Gait Disorders Evaluation and Management docx

Gait Disorders
Evaluation and
Management
DK2998_half-series-title 6/13/05 9:06 AM Page A
NEUROLOGICAL DISEASE AND THERAPY
Advisory Board
Louis R. Caplan, M.D.
Professor of Neurology
Harvard University School of Medicine
Beth Israel Deaconess Medical Center
Boston, Massachusetts
William C. Koller, M.D.
Mount Sinai School of Medicine
New York, New York
John C. Morris, M.D.
Friedman Professor of Neurology
Co-Director, Alzheimer’s Disease Research Center
Washington University School of Medicine
St. Louis, Missouri
Bruce Ransom, M.D., Ph.D.
Warren Magnuson Professor
Chair, Department of Neurology
University of Washington School of Medicine
Seattle, Washington
Kapil Sethi, M.D.
Professor of Neurology
Director, Movement Disorders Program
Medical College of Georgia
Augusta, Georgia

Mark Tuszynski, M.D., Ph.D.
Associate Professor of Neurosciences
Director, Center for Neural Repair
University of California–San Diego
La Jolla, California
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DK2998_half-series-title 6/13/05 9:06 AM Page F
Gait Disorders
Evaluation and
Management
edited by
Jeffrey M. Hausdorff, MSME, PhD
Tel Aviv Sourasky Medical Center
Sackler School of Medicine, Tel Aviv University
Tel Aviv, Israel
Harvard Medical School
Boston, Massachusetts, U.S.A.
Neil B. Alexander, MD
University of Michigan
Ann Arbor VA Health Care System GRECC

Ann Arbor, Michigan, U.S.A.
Boca Raton London New York Singapore
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Preface
The ability to walk safely, easily, and in an aesthetically pleasing manner is
a skill learned early and highly prized. Although it is typically taken for
granted, gait is key to mobility and functional independence and at the
core of our ability to carry out many activities of daily living. In older adults
and patients with neurological deficits, ease and safety in walking may
become compromised, and gait is often viewed as abnormal, i.e., as a dis-
order. Wh ile not an inevitable part of aging, gait disorders are common
among older adults and in patients with neurological disease. By some esti-
mates, as much as 20% of non-institutionalized older adults admit to walk-
ing difficulties or require the assistance of another person or special
equipment to walk. Left untreated, gait disorders may contribute to reduced
physical activity, impaired mental health, falls, fear of falling, frailty, nur-
sing home admission, and loss of independence.
Fortunately, when a gait disorder appears, a diagnostic and management
strategy can be developed that may limit the extent of the disorder and its
functional impact. When properly managed, the risk of falling, for example,
can often be reduced. A major goal of this book is to provide clinicians, thera-
pists and others treating gait disorders with an understanding of the mechan-
isms underlying gait disorders and how to best manage these disorders. To a
large extent, the content in this book is self-contained and assumes minimal
pre-requisite understanding of motor control and gait. As such, it should
also prove helpful to patients and their caregivers who want to better under-
stand and manage their own gait disorders as well as to students and inves-
tigators in a variety of disciplines who would like to learn more about this
field.

The book is divided into three major sections. Section I serves as the
foundation. Here, experts in the field summarize the motor control, physiol-
ogy and biomechanics of walking; review the current understanding of how
iii
and why gait and balance often change with aging and neurological disease;
and describe gait disorders that are common in older adults and in patients
with neurological disease. Section II examines clinical tools available for the
evaluation of gait disorders and falls and provides a detailed, practical plan
for the evaluation and assessment of gait disorders and fall risk. In Section
III, experts describe the current state-of-the-art of management of gait
disorders in general and offer a guide to the management of certain specific
problems that commonly affect gait in older adults, in patients with foot
and ankle disorders, hip fracture and replacement, and neurological
disease.
Describing a wide range of assessment tools, diagnostic evaluation
strategics, and clinical approaches to gait, this reference:
 introduces as new classification scheme to encompass the full range
of mobility capacity in all older adults
 reviews the physiology and biomechanics of gait and common gait
disorders
 covers cognitive and behavioral influences on gait and falling
 details clinical and evidence-based methods for gait disorder and
fall analysis, as well as techniques for gait optimization in patients
with neurological disorders, foot and ankle disorders, and post-hip
surgery,
 presents a state-of-the-art strategy for multidimensional fall risk
assessment and fall reduction
 features a detailed review of exercise strategies including Tai Chi to
improve balance and gait
People of all ages may have gait disorders. While there is much overlap

