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Felfela K, Jooshani N, Möhwald K, Huppert D, Becker-Bense S, Schöberl F, Schniepp R, Filippopulos F, Dieterich M, Wuehr M, Zwergal A. Evaluation of a multimodal diagnostic algorithm for prediction of cognitive impairment in elderly patients with dizziness. J Neurol 2024:10.1007/s00415-024-12403-3. [PMID: 38702563 DOI: 10.1007/s00415-024-12403-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND The current diagnostic workup for chronic dizziness in elderly patients often neglects neuropsychological assessment, thus missing a relevant proportion of patients, who perceive dizziness as a subjective chief complaint of a concomitant cognitive impairment. This study aimed to establish risk prediction models for cognitive impairment in chronic dizzy patients based on data sources routinely collected in a dizziness center. METHODS One hundred patients (age: 74.7 ± 7.1 years, 41.0% women) with chronic dizziness were prospectively characterized by (1) neuro-otological testing, (2) quantitative gait assessment, (3) graduation of focal brain atrophy and white matter lesion load, and (4) cognitive screening (MoCA). A linear regression model was trained to predict patients' total MoCA score based on 16 clinical features derived from demographics, vestibular testing, gait analysis, and imaging scales. Additionally, we trained a binary logistic regression model on the same data sources to identify those patients with a cognitive impairment (i.e., MoCA < 25). RESULTS The linear regression model explained almost half of the variance of patients' total MoCA score (R2 = 0.49; mean absolute error: 1.7). The most important risk-predictors of cognitive impairment were age (β = - 0.75), pathological Romberg's sign (β = - 1.05), normal caloric test results (β = - 0.8), slower timed-up-and-go test (β = - 0.67), frontal (β = - 0.6) and temporal (β = - 0.54) brain atrophy. The binary classification yielded an area under the curve of 0.84 (95% CI 0.70-0.98) in distinguishing between cognitively normal and impaired patients. CONCLUSIONS The need for cognitive testing in patients with chronic dizziness can be efficiently approximated by available data sources from routine diagnostic workup in a dizziness center.
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Affiliation(s)
- K Felfela
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - N Jooshani
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - K Möhwald
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - D Huppert
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - S Becker-Bense
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - F Schöberl
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - R Schniepp
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - F Filippopulos
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - M Dieterich
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- Cluster for Systems Neurology, SyNergy, Munich, Germany
| | - M Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - A Zwergal
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany.
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2
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Boborzi L, Decker J, Rezaei R, Schniepp R, Wuehr M. Human Activity Recognition in a Free-Living Environment Using an Ear-Worn Motion Sensor. Sensors (Basel) 2024; 24:2665. [PMID: 38732771 PMCID: PMC11085719 DOI: 10.3390/s24092665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/16/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024]
Abstract
Human activity recognition (HAR) technology enables continuous behavior monitoring, which is particularly valuable in healthcare. This study investigates the viability of using an ear-worn motion sensor for classifying daily activities, including lying, sitting/standing, walking, ascending stairs, descending stairs, and running. Fifty healthy participants (between 20 and 47 years old) engaged in these activities while under monitoring. Various machine learning algorithms, ranging from interpretable shallow models to state-of-the-art deep learning approaches designed for HAR (i.e., DeepConvLSTM and ConvTransformer), were employed for classification. The results demonstrate the ear sensor's efficacy, with deep learning models achieving a 98% accuracy rate of classification. The obtained classification models are agnostic regarding which ear the sensor is worn and robust against moderate variations in sensor orientation (e.g., due to differences in auricle anatomy), meaning no initial calibration of the sensor orientation is required. The study underscores the ear's efficacy as a suitable site for monitoring human daily activity and suggests its potential for combining HAR with in-ear vital sign monitoring. This approach offers a practical method for comprehensive health monitoring by integrating sensors in a single anatomical location. This integration facilitates individualized health assessments, with potential applications in tele-monitoring, personalized health insights, and optimizing athletic training regimes.
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Affiliation(s)
- Lukas Boborzi
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University of Munich, 81377 Munich, Germany
| | - Julian Decker
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University of Munich, 81377 Munich, Germany
| | - Razieh Rezaei
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University of Munich, 81377 Munich, Germany
| | - Roman Schniepp
- Institute for Emergency Medicine and Medical Management, Ludwig-Maximilians-University of Munich, 80336 Munich, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University of Munich, 81377 Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University of Munich, 81377 Munich, Germany
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Masouris I, Wischmann J, Schniepp R, Müller R, Fuhry L, Hamann GF, Trumm C, Liebig T, Kellert L, Schöberl F. Basilar artery occlusion: drip-and-ship versus direct-to-center for mechanical thrombectomy within the Neurovascular Network of Southwest Bavaria (NEVAS). J Neurol 2024; 271:1885-1892. [PMID: 38095722 DOI: 10.1007/s00415-023-12126-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Recent clinical trials revealed a substantial clinical benefit for mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO). While urban areas are sufficiently covered with comprehensive stroke centers and MT expertise, rural areas lack such resources. Structured telemedical stroke networks offer rural hospitals instant consultation by stroke experts, enabling swift administration of intravenous thrombolysis (IVT) on-site and transportation for MT. For BAO patients, data on performance and clinical outcomes in telemedical stroke networks are lacking. METHODS We retrospectively analyzed data from patients with acute BAO eligible for MT: those treated directly in our comprehensive stroke center (direct-to-center/DC) and those treated in rural hospitals that were telemedically consulted by the Neurovascular Network of Southwest Bavaria (NEVAS) and transferred to our center for MT (drip-and-ship, DS). Key time intervals, stroke management performance and functional outcome after 90 days were compared. RESULTS Baseline characteristics, including premorbid status and stroke severity, were comparable. Time from symptom onset to IVT was identical in both groups (118 min). There was a delay of 180 min until recanalization in DS patients, mainly due to patient transport for MT. Procedural treatment time intervals, success of recanalization and complications were comparable. Clinical outcome at 3 months follow-up of DS patients was not inferior to DC patients. CONCLUSION We show for the first time that patients with BAO in rural areas benefit from a structured telemedicine network such as NEVAS, regarding both on-site processing and drip-and-ship for MT. Clinical outcomes are comparable among DS and DC patients.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany.
| | - J Wischmann
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - R Schniepp
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - R Müller
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - L Fuhry
- Department of Neurology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - G F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - C Trumm
- Institute of Neuroradiology, LMU University Hospital, LMU, Munich, Germany
| | - T Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU, Munich, Germany
| | - L Kellert
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - F Schöberl
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
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Masouris I, Kellert L, Pradhan C, Wischmann J, Schniepp R, Müller R, Fuhry L, Hamann GF, Pfefferkorn T, Rémi JM, Schöberl F. Telemedical stroke care significantly improves patient outcome in rural areas: Long-term analysis of the German NEVAS network. Int J Stroke 2024:17474930241234259. [PMID: 38346936 DOI: 10.1177/17474930241234259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Comprehensive stroke centers (CSC) offer state-of-the-art stroke care in metropolitan centers. However, in rural areas, sufficient stroke expertise is much scarcer. Recently, telemedical stroke networks have offered instant consultation by stroke experts, enabling immediate administration of intravenous thrombolysis (IVT) on-site and decision on thrombectomy. While these immediate decisions are made during the consult, the impact of the network structures on stroke care in spoke hospitals is still not well described. AIMS This study was performed to determine if on-site performance in rural hospitals and patient outcome improve over time through participation and regular medical staff training within a telemedical stroke network. METHODS In this retrospective study, we analyzed data from stroke patients treated in four regional hospitals within the telemedical Neurovascular Network of Southwest Bavaria (NEVAS) between 2014 and 2019. We only included those patients that were treated in the regional hospitals until discharge at home or to neurorehabilitation. Functional outcome (modified Rankin scale) at discharge, mortality rate and periprocedural intracranial hemorrhage served as primary outcome parameters. Door-to-imaging and door-to-needle times were secondary outcome parameters. RESULTS In 2014-2019, 5,379 patients were treated for acute stroke with 477 receiving IVT. Most baseline characteristics were comparable over time. For all stroke patients, door-to-imaging times increased over the years, but significantly improved for potential IVT candidates and those finally treated with IVT. The percentage of patients with door-to-needle time <30 min increased from 10% to 25%. Clinical outcome at discharge improved for all stroke patients treated in the regional hospitals. Particularly for patients treated with IVT, good clinical outcome (modified Rankin scale 0-2) at discharge increased from 2014 to 2019 by 19% and mortality rates dropped from 13% to 5%. CONCLUSIONS 24-h/7-day telemedical support and regular on-site medical staff training within a structured telemedicine stroke network such as NEVAS significantly improve on-site stroke care in rural areas, leading to a considerable benefit in clinical outcome. DATA ACCESS STATEMENT The data that support the findings of this study are available upon reasonable request and in compliance with the local and international ethical guidelines.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Cauchy Pradhan
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Roman Schniepp
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Robert Müller
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | - Leonard Fuhry
- Department of Neurology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Günzburg, Germany
| | | | - Jan M Rémi
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Florian Schöberl
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
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Conrad J, Huppert A, Ruehl RM, Wuehr M, Schniepp R, Zu Eulenburg P. Disability in cerebellar ataxia syndromes is linked to cortical degeneration. J Neurol 2023; 270:5449-5460. [PMID: 37480400 PMCID: PMC10576698 DOI: 10.1007/s00415-023-11859-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/24/2023]
Abstract
OBJECTIVE We aimed to relate clinical measures of disability in chronic cerebellar degeneration to structural whole-brain changes using voxel-based and surface-based morphometry (vbm and sbm). We were particularly interested in remote effects of cerebellar degeneration in the cerebral cortex. METHODS We recruited 30 patients with cerebellar degeneration of different aetiologies (downbeat nystagmus syndrome, DBN n = 14, spinocerebellar ataxia, SCA n = 9, sporadic adult late-onset ataxia, SAOA n = 7). All patients were thoroughly characterised in the motor, cognitive, vestibular and ocular-motor domains. Vbm and sbm were used to evaluate structural differences between cerebellar degeneration patients and a group of healthy age- and gender-matched volunteers. Linear regression models were used to correlate functional measures of disease progression and postural stability with whole brain volumetry. RESULTS Patients with SCA and SAOA showed widespread volume loss in the cerebellar hemispheres and less prominently in the vermis. Patients with DBN showed a distinct pattern of grey matter volume (GMV) loss that was restricted to the vestibular and ocular-motor representations in lobules IX, X and V-VII. Falls were associated with brainstem white matter volume. VBM and SBM linear regression models revealed associations between severity of ataxic symptoms, cognitive performance and preferred gait velocity. This included extra-cerebellar (sub-)cortical hubs of the motor and locomotion network (putamen, caudate, thalamus, primary motor cortex, prefrontal cortex) and multisensory areas involved in spatial navigation and cognition. CONCLUSION Functional disability in multiple domains was associated with structural changes in the cerebral cortex.
