Examining Stance and Gait
Observe patient from the front, back, and sides. Ask patient to rise quickly from chair, walk at slow pace, then fast pace, then turn around; walking successively on toes, on heels, and tandem.
Note body and head posture (normal = erect), shoulders (no scoliosis or kyphosis), arm swing (present and equal), foot base (narrow), stride (full, symmetric, without shuffling), cadence (regular), speed, steadiness, turning (in one step).
Gait in Hemiparesis
Combined effects of spasticity, incoordination, weakness. Affected arm flexed at elbow and leg extended. Paretic leg swings outward at the hip (circumduction). Paretic arm moves little, remaining flexed and adducted; arm swing.
Gait in Spastic Paraparesis
Combined effects of spasticity, incoordination, weakness of both legs. Slow, stiff movements at knees and hips, with evident effort. Legs usually maintained extended or slightly flexed at hips and knees, often adducted at hips. Short steps, side-to-side trunk movements, circumduction of legs. Each leg may cross in front of the other (“scissors gait”).
Gait in Parkinsonism
Combined effects of akinesia (difficulty initiating movement), dystonia (fixed abnormal posture), rigidity, and tremor.
Difficulty rising from chair. Flexed posture with few automatic limb movements. Reduced arm swing. Short steps, sometimes becoming successively shorter and more rapid (festination).
Several steps for turning. Poor recovery of balance when pulled from behind; normals restore balance with 1–2 steps. Motor “freezing” (sudden brief inability to move legs). Rest tremor often emerges during walking.
Gait in Cerebellar Disease
Wide-based stance, unsteady balance, cautious steps of variable length and cadence; lurching from side to side (“ataxic gait”).
Narrow-based stance difficult to attain with eyes open or closed. In mild disease, problem may appear only on tandem-walking.
Cerebellar vermis lesions: gait may be affected alone, without limb ataxia.
Unilateral lesions: gait predominantly affected on side ipsilateral to lesion; falling toward that side. Movement of limbs ipsilateral to lesion also affected (inaccurate reaching, intention tremor, decreased tone, scoliosis toward side of lesion).
Bilateral cerebellar hemisphere lesions: gait and limb movements affected on both sides.
Gait in Sensory Ataxia
Loss of proprioceptive sensation due to lesions of peripheral or central sensory fibers.
Wide-based stance, cautious steps of variable length, constantly watching the ground. Feet lifted higher than normal and flung abruptly to ground (“stomping gait”).
Psychogenic Gait Disorders
Bizarre gait, unlike any other disorder of gait evoked by neurologic disease. Objective signs of neurologic disease missing. Inconsistencies in examination sometimes present (e.g., positions demonstrating excellent balance briefly achieved in spite of difficulty walking just before or afterwards); usually do not fall or sustain injury despite dramatic staggering.
Gait in Cerebral Palsy
Cerebral palsy: diverse motor abnormalities caused by non-progressive cerebral lesions present from birth or early infancy.
Slow, stiff walk; “scissoring” (crossing of feet at each step due to spasticity of hip adductors).
Extensive lesions: legs adducted and internally rotated at the hips, extended or slightly flexed at the knees, with plantar flexion at the ankles; arms adducted at the shoulders and flexed at the elbows and wrists (spastic quadraplegia).
Athetotic cerebral palsy: slow, writhing movements of arms and neck, with facial grimacing. Movements brought on by walking.
Gait in Chorea
Brief movements randomly involving face, trunk, or limbs and occurring at random times. Result in sudden changes in trunk posture, walking speed, path.
Gait in Dystonia Musculorum Deformans
Inversion of one foot at ankle (often first symptom). Then other postural abnormalities, often exacerbated by walking.
Gait in Muscular Dystrophy
Exaggerated lumbar lordosis and protuberant abdomen because of weak abdominal and paravertebral muscles. Legs spread apart; waddling motion of pelvis. Rising from floor or chair: forward trunk flexion, placement of hands on knees, followed by marching of hands up the thighs to push the trunk up (Gower sign).
Gait Disorders Associated with Aging
Not all indicative of disease.
Often seen in healthy elderly people. Slightly wide base, short stride, slow speed, turning in several steps. No hesitancy in initiation of gait; no shuffling or freezing. Normal rhythm. Mild dysequilibrium in response to a push; difficulty balancing on one foot.
Typical of progressive supranuclear palsy.
Difficulty maintaining upright posture; hyperextension of trunk and neck; parkinsonian signs.
Poor postural adjustments in response to jostling. Combination of postural instability and preserved speed of walking and turning characteristically results in falls on turning.
Difficulty walking, standing, or even sitting without support.
Balance problem: cannot bring legs under the center of gravity; falls back on rising from chair.
Wide base, shuffling steps, dysequilibrium. Hesitation in starting to walk or turn.
Usually with dementia, signs of frontal release (suck, snout, and grasp reflexes), motor perseveration, urinary incontinence, pseudobulbar palsy, exaggerated muscle stretch reflexes, and extensor plantar responses.
Isolated Gait Ignition Failure
Difficulty starting and continuing to walk without dementia, apraxia, parkinsonism, or poor balance.
Steps short and shallow (shuffling) initially, then normal.
“Freezing” of gait may occur with distraction.
“Magnetic gait” or “apraxia of gait”: terms used for this disorder as well as for frontal dysequilibrium.
Frontal Gait Disorder
Often used to describe gait associated with normal pressure hydrocephalus (NPH). Wide base, short steps with shuffling, difficulty in gait initiation and turning, poor recovery with jostling. May be accompanied by urinary incontinence, dementia, frontal release signs (e.g., suck, snout, grasp reflexes). If accompanied by hydrocephalus on imaging, gait disorder may improve with ventriculoperitoneal shunting.
Gait in Lower Motor Neuron Disorders
Distal weakness: footdrop, high step (“steppage gait”). Unilateral or bilateral, depending on nature of disorder (compression of one peroneal nerve vs. CMT, motor neuron disease.)
Proximal weakness: hip and pelvis muscles used to lift legs (“waddling gait”).