F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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in the muscles and joints of the hips, legs and feet interferes with his stepping move
ments, which become irregular, and the feet are not properly placed on the ground. His
unsteadiness, due to loss of postural sensibility in the trunk, is particularly obvious
in turning movements.
Physiotherapy of the ataxic gait is based on the pioneer work of Frenkel-Heyden
(1900) on the compensatory training in tabes dorsalis, and spinal specialists as well as
physiotherapists should be fully familiar with the details of his technique of compensating
for the loss of postural sensibility under visual influence. Here again, as described in the
foregoing section on the spastic gait, walking exercises in front of a mirror are indis
pensable. Patients with this type of incomplete spinal cord or cauda equina lesions will
usually be able to walk on one, or in more severe cases, on two sticks. It may be noted
that in combined pyramidal and posterior column lesions, as is the case in multiple
sclerosis and combined degeneration of the cord in pernicious anaemia, the patient is
much worse in the dark, as he has great difficulty in controlling his spastic legs and feet.
The swaying-shambling gait.
This type of gait is the result of unilateral or bilateral paralysis
of the gluteal muscles in cauda equina lesions or polio. The essential features of the
abnormality of movement patterns in this condition differ, depending on whether the
paralysis affects the gluteus maximus or medius.
The gluteus maximus gait.
The characteristic feature is the backward thrust of the trunk,
causing the line of gravity to fall behind the centre of the hip joints, and thus acting as an
extension force to prevent jack-knifing of the hip joints. The gravity is balanced by the
tension of the ilio-femoral ligament. The backward swaying gives the gait a clumsy
appearance, and difficulties arise, especially on fast walking as the steps are shortened
due to the backward swaying. The task of the physiotherapist is to train the patient to
raise himself from hip-flexion to the upright position in parallel bars and later on sticks
with the aid of trick movements. As long as biceps and quadriceps are strong, the para
lysis of the gluteus maximus can be compensated. However, with additional weakness
or paralysis of the quadriceps, walking without long calipers and short corsets stabilizing
the hips is impossible. Furthermore, flexion contractures of the hips as a result of the
gluteus maximus paralysis have to be counteracted by early hip extension exercises.
The gluteus medius gait.
The characteristic feature is sideways swaying, producing a
shambling type ofgait. This muscle normally abducts the leg and fixes the pelvis by secur
ing the rim of the pelvis against the trochanter. Moreover, this muscle also rotates
the leg inwards. Therefore, unilateral paralysis of this muscle results in considerable
deformity of hip and leg. The pelvis drops and the leg on the side of the paralysis
assumes, during the swinging phase of gait, an adductory position, combined with outward
rotation of the foot. The abnormal movement pattern during walking is an alternating
shift of the body to the sound side during the swinging phase of the leg and to the
affected side during the supporting phase of the involved limb. In bilateral paralysis of
the gluteus medius, the waddling gait is greatly increased and resembles that of a con
genital dislocation of the hip. The gluteus medius gait can be greatly improved by long
