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Presentation on theme: "GAIT- BALANCE DISORDER AND ASSISTIVE DEVICES"— Presentation transcript:

Kashif A. Siddiqui, MD Geriatrics Medicine Baylor College of Medicine BROOKE SALZMAN, MD, Thomas Jefferson University, Philadelphia, Pennsylvania Am Fam Physician. 2010;82(1):61-68 SARA M. BRADLEY, MD, and CAMERON R. HERNANDEZ, MD, Mount Sinai School of Medicine, New York Am Fam Physician. 2011;84(4):

2 Objectives Normal Gait Abnormal Gait Pattern
Basic Understanding of Gait Disorder Evaluation & Interventions Basic Understanding of Assistive Devices

3 Definitions Gait Series of rhythmical , alternating movements of trunk & limbs resulting in forward progression of the COG Gait Cycle Begins when reference foot contacts the ground, Ends with subsequent floor contact of the same foot

4 Step length Stride Length Walking base
Right step Length = Left step Length (Normal Gait) Stride Length Double the step length Walking base Side-to-side distance between the line of the two feet

5 Comfortable Walking Speed (CWS)
Least energy consumption per unit distance Average = 1.4 meter/sec

6 Path of Center of Gravity
Center of Gravity (CG): midway between the hips Few cm in front of S2 Least energy consumption if CG travels in straight line

7 Path of C.G Vertical displacement: Rhythmic up & down movement
Highest point: midstance Lowest point: double support Average displacement: 5cm Path: extremely smooth sinusoidal curve

8 Path of Center of Gravity
Overall displacement: Sum of vertical & horizontal displacement Figure ‘8’ movement of CG as seen from AP view Horizontal plane Vertical plane

9 Gait & Aging No clearly accepted standards to define normal Gait in Older Adults Changes at Aging 10-20 % reduction in Gait Velocity & Stride Length. Increase Stance Width. Increase time spent in the Double Support Phase. Bent Posture. Slow & Wide Based Gait. Up to 20% maintain normal Gait pattern into very old age, reinforcing that Aging not inevitably accompanied by disordered Gait.

10 Gait & Balance Disorder
Most common causes of falls in Older Adults Evaluation of Gait & Balance disorder parallels the evaluation of FALLS It can lead to Injury & Disability loss of independence & reduces level of functioning limited quality of life Increase morbidity & mortality 60% yrs, 25% yrs, & 30% 65 yrs have difficulty : walking 3 blocks or climbing 1 flight of stairs 20 % require Assistive Devices to ambulate American Geriatrics Society/British Geriatrics Society clinical practice guideline: prevention of falls in older persons Accessed June 3, 2010

11 Falls related statistics
5.8 million US Adults reported Falls NH Residents (1.6 falls/bed/year) 10–25% NH falls result in ER visits/hospital care Mostly minor injuries 10-15% resulting in fracture 5% in serious soft tissue injury or head trauma Leading cause (75%) of injury deaths for >65 yr 60% fatal falls happen at home 30% in public places 10% in institutions

12 Gait & Balance Disorder
Multifactorial Etiology Comprehensive Assessment required to determine Contributing factors Targeted interventions Most Gait changes in Older Adults related to underlying Medical conditions Sudarsky L. Gait disorders: prevalence, morbidity, and etiology. Adv Neurol. 2001;87:

13 Causes of Gait & Balance Disorder
Affective Disorder & Psychiatric Conditions Depression Fear of falling Sleep Disorders Substance Abuse Cardiovascular Disease CHF CAD Orthostatic Hypotension PAD Thromboembolic Arrhythmias Neurological Delirium Dementia Multiple Sclerosis Myelopathy NPH Parkinson Disease Stroke Vestibular Disorders Cerebellar Dysfunction Sensory Abnormalities Hearing Impairment Peripheral Neuropathy Visual Impairment Alexander NB. Gait disorders in older adults. J Am Geriatr Soc. 1996; 44(4):

14 Causes (cont.) Infectious & Metabolic Others Musculoskeletal Disease
Diabetes Mellitus Hepatic Encaph. HIV Hypothyroidism Hyperthyroidism Obesity Tertiary Syphilis Uremia Vitamin B12 Deficiency Others Recent Surgery Recent Hospitalization Musculoskeletal Disease Osteoarthritis Osteoporosis Gout Spinal Stenosis Cervical Spondylosis Podiatric Conditions Medications Antiarrythmics, Digoxin Diuretics Narcotics Antidepressants, Psychotropics Anticonvulsants Alexander NB. Gait disorders in older adults. J Am Geriatr Soc. 1996; 44(4):

