GAIT IMPAIRMENT Suggestions for Lecturer -1-hour to 1½-hour lecture -Use GNRS slides alone or to supplement your own teaching materials. -Refer to GNRS and Geriatrics at Your Fingertips for further content. -For strength of evidence (SOE) levels, see related GNRS chapter text. -The GNRS Teaching Slides reflect care that can be provided to older adults in all settings. The words patient, resident, and older adult have been used interchangeably, as have the words provider, clinician, and primary care provider. Given the continually ongoing changes in health care today, some of the guidelines around reimbursement may have changed since publication.

OBJECTIVES Know and understand: How to perform a diagnostic evaluation of gait dysfunction How to conduct a gait assessment of the older adult Understand interventions that can possibly reduce impairment

TOPICS COVERED Epidemiology Conditions That Contribute to Gait Impairment Gait Assessment Interventions to Reduce Gait Disorders

Gait disorders are common and a predictor of functional decline EPIDEMIOLOGY Gait disorders are common and a predictor of functional decline Certain gait-related mobility disorders progress with age and are associated with morbidity and mortality Community-dwelling older adults with gait disorders, particularly neurologically abnormal gaits, are at higher risk of institutionalization and death At least 20% of community dwelling older adults admit to difficulty with walking or require assist with mobility. Age-related gait changes (slowed speed) are most apparent after age 75 to 80 years. Most gait disorders appear in connection with underlying disease.

GLOSSARY OF GAIT ABNORMALITIES (1 of 2) Term Description Antalgic gait Pain-induced limp with shortened phase of gait on painful side Circumduction Outward swing of leg in semicircle from the hip Equinovarus Excessive plantar flexion and inversion of the ankle Festination Acceleration of gait Foot drop Loss of ankle dorsiflexion secondary to weakness of ankle dorsiflexors Foot slap Early, frequent audible foot-floor contact with steppage gait compensation Genu recurvatum Hyperextension of knee Topic Slide 5

GLOSSARY OF GAIT ABNORMALITIES (2 of 2) Term Description Propulsion Tendency to fall forward Retropulsion Tendency to fall backward Scissoring Hip adduction such that the knees cross in front of each other with each step Steppage gait Exaggerated hip flexion, knee extension, and foot lifting, usually accompanied by foot drop Trendelenburg gait Shift of the trunk over the affected hip, which drops because of hip abductor weakness Turn en bloc Moving the whole body while turning Topic Slide 6

CONDITIONS CONTRIBUTING TO GAIT DISORDERS IN PRIMARY CARE Usually multifactorial: Degenerative joint disease Acquired musculoskeletal deformities Intermittent claudication Orthopedic surgery Stroke Postural hypotension Dementia Fear of falling Although older adults can maintain a relatively normal gait pattern well into their 80s, some slowing occurs, and decreased stride length thus becomes a common feature in descriptions of gait disorders of older adults. Some authors have proposed the emergence of an age-related gait disorder without accompanying clinical abnormalities, ie, essential “senile” gait disorder. This gait pattern is described as broad-based with small steps, diminished arm swing, stooped posture, decreased flexion of the hips and knees, uncertainty and stiffness in turning, occasional difficulty initiating steps, and a tendency toward falling. These and other nonspecific findings (eg, the inability to perform tandem gait) are similar to gait patterns found in a number of other diseases, and yet the clinical abnormalities are insufficient to make a specific diagnosis. This “disorder” may be a precursor to an as-yet-undiagnosed disease (eg, related to subtle extrapyramidal symptoms) and is likely to be a manifestation of concurrent, progressive cognitive impairment (eg, Alzheimer disease or vascular dementia). Thus, “senile” gait disorder may reflect a number of potential diseases and is generally not useful in labeling gait disorders in older adults.

