Chapter 8: Gait Disturbance

Barbara Scherokman, MD, FAAN, FACP; Patrick C. Alguire, MD, FACP

I. CASE HISTORIES

Case 8-1. A 58-year-old man with a history of hypertension awoke on the day of admission with a moderate global headache and inability to walk due to imbalance. He denies previous difficulty walking, double vision, dizziness, leg weakness, and numbness of his feet. On examination he has a wide-based gait and is unable to tandem walk. The remainder of his examination is normal. 

1. Where would you localize his neurologic problem?
2. What are the likely etiologies?
3. What would be your first step in evaluating this patient?

Case 8-2. A 70-year-old woman presents with difficulty with her balance and several falls over the past six months. This came on gradually and has gotten somewhat worse. She has a history of hypertension and diabetes, which have been treated with medications over the past year. She denies double vision and leg weakness but admits to numbness of both feet that has gradually gotten worse over the past several months. At times she becomes lightheaded when getting up from a seated position. On examination she has evidence of cataracts. She has a slightly wide-based gait, turns on three steps, and is able to tandem walk if she looks at her feet. She has a Romberg sign and a moderate stocking-distribution decrease in pain, vibration, and position sensation. 

1. What part or parts of the nervous system could be implicated in causing her gait disorder?
2. What measures could be taken to help improve her gait?

II. DISORDERS

A normal gait is a very complex and fluid set of movements. The arms move synchronously with the opposite leg, the ankles nearly touch, and the heel strikes first. A normal gait requires the integration of the following systems: visual, vestibular, auditory, cerebellar, basal ganglia, sensory, and muscular. An abnormality in any one of the systems can cause a problem with gait and can lead to falls. Gait disturbance is a very common symptom, and falls due to loss of balance are a major source of morbidity and mortality in older people. Since the gait examination tests many parts of the nervous system, it is an excellent neurologic screening test. Many medications, including antihypertensives, may also contribute to a gait abnormality. Before an abnormal gait can be attributed to a neurologic cause, however, joint stiffness, joint deformity, and pain should be ruled out. 

As in all neurologic disorders, the examination is used to localize the problem in the nervous system, and the time course is then used to narrow down the possible etiologies.  Table 8-1 categorizes etiologies based on localization and time course.

Table 8-1 Neurologic Disorders Causing Gait Disturbance

 III. HISTORY

In addition to determining the suddenness of onset of the symptom, important historical points for evaluation of gait disturbances fall under the categories included in Table 8-2.

Table 8-2 Important Historical Points

IV. EXAMINATION

Normal performance of coordination tests depends on the integration of multiple sensory and motor pathways. First test limb coordination (cerebellar function) with the patient seated on the examination table. Finger-to-nose testing (Video 8-1) should be done by asking the patient to repeatedly touch his or her nose, followed by touching your finger. It is best to hold your finger at the extreme of the patient's reach and to move your finger occasionally to different locations. In this way the system is stressed, and small abnormalities can be seen. Next check rapid alternating movements (Video 8-2) by asking the patient to rapidly alternately pronate and supinate in the palm of his or her hand or on the thigh. Listen to the sound the slaps make to ensure rapid and smooth movements. An alternate method to check rapid alternating movements is to ask the patient to tap his or her outstretched fingers as rapidly and as smoothly as possible on the other palm (Video 8-3). Again, listen for a fast and even sound. Incoordination of one arm or hand could occur either from a cerebellar abnormality on that side or from weakness or spasticity. 

Strength is tested because weakness can cause poor coordination. Lower extremity strength can be tested with the patient on the examination table (Video 8-4). Both proximal and distal strength (Video 8-5) should be tested. If the patient seems to suddenly "give way" during strength testing, the problem could be due to pain or the patient is not exerting full effort.

The next step in gait evaluation is to ask the patient to sit in a chair and then observe how easily the patient can get out of the chair. Patients who have difficulty getting out of a chair could either have weakness of their legs or have a problem with falling backwards as in Parkinson disease (Video 8-6).

