What is the appropriate evaluation and management for a patient presenting with an abnormal gait, considering potential underlying neurological or musculoskeletal conditions?

Evaluation and Management of Abnormal Gait

When a patient presents with abnormal gait, immediately perform the "Get Up and Go Test" (observe standing from a chair without arm use, walking several paces, and returning) to determine if further evaluation is needed. 1

Initial Clinical Assessment

Immediate Observation and History

• Observe gait quality directly: posture, stride length, base width, speed, fluidity, arm swing, bilateral symmetry, and any neurologic signs 2
• Ask specifically about falls: all patients should be questioned at least annually about fall history 1
• Document specific gait descriptors:
  • Kyphotic posture during gait suggests Parkinson's disease, dementia with Lewy bodies, or progressive supranuclear palsy 3
  • Waddling gait indicates proximal muscle weakness from neuromuscular disorders 4
  • Slow-hesitant gait, astasia-abasia, bouncing, wide-based gait, or scissoring suggests functional gait disorder 5

Critical Red Flags Requiring Urgent Evaluation

• Motor regression (loss of previously acquired skills) indicates neurodegenerative process 4
• Respiratory insufficiency with weakness signals high risk of respiratory failure 4
• Fasciculations, particularly tongue fasciculations, indicate lower motor neuron disorders like spinal muscular atrophy 1, 4
• Gower maneuver (inability to rise from floor without pushing up with arms) suggests muscular dystrophy 1

Structured Physical Examination

Neuromotor Assessment

• Cranial nerve examination: eye movements, visual confrontation, pupillary reactivity, facial expression, oromotor movement, tongue fasciculations, shoulder shrug 1
• Strength assessment by functional observation: antigravity movement, sequential transitions from sitting to walking, running, climbing, hopping, skipping 1
• Muscle examination: bulk, texture, joint flexibility, presence of atrophy 1
• Tone assessment:
  • Postural tone via ventral suspension in infants 1
  • Scarf sign in infants and popliteal angles after first year 1
• Reflex testing: diminished/absent reflexes suggest lower motor neuron disorders; increased reflexes with abnormal plantar reflex indicate upper motor neuron dysfunction 1

Vascular Assessment (When Claudication Present)

• Ankle-brachial index (ABI): initial test to confirm lower-limb perfusion status; ABI ≤0.90 confirms peripheral artery disease 1
• Post-exercise ABI: if resting ABI >0.90 with clinical suspicion, >20% decrease post-exercise confirms PAD 1
• Toe pressure or toe-brachial index: mandatory in patients with diabetes or renal failure if resting ABI is normal 1

Fall Risk Assessment

• Cardiovascular status: heart rate, rhythm, postural pulse and blood pressure, carotid sinus stimulation response if appropriate 1
• Vision, hearing, and balance assessment: sensory or motor function alterations substantially increase fall risk when combined with cognitive impairments 3
• Environmental hazards: home safety assessment for trip hazards, lighting, assistive device needs 3

Diagnostic Testing Algorithm

Laboratory Studies

• Measure serum creatine kinase (CK) in all children with motor delay and low tone: CK >1000 U/L suggests Duchenne muscular dystrophy; CK >3× normal in any child indicates muscle destruction 1, 4
• Thyroid-stimulating hormone: perform even without classic thyroid disease signs in children with hypotonia or neuromuscular weakness 1, 4

Imaging Studies

• MRI brain without contrast:
  • First-line for suspected motor neuron disease, Parkinsonian syndromes, neurodegeneration 1
  • Indicated when abnormal neurologic examination findings present 4
• Spinal imaging: obtain when tethered cord syndrome suspected (progressive weakness, gait disturbance, muscle atrophy, cutaneous markers) 4
• Duplex ultrasound: first-line imaging for PAD screening when vascular claudication suspected 1

Management Approach

Multifactorial Interventions for Community-Dwelling Patients

• Gait training and assistive device advice 1
• Medication review and modification, especially psychotropic medications 1
• Exercise programs with balance training component 1
• Treatment of postural hypotension 1
• Environmental hazard modification 1
• Treatment of cardiovascular disorders including arrhythmias 1

Physical Therapy Referral

• Physical therapy assessment and treatment improves function and reduces safety risks in patients with gait and balance disorders 3
• Home occupational therapy with safety assessment mitigates fall risks through assistive devices, night lights, elimination of trip hazards 3

Specialist Referral Criteria

Pediatric Neurology

• Abnormal neurologic examination 4
• Motor regression 4
• Suspected neuromuscular disorder (elevated CK, fasciculations, progressive weakness) 4

Pediatric Orthopedics

• Hip pathology (developmental dysplasia, Perthes disease, slipped capital femoral epiphysis) 1, 4
• Significant limb deformity or length discrepancy 1, 4
• Spinal deformity (scoliosis, kyphosis) 1
• Neuromuscular-related disability (cerebral palsy, spina bifida, muscular dystrophy) 1

Genetics Consultation

• Dysmorphic features or multiple congenital anomalies 4
• Suspected metabolic or mitochondrial disorders (organomegaly, worsening during metabolic stress) 4

Geriatric or Movement Disorder Specialist

• Recurrent falls or fall with injury 1
• Kyphotic posture suggesting Parkinsonian syndrome 3
• Suspected chronic subdural hematoma (gait impairment with altered consciousness, particularly in elderly with or without trauma history) 6

Common Pitfalls to Avoid

• Do not dismiss gait abnormalities as "psychogenic" without thorough evaluation: functional gait disorders exist but require positive diagnostic features (slow-hesitant gait, astasia-abasia, bouncing with knee buckling) rather than diagnosis of exclusion 5
• Do not overlook chronic subdural hematoma in elderly: symptoms overlap with common geriatric conditions and lack of clear trauma history contributes to delayed recognition 6
• Do not delay CK testing in children with suspected muscle weakness: early diagnosis of Duchenne muscular dystrophy is critical, and approximately one-third of cases are new mutations without family history 1
• Do not assume normal ABI excludes PAD in diabetics or renal failure patients: measure toe pressure or toe-brachial index as ABI may be falsely elevated 1