How to detect and treat gait disorders
By Yasmine Iqbal
Ask Mary Harward, FACP, a geriatrician based in Orange, Calif., about when she starts evaluating senior patients for gait problems and she has a ready answer: when she sees them come through the door.
"I'll just pause and watch them walk for a moment," she said. "I note how fast they're walking, if they need assistance or if they seem unsteady. I get a lot of information from just seeing how they move."
Taking time to assess gait is an important part of patient evaluation. That's because a shuffling, unstable or otherwise abnormal gait can be a key indicator that something—or several somethings—may be wrong. According to a study in the July 2005 issue of Cleveland Clinic Journal of Medicine, at least 20% of noninstitutionalized elderly adults admit to having trouble walking or need assistance or special equipment to walk.
"Of all the clinical measures we have that predict mortality and a person's likelihood of being institutionalized, gait disorders are one of the best," said Neil B. Alexander, ACP Member, a geriatrician at the University of Michigan in Ann Arbor, Mich., and one of that article's co-authors. "A person's gait is an excellent indicator of how impaired that person is."
Simple tests for gait and balance can be administered in just a few minutes. What takes more time, experts say, is figuring out the root causes of gait disorders.
In addition to signaling existing health problems, gait disorders—if left untreated—can lead to new ones. Most notably, they put patients at risk for falls. The American Geriatrics Society (AGS) estimates that between 35% and 40% of generally healthy seniors over age 65 fall every year, with 5% suffering injuries that require hospitalization.
But even if seniors don't fall, gait problems can have serious consequences. "Gait disorders may put tremendous restrictions on a person's independence and create many barriers," said Stephanie A. Studenski, ACP Member, a geriatrician at the University of Pittsburgh Medical Center in Pittsburgh. "A great number of people aren't falling because they're not moving."
And when they do walk, it can be exhausting. "Having an abnormal gait can take up a lot of energy," Dr. Alexander said. "Improving the gait pattern may help make things less taxing and painful."
Assessing a patient's gait shouldn't take more than a few minutes. But pinpointing a specific cause for an abnormal gait may be a challenge because gait disorders tend to have multiple causes. In this first of an occasional "On Aging" series, ACP Observer asked geriatricians for recommendations on how to evaluate gait and balance and on what treatments and interventions are most successful.
Gait disorder screening
Geriatricians recommend regularly administering a few simple gait tests every year once patients reach their 60s.
"After 65, a person's gait declines every year," Dr. Harward said. In its 2001 fall prevention guidelines, the AGS recommended asking senior patients if they've fallen in the past year. But Dr. Studenski urged physicians to go beyond that recommendation and ask elderly patients if they've been cutting back on activity because they feel unsteady.
Even when their answer is no, she said, give them a few quick tests anyway. "Certain gait tests don't take longer than taking a blood pressure and they can be administered by your staff as part of an intake screen," she said. If you do have staff administering balance tests, make sure they know how to brace themselves and spot patients properly if they start to falter.
When assessing gait, you also need to evaluate patients' balance and ability to recover from a sudden balance shift. Here are techniques to use:
Observation. "Try to grab opportunities to watch your patients walk in a natural state, like when they first come into your office or if they leave to go to the bathroom," Dr. Harward said. "That's what gives you the most information. "
You'll get better information, she added, by watching them on the sly. "If you say, 'I'm going to watch you walk,' patients tend to become stiff and more anxious, which may predispose them to fall."
Generally, Dr. Alexander said, walking problems are easy to spot: Anything that a clinician thinks is different from a normal gait is probably a gait disorder. "If it looks abnormal," he said, "it probably is."
Gait speed. Use a stopwatch to time patients as they walk a few paces. Normal walking speed should be at least 1.0 meter per second (2.0 miles per hour). "A gait speed test is very easy to understand and administer, and you can use it to screen out patients who don't have a gait condition," said Dr. Studenski.
Balance. To evaluate balance problems, have patients hold three different stances for at least 10 seconds.
First, have them stand with their feet together. Then ask them to take a semi-tandem stance, with the heel of one foot touching the side of the big toe of the other foot. The final stance is the full tandem, with the heel of one foot directly in front of the other foot's toes. Patients will need varying levels of therapy depending on how long they can hold each stance. Those who have trouble with the first—and easiest—stance will almost certainly need assistive devices and physical therapy.
