Gait is a highly co-ordinated action. It requires the integration of sensory and motor information and the functioning of many separate areas. It needs correct sensory function, muscle strength, propriception, balance, and a properly functioning CNS (vestibular system and cerebellum).
By observing gait you can learn a lot about the functioning of these areas.
- Take a detailed history with any patient that has walking difficulties.
- Observe the patient’s gait. Ideally you should observe it as they walk in the room – they may be less self conscious at this time.
- Not if the gait is symmetrical or asymmetrical.
- Pace size
- Posture and arm swing
- Foot separation (left from right)
- Co-ordination of legs
- Knee lifting (does one lift higher than the other)
- Check if the patient is in pain
- Look for orthopaedic problems.
- If the gait appears normal, you should ask the subject to ‘heel-toe’ walk and check if they are steady.
- If it is abnormal, you should take the observations you have made and try and match it to:
Frontal lobe damage
The patient has problems integrating cortical information. This can be caused by hydrocephalus or cerebrovascular disease.
The gait will have short steps and a broad base. It is like the patient has forgotten how to walk. Do not confuse with ataxic gait.
Muscle/hip disease (Myopathic gait)
The patient will walk with their hip forwards and waddle. The patient has trouble stabilising their hips as they walk, and so the hips will tilt downwards on the side of the non-weight bearing leg. The hips will therefore move up and down as the patient walks. The patient will shift their weight over the weight bearing leg so that the shoulders will drop on the opposite side that the hips drop!
- May be bilateral. In which case, they walk ‘bow-legged’.
- Almost all proximal weakness is due to muscle (and not joint) weakness.
Crossing over/ scissoring gait
Spasticity* (Diplegic gait) – or spastic paraparetic gait.
This has its effect bilaterally. The lower extremities are particularly affected.adductors are over active (spacicity) It is often caused by a lesion in the periventricular region. The lower extremities are affected more than the upper extremities, due to the arrangement of the corticospinal axons - the one to the legs are closer to the periventricular region.
The toes point inwards and the knees are bent. Pateint leans over forwards slightly. Each time they take a step, the leg swings outwards then inwards – circumduction. Steps are short. They stand on their toes, and drag their toes along the floor.
* This is a condition where some of the muscles of the body are continually contracted.
Mainly caused by spinal cord lesion.
Unilateral UMN lesion.
Often caused by MS or stroke. Similar to diplegic gait, but only seen in one leg. The other leg walks normally. The patient will have a flexed arm and extended leg on the side of the lesion (antigravity reflexes). To move the affected lower limb the patient has to circumduct it.
Caused by hemisphere problem – controlateral to the affected side.
They may also have language problems
Basal Ganglia Defect
Slow and shuffling gate with small paces. Patient bent over forwards. There is usually reduced arm swing that is often unilateral. The hands will often tremor and this may increase upon walking. Turning is very sow and difficult. Marche a petit pas – the march of the little steps – this often usually refers to a gait will small steps and swinging arms, not usually Parkinson’s.
The patient’s face may appear expressionless / miserable.
- Parkinson’s is always an a-symmetric disorder! It always starts on one side, and then, typically after 3-5 years it spread to the other side.
Broad based, compensatory gait. Patients swing from side to side and may fall. They often appear drunk. There are big lurching steps from side to side and a lot of stumbling. This gait is also often seen in patients with severe propriceptive damage. Lots of movement of the trunk.
- Use Romberg’s test to differentiates cerebellar disorder from sensory disorder.
- Ask the patient to put their feet together, close their eyes, and hold their hands out in front of them. If the patient is more unsteady with their eyes closed than with them open, it is a positive Romberg’s, and there is sensory (propriceptive disorder). If they are equally unsteady with eyes open and eyes closed, they are Romberg’s negative.
- Almost all sensory loss is due to lower sensory neuron loss – i.e. peripheral neuropathy.
- Other features of cerebellar disease:
- Speech problems
- May sound drunk
- May lose normal flow of speech (eg. Hip.o . pot .o .mus.)
- Phasic shift
High Stepping / Drop Foot Gait
Lesion of peripheral nerves (both bilateral and unilateral) Also known as Neuropathic gait.
The patient lifts the knee high and slaps down the foot upon walking. Usually seen in diseases effecting nerves. The extremities are most affected. The dorsiflexors are weak, so the patient has to life the knee high to avoid dragging the toe. It is almost always a LMN disorder.
- Muscle disorders are more likely to be unilateral, but nerve disorders (e.g. compression, lesion) can also be unilateral.
- Muscle disorders are more commonly proximal than distal.
- MND is a common cause
- Wasting of lower legs?
Cerebellar diseases are the main cause of clumsyness, ataxia and poor co-ordination. Cerebellar syndromes are associated with many diseases, including:
- Structural Lesions:
- Toxins – particularly alcohol, anticonvulsants and chemotherapy agents
- Inherited disorders
This examines the proprioceptive and balance pathways and it should always be used when assessing gait.
Ask the patient to stand straight with feet together and eyes open. The patient should not sway. Then ask them to close their eyes. If the proprioceptive and visual pathways are intact then the patient will not sway. If the patient starts to sway, we say it is Romberg’s test positive.
- If the patient sways with their eyes both open and closed, then this is due to a cerebellar lesion – a cerebellar lesion can’t be compensated for by input from other systems, but a vestibular or proprioceptive defect can be.
- If the patient sway only when eyes are closed –then this is a vestibular or proprioceptive defect. With eyes open the patient is able to compensate for their poor balance using other stimuli (i.e. seeing, rather than sensing where the limbs are in space), but with the eyes closed, this compensation is lost.
Other disorders that may affect gait
PSP – pseudobulbar palsy
Gravelly voice, very rigid, erect and stiff posture. Patient has difficulty turning. Often looking a bit menacing – they don’t blink very often. Usually about 70 years of age.
In young men, a similar gait may be caused by ankylosing spondylitis.
Akaphysia. Dystonias. Very fidgety. Involuntary movements. Causes:
- Wilson’s disease