Gait disturbances Can you describe what happens? Can you rate if from 1 to 10? Do you feel that both sides are affected? What were you doing when you first noticed it Can you think of anything that might have caused it? Did anything in your life change? How ahs this been affecting your life? When did this happen? Constant or episodic? If yes: How often Duration How has this changed over time? Have you had anything like this before? Does anything make it worse? Does anything make it better? Associated features: Differentials: Hemiplegic gait -> lesion in the central nervous system e.g. stroke, space occupying lesion, trauma and MS. Spastic flexion of upper limb and extension of the lower limb. Circumduction their leg to prevent their feet from dragging on the ground. Unilateral Reduced power Sensory deficits Hyper-reflexia with or without clonus. Positive Babinski Diplegic gait: Causes -> spinal spondylitis, spinal tumor, transverse myelitis, spinal infarct, cerebral palsy, MS, bilateral brain infracts, midline brain tumor e.g. paraspinal meningioma. Scissors like Similar to hemiplegic but bilateral in nature Knees forced together due to space of adductor muscles -> result in leg overlap. Hypertonia Hyper-reflexia with or without clonus Positive Babinski Reduced power Sensory deficits Wasting and fasciculations. Parkinsonian gait: Slow initiation Stop length Arm swing -> reduced on one side or both. Posture Tremor Turning -> impaired balance on turning or hesitancy is common due to postural instability. Slow movement Rigidity Hypomimia -> loss of facial muscle expression. Causes: vascular PD, dementia with Lewy bodies, PD pulse syndromes e.g. multisystem atrophy and progressive supranuclear palsy. Drug induced Dementia pugilistic Ataxic gait Associated with midline cerebellar disease e.g. alcoholic cerebellar degermation, vestibular disease e.g. labyrinthitis or loss of proprioception (sensory ataxia) Stance, stability and turning. Cerebral ataxia: Nystagmus Turning difficulties Ataxic dysarthria Dysmetria Intention tremor Dysdiadochokinesia Sensory ataxia Romberg’s sign Impaired proprioception Impaired vibration sensation Absence of other cerebral signs such as dysmetria, nystagmus and dysarthria. Presence of other sensory changes. Vestibular ataxia Vertigo Nausea Vomiting Neuropathic gait: High stepping gait Causes: isolated common peroneal nerve palsy secondary to trauma or compression, L5 radiculopathy e.g. disc prolapse. Weakness of muscles of the distal limb Foot drop and dragging of the toes during the swing phase of the gait cycle, due to weakness of the dorsiflexors. Generalized polyneuropathy involving multiple nerves (e.g. diabetic neuropathy, motor neurone disease, CharcotMarie Tooth disease) Features of peripheral vascular disease Features of sensory impairment Distal muscle weakness Reduced or absent reflexes. Myopathic gait: Causes: hyperthyroidism, hypothyroidism, Cushing disease, acromegaly, polymyositis, DMD, BMD, myotonic dystrophy. Weakness of the hip abductors resulting in waddling appearance. Inability to stabilise the pelvis during a stance phase -> Generalized polyneuropathy involving multiple nerves (e.g. diabetic neuropathy, motor neurone disease, Charcot-Marie Tooth disease) Difficulty standing from a seated position without the use of arms. Difficulty standing from a squat or sitting up from lying position. Generalized polyneuropathy involving multiple nerves (e.g. diabetic neuropathy, motor neurone disease, CharcotMarie Tooth disease) Choreiform gait Involuntary movements such as: Oral-facial dyskinesia -> grimacing or lip smacking. Choreic movements of the upper and lower lips -> writhing, dance like semi purposeful movements. May be present at rest but made worse by movement. Causes: Basal Ganglia diseases -> Huntington’s disease, Sydenham’s chorea, cerebral palsy (choreiform type). Wilson’s disease, dopaminergic medications e.g. PD meds. Antalgic gait: Abnormal pattern which develops due to pain. Typically, the stance phase is reduced on the affected leg -> limping appearance. Causes: OA, inflammatory joint pain, lower limb fractures Nerve entrapment e.g. sciatica.