1. Ataxia and Gait Disturbances Presented by A. Hillier, D.O. EM Resident St. John West Shore Hospital

2. Ataxia and Gait Disturbances Generally symptoms of another disease Ataxia Failure to produce smooth intentional movements Gait Disturbance Inability to perform smooth coordinated gait May be described by patient as -Weakness-Dizziness -Stroke-Falling

3. Ataxia and Gait Disturbances Pathophysiology Result from any condition that affects the central and peripheral nervous systems Ataxia: Types Motor ataxia Sensory ataxia

4. Ataxia and Gait Disturbances Motor Ataxia Caused by cerebellar disorders Intact sensory receptors and afferent pathways Integration of proprioception is faulty Midline cerebellar lesions cause truncal ataxia Lateral cerebellar lesions cause limb ataxia Thalamic infarcts may cause contralateral ataxia with sensory loss

5. Ataxia and Gait Disturbances Sensory Ataxia Failure of proprioceptive information to the CNS May be due to disorders of spinal cord or peripheral nerves Can be compensated for by visual inputs

6. Ataxia and Gait Disturbances Differential Diagnoses Intoxication Ethanol Sedative-hypnotics Anticonvulsants Hyponatremia Cerebellar disorders Tumor Hydrocephalus Cerebral vascular accidents Inborn errors of metabolism Multiple Sclerosis Thalamic disorders Parkinson’s Disease Cervical spondylosis Posterior column disorders Peripheral neuropathy Vestibulopathy Disequilibrium of aging

7. Ataxia and Gait Disturbances Definitions Best to use descriptive terms for gait disturbances Motor ataxia: wide-based with irregular, unsteady steps Sensory ataxia: abrupt leg movement and slapping impact of feet Festinating gait: narrow-based miniature shuffling steps. Commonly seen in PD

8. Ataxia and Gait Disturbances Apraxic gait: difficult initiating gait. May be seen in NPH and PD Equine gait: high stepping gait due to peroneal weakness Functional gait disorder: unable to walk normally despite intact motor, sensory and cerebellar function. Often a conversion disorder called astasia-abasia

9. Ataxia and Gait Disturbances History Onset Rapidity Previous symptoms PMH Medications Social Alcohol intake Illicit drug use Associated Symptoms Headache Drowsiness Dizziness Vertigo Tinnitus Fever Nausea/vomiting Weakness Paresthesia

10. Ataxia and Gait Disturbances Physical Exam Gait testing Tandem gait Orthostatic VS Full neurologic exam Cerebellar function  Dysmetira  Dysdiadochokinesia  Dyssynergia  Stewart-Holmes rebound sign  Rhomberg

11. Ataxia and Gait Disturbances Specific Populations Geriatric Patient Gait normally changes with age Shortened strideWidened base Slow gait Senile gait may represent neuronal loss, reduced proprioception, slowing of corrective responses and weakness Can also be present in other neurodegenerative diseases Occurs in ~25% of elderly population Treatment Symptomatic Usually admitted to rule out other life-threatening entities

12. Ataxia and Gait Disturbances The Alcoholic Patient Any gait abnormality in an alcoholic patient should raise concern about nutritional deficiencies If acute ataxia is associated with confusion and eye movement abnormalities Wernicke encephalopathy needs to be considered Still other intracranial pathology needs to be ruled out Treatment IV hydration, Vit B1 and dextrose Most often need to be admitted

13. Ataxia and Gait Disturbances Children May appear well, but wobbly when sitting Intoxications are most common, followed by infection/inflammation Ask about family member home medications PMH PFH Differential diagnoses Drug Intoxication Infection or inflammation Neoplasm Trauma Inborn errors of metabolism Hydrocephalus Idiopathic Disposition Rule out life threatening processes Most are admitted Pediatric neurology consult

14. Questions?

15. 1. Which of the following are the most frequently encountered causes of gait disturbances? a. Intoxication b. Parkinson Disease c. Multiple sclerosis d. Disequilibrium of aging e. All of the above

16. 1. Which of the following are the most common causes of gait disturbances? E All of the above are true. These are the most commonly seen etiologies for gait disturbances.

17. 2. It is best when describing a patients’ gait to a colleague, that you use terms such as apraxic, festinating and equine. T or F? False. It is better to use descriptive terms when describing gait, because different terms may mean different things to different people. Similar to the use of lethargy, obtundation and stupor.

18. 3. A 42 year old alcoholic patient develops an ataxic gait in association with confusion and ocular changes. What is this syndrome called? Wernicke encephalopathy. It is the syndrome of ophthalmoplegia, confusion and ataxia. Due to thiamine deficiency from chronic malnutrition Treatment is hydration, thiamine and glucose.

19. 4. The most common cause of childhood ataxia is inflammatory. T or F? False Inflammatory is the 2 nd leading cause of childhood ataxia due to infection or immunizations Unfortunately intoxication is the most common.

20. 5. Which of the following are probably not necessary to help determine the etiology of ataxia in a child? a. Urine drug screen and ethanol level b. Head CT c. Neurologic exam with emphasis on cerebellar testing d. VDRL/RPR e. Gait testing

21. 5. Which of the following are probably not necessary to help determine the etiology of ataxia in a child? D All of the above are important in trying to determine the etiology of ataxia in an adult. However, testing for neurosyphilis in a child is probably unnecessary.