GAIT- BALANCE DISORDER
AND
ASSISTIVE DEVICES
Kashif A. Siddiqui, MD
Geriatrics Medicine
Baylor College of Medicine
BROOKE SALZMAN, MD, Thomas Jefferson University, Philadelphia, Pennsylvania
Am Fam Physician. 2010;82(1):61-68
SARA M. BRADLEY, MD, and CAMERON R. HERNANDEZ, MD, Mount Sinai School of Medicine, New York
Am Fam Physician. 2011;84(4):405-411
Objectives
•
•
•
•
•
Normal Gait
Abnormal Gait Pattern
Basic Understanding of Gait Disorder
Evaluation & Interventions
Basic Understanding of Assistive Devices
Definitions
Gait
Series of rhythmical , alternating movements of trunk &
limbs resulting in forward progression of the COG
Gait Cycle
Begins when reference foot contacts the ground,
Ends with subsequent floor contact of the same foot
Step length
Right step Length = Left step Length (Normal Gait)
Stride Length
Double the step length
Walking base
Side-to-side distance between the line of the two feet
Comfortable Walking Speed (CWS)
Least energy consumption per unit distance
Average = 1.4 meter/sec
Path of Center of Gravity
• Center of Gravity (CG):
o midway between the hips
o Few cm in front of S2
• Least energy
consumption if CG
travels in straight line
Path of C.G
Vertical displacement:
• Rhythmic up & down
movement
• Highest point: midstance
• Lowest point: double support
• Average displacement: 5cm
• Path: extremely smooth
sinusoidal curve
Path of Center of
Gravity
Overall displacement:
• Sum of vertical &
horizontal displacement
• Figure ‘8’ movement of
CG as seen from AP view
Horizontal
plane
Vertical
plane
Gait & Aging
• No clearly accepted standards to define normal
Gait in Older Adults
• Changes at Aging
o
o
o
o
o
10-20 % reduction in Gait Velocity & Stride Length.
Increase Stance Width.
Increase time spent in the Double Support Phase.
Bent Posture.
Slow & Wide Based Gait.
• Up to 20% maintain normal Gait pattern into very
old age, reinforcing that Aging not inevitably
accompanied by disordered Gait.
Gait & Balance Disorder
• Most common causes of falls in Older Adults
• Evaluation of Gait & Balance disorder parallels the
evaluation of FALLS
• It can lead to
o
o
o
o
Injury & Disability
loss of independence & reduces level of functioning
limited quality of life
Increase morbidity & mortality
• 60% 80-84 yrs, 25% 70-74 yrs, & 30% 65 yrs have
difficulty :
o walking 3 blocks or
o climbing 1 flight of stairs
• 20 % require Assistive Devices to ambulate
American Geriatrics Society/British Geriatrics Society clinical practice guideline: prevention of falls in older persons
http://www.medcats.com/FALLS/frameset.htm. Accessed June 3, 2010
Falls related statistics
• 5.8 million US Adults reported Falls
o NH Residents (1.6 falls/bed/year)
o 10–25% NH falls result in ER visits/hospital care
• Mostly minor injuries
o 10-15% resulting in fracture
o 5% in serious soft tissue injury or head trauma
• Leading cause (75%) of injury deaths for >65 yr
o 60% fatal falls happen at home
o 30% in public places
o 10% in institutions
Gait & Balance Disorder
• Multifactorial Etiology
• Comprehensive Assessment required to determine
o Contributing factors
o Targeted interventions
• Most Gait changes in Older Adults related to
underlying Medical conditions
Sudarsky L. Gait disorders: prevalence, morbidity, and etiology. Adv Neurol. 2001;87:111-117.
Causes of Gait & Balance
Disorder
• Affective Disorder &
Psychiatric Conditions
o
o
o
o
Depression
Fear of falling
Sleep Disorders
Substance Abuse
• Cardiovascular Disease
o
o
o
o
o
o
CHF
CAD
Orthostatic Hypotension
PAD
Thromboembolic
Arrhythmias
• Neurological
o
o
o
o
o
o
o
o
o
Delirium
Dementia
Multiple Sclerosis
Myelopathy
NPH
Parkinson Disease
Stroke
Vestibular Disorders
Cerebellar Dysfunction
• Sensory Abnormalities
o Hearing Impairment
o Peripheral Neuropathy
o Visual Impairment
Alexander NB. Gait disorders in older adults. J Am Geriatr Soc. 1996; 44(4):434-451
Causes
• Infectious & Metabolic
o
o
o
o
o
o
o
o
o
Diabetes Mellitus
Hepatic Encaph.
HIV
Hypothyroidism
Hyperthyroidism
Obesity
Tertiary Syphilis
Uremia
Vitamin B12 Deficiency
• Others
o Recent Surgery
o Recent Hospitalization
(cont.)