in the evaluation and management of gait disorders in the yo ung and the
old, there are also unique differences. In many young adults, a single cause
of a gait disturbance can often be pinpointed. Older adults often have multi-
ple deficits that may contribute to or exacerbate the gait disorder. Many
older adults often have multiple conditions that affect their gait, further
complicating evaluation and management. In this book, we place a special
focus on the gait disorders of older adults and in patients with common neu-
rological diseases, but note of course, that much of the presentation may be
applicable to other populations as well.
Gait is influenced by many factors and can be studied from multiple
perspectives. One key to successful evaluation a nd management of gait
disorders is appreciation of this diversity and the interaction among a vari-
ety of apparently disparate factors. Neurologists, geriatricians, neuropsy-
chologists, biomechanists, physiatrists, neuroscientists, and physical
therapists are actively involved in the study and treatment of gait disorders
among older adults. Reflecting this wide spectrum, we note that experts
from numerous and varied disciplines have contributed to this book. We
iv Preface
hope that this product will produce a synergistic effect and prove useful to
students, clinicians, patients and investigators, who may be interested in
improving their understanding and treatment of a multi- factorial problem
common to many older adults and patients with neurological disease.
Jeffrey M. Hausdorff
Neil B. Alexander
Preface v

Acknowledgments
Dr. Hausdorff acknowledges the support of the National Institute on Aging
(NIA) Grant AG08812 (Harvard Medical School Claude D. Pepper Older
Americans Independence Center) and Grant AG14100, the National Center

for Research Resources Grant RR13622, the National Institute of Child
Health and Human Development Grant HD39838 as well as support from
the US-Israel Bi-National Foundation.
Dr. Alexander acknowledges the support of the National Institute on
Aging (NIA) Grant AG08808 (University of Michigan Claude D. Pepper
Older Americans Independence Center) as well as the Office of Research
and Development, Medical Service and Rehabilitation Research and Devel-
opment Service of the Department of Veterans Affairs. Dr. Alexander is a
recipient of a K24 Mid-Career Investigator Award in Patient-Oriented
Research AG109675 from NIA.
vii

Contents
Preface . . . . iii
Acknowledgments . . . . vii
Contributors . . . . xv
Section I. Gait Disorders and Mobility in Older Adults:
Fundamental Concepts
1. Gait, Mobility, and Function: A Review and Proposed
Classification Scheme . . 1
Stephanie Studenski
I. Introduction . . . . 1
II. Epidemiology . . . . 2
III. The Language of Mobility Assessment . . . . 3
IV. An Overview of Approaches to the Causes of
Mobility Disability . . . . 10
V. Treatment of Dysmobility to Improve Function or
Prevent Disability . . . . 11
VI. Summary . . . . 13
References . . . . 14

2. Clinical Evaluation of Gait Disorders: No-Tech and
Low-Tech . . . 19
Neil B. Alexander
I. Self-Report Measures . . . . 19
II. Performance-Based Measures . . . . 20
III. Summary . . . . 29
References . . . . 30
ix
3. Laboratory-Based Evaluation o f Gait D isorders: High-Tech . . . 37
Patrick O. Riley and D. Casey Kerrigan
I. Introduction . . . . 37
II. Gait Analysis Laboratory Methods . . . . 38
III. Biomechanical Concepts Pertinent to Gait . . . . 44
IV. Normal Kinematic and Kinetic Parameters . . . . 46
V. Clinical Application of Laboratory Gait Analysis . . . . 5 0
VI. Gait Analysis—Current Developments . . . . 55
VII. Summary . . . . 57
References . . . . 58
4. Age-Associated Changes in the Biomechanics of Gait and
Gait-Related Falls in Older Adults . . . . 63
James A. Ashton-Miller
I. Prevalence of Gait Problems Among Older Adults . . . . 63
II. Age-Related Changes in Biomechanical
Capacities . . . . 63
III. Gait on Level Surfaces . . . . 70
IV. Obstacle Avoidance During Level Gait . . . . 81
V. Gait on Surfaces that Are not Level . . . . 83
VI. Trips and Slips . . . . 86
VII. Age and Gender Differences in Falls and
Fall-Related Injury Rates . . . . 90

