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

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

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

4. 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
wearing long pants  “being pulled down” to the ground from behind like a belt pulling him down
removing his wallet and keys out of his pocket, better and when he puts his items back in his pocket he feels worse.

5. 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 EtOH abuse
Family Hx: no h/o vascular, autoimmune, or neurologic or gait disorders

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

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

8. 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

9. 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

10. 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

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

12. 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)

13. 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

14. References
Fasano, Alfonso MD, PhD; Bloem, Bastiaan R. MD, PhD. CONTINUUM: Lifelong Learning in Neurology: Movement Disorders . October Volume 19 - Issue 5, - p 1344–1382 Nadeau SE. Gait apraxia: further clues to localization. Eur Neurol. 2007;58(3): Denes G, mantovan MC, Gallana A, Cappelletti JY. Limb-kinetic apraxia. Mov Disord may; 13(3): PubMed PMID: Quencer K, Okun MS, Crucian G, Fernandez HH, Skidmore F, Heilman KM. Limb-kinetic 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 :1

15. Questions?
Thank You