586 CLEVELANDCLI NI CJ OURNALOFMEDI CI NEVOLUME72NUMBER7J ULY2005NEIL B. ALEXANDER, MDInstitute of Gerontology; Division of GeriatricMedicine, Department of Internal Medicine,University of Michigan; Ann Arbor VeteransHealth Care System, Geriatric ResearchEducation and Clinical Center, Ann Arbor, MIALLON GOLDBERG, PhDInstitute of Gerontology; Division of GeriatricMedicine, Department of Internal Medicine,University of Michigan; Ann Arbor VeteransHealth Care System, Geriatric ResearchEducation and Clinical Center, Ann Arbor, MIGait disorders:Search for multiple causesREVIEW ABSTRACTGait disorders predict functional decline in older adults.They are often the result of multiple causes, so a fullassessment should consider different sensorimotor levelsand should include a focused physical examination andevaluation of functional performance. Exercise andmedical and surgical interventions are effective and canreduce the degree of gait disorder, but usually notwithout some residual impairment. Orthoses and mobilityaids are also important interventions to consider. KEYPOI NTSIn assessing gait disorders, it is helpful to categorize theproblem according to the level of the sensorimotordeficit.Dementia and depression contribute to gait disorder butmay not be the sole causes.Acute gait disorder may be the presenting feature ofacute systemic decompensation in an older adult, and itwarrants evaluation for myocardial infarction or sepsis.A formal neurologic assessment is critical and shouldinclude strength and tone, sensation (includingproprioception), coordination (including cerebellarfunction), standing, and gait. Vision screening, at least foracuity, is essential.The Timed Up and Go (TUG) test is a simple tool forassessing stability. A fall or any difficulty or unsteadinessduring the TUG test requires a more extensive evaluationof gait and fall risk factors.AIT DISORDERS IN ELDERLY patients oftenleadtofallsanddisability.Theyareastrong predictor of functional decline.Moreoftenthannot,agaitdisorderrep-resents the combined effects of more than onecoexisting condition, so the evaluation shouldtakecomorbiditiesintoconsiderationandshould include assessment of different levels ofsensorimotor deficits.Inthisarticle,wereviewtheprevalence,impact,andcausesofgaitdisordersintheelderly.Wealsooutlineappropriateclinicalassessmentsandinterventionsknowntoreduce the severity of gait disorders. INCIDENCE AND PREVALENCEOF GAIT DISORDERSAtleast20%ofnoninstitutionalizedolderadults admit having trouble walking or requiretheassistanceofanotherpersonorspecialequipmenttowalk.1Limitationsinwalkingalso increase with age.Insomesamplesofnoninstitutionalizedadults age 85 and older, the prevalence of lim-itationinwalkingcanbeover54%.1Whileage-relatedchangessuchasgaitspeedaremost apparent after age 75 or 80, most gait dis-ordersappearinconnectionwithunderlyingdiseases,particularlyasdiseaseseverityincreases.Forexample,ageover85,threeormore chronic conditions, and the occurrenceof stroke, hip fracture, or cancer predict cata-strophic loss of walking ability.2What is normal, and what is not?Determining that a gait is disordered can bedifficult, as there are no clearly accepted stan-dardsastowhatisanormalgaitinolderG on September 14, 2013. For personal use only. All other uses require permission. www.ccjm.org Downloaded from CLEVELANDCLI NI CJ OURNALOFMEDI CI NEVOLUME72NUMBER7J ULY2005 589adults.Somebelieveaslowedgaitisadisor-dered gait, and others believe that any aesthet-icabnormalityeg,deviationinsmoothness,symmetry,andsynchronyofmovementpat-ternsconstitutesagaitdisorder.However,aslowedoraestheticallyabnormalgaitmayinfact provide the older adult with a safe gait pat-tern that helps maintain independence.Gait disorders tendto be multifactorial, progressiveIn older patients, attributing a gait disorder toa single disease is particularly difficultand isoftennotadvisablebecausemanydifferentconditions can result in similar gait abnormal-ities.3Recentlongitudinalstudiessuggestthatcertain gait-related mobility disorders progresswith age