Walking, standing up from a chair, turning, and leaning are important for being able to move around independently. Gait speed, the time it takes to stand up out of a chair, and the ability to stand with one foot in front of the other (tandem stance) help predict an older person's ability to do daily and other activities such as shopping, traveling, and cooking.
Walking without assistance requires coordination by areas of the brain that control attention, strength, sensation, and coordination of the perceptions of the senses and muscle contraction (see figure ) for safe and steady walking. Dementia and other neurologic disorders can significantly affect walking by impairing these areas of the brain.
Normal Age-Related Changes in Gait
Some elements of gait normally change as people get older; others do not.
Speed of walking (gait velocity) remains the same until about age 70, and then it slows down. Speed of walking is a powerful predictor of mortality—as powerful as the number of chronic medical conditions and hospitalizations a person has. At age 75, slow walkers die 6 years or more before walkers with a normal speed and 10 years or more before fast walkers.
Speed of walking slows because older people take shorter steps. The most likely reason for shortened step length (the distance from one heel strike to the next) is weakness of the calf muscles. Calf muscles propel the body forward, and calf muscle strength declines with age. However, older people seem to compensate for decreased calf strength by using their hip flexor and extensor muscles more than young adults.
Cadence, which is the number of steps taken in a minute, does not slow down with age. Every person has a preferred cadence, which is related to leg length. Tall people take longer steps at a slower cadence; short people take shorter steps at a faster cadence.
Double stancetime refers to the time when both feet are on the ground while taking a step. This phase of a step is a more stable position for moving forward than when only one foot is on the ground. The percentage of time spent in double stance increases with age. Older people may increase the time spent in double stance even more when they walk on uneven or slippery surfaces, when they feel off-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. Older people walk upright, with no forward lean. However, older people walk with more downward rotation of the pelvis and with an increased curve of the lower back (called lumbar lordosis). Usually, weak abdominal muscles, tight hip flexor muscles, and increased abdominal fat contribute to this change in posture. Older people also walk with their legs rotated laterally (toes out) about 5 degrees, possibly because their hips are less able to turn inward or they are trying to increase stability. Foot clearance in swing is unchanged with age.
Abnormal Changes in Gait
A number of disorders can contribute to a dysfunctional or unsafe gait. Common causes are
Neurologic disorders, including dementia Dementia Dementia is a slow, progressive decline in mental function including memory, thinking, judgment, and the ability to learn. Typically, symptoms include memory loss, problems using language and... read more and Parkinson disease Parkinson Disease (PD) Parkinson disease is a slowly progressive degenerative disorder of specific areas of the brain. It is characterized by tremor when muscles are at rest (resting tremor), increased muscle tone... read more
A gait can be abnormal in various ways, and certain types of abnormalities help doctors understand what is causing the gait problem.
Asymmetry: When healthy, a person’s body moves symmetrically while walking (that is, motions are equal on the right and left sides). If a person consistently does not have symmetry while walking, the cause is often a problem with nerves or bones and joints on one side of the body—for example, a limp caused by a painful hip or ankle. If the reason for the lack of symmetry is not obvious, the cause may be malfunction of the brain or the use of certain drugs.
Loss of synchrony: Normal synchrony of gait involves moving the upper and lower limbs in a regular, rhythmic way and smooth coordination of the limbs. Synchrony enables a person to move forward. Neurologic or musculoskeletal disorders that affect specific aspects of gait result in loss of synchrony.
Difficulty starting or continuing to walk: Older people may have difficulty starting or continuing to walk. When they start to walk, their feet may appear stuck to the floor, typically because they do not shift their weight to one foot to allow the other foot to move forward. Doctors may look for a movement disorder, such as Parkinson disease Parkinson Disease (PD) Parkinson disease is a slowly progressive degenerative disorder of specific areas of the brain. It is characterized by tremor when muscles are at rest (resting tremor), increased muscle tone... read more , to find the cause of this gait problem. Once gait is started, a person's 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 problem with the frontal lobe of the brain Cerebrum . Scuffing the feet is not normal (and is a risk factor for tripping). Causes of scuffing include Parkinson disease and weakness and/or numbness of the feet caused by nerve damage Mononeuropathy Mononeuropathy is damage to a single peripheral nerve. Pressure on a nerve for a long time is the most common cause of mononeuropathy. The affected area may tingle, feel prickly, or be numb... read more .
Retropulsion: Retropulsion is when a person unintentionally steps backward when trying to start walking or falls backward while walking. Doctors may look for a problem with the front lobes of the brain, parkinsonism Parkinsonism Parkinsonism refers to symptoms of Parkinson disease (such as slow movements and tremors) that are caused by another condition. Parkinsonism is caused by brain disorders, brain injuries, or... read more , syphilis Syphilis Syphilis is a sexually transmitted infection caused by the bacteria Treponema pallidum. It can occur in three stages of symptoms, separated by periods of apparent good health. Syphilis... read more , small strokes Overview of Stroke A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply (cerebral infarction). Symptoms occur suddenly... read more , or progressive supranuclear palsy Progressive Supranuclear Palsy (PSP) Progressive supranuclear palsy is characterized by slow movements, muscle stiffness (rigidity), problems moving the eyes, and a tendency to fall backward. Progressive supranuclear palsy progresses... read more as the possible cause.
