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.