The 'get-up and go' test,1 devised to assess falls risk in the elderly, can be a useful tool for the busy GP.
The test requires the patient to rise from a waiting-room style armchair and walk 3m (with usual walking aids), turn and return to the chair.
The presence of slowness, hesitancy, abnormal trunk or arm movements, staggering or stumbling is used to grade the patient from 1 (normal) to 5 (severely abnormal). A score of 3 (mildly abnormal) or more suggests a risk of falling.
The original test was difficult to standardise, so it was modified as the 'timed-up and go' test.2 A slow time suggests an increased risk of falls.
Although uncertainty remains over the scoring criteria,3 the basic test provides a useful framework to assess a patient with poor mobility, instability and falls.
When observing a patient sitting, standing, walking and turning, the GP must piece together the clues that may explain the tendency to fall.
- Blank, 'mask-like' facies is a sign of parkinsonism, as is the 'pill rolling' tremor seen at rest. Checking for cogwheel rigidity (parkinsonism) or past pointing (cerebellar lesions) can help to differentiate pathological tremors from benign essential tremor.
- Vision plays a vital part in balance. Simple observations, such as whether spectacles are clean and up to date or whether there are cataracts, may be useful. Multifocal lenses may increase the risk of falls.4
- Inappropriate or worn footwear can increase the chance of a fall.
- Note that environmental factors, such as loose rugs at home, are important contributors to falls.
- Pain on standing is likely to indicate arthritic pains, but may be due to foot conditions.
- Difficulty standing indicates proximal myopathy, which could be caused by osteomalacia, long-term steroid use, hypothyroidism, diabetes or potassium deficiency.
- Leg and spinal deformities can impair balance and mobility. Standing (and walking) with hips flexed and externally rotated is seen in hip osteoarthritis. Varus and valgus deformities can be present in knee arthritis. Severe kyphosis is seen in osteoporosis.
- Marked unsteadiness while standing (with eyes open) is a sign of cerebellar dysfunction.
- Unsteadiness while standing (with eyes closed) indicates a loss of joint proprioception. This is a positive Romberg's test.
Consider the speed, asymmetry, step characteristics and stability of the patient's gait.
- With age, it is normal for walking to slow because step length shortens and step rate decreases.
- In Parkinson's disease, there can be a delay in initiating walking and gait can be festinant.
- Painful joints may cause a one-sided limp, minimising stance time on the affected leg.
- A peroneal nerve palsy (owing to trauma to the nerve or mononeuropathy, such as in diabetes) or S1 nerve root compression (commonly owing to a vertebral disc prolapse) causes unilateral foot drop; the knee is lifted high to compensate.
- Hemiparesis (such as in stroke survivors) will cause unilateral spasticity. The affected leg may drag or be swung from the hip. The arm on the same side may also be held in a fixed flexed deformity.
Step width, length and height
- Small, shuffling steps with stoop and unilateral loss of arm swing are typical of parkinsonism.
- Small paces with an upright posture and marked arm swing are seen in diffuse cerebrovascular disease.
- Dorsal column lesions or peripheral neuropathy will cause a high-stepping, wide-based gait, owing to a loss of proprioception. Possible causes include diabetes, vitamin B12 deficiency and alcoholism.
- Cerebral palsy and multiple sclerosis can result in a scissoring gait, where the feet cross the midline, owing to spasticity in the hip adductor muscles.
- Proximal myopathy can cause a waddling, duck-like gait.
- The righting reflexes that maintain postural stability deteriorate with age and sway increases.
- Cerebellar ataxia is a broad-based gait where the patient cannot walk in a straight line and may be unable to stand without falling.
- A lurching, disjointed gait suggests apraxia. This loss of gait co-ordination is due to cortical pathology, such as in cerebrovascular disease or normal pressure hydrocephalus.
Slowness and difficult turning are signs of parkinsonism. The consequence of a fall can be fear of further falls. This can lead to a fearful gait, with a reduced step length and rate, increased double stance time and increased stride width.
At its extreme, fear can cause the patient to become reliant on using furniture for support and incapable of walking outside of the home.
The 'get-up and go' test has its limitations, but it highlights the importance of observation in assessing patients with mobility problems.
The small size of consulting rooms and the brevity of consultations makes detailed falls assessment difficult for GPs, but getting patients up and walking can provide a significant amount of useful clinical information in very little time and space.
- Dr Jopling is a GP in London. Thanks to Dr Julian Oram for reviewing this article
1. Mathias S, Nayak USL, Isaacs B. Arch Phys Med Rehabil 1986; 67: 387-9.
2. Podsiadlo D, Richardson S. J Am Geriatr Soc 1991; 39: 142-8.
3. Nordin E, Lindelof N, Rosendahl E et al. Age Ageing 2008; 37: 442-8.
4. Lord SR, Smith ST, Menant JC. Clin Geriatr Med 2010; 26(4): 569-81.