• Musculoskeletal
Disease
o
o
o
o
o
o
Osteoarthritis
Osteoporosis
Gout
Spinal Stenosis
Cervical Spondylosis
Podiatric Conditions
• Medications
o
o
o
o
o
Antiarrythmics, Digoxin
Diuretics
Narcotics
Antidepressants, Psychotropics
Anticonvulsants
Alexander NB. Gait disorders in older adults. J Am Geriatr Soc. 1996; 44(4):434-451
Evaluation
• History
o
o
o
o
o
o
Acute and Chronic Medical problems
Complete ROS
Falls History (Previous Falls, Injury resulted, circumstances, & associated Sx.
Nature of Difficulty with Walking (e.g. Pain, imbalance)
Surgical History
Usual Activity, mobility status, and level of function
• Medication review
o New medication or dosing review
o Number and type of medications
Hough JC, McHenry MP, Kammer LM. Gait disorders in the elderly. Am Fam Physician. 1987;35(6):191-196
Sudarsky L. Clinical approach to gait disorders of aging: an overview. In: Masdeu JC, Sudarsky L, Wolfson L, eds. Gait Disorders of
Aging: Falls and Therapeutic Strategies. Philadelphia, Pa.: Lippincott-Raven; 1997:147-157
Evaluation
• Presence of environmental Hazards
o
o
o
o
o
o
o
Clutter
Electrical Cords
Lack of grab bars near bathtub & toilets
Low chairs
Poor Lighting
Slippery Surfaces
Throw rugs
Evaluation
• Physical Examination
o Vitals
• (Wt. Ht. Orthostatic BP & Pulse)
o Affective/cognitive
• (Delirium, Dementia, Depression, Fear of Falling)
o Cardiovascular
• (Murmur, Arrhythmias, Carotid Bruit, Pedal Pulses)
o Musculoskeletal
• (Joint swelling, deformity, Limited ROM or instability)
o Neurological
• (M/S strength, tone, reflexes, coordination, sensation tremors,
cerebellar, vestibular, sensory & proprioception)
Evaluation
Gait & Balance Performance Testing
1. Direct observation of gait & Balance
• Watching patient enter and sitting in examination room
o Stance
o posture
o Velocity
o step length
o Symmetry
o Cadence
o fluidity of movement
o instability & need of assistance
Evaluation
Gait & Balance Performance Testing
2. Functional Reach Test
• Reliable
• Valid
• Quick diagnostic tool
• Inability to reach at least 7 inches
predictive of fall
Duncan PW, Studenski S, Chandler J, Prescott B. Functional reach: predictive validity in a
sample of elderly male veterans. J Gerontol. 1992; 47(3):M93-M98
Evaluation
Gait balance & performance testing
3. Timed Up & Go Test
• Reliable Diagnostic tool (Sensitivity 80% & Specificity 80%)
• Quick to administer
• (Pt arise from a chair, without using arms, walk 3 meter, turn, return to
the chair and sit down. They allowed to use their usual walking aids.)
• Score < 10 sec normal
• Score > 14 Sec Abnormal
• Score > 20 Sec Severe gait impairment
Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “get-up and go” test. Arch Phys Med Rehabil. 1986;67(6):387-389
Evaluation
Gait & Balance Performance Testing
4.
Single leg stance test
• Best balance measure for any individual
• If one can stay on one leg for >10 sec,
usually no significant balance problems
Evaluation
• Other Diagnostic Testing
o Role of Lab testing in diagnostic evaluation has not been well studied
o Tests useful when H&P raises suspicious for abnormality
o CBC
o Metabolic Panel
o Thyroid Function
o RPR
o Vitamin B12 Level
o CT head
o Hearing Test
o Visual Screening
Gait Patterns
• Antalgic
o Description: Limited ROM,
limping, slow, short steps,
unable to bear full weight
o Signs: Pain worse with
movement & weight bearing
o Causes: DJD, Trauma
• Waddling
o Description: Lumbar lordosis,
swaying, wide based
o Signs: Hip dislocation, proximal
m/s weakness, uses arm to get
up from chair
o Causes: Muscular dystrophy &
Myopathy
• Parkinsonian
o Description: Short stepped,
shuffling, hip, knee & spine
flexed
o Signs: Bradykinesia, muscular
rigidity, reduce arm swing
o Causes: Parkinson disease
• Choreic
o Description: Dance-like,
irregular, slow, wide based
o Sign: Choreoathetoic
movement of UE
o Causes: Huntington Disease,
Levodopa induced dyskinesia
Gait Pattern
• Cerebellar Ataxia
o Description: Staggering, wide
based
o Signs: Dysarthria, Dysmetria,
dysdiadokinesia, Intentional
Tremors, Nystagmus, Romberg's
o Causes: Cerebellar
Degeneration, Stroke, MS,
Thiamine, Vitamin B12 Def.
