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Gait disorders encompass a number of issues, including slowing of gait speed and loss of smoothness, symmetry, or synchrony of body movement.
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Existing evidence suggests that prevalence rates of severe and chronic LBP increase with older age. As compared to working-age adults, older adults are more likely to develop certain LBP pathologies e. Importantly, various age-related physical, psychological, and mental changes e. Collectively, by understanding the impacts of various factors on the assessment and treatment of older adults with LBP, both clinicians and researchers can work toward the direction of more cost-effective and personalized LBP management for older people. The average lifespan of humans has dramatically increased in the last decade due to the advance in medicine [ 1 ]. However, the fast-growing aging population also increases the likelihood of non-communicable diseases e. Low back pain LBP is the most common health problem among older adults that results in pain and disability [ 4 , 7 — 10 ]. However, recent studies have revealed that LBP remains ubiquitous among older adults at their retirement ages [ 20 , 21 ]. It is noteworthy that both the incidence and prevalence of severe and chronic LBP increase with older age [ 13 , 29 , 30 ]. Docking et al.
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Gait disorders encompass a number of issues, including slowing of gait speed and loss of smoothness, symmetry, or synchrony of body movement. For older adults, walking, standing up from a chair, turning, and leaning are necessary for independent mobility. Gait speed, chair rise time, and the ability to do tandem stance standing with one foot in front of the other—a measure of balance are independent predictors of the ability to do instrumental activities of daily living eg, shopping, traveling, cooking and of the risk of nursing home admission and death.

Walking without assistance requires adequate attention and muscle strength plus effective motor control to coordinate sensory input and muscle contraction. Gait speed, chair rise time, and the ability to do tandem stance are independent predictors of the ability to do instrumental activities of daily living and of the risk of nursing home admission and death.

Gait velocity is a powerful predictor of mortality—as powerful as an older person's number of chronic medical conditions and hospitalizations. Gait velocity slows because older people take shorter steps at the same rate cadence.

The most likely reason for shortened step length the distance from one heel strike to the next is weakness of the calf muscles, which propel the body forward; calf muscle strength is substantially decreased in older adults. However, older people seem to compensate for decreased lower calf power by using their hip flexor and extensor muscles more than young adults.

Each person has a preferred cadence, which is related to leg length and usually represents the most energy-efficient rhythm. Tall people take longer steps at a slower cadence; short people take shorter steps at a faster cadence.

Double stance time ie, time with both feet on the ground during ambulation—a more stable position for moving the center of mass forward increases with age. Increased time in double stance reduces the time the swing leg has to advance and shortens step length. Older people may increase their double stance time even more when they walk on uneven or slippery surfaces, when they have impaired balance, or when they are afraid of falling.

They may appear as if they are walking on slippery ice. Walking posture changes only slightly with aging. Older adults walk upright, with no forward lean. However, older people walk with greater anterior downward pelvic rotation and increased lumbar lordosis.

This posture change is usually due to a combination of weak abdominal muscles, tight hip flexor muscles, and increased abdominal fat. Foot clearance in swing is unchanged with advancing age. Joint motion changes slightly with aging. Ankle plantar flexion is reduced during the late stage of stance just before the back foot lifts off. The overall motion of the knee is unchanged. Hip flexion and extension are unchanged, but the hips have increased adduction. Pelvic motion is reduced in all planes. Musculoskeletal disorders eg, spinal stenosis.

Causative neurologic disorders include dementias , movement and cerebellar disorders , and sensory or motor neuropathies. There are many manifestations of gait abnormality. Some help suggest certain causes. Video demonstrations of selected abnormal gaits are available from the NeuroLogic Exam website. Loss of symmetry of motion and timing between left and right sides usually indicates a disorder.

When healthy, the body moves symmetrically; step length, cadence, torso movement, and ankle, knee, hip, and pelvis motion are equal on the right and left sides. A regular asymmetry occurs with unilateral neurologic or musculoskeletal disorders eg, a limp caused by a painful ankle.

Unpredictable or highly variable gait cadence, step length, or stride width indicates breakdown of motor control of gait due to a cerebellar or frontal lobe syndrome or use of multiple psychoactive medications. Difficulty initiating or maintaining gait may occur. When patients first start walking, their feet may appear stuck to the floor, typically because patients do not shift their weight to one foot to allow the other foot to move forward.

This problem may represent isolated gait initiation failure, Parkinson disease , or frontal or subcortical disease. Once gait is initiated, steps should be continuous, with little variability in the timing of the steps. Freezing, stopping, or almost stopping usually suggests a cautious gait, a fear of falling, or a frontal lobe gait disorder. Scuffing the feet is not normal and is a risk factor for tripping. Retropulsion is walking backwards when initiating gait or falling backwards while walking.

