Prevalence and severity of freezing of gait in a Danish cohort of people with Parkinson's disease

INTRODUCTION

Parkinson's disease (PD) is a widespread neurodegenerative disorder characterised by wide range of symptoms. Freezing of gait (FoG), a transient feeling that the patient's feet are nailed to the floor, resulting in an inability to move, is a particularly distressful symptom. The assessment of FoG can be challenging. Often, clinicians are reliant on patients' subjective experiences and patient questionnaires such as the Freezing of Gait Questionnaire (FOGQ) and its updated version, the New FOGQ (NFOGQ).Until now, the NFOGQ has not been validated and piloted for use in Danish. Therefore, few attempts have been made to assess the prevalence and severity of FoG in Danish patients with PD.

METHODS

This report describes a two-step process of adapting the NFOGQ into Danish and piloting its use among a cohort of patients with PD. A satisfactory translation (Danish NFOGQ) was produced and successfully piloted.

RESULTS

The translation showed robust test-retest reliability after two weeks. Patients fully understood the questionnaire. Using the Danish NFOGQ in an online prevalence survey, we found that 35.7% of respondents had experienced FoG and that the prevalence correlated with disease duration.

CONCLUSION

The Danish NFOGQ appears to be appropriate for assessing FoG in Danish patients with PD in both clinical and research settings.

FUNDING

None.

TRIAL REGISTRATION

Not relevant.

Clinical features and related factors of freezing of gait in patients with Parkinson's disease

BACKGROUND

Freezing of gait (FOG) is a disabling paroxysmal gait disorder that prevents starting or resuming walking, which seriously negatively affects patients' quality of life (QOL). The diagnosis and treatment of FOG remain a huge medical challenge. The purpose of this study was to explore the clinical characteristics and related factors of FOG in patients with Parkinson's disease (PD).

METHODS

The motor and nonmotor symptoms of a total number of 77 PD patients were evaluated. Patients with or without FOG were defined as a score ≥1 in the new freezing of gait questionnaire (NFOG-Q). A comparative study between patients with and without FOG was conducted.

RESULTS

In this investigation, the prevalence of FOG was 48%. The patients with FOG had longer disease duration, higher Hoehn-Yahr stage (H-Y stage), higher dose of dopaminergic agents, and higher nonmotor and motor symptom scores. A significant positive correlation was found between the NFOG-Q score and the H-Y stage, PIGD subscore, PDQ-39, and the attention/memory in the nonmotor symptoms assessment scale (NMSS) subitem (r > 0.5, p < .05). The binary logistic regression analysis showed that the higher H-Y stage, higher rigidity subscore and Unified Parkinson's Disease Rating Scale II (UPDRS II) score, and UPDRS III score were significantly correlated with the occurrence of FOG (p < .05). In the analysis of the frequency of FOG, the prevalence of FOG in H-Y stage was higher in the middle and late stages, and the prevalence of FOG increased with the increase in PDQ-39 scores.

CONCLUSION

The severity of FOG was significantly positively correlated with the H-Y stage, PIGD subscore, PDQ-39 score, and attention/memory score. Based on our findings, we conclude that the clinical characteristics of rigidity can be used as a potential predictor of FOG.

Health Profile of Preterm Males With Duchenne Muscular Dystrophy

In this retrospective cohort study, we characterize the health profile of preterm males with Duchenne muscular dystrophy. Major clinical milestones (ambulation cessation, assisted ventilation use, and onset of left ventricular dysfunction) and corticosteroids use in males with Duchenne muscular dystrophy identified through a population-based surveillance system were analyzed using Kaplan-Meier survival curves and Cox proportional hazards modeling. The adjusted risk of receiving any respiratory intervention among preterm males with Duchenne muscular dystrophy was 87% higher than among the corresponding full-term males with Duchenne muscular dystrophy. The adjusted risks for ambulation cessation and left ventricular dysfunction were modestly elevated among preterm compared to full-term males, but the 95% confidence intervals contained the null. No difference in the start of corticosteroid use between preterm and full-term Duchenne muscular dystrophy males was observed. Overall, the disease course seems to be similar between preterm and full-term males with Duchenne muscular dystrophy; however, pulmonary function seems to be affected earlier among preterm males with Duchenne muscular dystrophy.

The effect of body weight-supported overground gait training for patients with Parkinson's disease: A retrospective case-control observational study

Objective

To evaluate the effects of body weight-supported overground gait training (BWSOGT) on motor abilities, such as gait and balance, in patients with Parkinson’s disease (PD).

Design

Retrospective case-controlled observational study with a 4-week follow-up.

Setting

Inpatient rehabilitation.

Participants

We selected 37 of 68 patients with PD. Inclusion criteria were (1) Hoehn & Yahr stage II–IV, (2) no medication adjustment during the study period, (3) at least 1 week since last medication adjustment, and (4) ability to walk more than 10 meters on their own. Exclusion criteria were (1) cerebrovascular disease or other complications affecting movement, (2) difficulty in measurement, (3) early discharge, (4) medication change during the study, and (5) development of complications.

Interventions

Patients were divided into two groups. Patients in Group I underwent 20 minutes of BWSOGT with a mobile hoist in addition to the standard exercises; Group II performed 20 minutes of gait training in place of BWSOGT. In both groups, training was performed for a total of 15 times/4 weeks.

Main outcome measure(s)

Participants were evaluated using the Unified Parkinson’s Disease Rating Scale total, part II, and part III; 10-m walk test; velocity; stride length; 6-minute walk test; timed up and go test; Berg Balance Scale; and freezing of gait before and after the intervention.

Results

There were significant decreases in the Unified Parkinson’s Disease Rating Scale total, part II, and part III in both groups; however, 6-minute walk test, timed up and go test, and freezing of gait results only improved in Group I.

Conclusions

BWSOGT for patients with PD improves gait ability and dynamic balance more than standard gait training.

Foot ulcer recurrence, plantar pressure and footwear adherence in people with diabetes and Charcot midfoot deformity: A cohort analysis

AIMS

To investigate people with Charcot midfoot deformity with regard to plantar pressure, footwear adherence and plantar foot ulcer recurrence.

METHODS

Twenty people with diabetes, Charcot midfoot deformity, plantar foot ulcer history and custom-made footwear were assessed with regard to barefoot and in-shoe plantar pressures during walking, footwear adherence (% of daily steps over 7-day period) and plantar foot ulcer recurrence over 18 months. In a cohort design, they were compared to 118 people without Charcot foot (non-Charcot foot group) with custom-made footwear and similar ulcer risk factors.

RESULTS

Median (interquartile range) barefoot midfoot peak pressures were significantly higher in the Charcot foot group than in the non-Charcot foot group [756 (260-1267) vs 146 (100-208) kPa; P<0.001]. In-shoe midfoot peak pressures were not significantly higher in the Charcot foot group [median (interquartile range) 152 (104-201) vs 119 (94-160) kPa] and significantly lower for all other foot regions. Participants in the Charcot foot group were significantly more adherent, especially at home, than participants in the non-Charcot foot group [median (interquartile range) 94.4 (85.4-95.0)% vs. 64.3 (25.4-85.7)%; P=0.001]. Ulcers recurred in 40% of the Charcot foot group and in 47% of the non-Charcot foot group (P=0.63); midfoot ulcers recurred significantly more in the Charcot foot group (4/8) than in the non-Charcot foot group (1/55; P=0.001).

CONCLUSIONS

Effective offloading and very high footwear adherence were found in people with diabetes and Charcot midfoot deformity. While this may help protect against plantar foot ulcer recurrence, a large proportion of such people still experience ulcer recurrence. Further improvements in adherence and custom-made footwear design may be required to improve clinical outcome.

