Red flags
- Acute-onset gait disturbance -> stroke, cord compression, cauda equina until excluded
- Gait disturbance with sphincter dysfunction/saddle anaesthesia -> cauda equina/cord compression - emergency
- Rapidly progressive gait failure over days-weeks -> Guillain-Barre syndrome, cord compression, paraneoplastic
- Gait disturbance with new incontinence and cognitive decline -> normal pressure hydrocephalus triad
- Falls with head strike on anticoagulation
Differential by mechanism
Classic gait patterns localise
| Pattern | Description | Localisation |
|---|---|---|
| Spastic (scissoring) | Stiff-legged, circumduction | Upper motor neuron - cord/brain |
| Parkinsonian | Shuffling, stooped, reduced arm swing, festination | Basal ganglia |
| Ataxic (cerebellar) | Wide-based, unsteady, worse eyes closed no worse (Romberg negative) | Cerebellum |
| Sensory ataxic | Wide-based, stamping, worse with eyes closed (Romberg positive) | Dorsal columns/peripheral sensory |
| Steppage (foot drop) | High-stepping to clear the foot | Peripheral nerve (common peroneal, L5 radiculopathy) |
| Waddling | Trendelenburg, pelvic drop | Proximal myopathy |
| Antalgic | Shortened stance phase on painful side | Musculoskeletal pain |
| Frontal/apraxic ("magnetic") | Shuffling, feet appear stuck to floor, wide-based | Frontal lobe disease, NPH |
By cause
- Neurological: stroke, Parkinson's/parkinsonism, cerebellar disease, myelopathy, peripheral neuropathy, NPH
- Musculoskeletal: osteoarthritis, deformity, pain
- Cardiovascular: orthostatic hypotension, deconditioning
- Multifactorial (common in older adults): combination of mild sensory, visual, musculoskeletal and vestibular deficits summing to instability without one dominant cause
Focused history
- Onset and tempo - acute (vascular/compressive) vs gradual (degenerative)
- Associated symptoms - weakness, sensory change, sphincter dysfunction, cognitive change, tremor
- Falls history, fear of falling
- Medications - sedatives, antihypertensives, anything causing postural hypotension or ataxia
- Alcohol use, vitamin B12 status/diet
- Prior stroke, diabetes (neuropathy), joint disease
Focused examination
- Watch the gait first - pattern recognition before formal neuro exam
- Romberg test - distinguishes sensory ataxia (positive) from cerebellar (negative, unsteady even eyes open)
- Tone, power, reflexes, plantar responses (UMN vs LMN pattern)
- Cerebellar signs - dysmetria, dysdiadochokinesia, nystagmus
- Sensory exam - vibration/proprioception (dorsal columns), pinprick
- Postural BP
- Cognitive screen if frontal/NPH pattern suspected
- Timed Up and Go, gait speed as objective measures
Investigation strategy
- Directed by the localising pattern found on exam, not a blanket panel
- MRI spine if myelopathic pattern or red flags (cord compression)
- MRI brain if cerebellar, parkinsonian, or frontal/NPH pattern (look for ventriculomegaly out of proportion to atrophy in NPH)
- Nerve conduction studies/EMG if peripheral neuropathy or myopathy suspected
- B12, TFT, HbA1c, syphilis serology if peripheral neuropathy/sensory ataxia
- Postural BP, ECG if cardiovascular contribution suspected
- Lumbar puncture (large-volume, with pre/post gait assessment) if NPH suspected
Management
Sequence
1. Exclude an emergency (cord compression, acute stroke) first
2. Treat the identified cause - decompression, dopaminergic therapy, B12 replacement, disease-modifying therapy as appropriate
3. Multidisciplinary rehabilitation regardless of cause - physiotherapy (gait retraining, strength, balance), OT (aids, home safety), podiatry
By cause
- NPH: large-volume LP trial -> ventriculoperitoneal shunt if gait improves
- Parkinsonian: dopaminergic therapy, physiotherapy for freezing/festination
- Sensory ataxic: treat cause (B12 replacement), visual cueing strategies, walking aids
- Multifactorial (older adults): falls-style multifactorial assessment and intervention (see Falls note) rather than searching for one unifying diagnosis
General
- Walking aids matched to the specific gait pattern (four-point vs single-point stick vs frame)
- Home safety assessment, footwear review
- Address fear of falling - graded exposure and confidence-building alongside physical rehab
Traps
- Ordering an undirected battery of tests instead of localising the pattern first
- Missing cord compression because weakness was mild and sensory level not specifically sought
- Attributing gait disturbance in an older adult to "just age" without considering NPH, B12 deficiency, or myelopathy
- Missing multifactorial gait disturbance by searching for one unifying neurological diagnosis when several small deficits are summing
- Under-using formal gait speed/Timed Up and Go measures to track objective progress
Talk track
Watch the gait first - the pattern (spastic, parkinsonian, ataxic, sensory ataxic, steppage, waddling, antalgic, frontal/apraxic) localises before any test is ordered. Romberg distinguishes sensory ataxia from cerebellar disease. Exclude cord compression and acute stroke as emergencies, then investigate and treat by the localised pattern, with multidisciplinary rehabilitation running in parallel regardless of the final diagnosis - especially in older adults where the cause is often multifactorial rather than singular.
Study aid only. These notes are written with the help of AI. Not for guiding clinical decisions.