Abnormal Tandem Gait Research Articles

Prevalence and risk factors for abnormal tandem gait in patients with essential tremor syndrome: A cross-sectional study in Southwest China.

Patients with essential tremor (ET) syndrome have more prevalent and more serious gait and balance impairments than healthy controls. In this cross-sectional study, we explored whether balance impairments are associated with falls as well as more pronounced non-motor symptoms in patients with ET syndrome. We assessed the tandem gait (TG) test, as well as falls or near-falls that occurred over the previous year. Non-motor symptoms-including cognitive deficits, psychological and sleep disorders-were evaluated. In univariate analyses, statistical significance was corrected for multiple comparisons using the Benjamini-Hochberg method. Multiple logistic regression was utilized to evaluate the risk factors of poor TG performance in patients with ET syndrome. A total of 358 patients with ET syndrome were divided into the abnormal TG (a-TG) and normal TG (n-TG) groups based on their performances in the TG test. We revealed that 47.2% of patients with ET syndrome had a-TG. The patients with a-TG were older, were more likely female, and were more likely present with cranial tremors and falls or near-falls (all adjusted P < 0.01). The patients with a-TG had significantly lower Mini-Mental Status Examination scores, as well as significantly higher Hamilton Depression/Anxiety Rating Scale and Pittsburgh Sleep Quality Index scores. Multiple logistic regression analysis demonstrated that female sex (OR 1.913, 95% CI: 1.180-3.103), age (OR 1.050, 95% CI: 1.032-1.068), cranial tremor scores (OR 1.299, 95% CI: 1.095-1.542), a history of falls or near-falls (OR 2.952, 95% CI: 1.558-5.594), and the presence of depressive symptoms (OR 1.679, 95% CI: 1.034-2.726) were associated with the occurrence of a-TG in patients with ET syndrome. TG abnormalities may be a predictor of fall risk in patients with ET syndrome and are associated with non-motor symptoms, especially depression.

Factors associated with mortality in early stages of parkinsonism

Prognosis of patients with parkinsonism varies greatly between the various parkinsonian syndromes. However, it is often difficult to distinguish the different forms, particularly in early stages. We examined predictors of mortality and functional outcome in patients with recent-onset parkinsonism with an initially uncertain diagnosis (n = 156). Patients were recruited between 2003 and 2006, comprehensively investigated, and followed prospectively (up to 15 years, mean 7 years). A final clinical diagnosis was established after follow-up. Independent predictors of mortality were investigated with multivariable Cox regression and combined into a simple prediction model. Model performance to predict 5- and 10-year mortality and functional outcome after 3 years was evaluated and externally validated in a second cohort of 62 patients with parkinsonism with an initially uncertain diagnosis. Ninety-one patients died (58%). Orthostatic hypotension, impaired cognition, abnormal tandem gait, and elevated neurofilament light chain concentration in serum or CSF were associated with mortality. A simple model that combined these factors showed excellent performance for prediction of functional outcome after 3 years and mortality after 5 and 10 years (c-statistic ~0.90 for all models). Model performance was confirmed after external validation: prediction of functional outcome after 3 years (c-statistic 0.89, 95% CI 0.80–0.98) and mortality after 5 years (c-statistic 0.91, 95% CI 0.84–0.99) were comparable to the results in the discovery cohort. These findings help clinicians to estimate a patient’s prognosis, irrespective of the specific diagnosis.

The Phenomenology of Primary Orthostatic Tremor.

ABSTRACTBackgroundThe presence and prevalence of several neurological signs in patients with primary orthostatic tremor have not been systematically studied.ObjectivesTo assess the prevalence of clinical features of primary orthostatic tremor.MethodsVideo‐based assessment by four raters of standardized neurological examination of 11 patients with primary orthostatic tremor.ResultsOn standing, bent knees (7/11), hem sign (6/10), and a broad base of support (6/11) were the three most prevalent signs. Examination of gait revealed abnormal tandem gait (9/11) and bent knees (6/11) as the most prevalent clinical signs. In the arms, none of the patients displayed bradykinesia, ataxia, or dystonia. In the legs, ataxia was absent in all patients and bradykinesia was present in only one patient.ConclusionsAbnormal tandem gait, bent knees, hem sign, and broad base on standing are the most prevalent clinical signs in primary orthostatic tremor. We did not encounter clear extrapyramidal or unequivocal cerebellar signs.