Cerebral small vessel disease may worsen motor function, cognition, and mood in Parkinson's disease

INTRODUCTION

Emerging evidence has suggested that cerebral small vessel disease (CSVD) may worsen motor function and cognition in Parkinson's disease (PD). However, the effect of CSVD on anxiety and depression in patients with PD remains unknown. This study explored the multi-dimensional effects of CSVD on PD outcomes (motor, cognition, and depression/anxiety).

METHODS

This cross-sectional study included 431 patients with PD from Beijing Tiantan Hospital from May 2016 to August 2019. CSVD imaging markers were assessed and the four-point CSVD burden score was calculated. Motor function (MDS-UPDRS III score and subscores), cognition (MMSE, MoCA), anxiety (HAMA), and depression (HAMD) were assessed in these patients. The associations of CSVD with these outcomes were analyzed using the Spearman's correlation and multivariable linear regression models.

RESULTS

Motor dysfunction, cognitive impairment, depression, and anxiety were significantly worse in patients with severe CSVD than in those with mild CSVD. Multivariable linear regression showed that CSVD burden was significantly associated with motor dysfunction (MDS-UPDRS III score and rigidity and bradykinesia subscores), impaired cognition, and high levels of depression and anxiety. A marginally significant association was observed between CSVD burden and gait/postural instability in multivariable regression analysis. Among the CSVD imaging markers, white matter hyperintensity, number of lacunes, and microbleeds were positively correlated with the severity of motor, cognitive, and emotional impairments, while the perivascular space in the basal ganglia was only correlated with cognitive impairments.

CONCLUSIONS

Comorbid CSVD may affect multiple functional domains in patients with PD. Management of cerebrovascular disease may improve PD outcomes.

Wearables for gait and balance assessment in the neurological ward - study design and first results of a prospective cross-sectional feasibility study with 384 inpatients

BACKGROUND

Deficits in gait and balance are common among neurological inpatients. Currently, assessment of these patients is mainly subjective. New assessment options using wearables may provide complementary and more objective information.

METHODS

In this prospective cross-sectional feasibility study performed over a four-month period, all patients referred to a normal neurology ward of a university hospital and aged between 40 and 89 years were asked to participate. Gait and balance deficits were assessed with wearables at the ankles and the lower back. Frailty, sarcopenia, Parkinsonism, depression, quality of life, fall history, fear of falling, physical activity, and cognition were evaluated with questionnaires and surveys.

RESULTS

Eighty-two percent (n = 384) of all eligible patients participated. Of those, 39% (n = 151) had no gait and balance deficit, 21% (n = 79) had gait deficits, 11% (n = 44) had balance deficits and 29% (n = 110) had gait and balance deficits. Parkinson's disease, stroke, epilepsy, pain syndromes, and multiple sclerosis were the most common diseases. The assessment was well accepted.

CONCLUSIONS

Our study suggests that the use of wearables for the assessment of gait and balance features in a clinical setting is feasible. Moreover, preliminary results confirm previous epidemiological data about gait and balance deficits among neurological inpatients. Evaluation of neurological inpatients with novel wearable technology opens new opportunities for the assessment of predictive, progression and treatment response markers.

Cerebral Amyloid Deposition Is Associated with Gait Parameters in the Mayo Clinic Study of Aging

OBJECTIVES

To determine the cross-sectional association between cerebral amyloid-beta (Aβ) deposition and gait.

DESIGN

Cross-sectional.

SETTING

Population-based cohort study in Olmsted County, MN.

PARTICIPANTS

Cognitively normal individuals (n = 611), aged 50 to 69 years, enrolled in the Mayo Clinic Study of Aging with concurrent PiB-PET imaging and gait assessment. Participants with a history of stroke, alcoholism, Parkinson's disease, subdural hematoma, traumatic brain injury, or normal pressure hydrocephalus were excluded.

MEASUREMENTS

PiB-PET SUVR was measured in prefrontal, orbitofrontal, parietal, temporal, anterior cingulate, posterior cingulate, and motor-specific regions of interest (ROIs). Gait parameters (speed, cadence, stride length, double support time, and intra-individual stance time variability) were measured using GAITRite® instrumentation. Linear regression models were adjusted for age, sex, body mass index, education, APOE ε4 allele, Charlson comorbidity index, and depression. In secondary analyses, we additionally adjusted for neurodegeneration (hippocampal volume, FDG PET SUVR, and cortical thickness) in AD-associated regions.

RESULTS

In fully adjusted models including neuroimaging measures of neurodegeneration, higher PiB-PET SUVR across all ROIs was associated with slower gait speed (P < .05 except for the parietal ROI), lower cadence and longer double support time (P ≤ .05 except for the motor ROI), and greater stance time variability (P < .05). In sex-stratified analyses, the association between higher PiB-PET SUVR across all ROIs and measures of gait was only present among women.

CONCLUSION

PiB-PET SUVR across ROIs, independent of general measures of AD-associated neurodegeneration, is associated with poorer performance on multiple gait parameters among cognitively normal women, aged 50 to 69 years. Longitudinal studies are needed to determine whether Aβ predicts gait decline in both women and men.

The Role of Gait Analysis in the Evaluation of Patients with Cervical Myelopathy: A Literature Review Study

BACKGROUND

Gait analysis represents one of the newest methodologies used in the clinical evaluation of patients with cervical myelopathy (CM).

OBJECTIVE

To describe the role of gait analysis in the clinical evaluation of patients with CM, as well as its potential role in the evaluation of the functional outcome of any surgical intervention.

METHODS

A literature review was performed in the PubMed, OVID, and Google Scholar medical databases, from January 1995 to August 2016, using the terms "analysis," "anterior," "cervical myelopathy," "gait," "posterior," and "surgery." Clinical series comparing the gait patterns of patients with CM with healthy controls, as well as series evaluating gait and walk changes before and after surgical decompression, were reviewed. Case studies were excluded.

RESULTS

Nine prospective and 3 retrospective studies were found. Most of the retrieved studies showed the presence of characteristic, abnormal gait patterns among patients with CM, consisting of decreased gait speed, cadence, step length, stride length, and single-limb support time. In addition, patients with CM routinely present increased step and stride time, double-limb support time, and step width, and they have altered knee and ankle joint range of motion, compared with healthy controls. Moreover, gait and walk analysis may provide accurate functional assessment of the functional outcome of patients with CM undergoing surgical decompression.

CONCLUSIONS

Gait analysis may well be a valuable and objective tool along with other parameters in the evaluation of functionality in patients with CM, as well as in the assessment of the outcome of any surgical intervention in these patients.

Vascular disease and vascular risk factors in relation to motor features and cognition in early Parkinson's disease

OBJECTIVE

The purpose of this study was to examine the relationship between vascular disease (and vascular risk factors), cognition and motor phenotype in Parkinson's disease (PD).

METHODS

Recently diagnosed PD cases were enrolled in a multicenter prospective observational longitudinal cohort study. Montreal cognitive assessment (normal >23, mild cognitive impairment 22 to 23 or lower but without functional impairment, and dementia 21 or less with functional impairment) and Movement Disorder Society Unified PD Rating Scale part 3 (UPDRS 3) scores were analyzed in relation to a history of vascular events and risk factors.

RESULTS

In 1759 PD cases, mean age 67.5 (standard deviation 9.3) years, mean disease duration 1.3 (standard deviation 0.9) years, 65.2% were men, 4.7% had a history of prior stroke or transient ischemic attack, and 12.5% had cardiac disease (angina, myocardial infarction, heart failure). In cases without a history of vascular disease, hypertension was recorded in 30.4%, high cholesterol 27.3%, obesity 20.7%, diabetes 7.2%, and cigarette smoking in 4.6%. Patients with prior stroke or transient ischemic attack were more likely to have cognitive impairment (42% vs 25%) and postural instability gait difficulty (53.5% vs 39.5%), but these findings were not significant after adjustment for age, sex, and disease duration (P = .075). The presence of more than 2 vascular risks was associated with worse UPDRS 3 motor scores (beta coefficient 4.05, 95% confidence interval 1.48, 6.61, p = .002) and with cognitive impairment (ordinal odds ratio 2.24, 95% confidence interval 1.34, 3.74, p = .002). In 842 patients (47.8%) with structural brain imaging, white matter leukoaraiosis, but not lacunar or territorial infarction, was associated with impaired cognition (p = .006) and postural instability gait difficulty (p = .010).