15 Evaluation History Medication review
Acute and Chronic Medical problems Complete ROS Falls History (Previous Falls, Injury resulted, circumstances, & associated Sx. Nature of Difficulty with Walking (e.g. Pain, imbalance) Surgical History Usual Activity, mobility status, and level of function Medication review New medication or dosing review Number and type of medications Hough JC, McHenry MP, Kammer LM. Gait disorders in the elderly. Am Fam Physician. 1987;35(6): Sudarsky L. Clinical approach to gait disorders of aging: an overview. In: Masdeu JC, Sudarsky L, Wolfson L, eds. Gait Disorders of Aging: Falls and Therapeutic Strategies. Philadelphia, Pa.: Lippincott-Raven; 1997:

16 Evaluation Presence of environmental Hazards Clutter Electrical Cords
Lack of grab bars near bathtub & toilets Low chairs Poor Lighting Slippery Surfaces Throw rugs

17 Evaluation Physical Examination Vitals
(Wt. Ht. Orthostatic BP & Pulse) Affective/cognitive (Delirium, Dementia, Depression, Fear of Falling) Cardiovascular (Murmur, Arrhythmias, Carotid Bruit, Pedal Pulses) Musculoskeletal (Joint swelling, deformity, Limited ROM or instability) Neurological (M/S strength, tone, reflexes, coordination, sensation tremors, cerebellar, vestibular, sensory & proprioception)

18 Evaluation Gait & Balance Performance Testing
Direct observation of gait & Balance Watching patient enter and sitting in examination room Stance posture Velocity step length Symmetry Cadence fluidity of movement instability & need of assistance

19 Evaluation Gait & Balance Performance Testing Functional Reach Test
Reliable Valid Quick diagnostic tool Inability to reach at least 7 inches predictive of fall Duncan PW, Studenski S, Chandler J, Prescott B. Functional reach: predictive validity in a sample of elderly male veterans. J Gerontol. 1992; 47(3):M93-M98

20 Evaluation Gait balance & performance testing Timed Up & Go Test
Reliable Diagnostic tool (Sensitivity 80% & Specificity 80%) Quick to administer (Pt arise from a chair, without using arms, walk 3 meter, turn, return to the chair and sit down. They allowed to use their usual walking aids.) Score < 10 sec normal Score > 14 Sec Abnormal Score > 20 Sec Severe gait impairment Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “get-up and go” test. Arch Phys Med Rehabil. 1986;67(6):

21 Evaluation Gait & Balance Performance Testing Single leg stance test
Best balance measure for any individual If one can stay on one leg for >10 sec, usually no significant balance problems

22 Evaluation Other Diagnostic Testing
Role of Lab testing in diagnostic evaluation has not been well studied Tests useful when H&P raises suspicious for abnormality CBC Metabolic Panel Thyroid Function RPR Vitamin B12 Level CT head Hearing Test Visual Screening

23 Gait Patterns Antalgic Waddling Parkinsonian Choreic
Description: Limited ROM, limping, slow, short steps, unable to bear full weight Signs: Pain worse with movement & weight bearing Causes: DJD, Trauma Waddling Description: Lumbar lordosis, swaying, wide based Signs: Hip dislocation, proximal m/s weakness, uses arm to get up from chair Causes: Muscular dystrophy & Myopathy Parkinsonian Description: Short stepped, shuffling, hip, knee & spine flexed Signs: Bradykinesia, muscular rigidity, reduce arm swing Causes: Parkinson disease Choreic Description: Dance-like, irregular, slow, wide based Sign: Choreoathetoic movement of UE Causes: Huntington Disease, Levodopa induced dyskinesia