and that this progression is associat-ed with disease and death. When measured bytheUnifiedParkinsonDiseaseRatingScale(UPDRS),whichincludesabnormalitiesinrising from a chair and turning, gait and pos-turaldisordersincreasedinmost(79%)ofanondemented sample of Catholic clergy with-outclinicalParkinsondisease(meanage75)followedforupto7yearsinaprospectivecohortstudy.4Thisincreasewasmorecom-mon in older subjects and was associated witha higher death rate.These observations raise several questions.TheUPDRSmaybemoreappropriateforpatients known to have Parkinson disease, butanincreasedUPDRSscoremayrepresentincreasedparkinsoniansignswithageinpatientswithoutadiagnosisofparkinsonism,as well as an increase in associated disease andinactivity.Itisalsounclearwhethersubjectsin this cohort developed other overt neurolog-icdisease,dementia,orboth.Forexample,declining gait speed is one of the factors thatcanindependentlypredictcognitivedeclineprospectively in healthy older adults.5Cerebrovasculardisease,bothsubclinicalandclinicallyevident,isincreasinglyrecog-nizedasamajorcontributortogaitdisorders(seediscussionofassessmentbelow).Non-dementedpatientswithclinicallyabnormalgait(particularlyunsteady,frontal,orhemi-pareticgait)whoarefollowedforapproxi-mately 7 years are at higher risk of developingnon-Alzheimerdementia,particularlyvascu-lar dementia.6Of note, at baseline, those withabnormalgaitmaynothavemetcriteriafordementiabutalreadyhadabnormalitiesinneuropsychologicalfunction,suchasvisual-perceptual processing and language skills.Gaitdisorderswithnoapparentcause(idiopathicorsenilegaitdisorder)areassociated with a higher death rate, primarilyfrom cardiovascular causes; these cardiovascu-lar causes are likely linked to concomitant andpossibly undetected cerebrovascular disease.7 CONDITIONS THAT CONTRIBUTETO GAIT DISORDERSDisorderedgait,definedasagaitthatisslowed, aesthetically abnormal, or both, is notnecessarily an inevitable consequence of agingbut rather a reflection of the increased preva-lenceandseverityofage-associateddiseases.8Theseunderlyingdiseases,neurologicandnonneurologic,contributetodisorderedgait.Elderlypatientsusuallyhavemorethanonecondition contributing to their gait disorder.When asked what makes walking difficult,patientsmostoftencitepain,stiffness,dizzi-ness,numbness,weakness,andsensationsofabnormal movement.9Conditions seen in theprimary care setting that can contribute to gaitdisordersincludedegenerativejointdisease,acquiredmusculoskeletaldeformities,inter-mittentclaudication,impairmentsfollowingorthopedicsurgeryandstroke,andposturalhypotension.9Inagroupofcommunity-dwellingadultsoverage88,jointpainwasbyfarthemostcommoncontributor,followedbystrokeandvisual loss.8Thediagnosesfoundinaneurologicalreferralpopulationwereprimarilyneurologi-callyoriented10,11andincludedfrontalgaitdisorders(usuallyrelatedtonormal-pressurehydrocephalus and cerebrovascular processes),sensorydisorders(alsoinvolvingvestibularandvisualfunction),myelopathy,previouslyundiagnosedParkinsondiseaseorparkinson-ian syndromes, and cerebellar disease.Conditions that cause severe gait impair-ment,suchashemiplegiaandseverehiporknee disease, are often not mentioned in theseneurologicreferralpopulations.Thus,manygait disorders, particularly those that are clas-Declining gaitspeed predictscognitivedecline inhealthy olderadults on September 14, 2013. For personal use only. All other uses require permission. www.ccjm.org Downloaded from 590 CLEVELANDCLI NI CJ OURNALOFMEDI CI NEVOLUME72NUMBER7J ULY2005sicanddiscrete(eg,relatedtostrokeandosteoarthritis)andthosethataremildorrelated to irreversible disease (such as vasculardementia), are presumably diagnosed in a pri-mary care setting and treated without referralto a neurologist. Dementia and fear of fallingalso contribute to gait disorders.Lesscommoncontributorstogaitdisor-dersincludemetabolicdisordersrelatedtorenal or hepatic disease, tumors of the centralnervoussystem,subduralhematoma,depres-sion,andpsychotropicmedications.Casereports also document reversible gait