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Affiliation(s)
- Julian Conrad
- German Center for Vertigo and Balance Disorders and Department of Neurology, Munich University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
- German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany.
- Division for Neurodegenerative Diseases, Department of Neurology, Universitaetsmedizin Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany.
| | - Anna Huppert
- German Center for Vertigo and Balance Disorders and Department of Neurology, Munich University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ria Maxine Ruehl
- German Center for Vertigo and Balance Disorders and Department of Neurology, Munich University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany
| | - Roman Schniepp
- German Center for Vertigo and Balance Disorders and Department of Neurology, Munich University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany
| | - Peter Zu Eulenburg
- German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany
- Institute for Neuroradiology LMU Munich, Munich, Germany
- Graduate School of Systemic Neurosciences-GSN, LMU Munich, Munich, Germany
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Ehrnthaller C, Rellensmann K, Baumbach SF, Wuehr M, Schniepp R, Saller MM, Böcker W, Polzer H. Pedobarographic evaluation of five commonly used orthoses for the lower extremity. Arch Orthop Trauma Surg 2023; 143:4249-4256. [PMID: 36571629 PMCID: PMC10293377 DOI: 10.1007/s00402-022-04729-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 12/06/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Orthoses are designed to achieve immobilization or off-loading of certain regions of the foot. Yet, their off-loading capacity for the specific regions has not yet been studied. Therefore, the aim of this study was to analyze the plantar pressure distribution of five commonly applied orthoses for foot and ankle in a healthy population. MATERIALS AND METHODS Five orthoses (postoperative shoe, forefoot relief shoe, short walker boot, high walker boot, and calcaneus fracture orthosis) were compared pedobarographically using insoles on a treadmill to a ready-made running shoe in eleven healthy subjects (median age 29 years). Peak pressure, maximum force, force-time integral, contact time, and contact area were evaluated separately for the forefoot, midfoot, and hindfoot. RESULTS The forefoot relief shoe, the short- and high walker boot significantly reduced the peak pressure at the forefoot with no significant differences between these orthoses. None of the five orthoses off-loaded the midfoot, but the calcaneus fracture orthosis and the short walker boot instead increased midfoot load. For the hindfoot, the calcaneus fracture orthosis was the only device to significantly reduce the peak pressure. CONCLUSIONS This is the first study to investigate the specific off-loading capacities of different orthoses for specific foot regions in a healthy collective. The knowledge of absolute and relative load shifts for the different orthoses is of fundamental interest for targeted clinical decision-making of physicians.
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Affiliation(s)
- C Ehrnthaller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - K Rellensmann
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - S F Baumbach
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - M Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - R Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - M M Saller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - W Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - Hans Polzer
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany.
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Bertram J, Krüger T, Röhling HM, Jelusic A, Mansow-Model S, Schniepp R, Wuehr M, Otte K. Accuracy and repeatability of the Microsoft Azure Kinect for clinical measurement of motor function. PLoS One 2023; 18:e0279697. [PMID: 36701322 PMCID: PMC9879399 DOI: 10.1371/journal.pone.0279697] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 12/13/2022] [Indexed: 01/27/2023] Open
Abstract
Quantitative assessment of motor function is increasingly applied in fall risk stratification, diagnosis, and disease monitoring of neuro-geriatric disorders of balance and gait. Its broad application, however, demands for low-cost and easy to use solutions that facilitate high-quality assessment outside laboratory settings. In this study, we validated in 30 healthy adults (12 female, age: 32.5 [22 - 62] years) the performance and accuracy of the latest generation of the Microsoft RGB-D camera, i.e., Azure Kinect (AK), in tracking body motion and providing estimates of clinical measures that characterise static posture, postural transitions, and locomotor function. The accuracy and repeatability of AK recordings was validated with a clinical reference standard multi-camera motion capture system (Qualisys) and compared to its predecessor Kinect version 2 (K2). Motion signal quality was evaluated by Pearson's correlation and signal-to-noise ratios while the accuracy of estimated clinical parameters was described by absolute and relative agreement based on intraclass correlation coefficients. The accuracy of AK-based body motion signals was moderate to excellent (RMSE 89 to 20 mm) and depended on the dimension of motion (highest for anterior-posterior dimension), the body region (highest for wrists and elbows, lowest for ankles and feet), and the specific motor task (highest for stand up and sit down, lowest for quiet standing). Most derived clinical parameters showed good to excellent accuracy (r .84 to .99) and repeatability (ICC(1,1) .55 to .94). The overall performance and limitations of body tracking by AK were comparable to its predecessor K2 in a cohort of young healthy adults. The observed accuracy and repeatability of AK-based evaluation of motor function indicate the potential for a broad application of high-quality and long-term monitoring of balance and gait in different non-specialised environments such as medical practices, nursing homes or community centres.
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Affiliation(s)
- Johannes Bertram
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Munich, Germany
| | | | | | - Ante Jelusic
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Munich, Germany
| | | | - Roman Schniepp
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Munich, Germany
| | - Karen Otte
- Motognosis GmbH, Berlin, Germany
- * E-mail:
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Möhwald K, Schniepp R. Konzepte der Sturzrisikoabschätzung bei neurogeriatrischen
Patienten. Fortschr Neurol Psychiatr 2022; 90:589-599. [DOI: 10.1055/a-1801-3310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Neurogeriatrische Patienten sind sturzgefährdet. Dieser Beitrag
beschreibt allgemeine, klinische und mobilitätsbezogene
Sturzrisikofaktoren und gibt eine Übersicht zur Identifikation von
sturzgefährdeten Patienten sowie praxisbezogene Instruktionen zur
Durchführung eines strukturierten, multimodalen Sturzassessments. Die
Routinediagnostik wird dadurch um standardisierte klinische Untersuchungen sowie
apparative und mobile Bewegungsanalysen erweitert.
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Möhwald K, Wuehr M, Decker J, Asch EM, Schenkel F, Illigens B, Schniepp R. Quantification of pathological gait parameter thresholds of idiopathic normal pressure hydrocephalus patients in clinical gait analysis. Sci Rep 2022; 12:18295. [PMID: 36316420 PMCID: PMC9622747 DOI: 10.1038/s41598-022-22692-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
The aim of the study was to distinguish the hypokinetic gait disorder in idiopathic normal pressure hydrocephalus (NPH) patients from the gait decline in the elderly population by quantifying pathological gait parameter thresholds utilizing a multiple condition gait assessment. 55 NPH patients and 55 age-matched healthy subjects underwent a standardized gait assessment with eight gait conditions. Spatiotemporal gait parameters were assessed through a pressure-sensitive carpet. Statistical analysis consisted of a binary logistic regression (BLR) model, logistic curve-fit evaluated by a Chi-square goodness-of-fit-test, receiver operating characteristic models with area under the curves (AUC), and inverse BLR. Most discriminative gait parameter thresholds were observed in pace, gait cycle, and support gait domains. The most distinct gait conditions were preferred walking speed and semantic dual task. During preferred walking speed, the most significant gait parameter thresholds were stride length ≤ 1.02 m (sensitivity 0.93/specificity 0.91/AUC 0.96), gait velocity ≤ 0.83 m/s (0.80/0.91/0.93), double support phase ≥ 27.0% (0.96/0.76/0.91), and stride length coefficient of variation ≥ 3.4% (0.93/0.72/0.90). In conclusion, the hypokinetic gait disorder in NPH can be quantitatively differentiated from gait patterns of the elderly population. In future studies, this approach may be useful to differentiate clinical entities with similar gait disorders utilizing instrumented gait analysis procedures.
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Affiliation(s)
- Ken Möhwald
- grid.5252.00000 0004 1936 973XDepartment of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany ,grid.5252.00000 0004 1936 973XGerman Center for Vertigo and Balance Disorders (DSGZ), University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany ,grid.440925.e0000 0000 9874 1261Division of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
| | - Max Wuehr
- grid.5252.00000 0004 1936 973XGerman Center for Vertigo and Balance Disorders (DSGZ), University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Julian Decker
- grid.490431.b0000 0004 0581 7239Schoen Klinik Bad Aibling, Kolbermoorer Str. 72, 83043 Bad Aibling, Germany
| | - Eric-Manuel Asch
- grid.5252.00000 0004 1936 973XGerman Center for Vertigo and Balance Disorders (DSGZ), University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Fabian Schenkel
- grid.5252.00000 0004 1936 973XGerman Center for Vertigo and Balance Disorders (DSGZ), University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Ben Illigens
- grid.440925.e0000 0000 9874 1261Division of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany ,grid.38142.3c000000041936754XBeth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 USA
| | - Roman Schniepp
- grid.5252.00000 0004 1936 973XDepartment of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany ,grid.5252.00000 0004 1936 973XGerman Center for Vertigo and Balance Disorders (DSGZ), University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
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10
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Ippisch R, Jelusic A, Bertram J, Schniepp R, Wuehr M. mVEGAS - mobile smartphone-based spatiotemporal gait analysis in healthy and ataxic gait disorders. Gait Posture 2022; 97:80-85. [PMID: 35914387 DOI: 10.1016/j.gaitpost.2022.07.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Quantitative gait assessment is increasingly applied in fall risk stratification, diagnosis, and disease monitoring of neuro-geriatric gait disorders. Its broad application, however, demands for low-cost and mobile solutions that facilitate high-quality assessment outside laboratory settings. The aim of this study was to present and evaluate the concurrent validity of a mobile and low-cost gait assessment tool (mVEGAS) that combines body-fixed inertial sensors and a smartphone-based video capture for spatiotemporal identification of gait sequences. METHODS Initially, we examined potential interferences of wearing mVEGAS with walking performance in a cohort of 20 young healthy individuals (31.1 ± 10.1 years; 8 females). Subsequently, we assessed the concurrent validity of mVEGAS as compared to a pressure-sensitive gait carpet (GAITRite) in a cohort of 26 healthy individuals (55.8 ± 14.3 years; 10 females) and 26 patients (55.7 ± 14.0; 14 females) with moderate to severe degrees of cerebellar gait ataxia. All participants were instructed to walk at preferred, slow, and fast walking speed and standard average and variability gait measures including velocity, stride length, stride time, base of support, swing and double support phase were examined for agreement between the two systems by absolute error and intraclass correlation coefficients (ICC). RESULTS Wearing mVEGAS did only marginally interfere with normal walking behavior. mVEGAS-derived average and variability gait measures exhibited good to excellent concurrent validity in healthy individuals (ICCs ranging between 0.645 and 1.000) and patients with gait ataxia (ICCs ranging between 0.788 and 1.000) SIGNIFICANCE: mVEGAS may facilitate high-quality and long-term gait monitoring in different non-specialized environments such as medical practices, nursing homes or community centers.
