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An Unusual Gait Abnormality:
Placing hands over head or pulling up pants
improves walking
Tara Kimbason, PGY 3
Feb 21, 2015
Objectives
• To learn from an unusual gait abnormality case
• Discuss ways to approach a challenging case
• Discuss diagnosis and review of the condition
Disclosures
The authors report no disclosures
Tara Kimbason, PGY 3
Mentor: Efrain Perez-Vargas, MD
PD: Jonathan Hosey, MD
History
• An 83-year-old right-handed male with h/o well-controlled
essential tremors who complains of walking problems that he
noticed 5 years ago with slowness and decreased balance
• Associated with upper and lower extremity weakness, fatigue,
intermittent clumsy hands and rigidity
• “Extreme fatigue" with walking
- feels like “a car without an engine”
- takes frequent rest periods
- worsens with wearing long pants or placing his wallet or
keys in his pockets
- improves with placing his hands over his head or pulling
the waistband off of his body
History
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No head/neck trauma, or head/neck/back pain
No difficulty initiating or stopping gait; no falls
No visual disturbance, dysarthria, dysphagia
No autonomic symptoms
No sleep-wake dysfunction
No dementia or hallucinations
PMHx: essential tremors, depression, hypertension
Medications: propranolol, SSRI
Allergies: NKDA
Social Hx: no smoking or EtOH abuse
Family Hx: no h/o vascular, autoimmune, neurologic disorders
Focused Neurologic Examination
Neurologic Examination:
other pertinent negatives
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Clear mentation and memory
No language/speech dysfunction
No cogwheel rigidity or dystonia
No weakness or sensory deficit
Phenomenology
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A slowly progressive gait difficulty
Bradykinesia
LE more affected > UE
Asymmetry of mild incoordination
Postural instability
Reduced step length and height
Gait improves with sensory tricks
Differential Diagnosis
• Parkinsonism:
Idiopathic Parkinson’s disease
Progressive supranuclear palsy
Multiple system atrophy
Corticobasal degeneration
Other parkinsonian syndromes
• Multi-infarct states:
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Vascular parkinsonism
Gait ignition failure
NPH
Frontal lobe lesions (mass, infarcts)
Idiopathic
Functional gait disorder with sensory trick
Gait apraxia
Investigations and Results
• Thyroid function
- wnl
• MRI of brain and spine
- small vessel ischemic changes in white
matter
- no spinal stenosis or cord
enhancement
• EMG of lower extremities
- no evidence of myopathy or motor neuron
involvement
Parkinsonism Diagnostic Criteria
1.
2.
3.
4.
5.
6.
Tremor at rest
Bradykinesia*
Rigidity
Loss of postural reflexes*
Flexed posture
Freezing (motor blocks)
Definite: 2+ (include tremor or bradykinesia)
Probable: tremor or bradykinesia
Possible : 2+ (3 to 6)
Diagnosis
Parkinsonian gait
• Impairment of scaling function
and defective internal cueing
-amplitude reduction
-reduced step height
-reduction/abolishment of
automatic synkinetic arm
swing
Probable Parkinson disease
• Asymmetrical arm swing
and step-length
• Responded to levodopacarbidopa
• Gait is more variable due to
lack of automaticity
Gait Abnormality in Parkinson Disease
• A dopaminergic deficiency plays a major role in
levodopa-responsive cases, possibly in regions
outside the putamin
– improve bradykinesia and rigidity but not freezing
• BG dysfunction  failure in generating
adequate movement amplitude - “sequence
effect”
• Precise pathophysiology of freezing gait
unknown (dysfunction in organized network
involving frontal lobe, NE deficiency)
Conclusion
• Diagnosis can be challenging with atypical
presentation
• Correctly diagnosing neurologic cases
requires a combination of excellent
observational skills, history taking,
examinational skills, and appropriate
diagnostic evaluations
References
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Learning in Neurology: Movement Disorders. October 2013 - Volume 19 - Issue 5, p 1344–1382
Fahn S and J. Jankovic Principles and Practice of Movement Disorders. Churchill
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Denes G, mantovan MC, Gallana A, Cappelletti JY. Limb-kinetic apraxia. Mov
Disord. 1998 may; 13(3):468-476. PubMed PMID: 9613739
Quencer K, Okun MS, Crucian G, Fernandez HH, Skidmore F, Heilman KM. Limbkinetic apraxia in Parkinson disease. Neurology 2007;68:150–151.
Landau WM, Mink JW. Is decreased dexterity in Parkinson disease due to apraxia?
Neurology 2007;68:90–91.
Leiguarda R, Marsden CD. Limb apraxias: higher-order disorders of sensorimotor
integration. Brain 2000;123:860–879.
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Zadikoff C, Lang AE. Apraxia in movement disorders. Brain 2005;128:1480–1497.
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Questions?
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