Doctor I can t walk properly - a guided walk around some gait problems

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1 Doctor I can t walk properly - a guided walk around some gait problems Dr Jeremy Rees Consultant Neurologist National Hospital for Neurology and Neurosurgery, Queen Square

2 Walking difficulties Accurate clinical assessment is crucial Diagnostic tests not always available and may be misleading Problem could be neurological, rheumatological, orthopaedic or podiatric

3 Assuming neurological problem

4 Ask yourselves.. 1. Is the problem central or peripheral? Walking difficulties may be due to lesions in: Brain Supratentorial usually deep white frontal matter/basal ganglia Posterior fossa or connections e.g. cerebellum, vestibular nuclei Spinal cord Peripheral nervous system i.e. neuromuscular 2. Is the problem due to one or more of balance weakness numbness pain or none of these?

5 History Mode of onset - acute, subacute or chronic Progression slow, rapid Associated symptoms vertigo, headache, tremor, numbness, bowel/bladder etc. Previous history e.g. cerebrovascular disease, alcohol

6 Examination MRC Scale for Grading Muscle Strength Get the patient to walk Score Muscle Response Test for postural stability, heel toe, Romberg 0 No Movement Test 1 legs Muscle on belly moves the couch but the joint does not move 2 Joint moves with gravity eliminated 3 Joint moves against gravity 4 Joint moves against gravity and some resistance 5 Full strength Tone Power Coordination Reflexes Sensation

7 Investigations Bloods e.g. suspect B12 def, GGT Imaging CT for vascular/parkinsonism/tumour/hydrocephalus MRI for posterior fossa/spinal cord Neurophysiology NCS for neuropathy axonal vs demyelinating EMG for myopathy

8 Differential Diagnosis Brain parkinsonism small vessel disease Normal Pressure Hydrocephalus Cerebellar ataxia Spinal cord compression demyelination Neuromuscular Guillain Barré Syndrome myopathy Charcot Marie Tooth

9 Parkinsonism PD rarely presents with gait problems Consider vascular parkinsonism or PSP (presents with early falls and akinetic rigidity) Look for other signs e.g. posture, mask face, tremor/rigidity/bradykinesia Test for postural instability (reverse tug) Forward stoop PD; Backward stoop - vascular

10 Differential Diagnosis Brain parkinsonism small vessel disease Normal Pressure Hydrocephalus cerebellar ataxia Spinal cord compression demyelination Neuromuscular Guillain Barré Syndrome Myopathy Charcot Marie Tooth

11 Small vessel disease Atherosclerotic pseudoparkinsonism Lower body only Marche a petits pas Backward stoop

12 Differential Diagnosis Brain parkinsonism small vessel disease Normal Pressure Hydrocephalus cerebellar ataxia Spinal cord compression demyelination Neuromuscular Guillain Barré Syndrome Myopathy Charcot Marie Tooth

13 Normal Pressure Hydrocephalus Classic triad Gait apraxia Dementia Urinary Incontinence One not to be missed as potentially treatable with shunting

14 Normal pressure hydrocephalus

15 Differential Diagnosis Brain parkinsonism small vessel disease Normal Pressure Hydrocephalus cerebellar ataxia Spinal cord compression demyelination Neuromuscular Guillain Barré Syndrome Myopathy Charcot Marie Tooth

16 Cerebellar ataxia Ataxic broad based gait with negative Romberg s but unable to stand with feet together Look for other cerebellar signs Jerky pursuits, nystagmus Dysarthria Limb ataxia, dysmetria, dysdiadochokinesis If midline, consider vermis lesion, alcohol Genetic ataxias can present in late adulthood

17 Cerebellar atrophy

18 Vermis tumour

19 Differential Diagnosis Brain parkinsonism small vessel disease Normal Pressure Hydrocephalus cerebellar ataxia Spinal cord compression demyelination Neuromuscular Guillain Barré Syndrome Myopathy Charcot Marie Tooth

