An Unusual Gait Abnormality Placing hands over head

An Unusual Gait Abnormality: Placing hands over head or pulling up pants improves walking Tara Kimbason, PGY 3 Feb 21, 2015

Disclosures the authors report no disclosures Tara Kimbason, PGY 3 Mentor: Efrain Perez-Vargas, MD PD: Jonathan Hosey, MD

Objectives • To learn from an unusual presentation of gait abnormality • Discuss ways to approach challenging cases • Discuss diagnosis and relevant review of the condition

History • An 83 -year-old right-handed male complains of abnoral gait • First noticed 5 years ago with slowness and decreased balance • Associated with upper and lower extremity weakness, clumsy hands, tremor, fatigue, rigid when sitting • “Extreme fatigue" with walking, requiring frequent rest periods - “a car without an engine” - wearing long pants “being pulled down” to the ground - removing his wallet and keys out of his pocket better - placing his hands over his head or pull the waistband off of his body improves his gait

History • • No falls, head/neck trauma or back pain No difficulty initiating or stopping gait No visual loss, dysarthria, dysphagia, vertigo, headache No autonomic symptoms (normal bowel, bladder, and sexual function) • No sleep-wake dysfunction (sleep maintenance insomnia, REM sleep behavior disorder, EDS) • No hallucinations • • • PMHx: essential tremors, hypertension, depression Medications: propranolol, SSRI Allergies: NKDA Social Hx: no smoking or Et. OH abuse Family Hx: no h/o vascular, autoimmune, or neurologic or gait disorders

Focused Neurologic Examination Video • Attached as separated video due to its file size

Neurologic Examination: other pertinent negatives • Intact mentation • No language/speech dysfunction (aphasia, hypophonia, dysarthria) • No cogwheel rigidity or dystonia

Phenomenology • A slowly progressive gait difficulty • Asymmetry of mild incoordination and bradykinesia (arm swing, slowness) • LE more affected > UE • Postural instability • Antalgic gait improves with sensory trick

Differential Diagnosis • Parkinsonism: Idiopathic Parkinson’s disease Progressive supranuclear palsy Multiple system atrophy Corticobasal degeneration Other parkinsonian syndromes • Multi-infarct states: • • • Vascular parkinsonism Gait ignition failure Gait caricature Frontal lobe lesions (mass, infarcts) NPH Idiopathic Functional gait disorder Superman sensory trick / Crazy pants sensory trick

Investigations and Results • Thyroid function – wnl • MRI of spine - spinal stenosis or cord enhancement - small vascular ischemic changes in white matter • EMG of his lower extremities - no evidence of a myopathy - no evidence of motor neuron involvement

Diagnosis: Parkinson’s disease • Responded to levodopa-carbidopa • Variations in gait abnormality

Requirements for Normal Gait 1. equilibrium arise to erect posture support erect posture (stand) adapt to environment (protect) 2. Locomotion initiate steps stepping adapt to environment 3. Other factors mechanical support (bones, joint; not limping) general health/cardiorespiratory (tolerance, slowness)

Conclusion • Diagnosis can be challenging with atypical presentation • Correctly diagnosing neurologic cases requires a combination of excellent observational skills, history taking, examinational skills, and approriate diagnostic evaluation

References Fasano, Alfonso MD, Ph. D; Bloem, Bastiaan R. MD, Ph. D. CONTINUUM: Lifelong Learning in Neurology: Movement Disorders. October 2013 - Volume 19 - Issue 5, - p 1344– 1382 Nadeau SE. Gait apraxia: further clues to localization. Eur Neurol. 2007; 58(3): 142145 Denes G, mantovan MC, Gallana A, Cappelletti JY. Limb-kinetic apraxia. Mov Disord. 1998 may; 13(3): 468 -476. Pub. Med PMID: 9613739 Quencer K, Okun MS, Crucian G, Fernandez HH, Skidmore F, Heilman KM. Limbkinetic apraxia in Parkinson disease. Neurology 2007; 68: 150– 151. Landau WM, Mink JW. Is decreased dexterity in Parkinson disease due to apraxia? Neurology 2007; 68: 90– 91. Leiguarda R, Marsden CD. Limb apraxias: higher-order disorders of sensorimotor integration. Brain 2000; 123: 860– 879. Leiguarda R. Apraxias as traditionally defined. In: Freund H-J, Jeannerod M, Hallett M, Leiguarda R, eds. Higher-order motor disorders. Oxford: Oxford University Press 2000; 303– 338. Zadikoff C, Lang AE. Apraxia in movement disorders. Brain 2005; 128: 1480– 1497. Jose M. Ferro, Andrew Kertesz and Cynthia M. Shewan. Apraxia and aphasia: The functional‐anatomical basis for their dissociation. Neurology January 1984 34: 1

Questions? Thank You