Criteria
Classification of functional motor levels[97]
This traditional classification system is based on the motor level of the lesion as determined by manual muscle strength testing and may be applied to all age groups.
Thoracic: typically do not walk unless in reciprocating gait orthosis; none or minimal leg movement.
Mid lumbar: typically walk short distances, with ankle-foot orthoses (AFOs) or higher braces; walker or crutches used.
Low lumbar: typically walk outdoors; may use walker, crutches, or cane as well as AFOs.
Sacral: typically have few or no limitations in walking, but may need AFOs or supportive shoe inserts.
A more functional classification system that divides patients into 3 groups based on prognosis for ambulation is also used.[98]
Thoracic/high lumbar: characterised by lack of quadriceps strength such that long leg (hip-knee-ankle) bracing is required for household ambulation and a wheelchair is used from an early age for mobility in the community.
Low lumbar: refers to L3 and L4 functional motor levels associated with good quadriceps strength and medial hamstring function, but weak gluteus medius and gluteus maximus function. This results in a Trendelenburg gait that stresses the medial aspect of the knee joint and that is energy inefficient. The use of forearm crutches for a swing-through gait and AFOs are recommended to maintain alignment and to improve functional mobility, and to prevent knee joint arthritis in later years. Community ambulation is possible; the use of a wheelchair is often preferred for longer distances.
High sacral: characterised by a weakness of the intrinsic muscles of the foot with or without a weakness in the ankle plantar flexors, such that there is no discernable gait abnormality. Prognosis for lifelong ambulation is excellent. Those with weak plantar flexors benefit from AFOs but do not generally need to use crutches.
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