Abnormal Tandem Gait Research Articles

A reappraisal of the ten steps test for identifying atypical parkinsonism

IntroductionGait abnormalities are prominent in atypical parkinsonian disorders and clinical signs such abnormal tandem walk have been suggested as a red flag for differential diagnosis. The objective is to determine the sensibility and specificity of the ten-steps test to discriminate atypical parkinsonisms from Parkinson's disease. MethodsA sample of subjects with a parkinsonian disorder was evaluated. The ten-steps test was applied to all subjects. A Bayesian analysis model was used to calculate sensibility and specificity. ResultsA total of 32 subjects with atypical parkinsonism and 54 subjects with Parkinson's disease were included. Abnormal tandem gait had a sensitivity of 90.6% and specificity of 66.6% to differentiate between groups. When adjusted to the actual atypical parkinsonism prevalence the positive predictive value fall from 61.7% to 13.8%. ConclusionThe ten-steps test provides additional information for the differential diagnosis in parkinsonian disorders but can only be regarded as a red flag.

A Prospective Pilot Study of Predictors of Acute Stroke in Emergency Department Patients With Dizziness

To prospectively examine undifferentiated emergency department (ED) patients with dizziness to identify clinical features associated with acute stroke. We conducted a pilot study from November 1, 2009, through October 30, 2010, of adult patients with dizziness presenting to 3 urban academic EDs. Data collected included demographic characteristics, medical history, presenting symptoms, examination findings, clinician pretest probability of stroke, and neuroimaging results. Logistic regression was used to identify variables with a significant association with acute stroke (P<.05). During the study period, we enrolled 473 patients (mean ± SD age, 56.7±19.3 years; 60% female; and 71% white). We found 30 acute, serious diagnoses (6.3%), including 14 ischemic strokes, 2 subarachnoid hemorrhages, 7 mass lesions, 2 demyelinating lesions, 2 severe vertebral artery stenoses, 2 acute coronary syndromes, and 1 case of hydrocephalus and meningitis). We identified 6 clinical variables associated with stroke: age (odds ratio [OR], 1.04; 95% CI, 1.0-1.07), hyperlipidemia (OR, 3.62; 95% CI, 1.24-10.6), hypertension (OR, 4.91; 95% CI, 1.46-16.5), coronary artery disease (OR, 3.33; 95% CI, 1.06-10.5), abnormal tandem gait test result (OR, 3.13; 95% CI, 1.10-8.89), and high or moderate physician pretest probability for acute stroke (OR, 18.8; 95% CI, 4.72-74.5). Most ED patients with dizziness do not have a serious cause of their symptoms. Although the small number of outcomes precluded development of a multivariate model, we identified several individual high-risk variables associated with acute ischemic stroke. Further study will be needed to validate the findings of this pilot investigation.

Hypothyroidism and Severe Neuropsychiatric Symptoms: A Rapid Response to Levothyroxine

Hypothyroidism is often associated with altered cognitive function and depression, although patients may also present with disorientation, memory impairment, dementia, auditory distortions, psychomotor retardation and psychosis. Although most patients achieve symptom resolution with levothyroxine replacement therapy, a minority have persistent symptoms. This report presents a case of rapid improvement of neu -ropsychiatric symptoms with levothyroxine replacement. To prepare this case report, we reviewed studies published in PubMed up to February 2012. The following mesh terms were used as keywords in our search: “hypothyroidism”, “dementia” and “cognition disorders”. An 81-year-old man presented to the hospital with behav -ioral disturbance, memory impairment, agnosia, apraxia and paranoid delusions but demonstrated no sensory disturbance. His symptoms had started 4 years previously but had worsened over the past year. His daughter reported that he had hyperten -sion, seizures and inguinal hernia, all of which had remained untreated, and stated that he was not taking any medications. He had no personal history of mood or psychotic disorders; however, one brother had committed suicide, and two of his daughters had mental retardation. He had dry skin, no tendon reflexes, an abnormal tandem gait and suffered from fatigue and intolerance to cold. His Mini-Mental score was 15 (one year of studies). His TSH was 222.28, free thyroxine 1,000. An EEG revealed diffuse slowing, and an MRI showed possible ischemic sequelae and posterior-parietal encephalomalacia, most likely due to an old trauma. We administered up to 100 µg levothyroxine, haloperidol, and valproate. After ten days, he felt no fatigue and had no delusions, his memory and orientation had improved, and his Mini-Mental score had increased to 19. After 40 days, his Mini-Mental score had increased to 21, his free thyroxine was 0.7 and his TSH was 23. He was sent home with a planned outpatient follow-up.The main diagnosis was reversible dementia due to hypo -thyroidism, but mental retardation and vascular or Alzheimer dementia cannot be excluded. Hashimoto’s encephalopathy (HE) was also considered due to his high anti-TPO levels.Regarding overt hypothyroidism, we identified one study that documented a deficit in verbal memory that improved with levothyroxine therapy, suggesting that this deficit is reversible.

