Combined Gait Disorder: a Diagnostic Challenge –A Case Report

Balneo Research Journal DOI: http://dx.doi.org/10.12680/balneo.2017.135 Vol.8, No.1, February, 2017

Combined gait disorder: a diagnostic challenge –a case report

Ioana Stanescu ¹, Gabriela Dogaru ¹

1. "Iuliu Hatieganu" University of Medicine and Pharmacy Cluj-Napoca, Romania 2. Clinical Rehabilitation Hospital Cluj-Napoca, Romania

ABSTRACT

Gait disorders are a major cause of functional impairment and morbidity, especially in the elderly population. Prevalence of gait disorders is higher in persons over 60: is estimated to be around 15% at 60 years of age and more than 50% in people > 80 years. Most gait disorders are multifactorial and have both neurologic and non-neurologic components. Neurological gait abnormalities result from focal or diffuse lesions occurring in the neural pathways linking the cortical motor centers to the peripheral neuromuscular systems. Nonneurological gait abnormalities include gait limitations caused by musculoskeletal, cardiac, or respiratory diseases. Assessment of a gait abnormality should include history, clinical presentation and additional diagnostic tests. Finding the ethiology of a gait disorder could be a challenge for the practitioners in many cases, requiring interdisciplinary cooperation.

Key words: gait disorder, neurologic evaluation, hyperuricemia

Balneo Research Journal DOI: http://dx.doi.org/10.12680/balneo.2017.135 Vol.8, No.1, February, 2017

Walking relies on a complex, than the prevalence of neurological gait simultaneous interaction of the motor abnormalities, including combined (20.8% system, sensory control, and cognitive versus 15.7%). Causes of pure non- functions. Gait disorders are a major cause of neurological gait abnormalities included in functional impairment and morbidity, more than 80% of cases arthritis or joint especially in the elderly population, where deformities, and less frequent chronic lung gait impairment is a common complain. Gait disease, angina pectoris , cardiac failure and troubles increases the risk of falls, fractures, peripheral vascular disease. Causes of loss of autonomy, institutionalization and neurological gait troubles include ataxic gait even death. Also, gait disturbances in the - the most frequent, followed by hemiparetic elderly are a risk factor for future , frontal, parkinsonian and neuropathic gait. cardiovascular disease and dementia. [3]. Prevalence of gait disorders is higher In the population-based Bruneck in persons over 60: is estimated to be around Study cohort (2), which includes persons of 15% at 60 years of age and more than 50% 60 to 97 years, gait abnormalities have in people > 80 years old [1] almost the same prevalence (32.2% of study Classification of gait abnormalities population), but neurological gait disorders could be based on clinical features of gait were more common (24.0% versus 17.4% (associated signs and symptoms) or on non-neurological gait abnormalities) in this etiology of gait disorder (underlying cause) study population. In this study, non- [2] neurological gait disorders were more Risk factors for gait and balance frequent in females and occurred disturbances include old age, vascular risk predominantly due to orthopaedic reasons. factors (e.g. high blood pressure or diabetes). Common causes of disturbed gait in Occurrence of cerebrovascular the elderly are neurological deficits, disease in the elderly, particularly of cerebral including sensory deficits (e.g. peripheral small vessel disease, also appears to play neuropathy and vestibulopathy), some role in the development of gait and neurodegeneration (e.g. cerebellar ataxia and balance impairment. parkinsonian syndromes), cognitive Most gait disorders are multifactorial impairment (e.g. degenerative dementia), and have both neurologic and non-neurologic joint degeneration (e.g. coxarthrosis) and components. Neurological gait abnormalities general loss of muscle mass (sarcopenia). result from focal or diffuse lesions occurring Furthermore, a fear of falling also in the neural pathways linking the cortical contributes to the gait disorder [4] . motor centers to the peripheral Assessment of a gait abnormality neuromuscular systems. should include history, clinical presentation Non neurological gait abnormalities and additional diagnostic tests [5]. include gait limitations caused by History should mention duration and musculoskeletal, cardiac, or respiratory course of gait disorder (episodic or diseases (eg arthritis, cardiac disease, chronic continuous, sudden onset or slow lung disease, and peripheral vascular progression), precipitating and exacerbating disease). factors (darkness, fobia), accompanying In The Einstein Aging study which symptoms and signs (dizziness, pain, etc), includes persons aged 70 and older, 35% of associated diseases (diabetes, heart failure), study participants were diagnosed with medication use and frequency of falls [6]. abnormal gaits: 41,6% presented with Clinical presentation allows neurological, 48,2% with non-neurological recognition of a typical gait pattern, such as and 10,1% with combined gait abnormalities hemiparetic / spastic, ataxic, steppage, [3]. In this population the prevalence of non- parkinsonian, dyskinetic, frontal, anxious or neurological gait abnormalities was higher psychogenic gait [5]. This includes precise

