Gait Disorders- Assessment and Intervention

Gait Disorders- Assessment and Intervention

“Don’t walk behind me, I may not lead. Don’t walk ahead of me, I may not follow.Walk next to me & be my friend.”

Albert Camus

Ali AL-MemarConsultant Neurologist- St Georges Hospital , London UK

One Day Essential | Neurology

Friday 25 January 2019

Road Map

• Road Map

• Normal Gait

• Epidemiology of Gait disorders

• Classification of Gait disorders

• Abnormal Gait Pattern /pattern recognition

• Clinical assessment of Gait

• Clinical Evaluation & Interventions

Road Map

Normal Gait

Gait

Series of rhythmical , alternating movements of trunk & limbs resulting in forward progression of the COG

Human Gait depends on complex interplay of major parts of :

1- the Nervous system

2-Musckloskeletal system

3- cardiorespiratory systemThere are (4) major criteria essential to walking: • Equilibrium:

The ability to assume an upright posture and maintain balance.• Locomotion:

The ability to initiate and maintain rhythmic stepping• Musculoskeletal Integrity:

Normal bone, joint, and muscle function • Neurological Control:

Must receive and send messages telling the body how and when to move.(visual, vestibular, auditory, sensory-motor input)

Normal Gait

Gait Cycle

Center of Gravity (COG) COG

• Center of Gravity (CG):

• midway between the hips

• Few cm in front of S2

• Least energy consumption if CG travels in straight line

• The Location of the COG changes constantly with every position of the body and limbs

Gait Cycle

Gait Cycle

Begins when reference foot contacts the ground,

Ends with subsequent floor contact by the same foot

Step length

Right step Length = Left step Length (Normal Gait)

Stride Length

Double the step length

Walking base

Side-to-side distance between the line of the two feet

Gait Cycle

Gait Cycle

• The gait cycle is divided into the stance and swing phase.

• The stance phase constitutes approximately 60 % of the gait cycle and is subdivided into initial contact (heel strike), loading response, mid-stance, terminal stance and pre-swing.

• Both feet are on the ground at the beginning and end of the stance phase.

• Each of these two double support periods lasts for approximately 10–12 % of the gait cycle.

• The swing phase takes up about 40 % of the gait cycle and is subdivided into initial swing (toe-off), mid-swing (tibia vertical) and terminal swing, terminated by the heel striking the ground

Gait Cycle

Gait Cycle

• To start walking, one leg is raised and directed forward by flexing the hips and knee.

• Activation of the supporting contralateral leg and trunk muscles moves the body’s centre of gravity over the weight-bearing leg and forward.

• The heel of the swinging leg is then placed on the ground.

• The body weight is gradually shifted to the sole and then onwards to the toes.

• During mid-stance, the opposite leg is lifted and moves forward until the heel strikes the ground.

• Meanwhile, the body is held upright, the shoulders and pelvis remain relatively level and each arm swings in the direction opposite to that of its ipsilateral leg.

Gait Cycle

Measures of Gait

Measures of gait include :

1- walking speed

2- cadence (number of steps per unit of time)

3-walking base width (measured from midpoint to midpoint of both heels),

4-step length (measured from the point of foot contact to the point of contralateral foot contact)

5- stride length (linear distance covered by one gait cycle).

The preferred walking speed in healthy adults up to the age of 59 years is approximately 1.4 m/s.

The average cadence in young adults was reported to range between 115 and 120 steps/min.

Average stride lengths in healthy adults range between 150 and 170 cm.

Ageing is associated with a decline in gait speed and step length whereas cadence remains relatively stable.

Elderly patients prefer a 40 % wider step width than young persons (average step width in elderly women approximately 8 cm and in elderly men 10 cm) .

Measures of Gait

Basic Neuroanatomy

• Power-Motor System

• 1-CST (UMN)

• 2- Anterior horn cells and MPN (LMN)

• Speed-Basal Ganglia

• Coordination- Cerebellum

• Sensory-• 1-Sensory Cortex,

• 2-Spinal connections (STT,Post Column)

• 3- sensory peripheral nerves

Role of cognition

• Frontal executive functions, visuospatial perception and attention all contribute to walking safely. Cognitive impairment will have a negative effect on all aspects of gait performance.

• Psychological factors also influence gait. For instance, depression is associated with slower gait and anxiety may lead to an overly cautious gait.

• The role of cognition for gait is revealed in the multitask paradigm where persons are asked to perform mental tasks while walking. Elderly persons who walk while talking have a significantly higher risk of falling .