VIII. Fall-Related-Injury Biomechanics . . . . 91
IX. Conclusions . . . . 93
References . . . . 93
5. Neuromuscular and Biomechanical Elements of Postural
Equilibrium 101
Karen L. Reed-Troy and Mark D. Grabiner
I. Introduction . . . . 101
References . . . . 113
6. Neuropsychological Influences on Gait in the Elderly . . . . 117
Bruno Giordani and Carol C. Persad
I. Behavioral Control System . . . . 119
II. Individual Modulating Factors . . . . 123
III. Environmental Modulating Factors . . . . 126
IV. Task-Specific Modulating Factors . . . . 127
V. Methodological Approaches for Clarifying Behavioral
Control System Factors in Walking . . . . 129
x Contents
VI. Practical Clinical Implications for a Behavioral Control
System Approach . . . . 134
References . . . . 135
7. Gait Assessments and Interventions: A Glimpse into the
Future . . . . . 143
Jennifer Healey and Jeffrey M. Hausdorff
I. Monitoring Everywhere . . . . 143
II. Pre
ˆ
ta
`
Porter (Ready to Wear) . . . . 144
III. Home Safe Home . . . . 146

IV. Shaking Things Up . . . . 147
V. Look Who’s Walking . . . . 148
VI. The Information World . . . . 148
References . . . . 149
Section II. Gait Disorders and Falls: Assessments and Interventions
8. Common Gait Disturbances: A Clinical Overview . . . . . . 153
Neil B. Alexander and Allon Goldberg
I. Epidemiology . . . . 153
II. Diagnoses Contributing to Gait Disorders . . . . 155
III. Approach to Assessment . . . . 156
IV. Interventions to Reduce Gait Disorders . . . . 161
V. Conclusions . . . . 164
References . . . . 164
9. Fall Risk Assessment: Step-by-Step . . 169
Laurence Z. Rubenstein and Karen R. Josephson
I. Introduction . . . . 169
II. Epidemiology . . . . 170
III. Causes of Falls . . . . 172
IV. Risk Factors for Falls . . . . 173
V. Multidimensional Fall-Risk Assessment . . . . 177
References . . . . 181
10. Best Clinical Practice Models to Reduce Falls . 185
Robert J. Przybelski and Jane Mahoney
I. Introduction . . . . 185
II. Overview of Evidence Base for Falls
Interventions . . . . 186
III. Specific Components of a Multifactorial
Intervention . . . . 192
Contents xi
IV. Conclusion . . . . 200

References . . . . 200
11. Fear of Falling . . . . 207
Sharon L. Tennstedt
I. Introduction . . . . 207
II. Consequences of Fear of Falling . . . . 208
III. Factors Associated with Fear of Falling . . . . 209
IV. Assessment of Fear of Falling . . . . 209
V. Interventions for Fear of Falling . . . . 210
VI. Communication About the Problem . . . . 214
References . . . . 215
12. Therapeutic Exercise to Improve Balance and Gait
and Prevent Falls . . 219
Tanya A. Miszko and Steven L. Wolf
I. Introduction . . . . 219
II. Factors Associated with Abnormal Balance
and Gait . . . . 220
III. Exercise Programs to Improve Balance . . . . 221
IV. Exercise Programs to Improve Gait . . . . 228
V. An Example of Interfacing Exercise Design
Principles to the Patient: Cerebrovascular
Accident (Stroke) . . . . 236
VI. Exercise to Reduce Falls . . . . 237
VII. Issues to Consider When Interpreting
the Literature . . . . 239
VIII. Summary . . . . 241
References . . . . 242
Section III. Gait Disorders in Specific Disease Groups: Assessment and
Intervention
13. Clinical Gait Analysis in Neurology . . . . 247
Meg Morris, Belinda Bilney, Karen Dodd, Sonia Denisenko,