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Affiliation(s)
- R Ippisch
- Outpatient Center for Neurology, Psychiatry and Psychotherapy, Germering, Germany
| | - A Jelusic
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Munich, Germany
| | - J Bertram
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Munich, Germany
| | - R Schniepp
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Munich, Germany; Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - M Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Munich, Germany.
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11
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Dietrich H, Pradhan C, Heidger F, Schniepp R, Wuehr M. Downbeat nystagmus becomes attenuated during walking compared to standing. J Neurol 2022; 269:6222-6227. [PMID: 35412151 DOI: 10.1007/s00415-022-11106-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 03/24/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
Downbeat nystagmus (DBN) is a common form of acquired fixation nystagmus related to vestibulo-cerebellar impairments and associated with impaired vision and postural imbalance. DBN intensity becomes modulated by various factors such as gaze direction, head position, daytime, and resting conditions. Further evidence suggests that locomotion attenuates postural symptoms in DBN. Here, we examined whether walking might analogously influence ocular-motor deficits in DBN. Gaze stabilization mechanisms and nystagmus frequency were examined in 10 patients with DBN and 10 age-matched healthy controls with visual fixation during standing vs. walking on a motorized treadmill. Despite their central ocular-motor deficits, linear and angular gaze stabilization in the vertical plane were functional during walking in DBN patients and comparable to controls. Notably, nystagmus frequency in patients was considerably reduced during walking compared to standing (p < 0.001). The frequency of remaining nystagmus during walking was further modulated in a manner that depended on the specific phase of the gait cycle (p = 0.015). These attenuating effects on nystagmus intensity during walking suggest that ocular-motor control disturbances are selectively suppressed during locomotion in DBN. This suppression is potentially mediated by locomotor efference copies that have been shown to selectively govern gaze stabilization during stereotyped locomotion in animal models.
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Affiliation(s)
- Haike Dietrich
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - Cauchy Pradhan
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - Felix Heidger
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - Roman Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany.
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12
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Wuehr M, Decker J, Schenkel F, Jahn K, Schniepp R. Impact on daily mobility and risk of falling in bilateral vestibulopathy. J Neurol 2022; 269:5746-5754. [PMID: 35286481 PMCID: PMC9553788 DOI: 10.1007/s00415-022-11043-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 01/05/2023]
Abstract
Abstract
Objective
To study the behavioral relevance of postural and ocular-motor deficits on daily activity and risk of falling in patients with bilateral vestibular hypofunction (BVH).
Methods
Thirty patients with BVH and 30 age- and gender-matched healthy controls participated in a continuous 2-week assessment of daily activities and mobility using a body-worn inertial sensor and a 6-month prospective fall risk assessment. At inclusion, patients and controls further underwent a multi-modal clinical, score- and instrument-based assessment of general health and balance status. We analyzed the relationship between clinical, lab-, and sensor-based measures and their validity to identify those patients at a risk of general, frequent, and severe falling.
Results
Patients exhibited impairments in daily activity in particular in terms of reduced ambulatory activity (p = 0.009). 43% of patients experienced falls (13% in controls, p = 0.008) and 70% of these patients reported recurrent falling (0% in controls, p = 0.001) during prospective assessment. Severe fall-related injuries that would require medical attention neither occurred in patients nor in controls. Classificatory models based on multi-modal clinical, lab-, and sensor-based measures of balance and mobility identified patients who fell with an accuracy of 93% and patients who recurrently fell with an accuracy of 89%.
Conclusion
BVH is linked to particular impairments of patients’ daily activities which in turn are related to patients’ fall risk. Hence, off-laboratory measures of daily mobility may supplement standard clinical assessment in BVH to more adequately capture the burden of disease and to reliably identify those patients at a specific risk of falling.
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13
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Stöcklein S, Brandlhuber M, Lause S, Pomschar A, Jahn K, Schniepp R, Alperin N, Ertl-Wagner B. Decreased Craniocervical CSF Flow in Patients with Normal Pressure Hydrocephalus: A Pilot Study. AJNR Am J Neuroradiol 2022; 43:230-237. [PMID: 34992125 PMCID: PMC8985674 DOI: 10.3174/ajnr.a7385] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Normal pressure hydrocephalus is characterized by systolic peaks of raised intracranial pressure, possibly due to a reduced compliance of the spinal CSF spaces. This concept of a reduced spinal CSF buffer function may be reflected by a low cervical CSF outflow from the cranium. The aim of this study was to investigate craniospinal CSF flow rates by phase-contrast MR imaging in patients with normal pressure hydrocephalus. MATERIALS AND METHODS A total of 42 participants were included in this prospective study, consisting of 3 study groups: 1) 10 patients with normal pressure hydrocephalus (mean age, 74 [SD, 6] years, with proved normal pressure hydrocephalus according to current scientific criteria); 2) eighteen age-matched healthy controls (mean age, 71 [SD, 5] years); and 3) fourteen young healthy controls (mean age, 21 [SD, 2] years, for investigation of age-related effects). Axial phase-contrast MR imaging was performed, and the maximal systolic CSF and total arterial blood flow rates were measured at the level of the upper second cervical vertebra and compared among all study groups (2-sample unpaired t test). RESULTS The maximal systolic CSF flow rate was significantly decreased in patients with normal pressure hydrocephalus compared with age-matched and young healthy controls (53 [SD, 40] mL/m; 329 [SD, 175] mL/m; 472 [SD, 194] mL/m; each P < .01), whereas there were no significant differences with regard to maximal systolic arterial blood flow (1160 [SD, 404] mL/m; 1470 [SD, 381] mL/m; 1400 [SD, 254] mL/m; each P > .05). CONCLUSIONS The reduced maximal systolic craniospinal CSF flow rate in patients with normal pressure hydrocephalus may be reflective of a reduced compliance of the spinal CSF spaces and an ineffective spinal CSF buffer function. Systolic craniospinal CSF flow rates are an easily obtainable MR imaging-based measure that may support the diagnosis of normal pressure hydrocephalus.
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Affiliation(s)
| | | | - S.S. Lause
- Department of Dermatology (S.S.L.), Bethesda Hospital, Freudenberg, Germany
| | - A. Pomschar
- Radiological Office (A.P.), Centre for Radiology, Munich, Germany
| | - K. Jahn
- Neurology, and Friedrich-Baur-Institute (FBI) of the Department of Neurology (K.J.)
| | - R. Schniepp
- Neurology (R.S.), Ludwig-Maximilians-University Munich, Munich, Germany
| | - N. Alperin
- Department of Radiology (N.A.), University of Miami, Coral Gables, Florida
| | - B. Ertl-Wagner
- Department of Medical Imaging (B.E.-W.), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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14
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Assländer L, Giboin LS, Gruber M, Schniepp R, Wuehr M. No evidence for stochastic resonance effects on standing balance when applying noisy galvanic vestibular stimulation in young healthy adults. Sci Rep 2021; 11:12327. [PMID: 34112904 PMCID: PMC8192540 DOI: 10.1038/s41598-021-91808-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/28/2021] [Indexed: 11/24/2022] Open
Abstract
Noisy galvanic vestibular stimulation (nGVS) at imperceptible levels has been shown to reduce body sway. This reduction was commonly attributed to the mechanism of stochastic resonance (SR). However, it has never been explicitly tested whether nGVS-induced effects on body sway consistently follow a SR-like bell-shaped performance curve with maximal reductions in a particular range of noise intensities. To test this, body sway in 21 young healthy participants was measured during varying nGVS amplitudes while standing with eyes closed in 3 conditions (quiet stance, sway referencing, sinusoidal platform tilts). Presence of SR-like response dynamics in each trial was assessed (1) by a goodness-of-fit analysis using an established SR-curve model and (2) by ratings from 3 human experts. In accordance to theory, we found reductions of body sway at one nGVS amplitude in most trials (75–95%). However, only few trials exhibited SR-like bell-shaped performance curves with increasing noise amplitudes (10–33%). Instead, body sway measures rather fluctuated randomly across nGVS amplitudes. This implies that, at least in young healthy adults, nGVS effects on body sway are incompatible with SR. Thus, previously reported reductions of body sway at particular nGVS intensities more likely result from inherent variations of the performance metric or by other yet unknown mechanisms.
