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Gait Disorders in the Elderly

by James O. Judge, MD

Gait disorders encompass a number of issues, including slowing of gait speed and loss of smoothness, symmetry, or synchrony of body movement.

For the elderly, walking, standing up from a chair, turning, and leaning are necessary for independent mobility. Gait speed, chair rise time, and the ability to do tandem stance (standing with one foot in front of the other—a measure of balance) are independent predictors of the ability to do instrumental activities of daily living (eg, shopping, traveling, cooking) and of the risk of nursing home admission and death.

Walking without assistance requires adequate attention and muscle strength plus effective motor control to coordinate sensory input and muscle contraction.

Pearls & Pitfalls

  • Gait speed, chair rise time, and the ability to do tandem stance are independent predictors of the ability to do instrumental activities of daily living and of the risk of nursing home admission and death.

Normal Age-Related Changes in Gait

Some elements of gait normally change with aging; others do not.

Gait velocity (speed of walking) remains stable until about age 70; it then declines about 15%/decade for usual gait and 20%/decade for fast walking. Gait velocity is a powerful predictor of mortality—as powerful as an elderly person's number of chronic medical conditions and hospitalizations. At age 75, slow walkers die ≥ 6 yr earlier than normal velocity walkers and ≥ 10 yr earlier than fast velocity walkers. Gait velocity slows because elderly people take shorter steps at the same rate (cadence). The most likely reason for shortened step length (the distance from one heel strike to the next) is weakness of the calf muscles, which propel the body forward; calf muscle strength is substantially decreased in elderly people. However, elderly people seem to compensate for decreased lower calf power by using their hip flexor and extensor muscles more than young adults.

Cadence (reported as steps/min) does not change with aging. Each person has a preferred cadence, which is related to leg length and usually represents the most energy-efficient rhythm. Tall people take longer steps at a slower cadence; short people take shorter steps at a faster cadence.

Double stance time (ie, time with both feet on the ground during ambulation—a more stable position for moving the center of mass forward) increases with age. The percentage of time in double stance goes from 18% in young adults to 26% in healthy elderly people. Increased time in double stance reduces the time the swing leg has to advance and shortens step length. Elderly people may increase their double stance time even more when they walk on uneven or slippery surfaces, when they have impaired balance, or when they are afraid of falling. They may appear as if they are walking on slippery ice.

Walking posture changes only slightly with aging. Elderly people walk upright, with no forward lean. However, elderly people walk with greater anterior (downward) pelvic rotation and increased lumbar lordosis. This posture change is usually due to a combination of weak abdominal muscles, tight hip flexor muscles, and increased abdominal fat. Elderly people also walk with their legs rotated laterally (toes out) about 5°, possibly because of a loss of hip internal rotation or in order to increase lateral stability. Foot clearance in swing is unchanged with advancing age.

Joint motion changes slightly with aging. Ankle plantar flexion is reduced during the late stage of stance (just before the back foot lifts off). The overall motion of the knee is unchanged. Hip flexion and extension are unchanged, but the hips have increased adduction. Pelvic motion is reduced in all planes.

Abnormal Changes in Gait

Causes

A number of disorders can contribute to dysfunctional or unsafe gait. They particularly include

Causative neurologic disorders include dementias (see Dementia), movement and cerebellar disorders (see Movement and Cerebellar Disorders), and sensory or motor neuropathies (see Hereditary Neuropathies).


Manifestations

There are many manifestations of gait abnormality. Some help suggest certain causes. (Video demonstrations of selected abnormal gaits are available for viewing here .)

Loss of symmetry of motion and timing between left and right sides usually indicates a disorder. When healthy, the body moves symmetrically; step length, cadence, torso movement, and ankle, knee, hip, and pelvis motion are equal on the right and left sides. A regular asymmetry occurs with unilateral neurologic or musculoskeletal disorders (eg, a limp caused by a painful ankle). Unpredictable or highly variable gait cadence, step length, or stride width indicates breakdown of motor control of gait due to a cerebellar or frontal lobe syndrome.

