1. Gait disorders

2. Normal gait • The Gait cycle • Comprised of swing and stance phases • A stride is one full gait cycle • Stance • Starts with heel striking the ground and ends with pushing off via plantar flexion • Swing • Starts when toes lift off the ground and ends with the heel strike

3. Examination of gait • Ensure patient’s legs are clearly visible • Ask the patient to walk normally for a few metres then back • Ask the patient to walk heel-to-toe (cerebellar lesion) • Ask the patient to walk on their heels (Foot drop caused by L4/5 lesion) • Ask the patient to walk on their toes (S1 lesion) • Romberg’s test – Ask patient to stand with feet together then close their eyes, compare the steadiness in both • Unsteadiness with eyes open shows cerebellar dysfunction • Unsteadiness after eye closure shows proprioceptive loss

4. Types of gait and their sources • Psychogenic or psychiatric – Variable • Cerebral – Cautious, Parkinsonian, ataxic, spastic, magnetic • Basal ganglia – Parkinsonism • Thalamus – ataxia • Cerebellum – ataxia • Brainstem – ataxia • Frontal lobe - apraxia • Spinal cord – spasticity or scissoring • Peripheral nerve (proprioception, vestibular, visual) – sensory ataxia, cautious • NMJ – waddling • Muscle - waddling

5. Causes of ataxia • Malabsorption syndromes leading to Vitamin E deficiency • Hypothyroidism • Aminoacidopatis, leukodystrophy • Alcohol • Lyme disease • Legionella • Sensory ataxia: posterior column spinal disorder (loss of proprioceptive sense), +ve Romberg’s, caused by diabetic neuropathy and Vit B12 deficiency

6. Cerebellar ataxia • Broad-based gait with posture erect but feet separated • Jerky, unsure steps varying in size • Patient staggers to affected side if there is a unilateral cerebellar lesion • Heel-to-toe walking is impaired • Turning can cause instability • Trouble starting a balance movement: rising off a chair or starting to stand up straight

7. Apraxic gait • Bilateral frontal lobe disease with the inability to plan and execute sequential movements • Wide-based, short strides, shuffling • Difficulty with beginning walking and turns • Strength is normal • Feet appear glued to the floor when erect but move normally when supine • Causes: vascular disease, communicating hydrocephalus

8. Hemiparetic gait • Residual sign of stroke • Abnormal posture of limbs produced by spasticity: leg swung in lateral arc Paraparetic gait • Caused by spinal cord disease or cerebral palsy • Both legs move in a slow and stiff manner with circular movements (scissoring gait)

9. Steppage gait • Due to foot drop (weakness of dorsiflexion) • Unilateral weakness: L5 radiculopathy, sciatic or peroneal neuropathy • Bilateral: distal polyneuropathy or lumbosacralpolyradiculopathy • Leg is lifted high above the ground to keep the toes high

10. Waddling gait • Caused by proximal limb weakness most often from myopathy, NMJ disease or proximal symmetric muscular atrophy • Trunk and pelvic muscle weakness results in excessive pelvic sway during movement (weakness of hip flexion)

11. Parkinsonian gait • Forward stoop, with modest flexion of hips and knees • Short rapid steps (shuffling gait) • Difficulty with gait initiation and turning • Upper body gradually leans further ahead of feet

12. Choreic gait • Intermittent irregular movement that disrupts smooth flow of normal gait (pelvic lurch)

13. Investigations • Imaging • MRI brain to see any cerebral lesions, normal pressure hydrocephalus, subdural haematoma, cerebellar atrophy, white matter disease • MRI spine to see spinals tenosis • Leg X-rays to see fractures • Lumbar puncture • Raised WCC or protein can indicate syhpillis infection (demyelination of nerves of the dorsal column) • Blood tests • Electrolytes: imbalances can impair motor function and gait • LFTs: sense of balance is particularly imapired in patients with chronic renal disease and those with hepatic failure • Toxic screen/drug levels • Testing for syphillis • BSL: diabetic neuropathy • Vit B12 – peripheral neuropathy

14. Treatment • Treat the cause • Cease drugs that worsen gait disorders • Muscarinic agonists • Anti-cholinesterases • Neuroleptics

15. Non-pharm treatment of gait disorders • Psychiatric counselling • Education • Physiotherapy • Modification of home to prevent falls • Canes: widen a person’s base of support • Crutches: increase the base of support and improve lateral stability and can be used for full weight bearing • Walking frame: improves balance by increasing patient’s base of support and enhancing lateral stability • Disadvantages • Difficulty manoeuvring through doorways and up stairs • Reduction in normal arm swing • Poor posture with abnormal flexion of the back

16. Consequences and complications • Falls • Injuries sustained in a fall are a major cause of morbidity and a major reason for hospital admission • Physical disability • Social impact: restriction of daily functioning, loss of independence, decreased quality of life