1
|
Corazza LA, Reis Rosa AB, Tonholo Silva TY, Rezende Filho FM, Maranhão-Filho PA, Pedroso JL, Barsottini OGP, Espay AJ. Functional ataxia in a specialized ataxia center. Parkinsonism Relat Disord 2024; 120:106006. [PMID: 38244461 DOI: 10.1016/j.parkreldis.2024.106006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/03/2023] [Accepted: 01/11/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Functional gait is a disorder of ambulation and balance internally inconsistent and incongruent with the phenotypic spectrum of neurological gait disorders. OBJECTIVES This paper aims to clinically characterize patients with functional ataxia. METHODS Patients with functional ataxia were analyzed out of 1350 patients in Ataxia Unit of the Federal University of São Paulo circa 2008 to 2022. RESULTS Thirteen patients (1 %) presented with functional ataxia; all female, with a median age of 34.8 years. Six (46.2 %) had psychiatric comorbidities and 7 (53.8 %) endorsed a trigger. Diagnostic features included variable base and stride (100 %), "huffing and puffing" (30.7 %), knee-buckling (30.7 %), uneconomic posturing (38.5 %), tightrope walking (23 %), and trembling gait (15.4 %). Remarkably, no falls were reported in any case. 53.8 % recovered fully or partially, despite no treatment. CONCLUSIONS Variability of base and stride are universal features of functional ataxia, yet falls are inconspicuous. Functional Ataxia is rare even in a specialized ataxia center.
Collapse
Affiliation(s)
- Luíza Alves Corazza
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Augusto Bragança Reis Rosa
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Thiago Yoshinaga Tonholo Silva
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Flávio Moura Rezende Filho
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | | | - José Luiz Pedroso
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.
| | - Orlando Graziani Povoas Barsottini
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Alberto J Espay
- Department of Neurology, James J and Joan A Gardner Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
2
|
Mermelstein S, Barbosa P, Kaski D. Neurological gait assessment. Pract Neurol 2024; 24:11-21. [PMID: 38135498 DOI: 10.1136/pn-2023-003917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2023] [Indexed: 12/24/2023]
Abstract
Gait disorders are a common feature of neurological disease. The gait examination is an essential part of the neurological clinical assessment, providing valuable clues to a myriad of causes. Understanding how to examine gait is not only essential for neurological diagnosis but also for treatment and prognosis. Here, we review aspects of the clinical history and examination of neurological gait to help guide gait disorder assessment. We focus particularly on how to differentiate between common gait abnormalities and highlight the characteristic features of the more prevalent neurological gait patterns such as ataxia, waddling, steppage, spastic gait, Parkinson's disease and functional gait disorders. We also offer diagnostic clues for some unusual gait presentations, such as dystonic, stiff-person and choreiform gait, along with red flags that help differentiate atypical parkinsonism from Parkinson's disease.
Collapse
Affiliation(s)
- Sofia Mermelstein
- Neurology, Pedro Ernesto University Hospital, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Barbosa
- Divisão de Neurologia, Grupo de Distúrbios do Movimento, Universidade de São Paulo Hospital das Clínicas, Sao Paulo, São Paulo, Brazil
| | - Diego Kaski
- Clinical and Movement Neurosciences, UCL, London, UK
| |
Collapse
|
3
|
Diagnosis of psychogenic (functional) gait disorders. ACTA BIOMEDICA SCIENTIFICA 2023. [DOI: 10.29413/abs.2023-8.1.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
Psychogenic gait is common in patients with medically unexplained neurological symptoms and provides significant challenges to healthcare providers. Clinicians may arrive at a correct diagnosis earlier if distinctive positive signs are identified and acknowledged. Psychogenic disorders of posture and gait are common and are the major manifestation in 8–10 % of patients with psychogenic movement disorders. Psychogenic movement disorders can present with varied phenomenology that may resemble organic movement disorders. The diagnosis is based on clinical evaluation with a supporting history and classic features on neurologic examination. In functional gait disorders, walking is often bizarre and does not conform to any of the usual patterns observed with neurologic gait disorders. Astasia-abasia, an inability to stand (astasia) or walk (abasia) in the absence of other neurologic abnormalities, was the term applied by investigators in the mid to late 19thcentury to describe certain patients with a frankly functional gait. Other descriptive terms include gaits that resemble walking on ice, walking a sticky surface, walking through water (bringing to mind excessive slowness), tightrope walking, habitual limping, and bizarre, robotic, knock-kneed, trepidant, anxious, and cautious gaits. Ancillary testing, such as imaging and neurophysiologic studies, can provide supplementary information but is not necessary for diagnosis.