Balneo Research Journal DOI: http://dx.doi.org/10.12680/balneo.2017.135 Vol.8, No.1, February, 2017

clinical tests, such as “timed up-and-go test”, of his right ankle was noted, and the patient pull-test, measure of step length, walking complains of pain in both ankles and in the speed, etc. left knee. Additional paraclinical investigations Because the gait trouble did not most frequently used are neuroimaging improve, on next day the patient was studies, measure of nerve conduction admitted to the emergency department of the velocities, vestibular and visual testing. New local hospital with stroke suspicion. diagnostic modalities have evolved: dual tasking (patient is asked to walk while The clinical examination reveals at performing either a cognitive or a motor admission BP=140/80 mHg, rhythmic heart task), video gait analysis and functional rate 80/min, peripheral pulses were present al neuroimaging (fMRI and 18FDG-PET). lower limbs, skin pallor, painful tumefaction After using this complex algorithm in at the right ankle, without ecchimosis, . the management of a gait disorder, finding The neurologic examination reveals a the precise cause and the appropriate conscient and oriented patient, cranial nerves treatment could be a challenge for the examination was normal, in the upper limbs practitioners, and implies a multidisciplinary no motor deficit was detected, a mild motor approach. deficit of 4/5 BMRC grade is noted at right We present the case of a 81-year old lower limb, but the osteotendinous reflexes retired teacher, which complains of a sudden were normal and symmetrical and the plantar gait disorder with onset in new year eve. Gait responses were in flexion. No coordination became impossible, the patient fell severe troubles and no sensory disturbancies were unsteadiness, he can walk only with the aid noted. The patient can stand only with the of 2 persons, and drag his right leg. A fall is aid of 2 persons and cannot walk at all. reported with a right ankle strain and after Biochemical examinations confirm this episode, the patient refuses to walk. hyperglycemia at 149 mg/dl, elevated values His medical history include diabetes of CK at 608 UI/L, normal values of mellitus, arterial hypertension, cholesterol and triglycerides, normal hyperuricemia and Alzhemier dementia. The ionogram and elevated values of uric acid at patient is taking metformine, aspirin, 8,28 mg/dl. Hemogram were normal, and C allopurinol, candesartan and rivastigmine reactive Protein (CRP) was mildly elevated for his medical conditions. (1,5 mg/dl). A previous CT scan was performed 2 Emergency cerebral CT scan found years ago for a minor cranio-cerebral no acute ischemic lesions, cortical atrophy tramatism after an accidental fall, finding with related dilatation of the ventricular important cortical atrophy and normal system, diffuse ischemia of white matter pressure hydrocephalus, but the (leukoaraiozis). Cerebral MRI confirms the neurosurgical opinion at that time was for small vessel disease with lacunes and diffuse conservative treatment, and did not provide ischemia of the white matter, cortical atrophy any indication for shunting. with “ex vacquo” hydrocephalus, but no The patient refuses to go at the acute ischemic lesions ware detected of hospital, and remain at home for the first 24 diffusion / perfusion sequences. hours, being monitored by the family. Blood Radiography of the right ankle pressure was 130/80 mmHg, glycemia was reveals signs of an old fracture of the internal 145 mg/dl, no motor deficit was noted on the malleola. bed plane, the patient can sit without support, The psychologic examination eats normally, has no sphincterian confirms moderate cognitive dysfunction, incontinence, was conscious, but has loss of autonomy (GAFS score of 20, MMSE confusional episodes in the evening, as he score of 18/30), an important memory deficit usually has. He sleeps well at night. Swelling

Balneo Research Journal DOI: http://dx.doi.org/10.12680/balneo.2017.135 Vol.8, No.1, February, 2017

(level 1 of 5), but with normal executive BIBLIOGRAPHY functions (BREF score of 16/18). The patient receives aspirin, 1. Pinter D, Ritchie SJ, Doubal F, fraxiparine, metformin, rosuvastatin and Gattringer T, Morris Z, Bastin ME, del C. rivastigmine. Valdés Hernández M, Royle NA, Corley J, Three days later, the gait and stance Muñoz Maniega S, Pattie A, Dickie DA, disorder remains unchanged, but right ankle Staals J, Gow AJ, Starr MJ, Deary IJ, joint and left knee joint became swollen, Enzinger C, Fazekas F, Wardlaw J, Impact eritematous and very painfull. CRP was of small vessel disease in the brain on gait elevated at 3.3 mg/dl and uric acid at 10,34 and balance. Sci Rep. 2017; 7: 41637 mg/dl. An acute gout attack was suspected 2. Mahlknecht P. et al. Prevalence and and treated with colchicine, allopurinol and Burden of Gait Disorders in Elderly Men and high doses of. NSAIDs. Women Aged 60–97 Years: A Population- After treatment and pain resolution, Based Study. PLoS One 8, 1–7 (2013). kinesitherapy was initiated. After 5 days, the 3. Verghese J, LeValley A, Hall CB, patient improves his neurologic condition: he Katz MJ, Ambrose AF, Lipton RB. could stand with unilateral support, and Epidemiology of gait disorders in begin to walk with unilateral assistance, and community-residing older adults. J Am no motor deficit in his lower limbs was Geriatr Soc. 2006 Feb; 54(2):255-61 noted. 4. Jahn K, Heinze C, Selge C, The patient and his family has give Heßelbarth K, Schniepp R. Gait disorders in their consent for publishing his clinical data. geriatric patients. Classification and therapy. Although this patient had major Nervenarzt. 2015 Apr; 86(4):431-9 neurologic conditions which could lead 5. Jahn K, Zwergal A, Schniepp R. Gait independently to a gait disorder of disturbances in old age: classification, neurologic cause (cerebral small vessel diagnosis, and treatment from a neurological disease, Alzheimer dementia, perspective. Dtsch Arztebl Int. 2010 hydrocephalus), the actual cause of his gait Apr;107(17):306-15 disorder was a non neurologic condition. 6. Snijders AH, van de Warrenburg BP, Evaluation of the etiology of a gait disorder Giladi N, Bloem BR. Neurological gait should include besides a complete disorders in elderly people: clinical approach neurological examination, an osteo-articulary and classification. Lancet Neurol. 2007 Jan; and metabolic evaluation. 6(1):63-74