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Affiliation(s)
- L Assländer
- Human Performance Research Centre, University of Konstanz, Konstanz, Germany.
| | - L S Giboin
- Human Performance Research Centre, University of Konstanz, Konstanz, Germany
| | - M Gruber
- Human Performance Research Centre, University of Konstanz, Konstanz, Germany
| | - R Schniepp
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Munich, Germany.,Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
| | - M Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Munich, Germany
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15
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Schniepp R, Möhwald K, Wuehr M. [Options for the symptomatic treatment of chronic neurological gait disorders]. Fortschr Neurol Psychiatr 2021; 89:243-253. [PMID: 33893628 DOI: 10.1055/a-1472-5860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Gait and mobility impairments are common and relevant in patients with chronic neurological disorders. It reduces the health-related quality of life and induces falls with morbidity. Symptomatic treatment options are therefore necessary in order to improve the health status of patients with neurological disorders.By means of a selective literature research focusing on studies with specific gait-related outcome measures. We discuss the differential treatment options for (1) hypokinetic gait disorders (Parkinson´s disease, Normal pressure hydrocephalus, vascular encephalopathy), (2) gait unsteadiness with ataxia (sensory and cerebellar ataxia), and (3) gait with spasticity and paresis (due to multiple sclerosis). Therapeutical options for the symptomatic treatment of gait disorders comprise non-pharmacological and pharmacological approaches. Both address the functional domains of "locomotion", "postural control", "modulation" and "adaptability" of gait.Pharmacological options are orientated to pathophysiology of the underlying diseases. Supportive physiotherapeutic interventions offer broader and unspecific options for treatment. Clinical conditions that specifically disturb the execution of locomotion or gait can also be addressed by the provision of physical therapy or supportive devices.Effective options for the symptomatic treatment of patients with neurological gait disorders are available. Applications of options addressing the pathophysiology of the underlying disease, a functional domain-based exercise and physiotherapy program, and the provision of walking aides for specific symptoms that further worsen gait performance can be recommended.
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Affiliation(s)
- Roman Schniepp
- Deutsches Schwindel- und Gleichgewichtszentrum, Ludwig-Maximilians Universität München.,Neurologische Klinik, Ludwig-Maximilians Universität München
| | - Ken Möhwald
- Deutsches Schwindel- und Gleichgewichtszentrum, Ludwig-Maximilians Universität München.,Neurologische Klinik, Ludwig-Maximilians Universität München
| | - Max Wuehr
- Deutsches Schwindel- und Gleichgewichtszentrum, Ludwig-Maximilians Universität München
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16
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Wuehr M, Jooshani N, Schniepp R. [Concepts for diagnosis, course and fall risk assessment in neurological gait disorders]. Fortschr Neurol Psychiatr 2021; 89:233-242. [PMID: 33882582 DOI: 10.1055/a-1418-8476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Quantitative gait assessment is increasingly applied in the diagnosis, disease monitoring, and risk stratification of neurological gait disorders. However, it is unclear, which measurement approaches, examination conditions, and gait characteristics are appropriate for answering specific clinical questions. The aim of this review was to provide generally applicable concepts and strategies for the measurement, analysis, and interpretation of gait function in the clinical context and to discuss their implementation in clinical practice. The first part of the article introduces currently available stationary and mobile measurement technologies that enable assessment of gait in clinical environments and to continuously track patients' mobility in the context of everyday life. Furthermore, the selection of adequate examination conditions and concepts that facilitate the parametrization of gait are discussed. The subsequent parts of the article address concrete clinical fields of application for quantitative gait analysis. With the help of exemplary cases from current research, the following issues are dicussed: (1) how specific patterns in gait assessments can guide differential diagnosis; (2) how quantitative gait measures can support the early diagnosis as well as the monitoring of disease progression and intervention outcomes in neurological gait disorders and finally, (3) the contribution of stationary gait and mobile mobility assessment for fall risk prognosis in patients with neurological gait impairments.
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Affiliation(s)
- Max Wuehr
- Deutsches Schwindel- und Gleichgewichtszentrum, Ludwig-Maximilians Universität, Klinikum der Universität München
| | - Nima Jooshani
- Deutsches Schwindel- und Gleichgewichtszentrum, Ludwig-Maximilians Universität, Klinikum der Universität München
| | - Roman Schniepp
- Deutsches Schwindel- und Gleichgewichtszentrum, Ludwig-Maximilians Universität, Klinikum der Universität München.,Neurologische Klinik, Ludwig-Maximilians Universität, Klinikum der Universität München
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17
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Schniepp R, Huppert A, Decker J, Schenkel F, Schlick C, Rasoul A, Dieterich M, Brandt T, Jahn K, Wuehr M. Fall prediction in neurological gait disorders: differential contributions from clinical assessment, gait analysis, and daily-life mobility monitoring. J Neurol 2021; 268:3421-3434. [PMID: 33713194 PMCID: PMC8357767 DOI: 10.1007/s00415-021-10504-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/27/2022]
Abstract
Objective To evaluate the predictive validity of multimodal clinical assessment outcomes and quantitative measures of in- and off-laboratory mobility for fall-risk estimation in patients with different forms of neurological gait disorders. Methods The occurrence, severity, and consequences of falls were prospectively assessed for 6 months in 333 patients with early stage gait disorders due to vestibular, cerebellar, hypokinetic, vascular, functional, or other neurological diseases and 63 healthy controls. At inclusion, participants completed a comprehensive multimodal clinical and functional fall-risk assessment, an in-laboratory gait examination, and an inertial-sensor-based daily mobility monitoring for 14 days. Multivariate logistic regression analyses were performed to identify explanatory characteristics for predicting the (1) the fall status (non-faller vs. faller), (2) the fall frequency (occasional vs. frequent falls), and (3) the fall severity (benign vs. injurious fall) of patients. Results 40% of patients experienced one or frequent falls and 21% severe fall-related injuries during prospective fall assessment. Fall status and frequency could be reliably predicted (accuracy of 78 and 91%, respectively) primarily based on patients' retrospective fall status. Instrumented-based gait and mobility measures further improved prediction and provided independent, unique information for predicting the severity of fall-related consequences. Interpretation Falls- and fall-related injuries are a relevant health problem already in early stage neurological gait disorders. Multivariate regression analysis encourages a stepwise approach for fall assessment in these patients: fall history taking readily informs the clinician about patients' general fall risk. In patients at risk of falling, instrument-based measures of gait and mobility provide critical information on the likelihood of severe fall-related injuries. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10504-x.
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Affiliation(s)
- Roman Schniepp
- Department of Neurology, Ludwig-Maximilians University of Munich, Marchioninistrasse 15, 81377, Munich, Germany. .,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University of Munich, Munich, Germany.
| | - Anna Huppert
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Julian Decker
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University of Munich, Munich, Germany.,Schön Klinik, Bad Aibling, Germany
| | - Fabian Schenkel
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Cornelia Schlick
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Atal Rasoul
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Marianne Dieterich
- Department of Neurology, Ludwig-Maximilians University of Munich, Marchioninistrasse 15, 81377, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Klaus Jahn
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University of Munich, Munich, Germany.,Schön Klinik, Bad Aibling, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University of Munich, Munich, Germany
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18
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Möhwald K, Wuehr M, Schenkel F, Feil K, Strupp M, Schniepp R. The gait disorder in primary orthostatic tremor. J Neurol 2020; 267:285-291. [PMID: 32915312 PMCID: PMC7718181 DOI: 10.1007/s00415-020-10177-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To uncover possible impairments of walking and dynamic postural stability in patients with primary orthostatic tremor (OT). METHODS Spatiotemporal gait characteristics were quantified in 18 patients with primary OT (mean age 70.5 ± 5.9 years, 10 females) and 18 age-matched healthy controls. One-third of patients reported disease-related fall events. Walking performance was assessed on a pressure-sensitive carpet under seven conditions: walking at preferred, slow, and maximal speed, with head reclination or eyes closed, and while performing a cognitive or motor dual-task paradigm. RESULTS Patients exhibited a significant gait impairment characterized by a broadened base of support (p = 0.018) with increased spatiotemporal gait variability (p = 0.010). Walking speed was moderately reduced (p = 0.026) with shortened stride length (p = 0.001) and increased periods of double support (p = 0.001). Gait dysfunction became more pronounced during slow walking (p < 0.001); this was not present during fast walking. Walking with eyes closed aggravated gait disability as did walking during cognitive dual task (p < 0.001). CONCLUSION OT is associated with a specific gait disorder with a staggering wide-based walking pattern indicative of a sensory and/or a cerebellar ataxic gait. The aggravation of gait instability during visual withdrawal and the normalization of walking with faster speeds further suggest a proprioceptive or vestibulo-cerebellar deficit as the primary source of gait disturbance in OT. In addition, the gait decline during cognitive dual task may imply cognitive processing deficits. In the end, OT is presumably a complex network disorder resulting in a specific spino-cerebello-frontocortical gait disorder that goes beyond mere tremor networks.
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Affiliation(s)
- Ken Möhwald
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany. .,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany
| | - Fabian Schenkel
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany
| | - Katharina Feil
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Strupp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Roman Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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19
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Wuehr M, Huppert A, Schenkel F, Decker J, Jahn K, Schniepp R. Independent domains of daily mobility in patients with neurological gait disorders. J Neurol 2020; 267:292-300. [PMID: 32533324 PMCID: PMC7718193 DOI: 10.1007/s00415-020-09893-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/03/2020] [Accepted: 05/05/2020] [Indexed: 12/31/2022]
Abstract
The aim of this study was to establish a comprehensive and yet parsimonious model of daily mobility activity in patients with neurological gait disorders. Patients (N = 240) with early-stage neurological (peripheral vestibular, cerebellar, hypokinetic, vascular or functional) gait disorders and healthy controls (N = 35) were clinically assessed with standardized scores related to functional mobility, balance confidence, quality of life, cognitive function, and fall history. Subsequently, daily mobility was recorded for 14 days by means of a body-worn inertial sensor (ActivPAL®). Fourteen mobility measures derived from ActivPAL recordings were submitted to principle component analysis (PCA). Group differences within each factor obtained from PCA were analyzed and hierarchical regression analysis was performed to identify predictive characteristics from clinical assessment for each factor. PCA yielded five significant orthogonal factors (i.e., mobility domains) accounting for 92.3% of the total variance from inertial-sensor-recordings: ambulatory volume (38.7%), ambulatory pattern (22.3%), postural transitions (13.3%), sedentary volume (10.8%), and sedentary pattern (7.2%). Patients' mobility performance only exhibited reduced scores in the ambulatory volume domain but near-to-normal scores in all remaining domains. Demographic characteristics, clinical scores, and fall history were differentially associated with each domain explaining 19.2–10.2% of their total variance. This study supports a low-dimensional five-domain model for daily mobility behavior in patients with neurological gait disorders that may facilitate monitoring the course of disease or therapeutic intervention effects in ecologically valid and clinically relevant contexts. Further studies are required to explore the determinants that may explain performance differences of patients within each of these domains and to examine the consequences of altered mobility behavior with respect to patients' risk of falling and quality of life.