CONCLUSION

Vascular comorbidity is significantly associated with cognitive and gait impairment in patients with early PD, which may have prognostic and treatment implications. © 2016 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Burden of disease in adult patients with hypophosphatasia: Results from two patient-reported surveys

BACKGROUND

Hypophosphatasia (HPP) is a rare metabolic bone disease caused by loss-of-function mutation(s) in the tissue-nonspecific alkaline (TNSALP) phosphatase gene, which manifests as rickets and/or osteomalacia with systemic complications and affects patients of all ages. The burden of disease is poorly characterized in adult patients.

AIMS

We assessed patient-reported burden of disease using two surveys reasonably specific for HPP symptomatology, the Hypophosphatasia Impact Patient Survey (HIPS) and the Hypophosphatasia Outcomes Study Telephone interview (HOST).

METHODS

Patients with HPP were invited to participate via patient advocacy groups or their medical provider. Survey questions captured demography, HPP-related medical history, mobility, and health-related quality of life (using Short Form 12 [version 2] Health Survey [SF-12v2]) via internet report (HIPS) or telephone interview (HOST).

RESULTS

One hundred twenty-five adults responded (mean [standard deviation, SD] age: 45 [14.3] years). Eighty-four patients (67%) reported pediatric-onset of their symptoms. Common clinical features in the study population included pain (95% of patients), fractures (86% of patients) muscle weakness (62%) and unusual gait (52%). Use of assistive devices for mobility (60%) was also prevalent. Twenty-six percent of patients reported more than 10 fractures. Seventy-four percent of patients had undergone orthopedic/dental surgical procedures. The health profile of patients responding on the SF-12 showed a broad and substantial impact of HPP on health-related quality of life, with domains related to physical ability showing the greatest decrement compared to normative data.

CONCLUSIONS

In aggregate, these data indicate that HPP can confer a high burden of illness in adulthood.

A prospective study of freezing of gait with early Parkinson disease in Chinese patients

This study investigated the risk factors for freezing of gait (FOG) in the early stage of Parkinson disease in China, using a sample of 248 patients who were followed for 3 years. Part III of the Unified Parkinson Disease Rating Scale and the modified Hoehn-Yahr grading scale were used to evaluate the severity of motor symptoms. Nonmotor symptoms were assessed using the Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale (HAMD), and Non-Motor Symptoms Scale (NMSS). The end-point was the presence of FOG at the end of follow-up; patients with FOG were classified as freezers. The risk factors for FOG were analyzed at the end of the first, second, and third years after baseline. There were 40 freezers (16.13%) 1 year later, 98 (39.52%) 2 years later, and 128 (51.61%) 3 years later. FOG 3 years later was associated with the following variables: depression (P = 0.003), older age, living in the countryside, lower education, akinetic-rigid style, lower limbs as site of onset, early use of levodopa, higher daily dose of levodopa, and not using amantadine or selegiline and dopamine receptor agonists (P < 0.001). Early use of amantadine, selegiline, and dopamine receptor agonists was negatively related to FOG (P < 0.001). Binary logistic regression found that FOG was associated with lower education (odds ratio [OR] = 0.012, P < 0.001), akinetic-rigid style (OR = 4.881, P = 0.024), not using dopamine receptor agonists (OR = 4.324, P = 0.035), cognitive disturbances (OR = 0.331, P = 0.007), and sleep disorders (OR = 2.418, P = 0.036). However, the cardiovascular domain of the NMSS (OR = 2.729, P = 0.001) was the only risk factor for FOG 1 year later. Two years later, FOG was associated with mixed style (OR = 0.189, P = 0.005), lower limbs as site of onset (OR = 4.772, P = 0.008), not using dopamine receptor agonists (OR = 0.031, P < 0.001), and the anxiety/somatic domain of the HAMD (OR = 0.596, P = 0.033). Scores at baseline, patients with Parkinson disease were more likely to experience FOG if: they were older, or from the countryside; had an akinetic-rigid style, anxiety, or higher NMSS scores; they used levodopa early or did not use amantadine or selegiline; their lower limbs were the site of onset; or they had more severe motor disability or higher HAMD scores at baseline.

Gait characteristics in older adults with diabetes and impaired fasting glucose: The Rotterdam Study

AIMS

To investigate the association of diabetes mellitus and impaired fasting glucose with gait in the general middle-aged and elderly population.

METHODS

We performed a cross-sectional study on 3019 participants from the population-based Rotterdam Study (aged >45years, 54% women). The presence of diabetes mellitus and impaired fasting glucose was evaluated by measuring serum glucose levels and by documenting anti-diabetic treatment. Participants underwent gait analysis using an electronic walkway. Thirty gait variables were summarized into five independent gait domains for normal walking (Rhythm, Variability, Phases, Pace and Base of Support), one for turning (Turning) and one for walking heel to toe (Tandem), which were averaged into Global Gait. Linear regression analyses were performed to determine the association of diabetes, impaired fasting glucose and continuous glucose levels within the normal range with gait.

RESULTS

Diabetes mellitus was associated with worse Global Gait (Z-score difference -0.19, 95% confidence interval (CI) -0.30; -0.07), worse Pace (-0.20, 95% CI -0.30; -0.10) and worse Tandem (-0.21, 95% CI -0.33; -0.09), after adjusting for age, sex, height and weight. The association with Tandem remained significant after additional adjustment for cardiovascular risk factors. Impaired fasting glucose and continuous glucose levels within the normal range were not associated with any of the gait domains.

CONCLUSION

In our population-based study diabetes mellitus was associated with worse Global Gait, which was mostly reflected in Pace and Tandem. These associations were partly driven by other cardiovascular risk factors, emphasizing the importance of optimal control of cardiovascular risk factor profiles in patients with diabetes.

Accelerated Longitudinal Gait Speed Decline in HIV-Infected Older Men

BACKGROUND

Gait speed predicts functional decline, disability, and death and is considered a biomarker of biological aging. Changes in gait speed in persons aging with HIV may provide an important method of gauging health and longevity in an under assessed population. The objective of this study was to evaluate and quantify the rate of gait speed decline in HIV-infected (HIV⁺) men compared with HIV-uninfected (HIV⁻) men.

METHODS

The study was nested in the Multicenter AIDS Cohort Study. The primary outcome was usual gait speed in meters per second measured between 2007 and 2013. Differences in the rate of gait speed decline and the incidence of clinically slow gait (<1.0 m/s) were assessed using multivariate linear regression models and Cox proportional hazards models, respectively.

RESULTS

A total of 2025 men (973 HIV⁺ and 1052 HIV⁻) aged 40 years and older contributed 21,187 person-visits (9955 HIV⁺ and 11,232 HIV⁻) to the analysis. Average gait speeds at the age 50 years were 1.24 and 1.19 m/s in HIV⁻ and HIV⁺ men, respectively (P < 0.001). In fully adjusted models, gait speed decline averaged 0.009 m/s per year after age 50 years (P < 0.001); this decline was 0.025 m/s per year greater in HIV⁺ men (P < 0.001). Moreover, HIV⁺ men had a 57% greater risk of developing clinically slow gait (adjusted hazard ratio = 1.57, 95% confidence interval: 1.27 to 1.91).

CONCLUSIONS

These findings indicate a faster rate of functional decline in HIV-infected men, suggesting greater risks of disability and death with advancing age.

Gait speed and cognitive decline over 2 years in the Ibadan study of aging

BACKGROUND

The evidence suggesting that gait speed may represent a sensitive marker for cognitive decline in the elderly requires support from diverse racial groups.

