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JohannaPalmio

Gait Disturbances

Essentials

  • Difficulty in walking is caused by functional disturbance of the nervous system, muscle system, skeletal system, joints or blood circulation.
  • In a young or working-aged person gait disturbance is most often caused by a specific disease.
  • In elderly persons a slowly progressing gait disturbance is often associated with several concomitant underlying diseases.

Non-neurological causes of gait disturbance

  • Fracture of lower extremity
  • Joint symptoms, arthritis, arthrosis
  • Poor general health, sarcopenia
  • Orthostatic hypotonia (orthostatic test: see Brief Orthostatic Test; review all medications!)
  • Arterial insufficiency in lower extremities (claudication pain, absent pulses, skin changes)
  • Localized leg/foot pain (calluses, toe misalignment, fallen plantar arch, etc.)
  • Old traumas
  • Impaired vision

Neurological causes of gait disturbance

  • A neurological aetiology of gait disturbance is the more likely the younger the patient.
  • Compression of the spinal cord, paraparesis Diseases of the Spinal Cord
    • A history of acute weakness in the lower extremities is significant. This is an emergency and the patient should immediately be referred to a hospital.
  • Compression of lumbar nerve roots and cauda equina
    • Especially in a young patient, the main symptom is back pain radiating down the leg. This condition is not called gait dysfunction, but sciatica.
    • Difficulty in walking is a description used by the elderly, in whom the symptoms of chronic stenosis of the lumbar spine have become acute.
    • Cases where the condition is accompanied by sphincter dysfunction and sensory deficits in the buttocks, i.e. cauda equina syndrome, are emergencies and the patient should immediately be referred to a hospital.
  • Subdural haematoma (especially if bilateral Traumatic Cerebral Haemorrhages)
    • Symptoms include weakness of the lower extremities, confusion, impaired or fluctuating consciousness, and possible signs of increased intracranial pressure or mild hemiparesis.
    • The history may include (even a slight) head injury.
    • Risk groups: the elderly, alcoholics, and patients receiving anticoagulant medication.
  • Multiple lacunar infarcts or vascular (frontobasal) degeneration in the brain
    • Among the most common causes of a slowly or gradually developing gait abnormality in the elderly.
    • Apraxic gait (the feet are strong enough, but the patient is unable to take any steps or the steps are short; legs are "glued to the floor") is a typical presentation.
    • Tendency to fall Falls of the Elderly
  • Normal-pressure hydrocephalus (NPH) triad
  • Parkinson's disease or other parkinsonism Parkinson's Disease
    • Rarely diagnosed on the basis of gait disturbance, because the symptom does not develop until a later stage in the disease, although the patient's steps may become shorter also in the beginning of the disease.
  • Alcoholism Neurological Disorders and Alcohol
    • Cerebellar degeneration (widened gait, poor balance, ataxia predominantly in the lower extremities Ataxia)
    • Polyneuropathy with such severe pain in the feet (hyperalgesia, allodynia) in the acute stage that it prevents walking
    • Myopathy (rare)
  • Polyradiculitis Guillain-Barré Syndrome (Polyradiculitis)
    • Causes increasing weakness in the lower limbs accompanied by sensory disturbances within a few days, and later on also upper extremity symptoms. Tendon reflexes are decreased or absent.
  • Myelitis Diseases of the Spinal Cord and MS Multiple Sclerosis (Ms)
    • A spinal inflammatory focus causes lower extremity weakness and sensory loss developing within a few days. The presentation often includes sphincter dysfunction.
  • Polyneuropathy Polyneuropathies
    • Diabetes Diabetic Neuropathy is the most common cause.
    • Symptoms usually develop slowly. Both muscle weakness in the lower extremities and a stocking type sensory loss are in most cases present. Reflexes are attenuated or absent.
  • Several other neurological disorders (brain or spinal canal tumour, slow infection, myopathy, ALS, cerebellar diseases, etc.) may cause gait disturbance. Whenever the cause of the deteriorated ability to walk is unclear, neurological examination should be considered.

References

  • Giladi N, Horak FB, Hausdorff JM. Classification of gait disturbances: distinguishing between continuous and episodic changes. Mov Disord 2013;28(11):1469-73. [PubMed]
  • John G. Nutt. Higher-level gait disorders: An open frontier. Mov Disord 2013 Sep 15;28(11):1560-5.