GAIT DYSFUNCTIONS

Gait dysfunctions are changes in your normal walking pattern, often related to a disease or abnormality in different areas of the body. Gait dysfunctions are among the most common causes of falls in older adults, accounting for approximately 17% of falls. This guide will help you better understand how gait dysfunctions are categorized, and how treatment by a physical therapist can help you regain a healthy gait. Physical therapists are experts at identifying the root causes of gait dysfunctions, and designing treatments that restore gait.

What are Gait Dysfunctions?

Gait dysfunctions make the pattern of how you walk (ie, your gait) appear “abnormal." Most changes in gait are related to underlying medical conditions. Gait dysfunctions can be related to disorders involving the inner ear; nervous system disorders such as Parkinson's disease; muscle diseases such as muscular dystrophy; and musculoskeletal abnormalities such as fractures. In many cases, treatment of the underlying medical condition will help normalize the gait pattern.

Common classifications of gait dysfunction include:

• Antalgic. This type of gait dysfunction is often caused by bearing weight on a painful leg. It can be related to arthritis or a traumatic injury, and is what many people refer to as a "limp." People with this dysfunction take slow and short steps, and quickly try to shift their weight off of the sore leg, ankle, or foot, and back onto the unaffected leg.
• Cerebellar Ataxia. This gait dysfunction is often seen in individuals who have a condition of the cerebellum (a region of the brain), drug or alcohol intoxication, multiple sclerosis, or have experienced a stroke. The affected individual will have a wide-based stance (feet wide apart), and display inconsistent and erratic foot placement.
• Parkinsonian. This type of gait dysfunction is often related to Parkinson’s disease and is characterized by short, shuffled steps.
• Steppage. This dysfunction occurs in people with "foot drop" (an inability to lift the ankle), which is related to conditions, such as lumbar radiculopathy and neuropathy. Because the ankle will "slap" off of the ground, the individual will often lift the leg higher at the knee and hip, to clear the foot when taking a step./li>
• Vestibular Ataxia. This pattern is often related to vertigo, Meniere’s disease (an inner-ear condition), and labyrinthitis (a type of inner-ear disorder in 1 ear). It causes people to walk unsteadily, often falling toward 1 side. 
• Waddling. This pattern often arises from muscular dystrophy and myopathy, and causes individuals to walk on their toes, while swaying side-to-side.

Note: These are only a few of the many possible gait dysfunctions. If you suspect you are walking differently, call your physical therapist for a gait assessment.

How Is It Diagnosed?

There are many different strategies and tools that can help a physical therapist diagnose a gait dysfunction. While other health care professionals are educated in the screening for potential conditions related to the gait abnormality, a physical therapist is the expert in diagnosing the actual type of gait dysfunction. Your physical therapist will ask you questions, such as:

• When did you notice you were walking differently?
• Is the problem getting better or worse?
• Has it resulted in a fall or any additional problems?
• Are you in pain while you walk?
• Have there been any recent changes in your medical history, including changes in medications?

Your physical therapist will also conduct certain tests to learn more about your condition. Your assessment may include:

• Observation. Your physical therapist will ask you to walk back and forth, to observe any abnormalities in your gait pattern. 
• Gait speed measurements. Your physical therapist will time your walking speed. Studies have shown that complications like falling are related to how fast you walk.
• Balance tests. Your physical therapist may also assess your balance to determine your risk of falling.
• Strength and range-of-motion measurements. These tests can help determine whether the dysfunction is due to musculoskeletal limitations. A physical therapist may utilize tools, such as a goniometer to measure your joint motion, or dynamometer to measure your strength. 
• Reflex and sensation screenings. These measurements will help your physical therapist determine whether a neurological (brain or nervous system) condition is present.

How Can a Physical Therapist Help?

Physical therapists play a vital role in helping individuals improve their gait. Your physical therapist will work with you to develop a treatment plan to help address your specific needs and goals. Your physical therapist will design an individualized program to treat your specific condition.

The treatment strategy may include:

Pre-Gait Training. Your physical therapist may begin your treatment by having you perform activities and exercises that will help you understand how to improve your gait, without taking a single step. These exercises may include simple activities, such as having you stand and lift your leg in place, to more complex strategies like stepping in place and initiating contact with your heel to the ground, prior to other portions of the foot. 

Gait Training. Your physical therapist will help you focus on retraining the way you walk. Because the underlying condition may be vestibular, neurological, or muscular, variations in the training exist. Your physical therapist will design the safest and best training for your specific condition.