OBJECTIVE

We investigated the relationship between gait speed and cognitive decline over 2 years in a community dwelling sample of elderly Africans.

METHODS

Data are from the Ibadan study of aging (ISA) conducted among a household multi-stage probability sample of 2149 Yoruba Nigerians aged 65 years or older. Gait speed was measured as the time taken to complete a 3 or 4m distance at normal walking speed. We assessed cognitive functions with a modified version of the 10-word learning list and delay recall test, and examined the relationship between baseline gait speed, as well as gait speed changes, and follow-up cognition using multiple linear regression and longitudinal analyses using random effects.

RESULTS

Approximately 71% of 1461 participants who were dementia free and who had their gait speed measured at baseline (2007) were successfully followed up in two waves (2008 and 2009). Along with increasing age, poor health and economic status, a slower baseline gait speed was independently associated with poorer follow-up cognition in both linear regression (1.2 words, 95% CI=0.48-2.0) and longitudinal analyses (0.8 words, 95% CI=0.44-1.2). Also, a greater change in gait speed between 2007 and 2009 was associated with the worst follow-up cognition (0.3 words, 95% CI=0.09-0.51).

CONCLUSION

The finding that a substantial change in gait speed was associated with reduced cognitive performance is of potential importance to efforts aimed at early identification of cognitive disorders in this population.

Gait patterns in twins with cerebral palsy: similarities and development over time after multilevel surgery

To examine gait patterns and gait quality, 7 twins with cerebral palsy were measured preoperatively and after surgical intervention. The aim was to study differences and/or similarities in gait between twins, the influence of personal characteristics and birth conditions, and to describe the development of gait over time after single event multilevel surgery. A standardized clinical exam and a three-dimensional gait analysis were performed. Gait patterns were classified according to Sutherland and Davids, and the Gillette Gait Index was calculated as a global measure of the gait impairment. Next to subject characteristics at time of first measurement, and at time of birth, birth conditions were collected. Gait patterns were determined as crouch gait in 13 legs, as stiff gait in 6 legs and as jump gait in 8 legs. One leg showed a normal gait pattern. The knee flexion-extension angle correlated most constant with the knee flexion-extension angle of the contralateral leg (range 0.91-0.99). Correlations with the legs of the sibling showed variable correlations (range 0.44-0.99); with all other legs medium to high correlations of 0.73-0.91 were found. The Gillette Gait Index was found to initially decrease after surgical intervention. Similar correlations were found between twins or between legs for the gait pattern expressed by the knee flexion-extension angle, and the Gillette Gait Index improved after surgery. It seems that gait quality in twins with cerebral palsy is characterized predominantly by the traumatic disorder: genetic dispositions and personal characteristics only play a negligible role.

Hearing loss and gait speed among older adults in the United States

BACKGROUND

Previous studies have suggested that hearing loss, which is highly prevalent but undertreated in older adults, may be associated with gait and physical functioning. Determining if hearing loss is independently associated with gait speed is critical toward understanding whether hearing rehabilitative interventions could help mitigate declines in physical functioning in older adults.

METHODS

We analyzed cross-sectional data from the 1999 to 2002 cycles of the National Health and Nutritional Examination Survey during which participants 50-69 years (n=1180) underwent hearing and gait speed assessments. Hearing was defined by a pure tone average of hearing thresholds at 0.5-4kHz tones in the better-hearing ear. Gait speed was obtained in a timed 20-ft (6.1m) walk. Linear and logistic regression models were used to examine the association between hearing loss and gait speed while adjusting for demographic and cardiovascular risk factors. Analyses incorporated sampling weights to yield results generalizable to the U.S. population.

RESULTS

In a model adjusted for demographic and cardiovascular risk factors, a hearing loss was associated with slower gait speed (-0.05m/s per 25dB of hearing loss [95% CI: -0.09 to -0.02]) and an increased odds of having a gait speed <1.0m/s (OR=2.0 per 25dB of hearing loss, 95% CI: 1.2-3.3). The reduction in gait speed associated with a 25dB hearing loss was equivalent to that associated with an age difference of approximately 12 years.

CONCLUSIONS

Greater hearing loss is independently associated with slower gait speed. Further studies investigating the mechanistic basis of this association and whether hearing rehabilitative interventions could affect gait and physical functioning are needed.

Diabetes is associated with postural instability and gait difficulty in Parkinson disease

BACKGROUND

Comorbid diabetes may be associated with more severe motor impairment in Parkinson disease. In normal elderly individuals, diabetes is associated with parkinsonian features, including gait difficulty and rigidity, though not tremor. Whether diabetes contributes to increased motor dysfunction in Parkinson disease by exacerbating nigrostriatal dopaminergic denervation or through intensification of extranigral pathology is unknown.

METHODS

We performed a case-control study (n = 39) involving 13 Parkinson disease subjects (age 66.4yrs ± 5.5; duration of disease 6.9yrs ± 4.4) with diabetes and 26 age, gender, and duration-of-disease-matched Parkinson disease controls without diabetes. All subjects underwent [(11)C]dihydrotetrabenazine vesicular monoamine transporter type-2 positron emission tomography imaging to assess striatal dihydrotetrabenazine distribution volume ratio and Unified Parkinson disease rating scale motor examination to determine rigidity, bradykinesia, tremor, and postural instability and gait difficulty subscores. Magnetic resonance imaging scans were analyzed to assess leukoaraiosis burden.

RESULTS

After controlling for nigrostriatal dopaminergic denervation, Parkinson disease subjects with diabetes displayed greater postural instability and gait difficulty subscores (t = 3.81, p = 0.0005). There were no differences in bradykinesia, rigidity, or tremor subscores between cases and controls. The association between diabetes and postural instability and gait difficulty persisted after controlling for comorbid hypertension and body mass index. Leukoaraiosis, distal vibratory sense, and levodopa dose equivalents did not differ significantly between cases and controls.

CONCLUSIONS

Diabetes may contribute to postural instability and gait difficulty in Parkinson disease through mechanisms other than nigrostriatal dopaminergic denervation.

Gait and balance disorders in cancer patients

Cancer and cancer treatments can produce both acute and chronic effect which can to provide to functional changes, that is important for the patient, and the health care provider. Balance and gait disorders are interrelated, and important it to the performance of activities daily living. The goal of paper is review information on gait and balance disorders in cancer patients. This article presented physiopathology of gait and balance disorders in patients with cancer, their possibility clinical assessment as well as treatment. Cancer and cancer treatments can cause neurologic, musculoskeletal and systemic effects, which can influence on body movement dysfunction. Cancer can affect nerves by direct infiltration or compression by tumor, fibrosis from radiotherapy, neurotoxicity from chemotherapy, or paraneoplastic disorders. Treatment of balance and gait disorders in cancer patients should incorporate both medical and rehabilitative intervention.

[Locomotive syndrome and frailty. Locomotive Syndrome in the super-aged society]

Japan has already rushed in the Super-aged society, and up to 5 million aged people presumably are under the support-demanding condition. In 2007, Japanese Orthopedic Association advocated the new concept "Locomotive Syndrome" in order to make all the nation people realize an importance of locomotive organ. "Locomo Index 25" is a newly developed questionnaire to evaluate locomotive function, consisted of 25 questions. Nation-wide surveillance with this questionnaire would be effective in early detection of Locomotive Syndrome.

Ventriculomegaly and balance disturbances in patients with TIA

OBJECTIVES

Dilated ventricles and gait disturbances are common in the elderly, and these are also features of the treatable syndrome idiopathic normal pressure hydrocephalus (INPH). Many studies report an association between hypertension, vascular disease and INPH. The objective of this study was to study the frequency of ventriculomegaly, with or without hydrocephalic symptoms, in patients who had suffered from a transitory ischaemic attack (TIA).

METHODS

Gait, Romberg sign, tandem standing and one-leg stance were consecutively evaluated in elderly > 24 h after a TIA. Ventricular size, white matter lesions and atrophy were assessed on computed tomography scans. Exclusion criteria were conditions possibly influencing the balance tests.