Observe the patient walking away and then toward you (Video 8-7) in a long hallway rather than in a small examination room. Observe how the patient swings the arms (failure to swing the arms may be seen in Parkinson disease), how far apart the heels fall (normal is several inches apart, and a wide-based gait is suggestive of a cerebellar disorder), how stiff the legs are (spasticity, which is suggestive of a brain or spinal cord motor problem), and whether the patient has to lift the feet excessively high as seen in footdrop. When the patient turns, count how many steps it takes to complete the turn. Normal turns take about two steps (more steps suggest Parkinson disease). Heel-to-toe walking (tandem gait, which tests the cerebellum) (Video 8-8) should be tested making sure the patient has proper support should a fall occur. Ask the patient to walk on their heels and toes (tests strength) (Video 8-9, Video 8-10). The Romberg test (checks posterior column position sense) (Video 8-11) is done by asking the patient to stand and balance with the eyes open. Some patients may need to spread their feet apart somewhat to get their balance. Reassure the patient that you will catch him or her if a fall occurs. The patient is asked to close the eyes, and if the patient falls, then a Romberg sign is present. This is indicative of poor position sense that can be overcome by visual cues. Swaying back and forth is not a Romberg sign. These small corrective movements are normal and indicate that the patient can feel himself or herself leaning. These swaying movements indicate that the patient is very aware of his or her position in space. A true Romberg sign occurs when a patient is not aware that he or she is falling and makes no attempt to correct the falling position. Postural stability (abnormal in Parkinson disease) (Video 8-12) is tested by asking patients to obtain balance with the eyes open and telling them that you will push on them. Reassure the patient that you will not let him or her fall. Stand behind the patient and pull on the shoulders to see if the patient tends to fall backward. You can also push on the back or shoulders to determine whether the patient falls forward or sideways. Falling backward is referred to as retropulsion. Falling forward or to the side is called propulsion or lateropulsion respectively.

V. CLUES TO DIAGNOSIS

There are five basic types of abnormal gaits: parkinsonian, spastic, ataxic, slapping, and dystrophic. Each type of abnormal gait will be discussed in detail. 

Patients with Parkinson's disease frequently have difficulty getting out of a chair (Video 8-13) because they lose the associated movement of placing their feet underneath themselves. Also patients with Parkinson disease frequently fall backward. A parkinsonian gait (Video 8-14) consists of a stooped posture with a stiff appearance of leg movement. The arms tend to be flexed slightly at the elbow, and there is little or no arm swing. Most commonly Parkinson signs begin unilaterally and then progress to involve both sides of the body. Patients tend to take short, shuffling steps and accelerate the further they walk (festinating gait). A normal person turns by taking two steps, but a patient with Parkinson disease takes more than two steps to turn. Retro-/pro-/lateropulsion can be checked to determine if the patient has postural instability
(Video 8-15), which is common in Parkinson's disease. 

There are two varieties of spastic gait:  hemiparetic (one leg) and paraparetic (both legs).  Spasticity causes the extremity to be stiff. In a hemiparetic gait the spastic stiff leg is circumducted (the leg swings in a semicircle from a medial to lateral direction) as the patient walks, and the toe hits the ground before the heel does. Often the arm on the paretic side does not swing well and is flexed at the elbow. With paraparetic spastic gait (Video 8-16) both legs are stiff and the patient takes on the appearance of wading in waist-deep water since the arms move much more than the legs. There is pronounced adduction of the thighs, which can cause a "scissors" gait. A Babinski sign is usually found in the spastic leg.

Another type of gait is an ataxic gait (Video 8-17). This is a wide-based gait with difficulty or inability to tandem walk (Video 8-18). Patients may veer to one side or the other as they walk. They may also have incoordination of their upper extremities. If the patient's trunk moves from side to side as he or she walks, this is a sign of truncal ataxia (titubation). Typically, patients who have midline cerebellar degeneration, as is often seen in chronic alcohol use, have difficulty with tandem gait but have normal coordination of their upper extremities. Unilateral cerebellar lesions often cause incoordination of the arm and leg on the same side as the lesion. A cerebellar abnormality is implicated in ataxia only if weakness, spasticity, and position-sense abnormality are absent.

A slapping gait or steppage gait (Video 8-19) occurs when the patient has either a footdrop from weakness of the foot dorsiflexors or poor position sense in the feet. With a footdrop the patient flexes the hip so that the foot will clear the floor. Patients with poor position sense have a wide-based gait, their feet slap the floor, and they require visual assistance to walk. Patients with a slapping gait from poor position sense often have great difficulty ambulating in the dark. 

