What are the treatment options for patients with gait impairment?

Treatment Options for Gait Impairment

The most effective treatment for gait impairment requires a multidisciplinary approach tailored to the underlying cause, with supervised exercise therapy being the cornerstone intervention for most patients with gait disorders. 1

Assessment and Diagnosis

Before initiating treatment, proper assessment is essential:

• Gait speed measurement (cut-off below 0.8m/s) is strongly recommended for patients with cognitive complaints as it predicts future dementia risk 1
• Dual-task gait testing helps identify individuals at higher risk of cognitive decline 1
• Assessment for parkinsonism is recommended as it increases dementia risk threefold 1
• Evaluation of physical and cognitive function, including falls history, is critical for all patients 1
• Testing should include assessment of strength, coordination, sensation (particularly joint position sense), and hypertonicity 1

Treatment Options Based on Etiology

1. Neurological Causes

• Parkinson's Disease:

  • Levodopa therapy is the primary pharmacological treatment for parkinsonian gait disorders 2
  • Physical therapy focusing on gait training and balance exercises 1
  • Careful monitoring for side effects including somnolence that may affect safety 2

• Stroke-Related Gait Disorders:

  • Supervised exercise therapy (SET) is recommended to improve walking performance 1
  • Functional electrical stimulation (FES) for patients with ankle/knee/wrist motor impairment 1
  • FES is specifically recommended for gait training after stroke 1
  • Treadmill training, with or without body-weight support, improves walking performance 1

• Multiple Sclerosis and Other Neuromuscular Diseases:

  • Focus on addressing the eight key determinants of gait performance: toe-off timing, stride length, step duration, cadence, ankle angle at foot strike, knee extensor strength, and timing variability in hip flexion-extension 3

2. Vascular Causes (Peripheral Arterial Disease)

• Supervised Exercise Therapy (SET):

  • First-line treatment for claudication-related gait impairment 1
  • Improves walking performance, functional status, and quality of life 1
  • Should be offered before considering invasive interventions 1

• Structured Community-Based Exercise Programs:

  • Effective alternative when SET is unavailable 1
  • Should incorporate behavioral change techniques 1

• Alternative Exercise Programs:

  • Non-walking structured exercise (arm ergometry, recumbent stepping) can benefit patients who cannot walk 1

3. Orthotic and Assistive Devices

• Lower-Extremity Orthoses:

  • Ankle-foot orthoses (AFOs) for patients with persistent weakness and instability 1
  • Initially use prefabricated braces, with customized orthoses only for long-term needs 1

• Walking Assistive Devices:

  • Single point canes: Fitted to patient with rubber tips for improved traction 1
  • Tripod/quad canes: Provide more stability but are heavier and bulkier 1
  • Walkers: Support more body weight; lightweight and foldable options for outside use 1
  • Rolling walkers: More energy-efficient but require greater coordination 1

• Wheelchairs:

  • Prescribed based on careful assessment of patient and environment 1
  • Recommended for patients with severe motor weakness or those who easily fatigue 1

4. Specialized Interventions

• Robot-Assisted Therapy:

  • Beneficial for upper extremity motor rehabilitation 1
  • Provides motor practice with less therapist assistance 1
  • Improves proximal arm function but may not address distal limb function 1

• Constraint-Induced Movement Therapy:

  • Effective for upper extremity function in stroke patients 1
  • Modified intensity (30 minutes, 3 days/week) with 5-6 hours of mitt wearing shows benefits 1

• Virtual Reality Environments:

  • Provides controlled multimodal sensory information 1
  • May enhance motor rehabilitation outcomes 1

Special Considerations

• Elderly Patients:

  • Assess for frailty as a marker of future dementia 1
  • Evaluate sleep disturbances which may indicate preclinical dementia 1
  • Consider that nearly one-third of elderly patients with gait impairment have potentially treatable causes 4

• Post-Revascularization:

  • SET after revascularization improves outcomes in peripheral arterial disease 1
  • Exercise therapy is contraindicated in critical limb-threatening ischemia but can be considered after successful revascularization 1

• Fall Prevention:

  • Patients with gait disorders should not walk barefoot and should have protective measures in place 1
  • Home safety evaluation and modifications are recommended 1
  • Regular reassessment of driving ability is necessary for safety 1

Common Pitfalls and Caveats

• Unstructured exercise programs ("go out and walk") have not been shown to be effective and should only be used when structured programs are unavailable 1
• Hypertonicity assessment lacks clear recommendations, and the Modified Ashworth Scale has questionable validity and interrater reliability 1
• Clinicians should obtain training to establish administration and scoring consistency for assessment tools 1
• Patients taking levodopa should be cautioned about driving and operating machinery due to potential somnolence 2
• Monitor for hyperpyrexia and confusion resembling neuroleptic malignant syndrome when adjusting antiparkinsonian medications 2