Gait

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A gait disturbance is a gait pattern that deviates from a "normal" gait. Synchrony, fluency, smoothness, and symmetry may be affected. A gait disturbance can be caused by problems at any level of the neuraxis, and they can be classified on an anatomical basis. This type of classification scheme categorises gait disturbances into low-level, middle-level, and high-level gait disorders. Particularly in the elderly, multiple factors may be in play causing a gait disturbance.

Gait Disorder Classifications

Higher, Middle, and Lower Level Gait Disorder Anatomical Correlations.

Levels	Anatomical Level	Balance and Gait Pattern
Higher	Psychological / psychiatric	Variable: slow, buckling knees
Higher	Cortical and subcortical	Different patterns: cautious, parkinsonian, ataxic, spastic, magnetic, gait ignition failure, disequilibrium
Middle	Basal ganglia	Parkinsonian / dystonic / choreic
Middle	Thalamus	Astasia / ataxia
Middle	Cerebellum	Cerebellar ataxia
Middle	Brain stem	Ataxia / spasticity
Middle	Spinal cord	Spastic gait / tabetic gait
Lower	Peripheral nerve Proprioception, vestibular visual	Sensory ataxia / vestibular disequilibrium / visual disequilibrium
Lower	Neuromuscular junction	Waddling
Lower	Muscle	Waddling, steppage, Trendelenburg
Lower	Skeleton	Antalgic / compensatory for deformities

See below for a demonstration of neurological gait conditions (Hemiplegic, Parkinsonian, Cerebellar, Stomping, Scissoring, Trendelenburg, Foot-drop, Choreiform)

Lower Level Gait Disorders

Lower level gait disorders are caused by pathology of the muscles, skeleton, peripheral nerves, peripheral vestibular system, and anterior visual pathway.

Steppage Gait

This is seen with weakness of food dorsiflexion, which may be due to peroneal nerve injury, radiculopathy, and demyelinating neuropathy. It may be unilateral or bilateral. The patient exaggerates knee and hip flexion to avoid tripping. The step is high and short, and at the end of each swing phase the foot may slap the floor.

Waddling and Trendelenburg Gaits

A waddling gait pattern is seen with weakness of the bilateral hip girdle muscles as well as in bilateral hip joint osteoarthritis or other bilateral hip joint diseases. The gait is wide based, and has short steps. There is increased alternating lateral body sway, and excessive drop of the hips. By swaying laterally the patient places their weight down the centre of gravity through each hip to reduce pain. There may be increased arm abduction and an exaggerated lumbar lordosis.

Trendelenburg gait manifests as ipsilateral lurching of the torso with a contralateral hip drop while standing on the affected side. It is caused by unilateral hip abductor weakness.

Lurching Gait

The lurching gait is caused by Gluteus Maximus weakness.

Sensory ataxia

The sensory ataxic gait is wide based with a variable step length and marked stride-to-stride variability. There is usually unsteadiness. Romberg sign is often positive. This gait pattern is not specific to any anatomical location, and may be seen in pathology of proprioception (sensory ataxia), cerebellum (cerebellar ataxia), pons, and thalamus.

Visual disequilibrium

Acute visual distortion such as using new prescription glasses may cause a sense of loss of balance. There may be cautiousness in gait, with tentative steps and an increased base of support.

Vestibular disequilibrium

Acutely there may be vertigo, nystagmus, and a tendency to fall onto the affected side. Chronically, the symptoms may be less marked, but the gait is often still wide based and cautious. There is difficulty with Romberg test and tandem walking, but assistance is not required to walk.

Sensory disequilibrium

There is conflict among inputs from the visual, proprioceptive, and vestibular pathways. Loss of two of these pathways, or loss of one without CNS adaptation, may lead to this becoming chronic. The gait is slow and cautious, and there is increased bipedal support.