the gait and its disorders

1. The gait disorders
DR.D. N . SURYA
POSTGRADUATE INTERNAL MEDICINE

2. Introduction
• The maintenance of an upright posture and the act of walking are
among the first, and ultimately most complex, motor skills humans
acquire
• individual's pattern of walking may be so distinctive they can be
recognized by the characteristics of their gait or even the sound of
their steps.
• Many diseases of the nervous system are identified by the
disturbances of gait and posture.

3. ANATOMICAL ASPECTS OF GAIT
Neuroanatomical structures responsible for equilibrium and
locomotion
1. Brainstem (subthalamic, midbrain)
2. Cerebellar locomotor regions project through
descending reticulospinal pathways from the
pontomedullary reticular formation into ventromedial
spinal cord.

4. • Prefrontal cortex - modulates midbrain and
cerebellar locomotor regions-
• Parietal cortex - integrates sensory inputs
indicating position.and orientation in space, the
relationship to gravitational forces,the speed and
direction of movement.
• Cerebellum - modulates the rate, rhythm,
amplitude, and force of stepping.

5. DISORDERS OF BALANCE
 Balance is the ability to maintain equilibrium
 The reflexes required to maintain upright posture require input from cerebellar,
vestibular, and somatosensory systems;
 the premotor cortex and corticospinal and reticulospinal tracts mediate output to
axial and proximal limb muscles.
 These responses are physiologically complex.
 Failure can occur at any level and presents as difficulty maintaining posture while
standing and walking.
(1) vertigo
(2) nystagmus
(3) impaired standing balance.

6. ESSENTIALS OF GAIT
There are four major criteria essential to walking.
 Equilibrium: The ability to assume an upright posture and maintain
balance. Locomotion The ability to initiate and maintain rhythmic
stepping
 Musculoskeletal Integrity: Normal bone, joint, and muscle function
 Neurological Control: Must receive and send messages telling the body
how and when to move. (visual, vestibular, auditory, sensori-motor input)
 Forces for gait: Muscular force ,Gravitational force. Forces of
momentum. Floor reaction force.

7. There are four neurological components to maintaining
balance/gait and preventing falls:
1.Inner ears (vestibular system): This gives us equilibrium,
specifically by providing information to the brain as to where
each inner ear is in three dimensions. When the vestibular
system is not working, typically the patient will experience
vertigo (room spinning phenomenon).
2.Vision: This allows us to see where the horizon is and
irregularities in the walking surface. Low vision is more
problematic when patients attempt to get out of bed and walk
(e.g., to the restroom) in the middle of the night without
turning on a light.

8. 3.Brain (frontal lobes, basal ganglia and cerebellum): This provides
for the motor program of walking, as well as coordination. A motor
program is what enables the brain to cohesively put together the
alternating flexion and extension of hip, knee and ankle joints and other
joints, to create the proper stride length, stance, posture, arms wing and
gait speed.
4.Peripheral nerves, muscles and spinal cord: This provides the
strength and sensation to enact the walking program.
In addition to these broad categories of neurological causes, there are
many non-neurological causes such as osteoarthritis (wear-and-tear
arthritis) affecting the back, hips, knees or ankles. This may cause an
antalgic gait, i.e. limping, where the patient reduces the amount of time
pressure is placed on the painful leg.

9. GAIT & GAIT CYCLE
 Human gait refers to locomotion achieved through the movement of
human limbs.
 Gait is a series of rhythmical & alternating movements of trunk & limbs
which result in forward progression of center of gravity & the body.
 Gait is a sequence of foot movements by which aperson moves
forward.
 The gait cycle is a repetitive pattern involving steps and strides.

