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Gait Disorders (Chapter 10) Aspen 2019 Hallett: Gait (no videos) Summer 2020 Gait Disorders (Chapter 10) Aspen 2019 1 Extent of the Problem • Major problem in the population, especially in the elderly • Significant cause of disability • Common causes include stroke, peripheral neuropathy, brain or spinal cord trauma, Parkinson’s disease 2 1 Hallett: Gait (no videos) Summer 2020 Capability for Gait • Highly complex motor control problem • Balance – Assume upright position, support, react to perturbations • Locomotion – Initiate steps, steps, adapt steps to circumstances 3 Multiple levels of control • Stepping machinery in the spinal cord • Whole brain gets involved, including cerebral cortex – Walking requires some attention – Why else would it be difficult to walk and chew gum at the same time? – “Stops walking when talking” test can bring out abnormalities • Lundin-Olsson et al. 1997 4 2 Hallett: Gait (no videos) Summer 2020 CLR Nutt, Bloem, Giladi, Hallett, Horak, Nieuwboer Lancet Neurology 2011 5 Gait Cycle 6 3 Hallett: Gait (no videos) Summer 2020 Elemental Descriptions of Gait • Stride length • Cadence • Deviation from direction of travel • Base (standing and walking) • Angular movement of joints • Variability • Rigidity/fluidity • Initiation and maintenance of walking • Adaptability » Modified from Nutt 2001 7 Elemental Disorders of Gait • Weakness: myopathy, neuropathy • Dysmetric: ataxia, chorea • Stiff/rigid: spasticity, parkinsonism, dystonia • Veering: vestibular disorders • Freezing: parkinsonism,frontal gait disorder – Motor block, lack of movement – Rapid side to side shifing of weight (slipping clutch syndrome) • Marché à petit pas: parkinsonism,frontal gait disorder • Festination: parkinsonism » Modified from Nutt 2001 8 4 Hallett: Gait (no videos) Summer 2020 Anatomical/Physiological Classification of Gait • Lowest-level disorders – Muscle, nerve, root, elemental sensory deficits (vision, neuropathy) • Middle-level disorders – Corticospinal tract, cerebellum, basal ganglia • Highest-level disorders – Cerebral hemispheres, functional (psychogenic) » Nutt, Marsden and Thompson 1993 9 Lowest-level Gait Disorders • Myopathic • Peripheral neuropathic • Sensory ataxic • Vestibular • Visual deficits 10 5 Hallett: Gait (no videos) Summer 2020 Gait patterns with Weakness • Steppage: foot drop with compensatory increased flexion of hip and knee • Waddle: weakness of hip abductors leading to dropping of the opposite side of the pelvis 11 Middle-level Gait Disorders • Hemiplegia and paraplegia (spasticity) • Ataxia • Parkinsonian • Dystonic • Choreic • Myoclonic 13 6 Hallett: Gait (no videos) Summer 2020 Hemiplegia and paraplegia (spasticity) • Hemiparetic: Stiff extended leg that circumducts during swing with scraping of the toe • Paraparetic: Stiffness of both legs with scissoring 14 Stiff-legged Gait • Stiff-person syndrome, reduction of range of motion of all joints including spine 17 7 Hallett: Gait (no videos) Summer 2020 Parkinsonian gait • First manifestation is that gait slows, more due to step length than cadence • Lack of arm swing, tremor of hands • Short, shuffling, slow steps possibly with festination • En bloc turns • Narrow base • Poor balance • Freezing that may improve with external cues 19 Lancet Neurol 2011; 10: 734–44 22 8 Hallett: Gait (no videos) Summer 2020 23 “We propose that this new gait pattern, which we term “gunslinger’s gait,” may result from a behavioural adaptation, possibly triggered by KGB or other forms of weapons training where trainees are taught to keep their right hand close to the chest while walking, allowing them to quickly draw a gun when faced with a foe.” 25 9 Hallett: Gait (no videos) Summer 2020 Dystonic gait • Action dystonia of the legs with walking, often inversion of the foot • Can affect the trunk and arms • Walking backwards might be better than forwards 26 30 10 Hallett: Gait (no videos) Summer 2020 Note also manganese toxicity itself and methcathinone (ephedrine) toxicity 31 33 11 Hallett: Gait (no videos) Summer 2020 Hobby Horse Gait of DYT4 35 Ataxic gait • Poor balance • Irregular stepping is principal feature • Slow with reduced stride length • Normal and then widened base • Note that similar patterns, but mild, are seen in essential tremor 37 12 Hallett: Gait (no videos) Summer 2020 Choreic gait • Dancing gait • Uncoordinated stepping 39 Myoclonic gait • Bouncy gait 41 13 Hallett: Gait (no videos) Summer 2020 Orthostatic Myoclonus Seen mainly in the setting of other gait disorders, such as frontal gait disorder Treatable, at least to some extent, with clonazepam Glass, G. A. et al. Neurology 2007;68:1826-1830 