20 Spinal cord compression Consider in all patients with known cancer Ask about previous radicular back pain Classic triad back pain weak legs sensory loss to mid abdomen

21 Management of cord compression WALK IN WALK OUT High dose dexamethasone Radiotherapy for radiosensitive tumours lymphoma, myeloma, breast, prostate, kidney, colon, lung, melanoma When to operate: radioresistant tumours spinal instability Progression after radiotherapy

22 Differential Diagnosis Brain parkinsonism small vessel disease Normal Pressure Hydrocephalus cerebellar ataxia Spinal cord compression demyelination Neuromuscular Guillain Barré Syndrome Myopathy Charcot Marie Tooth

23 Spinal cord demyelination May be first symptom of MS Classic triad Weakness of legs Sensory loss Early bladder involvement Many causes e.g. post viral, other CTD Variable prognosis

24 Differential Diagnosis Brain parkinsonism small vessel disease Normal Pressure Hydrocephalus cerebellar ataxia Spinal cord compression demyelination Neuromuscular Guillain Barré Syndrome Myopathy Charcot Marie Tooth

25 Guillain Barre Syndrome

26 GBS Post-infectious in 60% Acute areflexic paralysis CSF protein EMG/NCS demyelination + axonal loss IVIg 0.4g/kg/day for 5 days Watch for respiratory failure (25% ventilated) and autonomic disturbance 80% recover completely 5% mortality

27 Differential Diagnosis Brain parkinsonism small vessel disease Normal Pressure Hydrocephalus cerebellar ataxia Spinal cord compression demyelination Neuromuscular Guillain Barré Syndrome Myopathy Charcot Marie Tooth

28 Myopathy

29 Myopathy Many causes Genetic in children e.g. Duchenne s Acquired in adults e.g. polymyositis Presents with proximal weakness i.e. difficulty climbing stairs, chairs, car seat Gait is waddling Look for other muscle weakness with preserved reflexes and sensation Check creatine kinase, ESR, TFTs, Ca Refer for EMG studies and?biopsy

30 Gower s sign

31 Acute muscle disease Proximal weakness, distal strength and reflexes preserved CPK, usually > 1000 IU/l EMG shows acute myopathic changes Beware viral myositis due to Coxscakie infection (myocarditis)

32 Differential Diagnosis Brain parkinsonism small vessel disease Normal Pressure Hydrocephalus cerebellar ataxia Spinal cord compression demyelination Neuromuscular Guillain Barré Syndrome Myopathy Charcot Marie Tooth

33 Charcot Marie Tooth

34 Charcot Marie Tooth Commonest hereditary neuropathy Family history may not be obvious e.g. dad has funny feet Sensory symptoms often minimal Steppage gait due to bilateral foot drop Look for wasted hands, glove and stocking sensory loss, pes cavus and loss of reflexes

35 Charcot Marie Tooth

36 Case Histories

37 Case History 1 36 yr old lawyer Previous marathon runner 3 months neck pain and difficulty running Increasing difficulties walking Erectile dysfunction not previously mentioned Seen by rheumatologist MRI L/S normal Now walking on crutches Stiff legs, mute plantars, sensory level at T8

38

39 Case History - 2 AB, 71F, mastectomy 1 yr ago 3-4 months lumbar back pain X-ray - vertebral metastases - RT Rapid onset walking difficulties after discharge with ARF secondary to diarrhoeal illness On examination, unable to stand Very depressed Face, neck, arms mildly weak, legs severe weakness pyramidal distribution No sensory loss, absent reflexes in legs MRI spine showed mets but no cord compression

40 Case History 3 52M wheeler dealer BMT for CLL 8/12 ago URTI/flu 2/52 ago Difficulty walking/constipation over 5 days Asymmetric pyramidal weakness, sensory level to PP/temp at T8, brisk reflexes

41 MRI

42 Conclusions Walking difficulties many and varied Often multifactorial Look for reversible causes

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