Approach to unsteadiness, gait disturbance, or falls: Clinical sciences

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Introduction0:00–0:34

Unsteadiness, gait disturbance, or falls are common concerns, particularly in older individuals, which can significantly affect everyday activities and the patient’s overall quality of life.
Now, these concerns can occur due to motor weakness, sensory loss, incoordination, or movement disorders. There are several different types of gait, including spastic, stomping, steppage, ataxic, and Parkinsonian gait.

Focused H&P0:34–1:06

Alright, if the patient presents with unsteadiness, gait disturbance, or falls, your first step is to obtain a focused history and physical examination.
These patients report difficulty walking, sometimes in combination with decreased balance and a history of near-falls or falls.
Additionally, there might be a family history of difficulty walking. On physical exam, you will find an abnormal gait, so your next step is to assess the type of gait dysfunction.
First, let’s focus on spastic gait. Spastic gait is associated with stiff legs and poor floor clearance.

Spastic gait1:06–1:50

Often, you will see circumduction of the legs because they have trouble lifting the feet adequately off the floor. In other words, the patient will bring the leg outward and then inward in a half-circular motion to take a step.
Also, their toes typically scrape the floor as they walk. You can confirm this by looking at the soles of their shoes.
These findings are suggestive of spastic gait, so your next step is to assess the underlying cause. Let’s start with cervical myelopathy.

Cervical myelopathy1:50–2:31

These individuals usually report weakness and numbness of the arms and legs, as well as neck pain. Also, they might have a known history of disc herniation, spinal stenosis, or recent trauma to the neck and back.
On the exam, you will find weakness and sensory loss in all extremities, as well as spasticity and hyperreflexia in all extremities.
At this point, consider cervical myelopathy and obtain a cervical spine CT or MRI. If imaging shows compression of the cervical spinal cord, such as from a disc herniation, diagnose cervical myelopathy.
Next up is cerebral palsy. History typically reveals in-utero or perinatal brain injury, such as from perinatal asphyxia; and delays in motor milestones.

Cerebral palsy2:31–3:01

The patient might also have a history of cognitive delay, premature birth, and epilepsy. On physical exam, you will find unilateral or bilateral weakness, as well as spasticity and hyperreflexia.
These findings are highly suggestive of cerebral palsy. Alright, let’s discuss stomping gait, which is characterized by forceful steps.

Stomping gait3:01–4:58

This gait occurs with loss of sensation, more specifically proprioception in lower extremities. Therefore, patients cannot tell if their foot landed or not, so they have to see it, which is why they tend to look at their feet when walking; or feel it by stomping.
The gait is wide-based, unsteady, and worsens with no visual cues. For example, your patient will report difficulty walking in the dark or when they close their eyes.
These findings are suggestive of stomping gait, which is also known as sensory ataxia gait. This type of gait is specific for conditions associated with proprioceptive sensory loss such as diabetic polyneuropathy, subacute combined degeneration from B12 deficiency, and tabes dorsalis.
To differentiate between these conditions, you need to obtain labs, including hemoglobin A1c, vitamin B12 levels, serologic syphilis testing and CSF-VDRL, as well as imaging, more specifically, an MRI of the spine.
If the hemoglobin A1c is elevated, diagnose diabetic polyneuropathy as the likely cause of gait disturbance. On the flip side, if the vitamin B12 level is low and the spine MRI shows longitudinal hyperintensities in the lateral and posterior aspects of the spinal cord, diagnose subacute combined degeneration from B12 deficiency.
Finally, if the serologic syphilis testing is positive, the CSF-VDRL is positive, and the spine MRI shows a longitudinal hyperintensity in the posterior cord due to dorsal column injury, diagnose tabes dorsalis, which is a late neurologic manifestation of syphilis infection.
Switching gears and moving on to steppage or high-stepping gait. These patients present with foot drop and walk with excessive hip flexion and high steps.

Steppage/High-stepping gait4:58–5:21

When you identify a patient with steppage gait, your next step is to assess for family history of gait abnormality. If family history is present, consider Charcot-Marie-Tooth disease, and send genetic testing.

Charcot-Marie-Tooth disease5:21–5:37

If genetic testing shows duplication of the PMP22 gene on chromosome 17, diagnose Charcot-Marie-Tooth type 1A. On the flip side, if there’s no family history of gait abnormality, consider peroneal neuropathy or L5 radiculopathy.

Peroneal neuropathy5:37–6:23

Individuals with peroneal neuropathy typically report numbness and tingling of the lateral shin and the top of the foot.
They might also report risk factors like repeated or sustained leg crossing or squatting, prolonged immobility, a tight cast or clothing compressing the knee, or recent knee trauma.
The physical exam shows weakness of ankle dorsiflexion and eversion, as well as weakness of toe extension. Also, you will notice sensory loss in the lateral shin and the dorsum of the foot.
With these findings, you should think of compressive peroneal neuropathy at the knee. Similarly, individuals with L5 radiculopathy will also report numbness and tingling of the lateral shin and the top of the foot.