24 Gait Pattern Cerebellar Ataxia Sensory Ataxia Vestibular Ataxia
Description: Staggering, wide based Signs: Dysarthria, Dysmetria, dysdiadokinesia, Intentional Tremors, Nystagmus, Romberg's Causes: Cerebellar Degeneration, Stroke, MS, Thiamine, Vitamin B12 Def. Alcohol Sensory Ataxia Description: Unsteady, worse without visual input Signs: Impaired position & vibration, Romberg's Causes: Dorsal Column, Neuropathy Vestibular Ataxia Description: Unsteady, falling on one side, Postural instability Signs: Nausea, Normal sensation, Nystagmus Causes: Menieres, Acute Labrynthitis. Cautious Description: Slow, wide based, careful (Walking on Ice) Signs: Associated with Anxiety, fear of falling, Open spaces Causes: Deconditioning, Post fall syndrome, visual impairment

25 Gait Pattern Frontal gait disorder Senile gait disorder Psychogenic
Description: Freezing, start & turn hesitation Signs: Dementia, Incontinence Causes: NPH, Multi-infarct state, Frontal lobe degeneration Senile gait disorder Description: Slow, broad based, shuffling & cautious walking pattern Signs: when underlying disease can not be identified Causes: May present early manifestation of subclinical ds. Psychogenic Description: Bizarre, Non physiologic gait Signs: Absence of neurological signs Causes: Factitious, Somatoform disorder & Malingering

26 Intervention Interventions may impact important Functional outcomes, including Reduction in Falls Fear of falling Overall limitation in mobility Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev. 2009;(2):CD Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331(13):

27 Intervention Gait Disorder secondary to Medical Conditions
(Arthritis, Vitamin B12, Thyroid Problems, Arrhythmias, Depression etc.) respond well to Medical Therapies. Adjustment in Medication improves gait disorder Limited data available, Surgery may improve Gait Cervical spondylotic myelopathy Lumbar spinal stenosis Normal pressure hydrocephalus Arthritis of hip or knee Improving Sensory Input Visual Correction Hearing Aids Engsberg JR, Lauryssen C, Ross SA, Hollman JH, Walker D, Wippold FJ II. Spasticity, strength, and gait changes after surgery for cervical spondylotic myelopathy: a case report. Spine (Phila Pa 1976). 2003;28(7):E136-E139. Krauss JK, Faist M, Schubert M, et al. Evaluation of gait in NPH before and after shunting. In: Ruzicka E, Hallet M, Jankovic J, eds. Gait Disorders. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2001.

28 Intervention Other options includes
EXERCISE INTERVENTION & PHYSICAL THERAPY Target strengths Balance training Functional exercises Flexibility Evidence supports HOME ENVIRONMENT ASSESSMENT prevent falls & related injuries Above Interventions augment Gait, Function & Reduces number of falls Schenkman M, Riegger-Krugh C. Physical intervention for elderly patients with gait disorders. In: Masdeu JC, Sudarsky L, Wolfson L, eds. Gait Disorders of Aging: Falls and Therapeutic Strategies. Philadelphia, Pa.: Lippincott-Raven; 1997:

29 Interventions Modest improvement in Gait & Balance achievable by ASSISTIVE DEVICES. Unfortunately, most cases its unlikely that Gait Disorder are reversible

30 Assistive Devices 6.1 million use assistive devices, 2/3 >65 years of age ASSISTIVE DEVICES IMPROVE: Balance Reduce pain Compensate for weakness or injury Increase Mobility & Confidence ASSISTIVE DEVICE SELECTION DEPENDS: Amount of support assistive device offers Coordination required Strength, ROM, Balance, Stability, General Condition, & WB restrictions Bateni H, Maki BE. Assistive devices for balance and mobility: benefits, demands, and adverse consequences. Arch Phys Med Rehabil. 2005; 86(1): Faruqui SR, Jaeblon T. Ambulatory assistive devices in orthopaedics: uses and modifications. J Am Acad Orthop Surg. 2010; 18(1):

31 Assistive Device Patients get Assistive Device without recommendations from Medical Professional Evaluation should be done routinely for proper Fit & Use Cane preferred for balance with one UE Crutches or a walker appropriate for Both CORRECT HEIGHT & FIT Correct height of cane/walker At the level of the patient’s wrist crease, as measured with the patient standing upright with arms relaxed at his or her sides, the patient’s elbow naturally flexed at 15 – 30 degree angle

