Gait and balance disorders

Disorders of Gait The heterogeneity of gait disorders observed in clinical practice reflects the large network of neural systems involved in the task. There is the potential for abnormalities to develop, and walking is vulnerable to neurologic disease at every level. Gait disorders have been classified descriptively, based on the abnormal physiology and biomechanics. One problem with this approach is that many failing gaits look fundamentally similar. This overlap reflects common patterns of adaptation to threatened balance stability and declining performance.

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Toppling Falls Some patients maintain tone in antigravity muscles but fall over like a tree trunk, as if postural defenses had disengaged. There may be a consistent direction to such falls. The patient with cerebellar pathology may lean and topple over toward the side of the lesion. Patients with lesions of the vestibular system or its central pathways may experience lateral pulsion and toppling falls. Patients with progressive supranuclear palsy often fall over backwards. Falls of this nature occur in patients with advanced Parkinson's disease once postural instability has developed.

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Falls Falls are a common event, particularly among the elderly. Modest changes in balance function have been described in fit older subjects as a result of normal aging. Subtle deficits in sensory systems, attention, and motor reaction time contribute to the risk, and environmental hazards abound. Epidemiologic studies have identified a number of risk factors for falls, summarized in Table 24-3. A fall is not a neurologic problem, nor reason for referral to a specialist, but there are circumstances in which neurologic evaluation is appropriate.

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Neuromuscular Disease Patients with neuromuscular disease often have an abnormal gait, occasionally as a presenting feature. With distal weakness (peripheral neuropathy) the step height is increased to compensate for foot drop, and the sole of the foot may slap on the floor during weight acceptance. Neuropathy may be associated with a degree of sensory imbalance, as described above. Patients with myopathy or muscular dystrophy more typically exhibit proximal weakness. Weakness of the hip girdle may result in a degree of excess pelvic sway during locomotion.

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Parkinsonism and Freezing Gait Parkinson's disease (Chap. 366) is common, affecting 1% of the population 55. The stooped posture and shuffling gait are characteristic and distinctive features. Patients sometimes accelerate (festinate) with walking or display retropulsion. There may be difficulty with gait initiation (freezing) and a tendency to turn en bloc. Imbalance and falls may develop as the disease progresses over years.

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Harrison's Internal Medicine Chapter 24. Gait and Balance Disorders Prevalence, Morbidity, and Mortality Gait and balance problems are common in the elderly and contribute to the risk of falls and injury. Gait disorders have been described in 15% of individuals over the age of 65. By age 80, one person in four will use a mechanical aid to assist ambulation. Among those 85 and older, the prevalence of gait abnormality approaches 40%. In epidemiologic studies, gait disorders are consistently identified as a major risk factor for falls and injury.

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