Coordination Gait and Equilibrium

Tinetti Functional Test

As in all aspects of physical examination, the practitioner needs to establish whether their observations are that of viewing the cause or merely the effect. Is the individual’s posture indicative of some ergonomic or biomechanical factor or the expression of an organic underlying process? Is there a component responsible for hip flexion? Do they need their arms to assist them to their feet? Conversely, if while sitting, they find it more comfortable to be flexed from the hips with elbows on knees, is this posture preferred for compensatory reasons or poor body mechanics?

A person who finds it necessary to rise in stages; utilizing their arms and which appear to be unsteady once on their feet, present manifestations of possible proprioceptive and/or cerebellar impairment. Decreased knee extension may be attributed to arthrodial or muscular deficit causation.

Shuffling gait, hyper and hypo knee extension, high stepping, toe dragging, inability to stop or turn without support are abnormal signs of ambulation. These signs suggest further evaluation into the issues of visual impairment either of a near or central vision loss, diminished hip or knee strength, proprioceptive impairment of toes, or frontal lobe dysfunction. Vascular claudication will also exhibit ambulatory dysfunction. However, these anomalies are usually not detected in the Tinetti due to greater distances being necessary to depict these abnormalities than this test affords.

Upon returning to their seat, falling into the chair or sitting unevenly is suggestive of poor hip or knee flexion, which can be due to functional inability or lack of social amenity.

