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Ataxia and Gait Disturbances Presented by A. Hillier, D.O. EM Resident St. John West Shore Hospital Ataxia and Gait Disturbances Generally symptoms of another disease Ataxia Gait Disturbance Failure to produce smooth intentional movements Inability to perform smooth coordinated gait May be described by patient as -Weakness -Stroke -Dizziness -Falling Ataxia and Gait Disturbances Pathophysiology Result from any condition that affects the central and peripheral nervous systems Ataxia: Types Motor ataxia Sensory ataxia Ataxia and Gait Disturbances Motor Ataxia Caused by cerebellar disorders Intact sensory receptors and afferent pathways Integration of proprioception is faulty Midline cerebellar lesions cause truncal ataxia Lateral cerebellar lesions cause limb ataxia Thalamic infarcts may cause contralateral ataxia with sensory loss Ataxia and Gait Disturbances Sensory Ataxia Failure of proprioceptive information to the CNS May be due to disorders of spinal cord or peripheral nerves Can be compensated for by visual inputs Ataxia and Gait Disturbances Differential Diagnoses Intoxication Ethanol Sedative-hypnotics Anticonvulsants Hyponatremia Cerebellar disorders Tumor Hydrocephalus Cerebral vascular accidents Inborn errors of metabolism Multiple Sclerosis Thalamic disorders Parkinson’s Disease Cervical spondylosis Posterior column disorders Peripheral neuropathy Vestibulopathy Disequilibrium of aging Ataxia and Gait Disturbances Definitions Best to use descriptive terms for gait disturbances Motor ataxia: wide-based with irregular, unsteady steps Sensory ataxia: abrupt leg movement and slapping impact of feet Festinating gait: narrow-based miniature shuffling steps. Commonly seen in PD Ataxia and Gait Disturbances Apraxic gait: difficult initiating gait. May be seen in NPH and PD Equine gait: high stepping gait due to peroneal weakness Functional gait disorder: unable to walk normally despite intact motor, sensory and cerebellar function. Often a conversion disorder called astasia-abasia Ataxia and Gait Disturbances History Onset Rapidity Previous symptoms PMH Medications Social Alcohol intake Illicit drug use Associated Symptoms Headache Drowsiness Dizziness Vertigo Tinnitus Fever Nausea/vomiting Weakness Paresthesia Ataxia and Gait Disturbances Physical Exam Gait testing Full neurologic exam Tandem gait Orthostatic VS Cerebellar function Dysmetira Dysdiadochokinesia Dyssynergia Stewart-Holmes rebound sign Rhomberg Ataxia and Gait Disturbances Specific Populations Geriatric Patient Gait normally changes with age Shortened stride Slow gait Widened base Senile gait may represent neuronal loss, reduced proprioception, slowing of corrective responses and weakness Can also be present in other neurodegenerative diseases Occurs in ~25% of elderly population Treatment Symptomatic Usually admitted to rule out other life-threatening entities Ataxia and Gait Disturbances The Alcoholic Patient Any gait abnormality in an alcoholic patient should raise concern about nutritional deficiencies If acute ataxia is associated with confusion and eye movement abnormalities Wernicke encephalopathy needs to be considered Still other intracranial pathology needs to be ruled out Treatment IV hydration, Vit B1 and dextrose Most often need to be admitted Ataxia and Gait Disturbances Children Differential diagnoses Drug Intoxication May appear well, but Infection or inflammation wobbly when sitting Neoplasm Intoxications are most Trauma common, followed by Inborn errors of metabolism infection/inflammation Ask about family member Hydrocephalus Idiopathic home medications PMH Disposition Rule out life threatening processes PFH Most are admitted Pediatric neurology consult Questions? 1. Which of the following are the most frequently encountered causes of gait disturbances? a. b. c. d. e. Intoxication Parkinson Disease Multiple sclerosis Disequilibrium of aging All of the above 1. Which of the following are the most common causes of gait disturbances? E All of the above are true. These are the most commonly seen etiologies for gait disturbances. 2. It is best when describing a patients’ gait to a colleague, that you use terms such as apraxic, festinating and equine. T or F? False. It is better to use descriptive terms when describing gait, because different terms may mean different things to different people. Similar to the use of lethargy, obtundation and stupor. 3. A 42 year old alcoholic patient develops an ataxic gait in association with confusion and ocular changes. What is this syndrome called? Wernicke encephalopathy. It is the syndrome of ophthalmoplegia, confusion and ataxia. Due to thiamine deficiency from chronic malnutrition Treatment is hydration, thiamine and glucose. 4. The most common cause of childhood ataxia is inflammatory. T or F? False Inflammatory is the 2nd leading cause of childhood ataxia due to infection or immunizations Unfortunately intoxication is the most common. 5. Which of the following are probably not necessary to help determine the etiology of ataxia in a child? a. b. c. d. e. Urine drug screen and ethanol level Head CT Neurologic exam with emphasis on cerebellar testing VDRL/RPR Gait testing 5. Which of the following are probably not necessary to help determine the etiology of ataxia in a child? D All of the above are important in trying to determine the etiology of ataxia in an adult. However, testing for neurosyphilis in a child is probably unnecessary.