CLASSIFICATION OF GAIT DISORDERS May classify by abnormal sensorimotor level: Low: peripheral sensory dysfunction Low: peripheral motor dysfunction Middle: postural and locomotor impairment High: cognitive and white matter disorders These levels may overlap when certain disorders involve multiple levels, eg, Parkinson disease involving high (cortical) and middle (subcortical) structures

PERIPHERAL SENSORY DYSFUNCTION Condition or disease Clinical/physical findings Gait abnormalities Peripheral neuropathy, proprioceptive deficits Loss of touch sense, loss of position sense Possible steppage gait; wide-based, unsteady, uncoordinated, especially without visual input; may lift feet high and slap on ground to increase sensory feedback Vestibular disorders Dysequilibrium, abnormal Romberg Weaving (“drunken”), falling to one side Visual impairment Visual loss Tentative, uncertain, uncoordinated See GRS8 Table 31.2

PERIPHERAL MOTOR DYSFUNCTION Condition or disease Clinical/physical findings Gait abnormalities Painful or deforming conditions Pain and decreased motion of hip, knee, or spine; signs of arthritis; thoracic kyphosis; decreased lumbar lordosis; stooped posture Antalgic gait with shortened stance phase on affected side; Trendelenburg gait; buckling of painful limb with weight bearing Focal myopathic, neuropathic weakness Proximal muscle weakness, distal muscle weakness, exaggerated lumbar lordosis (secondary to pelvic girdle weakness) Trendelenburg gait, waddling gait, steppage gait with foot drop or foot slap

POSTURAL AND LOCOMOTOR IMPAIRMENT Condition or disease Clinical/physical findings Gait abnormalities Cerebellar ataxia Poor trunk control, incoordination or other cerebellar signs Wide-based with increased trunk sway, irregular stepping, staggering, especially on turns Parkinsonism Rigidity, bradykinesia, tremor, stooped posture Small shuffling steps, hesitation, festination, propulsion, retropulsion, turning en bloc, absent arm swing, freezing of gait Hemiplegia or hemiparesis Arm and leg weakness, spasticity, equinovarus, genu recurvatum Leg circumduction, loss of arm swing, foot drag or scrape Paraplegia or paraparesis Leg weakness, spasticity Bilateral leg circumduction, scraping feet, possibly also scissoring

COGNITIVE AND WHITE MATTER DISORDERS Condition or disease Clinical/physical findings Gait abnormalities Frontal lobe disease, dementia, normal-pressure hydrocephalus Cognitive impairment, weakness and spasticity, urinary incontinence Range of findings may include difficulty initiating gait, freezing, leg apraxia, and shuffling gait similar to that seen in Parkinson disease but with wider base, upright posture, preservation of arm swing Dementia (Alzheimer disease, vascular) Mid- to late-stage dementia, may have fear of falling Cautious gait with normal to widened base, shortened stride, decreased velocity, en bloc turns

GAIT ASSESSMENT: KEY POINTS Careful medical history and physical exam can elucidate contributing factors Laboratory and diagnostic imaging may be warranted, depending on history and physical exam Use a gait assessment tool (eg, timed Get Up and Go) Establish person’s comfortable gait speed; use as both assessment and outcome measure Remember that most gait disorders are associated with underlying disease

HISTORY & PHYSICAL EXAM (1 of 3) Evaluate for evidence of subacute metabolic disease, acute cardiopulmonary disorders, other acute illness Attempt to identify motion-related factors, eg, by provoking both vestibular and orthostatic responses Dix-Hallpike test for vestibular dysfunction Supine and standing BP to exclude orthostatic hypotension Vision screening, at least for acuity, is essential

HISTORY & PHYSICAL EXAM (2 of 3) Evaluate neck, spine, extremities, and feet for pain, deformities, and limited range of motion, particularly regarding subtle hip or knee contractures Measure leg-length discrepancies, such as can occur with a hip prosthesis and either as an antecedent or subsequent to lower back pain Simply evaluate the distance from the anterior superior iliac spine to the medial malleolus

