Clinical History

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Gait and balance difficulties generally present as complaints of slow or unsteady walking and of falls. Questions about the speed of walking, the length of the steps taken, the width between the feet, and any difficulties experienced with initiating walking provide clues to the gait disorder. Additionally, the ability to turn and a tendency to trip or bump into things or appear drunk are important clues. The environment or conditions in which the person finds it difficult to walk also offer clues to the gait pattern and guide the physical examination. The clinician should specifically inquire about difficulties in turning over in bed, getting in or out of a car, and arising from a chair because these can be indicators of imbalance.

Falls require a detailed history because they are unlikely to be observed during the examination. Several recent falls that are clearly remembered by the patient or a family member should be explored in detail. Details of the exact location and activity of the patient when the fall occurred may indicate environmental or patient-related precipitants. Had the patient just arisen from a lying or sitting position, suggesting orthostatic hypotension? Or did the feet "get tangled" while turning around, suggesting incoordination?

Did the patient trip, suggesting weakness of the dorsiflexors of the ankle, increased tone characteristic of spasticity, or the shuffling of parkinsonism? Was there lightheadedness, vertigo, or loss of consciousness, suggesting orthostatic hypotension, a labyrinthine disorder, or syncope? How exactly did the patient fall? Crumpling (breaking at the knees) suggests a loss of consciousness (syncope, seizure) or of strength (transient ischemic attack). Falling backward like a log is particularly common in patients with extrapyramidal disorders. Was falling related in any way to meals, suggesting postprandial hypotension, or to drug intake, suggesting drug-induced hypotension or impairment of attention and coordination?

In other aspects of the history, the physician should probe for evidence of proprioceptive, vestibular, and visual disturbances and for signs of pain or deformity of the bones and joints that could affect gait. Weakness sufficient to disturb balance and gait is generally recognized by the patient. Slowness and clumsiness in other motor activities and dysarthria may offer clues to cerebellar and extrapyramidal disorders. Urinary urgency and incontinence are common in multi-infarct states and normal pressure hydrocephalus. The process of taking the history usually reveals whether the patient's judgment or attention span might contribute to falls.

The mode of onset of gait difficulties gives clues to the disease process producing them. Sudden onset suggests vascular disease; gradual onset suggests a degenerative disorder. The medication history is also very important because some drugs can affect the sensory-motor systems, thereby causing balance and gait disturbances. Examples of such drugs include the benzodiazepines, which affect the vestibular system; phenytoin, which affects the cerebellum; and neuroleptics, which involve the basal ganglia. Falls are associated with sedative-hypnotics, which may affect attention and judgment, and with drugs that produce orthostatic hypotension.

TABLE 18-1 -- CLINICO-ANATOMICAL CORRELATION OF DISORDERS OF GAIT AND BALANCE

Anatomic Location

Gait Abnormality

Associated Findings

Cerebral cortex

Freezing

Dementia

Disequilibrium

Grasp reflex

Falls

Hyperreflexia

Urinary urgency and incontinence

Brain stem

Disequilibrium

Eye movement and pupillary abnormalities

Astasia

Basal ganglia

Freezing

Rigidity, tremor

Hypokinetic gait

Bradykinesia

Hyperkinetic gait

Chorea and dystonia

Astasia

Cerebellum

Ataxia

Dysmetric limbs

Dysmetric eye movements

Vestibular system

Ataxia

Nystagmus

Difficulty with tandem walking

Spinal cord

Spastic gait

Sensory level/loss

Sensory ataxia

Increased DTRs

Babinski's sign

Peripheral nerve

Foot drop

Reduced or absent DTRs

Sensory ataxia

Peripheral weakness

Peripheral sensory loss

Muscle and neuromuscular junction

Waddle

Hip and shoulder weakness

DTRs, Deep tendon reflexes

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