Wobbly gait is a walking abnormality that can be caused by disease or injury to the musculoskeletal system, including bones, joints, blood vessels, peripheral nerves, muscles and soft fabrics. Another large group of causes of unsteadiness is damage to the parts of the nervous system that control the movements of the legs when walking.
The first group of reasons includes diseases such as osteochondrosis, arthritis, injuries to the spine and lower extremities, muscle bruises, and foot deformities associated with uncomfortable shoes.
The second - weakness in the limbs due to a stroke, Parkinson's disease, multiple sclerosis, encephalopathy and other diseases.
Unsteadiness can sometimes be the result of temporary causes such as injury or infection, or it can be a permanent problem characterized by weakness in the legs.
Gait disturbance can range from subtle to severe, leading to limited ability to self-care.
One of the common causes of unsteadiness is osteochondrosis, a degenerative disease of cartilage and bone tissue. This process can develop in any bone and joint structure. However, traditionally the term “osteochondrosis” is used mainly in relation to damage to the spine.
The essence pathological process with this disease, degenerative changes occur in the intervertebral disc (the cartilaginous “lining” between the vertebrae): impaired blood supply, deterioration of nutrition, loss of fluid. Disc deformation leads to a narrowing of the space between the vertebrae and a change in its configuration.
As a result, spinal nerves may be pinched in the intervertebral space. If the infringement occurs in the cervical region, pain appears in the neck, shoulder, and weakness in the arm occurs. Osteochondrotic lesion thoracic manifests itself primarily as back pain.
If the disease occurs in the lumbosacral region, the pain is localized in the lower back and may spread to the legs. This form of osteochondrosis is characterized by the appearance of areas where skin sensitivity is reduced, as well as impaired mobility and weakness of the lower extremities. 
What causes these symptoms?
The answer to this question is quite simple, but requires a slight retreat towards the basics of anatomy and physiology.
Along the entire length of the spinal column, spinal nerves emerge from it. Some of the branches of these nerve trunks provide sensitivity to certain areas of the skin, the other part controls activity skeletal muscles. The branches supplying the muscles, after leaving the spine, form nerve plexuses and only after that are directed to the muscles.
The nerves that “control” the work of the legs come from the lumbar and sacral regions spine and form two plexuses of the same name. The most significant branch of the lumbar plexus is the femoral nerve, the sacral - the sciatic.
Each of these nerve trunks delivers control impulses to several muscles of the lower extremities. If the nerve root is compressed in the intervertebral space, the conduction of nerve impulses to the muscles worsens, and weakness appears in the leg (or both legs with bilateral damage). Due to weakness, the gait becomes unsteady.
In addition to movement control disorder, pain also plays a role in the appearance of difficulties when walking.
What to do
Unsteadiness of gait is a fairly serious symptom. It is necessary to urgently consult a doctor, especially if weakness in the legs increases rapidly. A full examination is necessary in order to exclude situations requiring surgical intervention. Such conditions may include, for example, a progressive herniation of the intervertebral disc, compressing the nervous tissue.
Steps, on the one hand, are ordinary daily movement, on the other hand, they are a complex process of activity of the central nervous system, brain, muscles, skeletal system, organs of vision and inner ear. But sometimes gait disturbances begin. Let's figure out why they happen. But let's start with the symptoms for which you should consult a specialist.
Symptoms
Gait disturbance is scientifically called dysbasia. It is expressed in the following symptoms:- difficulty climbing stairs;
- turns are difficult;
- twitching, lack of confidence in the legs;
- regular appearance of the sensation of wooden muscles;
- constant stumbling, falling and collisions with the environment;
- significant physical exhaustion resulting in muscle weakness.
- it is impossible to bend the joints normally.
Causes
Dysbasia may result various diseases, some of them are not related to the musculoskeletal system.
It is customary to identify 2 main reasons for gait disturbance:
- determined by the anatomy of the human body;
- caused by neurology.
- uneven legs;
- pain syndrome;
- anteversion of the femur.
- deterioration of blood circulation in the brain;
- peripheral neuropathy;
- disruption of the cerebellum;
- paralysis peroneal nerve;
- cerebral paralysis;
- Parkinson's disease;
- sclerosis;
- disorders in the frontal lobe of the brain.
Important! The most common cause of dysbasia is various diseases of the central nervous system. They are often caused by uncontrolled consumption of sedatives, alcoholic beverages, and drugs.
Sometimes dysbasia is associated with a lack of B vitamins, in particular B 12. When there are not enough of them in the body, the legs and arms go numb, and the balance is upset.
Problems with stability and loss of sensation in the arms and legs also occur in people with diabetes.
Older people with low vision may experience worsening gait. It should be understood that we are talking about a strong degree of myopia.
Gait disturbances may also be associated with infections in the inner ear. They cause loss of balance.
Kinds
In general, the concept of dysbasia involves gait disturbances in diseases that arise at different levels of the musculoskeletal system. Dysbasia can manifest itself in different ways. But its manifestations can still be structured.It is divided into the following types:
- ataxic;
- hemiparetic;
- parasympathetic;
- spastic-atactic;
- hypokinetic;
- apraxia (frontal dysbasia);
- idiopathic senile dysbasia;
- peroneal walking;
- "duck" gait;
- dysbasia in diseases of the musculoskeletal system;
- movement disorders due to mental disability, psychogenic disorders, epilepsy.
Additional Information. To indicate neurological diseases The concept of astasia-abasia is often used. This means having problems with balance and walking at the same time.
Let's take a closer look at some types of dysbasia.
Hemiplegic walking characteristic of spastic hemiparesis. In advanced situations, there is a deformed position of the arms and legs, namely, the shoulder turns inward, and the rest of the arm from the elbow to the tips of the fingers is bent, and the leg, on the contrary, is bent at the knee. The movement of the injured leg begins with the hip abducted and making a circular movement, while the body is directed in the other direction.
In simpler variants of the disease, the hand is in its normal position, but when moving it remains static. It is difficult for the patient to bend his leg, while it is turned outward. This gait often remains as a consequence of a stroke.
Paraparetic walking characterized by the fact that it is difficult to rearrange the lower limbs, there is tension, as with hemiparesis, movements are carried out in a circle. In most patients, the lower limbs cross like scissors.