HISTORY & PHYSICAL EXAM (3 of 3) A formal neurologic assessment is critical; assess strength and tone, sensation (including proprioception), coordination (including cerebellar function), station, and gait The Romberg test screens for simple postural control and whether the proprioceptive and vestibular systems are functional Given the importance of cognition as a risk factor, assessing cognitive function is also indicated

LABORATORY & IMAGING ASSESSMENTS A CBC, serum chemistries, and other metabolic studies may be useful when systemic disease is suspected Head or spine imaging, including radiography, CT, or MRI, are not indicated unless history and physical examination identifies neurologic abnormalities, either preceding or of recent onset, related to the gait disorder Cerebral white matter changes, often considered to be vascular (termed leukoaraiosis), have been increasingly associated with nonspecific gait disorders. Periventricular high signal measurements on MRI as well as increased ventricular volume, even in apparently healthy older adults, are associated with gait slowing. White-matter hyperintensities on MRI correlate with longitudinal changes in balance and gait, and the periventricular frontal and occipitoparietal regions appear to be most affected. Functional MRI generally supports these structural MRI findings, and diffusion tensor imaging techniques show that small-vessel disease, even in normal-appearing white matter, can affect gait. Age-specific guidelines for these evaluations and their sensitivity, specificity, and cost-effectiveness remain to be determined.

COMFORTABLE GAIT SPEED Measure as part of a timed walk For a short distance (eg, 10 feet) or As a distance walked over time (eg, 6 min) Predicts disease activity (eg, arthritis), cardiac and pulmonary function, mobility and ADL disability, institutionalization, and mortality Comfortable gait speed and a related measure, distance walked (as measured by the 6-minute walk test), are powerful predictors of a number of important outcomes, such as falls, disability, hospitalization, institutionalization, and mortality. Gait speed is faster in individuals who are taller, who have a lower disease burden, and who are more active and less functionally disabled. Usual gait speed is frequently tested from a standing start over a distance of 4 meters. A recent pooled analysis of nine cohort studies of community-dwelling older adults found that usual gait speed predicted 5- and 10-year survival as accurately as a number of other important clinical variables such as age and chronic conditions. The likelihood of poor health and function increases at usual walking speed cut-offs of 0.8 or 1.0 meter per second (m/s) and particularly below 0.6 m/s; speeds >1.0 m/s and perhaps 1.2 m/s are associated with better functional outcomes and increased life expectancy. Several studies have found age- and disease-associated deficits in the ability to walk and perform a simultaneous cognitive task (“dual tasking,” such as talking while walking), and also linked these deficits with increased fall risk, often using a measure of gait variability.

THE TIMED GET UP AND GO TEST Record the time it takes a person to: Rise from a hard-backed chair with arms, walk 10 feet (3 meters), turn, return to the chair and sit down Most adults can complete in 10 sec and most frail older adults can complete in 11 to 20 sec ≥14 sec =  falls risk >20 sec  comprehensive evaluation One study suggests a TUG score of ≥14 seconds as an indicator of fall risk. Other investigators have found limitations in TUG in the presence of cognitive impairment and difficulty in completing the test because of immobility, safety concerns, or refusal.

INTERVENTIONS TO REDUCE GAIT DISORDERS Many conditions causing a gait disorder are, at best, only partially treatable Other outcomes, such as pain reduction, may be equally important in justifying treatment Comorbidity, disease severity, and overall health status tend to strongly influence outcome Improvement in gait performance is a reasonable goal as long as gait remains safe

EXERCISE & PHYSICAL THERAPY Knee osteoarthritis: PT can modestly improve gait speed, with residual disability RCTs focusing on strengthening, walking, and aerobic training have shown positive outcomes on physical function, including improved walking Parkinson gait disorders: audio and video cueing by a PT might improve gait speed Post-stroke: RCTs support strength training, EMG biofeedback, and functional electrical stimulation as adjuncts to gait training RCT = randomized controlled trial; EMG = electromyographic. A few studies of group exercise have shown improvements in gait parameters such as gait speed. Generally, the most consistent effects are with varied types of exercise provided in the same program, such as leg resistance, standing balance, and flexibility exercises.

