, absence of early detectable spasticity does not rule out spastic cerebral palsy 1
• Multiple motor disorders often coexist, with spasticity and dystonia frequently occurring together 1
• As voluntary activity increases, some symptoms may resolve while others worsen 1
• Early diagnosis and intervention are crucial to optimize motor and cognitive plasticity and prevent secondary complications 1, 2
• Velocity-based hyperreflexia better explains spastic gait patterns than force-based hyperreflexia 3, 6