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Examination of Gait



Ovid: Field Guide to the Neurologic Examination

Authors: Lewis, Steven L.
Title: Field Guide to the Neurologic Examination, 1st Edition
> Table of Contents > Section 2 – Neurologic Examination > Gait Examination > Chapter 39 – Examination of Gait

Chapter 39
Examination of Gait
PURPOSE
The main purpose of the examination of gait is to
localize neurologic dysfunction by looking for characteristic patterns
of gait abnormalities.
WHEN TO PERFORM THE GAIT EXAMINATION
Gait should be assessed in all patients in whom
ambulation can be attempted as part of a standard neurologic
examination. In patients who can attempt it safely, tandem gait should
also be examined in most patients as part of a standard neurologic
examination. Testing the patient’s ability to walk on the heels or the
toes needs only to be performed when weakness of foot dorsiflexion or
plantar flexion is suspected.
NEUROANATOMY OF GAIT
Walking requires the coordinated effort of several neurologic structures and functions:
  • The frontal lobes to generate the motor pathways to initiate gait
  • Cerebellar (and vestibular) function for coordination and balance
  • The basal ganglia for appropriate speed of movement
  • Muscle strength to move the legs and to overcome gravity to remain upright
  • Sensation, particularly proprioception, to know where the feet and legs are in space
EQUIPMENT NEEDED TO EXAMINE GAIT
None.
HOW TO EXAMINE GAIT
Gait
  • The gait can be tested with the patient’s
    shoes on or off. If gait is tested outside the patient’s room, it is
    best to have the patient wear shoes. In a patient without a suspicion
    for a significant gait problem, testing the patient’s gait inside the
    examination room (or simply observing the patient when he or she walks
    into or out of the room) may suffice to prove that gait is normal. When
    an abnormality of gait is suspected, watching the gait for a longer
    distance, such as in a hallway, may be necessary.
  • Ask the patient to walk, and observe the
    patient’s base (how far the legs are apart), stride, and balance. In
    some cases, you may only need to see

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    the
    patient walk a few steps to confirm that the gait is normal, and, in
    other cases, you may want to watch the patient walk a longer distance.