To test for postural control and proprioceptive and vestibular system dysfunction, Dr. Alexander suggested having patients hold a simple bipedal stance and close their eyes for 10 seconds.
And to evaluate their ability to adapt to a shift in balance, have patients again take a bipedal stance with an assistant standing behind them. Then very gently press on their sternum. "I normally do this test three times," Dr. Harward said, "to see if the patient can recover from a gentle push."
"Timed Get Up and Go" test. Time patients as they rise from a chair without using the armrests, walk 10 feet, turn around and walk back to the chair. If it takes them longer than 14 seconds to complete the series, that may indicate problems with strength, balance or gait. "If they take more than 20 seconds, it's a real cause for worry," Dr. Harward said.
Finding root causes
Gait disorders can show up as a patient's medical condition gradually worsens or can be the first sign of a new complication.
'If you don't find at least two contributors to an abnormal gait, you aren't looking hard enough.'
—Neil B. Alexander, FACP
And gait disorders rarely have a single cause. Instead, they're usually related to a variety of age-associated diseases, as well as generalized weakness. "If you don't find at least two contributors to an abnormal gait," said Dr. Alexander, "you aren't looking hard enough."
Experts generally divide gait disorder causes into structural and neurological problems. Structural problems include arthritis and other degenerative joint diseases; muscle deconditioning; acquired impairments following knee or hip surgeries; back or spine problems; and other musculoskeletal disorders. These can lead to pain, stiffness, weakness and numbness, which can all contribute to an abnormal walk.
Obesity often makes structural problems worse. "Obesity and overweight causes more wear and tear on the joints," said Dr. Harward. "It multiplies the effects of any medical issue—and can also lead to immobility, especially if patients can't support themselves."
Neurological problems involve Parkinson's or other neurological diseases, impairments following stroke or other cerebrovascular incidents, and vision or inner ear problems that affect balance. Diabetes, which can lead to nerve damage, can cause sensory problems that contribute to gait disorders, while dementia and fear of falling can also be factors.
Certain medications have been linked to disordered gait and falls. The chief culprits are psychotropic medications, such as neuroleptics, benzodiazepines and antidepressants. Blood pressure medications, diuretics—which can affect blood pressure—and steroids, which can weaken muscles if taken over a long period of time, can also cause unsteadiness or dizziness. Drug interactions and high dosages can also affect gait.
"In general," Dr. Harward said, "patients who take four or more prescription medications are more likely to fall."
How to help
Addressing gait disorders involves unraveling the problems that contribute to them and referring patients to specialists, such as orthopedists and neurologists, if needed. But once the major structural and neurological problems are under control, there are ways to help keep your patients on the move.
Address polypharmacy. Dr. Studenski recalled one 70-year-old patient who was wheelchair-bound for more than a year after suffering multiple falls. He also had a host of medical problems, including chronic obstructive pulmonary disease, cardiac arrhythmia and drug-induced lupus syndrome.
"By the time I saw him, the patient was on 18 medications and he'd developed a number of medication-related complications," she said. Over the next six months, she gradually got him down to three daily medications and prescribed physical therapy to help with his inactivity and weakness. As a result, he's been walking without assistive devices for eight years.
"It's sometimes scary to think about how to address a downward spiral like that," she said. "But often, the cases where you can achieve dramatic improvements in gait involve cutting down on polypharmacy."
She urged physicians to go slow when reducing a patient's medication, and said it might take some digging to uncover the patient's real problem.
"If your patient is having trouble sleeping, for example, find out why—perhaps it's pain or incontinence," she said. "Then try to fix the cause rather than prescribing a sleeping pill. Make sure every medication the patient is already on has a clear indication, use the lowest possible dose and consider alternative medications that aren't sedating."
Prescribe exercise. Exercise strengthens muscles, improves balance and contributes to general overall health, allowing patients to either minimize the effects of gait disorders or overcome them. David B. Reuben, FACP, director of the geriatrics program at the David Geffen School of Medicine at the University of California, Los Angeles, regularly suggests that patients join community-based walking programs and try balance exercises such as Tai Chi, yoga and Pilates. (Also see "Exercise, fall prevention and gait disorder resources.")
