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This is a clinician-written, evidence-based guide aligned to the MCC Examination Objectives. It is structured by clinical presentation — the way the MCCQE tests and the way patients actually present. Management reflects current Canadian guidelines (CMA, CFPC, CPS). Always cross-reference with institutional protocols and clinical judgment.
Key points
- Observe gait before touching the patient: base, stride, arm swing, turning, posture and need for aids.
- Acute ataxia is cerebellar stroke/haemorrhage until proven otherwise.
- Sensory ataxia worsens with eyes closed and has impaired vibration/proprioception.
- Parkinsonian gait has shuffling, reduced arm swing and en bloc turning; NPH has magnetic gait with cognitive and urinary symptoms.
- Gait problems require falls-risk assessment and medication review.
Approach to the Presentation
Classify gait by pattern and time course. Acute vertigo/ataxia needs central cause exclusion. Chronic gait disturbance often reflects multi-factorial disease: neuropathy, vision, vestibular dysfunction, Parkinsonism, arthritis, medications and cognition.
Differential Diagnosis
| diagnosis | likelihood | key features | distinguishing test |
|---|---|---|---|
| Cerebellar stroke/haemorrhage | must-not-miss | Acute wide-based gait, dysmetria, nystagmus, vomiting, headache, inability to sit/stand | Urgent CT/MRI brain and vascular imaging |
| Cervical/thoracic myelopathy | must-not-miss | Spastic gait, falls, hand clumsiness, hyperreflexia, sensory level, bladder symptoms | MRI spine |
| Parkinson disease | common | Shuffling gait, reduced arm swing, stooped posture, freezing, rest tremor/bradykinesia | Clinical |
| Sensory ataxia / neuropathy | common | Stomping gait, worse in dark, loss of vibration/proprioception, positive Romberg | B12/A1c and NCS if needed |
| Vestibular disorder | common | Veering, vertigo, nausea, nystagmus | Vestibular exam/Dix-Hallpike |
| Musculoskeletal/antalgic gait | common | Pain-limited limp, hip/knee/foot pathology | MSK exam and targeted imaging |
| Medication/alcohol effect | common | Sedatives, anticonvulsants, alcohol causing ataxia or falls | Medication review |
| Normal-pressure hydrocephalus | less common | Magnetic gait, urinary urgency/incontinence, cognitive decline | CT/MRI ventriculomegaly; specialist tap test |
| Frontal gait disorder | less common | Difficulty initiating, broad-based short steps, vascular cognitive impairment | Brain imaging |
Red Flags & Key History
Symptoms
Acute onset ataxia or inability to walk
Back/neck pain with spastic gait or bladder symptoms
Recurrent falls with injury
Cognitive decline plus urinary symptoms
Worse in dark
Signs
Truncal ataxia
Hyperreflexia/clonus/Babinski
Positive Romberg with proprioceptive loss
Shuffling with reduced arm swing
Approach to Investigation
First-line
Direct gait observationNormal walk, tandem, turns, chair rise, Romberg if safe.
Full neuro/MSK examPower, tone, reflexes, cerebellar signs, proprioception, vision, feet and joints.
Medication and falls reviewSedatives, antihypertensives, anticholinergics and alcohol.
Second-line
MRI/CT brainAcute ataxia, focal signs, NPH or central cause.
MRI spineMyelopathic signs or sensory level.
B12, A1c, TSH, CBCReversible gait contributors.
Specialist
Physio/OT/falls clinic/neurologyFalls risk, progressive neurological gait, Parkinsonism or suspected NPH/myelopathy.
Management Principles
MCC Ataxia (gait) objective + Canadian Parkinson guideline1
Emergency gait syndromes
- Activate stroke pathway for acute ataxia
- Urgent MRI spine for myelopathy/cord features
2
Chronic gait/falls
- Multifactorial falls assessment, medication reduction, vision/footwear review and strength/balance training
- Treat underlying neuropathy, Parkinsonism, NPH or MSK pain
3
Rehabilitation
- Physiotherapy, occupational therapy, gait aids and home safety interventions
Complications & Pitfalls
- Not watching the gait: the pattern is often diagnostic.
- Missing cerebellar stroke: acute inability to walk is central until proven otherwise.
- Ignoring myelopathy: spastic gait plus hand clumsiness needs spine MRI.
- Forgetting medications: sedatives and anticholinergics are common falls causes.
MCCQE1 Exam Tips
- 1Acute ataxia = posterior circulation stroke until proven otherwise.
- 2Positive Romberg = sensory or vestibular dependence, not cerebellar ataxia by itself.
- 3NPH gait is the earliest and most treatment-responsive feature.
- 4Parkinson gait has reduced arm swing and en bloc turning.
- 5Myelopathy causes spastic gait and hyperreflexia.
- 6Falls prevention is a management answer, not just diagnosis.
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