Ataxia and Gait Disturbances

							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
       Failure to produce smooth intentional
        movements
   Gait Disturbance
       Inability to perform smooth coordinated gait
   May be described by patient as
    -Weakness               -Dizziness
    -Stroke                 -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                   Multiple Sclerosis
           Ethanol                   Thalamic disorders
           Sedative-hypnotics        Parkinson’s Disease
           Anticonvulsants           Cervical spondylosis
      Hyponatremia                   Posterior column disorders
      Cerebellar disorders           Peripheral neuropathy
      Tumor                          Vestibulopathy
      Hydrocephalus                  Disequilibrium of aging
      Cerebral vascular accidents
      Inborn errors of metabolism
    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                      Associated Symptoms
       Rapidity                        Headache
       Previous symptoms               Drowsiness
       PMH                             Dizziness
                                        Vertigo
       Medications
                                        Tinnitus
       Social
                                        Fever
            Alcohol intake
                                        Nausea/vomiting
            Illicit drug use
                                        Weakness
                                        Paresthesia
Ataxia and Gait Disturbances
   Physical Exam
       Gait testing        Full neurologic exam
                                 Cerebellar function
       Tandem gait                 Dysmetira
                                    Dysdiadochokinesia
                                    Dyssynergia
       Orthostatic VS
                                    Stewart-Holmes
                                     rebound sign
                                    Rhomberg
    Ataxia and Gait Disturbances
   Specific Populations
       Geriatric Patient
       Gait normally changes with age
            Shortened stride         Widened base
            Slow gait
       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
       May appear well, but       Drug Intoxication

        wobbly when sitting        Infection or inflammation

       Intoxications are most     Neoplasm

        common, followed by        Trauma

        infection/inflammation     Inborn errors of metabolism

       Ask about family member  Hydrocephalus
        home medications           Idiopathic

       PMH                     Disposition
       PFH                        Rule out life threatening processes

                                   Most are admitted

                                   Pediatric neurology consult
Questions?
1. Which of the following are the most frequently
encountered causes of gait disturbances?


a.   Intoxication
b.   Parkinson Disease
c.   Multiple sclerosis
d.   Disequilibrium of aging
e.   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.   Urine drug screen and ethanol level
b.   Head CT
c.   Neurologic exam with emphasis on cerebellar
     testing
d.   VDRL/RPR
e.   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.