Advanced Outcomes: Lower Limbs

Project leads: Björn Zörner, MD, Marc Bolliger, PhD, Armin Curt, Prof. Dr., Spinal Cord Injury Center, Balgrist University Hospital, Zurich

Individual walking patterns can vary considerably between healthy subjects and depend on biological factors
(age, sex) as well as mood and environment. However, principal aspects of “normal gait” comprising smooth,
precise, stable, symmetric, rhythmic, coordinated, economical and adaptable movements are achieved by an
optimal interaction between the nervous system and musculoskeletal structures. Within the CNS different
neuroanatomical subsystems such as the sensorimotor cortex, basal ganglia, cerebellum, brain stem and spinal
cord mediate efficient human locomotion. These neuroanatomical subsystems provide specific inputs within a
complex hierarchical organization [Ivanenko 2009] while disturbances in these structures lead to gait impairments.

Gait disorders are among the most frequent symptoms in neurology
with serious consequences including isolation, economic disadvantages
and increased risk of falls and death [Wilson 2002, Stolze 2004, 2005,
2008]. In neurological inpatients, gait disorder is diagnosed in more than
60% of the individuals due to, e.g., stroke, Parkinson’s disease, multiple
sclerosis and spinal disorders [Stolze 2005]. However, walking deficits
after damage to a particular neuroanatomical system are often variable
and unspecific, thereby hindering correct diagnosis and optimal
treatment [Stolze, 2001, 2008]. In addition, outcome measures are often
inappropriate for the identification of the underlying pathophysiology and
affected neuroanatomy.

The most commonly used scores and clinical outcome measures for the evaluation of walking function are often
subjective or have a low sensitivity especially with regards to improvements or compensatory strategies. For the
assessment of walking ability in humans, 3-D gait analysis combined with selected clinical tests is considered
the gold standard [Cameron & Wagner, 2011]. In addition, animal studies demonstrated that different forms of
locomotor behaviour such as overground walking, climbing and swimming differ with regards to the motor pattern,
sensory input and, most importantly, the participating CNS networks and, therefore, might be differentially affected
by a given CNS injury. Hence, a comprehensive analysis of gait should also include different types of ambulation
to link neuroanatomical changes to functional outcome [Zörner 2010]. However, comparative studies using a
multimodal gait analysis approach in neurological diseases are rare [Stolze, 2008].


Ivanenko YP, Poppele RE, Lacquaniti F, Distributed neural networks for controlling human locomotion: lessons
from normal and SCI subjects. Brain Res Bull. 2009 Jan 15;78(1):13-21.
Wilson RS, Schneider JA, Beckett LA, Evans DA, Bennett DA, Progression of gait disorder and rigidity and risk of
death in older persons. Neurology. 2002 Jun 25;58(12):1815-9.
Stolze H, Klebe S, Zechlin C, Baecker C, Friege L, Deuschl G, Falls in frequent neurological diseases--prevalence,
risk factors and aetiology. J Neurol. 2004 Jan;251(1):79-84.
Stolze H, Klebe S, Baecker C, Zechlin C, Friege L, Pohle S, Deuschl G, Prevalence of gait disorders in hospitalized
neurological patients. Mov Disord. 2005 Jan;20(1):89-94.
Stolze H, Vieregge P, Deuschl G, Gait disturbances in neurology. Nervenarzt. 2008 Apr;79(4):485-99.
Stolze H, Kuhtz-Buschbeck JP, Drücke H, Jöhnk K, Illert M, Deuschl G, Comparative analysis of the gait disorder
of normal pressure hydrocephalus and Parkinson's disease. J Neurol Neurosurg Psychiatry. 2001 Mar;70(3):289-97.
Cameron MH, Wagner JM, Gait abnormalities in multiple sclerosis: pathogenesis, evaluation, and advances in
treatment. Curr Neurol Neurosci Rep. 2011 Oct;11(5):507-15.
Zörner B, Filli L, Starkey ML, Gonzenbach R, Kasper H, Röthlisberger M, Bolliger M, Schwab ME, Profiling
loco-motor recovery: comprehensive quantification of impairments after CNS damage in rodents. Nat Methods.
2010 Sep;7(9):701-8.