GAIT DISTURBANCES
GAIT DISTURBANCES: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the Following Questions:
- Are there abnormalities on neurologic examination? An abnormal neurologic examination should make one think of multiple sclerosis, peripheral neuropathy, muscular dystrophy, Parkinson's disease, Huntington's chorea, and a host of degenerative neurologic conditions.
- Is there a painful limp? The findings of a painful limp should make one suspect hip, knee, or ankle joint pathology. A herniated lumbar disk may also cause a characteristic antalgic gait.
- Is the gait characteristic of a particular type? Characteristic gaits include the short-stepped shuffling gait of Parkinson's disease, the ataxic gait of multiple sclerosis and cerebellar disorders, the reeling, clownish gait of Huntington's chorea, the pelvic tilt of muscular dystrophy, and the steppage gait of peripheral neuropathy.
- Could the gait disturbance be due to malingering or hysteria? The gait of conversion hysteria is quite remarkable. The patient has a normal neurologic examination and has no difficulty maintaining balance while sitting down, but there is total inability to walk or stand without reeling about.
DIAGNOSTIC WORKUP
Routine orders would include a CBC, sedimentation rate, chemistry panel, VDRL test, and urinalysis. If there is a painful limp, x-rays of the hip, knee, or ankle on the affected side should be performed. An x-ray of the lumbar spine will not usually be of great assistance, however. If plain x-rays are negative, a CT scan or MRI of the lumbar spine, hip, knee, or ankle may be of assistance in the diagnosis. A bone scan may pick up obscure fractures and other pathology.
If there are abnormalities on the neurologic examination, MRI or CT scan of the appropriate level of suspected pathology will be done. A spastic gait with abnormal cranial nerve findings would suggest a cerebral tumor or other brain disease, and a CT scan or MRI of the brain should be done. Keep in mind that the MRI is almost double the cost of a CT scan, and the diagnostic yield is not that much greater in many cases.
A spastic gait without cranial nerve signs or papilledema would suggest a spinal cord disorder, and an MRI or CT scan of the appropriate level of the spinal cord should be done. A CT scan of the cervical spine, however, is not very useful and MRI is preferred.
If multiple sclerosis is suspected, a spinal tap for myelin basic protein or gamma globulin levels should be done. A VEP study, a BSEP study, or a SSEP study will also be useful in diagnosing multiple sclerosis.
If there is an ataxic gait, cerebellar disorder should be suspected, and a CT scan of the brain may be done. However, an ataxic gait may also suggest multiple sclerosis, pernicious anemia, and tabes dorsalis. If the VDRL test is negative, a FTA-ABS test should be done. Blood levels for vitamin B
12
and folic acid will help diagnose pernicious anemia. A Schilling test, however, is sometimes necessary to facilitate this diagnosis. If muscular dystrophy is suspected, electromyographic examination and muscle biopsy will help confirm the diagnosis. If the patient has a steppage gait, the workup of peripheral neuropathy should be done, as noted on
page 350
.
Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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