What is the appropriate management for a patient presenting with mobility issues, abnormality of gait, or balance problems?

Management of Mobility Issues, Abnormality of Gait, and Balance Problems

For patients presenting with mobility issues, abnormality of gait, or balance problems, a multifactorial assessment followed by targeted interventions addressing specific risk factors is strongly recommended as the most effective approach to improve outcomes and reduce fall risk.

Assessment Components

Initial Screening

• Ask all older persons about falls at least once yearly 1
• Perform the "Get Up and Go Test" or Timed Up and Go (TUG) Test - observe patient standing from a chair without using arms, walking several paces, and returning 1, 2
  • Time >12 seconds indicates increased fall risk
  • Patients demonstrating difficulty or unsteadiness require further assessment

Comprehensive Assessment

• Balance evaluation using standardized tests:

  • 4-Stage Balance Test - inability to hold tandem stand for 10 seconds indicates increased risk 2
  • Berg Balance Scale - 14-item scale with scores 0-56 (higher scores indicate better performance) 2
  • 30-Second Chair Stand Test - assesses lower extremity strength 2

• Gait assessment:

  • Observe for asymmetry, decreased step length, increased step width, decreased speed
  • Evaluate for specific gait patterns that may indicate underlying pathology 3

• Additional evaluations:

  • Medication review - identify medications that may affect balance and gait 1, 2
  • Orthostatic blood pressure measurement 1
  • Vision assessment 1
  • Neurological examination - mental status, muscle strength, proprioception, reflexes 1
  • Cardiovascular assessment - heart rate, rhythm, postural pulse 1
  • Home environment assessment for hazards 1, 2

Intervention Strategies

Exercise and Physical Therapy

• Implement individualized, progressive balance and mobility training as the cornerstone of management for all patients with gait and balance disorders 1
• Provide specific exercise components:
  • Balance training at least 3 days/week 2
  • Strength training exercises twice weekly focusing on lower extremities 2
  • Task-specific training with functional tasks graded to challenge individual capabilities 1
  • Intensive, repetitive mobility-task training for gait limitations 1

Assistive Devices and Orthotics

• Prescribe appropriate assistive devices (cane, walker) for gait and balance impairments 1
• Use ankle-foot orthoses (AFOs) for ankle instability or dorsiflexor weakness 1
• Ensure proper fitting and training in the use of assistive devices 1

Environmental Modifications

• Evaluate home environment for hazards (loose rugs, clutter) 1, 2
• Install grab bars in bathrooms and other needed areas 2
• Ensure adequate lighting, including night lights 2
• Recommend appropriate non-skid footwear 2

Medication Management

• Review and modify medications, especially psychotropics, antiarrhythmics, digoxin, and diuretics 1, 2
• Consider discontinuation of high-risk medications when possible 2
• Use caution with medications like baclofen that may cause sedation and affect balance 4

Additional Interventions

• For stroke patients:

  • Consider botulinum toxin injections for spasticity that interferes with gait 1
  • Provide enriched environments to increase engagement with cognitive activities 1
  • Consider community or home-based rehabilitation when appropriate 1

• For functional neurological disorders:

  • Encourage optimal postural alignment at rest and within function 1
  • Promote even weight distribution in sitting, transfers, standing, and walking 1
  • Use sensory grounding techniques and general relaxation techniques 1

Follow-up and Monitoring

• Schedule regular follow-up to assess progress and adjust interventions 1
• Monitor for changes in medication regimens that may affect balance 1
• Reassess balance and gait periodically using standardized measures 2

Common Pitfalls to Avoid

• Attributing balance problems solely to aging rather than identifying treatable causes 2, 5
• Overlooking medication effects on balance and coordination 2
• Implementing generic interventions rather than tailoring to specific risk factors 2
• Using splinting for functional dystonia, which may worsen symptoms 1
• Failing to consider psychological factors like fear of falling 2

By implementing this comprehensive approach to mobility, gait, and balance disorders, clinicians can effectively reduce fall risk and improve functional outcomes for patients with these common and potentially debilitating conditions.