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Affiliation(s)
- Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany.
| | - A Huppert
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
| | - F Schenkel
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
| | - J Decker
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
- Schoen Clinic, Bad Aibling, Germany
| | - K Jahn
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
- Schoen Clinic, Bad Aibling, Germany
| | - R Schniepp
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
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20
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Schniepp R, Möhwald K, Wuehr M. Key gait findings for diagnosing three syndromic categories of dynamic instability in patients with balance disorders. J Neurol 2020; 267:301-308. [PMID: 32462346 PMCID: PMC7718186 DOI: 10.1007/s00415-020-09901-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 01/29/2023]
Abstract
With the emergence of affordable, clinical-orientated gait analysis techniques, clinicians may benefit from a general understanding of quantitative gait analysis procedures and their clinical applications. This article provides an overview of the potential of a quantitative gait analysis for decision support in three clinically relevant scenarios of early stage gait disorders: scenario I: gait ataxia and unsteadiness; scenario II: hypokinesia and slow gait; scenario III: apparently normal gait with a specific fall tendency in complex mobility situations. In a first part, we justify the advantages of standardized data collection and analysis procedures including data normalization and dimensionality reduction techniques that facilitate clinical interpretability of instrument-based gait profiles. We then outline typical patterns of pathological gait and their modulation during different walking conditions (variation of speed, sensory perturbation, and dual tasking) and highlight key aspects that are particularly helpful to support and guide clinical decision-making.
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Affiliation(s)
- Roman Schniepp
- Department of Neurology, Ludwig-Maximilian University of Munich, Munich, Bavaria, Germany. .,German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilian University of Munich, Munich, Bavaria, Germany.
| | - Ken Möhwald
- Department of Neurology, Ludwig-Maximilian University of Munich, Munich, Bavaria, Germany.,German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilian University of Munich, Munich, Bavaria, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig-Maximilian University of Munich, Munich, Bavaria, Germany
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21
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Huppert A, Wuehr M, Decker J, Schenkel F, Jahn K, Dieterich M, Brandt T, Schniepp R. P68 Associations between in- and off-laboratory mobility assessment and falls in patients with neurological gait disorders – PAss FaMous study. Clin Neurophysiol 2020. [DOI: 10.1016/j.clinph.2019.12.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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22
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Dietrich H, Heidger F, Schniepp R, MacNeilage P, Glasauer S, Wuehr M. P85 Head motion predictability explains phase- and speed-dependent suppression of vestibular balance control during walking. Clin Neurophysiol 2020. [DOI: 10.1016/j.clinph.2019.12.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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23
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Möhwald K, Wuehr M, Decker J, Schenkel F, Jahn K, Schniepp R. P86 Predictive measures for fall events in patients with cerebellar disorders – Results from the PAss FaMous study. Clin Neurophysiol 2020. [DOI: 10.1016/j.clinph.2019.12.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Dietrich H, Heidger F, Schniepp R, MacNeilage PR, Glasauer S, Wuehr M. Head motion predictability explains activity-dependent suppression of vestibular balance control. Sci Rep 2020; 10:668. [PMID: 31959778 PMCID: PMC6971007 DOI: 10.1038/s41598-019-57400-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 12/21/2019] [Indexed: 11/25/2022] Open
Abstract
Vestibular balance control is dynamically weighted during locomotion. This might result from a selective suppression of vestibular inputs in favor of a feed-forward balance regulation based on locomotor efference copies. The feasibility of such a feed-forward mechanism should however critically depend on the predictability of head movements (HMP) during locomotion. To test this, we studied in 10 healthy subjects the differential impact of a stochastic vestibular stimulation (SVS) on body sway (center-of-pressure, COP) during standing and walking at different speeds and compared it to activity-dependent changes in HMP. SVS-COP coupling was determined by correlation analysis in frequency and time domains. HMP was quantified as the proportion of head motion variance that can be explained by the average head trajectory across the locomotor cycle. SVS-COP coupling decreased from standing to walking and further dropped with faster locomotion. Correspondingly, HMP increased with faster locomotion. Furthermore, SVS-COP coupling depended on the gait-cycle-phase with peaks corresponding to periods of least HMP. These findings support the assumption that during stereotyped human self-motion, locomotor efference copies selectively replace vestibular cues, similar to what was previously observed in animal models.
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Affiliation(s)
- H Dietrich
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - F Heidger
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - R Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - P R MacNeilage
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
- Department of Psychology, Cognitive and Brain Sciences, University of Nevada, Nevada, USA
| | - S Glasauer
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
- Institute of Medical Technology, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
| | - M Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany.
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Abstract
Cerebellar dizziness and vertigo account for approximately 10% of diagnoses in a tertiary dizziness center. This term summarizes a large group of disorders with chronic (degenerative, hereditary, acquired cerebellar ataxias), recurrent (episodic ataxias), or acute (stroke, inflammation) presentations. Key to the diagnosis is a comprehensive examination of central ocular motor and vestibular function. Patients with cerebellar dizziness and vertigo usually show a pattern of deficits in smooth pursuit, gaze-holding, saccade accuracy, or fixation-suppression of the vestibulo-ocular reflex. Central fixation nystagmus (e.g., downbeat nystagmus), gaze-evoked nystagmus, central positional nystagmus, or head-shaking nystagmus with cross-coupling (i.e., horizontal head shaking causing inappropriate vertical nystagmus) occurs frequently. Overlap syndromes with peripheral vestibular disorders, such as cerebellar ataxia, neuropathy, and vestibular areflexia, exist rarely. Posturography and gait analysis can contribute to diagnostic differentiation, estimation of the risk of falls, as well as quantification of progression and treatment effects. Patients with cerebellar dizziness and vertigo should receive multimodal treatment, including balance training, occupational therapy, and medication.
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Affiliation(s)
- Andreas Zwergal
- Department of Neurology, University Hospital, Ludwig Maximilians University Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilians University Munich, Munich, Germany
| | - Katharina Feil
- Department of Neurology, University Hospital, Ludwig Maximilians University Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilians University Munich, Munich, Germany
| | - Roman Schniepp
- Department of Neurology, University Hospital, Ludwig Maximilians University Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilians University Munich, Munich, Germany
| | - Michael Strupp
- Department of Neurology, University Hospital, Ludwig Maximilians University Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilians University Munich, Munich, Germany
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26
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Finsterwalder S, Wuehr M, Gesierich B, Dietze A, Konieczny MJ, Schmidt R, Schniepp R, Duering M. Minor gait impairment despite white matter damage in pure small vessel disease. Ann Clin Transl Neurol 2019; 6:2026-2036. [PMID: 31524338 PMCID: PMC6801180 DOI: 10.1002/acn3.50891] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/29/2019] [Accepted: 08/12/2019] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Gait impairment is common in patients with cerebral small vessel disease (SVD). However, gait studies in elderly SVD patients might be confounded by age-related comorbidities, such as polyneuropathy or sarcopenia. We therefore studied young patients with the genetically defined SVD CADASIL. Our aim was to examine the effects of pure SVD on single and dual task gait, and to investigate associations of gait performance with cognitive deficits and white matter alterations. METHODS We investigated single task walking and calculatory, semantic, or motoric dual task costs in 39 CADASIL patients (mean age 50 ± 8) using a computerized walkway. We obtained 3.0T MRI and neuropsychological data on processing speed, the main cognitive deficit in CADASIL. Spatiotemporal gait parameters were standardized based on data from 192 healthy controls. Associations between white matter integrity, assessed by diffusion tensor imaging, and gait were analyzed using both a global marker and voxel-wise analysis. RESULTS Compared to controls, CADASIL patients showed only mild single task gait impairment, and only in the rhythm domain. The semantic dual task additionally uncovered mild deficits in the pace domain. Processing speed was not associated with gait. White matter alterations were related to single task stride length but not to dual task performance. INTERPRETATION Despite severe disease burden, gait performance in patients with pure small vessel disease was relatively preserved in single and dual tasks. Results suggest that age-related pathologies other than small vessel disease might play a role for gait impairment in elderly SVD patients.
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Affiliation(s)
- Sofia Finsterwalder
- Institute for Stroke and Dementia ResearchUniversity HospitalLMU MunichMunichGermany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders DSGZDepartment of NeurologyUniversity HospitalLMU MunichMunichGermany
| | - Benno Gesierich
- Institute for Stroke and Dementia ResearchUniversity HospitalLMU MunichMunichGermany
| | - Anna Dietze
- German Center for Vertigo and Balance Disorders DSGZDepartment of NeurologyUniversity HospitalLMU MunichMunichGermany
| | - Marek J. Konieczny
- Institute for Stroke and Dementia ResearchUniversity HospitalLMU MunichMunichGermany
| | | | - Roman Schniepp
- German Center for Vertigo and Balance Disorders DSGZDepartment of NeurologyUniversity HospitalLMU MunichMunichGermany
| | - Marco Duering
- Institute for Stroke and Dementia ResearchUniversity HospitalLMU MunichMunichGermany
- Munich Cluster for Systems Neurology (SyNergy)MunichGermany
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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28
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Wuehr M, Schlick C, Möhwald K, Schniepp R. Walking in orthostatic tremor modulates tremor features and is characterized by impaired gait stability. Sci Rep 2018; 8:14152. [PMID: 30237442 PMCID: PMC6147915 DOI: 10.1038/s41598-018-32526-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/06/2018] [Indexed: 11/13/2022] Open
Abstract
Primary orthostatic tremor (OT) is characterized by high-frequency lower-limb muscle contractions and a disabling sense of unsteadiness while standing. Patients consistently report a relief of symptoms when starting to ambulate. Here, we systematically examined and linked tremor and gait characteristics in patients with OT. Tremor and gait features were examined in nine OT patients and controls on a pressure-sensitive treadmill for one minute of walking framed by two one-minute periods of standing. Tremor characteristics were assessed by time-frequency analysis of surface EMG-recordings from four leg muscles. High-frequency tremor during standing (15.29 ± 0.17 Hz) persisted while walking but was consistently reset to higher frequencies (16.34 ± 0.25 Hz; p < 0.001). Tremor intensity was phase-dependently modulated, being predominantly observable during stance phases (p < 0.001). Tremor intensity scaled with the force applied during stepping (p < 0.001) and was linked to specific gait alterations, i.e., wide base walking (p = 0.019) and increased stride-to-stride fluctuations (p = 0.002). OT during walking persists but is reset to higher frequencies, indicating the involvement of supraspinal locomotor centers in the generation of OT rhythm. Tremor intensity is modulated during the gait cycle, pointing at specific pathways mediating the peripheral manifestation of OT. Finally, OT during walking is linked to gait alterations resembling a cerebellar and/or sensory ataxic gait disorder.