This gait is often found with problems with the spinal cord and cerebral palsy in children.
"Rooster" gait is expressed in insufficient, poor foot function with back side. When moving, the entire foot or some part of it hangs down; therefore, a person must place his foot higher so that his toes do not touch the floor surface.
Impairment in one leg occurs with radiculopathy, pinching of the sciatic or peroneal nerve. On two legs - with polyneuropathy, as well as radiculopathy.
"Duck" gait caused by weakness of some muscles of the lower extremities. This situation is often worrying with myopia, in addition, with damage to the neuromuscular synapse or spinal amyotrophy.
Due to great weakness, it is difficult to lift the leg from the floor; this can only be done by tilting the body; turning the pelvis ensures the movement of the leg forward. This disease usually affects both legs, so when walking a person seems to fall to the right and then to the left.
How to fix a duck walk (video)
For a more detailed analysis of the “duck” gait, we recommend watching the following video. It examines in detail the question of how to correct a “duck” gait.
Parkinsonian walking manifests itself in hunching, legs and arms are bent, tremor (shaking) is often visible. Before the first step, bend forward. Then it’s the turn of the small, shuffling steps. At the same time, the speed of movement is constantly increasing, the body is ahead of the legs. Because of this, the patient constantly falls.
Apraxic gait characterized by duality. On the one hand, the patient easily performs movements. But when asked to perform any movement, he cannot budge for a long time. This is caused by damage to the frontal lobe, as a result of which planning and performing a number of movements is difficult for the patient.
Choreoathetous gait characterized by the fact that measured, calm walking is disrupted by sudden, involuntary movements. It results in a loose gait.
For cerebellar gait The step is too wide, while the speed and length of the steps are constantly changing. This gait is also called a drunken gait.
Such a patient may lose balance when changing position. But closing his eyes, he can walk. Walking with this disorder can be either slow or fast, but always with an irregular rhythm.
If we are talking about sensory ataxia, then walking with it is similar to cerebellar. But as soon as you close your eyes, the patient immediately loses his balance.
Vestibular ataxia lies in the fact that a person constantly rolls either to the right or to the left. Moreover, this happens both during movement and during static conditions.
During the period of hysteria the following happens. The patient keeps his balance well and walks smoothly if he is distracted by something. But then there is a demonstrative fall.
Diagnostics
Since the causes of dysbasia are very different, you may need the help of various specialists, such as a neurologist, traumatologist, orthopedist, otolaryngologist, ophthalmologist, surgeon. You should start with a therapist who will collect anamnesis and, if necessary, refer you to a specialist for further treatment.Walking is a biomechanical process that involves both the muscles, joints and bones of a person, as well as his nervous system. Therefore, a violation of even one of the systems leads to quite significant changes in walking.
Joint disorders
Duck walk. With it, a person shifts from one leg to another. This gait appears with congenital dislocation, pelvic distortion or loss of mobility in the hip joint (dysplasia hip joint). In this case, the person tries to spare the sore leg and move the healthy leg more.
Compass. When walking, your knees do not bend. Pain in the knee joints leads to the fact that over time a person gets used to walking like this. The cause may be arthrosis or valgus deformity of the knees (X-shaped curvature of the legs).
Small steps cause long periods of walking in high heels. In this case, the joints and bones of the thumbs are deformed.
Sometimes people walk with caution, trying not to turn their heads. This happens when cervical osteochondrosis, when the muscles of the neck and shoulders are tense, as well as with severe headaches and migraines.
Nervous disorders
If a person walks hunched over on half-bent legs with mincing shuffling steps, while the body is tilted forward, and the legs seem to lag behind him, then he most likely has Parkinson's disease.
Overly nervous step, when a person is all “on hinges,” then this is a sign of neuroses. On the contrary, low hand mobility and retardation of movements indicate serious psychological disorders, up to schizophrenia.
The inability of a person to move in the dark indicates sensory-motor disorders, and the gait of a “drunk person” can indicate not only intoxication, but also a disorder of the cerebellum.
Vascular disorders
Intermittent claudication is a smokers' disease that is caused by cramps peripheral vessels lower extremities. Due to poor circulation in the legs, a person gets tired quickly. After walking 100-200 meters, the step deteriorates and the person must stop in order to go further.
Uncertainty when walking, unsteadiness, frequent falls and constant search support indicates a disorder of the brain. In turn, the causes of these violations may be vascular disorders discirculatory in nature, which are typical for older people.
If a person walks with one leg puts it normally, but drags the second one, describing an arc to it, then most likely he had a cerebral hemorrhage.
Unsteady position when walking blood supply disturbances in the lower extremities with varicose veins may also serve, diabetes mellitus or atherosclerosis of the lower extremities.
Biomechanical disorders
Lameness occurs when the leg is anatomically shortened, that is, when one leg is shorter than the other. The causes may be a congenital feature, trauma, fractures, as well as osteomelitis. Also, a lame gait can develop due to functional shortening of the leg. Here, the culprits are usually scoliosis, hip dysplasia, pelvic distortion, arthritis or arthrosis.
See a doctor urgently!
Psychologists say that an ugly gait caused by illness directly affects the feeling of self-confidence and creates additional psychological complexes. With the correct gait, a person’s entire system works in harmony and nothing hurts. Incorrect gait not related to serious illnesses, corrected with the help of gymnastics and special devices. Therefore, it is recommended to consult a doctor and stay healthy physically and psychologically.
Violations and their causes in alphabetical order:
gait disturbance -
Walking- one of the most complex and at the same time common types of physical activity.
Cyclic walking movements trigger the lumbosacral centers of the spinal cord and regulate the cerebral cortex, basal ganglia, brain stem structures and cerebellum. This regulation involves proprioceptive, vestibular and visual feedback afferentation.
Gait The human brain is a harmonious interaction of muscles, bones, eyes and inner ear. The coordination of movements is carried out by the brain and the central nervous system.
If there are disturbances in certain parts of the central nervous system, various movement disorders may occur: a shuffling gait, sudden jerking movements, or difficulties in bending joints.
Abasia(Greek ἀ- prefix with the meaning of absence, non-, without- + βάσις - walking, gait) – also dysbasia– disturbance of gait (walking) or inability to walk due to gross gait disturbances.
