Clinical neurokinesiology of spastic gait

Locomotor control requires a spatiotemporal coordination of passive and active forces across the movement system. Both anticipatory and reactive strategies operate in locomotor control. Mammalian locomotion is based on a rhythmic, "pacemaker" activity of spinal stepping generators. Reflex modification of the gait cycle is task-, context- and especially phase-dependent. In spasticity, together with disturbed supraspinal control, the phase-dependent reflex modulation of the gait cycle is severely impaired and there is altered modulation and timing of muscle activation and relaxation during voluntary movement. There is also a poor correlation between EMG activity and tension development in the spastic muscle. The tension increases without sufficient muscle activation and disconnection and dyscoordination between muscle activation, tension development and motor performance develops. The pattern of muscle activation and the development of increased muscle tone in patients with spasticity may be dramatically different in active movement from that observed in clinical testing of the passive muscles. Strategies used in the functional treatment of spasticity should be aimed at training and activating residual motor function, suppression of pathological and unfavourable movement and postural patterns and preventing secondary complications. In the 1990s a number of new specific instrumental methods and technical equipment supporting gait rehabilitation in patients with CNS lesions were developed: rhythmic auditory stimulation and other types of rhythmic stimulation, partial body support, usually with treadmill walking, complex orthotic support of bipedal locomotion, multichannel functional electrical stimulation, usually with programmable computer control, and advanced gait trainers. In therapy of spastic gait, the functional goals should be clearly determined from the kinesiological point of view of the impairment, and the impact on disability and handicap should be considered and a multidisciplinary approach is essential. (Ref. 139.)