It may occur with frontal gait disorders, parkinsonism, central nervous system syphilis , and progressive supranuclear palsy. Footdrop causes toe dragging or a stepping gait ie, exaggerated lift of the leg to avoid catching the toe. It may be secondary to anterior tibialis weakness eg, caused by trauma to the peroneal nerve at the lateral aspect of the knee or a peroneal mononeuropathy usually associated with diabetes , spasticity of calf muscles gastrocnemius and soleus , or lowering of the pelvis due to muscle weakness of the proximal muscles on the stance side particularly the gluteus medius.

Low foot swing eg, due to reduced knee flexion may resemble footdrop. Short step length is nonspecific and may represent a fear of falling or a neurologic or musculoskeletal problem. The side with short step length is usually the healthy side, and the short step is usually due to a problem during the stance phase of the opposite problem leg.

For example, a patient with a weak or painful left leg spends less time in single stance on the left leg and develops less power to move the body forward, resulting in shorter swing time for the right leg and a shorter right step.

The normal right leg has a normal single stance duration, resulting in a normal swing time for the abnormal left leg and a longer step length for the left leg than for the right leg. As gait speed decreases, step width increases slightly. Wide-based gait can be caused by cerebellar disease or bilateral knee or hip disease.

Variable step width lurching to one side or the other suggests poor motor control, which may be due to frontal or subcortical gait disorders. Circumduction moving the foot in an arc rather than a straight line when stepping forward occurs in patients with pelvic muscle weakness or difficulty bending the knee.

Spasticity of the knee extensor muscles is a common cause. Forward lean can occur with kyphosis and with Parkinson disease or disorders with parkinsonian features associated with dementia particularly vascular dementia and Lewy body dementia. Festination is a progressive quickening of steps usually with forward lean , whereby patients may break into a run to prevent falling forward.

Festination can occur with Parkinson disease and rarely as an adverse effect of dopamine -blocking drugs typical and atypical antipsychotics. Sideward trunk lean that is consistent or predictable to the side of the stance leg may be a strategy to reduce joint pain due to hip arthritis or, less commonly, knee arthritis antalgic gait.

In a hemiparetic gait, the trunk may lean to the strong side. In this pattern, the patient leans to lift the pelvis on the opposite side to permit the limb with spasticity inability to flex the knee to clear the floor during the swing phase. Irregular and unpredictable trunk instability can be caused by cerebellar, subcortical, or basal ganglia dysfunction.

Arm swing may be reduced or absent in Parkinson disease and vascular dementias. Arm swing disorders may also be adverse effects of dopamine -blocking drugs typical and atypical antipsychotics. The goal is to determine as many potential contributing factors to gait disorders as possible.

A performance-oriented mobility assessment tool may be helpful see table Performance-Oriented Assessment of Mobility , as may other clinical tests eg, a screening cognitive examination for patients with gait problems possibly due to frontal lobe syndromes. Clinical Meaning. Parkinson disease.

Isolated gait initiation failure stroke or dementia. Right step length and height right swing foot. Completely clears floor. Left step length and height left swing foot. Step symmetry.

Step continuity. Fear of falling, frequent in dementia. Path estimated in relation to floor tiles that are 12 in [30 cm] wide; observed excursion of one foot over about 10 ft of the course. Straight without a walking aid. Stride width step width. Normal-pressure hydrocephalus. Adapted from Tinetti M: Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society —, ; used with permission. Assessing all components of gait see table Performance-Oriented Assessment of Mobility.

In addition to the standard medical history, older patients should be asked about gait-related issues. First, they are asked open-ended questions regarding any difficulty with walking, balance, or both, including whether they have fallen or fear they might fall. Then specific capabilities are assessed; they include whether patients can go up and down stairs; get in and out of a chair, shower, or tub; and walk as needed to buy and prepare food and do household chores.

If they report any difficulties, details of the onset, duration, and progression are sought. History of neurologic and musculoskeletal symptoms and known disorders is important. A thorough physical examination is done with emphasis on the musculoskeletal examination and the neurologic examination. Lower-extremity strength is assessed. Proximal muscle strength is tested by having patients get out of a chair without using their arms.

Calf strength is measured by having patients face a wall, put their palms on the wall to assist balance , and rise onto their toes first using both feet and then using one foot at a time. Strength of hip internal rotation is assessed. Routine gait assessment can be done by a primary care practitioner; an expert may be needed for complex gait disorders. Assessment requires a straight hallway without distractions or obstructions and a stopwatch. Patients should be prepared for the examination. They should be asked to wear pants or shorts that reveal the knees and be informed that several observations may be needed but that they will be allowed to rest if fatigued.

Assistive devices provide stability but also affect gait. Use of walkers often results in a flexed posture and discontinuous gait, particularly if the walker has no wheels. If safe to do so, the practitioner should have the patient walk without an assistive device, while remaining close to or walking with the patient with a gait belt for safety. If patients use a cane, the practitioner can walk with them on the cane side or take their arm and walk with them.



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