1. In a broad sense, the term abasia means gait disturbances with lesions involving various levels of the system of organizing the motor act, and includes such types of gait disturbances as ataxic gait, hemiparetic, paraspastic, spastic-atactic, hypokinetic gait (with parkinsonism, progressive supranuclear paralysis and other diseases), apraxia of walking (frontal dysbasia), idiopathic senile dysbasia, peroneal gait, duck gait, walking with pronounced lordosis in the lumbar region, hyperkinetic gait, gait in diseases of the musculoskeletal system, dysbasia in mental retardation, dementia, psychogenic disorders, iatrogenic and drug dysbasia, gait disturbances in epilepsy and paroxysmal dyskinesia.
2. In neurology the term is often used astasia-abasia, with integrative sensorimotor disorders, more often in the elderly, associated with a violation of postural or locomotor synergies or postural reflexes, and often a variant of imbalance (astasia) is combined with a walking disorder (abasia). In particular, frontal dysbasia (gait apraxia) is distinguished when it is affected frontal lobes brain (as a result of stroke, dyscirculatory encephalopathy, normal pressure hydrocephalus), dysbasia in neurodegenerative diseases, senile dysbasia, as well as gait disturbances observed in hysteria (psychogenic dysbasia).
What diseases cause gait disturbance:
A certain role in the occurrence of gait disorders belongs to the eye and inner ear.
Older people with deteriorating vision develop gait disturbances.
A person with an inner ear infection may exhibit balance problems that lead to disturbances in their gait.
One of the common sources of gait disturbances is functional disorders of the central nervous system. These may include conditions associated with sedatives, alcohol, and drug abuse. Apparently, a certain role in the appearance of gait disorders plays poor nutrition, especially in older people. Vitamin B12 deficiency often causes numbness in the limbs and poor balance, leading to changes in gait. Finally, any disease or condition that affects nerves or muscles can cause gait disturbances.
One such condition is a pinched disc in the lower back. This condition is treatable.
More serious disorders that cause gait changes include amyotrophic lateral sclerosis (Lou Gehrig's disease), multiple sclerosis, muscular dystrophy, and Parkinson's disease.
Diabetes often causes loss of sensation in both legs. Many people with diabetes lose the ability to determine the position of their legs in relation to the floor. Therefore, they experience postural instability and gait disturbances.
Some diseases are accompanied by gait disturbances. If there are no neurological symptoms, the cause of the gait disorder is difficult to find out even for an experienced doctor.
Hemiplegic gait is observed with spastic hemiparesis. In severe cases, an altered position of the limbs is characteristic: the shoulder is adducted and turned inward, the elbow, wrist and fingers are bent, the leg is extended at the hip, knee and ankle joints. The step with the affected leg begins with abduction of the hip and movement in a circle, while the body deviates in the opposite direction (“the hand asks, the leg squints”).
With moderate spasticity, the position of the arm is normal, but its movements in time with walking are limited. The affected leg bends poorly and is turned outward.
Hemiplegic gait is a common residual disorder after stroke.
With a paraparetic gait, the patient moves both legs slowly and tensely, in a circle - the same as with hemiparesis. Many patients have legs that cross like scissors when walking.
Paraparetic gait is observed with spinal cord lesions and cerebral palsy.
Cock gait is caused by insufficient dorsiflexion of the foot. When stepping forward, the foot partially or completely hangs down, so the patient is forced to raise his leg higher - so that the toes do not touch the floor.
Unilateral disorder occurs with lumbosacral radiculopathy, neuropathy of the sciatic nerve or peroneal nerve; bilateral - for polyneuropathy and lumbosacral radiculopathy.
The duck gait is explained by the weakness of the proximal muscles of the legs and is usually observed with myopathies, less often with lesions of the neuromuscular junction or spinal amyotrophy.
Due to weakness of the hip flexors, the leg is lifted off the floor due to the tilt of the torso, the rotation of the pelvis promotes the movement of the leg forward. Weakness of the proximal leg muscles is usually bilateral, so the patient walks in a waddling manner.
With a parkinsonian (akinetic-rigid) gait, the patient is hunched over, his legs are bent, his arms are bent at the elbows and pressed to the body, and a pronation-supination rest tremor (with a frequency of 4-6 Hz) is often noticeable. Walking begins by leaning forward. Then follow mincing, shuffling steps - their speed steadily increases, as the body “overtakes” the legs. This is observed when moving both forward (propulsion) and backward (retropulsion). Having lost balance, the patient may fall (see "Extrapyramidal disorders").
Apraxic gait is observed with bilateral damage to the frontal lobe due to impairment of the ability to plan and execute a sequence of actions.
Apraxic gait resembles Parkinsonian gait - the same “supplicant pose” and mincing steps - however, upon detailed examination, significant differences are revealed. The patient easily performs the individual movements necessary for walking, both lying and standing. But when he is asked to go, he cannot budge for a long time. Having finally taken a few steps, the patient stops. After a few seconds, the attempt to walk is repeated.
Apraxic gait is often associated with dementia.
With choreoathetotic gait, the rhythm of walking is disrupted by sudden, violent movements. Due to chaotic movements in the hip joint, the gait looks “loose.”
With a cerebellar gait, the patient places his legs wide apart, the speed and length of steps change all the time.
When the medial zone of the cerebellum is damaged, a “drunk” gait and ataxia of the legs are observed. The patient maintains balance both with open and closed eyes, but loses it when the position changes. The gait may be fast, but it is not rhythmic. Often, when walking, the patient experiences uncertainty, but this goes away if he is at least slightly supported.
When the cerebellar hemispheres are damaged, gait disturbances are combined with locomotor ataxia and nystagmus.
The gait with sensory ataxia resembles a cerebellar gait - legs widely spaced, loss of balance when changing position.
The difference is that when the eyes are closed, the patient immediately loses balance and, if not supported, may fall (instability in the Romberg position).
Gait of vestibular ataxia. With vestibular ataxia, the patient always falls to one side - regardless of whether he is standing or walking. There is obvious asymmetrical nystagmus. Muscle strength and proprioceptive sensation are normal - in contrast to unilateral sensory ataxia and hemiparesis.