SURGERY Compressive cervical myelopathy, normal-pressure hydrocephalus: No well-designed RCT has compared surgery with nonoperative treatment Lumbar stenosis: Good evidence that laminectomy or lumbar fusion can reduce pain, improve maximal walking distance in older adults Also good evidence that oral NSAIDs, heat, exercise, mobilizations, etc. can modestly improve walking Hip and knee osteoarthritis: Multidisciplinary rehabilitation after surgery can result in sizable gains in gait speed and joint motion

MOBILITY AIDS Lifts (internal or external) to correct limb length inequality, used in a conservative, gradually progressive manner Ankle braces, shoe inserts, shoe body and sole modifications Walking shoes with low heels, relatively thin firm soles, and if feasible, high, fixed heel collar support Canes and walkers reduce load on a painful joint and increase stability Light touch on a wall, or “furniture surfing,” provides feedback and enhances balance

SUMMARY Gait disorders are a predictor of functional decline in older adults The cause of gait impairment in older adults is usually multifactorial, so a detailed physical examination, functional performance evaluation, and sometimes laboratory tests and imaging must be performed Various interventions, ranging from exercise to medical treatment to surgery, can improve gait speed and other gait parameters, but some residual impairment is often present

QUESTION 1 (1 of 2) Which of the following clinical tests is the best single predictor of institutionalization, disability, and morbidity in older adults? Muscle strength using chair stand test Balance using a standardized balance scale Gait speed Hand-grip strength

QUESTION 1 (2 of 2) Which of the following clinical tests is the best single predictor of institutionalization, disability, and morbidity in older adults? Muscle strength using chair stand test Balance using a standardized balance scale Gait speed Hand-grip strength ANSWER: C In addition to age and sex, gait speed is associated with survival in community-dwelling older adults. Walking requires adequate function of cardiovascular, pulmonary, nervous, and musculoskeletal systems. Slowed gait may represent undiagnosed disease, physical deconditioning, or both. Gait speed can be easily assessed in a clinic setting using a 4-m walkway and a stopwatch. It has been suggested that walking speed >1 m/sec represents healthy aging and that speed <0.6 m/sec increases the likelihood of functional decline and death. Slow gait speed is associated with subsequent institutionalization, disability, and other adverse events in older adults. Assessments of muscle strength (using the chair stand test) and balance (using a standardized balance scale) have been used in combination with gait speed to predict nursing-home admission and mortality. Gait speed alone is almost as good a predictor as the combination of muscle strength, balance, and gait speed. Grip strength has been shown to be a predictor of impaired mobility. However, there is variability in the methods and instruments used to measure grip strength, and a hand-grip dynamometer is often not available. A longer test, such as the 6-minute walk test, provides additional predictive information, but the test is not practical in many clinical settings because it requires a walkway without traffic and a longer time for testing. In addition, there appears to be a practice effect, leading to the recommendation that the test be repeated—for a total of ≥12 minutes—to obtain the most accurate result.

CASE 1 (1 of 3) A 75-year-old woman comes to the office for her 6-month follow-up visit. She lives independently and is independent in instrumental activities of daily living. She reports both a decline in her ability to walk long distances and difficulty crossing streets: the light changes before she can reach the opposite side. She has no numbness, tingling, or changes in sensation in her extremities. During the appointment, she at times uses the wall for support. Physical examination is otherwise unremarkable.

CASE 1 (2 of 3) Which of the following is the most appropriate next step? Refer to social work for long-term care options. Refer for an individualized, supervised exercise program. Refer to a neurologist. Obtain MRI of the head and spine. Obtain glucose, vitamin B12, and thyroid levels.