• Further investigations have shown that patients with dementia walk slowly but in relation to their motor and cognitive deficits, they actually walk too fast leading to an increased risk of falling .

• These multiple interactions demonstrate that improving cognitive functioning may have an essential role in the rehabilitation of gait disorders.

Role of cognition

Epidemiology of gait disorders

• in 488 persons: between the ages of 60 and 97 years one third of this population had a gait disorder, with a marked increase in prevalence with age.

• Between the ages of 60 and 69 years, the prevalence was 10 % and in those over 80 years it was >60 % .

• In two thirds of those affected by any gait disorder, the cause was neurological and in approximately one half, the cause was non-neurological, indicating that there was a considerable overlap of patients affected by neurological as well as by non-neurological gait disorders.

• Among the neurological causes :

• Sensory ataxia (18 %) parkinsonian (16 %) gait disorders were the most common

• Frontal (8 %), followed by cerebellar ataxic gait disorders, spastic, vestibular and dyskinetic gait disorders.

• In approximately one third of the patients the gait disorder was due to more than one neurological cause, making a precise classification difficult



• In elderly persons, pre-existing difficulties with walking and balance are more commonly the cause of falls than acute disturbances, such as syncope, seizures or stroke.

• Approximately 10–15 % of these falls lead to serious injuries, such as traumatic brain injury or hip fractures.

• It has been estimated that inadvertent injuries are the fifth most common cause of death in elderly persons .

• Factors that might precipitate falls in the home include loose carpets on wooden floors.

• Polypharmacy is regarded as an important risk factor for falls in the elderly; however, newer studies suggest that polypharmacy only poses a risk if it includes medications that increase the risk for falls, such as sedatives, antidepressants and benzodiazepines


Risk factors for falls

Female gender, low body weight, age >80 years

Number of falls in previous year/month

Use of sedatives, particularly with long half-life

Limited physical activity

Difficulties rising from sitting position

Reduced muscle strength in the lower limbs

Impaired balance Standing

Walking

Turning

Impaired postural reflexes

Impaired vision

Impaired cognitive functions, depression, anxiety

Risk factors for falls

Phenomenological classification of gait disorders (modified from Ružička and Jankovic )

Gait disorder Characteristics

Hemispastic gait Unilateral extension and circumduction

Paraspastic gait Bilateral extension and adduction, stiff

Ataxic gait Broad base, lack of coordination

Sensory ataxic gait Cautious, worsening without visual input

Cautious gait Broad based, cautious, slow, anxious

Freezing gait Blockage, e. g. on turning

Propulsive gait Centre of gravity in front of body, festination

Astasia Primary impairment of stance/balance

Dystonic gait Abnormal posture of foot/leg

Choreatic gait Irregular, dance-like, broad-based

Steppage gait Weakness of foot extensors

Waddling gait Broad-based, swaying, drop of swinging leg

Antalgic gait Shortened stance phase on affected side

Vertiginous gait Insecure, tendency to fall to one side

Psychogenic gait disorder Bizarre, rarely falls

Phenomenological classification of gait disorders(modified from Ružička and Jankovic )

Gait Recognition Patterns

Neurological• Parkinsonian

• Description: Short stepped, shuffling, hip, knee & spine flexed

• Signs: Bradykinesia, muscular rigidity, reduce arm swing

• Causes: Parkinson disease

• Chorea

• Description: Dance-like, irregular, slow, wide based

• Sign: Choreoathetosis movement of UE

• Causes: Huntington Disease, Levodopa induced dyskinesia

Neurological• Frontal gait disorder

• Description: Freezing, start & turn hesitation

• Signs: Dementia, Incontinence

• Causes: NPH, Multi-infarct state, Frontal lobe degeneration

• Cerebellar Ataxia

• Description: Staggering, wide based

• Signs: Dysarthria, Dysmetria, dysdiadokinesia, Intentional Tremors, Nystagmus, Romberg's

• Causes:CerebellarDegeneration, Stroke, MS, Tumor Alcohol


Neurological• Sensory Ataxia

• Description: Unsteady, worse without visual input

• Signs: Impaired position & vibration, Romberg's

• Causes: Dorsal Column, Neuropathy

• Vestibular Ataxia

• Description: Unsteady, falling on one side, Postural instability

• Signs: Nausea, Normal sensation, Nystagmus

• Causes: Meniere's, Acute Labyrinthitis.