32 Assistive Devices INSTRUCTIONS FOR PROPER USE: Cane:
Should be held contralateral to weak/painful LE & advanced simultaneously with Contralateral Leg. Need upright posture without forward or lateral leaning. Take time when turning & should not lift the device off the ground. Walker: Both feet should stay between the posterior legs or wheels. Take time when turning and should not lift the device off the ground. Kumar R, Roe MC, Scremin OU. Methods for estimating the proper length of a cane. Arch Phys Med Rehabil. 1995; 76(12):

Navigating Stairs with Cane/Walker: Patients with unilateral LE impairment advance the Unimpaired Extremity first when going up stairs AND advance the Impaired Extremity first when going down stairs. Simply remember this phrase, “Up with the good and down with the bad.” A video about how to use a cane is available online at

34 CANES STANDARD CANE Indications: Advantages: Disadvantages:
Mild ataxia (sensory, vestibular, or visual) Mild arthritis Advantages: Inexpensive Adjustable Improves balance Disadvantages: Umbrella handle cause carpal tunnel syndrome Not for weight bearing

35 CANES OFFSET CANE Indication: Advantages: Disadvantages:
Moderate arthritis Advantages: Inexpensive Intermittent weight bearing Shotgun handle put less pressure on palm Disadvantages: Commonly used incorrectly Liu HH, Eaves J, Wang W, Womack J, Bullock P. Assessment of canes used by older adults in senior living communities. Arch Gerontol Geriatr. 2011; 52(3):

36 CANES QUADRIPOD Indications: Advantages: Disadvantages: Hemiparesis
Increased base of support bear large weight Stands freely on its own Disadvantages: Slightly heavier Awkward to use correctly with all four points on ground simultaneously Laufer Y. Effects of one-point and four-point canes on balance and weight distribution in patients with hemiparesis. Clin Rehabil. 2002; 16(2):

37 CRUTCHES AXILLARY CRUTCHES Indication: Advantages: Disadvantages:
Lower extremity fracture Advantages: Inexpensive Completely redistribute weight off of lower extremities Permits % weight-bearing support Disadvantages: Difficult to learn to use Requires energy & strength Risk of nerve or artery compression

38 CRUTCHES FOREARM CRUTCHES: Indication: Advantages: Disadvantages:
Paraparesis Advantages: Frees hands without having to drop crutch Less cumbersome to use, particularly on stairs No Axillary compression Disadvantages: Permits only occasional weight bearing

39 WALKERS STANDARD WALKER Indications: Advantages: Disadvantages:
Severe myopathy severe neuropathy Cerebellar ataxia Advantages: Most stable walker Folds easily Disadvantages: Slower Needs to be lifted up with each step Less natural gait

40 WALKERS FRONT-WHEELED WALKER Indications: Advantages: Disadvantages:
Severe myopathy Severe neuropathy Paraparesis Parkinsonism Advantages: Maintains normal gait pattern No need to be lifted up with each step Disadvantages: Large turning arc Less stable Cubo E, Moore CG, Leurgans S, Goetz CG. Wheeled and standard walkers in Parkinson’s disease patients with gait freezing. Parkinsonism Relat Disord. 2003; 10(1): 9-14

41 WALKERS ROLLATOR Indications: Advantages: Disadvantages:
Moderate arthritis Claudication Lung disease, CHF Advantages: Easy to propel Highly movable Small turning arc Has seat & basket Disadvantages: Not for weight bearing Less stable Does not fold easily

42 Selection of AD

43 Assistive Devices List providing stability & support from most to the least : Parallel bars Walker Axillary crutches Forearm crutches Two canes One cane

44 Assistive Devices List requiring Coordination from least to the most:
Parallel bars Walker One cane Two canes Axillary crutches Forearm crutches

45 Conclusion Comprehensive evaluation with targeted interventions reduce falls by 30-40% Gait Disorder evaluation the most effective strategy for falls prevention Limited evidence supporting the effectiveness of interventions for gait & balance disorders Harris MH, Holden MK, Cahalin LP, Fitzpatrick D, Lowe S, Canavan PK.Gait in older adults: a review of the literature with an emphasis toward achieving favorable clinical outcomes, part II. Clin Geriatrics. 2008; 16(8):37-45.

46 “Don’t walk behind me, I may not lead
“Don’t walk behind me, I may not lead. Don’t walk ahead of me, I may not follow. Walk next to me & be my friend.” Albert Camus

47 Thank you !!


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