Gait disturbance resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo M.D.

Synonyms and Keywords: disequilibrium, ataxia, spasticity, paresis, hypokinesia, imbalance

Overview

Gait disturbance refers to an impaired sense or absence of balance or equilibrioception that primarily occurs during standing or walking and usually without any cephalic sensations like headache, nausea, and vomiting. It is one among the causes of dizziness and it is typically a more complex category with more continuous symptoms than the other causes of dizziness like presyncope and vertigo.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Intoxications
• Head trauma
• Carbon monoxide poisoning

Common Causes

• Osteoarthritis
• Pelvic girdle pain
• Ataxia

• Hip dysplasia
• Polio
• Multiple sclerosis

• Cerebellar lesions
• Cerebellar degeneration

• Parkinson's disease

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Gait disturbance according to the American Academy of Neurology guidelines:

Gait disturbance

When?

Always with movement (may vary in severity)

Intermittently during movement (may vary in severity and frequency)

Continuous and intermittent disturbances are present at least once

Continuous

Episodic

Mixed

Transient inability to create effective stepping?

Unintentional increase in speed, usually with small steps?

Transient imbalance?

Freezing

Festination

Disequilibrium

Disequilibrium and hypermetria of stance and gait?

Associated with increased postural tone?

Slow or small steps and/or slow or small postural?

Involuntary movements?

Associated with muscle weakness or paralysis?

Static or axial postural deformities?

Secondary to musculoskeletal or central pain?

Present at a higher level?

Difficult to classify the continuous nature of the gait disturbance?

Ataxic

Spastic

Bradykinetic/hypokinetic

Dyskinetic/Choreic/Dystonic

Paretic

Trunkal disturbance

Antalgic

Frontal disturbance

Undetermined

Treatment

Treat the underlying cause.

Do's

• Perform a top-down visual orientation evaluation to assess symmetry, quantity, and quality of arm swing; pelvic rotation; knee motion; pelvic tilt; and lateral trunk shift.
• Perform a bottom-up orientation evaluation to assess ankle, subtalar, midfoot, and hallux motion symmetry, quantity, and quality.
• Perform a thorough evaluation of gait, measuring gait on a level surface, change in gait speed, gait with horizontal head turns, gait with vertical head turns, gait with pivot turn, step over obstacle, gait with narrow base of support, gait with eyes closed, ambulating backwards, and steps.
• Be aware of the patients' surroundings and be always aware for possible falls.
• Three dimensional analysis systems may be used as a tool as it is currently the gold standard for measuring spatiotemporal variables and joint kinematics.
• Innovative pressure measurement technology may provide unique insight on mechanical dysfunctions and gait abnormalities.

Don'ts

• Do not delay brain imaging when TBI is suspected.
• Do not perform walking tests in patients with severe acute gait disturbance.