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4:15 - 5:30 PM GAITS Abnormal Gaits: (AN AUGENBLICK APPROACH) An Eyeblink Diagnosis SPEAKER Salvatore Mangione, MD Sal Mangione, MD* Thomas Jefferson University Philadelphia – Pennsylvania *Disclosure of relevant financial relationship in the past 12 months: I have no financial relationships with commercial entities producing health-care related products and/or services. Desiree Jennings Desiree Jennings Washington Redskin Cheerleader Flu Shot DYSTONIC GAIT! Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. LACK OF AWARENESS IN PRIMARY CARE In a cohort of 372 subjects over age 65 enrolled in health management plans, only 57 had documented falls. Yet, the number of actual falls doubled when the patients were eventually interviewed. More disturbingly, only 7% of the patients had their gaits and balance checked; 28% received a neurologic assessment; 25% had their vision tested; and only 6% were evaluated for orthostatic changes in blood pressure. The authors concluded that “Community physicians appear to underdetect falls and gait disorders. Detected falls often receive inadequate evaluation, leading to a paucity of recommendations and treatments.” Rubenstein LZ et al. Detection and management of falls and instability in vulnerable elders by community physicians. J Am Geriatr Soc. 2004 Sep;52(9):1527-31. LACK OF AWARENESS IN PRIMARY CARE In a commentary to this study, Dr. Joseph H. Friedman (Gait Abnormalities Are Too Hard To Evaluate, So Why Bother? Medicine and Health Rhode Island, Feb 2005) concluded that “gait is not assessed in either the hospital or the outpatient setting simply because doctors have not been taught how to do this. [In fact,] gait is not simple to assess. It is a motor program that is altered by an infinite number of combinations of disturbances.” He also urged “…teaching doctors how to assess gait, and hopefully recognizing the more common abnormalities. I am specifically asking every doctor to acknowledge that gait, especially in the elderly, is a major aspect of health and should be checked.” Fred HL. The Texas heart Journal 2005, p. 255-257. Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. PSYCHOGENIC GAIT Narrowing of base, with legs crossing the midline Sudden buckling of knees (like the Tin Man in Wizard-of-Oz) Uneconomic postures Extremely theatrical arm-swinging Non-physiologic behavior (running is the first thing to go in gait abnormalities) Walking-on-ice pattern Sahelanthropus Ardipithecus (biped and quadruped) 5k Hx Laetoli Footprints (grasping big toe) 10k Agriculture 1969 AD Australopithecus (4-2M) (strictly biped) Homo (2M - now) 50k Out of Africa (endurance running?) 200k Homo Sapiens (click lang.) 700k First use of fire; societal cultures 1.5-1 Evidence of meat-eating becomes strong 1.8 Homo Erectus (8-1,200 cc): Africa and then Asia 2 Homo Abilis (6-700 cc): Earliest known stone tools in Africa 3.4 M BC 2.2 Brain expansion in response to weather upheavals and ? fish diet 4 Earliest known fossils of hominids (A. Afarensis, “Lucy”) Neil Armstrong’s Footprints 6 Origin of bipedalism in Africa – Great Apes split into two genuses Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. GAIT – WHY BOTHER? Gait disturbances are common. “What goes… on four legs in the morning, They are especially common in the elderly, affecting 15% of subjects above 60, 25% of those older than 80, and 50% of people above 85. on two legs at noon, and on three legs in the evening?” In fact, half of all nursing home residents have problems walking. (Oedipus Rex, Sophocles*) In Goteborg, Sweden, one in four 79-year olds had to use a mechanical aid, and none could comfortably walk at 1.4 m/sec, which is the norm for street crossing. Hence, gait disturbances are a common risk factor for falls, injuries & loss of independence. In a study of more than 1,000 community living residents older than 72 years of age, 50% had suffered at least one fall during a 2.5 year period. Of these, 25% experienced a serious injury, and 5% had a fracture. In fact, gait disturbances are an important contributor to hip fractures — the sixth leading cause of death in the elderly. There are good historical precedents for this… * Oedipus = Swollen-footed, from having his ankles being pinned together by his father (same root as oedema) 1. Flexed Posture Head bent down GAIT NEUROPHYSIOLOGY – A PRIMER Spine flexed Elbows, Hips and Knees are also flexed Stance is the position assumed by a standing person, or station In Ambulation: (from the French derivative of the Italian “stanza”). It is also one of the phases of ambulation. Trunk further bent forward Upper Extremities do not swing Gait is instead the individual’s ambulating style (from the Old Lower Extremities remain flexed Norse “gata”, path), which is often so unique to be recognizable from a distance. 