Gait during hysteria. Astasia - abasia is a typical gait disorder during hysteria. The patient has preserved coordinated movements of the legs, both lying and sitting, but he cannot stand or move without assistance. If the patient is distracted, he maintains his balance and takes several normal steps, but then defiantly falls - into the hands of the doctor or onto the bed.
Which doctors should you contact if gait disturbance occurs:
Have you noticed a gait disturbance? Do you want to know more detailed information or do you need an inspection? You can make an appointment with a doctor– clinic Eurolab always at your service! The best doctors they will examine you and study you external signs and will help you identify the disease by symptoms, advise you and provide necessary help. you also can call a doctor at home. Clinic Eurolab open for you around the clock.
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If you have previously performed any research, Be sure to take their results to a doctor for consultation. If the studies have not been performed, we will do everything necessary in our clinic or with our colleagues in other clinics.
Is your gait impaired? It is necessary to take a very careful approach to your overall health. People don't pay enough attention symptoms of diseases and do not realize that these diseases can be life-threatening. There are many diseases that at first do not manifest themselves in our body, but in the end it turns out that, unfortunately, it is too late to treat them. Each disease has its own specific symptoms, characteristic external manifestations- so called symptoms of the disease. Identifying symptoms is the first step in diagnosing diseases in general. To do this, you just need to do it several times a year. be examined by a doctor to not only prevent terrible disease, but also to maintain a healthy spirit in the body and the organism as a whole.
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- Atactic gait:
- cerebellar;
- stamping (“tabetic”);
- with vestibular symptom complex.
- “Hemiparetic” (“mowing” or “triple shortening” type).
- Paraspastic.
- Spastic-atactic.
- Hypokinetic.
- Apraxia of walking.
- Idiopathic senile dysbasia.
- Idiopathic progressive freezing dysbasia.
- Gait in the “skater position” in idiopathic orthostatic hypotension.
- “Peroneal” gait - unilateral or bilateral stepping.
- Walking with hyperextension of the knee joint.
- "Duck" gait.
- Walking with pronounced lordosis in the lumbar region.
- Gait in diseases of the musculoskeletal system (ankylosis, arthrosis, tendon retraction, etc.).
- Hyperkinetic gait.
- Dysbasia in mental retardation.
- Gait (and other psychomotor skills) in advanced dementia.
- Psychogenic gait disorders of various types.
- Dysbasia of mixed origin: complex dysbasia in the form of gait disturbances against the background of certain combinations of neurological syndromes: ataxia, pyramidal syndrome, apraxia, dementia, etc.
- Iatrogenic dysbasia (unsteady or “drunk” gait) due to drug intoxication.
- Dysbasia caused by pain (antalgic).
- Paroxysmal gait disturbances in epilepsy and paroxysmal dyskinesias.
Atactic gait
Movements in cerebellar ataxia are poorly commensurate with the characteristics of the surface on which the patient walks. Balance is disturbed to a greater or lesser extent, which leads to corrective movements that give the gait a chaotic character. Characteristic, especially for lesions of the cerebellar vermis, is walking on a wide base as a result of instability and staggering.
The patient often staggers not only when walking, but also when standing or sitting. Sometimes titubation is detected - a characteristic cerebellar tremor of the upper half of the body and head. Dysmetria, adiadochokinesis, intention tremor, and postural instability are identified as accompanying signs. Other characteristic signs may also be detected (scanned speech, nystagmus, muscle hypotonia, etc.).
Main reasons: cerebellar ataxia accompanies a large number of hereditary and acquired diseases that occur with damage to the cerebellum and its connections (spinocerebellar degenerations, malabsorption syndrome, alcoholic cerebellar degeneration, multiple system atrophy, late cerebellar atrophy, hereditary ataxias, OPCA, tumors, paraneoplastic cerebellar degeneration and many other diseases).
If the conductors of deep muscle sense are damaged (most often at the level rear pillars) sensitive ataxia develops. It is especially pronounced when walking and is manifested by characteristic movements of the legs, which are often defined as a “stamping” gait (the leg is forcefully lowered with the entire sole to the floor); in extreme cases, walking is generally impossible due to loss of deep sensitivity, which is easily revealed by examining the muscle-articular sense. A characteristic feature of sensitive ataxia is its correction by vision. The Romberg test is based on this: when the eyes are closed, sensory ataxia increases sharply. Sometimes, with the eyes closed, pseudoathetosis is detected in the arms extended forward.
Main reasons: Sensitive ataxia is characteristic not only of damage to the posterior columns, but also of other levels of deep sensitivity ( peripheral nerve, dorsal root, brain stem, etc.). Therefore, sensitive ataxia is observed in the picture of such diseases as polyneuropathy (“peripheral pseudotabes”), funicular myelosis, tabes dorsalis, complications of treatment with vincristine; paraproteinemia; paranesplastic syndrome, etc.)
With vestibular disorders, ataxia is less pronounced and manifests itself more in the legs (staggering when walking and standing), especially at dusk. Severe damage to the vestibular system is accompanied by a detailed picture of the vestibular symptom complex (systemic dizziness, spontaneous nystagmus, vestibular ataxia, autonomic disorders). Mild vestibular disorders (vestibulopathy) are manifested only by intolerance to vestibular loads, which often accompanies neurotic disorders. With vestibular ataxia there are no cerebellar signs and impairment of muscle-articular sense.
Main reasons: The vestibular symptom complex is characteristic of damage to the vestibular conductors at any level ( sulfur plugs in the external auditory canal, labyrinthitis, Meniere's disease, acoustic neuroma, multiple sclerosis, degenerative lesions of the brain stem, syringobulbia, vascular diseases, intoxications, including drugs, traumatic brain injury, epilepsy, etc.). A kind of vestibulopathy usually accompanies psychogenic chronic neurotic conditions. For diagnosis, analysis of complaints of dizziness and accompanying neurological manifestations is important.