RESULTS

eventy-six patients with TIA out of 105 were included. Ventriculomegaly [Evans Index (EI) > 0.30] was observed in 19.7% and very large ventricles (EI > 0.33) in 7.9%. Ventriculomegaly was found in 58% of the patients with a previous 'history of balance or gait disturbance', but only in 12% of those without any prior disturbance (chi-square test; P = 0.0009). Three out of 76 patients with TIA (3.9%) fulfilled both radiological and clinical criteria for 'possible INPH'.

CONCLUSION

Ventriculomegaly is a common finding in elderly. One out of 20 patients with TIA may suffer from INPH, existing before and independent of the TIA diagnosis. Therefore, patients presenting with ventriculomegaly and gait/balance disturbances not attributable to other causes should be referred to a hydrocephalus centre or a neurologist with special interest in INPH.

Evaluation of postural balance in postmenopausal women and its relationship with bone mineral density--a cross sectional study

BACKGROUND

Low bone mineral density (BMD) and falls are common problems encountered in the postmenopausal women. The purpose was to evaluate the association between postural balance and BMD in postmenopausal women and its relation to risk for falls.

METHODS

In this cross-sectional study, 225 women in amenorrhea > 12 months and age ≥ 45 years were included and divided, according to BMD, in T-score values > -2.0 SD (n = 140) and ≤ -2 SD (n = 85). Those with neurological or musculoskeletal disorders, history of vestibulopathies, uncorrected visual deficit or drug use that could affect balance were excluded. History of falls (last 24 months), clinical and anthropometric characteristics were evaluated. Postural balance was assessed by stabilometry (force platform). For statistical analysis were used Wilcoxon's Test, Chi-Square Test and logistic regression method for fall risk (Odds Ratio-OR).

RESULTS

Patients with BMD > -2.0 SD were younger, with shorter time since menopause, and showed higher BMI as compared to those with low BMD (≤ -2 SD) (p < 0.05). It was observed that 57.8% of the participants reported fall episodes without significant difference distribution between the groups (p = 0.055). No differences were found from the comparison between the groups (p > 0.05) for stabilometric parameters. Risk for falls increased with age (OR 1.07; CI 95% 1.01-1.13), current smoking (OR 2.19; CI 95% 1.22-3.21) and corrected visual deficit (OR 9.06; CI 95% 1.14-4.09). In contrast, hormone therapy (HT) use was significantly associated with reduced risk for falls (OR 0.48; CI 95% 0.26-0.88).

CONCLUSIONS

In postmenopausal women, BMD did not show association with postural balance or risk for falls. Age, smoking and corrected visual deficit were clinical indicators of risk for falls whereas HT use showed to be a protective factor.

Slower gait, slower information processing and smaller prefrontal area in older adults

BACKGROUND

Slower gait in older adults is related to smaller volume of the prefrontal area (PFAv). The pathways underlying this association have not yet been explored. Understanding slowing gait could help improve function in older age. We examine whether the association between smaller PFAv and slower gait is explained by lower performance on numerous neuropsychological tests.

HYPOTHESIS

We hypothesise that slower information processing explains this association, while tests of language or memory will not.

METHODS

Data on brain imaging, neuropsychological tests (information processing speed, visuospatial attention, memory, language, mood) and time to walk 15 feet were obtained in 214 adults (73.3 years, 62% women) free from stroke and dementia. Covariates included central (white matter hyperintensities, vision) and peripheral contributors of gait (vibration sense, muscle strength, arthritis, body mass index), demographics (age, race, gender, education), as well as markers of prevalent vascular diseases (cardiovascular disease, diabetes and ankle arm index).

RESULTS

In linear regression models, smaller PFAv was associated with slower time to walk independent of covariates. This association was no longer significant after adding information processing speed to the model. None of the other neuropsychological tests significantly attenuated this association.

CONCLUSIONS

We conclude that smaller PFAv may contribute to slower gait through slower information processing. Future longitudinal studies are warranted to examine the casual relationship between focal brain atrophy with slowing in information processing and gait.

Falls in people with chronic obstructive pulmonary disease: an observational cohort study

STUDY OBJECTIVE

To investigate incidence, risk factors and impact of falls on health related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Observational cohort study.

METHODS

Patients completed these questionnaires at baseline and at 6-months: Medical Outcomes Study Short Form 36 (SF-36), Chronic Respiratory Questionnaire (CRQ), Activities Balance Confidence (ABC) Scale and a form to record demographic data, medications, co-morbidities, oxygen use, acute exacerbations, fall history and assistive device use. Physical activity was measured with the Physical Activity Scale for the Elderly (PASE) only at baseline. Fall incidence was monitored through monthly fall diaries. Patients were categorized as non-fallers (0 falls) or fallers (≥ 1 falls).

RESULTS

Data from 101 patients with a forced expiratory volume in 1 s of 46.4 ± 21.6% predicted were analyzed. Thirty-two patients (31.7%) reported at least one fall during the 6-months. Fall incidence rate was 0.1 (95% CI: 0.06-0.14) falls per person-month. Fallers tended to be older (p = 0.04), female (p = 0.04) and oxygen dependent (p = 0.02), have a history of previous falls (p < 0.001), more co-morbidities (p = 0.007) and take more medications (p = 0.001). Previous falls (OR = 7.36; 95% CI: 2.39-22.69) and diagnosis of coronary heart disease (OR = 7.07; 95% CI: 2.14-23.36) were the most important predictors of falls. The Dyspnea Domain of the CRQ declined significantly more (p = 0.02) in the fallers group at 6-months.

CONCLUSIONS

Patients with COPD have a high susceptibility to falls, which is associated with a worsening of dyspnea perception as related to HRQoL. Fall prevention programs in COPD are recommended.

Clinical and biochemical study of 29 Brazilian patients with metachromatic leukodystrophy

Metachromatic leukodystrophy (MLD) is a lysosomal disorder caused by arylsulfatase A (ARSA) deficiency. It is classified into three forms according to the age of onset of symptoms (late infantile, juvenile, and adult). We carried out a cross-sectional and retrospective study, which aimed to determine the epidemiological, clinical, and biochemical profile of MLD patients from a national reference center for Inborn Errors of Metabolism in Brazil. Twenty-nine patients (male, 17) agreed to participate in the study (late infantile form: 22; juvenile form: 4; adult form: 1; asymptomatic: 2). Mean ages at onset of symptoms and at biochemical diagnosis were, respectively, 19 and 39 months for late infantile form and 84.7 and 161.2 months for juvenile form. The most frequently reported first clinical symptom/sign of the disease was gait disturbance and other motor abnormalities (72.7%) for late infantile form and behavioral and cognitive alterations (50%) for juvenile form. Leukocyte ARSA activity level did not present significant correlation with the age of onset of symptoms (r = -0.09, p = 0.67). Occipital white matter and basal nuclei abnormalities were not found in patients with the late infantile MLD. Our results suggest that there is a considerable delay between the age of onset of signs and symptoms and the diagnosis of MLD in Brazil. Correlation between ARSA activity and MLD clinical form was not found. Further studies on the epidemiology and natural history of this disease with larger samples are needed, especially now when specific treatments should be available in the near future.

Gait symmetry in patients with unilateral partial hip arthroplasty

OBJECTIVES

In this study gait deviations symmetry and asymmetry in patients with unilateral partial hip arthroplasty was determined.

PATIENTS AND METHODS

Gait characteristics and time since operation (11.9+/-6.1; range 7 to 29 months) of 16 patients (9 females, 7 males; mean age 61.5+/-16.5 years; range 27 to 86 years) with unilateral partial hip arthroplasty were evaluated. Ten healthy volunteers (3 females, 7 males; mean age 54.1+/-11.9 years; range 35 to 65 years) were included in the study as control group. Quantitative gait data was collected with the Vicon 370 System (Oxford Metrics, Oxford, UK). Spatio-temporal (walking velocity, cadence, step time, step length, double support time) and kinematic (joint rotation angles of pelvis and hip in sagittal plane) data were processed by using Vicon Clinical Manager software package. Spatio-temporal and kinematic gait symmetry indices of both groups were calculated.