2. Shuffling Gait Reduced Step Height Reduced Step Length In fact, gaits can say a lot not only about neuromuscular Shortened Stride (patho)physiology, but also about mood (like depression), Feet barely clearing the ground occupation, and even character. 1987 Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. There are two phases in the gait cycle: stance and swing. Stance begins when one heel strikes the ground and it lasts for the entire period during which that foot stays grounded. Hence, it is a weight-bearing phase. Stance is mostly due to contraction of the extensors: the gluteus maximus Swing is instead the interval between the lifting of that foot’s toes off the early on, quadriceps in the middle, and plantar flexors (soleus and floor and the time the heel of the same foot strikes the ground again. gastrocnemius) towards the end. Since during this time the foot is airborne, ‘‘swing’’ is the non–weight- bearing phase of the cycle. Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. STRIDE Stance is mostly due to contraction of the extensors: the gluteus maximus Stance and swing make up a stride, which corresponds to the interval early on, quadriceps in the middle, and plantar flexors (soleus and between the time one heel hits the floor until it strikes it again. gastrocnemius) towards the end. Swing is instead mostly due to contraction of the flexors: iliopsoas (for hip), For 20–25% of the cycle the stance of the two legs overlaps, insofar as both hamstrings (for knee), and tibialis anterior (for ankle). feet are on the ground (double-limb support). This time increases with age. Through it all the Long Extensors dorsiflex foot for toe clearance. GAIT – IMPORTANT DIAGNOSTIC CLUES Symmetry versus asymmetry Height, length and cadence of steps (length of stride) A relatively healthy subgroup of 153 Presence of muscle weakness (hypotonia) Gait Impairment community residents aged 88 Presence of stiffness in the limbs (hypertonia) years and older Presence of bladder or bowel dysfunction (spastic paraplegia) Difficulty in initiating or terminating walking (Parkinson’s) Association with vertigo or light-headedness (cerebellar, vestibular) Association with pain, numbness, or tingling in the limbs (neuropathy) Worsening of disturbance at night (posterior column disease) Acute onset — suggesting vascular disease versus drugs (alcohol, benzodiazepines, neuroleptics, and orth. hypotension-inducing agents) Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Ataxic (Sens/Cereb/Tox) A relatively healthy Spastic - Diplegic subgroup of 153 Gait Impairment community 3 2 2 Spastic - Hemiplegic 7 27 (18+7+2) residents aged 88 Rigid (Parkinsonian) years and older 12 Apraxic (NPH) 17 20 Neuropathic Neuro-muscular Choreiform Myopathic Non-Neuromuscular (Joint Pain) Neuro-muscular Causes of Gait Impairment ABNORMAL GAITS “THE MAGNIFICENT 7” Besides antalgic ambulation (limp), there are seven gaits that are useful because of their localizing value, insofar as they can pinpoint both the level and the system involved (sensory, cerebellar, basal ganglia, extra-pyramidal, pyramidal, peripheral neural, and muscular): 1. Ataxic – Sensory/Cerebellar/Toxic 2. Diskinetic/Choreiform – Basal Ganglia 3. Hypokinetic/Rigid * (Parkinsonian/Apraxic – Extra-Pyramidal/NPH) 4. Spastic/Hemiplegic*– Pyramidal 5. Spastic/Diplegic (Myelopathic) – Pyramidal “Augenblick Diagnose” 6. Neuropathic – Motor (Weak gait) 7. Myopathic – Muscular (Weak gait) * Remember the difference between the two forms of hypertonicity, “Rigid” And “Spastic”. Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. GAIT – AUGENBLICK ASSESMENT GAIT – AUGENBLICK ASSESMENT From front, back and side, assess: How the patient stands (normal vs wide-based) Posture (normal, stooped, kyphotic /simian-like and swaying) How the patient stands with eyes first open and then closed (Romberg’s) How the patient gets up from a chair (Parkinson’s or myodystrophy) How the patient walks with eyes first open and then closed (sensory ataxia How the patient initiates walking (also useful in Parkinson’s) worsens with closed, whereas cerebellar ataxia does poorly either way) How the patient walks at a slow pace How the patient copes with sudden postural challenges, such as modest nudging or pull from behind after adequate warning; inadequate postural How the patient walks at a fast pace reflexes (as often seen in nursing home residents) will cause a few steps of retropulsion, and even a tendency to fall backward. How the patient turns How the patient walks on toes (Parkinson’s can’t do it, but also sensory How the patient walks a straight line in tandem (i.e., heel to toe) – this is ataxia, spastic hemiplegia, or paresis of the soleus/gastrocnemius) useful in all gait disorders because it narrows the base.
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