Motor impairment after severe traumatic brain injury: A longitudinal multicenter study

Neuromotor impairment is a common sequela of severe traumatic brain injury (TBI) but has been understudied relative to neurocognitive outcomes. This multicenter cohort study describes the longitudinal course of neurological examination-based motor abnormalities after severe TBI. Subjects were enrolled from the four lead Department of Veterans Affairs and Defense and Veterans Brain Injury Center sites. The study cohort consisted of 102 consecutive patients (active duty, veteran, or military dependent) with severe TBI who consented during acute rehabilitation for data collection and completed all follow-up evaluations. Paresis, ataxia, and postural instability measures showed a pattern of improvement over time, with the greatest improvement occurring between the inpatient (baseline) and 6-month follow-up assessments. Involuntary movement disorders were rare at all time points. Two years following acute rehabilitation, more than one-third of subjects continued to display a neuromotor abnormality on basic neurological examination. Persistence of tandem gait abnormality was particularly common.

Relationship Between Essential Tremor and Cerebellar Dysfunction According to Age

BackgroundThe cerebellum and its neural circuitry have been assumed to play a major role in the pathophysiology of essential tremor (ET). In this study, we sought to find associations between ET and cerebellar dysfunction.MethodsWe performed tandem gait test in 41 ET patients and 44 age-matched controls. Investigators assessed tandem gait by counting the number of missteps during ten-step tandem walk and each subject repeated the trial three times.ResultsET patients had a higher average and total numbers of missteps during tandem gait tests than control subjects (p<0.05). Sex-adjusted odds ratio of the association between tandem gait abnormality and ET was 3.40 (95% confidence intervals 1.06-10.85). According to age stratification, aged ET patients (age ≥70 years) showed significantly higher prevalence of tandem gait abnormality than young ones. Interaction terms determined by a likelihood ratio test was also statistically significant (p<0.05).ConclusionsDysfunction of cerebellar neural circuitry may be associated with the pathophysiological mechanism of ET. In addition, aging may be an important factor modifying the association.

Neurological and cognitive abnormalities associated with chronic petrol sniffing.

Substance abuse through the deliberate inhalation of petrol (petrol sniffing or gasoline sniffing) is prevalent in inner-urban and remote rural communities. Although acute toxic encephalopathy is a well-documented consequence of petrol sniffing, the neurological and cognitive effects of chronic petrol sniffing are unknown. A structured neurological examination and the Cambridge Neuropsychological Test Automated Battery (CANTAB) were used to assess neurological and cognitive function in 33 current-sniffers (individuals who had sniffed petrol for >6 months), 30 ex-sniffers (individuals who had sniffed petrol in the past but had abstained for 6 months) and 34 matched non-sniffers (individuals who had never sniffed petrol). No subject was, or had been, encephalopathic from petrol sniffing and all were residing in their community. Blood lead and hydrocarbon levels and information about petrol sniffing behaviour were obtained from each subject. When compared with non-sniffers, current-sniffers showed higher rates of abnormal tandem gait, rapid alternating hand movements, finger to nose movements, postural tremor, bilateral palmomental reflexes and brisk deep reflexes. Cognitive deficits occurred in the areas of visual attention, visual recognition memory and visual paired associate learning. Ex-petrol sniffers showed higher rates of abnormal tandem gait and bilateral palmomental reflexes and cognitive deficits in the areas of visual recognition memory and pattern-location paired associate learning. Blood lead levels and length of time of petrol sniffing correlated significantly with the magnitude of neurological and cognitive deficits. Blood hydrocarbon levels were not related to neurocognitive deficits, although this may have been due to methodological difficulties in obtaining hydrocarbon levels. These results suggest that subtle neurological and cognitive abnormalities do occur in individuals who abuse petrol but who do not have acute toxic encephalopathy and that the severity of these abnormalities is reduced with abstinence.

Gait abnormality in essential tremor.

Essential tremor (ET) has been described as a monosymptomatic disorder. In reports describing large series of patients with ET, there are rare patients who exhibit a noticeable gait disorder. However, we have observed that patients with ET and normal gait often exhibit an abnormality of tandem gait. To investigate this observation, we examined whether a gait disorder was present in 36 consecutive patients (mean age 69) with ET. We employed a tremor rating scale that scored tremor amplitude, location, and disability. In all patients, gait and tandem gait were separately evaluated. Eighteen of 36 patients (50%) exhibited tandem gait abnormalities in the presence of a normal narrow-based gait compared to 11 of 40 age-matched controls (28%) (p < 0.05). Abnormality of tandem gait was more frequently present in older ET patients and those with > 5 years of disease duration. No relationship was found between presence of tandem gait abnormality and gender, tremor severity, head involvement, or positive family history. The finding of a tandem gait abnormality in 50% of ET patients suggests that cerebellar dysfunction may be important in its pathophysiology.