A patient's gait can be difficult to describe in a reproducible fashion. Observe the patient walking toward you and away from you in an open area with plenty of room. Note stance (how far apart the feet are), posture, stability, how high the feet are raised off the floor, trajectory of leg swing and whether there is circumduction (an abnormal arced trajectory in the medial to lateral direction), leg stiffness and degree of knee bending, arm swing, tendency to fall or swerve in any particular direction, rate and speed, difficulty initiating or stopping gait, and any involuntary movements that are brought out by walking. Turns should also be observed closely. When following a patient over several visits, it may be useful to time him walking a fixed distance and to count the number of steps taken and the number of steps required to turn around. The patient's ability to rise from a chair with or without assistance should also be recorded.
To bring out abnormalities in gait and balance, ask the patient to do more difficult maneuvers. Test tandem gait by asking the patient to walk a straight line while touching the heel of one foot to the toe of the other with each step. Patients with truncal ataxia caused by damage to or toxic/metabolic influences of the cerebellar vermis (see Figure 15.3 in Neuroanatomy through Clinical Cases 3e) or associated pathways will have particular difficulty with this task. These patients tend to have a wide-based, unsteady gait and become more unsteady when attempting to keep their feet close together. To bring out subtle gait abnormalities or asymmetries, it may be appropriate in some cases to ask patients to perform so-called forced gait testing by asking them to walk on their heels, their toes, or the insides or outsides of their feet; to stand or hop on one leg; or to walk up stairs.
Gait apraxia is a perplexing (and somewhat controversial) abnormality in which the patient is able to carry out all of the movements required for gait normally when lying down, but is unable to walk in the standing position, thought to be associated with frontal disorders or normal pressure hydrocephalus (see KCC 5.7 in Neuroanatomy through Clinical Cases 3e).Go to Video 68 Go to Video 69
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