Walking difficulties and clumsiness

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:

Related posts:

CNS neoplasia I: Intracranial tumours Parkinson’s disease and other akinetic rigid syndromes II Head injury Blackouts and ‘funny do’s’ Organization of the nervous system Peripheral neuropathies I: Clinical approach and investigations

Stay updated, free articles. Join our Telegram channel
Tags:
Jun 10, 2016 | Posted by in NEUROLOGY | Comments Off on Walking difficulties and clumsiness

Full access? Get Clinical Tree
Get Clinical Tree app for offline access