10. NORMAL GAIT CYCLE-
Single gait cycle or stride is defined:
• Period of when one foot contacts the ground to that same
foot contacts the ground again
-Each stride has 2 phases:
• Stance Phase Foot in contact with ground
• Swing Phase Foot not in contact with ground

11. • Initiation of gait
by a series of shifts in the center of pressure beneath the
feet first posteriorly, then laterally toward the stepping
foot, and finally toward the stance foot to allow the stepping
foot to swing forward.
• Center of Gravity (CG)
⚫ Midway between the hips Few cm in front of S2 SACRUM

14. GAIT CYCLE
An alternative classification of gait involves the
following eight phases:
• Initial Contact
• Loading Response
• Midstance
• Terminal Stance
• Pre swing
• Initial Swing
• Mid Swing
• Late Swing

19. ABNORMAL GAIT CAUSES
 1. Pain
 2. Impaired Joint Mobility (arthritis, contractures)
 3. Muscle weakness (Myopathy, neuropathy)
 4. Spasticity (stroke, cord lesion)
 5. Sensory/balance deficit (neuropathy, stroke)
 6. Impaired central processing (dementia, stroke,
delirium,drugs)

20. What are the types of gait
abnormalities ?
There are several different types of gait abnormalities, the most common
include
• Antalgic gait: An antalgic gait is the result of pain.
It’s the most common type of abnormal gait. It
you limp (avoiding stepping with or putting pressure
on your affected leg or foot).
• Propulsive gait (Parkinsonian gait): This type of gait
affects people diagnosed with parkinsonism or
Parkinson’s disease. Characteristics of a propulsive
include a stooping, rigid posture and your head and
neck bending forward. Your steps are usually short
fast to maintain your center of gravity (festinating

21. SPASTIC HEMIPARETIC GAIT
• Arm is adducted, internally rotated at the shoulder, and flexed at the
elbow, with pronation of the forearm and flexion of the wrist and fingers.
• Leg is slightly flexed at the hip and extended at the knee, with plantar
flexion and inversion of the foot. Swing phase of each step is
accomplished by slight lateral flexion of the trunk toward the unaffected
side and hyperextension of the hip on that side to allow slow
circumduction of the extended paretic leg as it swings forward from the
hip, dragging the foot

22. Hemiplegic Gait.
Weakness in distal muscles(foot drop
extensor hypertonia in lower limb.)
and
Most commonly seen in stroke.
with mildhemepresis, loss of
normal arm swing.
⚫ Slight circumduction may be the
only abnormalities
HEMIPLEGIC/ SPASTIC/ CIRCUMDUCTION GAIT

23. Myopathic Gait
• Hip girdle muscles are responsible for keeping the pelvis level when
walking. If you have weakness on one side, this will lead to a drop in the
pelvis on the contralateral side of the pelvis while walking (Trendelenburg
sign). With bilateral weakness, you will have dropping of the pelvis on
both sides during walking leading to waddling. This gait is seen in patient
with myopathies, such as muscular dystrophy
Abductor weakness OF ONE
SIDE
TRENDELENBERG sign
positive Pelvis drop ON
OPPOSITE SIDE

24. TRENDELENBERG GAIT WADDLING GAIT

25. MYOPATHIC GAIT(waddling gait)
 •Weakness of proximal leg and hip-
girdle muscles interferes with
stabilizing the pelvis and legs on the
trunk.
 Exaggerated rotation of the pelvis
with each step
 Hips are slightly flexed as a result of
weakness of hip extension, and an
exaggerated lumbar lordosis occurs.
Gower's sign.

26. Steppage Gait
• Seen in patients with foot drop (weakness of foot dorsiflexion),
the cause of this gait is due to an attempt to lift the leg high
enough during walking so that the foot does not drag on the
floor.
• PROPULSIVE GAIT. If unilateral, causes include peroneal nerve
palsy and L5 radiculopathy.
• If bilateral, causes include amyotrophic lateral sclerosis, Charcot-
Marie-Tooth disease

27. STEPPAGE GAIT

28. High stepping gait CROUCHING GAIT

29. SENSORY ATAXIA (SLAPPING/STAPMING GAIT)
• Adopt a wide base and advance cautiously, taking slow steps under
visual guidance.
• Feet are thrust forward with variable direction and height.
• Sole of the foot strikes floor forcibly with a slapping sound (slapping
gait).
• Walking on uneven surfaces and dark is particularly difficult.
• Romberg test.
• Large-diameter peripheral neuropathies, posterior root or dorsal root
ganglionopathies, and dorsal column lesions.

