Paretic gait occurs with flaccid lower paresis due to myelopathy, traumatic and non-traumatic lesions of the peripheral nerves, polyneuropathy, poliomyelitis, neurosarcoidosis, neuroacanthocytosis. It is characterized by a decrease in step length, difficulty in lifting the leg from the surface. The cause of paretic gait is established on the basis of complaints, anamnesis, neurological examination data, imaging, electrophysiological, laboratory techniques. Therapy includes analgesics, hormones, neurometabolic agents, therapeutic blockades. Sometimes surgical interventions are required.
general characteristics
Paretic gait is a walking disorder in which, due to the weakness of all or certain muscle groups, the patient has difficulty in raising and moving the leg. Can be single or double sided. There is a trend towards a decrease in stride length. The patient either drags his feet along the ground, or uses special compensatory techniques, involving intact muscle groups, which leads to the presence of special varieties of paretic gait:
- Duck. It is revealed with weakness in the proximal parts of the lower extremities. The body is overbent, the stomach is pushed forward. When walking, a person rolls heavily from side to side.
- Stork gait. It develops with damage to the extensor of the distal legs. Accompanied by a sharp flexion of the hips, a high rise of the feet.
- Steppage. A more pronounced version of the previous version. The leg is raised high, sharply thrown forward, flattened to the surface with a characteristic slap.
- Calcaneal . Formed with weakness of the flexors of the foot. There is dorsiflexion of the foot with support on the heel.
Along with a paretic gait, patients show a decrease in tone and muscle hypotrophy. Reflexes are reduced, pathological signs are absent. Sometimes fasciculations are noted.
Why does paretic gait occur?
Cauda equina syndrome
Cauda syndrome develops when there is a violation of the conduction of the spinal nerves located below the 1st lumbar vertebra (the level at which the spinal cord ends). Paretic gait is observed in the following pathologies:
- Spinal injuries. The symptom becomes a consequence of fractures and fracture-dislocations of the lumbar vertebrae, damage to the sacrum and coccyx. It occurs as a result of a violation of the integrity of the nerves, compression by fragments, hemorrhages, hematomas.
- Intervertebral hernias. Formed against the background of lumbar osteochondrosis. Compression of nerve fibers is caused by prolapse of the hernia or its sequestration with the movement of a free lying fragment into the cavity of the spinal canal.
- Spinal deformities. Congenital anomalies include vertebral splitting, lumbarization, sacralization. The list of acquired deformities includes spondylarthrosis, spondylosis. Some pathologies, such as spondylolysis, can be either congenital or acquired.
- Spondylolisthesis. The displacement of one vertebra relative to another is caused by malformations, spondylolysis, degenerative changes. It can develop in the long term after fractures of the arch and articular processes of the lumbar vertebrae. Sometimes it is formed against the background of bone defects after neoplasia, arthrogryposis, Paget's disease.
- Tumors of the cauda equina. They make up 11-15% of the total number of spinal cord neoplasms. They can be benign or malignant, primary or metastatic. The most common are neuromas, meningiomas, lipomas, ependymomas, and teratomas. Metastases are most often found in breast, lung, and prostate cancers.
- Inflammatory diseases . The defeat of the lumbar region accounts for one third of cases of spinal tuberculosis. Osteomyelitis is a nonspecific infectious and inflammatory process that can cause compression of the cauda equina.
- Vascular pathologies . Hemorrhagic and ischemic spinal strokes are rare. They are formed due to congenital and acquired vascular diseases, external compression of the arteries or their damage during surgery.
With spinal cord injuries, disorders of the spinal circulation, the symptoms occur acutely at the time of injury or progress rapidly over several days. For other pathologies, gradual development is characteristic. The first manifestations of cauda equina syndrome are lower back pain radiating to the leg, paresthesia in the lower limb. Then there is numbness, slight weakness in the feet and legs.