Collapse
|
4
|
Mishra A, Pandey S. Functional Neurological Disorders: Clinical Spectrum, Diagnosis, and Treatment. Neurologist 2022; 27:276-289. [PMID: 35858632 DOI: 10.1097/nrl.0000000000000453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Functional neurological disorders (FNDs) are common but often misdiagnosed. REVIEW SUMMARY The incidence of FNDs is between 4 and 12 per 100,000, comparable to multiple sclerosis and amyotrophic lateral sclerosis, and it is the second most common diagnosis in neurology clinics. Some clues in the history are sudden onset, intermittent time course, variability of manifestation over time, childhood trauma, and history of other somatic symptoms. Anxiety and depression are common, but not necessarily more than in the general population. Although there are no tests currently capable of demonstrating whether symptoms are willfully produced, there may not be a clear categorical difference between voluntary and involuntary symptoms. The prognosis of an FND is linked to early diagnosis and symptom duration, but unfortunately, the majority of the patients are diagnosed after considerable delays. CONCLUSIONS A positive diagnosis of FNDs can be made on the basis of history and neurological signs without reliance on psychological stressors. Past sensitizing events and neurobiological abnormalities contribute to the pathogenesis of FNDs. Physical rehabilitation and psychological interventions alone or in combination are helpful in the treatment.
Collapse
Affiliation(s)
- Anumeha Mishra
- Department of Neurology, Govind Ballabh Pant Postgraduate institute of medical education and research; New Delhi, India
| | | |
Collapse
|
5
|
Singh D. Functional dystonia: A pitfall for the foot and ankle surgeon. Foot Ankle Surg 2022; 28:691-696. [PMID: 34649761 DOI: 10.1016/j.fas.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/23/2021] [Accepted: 10/05/2021] [Indexed: 02/04/2023]
Abstract
Functional dystonia represents a condition where psychological distress is being expressed as involuntary muscle contractions. In the foot and ankle, it most commonly presents as a sudden onset of a painful fixed ankle/hindfoot deformity in a female patient with a history of trivial trauma or surgery. The "fixed deformity" found on clinical examination is usually correctable under general anesthesia. Less commonly, it can present in the toes or may present as paroxysmal muscle movements rather than a fixed deformity. CRPS may occur concurrently with the dystonia. Failure to consider the diagnosis leads to a long delay in appropriate diagnosis, patient distress and unnecessary or even harmful surgery. A better approach to this clinical syndrome is to define it as fixed abnormal posturing that is most commonly psychogenic. Early referral to a movement disorder clinic is recommended. The prognosis is generally poor as less than a quarter of patients report subjective long-term improvement even when managed in a movement disorder clinic. Foot and ankle surgeons should, whenever possible, avoid operating on patients with functional dystonia in order to avoid symptomatic deterioration.
Collapse
Affiliation(s)
- Dishan Singh
- Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, United Kingdom.
| |
Collapse
|
6
|
García-Cabeza I, Epifanio MDM. ASTASIA-ABASIA, PSYCHOGENIC OR ORGANIC? IT ́S NOT EASY. ACTAS ESPANOLAS DE PSIQUIATRIA 2022; 50:160-162. [PMID: 35643974 PMCID: PMC10803837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/01/2022] [Indexed: 06/15/2023]
Abstract
Astasia-abasia was described by Paul Blocq as a psychogenic condition; later, several brain injuries have been described for its explanation too.