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Affiliation(s)
- M Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.
| | - C Schlick
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany
| | - K Möhwald
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - R Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Munich, Germany
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29
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Breitkopf K, Decker J, Wuehr M, Schenkel F, Brandt T, Schniepp R. P124. Evaluation of gait parameters in functional gait disorders. Clin Neurophysiol 2018. [DOI: 10.1016/j.clinph.2018.04.738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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30
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Möhwald K, Wühr M, Feil K, Schenkel F, Schlick C, Jahn K, Dieterich M, Brandt T, Schniepp R. P31. Gait disturbance in patients with orthostatic tremor. Clin Neurophysiol 2018. [DOI: 10.1016/j.clinph.2018.04.672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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31
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Dietrich H, Wuehr M, Pradhan C, Schniepp R. P118. Speed- and phase-dependent suppression of downbeat nystagmus during locomotion. Clin Neurophysiol 2018. [DOI: 10.1016/j.clinph.2018.04.732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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32
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Kunz M, Siller S, Nell C, Schniepp R, Dorn F, Huge V, Tonn JC, Pfister HW, Schichor C. Low-Dose versus Therapeutic Range Intravenous Unfractionated Heparin Prophylaxis in the Treatment of Patients with Severe Aneurysmal Subarachnoid Hemorrhage After Aneurysm Occlusion. World Neurosurg 2018; 117:e705-e711. [PMID: 29959066 DOI: 10.1016/j.wneu.2018.06.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND While prophylaxis with intravenous unfractionated heparin (UFH) can effectively prevent venous thromboembolism (VTE) during the neurocritical care of patients with severe aneurysmal subarachnoid hemorrhage (aSAH), the risk for intracranial bleeding complications might increase. Owing to this therapeutic dilemma, the UFH administration regimen in this critical patient population remains highly controversial. METHODS We performed a retrospective analysis of patients with severe aSAH (Fisher grade 3-4) receiving either low-dose (activated partial thromboplastin time [aPTT] <40 seconds) or therapeutic range (aPTT 50-60 seconds) UFH during intensive care unit (ICU) treatment after complete surgical/endovascular aneurysm occlusion. The primary outcome was the rate of bleeding/VTE complications and the investigation of potential risk factors. RESULTS This study series comprised 410 patients with aneurysmal SAH (aSAH), with a mean age of 54.7 ± 12.6 years, a male:female ratio of 1:2.2, and aSAH-associated intracerebral hemorrhage (ICH) in 33.2%. After complete aneurysm occlusion, 112 patients (27.3%) received therapeutic dose UFH and 298 patients (72.7%) received low-dose UFH. VTE events occurred in 5.4% of the low-dose UFH cohort and in 6.3% of the therapeutic dose UFH cohort, with no significant differences in the rate and severity of VTE events. However, an increase in initial SAH-associated ICH was significantly (P = 0.007) more frequent in the therapeutic dose cohort (18.8% vs. 3.4%). Heparin-induced thrombocytopenia (HIT) was the sole risk factor for VTE (P < 0.001), and both an aPTT ≥50 seconds under UFH administration (P = 0.007) and the initial presence of SAH-associated ICH (P = 0.035) were significant risk factors for intracranial bleeding complications. CONCLUSIONS Even in high-risk neurocritical patients with severe SAH and prolonged ICU treatment, low-dose UFH-administration for VTE prophylaxis is equally effective as therapeutic UFH administration and carries a lower risk of bleeding complications.
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Affiliation(s)
- Mathias Kunz
- Department of Neurosurgery, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Sebastian Siller
- Department of Neurosurgery, University Hospital, Ludwig Maximilian University, Munich, Germany.
| | - Carolina Nell
- Department of Neurosurgery, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Roman Schniepp
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Franziska Dorn
- Institute of Neuroradiology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Volker Huge
- Institute of Anesthesiology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Christian Schichor
- Department of Neurosurgery, University Hospital, Ludwig Maximilian University, Munich, Germany
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Wuehr M, Schlick C, Möhwald K, Schniepp R. Proprioceptive muscle tendon stimulation reduces symptoms in primary orthostatic tremor. J Neurol 2018; 265:1666-1670. [PMID: 29767354 DOI: 10.1007/s00415-018-8902-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/03/2018] [Accepted: 05/05/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Primary orthostatic tremor (OT) is characterized by high-frequency lower limb muscle contractions and a disabling sense of unsteadiness while standing. To date, therapeutic options for OT are limited. Here, we examined the effects of proprioceptive leg muscle stimulation via muscle tendon vibration (MTV) on tremor and balance control in patients with primary OT. METHODS Tremor in nine patients with primary OT was examined during four conditions: standing (1), standing with MTV on the bilateral soleus muscles (2), lying (3), and lying with MTV (4). Tremor characteristics were assessed by frequency domain analysis of surface EMG recordings from four leg muscles. Body sway was analyzed using posturographic recordings. RESULTS During standing, all patients showed a coherent high-frequency tremor in leg muscles and body sway that was absent during lying (p < 0.001). MTV during standing did not reset tremor frequency, but resulted in a decreased tremor intensity (p < 0.001; mean reduction: 32.5 ± 7.1%) and body sway (p = 0.032; mean reduction: 37.2 ± 6.8%). MTV did not affect muscle activity during lying. Four patients further reported a noticeable relief from unsteadiness during stimulation. CONCLUSION Proprioceptive stimulation did not reset tremor frequency consistent with the presumed central origin of OT. However, continuous MTV influenced the emergence of OT symptoms resulting in reduced tremor intensity, improved posture, and a relief from unsteadiness in half of the examined patients. These findings indicate that MTV either directly interferes with the peripheral manifestation of the central oscillatory pattern or prevents proprioceptive afferent feedback from becoming extensively synchronized at the tremor frequency.
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Affiliation(s)
- M Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - C Schlick
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - K Möhwald
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - R Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
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Wuehr M, Boerner J, Pradhan C, Decker J, Jahn K, Brandt T, Schniepp R. Stochastic resonance in the human vestibular system – Noise-induced facilitation of vestibulospinal reflexes. Brain Stimul 2018; 11:261-263. [DOI: 10.1016/j.brs.2017.10.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/21/2017] [Indexed: 11/26/2022] Open
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Selge C, Schoeberl F, Zwergal A, Nuebling G, Brandt T, Dieterich M, Schniepp R, Jahn K. Gait analysis in PSP and NPH. Neurology 2018; 90:e1021-e1028. [DOI: 10.1212/wnl.0000000000005168] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/22/2017] [Indexed: 12/21/2022] Open
Abstract
ObjectiveTo test whether quantitative gait analysis of gait under single- and dual-task conditions can be used for a differential diagnosis of progressive supranuclear palsy (PSP) and idiopathic normal-pressure hydrocephalus (iNPH).MethodsIn this cross-sectional study, temporal and spatial gait parameters were analyzed in 38 patients with PSP (Neurological Disorders and Stroke and Society for Progressive Supranuclear Palsy diagnostic criteria), 27 patients with iNPH (international iNPH guidelines), and 38 healthy controls. A pressure-sensitive carpet was used to examine gait under 5 conditions: single task (preferred, slow, and maximal speed), cognitive dual task (walking with serial 7 subtractions), and motor dual task (walking while carrying a tray).ResultsThe main results were as follows. First, both patients with PSP and those with iNPH exhibited significant gait dysfunction, which was worse in patients with iNPH with a more broad-based gait (p < 0.001). Second, stride time variability was increased in both patient groups, more pronounced in PSP (p = 0.009). Third, cognitive dual task led to a greater reduction of gait velocity in PSP (PSP 34.4% vs iNPH 16.9%, p = 0.002). Motor dual task revealed a dissociation of gait performance: patients with PSP considerably worsened, but patients with iNPH tended to improve.ConclusionPatients with PSP seem to be more sensitive to dual-task perturbations than patients with iNPH. An increased step width and anisotropy of the effect of dual-task conditions (cognitive vs motor) seem to be good diagnostic tools for iNPH.