disordersduetoclinicallyoverthypothyroidismorhyperthyroidismanddeficiencyofvitaminB12and folate.3 DISEASE-RELATED FACTORSTHAT AFFECT GAITFactorsthatslowgaitspeedarealsoconsid-ered contributors to gait disorders. These fac-torsareoftendisease-associatedeg,relatedtocardiopulmonaryormusculoskeletaldis-easeand include reductions in leg strength,vision,aerobicfunction,standingbalance,andphysicalactivity,aswellasjointimpair-ment, previous falls, and fear of falling.1218Incombination, these factors may have an effectgreaterthanthesumofthesingleimpair-ments, such as when leg weakness is superim-posedonimpairedbalance.17Furthermore,theeffectofreducedstrengthandaerobiccapacityongaitspeedmaybenonlinear:ie,forveryimpairedpatients,smallimprove-ments in strength or aerobic capacity yield rel-ativelylargergainsingaitspeed,whereassmall improvements may yield little gait speedchange in a healthy older patient.15,19Whileolderadultsmaymaintainarela-tively normal gait pattern well into their 80s,someslowingoccurs,anddecreasedstridelengthbecomesacommonfeaturedescribedin gait disorders in the elderly.3Someauthorshaveproposedtheemer-genceofanage-relatedgaitdisorderwithoutaccompanyingclinicalabnormalities,ie,essential senile gait disorder.20This gait pat-ternisdescribedasbroad-based,withsmallsteps,diminishedarmswing,stoopedposture,flexion of the hips and knees, uncertainty andstiffnessinturning,occasionaldifficultyiniti-atingsteps,andatendencytowardfalling.These and other nonspecific findings, such asthe inability to perform tandem gait, are simi-lar to gait patterns found in a number of otherdiseases, and yet the clinical abnormalities areinsufficienttomakeaspecificdiagnosis.Thisdisorder may be a precursor to a still asymp-tomatic disease (eg, related to subtle extrapyra-midal signs) and is likely to appear with con-current, progressive cognitive impairment (eg,Alzheimer disease or vascular dementia).21While the concept of senile gait disorderreflects the multifactorial nature of gait disor-der, we feel it is generally not useful in label-ing gait disorders in older adults. APPROACH TO ASSESSMENTApotentiallyusefulapproachtoassessingcontributors to gait disorder (TABLE 1)22catego-rizesthesedeficitsaccordingtothelevelofsensorimotor deficit, ie, low, middle, and high.Low deficits:Peripheral sensory, peripheral motorDisorders due to deficits at the low sensorimo-torlevel(ie,generallydistaltothecentralnervous system) can be divided into peripher-al sensory and peripheral motor dysfunction.Inperipheralsensoryimpairment,unsteadyandtentativegaitiscommonlycaused by vestibular disorders, peripheral neu-ropathy,posteriorcolumn(proprioceptive)deficits, or visual ataxia.Peripheral motor impairment results fromarthritic,myopathic,andneuropathiccondi-tionsthatresultindeformityoftheextremi-ties,painfulweight-bearing,andfocalweak-ness. The resulting gait disorders are primarilycompensatory.ExamplesincludeTrendelen-burggait(hipabductorweaknesscausingweight shift over the weak hip); antalgic gait(avoidanceofexcessiveweight-bearingandshortening of stance on one side due to pain);andsteppagegait(excessivehipflexiontofacilitate foot clearance of the ground, seen inpatients with foot drop due to ankle dorsiflex-or weakness).Ifthegaitdisorderislimitedtothislowsensorimotorlevelandthecentralnervoussystem is intact, the patient adapts well to thegaitdisorderandcancompensatewithanFactors thatslow gait speedmay alsocontribute togait disordersGAIT DISORDERS ALEXANDER AND GOLDBERG on September 14, 2013. For personal use only. All other uses require permission. www.ccjm.org Downloaded from 592 CLEVELANDCLI NI CJ OURNALOFMEDI CI NEVOLUME72NUMBER7J ULY2005assistive device or learn to negotiate the envi-ronment safely.Middle deficits:Spasticity, parkinsonism, ataxiaDeficits at the middle level result from spastic-ity (due to myelopathy, vitamin B12deficien-cy,stroke),parkinsonism(idiopathicordrug-induced),andcerebellarataxia(eg,alcohol-induced). The execution of centrally selectedpostural and locomotor responses is