Balance and Coordination Training. Your physical therapist may prescribe balance activities for you to perform to help stabilize your walking pattern.

Neuromuscular Reeducation. Your physical therapist may employ neuromuscular reeducation techniques to activate any inactive muscle groups that may be affecting your gait.

Bracing or Splinting. If the gait dysfunction is due to significant weakness or paralysis of a ligament, your physical therapist may teach you how to use adaptive equipment, like a brace or splint, to help you move.

6 WAYS OBESITY CAN WEIGH ON THE BRAIN

Obesity not only impacts your physical health; it also impacts your brain. An assistant professor at Texas A&M Health Science Center School of Public Health, who’s received National Institute on Aging funding to study obesity’s effects on brain function in seniors, notes obesity can change the structure of the brain and cause atrophy.

1.     A higher BMI is associated with poorer episodic memory – or difficulty recalling past events – in young adults ages 18 to 35. The findings in a research article published in The Quarterly Journal of Experimental Psychology suggested that people who are overweight may experience memory slightly less vividly or in less detail. Other evidence indicates memory plays an important role in regulating what we eat; and clouded memory can make it harder to watch what one eats and lose weight.

2.     Midlife obesity is associated with a higher risk of dementia. Being obese in one’s 40’s through 60’s is associated with a higher risk of dementia as you age. It’s linked to an increased risk of Alzheimer’s, the most common form of dementia, and a leading cause of death in the US. The true cause is not clear, but it is clear that added pounds negatively affect cardiovascular health, which plays a significant role in brain function.

3.     Obesity in older individuals is associated with changes in brain activity that affect neuromuscular function – including making it harder to grab/grasp onto things. If your grip is not reliable, people can become a much higher risk of falls. It should also be noted, in studies where this information was proposed, obese individuals’ grasping ability was further impaired under stress.

4.     Researchers found obese subjects also expended more mental resources when walking, even though they were able to walk as well as non-obese test subject. And stress further taxed the brain of obese individuals, compared to their normal-weight counterparts. In addition to the physical challenge, the added mental burden of obesity might also lead individuals to tire more quickly.

5.     Being overweight may dull your ability to experience pleasure. One previous study published in the Journal of Neuroscience noted that an area of the brain called the striatum was less activated in women after they had gained weight. The striatum plays a key role in encoding the reward we get from eating certain foods, like those high in sugar that are associated with the release of the brain chemical dopamine, causing us to feel pleasure. In addition to high-fat, high sugar diets leading to being overweight has been associated with this same dulling effect, which experts say can lead a person to overeat to regain that fleeting sense of pleasure.

6.     Obesity raises the risk of depression, and depression can raise the risk of obesity. We definitely know it contributes, and it may also contribute to bipolar disorder.

Health experts say losing weight typically has a positive impact on brain health. Lifestyle changes, including partaking in a heart-healthy diet and exercising regularly, have also proven a beneficial strategy to optimize mental function. As the obesity epidemic rages on, more studies are underway to shed light on those negative effects – and to shed light to help us better understand how to prevent or reverse them. 

THE PT GUIDE TO TRAUMATIC BRAIN INJURIES

Traumatic brain injury (TBI) occurs when a trauma causes damage to the way the brain functions. The most common causes of TBI are falls, car crashes, and blows to the head. Approximately 1.7 million TBIs occur each year in the US, resulting in 52,000 deaths and 275,000 hospitalizations.

Approximately 80% of individuals with TBI are treated and released from the emergency department because their injury is classified as a concussion or mild traumatic brain injury. TBI can occur at any age, to anyone, but certain groups are more likely to experience a brain injury. Children under the age of 4 are at risk of injury from falls and child abuse. Adolescents aged 15-19 are at an increased risk due to sports and car crashes. People aged 75 years and older are at risk from falls.

Physical therapists help people with TBI regain their physical abilities, re-learn daily tasks, and improve their strength and overall fitness.

What is Traumatic Brain Injury?

Traumatic brain injury (TBI) occurs as the result of extreme force exerted on brain tissue. Common causes are falls, car crashes, or blows to the head. Movement of the brain that causes damage even though the skull is intact is called a closed injury. Damage caused by a wound that breaks through the skull, such as a gunshot or a puncture by a sharp object, is called a penetrating injury.

Those who sustain moderate-to-severe TBI require specialized hospital and rehabilitative care to address the serious physical, cognitive, and emotional changes that result from injury to the brain. Nearly half (43%) of those who need hospitalization for TBI will have some form of disability 1 year after the injury.