Collapse
Affiliation(s)
- Ignacio García-Cabeza
- Servicio de Psiquiatría de Adultos HGU Gregrorio Marañón. Universidad Complutense de Madrid
| | | |
Collapse
|
7
|
Castro P, Papoutselou E, Mahmoud S, Hussain S, Bassaletti CF, Kaski D, Bronstein A, Arshad Q. Priming overconfidence in belief systems reveals negative return on postural control mechanisms. Gait Posture 2022; 94:1-8. [PMID: 35189573 DOI: 10.1016/j.gaitpost.2022.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/01/2022] [Accepted: 02/13/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Modulation of postural control strategies and heightened perceptual ratings of instability when exposed to postural threats, illustrates the association between anxiety and postural control. RESEARCH QUESTION Here we test whether modulating prior expectations can engender postural-related anxiety which, in turn, may impair postural control and dissociate the well-established relationship between sway and subjective instability. METHODS We modulated expectations of the difficulty posed by an upcoming postural task via priming. In the visual priming condition, participants watched a video of an actor performing the task with either a stable or unstable performance, before themselves proceeding with the postural task. In the verbal priming paradigm, participants were given erroneous verbal information regarding the amplitude of the forthcoming platform movement, or no prior information. RESULTS Following the visual priming, the normal relationship between trunk sway and subjective instability was preserved only in those individuals that viewed the stable but not the unstable actor. In the verbal priming experiment we observed an increase in subjective instability and anxiety during task performance in individuals who were erroneously primed that sled amplitude would increase, when in fact it did not. SIGNIFICANCE Our findings show that people's subjective experiences of instability and anxiety during a balancing task are powerfully modulated by priming. The contextual provision of erroneous cognitive priors dissociates the normally 'hard wired' relationship between objective measures and subjective ratings of sway. Our findings have potential clinical significance for the development of enhanced cognitive retraining in patients with balance disorders, e.g. via modifying expectations.
Collapse
Affiliation(s)
- Patricia Castro
- Neuro-otology Unit, Department of Brain Sciences, Imperial College London, London, UK; Universidad del Desarrollo, Escuela de Fonoaudiología, Facultad de Medicina Clínica Alemana. Santiago, Chile; Departamento de Fonoaudiología, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Efstratia Papoutselou
- Neuro-otology Unit, Department of Brain Sciences, Imperial College London, London, UK
| | - Sami Mahmoud
- Fakultät für Medizin, Technische Universität München, München, Germany
| | - Shahvaiz Hussain
- Neuro-otology Unit, Department of Brain Sciences, Imperial College London, London, UK
| | | | - Diego Kaski
- Department of Clinical and Motor Neurosciences, Centre for Vestibular and Behavioural Neurosciences, University College London, London, UK
| | - Adolfo Bronstein
- Neuro-otology Unit, Department of Brain Sciences, Imperial College London, London, UK.
| | - Qadeer Arshad
- Neuro-otology Unit, Department of Brain Sciences, Imperial College London, London, UK; inAmind Laboratory, Department of Neuroscience, Psychology and Behaviour, University of Leicester, University Road, Leicester LE1 7RH, UK.
| |
Collapse
|
8
|
Hebb C, Raynor G, Perez DL, Nappi-Kaehler J, Polich G. The use of rhythmic auditory stimulation for functional gait disorder: A case report. NeuroRehabilitation 2022; 50:219-229. [DOI: 10.3233/nre-228005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Functional gait disorders (FGD) are a common and disabling condition. Consensus-based rehabilitation techniques for treating FGD and other functional neurological disorder presentations at large utilize a variety of therapeutic strategies, including distraction, novel approaches to movement, entrainment, stress/hypervigilance modulation, and psychotherapy. CASE REPORT: Here we present a case of a 24-year-old woman with a complex history of anxiety, depression, left frontal astrocytoma, postural orthostatic tachycardia syndrome (POTS) and FGD. During a multidisciplinary inpatient rehabilitation stay for FGD, the patient underwent rhythmic auditory stimulation (RAS) delivered by a neurologic music therapist in conjunction with physical therapy, occupational therapy, and psychotherapy. RESULTS: The RAS intervention appeared to play a significant role in symptom resolution for this patient. Improvement in the patient’s truncal displacement, foot dragging, and well as overall gait speed occurred following serial RAS trials performed over a single treatment session. Benefits persisted immediately following the intervention and upon subsequent reassessment. Although at four-year follow-up the patient’s FGD symptoms remained resolved, fatigue continued to limit her ambulatory capacity and overall endurance. CONCLUSION: RAS represents a unique therapeutic approach for treating FGD, complementary to existing consensus-based rehabilitation recommendations, and may warrant further consideration by the field.