Alcohol
• Sensory Ataxia
o Description: Unsteady, worse
without visual input
o Signs: Impaired position &
vibration, Romberg's
o Causes: Dorsal Column,
Neuropathy
• Vestibular Ataxia
o Description: Unsteady, falling
on one side, Postural instability
o Signs: Nausea, Normal
sensation, Nystagmus
o Causes: Menieres, Acute
Labrynthitis.
• Cautious
o Description: Slow, wide based,
careful (Walking on Ice)
o Signs: Associated with Anxiety,
fear of falling, Open spaces
o Causes: Deconditioning, Post
fall syndrome, visual
impairment
Gait Pattern
• Frontal gait disorder
o Description: Freezing, start &
turn hesitation
o Signs: Dementia, Incontinence
o Causes: NPH, Multi-infarct state,
Frontal lobe degeneration
• Senile gait disorder
o Description: Slow, broad
based, shuffling & cautious
walking pattern
o Signs: when underlying disease
can not be identified
o Causes: May present early
manifestation of subclinical ds.
• Psychogenic
o Description: Bizarre, Non
physiologic gait
o Signs: Absence of neurological
signs
o Causes: Factitious, Somatoform
disorder & Malingering
Intervention
• Interventions may impact important Functional
outcomes, including Reduction in
o Falls
o Fear of falling
o Overall limitation in mobility
Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people.
Cochrane Database Syst Rev. 2009;(2):CD000340.
Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the
community. N Engl J Med. 1994;331(13):821-827.
Intervention
• Gait Disorder secondary to Medical Conditions
o (Arthritis, Vitamin B12, Thyroid Problems, Arrhythmias, Depression etc.)
respond well to Medical Therapies.
• Adjustment in Medication improves gait disorder
• Limited data available, Surgery may improve Gait
o
o
o
o
Cervical spondylotic myelopathy
Lumbar spinal stenosis
Normal pressure hydrocephalus
Arthritis of hip or knee
• Improving Sensory Input
o Visual Correction
o Hearing Aids
Engsberg JR, Lauryssen C, Ross SA, Hollman JH, Walker D, Wippold FJ II. Spasticity, strength, and gait changes after surgery for
cervical spondylotic myelopathy: a case report. Spine (Phila Pa 1976). 2003;28(7):E136-E139.
Krauss JK, Faist M, Schubert M, et al. Evaluation of gait in NPH before and after shunting. In: Ruzicka E, Hallet M, Jankovic J, eds.
Gait Disorders. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2001.
Intervention
• Other options includes
o EXERCISE INTERVENTION & PHYSICAL THERAPY
• Target strengths
• Balance training
• Functional exercises
• Flexibility
o Evidence supports HOME ENVIRONMENT ASSESSMENT prevent falls &
related injuries
• Above Interventions augment Gait, Function &
Reduces number of falls
Schenkman M, Riegger-Krugh C. Physical intervention for elderly patients with gait disorders. In: Masdeu JC, Sudarsky L, Wolfson L,
eds. Gait Disorders of Aging: Falls and Therapeutic Strategies. Philadelphia, Pa.: Lippincott-Raven; 1997:327-353.
Interventions
• Modest improvement in Gait & Balance achievable
by ASSISTIVE DEVICES.
• Unfortunately, most cases its unlikely that Gait
Disorder are reversible
Assistive Devices
• 6.1 million use assistive devices, 2/3 >65 years of age
• ASSISTIVE DEVICES IMPROVE:
o
o
o
o
Balance
Reduce pain
Compensate for weakness or injury
Increase Mobility & Confidence
• ASSISTIVE DEVICE SELECTION DEPENDS:
o Amount of support assistive device offers
o Coordination required
o Strength, ROM, Balance, Stability, General Condition, & WB restrictions
Bateni H, Maki BE. Assistive devices for balance and mobility: benefits, demands, and adverse consequences. Arch Phys Med
Rehabil. 2005; 86(1): 134-145.
Faruqui SR, Jaeblon T. Ambulatory assistive devices in orthopaedics: uses and modifications. J Am Acad Orthop Surg. 2010; 18(1):
41-50.
Assistive Device
• Patients get Assistive Device without recommendations
from Medical Professional
• Evaluation should be done routinely for proper Fit & Use
o Cane preferred for balance with one UE
o Crutches or a walker appropriate for Both
• CORRECT HEIGHT & FIT
o Correct height of cane/walker
• At the level of the patient’s wrist crease, as measured with the patient
standing upright with arms relaxed at his or her sides, the patient’s elbow
naturally flexed at 15 – 30 degree angle
Assistive Devices
• INSTRUCTIONS FOR PROPER USE:
o Cane:
• Should be held contralateral to weak/painful LE & advanced
simultaneously with Contralateral Leg.
