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MDS 2021 | Diagnosing gait disorders: a structured approach for clinical use

Alfonso Fasano, MD, PhD, University of Toronto, Toronto, Canada, outlines the key stages of the sign-based approach he uses to diagnose disorders of gait, balance, and posture. Firstly, a patient must be assessed for issues they may be compensating for. Weakness, sensory issues, balance problems, pain, attention, and patient awareness can all impact how a patient presents, giving rise to features not necessarily characteristic of their underlying condition. Following this, gait must be assessed while also looking at accessory movements, posture, and sitting and standing. Dr Fasano discusses the need to also consider specific gait features, such as freezing of gait. Working through all stages in a structured manner is important for an accurate differential diagnosis. This interview took place during the 2021 International Congress of Parkinson’s Disease and Movement Disorders.

Transcript (edited for clarity)

First of all, this really needs to be emphasized, we need to use a structured approach. In anything we do, not just in medicine but in life, we need to have a clear sequence of maneuvers, for instance, or tasks that we’re supposed to do, because if we don’t follow them we may miss something, or it may also be more difficult for us to document what we’re doing, for instance, in clinical charts...

First of all, this really needs to be emphasized, we need to use a structured approach. In anything we do, not just in medicine but in life, we need to have a clear sequence of maneuvers, for instance, or tasks that we’re supposed to do, because if we don’t follow them we may miss something, or it may also be more difficult for us to document what we’re doing, for instance, in clinical charts. So, obviously the same applies to gait disorders. And I proposed in my talk, but also in other papers, a structured approach, that starts from understanding, again, what’s compensation and what’s not. And this means that the patient needs to be assessed also for power so, weakness issues, sensory problems, balance issues, pain, attention, which is another important part to keep into account. Patient’s awareness to the problem is also very important because you might have a patient with a lot of issues, but if the patient is not aware, you will see a completely different gait because it will be a non-compensated gait, maybe reckless, maybe fast, but not necessarily the problem that that patient has. So, those are certain aspects of the exam that needs to be established before you actually start seeing the actual gait.

And then you look at gait, and gait is a fascinating topic for many reasons. One of them is certainly that the trained eye can be very accurate in finding what’s going on. So, you don’t have to have a ‘gait lab’ or a ‘gait analysis’ to establish that the patient has asymmetric gait, short or long steps, narrow or wide base of support, variability of gait. Also, you look at accessory movements like the arm swinging, that can be another important source of information. Another important source of information is how the patients stand from a sitting position and sit down again. Patient’s posture is also very useful. And on top of that, and that will be the final part of the examination, the physician needs to know some specific gait features that are otherwise difficult to describe if you don’t really know them in advance. Example of this would be freezing of gait. Freezing of gait is a very characteristic gait problem. And once you’ve seen one patient, and obviously you know what it is, you recognize this for the future. And sometimes patients are not good at describing what happens at home, especially when they have freezing of gait. I should say, I met some patients that described that as “tremor” or “shaking of their legs”. And if the physician is not aware of freezing, this might just mislead the physician.

So, structured approach, starting from the general assessment of the patient, look at stepping and gait, look at posture and the way patient sits and stands up, and then recognizing specific features. This is the approach I follow.

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Disclosures

Dr Fasano reports the following disclosures:
Receipt of grants/research support: Boston Scientific, MJ Fox Foundation, Medtronic, University of Toronto, McLaughlin Centre
Receipt of honoraria or consultation fees: Abbott, Abbvie, American Academy of Neurology, Brainlab, Boston Scientific, Ceregate, Chiesi Farmaceutici, Inbrain, International Parkinson and Movement Disorder Society, Ipsen, Medtronic, Novartis, TEVA Canada, UCB pharma, Sunovion
Participation in a company sponsored advisory board: Abbott, Abbvie, Boston Scientific, Ipsen, Medtronic, Sunovion