RESULTS

Spatio-temporal and kinematic gait characteristics, but not the symmetry indices, of patients with unilateral partial hip arthroplasty were different from the control group (p>0.05).

CONCLUSION

Findings of this study reveal that patients with unilateral partial hip arthroplasty had various gait deviations compared to healthy subjects, but that symmetry was preserved.

Neurological gait abnormalities and risk of falls in older adults

To estimate the validity of neurological gait evaluations in predicting falls in older adults. We studied 632 adults age 70 and over (mean age 80.6 years, 62% women) enrolled in the Einstein Aging Study whose walking patterns were evaluated by study clinicians using a clinical gait rating scale. Association of neurological gaits and six subtypes (hemiparetic, frontal, Parkinsonian, unsteady, neuropathic, and spastic) with incident falls was studied using generalized estimation equation procedures adjusted for potential confounders, and reported as risk ratio with 95% confidence intervals (CI). Over a mean follow-up of 21 months, 244 (39%) subjects fell. Mean fall rate was 0.47 falls per person year. At baseline, 120 subjects were diagnosed with neurological gaits. Subjects with neurological gaits were at increased risk of falls (risk ratio 1.49, 95% CI 1.11-2.00). Unsteady (risk ratio 1.52, 95% CI 1.04-2.22), and neuropathic gait (risk ratio 1.94, 95% CI 1.07-3.11) were the two gait subtypes that predicted risk of falls. The results remained significant after accounting for disability and cognitive status, and also with injurious falls as the outcome. Neurological gaits and subtypes are independent predictors of falls in older adults. Neurological gait assessments will help clinicians identify and institute preventive measures in older adults at high risk for falls.

[Polyneuropathies in vitamin B1 deficiency in Reunion and Mayotte islands in 70 patients of Maori and Comorian descent]

Beriberi is an uncommon disorder related to thiamine deficiency. It is mainly found in underdeveloped countries among populations with poorly diversified diet, consisting largely of milled white cereals, a poor source of thiamine. In industrialized countries, thiamine deficiency with cardiac failure is more frequently found than the dry beriberi in high risk groups like chronic alcoholics. Nevertheless our attention was drawn to an outbreak of 70 cases of dry beriberi which occurred from 1997 to 2005 in the French territories of Reunion and Mayotte islands. It was characterized by an acute or sub-acute sensorimotor polyneuropathy with axonal lesions, affecting the lower limbs and occasionally the upper limbs, sometimes associated with cardiac beriberi. It affected young, non alcoholic individuals from the Mahoran and Comorian community who were in apparent good health when the illness occurred. Our study highlighted the feeding habits which are partly responsible for the development of the disease due to a chronic lack of thiamine and which probably contributed together with multiple cofactors to trigger off the illness. But many elements and mainly biological ones, also lead us to think that there is a genetic predisposition to develop this neuropathy.

Risk of fall for individuals with intellectual disability

Our aim was to identify risk factors for falling and establish a method to assess risk for falls in adults with intellectual disabilities. In a cross-sectional survey of 144 Japanese adults, we found that age, presence of epilepsy, and presence of paretic conditions were independent risk factors. The Tinetti balance and gait instrument was successfully administered to this population and resulted in high diagnostic accuracy (sensitivity 88.9%, specificity 91.9%) for identifying individuals at risk when the cutoff score was set at 25. Participants whose balance and gait deteriorated showed a decrease in the Tinetti score of at least 2 points per year. Thus, the Tinetti instrument may be an effective tool to detect an increased risk of fall in this population.

Health worry, physical activity participation, and walking difficulty among older adults: a mediation analysis

This study examined the effect of health worry (i.e., cognitive aspect of anxiety resulting from concern for health) on walking difficulty in a nationally representative sample (N = 7,527) of older adults (M age = 76.83 years). The study further tested whether physical activity mediates the effect of health worry on walking difficulty in a 6-year follow-up design. Results of a mediation analysis using structural equation modeling showed that people with a high degree of health worry engaged in less physical activity (beta = -.24, p < .001), and people who participated in less physical activity were more likely to report walking difficulty at the 6-year follow-up (beta = -.22, p < .001). There was a significant indirect effect from health worry to walking difficulty through physical activity (beta = .05, p < .001), controlling for demographic, psychosocial, and health related factors. Results suggested that inducing threat and worry may not be effective for physical activity promotion in the older population. More promising coping and regulation strategies are discussed.

Dizziness in an older community dwelling population: a multifactorial syndrome

OBJECTIVES

The aim of this study was to determine the prevalence and related predictors of dizziness in a sample of community-dwelling people 65 years of age and older living in a metropolitan area in Germany.

DESIGN

Prospective cohort study.

SETTING

Interdisciplinary Centre of Gerontology at the University of Erlangen- Nuremberg, Germany.

PARTICIPANTS

6000 people aged 65 years and older recruited and randomized from the registration office, 1801 were fully evaluated at baseline and were re-evaluated in a prospective follow-up two years later. A full data set was obtained for 620 participants, of which 297 (47.9%) were females. Mean age was 73.45 +/- 6.05. 200 participants (32.4%) were 65-69 years, 315 (51%) were 70-79 years, 92 (14.9%) 80-89 years and 11 (1.8%) 90 years and older.

MEASUREMENTS

Demographic, medical, functional and psychological factors were measured by a standardised questionnaire in 2004. In a follow-up survey participants were reevaluated in a prospective design two years later (2006), including a dizziness questionnaire, containing frequency, duration, space of dizziness and releasing positions and activities.

RESULTS

At the second measurement 181 persons (29.2%) reported dizziness in the last 6 months. Dizziness was age dependent, with a prevalence of 27% in participants aged 70 years and younger, up to 54% in the group of 90 years and older. 96 (68.2%) persons reported daily or weekly dizziness. 46 (27.9%) participants reported multiple sensations of dizziness. In 108 (59.7) persons dizziness was released by multiple positions or activities. The main predictors of dizziness were age, female gender, cardiovascular disease, osteoporosis, depression, sleep disorder, disturbance of memory, shortsightedness (defined by glasses), incontinence, 3 and more medical conditions, 4 and more medications, poor health status, falls and mobility problems. We found similar risk factors for dizziness and falls.

CONCLUSION

Dizziness is a very common symptom in older community dwelling persons. Comorbidity, poor health status and mobility problems are strong medical predictors; age and female gender and decline in mobility are important predictors as well. Our study suggests, that dizziness in older age is often caused by multifactorial medical and functional conditions. Gait disorders and mobility problems also seem to play an important role in dizziness among older people. Therefore, interventions in dizziness should be developed in a multifactorial way. We suggest, that the interventions to be tested first, should be those that have been previously successful in older persons with gait disorders and falls.

[Diagnosed morbidity in primary health care in the sanitary region of Sousse (Tunisia)]

Primary health care is one of the pillars of the Tunisian health care system. However, we have very little information about the specificities of general practice and the patterns of the morbidity encountered in this field. This study was interested on the diagnosed morbidity in primary health care settings. We aimed to illustrate the patterns of morbidity in general practice and identify the main diagnoses which are established by the general practitioners (GPs). The study design was descriptive and cross-sectional. 85 (out of 92) primary health centres of the province of Souse (Tunisia) have been included during one year, from June 2002 to May 2003. We have targeted a representative sample of 16.271 encounters in these primary care settings. On the methodological plan, we proceeded by a poll to two degrees; the first concerned the weeks within every season: 3 weeks were drawn out by lot; the second interested the encounters, proceeding by a systematic pull and the step of poll was fixed to 5. The International Classification of Primary Care (ICPC) was used to code recorded data. The main results of this study showed that among the 16.271 patient-doctor encounters we registered 24.882 reasons for encounter (RFE) (1.9 +/- 0.8 per encounter), 18.097 diagnoses (1.3 +/- 0.5 per encounter), and 40.190 procedures (3.2 +/- 1.9 per encounter). In this paper we have only explored the results of encounters related to the decision of general practitioners, i.e. the diagnosed morbidity. With regard to sex distribution there was a predominance of females (62%). The study population was relatively young as 50% were aged less than 25 years. According to ICPC chapters, we found that respiratory diseases were the main established diagnoses (43%) followed by digestive (10.1%), locomotive (8.9%) cardiovascular affections (8.7%) and skin diseases (8.4%). These five affections constituted alone about 80% of the total.