Neurological

• Hemipelagic Gait-CVA

• Spastic Paraparesis Gait

• Foot Drop Gait- CPN

• Myopathic Gait


Non Neurological• Antalgic

• Description: Limited ROM, limping, slow, short steps, unable to bear full weight

• Signs: Pain worse with movement & weight bearing

• Causes: DJD, Trauma

• Waddling

• Description: Lumbar lordosis, swaying, wide based

• Signs: Hip dislocation, proximal m/s weakness, uses arm to get up from chair

• Causes: Muscular dystrophy & Myopathy

Non Neurological• Senile gait disorder

• Description: Slow, broad based, shuffling & cautious walking pattern

• Signs: when underlying disease can not be identified

• Causes: May present early manifestation of subclinical ds.

• Psychogenic

• Description: Bizarre, Non physiologic gait

• Signs: Absence of neurological signs

• Causes: Factitious, Somatotisation

Gait Patterns

Fear of falling: Possible contributors Older Age, female gender, poor social support, H/O falls, depression and poor lower limb function

Lower personal mastery and poor dynamic balance are associated with fear of falling

Lack of social support, depressive symptoms, H/O multiple falls and presence of ≥ 2 chronic conditions are associated with fear-induced activity restriction

Fear of falling may not always precipitate activity restriction , half of those who report fear of falling do not restrict activities

Gait Patterns

Clinical Evaluation

• History

• Acute and Chronic Medical problems

• Complete Review of Systems (ROS)

• Falls History (Previous Falls, Injury resulted, circumstances )

• Nature of Difficulty with Walking (e.g. Pain, imbalance)

• Surgical History

• Usual Activity, mobility status, and level of function

• Medication review

• New medication or dosing review

• Number and type of medications

Clinical Evaluation

Clinical Evaluation

• Presence of environmental Hazards

• Clutter , Electrical Cords

• Lack of grab bars near bathtub & toilets

• Low chairs , Poor Lighting

• Slippery Surfaces ,Throw /rugs

• Physical Examination

• Vitals

• (Wt. Ht. Orthostatic BP & Pulse)

• Affective/cognitive

• (Delirium, Dementia, Depression, Fear of Falling)

• Cardiovascular

• (Murmur, Arrhythmias, Carotid Bruit, Pedal Pulses)

• Musculoskeletal

• (Joint swelling, deformity, Limited ROM or instability)

• Neurological

• (M/S strength, tone, reflexes, coordination, sensation tremors, cerebellar, vestibular, sensory & proprioception)

• Postural reflexes (pull or push test)

Clinical Evaluation

Evaluation :Gait & Balance Performance

1-Direct observation of gait & Balance

• Watching patient enter and sitting in examination room

• Stance (narrow/wide base) and Cadence

• Posture (trunk, neck and head, upright, bent or asymmetrical)

• Speed and step length ,lifting of feet, contact with ground

• Symmetry ,Arm swing

• fluidity of movement (smooth, stiff, insecure, symmetrical, limping) , Freezing

• instability & need of assistance

• Sitting unaided , Sitting down (“motor recklessness”)

• Standing up from a sitting position (unaided and with/without use of upper limbs)

• Gait initiation (blockage)

Evaluation : Gait & Balance Performance


2. Functional Reach Test

• Reliable

• Valid

• Quick diagnostic tool

• Inability to reach at least 7 inches predictive of fall



3. Timed Up & Go Test

• Reliable Diagnostic tool (Sensitivity 80% & Specificity 80%)

• Quick to administer

• (Pt arise from a chair, without using arms, walk 3 meter, turn, return to the chair and sit down. They allowed to use their usual walking aids.)

• Score < 10 sec normal

• Score > 14 Sec Abnormal

• Score > 20 Sec Severe gait impairment



4. Single leg stance test

• Best balance measure for any individual

• If one can stay on one leg for >10 sec, usually no significant balance problems


Complex tests of stance and gait

• Tandem stance

• Tandem gait

• Romberg’s test (standing with eyes closed and narrow base)

• Walking backwards

• Walking fast

• Walking slowly (in a deliberate manner)

• Running Turning quickly

• Turning on the spot

• Unterberger’s test (walking on the spot with eyes closed)

• Standing and walking on heels

• Standing and walking on toes

• Hopping on one foot

• Dual task manoeuvre (walking while talking or carrying objects)

Complex tests of stance and gait

Balance Scale

• Dynamic Gait Index

• Developed to quantify gait dysfunction in older adults during level surface walking as well as more complex functional tasks.