Collapse
Affiliation(s)
- Caitlin Hebb
- MedRhythms, Inc., Boston, MA, USA
- Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Geoffrey Raynor
- Department of Psychiatry, Brigham’s and Women’s Hospital, Boston, MA, USA
| | - David L. Perez
- Department of Neurology and Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ginger Polich
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Brigham’s and Women’s Hospital, Boston, MA, USA
| |
Collapse
|
9
|
Abstract
AIMS To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle. METHODS We carried out a retrospective search of our records from 2000 to 2019 of patients seen in our adult tertiary referral foot and ankle unit with a diagnosis of functional dystonia. RESULTS A total of 29 patients were seen. A majority were female (n = 25) and the mean age of onset of symptoms was 35.3 years (13 to 71). The mean delay between onset and diagnosis was 7.1 years (0.5 to 25.0). Onset was acute in 25 patients and insidious in four. Of the 29 patients, 26 had a fixed dystonia and three had a spasmodic dystonia. Pain was a major symptom in all patients, with a coexisting diagnosis of chronic regional pain syndrome (CRPS) made in nine patients. Of 20 patients treated with Botox, only one had a good response. None of the 12 patients who underwent a surgical intervention at our unit or elsewhere reported a subjective overall improvement. After a mean follow-up of 3.2 years (1 to 12), four patients had improved, 17 had remained the same, and eight reported a deterioration in their condition. CONCLUSION Patients with functional dystonia typically presented with a rapid onset of fixed deformity after a minor injury/event and pain out of proportion to the deformity. Referral to a neurologist to rule out neurological pathology is advocated, and further management should be carried out in a movement disorder clinic. Response to treatment (including Botulinum toxin (Botox) injections) is generally poor. Surgery in this group of patients is not recommended and may worsen the condition. The overall prognosis remains poor. Cite this article: Bone Joint J 2021;103-B(6):1127-1132.
Collapse
Affiliation(s)
- Julia Gray
- Foot and Ankle Unit, The Royal National Orthopaedic Hospital, London, UK
| | - Matthew Welck
- Foot and Ankle Unit, The Royal National Orthopaedic Hospital, London, UK
| | - Nicholas P Cullen
- Foot and Ankle Unit, The Royal National Orthopaedic Hospital, London, UK
| | - Dishan Singh
- Foot and Ankle Unit, The Royal National Orthopaedic Hospital, London, UK
| |
Collapse
|
10
|
Lin D, Castro P, Edwards A, Sekar A, Edwards MJ, Coebergh J, Bronstein AM, Kaski D. Dissociated motor learning and de-adaptation in patients with functional gait disorders. Brain 2020; 143:2594-2606. [DOI: 10.1093/brain/awaa190] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 12/20/2022] Open
Abstract
Abstract
Walking onto a stationary platform that had been previously experienced as moving generates a locomotor after-effect—the so-called ‘broken escalator’ phenomenon. The motor responses that occur during locomotor after-effects have been mapped theoretically using a hierarchal Bayesian model of brain function that takes into account current sensory information that is weighted according to prior contextually-relevant experiences; these in turn inform automatic motor responses. Here, we use the broken escalator phenomenon to explore motor learning in patients with functional gait disorders and probe whether abnormal postural mechanisms override ascending sensory information and conscious intention, leading to maladaptive and disabling gait abnormalities. Fourteen patients with functional gait disorders and 17 healthy control subjects walked onto a stationary sled (‘Before’ condition, five trials), then onto a moving sled (‘Moving’ condition, 10 trials) and then again onto the stationary sled (‘After’ condition, five trials). Subjects were warned of the change in conditions. Kinematic gait measures (trunk displacement, step timing, gait velocity), EMG responses, and subjective measures of state anxiety/instability were recorded per trial. Patients had slower gait velocities in the Before trials (P < 0.05) but were able to increase this to accommodate the moving sled, with similar learning curves to control subjects (P = 0.87). Although trunk and gait velocity locomotor after-effects were present in both groups, there was a persistence of the locomotor after-effect only in patients (P < 0.05). We observed an increase in gait velocity during After trials towards normal values in the patient group. Instability and state anxiety were greater in patients than controls (P < 0.05) only during explicit phases (Before/After) of the task. Mean ‘final’ gait termination EMG activity (right gastrocnemius) was greater in the patient group than controls. Despite a dysfunctional locomotor system, patients show normal adaptive learning. The process of de-adaptation, however, is prolonged in patients indicating a tendency to perpetuate learned motor programmes. The trend to normalization of gait velocity following a period of implicit motor learning has implications for gait rehabilitation potential in patients with functional gait disorders and related disorders (e.g. fear of falling).