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Schlick C, Rasoul A, Wuehr M, Gerth J, Dieterich M, Brandt T, Jahn K, Schniepp R. Gait variability predicts a subset of falls in cerebellar gait disorders. J Neurol 2017; 264:2322-2324. [PMID: 28993885 DOI: 10.1007/s00415-017-8634-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/25/2017] [Accepted: 09/28/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Cornelia Schlick
- German Center for Vertigo and Balance Disorders, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.
| | - Atal Rasoul
- German Center for Vertigo and Balance Disorders, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany
| | - Julia Gerth
- German Center for Vertigo and Balance Disorders, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany
| | - Marianne Dieterich
- German Center for Vertigo and Balance Disorders, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.,Department of Neurology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.,Institute of Clinical Neurosciences, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany
| | - Klaus Jahn
- German Center for Vertigo and Balance Disorders, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.,Schön Klinik Bad Aibling, Bad Aibling, Germany
| | - Roman Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany.,Department of Neurology, University Hospital Munich, Ludwig-Maximilians-University, Munich, Germany
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37
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Schniepp R, Möhwald K, Wuehr M. Gait ataxia in humans: vestibular and cerebellar control of dynamic stability. J Neurol 2017; 264:87-92. [PMID: 28397001 DOI: 10.1007/s00415-017-8482-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/31/2017] [Accepted: 04/01/2017] [Indexed: 01/15/2023]
Abstract
During human locomotion, vestibular feedback control is fundamental for maintaining dynamic stability and adapting the gait pattern to external circumstances. Within the supraspinal locomotor network, the cerebellum represents the key site for the integration of vestibular feedback information. The cerebellum is further important for the fine-tuning and coordination of limb movements during walking. The aim of this review article is to highlight the shared structural and functional sensorimotor principles in vestibular and cerebellar locomotion control. Vestibular feedback for the maintenance of dynamic stability is integrated into the locomotor pattern via midline, caudal cerebellar structures (vermis, flocculonodular lobe). Hemispheric regions of the cerebellum facilitate feed-forward control of multi-joint coordination and higher locomotor functions. Characteristic features of the gait disorder in patients with vestibular deficits or cerebellar ataxia are increased levels of spatiotemporal gait variability in the fore-aft and the medio-lateral gait dimension. In the fore-aft dimension, pathologic increases of gait fluctuations critically depend on the locomotion speed and predominantly manifest during slow walking velocities. This feature is associated with an increased risk of falls in both patients with vestibular hypofunction as well as patients with cerebellar ataxia. Pharmacological approaches for the treatment of vestibular or cerebellar gait ataxia are currently not available. However, new promising options are currently tested in randomized, controlled trials (fampridine/FACEG; acetyl-DL-leucine/ALCAT).
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Affiliation(s)
- Roman Schniepp
- Department of Neurology, University of Munich, Bavaria, Germany. .,German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Bavaria, Germany.
| | - Ken Möhwald
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Bavaria, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Bavaria, Germany
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Wuehr M, Brandt T, Schniepp R. Distracting attention in phobic postural vertigo normalizes leg muscle activity and balance. Neurology 2016; 88:284-288. [PMID: 27974646 DOI: 10.1212/wnl.0000000000003516] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 10/05/2016] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To examine the triggering causes of inadequate neuromuscular regulation of posture and subjective imbalance in patients with phobic postural vertigo (PPV), a subtype of functional dizziness. METHODS Postural performance was assessed by center-of-pressure displacements and surface EMG of lower-limb muscles (the tibialis anterior and soleus) in 10 patients with PPV and 10 healthy controls under 4 stance conditions: standing with eyes open or closed and with or without an additional cognitive dual task. The level of muscle cocontraction and the characteristics of open- and closed-loop postural control were analyzed. RESULTS At baseline (i.e., standing with eyes open without dual task), patients exhibited increased muscle cocontractions (p = 0.003), which were further associated with increased open-loop diffusion activity (p = 0.022) and a lowering of the primary feedback threshold for closed-loop control (p = 0.003). However, postural performance of patients improved considerably and normalized to that of healthy controls when performing an additional dual task. CONCLUSIONS PPV is characterized by a dissociation of subjective postural instability and objectively maintained balance capabilities. The dual-task effects on balance in patients with PPV indicate that this dissociation might result from an increased attention to postural adjustments at baseline, which is normally required only during demanding balance situations. This internal focus on balance control promotes an inappropriate neuromuscular regulation of posture, with increased muscle cocontractions, higher short-term body sway, and an oversensitivity to external stimuli. However, if patients are distracted, muscle cocontractions and balance control normalize. Such distraction may therefore be an effective coping strategy for preventing PPV attacks in susceptible patients.
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Affiliation(s)
- Max Wuehr
- From the German Center for Vertigo and Balance Disorders (M.W., T.B., R.S.), Institute for Clinical Neurosciences (T.B.), and Department of Neurology (R.S.), University of Munich, Germany.
| | - Thomas Brandt
- From the German Center for Vertigo and Balance Disorders (M.W., T.B., R.S.), Institute for Clinical Neurosciences (T.B.), and Department of Neurology (R.S.), University of Munich, Germany
| | - Roman Schniepp
- From the German Center for Vertigo and Balance Disorders (M.W., T.B., R.S.), Institute for Clinical Neurosciences (T.B.), and Department of Neurology (R.S.), University of Munich, Germany
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Schniepp R, Schlick C, Schenkel F, Pradhan C, Jahn K, Brandt T, Wuehr M. Clinical and neurophysiological risk factors for falls in patients with bilateral vestibulopathy. J Neurol 2016; 264:277-283. [DOI: 10.1007/s00415-016-8342-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 11/07/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW To identify the different indications for the treatment of neurologic disorders with the potassium channel blockers 4-aminopyridine (4-AP) and 3,4-diaminopyridine (3,4-DAP). RECENT FINDINGS 4-AP is an effective symptomatic treatment for downbeat nystagmus (DBN), episodic ataxia type 2 (EA2) (5-10 mg TID), and impaired gait in multiple sclerosis (MS) (10 mg BID). 3,4-DAP (5 mg/d-20 mg TID) improves symptoms in Lambert-Eaton myasthenic syndrome (LEMS) (randomized placebo-controlled trials for all 4 entities). 4-AP may also be effective in cerebellar gait ataxia of different etiologies (2 case series), upbeat nystagmus, and limb ataxia in MS (single cases). In the recommended dosages, they are well tolerated. The assumed mode of action is a blockade of mainly Kv1.5: in DBN, this increases the excitability of Purkinje cells (PC), and in EA2, restores the precision of resting discharge of PC. In MS, 4-AP improves the conduction of action potentials in demyelinated axons, and in LEMS, 3,4-DAP facilitates the transmission at the neuromuscular endplate by prolonging the action potential duration. SUMMARY There is sufficient evidence that APs are indicated for the symptomatic treatment of DBN, EA2, gait ataxia due to MS and cerebellar disorders, and LEMS with a reasonable risk-benefit profile.
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Affiliation(s)
- Michael Strupp
- University Hospital (MS, JT, AZ, RS, KF), Munich, Germany; and Albert Einstein College of Medicine (KK), New York, NY
| | - Julian Teufel
- University Hospital (MS, JT, AZ, RS, KF), Munich, Germany; and Albert Einstein College of Medicine (KK), New York, NY
| | - Andreas Zwergal
- University Hospital (MS, JT, AZ, RS, KF), Munich, Germany; and Albert Einstein College of Medicine (KK), New York, NY
| | - Roman Schniepp
- University Hospital (MS, JT, AZ, RS, KF), Munich, Germany; and Albert Einstein College of Medicine (KK), New York, NY
| | - Kamran Khodakhah
- University Hospital (MS, JT, AZ, RS, KF), Munich, Germany; and Albert Einstein College of Medicine (KK), New York, NY
| | - Katharina Feil
- University Hospital (MS, JT, AZ, RS, KF), Munich, Germany; and Albert Einstein College of Medicine (KK), New York, NY
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Jahn K, Kressig RW, Bridenbaugh SA, Brandt T, Schniepp R. Dizziness and Unstable Gait in Old Age: Etiology, Diagnosis and Treatment. Dtsch Arztebl Int 2016; 112:387-93. [PMID: 26157011 DOI: 10.3238/arztebl.2015.0387] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 03/18/2015] [Accepted: 03/18/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Dizziness and unsteady gait are common in the elderly but are too often dismissed as supposedly nonspecific, inevitable accompaniments of normal aging. For many affected persons, the factors leading to dizziness and gait impairment in old age are never identified, yet some of these factors can be specifically detected and treated. METHODS This review is based on publications (2005-2014) retrieved by a selective search in PubMed on the terms "aging," "dizziness," "elderly," "gait," "gait disorder," "geriatric," "locomotion," and "vertigo." RESULTS Dizziness interferes with the everyday activities of 30% of persons over age 70 and is so severe that it constitutes a reason for consulting a physician. The more common causes of dizziness and unsteady gait in old age are sensory deficits, such as bilateral vestibular failure, polyneuropathy, and impaired visual acuity; benign paroxysmal positioning vertigo; and central disorders such as cerebellar ataxia and normal-pressure hydrocephalus. Further relevant factors include sedative or antihypertensive medication, loss of muscle mass (sarcopenia), and fear of falling. Many elderly persons have multiple factors at the same time. Benign paroxysmal positioning vertigo can be effectively treated with specific physical maneuvers. Sedating drugs are indicated only for the treatment of acute rotatory vertigo and are not suitable for long-term use. Sarcopenia can be treated with physical training. CONCLUSION If a specific cause can be identified, dizziness and gait unsteadiness in old age can often be successfully treated. The common causes can be revealed by systematic clinical examination. Controlled clinical trials on the efficacy of treatments for elderly persons are urgently needed.