"Hemiparetic" gait
Hemiparetic gait is manifested by extension and circumduction of the leg (the arm is bent at the elbow joint) in the form of a “squinting” gait. When walking, a paretic leg is exposed to body weight for a shorter period than a healthy leg. Circumduction (circular movement of the leg) is observed: the leg extends at the knee joint with slight plantar flexion of the foot and performs a circular movement outward, while the body deviates slightly in the opposite direction; the homolateral arm loses some of its functions: it is bent at all joints and pressed against the body. If a stick is used when walking, it is used on the healthy side of the body (for which the patient bends over and transfers his weight to it). With each step, the patient raises the pelvis to lift the straightened leg off the floor and has difficulty moving it forward. Less commonly, the gait is upset by the “triple shortening” type (flexion in three joints of the leg) with a characteristic rise and fall of the pelvis on the side of paralysis with each step. Associated symptoms: weakness in the affected limbs, hyperreflexia, pathological foot signs.
The legs are usually extended at the knee and ankle joints. The gait is slow, the legs “shuffle” along the floor (the soles of the shoes wear out accordingly), sometimes they move like scissors with their crossing (due to increased tone of the adductor muscles of the thigh), on the toes and with a slight curling of the toes (“pigeon” toes). This type of gait disturbance is usually caused by more or less symmetrical bilateral damage to the pyramidal tracts at any level.
Main reasons: Paraspastic gait is most often observed under the following circumstances:
- Multiple sclerosis (characteristic spastic-atactic gait)
- Lacunar state (in elderly patients with arterial hypertension or other risk factors for vascular diseases; often preceded by episodes of minor ischemic vascular strokes, accompanied by pseudobulbar symptoms with speech impairment and vivid reflexes of oral automatism, gait with small steps, pyramidal signs).
- After a spinal cord injury (history, level of sensory disorders, urinary disorders). Little's disease ( special shape cerebral palsy; symptoms of the disease are present from birth, there is a delay in motor development, but normal intellectual development; often only selective involvement of the extremities, especially the lower ones, with a scissor-like movement of crossing the legs while walking). Familial spastic spinal palsy (hereditary slowly progressive disease, symptoms often appear in the third decade of life). In cervical myelopathy in the elderly, mechanical compression and vascular insufficiency cervical spinal cord often causes a paraspastic (or spastic-atactic) gait.
As a result of rare, partially reversible conditions, such as hyperthyroidism, portocaval anastomosis, lathyrism, damage to the posterior columns (with vitamin B12 deficiency or as paraneoplastic syndrome), adrenoleukodystrophy.
An intermittent paraspastic gait is rarely observed in the picture of “intermittent spinal claudication.”
Paraspastic gait is sometimes imitated by dystonia of the lower extremities (especially with the so-called dopa-responsive dystonia), which requires a syndromic differential diagnosis.
Spastic-atactic gait
With this gait disorder, a clear ataxic component is added to the characteristic paraspastic gait: unbalanced body movements, slight hyperextension in the knee joint, instability. This picture is characteristic, almost pathognomonic, of multiple sclerosis.
Main reasons: it can also be observed in subacute combined degeneration of the spinal cord (funicular myelosis), Friedreich's disease and other diseases involving the cerebellar and pyramidal tracts.
Hypokinetic gait
This type of gait is characterized by slow, stiff leg movements with decreased or absent friendly movements hands and tense posture; difficulty initiating walking, shortening the step, “shuffling”, difficult turns, marking time before starting to move, and sometimes “pulsion” phenomena.
Most Frequent etiological factors This type of gait includes:
- Hypokinetic-hypertensive extrapyramidal syndromes, especially parkinsonism syndrome (in which there is a slight flexor posture; there are no friendly movements of the arms while walking; there is also rigidity, a mask-like face, quiet monotonous speech and other manifestations of hypokinesia, rest tremor, phenomenon gear wheel; the gait is slow, “shuffling”, rigid, with a shortened stride; “pulsative” phenomena are possible when walking).
- Other hypokinetic extrapyramidal and mixed syndromes, including progressive supranuclear palsy, olivo-ponto-cerebellar atrophy, Shy-Drager syndrome, strio-nigral degeneration ("parkinsonism-plus" syndromes), Binswanger's disease, vascular "parkinsonism of the lower half of the body." In the lacunar state, there may also be a gait of the “marche a petits pas” type (small short irregular shuffling steps) against the background of pseudobulbar palsy with swallowing disorders, speech disorders and Parkinson-like motor skills. “Marche a petits pas” can also be observed in the picture of normal pressure hydrocephalus.
- Akinetic-rigid syndrome and a corresponding gait are possible with Pick's disease, corticobasal degeneration, Creutzfeldt-Jakob disease, hydrocephalus, frontal lobe tumor, juvenile Huntington's disease, Wilson-Konovalov disease, post-hypoxic encephalopathy, neurosyphilis and some other rarer diseases.
In young patients, torsion dystonia can sometimes begin with an unusual, tense, stiff gait due to dystonic hypertonicity in the legs.
Constantly active muscle fiber syndrome (Isaacs syndrome) is most often observed in young patients. Unusual tension of all muscles (mainly distal), including antagonists, blocks gait, as well as all other movements (armadillo gait)
Depression and catatonia may be accompanied by a hypokinetic gait.
Apraxia of walking
Apraxia of gait is characterized by the loss or decrease in the ability to properly use the legs in the act of walking in the absence of sensory, cerebellar and paretic manifestations. This type of gait occurs in patients with extensive cerebral damage, especially to the frontal lobes. The patient cannot imitate some movements with his legs, although certain automatic movements are preserved. The ability for a consistent composition of movements during “bipedal” walking decreases. This type of gait is often accompanied by perseveration, hypokinesia, rigidity and, sometimes, gegenhalten, as well as dementia or urinary incontinence.
A variant of walking apraxia is the so-called axial apraxia in Parkinson's disease and vascular parkinsonism; dysbasia in normal pressure hydrocephalus and other diseases involving frontal-subcortical connections. Isolated gait apraxia syndrome has also been described.
Idiopathic senile dysbasia
This form of dysbasia (“gait of the elderly,” “senile gait”) is manifested by a slightly shortened slow step, mild postural instability, and a decrease in cooperative arm movements in the absence of any other neurological disorders in elderly and old people. This dysbasia is based on a complex of factors: multiple sensory deficits, age-related changes in the joints and spine, deterioration of vestibular and postural functions, etc.