Collapse
Affiliation(s)
- Denise Lin
- Department of Brain Sciences, Neuro-otology Unit, Imperial College London, London, UK
| | - Patricia Castro
- Department of Brain Sciences, Neuro-otology Unit, Imperial College London, London, UK
- Universidad del Desarrollo, Escuela de Fonoaudiología, Facultad de Medicina Clínica Alemana, Santiago, Chile
| | - Amy Edwards
- Department of Brain Sciences, Neuro-otology Unit, Imperial College London, London, UK
| | - Akila Sekar
- Department of Brain Sciences, Neuro-otology Unit, Imperial College London, London, UK
| | - Mark J Edwards
- Department of Neurology, St George’s Hospital, London, UK
| | - Jan Coebergh
- Department of Neurology, St George’s Hospital, London, UK
| | - Adolfo M Bronstein
- Department of Brain Sciences, Neuro-otology Unit, Imperial College London, London, UK
| | - Diego Kaski
- Department of Brain Sciences, Neuro-otology Unit, Imperial College London, London, UK
- Department of Clinical and Motor Neurosciences, Centre for Vestibular and Behavioural Neurosciences, University College London, London, UK
| |
Collapse
|
11
|
Schniepp R, Möhwald K, Wuehr M. Clinical and automated gait analysis in patients with vestibular, cerebellar, and functional gait disorders: perspectives and limitations. J Neurol 2019; 266:118-122. [PMID: 31134375 DOI: 10.1007/s00415-019-09378-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/09/2019] [Accepted: 05/15/2019] [Indexed: 02/01/2023]
Abstract
This article outlines recent developments in the clinical and automated assessment of neurological gait disorders. With a primary focus on vestibular, cerebellar, and functional gait disorders, we discuss how instrumented gait examination may assist clinical decision making in these disorders with respect to the initial differential diagnosis and prognosis as well as the objective monitoring of disease progression and therapeutic interventions. We delineate strategies for data handling and analysis of quantitative gait examinations that can facilitate the clinical characterization and interpretation of walking impairments. These strategies include data normalization and dimensionality reduction procedures. We further emphasize the value of a comprehensive, standardized gait assessment protocol. Accordingly, the examination of walking conditions that challenge patients with respect to their biomechanical, sensory, or cognitive resources are particularly helpful to disclose and characterize the causes underlying their gait impairment. Finally, we provide a perspective on the emerging implementation of pattern recognition approaches within the framework of clinical management of gait disorders and discuss their potential to assist clinical decision making with respect to the differential diagnosis and the prognosis of fall risk in individual patients.
