Gait

Question 1

Spastic

Answer 1

Ascertain level of lesion
Look for signs suggestive of condition eg INO for MS, fasciculations re MND (also dysarthria and tongue fasciculations)

Causes

• demyelination disease
• cerebral palsy
• syringomelia
• MND
• Transverse Myelitis
• spinal cord compression
• anterior spinal artery infarction: sensory deficit with soaring of dorsal column
• hereditary spastic paraparesis
• tropical spastic paraparesis (HTLV1)
• parasagittal falx meningioma
• bilateral cerebral infarcts
• if evidence of significant peripheral neuropathy and cerebellar signs, friedrichs ataxia and B1/12 deficiency should be considered

Question 2

Parkinsonism

Answer 2

Idiopathic
Parkinson’s plus 
- PSP
- MSA (Autonomic, pyramidal and cerebellar signs)
- corticobasal degeneration
- dementia with lewy bodies 
- vascular Parkinsonism
- drug-induced
- toxic (MPTP, manganese)
- genetic (Huntington’s - more likely a kinetic-rigid syndrome, Wilson’s disease)
- dementia pugilistica (Mohammed Ali)
- normal pressure hydrocephalus (apraxic gait, cognitive dysfunction, urinary incontinence)

Question 3

Ataxic gait

Answer 3

Unsteady broad based stamping gait. If subtle then only seen with heel to toe
Look for other cerebellar signs
Ataxic gait/truncates ataxia due to damage to cerebellar vermis - alcoholic degeneration particularly affects this region
Gait ataxia is due to either cerebellar, vestibular or sensory.

Question 4

Apraxic Gait

Answer 4

May be confused with Parkinsonism

Difficulty initiating gait
Inability to lift feet (‘magnetic gait’)
Small steps
Normal heel to shin or cycling manoeuvre
Normal arm swing

Vascular Parkinsonism
Normal pressure hydrocephalus

Question 5

Neuropathic Gait

Answer 5

Ankle foot orthoses
High-stepping Gait (feet don’t dorsiflex)
Feet slap down

Unilateral or bilateral
Distal wasting, particularly with pes cavus, suggests Charcot Marie tooth
In the absence of motor signs, loss of proprioception can also cause high stepping gait

Reflexes may be absent or could be increased with wasting and fasciculations in MND

Peripheral neuropathy with peroneal muscle involvement:
Hereditary: CMT, HNPP
Diabetes
Vasculitis
Sarcoidosis
Paraproteinaemia
Amyloidosis
GBS
MND

Causes loss of joint space:
Tabes dorsalis
Subacute combined degeneration of spine
Diabetes
HIV
Sjogrens syandrome
Paraneoplastic syndromes

Question 6

Myopathic Gait

Answer 6

Difficulty sitting from lying or standing from sitting (without using arms)

Respiratory muscle weakness,

Weak neck flexors and extensors

Normal sensation and reflexes

Waddling Gait

Pseudohypertrophy of calf muscles in
muscular dystrophy

Features of systemic disease eg thyroid or cushings

Features of muscular dystrophy, dermatomyositis (gottrins papukes, heliotropic rash), myotonic dystrophy, inclusion body myositis (wasting of quadriceps and wrist flexors)

Fatiguability or diurnal variation in MG

Muscle biopsy scars (triceps and lateral quadriceps)