Chapter 024. Gait and Balance Disorders (Part 2)

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Disorders of Gait The heterogeneity of gait disorders observed in clinical practice reflects the large network of neural systems involved in the task. There is the potential for abnormalities to develop, and walking is vulnerable to neurologic disease at every level. Gait disorders have been classified descriptively, based on the abnormal physiology and biomechanics. One problem with this approach is that many failing gaits look fundamentally similar. This overlap reflects common patterns of adaptation to threatened balance stability and declining performance. The gait disorder observed clinically must be viewed as the product of a neurologic deficit and a functional adaptation....

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Chapter 024. Gait and Balance Disorders (Part 2) Disorders of Gait The heterogeneity of gait disorders observed in clinical practice reflects the large network of neural systems involved in the task. There is the potential for abnormalities to develop, and walking is vulnerable to neurologic disease at every level. Gait disorders have been classified descriptively, based on the abnormal physiology and biomechanics. One problem with this approach is that many failing gaits look fundamentally similar. This overlap reflects common patterns of adaptation to threatened balance stability and declining performance. The gait disorder observed clinically must be viewed as the product of a neurologic deficit and a functional adaptation. Unique features of the failing gait are often overwhelmed by the adaptive response. Some of the common patterns of abnormal gait are summarized below. Gait disorders can also be classified by etiology, as listed in Table 24-1. Table 24-1 Etiology of Gait Disorder
Cases Percent Sensory deficits 22 18.3 Myelopathy 20 16.7 Multiple infarcts 18 15.0 Parkinsonism 14 11.7 Cerebellar degeneration 8 6.7 Hydrocephalus 8 6.7 Toxic/metabolic 3 2.5 Psychogenic 4 3.3 Other 6 5.0
Unknown cause 17 14.2 Total 120 100% Source: Reproduced with permission from Masdeu et al. Cautious Gait The term cautious gait is used to describe the patient who walks with an abbreviated stride and lowered center of mass, as if walking on a slippery surface. This disorder is both common and nonspecific. It is, in essence, an adaptation to a perceived postural threat. A fear of falling may be associated. In one study, this disorder was observed in more than one-third of older patients with a higher level gait disturbance. Physical therapy often improves walking to the degree that follow-up observation may reveal a more specific underlying disorder. Stiff-Legged Gait Spastic gait is characterized by stiffness in the legs, an imbalance of muscle tone, and a tendency to circumduct and scuff the feet. The disorder reflects compromise of corticospinal command and overactivity of spinal reflexes. The patient may walk on his or her toes. In extreme instances, the legs cross due to increased tone in the adductors. Upper motor neuron signs are present on physical
examination. Shoes often reflect an uneven pattern of wear across the outside. The disorder may be cerebral or spinal in origin. Myelopathy from cervical spondylosis is a common cause of spastic or spastic-ataxic gait. Demyelinating disease and trauma are the leading causes of myelopathy in younger patients. In a chronic progressive myelopathy of unknown cause, workup with laboratory and imaging tests may establish a diagnosis of multiple sclerosis. A family history should suggest hereditary spastic paraplegia (HSP). Genetic testing is now available for some of the common HSP mutations. Tropical spastic paraparesis related to the retrovirus HTLV-I is endemic in parts of the Caribbean and South America. A structural lesion, such as tumor or spinal vascular malformation, should be excluded with appropriate testing. Spinal cord disorders are discussed in detail in Chap. 372. With cerebral spasticity asymmetry is common, involvement of the upper extremities is usually observed, and dysarthria is often an associated feature. Common causes include vascular disease (stroke), multiple sclerosis, and perinatal injury to the nervous system (cerebral palsy). Other stiff-legged gaits include dystonia (Chap. 382) and stiff-person syndrome. Dystonia is a disorder characterized by sustained muscle contractions, resulting in repetitive twisting movements and abnormal posture. It often has a genetic basis. Dystonic spasms produce plantar flexion and inversion of the feet,
sometimes with torsion of the trunk. In autoimmune stiff-person syndrome, there is exaggerated lordosis of the lumbar spine and overactivation of antagonist muscles, which restricts trunk and lower limb movement and results in a wooden or fixed posture.