LOCOMOTION AS AN AID IN DIAGNOSIS
One need not be a very experienced physician to know that there is a
group of diseases, mostly of the nervous system, which at a certain
point of their evolution, stamp the sufferer with a characteristic mode
of locomotion. To observe such a modification of the normal walk is
often sufficient to make a correct diagnosis.
It is strange, however, how little attention this important subject
has received from the medical profession. In fact, other than the work
of the brothers Weber, who established the physiology and mechanism
of human locomotion, of Neugebauer and of Gilles de la Tourette, who
developed the ichnogram method of gait study, scarcely anything of
importance has been done along these lines for the last quarter of
a century. The study of the mode of locomotion in various diseases
and ailments remains, therefore, a fertile field of research for the
podiatrist.
=Elements of Locomotion.= The act of locomotion or the _power_ of
progression is not a simple one. Various co-related movements combine
to form what we ordinarily term the _walk_. The three chief elements
are: (1) _Posture_, (2) _Station_, and (3) _Gait_. These three factors
may be influenced by local or general diseases, either separately or
together.
=Posture.= Posture is the term applied to the position of the body
in space and is not of much interest to the podiatrist except as
corroborative of the two other elements of locomotion. It has, however,
its value in diagnosis and the new practitioner of podiatry will do
well to learn to observe the position of the body at various angles
and in various diseases. One should learn early, for instance, that
_immobility_ is not always due to paralysis. It may be due to _pain_,
as in rheumatism or to a disinclination to move as in scurvy, rickets
or any condition causing dyspnea. The _restlessness_ in fevers and in
large hemorrhages, as well as the _throwing about_ in renal, gallstone
or intestinal colics, is known to all. Equally characteristic are
the _agitation_ and irregular movements in chorea and hysteria;
the _gun-hammer posture_ in cerebrospinal meningitis, and the
_opisthotonos_ in tetanus and strychnine poisoning.
=Station.= Station is the _power_ of standing more or less firmly
on one’s feet. It includes _attitude_ which is the _manner_ of
standing, i.e., the relation of the rest of the body to the erect
position. The carriage of the head and shoulders should be noted; the
shape of the entire body whether bending _forward_, as in “stooped
shoulders” (faulty attitude habit) and in paralysis agitans, or bending
_backward_, as in ascites and abdominal tumors, should be closely
studied and differentiated from the actual lordosis which is seen
in spinal diseases, in advanced pregnancy, in pseudo-hypertrophic
paralysis and in cretinism. The strictest attention should be paid to
the attitude of the lower limbs, their individual shapes and their
relation to each other when the erect position is assumed. The degree
of firmness with which the individual stands should always be taken
into consideration before a final diagnosis is made. _Swaying_ is the
term applied to any departure from the ideally rigid erect attitude and
perpendicular station. The normal individual, with eyes open and heels
close together, sways about one inch forward and three-quarters of an
inch from side to side. In functional and static ataxias, the swaying
may become so extreme as to produce absolute incapacity to stand.
=Gait.= This term means the specific _manner_ of walking. It is a
narrower term than locomotion which is the _power_ of walking. It
is, however, the chief factor in the act of progression and in the
majority of cases it is characteristic enough to stamp itself indelibly
on the normal as well as on the diseased individual. While in character
reading, gait expression may not be as popular as face expression, it
is often more reliable and in certain diseases it is simply invaluable
as an aid in diagnosis.
METHODS OF DIAGNOSIS
=A.--The Observation Method.= This is the usual method of ascertaining
the gait of an individual. It is practised by the average physician and
podiatrist and consists in observing the patient while he or she walks
up and down the room, taking notice of the peculiarities of gait which
may develop. The patient may be allowed to roam freely about the room
or should be directed to follow a carpet seam or a crack in the floor
at right angles to a previous line of vision. This may be varied by
opening or closing the eyes, stretching out the arms, with legs wide
apart, or keeping them close together. Brisk walking should alternate
with a slower gait and the effect of stopping abruptly and turning
sharply at command should be closely observed.
It is best to have the patient uncovered from the hips down. In women,
the nightgown or chemise can be pulled tightly between the thighs and
fastened anteriorly with a safety pin.
=Caution.= Due allowance should be made for nervousness and a careful
watch must be maintained against a serious fall.