Subsequently, the changes are aggravated, a paretic gait is formed, and independent movement becomes difficult. Other signs include dysfunction of the pelvic organs with loss of the sensation of fullness, the development of chronic constipation and urinary retention. In men, there are violations of potency, in women - anorgasmia.
Paretic gait
Peripheral nerve damage
Paretic gait in this pathology is unilateral. Depending on the etiology, it develops quickly or gradually. The clinical picture is determined by the localization of the lesion. Violation is provoked by the following factors:
- Traumatic injuries . There may be a complete or partial interruption, concussion, compression or contusion of the nerve trunk. The causes of injury are open wounds, dislocations, displacement of fragments during fractures, and surgical interventions.
- Compression . The most common lesion due to compression in a narrow anatomical canal or compression by pathological formations is peroneal neuropathy. A similar mechanism can be observed in neuropathy of the sciatic, tibial, and femoral nerves.
- Vascular diseases . Occlusion of arteries in obliterating endarteritis and obliterating atherosclerosis, deep vein thrombosis in patients with varicose veins provoke disturbances in the blood supply to the nerve with the development of ischemic neuropathy.
- Infections . Paretic gait due to inflammatory changes in the nerve trunks and plexuses can be observed in patients with brucellosis and HIV infection. With herpes, intercostal nerves are more often involved in the process, but in some cases, damage to the nerves of the lower extremities is possible.
Polyneuropathies
Symmetry of manifestations with the development of bilateral paretic gait is characteristic of this group of diseases. In most cases, paresis occurs in the distal limbs, steppage or stork gait is observed. The exception is acquired demyelinating pathologies, in which weakness is sometimes detected predominantly in the upper legs. The cause of the symptom is the following polyneuropathy:
- Acute inflammatory : Guillain-Barré syndrome, Fisher's syndrome.
- Chronic inflammatory : symptomatic polyneuropathies in SLE, periarteritis nodosa, systemic vasculitis, Sjögren's disease, hepatitis C, HIV, cancer, endocrine pathologies.
- Hereditary : Russi-Levi syndrome, Charcot-Marie-Tooth neural amyotrophy, Refsum disease, Dejerine-Sott hypertrophic neuropathy.
- Metabolic : hepatic, uremic, diabetic.
- Others : toxic, alimentary, polyneuropathy of pregnant women.
Myopathies
Myopathies manifest slight muscle weakness. The symptom gradually increases, accompanied by muscle atrophy, dysbasia by the type of paretic gait (usually duck). The disorders are symmetrical, the hips are more affected, which makes the lower legs look hypertrophied compared to the reduced upper limbs. Flaccid paralysis gradually gets worse.
Other reasons
Flaccid lower paresis with the formation of a paretic gait is detected in pathologies such as:
- Neurosarcoidosis. manifestation of systemic sarcoidosis. The symptom may be due to damage to the lower parts of the spinal cord with the development of radiculomyelopathy, involvement of peripheral nerves by the type of polyneuropathy.
- Neuroacanthocytosis. At the initial stages, mental disorders, hyperkinesis are detected. Subsequently, the hyperkinetic syndrome is replaced by manifestations of parkinsonism. Most patients develop progressive polyneuropathy.
- Polio. Violations occur on the 3rd-6th day of the paralytic form of the disease, asymmetrical, uneven, affecting mainly the proximal muscle groups. In the long-term period, functions are partially restored while maintaining residual effects: paretic gait, muscle atrophy, contractures, deformities, shortening of the limbs.
Diagnostics
The cause of paretic gait is established by a neurologist. The specialist collects complaints and anamnesis of life, finds out the time and circumstances of the onset of symptoms, the dynamics of the development of the disease. To clarify the pathology that provoked dysbasia, the following are prescribed:
- Neurological examination . During the examination, unilateral or bilateral muscle atrophy, a decrease or absence of reflexes in the affected area are revealed. Muscle strength is reduced. Accompanying sensory disturbances are often found.
