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

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.

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. 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. 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. 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. 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. 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. 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. 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. 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.