30. STOMPING GIAT
SENSORY ATAXIA
/SLAPPING /STAMPING

31. Proprioceptive Loss:
• Sensory Ataxia As our feet touch the ground, we receive proprioceptive
information .
• The sensory ataxic gait occurs when there is loss of this proprioceptive
input. POSTERIOR COLUMN
• This gait is also sometimes referred to as a stomping gait since patients
may lift their legs very high to hit the Wide, irregular, uneven steps ,
Unsteady, wide based gait
• Throw feet forward and out and bring them down first on heels and then
toes (double tapping sound).
• Positive Romberg (cannot stand with feet together and eyes closed)
Friedrich ataxia

32. FESTINATING/ PARKINSONIAN GAIT
•In this gait, the patient will have rigidity and bradykinesia.
•He will be stooped with the head and neck forward, with flexion at the
knees.
•The whole upper extremity is also in flexion with the fingers usually
extended.
•The patient walks with slow little steps
•Patient may also have difficulty initiating steps.
•The patient may show an involuntary inclination to take accelerating
steps, known as festination. This gait is seen in Parkinson's disease or any
other condition causing parkinsonism, such as side effects from drugs.
Involuntarily moves Short steps, Accelerating steps Difficult to start Difficult to stop

33. • Parkinson Gait Shuffling:
• small stepped gait without arm swing with high speed.
• Festinating: short quick stepped gait with stooped posture
due to displaced center of gravity.
• Freezing: sudden brief inability to move during mid stance.
• • Flat foot strike instead of heel strike

34. Instability in PD FESTINATING GAIT

35. HYPOKINETIC (PARKINSONIAN) GAIT
• Posture stooped, with flexion of the shoulders, neck, trunk ,
and knees.
• Asymmetrical reduction of arm swing and slowing in gait,
particularly when turning ,
• Start hesitation with small, shallow steps on a narrow base.-
Freezing Festination.

36. Scissor Gait/ Diplegic Gait
 Patients have involvement on both sides with spasticity in lower extremities
worse than upper extremities.
 The patient walks with an abnormally narrow base, dragging both legs and
scraping the toes
 This gait is seen in bilateral periventricular lesions and cerebral palsy.
 Extreme tightness of hip adductors which can cause legs to cross the midline
referred to as a ✂SCISSORS gait.
 Legs cross midline Adductors Spasticity

37. SISSORS GAIT

38. FRONTAL LOBE GAIT DISORDERS
• Cautious gait, a consequence of compensatory adjustments in response
to real or perceived disequilibrium -Isolated gait ignition failure,
• It is characterized by difficulty initiating or maintaining locomotion, and
caused by lesions in the frontal lobe, white matter connections, or basal
ganglia
• Frontal gait disorder(Magnetic gait) characterized by
• variable base (narrow to wide),
• decreased foot clearance,
• short shuffling steps,
• disequilibrium,
• start and turn hesitation,

39. Magnetic GAIT

40. • cerebellar ataxia
FLOCCULONODULAR LOBE
• Exhibit multidirectional body sway, disequilibrium , and severe
impairment of body and truncal motion.
• Standing and even sitting can be impossible, although when lying
down, the heel-shin test may appear normal, and upper limb
function may be relatively preserved .
• Limb ataxia due to involvement of the cerebellar hemispheres
• Steps are irregular and variable in timing (dyssynergia), length, and
direction (dysmetria).

