Synopsis
Analyse stance, walking and limb coordination as integrated outputs of cerebellar, vestibular, sensory, pyramidal, extrapyramidal, peripheral and musculoskeletal systems while preventing falls during testing.
- Observe the patient rising, initiating, walking, turning and sitting; record aid and assistance. The gait starts before the formal corridor walk and safety takes precedence over completing every manoeuvre.
- Describe components rather than naming a gait alone: base, posture, stride length, step height, cadence, symmetry, arm swing, foot placement, trunk movement, turning and response to dual task.
- Cerebellar dysfunction can cause broad base, variable step timing, veering, impaired tandem gait, dysmetria, intention tremor, dysdiadochokinesia, nystagmus and scanning or slurred speech.
- Romberg testing principally challenges proprioceptive and vestibular compensation. Disproportionate worsening after eye closure supports sensory or vestibular ataxia, not a positive cerebellar test.
- Finger–nose and heel–shin testing require adequate power, range, vision and comprehension. Compare sides, vary target position and interpret error with the rest of the neurological examination.
- Parkinsonian gait features include reduced arm swing, stooped posture, shortened steps, start or turning hesitation and festination; early recurrent falls or marked symmetry should trigger review for atypical parkinsonism.
- A high-stepping gait suggests distal dorsiflexion weakness; circumduction may compensate for a stiff or weak leg; waddling and Trendelenburg patterns point toward proximal or hip-abductor dysfunction.
- Frontal or higher-level gait disorder may show difficulty initiating, short shuffling steps and apparent 'magnetic' feet despite better leg movement when seated, usually with other frontal or cognitive features.
- Medication, alcohol, sedatives, anticonvulsants, vision, footwear, vestibular disease, arthritis, orthostatic hypotension and fear of falling can all alter gait without a primary cerebellar lesion.
- Acute vestibular bedside testing is specialist-sensitive: use HINTS only in continuous acute vestibular syndrome, only when trained, and never to override obvious focal neurology or an inappropriate clinical context.
- Document what made walking unsafe and arrange an alternative functional assessment; 'gait not tested' without reason hides an important risk decision.
Key red flags
Marked truncal instability, broad stance, titubation and gait ataxia out of proportion to limb dysmetria points toward vermian or midline cerebellar dysfunction. Acute severe truncal ataxia can be a posterior-circulation emergency.
Ipsilateral limb dysmetria, intention tremor, dysdiadochokinesia and rebound with associated gait veering supports a cerebellar hemisphere lesion, after excluding weakness, proprioceptive loss and visual limitation.
Vertigo, nausea, spontaneous nystagmus and veering may accompany peripheral vestibular disease, but central pathology becomes more likely with severe truncal ataxia, vertical or direction-changing nystagmus, skew or other focal signs.
Investigation priorities
Identify the strength, tone, sensation, eye movement, extrapyramidal, vestibular and joint contributors to gait dysfunction.
Management branches
Abrupt gait failure, limb dysmetria or continuous vertigo with new neurological signs or severe truncal instability.
- Perform ABCDE and glucose, establish last known well and examine speech, gaze, nystagmus, skew, fields, face, all limbs, sensation, coordination and ability to sit or stand safely.
- Activate the stroke service for urgent brain and vascular imaging; do not reassure from a negative FAST screen or an early normal non-contrast CT when the syndrome remains coherent.
- Use HINTS only if the patient has the correct continuous acute vestibular syndrome and the examiner is trained; follow specialist reperfusion, monitoring and swallow decisions.