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ABSTRACT

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Gait and balance disorders are common and a significant source of disability, decrease in quality of life, and falls. A description of the gait cycle and gait parameters is offered as a starting point of understanding gait abnormalities. Gait patterns such as parkinsonian gait, disequilibrium, high-level gait disorders, and the neural control of gait are discussed. This may help in the evaluation of individuals with abnormalities of gait and balance and allow to clinically localize the pathological process in the neuraxis or establish a non-neurological etiology. Recommendations regarding prevention of falls, evaluation of patients with gait difficulties, and management strategies to minimize disability and potentially increase quality of life are offered.

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INTRODUCTION

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Walking is often perceived as a simple task; we stand up and initiate walking without giving it much thought. However, this is actually a very complex motor skill with well-choreographed interplay of multiple anatomical structures including locomotor centers at the spinal cord, brainstem and cerebellum, basal ganglia, frontal lobes, the musculoskeletal system, and sensory inputs from visual, vestibular, and proprioceptive pathways.1 Consequently, any disruption to the multiple parts involved in generating and maintaining a normal posture and gait could be associated with a gait disorder.

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Gait and balance disorders are common and an important cause of disability and diminished quality of life especially among older adults. It is estimated that about 20% of noninstitutionalized older adults have difficulty walking or require an assistive device or someone’s help in order to ambulate.2

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The prevalence of gait difficulties among individuals older than 85 years has been estimated to be as high as 50%.3 One third of individuals over 65 may fall at least once a year;4 25% of the elderly with falls suffer a serious injury; and 5% have a fracture.5 The incidence of falls in hospitals and nursing facilities are almost 3 times the rates for community-dwelling people over 65 years of age. The incidence of injuries and fractures related to falls is also higher among institutionalized individuals.6

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CASE 29-1

A 68-year-old man with multiple vascular risk factors, rheumatoid arthritis, Sjögren syndrome, and Raynaud’s phenomenon presented to an outside hospital 3 years earlier with sudden onset of left-sided paresthesias and imbalance, veering to the left side. He was found to have multiple small right hemispheric ischemic strokes, he had good neurological recovery, and 6 weeks after the index event, his gait was normal. Brain imaging studies showed extensive periventricular white matter microangiopathic changes. He was neurologically stable until 3 months prior to his consultation with us, when he had a partial lung resection due to a nonmalignant pulmonary mass. After surgery, he noticed difficulty with balance, 15-pound weight loss, and diminished stamina. He also experienced decreased hearing in both ears and was evaluated by ENT who recommended vestibular rehabilitation. He continued to have walking difficulties and fell on rare ...

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