Gait and balance examination
Simple observation remains the essential approach, the “gold standard“ of gait investigation, from which an experienced observer can extract crucial information for differential diagnosis of the particular gait and balance problem.

History
Symptoms of balance and gait disorders often tend to be non-specific. As a rule, the patient complains of slowed-down walking, uncertainty in space, a perception of instability when standing or walking, or of falls. While gait or balance problems can (and should) be verified on examination, falls may not be observed during examination, and therefore finding more about the circumstances is essential.

Assessment
On examination, the basic features of posture and gait are scrutinised to reveal signs of pathological involvement (see table 1). The comprehensive gait and balance evaluation comprises observation of spontaneous postural and locomotion patterns pro vypnutí stačí znovu kliknout na ikonu spuštění videa at rest (while standing) and pro vypnutí stačí znovu kliknout na ikonu spuštění videa while walking, followed by maneuvers designed to assess the overall execution of the required movement, muscular strength, postural reflexes, signs of lateral instability etc.

The phenomenological classification of gait disorders is based on the integration of observed clinical characteristics with known anatomic and etiologic mechanisms:

Muscular weakness can usually be detected during neurological examination of the lower limbs, and tends to be brought out on execution of functional changes of position – sitting down, arising from a chair, standing and, in particular, walking. Base width is studied in spontaneous standing and in walking, when we take note of the base width changes and any possible deviations from the straight path suggesting disturbed lateral stability. Maneuvers while standing (feet close together, Romberg test), will help to reveal minor disturbances of lateral stability. Antero-posterior stability disturbance can be diagnosed with the push- and pull- (shoulder tug) tests (sudden posterior or anterior displacement produced by pushing or pulling on the shoulders). The gait parameters, such as stride length, cadence (number of strides per minute), gait speed and regularity, and fluidity of walking movements can all be ascertained by observing the subject’s “normal” or usual gait. After commands to start walking, change direction and stop, we explore gait initiation, maintenance and adaptation to changes in environmental conditions (surface changes, narrow passages etc.) or to intentional gait changes. Maneuvers while walking (walking with closed eyes, walking on the heels and tiptoes, walking backwards etc.) will expose lateral instability, disorders of proprioception, distal muscle weakness and other abnormal gait patterns.

- table 1
A

Neurological examination including assessment of the configuration of lower extremities, their attitude, range of active and passive movement, muscle tone and strength.

B

Getting up from lying to sitting, from sitting to standing position – looking for possible muscular weakness, disorder of motor coordination.

C Spontaneous stance
  • posture of trunk and extremities
  • base width (distance between the two feet)
D Maneuvers while standing
  • stance with feet close together, eyes open
  • Romberg test (the same as above, with eyes closed)
  • postural response to external stimuli in the antero-posterior direction – sudden posterior displacement produced by pulling (or pushing) on the shoulders (pull-test, shoulder-tug test or push-test) (caution – ensure protection against the risk of falling)
E Spontaneous gait (to be examined in the corridor or some other space offering at least 10 m of free space)
  • base width, stride length, cadence, fluidity of movements, deviations from given direction
  • starting and stopping, turning on the spot and while walking, spontaneously and in response to commands
  • walking through a constricted passage (doorway), clearing and avoiding obstacles
F Maneuvers while walking
  • tandem gait (feet placed toe-to-heel)
  • walking with eyes closed (Romberg test while walking)
  • walking backwards
  • walking on heels and on tiptoes