Difficulty initiating or maintaining gait may occur. When patients first start walking, their feet may appear stuck to the floor, typically because patients do not shift their weight to one foot to allow the other foot to move forward. This problem may represent isolated gait initiation failure, Parkinson disease, or frontal or subcortical disease. Once gait is initiated, steps should be continuous, with little variability in the timing of the steps. Freezing, stopping, or almost stopping usually suggests a cautious gait, a fear of falling, or a frontal gait disorder. Scuffing the feet is not normal (and is a risk factor for tripping).

Retropulsion is walking backwards when initiating gait or falling backwards while walking. It may occur with frontal gait disorders, parkinsonism, CNS syphilis, and progressive supranuclear palsy.

Footdrop causes toe dragging or a stepping gait (ie, exaggerated lift of the leg to avoid catching the toe). It may be secondary to anterior tibialis weakness (eg, caused by trauma to the peroneal nerve at the lateral aspect of the knee or a peroneal mononeuropathy usually associated with diabetes), spasticity of calf muscles (gastrocnemius and soleus), or lowering of the pelvis due to muscle weakness of the proximal muscles on the stance side (particularly the gluteus medius). Low foot swing (eg, due to reduced knee flexion) may resemble footdrop.

Short step length is nonspecific and may represent a fear of falling or a neurologic or musculoskeletal problem. The side with short step length is usually the healthy side, and the short step is usually due to a problem during the stance phase of the opposite (problem) leg. For example, a patient with a weak or painful left leg spends less time in single stance on the left leg and develops less power to move the body forward, resulting in shorter swing time for the right leg and a shorter right step. The normal right leg has a normal single stance duration, resulting in a normal swing time for the abnormal left leg and a longer step length for the left leg than for the right leg.

Wide-based gait (increased step width) is determined by observing the patient’s gait on a floor with 12-in (30-cm) tiles. The gait is considered wide based if the outside of the patient’s feet do not stay within the width of the tile. As gait speed decreases, step width increases slightly. Wide-based gait can be caused by cerebellar disease or bilateral knee or hip disease. Variable step width (lurching to one side or the other) suggests poor motor control, which may be due to frontal or subcortical gait disorders.

Circumduction (moving the foot in an arc rather than a straight line when stepping forward) occurs in patients with pelvic muscle weakness or difficulty bending the knee. Spasticity of the knee extensor muscles is a common cause.

Forward lean can occur with kyphosis and with Parkinson disease or disorders with parkinsonian features associated with dementia (particularly vascular dementia and Lewy body dementia).

Festination is a progressive quickening of steps (usually with forward lean), whereby patients may break into a run to prevent falling forward. Festination can occur with Parkinson disease and rarely as an adverse effect of dopamine-blocking drugs (typical and atypical antipsychotics).

Sideward trunk lean that is consistent or predictable to the side of the stance leg may be a strategy to reduce joint pain due to hip arthritis or, less commonly, knee arthritis (antalgic gait). In a hemiparetic gait, the trunk may lean to the strong side. In this pattern, the patient leans to lift the pelvis on the opposite side to permit the limb with spasticity (inability to flex the knee) to clear the floor during the swing phase.

Irregular and unpredictable trunk instability can be caused by cerebellar, subcortical, or basal ganglia dysfunction.

Deviations from path are strong indicators of motor control deficits.

Arm swing may be reduced or absent in Parkinson disease and vascular dementias. Arm swing disorders may also be adverse effects of dopamine-blocking drugs (typical and atypical antipsychotics).


Evaluation

The goal is to determine as many potential contributing factors to gait disorders as possible. A performance-oriented mobility assessment tool may be helpful ( Performance-Oriented Assessment of Mobility), as may other clinical tests (eg, a screening cognitive examination for patients with gait problems possibly due to frontal lobe syndromes).

Performance-Oriented Assessment of Mobility

Component

Findings

Score*

Clinical Meaning

Initiation of gait (immediately after being told to go)

Any hesitancy or multiple attempts to start

0

Parkinson disease

Isolated gait initiation failure (stroke or dementia)

Frontal gait disorder

No hesitancy

1

Right step length and height (right swing foot)

Does not pass left stance foot with step or does not clear floor completely with step

0

Arthritis

Foot problem

Stroke

Passes left stance foot

1

Completely clears floor

1

Left step length and height (left swing foot)

Does not pass right stance foot with step or does not clear floor completely with step