faulty, andthesensoryandmotormodulationofgaitisdisrupted.Initiationofgaitmaybenormal,butsteppingpatternsareabnormal.ClassicGaitdisordersvaryaccordingtothelevelofsensorimotordeficitLEVEL DEFICIT/CONDITION GAIT CHARACTERISTICSLow Peripheral sensory ataxia: Unsteady, uncoordinated (especially without visual input),posterior column, peripheral nerves, tentative, drunkenvestibular and visual ataxiaPeripheral motor deficit due to arthritis Avoids weight-bearing on affected side; shorter stance phase(antalgic gait, joint deformity) Painful hip may produce Trendelenburg gait (trunk shift over affected side)Painful knee is flexedPainful spine produces short, slow steps and decreased lumbar lordosisNon-antalgic features include contractures, deformity-limited motion,buckling with weight-bearingKyphosis and ankylosing spondylosis produce stooped postureUnequal leg length can produce abnormal trunk and pelvic motion,including Trendelenburg gaitPeripheral motor deficit due to Pelvic girdle weakness produces exaggerated lumbar lordosis and myopathic and neuropathic lateral trunk flexion (Trendelenburg and waddling gait)conditions (weakness) Proximal motor neuropathy produces waddling and foot slapDistal motor neuropathy produces distal weakness, especially ankledorsiflexion and foot drop, which may lead to exaggerated hipflexion, knee extension, foot lifting (steppage gait), and foot slapMiddle Spasticity from hemiplegia, hemiparesis Leg swings outward and in semi-circle from hip (circumduction);knee may hyperextend (genu recurvatum); ankle may show excessiveplantar flexion and inversion (equinovarus); with less paresis, somemay only lose arm swing and only drag or scrape the footSpasticity from paraplegia, paresis Circumduction of both legs; steps are short, shuffling, and scraping;when severe, hip adducts so that knees cross in front of each other(scissoring)Parkinsonism Small and shuffling steps, hesitation, acceleration (festination),falling forward (propulsion), falling backward (retropulsion), movingthe whole body while turning (turning en bloc), no arm swingingCerebellar ataxia Wide-based gait with increased trunk sway, irregular stepping,staggering (especially on turns)High Cautious gait Fear of falling with appropriate postural responses, normal to widenedgait base, shortened stride, slower, turning en blocFrontal-related or white-matter lesions: Frontal gait disorder: difficulty initiating gait; short, shuffling gait,cerebrovascular lesions, normal-pressure like parkinsonian, but with wider base, upright posture, arm swing,hydrocephalus leg apraxia, and freezing when turning or when attention is divertedMay also have cognitive, pyramidal, urinary disturbancesT A B L E 1GAITDISORDERS ALEXANDER ANDGOLDBERG on September 14, 2013. For personal use only. All other uses require permission. www.ccjm.org Downloaded from gaitpatternsappearwhenspasticityissuffi-cienttocauselegcircumductionandfixeddeformities(suchasequinovarus),whenparkinsonismproducesshufflingstepsandreduced arm swing, and when cerebellar atax-ia increases trunk sway sufficiently to require abroad base of gait support.High deficits:Slowed cognition, fear of fallingAt the high level, gait characteristics becomemorenonspecific,andcognitivedysfunctionand slowed cognitive processing become moreprominent. Behavioral aspects such as fear offalling play a role, particularly in cautious gait.Dementiaanddepressioncontributetobutmay not be the sole cause of the gait disorder.Frontal-related gait disorders often have acerebrovascular component and are not mere-ly the result of frontal masses and normal-pres-sure hydrocephalus. The severity of frontal dis-ordersrangesfromdifficultyinitiatinggaittofrontaldisequilibrium,inwhichpatientscan-notstandwithoutsupport.Cerebrovascularinsults to the cortex and the basal ganglia andtheir interconnections may relate to difficultyinitiatinggaitandapraxia.23,24Cognitive,pyramidal,andurinarydisturbancesmayalsoaccompany the gait disorder.Gait disorders in this category have beengivenanumberofoverlappingdescriptions,includinggaitapraxia,marchepetitspas,andarteriosclerotic(vascular)parkinsonism.As