Mary McDonald, MD Muskuloskeletal Module Gait Mary McDonald, MD Muskuloskeletal Module

Basic Components of Gait Stride Length-should be at least twice foot length Stance- widens with gait pathology Posture- upright, kyphotic, stooped Arm Swing- symmetrical Balance-especially with rising, turning Speed

Definitions Ataxic gait- unsteady, uncoordinated walk with a wide base of support and the feet thrown outward. Antalgic gait- a painful, limping gait to avoid pain of weight-bearing structures Apraxic gait-loss of ability to carry out familiar, purposeful movements in the absence of paralysis or other motor or sensory impairment

More Definitions Festinating Gait- characterized by flexed trunk and legs flexed stiffly at the knees and hips. Absent arm swing. Short steps with become faster over time. Seen in Parkinson’s Disease and other neurologic disorders

GAIT ASSESSMENT: KEY POINTS Use a gait assessment tool (eg, timed Get Up and Go test) Establish person’s comfortable gait speed Remember that most gait disorders are associated with underlying disease

THE GET UP AND GO TEST Record the time it takes a person to: Walk 10 feet (3 meters) Turn Return to the chair Rise from a hard-backed chair with arms Sit down

THE GET UP AND GO TEST Most adults can complete in 10 sec Most frail elderly adults can complete in 11 to 20 sec ≥14 sec =  falls risk >20 sec  comprehensive evaluation Results are strongly associated with functional independence in ADLs

CONDITIONS THAT CONTRIBUTE TO GAIT DISORDERS Degenerative joint disease Acquired musculoskeletal deformities Intermittent claudication Impairments following orthopedic surgery Impairments following stroke Postural hypotension Dementia Fear of falling Usually multifactorial

CLASSIFICATION OF GAIT DISORDERS May classify by abnormal sensorimotor level: low, middle, and high These levels may overlap when certain disorders involve multiple levels, eg, Parkinson’s disease involving high (cortical) and middle (subcortical) structures

LOW SENSORIMOTOR LEVEL GAIT DISORDERS Peripheral sensory Sensory ataxia (unsteady, uncoordinated) Vestibular ataxia (unsteady, weaving) Visual ataxia (tentative, uncertain) Peripheral motor Arthritic (antalgic, joint deformity) Myopathic and neuropathic (weakness)

MIDDLE SENSORIMOTOR LEVEL GAIT DISORDERS Spasticity Hemiplegia, hemiparesis (leg swings out) Paraplegia, paraparesis (bilateral circumduction) Parkinsonism (small shuffling steps, hesitation, festination, propulsion, retropulsion, turning en block, absent arm swing) Cerebellar ataxia (wide-based gait with increased trunk sway, irregular stepping)

HIGH SENSORIMOTOR LEVEL GAIT DISORDERS Cautious gait (fear of falling, with appropriate postural responses) Frontal-related gait disorders (spectrum, from gait ignition failure to frontal gait disorder to frontal disequilibrium) Cerebrovascular Normal-pressure hydrocephalus

FALLS Definition: coming to rest inadvertently on the ground or at a lower level One of the most common geriatric syndromes Most falls are not associated with syncope Falls literature usually excludes falls associated with loss of consciousness

EPIDEMIOLOGY OF FALLS Each year 30%–40% of community-dwelling persons aged ≥65, and about 50% of residents of long-term- care facilities, experience falls

EPIDEMIOLOGY OF FALLS Annual incidence of falls is close to 60% among those with history of falls Complications of falls are the leading cause of death from injury in persons aged ≥65

MORBIDITY AND MORTALITY Most falls by older adults result in some injury 10%–15% of falls by older adults result in fracture or other serious injury The death rate attributable to falls increases with age Mortality highest in white men aged ≥85: 180 deaths/100,000 population

SEQUELAE OF FALLS Associated with: Decline in functional status Nursing home placement Increased use of medical services Fear of falling Half of those who fall are unable to get up without help (“long lie”) A “long lie” predicts lasting functional decline

COSTS OF FALLS Annually, lifetime costs of fall-related injuries by older adults = $12.6 billion  Emergency department visits  Hospitalizations

CAUSES OF FALLS BY OLDER ADULTS Rarely due to a single cause May be due to the accumulated effect of impairments in multiple domains (such as other geriatric syndromes) Complex interaction of: Intrinsic factors (eg, chronic disease) Challenges to postural control (eg, changing position) Mediating factors (eg, risk taking)

CAUSES: INTRINSIC Age-related decline Chronic disease Acute illness Changes in visual function Proprioceptive system, vestibular system Chronic disease Parkinson’s disease Osteoarthritis Cognitive impairment Acute illness Medication use (see next slide)

CAUSES: MEDICATION USE Specific classes, eg: Benzodiazepines Antidepressants Antipsychotic drugs Recent medication dosage adjustments Total number of prescriptions

CAUSES: CHALLENGES TO POSTURAL CONTROL Environmental Changing positions Normal activities

TREATMENT Most favorable results with health screening followed by targeted interventions Aim to reduce intrinsic and environmental risk factors Interdisciplinary approach to falls prevention is most efficacious

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