43 Gait findings similar to those in ataxia 46 14 Hallett: Gait (no videos) Summer 2020 Highest-level Gait Disorders • Frontal gait disorder • Cautious gait • Functional (Psychogenic) gait • Cognitive disorders 47 Frontal Gait Disorder • Short steps, shuffling, hesitation on turns with some disequilibrium and some initiation failure (marché à petit pas) • Can involve only the lower part of the body, called “lower-half parkinsonism” 48 15 Hallett: Gait (no videos) Summer 2020 Frontal Gait Disorder versus Parkinson Gait Frontal Gait Disorder Parkinson Gait • Wide-based • Narrow base • Normal arm swing • Reduced arm swing • No improvement with sensory • Improvement with sensory cues cues • Minimal response to L-DOPA • Good response to L-DOPA • Lack of festination • Possible festination From Alberto Espay 49 “Frontal Gait Disorders” • Etiologies include subcortical arteriosclerotic encephalopathy (Binswanger’s disease), multi- infarct state, normal pressure hydrocephalus, Frontotemporal dementia, corticobasal degeneration, PSP (primary progressive freezing gait) 50 16 Hallett: Gait (no videos) Summer 2020 55 Normal pressure hydrocephalus Atrophy 56 17 Hallett: Gait (no videos) Summer 2020 35 subjects with clinically confirmed iNPH and 45 matched healthy controls Best measures were simple linear measurements of vertical or horizontal frontal horn diameters 57 Underlying etiology might be PSP, AD, DLB, etc. 59 18 Hallett: Gait (no videos) Summer 2020 Neurosurgery on-line Of 328 total patients, 45% had an alternative diagnosis. 11% of all patients improved with treatment of an alternative diagnosis. Of 87 patients with treatable conditions, the highest frequency of pathologies included sleep disorders, and cervical stenosis, followed by Parkinson disease. Only 26% underwent shunting and those had a good response 62 “Fifty years is too long for our profession to continue recommending surgery for a disease whose very existence has never been subjected to a critical test.” “…I think that equipoise demands a moratorium on all shunting procedures for “iNPH.” 63 19 Hallett: Gait (no videos) Summer 2020 Cautious Gait • Widened base with slow, short steps • Turns en bloc • Arms tensed looking for support, and gait improves significantly with support • Anxiety • No freezing or shuffling • “like walking on ice” 64 Functional gait • AKA astasia-abasia, acrobatic gait • Unusual patterns of stance and gait, often inconsistent, and often demonstrating excellent balance • Common are: lurching without falls, sudden knee buckling, extreme slow motion • Positive psychiatric features 66 20 Hallett: Gait (no videos) Summer 2020 VIDEOS! 67 Cognitive Disorders • While gait is somewhat automatic, it does require some cognitive control • Gait may well deteriorate under dual task conditions 71 21 Hallett: Gait (no videos) Summer 2020 72 Multifactorial Etiology • Disorders of gait are often multifactorial – Particularly in the elderly! 73 22 Hallett: Gait (no videos) Summer 2020 Therapeutic Considerations • Etiologic considerations come first! – Treatable neuropathies – Normal pressure hydrocephalus? – Parkinson disease (in addition to regular treatment) • Physical therapy • Dance therapy • Therapy for Gait freezing 74 Physical Therapy Rutz & Benninger 2020 PM&R •All Category A recommendations –Cueing, auditory and visual – Treadmill walking – Aquatic obstacle training – Supervised slackline training 75 23 Hallett: Gait (no videos) Summer 2020 76 FOG Treatment Gao et al. 2020 Transl Neurodegen • Compensation strategies • Pharmacological – Dopaminergic drugs – Promising: istradefylline, rasagiline • Non-pharmacological – Invasive and non-invasive brain stimulation – Spinal cord stimulation – Vagus nerve stimulation – Physical therapy 77 24 Hallett: Gait (no videos) Summer 2020 Using external cues Using internal cues Changing balance requirements Altering the mental state Motor imagery or action observation New walking pattern 78 Small number of cases and possible biases recognized Maybe a benefit short term, but lost in long term (>12 months) 80 25 Hallett: Gait (no videos) Summer 2020 PPN DBS Snijders et al. Ann Neurol 2016;80:644 81 Page 278 82 26 Hallett: Gait (no videos) Summer 2020 p. 5 patients with PD had significant improvement at 6 months, including FOG 83 Movement Disorders 2020 on‐line 6 patients, all failed to have any benefit 84 27 Hallett: Gait (no videos) Summer 2020 Conclusion • Many different types of gait disorders – Leading to significant disability – Increasing possibility for falls • Therapies are often insufficient • There is much more work to do in this area 85 Questions? 86 28.
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