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Abstract
The present review was carried out to evaluate the gait changes in correlation with aging and in patients with different neurologic disorders, also it has emphasized the importance of gait examination and showed the two types of classifications and enumerated the gait disorders and did not forget the management approaches in helping patients with gait disorders to enjoy better quality of life.
Understanding the basic principles of normal gait provides a foundation for understanding pathological and compensatory gait deficits.
The normal gait cycle, defined as the period between successive points at which the heel of the same foot strikes the ground.
The normal gait seldom attracts attention, but it should be observed with care if slight deviations from normal are to be appreciated. The body is erect, the head is straight, and the arms hang loosely and gracefully at the sides, each moving rhythmically forward with the opposite leg. The feet are slightly everted, the steps are approximately equal, and the internal malleoli almost touch as each foot passes the other. The medial edges of the heels, as they strike the ground with each step, form a straight line. As each leg moves forward, there is coordinated flexion of the hip and knee, dorsiflexion of the foot, and a barely perceptible elevation of the hip, so that the foot clears the ground. Also, with each step, the thorax advances slightly on the side opposite the swinging lower limb.
The muscles of greatest importance in maintaining the erect posture are the erector spinae and the extensors of the hips and knees.
Gait disorders are caused by many neurological and nonneurological diseases and often reflect a broad range of dysfunctions of the central and peripheral nervous systems, the musculoskeletal system, or all.
The ability to walk freely is a basic component of quality of life, since gait is one of the most essential motor tasks required for independence and ambulation. The ability to walk freely is influenced by many disorders, as well as by normal aging.
Observation of the stance and gait of patients with neurologic symptoms may provide important diagnostic information and may immediately suggest particular disorders of motor or sensory function, or even specific diseases.
Gait disturbances can be classified according to the system affected, the phenomenology or objective signs, and the temporal aspects of the disturbance. The system-oriented classification helps in deciding at what level the disturbance originates. It is practical to work out the differential diagnosis of a person who does not walk well based on the level of the lesion.
Walking is one of the most complicated motor activities. Cyclical stepping movements produced by the lumbosacral spinal cord centers are modified by cortical, basal ganglionic, brainstem, and cerebellar influences based on proprioceptive, vestibular, and visual feedback.
The gait changes with advancing age. A typical constellation includes gait slowing, shortening of the stride, and widening of the base. This results in the appearance of a guarded gait, that is, the gait of someone about to slip and fall.
Many patients are aware of the loss of speed and adaptive balance and acknowledge the need to be careful. The nature of this senile gait is not fully understood but may represent a mild degree of neuronal loss, failing proprioception, slowing of corrective responses, or weakness of the lower extremities.
Senile gait disorder is thought to exist in up to one-quarter of the elderly population. Some authorities divide this disorder into components of gait ataxia with mild truncal instability and widened gait, and gait slowing with diminished spontaneous arm swing and bradykinesia.
Postural disorders are particularly frequent in the elderly population. The Duke study of normal aging estimated that gait disturbances affect 15% of the elderly, being the most frequent neurological impairment in this age group.
Among the elderly, falls are the leading source of injury-related deaths.
However, elements of the senile gait are also found in neurodegenerative diseases, and caution is urged to consider the possible presence of a neurodegenerative disorder such as Parkinson disease in elderly patients with gait impairment. Patients unable to walk or care for themselves need admission for supportive care.
Cerebellar gait: The main features of this gait are a wide base (separation of legs), unsteadiness, irregularity of steps, and lateral veering. Steps are uncertain, some are shorter and others longer than intended, and the patient may compensate for these abnormalities by shortening his steps and shuffling, i.e., keeping both feet on the ground simultaneously.
The spastic paraplegic or Para paretic gait is, in effect, a bilateral hemiplegic gait affecting only the lower limbs. Each leg is advanced slowly and stiffly, with restricted motion at the hips and Knees. The legs are extended or slightly bent at the knees and the thighs may be strongly adducted, causing the legs almost to cross, as the patient walks (scissors gait).
Choreoathetotic and Dystonic Gaits: Diseases characterized by involuntary movements and dystonic postures seriously affect gait. In fact, a disturbance of gait may be the initial and dominant manifestation of such diseases, and the testing of gait often brings out abnormalities of movement of the limbs and posture that are otherwise not conspicuous.
Waddling (Gluteal, or Trendelenburg) Gait: This gait is characteristic of the gluteal muscle weakness that is seen in progressive muscular dystrophy, but it occurs as well in chronic forms of spinal muscular atrophy, in certain inflammatory myopathies, lumbar nerve root compression, and with congenital dislocation of the hips.
In Frontal Lobe Disorder of Gait Standing and walking may be severely disturbed by diseases that affect the frontal lobes, particularly their medial parts and their connections with the basal ganglia. This disorder is sometimes spoken of as a frontal lobe ataxia or as an “apraxia of gait”.
Gait of sensory ataxia: The principal features of this gait disorder are the brusqueness of movement of the legs and stamping of the feet. The feet are placed far apart to correct the instability, and patients carefully watch both the ground and their legs. As they step out, their legs are flung abruptly forward and outward, in irregular steps of variable length and height. Many steps are attended by an audible stamp as the foot is forcibly brought down onto the floor (possibly to enhance joint position sense).
When examining patients’ stances and gaits, the physician should observe them from the front, back, and sides. Patients should be asked to rise quickly from a chair, walk normally at a slow pace and then at a fast pace, and then turn around. They should walk successively on their toes, on their heels, and then in tandem (i.e. placing the heel of one foot immediately in front of the toes of the opposite foot and attempting to progress forward in a straight line). They should stand with their feet together and the head erect, first with open eyes and then with closed eyes, to determine whether they can maintain their balance.
When confronted with a disorder of gait, the examiner must observe the patient’s stance and the attitude and dominant positions of the legs, trunk, and arms. It is good practice to watch patients as they walk into the examining room, when they are apt to walk more naturally than during the performance of special tests.
Routine assessment can be performed by a primary care physician; an expert may be needed for complex gait disorders. Assessment requires a straight hallway without distractions and a stopwatch for timing. A measuring tape and a T square or ruler with a right angle may be needed to measure stride length. Measurement of gait kinetics can only be performed reliably in a few laboratories with advanced computer and video technology.
Certain disorders of motor function manifest themselves most clearly as impairments of upright stance and locomotion; their evaluation depends on knowledge of the neural mechanisms underlying these peculiarly human functions. Analysis of stance, carriage, and gait is a particularly rewarding medical exercise; with some experience, the examiner can sometimes reach a neurologic diagnosis merely by noting the manner in which the patient enters the office.