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 DisturbancesDifferential 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

Tandem gait

Orthostatic VS

Full neurologic exam 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 Widened baseSlow 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

May appear well, but wobbly when sitting

Intoxications are most common, followed by infection/inflammation

Ask about family member home medications

PMH PFH

Differential diagnoses Drug Intoxication Infection or inflammation Neoplasm Trauma Inborn errors of metabolism Hydrocephalus Idiopathic

Disposition 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.