Idiopathic progressive freezing dysbasia
“Freezing dysbasia” is commonly seen in the presentation of Parkinson's disease; It is less common in multi-infarction (lacunar) conditions, multisystem atrophy and normal pressure hydrocephalus. But elderly patients have been described in whom “freezing dysbasia” is the only neurological manifestation. The degree of freezing varies from sudden motor blocks when walking to a complete inability to start walking. Biochemical tests blood, cerebrospinal fluid, as well as CT and MRI show a normal picture, with the exception of mild cortical atrophy in some cases.
Skater's gait in idiopathic orthostatic hypotension
This gait is also observed in Shy-Drager syndrome, in which peripheral autonomic failure (mainly orthostatic hypotension) becomes one of the leading causes. clinical manifestations. The combination of parkinsonian symptoms, pyramidal and cerebellar signs influences the gait characteristics of these patients. In the absence of cerebellar ataxia and severe parkinsonism, patients try to adapt gait and body posture to orthostatic changes in hemodynamics. They move with wide, slightly sideways, quick steps on their legs slightly bent at the knees, their torso bent low forward and their head down (“skater’s pose”).
"Peroneal" gait
Peroneal gait - unilateral (more often) or bilateral stepping. Steppage-type gait develops with the so-called foot drop and is caused by weakness or paralysis of dorsoflexion (dorsial flexion) of the foot and (or) toes. The patient either “drags” the foot when walking, or, trying to compensate for the drooping of the foot, raises it as high as possible in order to lift it off the floor. Thus, increased flexion in the hip and knee joints is observed; the foot is thrown forward and falls down onto the heel or the entire foot with a characteristic slapping sound. The support phase of walking is shortened. The patient is unable to stand on his heels, but can stand and walk on his toes.
The most common reason unilateral paresis of the foot extensors is a dysfunction of the peroneal nerve (compressive neuropathy), lumbar plexopathy, rarely damage to the roots of L4 and, especially, L5, as with a herniated intervertebral disc (“vertebral peroneal palsy”). Bilateral paresis of the extensors of the foot with bilateral “stepping” is often observed with polyneuropathy (paresthesia, sensory disturbances like stockings, absence or reduction of Achilles reflexes are noted), with peroneal muscular atrophy of Charcot-Marie-Tooth - a hereditary disease three types(there is a high arch of the foot, atrophy of the lower leg muscles (stork legs), absence of Achilles reflexes, sensory disturbances are minor or absent), with spinal muscular atrophy - (in which paresis is accompanied by atrophy of other muscles, slow progression, fasciculations, absence of sensory disturbances) and with some distal myopathies (scapulo-peroneal syndromes), especially with dystrophic Steinert-Baten-Gibb myotonia (Steinert-strong atten-Gibb).
A similar picture of gait disturbance develops when both distal branches of the sciatic nerve are affected (“foot drop”).
Walking with hyperextension of the knee joint
Walking with unilateral or bilateral hyperextension of the knee joint is observed with knee extensor paralysis. Paralysis of the knee extensors (quadriceps femoris) leads to hyperextension when supporting the leg. When the weakness is bilateral, both legs are hyperextended at the knee joints while walking; otherwise, transferring weight from foot to foot can cause changes in the knee joints. The descent down the stairs begins with a paretic leg.
Causes unilateral paresis include damage to the femoral nerve (prolapse knee reflex, impaired sensitivity in the area of innervation n. saphenous]) and lumbar plexus lesions (symptoms similar to those of the femoral nerve, but the abductors and iliopsoas muscles are also involved). The most common cause of bilateral paresis is myopathy, especially progressive Duchenne muscular dystrophy in boys, as well as polymyositis.
"Duck" gait
Paresis (or mechanical failure) of the abductor muscles of the thigh, that is, the hip abductors (mm. gluteus medius, gluteus minimus, tensor fasciae latae) leads to the inability to hold the pelvis horizontally in relation to the load-bearing leg. If the deficiency is only partial, then hyperextension of the trunk towards the supporting leg may be sufficient to shift the center of gravity and prevent pelvic distortion. This is the so-called Duchenne lameness, when there are bilateral disorders, this leads to an unusual “waddling” gait (the patient seems to waddle from one foot to the other, a “duck” gait). With complete paralysis of the hip abductors, the transfer of the center of gravity described above is no longer sufficient, which leads to a skew of the pelvis with each step in the direction of movement of the leg - the so-called Trendelenburg lameness.
Unilateral hip abductor palsy or insufficiency may be caused by damage to the superior gluteal nerve, sometimes as a result intramuscular injection. Even in an inclined position, there is insufficient strength for external abduction of the affected leg, but there are no sensory disturbances. A similar deficiency is found in unilateral congenital or post-traumatic hip dislocation or postoperative (prosthetic) damage to the hip abductors. Bilateral paresis (or insufficiency) is usually a consequence myopathies, especially progressive muscular dystrophy, or bilateral congenital hip dislocation.
Walking with pronounced lordosis in the lumbar region
If the hip extensors are involved, especially the m. gluteus maximus, then climbing the stairs becomes possible only when the movement starts with the healthy leg, but when going down the stairs, the affected leg goes first. Walking on a flat surface is impaired, as a rule, only with bilateral weakness of m. gluteus maximus; such patients walk with a ventrally inclined pelvis and an increased lumbar lordosis. With unilateral paresis of m. gluteus maximus, it is impossible to move the affected leg backward, even in a pronated position.
Reason There is always (rare) damage to the inferior gluteal nerve, for example due to intramuscular injection. Bilateral paresis m. gluteus maximus is found most often in the progressive form of pelvic girdle muscular dystrophy and Duchenne form.
Occasionally, the literature mentions the so-called lumbar-femoral extension rigidity syndrome, which manifests itself as reflex disorders of muscle tone in the extensors of the back and legs. IN vertical position The patient has a fixed, mildly expressed lordosis, sometimes with a lateral curvature. The main symptom is the “board” or “shield”: in a supine position with passive lifting of outstretched legs by both feet, the patient has no flexion in the hip joints. Walking of a jerky nature is accompanied by compensatory thoracic kyphosis and forward tilt of the head in the presence of rigidity of the cervical extensor muscles. Pain syndrome is not leading in clinical picture and often has a blurred, abortive character. A common cause of the syndrome: fixation of the dural sac and filum terminale by a cicatricial adhesive process in combination with osteochondrosis due to dysplasia of the lumbar spine or with a spinal tumor at the cervical, thoracic or lumbar level. Regression of symptoms occurs after surgical mobilization of the dural sac.
