Physiotherapy for higher-level gait disorders associated with cerebral multi-infarcts

Abstract

Patients with cerebral multi-infarct states (CMIS) may sometimes have severe gait impairments in the absence of obvious neurological deficits. In these higher-level gait disorders or gait apraxia, there may be prominent features of gait initiation failure, shuffling, freezing, difficulty making turns and disequilibrium. The detailed clinical features of these gaits have recently been described by Nutt, Marsden and Thompson (1993). The standard approach to these disorders is physiotherapist-administered gait re-training. The elements of such treatments, however, have not been clearly documented, nor has their relationship to the disordered gait parameters been clearly defined. This is an essential precursor to developing and evaluating rational therapies. The present paper addresses these problems by standardising the interventions currently used by physiotherapists for broadly similar disorders and combining them into an overall treatment schedule which can be used with this heterogeneous group of patients. A method is also proposed for recording this treatment. This schedule forms a modular approach to physiotherapy under three headings: (a) physiotherapy interventions for gait initiation failure and turning; (b) physiotherapy interventions to improve postural alignment and enhance balance reactions; and (c) physiotherapy interventions aimed at specific components of higher-level disordered gait in CMIS patients. This treatment schedule will clearly require evaluation in randomised controlled trials.