1. GAIT- BALANCE DISORDER AND ASSISTIVE DEVICES
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):

33. Assistive Devices INSTRUCTIONS FOR PROPER USE
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 !!