0

Arthritis

Foot problem

Stroke

Passes right stance foot

1

Completely clears floor

1

Step symmetry

Right and left step length not equal (estimated)

0

Unilateral

Musculoskeletal or focal neurologic deficit

Right and left step length equal (estimated)

1

Step continuity

Stopping or discontinuity between steps

0

Frontal gait disorder

Fear of falling

Steps appear continuous

1

Path (estimated in relation to floor tiles that are 12 in [30 cm] wide; observed excursion of one foot over about 10 ft of the course)

Marked deviation

0

Frontal gait disorder

Mild to moderate deviation or use of a walking aid

1

Straight without a walking aid

2

Trunk

Marked sway or use of a walking aid

0

Cerebellar, subcortical, and basal ganglia dysfunction

Antalgic gait (hip or knee arthritis)

No sway but flexion of knees, back pain, or arms spread out while walking

1

Fear of falling

No sway, no flexion, no use of arms, and no use of a walking aid

2

Stride width (step width)

Heels wide apart while walking

0

Hip disease

Cerebellar disease

Normal-pressure hydrocephalus

Heels almost touching while walking

1

*A perfect score is 12. A score of < 10 is usually associated with limitations in mobility-related function.

Adapted from Tinetti M: Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society 34:119–126, 1986; used with permission.

Evaluation is best approached in 4 parts:

  • Discussing the patient’s complaints, fears, and goals related to mobility

  • Observing gait with and without an assistive device (if safe)

  • Assessing all components of gait ( Performance-Oriented Assessment of Mobility)

  • Observing gait again with a knowledge of the patient’s gait components

History

In addition to the standard medical history, elderly patients should be asked about gait-related issues. First, they are asked open-ended questions regarding any difficulty with walking, balance, or both, including whether they have fallen (or fear they might fall). Then specific capabilities are assessed; they include whether patients can go up and down stairs; get in and out of a chair, shower, or tub; and walk as needed to buy and prepare food and do household chores. If they report any difficulties, details of the onset, duration, and progression are sought. History of neurologic and musculoskeletal symptoms and known disorders is important.


Physical examination

A thorough physical examination is done with emphasis on the musculoskeletal examination (see Evaluation of the Patient With Joint Disorders : Physical Examination) and the neurologic examination (see Evaluation of the Neurologic Patient : Neurologic Examination).

Lower-extremity strength is assessed. Proximal muscle strength is tested by having patients get out of a chair without using their arms. Calf strength is measured by having patients face a wall, put their palms on the wall, and rise onto their toes first using both feet and then using one foot at a time. Strength of hip internal rotation is assessed.


Gait assessment

Routine gait assessment can be done by a primary care practitioner; an expert may be needed for complex gait disorders. Assessment requires a straight hallway without distractions or obstructions and a stopwatch.

Patients should be prepared for the examination. They should be asked to wear pants or shorts that reveal the knees and be informed that several observations may be needed but that they will be allowed to rest if fatigued.

Assistive devices provide stability but also affect gait. Use of walkers often results in a flexed posture and discontinuous gait, particularly if the walker has no wheels. If safe to do so, the practitioner should have the patient walk without an assistive device, while remaining close to or walking with the patient with a gait belt for safety. If patients use a cane, the practitioner can walk with them on the cane side or take their arm and walk with them. Patients with a suspected peripheral neuropathy should walk touching the practitioner’s forearm. If gait improves with this intervention, proprioception from the arm is being used to supplement the missing proprioception from the leg; such patients usually benefit from using a cane, which transmits information about the type of surface or floor to the cane-holding hand.

Balance is assessed by measuring the time patients can stand on both feet in tandem stance (heel to toe) and on one foot (single stance); normal is 5 sec.

Gait velocity is measured using a stopwatch. Patients are timed while walking a fixed distance (preferably 6 or 8 m) at their preferred speed. The test may need to be repeated with patients walking as quickly as possible. Normal gait speed in healthy elderly people ranges from 1.1 to 1.5 m/sec.

Cadence is measured as steps/min. Cadence varies with leg length—about 90 steps/min for tall adults (1.83 m [72 in]) to about 125 steps/min for short adults (1.5 m [60 in]).