the severity of the dementia increases, par-ticularlyinpatientswithAlzheimerdisease,frontal-related symptoms also worsen.25Deficits at more than one levelIn elderly patients with multiple conditions, agaitdisorderlikelyrepresentsdeficitsatmorethan one sensorimotor level. One example is apatientwithlong-standingdiabeteswithperipheral neuropathy and a recent stroke whois now afraid of falling. Also, certain disordersmayactuallyinvolvemultiplesensorimotorlevels: eg, Parkinson disease affects high (cor-tical)andmiddle(subcortical)structures.Drugs such as sedatives, tranquilizers, and anti-convulsants may affect more than one level ofsensorimotorfunction:phenothiazines,forexample, can cause high-level effects (sedationandassociateddecreasedattention)andmid-level (extrapyramidal) effects. HISTORY AND PHYSICAL EXAMINATIONA careful medical history and a review of sys-tems help uncover the factors contributing tothegaitdisorder.Abriefsystemicevaluationforevidenceofacutecardiopulmonarydisor-ders (such as a myocardial infarction) or otheracuteillness(suchassepsis)iswarrantedbecause an acute gait disorder may be the pre-senting feature of acute systemic decompensa-tion in an older adult. Evaluation for subacutemetabolic disease (such as thyroid disorders) isalso warranted.Thephysicalexaminationshouldalsoattempttoidentifymotion-relatedfactors,suchasbyprovokingbothvestibularandorthostaticresponses.IntheDix-Hallpikemaneuver,whilethepatientisseatedonanexaminationtable,theexaminerholdsthepatients head, turns the head to one side, andlowers the head usually to 30 below the tablelevel.Thepatientthensitsup,andthemaneuver is repeated to the other side. Bloodpressure should be measured with the patientboth supine and standing to rule out orthosta-tic hypotension. Patients with dizziness and asensationofrelativemotionmaybeconsid-ered for additional vestibular screening utiliz-ingmotionoftheheadtoprovokeeitherchangesineyemotion(eg,headthrustorhead-shakingmaneuver)26ordisruptionsingait (as in the Dynamic Gait Index).27Visionscreening,atleastforacuity,isessential.Theneck,spine,extremities,andfeetshould be evaluated for pain, deformities, andlimitationsinrangeofmotion,particularlysubtlehipandkneecontractures.Leg-lengthdiscrepancies,suchasmayoccurafterplace-mentofahipprosthesis,28canbemeasuredsimply as the distance from the anterior supe-rioriliacspinetothemedialmalleolus,withthe patient supine.A formal neurologic assessment is criticalandshouldincludestrengthandtone,sensa-tion (including proprioception), coordination(including cerebellar function), standing, andgait. The Romberg test screens for simple pos-turalcontrolandforproprioceptiveandvestibularsystemdysfunctionwhentheeyesCLEVELANDCLI NI CJ OURNALOFMEDI CI NEVOLUME72NUMBER7J ULY2005 593Gait disordersare often dueto deficits atmore than onesensorimotorlevel on September 14, 2013. For personal use only. All other uses require permission. www.ccjm.org Downloaded from 594 CLEVELANDCLI NI CJ OURNALOFMEDI CI NEVOLUME72NUMBER7J ULY2005areclosed.Someinvestigatorshaveproposedthat being unable to stand on one leg for 5 sec-ondsisariskfactorforinjuriousfalls,29although even relatively healthy adults age 70and older may have difficulty standing on oneleg.30Given the importance of cognition as ariskfactor,screeningformentalstatusisalsoindicated. LABORATORY TESTING AND IMAGINGDepending on the findings of the history andphysicalexamination,furtherevaluationwithlaboratorytestinganddiagnosticimag-ing may be warranted. A complete blood cellcount,bloodchemistrypanel,andothermetabolicstudiesmaybeusefulwhenasys-temicdiseaseissuspectedofcontributingtothe gait disorder.Head or spinal imaging with plain radi-ography,computedtomography,ormagnet-icresonanceimaging(MRI)isofunclearuse, unless the history or physical examina-tionraisesthesuspicionofaneurologicabnormality either preceding the gait disor-der or of recent onset related to the gait dis-order.Insomecases,MRImaybehelpful.Changesinthecerebralwhitematterthatareoftenconsideredtobevascular(leukoaraiosis) have