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Affiliation(s)
- Klaus Jahn
- German Center for Vertigo and Balance Disorders, Großhadern Hospital, Ludwig-Maximilian-Universität, München, Schön Klinik Bad Aibling, Basel University and University Center for Geriatrics and Rehabilitation, Felix Platter Hospital, Basel, Switzerland, Institute for Clinical Neurosciences, Großhadern Hospital, Ludwig-Maximilian-Universität, Munich, Neurological Clinic and Policlinic, Großhadern Hospital, Ludwig-Maximilian-Universität Munich
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Möhwald K, Pradhan C, Wuehr M, Dieterich M, Brandt T, Jahn K, Schniepp R. EP 52. PREGAIT study – Pattern recognition and differential diagnosis of neurological gait disorders in instrumental and clinical gait analysis. Clin Neurophysiol 2016. [DOI: 10.1016/j.clinph.2016.05.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Schlick C, Wuehr M, Gerth J, Jahn K, Schniepp R. EP 99. Prediction of falls through gait variability and symptom severity in cerebellar syndromes. Clin Neurophysiol 2016. [DOI: 10.1016/j.clinph.2016.05.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Börner J, Pradhan C, Decker J, Schniepp R, Wühr M. EP 68. Stochastic resonance in the vestibular system. Clin Neurophysiol 2016. [DOI: 10.1016/j.clinph.2016.05.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Möhwald K, Wuehr M, Pradhan C, Dieterich M, Brandt T, Jahn K, Schniepp R. EP 51. Determination of gait improvement after lumbar puncture in idiopathic normal pressure hydrocephalus. Clin Neurophysiol 2016. [DOI: 10.1016/j.clinph.2016.05.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Decker J, Pradhan C, Brandt T, Jahn K, Schniepp R. EP 90. Combining motion capture and accelerometers for the assessment of rotation and acting forces in bilateral vestibulopathy patients during walking tasks. Clin Neurophysiol 2016. [DOI: 10.1016/j.clinph.2016.05.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schniepp R, Wuehr M, Schöberl F, Zwergal A. Erfassung motorisch-kognitiver Interaktionen bei Demenzerkrankungen im klinischen Alltag. Fortschr Neurol Psychiatr 2016; 84:469-79. [DOI: 10.1055/s-0042-110651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- R. Schniepp
- Klinik und Poliklinik für Neurologie, Campus Großhadern, Ludwig-Maximilians-Universität, München
| | - M. Wuehr
- Deutsches Zentrum für Schwindel und Gleichgewichtsstörungen (DSGZ), Campus Großhadern, Ludwig-Maximilians-Universität, München
| | - F. Schöberl
- Klinik und Poliklinik für Neurologie, Campus Großhadern, Ludwig-Maximilians-Universität, München
| | - A. Zwergal
- Klinik und Poliklinik für Neurologie, Campus Großhadern, Ludwig-Maximilians-Universität, München
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Schniepp R, Schlick C, Pradhan C, Dieterich M, Brandt T, Jahn K, Wuehr M. The interrelationship between disease severity, dynamic stability, and falls in cerebellar ataxia. J Neurol 2016; 263:1409-17. [PMID: 27159995 DOI: 10.1007/s00415-016-8142-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 04/20/2016] [Accepted: 04/24/2016] [Indexed: 11/26/2022]
Abstract
Cerebellar ataxia (CA) results in discoordination of body movements (ataxia), a gait disorder, and falls. All three aspects appear to be obviously interrelated; however, experimental evidence is sparse. This study systematically correlated the clinical rating of the severity of ataxia with dynamic stability measures and the fall frequency in patients with CA. Clinical severity of CA in patients with sporadic (n = 34) and hereditary (n = 24) forms was assessed with the Scale for the Assessment and Rating of Ataxia (SARA). Gait performance was examined during slow, preferred, and maximally fast walking speeds. Spatiotemporal variability parameters in the fore-aft and medio-lateral directions were analyzed. The fall frequency was assessed using a standardized interview about fall events within the last 6 months. Fore-aft gait variability showed significant speed-dependent characteristics with highest magnitudes during slow and fast walking. The SARA score correlated positively with fore-aft gait variability, most prominently during fast walking. The fall frequency was significantly associated to fore-aft gait variability during slow walking. Severity of ataxia, dynamic stability, and the occurrence of falls were interrelated in a speed-dependent manner: (a) Severity of ataxia symptoms was closely related to instability during fast walking. (b) Fall frequency was associated with instability during slow walking. These findings suggest the presence of a speed-dependent, twofold cerebellar locomotor control. Assessment of gait performance during non-preferred, slow and fast walking speeds provides novel insights into the pathophysiology of cerebellar locomotor control and may become a useful approach in the clinical evaluation of patients with CA.
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Affiliation(s)
- Roman Schniepp
- Department of Neurology, University of Munich, Munich, Germany.
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany.
| | - Cornelia Schlick
- Department of Neurology, University of Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
| | - Cauchy Pradhan
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
| | - Marianne Dieterich
- Department of Neurology, University of Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
- Institute for Clinical Neurosciences, University of Munich, Munich, Germany
| | - Klaus Jahn
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
- Schoen Klinik Bad Aibling, Bad Aibling, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
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Wuehr M, Nusser E, Decker J, Krafczyk S, Straube A, Brandt T, Jahn K, Schniepp R. Noisy vestibular stimulation improves dynamic walking stability in bilateral vestibulopathy. Neurology 2016; 86:2196-202. [PMID: 27164706 DOI: 10.1212/wnl.0000000000002748] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 03/04/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the effects of imperceptible levels of white noise galvanic vestibular stimulation (nGVS) on dynamic walking stability in patients with bilateral vestibulopathy (BVP). METHODS Walking performance of 13 patients with confirmed BVP (mean age 50.1 ± 5.5 years) at slow, preferred, and fast speeds was examined during walking with zero-amplitude nGVS (sham trial) and nonzero-amplitude nGVS set to 80% of the individual cutaneous threshold for GVS (nGVS trial). Eight standard gait measures were analyzed: stride time, stride length, base of support, double support time percentage as well as the bilateral phase coordination index, and the coefficient of variation (CV) of stride time, stride length, and base of support. RESULTS Compared to the sham trial, nGVS improved stride time CV by 26.0% ± 8.4% (p < 0.041), stride length CV by 26.0% ± 7.7% (p < 0.029), base of support CV by 27.8% ± 2.9% (p < 0.037), and phase coordination index by 8.4% ± 8.8% (p < 0.013). The nGVS effects on walking performance were correlated with subjective ratings of walking balance (ρ = 0.79, p < 0.001). Effect of nGVS on walking stability was most pronounced during slow walking. CONCLUSIONS In patients with BVP, nGVS is effective in improving impaired gait performance, predominantly during slower walking speeds. It primarily targets the variability and bilateral coordination characteristics of the walking pattern, which are linked to dynamic walking stability. nGVS might present an effective treatment option to immediately improve walking performance and reduce the incidence of falls in patients with BVP. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that in patients with BVP, an imperceptible level of nGVS improves dynamic walking stability.
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Affiliation(s)
- Max Wuehr
- From the German Center for Vertigo and Balance Disorders (M.W., J.D., S.K., A.S., T.B., K.J., R.S.), Department of Neurology (E.N., S.K., A.S., R.S.), and Institute for Clinical Neuroscience (T.B.), University of Munich; and Schoen Klinik Bad Aibling (K.J.), Germany.
| | - Eva Nusser
- From the German Center for Vertigo and Balance Disorders (M.W., J.D., S.K., A.S., T.B., K.J., R.S.), Department of Neurology (E.N., S.K., A.S., R.S.), and Institute for Clinical Neuroscience (T.B.), University of Munich; and Schoen Klinik Bad Aibling (K.J.), Germany
| | - Julian Decker
- From the German Center for Vertigo and Balance Disorders (M.W., J.D., S.K., A.S., T.B., K.J., R.S.), Department of Neurology (E.N., S.K., A.S., R.S.), and Institute for Clinical Neuroscience (T.B.), University of Munich; and Schoen Klinik Bad Aibling (K.J.), Germany
| | - Siegbert Krafczyk
- From the German Center for Vertigo and Balance Disorders (M.W., J.D., S.K., A.S., T.B., K.J., R.S.), Department of Neurology (E.N., S.K., A.S., R.S.), and Institute for Clinical Neuroscience (T.B.), University of Munich; and Schoen Klinik Bad Aibling (K.J.), Germany
| | - Andreas Straube
- From the German Center for Vertigo and Balance Disorders (M.W., J.D., S.K., A.S., T.B., K.J., R.S.), Department of Neurology (E.N., S.K., A.S., R.S.), and Institute for Clinical Neuroscience (T.B.), University of Munich; and Schoen Klinik Bad Aibling (K.J.), Germany
| | - Thomas Brandt
- From the German Center for Vertigo and Balance Disorders (M.W., J.D., S.K., A.S., T.B., K.J., R.S.), Department of Neurology (E.N., S.K., A.S., R.S.), and Institute for Clinical Neuroscience (T.B.), University of Munich; and Schoen Klinik Bad Aibling (K.J.), Germany
| | - Klaus Jahn
- From the German Center for Vertigo and Balance Disorders (M.W., J.D., S.K., A.S., T.B., K.J., R.S.), Department of Neurology (E.N., S.K., A.S., R.S.), and Institute for Clinical Neuroscience (T.B.), University of Munich; and Schoen Klinik Bad Aibling (K.J.), Germany
| | - Roman Schniepp
- From the German Center for Vertigo and Balance Disorders (M.W., J.D., S.K., A.S., T.B., K.J., R.S.), Department of Neurology (E.N., S.K., A.S., R.S.), and Institute for Clinical Neuroscience (T.B.), University of Munich; and Schoen Klinik Bad Aibling (K.J.), Germany
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Schniepp R, Strupp M, Wuehr M, Jahn K, Dieterich M, Brandt T, Feil K. Acetyl-DL-leucine improves gait variability in patients with cerebellar ataxia-a case series. Cerebellum Ataxias 2016; 3:8. [PMID: 27073690 PMCID: PMC4828858 DOI: 10.1186/s40673-016-0046-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 03/22/2016] [Indexed: 11/29/2022]
Abstract
Acetyl-DL-leucine is a modified amino acid that was observed to improve ataxic symptoms in patients with sporadic and hereditary forms of ataxia. Here, we investigated the effect of the treatment with Acetyl-DL-leucine on the walking stability of patients with cerebellar ataxia (10x SAOA, 2x MSA-C, 2x ADA, 1x CACNA-1A mutation, 2x SCA 2, 1x SCA 1). Treatment with Acetyl-DL-leucine (500 mg; 3-3-4) significantly improved the coefficient of variation of stride time in 14 out of 18 patients. Moreover, subjective ambulatory scores (FES-I and ABC) and the SARA scores were also improved under treatment. Further prospective studies are necessary to support these class III observational findings.
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Affiliation(s)
- Roman Schniepp
- Department of Neurology, University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany ; German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany
| | - Michael Strupp
- Department of Neurology, University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany ; German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany
| | - Klaus Jahn
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany ; Schoen Klinik Bad Aibling, Neurologie, Kolbermoorer Strasse 72, Bad Aibling, 83043 Germany
| | - Marianne Dieterich
- Department of Neurology, University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany ; German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany ; Institute of Clinical Neurosciences, University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany
| | - Katharina Feil
- Department of Neurology, University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany ; German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Campus Großhadern, Marchioninistrasse 15, Munich, 81377 Germany
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