Step length can be determined by measuring the distance covered in 10 steps and dividing that number by 10. Because shorter people take shorter steps and foot size is directly related to height, normal step length is 3 foot lengths, and abnormal step length is < 2 foot lengths. A rule of thumb is that if at least 1 foot length is visible between the patient’s steps, step length is normal.

Step height can be assessed by observing the swing foot; if it touches the floor, particularly in the middle of the swing phase, patients may trip. Some patients with fear of falling or a cautious gait syndrome purposefully slide their feet over the floor surface. This gait pattern may be safe on a smooth surface but is a risky strategy when walking on rugs because patients may trip.

Asymmetry or variability of gait rhythm can be detected when practitioners whisper “dum...dum...dum” to themselves with each of the patient’s steps. Some practitioners have a better ear than an eye for gait rhythm.


Testing

Testing is sometimes required.

CT or MRI of the brain is often done, particularly when there is poor gait initiation, chaotic cadence, or the appearance of a very stiff gait. These tests help identify lacunar infarcts, white matter disease, and focal atrophy and can help determine whether normal-pressure hydrocephalus should be considered.


Treatment

  • Strength training

  • Balance training

  • Assistive devices

Although determining why gait is abnormal is important, interventions to alter gait are not always indicated. A slowed, aesthetically abnormal gait may enable the elderly person to walk safely and without assistance. However, some treatment interventions can lead to improvement; they include exercise, balance training, and assistive devices ( Treatment of Gait Disorders).

Treatment of Gait Disorders

Common Problem

Treatment

Comments

Bone structure

Kyphotic posture due to compression fractures of the thoracic spine or poor posture

Thoracic extension, shoulder rotation, chin tuck exercises

Osteoporosis treatment to prevent new fractures

Compression fracture can be diagnosed by x-ray, and osteoporosis can be identified by bone mineral density testing.

Leg length differences

Heel lift

Usually, heel lift correction is not 100%.

Severe genu varus or valgus

Orthotics, bracing, strengthening of quadriceps

Knee replacement criteria should be reviewed.

Foot abnormality or pain

Hallux valgus (bunion)

Loss of longitudinal arch

Orthotics, podiatry care, custom shoes

Testing for plantar neuropathy with monofilament nylon is always done to detect risk of plantar ulceration.

Joint range of motion

Decreased hip internal rotation

Stretching of adductors, strengthening of abductors

Attempting to increase internal rotation by stretching is not usually effective but may prevent further loss of range of motion.

Decreased hip extension

Stretching of hip flexors, strengthening of hip extensors

Lying prone and doing thoracic extension is often recommended.

Decreased ankle dorsiflexion

Stretching of calf muscles

Height of high-heel shoes is reduced.

Hallux rigidus (loss of dorsiflexion of the great toe)

Podiatry or orthopedic referral

An orthotic should be considered.

Muscle power

Weak hip extension

Chair rise exercises

Chair rise test may be helpful in diagnosis.

Weak knee extension

Chair rise exercises, knee extension with ankle sandbags, squats

Chair rise test may be helpful in diagnosis.

Weak ankle plantar flexion

Heel raises (using body weight)

To increase resistance during heel raises, patients can wear a weighted vest, backpack, or waist belt; they may need to stabilize themselves against a wall.

Weak ankle dorsiflexion

Muscle strengthening (eg, toe rises), ankle foot orthotic for footdrop

Patients place sandbag weights over their metatarsals. With their back to the wall for safety, patients rise on their heels (ie, lift toes off the floor).

Weak hip abduction

Hip abduction with ankle weights, side-lying position on the floor

Sensory systems

Decreased or impaired position sense or balance when eyes are closed during a Romberg test

Appropriate footwear

Vitamin B 12 level should be checked.

Decreased or impaired plantar touch sensation as measured by Semmes-Weinstein monofilaments

Appropriate footwear

The patient should be assessed for diabetes and alcohol abuse.

Dizziness or vertigo

Motor control/balance

Tandem stance or single-leg stance < 5 sec or turning 360° (both to right and left) requires > 10 steps or patient is unsteady during turning

Balance training involving static and dynamic balance, tai chi, or the equivalent

Vitamin D supplementation (1000–2000 IU once/day) for frail elderly patients with limited sun exposure reduces risk of falls and injury.