[Illustration: Fig. 1
ICHNOGRAM OF A NORMAL GAIT]
=B.--The Ichnogram Method= consists in studying the impressions left by
_both_ soles (previously colored) when walking on paper for a distance
of about twenty-five feet. Ichnograms (from the Greek--_ichnos_--trace,
and _gramma_--to write) as a method of gait diagnosis are more exact
than the method of observation and should supplement it. Besides, they
inform us, at the same time, of the state of the plantar arch as each
_pelmatogram_ (the impression of a single foot) shows more or less
clearly a posterior oval which changes but little, and an anterior oval
as well as toe marks which undergo characteristic contour changes,
depending on the state of the ligaments, of the tarsal and metatarsal
bones and phalanges, and the relation of these structures to the
musculature and innervation of the foot.
Comparatively little has been accomplished along this line of endeavor,
although it offers a vast and fruitful field for podiatric research.
In fact this branch of podiatry deserves a special treatise, and it
will be discussed in fuller detail in our forthcoming book on Podiatry
Orthopedics.
[Illustration: Fig. 2
A. PELMATOGRAM OF A NORMAL FEMALE FOOT
B. MODIFIED PELMATOGRAM SHOWING WEIGHT BEARING POINTS]
[Illustration: Fig. 3
PELMATOGRAM OF A MALE, SHOWING FLAT FOOT]
=Classification of Gaits.= Strictly speaking there are only three types
of gait: (1) the _paretic_, (2) the _ataxic_ and (3) the _choreic_.
In some diseases there may be a combination of the three, while in
others one type of gait predominates during the early stage and another
during the later developments. At times, one comes across a gait that
combines characteristics of the three types and hence is difficult of
classification.
=I.--Paretic Gait.= _Paresis_ means a lessening of the normal motility
of a muscle, while the term _paralysis_ denotes entire absence of motor
power. We may have, therefore, two or three distinct paretic gaits
according to whether the muscle is slightly or severely weakened or
entirely paralyzed:
A.--The mild paretic gait.
B.--The moderate or flaccid paretic gait.
C.--The severe or spastic paretic gait.
=A.--The Mild Paretic Gait= is caused by muscular weakness due to a
large number of etiologic factors. It results in slowing of locomotion,
the steps being shortened on account of an exaggerated flexion at the
knee joint. The following are examples of mild paretic gaits:
(1) _The Pompous Gait._ The upper part of the body leans backward,
the back is hollowed, the abdomen is protuberant, the feet are widely
separated and appear to move with deliberation and dignity, giving the
impression of conscious importance--hence the name. This gait may be
seen in obesity, pregnancy, ascites, large abdominal tumors, cretinism
and rickets.
(2) _The Hobbling Gait._ The pelvis tilts towards the sound side,
while the trunk leans over to the affected side, causing more or
less pronounced _limping_. This gait is seen in people afflicted
with corns, rheumatism, gout, sciatica, plantar neuralgia, Morton’s
neuralgia, metatarsalgia, hip or knee joint disease or injury (recent
or old), sacro-iliac disease, sprains, inflammatory diseases of the
lower extremity, chimatlon, short leg, paralysis of one leg, abdominal
aneurism, and subacute and chronic appendicitis.
(3) _Intermittent Limping_ (disbasia angiosclerotica or intermittent
claudication) may be classified here and is a curious limping gait
which develops in arteriosclerosis of the lower extremities. There
are pain and fatigue on walking, which disappear after a short rest,
to reappear again soon after walking is resumed. The pulse is weak or
absent below the knee.
(4) _The Waddling or Goose Gait._ The pelvis and head of femur are
jerked forward at each step, knee advanced and extended only after
foot is flat upon the ground. There is more lordosis and swinging
of the body from side to side at each step, than in the pompous
gait. It resembles the gait of a goose. The patient cannot stand on
tiptoe. It is seen in: congenital dislocation of both hip joints and
in pseudo-hypertrophic muscular paralysis, a hereditary disease seen
mostly in boys under ten years of age, and characterized by inability
to get up from the floor.
(5) _The Wobbly Gait._ Resembles the above and is due to atrophy or
paralysis of the three glutei muscles and prevents the patient from
climbing. This inability to climb is also seen in those exhibiting the
waddling gait.
(6) _The Tottering Gait._ Seen in those who have taken large doses
of bromides for long periods; also in hydrocephalus, in Korsakoff’s
disease (psychosis polyneuritica) and in idiopathic muscular atrophy.
(7) _The Shuffling Gait_ is the gait seen in normal old age or senility
and is associated with slowly progressive loss of strength and
mentality. It is also seen in general paresis and is the “normal” gait
of the long-term prison inmate. The patient gives the impression of
being too lazy to lift his feet and instead pushes them along with his
legs.
