1. Mary McDonald, MD Muskuloskeletal Module
Gait
Mary McDonald, MD
Muskuloskeletal Module

2. Basic Components of Gait
Stride Length-should be at least twice foot length
Stance- widens with gait pathology
Posture- upright, kyphotic, stooped
Arm Swing- symmetrical
Balance-especially with rising, turning
Speed

3. Definitions
Ataxic gait- unsteady, uncoordinated walk with a wide base of support and the feet thrown outward.
Antalgic gait- a painful, limping gait to avoid pain of weight-bearing structures
Apraxic gait-loss of ability to carry out familiar, purposeful movements in the absence of paralysis or other motor or sensory impairment

4. More Definitions
Festinating Gait- characterized by flexed trunk and legs flexed stiffly at the knees and hips. Absent arm swing. Short steps with become faster over time. Seen in Parkinson’s Disease and other neurologic disorders

5. GAIT ASSESSMENT: KEY POINTS
Use a gait assessment tool (eg, timed Get Up and Go test)
Establish person’s comfortable gait speed
Remember that most gait disorders are associated with underlying disease

6. THE GET UP AND GO TEST Record the time it takes a person to:
Walk 10 feet (3 meters)
Turn
Return to the chair
Rise from a hard-backed chair with arms
Sit down

7. THE GET UP AND GO TEST Most adults can complete in 10 sec
Most frail elderly adults can complete in 11 to 20 sec
≥14 sec =  falls risk
>20 sec  comprehensive evaluation
Results are strongly associated with functional independence in ADLs

8. CONDITIONS THAT CONTRIBUTE TO GAIT DISORDERS
Degenerative joint disease
Acquired musculoskeletal deformities
Intermittent claudication
Impairments following orthopedic surgery
Impairments following stroke
Postural hypotension
Dementia
Fear of falling
Usually multifactorial

9. CLASSIFICATION OF GAIT DISORDERS
May classify by abnormal sensorimotor level: low, middle, and high
These levels may overlap when certain disorders involve multiple levels, eg, Parkinson’s disease involving high (cortical) and middle (subcortical) structures

10. LOW SENSORIMOTOR LEVEL GAIT DISORDERS
Peripheral sensory
Sensory ataxia (unsteady, uncoordinated)
Vestibular ataxia (unsteady, weaving)
Visual ataxia (tentative, uncertain)
Peripheral motor
Arthritic (antalgic, joint deformity)
Myopathic and neuropathic (weakness)

11. MIDDLE SENSORIMOTOR LEVEL GAIT DISORDERS
Spasticity
Hemiplegia, hemiparesis (leg swings out)
Paraplegia, paraparesis (bilateral circumduction)
Parkinsonism (small shuffling steps, hesitation, festination, propulsion, retropulsion, turning en block, absent arm swing)
Cerebellar ataxia (wide-based gait with increased trunk sway, irregular stepping)

12. HIGH SENSORIMOTOR LEVEL GAIT DISORDERS
Cautious gait (fear of falling, with appropriate postural responses)
Frontal-related gait disorders (spectrum, from gait ignition failure to frontal gait disorder to frontal disequilibrium)
Cerebrovascular
Normal-pressure hydrocephalus

13. FALLS
Definition: coming to rest inadvertently on the ground or at a lower level
One of the most common geriatric syndromes
Most falls are not associated with syncope
Falls literature usually excludes falls associated with loss of consciousness

14. EPIDEMIOLOGY OF FALLS
Each year 30%–40% of community-dwelling persons aged ≥65, and about 50% of residents of long-term- care facilities, experience falls

15. EPIDEMIOLOGY OF FALLS
Annual incidence of falls is close to 60% among those with history of falls
Complications of falls are the leading cause of death from injury in persons aged ≥65

16. MORBIDITY AND MORTALITY
Most falls by older adults result in some injury
10%–15% of falls by older adults result in fracture or other serious injury
The death rate attributable to falls increases with age
Mortality highest in white men aged ≥85: deaths/100,000 population

17. SEQUELAE OF FALLS Associated with:
Decline in functional status
Nursing home placement
Increased use of medical services
Fear of falling
Half of those who fall are unable to get up without help (“long lie”)
A “long lie” predicts lasting functional decline

18. COSTS OF FALLS
Annually, lifetime costs of fall-related injuries by older adults = $12.6 billion
 Emergency department visits
 Hospitalizations

19. CAUSES OF FALLS BY OLDER ADULTS
Rarely due to a single cause
May be due to the accumulated effect of impairments in multiple domains (such as other geriatric syndromes)
Complex interaction of:
Intrinsic factors (eg, chronic disease)
Challenges to postural control (eg, changing position)
Mediating factors (eg, risk taking)

20. CAUSES: INTRINSIC Age-related decline Chronic disease Acute illness
Changes in visual function
Proprioceptive system, vestibular system
Chronic disease
Parkinson’s disease
Osteoarthritis
Cognitive impairment
Acute illness
Medication use (see next slide)

21. CAUSES: MEDICATION USE
Specific classes, eg:
Benzodiazepines
Antidepressants
Antipsychotic drugs
Recent medication dosage adjustments
Total number of prescriptions

22. CAUSES: CHALLENGES TO POSTURAL CONTROL
Environmental
Changing positions
Normal activities

23. TREATMENT
Most favorable results with health screening followed by targeted interventions
Aim to reduce intrinsic and environmental risk factors
Interdisciplinary approach to falls prevention is most efficacious

24. To view clips of different Gait dysfunction go to: http://www2. kumc
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