Clinical spectrum of higher level gait disorders (HLGD) in a tertiary care movement disorder clinic - A prospective study

Abstract

Gait disorders are classified into lower, middle, and higher sensorimotor levels (Nutt 1993). HLGD are common and disabling in the elderly. To study the burden, demographic profile and etiologic profile of HLGD in a tertiary care center in India. Patients presenting with Parkinsonism and predominant lower limb involvement in the form of gait difficulty (freezing, shuffling or slowness) and/or postural instability (imbalance or falls), not completely accounted for by visual, vestibular or proprioceptive deficits, were studied. Follow up was done for 3 months. 56 consecutive patients with HLGD, forming 3.38% of new referrals, were included. 23 patients (41%) fulfilled criteria for Progressive Supranuclear Palsy (PSP) (Höglinger 2017), 11 (20%) for vascular parkinsonism (VaP) (Winikates 1999), 9 (16%) for Normal pressure hydrocephalus (NPH) (Relkin 2013), and 2 (4%) had a multisensory gait disorder. 11 cases (20%) remained unclassified. Patients with PSP (Table 1) had REM Sleep behavior disorder (RBD), extraocular abnormalities (EOM), axial rigidity, masked facies, gait freezing, inability to arise from chair unsupported, severe postural instability on pull test, and midbrain atrophy on MRI brain. Patients with VaP had ≥2 vascular risk factors, pyramidal signs, broad-based asymmetric gait, and leukoaraiosis on MRI brain. NPH was a diagnosis of exclusion (Table 1) with ventriculomegaly on MRI, and improvement at lumbar tap test (LTT) which eventually predicted VP Shunt responsiveness. PSP is the commonest HLGD. VaP and NPH are other common HLGD. Reaching a diagnosis requires assessment of all features in unison. Clinical phenotype evolves with time on follow up.