Gait Flashcards
(17 cards)
disorders of gait
Frailty, fatigue, arthritis, orthopaedic deformity
gait d/o by etiology
sensory deficit, myelopathy, multiple infarcts, Parkinsonism, cerebellar degeneration, hydrocephalus, toxic/metabilic causes, psychogenic causes, other
spastic gait/stiff legged gait
stiffness in the legs, imbalance of muscle tone, tendency to circumduct and scuff the feet.
compromise of corticospinal command and overactivity of spinal reflexes. UMN signs on exam.
cerebral or spinal in origin.
Ddx:
- myelopathy from Cervical spondylosis, chronic progressive myelopathy - family hx, genetic testing, imaging
- demyelinating disease
- trauma
- tropical spastic paraparesis > HTLV1 - Caribbean and South America - imaging r/o vascular lesion/structural lesion
- cerebral spasticity - asymmetry common, upper extremity involved, dysarthria > causes: stroke, MS, cerebral palsy
- dystonia: sustained muscle contractions, repetitive twisting movements, abnormal posture, genetic basis. plantar flexion, inversion
- stiff person syndrome: autoimmune - exaggerated lordosis of lumbar spine, fixed posture
Parkinsonism & freezing gait
stooped posture, shuffling gait, accelerate with walking (festinate) retropulsion, tendency to en bloc, postural instability and fall as disease progress, pill rolling tremor
- Freezing gait: common in neurodegenerative d/o progressive supra nuclear palsy, multiple system atrophy, corticobasal degeneration
> pts with these d/o present with axial stiffness, postural instability, shuffling, freezing gait. falls within 1st year suggest Progressive supra nuclear palsy.
Huntington’s disease: unpredictable choric movements
Tardive dyskinesia-odd stereotypic gait d/o, in antipsychotic, D2 dopamine receptor blocker use
Gait apraxia/Frontal gait disorder
shuffling, freezing gait, imbalance, signs of cerebral dysfunction.
wide based, short stride, shuffling along the floor, difficulty with start and turns. > high-level motor control disorder
most common cause - vascular disease (subcortical small vessel disease) - lesions in frontal deep white matter and centrum ovale.
Binswanger’s disease - ischemic lesions in deep hemisphere white matter, hx- HTN, mental changes, dysarthria, pseudo bulbar affect (emotional disinhibition) increased tone, hyperreflexia in the lower limbs.
communicating hydrocephalus - periventricular white matter change, wide based gait, LP
Cerebellar gait ataxia
wide based, lateral instability of trunk, erratic foot placement, decompensation on balance when attempting to walk on narrow base. difficulty maintaining balance when turning - early feature.
unable to walk tandem heel to toe, sway in narrow base or tandem stance,
causes - stroke, trauma, tumour, neurodegenerative disease, multiple system atrophy, hereditary cerebellar degeneration.
alcholohic cerebellar degeneration - confirm with MRI - cerebellar atrophy
Sensory ataxia
depends on high quality afferent information from visual, vestibular, proprioception. when this information is lost or degraded balance impaired.
sensory ataxia of tabetic neurosyphilis, vitamin B 12 deficiency (large fibre sensory loss in the spinal cord and peripheral nervous system. joint position and vibration sense are diminished in lower limbs. often look down when walking.
neuromuscular disease
distal weakness (Peripheral neuropathy) step height is increased to compensate for foot drop and sole of foot may slap on the floor.
toxic & metabolic d/o
Alcohol
asterexis - renal &hepatic failure
sedative drugs - neuroleptics and long acting benzodiazepines
psychogenic gait d/o
anxiety / phobia - exaggerated caution while walking
disorder of balance
difficulty maintaining posture, standing, walking.
cerebellum and vestibular system organise antigravity responses - to maintain upright posture.
failure of disequilibrium can occur at - cerebellum, vestibular, somatosensory, higher level disequilibrium
vestibular d/o
vertigo, nystagmus, impaired standing balance
cerebellar ataxia
wide based gait - variable velocity - Romberg test +/- , heel-shin abnormal, initiation - normal, tun - unsteady, postural instability +, falls late event
sensory ataxia
narrow base, looks down, slow velocity, stride regular with path deviation, Romberg’s - unsteady, falls, heel-shin +/-, postural instability +++, frequent falls
frontal gait
wide based gait, very slow velocity, short shuffling stride, Romberg +/-, heel - shin - normal, initiation, hesitant, turns, hesitant multistep, postural instability ++++ poor postural synergies rising from chair, falls - frequent
fall patterns
- drop attacks: sudden collapsing fall without LOC, legs gave out - orthostatic hypotension, rare - colloid cysts of 3rd ventricle, intermittent obstruction of foramen of Monro
- toppling falls: some maintain tone in antigravity muscles, fall over like a tree trunk. cerebellar pathology - lean and topple over towards the side of the lesion. vestibular system lesion or its central pathways - lateral pulsion and toppling falls. Progressive supra nuclear palsy - fall backwards.
- gait freezing: Parkinson’s disease and related d/o. feet sticks to floor and centre of mass keeps moving > result in forward fall.
- sensory loss: somatosensory, visual, vestibular deficit. subjective imbalance, apprehension, fear of falling. deficit in joint position, vibration sense.
- weakness and frailty: lacks strength in antigravity muscles, difficulty rising from a chair, tire easily on walking, difficulty maintaining their balance after perturbation. unable to get up after a fall have to rain on floor until help arrives. Reconditioning treatable with resistance strength training, can increase muscle mass and leg strength.
Mx:
orthostatic BP, pulse
raising from chair and walking to be evaluated
improve lighting, installation of gab bars, non slip surfaces.
rehabilitation to improve muscle strength and balance stability
high intensity strength training with weights and machines to improve muscle mass.
Gait examination
make sure patient leg visible
- ask patient to cross hand while sitting and then get up from bed - looking for proximal myopathy
- walk > turn back > walk on heel to toe (exclude cerebellar lesion) > walk on toes (S1 lesion makes it difficult) > walk on heel L4-5 lesion with foot drop will make it difficult)
- Romberg test: ask patient to stand with feet together eyes open then close for 1 minute (positive when unsteadiness increase with eye closure - seen with loss of proprioceptive sensation) - marked unsteadiness with eyes open - seen with severe proprioceptive loss in cerebellar lesions or vestibular dysfunction.