• Dual task demands relevant to falls risk in elderly

• Applicable to assessing balance in other groups of patients including those with vestibular disorders, multiple sclerosis, head injury, and Parkinson’s

• Scores of 19 or less out of 24 indicate increased risk of falling in older adults (Shumway-Cook 1997)

• Berg Balance Scale

• Measure of static and dynamic balance in movements common in everyday life on 14-item scale (56 points)

• Useful for evaluating multiple falls risk in community living older adults

• No longer recommends a dichotomous 45 point cut-off

• Likelihood of multiple falls increases as score decreases

• Reliable test of balance in elderly in residential care – change of 8 points required to reveal genuine change

in function

• Discriminates persons with Parkinson’s disease who fall vs. those who do not fall

• Cut-off score of 44/56 recommended by Landers, 2008

Balance Scale

Limitations of Balance Scales and Screening Tools

• Screening for falls may increase fear of falling

• Falls are multifactorial, no scale captures all aspects

• Scales and balance screening tools have not been well tested in a wide range of populations/settings

• Uncertainty regarding predictive scores

• Scales test different aspects of balance, sensitivity for prediction and examination may be best with multiple tests

Limitations of Balance Scales and Screening Tools

Intervention

• Interventions may impact important Functional outcomes, including Reduction in

• Falls

• Fear of falling

• Overall limitation in mobility

• Gait Disorder secondary to Medical Conditions

• (Arthritis, Vitamin B12, Thyroid Problems, Arrhythmias, Depression etc.) respond well to Medical Therapies.

• Adjustment in Medication improves gait disorder-Parkinson disease

• Surgery may improve Gait

• Cervical spondylotic myelopathy

• Lumbar spinal stenosis

• Normal pressure hydrocephalus

• Arthritis of hip or knee

• Improving Sensory Input

• Visual Correction

• Hearing Aids

Intervention

Intervention :General measures to prevent falls and fall-related injuries

Check entire list of medication :

Avoid sedatives, particularly with long half-life

Avoid (classical) neuroleptics and tricyclic antidepressants

Check the indications for and dose of atypical neurolepticsAnxiolytic and antidepressant therapy , Behavioural therapy for anxiety, depression and dementia

Increase physical activity , Muscle training , Balance training

Therapy of orthostatic hypotension

Treatment for osteoporosis

Adequate footwear

Protective devices such as hip protectors

Remove risks at home and adjust personal environment

Electronic warning systems

Intervention :General measures to prevent falls and fall-related injuries

Intervention

EXERCISE INTERVENTION & PHYSICAL THERAPY

• Target strengths

• Balance training

• Functional exercises

• Flexibility

Evidence supports HOME ENVIRONMENT ASSESSMENT prevent falls & related injuries

Exercise intervention can improve the dysfunction and reduce the likelihood of falls and their complications :

• Many studies show benefits of muscle strength with gait parameters in older adults and the use of exercise to improve measures of balance and reduce incidence of falls

• Increases of 5-15% in ambulatory function after 8-12 weeks of a walking and endurance program

• Balance training improved force-plate balance parameters by 20-50%

• Tai chi improved balance (postural sway) by 32% and fall risk by 49% (OR 0.51, 95% CI 0.36-0.73)

• Aerobic conditioning improved balance by 20% in adults over age 70

• Use of a multidimensional exercise program that incorporates balance training and strengthening should improve postural stability and reduce fall risk

Intervention

Exercise Recommendations

1- Balance7 x/week, dynamic exercises focused on mobility, static exercise focused on single leg stand, 4-10 different exercises

2- Muscle Performance• 3 x/week, 8 to 10 exercises

• Aerobic Capacity• Chronic Dx - 3-5 x/week, 20-60 minutes, 50-70% Hrmax

• Frailty - > 3 x/week, at least 20 minutes, 11-13 Borg Scale

• Flexibility• 7 x/week, 3-5 reps each major muscle group, 10-30 s. hold

• Dance Therapy for PD

Exercise Recommendations

Assistive Devices : Canes

STANDARD CANE

• Indications:

• Mild ataxia (sensory, vestibular, or visual)

• Mild arthritis

• Advantages:

• Inexpensive

• Adjustable

• Improves balance

• Disadvantages:

• Umbrella handle cause carpal tunnel syndrome

• Not for weight bearing

Assistive Devices : Canes

OFFSET CANE

• Indication:

• Moderate arthritis

• Advantages:

• Inexpensive

• Intermittent weight bearing

• Shotgun handle put less pressure on palm

• Disadvantages:

