Gait disturbance

Gait disturbance is any abnormality in the way a person walks. Walking depends on vision, vestibular and proprioceptive input, central integration in the cerebellum, basal ganglia and frontal lobes, and intact motor and musculoskeletal output. Failure at any level changes gait, and the pattern directs the search for cause.

Clinical relevance. Gait disturbance causes falls, fractures, loss of independence and admission to care. A new or rapidly worsening gait disorder may signal stroke, cord compression, subdural haematoma, normal pressure hydrocephalus or Guillain Barré syndrome.

Classification by pattern.

• Hemiparetic: stiff leg held in extension with circumduction, arm flexed and held across the body (upper motor neuron).
• Spastic paraparetic: stiff, scissoring, slow steps with toe scraping (cord, bilateral cortical).
• Cerebellar ataxic: wide based, staggering, veering, worse on turning and tandem walking.
• Sensory ataxic: stamping, high stepping gait with eyes on the ground and positive Romberg test.
• Parkinsonian: short shuffling steps, reduced arm swing, stooped posture, en bloc turning, festination, freezing.
• Frontal (gait apraxia, magnetic gait): feet appear stuck to the floor, with hesitant start, small steps and wide base, and preserved leg movement when lying down.
• Steppage: high stepping to clear a dropped foot (peroneal nerve, L5 root, neuropathy).
• Waddling: pelvic drop and trunk lurch from weak hip girdle muscles (myopathy) or bilateral hip disease.
• Antalgic: shortened stance on the painful side.
• Vestibular: veering to one side with preserved base, worse in the dark.
• Choreic and dystonic, and functional (variable, bizarre, dramatic fluctuation, knee buckling without falling, improved with distraction).
• Cautious gait of ageing and fear of falling: slow, wide based, short strides, without a clear lesion.

Objective measures. Gait speed under 0.8 m/s over 4 metres predicts adverse outcomes. A Timed Up and Go of 12 seconds or more suggests increased fall risk in community dwelling older adults.

Temporal patterns. Sudden (stroke, cord infarct, hypoglycaemia), days to weeks (Guillain Barré syndrome, myelitis, subdural haematoma, drug effect), months to years (degenerative, hydrocephalus, myelopathy, neuropathy).

History. Onset and speed, progression, falls and near falls, injuries, freezing, legs giving way, leg stiffness or heaviness, pain (hip, knee, foot, back), numbness, balance in the dark, dizziness, visual change, urinary urgency or incontinence, cognitive change, tremor, mood, fear of falling, footwear and walking aids, and home hazards.

Drug history. Sedatives, benzodiazepines, antipsychotics, antidepressants, antihypertensives, diuretics, alpha blockers, nitrates, opioids, antiepileptics, alcohol, anticholinergics, hypoglycaemic agents, and total number of drugs. Occupational exposure to solvents and metals.

Examination

• Observe the patient rising from a chair, standing, initiating gait, walking at usual pace, turning, walking on toes and heels, and tandem walking. Note base width, stride length, arm swing, foot clearance, trunk posture, and pelvic movement.
• Romberg test, pull test for retropulsion, lying and standing blood pressure.
• Tone (spasticity, cogwheel rigidity, paratonia), power (including hip abductors and extensors, ankle dorsiflexors), reflexes, plantar responses, sensation (vibration and proprioception), cerebellar signs, eye movements, tremor and bradykinesia.
• Joints (hip, knee, foot range, deformity, leg length), spine and neck, feet and footwear, vision (acuity, cataract), hearing, cognition, and mood.
• Functional signs: Hoover sign, inconsistent weakness, give way weakness, and improvement with distraction.

Red flags

• Sudden onset, or onset with speech, visual or limb deficit
• Sensory level, bladder or bowel dysfunction, or saddle anaesthesia
• Rapidly progressive weakness or ascending weakness
• Head injury, fall on anticoagulants, or new drowsiness or headache
• Fever with back pain, or recent spinal procedure
• Rapid cognitive decline, or confusion with eye movement abnormality (Wernicke encephalopathy)
• Weight loss or cancer history
• Child with regression, limp with fever, or refusal to bear weight
• Severe injury from falls, or syncope

Special groups. Children: cerebral palsy, Duchenne muscular dystrophy (Gowers sign, calf pseudohypertrophy), hereditary neuropathy, developmental dysplasia of the hip, septic arthritis, and functional gait disorder. Older adults: usually multifactorial (drugs, orthostatic hypotension, sensory loss, myelopathy, degenerative brain disease, sarcopenia). Pregnancy: lumbosacral trunk compression and pelvic girdle pain. Region specific: poliomyelitis sequelae, tropical spastic paraparesis, konzo, lathyrism, leprosy and neurosyphilis.