(8) _The “Charlie Chaplin” Gait_ has been erroneously described as
an ataxic gait. It is rather a combination of the “funny part” of
several gaits in which the waddling, shuffling, tottering paretic gaits
predominate and to which some elements of the spastic paretic, as well
as the ataxic gaits, have been added. The inspiration must have come
originally to the celebrated movie star from some waddling cripple whom
he proceeded to imitate and later burlesqued.
=B.--The Moderate or Flaccid Paretic Gait.= In this form of the paretic
gait there is commonly a paresis of a certain group of muscles, usually
the extensors of the foot or the peronei, causing “toe drop” and
apparent lengthening of the affected extremity. It corresponds to the
“wrist drop” of the upper extremity. To compensate for the lengthening
of the limb, overflexion at the hip or knee, or at both joints, takes
place. The limb is flaccid or flabby.
The foot is lifted high up with each step in order to raise it clear
off the ground and avoid tripping. As the foot is brought down, heel
first, this gait may sometimes be confused with tabes and is therefore
sometimes referred to as the pseudo-tabetic gait. It is, however,
easily differentiated from the true tabetic gait by its characteristic
“high action” or “high stepping” quality which made Charcot compare it
to the gait of a horse and hence called it:
(1) _The Steppage Gait_, mostly seen in the chronic intoxications
producing neuritis. It resembles the gait of a man walking through
thick grass or brushwood and stepping over constantly recurring but
non-existent obstacles. The typical steppage gait is seen in arsenical
neuritis with ankle drop, also in alcoholic neuritis, polyneuritis
potatorum (ataxia of drunkards) and in lead neuritis (lead palsy,
plumbism, saturnism), in which first the peroneal muscles are affected,
later the extensor communis digitorum and finally the extensor
proprius hallucis. Phosphorus, copper and grain (ergotism) poisoning
may give rise to a neuritis in the lower extremities and produce the
characteristic steppage gait. Tuberculosis, malaria, diabetes and
diphtheria (motor form) may sometimes produce this gait. It may also
develop as a sequel of sunstroke (thermic fever, insolation) and in
fact following any disease which will cause peripheral neuritis of the
anterior tibial nerve.
(2) _The Prancing Gait_ is an exaggeration of the preceding gait.
It is seen in epidemic anterior poliomyelitis (infantile paralysis)
when the disease affects the anterior horn cells of the lumbar cord,
causing atrophy of the extensor muscles of the foot, resulting in
“foot drop.” It is also seen in acute ascending paralysis (Landry’s
disease), which is probably a form of poliomyelitis, and in progressive
hereditary muscular atrophy of the leg (Charcot-Marie-Tooth type) where
the muscles of the leg, not the foot, are primarily affected, i.e.,
first the peronei become atrophied, later the extensors of the toes
and finally the calcaneal muscles. Finally the prancing may be seen in
connection with certain tumors of the cord, unilateral hip disease,
dislocation or injury and in multiple neuritis and beriberi (epidemic
multiple neuritis).
=C.--The Spastic or Severe Paretic Gait.= The spastic gait is due to
the hypertonicity of the weakened muscles, the resulting stiffness
causing a slowing of locomotion and diminished excursion of the
affected limb. The hypertonicity is produced either by direct
stimulation of the motor cells in the anterior horn of the spinal cord,
as in traumatic myelitis, or by impulses coming down from the cerebral
cortex. The limb is spastic or rigid, due to the tonic spasm. When the
tonic spasm is of long standing, it is termed a _contracture_. The
lower extremity moves as a whole, the toes clinging to the ground,
scraping it and very often “catching.” Contrary to the moderate paretic
gait, this group presents difficulty in flexion which is partly
overcome by the elevation of the pelvis on the side of the swinging leg.
(1) _The Mowing or Hemiplegic Gait._ This is the prototype of
all spastic gaits and is encountered in its simplest form in all
hemiplegias, i.e., in paralysis of one side of the body, which may
be caused by cerebral hemorrhage, embolism, thrombosis, syphilis,
brain tumor, multiple sclerosis of a cerebral hemisphere, meningeal
hemorrhage or suppuration, Raynaud’s disease, general paresis of the
insane; sometimes it may be due to hysteria (functional hemiplegia)
or to uremia (transient hemiplegia). No matter what the cause of the
hemiplegia, there is always the typical mowing gait. This mowing
movement is due to the fact that the spastic limb swings lateralward,
describing an arc of a circle (outward), and strikes the ground in a
flail-like manner. Technically speaking, circumduction takes place by
tilting of the pelvis and the swinging of the foot outward and around
to the front. The patient afflicted with hemiplegia makes the same
movement with his limb as does the reaper with the hand in which he
holds the scythe. _Exception_: the only paralytic gait in which there
is no mowing movement occurs in hysterical (functional) paraplegia,
which is very rare. In this condition the leg is dragged forward
instead of outward.
