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cerebral palsy gait types spastic dyskinetic ataxic
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cerebral palsy types gait patterns spastic hemiplegia diplegia dyskinetic ataxic comparison
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https://www.physio-pedia.com/Cerebral_Palsy_Introduction
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Here is a comprehensive comparison of gait patterns across the different types of cerebral palsy (CP):
Gait Differences Across Types of Cerebral Palsy
CP Classification Overview
CP is classified by tone type and distribution (site of involvement):
| Tone Type | Brain Region Damaged | Key Feature |
|---|---|---|
| Spastic | Motor cortex / pyramidal | Velocity-dependent increased tone, hyperreflexia |
| Dyskinetic (dystonic/choreoathetoid) | Basal ganglia / extrapyramidal | Involuntary, uncoordinated movements |
| Ataxic | Cerebellum | Low tone, loss of coordination |
| Mixed | Multiple regions | Combination, often spasticity + dystonia |
1. Spastic CP (Most Common ~80%)
A. Spastic Hemiplegia (Unilateral CP)
Damage to the motor cortex on one side; arm more affected than leg. The Winters et al. (1987) classification, still the gold standard, describes four sequential gait types:
| Type | Key Feature | Description |
|---|---|---|
| Type 1 | Drop foot | Weak/silent dorsiflexors - foot drops during swing phase |
| Type 2 | True equinus | Type 1 + triceps surae contracture - plantarflexed throughout |
| Type 3 | Equinus + jump knee | Type 2 + hamstring/rectus femoris spasticity causing knee flexion/stiffness |
| Type 4 | Full stiff gait | Type 3 + hip flexor and adductor spasticity, pelvic rotation involved |
Classic hemiplegic features:
- Arm held flexed, pronated, adducted (arm does not swing)
- Affected leg: hip circumduction (the leg swings out in an arc to clear the ground)
- Toe-walking or foot drop on affected side
- Shortened stride on affected side
B. Spastic Diplegia (Bilateral CP, legs > arms)
Most commonly associated with periventricular leukomalacia (PVL) from prematurity. Also uses a four-type Rodda/Graham classification:
| Type | Key Feature | Description |
|---|---|---|
| Type 1 | True equinus | Plantarflexion at ankle, relatively normal knee and hip |
| Type 2 | Jump knee | Equinus + excessive knee flexion in stance |
| Type 3 | Apparent equinus | Ankle dorsiflexed but knee and hip excessively flexed (crouch-like with apparent equinus) |
| Type 4 | Crouch gait | Significant flexion at hip and knee, excessive dorsiflexion - most severe |
Classic diplegic features:
- Scissor gait - thighs strongly adducted, legs cross as patient walks
- Bilateral toe-walking (equinus)
- Short, stiff steps, restricted hip and knee motion
- Arms relatively spared but may show mild involvement
- As described in Adams and Victor's Principles of Neurology: "Each leg is advanced slowly and stiffly... the thighs may be strongly adducted, causing the legs almost to cross... as though wading waist-deep in water"
C. Spastic Quadriplegia (Total Body Involvement)
All four limbs involved; most severe form. Typically non-ambulant or very limited ambulation. Primary orthopedic concerns are hip subluxation and spinal deformity rather than gait management.
2. Dyskinetic CP (~15%)
Brain region: Basal ganglia / extrapyramidal system damage (commonly from kernicterus or hypoxic-ischemic injury)
Two sub-types with distinct gait features:
Dystonic
- Sustained or repetitive muscle contractions causing twisting, repetitive movements and abnormal postures
- Gait is slow, labored, with torsional movements of the trunk and limbs
- Muscle tone fluctuates (sometimes rigidly increased, sometimes low)
- Movements worsen with voluntary effort, emotion, or stress
Choreoathetoid
- Chaotic, jerky, uncontrolled movements (chorea) combined with slow, writhing movements (athetosis)
- Gait appears unpredictable and uncontrolled; sudden jerks of the legs, arms, and trunk
- Movements affect all four limbs
- No hyperreflexia or pyramidal signs (distinguishes from spastic CP)
- Balance and postural control are severely impaired
Key difference from spastic CP: Tone is variable rather than consistently increased; movements are involuntary and purposeless; scissor gait is NOT characteristic.
3. Ataxic CP (Least Common ~5-10%)
Brain region: Cerebellar damage or malformation
| Feature | Description |
|---|---|
| Base of support | Wide-based gait (legs spread wide for stability) |
| Balance | Severely impaired; frequent falls |
| Coordination | Movements performed with abnormal force and rhythm |
| Tremor | Intention tremor (worsens as limb approaches target) |
| Tone | Generalized hypotonia (low tone) |
| Steps | Irregular, unsteady, lurching (trunk ataxia) |
| Upper limbs | Past-pointing, over/undershooting |
The gait is often described as "drunken" - unsteady and staggering, quite distinct from the stiff, predictable pattern of spastic CP.
4. Mixed CP
Commonly a combination of spasticity and dystonia. "Spastic Ataxic Diplegia" is a recognized mixed subtype often associated with hydrocephalus. Gait features overlap between types; the predominant component usually dictates the clinical presentation.
Summary Comparison Table
| Feature | Spastic Hemiplegia | Spastic Diplegia | Dyskinetic | Ataxic |
|---|---|---|---|---|
| Limbs affected | One side (arm > leg) | Both legs | All four | All four |
| Tone | High (unilateral) | High (bilateral, legs) | Variable | Low |
| Gait pattern | Circumduction, arm flexed | Scissor, toe-walk, crouch | Jerky/writhing/twisting | Wide-based, unsteady |
| Foot strike | Toe-walking or drop foot | Bilateral toe-walking | Variable | Flat/irregular |
| Balance | Mildly impaired | Moderately impaired | Severely impaired | Severely impaired |
| Reflexes | Hyperreflexic | Hyperreflexic | Normal/absent pyramidal signs | Hyporeflexic |
| Brain lesion | Unilateral cortex | Periventricular (PVL) | Basal ganglia | Cerebellum |
| Ambulation | Usually independent | Usually independent | Variable | Independent but falls |
| Arm swing | Absent on affected side | Usually present | Involuntary movements | Dyscoordinated |
Sources: - Bailey and Love's Short Practice of Surgery 28th Ed, p. 653 | Adams and Victor's Principles of Neurology 12th Ed, p. 138 | Tintinalli's Emergency Medicine | Physio-pedia CP Introduction | CP Resource Gait Fact Sheet
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