clinical aproach to gait disorders

CLINICAL APROACH TO GAIT DISORDERS

DR. SUMIT KAMBLEDM SENIOR RESIDENTDEPT. OF NEUROLOGYGMC, KOTA

MODERATORDR. DILIP MAHESHWARIASSOCIATE PROFF. NEUROLOGY

NORMAL GAIT CYCLE

• Single gait cycle or stride is defined:• Period when 1 foot contacts the ground to when that same foot contacts

the ground again• Each stride has 2 phases:

• Stance Phase• Foot in contact with ground

• Swing Phase• Foot not in contact with ground

SUB-DIVISIONS OF SWING PHASE

SUB COMPONENT OF STANCE PHASE

PHYSIOLOGICAL AND BIOMECHANICAL ASPECTS OF GAIT • Posture- based on mechanical musculoskeletal linkages and

neurological control detecting and correcting body sway.

• Postural response1. Automatic righting reflexes keeping head upright on trunk 2. Supporting reactions controlling antigravity muscle tone 3. Anticipatory (feed-forward) postural reflexes occurring

before limb movement4. Reactive (feedback) postural adjustments counteracting body

perturbations during movement.

• Initiation of gait - heralded by a series of shifts in the center of pressure beneath the feet—first posteriorly, then laterally toward the stepping foot, and finally toward the stance foot to allow the stepping foot to swing forward.

• Center of Gravity (CG)• Midway between the hips• Few cm in front of S2

ANATOMICAL ASPECTS OF GAIT

• Neuroanatomical structures responsible for equilibrium and locomotion -

1. Brainstem (subthalamic, midbrain)2. Cerebellar locomotor regions project through descending reticulospinal pathways from the pontomedullary reticular formation into ventromedial spinal cord.

• Prefrontal cortex - modulates midbrain and cerebellar locomotor regions

• Parietal cortex - integrates sensory inputs indicating position and orientation in space, the relationship to gravitational forces, the speed and direction of movement.

• Cerebellum - modulates the rate, rhythm, amplitude, and force of stepping.

EPIDEMIOLOGY AND IMPACT• Gait disorders affect up to 15% of people > 60 years of age• >80% who are >85 years.• Patients hospitalized with neurologic disorders, 60% have gait

disturbance.

1. Sensory deficits, 18%2. Myelopathy, 17%3. Multiple infarcts, 15%4. Unknown cause, 14%5. Parkinsonism, 12%

6. Cerebellar degeneration, 7%7. Hydrocephalus, 7%8. Miscellaneous, 5%9. Psychogenic, 3 %10.Toxic/metabolic, 2.5%

ABNORMAL GAIT

1. Pain2. Impaired Joint Mobility (arthritis, contractures)3. Muscle weakness (Myopathy, neuropathy)4. Spasticity (stroke, cord lesion)5. Sensory/balance deficit (neuropathy, stroke)6. Impaired central processing (dementia, stroke, delirium,

drugs)

HISTORY: COMMON SYMPTOMS AND ASSOCIATIONS

WEAKNESS

• Hemiplegia or foot drop caused by weakness of ankle dorsiflexion - Catching or scraping a toe on the ground and a tendency to trip

• Weakness of knee extension - sensation that the legs will give way while standing or walking down stairs.

• Weakness of ankle plantar flexion - interferes with ability to stride forward, resulting in a shallow stepped gait.

• Proximal muscle weakness- Difficulty in climbing stairs or rising from a seated position.

• Axial muscle weakness - interfere with truncal mobility

SLOWNESS• Slowness of walking 1. Normal reaction to unstable or slippery surfaces2. Elderly3. Those who feel their balance is less secure because of any

musculoskeletal or neurological disorder4. Parkinson disease (PD) and other basal ganglia diseases

STIFFNESS• Presenting symptoms of a spastic paraparesis or hemiparesis. • Drag their legs, catch the toes of their shoes on any surface

irregularity and their legs suddenly give way, causing stumbling and falls.

• Leg muscle tone in some upper motor neuron syndromes and dystonia may be normal when the patient is examined in the supine position but is increased during walking.

• In childhood, an action dystonia of the foot is a common initial symptom of primary dystonia with stiffness, inversion, and plantar flexion of the foot and walking on the toes only becoming evident after walking or running.

• Patients with dopa-responsive dystonia typically develop symptoms in the afternoon (“diurnal fluctuation”).

