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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
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