1. DISEASE/DISORDER:
Definition
Gait is the sequence of movement that occurs during ambulation. Balance is the ability to maintain the line of gravity (vertical line from center of mass) of a body within the base of support with minimal postural sway. Normal gait and balance requires intact musculoskeletal and neurological systems, and integration of multiple sensory inputs and neuromuscular execution. Gait impairment may precede other impairments (ADL, cognitive impairment) and represent relatively early stage of disablement process. Gait is also increasing recognized as a reflection of overall health of an older individual predicting death and institutionalization. Therefore, gait evaluation should be included in physiatric evaluation of older adults for possible interventions.
Epidemiology including risk factors and primary prevention
The prevalence gait or balance impairment increases with age. Community-dwelling older adults of age 70 and older had a prevalence of abnormal gait of 35%.1 The pattern of gait abnormalities can be categorized as being neurological (i.e. stroke), non-neurological (i.e. osteoarthritis) or both. Non-neurological causes account for more than 50% of abnormal gait.1 Approximately 10% of abnormal gaits are reported to be due to both neurological and non-neurological etiologies.1 Men appear to have a higher incidence of neurological gait dysfunction, while women have a higher level of non-neurological gait abnormalities. Abnormal gait is associated with higher risk of institutionalization and death.2 More overall, the severe the gait abnormality, the higher the risk is for these negative outcomes.
Etiology
Gait dysfunction can result from any primary nervous system or musculoskeletal system disorders as well as from medical conditions affecting neuromusculoskeletal system (i.e. hypothyroidism).
- Central nervous system disorders: The frontal lobe, parietal cortex, basal ganglia, cerebellum and spinal cord are all involved in coordination of gait, so any abnormalities in those locations would cause dysfunction.
- Stroke, degenerative neurological disease (i.e. Parkinson’s disease)
- Normal pressure hydrocephalus
- Spinal cord lesions (i.e. cervical myelopathy)
- Peripheral nervous system disorders
- Neuropathies, systemic (i.e. vit B12 deficiency-also affect posterior column of spinal cord)
- Nerve injuries or neuropathies, local
- Myopathy (i.e. critical illness neuropathy)
- Neuromuscular transmission disorders
- Musculoskeletal disorders
- Arthritis
- Traumatic injuries (fractures, soft tissue injuries)
- Cardiopulmonary disease
- Peripheral arterial disease
- Poor endurance from chronic obstructive pulmonary disease
- Deconditioning
- Acute deconditioning: Bed rest can result in over 1% loss of muscle strength per day.3 Hospitalization for surgeries or medical illness often lead to gait impairment among older adults.
- Chronic deconditioning: Recent study of the 2003-2006 National Health and Nutrition Surveys (NHANES) showed that two thirds of older adults ≥ age of 60 spent average 9 hours/day of their waking hours.4 Physical inactivity exacerbated the sarcopenia, age-related muscle and strength loss and increases the risk of disability.
Patho-anatomy/physiology
Normal Gait is a result of a complicated interplay of multiple organ systems.
Normal gait requires:
- An ability to integrate sensory input (vision, proprioceptive, and vestibular)
- An execution system (frontal cortex for planning, the basal ganglia for initiation and automatization, the brainstem for integration, the cerebellum for coordination)
- Intact musculoskeletal system
- Supporting cardiovascular system
It is essential to differentiate gait changes related to normal aging versus pathological gait. As people age, they may have thinning of the frontal cortex, impaired sensory input (vision, vestibular dysfunction, proprioceptive loss), reduced muscle mass, strength, and power, and neuromuscular coordination. Healthy elderly adjust their gait patterns by increasing stride width, decreasing stride length and walking speed, and increasing the double support time. With normal aging, gait speed may decline to a certain degree. Gait speed of 1 m/sec or higher has been reported as a general guide for robust older adults without clinical gait abnormalities.5 Clinical gait abnormalities, however, indicate pathological processes.
Gait and balance was traditionally thought to be an automatic process. However, recent studies have shown that high level cognition plays an essential role for normal gait and balance.6 Degeneration of the cholinergic system in the brain is one of main changes associated with aging. The basal forebrain cholinergic complex projects throughout the cerebral cortex and the hippocampus. The cholinergic system plays a vital role in the top-down control of attentional orienting and stimulus discrimination. Recent imaging data support the relationship between central cholinergic activity and falls and slow gait speed in patients with Parkinson’s disease7 and older adults with cognitive impairment.8 Pilot studies also suggested that anti-cholinergic medications may be risk factors for falls. These findings may have implications in developing novel interventions using pharmacological agents in the future.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Overall gait changes with age include flexed trunk posture, decreased hip extension in late stance phase, weak ankle plantarflexion power during push off, and increased variability in stride time and length.9
Table 1. Specific gait patterns associated with particular diseases providing vital clues towards diagnosis.