- Electrophysiological Methods . Electromyography, electroneurography. electroneuromyography makes it possible to establish the level of damage (central or peripheral), to conduct differential diagnostics with the involvement of muscles, axons and neurons, to determine the extent of damage (complete or incomplete), the degree of compression.
- Nerve ultrasound. It is used to assess the thickness, structure and course of peripheral nerve trunks in mononeuropathies. It allows diagnosing traumatic injuries, inflammatory processes, structural anomalies, and detecting pathological changes in nearby tissues.
- Radiography. X-ray examination of the lumbar vertebrae, coccyx and sacrum with cauda syndrome is prescribed to detect injuries, deformities, degenerative and inflammatory changes, damage to bone structures by metastases and primary tumors. In case of nerve injuries due to fractures and dislocations, images of the lower leg, thigh, and knee joint are taken.
- Neuroimaging . CT and MRI of the brain are recommended for neuroacanthocytosis and neurosarcoidosis, MRI and CT of the spinal cord - for neurosarcoidosis, cauda equina syndrome. Possible expansion of the ventricles, thickening of the meninges, stenosis of the spinal canal, hernia, tumors, neoplasms, changes in bone tissue.
- Laboratory tests . Neurosarcoidosis, spinal neoplasia, myopathies are confirmed by histological examination. To clarify the cause of polyneuropathies, tests for antibodies, tests to assess the functions of the kidneys and liver, and the detection of diabetes mellitus are carried out. With neuroacanthocytosis, genetic diagnosis is required, with poliomyelitis, tests to determine the virus.
Therapeutic exercise for paresis of the legs
Treatment
Conservative therapy
The program for the treatment of diseases accompanied by paretic gait includes pathogenetic and symptomatic components, is carried out using drug and non-drug methods. Therapeutic tactics is determined by the nature of the pathology:
- Cauda syndrome . Patients are prescribed analgesics, muscle relaxants, glucocorticosteroids, vascular, neurometabolic drugs. With intense pain, blockades with corticosteroids are performed. In case of violation of pelvic functions, cleansing enemas, bladder catheterization may be indicated.
- Nerve damage . With signs of inflammation, NSAIDs, glucocorticosteroids are recommended. Vitamin preparations are effective to stimulate regeneration. Severe neuropathic pain is eliminated by therapeutic blockades, the use of anticonvulsants.
- Polyneuropathies . With hereditary polyneuropathies, symptomatic treatment is carried out using vitamins, neurotrophic agents. Hormones, human immunoglobulin, membrane plasmapheresis are effective in CIDP. Patients with diabetes need correction of insulin therapy.
- Myopathies . Pathogenetic therapy has not been developed. To improve metabolic processes in the muscles, vitamins, amino acids, anabolic steroids, anticholinesterase agents, potassium and calcium are prescribed several times a year.
The general principle of the treatment of paretic gait of any etiology is the active use of exercise therapy and physiotherapy to improve the condition of the affected muscles and nervous tissue. Kinesiotherapy can be active, passive, with the use of mechanical means. Physiotherapeutic techniques include drug electrophoresis, UHF, amplipulse therapy.
Patients are recommended massage, reflexology. Electrical stimulation is often effective. The restoration of muscle strength and the formation of new motor patterns allows at least partially compensating for paretic gait, expanding the ability to move independently.
Surgery
Taking into account the characteristics of the disease, the following operations are indicated:
- Cauda syndrome : removal of hematomas and neoplasms, various options for discectomy, expansion of the spinal canal by laminectomy, stabilization of the vertebrae.
- Nerve injuries : nerve suture, neurolysis, nerve decompression or plasty, neurotization, tendon-muscle complex grafting to improve limb function.
- Poliomyelitis : redressation of contractures, arthrodesis, tenodesis, osteotomy and resection of bones in deformities, surgical elimination of scoliosis.