Gait analysis patterns and rehabilitative interventions to improve gait in persons with hereditary spastic paraplegia: a systematic review and meta-analysis

Abstract

Background: Hereditary spastic paraplegias (HSPs) are a group of inheritance diseases resulting in gait abnormalities, which may be detected using instrumented gait analysis. The aim of this systematic review was 2-fold: to identify specific gait analysis patterns and interventions improving gait in HSP subjects.

Methods: A systematic review was conducted in PubMed, Cochrane Library, REHABDATA, and PEDro databases, in accordance with reporting guidelines of PRISMA statement and Cochrane's recommendation. The review protocol was recorded on the PROSPERO register. Patients with pure and complicated HSP of any age were included. All types of studies were included. Risk of bias, quality assessment, and meta-analysis were performed.

Results: Forty-two studies were included: 19 were related to gait analysis patterns, and 24 were intervention studies. The latter ones were limited to adults. HSP gait patterns were similar to cerebral palsy in younger subjects and stroke in adults. Knee hyperextension, reduced range of motion at knee, ankle, and hip, reduced foot lift, and increased rapid trunk and arm movements were reported. Botulinum injections reduced spasticity but uncovered weakness and improved gait velocity at follow-up. Weak evidence supported intrathecal baclofen, active intensive physical therapy (i.e., robot-assisted gait training, functional exercises, and hydrotherapy), and functional electrical stimulation. Some improvements but adverse events were reported after transcranial magnetic stimulation, transcutaneous spinal direct current stimulation, and spinal cord stimulation implant.

Conclusion: Knee hyperextension, non-sagittal pelvic movements, and reduced ROM at the knee, ankle, and hip represent the most peculiar patterns in HSP, compared to diplegic cerebral palsy and stroke. Botulinum improved comfortable gait velocity after 2 months. Nonetheless, interventions reducing spasticity might result in ineffective functional outcomes unveiling weakness. Intensive active physical therapy and FES might improve gait velocity in the very short term.

Keywords: botulinum toxins; gait analysis; gait disorders; physical therapy modalities; rehabilitation; spastic paraparesis; spasticity; walking.

Figure 1

PRISMA flow diagram.

Figure 2

Risk of bias of gait analysis pattern studies: ROBINS-I plot.

Figure 3

Risk of bias of RCT intervention studies: ROB2 plot.

Figure 4

Mean estimates obtained from the meta-analyses relative to Maximal and Comfortable Walking Velocity, SPRS, and TUG, for each examined time period. The error bars represent the standard errors of the estimates of the individual means from the meta-analysis models.

Figure 5

Forest plot (A) and funnel plot (B) for meta-analysis relative to Maximal Gait Velocity t₁ vs. t₀; Forest plot (C) and funnel plot (D) for meta-analysis relative to Maximal Gait Velocity t₂ vs. t₀; Forest plot (E) and funnel plot (F) for meta-analysis relative to Maximal Gait Velocity t₂ vs. t₁.

Figure 6

Forest plot (A) and funnel plot (B) for meta-analysis relative to Comfortable Gait Velocity t₁ vs. t₀; Forest plot (C) and funnel plot (D) for meta-analysis relative to Comfortable Gait Velocity t₂ vs. t₀; Forest plot (E) and funnel plot (F) for meta-analysis relative to Comfortable Gait Velocity t₂ vs. t₁.

Figure 7

Forest plot (A) and funnel plot (B) for meta-analysis relative to SPRS t₁ vs. t₀.

Figure 8

Forest plot (A) and funnel plot (B) for meta-analysis relative to TUG t₁ vs. t₀; Forest plot (C) and funnel plot (D) for meta-analysis relative to TUG t₂ vs. t₀; Forest plot (E) and funnel plot (F) for meta-analysis relative to TUG t₂ vs. t₁.