assessment of gait and balance
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22/04/2021
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Assessment of gaitand balanceProfessor Bas Bloem
Parkinson Centre Nijmegen (ParC)
Radboud University Medical Centre
@BasBloem
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The traditional way of teaching
Real life: never a full house
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Examine Phenomenology Differential
How this could work (table in the Nature Reviews paper!)
Examine Phenomenology Differential
Seated posture
How this could work (table in the Nature Reviews paper!)
Examine Phenomenology Differential
Seated posture Leaning or drifting to one side
How this could work (table in the Nature Reviews paper!)
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Examine Phenomenology Differential
Seated posture Leaning or drifting to one side
Parkinson disease
Pisa syndrome (MSA)
Pusher syndrome (stroke)
Vertebral columndeformity (scoliosis)
How this could work (table in the Nature Reviews paper!)
My main message
Rule 1: look carefully
Rule 2: start young
“Take home” message!
For each part of the talk
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“Take home” message!
For each part of the talk
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Example:Posture while standing
“Normal” aging ???
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“Take home” message!
Changes seen in old people
are usually not ‘normal ageing’
Now for abnormal postures
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This was the first presenting sign
What do you see here?
Courtesy of Karen Doherty & Andrew Lees
In fact, fully reversible
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Wedge‐shaped compression fractures
Osteogenic camptocormia
What do you see here?
Courtesy of Karen Doherty & Andrew Lees
TOO MUCH activity of abdominal muscles
TOO LITTLE activity of abdominal muscles
Dystonia Myopathy or myositis
An example: camptocormia
???
Jankovic Mov Disord 2010;25:527‐528van de Warrenburg Mov Disord 2007;22:2325‐2331
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What do you see here?
Courtesy of Karen Doherty & Andrew Lees
“Take home” message!
Postural misalignment includes:
• Dystonia (± parkinsonism)
• Weakness
• Vertebral column deformities
• Sensory (body scheme) changes
• Functional disorders
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“Take home” message!
Adequate treatment begins
with a proper diagnosis
An example: camptocormia
Cause Treatment
Parkinson’s disease Levodopa; deep brain surgery
Myositis of back muscles Steroids
Orthopedic cause Spinal surgery
Etc. etc.
…
Backpack treatment for camptocormia
Gerton et al., Mov Disord 2010;25:247–248
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Broad‐based gait
What do you see here?
Courtesy of Jay Nutt
What do you see here?
Courtesy of Jay Nutt
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Broad‐based freezing in vascular parkinsonism
Courtesy of Jay Nutt
What do you see here?
Abnormalities can be subtle
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What do you see here?
Courtesy of Jay Nutt
“Take home” message!
A broad base of support is a sensitive
but aspecific gait abnormality
Normal (to narrow) based gait
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What do you see here?
Parkinson MSAAbdo et al., JNNP 2006;77:1367‐1369
Parkinson patients can even do this!
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“Take home” message!
Narrow‐based gaits are related
to either Parkinson’s disease
(or to bilateral spasticity)
Scissoring gait
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Improvement with running
Gait scissoring(worse when walking fast)
Improvement walking backwards
Functional in a different way
Gait scissoring in frontal ataxia (Bruns)
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What do you see here?
What do you see here?
“Take home” message!
Scissoring gait has a limited differential:
1. Functional
2. Frontal ataxia
3. Spasticity
4. Chorea
5. Dystonia
6. Compensation in Parkinson
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Reduced arm swing
Reduced arm swing in Parkinson’s disease
What do you see here?
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Depression and no other symptoms
Nürnberger et al., 2015; video courtesy of Dr. Bentivoglio
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Reduced arm swing in Parkinson patient
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Arm swing remains abnormal during running
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But what if arm swing is PRESERVED?
Man with drug‐induced parkinsonism
Preserved arm swing
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Preserved arm swing in NPH
Freezing of gait
Continuous versus episodic problems
Continuous gait disorder
Episodic gait disorder
Normal
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Knee hyperextension during walking
What do you see here?
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What do you see here?
Courtesy of Jay Nutt
“Take home” message!
Knee locking can be seen in:
1. Cerebellar ataxia
2. Sensory ataxia
3. Proximal leg weakness
Stiff gait
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What do you see here?
Courtesy of Tony Lang
What do you see here?
Courtesy of Peter Brown
“Take home” message!
“Stiff” gait is also one of the basic
types of gait abnormalities
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“Take home” message!
Stiff gait can be seen in:1. Stiff person syndrome
2. Spasticity
3. Parkinsonism
4. Dystonia
5. Myotonia
Veering gait
What do you see here?
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What do you see here?
“Take home” message!
Veering generally represents
vestibular or cerebellar disorders
Limping gait
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What do you see here?
‘Antalgic’ pattern
THANK YOU!
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