Diagnosis of walking disorders

Diagnosis of walking and gait disturbance is carried out in 2 stages. At the stage of syndromic diagnostics, the features of walking disorders and clinical signs accompanying the patient are identified and analyzed, which make it possible to draw a conclusion about the leading neurological syndrome. Later, analyzing the data of additional methods of research during the disease, conduct nosological diagnosis. The motor and sensory disturbances inherent in this or that disease of the nervous system and attempts at their compensation often form a specific gait, which is a kind of visiting card of the disease, which makes it possible to diagnose at a distance. The ability to diagnose a patient's gait is one of the most important skills of a neurologist.

Observing the patient, you should focus on how he takes the first step, what is the speed of his walking, the length and frequency of the steps, whether the patient completely tears his legs off the floor or scuffs, how walking changes when turning, passing through a narrow opening, overcoming obstacles whether he is able to arbitrarily change the speed, the height of raising his legs and other parameters of walking. It should be noted how the patient rises from sitting or lying down, how to sit on a chair, how stable he is in Romberg's posture with his eyes open and closed, with his hands down and outstretched, walking on toes and heels, tandem walking, pushing forward, backwards or aside.

To check for postural stability, the doctor usually becomes behind the patient, warns about his subsequent actions and asks to keep his balance, remaining in place or taking a step back, after which he pushes him by the shoulders with such force that the patient takes a step back (Test of Tevenan ). Normally, the patient quickly restores balance by reflexively lifting socks, tilting the body forward or making one or two fast, corrective steps back. In pathology, he hardly balances the equilibrium, makes several small ineffective (counterproductive) steps back (retropulse), or falls without any attempt to keep the balance (like a saw-tree). Postural stability is usually taken as a result of the second attempt (the first is considered a trial one), but the result of the first attempt can be more informative, as it better correlates with the risk of falls. To identify the apraktic defect, the patient should be asked to simulate rhythmic locomotory movements in the position of lying or sitting, draw a figure or figure with the toe of the foot or perform a different symbolic action by the foot (for example, hit the ball).

Clinical evaluation of imbalance and walking disorders

Functions	Characteristic
Estimation of equilibrium (statics)	Rise from a chair and a bed (straightening synergies). Stability in a vertical position with open and closed eyes on a flat and uneven surface, in a conventional or special position, for example, by pulling one arm forward (supporting synergies). Stability in case of spontaneous or induced imbalance, for example, with anticipated or unexpected pushing back, forward, aside (reactive, rescue and protective synergies)
Assessment of walking (locomotion)	Initiation of walking, presence of starting delay, congealing. The pattern of walking (speed, width, height, regularity, symmetry, rhythmic steps, tearing off the feet from the floor, the area of support, friendly movements of the trunk and hands). The ability to perform turns when walking (turns with a single body, freezing, trampling, etc.). Ability to arbitrarily change the pace of walking and step parameters. Tandem walking and other special tests (walking backwards, with closed eyes, overcoming low barriers or on the steps, heel-knee test, leg movements sitting and lying, trunk movements)

To quantify the violations of walking used:

• clinical rating scales, for example, the scale of walking and balance GABS (Gait And Balance Scale), proposed by M. Thomas et al. (2004), or the scale of balance and motor activity M. Tinetti (1986);
• simple tests performed for a time, for example, a 3-meter test that measures the time for which the patient will rise from the chair, will pass 3 m, turn, return to the chair and sit down; It is shown that an increase in the test runtime (> 14 s) is associated with an increased risk of falls;
• Instrumental methods of walking analysis (for example, doppler, estimating the structure of the step cycle, kinematic analysis of walking, methods of autonomous monitoring of stepper movements); data from an instrumental study of walking disorders should always be analyzed in the context of clinical data.

At the stage of nosologic diagnostics, potentially removable causes, such as intoxication and metabolic disturbances (for example, vitamin B deficiency), normotensive hydrocephalus, infections (eg, neurosyphilis) should first be identified. It is important to study the course of the disease. The patient and his relatives should inquire in detail about the time of occurrence of walking disorders, the rate of their progression, the degree of mobility restriction. It is important to take into account that many patients with primary walking disturbance make complaints not on difficulty or uncertainty when walking, but on dizziness or weakness. The patient and his relatives need to be asked about the presence of falls and the circumstances under which they arise, fear of falling. It is necessary to find out a medical history: walking disorders can be aggravated under the influence of benzodiazepines and other sedatives, drugs that cause orthostatic arterial hypotension, neuroleptics.

With acute violations of walking and balance, it is necessary to exclude insufficiency of internal organs, violations of water-electrolyte balance, etc. Important is the analysis of concomitant manifestations, which can indicate the defeat of the musculoskeletal, cardiovascular system, sensory organs, peripheral nerves, spinal cord or brain, mental disorders. To exclude orthostatic arterial hypotension, you should measure blood pressure in a lying and standing position. It is necessary not only to identify these or other violations, but also to measure their severity with the nature and severity of the disorders. For example, the presence of pyramidal signs, violations of deep sensitivity or arthrosis of the hip joints can not explain the gait with a difficult beginning of walking and frequent pouring.

If suspected of CNS damage, neuroimaging is indicated. With the help of CT and MRI of the brain, cerebral vascular lesions, normotensive hydrocephalus, craniocerebral trauma, tumors, and some neurodegenerative diseases can be diagnosed. It should be cautious to interpret often detected in the elderly moderate cerebral atrophy, a thin periventricular band of leukoarose or single lacunar foci, which are often noted in healthy elderly people. When suspicion of normotensive hydrocephalus is sometimes resorted to a liquorodynamic test: excretion of 40-50 ml of CSF can lead to an improvement in walking, which predicts a positive effect of the shunting operation. When suspected of spondylogenic myelopathy, an MRI of the cervical spine is needed. Identification of integrative disorders of walking is the basis for the study of cognitive functions, especially reflecting the activity of the frontal lobes, as well as affective functions.

[1], [2], [3], [4]