Hyperkinetic gait
Hyperkinetic gait is observed with various types of hyperkinesis. These include diseases such as Sydenham's chorea, Huntington's chorea, generalized torsion dystonia (camel gait), axial dystonic syndromes, pseudo-expressive dystonia and foot dystonia. More rare causes of walking impairment are myoclonus, trunk tremor, orthostatic tremor, Tourette's syndrome, and tardive dyskinesia. In these conditions, the movements necessary for normal walking are suddenly interrupted by involuntary, erratic movements. A strange or “dancing” gait develops. (This gait in Huntington's chorea sometimes looks so strange that it may resemble psychogenic dysbasia). Patients must constantly combat these disturbances in order to move purposefully.
Gait disturbances in mental retardation
This type of dysbasia is a problem that has not yet been sufficiently studied. Awkward standing with the head too bent or straightened, pretentious position of the arms or legs, awkward or strange movements - all this is often found in children with delayed mental development. In this case, there are no disturbances in proprioception, as well as cerebellar, pyramidal and extrapyramidal symptoms. Many motor skills developed in childhood are age dependent. Apparently, unusual motor skills, including gait, in mentally retarded children are associated with delayed maturation of the psychomotor sphere. It is necessary to exclude comorbid mental retardation conditions: cerebral palsy, autism, epilepsy, etc.
Gait (and other psychomotor skills) in advanced dementia
Dysbasia in dementia reflects the total breakdown of the ability to organize, purposeful and adequate action. Such patients begin to attract attention with their disorganized motor skills: the patient stands in an awkward position, marks time, spins, being unable to purposefully walk, sit down and adequately gesture (disintegration of “body language”). Fussy, chaotic movements come to the fore; the patient looks helpless and confused.
Gait can change significantly in psychosis, in particular in schizophrenia (“shuttle” motor skills, movements in a circle, stamping and other stereotypies in the legs and arms while walking) and obsessive-compulsive disorders (rituals while walking).
Psychogenic gait disorders of various types
There are gait disturbances, often similar to those described above, but developing (most often) in the absence of ongoing organic damage to the nervous system. Psychogenic gait disorders often begin acutely and are provoked by an emotional situation. They are variable in their manifestations. They may be accompanied by agoraphobia. The predominance of women is typical.
This gait often looks strange and is difficult to describe. However, careful analysis does not allow us to classify it as a known example of the above-mentioned types of dysbasia. Often the gait is very picturesque, expressive or extremely unusual. Sometimes it is dominated by the image of falling (astasia-abasia). The patient's entire body reflects a dramatic call for help. During these grotesque, uncoordinated movements, patients appear to periodically lose their balance. However, they are always able to hold themselves up and avoid falling from any awkward position. When the patient is in public, his gait may even acquire acrobatic features. There are also quite characteristic elements of psychogenic dysbasia. A patient, for example, demonstrating ataxia, often walks, “braiding his hair” with his legs, or, showing paresis, “drags” his leg, “dragging” it along the floor (sometimes touching the floor with the dorsal surface thumb and feet). But a psychogenic gait can sometimes outwardly resemble the gait of hemiparesis, paraparesis, cerebellar diseases, and even parkinsonism.
As a rule, there are other conversion manifestations, which are extremely important for diagnosis, and false neurological signs (hyperreflexia, Babinski pseudosymptom, pseudoataxia, etc.). Clinical symptoms should be assessed comprehensively, it is very important in each such case to discuss in detail the likelihood of true dystonic, cerebellar or vestibular gait disorders. All of them can cause sometimes erratic changes in gait without sufficiently clear signs organic disease. Dystonic gait disorders more often than others may resemble psychogenic disorders. Many types of psychogenic dysbasia are known and their classifications have even been proposed. Diagnosis of psychogenic movement disorders should always obey the rule of their positive diagnosis and the exclusion of organic disease. It is useful to use special tests (Hoover test, weakness of the sternocleidomastoid muscle, and others). The diagnosis is confirmed by the effect of placebo or psychotherapy. Clinical diagnosis This type of dysbasia often requires special clinical experience.
Psychogenic gait disorders are rarely observed in children and the elderly
Dysbasia of mixed origin
Often there are cases of complex dysbasia against the background of certain combinations of neurological syndromes (ataxia, pyramidal syndrome, apraxia, dementia, etc.). Such diseases include cerebral palsy, multiple system atrophy, Wilson-Konovalov disease, progressive supranuclear palsy, toxic encephalopathies, some spinocerebellar degenerations and others. In such patients, the gait bears the features of several neurological syndromes at the same time and careful attention is needed. clinical analysis in each individual case in order to assess the contribution of each of them to the manifestations of dysbasia.
Dysbasia iatrogenic
Iatrogenic dysbasia is observed during drug intoxication and is often ataxic (“drunk”) in nature, mainly due to vestibular or (less often) cerebellar disorders.
Sometimes such dysbasia is accompanied by dizziness and nystagmus. Most often (but not exclusively) dysbasia is caused by psychotropic and anticonvulsant (especially difenin) drugs.
Dysbasia caused by pain (antalgic)
When there is pain while walking, the patient tries to avoid it by changing or shortening the most painful phase of walking. When the pain is unilateral, the affected leg bears weight for a shorter period. The pain may occur at a certain point in each step, but may be present throughout the entire act of walking or gradually decrease with continuous walking. Gait disturbances caused by pain in the legs most often manifest themselves externally as “lameness.”
Intermittent claudication is a term used to describe pain that occurs only when walking a certain distance. In this case, the pain is due to arterial insufficiency. This pain regularly appears when walking after a certain distance, gradually increases in intensity, and over time occurs at shorter distances; it will appear more quickly if the patient climbs up or walks quickly. The pain causes the patient to stop, but disappears after a short period of rest if the patient remains standing. The pain is most often localized in the lower leg area. Typical cause is stenosis or occlusion of blood vessels in the upper thigh (typical history, vascular risk factors, absence of foot pulses, murmur over proximal blood vessels, no other cause of pain, sometimes stocking-type sensory disturbances). In such circumstances, there may be additional pain in the perineum or thigh caused by occlusion of the pelvic arteries, such pain must be differentiated from sciatica or a process affecting the cauda equina.
