Walking difficulties and clumsiness

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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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:

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