Approach to unsteadiness and gait disorders

Approach to unsteadiness and gait disorders
Neurologist point of view

1. Approach to Unsteadiness
and Gait disorders
Ahmad Shahir Mawardi
Neurology Department
Hospital Kuala Lumpur
31
st
Oct 2018

3. Outlines
•Defination
•Physiology of normal gait
•Examinations
•Classifications
•Videos
•Investigations
•Take home messages

6. Walking (Gait cycle of human)

7. Unsteadiness
•Loss of one's equilibrium in regard to the
environment, often with a feeling of almost
falling, or the result of bumping into things.
•cerebral or cerebellar portions of the brain,
the spinal cord, vestibular system, or inner
ear.
•Unsteadiness is medically distinct from
dizziness, lightheadedness, and vertigo.

9. Frequency of etiologies of neurologically
referred undiagnosed gait disorders
“Other” etiologies include metabolic encephalopathy, antidepressant and
sedative drugs, toxic disorders, brain tumor, and subdural hematoma.
Sudarsky L. Clinical approaches to gait disorders of aging. In: Masdeu J, Sudarsky L,
Wolfson L, eds. Gait Disorders of Aging: Falls and Therapeutic Strategies.
Philadelphia: Lippincott-Raven; 1997, pp. 147–158

10. Midline syndromes
•characterized by imbalance.
•unsteady,unable to stand in Romberg
with eyes open or closed,
•unable to well perform tandem gait.
•truncal ataxia
•titubation
•eye movements. There may be
nystagmus, ocular dysmetria and poor
pursuit.
Hemispheric cerebellar syndromes
•characterized by incoordination of the
limbs.
•decomposition of movement, dysmetria,
and rebound.
•Dysdiadochokinesis
• Intention tremors, kinetic tremor
•The finger-to-nose and heel-to-knee
tests
• reflexes may be depressed
•Speech may be dysarthric, scanning, or
have irregular emphasis on syllables.

11. Risk Factors for Falls

14. Normal Gait and balance
•are evidenced by a rhythmicity and fluidity
that produce forward progression with a
•stable upper body and easy adaptability to
environmental demands
•the first and most elementary demand
being turning while walking.

15. •Gait is a form of body adaptation of the
underlying medical problems

16. Examination for Gait and Balance
Abnormalities
•While sitting in a chair
•Arising from sitting
•Standing
•Walking
•Turning
•Response to pull and push and release tests
•Sitting on an exam table

18. con't

20. Classification of Gait Patterns
•Hughlings Jackson’s hierarchy of levels of
nervous system dysfunction
–lowest level
–middle level
–highest level
•Further sub divided to sensory and motor
conditions in each level

21. Lowest-Level (Motor) Disorders
•impair force production for postural responses and
gait
*stereotyped: the clinical signs are always present and
do not vary from minute to minute

23. Lowest-Level (Sensory) Disorders
•inform the nervous system of body position,
support surface and direction of gravity

25. Middle-Level Neural Function
•basic locomotor and balance programs are intact but the
programs are altered by distortion of motor output.
–superimposed chorea, dysmetria, dystonia, spasticity and
parkinsonism.
•stereotyped and constantly present

27. Highest-Level Gait (motor) Patterns
•failure to interpret and integrate sensory information to
select and execute appropriate motor plans
–--> ineffective gait patterns and inappropriate postural
responses
•Not stereotyped and may vary minute to minute.

28. •characteristic of wide spread cerebral small vessel
disease, idiopathic normal pressure hydrocephalus and
some degenerative disorders.
•Can be mimicked !
•Cautious gait: sense of insecurity imposed by a diseased
CNS
•Careless: poor insight who adopt a gait pattern that is
inappropriate, generally too fast, for the environment or
their gait and balance abilities.

31. Highest-Level Sensory
Abnormalities
•Generally from strokes in temporal and parietal lobes,
distort the perception of postural verticality --> produce
the Pusher syndrome.
–patients actively push away from the nonhemiparetic side
•PSS: rarely recognized and poorly defined clinical phenomenon
–cause: dementia (no clear anatomical association).

33. Other
gaits

34. Investigations (I)
1. Blood work
–FBS, RP, LFT, TFT
–vitamin B12
–LP
2. Radiography of the hips, spine, and extremities
3. CT/MRI brain / spine
–enlarged ventricles, SOLs e.g subdural fluid collection, old
ischemic strokes, cerebral atrophy, and diffuse white matter
changes.
–Spine SOLs, spinal stenosis, or spinal deformities

35. Investigations (II)
4. NCS/EMG: neuropathic or myopathic
problem
5. Vestibular testing
6. Comprehensive gait and balance analysis
using instrumentation
–optoelectronic systems, quantitative
posturography, and shoe-integrated wireless
sensor systems

36. Take home messages (I)
•Gait and balance disorders are common, especially
among older adults, and a significant source of disability
and limited quality of life.
•An active lifestyle is an important part of minimizing the
risk of falls and balance difficulties as inactivity leads to
deconditioning.
•Walking is a complex motor behavior that can be
affected by lesions at multiple levels of the neuraxis and
musculoskeletal system.

37. Take home messages (II)
•A gait problem is the result of the primary gait difficulty
and the associated compensatory mechanism.
•A gait pattern can help establish what structures of the
neuraxis are affected and therefore localize the lesion
•Good proprioception, vision, and vestibular inputs are
needed to maintain good balance; impairment of at least
two of these inputs can seriously affect balance.

38. References
1. Critchley, M and Critchley, EA. John Hughlings Jackson:
Father of English Neurolgy.,1996.
2. Dale, ML, Curtze, C, and Nutt, JG. Apraxia of gait- or
apraxia of postural transitions? Parkinsonism Relat
Disord. 2018; 50:19-22.
3. Elble, RJ. Gait and dementia: moving beyond the notion
of gait apraxia. J Neural Transm. 2007; 114:1253-1258.
4. Nonnekes, J, Goselink, RJM, Ruzicka, E, et al.
Neurological disorders of gait, balance and posture: a
sign-based approach. Nat Rev Neurol. 2018; 14:183-
189.

39. Thank you
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