Useful Selected Questions to Ask/Facts to Establish (During Gait Assessment)

Remember: It is important to ask about falls and if they have occurred, their frequency and the circumstances in which they have occurred.

First, observe the patient attempting to arise from the chair or bed with their arms folded across their chest. Do they fall back into the chair and require more than one attempt? Do they require the use of their arms to push up or assistance to stand? Any staggering on arising? If struggling to stand, is there possible unilateral or bilateral lower limb disturbance?
Posture on standing (e.g. stooped, normal or hypererect, position of the arms and head and neck).
Ask the patient to walk forward for a minimum of 10 m, turn and walk back observing for and commenting upon gait initiation, stride length, cadence, corner turning, arm swing, gait base, unilateral weakness/dragging of a limb, waddling, foot drop, unsteadiness/veering or apparent discomfort/pain.
Next ask them to close their eyes and perform a Romberg’s test. A pull test assessing postural reflexes can also be performed (the examiner stands behind the patients and instructs them to maintain their balance when pulled backwards; the examiner pulls back briskly on the shoulders assessing the patient’s ability to recover, being careful to prevent the patient from falling and noting whether they step back to save themselves or take several steps back before correcting or need to be caught).
Depending on the clinical situation, further information is obtained by asking the patient to tandem walk, walk on their heels or on their toes or observe them running or walking backward.

Differential Diagnoses

Clinical conditions (types of gait disturbance)	Points to note
Spastic hemiparesis/paraparesis	Due to brain, brainstem or cord disturbance, accompanied by upper motor neurone signs. The lower limb or limbs may be held in extension requiring circumduction of the limb on walking to avoid the front of the foot catching on the floor. Spontaneous clonus may be observed
Gait suggestive of extrapyramidal disorder (PD, MSA, PSP, CBD) (Chapter 19)	May take several attempts to stand, once stood posture is typically stooped with shortened stride length and steps, shuffling steps, festination, gait initiation failure, freezing, en bloc turning and absence of arm swing. Non-degenerative conditions may also produce short shuffling steps, gait initiation failure and freezing and include vascular parkinsonism, normal pressure hydrocephalus and drug-induced parkinsonism
Broad-based gait	May be due to a cerebellar or sensory ataxia. To distinguish, look for associated symptoms and signs of cerebellar dysfunction versus symptoms and signs associated with proprioceptive loss (positive Romberg’s)
Foot drop (Chapters 9 and 23)	Can be central in origin, for example stroke or due to a peripheral disturbance, or seen in conditions with both upper and lower motor neuron signs, for example motor neurone disease
Waddling gait (Chapter 28)	Proximal lower limb weakness, which may be due to a disturbance of skeletal muscle leading to a waddling gait, problems in getting up from a chair and particular difficulty in getting up from a squatting position

Basic Investigations

Guided by the localisation of the problem and its likely aetiology.
MRI imaging: An acute problem localising to the cervical or thoracic cord will require urgent MRI imaging of the cord at the clinically apparent level and above. MRI or CT brain is appropriate in a patient with a parkinsonian gait disorder possibly
due to structural causes for example, normal pressure hydrocephalus.

Basic Management

Addressing the underlying cause. See relevant chapters in Part III (see differential diagnoses table above).
Multidisciplinary approaches involving for example physiotherapy as well as appliances such as walking aids, ankle orthosis, and so on should be considered.
Assessing and managing falls and falls risk is very important.

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