The gait disorder of advanced essential tremor
Gait disturbances are described as any deviations from normal walking or gait. These disturbances stem from numerous etiologies. Due to their different clinical presentations, a high index of suspicion is required. The etiology can be determined through lab work, clinical presentation, and diagnostic testing.
The evaluation of gait disorders includes the careful clinical observation of gait and a neurological and orthopedic examination based on the patient history, all of which guide the choice of ancillary diagnostic procedures if required and appropriate. This review is intended to be a guide for clinicians on the physiological basis of gait, the clinical examination and on typical causes of gait disorders.
Human gait depends on a complex interplay of major parts of the nervous, musculoskeletal and cardiorespiratory systems. The individual gait pattern is influenced by age, personality, mood and sociocultural factors. The preferred walking speed in older adults is a sensitive marker of general health and survival. Safe walking requires intact cognition and executive control. Gait disorders lead to a loss of personal freedom, falls and injuries and result in a marked reduction in the quality of life.
Walking is a common activity of daily living and at the same time a very complex one. It involves all levels of the nervous system and many parts of the musculoskeletal apparatus as well as the cardiorespiratory system. A person’s gait pattern is strongly influenced by age, personality and mood.
An abnormal gait is a change to your walking pattern. Everyone’s natural walking style is unique. However, injuries and medical conditions can affect your walking pattern.
What are the types of gait abnormalities? There are several different types of gait abnormalities, the most common include:
What are the symptoms of gait abnormalities? Signs and symptoms of gait abnormalities vary based on which type of abnormality you’re experiencing. Some of the most common symptoms include:
Gait disturbances of patients with essential tremor (ET) have been described anecdotally, but have never been investigated quantitatively. Recent studies provided evidence for a cerebellar-like hand tremor in some patients with ET. Therefore, we designed a study to assess cerebellar-like abnormalities of leg function. Twenty-five patients with ET, eight patients with cerebellar diseases (CD) and 21 age-matched healthy subjects were studied for their normal and tandem gait using a three-dimensional gait analysis system.
During normal walking, ET patients showed only slight abnormalities. However, ET patients exhibited abnormalities in tandem gait with an increased number of mis-steps and a broad-based, ataxic and dysmetric gait which was indistinguishable from the findings in CD. When ET patients were separated into groups of those with or without intention tremor of the hands, the gait disorder was found to be much more pronounced in the intention tremor group.
Patients with this gait disorder were more severely disturbed in their activities of daily living, and suffer from an advanced stage of ET. The present results quantitatively describe a gait disturbance in advanced ET which affects tandem gait, but leaves normal gait almost unaffected. This is strong evidence for a cerebellar-like disturbance in ET.
The evaluation of gait disorders includes the careful clinical observation of gait and a neurological and orthopedic examination based on the patient history, all of which guide the choice of ancillary diagnostic procedures if required and appropriate. This review is intended to be a guide for clinicians on the physiological basis of gait, the clinical examination and on typical causes of gait disorders.
Human gait depends on a complex interplay of major parts of the nervous, musculoskeletal and cardiorespiratory systems. The individual gait pattern is influenced by age, personality, mood and sociocultural factors. The preferred walking speed in older adults is a sensitive marker of general health and survival. Safe walking requires intact cognition and executive control. Gait disorders lead to a loss of personal freedom, falls and injuries and result in a marked reduction in the quality of life.
Walking is a common activity of daily living and at the same time a very complex one. It involves all levels of the nervous system and many parts of the musculoskeletal apparatus as well as the cardiorespiratory system. A person’s gait pattern is strongly influenced by age, personality and mood.
An abnormal gait is a change to your walking pattern. Everyone’s natural walking style is unique. However, injuries and medical conditions can affect your walking pattern.
What are the types of gait abnormalities? There are several different types of gait abnormalities, the most common include:
- Antalgic gait: An antalgic gait is the result of pain. It’s the most common type of abnormal gait. It makes you limp (avoiding stepping with or putting pressure on your affected leg or foot).
- Propulsive gait (Parkinsonian gait): This type of gait affects people diagnosed with parkinsonism or Parkinson’s disease. Characteristics of a propulsive gait include a stooping, rigid posture and your head and neck bending forward. Your steps are usually short and fast to maintain your center of gravity (festinating gait).
- Scissors gait: This type of gait gets its name because your knees and thighs hit or cross in a scissors-like pattern when you walk. Your steps may be slow and small. This type of gait usually affects people diagnosed with spastic cerebral palsy.
- Spastic gait (hemiplegic gait): A spastic gait causes you to walk with one stiff leg. When you lift that leg to walk, it either drags or swings around in a semicircular motion (circumduction). This type of gait is common among people diagnosed with cerebral palsy, multiple sclerosis or hemiplegia.