_Important shoe sign in paraplegia._ The sole of the shoe is worn down
on the inner side.
(2) _The Small-step Gait_ (la marche à petits pas). This gait is seen
in cerebral softening following an apoplectic stroke, especially in
pseudo-bulbar paralysis; the steps are very short and the feet are
lifted from the ground with difficulty, the patient seeming to count
his steps.
(3) _The Cross-legged Gait._ This gait is due to a spasm of the
adductors of the thigh causing the knees to rub against each other,
resulting in cross-legged progression, the lower limbs having a
tendency to cross during locomotion. It is seen in both Little’s
congenital and Erb’s syphilitic form of lateral spinal sclerosis. In
the syphilitic form, a dragging and shuffling gait is often associated
with the cross-legged type.
(4) _The Ill-defined Spastic Gaits._ Ill-defined spastic gaits are seen
in tetany (paroxysmal tonic spasm) from any cause, and in amyotrophic
lateral sclerosis, which is the spastic form of progressive muscular
atrophy (Charcot’s disease). This involution disease, due probably to
developmental defects of the lateral pyramidal tracts, has the combined
symptoms of spastic spinal paralysis, anterior poliomyelitis and bulbar
palsy, hence the difficulty in classifying it. Myelitis (inflammation
of the spinal cord) may be due to trauma, alcoholism, syphilis,
vertebral caries (compression myelitis), tumors, aneurism, hemorrhages
into the cord, etc., and will exhibit various gaits according to
the stage and severity of the disease. It may begin with a mild
paretic gait passing through several stages of the spastic gait or to
complete paraplegia (paralysis of both lower extremities). In complete
paraplegia there is of course no gait, as the patient cannot walk,
there being a loss of the power of locomotion but not of progression (a
patient so afflicted may still move from place to place on his hands).
(5) _The Dragging Gait._ In hemiplegia one foot only is dragged.
Dragging of both feet is seen in multiple neuritis, hereditary peroneal
atrophy, spasmodic spinal paralysis and spinal and syphilitic spinal
paralyses.
(6) _The Dromedary Gait_, so called on account of its resemblance to
the gait of a camel, is seen in children suffering with progressive
torsion spasm (Flatau-Sterling disease).
Finally, spastic paretic gaits are often observed in pellagra (maidism,
Italian leprosy, Alpine scurvy) and in lathyrism (lupinosis), where
the slow toxic spinal sclerosis finally leads to spastic paraplegia
and loss of the power of locomotion; also in caisson disease (divers’
paralysis).
=II.--The Ataxic Gait.= The ataxic gait may be either:
A--The Static ataxic gait, or
B--The Functional ataxic gait
and these are termed either (1) spinal or (2) cerebellar, according to
the location of the lesion.
=A.--The Static Spinal Ataxic Gait= is the most easily recognized gait,
and once seen, is never forgotten. There is an exaggeration of all the
movements of locomotion. The hips are overflexed and rotated laterally,
the foot is raised suddenly and too high, the toes are lifted and the
whole limb is thrown suddenly forward with unnecessary vehemence and is
then brought down heel first or flat-footed, with a stamping sound. The
feet are kept wide apart and while in the air they move in an undecided
manner, as if the patient was doubtful where to put them. The eyes of
the afflicted person are glued to the ground or fixed to the limbs so
as to supplement the lack of muscular and articular sensation by the
sense of sight.
In the cerebellar type of this gait the movement excursion is not as
extensive as in the spinal type. A sudden turning movement or an abrupt
sitting posture is difficult or impossible to assume in this type of
locomotion.
In order to test static ataxia, the patient is made to stand heels
and toes together, whereupon marked swaying takes place. The swaying
is increased when the eyes are closed and the patient looks like a
“chicken on a clothes line.” If there is more than one inch forward
swaying and more than three-quarters of an inch lateral swaying, the
patient is considered ataxic.
In the disease known as tabes dorsalis, or locomotor ataxia of
syphilis, the swaying may be so pronounced as to produce absolute
incapability to stand or to walk.
