Key factors in the development of lower limb co-ordination: implications for the acquisition of walking in children with cerebral palsy

PURPOSE: This paper explores differences in walking development between normal children and those with cerebral palsy and discusses their clinical implications. METHOD: A literature review (MEDLINE, RECAL) of walking development in normal children and those with cerebral palsy, including the use of walking aids. RESULTS: Normal neonates display reflexive stepping, at 8 months supported walking and then independent walking emerge at about 12 months. Transition from the wide-based, high stepping gait to narrower base, heel-toe gait with arm swing occurs within 6 months of walking. Gait is mature by 7 years. Children with cerebral palsy have delayed walking. Prognostic factors include retained reflexes, age of head control and of independent sitting. They retain kinematic and muscle activation patterns seen in supported walking. Older children show co-contraction patterns and lose range of motion at leg joints. Walking aids have been studied for energy consumption, but only independent walking patterns are described. Treadmills and partial weight relief have been used for walking training. CONCLUSIONS: Children with cerebral palsy fail to achieve the transition from supported stepping to mature gait patterns. Assessment tools to identify gait maturity need to be developed so that treatment that promotes transitions can be promoted and effectively monitored.