9.18a Gait, Especially in Old Age

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18a. Gait and Body position- Update 12 Septr 2021.

(Note: wheelchair info & advice at end.)

  The way we walk, or one's gait, depends on brain, spinal cord, muscle, bones and joints, and it also is affected by the pain walking may cause. The way normal persons walk is pushing off with back of heel and coming down, on first-touch to ground, on big toe of opposite foot. The 2-step walking cycle is 1 meter (c. 3 feet) in length from the pushing-off heel to the next alternate toe-tip, heel-to-ground touch and ranges from slow 2 miles per hour to fast 4 mph (3.2 to 6.4 km per hour).

The normal gait cycle, defined as the period between successive points at which the heel of the same foot strikes the ground, is illustrated in the below the Fig. The cycle is initiated by the heel strike of the right foot. The stance phase, during which one foot is in contact with the ground, occupies 60 to 65 percent of the cycle. The swing phase begins when the left toes leave the ground. For 20 to 25 percent of the walking cycle, both feet are in contact with the ground (double-limb support). In later life, when the steps shorten and the cadence (the rhythm and number of steps per minute) decreases, the proportion of double-limb support increases. Surface electromyograms show an alternating pattern of activity in the legs, predominating in the flexors during the swing phase and in the extensors during the stance phase.

Figure

The normal gait cycle. See text for details.

The old-age gait is small steps where the feet are not lifted enough, (a shuffle) so that the old person easily trips over low obstructions, and as it worsens it gets difficult to keep balance and one looks to hold on to nearby support. It is caused by the increasing leg muscle weakness and discoordination due to loss of brain and spinal neurons and to loss of muscle motor units in legs partly caused by the damage to motor neurons by wear and tear of living but also a result of poor posture during standing and walking and poor nutrition in the nervous system due to unhealthy overeating. It leads to a premature loss of ambulatory power, to falls, to fractures and to premature death. Just because one is becoming old is no good reason to walk that way; so one should strive to lift feet to clear obstacles, to straighten back and look ahead, and not to shuffle along.

The below diagram illustrates the changes in posture and gait that may accompany aging (“senile gait”). With aging (figure on left), there may occur a decrease in the length of the stride, and the excursion of the hip, and decrease in the elevation of the toes of the forward foot and the heel of the rear foot; also, a decrease in shoulder flexion on forward arm swing, and elbow extension on backward swing. Not shown here; but important to keep in mind, one's old age causes one, as a bad habit, unthinkingly, to walk with head down and bent back leading in some old women to the cervical or dowager hump and, in all persons, to accidents of forward banging into things they do not notice. One should oppose this bad habit by conscious reversal and constant alertness to the bad habit. (Like the famous old Japanese song "ue o muite, arukou" ("Walk with your head up.”)

Below on left Old Age Gait:

Figure

Below: Schematic depiction of three of the main disorders of gait. A. The Hemiplegic gait due to weakness on the right side of body., B. The Spastic, or scissors gait with close approximation of the feet and legs and flexion at the knees seen in cerebral palsy., and The Parkinsonian gait (not shown) with forward position of the upper torso, flexion of the neck and elbows, and short-stepped gait (A late phase of parkinsonism). This may be contrasted with the similar but distinctive gait of aging (C. In the below-figure.)

The best for good gait (and good health) is keeping  or achieving a healthy, low body weight (BMI 17 - 20), using blood test to monitor the deficiencies that become common in old age, and, against fractures, eating adequate calcium (Yogurt and low-fat, low-Na milk and take calcium and vitamin D). Also to go for low blood test LDL (<60) cholesterol by healthy eating and use of Statin lower-cholesterol pill, and for normal blood glucose by good low calorie eating. And be physically active, giving up automobile in favor of walking but also walking carefully to avoid falls. And, as I recently learned, hold on to support when you are on a moving vehicle like a subway train that may suddenly lurch and throw you to the floor.   Do not talk too much while you walk, because talk distracts attention and leads to accident. And as you age past 70, make an active effort to "walk young." It means picking up your feet so as not to shuffle, keeping a wide base on your feet, walking as briskly fast as is safe, keeping your stance erect by straightening your back to avoid the "crouched over" look, and always being alert, with eyes and ears and feel, to your place, position and balance, and to other things and persons in your vicinity.  Also, be sure your footwear is flat-soled, lightweight, and well ridged on bottom. And try to walk more on your toes than heels. And always keep the possibility of falling down and injuring head, bones and muscles, on your brain.

