GAIT- BALANCE GAIT- BALANCE DISORDERDISORDER

AND AND ASSISTIVE DEVICESASSISTIVE DEVICES

Kashif A. Siddiqui, MDKashif A. Siddiqui, MDGeriatrics Medicine

Baylor College of Medicine

BROOKE SALZMAN, MD, Thomas Jefferson University, Philadelphia, PennsylvaniaAm Fam Physician. 2010;82(1):61-68

SARA M. BRADLEY, MD, and CAMERON R. HERNANDEZ, MD, Mount Sinai School of Medicine, New YorkAm Fam Physician. 2011;84(4):405-411

ObjectivesObjectives

• Normal Gait• Abnormal Gait Pattern• Basic Understanding of Gait Disorder• Evaluation & Interventions• Basic Understanding of Assistive Devices

DefinitionsDefinitions

GaitSeries of rhythmical , alternating movements of trunk & limbs resulting in forward progression of

the COGGait Cycle

Begins when reference foot contacts the ground,Ends with subsequent floor contact of the same foot

Step lengthRight step Length = Left step Length (Normal Gait)

Stride LengthDouble the step length

Walking baseSide-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 Path of Center of GravityGravity

• Center of Gravity (CG):o midway between the hipso Few cm in front of S2

• Least energy consumption if CG travels in straight line

Path of C.GPath 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 Path of Center of GravityGravity

Overall displacement:• Sum of vertical &

horizontal displacement

• Figure ‘8’ movement of CG as seen from AP view

Horizontalplane

Verticalplane

Gait & AgingGait & Aging• No clearly accepted standards to define normal

Gait in Older Adults

• Changes at Agingo 10-20 % reduction in Gait Velocity & Stride Length.o Increase Stance Width.o Increase time spent in the Double Support Phase.o Bent Posture.o 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 Gait & Balance DisorderDisorder

• Most common causes of falls in Older Adults • Evaluation of Gait & Balance disorder parallels the

evaluation of FALLS• It can lead to

o Injury & Disabilityo loss of independence & reduces level of functioningo limited quality of lifeo 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 ambulateAmerican 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 statisticsFalls 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 injurieso 10-15% resulting in fractureo 5% in serious soft tissue injury or head trauma

• Leading cause (75%) of injury deaths for >65 yro 60% fatal falls happen at homeo 30% in public placeso 10% in institutions

Gait & Balance Gait & Balance DisorderDisorder

• Multifactorial Etiology

• Comprehensive Assessment required to determineo 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 & Causes of Gait & Balance DisorderBalance Disorder

• Neurologicalo Deliriumo Dementiao Multiple Sclerosiso Myelopathyo NPHo Parkinson Diseaseo Strokeo Vestibular Disorderso Cerebellar Dysfunction

• Sensory Abnormalitieso Hearing Impairmento Peripheral Neuropathyo Visual Impairment

• Affective Disorder & Psychiatric Conditionso Depressiono Fear of fallingo Sleep Disorderso Substance Abuse

• Cardiovascular Diseaseo CHFo CADo Orthostatic Hypotensiono PADo Thromboembolico Arrhythmias

Alexander NB. Gait disorders in older adults. J Am Geriatr Soc. 1996; 44(4):434-451

Causes Causes (cont.)(cont.)

• Musculoskeletal Diseaseo Osteoarthritiso Osteoporosiso Gouto Spinal Stenosiso Cervical Spondylosiso Podiatric Conditions

• Medicationso Antiarrythmics, Digoxino Diureticso Narcoticso Antidepressants,

Psychotropicso Anticonvulsants

• Infectious & Metabolico Diabetes Mellituso Hepatic Encaph.o HIVo Hypothyroidismo Hyperthyroidismo Obesityo Tertiary Syphiliso Uremiao Vitamin B12 Deficiency

• Otherso Recent Surgeryo Recent Hospitalization

Alexander NB. Gait disorders in older adults. J Am Geriatr Soc. 1996; 44(4):434-451

EvaluationEvaluation• History

o Acute and Chronic Medical problemso Complete ROSo Falls History (Previous Falls, Injury resulted, circumstances, &

associated Sx.o Nature of Difficulty with Walking (e.g. Pain, imbalance)o Surgical Historyo Usual Activity, mobility status, and level of function

• Medication reviewo New medication or dosing reviewo Number and type of medications

Hough JC, McHenry MP, Kammer LM. Gait disorders in the elderly. Am Fam Physician. 1987;35(6):191-196Sudarsky 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

EvaluationEvaluation• Presence of environmental Hazards

o Cluttero Electrical Cordso Lack of grab bars near bathtub & toiletso Low chairso Poor Lightingo Slippery Surfaceso Throw rugs

EvaluationEvaluation• 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)

EvaluationEvaluationGait & Balance Performance Testing

1. Direct observation of gait & Balance• Watching patient enter and sitting in examination room

o Stanceo postureo Velocityo step lengtho Symmetryo Cadenceo fluidity of movemento instability & need of assistance

EvaluationEvaluationGait & 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

EvaluationEvaluationGait 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

EvaluationEvaluationGait & 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

EvaluationEvaluation• Other Diagnostic Testing

o Role of Lab testing in diagnostic evaluation has not been well studiedo Tests useful when H&P raises suspicious for abnormality

o CBCo Metabolic Panelo Thyroid Functiono RPRo Vitamin B12 Levelo CT heado Hearing Testo Visual Screening