Hemiparetic and spastic

• Stroke, transient ischaemic attack, intracerebral haemorrhage, subdural haematoma
• Brain tumour, abscess, multiple sclerosis, cerebral palsy
• Spinal cord compression, cervical spondylotic myelopathy, myelitis, subacute combined degeneration, motor neuron disease, hereditary spastic paraplegia
• HTLV-1 associated myelopathy, HIV myelopathy, neurosyphilis, konzo, lathyrism

Cerebellar and vestibular

• Cerebellar stroke, tumour, multiple sclerosis, alcohol related degeneration, hereditary ataxias, paraneoplastic degeneration, gluten ataxia, hypothyroidism
• Drug toxicity (phenytoin, carbamazepine, lithium, benzodiazepines)
• Vestibular neuritis, benign paroxysmal positional vertigo, Meniere disease, bilateral vestibulopathy (gentamicin)

Parkinsonian and frontal

• Parkinson disease, atypical parkinsonism (multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration, dementia with Lewy bodies)
• Drug induced parkinsonism, vascular parkinsonism
• Normal pressure hydrocephalus, frontal lobe tumour, small vessel cerebrovascular disease, frontotemporal dementia

Sensory, neuropathic and lower motor neuron

• Peripheral neuropathy (diabetic, B12, alcohol, hereditary, inflammatory, paraproteinaemic), sensory neuronopathy
• Dorsal column disease (tabes dorsalis, subacute combined degeneration)
• Foot drop from peroneal neuropathy or L5 radiculopathy, lumbar canal stenosis (neurogenic claudication), cauda equina syndrome
• Guillain Barré syndrome, chronic inflammatory demyelinating polyneuropathy

Muscle and neuromuscular junction

• Inflammatory myopathy, muscular dystrophy, steroid myopathy, hypothyroid myopathy, hypokalaemia, hypophosphataemia, vitamin D deficiency myopathy
• Myasthenia gravis, Lambert Eaton syndrome

Musculoskeletal and other

• Hip and knee osteoarthritis, hip fracture, inflammatory arthritis, gout, foot deformity, plantar fasciitis, leg length discrepancy, painful foot lesions
• Peripheral arterial disease with claudication, deep vein thrombosis
• Orthostatic hypotension, anaemia, heart failure, chronic lung disease
• Visual impairment (cataract, macular degeneration, new multifocal lenses)
• Sarcopenia and frailty, deconditioning after illness, fear of falling
• Depression, anxiety, functional gait disorder, malingering

Reasoning. Exclude emergencies first. Then match the pattern to the level of the lesion, check the drug list, and test for reversible causes. Combine causes: older adults often have more than one.

Bedside tests. Lying and standing blood pressure after 5 minutes lying and at 1 and 3 minutes standing (a fall of 20 mmHg systolic or 10 mmHg diastolic is orthostatic hypotension), capillary glucose, pulse rhythm, visual acuity, hearing, cognitive screening, Timed Up and Go, and 4 metre gait speed.

Blood tests. Full blood count, urea, electrolytes, creatinine, calcium, magnesium, phosphate, glucose and HbA1c, liver function, thyroid stimulating hormone, vitamin B12, folate, 25 hydroxyvitamin D (under 25 nmol/L is deficient), creatine kinase, ESR and C reactive protein, HIV and syphilis serology. Add serum protein electrophoresis, tissue transglutaminase antibody with total IgA, paraneoplastic and antiGAD antibodies, copper and caeruloplasmin when relevant. ECG for syncope, dizziness or arrhythmia.

Imaging. Emergency CT or MRI brain for acute or subacute onset, head injury or anticoagulation. MRI brain for chronic progressive gait disorders (atrophy pattern, white matter disease, midbrain atrophy, cerebellar disease, hydrocephalus). MRI spine for any myelopathic signs, sensory level or bladder dysfunction. X-ray or MRI of hip, knee, foot and spine for musculoskeletal pain.

Further tests

• Nerve conduction studies and electromyography for neuropathy, radiculopathy and myopathy.
• Dopamine transporter imaging when parkinsonism is uncertain.
• Normal pressure hydrocephalus: CT or MRI shows ventriculomegaly disproportionate to atrophy (Evans index over 0.3); a high volume lumbar puncture (30 to 50 mL cerebrospinal fluid) with timed walk, stride length and cognition tested before and 2 to 4 hours after supports shunt responsiveness; a negative test does not exclude it.
• Lumbar puncture (after imaging) for inflammatory neuropathy, myelitis and infection.
• Genetic testing for hereditary ataxia, spastic paraplegia and neuropathy after counselling.
• Vestibular testing and audiometry for vestibular gait disorders.

Limitations. Normal brain imaging does not exclude cerebellar or small vessel disease early. White matter change is common in older adults without gait disorder. Functional gait disorder is diagnosed by positive signs, not exclusion alone.

Emergency causes. Acute stroke: immediate stroke team, alteplase 0.9 mg/kg IV (maximum 90 mg) or tenecteplase 0.25 mg/kg IV (maximum 25 mg) within 4.5 hours when haemorrhage is excluded, thrombectomy referral for large vessel occlusion, and aspirin 300 mg orally daily when thrombolysis is not given. Cord compression: dexamethasone 16 mg orally or IV daily with emergency spinal imaging and referral.