| Disease | Gait Findings |
| Peripheral neuropathy |
|
| Frontal lobe disease |
|
| Parkinsonian diseases |
|
| Cerebellar disease |
|
| Hemiparetic gait patterns |
|
| Myelopathy |
|
| Normal pressure hydrocephalus |
|
| Musculoskeletal or one-sided pain inducing diseases |
|
Specific secondary or associated conditions and complications
Compromised gait and balance are associated with falls. One third of the elderly living in the community fall each year which can lead to serious injuries such as hip fracture, traumatic brain injury, spinal cord injury and lacerations. Gait abnormality was identified as a predictor for fear of falling.10 Fear of falling may cause anxiety, reduce participation in family and community events, and therefore reduce quality of life. [Please see the Topic-Fall for details]
2. ESSENTIALS OF ASSESSMENT
History
The history should include key systems involved in gait and balance disorders are the nervous, cardiovascular, musculoskeletal, and endocrine systems. A comprehensive medication review and reconciliation is another important aspect of the patient interview. The following are additional questions which may provide insight into a possible gait/balance disorder.
Key questions to ask:
- Have you fallen in the past month? Past 6 months? Past year?
- Have you had “close calls” where you almost fell but caught yourself?
- Are you afraid of falling? What about during the winter months? Do you feel unsteady when standing or walking?
- Are you limiting your activities because of difficulty walking?
- Do you exercise regularly? What does your exercise consist of? Has this decreased over the past year?
- Has anyone, such as family or friends, commented on your walking or mobility over the past year?
Physical examination
Patients should have a full neurologic examination, including testing vision, hearing, vestibular function, muscle tone, reflexes, strength, sensation and balance. It is important to watch the patient walk, noting
- Ability to come from sit to stand
- Mid-line balance
- Width of stance, step length, cadence, gait speed, symmetry of gait, arm swing
- Ability to turn around
- Ability to stand with eyes closed (Romberg test).
A comprehensive musculoskeletal should also be performed including inspection,
- Active and passive range of motion of major joints (hip, knee, ankle)
- Deformity or Instability of joints (i.e. knee)
- Scoliosis, kyphosis
- Posture in standing
A cardiovascular exam should include pedal pulses (peripheral arterial disease), inspection of lower limb for edema, and presence of orthostatic hypotension.
Footwear should be inspected for wear pattern and deformation of upper material. Wear on the lateral heel is normal pattern however, it is excessive, foot may be positioned supinated and prone to inversion injuries. Medial plantar wear pattern is abnormal indicating collapsing arch and excessive pronation. Wear pattern under the forefoot often reflect the poor clearance of foot during swing phase (i.e. hemiplegic patient). Deformation or excess wear of the upper over the big toe may be from extensor Babinski response due to central nervous system disorders.
Functional assessment
Gait speed has been shown to correlate with functional status and long-term survival. 10 m walk test is commonly used for the measurement of gait speed. A speed greater than 1 meter/second correlates with a better life expectancy for a given age. A walking speed greater than 0.8 m/s correlates with being a community ambulator; a gait speed of 0.4-0.8 m/s correlates with being a household ambulator. Non-linear relationship between the leg strength and gait speed in older adults; in stronger individuals, there was no association between strength and gait speed, while in weaker individuals, there was an association.11 [Please see further details in Assessment and Treatment of Balance Disorders]
Laboratory studies & imaging
Laboratory studies are dependent upon the suspected diagnoses based on the history and physical examination. Consider ordering the following studies, depending on the differential:
- Electrodiagnostic studies
- Head CT/MRI
- Cervical spinal cord MRI
- Radiograph of hip, knee, or ankle
- Laboratory tests
- Vitamin B12,
- Hemoglobin A1C
- Serum protein electrophoresis
- Chemistry profile
- Liver function tests
- Thyroid function tests
- C-reactive protein
Environmental
Patients with unsteady gait need to be advised to modify their homes to reduce risk of falling. The entrance to the home and all areas in the home should be well lit. The stairways at entrance to the home and in the home should have railings, two if possible. Hallways and doors need to be wide enough to accommodate ambulatory aids. Bathrooms may need grab bars, raised toilet seats, and safe access to, and use of, bathtub or shower, with tub transfer bench and shower chair. The kitchen and closets may need to be modified to reduce the need for reaching or climbing. There should be no thick ply rugs (e.g., shag) or “throw” rugs. Clutter on the floors should be minimized.
Social role and social support system
Communication between the treatment team and the family is important. The family may notice problems with patient safety or gait before the patient does. The family may be more willing to discuss the problems with healthcare providers than the patient. The patient also may need help from the family in terms of transportation to doctor or therapy appointments and with follow-through on obtaining adaptive equipment, ambulatory aids or making home modifications.
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Proper diagnosis for the cause of the gait and balance disorder is the most important aspect of management and treatment. Identifying a treatable cause of the dysfunction can vastly improve the patient’s quality of life.
Medication reconciliation is a vital part of the plan. Polypharmacy and orthostatic hypotension as a medication side effect are frequent causes of fall. Patients need to be evaluated for orthostatic hypotension; medications need to be reviewed with a goal of minimizing the number associated with impaired cognition or falls.
