Ataxia

Ataxia: Excerpt from In a Page: Signs and Symptoms

Disorders of gait may arise from problems virtually anywhere in the nervous or musculoskeletal systems. Observation of gait is an important element of the neurologic examination. Gait abnormalities are described as slapping, stepping, or mixed. A slapping gait presents with a tendency to slap the feet firmly against the ground to improve proprioceptive input, whereas a steppage gait, as seen in patients with foot drop, involves carefully lifting the foot to prevent it from catching and tripping the patient.

Differential Diagnosis

• Orthopedic issues affecting the foot, ankle, leg, knee, or hip

• Peripheral neuropathy (sensory and/or motor)
  –Slapping gait: Sensory neuropathies may result in a tendency to slap the feet firmly against the ground to improve proprioceptive input
  –Steppage gait: Seen in patients with foot drop
  –The classic tabetic gait combines both stepping and slapping gaits
• Mononeuropathy/radiculopathy affecting the lower extremities may result in gait abnormalities (e.g., either a peroneal neuropathy or L5 radiculopathy can cause a unilateral steppage gait)
• Myelopathy
  –Patients with bilateral lower extremity weakness and hypertonicity secondary to a spinal cord lesion may exhibit a spastic gait with stiffness of both legs and a tendency toward scissoring of the legs with walking
• Brainstem or cortical lesions (e.g., multiple sclerosis, CVA)
  –Most commonly result in a hemiparetic gait with circumduction of the weak leg
• Cerebellar lesions
  –Result in an ataxic gait, which tends to be wide-based, irregular, and staggering
• Intoxications
• Parkinsonism
  –Patients exhibit stooped posture, decreased arm swing, and shuffling (take many small steps)
• Myopathies
  –Tend to produce a waddling gait because of weakness of the trunk, hip, and proximal lower extremity muscles
• Spinocerebellar ataxia
• Hereditary spastic paraparesis
• Hysterical gaits
• Inherited neuropathies (e.g., Charcot-Marie-Tooth disease)
• GALOP syndrome (gait disorder, autoantibodies, late age onset, polyneuropathy)
• Normal pressure hydrocephalus
• Infection (e.g., neurosyphillis, meningitis)
• Vitamin B₁₂ or thiamine deficiency

Workup and Diagnosis

• History and physical examination
  –Note history of injury, intoxication, and the events leading to onset of gait problems
  –Careful attention should be given not only to the type of gait disturbance, but also to associated findings on neurologic exam (e.g., symmetric distal sensory loss and hyporeflexia suggest a peripheral neuropathy; circumducting gait with hemiparesis, hemisensory loss, and ipsilateral hyperreflexia suggest a cerebral lesion)
• Orthopedic imaging and consult may be indicated, especially if localized lower extremity pain is prominent
• Neuroimaging (CT/MRI) may be indicated
• EMG/nerve conduction studies may help diagnose neuropathy or myopathy
• Labs may include CBC, chemistries, RPR, vitamin B₁₂ and folate levels, ESR, and other lab evaluation for neuropathy, if appropriate
• Drug screen or alcohol levels if intoxication suggested
• Anticonvulsant levels (especially phenytoin)
• Genetic testing: DNA testing is available for inherited neuropathies (e.g., CMT 1A, many of the SCAs)
• If the etiology of a gait abnormality is uncertain, a full gait analysis by a specially trained physical therapist, podiatrist, orthopedic surgeon, or neurologist is often indicated

Treatment

• Specific symptomatic measures to improve gait stability and efficiency may improve functional abilities
  –Assistive devices (e.g., canes, walkers, wheelchairs)
  –Orthotics (e.g., ankle-foot orthoses for foot drop)
  –Physical therapy
• Removing intoxicating substances if present
• Orthopedic pathologies may be resolved by rest, casting or orthotics, NSAIDs, or surgical therapy
• Peripheral neuropathy/mononeuropathy: Treat the underlying cause to improve gait or prevent worsening
• Radiculopathy: Physical therapy, medications (e.g., NSAIDs, muscle relaxants), local injection therapies (e.g., epidural injections), and/or surgical intervention
• Myelopathy: Treating the underlying cause may improve or prevent worsening of gait; spasticity may be treated with antispasticity agents (e.g., baclofen)
• Structural lesions of the brainstem, cerebellum, or cerebrum should be identified and treated if possible (e.g., multiple sclerosis)

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Spinocerebellar Ataxia

• Back to disease: Spinocerebellar Ataxia: Introduction
• Next Book Extract About Spinocerebellar Ataxia: Ataxia (In A Page: Pediatric Signs and Symptoms)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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