been increasingly associ-atedwithnonspecificgaitdisorders.Periventricular high-signal measurements onMRI and increased ventricular volume, evenin apparently healthy older adults,31are asso-ciatedwithslowingofgait.WhitematterhyperintensitiesonMRIcorrelatewithlon-gitudinalchangesinbalanceandgait,32andtheperiventricularfrontalandoccipitopari-etalregionsappeartobemostaffected.33Age-specificguidelines,sensitivity,specifici-ty,andcost-effectivenessoftheseworkupsremain to be determined. PERFORMANCE-BASED ASSESSMENTFormalkinematicandkineticanalyseshavenot been widely used in the clinical assessmentof balance and gait disorders in the elderly. Yetdiminutions in the speed and distance one canwalkcomfortablyarepowerfulpredictorsofanumberofimportantoutcomes,suchasdis-ability, institutionalization, and death.Peopletendtowalkfasteriftheyaretaller,healthier,moreactive,andlessfunc-tionally disabled.3Recently, it has been sug-gestedthatslow(impaired)walkingcanbedefined as slower than 0.6 m/sec, whereas fast(unimpaired)walkingisfasterthan1.0m/sec.34Anumberoftimedandsemiquantitativebalance and gait scales have been proposed asmeanstodetectandquantifyabnormalitiesand direct interventions. For example, higherabnormalgaitandbalancescalescoresmayincrease the risk of falling.35PerhapsthesimplesttoolintheclinicalsettingistheTimedUpandGo(TUG)test,36a timed sequence of rising from a chair,walking3meters,turning,andreturningtothe chair. A recent expert panel recommend-edthatpatientswhoreportasinglefalloranydifficultyorunsteadinessduringtheTUGtestrequireamoreextensiveevalua-tion of fall risk factors, many of which over-lapwithgaitdisorderriskfactors.37OnestudysuggestsaTUGtimeof14secondsormore as an indicator for fall risk.38Otherinvestigatorshavefoundlimita-tionsoftheTUGtestinpatientswhohavecognitive impairment and who have difficultycompletingthetestduetoimmobility,safetyconcerns,orrefusal.39Amoreusefulclinicalapproachmaybetoassessthedegreeofhumanassistancerequired(eithermanualorverbal cuing) for a patient to walk on differenttypesofsurfaces,aswellasthedistancethepatient can walk with or without an assistivedevice.40 INTERVENTIONSTO IMPROVE GAIT DISORDERSComorbidity,diseaseseverity,andoverallhealth status tend to strongly influence treat-mentoutcome.Inaddition,evenifacon-tributing condition is found, many conditionsthatcausegaitdisordersareonlyatbestpar-tiallytreatable,3andthepatientisoftenleftwith some degree of disability. Still, function-al outcomes such as reduction in weight-bear-ingpain,increaseinwalkingdistance,orreduction in overall walking limitation justifytreatment.Regainingprevious,morenormalIn the Timed Upand Go test,> 14 secondsindicates a riskof fallingGAIT DISORDERS ALEXANDER AND GOLDBERG on September 14, 2013. For personal use only. All other uses require permission. www.ccjm.org Downloaded from gaitpatternsmaybeunrealistic,butimprov-inggaitspeedisareasonablegoal,aslongasthe gait remains safe.Medical therapyWhatevidencedowehavethattreatmentofgaitdisordersiseffective?Manyoftheolderreportsdealingwithtreatmentandrehabilitationofgaitdisordersinolderadultsareretrospectivechartreviewsandcasestudies.Gaitdisorderspresumablysec-ondary to vitamin B12deficiency, folate defi-ciency,hypothyroidism,hyperthyroidism,kneeosteoarthritis,Parkinsondisease,andinflammatorypolyneuropathymayrespondto medical therapy.3Physical therapyPhysicaltherapyfordiseasessuchaskneeosteoarthritisandstrokebringsmodestimprovements. For example, a combined aer-obic, strength, and function-based group exer-ciseprogramincreasedgaitspeedapproxi-mately5%inpatientswithosteoarthritisofthe knee.41The focus is on strengthening theextensor groups (especially knee and hip) andstretching commonly shortened muscles (suchas the hip flexors 42). A recent review suggest-eduncleareffectsofconventionalphysicaltherapy in the treatment of gait disorders duetoParkinsondisease,43butanotherstudyfound that using audio and visual sensory cue-ing can improve gait speed.44Task-specific gait trainingRecentstudiessuggestthatthegaitimpair-ment