41. Ataxic gait

42. CHOREIC GAIT / HYPERKINETIC GAIT
• Random movements of chorea are often noticeable during
walking.
• Superimposition of chorea on the trunk and leg
movements of the walking cycle gives the gait a dancing
quality ,owing to the exaggerated motion of the legs and
arm swing .
• Chorea can also interrupt the walking pattern, leading to
a hesitant gait.

43. CHOREA/HYPERKINETIC GAIT

44. DYSTONIC GAIT
 Childhood-onset primary torsion dystonia - sustained
abnormal posturing of the foot (typically plantar flexion and
inversion) on attempting to run.
 Walking forward or backward or even running backward
may be normal at an early stage .
 Early stages - tonic extension of the great toe (striatal toe)
when walking .
 Birdlike (peacock) gait - excessive flexion of the hip and
knee and plantar flexion of the foot [during the swing
phase]

45. DYSTONIC GAIT

46. ■ CAUTIOUS GAIT
• The term cautious gait is used to describe the patient who walks with
an abbreviated stride, widened base, and lowered center of mass,
• If walking on a slippery surface. Arms are often held abducted. This
disorder is both common and nonspecific.
• There may be an associated fear of falling. This disorder can be
observed in more than one-third of older
• patients with gait impairment. Physical therapy often improves
walking

47. PSYCHOGENIC GAIT DISORDERS
(ATASIA-ABASIA)
 1. transient fluctuations in posture while walking,
 2. knee buckling without falls,
 3. excessive slowness and hesitancy.
 4. crouched, stooped or other abnormal posture of the trunk,
 5. exaggerated body sway or excessive body motion especially
brought out by tandem walking

48.  NON-NEUROLOGIC
CAUSES
 1. Visual loss
 2. Orthopedic disorders
 3. Rheumatologic disorders
 4. Pain
 5. Cardiorespiratory problems

49. APPROACH TO THE PATIENT
• onset and progression of disability. Slow onset and progressive
• Initial awareness of an unsteady gait often follows a fall.
• Stepwise evolution or sudden progression suggests vascular disease.
• Gait disorder may be associated with urinary urgency and incontinence,
particularly in patients with cervical spine disease or hydrocephalus.
• use of alcohol and medications that affect gait and balance.

50. • Arthritic and antalgic gaits are recognized by observation, although neurologic
and orthopedic problems may coexist.
• Characteristic patterns of abnormality are sometimes seen
• Cadence (steps per minute), velocity, and stride length can be recorded by timing
a patient over a fixed distance.
• Watching the patient rise from a chair provides a good functional assessment of
balance.
• Brain imaging studies may be informative in patients with an undiagnosed disorder
of gait.

51. • MRI is sensitive for cerebral lesions of vascular or
demyelinating disease and is a good screening test for occult
hydrocephalus.
• Patients with recurrent falls are at risk for subdural
hematoma.
• As mentioned earlier, many elderly patients with gait and
balance difficulty have white matter abnormalities in the
periventricular region and centrum semiovale .
• While these lesions may be an incidental finding

52. HISTORY
COMMON SYMPTOMS AND ASSOCIATIONSWEAKNESS
1 • Hemiplegia /foot drop caused by weakness of ankle
Dorsiflexion Catching or scraping a toe on the ground and a tendency to trip
2 . Weakness of knee extension - sensation that the legs will give way while
standing or walking down stairs.
3. Weakness of ankle plantar flexion - interferes with ability to stride forward,
resulting in a shallow stepped gait.
4• Proximal muscle weakness- Difficulty in climbing stairs or rising from a seated
position.
5. Axial muscle weakness - interfere with truncal mobility

53. SLOWNESSS
Slowness of walking
1. Normal reaction to unstable or slippery surfaces
2. Elderly
3. Those who feel their balance is less secure because of any musculoskeletal or
neurological disorder
4. Parkinson disease (PD) and other basal ganglia diseases
STIFFNESS
• Presenting symptoms of a spastic paraparesis or hemiparesis.
• Leg muscle tone in some upper motor neuron syndromes and dystonia may
be normal when the patient is examined in the supine position but
• stiffness increased during walking.

