The patient has difficulty standing, has a broad-based stance and an unsteady gait, with swaying from side to side. It has been described as the ‘dirty diaper’ gait. The patient may stagger or bump into walls and may be accused of being drunk. When asked to walk in a straight line the patient tends to veer towards the side of the lesion. Ask the patient to walk ‘heel to toe’ in a straight line and perform a heel–knee–shin test to demonstrate cerebellar ataxia. Significant causes are multiple sclerosis, alcoholic cerebellar degeneration and space-occupying lesions. Cannot climb stairs.
Basal ganglia gait (Parkinson type)
Identifying this disorder in its early stages can be difficult as the first sign may be a limp with one leg being described as weak or stiff or slow.2 However, the typical gait is a shuffling of the feet with small steps in a forward flexed posture, rather like a person walking with a belt around the ankles. This leads to a hurrying (festinant) gait as though there is an impending feeling of falling forward. There is hesitation in starting.
Spastic gait may be regarded as the typical bilateral or paraplegic gait, or as a hemiplegic gait. With the former the gait affects both legs—they are stiff or weak, leading to slow, jerking walking, dragging of the feet and scraping of the toes. This scuffing can be heard as the front of the shoe drags along the ground. Every step can be a struggle and the patient may appear as though walking through glue on the floor.
A scissor-type gait will develop with bilateral hip adduction. Spasticity is caused by a UMN lesion, including multiple sclerosis and spinal cord compression. The typical UMN posture is of a flexed upper limb and an extended lower limb.
With hemiplegia the patient drags the affected leg stiffly with the hips adducted, the knee extended and the foot plantar flexed, leading to scraping of the toes. Mounting stairs can be very difficult, especially if clonus is induced with dorsiflexion of the foot.
The patient cannot dorsiflex the foot, leading to a high-stepping gait with extra flexion of the hip and knee to lift the foot off the ground. The foot then slaps down on the ground.
If unilateral the patient tends to veer off to the side of the lesion.
With apraxia of gait (due to a prefrontal lobe lesion) there is a failure of control of the legs. The patient may stand up and try to walk but looks with bewilderment at the legs (the ‘glued to the floor’ effect) and moves them in an inappropriate manner with a broad-based, small-stepping unsteady gait. Turning is difficult. Apraxia is caused by bilateral cortical involvement, such as normal pressure hydrocephalus, multi-infarct states and tumours of the corpus callosum.2
With intermittent claudication of the cauda equina, due to spinal canal stenosis, the patient develops pain in the leg after walking a certain distance. However, weakness and numbness are usually more prominent than pain.
In a drop attack the patient suddenly falls to the ground, without other symptoms, and gets up almost immediately. There is no loss of consciousness. Drop attacks can be caused by disorders such as epilepsy, Parkinson disease and vertebrobasilar insufficiency. However, in most cases, particularly middle-aged and elderly women, there is no obvious cause. (See CHAPTER 54.)
Waddling (myopathic) gait
A waddling gait is usually caused by muscular dysfunction affecting the pelvic girdle muscles and trunk. There is a wide-based gait with a marked ‘rocking and rolling’ body swing from side to side and related compensatory movements of the pelvis, that is, a bilateral Trendelenburg gait. Cannot climb stairs.
The patient may complain when getting out of a low chair or going up or downstairs. The weakness can be demonstrated by asking the patient to squat down and, after a second, rise from the squatting position.2 Waddling of gait reflects extreme cases. Causes include myopathies, motor neurone disease and Guillain–Barré syndrome.
This causes a high-stepping gait as the foot is floppy and tends to flap, with walking similar to foot drop gait. Causes include peripheral neuropathy, myotonic dystrophy and peroneal muscular atrophy.