L5 radiculopathy6:23–7:09

But in contrast to peroneal neuropathy, these patients will also report low back pain that might shoot down the leg. They might also have a known history of a herniated disc or spinal stenosis.
Just as in peroneal neuropathy, the exam reveals weakness of ankle dorsiflexion and eversion, as well as toe extension. However, in L5 radiculopathy you will also notice weakness of ankle inversion, hip abduction, and hip extension.
There is also sensory loss in the lateral shin and the dorsum of the foot. These findings are consistent with an L5 radiculopathy.
Okay, let’s move on to ataxic gait, also known as cerebellar gait. This gait is wide-based and unsteady, with the patient veering to the side.

Ataxic gait7:09–7:54

Also, there is an irregular rhythm and stride length. If the ataxia is mild, it might only be prominent on tandem gait testing, which is performed by asking the patient to walk with the heel of one foot touching the toes of the other foot with each step, as if walking on a tightrope.
Once you identify an ataxic gait, your next step is to assess the underlying cause. In this case, you should think of alcoholic cerebellar degeneration and Friedreich ataxia.
First, let’s focus on alcoholic cerebellar degeneration. In this case, your patient will present with a history of excessive alcohol use.

Alcoholic cerebellar degeneration7:54–9:05

On physical exam, you will find ataxia of the lower extremities, such as on heel-to-shin testing, and possibly of the upper extremities, such as on finger-to-nose testing.
Also, you will identify truncal ataxia, with difficulty sitting or standing up straight. In some cases, you might detect titubation, which is a tremor of the head or upper trunk; or an intention tremor of the limbs, which is a side-to-side movement of the outstretched limb as it reaches a target.
With these findings, consider alcoholic cerebellar degeneration, and obtain brain imaging with a CT or MRI. If the brain imaging shows cerebellar atrophy, particularly of the vermis, which is the midline structure of the cerebellum, diagnose alcoholic cerebellar degeneration.
Here's a high-yield fact to keep in mind! Remember that the cerebellar vermis controls coordination of midline structures such as the head and trunk, while the cerebellar hemispheres control coordination of the ipsilateral limbs.

Friedreich Ataxia9:05–10:07

Next, let’s discuss hereditary causes of ataxic gait, more specifically Friedreich ataxia. The patient usually reports symptom onset during childhood or adolescence.
In addition to gait abnormalities, these individuals typically report gradual progression of numbness, incoordination, and sometimes weakness.
They might also report slurred speech or difficulty swallowing, while their history might reveal chronic conditions like cardiomyopathy or diabetes.
Next, the exam reveals loss of proprioceptive and vibratory sensation and a positive Romberg test, which indicates impaired proprioception.
Also, you will notice limb and truncal ataxia, and in some cases, limb weakness, scoliosis, pes cavus deformities, and hammertoes.
With these findings, consider Friedreich ataxia and obtain genetic testing. If you identify a mutation in the frataxin gene and expanded GAA trinucleotide repeats, diagnose Friedreich ataxia.

Parkinsonian gait10:07–10:33

Finally, let’s discuss the Parkinsonian gait. In this case, the patient will present with a forward-bent torso, hesitation in gait initiation, and short and shuffling steps.
Also, the patient has difficulty with turns, taking multiple steps to turn around. Once you recognize the parkinsonian gait, assess the underlying cause.
First, there’s Parkinson disease, which is associated with slowness of movement and shaky hands at rest. On the exam, you will notice bradykinesia, rigidity, and a pill-rolling tremor at rest, which is a hand tremor that looks like the patient is rolling a pill between their thumb and index finger.

Parkinson disease10:33–11:29

Also, you will find postural instability, such as with a positive pull test. To do this, stand behind the patient and suddenly pull back on their shoulders.
Individuals who can maintain their balance will either not take any steps backward or, at most, take one to two steps back.
However, individuals with Parkinson disease have postural instability, meaning they will take multiple small steps backward, and might even fall.
In that case, the pull test is positive. Finally, the exam will reveal decreased arm swing during ambulation.
These findings should point you toward Parkinson disease. On the flip side, another cause of Parkinsonian gait could be normal pressure hydrocephalus.

Normal pressure hydrocephalus11:29–12:24

In this case, history reveals cognitive decline, and urinary symptoms, including urinary urgency and frequency, or in some cases, incontinence.
Next, the physical exam will reveal postural instability and magnetic gait, which appears like the feet are stuck to the ground as the patient shuffles around.
Finally, in contrast to Parkinson disease, these individuals have a normal or increased arm swing during ambulation. At this point, consider normal pressure hydrocephalus, so obtain a brain CT or MRI, and perform a lumbar puncture.
If the brain imaging shows ventriculomegaly with minimal cortical atrophy, no obstruction of CSF flow, and normal opening pressure on lumbar puncture, diagnose normal pressure hydrocephalus.
Alright, as a quick recap… If your patient is presenting with unsteadiness, gait disturbance, or falls, first, assess the type of gait dysfunction.

Review12:24–13:10

Spastic gait is commonly seen in individuals with cervical myelopathy and cerebral palsy, while stomping gait is associated with diabetic neuropathy, subacute combined degeneration from B12 deficiency, and tabes dorsalis.
Next, steppage gait could be seen in conditions like Charcot-Marie-Tooth disease, peroneal neuropathy, and L5 radiculopathy; while ataxic gait can occur due to alcoholic cerebellar degeneration or Friedreich ataxia.
Finally, if you notice Parkinsonian gait, think of Parkinson disease or normal pressure hydrocephalus.
Approach to unsteadiness, gait disturbance, or falls: Video | Osmosis