[Gait disturbances in neurology]

Gait disorders lead to loss of mobility and therefore of an individual's autonomy. The greatest risk factor for gait disorders is old age. Other important factors include drugs and their side effects, cognitive impairment, and alcohol abuse. In successful aging there is only a slight decline in gait velocity. The classification into lower- (peripheral), middle- (spinal, basal ganglia), and higher-level gait disorders (e.g. frontal or psychogenic) is still common but contradictory. Gait disorders in neurology are frequent. Detailed descriptions of gait patterns in hypokinetic gait disorders, dystonic, hemi-, and paraparetic gait, ataxia, vestibular, neuromuscular, and psychogenic gait are given. Besides reduction of risk factors, improving the physical state (physiotherapy, sports), descriptions of walking aids, and the prevention of falls are extraordinarily important for the therapy of gait disorders.

Causes and risk factors of falls in patients with Parkinson's disease

BACKGROUND AND PURPOSE

Falls are a common and serious problem among Parkinson's disease (PD) patients. However, knowledge about the causes and risk factors of falls is limited. There have been a few attempts to classify the causes of falls. The classification suggested by Olanow seems to be the most comprehensive one. The aim of this study was to analyze retrospectively the causes of falls and risk factors of falls in PD patients.

MATERIAL AND METHODS

One hundred and four patients with moderately advanced PD were included in the study. The patients were asked to describe the circumstances and consequences of falls which occurred during 12 months preceding the examination. The falls were classified according to the Olanow classification of causes of falls.

RESULTS

Fifty-two patients (50%) reported at least one fall during the previous year with a mean number of 1.5 falls per year. The most common causes of falls were environmental factors, sudden falls and postural instability. There were no falls caused by severe dyskinesia, drugs or cardiovascular disorders. The only independent risk factors of the recurrent falls identified in this study were UPDRS part II score (OR 1.17, 95% CI: 1.02-1.37) and Mini Mental State Examination score (OR 0.85, 95% CI: 0.72-0.99).

CONCLUSIONS

Considering these results we may be able to prevent most falls by means of the education of patients about environmental factors and using adequate rehabilitation techniques concentrating on postural stability and gait.

[Gait disturbance in idiopathic normal pressure hydrocephalus]

The triad symptoms of idiopathic normal pressure hydrocephalus (iNPH), i.e., dementia, gait disturbance, and urinary incontinence may appear commonly in the elderly suffering from various brain diseases as well as in those with musculoskeletal disorders. It would not be easy to differentiate iNPH from other neurological diseases with musculoskeletal disorders in the elderly. Gait disturbance is an early and central clinical symptom, and its improvement after temporary removal of CSF and shunt surgery is the most notable. This paper reviews the nature, differential diagnosis, pathophysiology, and evaluation of iNPH gait. Broad-based, short-step, magnetic gait with start hesitation and increased instability on turning, which is often expressed as apraxic/ataxic gait, is the cardinal sign of iNPH. Although iNPH gait shares the features with gait in Parkinson disease, progressive supranuclear palsy, and cerebellar ataxia, the nature of iNPH gait is the closest to apraxia of gait, which is characterized primarily by gait ignition failure. The semiological similarity to apraxia of gait and the close relationship to frontal symptoms indicate that the iNPH gait is probably caused by frontal dysfunction. The gait subscale of the idiopathic normal pressure hydrocephalus grading scale and the timed "Up and Go" test are recommended as useful tools for measuring gait disturbance in iNPH.

Prevalence of Parkinson’s disease in Korea

The prevalence of neurodegenerative disorders is not well documented in Korea. We assessed the prevalence of Parkinson's disease in an elderly population in a newly industrialized city in a rural region. Subjects for this study were randomly selected from a community-based cohort study. The sample in the cohort represented approximately 1.3% (4700) of 362 625 adults (age>18 years) listed in the city register in 1998. Among this group, 4218 subjects (1086 subjects aged>60 years) agreed to be interviewed and underwent a physical examination and neuropsychological tests administered by a neurologist and neuropsychologist. All participants were examined. Participants who had bradykinesia and at least one other possible cardinal sign of parkinsonism at the neurologic screening, and those who reported that they had Parkinson's disease, or were taking antiparkinsonian drugs were identified. In our study, 16 subjects showed evidence of Parkinson's disease. The prevalence in this population was 0.37%. Prevalence increased with age, and prevalence was 1.47% for those aged older than 60 years. Postural instability and gait disturbance were more common in the older age group. The results of neuropsychological tests were as follows: (1) only two subjects had low scores (<20) in the Korea-version mini-mental status examination; (2) seven subjects scored 0.5, one subject scored 2 and the other eight subjects scored 0 in the clinical dementia rating. The results of our prevalence study are similar to those of studies carried out in Western countries. Age is a risk factor for Parkinson's disease in Korea.

Neonatal microstructural development of the internal capsule on diffusion tensor imaging correlates with severity of gait and motor deficits

Neonatal microstructural development in the posterior limbs of the internal capsule (PLIC) was assessed using diffusion tensor imaging (DTI) fractional anisotropy (FA) in 24 very-low-birthweight preterm infants at 37 weeks' gestational age and compared with the children's gait and motor deficits at 4 years of age. There were 14 participants with normal neonatal FA values (seven females, seven males; born at 27.6 weeks [SD 2.3] gestational age; birthweight 1027g [SD 229]) and 10 participants with low FA values in the PLIC (four females, six males; born at 28.4 weeks [SD 2.0] gestational age; birthweight 1041g [SD 322]). Seven of the 10 children with low FA and none of the children with normal FA had been diagnosed with CP by the time of gait testing. Among children with low neonatal FA, there was a strong negative correlation between FA of the combined left and right side PLIC and log NI (r=-0.89, p=0.001) and between FA and GMFCS (r=-0.65, p=0.04) at 4 years of age. There was no correlation between FA and gait NI or GMFCS at 4 years of age among children with normal neonatal FA. This preliminary study suggests neonatal DTI may be an important predictor of the severity of future gait and motor deficits.

Functional gait comparison between children with myelomeningocele: shunt versus no shunt

The aim of this study was to compare functional gait differences between patients with myelomeningocele (MM) who have a ventriculoperitoneal shunt (VPS) with those who do not. Our analyses were adjusted for confounding by age, lesion level, orthotic use, and assistive device use. The Functional Mobility Scale (FMS) was used to compare the shunted group (n=98; 60 males, 38 females; mean age 10y 2mo [SD 3y 11mo]; 73 sacral/19 low lumber/six high lumbar lesion level) with the non-shunted group (n=63; 32 males, 31 females; mean age 9y 11mo [SD 3y 11mo]; 45 sacral/12 low lumber/six high lumbar lesion level). Participants with a shunt had lower FMS 500 and FMS 50 scores compared with participants without a shunt; hence the participants without a shunt were more independent in their ambulation at medium and longer distances. For a subset of participants who underwent a three-dimensional gait analysis, we also collected temporal-spatial gait parameters (velocity, cadence, and stride length). Our results show that participants with MM and no shunt who underwent gait analysis(11 males, 10 females; mean age 9y 6mo [SD 4y]; 15 sacral/6 low lumber/0 high lumbar lesion level) tend to walk at a significantly greater velocity and stride length as compared with those with a shunt (33 males, 18 females; mean age 10y [SD 4y]; 38 sacral/13 low lumber/zero high lumbar lesion level). These data allow the treatment team to present more specific information regarding functional ambulatory expectations to patients with MM and their families.