Collapse
Affiliation(s)
- Roman Schniepp
- Department of Neurology, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany. .,German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Ken Möhwald
- Department of Neurology, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany.,German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Marchioninistrasse 15, 81377, Munich, Germany
| |
Collapse
|
12
|
Pirio Richardson S, Altenmüller E, Alter K, Alterman RL, Chen R, Frucht S, Furuya S, Jankovic J, Jinnah HA, Kimberley TJ, Lungu C, Perlmutter JS, Prudente CN, Hallett M. Research Priorities in Limb and Task-Specific Dystonias. Front Neurol 2017; 8:170. [PMID: 28515706 PMCID: PMC5413505 DOI: 10.3389/fneur.2017.00170] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 04/11/2017] [Indexed: 11/13/2022] Open
Abstract
Dystonia, which causes intermittent or sustained abnormal postures and movements, can present in a focal or a generalized manner. In the limbs, focal dystonia can occur in either the upper or lower limbs and may be task-specific causing abnormal motor performance for only a specific task, such as in writer’s cramp, runner’s dystonia, or musician’s dystonia. Focal limb dystonia can be non-task-specific and may, in some circumstances, be associated with parkinsonian disorders. The true prevalence of focal limb dystonia is not known and is likely currently underestimated, leaving a knowledge gap and an opportunity for future research. The pathophysiology of focal limb dystonia shares some commonalities with other dystonias with a loss of inhibition in the central nervous system and a loss of the normal regulation of plasticity, called homeostatic plasticity. Functional imaging studies revealed abnormalities in several anatomical networks that involve the cortex, basal ganglia, and cerebellum. Further studies should focus on distinguishing cause from effect in both physiology and imaging studies to permit focus on most relevant biological correlates of dystonia. There is no specific therapy for the treatment of limb dystonia given the variability in presentation, but off-label botulinum toxin therapy is often applied to focal limb and task-specific dystonia. Various rehabilitation techniques have been applied and rehabilitation interventions may improve outcomes, but small sample size and lack of direct comparisons between methods to evaluate comparative efficacy limit conclusions. Finally, non-invasive and invasive therapeutic modalities have been explored in small studies with design limitations that do not yet clearly provide direction for larger clinical trials that could support new clinical therapies. Given these gaps in our clinical, pathophysiologic, and therapeutic knowledge, we have identified priorities for future research including: the development of diagnostic criteria for limb dystonia, more precise phenotypic characterization and innovative clinical trial design that considers clinical heterogeneity, and limited available number of participants.
Collapse
Affiliation(s)
- Sarah Pirio Richardson
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Eckart Altenmüller
- Institute for Music Physiology and Musicians' Medicine (IMMM), Hannover University of Music, Drama and Media, Hannover, Germany
| | - Katharine Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, USA
| | - Ron L Alterman
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert Chen
- Division of Neurology, Department of Medicine (Neurology), Krembil Research Institute, University of Toronto, Toronto, ON, Canada
| | - Steven Frucht
- Robert and John M. Bendheim Parkinson and Movement Disorders Center, Mount Sinai Hospital, New York, NY, USA
| | - Shinichi Furuya
- Musical Skill and Injury Center (MuSIC), Sophia University, Tokyo, Japan
| | - Joseph Jankovic
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - H A Jinnah
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.,Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA.,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Teresa J Kimberley
- Department of Rehabilitation Medicine, Division of Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis, MN, USA
| | - Codrin Lungu
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Joel S Perlmutter
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Neurosciences, Washington University School of Medicine, St. Louis, MO, USA.,Department of Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA.,Department of Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Cecília N Prudente
- Department of Rehabilitation Medicine, Division of Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis, MN, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
13
|
Pirker W, Katzenschlager R. Gait disorders in adults and the elderly : A clinical guide. Wien Klin Wochenschr 2016; 129:81-95. [PMID: 27770207 PMCID: PMC5318488 DOI: 10.1007/s00508-016-1096-4] [Citation(s) in RCA: 241] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 09/14/2016] [Indexed: 01/22/2023]
Abstract
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. Acute onset of a gait disorder may indicate a cerebrovascular or other acute lesion in the nervous system but also systemic diseases or adverse effects of medication, in particular polypharmacy including sedatives. The prevalence of gait disorders increases from 10 % in people aged 60–69 years to more than 60 % in community dwelling subjects aged over 80 years. Sensory ataxia due to polyneuropathy, parkinsonism and frontal gait disorders due to subcortical vascular encephalopathy or disorders associated with dementia are among the most common neurological causes. Hip and knee osteoarthritis are common non-neurological causes of gait disorders. With advancing age the proportion of patients with multiple causes or combinations of neurological and non-neurological gait disorders increases. Thorough clinical observation of gait, taking a focused patient history and physical, neurological and orthopedic examinations are basic steps in the categorization of gait disorders and serve as a guide for ancillary investigations and therapeutic interventions. This clinically oriented review provides an overview on the phenotypic spectrum, work-up and treatment of gait disorders.
Collapse
Affiliation(s)
- Walter Pirker
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria. .,Department of Neurology, Wilhelminenspital, Vienna, Austria.
| | - Regina Katzenschlager
- Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Conditions, Donauspital, Vienna, Austria
| |
Collapse
|