Richard Baker, Fiona Dobson, and Jennifer McGinley
I. Gait Analysis in People with CP . . . . 248
II. Classifications of Gait Patterns Using Gait
Analysis in CP . . . . 251
III. Gait Analysis in PD and HD . . . . 254
IV. Huntington’s Disease . . . . 257
xii Contents
V. Gait Analysis in Stroke . . . . 258
VI. Summary and Conclusions . . . . 262
References . . . . 262
14. Treatment of Parkinsonian Gait Disturbances . . 273
Nir Giladi and Yacov Balash
I. Introduction . . . . 273
II. Treatment of Gait Disturbances in the
Early Stages of Parkinsonism . . . . 274
III. Treatment of Gait Disturbances in the
Advanced Stages of Parkinsonism . . . . 278
IV. Conclusions . . . . 283
References . . . . 283
15. Treatment of Axial Mobility Deficits in Movement
Disorders . . . 289
Bastiaan R. Bloem, Elif K. Orhan, and Frank-Erik De Leeuw
I. Introduction . . . . 289
II. Extrapyramidal Syndromes . . . . 290
III. Cerebrovascular Disorders . . . . 297
IV. Normal Pressure Hydrocephalus . . . . 301
V. Conclusions . . . . 302
References . . . . 303
16. Systems Approach to Gait Rehabilitation
Following Stroke . . . . . 309

Anouk Lamontagne and Joyce Fung
I. Introduction and Background . . . . 309
II. Treadmill Training . . . . 312
III. Weight Supported Locomotor Training . . . . 315
IV. Speed-Intensive Walking . . . . 321
V. Sensory Cues and Balance Adjustment During
Locomotion . . . . 326
VI. Concluding remarks . . . . 330
References . . . . 330
17. Optimizing Gait in Peripheral Neuropathy . . . . 339
James K. Richardson
I. Challenge of Walking and Importance of
Somatosensory Information . . . . 339
II. Epidemiology and Clinical Identification of
Peripheral Neuropathy . . . . 340
Contents xiii
III. Static Balance and PN . . . . 341
IV. Effect of PN on Mobility . . . . 342
V. Peripheral Neuropathy and Fall Risk . . . . 343
VI. Afferent and Efferent Impairments
Associated with PN . . . . 344
VII. Which Patients with PN Are More Likely to Fall? . . . . 348
VIII. Clinical Evaluation of Balance . . . . 348
IX. Evaluation of Gait . . . . 349
X. General Recommendation and Interventions . . . . 351
XI. Summary . . . . 355
References . . . . 355
18. Posthip Fracture and Hip Replacements . 361
Jeremy A. Idjadi, Kenneth Koval, and Joseph D. Zuckerman
I. Introduction . . . . 361

II. Goals . . . . 362
III. Preoperative . . . . 362
IV. Intraoperative . . . . 364
V. Postoperative . . . . 365
VI. Summary . . . . 373
References . . . . 373
19. Optimizing Gait in Older People with Foot and Ankle
Disorders . 379
Hylton B. Menz and Stephen R. Lord
I. Introduction . . . . 379
II. Prevalence and Consequences of
Foot Problems in Older People . . . . 380
III. Evaluation of Foot and
Ankle Problems in Older People . . . . 381
IV. Common Musculoskeletal Foot and Ankle Problems that
Can Affect Balance and Gait . . . . 382
V. Foot Problems Associated with Systemic Disease . . . . 387
VI. The Role of Footwear and Foot Orthoses . . . . 389
VII. Conclusions . . . . 391
References . . . . 391
Index 399
About the Editors 407
About the Book 409
xiv Contents
Contributors
Neil B. Alexander Mobility Research Center, Division of Geriatric
Medicine, Department of Internal Medicine, Institute of Gerontology,
University of Michigan and Ann Arbor VA Health Care System, Geriatric
Research Education and Clinical Center, Ann Arbor, Michigan, U.S.A.
James A. Ashton-Miller Biomechanics Research Laboratory, Department