• Commonly used incorrectly

Assistive Devices

QUADRIPOD

• Indications:

• Hemiparesis

• Advantages:

• Increased base of support

• bear large weight

• Stands freely on its own

• Disadvantages:

• Slightly heavier

• Awkward to use correctly with all four points on ground simultaneously

Assistive Devices : CRUTCHES

AXILLARY CRUTCHES

• Indication:

• Lower extremity fracture

• Advantages:

• Inexpensive

• Completely redistribute weight off of lower extremities

• Permits 80-100 % weight-bearing support

• Disadvantages:

• Difficult to learn to use

• Requires energy & strength

• Risk of nerve or artery compression

Assistive Devices : CRUTCHESFOREARM CRUTCHES:

• Indication:

• Paraparesis

• Advantages:

• Frees hands without having to drop crutch

• Less cumbersome to use, particularly on stairs

• No Axillary compression

• Disadvantages:

• Permits only occasional weight bearing

Assistive Devices : WALKERS

STANDARD WALKER

• Indications:

• Severe myopathy

• severe neuropathy

• Cerebellar ataxia

• Advantages:

• Most stable walker

• Folds easily

• Disadvantages:

• Slower

• Needs to be lifted up with each step

• Less natural gait

Assistive Devices : Walkers

FRONT-WHEELED WALKER

• Indications:

• Severe myopathy

• Severe neuropathy

• Paraparesis

• Parkinsonism

• Advantages:

• Maintains normal gait pattern

• No need to be lifted up with each step

• Disadvantages:

• Large turning arc

• Less stable

Assistive Devices : WALKERS

ROLLATOR

• Indications:

• Moderate arthritis

• Claudication

• Lung disease, CHF

• Advantages:

• Easy to propel

• Highly movable

• Small turning arc

• Has seat & basket

• Disadvantages:

• Not for weight bearing

• Less stable

• Does not fold easily

Non-Actuator

Devices

Functional

Electrical

Stimulation

Robotics

Virtual RealitySensor

Technology

New Technologies:

Changing Brains

Neurotechnology The Artificial Brain?

First pacemakers were introduced in the early 1960s

3 million people worldwide use them

1st cochlear implants developed in the late 1970s~ 225,000 fitted worldwide

Amazing? New?

Neuromodulation works by using electrical stimulation to improve control of an existing part of the nervous system. Examples include spinal cord stimulation systems used for chronic pain management that block pain signals to the brain and gastric stimulation systems, which are used to block the signals of hunger.

Deep brain stimulation (DBS) and

Spinal Cord Stimulation

Transcranial magnetic stimulation

(TMS)

Vagal nerve stimulation

There are three different types of neuromodulation

Neurology 2019

Deep brain stimulation (DBS)This involves the placement of an electrode inside the brain with a wire running down the neck connected to a battery pack or pulse generator under the skin in the chest or abdomen.Currently used to treat Parkinson's disease, epilepsy, stroke and severe obsessive compulsive disorders.Research is underway into its use to treat obesity, Tourette's syndrome, anorexia, addictions.

Neurology 2019

When a strong, rapid current is passed through a stimulating coil (top), a rapidly changing magnetic

field is produced, which induces current into the brain

Bolognini N , and Ro T J. Neurosci. 2010;30:9647-9650

©2010 by Society for Neuroscience

Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS)This involves the application of a magnetic field to induce electrical currents into the brain. It is a non-invasive procedure.Currently used in several countries to treat depression, or to enhance cognitive functions such as attention, understanding, perception.Future applications may include treatment for severe migraines.There is significant interest in the development of TMS to enhance mood and cognitive skills such as problem-solving and memory.

TCMS requires hospital visits 5 x 40 min visits each week for up to six weeks

As a result of this ion flow, action potentials are triggered in neurons that are within the induced current field, along with a subsequent period of deactivation, presumably through prolonged IPSPs. Because normal ongoing brain activity is disrupted by this induced current, TMS provides a way for investigators to produce a transient and reversible period of brain disruption or “virtual lesion.” Thus, unlike other experimental techniques [e.g., functional magnetic resonance imaging (fMRI), electroencephalography (EEG)/event-related potentials (ERPs)], TMS can assess whether a given brain area is necessary for a given function rather than simply correlated with it.

