Walking difficulties and clumsiness

Published on 10/04/2015 by admin

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Walking difficulties and clumsiness

Walking is very important to the way we live. The impact of losing this ability on a patient’s lifestyle can be readily appreciated. It is not surprising that the ability to walk independently is a prominent factor in all the scales of neurological disability.

Walking on two legs is a complicated process. It requires:

image an intact skeletal system
image muscular strength
image proprioception
image balance
image vision
image a complicated central system for coordination and integration of these elements
image a safe walking environment.

Any of the elements can cause malfunction. This section will consider the patterns of gait disturbance and a few problems associated with it, in particular syndromes of gait abnormality.

History

In taking the history of a patient with walking difficulties, consider particularly:

image the duration of progression of the gait disturbance documented by independent measures, such as aids used in walking and the distance that the patient is able to walk
image the current walking capacity in terms of distance or speed
image any falls; fear of falling or injury inhibit walking, especially in the elderly
image pain in either the legs or low back, either continuous or brought on by walking.

Frequently the history will clarify the walking difficulty, especially where there is pain, for example in a joint or calf pain brought on by distribution of vascular intermittent claudication. The onset of pain on walking can be neurogenic, usually arising from lumbar canal stenosis. This pain is usually radicular and is often associated with sensory symptoms. In some patients, the deterioration in walking can be entirely due to unilateral symptoms, for example the dragging of one or other leg.

Gait analysis

On watching a patient walk, the disturbance can be broadly subdivided into symmetrical and asymmetrical gait disturbances (Fig. 1).

image

Fig. 1 Gait analysis.

Asymmetrical gait disturbances

Non-neurological gait disturbances are usually asymmetrical. Any underlying orthopaedic problems, for example fixed hip joint or shortened limbs, are usually evident on closer inspection. The limp of someone in pain can usually be seen and corroborated by asking the patient about pain.

The basis of an asymmetrical gait caused by neurological abnormalities can usually be established by conventional neurological examination. These usually reflect unilateral abnormal tone or weakness. Three common patterns are:

1. Hemi-parkinsonian gait. The arm swing is reduced on one side, the posture is slightly stiff and the gait can be slightly hesitant.
2. Hemiplegic gait. One leg is stiff and is swung out and around, often catching the toe.
3. Foot drop. This is a high stepping gait where the heel is brought up high to avoid catching the toe. This is noisy and there is usually a slap as the foot is brought down. This usually reflects unilateral lower motor neurone abnormalities.

Symmetrical gait disturbances

In some patients there may be a symmetrical gait disturbance. These can be broadly divided into:

image broad-based gait, where the feet are widely spaced
image normally based gaits, with the feet a normal distance apart
image crossing or scissoring gait, where the feet cross. These indicate spasticity in both legs.

Heel/toe walking can bring out an imbalance. A patient with a broad-based gait will be unable to walk heel/toe.

Broad-based gait

The feet are separated to try and help balance, hence the inability to walk heel/toe. This usually reflects:

image a loss of proprioception (sensory ataxia)
image loss of coordination (ataxia).

Patients with impaired proprioception have a positive Romberg’s test.

Ataxia with normal sensation indicates a midline cerebellar disturbance. There may also be limb incoordination which produces a clumsy ataxic gait with more widespread cerebellar disease.

Narrow-based gaits

Patients with narrow-based gaits usually have abnormalities of either:

image stride length
image stride pattern
image posture
image arm swings.

Specific conditions

Patients usually have the following gait abnormalities (Table 1).

Table 1 Causes of gait disturbance

Parkinsonism See pages 88–89
Marche à petit pas Diffuse cerebrovascular disease
Apraxic gait
Normal-pressure hydrocephalus
Other diffuse cerebral diseases

Waddling gait
Muscle disease
Hip disease

Crossing-over gait
Spinal cord disease
Bilateral hemisphere disease
Ataxic gait Cerebellar syndrome (see Box 1)

Small steps

image Parkinsonism – short paced, stooped, poor arm swing. May have difficulty starting and stopping. When walking they appear to be falling forward, often trying to catch up with themselves (festinant gait).
image Marche à petit pas – small steps, upright posture, good arm swings. This usually reflects cerebrovascular disease.

Abnormal gait patterns

image Apraxic – great difficulty in starting with broken-up gait pattern. Almost seems to have forgotten how to walk. This usually reflects normal pressure hydrocephalus or diffuse cerebral disease.
image High stepping – bilateral foot drop produces high knee lift and slapping on walking. This can occur with a sensory ataxia, e.g. a patient with a peripheral neuropathy. Classically this is the pattern of gait seen in tabes dorsalis.
image Waddling – a patient with marked hip movement abnormalities will waddle in gait with prominent hip rotation. This can either reflect proximal pelvic weakness so that the pelvic position is not held normally, or bilateral hip disease.

Crossing-over gait – scissoring gait

Patients with bilateral leg spasticity with circumduction from both legs produce a scissoring gait.

Bizarre gait

When you see a patient who has a very bizarre gait, there are several factors to consider:

image Chorea – patients with severe chorea often have bizarre gaits (e.g. Huntington’s disease, Parkinson’s disease on treatment).
image Multiple diseases – patients with an orthopaedic problem and a neurological problem, e.g. a fixed hip and a contralateral hemiplegia.
image Non-organically determined gait – this should also be considered in a patient who seems to use a walking aid quite inappropriately, e.g. carrying a zimmer frame.

Clumsiness

Clumsiness is a symptom patients use to describe:

image weakness
image the effect of sensory loss, particularly posterior column loss
image bradykinesia
image incoordination.

These can usually be readily distinguished in the history or on examination. Examination needs to pay attention especially to the limb movements, including formal testing of coordination and any particular movement the patient has noticed provokes the problem, for example writing or holding a plate.

Cerebellar syndromes

Clumsiness, incoordination and ataxia are the major symptoms and signs found in cerebellar disease. Cerebellar syndromes occur in different diseases (Box 1). The clinical pattern can be divided into two broad categories: asymmetric syndromes due to focal lesions and symmetrical syndromes due to toxic, metabolic and degenerative causes. The most common causes are multiple sclerosis in younger patients, stroke in older patients and toxins including alcohol and some anticonvulsants. There are a number of rarer degenerative conditions, both inherited, such as the spinocerebellar ataxias (many genes have been identified for these conditions) and sporadic, such as multiple system atrophy. Paraneoplastic cerebellar syndromes can be associated with small cell lung and ovarian cancers, and antineuronal antibodies against the Purkinje cells may be found.

Box 1 Causes of cerebellar syndromes

image Multiple sclerosis
image Stroke
image Tumour
image Trauma
image Degeneration
image Metabolic – hypothyroidism
image Paraneoplastic
image Toxic – anticonvulsants and alcohol

Walking difficulties and clumsiness

image Walking is a very important function. Walking difficulties are a major cause of disability.
image Always examine a patient’s walking as it may be the only abnormality.
image There are relatively few readily recognizable patterns of gait abnormality.

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