Forward lean

Bradykinesia

Leg hypertonia

Parkinsonian signs

Physical therapy training to maintain or improve motor control/balance

CT or MRI can detect lacunar infarcts or white matter disease.

Vitamin B 12 level should be checked.

Physical and cardiovascular fitness

Dizziness due to postural hypotension

Review of drugs for possible cause, compression stockings

Fatigue, shortness of breath, inability to walk < 400 m at usual pace

Regular walking program

Patients should be assessed for angina, heart failure, pulmonary disease, and claudication.

A 6-min walking distance is measured.

Strength training

Frail elderly people with mobility problems achieve modest improvements with exercise programs. In elderly people with arthritis, walking or resistance training reduces knee pain, and gait may improve.

Resistance exercises can improve strength and gait velocity, especially in frail patients with slowed gait. Two or three training sessions a week are usually needed; resistance exercises consist of 3 sets of 8 to 14 repetitions during each session. The load is increased every week or two until a plateau of strength is reached.

Leg press machines train all the large muscle groups of the leg and provide back and pelvic support during lifting. However, these machines are not always accessible to elderly patients. Chair rises with weight vests or weights attached to the waist (waist belts) are an alternative. Instructions are required to reduce the risk of back injury due to excess lumbar lordosis. Step-ups and stair climbing with the same weights are also useful. Ankle plantar flexion can be done with the same weights.

Using knee extension machines or attaching weights to the ankle strengthens the quadriceps. The usual starting weight for frail people is 3 kg (7 lb). Resistance for all exercises should be increased every week until the patient reaches a plateau of strength.


Balance training

Many patients with balance deficits benefit from balance training. Good standing posture and static balance are taught first. Patients are then taught to be aware of the location of pressure on their feet and how the location of pressure moves with slow leaning or turning the torso to look to the left or right. Leaning forward (using a wall or counter for support), backward (with a wall directly behind), and to each side is then practiced. The goal is for the patient to be able stand on one leg for 10 sec.

Dynamic balance training can involve slow movements in single stance, simple tai chi movements, tandem walking, turns while walking, walking backwards, walking over a virtual object (eg, a 15-cm stripe on the floor), slow forward lunges, and slow dance movements. Multicomponent balance training is probably most effective in improving balance.


Assistive devices

Assistive devices can help maintain mobility and quality of life (see Therapeutic and Assistive Devices). New motor strategies must be learned. Physical therapists should be involved in choice of and training with assistive devices.

Canes are particularly helpful for patients with pain caused by knee or hip arthritis or with peripheral neuropathy of the feet because a cane transmits information about the type of surface or floor to the cane-holding hand. A quad cane can stabilize the patient but usually slows gait. Canes are usually used on the side opposite the painful or weak leg. Many store-bought canes are too long but can be adjusted to the correct height (see Figure: Correct cane height.) by cutting (a wooden cane) or moving the pin settings (an adjustable cane). For maximal support, cane length should be such that patients have their elbow flexed 20 to 30° when holding the cane.

Walkers can reduce the force and pain at arthritic joints more than a cane, assuming adequate arm and shoulder strength. Walkers provide good lateral stability and moderate protection from forward falls but do little or nothing to help prevent backward falls for patients with balance problems. When prescribing a walker, the physical therapist should consider the sometimes competing needs of providing stability and maximizing efficiency (energy efficiency) of walking. Four-wheeled walkers with larger wheels and brakes maximize gait efficiency but provide less lateral stability. These walkers have the added advantage of a small seat to sit on if patients become fatigued.


Prevention

Although no large-scale prospective studies have confirmed the effect of increasing physical activity on gait and independence, prospective cohort studies provide convincing evidence that high levels of physical activity help maintain mobility, even in patients with disease.

Regular walking or maintaining a physically active lifestyle is the most important recommendation. The adverse effects of deconditioning and of inactivity cannot be overstated. A regular walking program of 30 min/day is the best single activity for maintaining mobility; however, an active lifestyle that includes multiple shorter walking episodes is probably equivalent to a single 30-min walk. A safe walking course should be recommended. The patient should be instructed to increase gait speed and duration over several months.

Prevention also includes resistance and balance training. The effects of an active lifestyle on mood and confidence are probably as important as their effect on physiology.

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