Exercise interventions to improve gait has been traditionally multifaceted (e.g., strengthening, endurance, and flexibility programs) to address the underlying impairments. Overall these interventions showed only moderate improvement (~up to 16% increase in gait speed).9 The strengthening exercises focuses on prime movers of the lower limb and core muscles by the two to three sets of 10-12 reps of each muscle groups, twice a week on nonconsecutive days. Flexibility exercises are also recommended twice a week. Aerobic exercise is for sustaining the repeated motion of gait and general recommendation is 150 minutes of moderate activities per week. Recently, task specific motor training is introduced as an alternative approach to improve gait.9 The goal of this approach is more efficient use of physiological capacity in body systems for walking (i.e. optimal performance) over the maximum performance. Examples of these exercises are stepping forward and across, walking to set speed using metronome, correction of errors during treadmill walking, and changing directions of walking an oval path or spiral. Task-oriented motor learning exercise program has shown improvement in gait speed in both groups of elderly with moderate and mildly impaired gait.12,13
Some gait abnormalities can be relatively stabilized by lower limb bracing and ambulatory aids. Canes, crutches and walkers increase the base of support and allow proprioceptive feedback through the upper extremities, to compensate for impaired balance and compromised sensory feedback. Ambulatory assistive devices may be prescribed after a trial of different type of devices to improve the compliance. Balance and gait training can be helpful with proper assistive devices. Occupational therapists may recommend the safest way to perform basic and instrumental activities of daily living and home modifications.
The Affordable Care Act (ACA) funds an annual check-up for Medicare beneficiaries. Each check-up presents an opportunity to assess stability of gait. The ACA also promotes the concept of coordination among primary care, emergency rooms, and hospitals in identifying threats to well-being, including falls, each time that an elderly person engages the health care system.
Patient & family education
Patients and families need to be informed of any physical or cognitive deficits that put the patient at risk for falls. They need to be informed of all treatments and environmental modifications that need to be done to protect patient safety.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
New technologies have been promoted to improve balance. These include computer-assisted balance boards and posturography, virtual reality, use of Wii, Kinect or Nintendo games, and balance vests. There is a need to improve the access to rehabilitation services including at home, and funding for home modifications through local programs that support the elderly living in their own homes. Health care workers also need to be aware of community transportation programs that provide people with disabilities and the elderly with convenient and affordable means of transportation.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
Implementation of effective interventions (i.e. balance exercises in a longer term) in clinical practice is a challenge to the rehabilitation specialists. There is no consensus on how to fund home care, geriatric day care, or long-term care that may be necessary to protect or help elderly who are at risk for falls and associated injuries.
REFERENCES
- Verghese J, LeValley A, Hall CB, Katz MJ, Ambrose AF, Lipton RB. Epidemiology of gait disorders in community-residing older adults. J. Am. Geriatr. Soc. 2006;54(2):255-261.
- Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50-58.
- Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J. Gerontol. A. Biol. Sci. Med. Sci. 2008;63(10):1076-1081.
- Dunlop DD, Song J, Arnston EK, et al. Sedentary time in US older adults associated with disability in activities of daily living independent of physical activity. J Phys Act Health. 2015;12(1):93-101.
- Oh-Park M, Holtzer R, Xue X, Verghese J. Conventional and robust quantitative gait norms in community-dwelling older adults. J. Am. Geriatr. Soc. 2010;58(8):1512-1518.
- Oh-Park M. Interplay between cognition and mobility in older adults. Ann Geriatr Med Res. 2017;21(1):2-9.
- Bohnen NI, Muller ML, Koeppe RA, et al. History of falls in Parkinson disease is associated with reduced cholinergic activity. Neurology. 2009;73(20):1670-1676.
- Amboni M, Barone P, Hausdorff JM. Cognitive contributions to gait and falls: evidence and implications. Mov. Disord. 2013;28(11):1520-1533.
- Brach JS, Vanswearingen JM. Interventions to Improve Walking in Older Adults. Current translational geriatrics and experimental gerontology reports. 2013;2(4).
- Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J. Am. Geriatr. Soc. 2011;59(7):1225-1231.
- Buchner DM, Larson EB, Wagner EH, Koepsell TD, de Lateur BJ. Evidence for a non-linear relationship between leg strength and gait speed. Age Ageing. 1996;25(5):386-391.
- VanSwearingen JM, Perera S, Brach JS, Wert D, Studenski SA. Impact of exercise to improve gait efficiency on activity and participation in older adults with mobility limitations: a randomized controlled trial. Phys. Ther. 2011;91(12):1740-1751.
- Brach JS, Van Swearingen JM, Perera S, Wert DM, Studenski S. Motor learning versus standard walking exercise in older adults with subclinical gait dysfunction: a randomized clinical trial. J. Am. Geriatr. Soc. 2013;61(11):1879-1886.
Original Version of the Topic
George Forrest, MD, Zachary Schott, MD, Gabriel Radu, DO. Geriatric gait and balance disorders. 09/20/2013.
Author Disclosure
Mooyeon Oh-Park, MD
Nothing to Disclose
Tomas Salazar, MD
Nothing to Disclose