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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 • • • • • • • • • • • 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 • • • • Clear mentation and memory No language/speech dysfunction No cogwheel rigidity or dystonia No weakness or sensory deficit Phenomenology • • • • • • • 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: • • • • • 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 Fasano, Alfonso MD, PhD; Bloem, Bastiaan R. 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