of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan,
U.S.A.
Richard Baker School of Physiotherapy, La Trobe University and Hugh
Williamson Gait Laboratory, Royal Children’s Hospital, Victoria, Australia
Yacov Balash Movement Disorders Unit, Department of Neurology,
Tel Aviv Sourasky Medical Center and Sackler School of Medicine,
Tel Aviv University, Tel Aviv, Israel
Belinda Bilney BPT, School of Physiotherapy, La Trobe University,
Victoria, Australia
Bastiaan R. Bloem Department of Neurology, Radboud University
Nijmegen Medical Center, Nijmegen, The Netherlands
Frank-Erik De Leeuw Department of Neurology, Radboud University
Nijmegen Medical Center, Nijmegen, The Netherlands
Sonia Denisenko BPT, School of Physiotherapy, La Trobe University,
Victoria, Australia
xv
Fiona Dobson School of Physiotherapy, La Trobe University and Hugh
Williamson Gait Laboratory, Royal Children’s Hospital, Victoria, Australia
Karen Dodd BPT, School of Physiotherapy, La Trobe University,
Victoria, Australia
Joyce Fung School of Physical and Occupational Therapy, McGill
University, Montreal, Jewish Rehabilitation Hospital Research Centre,
Laval, Quebec, Canada
Nir Giladi Movement Disorders Unit, Department of Neurology, Tel
Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv
University, Tel Aviv, Israel
Bruno Giordani Neuropsychology Section, Depart ment of Psychiatry,
University of Michigan, Ann Arbor, Michigan, U.S.A.
Allon Goldberg Ann Arbor VA Health Care System, Geriatric Research
Education and Clinical Center, Ann Arbor, Michigan, U.S.A.

Mark D. Grabiner Department of Movement Sciences, University of
Illinois at Chicago, Chicago, Illinois, U.S.A.
Jeffrey M. Hausdorff Movement Disorders Unit, Tel Aviv Sourasky
Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv,
Israel and Division on Aging, Harvard Medical School, Boston,
Massachusetts, U.S.A.
Jennifer Healey Cambridge Research Laboratory, Hewlett–Packard,
Cambridge, Massachusetts, U.S.A.
Jeremy A. Idjadi NYU—The Hospital for Joint Diseases Orthopedic
Institute, New York, New York, U.S.A.
Karen R. Josephson Geriatric Research Education and Clinical Center
(GRECC), VA Greater Los Angeles Healthcare System, Sepulveda, California,
U.S.A.
D. Casey Kerrigan Department of Physical Medicine and Rehabilitation,
School of Medicine, University of Virginia, Charlottesville, Virginia, U.S.A.
Kenneth Koval Dartmouth-Hitchcock Medical Center, Orthopedic Surgery,
Lebanon, New Hampshire, U.S.A.
xvi Contributors
Anouk Lamontagne School of Physical and Occupational Therapy, McGill
University, Montreal, Jewish Rehabilitation Hospital Research Centre,
Laval, Quebec, Canada
Stephen R. Lord Prince of Wales Medical Research Institute, Randwick,
North South Wales, Sydney, Australia
Jane Mahoney Section of Geriatrics and Gerontology, University
of Wisconsin Medical School, Elder Care of Dane County, Madison,
Wisconsin, U.S.A.
Jennifer McGinley School of Physiotherapy, La Trobe University and
Hugh Williamson Gait Laboratory, Royal Children’s Hospital, Victoria,
Australia
Hylton B. Menz Musculoskeletal Research Centre, School of

Physiotherapy, La Trobe University, Bundoora, Victoria, Australia
Tanya A. Miszko Department of Physical Education and Sports Studies,
The University of Georgia, Prescriptive Health, Inc., Snellville, Georgia,
and Veterans Affairs Medical Center, Decatur, Georgia, U.S.A.
Meg Morris BPT, School of Physiotherapy, La Trobe University,
Victoria, Australia
Elif K. Orhan Department of Neurology, Medical School, University of
Istanbul, Istanbul, Turkey
Carol C. Persad Neuropsychology Section, Dep artment of Psychiatry,
University of Michigan, Ann Arbor, Michigan, U.S.A.
Robert J. Przybelski Section of Geriatrics and Gerontology, University of
Wisconsin Medical School, Falls Prevention Clinic, Madison, Wisconsin,
U.S.A.
Karen L. Reed-Troy Department of Movement Sciences, Unive rsity of
Illinois at Chicago, Chicago, Illinois, U.S.A.
James K. Richardson Department of Physical Medicine and
Rehabilitation, University of Michigan, Ann Arbor, Michigan, U.S.A.
Patrick O. Riley Department of Physical Medicine and Rehabilitation,
School of Medicine, University of Virginia, Charlottesville, Virginia, U.S.A.
Contributors xvii