Gait PatternsGait Patterns• Parkinsonian

o Description: Short stepped, shuffling, hip, knee & spine flexed

o Signs: Bradykinesia, muscular rigidity, reduce arm swing

o Causes: Parkinson disease

• Choreico Description: Dance-like,

irregular, slow, wide basedo Sign: Choreoathetoic

movement of UEo Causes: Huntington Disease,

Levodopa induced dyskinesia

• Antalgico Description: Limited ROM,

limping, slow, short steps, unable to bear full weight

o Signs: Pain worse with movement & weight bearing

o Causes: DJD, Trauma

• Waddlingo Description: Lumbar

lordosis, swaying, wide basedo Signs: Hip dislocation,

proximal m/s weakness, uses arm to get up from chair

o Causes: Muscular dystrophy & Myopathy

Gait PatternGait Pattern• Vestibular Ataxia

o Description: Unsteady, falling on one side, Postural instability

o Signs: Nausea, Normal sensation, Nystagmus

o Causes: Menieres, Acute Labrynthitis.

• Cautiouso Description: Slow, wide based,

careful (Walking on Ice)o Signs: Associated with Anxiety,

fear of falling, Open spaceso Causes: Deconditioning, Post

fall syndrome, visual impairment

• Cerebellar Ataxiao Description: Staggering, wide

basedo Signs: Dysarthria, Dysmetria,

dysdiadokinesia, Intentional Tremors, Nystagmus, Romberg's

o Causes: Cerebellar Degeneration, Stroke, MS, Thiamine, Vitamin B12 Def. Alcohol

• Sensory Ataxiao Description: Unsteady, worse

without visual inputo Signs: Impaired position &

vibration, Romberg'so Causes: Dorsal Column,

Neuropathy

Gait PatternGait Pattern• Psychogenic

o Description: Bizarre, Non physiologic gait

o Signs: Absence of neurological signs

o Causes: Factitious, Somatoform disorder & Malingering

• Frontal gait disordero Description: Freezing, start &

turn hesitationo Signs: Dementia, Incontinenceo Causes: NPH, Multi-infarct

state, Frontal lobe degeneration

• Senile gait disordero 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.

InterventionIntervention

• Interventions may impact important Functional outcomes, including Reduction in o Fallso Fear of fallingo 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.

InterventionIntervention• 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 Cervical spondylotic myelopathyo Lumbar spinal stenosiso Normal pressure hydrocephaluso Arthritis of hip or knee

• Improving Sensory Inputo Visual Correctiono 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.

InterventionIntervention• 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.

InterventionsInterventions• Modest improvement in Gait & Balance

achievable by ASSISTIVE DEVICES.

• Unfortunately, most cases its unlikely that Gait Disorder are reversible

Assistive DevicesAssistive Devices• 6.1 million use assistive devices, 2/3 >65 years of age

• ASSISTIVE DEVICES IMPROVE:o Balanceo Reduce paino Compensate for weakness or injuryo Increase Mobility & Confidence

• ASSISTIVE DEVICE SELECTION DEPENDS:o Amount of support assistive device offerso Coordination requiredo 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 DeviceAssistive Device• Patients get Assistive Device without

recommendations from Medical Professional

• Evaluation should be done routinely for proper Fit & Useo Cane preferred for balance with one UEo Crutches or a walker appropriate for Both

• CORRECT HEIGHT & FITo 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 DevicesAssistive 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): 1173-1175

Assistive DevicesAssistive Deviceso 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

CANESCANESSTANDARD 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

CANESCANESOFFSET CANE•Indication:

o Moderate arthritis

•Advantages:o Inexpensiveo Intermittent weight bearingo 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

CANESCANESQUADRIPOD•Indications:

o Hemiparesis

•Advantages:o Increased base of supporto bear large weighto 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

CRUTCHESCRUTCHESAXILLARY CRUTCHES•Indication:

o Lower extremity fracture

•Advantages:o Inexpensiveo Completely redistribute

weight off of lower extremitieso Permits 80-100 % weight-

bearing support

•Disadvantages:o Difficult to learn to useo Requires energy & strengtho Risk of nerve or artery

compression

CRUTCHESCRUTCHESFOREARM CRUTCHES:•Indication:

o Paraparesis

•Advantages:o Frees hands without having to

drop crutcho Less cumbersome to use,

particularly on stairso No Axillary compression

•Disadvantages:o Permits only occasional

weight bearing

WALKERSWALKERSSTANDARD WALKER•Indications:

o Severe myopathyo severe neuropathyo Cerebellar ataxia

•Advantages:o Most stable walkero Folds easily

•Disadvantages:o Slowero Needs to be lifted up with

each stepo Less natural gait

WALKERSWALKERSFRONT-WHEELED WALKER•Indications:

o Severe myopathyo Severe neuropathyo Paraparesiso Parkinsonism

•Advantages:o Maintains normal gait patterno No need to be lifted up with each

step

•Disadvantages:o Large turning arco 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

WALKERSWALKERSROLLATOR•Indications:

o Moderate arthritiso Claudicationo Lung disease, CHF

•Advantages:o Easy to propel o Highly movableo Small turning arco Has seat & basket

•Disadvantages: o Not for weight bearingo Less stable o Does not fold easily

Selection of ADSelection of AD

Assistive DevicesAssistive DevicesList providing stability & support from most to the least :

Parallel barsWalkerAxillary crutchesForearm crutchesTwo canesOne cane

Assistive DevicesAssistive DevicesList requiring Coordination from least to the most:

Parallel barsWalkerOne caneTwo canesAxillary crutchesForearm crutches

ConclusionConclusion• 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 !!Thank you !!