can be incrementally reduced with theuse of a body support and a treadmill to pro-vide task-specific gait training after total hiparthroplasty,45inParkinsondisease,46andparticularlyinpatientswithstroke-relatedhemiparesis.47However,aCochranereviewfound no statistically significant effect favor-ingtreadmilltrainingwithorwithoutbodysupportoverconventionaltrainingtoimprovegaitspeedordisabilityinstrokepatients.48Nevertheless,theCochranereview did find a small but clinically impor-tant trend (an improvement of 0.24 m/sec inthebodyweightsupportplustreadmillgroup)inthosewhocouldwalkindepen-dently.Group exerciseAfewstudiesofgroupexercisehaveshownimprovementingaitmeasuressuchasspeed.Generally, the most consistent effects are seenin programs that include a variety of exercises.A12-weekcombinedprogramoflegresis-tance,standingbalance,andflexibilityexer-cisesincreasedusualgaitspeed8%inmini-mallyimpairedresidentsofalifecarecom-munity.49Asimilar,varied,16-weekformatwithmoreintensiveindividualsupportandpromptinginselectdementedolderadults(meanMini-MentalStateExaminationscore15)resultedina23%improvementingaitspeed.50Thesestudiesnoteimprovementinfunctional,gait-orientedmeasures(althoughnot strictly measures of gait disorder), such asthedistancewalkedin6minutesinpatientswithkneeosteoarthritisundergoingeitheranaerobic or resistance training program.51Behavioral and environmentalmodificationsBehavioralandenvironmentalmodificationscan help patients negotiate their environmentmoresafelyandincludeimprovedlighting(particularlyforthosewithvestibularorsen-sory impairment) and elimination of pathwayhazardssuchasclutter,wires,andslipperyfloors. Furniture surfing and lightly touchingany firm surface like a wall52provide feedbackand enhance balance.53Orthoses and mobility aidsOrthoses and other mobility aids help reducegaitdisorders.Shoelifts(eitherinternalorexternal) to correct unequal limb length maybeusedinaconservative,graduallyprogres-sive manner,54even though we have few datatosupporttheirefficacy.Anklebraces,shoeinserts, shoe body and sole modifications, andtheir subsequent adjustments are part of stan-dard care for foot and ankle weakness, defor-mities,andpainbutarebeyondthescopeofthis review.55In general, well-fitting walking shoes withlowheels,relativelythin,firmsoles,and,iffeasible,high,fixedheel-collarsupportarerecommendedtomaximizebalanceandimprovegait.56Mobilityaidssuchascanesandwalkers57reduceloadonapainfuljointand increase stability.CLEVELANDCLI NI CJ OURNALOFMEDI CI NEVOLUME72NUMBER7J ULY2005 597Exerciseprogramsgive bestresultsif theyincludea variety ofexercises on September 14, 2013. For personal use only. All other uses require permission. www.ccjm.org Downloaded from 598 CLEVELANDCLI NI CJ OURNALOFMEDI CI NEVOLUME72NUMBER7J ULY2005SurgeryImprovementwithsomeresidualdisabilitymay be seen after surgical treatment for com-pressivecervicalmyelopathy,lumbarsteno-sis,andnormal-pressurehydrocephalus.Fewcontrolled prospective studies and even fewerrandomized studies compare surgical vs non-surgical treatment outcomes for these condi-tions.Anumberofproblemsplaguethepub-lishedstudies.Outcomessuchaspainandwalking disability are not reported separately.The source of the outcome rating is not clear-ly identified or blinded. The criteria for classi-fyingoutcomesdiffer.Theoutcomesmaybesubjectiveandsubjecttointerpretation.Thefollow-upintervalsarevariable.Thesubjectswho are reported in follow-up may be a highlyselect group. The selection factors for conser-vativevssurgicaltreatmentbetweenstudiesdifferorarenotspecified,andthereispubli-cationbias(onlypositiveresultsarepub-lished). Many of the surgical series include allages,althoughthemeanageisusuallyabove60. A few studies document equivalent surgi-caloutcomeswithconservative,nonsurgicaltreatment.Lumbarandcervicalstenosis. Manyolderadultswithlumbarstenosishavelesspainandcanwalkfartherafterlaminectomyandlumbarfusion,althoughtheyhaveresid-ualdisability.Inasomewhatyoungercohort(mean age 69) and after an average of 8 