15 - Abnormal Gait Flashcards
What is the definition of a gait disorder?
- Any type of unusual and uncontrollable problems with forward propulsion
- Will not see the characteristic fluid coordination of the stance and swing phases
We will focus on patients with gait problems related to profound neurological disorders
What is the purpose of a gait analysis?
- Gait analysis provides information on strength, balance, position sense, and coordination
- Indicates potential problem in brain, spinal cord, or peripheral nerve
What is the motor activity in normal gait dependent upon?
- Intact reflex arc (intact sensory nerve, functional synapse in spinal cord, intact motor nerve fiber, neuromuscular junction, and competent muscle)
- This is NOT dependent upon higher levels of motor function in brain and cord, but these higher levels may affect reflex
If your reflex is abnormal, what five areas could the problem be in?
- Sensory nerve
- Synapse of spinal nerve
- Motor nerve
- Neuro-muscular junction
- Muscle itself
What are brain areas that control motion?
- Corticospinal or pyramidal tract-regulate fine, discrete voluntary movement
- Extrapyramidal tracts-maintain muscle tone and control gross automatic movements
- Cerebellar system-by receiving both sensory and motor input, it coordinates muscular activity, maintains equilibrium, and helps control posture
Describe the corticospinal or pyrimidal tract
c
Describe the extrapyramidal tracts
c
Describe the cerebellar system
c
Describe the role of all higher motor pathways
All higher motor pathways affect motor activity only through the lower motor neuron
Describe what a lesion of any of these areas produces
Lesion in any of these areas produces characteristic effects on movement or reflex activity that can be used to help localize the lesion
What will you see in an upper motor nerve lesion
- Hyperreflexia
- Clonus
- Spastic weakness of arm extensors and leg flexors
- Discrete movements are lost
Describe clonus
Clonus-normal supraspinal inhibition of antagonistic muscles is lost
Describe the spastic weakness
Spastic weakness of arm extensors and leg flexors
- AKA Spasticity of arm flexors and leg extensors
- This includes the following leg flexors - flexors of hip, knee, and ankle dorsiflexors*** (last one was bold)
What will you see in a lower motor nerve lesion
- Hyporeflexia
- Muscle atrophy
- Flaccid weakness
- Fasciculations
Describe fasciculations
Fine movements of muscle seen under skin due to sensitization to acetylcholine
Describe a spastic gait
- We will refer to it as a hemiparetic/hemiplegic or STROKE gait
- Occurs in unilateral UMNL
- Seen in CVA, brain injury, brain abscess
- Spasticity-increased muscle tone due to UMNL
- Due to exaggeration of stretch reflex
- Rate sensitive or velocity-dependent (if stretched slowly, the tone is normal; if stretched rapidly, increased tone results)
Define paresis
Paresis-weakness
Define plegia
Plegia-spasticity
Define monoplegia
Monoplegia-one arm or leg
Define hemiplegia
Hemiplegia = unilateral arm and leg
Define diplegia
Diplegia = both arms or both legs (paraplegia)
Define quadriplegia
Quadriplegia = both arms and both legs
Describe common CVA patterns
- Cerebral hemisphere-hemiplegia
- Brain stem-quadriplegia
- Spinal cord-cervical:quadriplegia
- Spinal cord-below cervical:paraplegia
Describe the gait of a stroke patient
- Leg is extended and internally rotated because leg flexors (flexors is neurological definition which includes hip and knee flexors, and ankle dorsiflexors) weakened (hip, knee, ankle extended)
- Leg swings laterally and forward to clear ground (circumduction)
- Contralateral hip may tilt downwards to prevent toes from catching floor as leg advanced forward
- Ipsilateral arm flexes at elbow, adducts and internally rotates into trunk, and flexes wrist and fingers-due to weakness of arm extensors and de-differentiation
- In its mildest form, affected arm may just swing less than normal arm
Unilateral upper motor neuron lesion, usually stroke ***
What are the different foot types that can be seen in unilateral UMN lesion?
- Talipes equinovarus
- Talipes varus
- Talipes planovalgus
- Toe flexion
Describe talipes equinovarus
Dorsiflexor/evertor insufficiency or strong activity of their antagonists
Describe the talipes varus
Spasticity of tibialis anterior
Describe the talipes planovalgus
Worsened pre-CVA flatfoot caused by spastic achilles
Describe toe flexion
Spasticity of long flexors
What is a scissors gait?
- We will refer to it as the paraparetic/spastic diplegic or CP gait
- Bilateral upper motor nerve lesion
- CP, CVA, MS, spinal cord disease
What are the types of motor impairment in bilateral UMN lesion?
- Spastic hemiplegia-lesion of contralateral cerebral cortex
- Spastic diplegia-bilateral cerebral cortex
- Spastic quadriplegia
- Athetoid CP
Describe the diagnosis of CP in young children
Because brain is not fully myelinated until the age of 2, be careful making diagnosis of CP before age of 2
Describe the gait of a bilateral UMN lesion
- Legs are extended and thighs are tightly adducted
- Legs are circumducted
- Legs slightly flexed at hips and knees (crouching)
- Arms mildly flexed
- Mimicked by running in knee-deep water
What foot types will we see in a bilateral UMN lesion?