Age is associated with postural control performance following youth concussion.

To examine the effect of age on postural control outcomes among patients being seen during their initial post-concussion clinical visit. Youth patients were seen≤14 days post-concussion, and completed a series of postural control evaluations: tandem gait, Romberg, and Balance Error Scoring System (BESS) tests. We included 109 children 8-12 years of age (24% female, evaluated median = 7 [interquartile range = 4-10] days post-injury) and 353 adolescents aged 13-18 years (36% female, evaluated median = 7 [4-10] days post-injury). There was a higher proportion of children who demonstrated abnormal tandem gait relative to adolescents (26% vs. 11%; p < 0.001). They also made more BESS errors in single (median = 5 [2-10] vs. 4 [2-6] errors) and tandem (median = 3 [1-6] vs. 2 [0-4]) firm stances. After covariate adjustment, children demonstrated worse tandem gait (adjusted odds ratio = 3.05, 95% CI = 1.68-5.53) and more firm surface BESS errors (double stance β=0.51, 95% CI = 0.22-0.80; single stance β= 1.18, 95% CI = 0.42-1.95; tandem stance β= 0.98, 95% CI = 0.28-1.68) than adolescents. Tandem gait and BESS performance following concussion differ in children compared to adolescents who present within 2 weeks of injury. Clinicians assessing and managing concussion should recognize age differences in postural control performance when assessing those with concussion.

242. Telehealth: comparison of physical exam between telehealth visits and in-person visit for patients with spine pathology

<h3>BACKGROUND CONTEXT</h3> History, physical exams (PE) and imaging are used to diagnose spine pathology. There is limited data on differences in telehealth physical exam findings when compared to in person physical examinations in the same patient. Further analysis is required to determine differences in telehealth visits (TV) and office visits (OV) examinations and the clinical significance of these differences. <h3>PURPOSE</h3> To determine differences in TV and OV examinations and the clinical significance of these differences. <h3>STUDY DESIGN/SETTING</h3> Single-center retrospective cohort study. <h3>PATIENT SAMPLE</h3> This study included 296 patients (247 surgical and 49 non-surgical). <h3>OUTCOME MEASURES</h3> Tibialis anterior (TA) deficit, hand grip (HG), hand intrinsic (HI), bilateral lower extremity motor deficits, bilateral upper extremity motor deficits, tandem gait (TG) abnormalities, straight legged raise (SLR) abnormalities, and extremity sensation (ES) abnormalities. <h3>METHODS</h3> Included: patients with spine pathologies who received an initial TV and a subsequent OV post-March 2020. Excluded: patients who received telehealth and office visit by two separate providers, providers outside of the spine service, or patients with an initial office visit in the timeframe. The cohort was further analyzed by pathologies. Motor exam results were categorized dichotomously as "full-strength: antigravity" or deficit and other physical exam findings were classified as abnormal and normal. False positives (FP) were classified as abnormalities detected only in TV and false negatives (FN) were categorized as abnormalities detected only in OV. Relationships between the TV and OV exam findings were established using chi-squared analyses (α=0.05). <h3>RESULTS</h3> The total cohort's average age is 56.5, BMI=28.6, and 50% female. Among the cohort, 8.9% of lumbar radiculopathy (LR) patients' TV (w/ 5.1% being FP and 12.7% being FN) recorded a TA deficit, but 16.5% reported deficit in OV (p=0.048). Thus, TV either missed or falsely recorded 17.7% TA deficits. No deficits (0%) were recorded in both HG and HI in MY TV, but 12.5% and 15.6% had reported HG and HI deficits in OV, respectively. For tandem gait (TG), 21.9% MY (w/ 6.3% FP and 15.6% FN) patients' TV reported an abnormal tandem TG, but in OV, 31.3% (p=0.009) reported abnormalities. For straight-leg raise (SLR), 16.5% LR (w/ 5.1% FP and 7.6% FN) reported abnormal SLR in TV but 13.9% had abnormalities in OV (p<0.001). For extremity sensations, 8.9% LR TVs reported abnormalities and 8.9% LR OV reported abnormalities; however, there were 6.3% FP and 6.3% FN (p=0.046). <h3>CONCLUSIONS</h3> TA, TG, SLR, and motor sensation have the highest rates of FP and NP in the spine telehealth examination. There should be a low threshold for an OV in the setting of equivocal testing. During a pandemic, surgeons should rely on the TV history/examination and imaging to make a diagnosis. OV is appropriate in cases in which an accurate TA, TG, SLR, and ES is required. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Head injury assessment in rugby union: clinical judgement guidelines

Background/aimClinical judgement is a recognised component of a complete off-field concussion assessment. This study identifies guidance criteria for team medical staff when using clinical judgement in their decision-making process during...