• Need upright posture without forward or lateral leaning.
• Take time when turning & should not lift the device off the ground.
o Walker:
• Both feet should stay between the posterior legs or wheels.
• Need upright posture without forward or lateral leaning.
• Take time when turning and should not lift the device off the ground.
Kumar R, Roe MC, Scremin OU. Methods for estimating the proper length of a cane. Arch Phys Med Rehabil. 1995; 76(12): 11731175
Assistive Devices
o INSTRUCTIONS FOR PROPER USE
•
Navigating Stairs with Cane/Walker:
o Patients with unilateral LE impairment advance the Unimpaired
Extremity first when going up stairs AND advance the Impaired
Extremity first when going down stairs.
o
•
Simply remember this phrase,
“Up with the good and down with the bad.”
A video about how to use a cane is available online at
http://www.youtube.com/watch?v=fRn8ZZJMzno
CANES
STANDARD CANE
• Indications:
•
•
Mild ataxia (sensory, vestibular,
or visual)
Mild arthritis
• Advantages:
•
•
•
Inexpensive
Adjustable
Improves balance
• Disadvantages:
•
•
Umbrella handle cause carpal
tunnel syndrome
Not for weight bearing
CANES
OFFSET CANE
• Indication:
o Moderate arthritis
• Advantages:
o Inexpensive
o Intermittent weight bearing
o Shotgun handle put less
pressure on palm
• Disadvantages:
o Commonly used incorrectly
Liu HH, Eaves J, Wang W, Womack J, Bullock P. Assessment of
canes used by older adults in senior living communities. Arch
Gerontol Geriatr. 2011; 52(3): 299-303
CANES
QUADRIPOD
• Indications:
o Hemiparesis
• Advantages:
o Increased base of support
o bear large weight
o Stands freely on its own
• Disadvantages:
o Slightly heavier
o Awkward to use correctly with
all four points on ground
simultaneously
Laufer Y. Effects of one-point and four-point canes on balance
and weight distribution in patients with hemiparesis. Clin
Rehabil. 2002; 16(2): 141-148
CRUTCHES
AXILLARY CRUTCHES
• Indication:
o Lower extremity fracture
• Advantages:
o Inexpensive
o Completely redistribute weight
off of lower extremities
o Permits 80-100 % weightbearing support
• Disadvantages:
o Difficult to learn to use
o Requires energy & strength
o Risk of nerve or artery
compression
CRUTCHES
FOREARM CRUTCHES:
• Indication:
o Paraparesis
• Advantages:
o Frees hands without having to
drop crutch
o Less cumbersome to use,
particularly on stairs
o No Axillary compression
• Disadvantages:
o Permits only occasional weight
bearing
WALKERS
STANDARD WALKER
• Indications:
o Severe myopathy
o severe neuropathy
o Cerebellar ataxia
• Advantages:
o Most stable walker
o Folds easily
• Disadvantages:
o Slower
o Needs to be lifted up with each
step
o Less natural gait
WALKERS
FRONT-WHEELED WALKER
• Indications:
o
o
o
o
Severe myopathy
Severe neuropathy
Paraparesis
Parkinsonism
• Advantages:
o Maintains normal gait pattern
o No need to be lifted up with
each step
• Disadvantages:
o Large turning arc
o Less stable
Cubo E, Moore CG, Leurgans S, Goetz CG. Wheeled and
standard walkers in Parkinson’s disease patients with gait
freezing. Parkinsonism Relat Disord. 2003; 10(1): 9-14
WALKERS
ROLLATOR
• Indications:
o Moderate arthritis
o Claudication
o Lung disease, CHF
• Advantages:
o
o
o
o
Easy to propel
Highly movable
Small turning arc
Has seat & basket
• Disadvantages:
o Not for weight bearing
o Less stable
o Does not fold easily
Selection of AD
Assistive Devices
List providing stability & support from most to the least :
Parallel bars
Walker
Axillary crutches
Forearm crutches
Two canes
One cane
Assistive Devices
List requiring Coordination from least to the most:
Parallel bars
Walker
One cane
Two canes
Axillary crutches
Forearm crutches
Conclusion
• Comprehensive evaluation with targeted
interventions reduce falls by 30-40%
• Gait Disorder evaluation the most effective strategy
for falls prevention
• Limited evidence supporting the effectiveness of
interventions for gait & balance disorders
Harris MH, Holden MK, Cahalin LP, Fitzpatrick D, Lowe S, Canavan PK.Gait in older adults: a review of the literature with an emphasis
toward achieving favorable clinical outcomes, part II. Clin Geriatrics. 2008; 16(8):37-45.
“Don’t walk behind me, I may not lead.
Don’t walk ahead of me, I may not follow.
Walk next to me & be my friend.”
Albert Camus
Thank you !!