54.  In childhood, an action dystonia of the foot is a
common initial symptom of primary dystonia with
stiffness, inversion, and plantar flexion of the foot
and walking on the toes only becoming evident after
walking or running
 Patients with dopa-responsive dystonia typically
develop Symptoms in the afternoon ("diurnal
fluctuation").

55. IMBALANCE
1. Cerebellar ataxia
2. Sensory ataxia
3. Vestibulopathy
4. Vascular lesions of thalamus, and basal ganglia.
5. Wide-based unsteady gait is also feature of frontal lobe diseases
6. Imbalance in subcortical cerebrovascular disease and basal ganglia disorders
manifests when turning while walking . stepping backwards, bending over to
pick up something, or performing several tasks simultaneously.
FALLS
1. Collapsing falls(Tone is lost)- syncope or seizures.
2. Toppling falls (Muscle tone is retained) - impaired
static and dynamic postural responses that control
body equilibrium during standing and walking.

56. SENSORY SYMPTOMS AND PAIN
sensory complaints provides clue to the site of
the lesion producing walking difficulties.
• Radicular pain or paresthesias ,
• Sensations of tight bands around the trunk
• Distal symmetrical paresthesias of the limbs
Neurogenic claudication of the cauda equina
• Skeletal pain due to degenerative joint disease

58. EXAMINATION OF POSTURE AND WALKING
ARISING TO STAND FROM SEATED POSITION
1. Proximal muscle strength
2. Organization of truncal and limb movements
3. Stability
4. Stance base STANDING
 1. Posture
 2. Stance base
 3. Body sway
 4. Romberg test
 5. Postural reflexes (pull test)

59. WALKING
1. Initiation of stepping
2. Speed
3. Stance base
4. Step length
5. Cadence
6. Step trajectory (shallow, shuffling, or high stepping)
7. Associated trunk and arm movements
8. Trunk posture

60. TURNING WHILE WALKING
1.Number of steps to turn
2.Stabilizing steps
3.truncal and limb movement
4.Freezing
OTHER MANEUVERS
1. Tandem walking
2. Walking backwards
3. Running /Walking on toes, heels

61. Evaluation of gait

77. DIAGNOSING GAIT AND BALANCE PROBLEMS
• A physical and neurological examination can diagnose gait or
balance problems.
• Performance testing can then be used to assess individual gait
difficulties.
• hearing tests, inner ear imaging, and vision tests including
watching eye movement. Magnetic resonance imaging (MRI) or
a computed tomography (CT) scan can check the brain
• blood pressure/heart rates MONITOR.

80. Toppling falls (Muscle tone is
retained)
Tripping- foot , may also be a consequence of carelessness, secondary
to inattention, dementia, or poor vision.
• Proximal muscle weakness- legs giving way and falls.
• Unsteadiness and poor balance -Impairment of postural
responses.
• Spontaneous falls, especially backward, are an important clue to
diagnoses such as multiple system atrophy and progressive
supranuclear palsy

81. TREATMENT
 specific treatment may be possible once a diagnosis is established.
 Orthostatic changes in blood pressure and pulse should be recorded.
 re-evaluating benefits and burdens of medications that might increase fall risk.
 Treatment of cataracts.
 A home visit to look for environmental hazards can be helpful.
 improved lighting, installation of grab bars and nonslip surfaces, and use of adaptive
equipment.

82.  strength training with weights and machines is useful to improve muscle mass, even
in older patients.
 Improvements realized in posture and gait should translate to reduced risk of falls
and injury.
 Sensory balance training is another approach to improving balance stability.
 The National Institute on Aging provides online examples of balance exercises for
older adults.
 A Tai Chi exercise program has been demonstrated to reduce the risk of falls and
injury in patients with Parkinson’s disease.
 Cognitive training, including dual-task training, may improve mobility in older
adults with cognitive impairment

83. Thank you