Higher-Level Gait Disorder

Higher level gait disorder is a disturbance of walking caused by impaired cortical and subcortical integration of motor planning, with relatively preserved strength, sensation and cerebellar function. It includes frontal gait, cautious gait, freezing gait and isolated gait ignition failure.

It is common in older adults with cerebral small vessel disease and is a frequent cause of unexplained falls.

Pathophysiology. Damage to frontal cortex, basal ganglia and their white matter connections disrupts the planning, initiation and automatic control of gait. Common causes are cerebral small vessel disease, normal pressure hydrocephalus, frontal tumours and strokes, frontotemporal dementia, progressive supranuclear palsy and vascular parkinsonism.

Hesitation when starting to walk, feet that appear stuck to the floor, short shuffling steps, wide base, freezing in doorways and when turning, poor postural reflexes, and falls, particularly backwards. When lying down, leg movements such as cycling are normal. Cognitive impairment, urinary urgency and emotional lability often coexist.

Observe gait and turning and examine for parkinsonism, pyramidal signs and frontal release signs. Image the brain, preferably with MRI, for white matter disease, ventriculomegaly, frontal lesions and brainstem atrophy. Assess cognition. In suspected normal pressure hydrocephalus, measure gait before and after removal of 30 to 50 mL of cerebrospinal fluid by lumbar puncture.

Differential diagnosis.

• Parkinson disease and atypical parkinsonism.
• Multifactorial gait disorder, cervical myelopathy and cerebellar ataxia.
• Normal pressure hydrocephalus and frontal tumour.

Treat the underlying cause. Consider ventriculoperitoneal shunting for normal pressure hydrocephalus when the tap test improves gait. Control vascular risk factors (blood pressure, lipids, diabetes, antiplatelet therapy and smoking cessation). Use rhythmic auditory and visual cueing, physiotherapy and a gait aid. A time limited course of levodopa can be tried when parkinsonism is present. Avoid sedatives and anticholinergic drugs.

Monitoring. Gait, cognition and falls every 3 to 6 months.