Guillain Barré syndrome: intravenous immunoglobulin 0.4 g/kg daily for 5 days with forced vital capacity monitoring. Wernicke encephalopathy: thiamine 500 mg IV every 8 hours for 2 to 3 days, before glucose.

Reduce falls and injury (all patients)

• Review every drug and withdraw or reduce sedatives, antihypertensives, anticholinergics, opioids and psychotropic drugs when possible.
• Supervised balance and strength training (for example 30 minutes, 3 times each week, for at least 12 weeks), tai chi, gait and walking aid assessment, and occupational therapy home hazard review.
• Correct vision (cataract surgery, single vision distance glasses for walking), treat foot problems and provide suitable footwear.
• Vitamin D deficiency: colecalciferol 50,000 units orally weekly for 6 to 8 weeks, then 800 to 2,000 units daily; check calcium and renal function; assess bone density and treat osteoporosis after a fall related fracture.
• Orthostatic hypotension: fluids 2 to 3 L daily and salt 6 to 9 g daily when no heart failure, renal disease or supine hypertension, compression stockings, head up bed tilt 10 to 20 degrees, midodrine 2.5 mg orally three times daily increased weekly to a maximum of 10 mg three times daily (last dose at least 4 hours before bed; avoid in supine hypertension, urinary retention and severe cardiac disease), or fludrocortisone 0.05 to 0.1 mg daily increased weekly to a maximum of 0.3 mg daily (monitor potassium, oedema and supine blood pressure; avoid in heart failure).

Specific causes

• Parkinson disease: neurology referral; levodopa with carbidopa (25 mg/100 mg tablets) half to one tablet orally three times daily 30 minutes before food, increased every 3 to 7 days; usual maximum 8 tablets daily; cueing strategies, physiotherapy and a falls programme. Warnings: nausea, orthostatic hypotension, hallucinations, dyskinesia; avoid with non-selective monoamine oxidase inhibitors and in angle closure glaucoma.
• Normal pressure hydrocephalus: neurosurgical referral for ventriculoperitoneal shunt assessment.
• Cervical myelopathy: urgent spinal surgical referral for progressive deficit or severe signs.
• Spasticity: baclofen 5 mg orally three times daily, increased by 5 mg every 3 days to a usual 30 to 80 mg daily in 3 or 4 doses; maximum 100 mg daily; reduce in renal impairment; withdraw slowly (abrupt withdrawal can cause seizures and rebound spasticity); sedation and weakness limit use. Botulinum toxin injections and ankle foot orthoses for focal spastic or dropped foot; physiotherapy for contracture prevention.
• Subacute combined degeneration and B12 deficiency: hydroxocobalamin 1 mg IM on alternate days until no further improvement (up to 3 weeks), then 1 mg every 2 months.
• Hypothyroidism: levothyroxine 1.6 micrograms/kg orally daily (start at 25 to 50 micrograms in older adults and heart disease).
• Alcohol related disease: abstinence and thiamine 100 mg orally three times daily.
• Hip or knee osteoarthritis: topical diclofenac 1 percent gel (4 g to the knee four times daily; maximum 32 g daily across all joints), paracetamol 1 g every 6 hours (maximum 4 g daily; 2 g daily with weight under 50 kg, chronic alcohol use or liver disease), weight reduction, exercise therapy, and orthopaedic referral for joint replacement when function is severely limited.
• Myopathy: treat the cause (hypokalaemia, hypophosphataemia, vitamin D deficiency, thyroid disease, statin or corticosteroid effect); inflammatory myopathy: prednisolone 1 mg/kg daily (maximum 60 to 80 mg) by specialist decision.
• Peripheral neuropathy: treat the cause. Painful neuropathy: amitriptyline 10 mg orally at night increased by 10 mg weekly to 25 to 75 mg, duloxetine 30 mg daily for 1 week then 60 mg daily, gabapentin 300 mg at night increased every 3 to 7 days to 1.8 to 3.6 g daily in 3 doses (adjust to creatinine clearance), or pregabalin 75 mg twice daily increased to a maximum of 300 mg twice daily.
• Functional gait disorder: positive diagnosis, clear explanation, physiotherapy and occupational therapy with neuropsychiatric input; avoid repeated investigation.
• Vestibular disorders: vestibular rehabilitation exercises; Epley manoeuvre for posterior canal benign paroxysmal positional vertigo.

Monitoring. Gait speed, Timed Up and Go and falls diary at each review; orthostatic blood pressure after drug changes; neurological signs; weight and nutrition; mood.

Referral and escalation. Immediate for any red flag. Neurology for undiagnosed progressive gait disorders, parkinsonism, ataxia and myelopathy. Geriatric falls service, physiotherapy and occupational therapy for multifactorial falls. Orthopaedics for painful hip or knee disease. Ophthalmology for visual impairment.

Admission criteria. Acute neurological deficit, rapidly progressive weakness, spinal red flags, injury from falls, inability to mobilise safely, syncope with high risk features, or delirium.

Discharge and safety netting. Follow up in 2 to 4 weeks. Return for new weakness, numbness, speech or visual change, loss of bladder or bowel control, head injury, repeated falls, or severe pain.