Body position: Neurologically the 2 main body positions - standing erect and lying flat - are part of 2 opposite neurological states of the autonomic nervous system: 1) in the erect position the sympathetic system nerves are dominating, which means the body is flooded with epinephrine (adrenaline) and norepinephrine which prepares an animal for fight or flight; and, 2) Lying flat at rest, the parasympathetic system is dominating - its neurotransmitters, mainly acetylcholine, and vagus nerve stimulation oppose the fight or flight state and favor rest and digest. This could have significance for good health practices generally. First, a reason the body needs several hours of sleep a day is not simply lack of sleep (We only need a few hours sleep a day) but lack of the restful, digest-full, healing parasympathetic position part of a 24-hour day. It means even if you do not always sleep; you should at least lie down several hours in a 24-hour day. (Not necessarily in one time segment.) Also the constant sympathetic heart and blood pressure stimulation you get with not-enough lying flat worsens hypertension (high BP) and heart disease. And it makes for glaucoma increased pressure in the eyes because the sympathetic nerve dominance of a 24-hour day with not-enough lying flat leads to too much eye pupil dilatation that ups internal eye pressure. Then, too, when you lie flat you eat less and thus get a lower LDL cholesterol and less overweight. So balance your 24-hour day with selected hourly lie-flat reposes. It does not always need to be on a bed or mat; I often stay overnight in my office and then I use 3 or 4 office stools shoved together for my lie-flat reposes.

Also to mention is the ataxic gait best noted in drunks. (Cf. the 1940s Hollywood character actor, Jack Norton, who, even though he was a teetotaler, perfectly simulated the drunken walk seen best in 1944 movie Cover Girl, even though he was a teetotaler.) It is a lurching gait where the walker seems not to control his stop points and so tends to lurch forward esp. when getting up from a chair or making a turn. It is caused by dysfunction of the cerebellum and disease of peripheral sensory nerves.  A good test for this dysfunction is the Romberg test (after Moritz Romberg, German-Jewish late 19th C. neurologist): the patient is asked to stand erect with feet together and lights are turned down; a positive test is the subject losing his or her balance and it worsening in the dark. It means trouble in either the spinal cord and peripheral nerves to feet or in cerebellum.  When not caused by drugs or alcohol, this dysfunction develops gradually and once it starts to get noticed one has to become very careful or one will lurch into a wall or other hard place, or even off a railway station platform. Drug- and alcohol-caused ataxia are acute and temporary and a sure sign one is overdosed and ought to be put to bed.
Finally to mention is the so-called antalgic gait of a person for whom stepping is painful because of arthritis of hip or knee or of soreness of leg bones or muscles. There are several variations depending on the source of the pain but all present what I call "a very careful walk", i.e., as though the person is walking over uncooked eggs in shell and trying not to crack then. (Or like the late entertainer, Tiny Tim, trying not to by a tiptoe through the tulips. Such a gait becomes strongly influenced by the pain conditioning effect, i.e., the person becomes so frightened of causing pain that it affects his gait even though the gait may not cause immediate pain. This is important to understand because self-psychoanalysis can de-condition one against the affect. Depending on the source of the pain the person also assumes unusual stances, e.g., the bent back of lumbosacral hip pains. Such persons initiate the walking slowly, may have an obvious limp, step lightly and they never go too fast or jump in the air. They are not nimble. 
    Wheelchair: At some point, in many persons' lives, a wheelchair may become a livelihood-lifechanger. The important points about purchasing a wheelchair is lightwaight. Most wheelchairs in hospital weigh around 25 kgs, which is much too heavy for carrying. However, you can buy a 9-kg aluminum, sideways fold-up wheelchair which makes a tremendous difference. Wheelchairs should should be used in situations where they can take you between one place to another where it would be very inconvenient to walk too slowly or painfully. I am not commenting here about motorized wheelchairs. These may obviously be useful for a life-long chronic loss of gait.  Also a wheelchair is frequently used as part of “wheelchair-walking” where one uses the wheelchair to take the load off one’s body when legs are weak or walking is painful. One then walks, leaning forward on the chair and pushing it forward. It is very convenient for shopping.
          END OF CHAPTER. To read next click 9.18b Unconsciousness, Coma and Related States