Frontal Gait Disorder

Frontal gait disorder is a form of gait apraxia in which a person cannot use the legs for walking despite normal strength, sensation and coordination when tested lying down. It is often called magnetic gait.

It is seen most often in older people with normal pressure hydrocephalus, extensive small vessel disease or frontal lobe disease.

Pathophysiology. Lesions in the frontal lobes, supplementary motor area, basal ganglia and their connections interrupt the programming of postural and locomotor sequences. Causes include hydrocephalus, vascular disease, frontal tumours or subdural collections, frontotemporal dementia and progressive supranuclear palsy.

Feet seem glued to the floor, with difficulty initiating gait, short shuffling steps, a wide base, an upright or retropulsed posture, freezing at doorways and turns, and en bloc turning. Falls, often backwards, are common. Lying down, the patient can cycle the legs and perform heel shin testing normally. Dementia, urinary urgency and incontinence, and pseudobulbar affect may accompany it.

Examine for apraxia, frontal release signs, parkinsonism and spasticity. Obtain MRI brain for ventricular size, white matter change, focal lesion and midbrain atrophy. Test cognition and consider a lumbar puncture tap test (30 to 50 mL of cerebrospinal fluid) with gait timed beforehand and after.

Differential diagnosis.

• Parkinson disease and vascular parkinsonism.
• Progressive supranuclear palsy.
• Cervical myelopathy and cerebellar disease.
• Multifactorial gait disorder.

Shunt surgery for normal pressure hydrocephalus is the only treatment that can reverse the gait disorder, and works best when gait is the leading symptom and treatment is given early. Remove compressive lesions where possible. Control blood pressure and vascular risk factors in small vessel disease. Offer physiotherapy with cueing strategies and walking aids, and review sedative drugs.

Referral and escalation. Refer urgently to neurology or neurosurgery for suspected hydrocephalus or a mass lesion.