Proximal muscle weakness leads to a dystrophic or circumduction gait.  These patients have a pronounced lumbar lordosis and marked waddling because of difficulty in stabilizing their pelvis as they walk. The patients throw their hips from side to side to shift their body weight. They complain of marked difficulty climbing stairs and frequently have to use the handrail to pull themselves up with their arms. Patients with proximal muscle weakness also must use their hands to get out of a chair.

VI. RED FLAGS AND WHEN TO REFER

In general, the more rapid the onset of gait difficulty the more rapid the workup and referral should be (Table 8-3). Sudden onset of gait difficulty could be due to either a cerebellar/brainstem infarction or hemorrhage and requires an urgent head computed tomography (CT) and admission. Sudden onset of bilateral leg weakness can occur from a cord infarction, compressive myelopathy, or a plaque from demyelinating disease. A patient with sudden bilateral leg weakness needs an urgent total spine magnetic resonance imaging and admission. 

Subacute ataxia or leg weakness requires referral to a neurologist within several days. Chronic gait difficulty can be investigated over one to two weeks. 

Table 8-3 Time Frame for Evaluation and Referral

VII. CASE DISCUSSIONS

Case 8-1. This patient develops an inability to walk during the time that he has been asleep, which would make this either an acute or subacute onset of gait dysfunction. The wide-based gait and inability to tandem walk would localize to the cerebellum. The most likely etiologies would be a cerebellar vascular event, such as a hemorrhage or infarction. His noncontrast head CT scan shows a hemorrhage in the right cerebellar hemisphere. He is admitted for observation since the proximity of this lesion to his fourth ventricle could lead to obstructive hydrocephalus if edema develops around the hemorrhage. Edema could also develop around an infarct, which emphasizes a need to observe the patient in the hospital setting for several days even if the head CT scan is normal.

Case 8-2. The cause of this patient's gait disorder is multifactorial (the neurologic term is disequilibrium), and this is a typical presentation for elderly patients who complain of difficulty with their balance. She most likely has decreased visual acuity. Her antihypertensive medications could cause orthostatic dizziness. She appears to have a peripheral neuropathy, which can interfere with walking because of numbness and position-sense loss. She may benefit from an ophthalmology consultation and adjustment of her antihypertensives; physical therapy can be very helpful in this situation.

VIII. CME QUESTIONS

1. A 60-year-old woman awakens with inability to walk and is found on the floor by her family. Her examination shows left face, arm, and leg weakness and numbness. Her head CT shows no acute changes. What is the most likely cause of her inability to walk?

a. A right cerebellar infarction
b. A right hemisphere infarction
c. Both a and b are possible causes
d. Drug toxicity

2. A 68-year-old man is brought into the clinic because of a problem of falling for the past six months. The family has also noticed a progressive problem with his memory. On gait examination the patient has bradykinesia, a stooped posture, no arm swing, and he completed a turn with five steps. There is mild retropulsion. What is the most likely etiology of his falling over the past six months?

a. Hereditary cerebellar degeneration
b. Parkinson disease
c. Possible demyelinating disease
d. None of the above 

3. A patient with a "scissors" gait from increased adductor tone would most likely be suffering from a lesion in which of the following parts of the nervous system?

a. A lesion in the right hemisphere
b. Compression of the spinal cord
c. Guillain-Barré syndrome if the onset was subacute
d. Proximal muscle weakness from a myopathy

4. Which of the following would be considered to be a Romberg sign?

a. The patient falls backward when standing with the eyes open and the examiner pushes the patient's sternum
b. The patient falls when attempting to stand with the feet together and eyes open
c. The patient falls without corrective movements when closing the eyes when standing
d. The patient starts to sway to and fro when closing the eyes

5. A very thin diabetic patient presents with a "slapping" gait. On examination the patient has bilateral foot dorsiflexor weakness. Possible causes include which of the following?

a. Bilateral vibration sense loss in the feet
b. Compression of the spinal cord
c. Pressure on the peroneal nerves when crossing the legs
d. Both a and c

CME Answers

1.b
2.b
3.b
4.c
5.c