Hallett: Gait (no videos) Summer 2020
Gait Disorders (Chapter 10) Aspen 2019
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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
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Capability for Gait
• Highly complex motor control problem • Balance – Assume upright position, support, react to perturbations • Locomotion – Initiate steps, steps, adapt steps to circumstances
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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
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CLR
Nutt, Bloem, Giladi, Hallett, Horak, Nieuwboer Lancet Neurology 2011
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Gait Cycle
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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
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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
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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
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Lowest-level Gait Disorders
• Myopathic • Peripheral neuropathic • Sensory ataxic • Vestibular • Visual deficits
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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
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Middle-level Gait Disorders
• Hemiplegia and paraplegia (spasticity) • Ataxia • Parkinsonian • Dystonic • Choreic • Myoclonic
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Hemiplegia and paraplegia (spasticity)
• Hemiparetic: Stiff extended leg that circumducts during swing with scraping of the toe • Paraparetic: Stiffness of both legs with scissoring
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Stiff-legged Gait
• Stiff-person syndrome, reduction of range of motion of all joints including spine
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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
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Lancet Neurol 2011; 10: 734–44
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“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.”
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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
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Note also manganese toxicity itself and methcathinone (ephedrine) toxicity
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Hobby Horse Gait of DYT4
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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
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Choreic gait
• Dancing gait • Uncoordinated stepping
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Myoclonic gait
• Bouncy gait
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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
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Gait findings similar to those in ataxia
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Highest-level Gait Disorders
• Frontal gait disorder • Cautious gait • Functional (Psychogenic) gait • Cognitive disorders
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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”
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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
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“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)
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Normal pressure hydrocephalus Atrophy
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35 subjects with clinically confirmed iNPH and 45 matched healthy controls
Best measures were simple linear measurements of vertical or horizontal frontal horn diameters
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Underlying etiology might be PSP, AD, DLB, etc.
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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
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“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.”
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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”
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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
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VIDEOS!
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Cognitive Disorders
• While gait is somewhat automatic, it does require some cognitive control • Gait may well deteriorate under dual task conditions
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Multifactorial Etiology
• Disorders of gait are often multifactorial – Particularly in the elderly!
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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
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Physical Therapy Rutz & Benninger 2020 PM&R
•All Category A recommendations –Cueing, auditory and visual – Treadmill walking – Aquatic obstacle training – Supervised slackline training
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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
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Using external cues Using internal cues Changing balance requirements Altering the mental state Motor imagery or action observation New walking pattern
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Small number of cases and possible biases recognized Maybe a benefit short term, but lost in long term (>12 months)
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PPN DBS
Snijders et al. Ann Neurol 2016;80:644
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Page 278
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p. 5 patients with PD had significant improvement at 6 months, including FOG
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Movement Disorders 2020 on‐line
6 patients, all failed to have any benefit
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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
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Questions?
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