Longitudinal prediction of falls and near falls frequencies in Parkinson\u2019s disease: a prospective cohort study

Introduction and objectiveSeveral prediction models for falls/near falls in Parkinson’s disease (PD) have been proposed. However, longitudinal predictors of frequency of falls/near falls are poorly investigated. Therefore, we aimed to identify short- and long-term predictors of the number of falls/near falls in PD.MethodsA prospective cohort of 58 persons with PD was assessed at baseline (mean age and PD duration, 65 and 3.2 years, respectively) and 3.5 years later. Potential predictors were history of falls and near falls, comfortable gait speed, freezing of gate, dyskinesia, retropulsion, tandem gait (TG), pain, and cognition (Mini-Mental State Exam, MMSE). After each assessment, the participants registered a number of falls/near falls during the following 6 months. Multivariate Poisson regression was used to identify short- and long-term predictors of a number of falls/near falls.ResultsBaseline median (q1–q3) motor (UPDRS) and MMSE scores were 10 (6.75–14) and 28.5 (27–29), respectively. History of falls was the only significant short-time predictor [incidence rate ratio (IRR), 15.17] for the number of falls/near falls during 6 months following baseline. Abnormal TG (IRR, 3.77) and lower MMSE scores (IRR, 1.17) were short-term predictors 3.5 years later. Abnormal TG (IRR, 7.79) and lower MMSE scores (IRR, 1.49) at baseline were long-term predictors of the number of falls/near falls 3.5 years later.ConclusionAbnormal TG and MMSE scores predict the number of falls/near falls in short and long term, and may be indicative of disease progression. Our observations provide important additions to the evidence base for clinical fall prediction in PD.

P5344Paradigme shift to disequilibrium in the genesis of orthostatic intolerance in patients with chronic fatigue syndrome

Abstract Background Chronic fatigue syndrome (CFS) characterized by severe disabling fatigue and prolonging post-exertional malaise. The dysfunction of the central nervous system associated with myalgic encephalomyelitis (ME) has been postulated as the main cause of CFS. Orthostatic intolerance (OI) causes a marked reduction in the activities of daily living and impairs the quality of life in patients with ME/CFS. OI has been surmised to be a cardiovascular symptom with cerebral hypo-perfusion and exaggerated sympathetic nervous activation. Purpose Postural instability or disequilibrium may be involved in the etiology of OI because postural stability is an essential element for static balance. Methods The study comprised 72 patients with ME/CFS (18 men and 54 women; mean age, 37±10 years), who underwent neurological examinations and the active 10-min standing test. Results Disequilibrium defined as instability on standing with their feet together and eyes shut, was detected in 23 (32%) patients while postural orthostatic tachycardia in 16 (22%). Compared with 49 patients without disequilibrium, patients with disequilibrium more prevalently failed to complete the 10-min standing test (74% vs. 4%, p&lt;0.01) and body sway was significantly more prevalently observed during the test (100% vs. 12%, p&lt;0.01). The performance status score was significantly higher in patients with disequilibrium than those without it (median: 7 vs. 5, p&lt;0.01), suggesting more severely restricted activity of daily living in the former. The prevalence of postural orthostatic tachycardia during the standing test was comparable between the patients with disequilibrium (23%) and those without it (22%, p=1.00). The 19 (26%) patients who failed to complete the 10-min standing test had disequilibrium more prevalently than those who completed it (89% vs. 11%, p&lt;0.01). Performance status score was significantly higher in patients who failed to complete it than those who completed it (median: 6 vs. 5, p&lt;0.01), suggesting more severe restriction of activity of daily living in the former. Significantly higher rates of disequilibrium (89% vs. 11%, p&lt;0.01), unstable standing on one leg (84% vs. 17%, p&lt;0.01) as well as abnormal tandem gait (79% vs. 11%, p&lt;0.01) were noted in patients who failed to complete it than those who completed it. Body sway during the standing test was significantly more prevalently observed in the patients who failed to complete it than those who completed it (89% vs. 23%, p&lt;0.01). The prevalence of postural orthostatic tachycardia during the standing test was comparable between the patients who failed to complete it and those who completed it (21% vs. 23%, p=1.00). Among the patients who failed to complete it 8 had the previous study records which revealed that 6 of them had completed it 6–24 months before when all the 6 patients had had no disequilibrium. Conclusion Disequilibrium should be recognized as an important cause of OI in patients with ME/CFS.