Severe TBI often causes a period of unconsciousness, called a coma, when the patient's eyes remain closed, and he or she is not responsive to outside stimulation. Consciousness may gradually improve, but many brain functions can be affected by the injury, including those guiding thought, movement, sensation, and behavior.

Signs and Symptoms

Because the brain controls our ability to move, think, sense, and socialize, the symptoms that result from TBI can vary widely. They may include:

• Physical symptoms, which can include weakness or difficulty moving the arms, legs, body, and head. The affected person may have difficulty sitting, standing, balancing, walking, or lying down and changing in bed.
• Cognitive symptoms, which can include difficulty remembering, paying attention, or solving problems. The affected person may have a reduced awareness of these difficulties, which can cause safety concerns.
• Sensory symptoms, which can include changes in vision, hearing, or the sense of touch. Balance senses that are aided by the inner ear may also be impaired.
• Emotional and behavioral symptoms, which can include difficulty in controlling emotions, or a change in personality. If cognitive deficits are significant, the affected person's inability to understand what has happened may result in significant emotional agitation.

How Is It Diagnosed?

Upon the patient's arrival at the hospital, an attending doctor will diagnose the level of the TBI by assessing factors such as the ability to open the eyes, to speak, and to move in response to a command.

In moderate or severe injuries, imaging studies will be conducted (such as MRI, CT scan) to determine what parts of the brain are injured or if there is any bleeding or fluid that could be pressing on the brain tissue. A physical therapist (PT) often works with the medical team to understand what areas of the brain are injured so that the PT evaluation can focus on potential problem areas.

With a severe injury, the patient may be in a coma; the eyes are shut and there is no response to external stimuli. Over time, the patient will likely be able to open his or her eyes. Sometimes eye opening is accompanied by rapid recovery of other abilities such as talking and physical movement. For other patients, recovery is slower.

When a patient is said to be in a vegetative state, some basic brain functions resume, such as eye-opening on a regular sleep/wake cycle, breathing, and digestive functions, but he or she is unaware of surrounding activity. During this phase, a physical therapist will help with positioning and equipment that will ensure proper posture and flexibility, reduce the likelihood of any problems such as bed sores, and encourage responsiveness to the environment.

When a patient is said to be in a minimally conscious state, he or she shows beginning signs of awareness (the ability to do purposeful things) but these responses are often not consistent. During this phase, a physical therapist will help with stretching, positioning, and equipment use while trying to increase consistent responses to commands for movement and communication.

How Can a Physical Therapist Help?

By working with the patient and his or her family, goals are developed to improve physical independence. Physical therapists help patients with TBI regain functions such as getting in and out of bed and changing their position in bed, sitting down, rising to stand, walking, and using a wheelchair.

The physical therapist uses exercise and task-specific training to help the patient improve:

• The ability to maintain alertness and follow commands
• Muscle and joint flexibility that may be reduced after inactivity
• The ability to move around in bed, to sit without support, and to stand up
• The ability to balance safely when sitting, standing, or walking
• The ability to move by strengthening and the practicing of functional activities
• Balance and coordination
• Strength and energy, reducing any feelings of fatigue that occur from inactivity or the injury to the brain itself
• A return to sports and fitness activities

If limitations prevent the return to pre-injury activities, a physical therapist can help the patient improve mobility and master the use of equipment such as an ankle brace, a walker, or a wheelchair.

Can this Injury or Condition be Prevented?

Traumatic brain injuries can be prevented by taking steps to protect the head when engaged in risky activities, and by lessening participation in those activities. Awareness of the signs and symptoms of injury can help quicken response time should a TBI occur.

• Always use an appropriate helmet when taking part in activities that increase the risk of falling, such as biking, rock climbing, motorcycling, skateboarding, skiing, or skating.
• Always use your car's seatbelts; infants must be secured in an appropriate car seat according to safety requirements and instructions.

For small children:

• Provide appropriate adult supervision in fall-prone areas such as playgrounds.
• Use child barriers to prevent home-based falls around areas such as stairs and second-story windows.

For adolescents:

• Educate teens about the many factors associated with death and brain injury in car crashes, including the use of alcohol or other substances, speeding, or texting or phone use while driving.
• Educate teens about mild TBI (see concussion guide) or severe injuries related to sports.

For older adults:

• Educate older loved ones about the risk of falls in the home related to daily mobility and to housework activities that carry a greater risk of brain injury, such as using a ladder or footstool, walking on a wet floor, or vacuuming stairs.