- Steppage gait (neuropathic gait): This type of gait causes a high step, where you elevate your hip to lift your leg higher than normal. Your foot may appear floppy when it drops. Your toes usually point down and scrape the ground when you walk. Muscle atrophy or a peroneal nerve injury (like from spinal stenosis or a herniated disc), can cause a steppage gait.
- Waddling gait: A waddling gait causes you to exaggerate the movement of your upper body, which creates a waddling or duck-like walk. Progressive muscular dystrophy or hip dislocation present from birth can produce a waddling gait.
- Crouching gait: A crouching gait causes your ankles, knees and hips to flex while you walk. It can look like you’re about to bend down as you’re walking. Your toes may drag. This type of gait is common if you have cerebral palsy.
- Ataxic gait: This type of gait occurs with cerebellar degeneration. It causes irregular steps that affect your ability to walk in a straight line when you walk heel to toe. You may feel unsteady if you have an ataxic gait.
- Shuffling gait: Shuffling is walking without lifting your feet completely off the ground. It causes your feet to drag. You may shuffle if you feel off balance or have an injury that prevents you from lifting your feet off the ground when you walk.
- Lurching gait: A lurching gait is common among people affected by paralysis or weakness of the gluteus area (the muscles near your hips and butt). It causes a slow and long stride. Your upper body can jerk forward or backward to lessen the weight on your affected leg.
What are the symptoms of gait abnormalities? Signs and symptoms of gait abnormalities vary based on which type of abnormality you’re experiencing. Some of the most common symptoms include:
- Dragging or shuffling your feet.
- Feeling out of balance when you walk.
- Stiff muscles or joints in your hips and legs.
- Swaying side to side with each step (waddle).
- Walking with your head and neck bent toward the ground.
- Taking higher than normal steps and dropping your feet with each step.
- Taking small steps.
- Pain when walking.
Gait disturbances of patients with essential tremor (ET) have been described anecdotally, but have never been investigated quantitatively. Recent studies provided evidence for a cerebellar-like hand tremor in some patients with ET. Therefore, we designed a study to assess cerebellar-like abnormalities of leg function. Twenty-five patients with ET, eight patients with cerebellar diseases (CD) and 21 age-matched healthy subjects were studied for their normal and tandem gait using a three-dimensional gait analysis system.
During normal walking, ET patients showed only slight abnormalities. However, ET patients exhibited abnormalities in tandem gait with an increased number of mis-steps and a broad-based, ataxic and dysmetric gait which was indistinguishable from the findings in CD. When ET patients were separated into groups of those with or without intention tremor of the hands, the gait disorder was found to be much more pronounced in the intention tremor group.
Patients with this gait disorder were more severely disturbed in their activities of daily living, and suffer from an advanced stage of ET. The present results quantitatively describe a gait disturbance in advanced ET which affects tandem gait, but leaves normal gait almost unaffected. This is strong evidence for a cerebellar-like disturbance in ET.
Gait ataxia in essential tremor is differentially modulated by thalamic stimulation
Alfonso Fasano 1, Jan Herzog, Jan Raethjen, Franziska E M Rose, Muthuraman Muthuraman, Jens Volkmann, Daniela Falk, Rodger Elble, Günther Deuschl
Alfonso Fasano 1, Jan Herzog, Jan Raethjen, Franziska E M Rose, Muthuraman Muthuraman, Jens Volkmann, Daniela Falk, Rodger Elble, Günther Deuschl
Patients with advanced stages of essential tremor frequently exhibit tandem gait ataxia with impaired balance control and imprecise foot placement, resembling patients with a cerebellar deficit. Thalamic deep brain stimulation, a surgical therapy for otherwise intractable cases, has been shown to improve tremor, but its impact on cerebellar-like gait difficulties remains to be elucidated. Eleven patients affected by essential tremor (five females; age 69.8 ± 3.9 years; disease duration 24.4 ± 11.2 years; follow-up after surgery 24.7 ± 20.3 months) were evaluated during the following conditions: stimulation off, stimulation on and supra-therapeutic stimulation. Ten age-matched healthy controls served as the comparison group. Locomotion by patients and controls was assessed with (i) overground gait and tandem gait; (ii) balance-assisted treadmill tandem gait and (iii) unassisted treadmill gait. The two treadmill paradigms were kinematically analysed using a 3D opto-electronic motion analysis system. Established clinical and kinesiological measures of ataxia were computed. During stimulation off, the patients exhibited ataxia in all assessment paradigms, which improved during stimulation on and worsened again during supra-therapeutic stimulation. During over ground tandem gait, patients had more missteps and slower gait velocities during stimulation off and supra-therapeutic stimulation than during stimulation on. During balance-assisted tandem gait, stimulation on reduced the temporospatial variability in foot trajectories to nearly normal values, while highly variable (ataxic) foot trajectories were observed during stimulation off and supra-therapeutic stimulation. During unassisted treadmill gait, stimulation on improved gait stability compared with stimulation off and supra-therapeutic stimulation, as demonstrated by increased gait velocity and ankle rotation. These improvements in ataxia were not a function of reduced tremor in the lower limbs or torso. In conclusion, we demonstrate the impact of thalamic stimulation on gait ataxia in patients with essential tremor with improvement by stimulation on and deterioration by supra-therapeutic stimulation, despite continued control of tremor. Thus, cerebellar dysfunction in these patients can be differentially modulated with optimal versus supra-therapeutic stimulation. The cerebellar movement disorder of essential tremor is due to a typical cerebellar deficit, not to trembling extremities. We hypothesize that deep brain stimulation affects two major regulating circuits: the cortico-thalamo-cortical loop for tremor reduction and the cerebello-thalamo-cortical pathway for ataxia reduction (stimulation on) and ataxia induction (supra-therapeutic stimulation).
