What is the workup for an unsteady gait?

From the Guidelines

The workup for unsteady gait should begin with a thorough history and physical examination to identify potential causes, including assessing for acute versus chronic onset, associated symptoms, medication use, and past medical history. This approach is supported by the American Heart Association/American Stroke Association guidelines for adult stroke rehabilitation and recovery 1. The physical examination should include a complete neurological assessment focusing on strength, sensation, coordination, reflexes, and specific gait testing.

Some key points to consider in the workup include:

• Laboratory tests such as complete blood count, comprehensive metabolic panel, vitamin B12, folate, thyroid function tests, and hemoglobin A1c
• Imaging studies like brain and spine MRI to evaluate for structural abnormalities, stroke, or multiple sclerosis
• Vestibular function testing if vertigo is present
• Electrodiagnostic studies like EMG/NCS if peripheral neuropathy is suspected
• Medication review, especially in elderly patients, as polypharmacy often contributes to gait instability

The use of adaptive equipment, durable medical devices, orthotics, and wheelchairs can also be beneficial in managing gait impairments, as outlined in the guidelines 1. Walking devices, such as canes, walkers, and rolling walkers, can increase the base of support around a patient’s center of gravity and reduce the balance and effort needed to walk. Wheelchairs can enhance mobility for individuals who cannot ambulate safely.

Specialized assessments like the Tinetti Balance and Gait Evaluation or Berg Balance Scale can quantify fall risk, which is essential in determining the appropriate treatment plan 1. A comprehensive approach is necessary because unsteady gait has numerous potential causes, including neurological disorders, medication side effects, vestibular dysfunction, orthopedic problems, and normal aging changes, requiring systematic evaluation to determine appropriate treatment.

From the Research

Workup for Unsteady Gait

The workup for an unsteady gait involves a comprehensive approach, including:

• A thorough history and physical examination to characterize the gait disturbance 2
• Observation of the patient's gait to identify specific patterns, such as frontal gait, spastic hemiparetic gait, parkinsonian gait, cerebellar ataxic gait, and sensory ataxic gait 3
• Ancillary testing, such as video electroencephalogram and electromyogram, to rule out underlying conditions like hyperekplexia 4
• Evaluation of temporal-spatial, kinematic, and kinetic gait parameters to identify abnormal gait patterns 5
• Assessment of musculoskeletal and neurological causes, including myelopathic gait, stooped gait of lumbar spinal stenosis, and steppage gait 3

Key Components of the Workup

The workup for an unsteady gait should include:

• A chief complaint-based phenomenological characterization of gait 2
• A systematic approach to the gait examination, including observation of gait patterns and assessment of gait velocity, step length, and foot clearance 6
• An algorithmic approach to ancillary testing, based on historical and examination features 2
• Consideration of treatable causes of gait disturbance, such as normal-pressure hydrocephalus, vitamin B(12) deficiency, Parkinson's disease, and painful disorders of the lower extremity 3

Gait Pattern Analysis

Gait pattern analysis can help identify specific gait patterns and guide the therapeutic approach and monitoring 5. This can include:

• Assessment of gait speed and maximal hip extension angle to predict subgroup classification 5
• Identification of abnormal gait patterns, such as fast gait speed with adequate maximal hip extension, fast gait speed with inadequate maximal hip extension, and slow gait speed 5