Footdrop: Footdrop is difficulty lifting the front part of the foot because of weakness or paralysis of the muscles involved. A person's toe drags when taking a step. To avoid catching the toe, people with a dropped foot may lift their leg higher than normal during a step. Footdrop may be caused by nerve damage or muscle weakness.
Short step length: Short step length may be caused by a fear of falling or by a nerve or muscle problem. The leg with the short step is usually the healthy one, and the short step usually occurs when a person spends less time on the problem leg than on the normal leg during walking.
Increased step width: As gait speed decreases, step width normally increases slightly. A wide-based gait can be caused by a problem in the knees, hips,the brain's cerebellum. Variable step width (lurching to one or both sides) may be due to poor muscle control because of a problem in the brain.
Circumduction: Circumduction is moving the foot in an arc rather than a straight line when stepping forward. Circumduction may caused by pelvic muscle weakness or difficulty bending the knee.
Forward lean: Leaning forward while walking can occur in people with kyphosis Kyphosis Kyphosis is an abnormal curving of the spine that causes a humpback. (See also Overview of Bone Disorders in Children.) The upper back normally curves forward somewhat. Some children have a... read more , Parkinson disease Parkinson Disease (PD) Parkinson disease is a slowly progressive degenerative disorder of specific areas of the brain. It is characterized by tremor when muscles are at rest (resting tremor), increased muscle tone... read more , or certain types of dementia (particularly vascular dementia Vascular Dementia Vascular dementia is loss of mental function due to destruction of brain tissue because its blood supply is reduced or blocked. The cause is usually strokes, either a few large ones or many... read more and Lewy body dementia Dementia With Lewy Bodies and Parkinson Disease Dementia Dementia with Lewy bodies is progressive loss of mental function characterized by the development of Lewy bodies in nerve cells. Parkinson disease dementia is loss of mental function characterized... read more ).
Festination: Festination is a progressive quickening of steps (usually while leaning forward) that can cause a person to break into a run to prevent falling forward. Festination can occur in people with Parkinson disease Parkinson Disease (PD) Parkinson disease is a slowly progressive degenerative disorder of specific areas of the brain. It is characterized by tremor when muscles are at rest (resting tremor), increased muscle tone... read more and rarely as a side effect of dopamine-blocking medications (such as certain antipsychotics Antipsychotic Drugs Psychosis refers to symptoms such as delusions, hallucinations, disorganized thinking and speech, and bizarre and inappropriate motor behavior that indicate loss of contact with reality. A number... read more ).
Trunk lean: A person whose trunk leans sidewards may be compensating for joint pain due to arthritis Osteoarthritis (OA) Osteoarthritis is a chronic disorder that causes damage to the cartilage and surrounding tissues and is characterized by pain, stiffness, and loss of function. Arthritis due to damage of joint... read more or foot drop.
Arm swing changes: People with Parkinson disease Parkinson Disease (PD) Parkinson disease is a slowly progressive degenerative disorder of specific areas of the brain. It is characterized by tremor when muscles are at rest (resting tremor), increased muscle tone... read more or vascular dementia Vascular Dementia Vascular dementia is loss of mental function due to destruction of brain tissue because its blood supply is reduced or blocked. The cause is usually strokes, either a few large ones or many... read more may swing their arms less while walking or not swing them at all. Side effects of dopamine-blocking medications can also cause changes in arm swing.
Evaluation of Gait
Doctors try to determine as many potential contributing factors to gait disorders as possible by
Discussing the person’s complaints, fears, and goals related to mobility
Observing gait with and without an assistive device, such as a cane or walker (if safe)
Assessing all components of gait (initiation of gait, right step length and height, left step length and height, and symmetry)
Observing gait again with a knowledge of the person’s gait components
Doctors do a physical examination and ask open-ended questions about any difficulty with walking, balance, or both, including whether the person has fallen (or fear they might fall). Doctors also ask about specific capabilities, such as whether the person 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 tasks. Doctors also assess the person's muscle strength, especially in the calves and thighs.
Sometimes doctors do tests, including computed tomography (CT Computed Tomography (CT) Computed tomography (CT) is a type of medical imaging that combines a series of x-rays to create cross-sectional, detailed images of internal structures. In computed tomography (CT), which used... read more ) or magnetic resonance imaging (MRI Magnetic Resonance Imaging (MRI) Magnetic resonance imaging (MRI) is a type of medical imaging that uses a strong magnetic field and very high frequency radio waves to produce highly detailed images. During an MRI, a computer... read more ), to determine whether the abnormal gait is due to a disorder of the brain, spine, or other part of the body.