=B.--The Cerebellar (functional) Ataxic Gaits.= These gaits are
produced by a disturbance of the equilibrium accompanied by vertigo
resulting in a very irregular swaying from side to side, resembling the
gait of an intoxicated person.
The patient makes short steps, keeps his feet wide apart, staggers,
rolls, sways to and fro and reaches a set point by zigzagging toward
it. The swaying is relieved when support is given under the armpits.
(1) _The Titubating Gait_ is a form of functional cerebellar ataxic
gait seen in the following affections: Friedreich’s (disease) ataxia;
hereditary cerebellar ataxia; dementia paralytica; ataxic paraplegia;
labyrinthine disease and to some extent in vertigo; syringomyelia; and
in some cases of general paresis, and various chronic intoxications
like lead or arsenic or alcohol poisoning affecting the cerebrospinal
system.
(2) _The Reeling or Staggering Gait_ is seen in acute alcoholic
intoxication and Mésnière’s disease (disease of the middle cerebellar
lobe).
=III.--The Choreic Gait.= The choreic gait, sometimes called _tremor_
gait, spasmodic or hysterical gait, is very variable in quality
depending on the cause of the tremor. It consists of a series of
quivering or trembling movements of varying intensity, but nearly all
due to clonic spasm and disappearing during sleep or passive motion.
This distinguishes it from the spastic or paraplegic gait in which
the spasm is tonic in quality, lasting from one minute to one month.
The clonic spasm, on the other hand, consists in rapidly alternating
contractions and relaxations of the muscle.
(1) _The Stumbling Gait_ is seen in chorea (St. Vitus’ dance) and
Huntington’s (hereditary) chorea, in Friedreich’s paramyoclonus
multiplex (which is not to be confounded with Friedreich’s ataxia),
in Unverricht’s progressive myoclonus, and in multiple sclerosis
of the spinal cord. The gait resembles that of a schoolboy, who
clownishly stumbles or trips over his heel to attract attention.
Technically it consists of spasmodic adduction, extension and outward
rotation of the legs which soon renders locomotion impossible. When
these abrupt twitchings and jerking movements, which are involuntary
and purposeless, affect only one-half of the body, we speak of the
condition as hemichorea. The patient appears restless, unsettled and
fidgety.
(2) _The Festination Gait_ is typical of the disease known as
paralysis agitans (Parkinson’s disease, shaking palsy) and is an
advanced choreic gait in which there may be observed the curious
phenomena of propulsion and retropulsion, i.e., the impossibility of
stopping, once the patient is pushed either forward or backward. In
some instances, when pulled suddenly backward, the patient will take
a few backward steps with increasing rapidity, also the body remains
in the characteristic posture of paralysis agitans; namely, in the
forward-leaning attitude. In festination “the body tries to overtake
its centre of gravity” (Trousseau).
(3) _The Saltatory Gait_ (“The jumpers”), is a very rare condition
occurring the instant the weight of the body is put upon the feet. It
consists in strong and rapid contractions of the muscles of the thigh
and leg causing the patient to jump up violently. It is probably a
hysterical spasm.
(4) _The Myotonia Gait_ occurs in Thomsen’s disease and consists of
tonic, _painless_ spasms whenever a certain group of muscles begin
to functionate. The steps are first checked and delayed; but this
gradually wears off. This curious condition returns again when the same
group of muscles are called into action. Owing to the tonic spasms,
this gait might have been properly classified as a spastic paretic
gait, were it not for the fleeting and irregular character of the
spasticity.
(5) _The Hysteria Gait_, known also as astasia-abasia, is notable by
the ease with which it may simulate any and all of the gaits described
above, the spastic as well as the flaccid types of paralyses,--even
the cross-legged gait, ending in complete inability to stand or walk.
It differs from all of them, however, in the ability of the patient to
perform all the nervous functions of the limb when lying in bed. The
hysterical gait may also end in:
_Catalepsy_ which is a state of muscular rigidity enabling a limb to
maintain a posture in opposition to gravity for one hour or more (waxy
flexibility). This curious phenomenon of retaining the leg or any other
part of the body in a fixed attitude (given to it by the operator)
is sometimes seen in catatonia, general paresis, brain tumors and,
(rarely) in meningitis.
(The above chapter was especially prepared for “Practical
Podiatry” by Paul Luttinger, M.D., Professor of Bacteriology in
The First Institute of Podiatry. It is the first compilation of
its kind ever published and should prove a valuable aid to both
practitioners of medicine and of podiatry--_Editor_).