  • Ask the patient to turn around and walk
    back to the starting point. Watch how the patient turns (this is
    particularly important in the assessment of parkinsonism; see Chapter 46, Examination of the Patient with a Movement Disorder), and then observe the gait again as the patient walks back.
Tandem Gait
  • Ask the patient to walk a straight line,
    “like walking a tightrope.” It is often helpful to show the patient a
    line on the floor on which to walk.
  • Observe the patient’s ability to walk a few (e.g., four or five) steps in this way.
Walking on the Heels or Toes
  • To test heel walking, ask the patient to
    walk forward on his or her heels (dorsiflexing the feet). Observe as
    the patient walks four or five steps forward.
  • To test toe walking, ask the patient to
    walk forward on his or her toes (plantar flexing the feet), and observe
    as the patient walks four or five steps forward.
NORMAL FINDINGS
The normal gait should have a narrow base (the feet
should be approximately shoulder-width apart), and it should be steady
with good stride length. Patients should be able to perform tandem gait
without significant difficulty and without needing to hold on to the
wall or falling to either side. It is not unusual for elderly patients
to have some difficulty with tandem gait, however; if the gait is
otherwise normal, mild problems with tandem gait can probably be
considered a variation of normal in this population.
If tested, patients should also be able to walk a few
steps on their heels (maintaining dorsiflexion of the feet) and their
toes (maintaining plantar flexion of the feet) without difficulty.
ABNORMAL FINDINGS
Routine Gait Testing
  • A wide-based and unsteady gait, resembling the gait that can be seen from alcohol intoxication (a drunken gait), is called gait ataxia
    and suggests cerebellar dysfunction. If the patient with an ataxic gait
    does not have a propensity to fall toward one particular side, the
    pathology is most likely in the midline (vermis) of the cerebellum. An
    ataxic gait with consistent veering to one side suggests dysfunction of
    the cerebellar hemisphere on the side that the patient is falling
    toward (i.e., falling toward the left suggests left cerebellar
    dysfunction).
  • A wide-based, unsteady (ataxic) gait can
    also be seen due to severe sensory dysfunction in the feet and legs;
    this is referred to as a sensory ataxia. Sensory ataxias predominantly occur when there is severe proprioceptive and vibratory sensation loss in the lower extremities.
  • A narrow-based shuffling gait, often with a stooped posture, is called a parkinsonian gait.
    There may be diminished arm swing, difficulty making turns without
    taking extra steps, and a resting tremor of the hands, depending on the
    cause and severity of the underlying dysfunction. The finding of a
    parkinsonian gait suggests Parkinson’s disease or other causes of
    parkinsonism (see Chapter 46, Examination of the Patient with a Movement Disorder).
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  • Some patients have difficulty initiating
    steps after standing and may even complain that their feet are “glued”
    to the floor; after initiating gait, their steps are short and
    hesitant. This gait is called an apractic gait
    because the patient has normal motor mechanisms, but the brain can’t
    figure out how to perform the sequence of maneuvers to walk (apraxia
    refers to the inability to perform a complex task despite normal motor
    function). The finding of an apractic gait suggests frontal lobe
    dysfunction, such as can occur from some chronic dementing illnesses,
    hydrocephalus, or structural frontal lobe lesions.
  • Patients with a hemiparesis often have a
    characteristic hemiparetic gait. The leg is stiff and extended with
    circumduction at the hip; the affected arm is also usually held in a
    flexed position. Hemiparetic gaits usually occur from unilateral
    cerebral hemispheric lesions affecting the corticospinal tracts; these
    usually cause upper motor neuron weakness predominantly affecting
    extensors of the arm and flexors of the leg, with relative preservation
    of strength in arm flexors and leg extensors.
  • Patients with bilateral upper motor
    neuron weakness in the legs have bilaterally stiff legs, which, because
    of the bilateral circumduction, have a scissoring quality as the
    patient propels forward. This paraparetic gait disorder most commonly
    occurs due to spinal cord dysfunction, but it can also be seen due to
    bilateral cerebral hemisphere lesions.
  • Weakness in foot dorsiflexion (foot drop) causes a characteristic gait called a steppage gait;
    the patient needs to lift the leg to avoid tripping on the involved
    foot. This gait disorder, which can be unilateral or bilateral, can
    occur due to any cause of foot dorsiflexion weakness, usually from
    peripheral etiologies.
  • Another kind of gait abnormality that can occur due to nonneurologic causes is called an antalgic gait.
    This refers to the gait that occurs due to pain, particularly pain in
    an extremity, such as due to a hip problem or other musculoskeletal
    process.
Tandem Gait Testing
Abnormalities on tandem gait manifest as unsteadiness
during the maneuver or inability to perform tandem gait without the
likelihood of falling. Although most likely to be affected due to
cerebellar dysfunction, difficulties with tandem gait are nonspecific
and can occur due to any of the gait disorders described previously.
Heel or Toe Walking
  • Difficulty walking forward on one or both heels suggests any cause of unilateral or bilateral foot dorsiflexion weakness.
  • Difficulty walking forward on the one or
    both toes suggests any cause of unilateral or bilateral foot
    plantar-flexion weakness. The finding of difficulty walking on the
    plantar-flexed foot can be a particularly helpful sign when weakness of
    plantar flexion is suspected but not seen on routine motor testing.
    This is because power in plantar flexors is usually quite strong, and
    it may take the patient’s inability to lift his or her own weight to
    confirm weakness of plantar flexion.
ADDITIONAL POINTS
  • It is sometimes difficult to distinguish
    a parkinsonian gait from an apractic gait. Parkinsonian gaits are
    usually more narrow based than the gaits that occur due to frontal lobe
    dysfunction, however. Apractic gaits are sometimes referred to as magnetic gaits because the feet appear stuck to the floor.
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  • Tandem gait can sometimes be improved by
    asking the patient to walk quickly. In patients who are cautious and
    deliberate and seem slightly unsteady when performing this maneuver,
    you may find them to be more steady (i.e., normal) as they speed up.
  • Although this chapter discusses the
    evaluation of gait for diagnostic purposes, another important purpose
    of gait evaluation is to assess the patient’s safety in ambulation.

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