Cauda equina claudication (caudogenic) is a term used to describe pain due to root compression, observed after walking various distances, especially when descending. Pain is a consequence of compression of the roots of the cauda equina in the narrow spinal canal at the lumbar level, when the addition of spondylous changes causes an even greater narrowing of the canal (canal stenosis). Therefore, this type of pain is most often found in older patients, especially men, but can also occur in young adults. Based on the pathogenesis of this type of pain, the observed disorders are usually bilateral, radicular in nature, mainly in the posterior perineum, upper thigh and lower leg. Patients also complain of back pain and pain when sneezing (Naffziger's sign). Pain during walking causes the patient to stop, but usually does not completely disappear if the patient stands. Relief occurs when the position of the spine changes, for example, when sitting, bending sharply forward, or even squatting. The radicular nature of the disorders becomes especially obvious if there is a shooting nature of the pain. There are no vascular diseases; radiography reveals a decrease in the sagittal size of the spinal canal in the lumbar region; myelography shows a violation of the passage of contrast at several levels. Differential diagnosis usually possible, given the characteristic location of pain and other features.
Pain in the lumbar region when walking may be a manifestation of spondylosis or damage to the intervertebral discs (history of acute back pain radiating along the sciatic nerve, sometimes the absence of Achilles reflexes and paresis of the muscles innervated by this nerve). Pain may be a consequence of spondylolisthesis (partial dislocation and “slippage” of the lumbosacral segments). It can be caused by ankylosing spondylitis (ankylosing spondylitis), etc. X-rays of the lumbar spine or MRI often clarify the diagnosis. Pain due to spondylosis and intervertebral disc pathology often increases with prolonged sitting or uncomfortable posture, but may decrease or even disappear with walking.
Pain in the hip and groin area is usually the result of arthrosis of the hip joint. The first few steps cause a sharp increase in pain, which gradually decreases as you continue to walk. Rarely, pseudoradicular irradiation of pain along the leg, impaired internal rotation of the hip, causing pain and a feeling of deep pressure in the femoral triangle, are observed. When a cane is used when walking, it is placed on the side opposite the pain to transfer body weight to the healthy side.
Sometimes, while walking or after standing for a long time, pain in the groin area may occur due to damage to the ilioinguinal nerve. The latter is rarely spontaneous and is more often associated with surgical interventions (lumbotomy, appendectomy), in which the nerve trunk is damaged or irritated by compression. This reason is confirmed by the history of surgical manipulations, improvement in hip flexion, the most severe pain in the area two fingers medial to the anterior superior iliac spine, sensory disturbances in the iliac region and the scrotum or labia majora.
Burning pain outer surface hip is characteristic of meralgia paresthetica, which rarely leads to a change in gait.
Local pain in the area of long tubular bones, which occurs when walking, should raise suspicion of the presence of a local tumor, osteoporosis, Paget's disease, pathological fractures, etc. Most of these conditions, which can be detected by palpation (pain on palpation) or x-rays, are also characterized by back pain. Pain along the anterior surface of the lower leg may appear during or after long walking, or other excessive tension of the lower leg muscles, as well as after acute occlusion of the vessels of the leg, after surgery on the lower limb. Pain is a manifestation of arterial insufficiency of the muscles of the anterior region of the leg, known as anterior tibial arteriopathic syndrome (severe increasing painful swelling; pain from compression of the anterior parts of the leg; disappearance of pulsation in the dorsal artery of the foot; lack of sensitivity on the dorsum of the foot in the area of innervation of the deep branch of the peroneal nerve; paresis of the extensor digitorum and extensor pollicis brevis muscles), which is a variant of muscle compartment syndrome.
Pain in the foot and toes is especially common. Most cases are caused by foot deformities such as flat feet or wide feet. This pain usually appears after walking, after standing in shoes with hard soles, or after carrying heavy objects. Even after a short walk, a heel spur can cause pain in the heel and increased sensitivity to the pressure of the plantar surface of the heel. Chronic Achilles tendonitis manifests itself, in addition to local pain, as palpable thickening of the tendon. Pain in the forefoot is observed in Morton's metatarsalgia. The cause is pseudoneuroma of the interdigital nerve. At the beginning, pain appears only after long walking, but later it can appear after short episodes of walking and even at rest (pain is localized distally between the heads of the III-IV or IV-V metatarsal bones; it also occurs when the heads of the metatarsal bones are compressed or displaced relative to each other; lack of sensitivity on the contacting surfaces of the toes; disappearance of pain after local anesthesia into the proximal intertarsal space).
Sufficiently intense pain on the plantar surface of the foot, which forces you to stop walking, can be observed with tarsal tunnel syndrome(usually with an ankle dislocation or fracture, pain occurs behind the medial malleolus, paresthesia or loss of sensation on the plantar surface of the foot, dry and thin skin, lack of sweating on the sole, inability to abduct the toes compared to the other foot). Sudden onset of visceral pain (angina pectoris, pain due to urolithiasis, etc.) can affect gait, significantly change it and even cause walking to stop.
Paroxysmal gait disturbances
Periodic dysbasia can be observed with epilepsy, paroxysmal dyskinesias, periodic ataxia, as well as with pseudoseizures, hyperekplexia, and psychogenic hyperventilation.
Some epileptic automatisms include not only gesticulation and certain actions, but also walking. Moreover, there are known forms of epileptic seizures that are provoked only by walking. These seizures sometimes resemble paroxysmal dyskinesias or apraxia of gait.
Paroxysmal dyskinesias that begin while walking can cause dysbasia, stopping, falling of the patient, or additional (forced and compensatory) movements while walking continues.
Periodic ataxia causes periodic cerebellar dysbasia.
Psychogenic hyperventilation often not only causes lipothymic states and fainting, but also provokes tetanic convulsions or demonstrative motor disorders, including periodic psychogenic dysbasia.
Hyperekplexia can cause gait disturbances and, in severe cases, falls.
Myasthenia gravis sometimes causes periodic leg weakness and dysbasia.