He also requires his patients to keep exercise journals, which they must bring to every visit. "I tell them that they must build regular exercise—at least three sessions a week—into their daily lives," Dr. Reuben said. "Some of my patients tell me that a doctor has never stressed the importance of exercise before."
Jerry O. Ciocon, FACP, a geriatrician at the Cleveland Clinic Florida in Weston, Fla., has done informal studies to determine if exercise affects gait in older patients. One study involved putting 50 patients through a one-month program of cardiovascular and physical strengthening.
"That intervention alone led to improved gait and fewer falls," he said. Dr. Ciocon regularly involves his patients' caregivers in discussions about exercise and encourages them to motivate patients to make physical activity a priority.
Work with physical therapists. Physical and occupational therapists can be invaluable in providing appropriate therapy, designing home exercise programs, assessing patients at home, and recommending assistive devices and teaching patients how to use them properly. Unfortunately, Dr. Studenski said, many internists don't refer patients to physical therapists unless their gait problems are extreme. "But most people who have trouble walking could benefit from at least a try at physical therapy," she said.
Suggest assistive devices. This can be tricky, because many patients will avoid using canes and walkers at all costs. For patients with mild impairments, it can help to be creative. Dr. Studenski, for example, never had any luck convincing her elderly father, "a retired curmudgeon," to use a cane because he felt it would immediately mark him as disabled. But then a friend gave him a hiking stick.
"It's the coolest thing—like something a young mountain man would use—and he takes it with him everywhere," she said. Because there are so many kinds of assistive devices and many kinds of walking problems, geriatricians say it's best to consult a specialist who can fit the device to the patient.
Some geriatricians suggest hip pads for patients with osteoporosis and a history of falls—but point out that most patients are reluctant to wear them because they tend to be bulky and uncomfortable. "I had a patient who refused to use hip pads," Dr. Harward said. "It took a fall that resulted in a hip fracture to convince her otherwise. The people who think 'it's not going to happen to me' are the most difficult people to convince." (Also see, "A footnote on footwear.")
Although any intervention will likely lead to improvements, promoting compliance also takes patience and a willingness to listen. Taking a demanding stance and chastising seniors about their lack of exercise, for instance, usually doesn't work.
"Sometimes seniors will make choices—like not exercising or not using a cane—that go against their doctors' judgment," said UCLA's Dr. Reuben. "All you can do is make them aware of the consequences and try to protect them as best you can."
Yasmine Iqbal is a freelance health and science writer in Philadelphia.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Sturdy, well-fitting shoes give patients a stable base of support as they walk—and cut the risk of falls. Here's a list of footwear to avoid:
- Going barefoot or wearing stockings, both of which make it much harder to maintain balance.
- Bedroom slippers that don't fit on the heel.
- High-heeled shoes.
- Open-toed shoes, especially for patients with peripheral diabetes or vascular disease.
- Shoes with too little or too much tread. The former can lead to slipping, but the latter can cause patients to trip, particularly if they tend to shuffle or not lift their feet when they walk.
"The data on whether shoes actually prevent falls isn't completely clear," said Neil B. Alexander, ACP Member, a Michigan-based geriatrician. "But in general, patients should stick to shoes that provide support, have low heels and are neither too slippery nor too 'grippy' in the soles."
- American Physical Therapy Association. Type "Balance and Falls" into the search box.
- American Senior Fitness Association
- Centers for Disease Control and Prevention "Physical Activity for Everyone" site.
- Medline Plus "Exercise for Seniors"
- National Center for Injury Prevention and Control "Preventing Falls Among Seniors"
- National Council on the Aging "Falls Prevention"
- National Institute on Aging "Exercise: Getting Fit for Life"
- NIH SeniorHealth "Exercise for Older Adults"
- NIH SeniorHealth "Balance Problems"
Internist Archives Quick Links
Reviews of the World's Top Medical Journals—FREE to ACP Members!
ACP JournalWiseSM is mobile optimized with optional email alerts! Get access to reviews from over 120 of the world’s top medical journals alerting you to the highest quality, most clinically relevant new articles based on your preferred areas of specialty. ACP Members register your FREE account now!
New CME Option: Internal Medicine 2014 Recordings
New CME Package
Includes 75 of the most popular sessions in internal medicine and the subspecialties. Stream the sessions, answer brief quizzes and earn CME credit. See details.