Prospective study of anxiety, post-traumatic stress and depression on postural control, gait, otolith and visuospatial function in military service members with persistent post-concussive symptoms

Military service members often report both affective and vestibular complaints after mild traumatic brain injury (mTBI), but associations between symptoms and vestibular deficits can be subtle and inconsistent. From two complementary studies, one of military service members with persistent post-concussive symptoms after mTBI (NCT01611194) and the other of adult volunteers with no history of brain injury (NCT01925963), affective symptoms were compared to postural control, gait, otolith and visuospatial function. The studies enrolled 71 participants with mTBI and 75 normative controls. Participants with mTBI had significantly reduced postural equilibrium on the sensory organization test (SOT), and more so in those with high anxiety or post-traumatic stress. Cervical and ocular vestibular evoked myogenic potentials (cVEMP; oVEMP) showed prolonged latencies in mTBI participants compared to controls; oVEMPs were significantly delayed in mTBI participants with high anxiety, post-traumatic stress or depression. A subset of the mTBI group had abnormal tandem gait and high anxiety. Anxiety, post-traumatic stress, and depression did not correlate with performance on the 6-Minute Walk Test, visuospatial neuropsychological measures, and the Satisfaction with Life Scale in the mTBI group. In this study military service members with mTBI reported affective symptoms, concurrently with vestibular-balance concerns. Worse scores on affective measures were associated with abnormal findings on measures of postural control, gait and otolith function.

Clinical Characteristics of Essential Tremor in South India: A Hospital-Based Cohort Study.

Introduction:Essential tremor (ET) is the most common adult movement disorder. Classic ET is characterized by action tremor of hands (95% cases), and tremor involving other regions is less common. Recent studies have revealed a few patients exhibiting nontremor features that include cognitive disorders, tandem gait abnormality, mood fluctuations, olfactory abnormality, hearing impairment, and sleep disorders. Very few studies on ET have so far been conducted in India, and the present study is a pioneering attempt to evaluate the clinical characteristics of patients diagnosed with ET.Materials and Methods:A standardized assessment protocol was used to collect data. Diagnosis of ET was established using consensus criteria established by the Movement Disorder Society. Tremor Research Group Essential Tremor Rating Assessment Scale was used to evaluate tremor impact. The severity of hand tremor was assessed by Glass Scale, and cognitive function was assessed by Mini–Mental Status Examination.Results:Out of the 45 patients enrolled, 73.3% were male and 26.6% were female, with a mean age of 44 ± 15 years. Postural tremor was observed in all, followed by intention tremor in 9 and rest tremor in 6 patients. Tremor of the hand was identified to be most predominant (100%). Voice tremor was observed in 15 (33.3%) patients and head tremor in 12 patients (26.6%) who were all females. Leg tremor was observed in 12 patients (26.6% of patients) and tongue tremor in 6 (13%) patients. Baseline asymmetry of tremor was observed in 60% of patients and positive family history in 35% of patients. The most common nontremor feature was tandem gait abnormality (40%). Moreover, most of the patients had Glass Scale II.Conclusion:Baseline asymmetry of tremor and male predominance were observed in the study. While hand tremor was the most common form of tremor, tandem gait abnormality was the most common nontremor feature as observed in patients with ET.

Incidence of acute cerebral infarction or space occupying lesion among patients with isolated dizziness and the role of D-dimer.

