Gait disorders: types, symptoms and characteristics.

A review of the different types of gait disorders and how they affect movement.

Gait disorders greatly affect older adults and contribute to increased morbidity due to the falls they cause.

With each passing day, gait disorders and their consequences are becoming more frequent as we live in increasingly long-lived societies. That is why it is important to know what It is therefore important to know what the different types of gait disorders are and what symptoms characterize them.and what symptoms characterize them.

Normal gait

Gait disorders always involve a failure in balance and in our locomotion system, and generally, they usually affect older people who see how their musculoskeletal systems and postural reflexes deteriorate with aging.

In order to understand how a gait disorder occurs, let us first look at what, in general terms, is the mechanism of normal gait.which can be divided into three phases: toe-off, forward and support.

Take-off

While the knee is locked in extension, the soleus and calf muscles propel the limb, lifting the heel off the ground, at the same time as the muscles of the lower leg are in the same position.while the abductor muscles and quadriceps of the contralateral limb prevent the pelvis from tilting by keeping it fixed.

Forward

With the contralateral limb bearing the full load, the reference limb is lifted and moved forward. To do this, both the hip and knee are progressively flexed, while the ankle and foot are progressively extended to avoid rubbing against the ground.

Ground support

It starts with the heel and immediately involves the entire sole of the foot, keeping the knee slightly flexed. It is at this moment that the toe-off phase of the contralateral limb begins..

Clinical features of gait disorders

Gait disorders may or may not have a neurological origin.. Common non-neurological causes include osteoarthritis of the hip and knee, orthopedic deformities and visual deficits.

The characteristics of a gait disorder may indicate the etiology. Difficulty in initiating gait may be due to Parkinson's disease or frontal subcortical disease. And when gait difficulties are associated with cognitive deficit and urinary incontinence, normotensive hydrocephalus is suspected.

On the other hand, gait shortening is quite nonspecific, but can be found in neurological, musculoskeletal or cardiorespiratory problems.. When there is a loss of symmetry in the movement between the two hemispheres, it usually means that there is a unilateral neurological or musculoskeletal disorder.

If the patient presents high variability in cadence, step length and width, it usually indicates a possible gait motor control disorder due to a cerebellar or frontal syndrome or a multiple sensory deficit. And in patients with a deviated gait, cerebellar and vestibular diseases are often found.

Instability for trunk control can be caused by disturbances in the cerebellum, in frontal subcortical areas and in the basal ganglia.

On the other hand, slowing of gait usually represents degeneration of the basal ganglia and extrapyramidal dysfunction, and very possibly involves early-stage parkinsonism.

Main gait disorders

Gait disorders usually have a multifactorial etiology and it is therefore important to make a thorough diagnosis. A good observation of the patient's gait, signs and symptoms can guide the practitioner to the origin of the predominant disorder.

The main gait disorders are described below:

Due to neurological problems.

This type of gait disorder affects 20-50% of older adults and is one of the most common causes of falls.

1. Hemiplegic or reaper's gait

It is caused by hemiplegia or paresis of the lower extremity, as a consequence of suffering a stroke or other brain injury. The subject has to swing the leg in an outward arc (circumduction) to ensure take-off. (circumduction) to ensure take-off.

At the same time, there is a lateral flexion of the trunk towards the healthy side and a small base of support is maintained, so there is a high risk of falling.

2. Scissors gait

This gait disorder is a type of bilateral circumduction; that is, the person's legs cross while walking. The ankle dorsiflexor muscles are weak and the feet scrape the ground. The patient takes short, effortful steps.

The most common causes are cervical spondylosis and lacunar infarction or multi-infarct dementia..

3. Parkinsonian or festinant gait

The typical gait of Parkinson's disease is bradykinetic, with short, very slow steps that are poorly off the ground.. The person walks maintaining flexion of the hips, knees and elbows, leaning the trunk forward and without swinging movement of the arms.

There is usually a loss of forward balance, as the body begins to move before the feet. With the progression of the movement, the steps usually become faster and, sometimes, they have difficulty stopping and can easily lose their balance.

4. Apraxic gait

It usually appears when there are frontal lobe alterations and is characterized by a wide base of support, a slightly flexed posture and small, hesitant and shuffling steps.

Initiation of gait is usually complicated and patients remain "stuck" to the ground and may sway and fall to the ground.and may sway and fall with the effort of lifting the foot. This gait disorder may appear in patients with Alzheimer's disease, dementia of vascular origin or normotensive hydrocephalus.

5. Ataxic gait

This gait disorder usually occurs in posterior chordal lesions. There is a broad base of support and the patient has a strong gait.. There is usually a loss of positional sense, so that sufferers do not know where their feet are and throw them forward and outward.

These patients often have balance problems and stagger from side to side.. Along with ataxic gait, there are often also significant vitamin B12 deficiencies, spinocerebellar degeneration and cervical spondylosis.

Circulatory problems

In addition to the problems generated by immobility and disuse, there are other pathologies that cause circulatory problems and gait disturbance.

1. Claudicating gait

After a greater or lesser number of steps, the patient experiences numbness, tingling, cramps or pain that force him to stop for a period of time before resuming walking.

2. Musculoskeletal problems

There are other types of conditions that cause muscle weakness and gait disturbancesThese include hypo- and hyperthyroidism, polymyalgia rheumatica, polymyositis, osteomalacia and neuropathies, as well as prolonged use of drugs such as diuretics and corticosteroids.

Any loss of proximal muscle strength leads to unstable and awkward gait.

3. Penguin gait

In this gait disorder, there is a tilt of the trunk outside the foot that is elevated by weakness of the gluteus medius and the inability to stabilize the weight of the hip. These patients have difficulty getting up from low places and climbing stairs..

4. Antalgic gait

This gait disorder occurs in patients with arthritic problems with numbness and pain. The foot is usually placed flat on the ground to reduce impact shock. The toe-off phase is avoided to decrease the transmission of forces through the altered hip.

There is usually a decrease in the static phase of the affected leg and a decrease in the swing phase of the other leg, so that the stride length is reduced.The length of the step is shorter on the good side and the walking speed decreases.

Falls in this type of condition

Falls in the elderly population represent a real public health problem. Approximately 30% of people over 65 years of age who are independent and autonomous suffer at least one fall a year. In those over 75 years of age, the percentage rises to 35%, and up to 50% in the elderly over 85 years of age.

Death rates due to falls are increasing exponentially. with increasing age, in both sexes and in all racial groups.

On the other hand, falls are more frequent in women, although with advancing age, the tendency is to become more equal. In addition, it should be noted that a fall is a risk factor in itself for further falls; for example, in a patient's medical record, a history of a fall is recorded in the patient's medical history, a history of having had a fall is considered a predictor of future hip fracture..

The vast majority of falls occur indoors, unrelated to any particular time of day or time of year. The most frequent places for falls are the bathroom, the kitchen and the bedroom. And the activity most likely to lead to falls is walking. One out of every ten falls occurs on stairs, the descent being more dangerous than the ascent, as well as the first and last steps.

In the event of a fall, the first thing the professional should do is: make a global assessment of the person; identify the risk factors and circumstances of the fall; make an early estimate of the short- and long-term consequences; and, finally, try to prevent further falls.

Bibliographic references:

• Palencia R. Gait disorders: diagnostic protocol. Bol Ped 2000; 40: 97 - 99.
• Villar T, Mesa MP, Esteban AB, Sanjoaquín AC, Fernández A. Gait disturbances, instability and falls. Chapter 19. Geriatrics treatise for residents. Madrid: SEGG; 2007