yearsoffollow-upaftersurgeryforlumbarstenosis,approximatelyhalfreportedthattheycouldnotwalktwoblocks,andmanyattributedtheirdecreasedwalkingabilitytotheirbackproblem.58Part of the problem in determining long-termsurgicaloutcomesinpatientswithlum-barstenosisisthatcomorbidconditionssuchascardiovascularormusculoskeletaldiseasealsoinfluencemobility.59Nevertheless,improvementcanbeseeninsomepatientsoverage75(meanage78).Arecentuncon-trolledstudyfoundthatthe45%ofpatientswith preoperative severe limitation of ambu-latory ability had either minimal or moder-atelimitationpostoperativelyafteranaver-age of 1.5 years of follow-up.60Nonsurgicaltreatmentoflumbarsteno-siseg,oralanti-inflammatorydrugs,heat,exercise,mobilization,epiduralinjectionsmay also result in modest improvements, suchas in walking tolerance.61Recent studies involving gait outcomes inolder adults with cervical stenosis are limited.In a case report, a 65-year-old woman under-went surgery for cervical myelopathy and hadsubsequentimprovementingaitspeed.62Significant improvement in walking speed canbeexpectedinmostpatientsaftersurgicaldecompression of cervical myelopathy.63Normal-pressurehydrocephalus. Inarecentnoncontrolledstudyofpatientswhounderwentshuntingfornormal-pressurehydrocephalus (follow-up interval not speci-fied), walking speed increased by over 10% in75% of the patients and by more than 25% inover 57% of the patients.64While there maybeinitialimprovementaftershuntplace-ment, long-term results are often disappoint-ing: eg, 65% of patients who undergo shunt-inghaveinitialimprovementintheirgaitdisorder,butonly26%maintainthisimprovementby3-yearfollow-up.65Thepoorlong-termoutcomesmayberelatedtoconcurrent cerebrovascular and cardiovascu-lar disease, a frequent cause of death in thesecohorts.66Gait outcomes after shunting maybebetterinthoseinwhomthegaitdistur-bance precedes cognitive impairment and inthosewhorespondwithgaitspeedimprove-mentafteratrialofcerebrospinalfluidremoval.67,68Jointreplacementforosteoarthritis.Outcomesforhipandkneereplacementforosteoarthritisarebetterthanforsurgeryfortheotherconditionsdiscussedabove,although these studies have some of the samemethodologicalproblemsasthosementionedabove. Other than pain relief, sizable gains ingait speed and joint motion occur, but there isoftenresidualwalkingdisabilityduetoresid-ualpathologyonthetreatedsideandsymp-toms on the untreated side.Despiterehabilitationaftertotalkneereplacement, patients are often left with someweakness,stiffness,andaslowedoralteredgait.69,70Simplefunctionmaybemaintainedafter knee replacement, such as the ability tosafelyclearanobstacle,butusuallyattheexpenseofadditionalcompensationbytheipsilateral hip and foot.71GAIT DISORDERS ALEXANDER AND GOLDBERGWeakness,stiffness, andslowed gait areoften seen aftertotal kneereplacement on September 14, 2013. For personal use only. All other uses require permission. www.ccjm.org Downloaded from REFERENCES1. Ostchega Y, Harris TB, Hirsch R, Parsons VL, Kington R. The preva-lence of functional limitations and disability in older persons in theUS: data from the National Health and Nutrition Examination SurveyIII. J Am Geriatr Soc 2000; 48:11321135.2. 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GaitPosture 2003; 18:95104.ADDRESS: Neil Alexander, MD, Geriatrics Center, CCGCB Room 1111, 1500East Medical Center Drive, Ann Arbor, MI 48109-0926; e-mailnalexand@umich.edu.GAIT DISORDERS ALEXANDER AND GOLDBERGONE ONE MINUTE MINUTECONSULT CONSULTBRIEF ANSWERSTO SPECIFICCLINICAL QUESTIONSQ:PL EASEPRI NTCL EARLYWhat questions do you want answered?We want to know what questions you want addressed in 1-Minute Consult.All questions should be on practical, clinical topics. You may submit questions by mail, phone, fax, or e-mail.Cleveland Clinic Journal of Medicine, 9500 Euclid Ave., NA32, Cleveland, OH 44195PHONE 2164442661 FAX 2164449385 E-MAIL ccjm@ccf.orgNAMEADDRESSCITY STATE ZIPPHONEEMAIL600 CLEVELANDCLI NI CJ OURNALOFMEDI CI NEVOLUME72NUMBER7J ULY2005 on September 14, 2013. For personal use only. All other uses require permission. www.ccjm.org Downloaded from