CASE 1 (3 of 3) Which of the following is the most appropriate next step? Refer to social work for long-term care options. Refer for an individualized, supervised exercise program. Refer to a neurologist. Obtain MRI of the head and spine. Obtain glucose, vitamin B12, and thyroid levels. ANSWER: B The patient reports a decline in walking endurance and speed, demonstrated by her inability to cross streets within the time provided by the traffic lights. She reports no changes in peripheral sensation, and there are no neurologic findings. Using the wall for support suggests that her balance is impaired and that she may benefit from use of an assistive device. She is an ideal candidate for a structured, supervised exercise program. An appropriate exercise program would likely result in an improvement in walking endurance, speed, balance, and strength. If improvement does not occur, additional assessments may be needed. According to the ACOVE (Assessing Care of Vulnerable Elders) quality indicators, there should be documentation of a structured or supervised exercise program offered in the previous 6 months or within 3 months after the report of decline to meet high quality-of-care standards. The patient’s symptoms and normal physical examination do not suggest the need for MRI of the head and spine, or referral to a neurologist. Her change in gait speed and balance can be explained by poor endurance alone. Although a stroke, tumor, or other neurologic disease could affect gait and balance, the abnormality would consistently impair her ability to walk. For example, after a stroke in the cerebellum, patients demonstrate an ataxic gait pattern and instability whenever they walk, not just with longer distances, as this patient is demonstrating. She has no symptoms of peripheral neuropathy; hence, laboratory assessment for diabetes mellitus, vitamin B12 deficiency, and thyroid disease is not indicated. The patient’s function has declined but not to a degree that warrants a social work referral for consideration of long-term care options.

CASE 2 (1 of 3) An 86-year-old woman is admitted to the hospital with pneumonia. Her baseline ambulatory status is borderline: she can walk short distances in her home independently without an assistive device, but she is unable to manipulate stairs, rough terrain, or curbs.

CASE 2 (2 of 3) Which of the following inpatient interventions is most likely to allow her to maintain her current walking ability? Physical therapy evaluation Occupational therapy evaluation Instruction to spend time “out of bed to tolerance” Instruction to walk 3 times/day Instruction to sit in bedside chair for an hour each morning and evening

CASE 2 (3 of 3) Which of the following inpatient interventions is most likely to allow her to maintain her current walking ability? Physical therapy evaluation Occupational therapy evaluation Instruction to spend time “out of bed to tolerance” Instruction to walk 3 times/day Instruction to sit in bedside chair for an hour each morning and evening ANSWER: D Hospitalization is associated with bed rest and low mobility that can be detrimental to functional status, especially for a patient with borderline ambulatory ability. The best way to prevent functional decline is to have the patient walk 2 to 3 times/day. The exact amount needed to prevent decline is unknown and most likely is related to the physical status of the patient. For example, currently it is not clear whether walking 2 times/day for 10-minute sessions is better than walking 4 times/day for 5- minute sessions. Physical therapy evaluation alone would not guarantee that the patient would participate in a daily walking program while she is in the hospital. However, physical therapy evaluation can be helpful to determine whether an assistive device is needed, the patient is safe walking alone, or other therapeutic strategies would be beneficial. Occupational therapy evaluation would not maintain walking ability. An order specifying “out of bed to tolerance” does not guarantee that the patient will actually walk while she is in the hospital. Sitting in a chair 2 times/day may be beneficial in terms of changing position and posture, but it would not help the patient maintain her current ambulatory status.

Copyright © 2014 American Geriatrics Society GNRS4 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS4 Teaching Slides modified from GRS8 Teaching Slides based on chapter by Neil B. Alexander, MD and questions by Claire Peel, PT, MS, PhD Managing Editor: Andrea N. Sherman, MS Copyright © 2014 American Geriatrics Society Slide 33