BackgroundTo determine the incidence of acute cerebral infarction or space occupying lesion (SOL) among patients with isolated vertigo or dizziness (IVD) and to evaluate the role of cerebellar function test (CFT) and D-dimer to discriminate ACI/SOL and non-ACI/SOL.MethodsA retrospective study of consecutive emergency department (ED) patients with IVD during one year was conducted. ACI was based on the diffusion-weighted magnetic resonance imaging (DW-MRI), and SOL was based on the concurrent MRI sequences. A sensitivity analysis of CFT and D-dimer was also performed.ResultsAmong the 468 patients enrolled, 13 patients (2.8%) had ACI, 11 at cerebellum, 1 at occipital lobe, and 1 at centrum semiovale. Twenty-five patients (5.3%) had SOL. Aneurysm is most frequent (n = 7), followed by meningioma (n = 4) and venous anomaly (n = 4). In total, ACI/SOL was found in 8.1% (n = 38). Abnormal findings in finger-to-nose (FN), heel-to-shin (HTS), and rapid alternative movement (RAM) tests were significantly higher in ACI or ACI/SOL group, while gait disturbance, tandem gait abnormality, and Romberg’s test were not. CFT sensitivities were low for ACI as well as for ACI/SOL, but specificities were high for ACI and ACI/SOL. D-dimer level showed a sensitivity of 100% at >0.18 mg/L for ACI and >0.15 mg/L for ACI/SOL. However, specificity was low at corresponding D-dimer level. Among the subgroup (n = 411) who did not show any abnormality in CFT, 9 patients (2.2%) had ACI, and 33 patients (8.0%) had ACI/SOL.ConclusionThe present study reports a clinically significant incidence of ACI/SOL among ED patients with IVD. D-dimer showed high sensitive and low specificity, while CFT showed low sensitivity and high specificity.

CLINICAL PREDICTORS OF SYMPTOM RESOLUTION FOR CHILDREN AND ADOLESCENTS WITH SPORT-RELATED CONCUSSION

Background: Early prognosis of expected recovery duration after a sport-related concussion is a challenging task for sports medicine clinicians, as various pre-morbid, injury characteristic, and functional factors have been identified to help predict recovery. The purpose of this investigation was to determine which variables obtained as a part of a routine concussion clinical evaluation were independently associated with symptom resolution time among pediatric patients evaluated after sport-related concussion by a sports medicine physician. Methods: We conducted an analysis of data collected from a prospective clinical registry of children with concussion. Patients included in the current investigation were seen for care at a pediatric sports medicine concussion clinic between January 1, 2015 to August 31, 2017, were less than 19 years of age, evaluated within 10 days of a sport-related concussion, and followed until they no longer reported symptoms. The primary outcome variable was the number of days from injury until symptom resolution. The predictor variables included those assessed during the initial clinical evaluation. They were obtained via a medical history form (pre-injury history of attention-deficit/hyperactivity disorder, learning disability, anxiety, depression, and migraine or headaches), the Health and Behavior Inventory (HBI) symptom frequency questionnaire, headache severity rating (rated on a scale from 0-10), sleep disturbance questionnaire, and performance on a set of balance, vestibular, and oculomotor function tests (Balance Error Scoring System, Romberg, tandem gait, gaze stability, and near point of convergence). Tests were considered abnormal if patients could not maintain balance or demonstrated exaggerated upper body movement (Romberg/tandem gait tests), if they reported symptom provocation after test administration (gaze stability), or if the near point of convergence was greater than 5 cm from the tip of the nose. To identify the independent factors associated with symptom resolution time, we first constructed univariate Cox proportional models with time to symptom resolution as the outcome and each clinical variable as a separate predictor variable. Predictor variables with a univariate significance level of p &lt; 0.05 were then used to construct a multivariate Cox proportional hazards model where total duration of concussion symptoms remained the outcome variable. Results: We examined data from 351 children and adolescents (mean age= 14.6±2.2 years, 33% female, evaluated 5.6±2.6 days after concussion) who required a median of 11.5 [interquartile range= 7-21] days for symptom resolution. One hundred and sixty-three (46%) of patients reported a prior history of concussion, while other pre-injury health conditions were reported less often (Table 1). The most commonly endorsed symptoms by patients at the initial visit were headaches, difficulty paying attention, difficulty concentrating, and getting distracted easily (Table 2). The most common abnormal vestibular or oculomotor test was symptom provocation brought on by gaze stability testing, while 20% of patients had an abnormal Romberg test, 15% demonstrated abnormal tandem gait, and 15% had abnormal near point of convergence (Table 3). Results from univariate Cox proportional hazards models indicated headache severity, headache frequency, confusion, forgetfulness, attentional difficulties, trouble remembering, getting tired often, getting tired easily, dizziness, and an abnormal Romberg test were associated with a longer symptom duration (Tables 2 and 3). The multivariate Cox proportional hazard model indicated that an abnormal Romberg test was independently associated with a longer symptom duration after adjusting for the effect of all other covariates included in the model (Table 4 and Figure 1). Headache frequency and “being tired easily” were not included in the final model due to collinearity with headache severity and “being tired a lot”, respectively. Conclusions: For adolescent and child patients assessed within 10 days of concussion, an abnormal Romberg test was independently associated with longer symptom duration during recovery. This is in line with other recent studies investigating early predictors of symptom resolution, demonstrating that postural instability appears to provide valuable prognostic information for sports medicine clinicians. [Table: see text]