IMBALANCE 1. Cerebellar ataxia 2. Sensory ataxia 3. Vestibulopathy4. Vascular lesions of thalamus, and basal ganglia.5. Wide-based unsteady gait is also feature of frontal lobe

diseases 6. Imbalance in subcortical cerebrovascular disease and basal

ganglia disorders manifests when turning while walking, stepping backwards, bending over to pick up something, or performing several tasks simultaneously,

FALLS1. Collapsing falls(Tone is lost )- syncope or seizures.2. Toppling falls (Muscle tone is retained) - impaired static and

dynamic postural responses that control body equilibrium during standing and walking.

Toppling falls (Muscle tone is retained)• Tripping - foot drop or shallow steps, may also be a

consequence of carelessness secondary to inattention, dementia, or poor vision.

• Proximal muscle weakness- legs giving way and falls. • Unsteadiness and poor balance• Impairment of postural responses.• Spontaneous falls, especially backward, are an important clue to

diagnoses such as multiple system atrophy and progressive supranuclear palsy

SENSORY SYMPTOMS AND PAIN• Distribution of any accompanying sensory complaints provides

clue to the site of the lesion producing walking difficulties.

• Radicular pain or paresthesias, • Sensations of tight bands around the trunk• Distal symmetrical paresthesias of the limbs• Neurogenic claudication of the cauda equina• Vascular intermittent claudication• Skeletal pain due to degenerative joint disease

URINARY INCONTINENCE• Spinal cord lesion

• Parasagittal cerebral lesions such as frontal lobe tumors (parasagittal meningioma), frontal lobe infarction caused by anterior cerebral artery occlusion, and hydrocephalus.

• Urinary urgency and urge incontinence are also common in parkinsonism and subcortical white-matter ischemia.

COGNITIVE CHANGES

• Slowing of gait may be a marker of impending cognitive impairment and dementia.

• Executive dysfunction including inattention, impaired multitasking, and set switching may predict later development of falls in older adults without dementia or impaired mobility

• Dementia with disinhibition and impulsivity are associated with reckless gait problems and falls.

EXAMINATION OF POSTURE AND WALKING

ARISING TO STAND FROM SEATED POSITION1. Proximal muscle strength 2. Organization of truncal and limb movements 3. Stability 4. Stance base

STANDING 5. Posture 6. Stance base 7. Body sway 8. Romberg test 9. Postural reflexes (pull test)

WALKING 1. Initiation of stepping 2. Speed 3. Stance base 4. Step length 5. Cadence 6. Step trajectory (shallow, shuffling, or high stepping) 7. Associated trunk and arm movements 8. Trunk posture

TURNING WHILE WALKING 9. Number of steps to turn 10. Stabilizing steps 11. En bloc (truncal and limb movement) 12. Freezing

OTHER MANEUVERS 13. Tandem walking 14. Walking backwards 15. Running Walking on toes, heels

CLASSIFICATION OF GAIT PATTERNS

A. MYOPATHIC GAIT (waddling gait)

• Weakness of proximal leg and hip-girdle muscles interferes with stabilizing the pelvis and legs on the trunk.

• Exaggerated rotation of the pelvis with each step and a waddling gait.

• Hips are slightly flexed as a result of weakness of hip extension, and an exaggerated lumbar lordosis occurs.

• Gower’s sign.

Waddling Gait (online-video-cutter.com).mp4

NEUROGENIC WEAKNESS (STEPPAGE GAIT)

• Seen in patients with foot drop (weakness of foot dorsiflexion), • Lift the leg high enough during walking so that the foot does

not drag on the floor.

• Unilateral- Peroneal and Sciatic nerve palsy and L5 radiculopathy.

• Bilateral - amyotrophic lateral sclerosis, Charcot-Marie-Tooth disease and other peripheral neuropathies and scapuloperoneal syndromes.

• Weakness of ankle plantar flexion produces a shallow stepped gait.

• Femoral neuropathy produces weakness of knee extension and buckling of the knee when walking or standing. This may first be evident when walking down stairs.

High steppage gait.mp4

SENSORY ATAXIA (SLAPPING/STAPMING GAIT)

• Adopt a wide base and advance cautiously, taking slow steps under visual guidance.

• Feet are thrust forward with variable direction and height.• Sole of the foot strikes floor forcibly with a slapping sound

(slapping gait). • Walking on uneven surfaces and dark is particularly difficult.• Romberg test. • Large-diameter peripheral neuropathies, posterior root or dorsal

root ganglionopathies, and dorsal column lesions.

VESTIBULAR IMBALANCE AND GAIT

• Acute peripheral vestibular disorders result in leaning and unsteady veering to the side of the lesion

• Unsteadiness and veering while running may be less evident than when walking in acute vestibulopathy.

• In chronic vestibular failure, gait may be normal, though unsteadiness can be unmasked during eye closure and rotation of the head from side to side while walking.

