STUDY - Technical - New Dacian's Medicine
Gait,
abnormal (Classical / Allopathic Medicine)
A bizarre gait is
characterized by a theatrical or bizarre quality with key
organic elements missing, such as a spastic gait without hip
circumduction or leg “paralysis” with normal reflexes and
motor strength. It has no obvious organic basis; rather, it's
produced unconsciously by a person with a somatoform disorder
(hysterical neurosis) or consciously by a malingerer. The gait
has no consistent pattern. Signs include wild gyrations,
exaggerated stepping, leg dragging, or mimicking unusual walks
such as that of a tightrope walker.
A propulsive gait
is characterized by a stooped, rigid posture - the patient's
head and neck are bent forward; his flexed, stiffened arms are
held away from the body; his fingers are extended, and his
knees and hips are stiffly bent. During ambulation, this
posture results in a forward shifting of the body's center of
gravity and consequent impairment of balance, causing
increasingly rapid, short, shuffling steps with involuntary
acceleration (festination) and lack of control over forward
motion (propulsion) or backward motion (retropulsion).
A propulsive gait
is a cardinal sign of advanced Parkinson's disease; it results
from progressive degeneration of the ganglia, which are
primarily responsible for smooth-muscle movement. Because this
sign develops gradually and its accompanying effects can be
wrongly attributed to aging, propulsive gait commonly goes
unnoticed or unreported until severe disability results.
A spastic gait -
sometimes referred to as a paretic or weak gait - is a stiff,
foot-dragging walk caused by unilateral leg muscle
hypertonicity. This gait indicates focal damage to the
corticospinal tract. The affected leg becomes rigid, with a
marked decrease in flexion at the hip and knee and, possibly,
plantar flexion and equinovarus deformity of the foot. Because
the patient's leg doesn't swing normally at the hip or knee,
his foot tends to drag or shuffle, scraping his toes on the
ground. To compensate, the pelvis of the affected side tilts
upward in an attempt to lift the toes, causing the patient's
leg to abduct and circumduct. Also, the arm swing is hindered
on the same side as the affected leg.
A spastic gait
usually develops after a period of flaccidity (hypotonicity)
in the affected leg. Whatever the cause, the gait is usually
permanent after it develops.
HISTORY:
Ask the patient when he first noticed the gait impairment and whether it developed suddenly or gradually.
Ask the patient if the impairment waxes and wanes or if it has progressively worsened.
Ask the patient if fatigue, hot weather, or warm baths, or showers worsen the gait.
Review the patient's medical history for neurologic disorders, recent head trauma, and degenerative disease.
Determine if the change in gait coincides with a stressful period or event, such as the death of a loved one or the loss of a job.
Ask the patient about associated symptoms, and explore reports of frequent unexplained illnesses and multiple physician visits. Subtly try to determine if he'll gain anything from malingering — for example, added attention or an insurance settlement.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Ask the patient if he has been taking any tranquilizers, especially phenothiazines. Also, ask him about his alcohol intake.
Ask the patient if he has been acutely or routinely exposed to carbon monoxide or manganese.
Ask the patient when he first noticed the gait impairment and whether it developed suddenly or gradually.
Ask the patient if the impairment waxes and wanes or if it has progressively worsened.
Ask the patient if fatigue, hot weather, or warm baths, or showers worsen the gait.
Review the patient's medical history for neurologic disorders, recent head trauma, and degenerative disease.
Determine if the change in gait coincides with a stressful period or event, such as the death of a loved one or the loss of a job.
Ask the patient about associated symptoms, and explore reports of frequent unexplained illnesses and multiple physician visits. Subtly try to determine if he'll gain anything from malingering — for example, added attention or an insurance settlement.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Ask the patient if he has been taking any tranquilizers, especially phenothiazines. Also, ask him about his alcohol intake.
Ask the patient if he has been acutely or routinely exposed to carbon monoxide or manganese.
PHYSICAL
ASSESSMENT:
Test the patient's reflexes and sensorimotor function, noting any abnormal response patterns.
Observe the patient for normal movements when he's unaware of being watched.
Test and compare strength, range of motion, and sensory function in all limbs. Also, palpate for muscle flaccidity or atrophy.
Test the patient's reflexes and sensorimotor function, noting any abnormal response patterns.
Observe the patient for normal movements when he's unaware of being watched.
Test and compare strength, range of motion, and sensory function in all limbs. Also, palpate for muscle flaccidity or atrophy.
SPECIAL
CONSIDERATIONS:
A full neurologic workup may be necessary to completely rule out an organic cause of the patient's abnormal gait.
A full neurologic workup may be necessary to completely rule out an organic cause of the patient's abnormal gait.
PEDIATRIC
POINTERS:
A bizarre gait is rare before age 8. More common in prepubescence, it usually results from conversion disorder.
A propulsive gait, usually with severe tremors, typically occurs in juvenile parkinsonism, a rare form. Other possible but rare causes include Hallervorden-Spatz disease and kernicterus. Such effects are usually temporary, disappearing within a few weeks after therapy is discontinued.
Causes of a spastic gait in children include sickle cell crisis, cerebral palsy, porencephalic cysts, and arteriovenous malformation that causes hemorrhage or ischemia.
A bizarre gait is rare before age 8. More common in prepubescence, it usually results from conversion disorder.
A propulsive gait, usually with severe tremors, typically occurs in juvenile parkinsonism, a rare form. Other possible but rare causes include Hallervorden-Spatz disease and kernicterus. Such effects are usually temporary, disappearing within a few weeks after therapy is discontinued.
Causes of a spastic gait in children include sickle cell crisis, cerebral palsy, porencephalic cysts, and arteriovenous malformation that causes hemorrhage or ischemia.
PATIENT
COUNSELING:
If the patient is learning to perform activities of daily living, assist him as appropriate. Encourage independence and self-reliance, and advise the family to allow plenty of time for these activities. Refer the patient to a physical therapist or for psychological counseling, as necessary.
If the patient is learning to perform activities of daily living, assist him as appropriate. Encourage independence and self-reliance, and advise the family to allow plenty of time for these activities. Refer the patient to a physical therapist or for psychological counseling, as necessary.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)