Tandem gait abnormality in Parkinson disease: Prevalence and implication as a predictor of fall risk

IntroductionWe report the prevalence of abnormal tandem gait (TG) in patients with idiopathic Parkinson disease (PD) and its association with symptoms of subjective unsteadiness, falls, freezing of gait, and cognitive impairment. MethodsWe assessed subjective balance impairment, fall history, antero-posterior postural instability, and TG in PD patients (Hoehn and Yahr (HY) stage 0–4). We recorded the age, sex, current medications, HY stage, Schwab and England (S&E) scale score, and MOCA score for each patient. Logistic regression was used to evaluate age-adjusted associations between TG and other demographic and clinical factors. ResultsA total of 102 patients with PD were assessed. Of those, 63.5% of HY 2 patients and 100% of HY 2.5 and 3 patients had a TG abnormality. The presence of TG abnormality was associated with subjective imbalance, falls, freezing of gait, S&E < 80, and MOCA score <24 after adjustment for age. ConclusionsTG abnormality is common in PD, precedes the development of antero-posterior postural instability, is associated with cognitive impairment, and may predict fall risk. A longitudinal study will help determine if TG is a predictor of impending progression from HY 2 to HY 3.

Clinical differences in patients with Parkinson’s disease according to tandem gait performance

Some of patients with Parkinson’s disease (PD) have abnormal tandem gait (TG) performance without any symptoms and signs of cerebellar dysfunction. Clinical difference between patients with good and poor TG performance has not yet been studied. We report the relationship between tandem gait performance and clinical characteristics including 37 patients with PD who had no evidence of cerebellar dysfunction. Using tandem gait test, the patients were divided into two groups (good-TG and poor-TG). We evaluated the two groups with Montreal Cognitive Assessment (MoCA), Mini Mental Status Examination (MMSE), Frontal Assessment Batter (FAB), Beck Depression Index (BDI-II), REM Sleep Behavior Disorder Single-Question Screen (RBD1Q), MDS-UPDRS items related to axial disability and freezing. Fifteen participants were classified as good-TG group and 22 were as poor-TG group. Participants in good-TG group had higher MoCA score and lower BDI-II score. The proportion of participants who answered “yes” to RBD1Q was lower in good-TG group (27%, 4 of 15) than that in poor-TG group (55%, 12 of 22). All participants in good-TG group marked “0” for the MDS-UPDRS item 2.13 which addresses freezing event over the past week, whereas 18% (4 of 22) of participants in poor-TG group marked “1”. In conclusion, tandem gait performance may be related to various clinical characteristics including cognitive function, mood, RBD, and freezing in patients with PD.

The Prevalence of Tandem Gait Abnormality in Parkinson’s Disease (P2.075)

The Prevalence of Tandem Gait Abnormality in Parkinson’s Disease (P2.075)

Essential tremor: state of the art

Essential tremor (ET) is currently classified as asyndrome rather than aunique disease, primarily involving monosymptomatic action tremor in both hands. Different etiologies are presumed to underlie this condition. Currently only afew monogenetic conditions are known to present with this syndrome. If accompanied by additional symptoms that do not in themselves constitute a new syndrome, such as abnormal tandem gait or postures, the syndrome should be diagnosed as "ET plus". ET is associated with abnormal rhythmic activation of the cerebello-thalamo-cortical tremor circuit. Despite its strong heritability, the genetics of ET have not been elucidated as yet. Age-correlated tremor is one of the presumed subgroups of ET. Late onset is associated with a shortened life expectancy. From a treatment perspective, propranolol and primidone represent the drugs of first choice, followed by topiramate. Deep brain stimulation of the Vim nucleus of the thalamus is a proven treatment option in severely affected patients.

