10. CGA in Primary Care Settings: Patients presenting with mobility and balance issues

Diagnosis in managing gait and balance problems

It is important to attempt to make a diagnosis in gait and balance disturbance before referral to physiotherapy in order to avoid worsening the situation. For example:

• Failure to control pain in an arthritic condition resulting in inability to take part in strength training to improve walking and the need for the physiotherparist to refer back to the HP before definitive treatment can begin.
• Failure to diagnose an early case of Motor Neurone Disease or Parkinson’s resulting in failure to make specialist referrals or spot other problems e.g. swallowing / speech.
• Failure to guide the patient accurately as to the likely trajectory of their problem thus potentially setting too low or too high an expectation.

History taking

As with all parts of CGA, it is important to actively listen to the patient for key cues that will guide your diagnosis and management.

Building a thorough, corroborated picture of what a patient can currently do or not do is key. To diagnose and manage problems identified, it is also critical to also understand their prior levels of mobility and to be specific about the time period of deterioration. To make interventions relevant you also need to understand what the patient needs to be able to do to live their normal daily life with the support they have.

It is also helpful to ask about prior intervention that patients have had for gait and balance problems. If a patient has failed to improve with appropriate intervention before, then re-referring is unlikely to benefit the patient. Patients and carers often need reassurance and support at this stage because they sometimes feel that further therapy will resolve their problems when in actual fact they need support to adjust to a reduced level of mobility.

Establishing current and prior function

To establish current and prior function in walking, balance and associated functional tasks, ask:

• Can the patient walk outdoors; how far, do they need an aid or someone to go with them?
• Can the patient walk indoors the distances they need to be able to manage; do they need an aid or anyone to help them?
• Has the patient noticed any changes in their walking pattern? Important changes to seek are:
  
  • Shorter steps / shuffling.
  • Feet feeling stuck to the floor, difficulty getting started or going through doorways, feeling like they can’t stop (festination), feet close together.
  • Tendency to fall backwards (occurs for a variety of biomechanical, musculoskeletal or neurological problems but can progress and become disabling. Can affect ability to stand from a chair in time. Requires physiotherapy to address the underlying causes as early as possible).
  • Not being able to put weight through one leg properly, resulting in a shorter step on one side.
  • Walking with feet too wide apart or too close together.
  • Swinging one leg out to the side (circumduction).
  • Uncoordinated walking, inability to maintain walking in a straight line, veering from course.
  • Feeling like they can’t feel their feet or ‘are walking on cotton wool.’
• Has the patient started to restrict activity because they don’t have the confidence in maintaining balance doing normal daily tasks they usually can do?
• Have they started to fall?
• Do they feel ‘off balance’ / unsteady / dizzy during normal mobility or functional tasks?
• Ask about functional ability specifically:
  
  • Difficulty getting up from chair / bed / toilet.
  • Difficulty getting into bed / out of bed; has the patient taken to sleeping in their chair rather than going to bed?
  • Difficulty with stairs / steps (don’t forget to ask about steps getting into the house as well as steps within their property).

Understanding a patient’s confidence levels is key. It is not just what they can do, it is how confident they feel doing it. Take loss of confidence in doing tasks seriously as it is strongly correlated with objective impairment of abilities and higher falls risk.

Understanding time periods

Understanding time periods guides diagnosis and goal setting. Where there is sudden loss of mobility, question carefully.  Is this:

Genuine sudden loss (likely to indicate an significant event (e.g. fall or injury) or significant illness (e.g. infection)

OR

A gradual decline over a period of time during which the patient’s functional reserve has been reducing and their frailty increasing, culminating in a patient reaching a critical point where they no longer have the ability to do certain tasks. Sometimes a relatively minor insult at this stage can render a patient unable to walk / function (the ‘stuck in chair’ / ‘off legs’ scenario). It is important to recognise this, as treatment focussing on the minor insult may temporarily help mobility, but failure to address underlying problems and to increase functional reserve will not result in sustainable improvement.

Goal-setting and prior intervention

If the patient has an established diagnosis for their walking and balance problem, for which they have received adequate quantity and quality of physiotherapy which has not resulted in improvement, then the physician should take an approach with the patient around compensating and helping them manage their deficit. This may still involve re-referral to a physiotherapist if the patient’s condition has changed or further help is needed in developing management strategies.

OR

If they have a new, modifiable problem, or one for which they have not had intervention for whatever reason, then the focus should be on trying to remediate the problem through appropriate strength and balance training, providing the patient is willing and able to participate.