- Talipes equinus
- Hallux valgus
- Talipes varus-spastic hemiplegia
- Talipes valgus-spastic diplegia
- Talipes calcaneus
- Claw toes
Describe a cerebellar ataxic gait
- We will refer to it as the DRUNK gait
- Cerebellar lesion
- Broad-based, speed and length of stride varies irregularly from step to step
- Posture is erect, feet are separated
- Difficulty walking tandem
- Difficulty standing with feet together, even with eyes open. Closing eyes makes situation worse. (NOT a positive Romberg)
NO ROMBERG SIGN ***
Romberg sign is present is when you close your eyes only, but not when your eyes are open (here they are unstable with eyes open)
What population is cerebellar gait common in?
NORMAL in children
Describe sensory ataxic gait
- Resembles drunk gait
- Problem with proprioceptors or peripheral nerve
- However, can maintain balance with eyes open, but lose balance when eyes closed (positive Romberg test)
POSITIVE ROMBERG SIGN ***
What population will commonly display a sensory ataxic gait?
Commonly seen in diabetics with loss of position sense who need to look at floor to tell them where their foot is located in space
** diabetics often lose the peripheral proprioception **
POSITIVE ROMBERG SIGN ***
Describe a vestibular gait
- Pathology located in inner ear
- Falling to affected side whether standing or walking
- Asymmetric nystagmus
- NORMAL proprioception and muscle strength exclude sensory ataxia and hemiparesis
They will have an ataxia, but they also lean to the affected quite a bit ***
Describe a steppage gait
- We will refer to it as the DROPFOOT gait or neuropathic gait ***
- Weakness of ankle dorsiflexion, leg lifted higher (by flexing hip and knee) than normal during swing phase to prevent toes from catching on floor
This is just a weakness of the ankle dorsiflexors *** more of a spastic weakness
What is causing the steppage gait if it is unilateral?
If unilateral: L5 radiculopathy, sciatic neuropathy, peroneal neuropathy
What is the cause of the steppage gait if it is bilateral?
If bilateral: distal polyneuropathy (DIABETES***), lumbosacral polyradiculopathy
What is a waddling gait?
- We will refer to it as the Trendelenberg or “gluteus medius limp” or “duck walk” or myopathic gait***
- Proximal lower limb weakness (hip girdle, primarily gluteus medius which is hip abductor) due to myopathy, neuromuscular junction disease, proximal symmetric spinal muscle atrophy
- May see with hip DJD (due to the pain)
Most COMMON cause of this is muscular dystrophy
Describe the weakened muscles seen in waddling gait
- When muscles too weak to keep the pelvis level when the unaffected foot is picked up, the pelvis will drop down on the unaffected side, producing pelvic rocking
- Trunk tilts towards the affected side to lift hip on unaffected side and provide extra distance between the foot and the floor
UNAFFECTED side drops down unless it is bilateral, then both will drop
Then the trunk goes to the AFFECTED side
What else do we see in waddling gait?
- Pelvis is rotated forward to assist with forward motion of the unaffected side
- Because pelvic girdle weakness is usually bilateral, pelvic tilt and rotation alternates from side to side, giving waddling appearance
What else do we call a steppage gait?
Neuropathic gait
What else do we call a waddling gait?
Myopathic gait
What is a Parkinsonian gait?
- A form of extrapyramidal disease
- Lesion of substantia nigra causing decreased dopamine levels
- Hypokinetic gait
HYPOkinetic ***
Describe the gait seen in Parkinson patients
- Forward rigid stoop with head and neck bent forward, with modest flexion at hips and knees
- Arms flexed at elbows and adducted at shoulders, with resting pronation-supination tremor
- Trouble arising from chair
- Center of gravity tends to remain in back of legs, so once standing, there is tendency to fall backwards (retropulse***)
- Gait initiated with short, shuffling steps which is exacerbated when turning (“pedestal turns”)-must stop before turning
What is festination seen in Parkinson patients?
Festination occurs-once center of gravity gets in front of legs, body tries to catch up with center of gravity with increasing speed
What else do we call the Parkinson gait?
HYPOkinetic gait
What is a choreoathetotic gait?
- Extrapyramidal process; we will call it the WORM-LIKE gait
- Wildly ataxic gait/hyperkinetic gait-gait interrupted by abrupt large amplitude involuntary movements
- Similar movements seen in arms, neck, face
- Balance not affected
A combination of chorea and athetosis - very disabling gate that is HYPERkinetic
What else do we call the choreoathetotic gait?
WORM-LIKE gait
What is an antalgic gait?
Patient favors (dose not put normal weight) on painful extremity which usually results in limited knee flexion and less prominent heel strike and toe off, shortened stance phase and smaller steps
What is an equinus gait?
- Pronounced toe-walking gait
- Usually secondary to congenitally tight gastroc-soleus or sudden growth spurt
- Always consider neurological disorder like CP, myelomeningocele, spastic hemiplegia
If it has been present from birth an it is a spastic type, you have to think spastic cerebral palsy
MORE LIKELY is due to recent growth spurt or due to tight gastroc-soleus ***