Ability to Walk Can Foretell the Future (NIH)
Exercise tests can be used to predict a person's risk of cardiovascular disease and mortality. But they can be too rigorous for many older adults. A new study led by researchers at the University of Pittsburgh School of Medicine shows that an extended walking test is effective at predicting health outcomes in older adults.
The researchers, supported by a grant from NIH's National Institute on Aging, enrolled 3,075 people between 70 and 79 years old living in Pittsburgh, Pennsylvania, and Memphis, Tennessee. Some people were excluded from the test for medical safety. Those who participated were asked to walk a quarter of a mile in a hallway (10 laps) after a 2-minute warm-up, and were given encouragement at each lap. They were told to "walk as quickly as you can, without running, at a pace you can maintain." Of the 2,680 eligible for the test, 86% completed the full distance, while 13% couldn't.
The researchers report in the May 3, 2006 issue of the Journal of the American Medical Association that exclusion from the walking test or an inability to complete it were associated about 5 years later with a higher risk of mortality, cardiovascular disease and mobility limitations or disabilities. Among those able to complete a test, each additional minute it took them to finish was associated with a 29% higher rate of mortality, a 20% higher rate of cardiovascular disease and a 52% higher rate of mobility problems.
This study shows that, in apparently well-functioning older adults, a relatively simple test can expose a wide range of function and health risk. This finding highlights the importance of fitness in older adults. People who stay physically active into their 70s raise their chance of living longer and healthier lives into their 80s.
Exercise tests can be used to predict a person's risk of cardiovascular disease and mortality. But they can be too rigorous for many older adults. A new study led by researchers at the University of Pittsburgh School of Medicine shows that an extended walking test is effective at predicting health outcomes in older adults.
The researchers, supported by a grant from NIH's National Institute on Aging, enrolled 3,075 people between 70 and 79 years old living in Pittsburgh, Pennsylvania, and Memphis, Tennessee. Some people were excluded from the test for medical safety. Those who participated were asked to walk a quarter of a mile in a hallway (10 laps) after a 2-minute warm-up, and were given encouragement at each lap. They were told to "walk as quickly as you can, without running, at a pace you can maintain." Of the 2,680 eligible for the test, 86% completed the full distance, while 13% couldn't.
The researchers report in the May 3, 2006 issue of the Journal of the American Medical Association that exclusion from the walking test or an inability to complete it were associated about 5 years later with a higher risk of mortality, cardiovascular disease and mobility limitations or disabilities. Among those able to complete a test, each additional minute it took them to finish was associated with a 29% higher rate of mortality, a 20% higher rate of cardiovascular disease and a 52% higher rate of mobility problems.
This study shows that, in apparently well-functioning older adults, a relatively simple test can expose a wide range of function and health risk. This finding highlights the importance of fitness in older adults. People who stay physically active into their 70s raise their chance of living longer and healthier lives into their 80s.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5318488/#:~:text=The%20causes%20of%20gait%20disorders,arterial%20occlusive%20disease%20and%20obesity).
https://my.clevelandclinic.org/health/symptoms/21092-gait-disorders
https://www.nih.gov/news-events/nih-research-matters/ability-walk-can-foretell-future
https://my.clevelandclinic.org/health/symptoms/21092-gait-disorders
https://www.nih.gov/news-events/nih-research-matters/ability-walk-can-foretell-future