Somatic Walking Test

Gait Analysis

• Heel-Toe Gait – the normal, symmetrical non-pathognomonic means of ambulation whereby the heel strikes the surface first with the toes striking last and are utilized to propel forward.
• Antalgic Gait (Compensatory Gait) – when pain is produced by weight-bearing on a lower extremity, the individual puts the affected extremity down carefully and takes a short step to get the weight off the painful limb as soon as possible. The good limb is brought forward rapidly and lands vigorously on the floor. Limping may be associated with a variety of conditions, including shortening of the lower extremity and deformity of the foot. Low back and/or pelvic concomitants guarding or splinting may also cause an irregular gait, or the inadvertent overloading of the non-affected limb. It is not uncommon for an individual to have a chief complaint of leg or foot pain when a clinically silent low back or pelvic anomaly initiated the genesis of the condition. Scoliosis, hyperkyphosis, slipped rib, long second metatarsal, small hemi-pelvis, pathological short leg, and cervical abnormalities may also affect gait. Abnormal tone of muscles or ligaments encourages structural deviation whether recumbent, sitting, standing or walking.
• Drag-To Gait - this gait consists of dragging rather than lifting the feet during bilateral crutch ambulation.
• Point Gait – this assisted gait maintains one crutch and one foot in contact with the surface simultaneously.
• Swing Gait – this form of assisted ambulation swings the legs between the crutches while only the crutches are maintaining contact with the surface.
• Swing-To Gait - this form of assisted ambulation requires the crutches be advanced and the legs are swung to the same point that the crutches are making contact to the surface.
• Swing-Through Gait - this form of assisted ambulation is similar to the swing-to gait with the exception of the legs being swung past the crutches.
• Four-Point Gait – ambulation whereby one crutch is moved then the contralateral leg; then the other crutch is moved with the resulting movement of that contralateral leg.
• Three-Point Gait – this form of assisted ambulation requires the crutches and the effected limb to be advanced to the same point simultaneously.
• Two-Point Gait - this form of assisted ambulation requires the ipsilateral limb and crutch be moved simultaneously to the same point.
• Ataxic Gait – a dyskinetic unsteady wide based form of walking which is suggestive of neurologic impairment; for more specificity review Friedreich’s or Charcot’s ataxia, tabetic gait and swaying gait or cerebellar ataxia
• Tabetic Gait (Ataxic Gait) – this form of ataxic ambulation frequently accompanies tabes dorsalis; it has the wide base of the cerebellar gait but unlike the cerebellar gait the limbs are not loose and there is a definite foot plant rather than a flopping; the individual has a tendency to look at their feet while walking.
• Friedreich’s Ataxia (Charcot’s Gait/Inherited Spinal Ataxia) - An unsteady gait resulting from muscle weakness and the progression of a clawed foot, it is caused by spinal cord and tract degeneration it usually has its onset at puberty and is considered to be an inherited condition.
• Cerebellar Gait (Swaying/Ataxic Gait) – this swaying gait is similar to the drunken/staggering gait in the regard that the limbs are loose and uncoordinated and turning is performed with a definite stagger. How it differs is there is a pronounced planting of the foot and a tendency to reel or veer to one side; occasionally to avoid veering and potentially falling, the individual finds it necessary to maintain contact with the wall while walking. This simple touch helps to re-establish their equilibrium at which time you will observe an erect posture with a definite foot plant. Should a wall not be accessible and this condition be progressed the individual will require a walker or stroller for ambulation. It is frequently observed in cerebral spinal degeneration (multiple sclerosis), Polyneuropathy (alcohol neuritis), progressive supranuclear palsy and cerebellar tumor or atrophy. With acute onset in the elderly the causation is usually vascular.
• Myopathic gait (Dystrophic/Waddling/Clumsy Gait) - this form of ambulation resembles a penguin waddle, with exaggerated lateral side bending and hip elevation; it is observed in neuromuscular diseases with resulting atrophy such as Muscular Dystrophy as well as some forms of polyneuropathy. There is a pronounced anterior displacement of the abdomen and pelvic tilt as a means of compensation.
• Hysterical gait – is a non-organic form of ambulatory dysfunction which resembles an exaggerated ataxia, mono or hemiplegia or dyskinesia, it is usually wild and exaggerated or retarded and slow motion. However, since there is no organic foundation for this dysfunction, the person can use the limb normally if distracted or perceives a sense of urgency in ambulation.
• Stuttering Gait – this form of ambulation is typified by a periodic reluctance to continue thus it derives its name stuttering; it is observed with schizophrenics or as a form of hysterical ataxia as well as in severe neurologic impairment.
• Abasia - a form of hysterical ataxia, the individual has the ability to move their legs while sitting or recumbent but expresses an inability to stand or walk.
• Astasia - Inability to stand due to muscular incoordination.
• Helicopod Gait – this form of ambulation is observed with numerous conversion disorders whereby the feet trace half circles.
• Calcaneus Gait – this gait anomaly is a direct result of paralysis of the gastrocnemius and soleus resulting in an inability to plantar flex and the tibia to push off over the talus at the end of the stance.
• Double Step Gait - alteration of gait; which consist of a regular rhythmic gait sequence being interrupted with a quicker step.
• Intermittent Double-Step Gait – a hemiplegic double step gait proceeded with a pause.
• Hip Extensor Gait (Maximus Gait) – this gait abnormality is due to an expressed weakness of the hip extensors, especially the gluteus maximus, which results in the anterior hip rotating while the trunk and lumbar region move posteriorly, resembling a lunging or lurching of the pelvis on the ipsilateral side of dysfunction.
• Uncompensated Gluteus Medius Gait (Trendelenburg Gait) - is typified by a loss of translatory pelvic rotation on the affected side during walking; the hemipelvis remains fixed due to a weakened gluteus medius; translation of the non-effected hemipelvis is normal.
• Compensated Gluteus Medius (Gluteal Gait/Trendelenburg Symptom) – a waddling or listing gait as observed in muscular dystrophy; if only one side is affected as in hip dislocation or weakness of the gluteus medius, listing will occur to the affected side to avoid weight bearing on the affected side.
• Hemiplegic gait - this form of ambulation is similar to the compensated gluteus medius gait however, the leg remains rigid and is swung forward in a semicircle with the body listing to the effected side; usually the arm is flexed and the toes are down to gain greater body mechanics to propel the effected limb into abduction & circumduction; classically portrayed by Dennis Weaver on Gunsmoke.
• Paraplegic Spastic Gait – this dysfunctional gait usually resembles an individual ambulating with legs close together and rigid, with an almost toe tripping motion while walking; which is due to CNS involvement.
• Propulsion Gait (Festinating Gait) – an individual exhibiting this gait usually has short slow steps which can spontaneously burst into rapid short steps, as their trunk is usually forward it appears they are chasing their center of gravity. Since this condition is frequently seen in Parkinson’s, foot fixation can occur. Therefore you have an individual that can start walking slowly and require the stability of touching the wall, with immediate bursts into short rapid steps only to have a sudden stop as if their shoes were nailed to the floor. Frequently having them turn one way or the other will release the foot fixation.
• Steppage Gait (Drop Foot/Equine gait) - this form of ambulation is typified by a high stepping, foot flopping, toe dragging gait; it is characteristic of anterior tibial muscular damage or atrophy, as observed in alcoholic neuritis, poliomyelitis or peroneal nerve damage. When bilateral it resembles the famous prance of the Clydesdale horses.
• Quadriceps Gait – when the quadriceps are paralyzed, atrophied or extremely hypotonic the individual appears to have a hyperextension of the knee and a lunging trunk motion during ambulation.
• Scissors Gait – this gate is typified by a spastic lurching crossover pattern of the legs while walking. Their footprints, when observed, have the right sole imprint on the left and the left on the right. As their equilibrium is off, falling, especially while walking down a grade, is common.
• Staggering (drunken) Gait - while usually typified by a weaving motion of the trunk and staggering motion of the legs, it may also resemble a scissor gait with the legs crisscrossing over one another. Regardless of the form of staggering cerebral function is usually impaired unless the gait is secondary to a neuropathy, paresis or hypoglycemia. While this gait is more closely associated with alcohol or recreational drug consumption, diabetics experiencing low blood sugar also manifest this sign and unfortunately, there have been numerous individuals arrested for public intoxication only to lapse into a diabetic coma in a drunk tank. Paralysis and proprioceptive dysfunction may also elicit this gait, however, cognitive ability and the ability to speak clearly will not be impaired as in intoxication or hypoglycemia.

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