Treatment of Gait Disorders
A gait disorder does not always need to be treated or modified. A slow, abnormal gait may help an older person walk safely and without assistance. However, doctors may offer to treat a person's gait to help improve quality of life. Treatments include exercise Exercise in Older Adults Most people over age 65 do not exercise at recommended levels despite the known health benefits of exercise including Longer survival Improved quality of life (for example, endurance, strength... read more , balance training, and assistive devices.
Frail older people with mobility problems may improve with an exercise program. Walking Walking There are many forms of exercise, and each type has its advantages and disadvantages. Some types of exercise expend more calories than others (see table ). Different forms of exercise (for example... read more or strength (resistance) training Strength training People should consult their doctor before beginning competitive sports or an exercise program. Doctors ask about known medical disorders in the person and family members and about symptoms the... read more may reduce knee pain and improve gait in people with arthritis Osteoarthritis (OA) Osteoarthritis is a chronic disorder that causes damage to the cartilage and surrounding tissues and is characterized by pain, stiffness, and loss of function. Arthritis due to damage of joint... read more . Resistance exercises can improve strength, especially if the person is frail and has a slow gait. People usually need two or three training sessions a week until reaching their strength goal. Using good form during each exercise is important to reduce soreness or injury.
A combination of leg press machines (or alternatively chair rises with weight vests or weights attached to the waist), step ups, stair climbing, and knee extension machines may be recommended to strengthen all the large muscle groups involved in walking.
Nordic walking is a walking exercise that exercises the whole body. It includes adjustable length walking poles. Compared with traditional walking, the Nordic walking motion uses shoulder and arm muscles and requires greater pelvic rotation, increasing step length and walking speed. When starting a Nordic walking program, frail walkers need supervision and training to use the walking sticks safely.
Many people with balance problems improve with balance training. First, health care professionals help teach people a good standing posture and balance while standing still. People 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 to look to the left or right. People practice leaning forward (using a wall or counter for support), backward (with a wall directly behind), and to each side. The goal is to be able stand on one leg for 10 seconds.
Balance training can also be more dynamic. Dynamic balance training can involve slow movements in a single stance, simple tai chi Tai chi There are many forms of exercise, and each type has its advantages and disadvantages. Some types of exercise expend more calories than others (see table ). Different forms of exercise (for example... read more movements, tandem (heel to toe) walking, turns while walking, walking backward, walking over a virtual object (for example, a stripe on the floor), slow forward lunges, and slow dance movements.
Assistive devices, such as canes and walkers, can help people maintain mobility and quality of life Quality of Life in Older People Quality of life is often defined as the degree to which a person is healthy, comfortable, and able to participate in or enjoy life events. As such, it is highly personal. What one person views... read more . Physical therapists Physical Therapy (PT) Physical therapy, a component of rehabilitation, involves exercising and manipulating the body with an emphasis on the back, upper arms, and legs. It can improve joint and muscle function, helping... read more help select the proper device and teach people how to use it.
Canes are particularly helpful for people with pain caused by knee or hip arthritis Osteoarthritis (OA) Osteoarthritis is a chronic disorder that causes damage to the cartilage and surrounding tissues and is characterized by pain, stiffness, and loss of function. Arthritis due to damage of joint... read more or with peripheral neuropathy Overview of the Peripheral Nervous System The peripheral nervous system refers to the parts of the nervous system that are outside the central nervous system, that is, those outside the brain and spinal cord. Thus, the peripheral nervous... read more of the feet because a cane transmits information about the type of surface or floor to the cane-holding hand. A quad cane (one with four small feet at the bottom) 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 ).
Walkers can reduce the force and pain at an arthritic joint more than a cane, in people with enough arm and shoulder strength to use them. Walkers provide good stability and moderate protection from forward falls but do little or nothing to help prevent backward falls for people with balance problems. When prescribing a walker, a physical therapist considers the sometimes competing needs of providing stability and maximizing walking efficiency. Four-wheeled walkers with larger wheels and brakes maximize efficiency but provide less stability.
Just the Right Height
Using a cane that is the correct height is important. A cane that is too long or too short can cause low back pain, poor posture, and instability. The cane should be held on the side opposite the weak leg.
Prevention of Gait Disorders
Physical activity, done at recommended levels, help older people maintain mobility, even in people with disease.
Regular walking or maintaining a physically active lifestyle is critical to keeping a healthy gait. The adverse effects of being inactive cannot be overstated. A regular walking program of 30 minutes each day is the best single activity for maintaining mobility. However, walking on flat terrain does not increase strength in a person who is weak. Including inclined surfaces, such as hills, during the walk can help maintain leg strength. The use of canes or walking sticks that are adjustable can provide confidence and safety for older adults.
Prevention also includes strength Strength training Gait disorders are abnormalities in how people walk, such as losing speed, smoothness, symmetry, or balance. Walking, standing up from a chair, turning, and leaning are important for being able... read more and balance training Balance training Gait disorders are abnormalities in how people walk, such as losing speed, smoothness, symmetry, or balance. Walking, standing up from a chair, turning, and leaning are important for being able... read more .