Neurology 2019

Brain-machine interfaces (BMIs)devices that detect intent—typically intended movement—frombrain activity, and translate it into an output action, such ascontrol of a cursor on a screen or a robotic arm.1) acquiring a neural signal that can be consciously controlled; 2) analyzing that signal to identify an intended motor output; and 3) executing the intended action

Neurology 2019

Neural Prostheses and Neural Rehabilitation is used in conjunction with a planned training program to replace or improve function of an impaired nervous system or to provide a better, more controllable prosthesis following loss of a limb.

Neurology 2019

Retinal ImplantsRetinal Implants

Jennifer French US Sailing Paralympic Silver MedalistWhile snowboarding in 1998, French suffered a severe spinal cord injury that left her a quadriplegic.The following year she received implants that allowed her to stand and, ultimately, walk down the aisle at her wedding. She is the first woman to receive an implanted neural prosthetic device allowing her to use paralyzed lower limbs.

Claire Lomas & ReWalk

Claire Lomas is an event rider who was paralysed from the chest down following an injury. Using the ReWalk bionic suit, she completed the London Marathon in 17 days.

The ReWalk exoskeleton suit uses motorized legs that power knee and hip movement and is controlled by on-board computers and motion sensors, restoring self-initiated walking without needing tethers or switches to begin stepping.

ReWalk controls movement using subtle changes in centre of gravity, mimics natural gait and provides functional walking speed. A forward tilt of the upper body is sensed by the system, which triggers the first step. Repeated body shifting generates a sequence of steps, which allows natural and efficient walking.

The ReWalk also sits, stands, allows turning and has the ability to climb and descend stairs. Using crutches for support, the user can walk and speak eye-to-eye with others on city streets and also navigate slopes and uneven terrain.

Claire Lomas & ReWalk

Neuro Pharmaceuticals is an emerging field of therapy, applied through the use of devices combined with pharmaceuticals, particularly for cognition and emotional treatments. Examples include pumps for baclofen to treat spasticity or morphine for chronic pain.

Intrathecal pump delivers medication to spinal fluid. There is no feedback loop.

Neurology 2019

Summary• Bipedal gait is a fundamental function that determines human life beyond early infancy almost as much as speech,

higher cognitive abilities and use of complex tools.

• As the prevalence of gait disorders increases with age, the number of people affected will substantially increase in the coming decades due to the expected demographic changes.

• Gait disorders lead to a loss of personal freedom and to reduced quality of life.

• Gait impairments are also precursors of falls and therefore of potentially severe injuries in elderly persons.

• The causes of gait disorders include neurological, orthopaedic, medical and psychiatric conditions and multifactorial aetiology becomes more common with advancing age, making classification and management more complex.

• Any gait disorder should be thoroughly investigated in order to improve patient mobility and independence, to prevent falls and to detect the underlying causes as early as possible.

• Thorough clinical observation of gait, careful history taking focussed on gait and falls and physical, neurological and orthopaedic examinations are basic steps in the categorization of gait disorders and serve as a guide for ancillary investigations and therapeutic interventions.

Summary

Summary• Prevention and treatment of iatrogenic, especially medication-induced, gait disorders are

important measures to reduce the burden of falls in the geriatric population.

• Several gait disorders are amenable to specific treatment. Levodopa is the drug of choice for the treatment of the gait disorder of PD and in some other parkinsonian syndromes.

• In normal pressure hydrocephalus, cervical spondylotic myelopathy, lumbar spinal stenosis and hip or knee osteoarthritis, surgical treatment should be considered.

• Patients with gait disorders not amenable to specific treatment (e. g. many neuromuscular conditions, frontal gait disorders) may benefit from multimodal rehabilitation, gait training, use of assistive devices and fall prevention measures.

• Commonly used exercise interventions such as muscle strength, power and resistance training as well as coordination training can improve habitual and maximum gait speed in elderly subjects .

• These exercise programs can be individualized according to the type of gait impairment, the therapist’s experience and patient’s preferences.

Summary

Conclusions

• Comprehensive evaluation with targeted interventions reduce falls by 30-40%

• Gait Disorder evaluation the most effective strategy for falls prevention

• Emerging evidence supports a cognitive component to measuring falls and treating fall risks.

• Encourage exercise to improve muscle strength and balance

• Consider assistive devices and use OT for home safety assessments

• Screen for fear of falling and counsel to improve mobility

• Neurotechnology is future technology that improves or repairs nervous system function or facilitates understanding of the nervous system.

Conclusions

Graphic representation of the step sequence in classical gait disorders

Graphic representation of the step sequence in classical gait disorders

Thank you !!

Gait Disorders- Assessment and Intervention

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