Signs and Symptoms of Acoustic Neuroma at Initial Presentation: An Exploratory Analysis.

IntroductionThe objective of this study was to describe the most common clinical features associated with an acoustic neuroma diagnosis and to identify those features associated with larger tumour size at initial diagnosis.MethodsThe clinical information of 945 consecutive patients diagnosed with acoustic neuroma at a single centre between 1992 and 2015 was analysed. Clinical features were examined and the relationship between these features and tumour size (>2.5 cm) was analysed using descriptive statistics and logistic regression analysis. Statistical analysis was performed in R version 3.1.1.ResultsThe most common presenting symptom was a unilateral hearing loss in 752 patients (80%), with a progressive pattern in 90% of these cases. The second most common presenting symptom was unilateral tinnitus, accounting for 6.3%, while ataxia, vertigo and headache accounted for 3.8%, 3.4% and 2%, respectively. The diagnosis of acoustic neuroma was an incidental finding in 20 patients (2.1%). Temporal analysis demonstrated a downward trend in the number of patients presenting with hearing loss and an increased proportion of patients presenting with other symptoms. On multivariate analysis, larger tumour size was associated with abnormal tandem gait (odds ratio 8.9, p=0.02), subjective facial weakness (odds ratio 5.3, p< 0.001), abnormal facial sensation on examination (odds ratio 3.0, p=0.03) and headache (odds ratio 2.6, p< 0.001).ConclusionThe majority of patients with acoustic neuroma present with the classic, progressive, unilateral hearing loss. However, the pattern of presentation in acoustic neuroma patients is changing. Features in the history indicative of a larger tumour are headaches and subjective facial weakness, whilst concerning features on examination are abnormal tandem gait and altered facial sensation.

How tandem gait stumbled into the neurological exam: a review.

Tandem gait testing is an integral part of the neurological exam. It is informative in a wide variety of disorders ranging from cerebellar disease to vestibular and peripheral neuropathies, parkinsonism, and other neurodegenerative conditions. We discuss the history and development of tandem gait testing as well as its technique, utility, and limitations in the assessment of neurological conditions. Tandem gait has emerged as a tool in the assessment of cerebellar disease, Huntington disease, idiopathic Parkinson's disease, atypical parkinsonism, peripheral neuropathies, and vestibulopathies. Its origin can be deduced from experimental observation and clinical experience as far back as the early nineteenth century. Despite the long history and ubiquitous performance of tandem gait testing, there is no standardized, guideline-based protocol to model for more homogenous research and clinical practices. Such a protocol should be developed using historical texts and manuscripts as well as the consensus of the medical research community. With standard protocols, further studies could define the sensitivity of abnormal tandem gait testing in cerebellar disorders, more diffuse neurodegeneration, and peripheral pathologies. Tandem gait can be a useful marker of dysfunction in neurologic conditions whose pathologies extend beyond the vermis or vestibulocerebellar module to include interconnected networks throughout the nervous system.

X-linked adrenoleukodystrophy presenting with positional downbeat nystagmus

A 20-year-old man presented with dizziness and gait disturbance for approximately 2 months. Neurologic examination revealed spontaneous downbeat nystagmus (DBN), limb ataxia, and abnormal tandem gait (video on the Neurology ® Web site at [Neurology.org][1]). Video-oculography showed augmented DBN during position change (figure 1). MRI revealed diffuse atrophy and signal changes in the brainstem and cerebellum (figure 2). The plasma levels of very long-chain fatty acids (C26:0 concentration, C24:0/C22:0 ratio, and C26:0/C22:0 ratio) were elevated. Subsequent genetic testing revealed a missense mutation in the ABCD1 gene. The olivopontocerebellar form of X-linked adrenoleukodystrophy should be considered a rare but possible diagnosis in young men with dizziness and DBN.1,2 Acknowledgment: All the clinical information and materials used in the present study were permitted for scientific use with written informed consent. This study was approved by the institutional review board of Chonnam National University Hospital. [1]: http://neurology.org/lookup/doi/10.1212/WNL.0000000000002749

Time to Change from a Symptom-based Concussion Assessment to a Structured Physical Examination.

Time to Change from a Symptom-based Concussion Assessment to a Structured Physical Examination.