SPASTIC HEMIPARETIC GAIT

• Arm is adducted, internally rotated at the shoulder, and flexed at the elbow, with pronation of the forearm and flexion of the wrist and fingers.

• Leg is slightly flexed at the hip and extended at the knee, with plantar flexion and inversion of the foot.

• Swing phase of each step is accomplished by slight lateral flexion of the trunk toward the unaffected side and hyperextension of the hip on that side to allow slow circumduction of the extended paretic leg as it swings forward from the hip, dragging the foot or catching the toe on the ground beneath.

Abnormal Gait Exam Hemiplegic Gait Demonstration (online-video-cutter.com).mp4

SCISSORS GAIT

• Bilateral spastic paresis of legs

• Legs move slowly and stiffly and the thighs are strongly adducted such that the legs may cross as the patient walks

Scissoring gait in a cerebral palsied child.mp4

CEREBELLAR ATAXIA

• Midline cerebellar structures, vermis, and anterior lobe - loss of truncal balance, increased body sway, dysequilibrium, and gait ataxia.

• Stance- Wide-based • Lurching and staggering quality that is more pronounced when

walking on a narrow base or during heel-to-toe walking, resembling acute alcohol intoxication.

• Anterior lobe atrophy develop a 3-Hz anteroposterior sway of the trunk and a rhythmic truncal and head tremor (titubation) that is superimposed on the gait ataxia.

• Flocculonodular lobe - exhibit multidirectional body sway, dysequilibrium, and severe impairment of body and truncal motion. Standing and even sitting can be impossible, although when lying down, the heel-shin test may appear normal, and upper limb function may be relatively preserved.

• Limb ataxia due to involvement of the cerebellar hemispheres is characterized by a decomposition of normal leg movement. Steps are irregular and variable in timing (dyssynergia), length, and direction (dysmetria).

Cerebellar Gait.mp4

HYPOKINETIC (PARKINSONIAN) GAIT • Posture - stooped, with flexion of the shoulders, neck, trunk,

and knees. • Asymmetrical reduction of arm swing and slowing in gait,

particularly when turning • Start hesitation before breaking into a more normal stepping

pattern with small, shallow steps on a narrow base.• Freezing• Festination. • Retropulsion and propulsion

Freezing of gait (1).mp4

FRONTAL LOBE GAIT DISORDERS

• Cautious gait, a consequence of compensatory adjustments in response to real or perceived disequilibrium

• Isolated gait ignition failure, characterized by difficulty initiating or maintaining locomotion, and caused by lesions in the frontal lobe, white matter connections, or basal ganglia

• Frontal gait disorder(Magnetic gait) characterized by variable base (narrow to wide), decreased foot clearance, short shuffling steps, disequilibrium, and start and turn hesitation, and caused by lesion in the frontal lobe and white matter

Classic NPH Gait Pre-Shunt Surgery.mp4

CHOREIC GAIT • Random movements of chorea are often most noticeable during

walking.

• Superimposition of chorea on the trunk and leg movements of the walking cycle gives the gait a dancing quality owing to the exaggerated motion of the legs and arm swing.

• Chorea can also interrupt the walking pattern, leading to a hesitant gait.

Dancing gait-Gait during chorea (Choreoform gait) (online-video-cutter.com).mp4

DYSTONIC GAIT

• Childhood-onset primary torsion dystonia - sustained abnormal posturing of the foot (typically plantar flexion and inversion) on attempting to run.

• Walking forward or backward or even running backward may be normal at an early stage.

• Early stages - tonic extension of the great toe (striatal toe) when walking.

• Birdlike (peacock) gait - excessive flexion of the hip and knee and plantar flexion of the foot in a during the swing phase.

Jean Abbott - Dopa Responsive Dystonia (online-video-cutter.com).mp4

PSYCHOGENIC GAIT DISORDERS (ATASIA-ABASIA)

• 1. transient fluctuations in posture while walking,• 2. knee buckling without falls,• 3. excessive slowness and hesitancy,• 4. crouched, stooped or other abnormal posture of the trunk,• 5. complex postural adjustments with each step,• 6. exaggerated body sway or excessive body motion especially

brought out by tandem walking, and• 7. trembling, weak legs.

4. Atasia-Abasia - Video Library of Gait Disorders.mp4

NON-NEUROLOGIC CAUSES

1. Visual loss2. Orthopedic disorders3. Rheumatologic disorders4. Pain5. Cardiorespiratory problems

THANK YOU

REFERENCES

• Bradleys Neurology in Clinical Practice 7th edition• DeJongs The Neurological Examination 7th edition• Uptodate. Com• Jacquelin perry, GAIT ANALYSIS normal and pathological

function• Gait Disorders Evaluation and Management Jeffrey M.

Hausdorff