What the patient needs to be able to do

What the patient needs to be able to do will help determine goals for intervention. There is a need to explore the distinction between what the patient would like to be able to do – which might be based on historical patterns of movement or ability and what the patient needs to be able to do to achieve one or other overall goals. For example, a patient who used to play tennis three times weekly, might wish to be able to continue to do this – but  because of his severe osteoarthritis and age-related gait problem, it is more feasible to find a way of him achieving the goal of being able to get to the village cricket club twice a week.

Gait and balance assessment

Gait and balance assessment simply means watching the patient walk. If possible, it is better to observe the patient whilst they are unaware of being watched but this is not always possible or appropriate. Watching them walk down your surgery corridor or around their own home is all that is needed.

Although not an exhaustive list, key things to watch for (and then examine and address) might be:-

• Foot drop (peripheral neuropathy, nerve palsy, damage from previous CVAs).
• High stepping gait / heavy foot placement (possible foot drop).
• Trendelenburg(waddling) gait (hip weakness due to specific musculoskeletal problems around the hip).
• Parkinsonian signs (narrow base, freezing, festination, loss of arm swing).
• Ataxic gait (cerebellar issues, MSA).
• Flexed hips and knees (PD, lower extremity musculoskeletal deficits resulting in muscle weakness or tightness).
• Wide-based gait.
• Leaning too far forwards or backwards.
• Short steps / shuffling gait (PD, cerebrovascular disease).
• Antalgic gait (less time spent in stance phase on one leg – usually due to weakness or pain).
• Circumduction of one leg in walking.

Simple tests for walking and balance

The following tests are recommended because they are evidence-based, have satisfactory reliability and validity and take less than five minutes. They are also easily completed in a surgery setting or in the patient’s home and require no special equipment.

Timed up and go test

• This test measures functional mobility in the older population. 
• The patient should sit in a chair of knee height. They should be asked to stand up, walk three metres, turn round, return to the chair and sit down.
• You should time the patient, starting timing when the patient starts to try and stand up and stopping when the patient is sitting down again.
• The patient may not use a walking aid so if they need one then this is not an appropriate test and they already have a mobility problem rendering the test unnecessary.
• Timed up and go duration increases with worsening mobility.

Normal scores are between 8 and 11 seconds for people between 65 and 99. If a patient takes more than 12 seconds then their mobility may be considered impaired. See also the demonstration video Timed Up and Go.

180 degree turn test

• This measures dynamic balance. It should not be used in patients who require a walking aid to turn, are not able to fully weight-bear or who cannot follow instructions.
• A patient should sit in a chair from which they can easily stand up. Backs of chairs or other stable hand-holds should surround the patient in front and to the side forming a square or circle.
• The patient should stand up and you should stand behind them.
• You ask the patient to turn around and face you (turn 180 degrees). 
• The patient should not hold on unless they need to, in which case they have failed the test.
• You should count the number of steps they take.

Patients who take five or more steps have an increased relative risk of falling in the following year and might be considered to have balance impairment. 

Gait speed

• Ask a patient to walk a distance of four metres.
• If they take longer than five seconds then their gait speed can be considered slow (i.e. less than 0.8 m/s). 
• Gait speed is correlated with increased risk of falling. 

Chair stand

• Ask the patient to sit in a chair which is at knee height.
• Ask them to stand from the chair.
• Patients who require use of their arms to stand are likely to have lower limb strength impairment. 
• Lower limb strength impairment is correlated with risk of falls and with poor balance.

Onward referral

Patients who pass all of these tests but who report worsening quality of mobility or reduced confidence should be referred on to a therapist for more detailed assessment. In the event of detecting a gait and balance problem the following onward referrals should be considered:

• Referral to outpatient or ambulatory services for secondary medical opinion if this is needed to reach or confirm the diagnosis and to support with the initial management plan.
• Referral to physiotherapy services for:
  
  • More detailed gait and balance assessment.
  • Strength and balance training.
  • Re-education of walking techniques which may or may not include provision of walking aids.
  • Advice on how to build confidence with walking and balance.
  • Falls prevention advice relating to strength, walking and balance.
• Referral to Occupational Therapy services for a holistic assessment of the patient’s functional abilities and how to enable them to be as independent and safe as possible. This could include the provision of aids around the home.
• Referral to services which may provide additional support during times of worse functional ability. Many local councils and community NHS trusts will have access to a range of rapid response, enhanced support at home and telecare services that can support with maintaining safety and independence.
• Referral to community-based exercise options for patients who are fit enough to pursue this. Many local councils and voluntary sector groups offer exercise classes for older people run by exercise instructors with recognised qualifications in managing older people.
• Referral to services which support social inclusion. Having a problem with walking or balance can be a time where people become stranded in their own home or have less than their usual levels of social contact. Consideration for befriending services, social activity groups, University of the Third Age (U3A) can help to reduce the psychological impact of reduced mobility and help maintain quality of life.