Cerebellar ataxia in the eastern and southern parts of Norway

INTRODUCTION

The relative frequencies of different ataxias vary among different ethnic and geographic groups. The aim of this study was to examine patients with cerebellar ataxia and find the occurrence of autosomal dominant and recessive cerebellar ataxias in the population of the southern and eastern parts of Norway and estimate its prevalence.

MATERIALS AND METHODS

Probands were systematically tested for spinocerebellar ataxia 1, 2, 3, 6 and Friedreich's ataxia. A total of 94 patients with ataxia were assessed.

RESULTS

We registered 60 patients from 39 unrelated families with hereditary ataxias. One family with SCA2 (two patients), one family with Friedreich's ataxia (two patients), two patients heterozygote for Friedreich's ataxia and one metabolic ataxia were identified.

CONCLUSIONS

We have few Friedreich's ataxia and SCA 1,2,3 and 6 in our population. Prevalence in Oslo County was estimated at 2.2/100,000 for autosomal recessive and 3.0/100,000 for autosomal dominant ataxia, respectively.

Gait and posture impairment, parkinsonism and cognitive decline in older people

Our objective was to examine the frequency of gait and posture impairment and parkinsonism in 3 waves of the Canadians Study of Health and Aging (CSHA) and to determine their relationship to the development of cognitive impairment-not dementia (CIND) and dementia. A secondary analysis of a Canadian population-based cohort study was performed. People 65 years of age and older without cognitive impairment or dementia underwent examination for the presence of gait or posture impairment (GPI) or parkinsonism (based on the presence of 2/3 signs among resting tremor, rigidity or bradykinesia), both defined by a clinical examination. Risk for development of cognitive impairment or dementia was examined at 5 and 10 year follow up in pre-specified logistic regression models adjusted for age, sex, education and in separate models, frailty. The frequency of GPI ranged from 25 to 30% in cognitively unimpaired to 46-53% in CIND and demented subjects. Parkinsonism was more common with increasing cognitive impairment at each wave of the CSHA. Both GPI and parkinsonism predicted cognitive decline. Frailty reduced, but did not eliminate the impact of these motor measures and was itself a significant predictor of cognitive decline. In conclusion, motor impairment and frailty are common in older people and are associated with an increased risk of cognitive decline and dementia. GPI is common in CIND, while GPI and parkinsonism are both common in dementia.

High risk neurological gait syndrome and vascular dementia

We defined a 'high-risk neurological gait' (HRNG) syndrome based on presence of any one of hemiparetic, frontal, and unsteady gaits, and examined its validity to predict vascular dementia (VD) over 3 and 5 years in 399 nondemented older adults, age 75 and over. Cox analysis was used to estimate hazard ratios (HR) for VD adjusted for potential confounders. At baseline, 54 subjects had HRNG. 14 subjects developed VD over 3 years and 25 by 5 years. HRNG predicted risk of VD within the first three (HR 3.3, 95% CI 1.8-5.9) and five years (HR 2.7, 95% CI 1.7-4.2). Including executive dysfunction (Digit symbol scores <16) improved validity; subjects with HRNG and executive dysfunction (HR 12.5, 95% CI 5.5-28.4) or either (HR 5.9, 95% CI 3.6-9.7) had higher risk of VD over five years. Diagnosing HRNG is a clinically relevant approach to identifying older adults at high risk of VD over short intervals.

High concurrent presence of disability in multiple sclerosis

OBJECTIVES

(1) To explore functioning and concurrent presence of disabilities - concerning cognition, manual dexterity, walking, energy, mood, activities of daily living (ADL), and social/lifestyle activities - in persons with multiple sclerosis (PwMS) cared for at an outpatient MS clinic. 2) To describe the PwMS' perceived physical and psychological impact and associations with the same disabilities.

MATERIAL/METHODS

A descriptive cross-sectional study was carried out in 219 PwMS at the MS Centre, Karolinska University Hospital. Logistic regression employing proportional odds models was used to identify the associations of the disabilities with the perceived physical and psychological impact.

RESULTS

In this sample the distribution with regard to disease severity as per Expanded Disability Status Scale was; mild 59.5%, moderate 17% and severe 23.5%. Despite the high proportion with mild disease severity disability regarding cognition was found in 49%, manual dexterity 76%, walking 43%, energy 67%, mood 29%, ADL 44% and social/lifestyle activities in 48%. Two or more disabilities were found in 80%, 24 % had six or seven disabilities. Disability regarding energy, mood, walking, manual dexterity and ADL was significantly associated with increase in the perceived physical impact, whereas disability in energy and mood was significantly associated with increase in the perceived psychological impact.

CONCLUSIONS

The presence of several concurrent disabilities, some significantly associated with high perceived physical and psychological impact, in the majority of PwMS in outpatient clinics highlights the importance to identify disabilities, in particular fatigue and depressed mood, in order to supply health care interventions aiming to improve the life situation of PwMS.

Vestibular symptoms and otoneurological findings in retired offshore divers

INTRODUCTION

Inner ear barotraumas and decompression sickness (DCS) may cause acute vestibular symptoms in divers. The result may be irreversible damage to the vestibular end organs or their central connections. We examined a group of offshore divers in order to find out how many divers experience vestibular symptoms later in life and how this was related to occupational history and objective findings.

METHODS

A questionnaire was sent to 230 offshore divers (mean age 52 yr) and 166 age-matched non-diving controls. Most of the divers had retired from diving. A subgroup (n=96) of the divers was referred for examination, including a clinical otoneurological examination, electronystagmography, bithermal caloric tests, and platform posturography. In addition, 42 of the controls were examined.

RESULTS

The prevalence of dizziness (28%), spinning vertigo (14%), and unsteady gait (25%) was significantly higher in divers than controls (p < 0.0005). These symptoms were strongly associated with a previous history of DCS, particularly type I, which was reported by 61% of the divers. Symptoms were less strongly associated with the number of dives. In referred divers with dizziness, the prevalence of abnormal postural sway, nystagmus, canal paresis, or pathological smooth pursuit was 32%, 9%, 7%, and 11%, respectively.

DISCUSSION

Reasons for the high prevalence of vestibular symptoms among the divers are discussed. The high exposure to DCS is probably an important factor.

Diabetes and Parkinsonian Signs in Older Persons

We examined the relation of type 2 diabetes mellitus to parkinsonian signs in older persons. Participants were 1030 women and men (mean age 80.3 y, education 14.5 y, Mini-Mental State Examination 27.9) without dementia or Parkinson disease, enrolled in the Rush Memory and Aging Project, an epidemiologic study of aging. We used separate linear and logistic regression models, adjusted for age, sex, and education, to examine the relation of diabetes, identified by history and medication inspection, to each of the scores of global parkinsonian signs and 4 separate parkinsonian signs. Diabetes was present in 140 (14%) participants. Most participants had mild parkinsonian signs. Diabetes was associated with a more severe global parkinsonian signs score (beta=0.20, SE=0.10, P=0.05) and postural reflex impairment-gait disturbance (beta=0.40, SE=0.17, P=0.02), but not with bradykinesia, rigidity, or tremor. Associations were no longer significant after controlling for vascular risk factors or conditions, particularly body mass index and congestive heart failure. Overall, there was no evidence that vascular variables modified the relation of diabetes to parkinsonian signs. In summary, we found that diabetes was associated with parkinsonian signs, especially postural reflex impairment-gait disturbance, and that vascular factors may play a role in this association.

Vitamin D deficiency in community older adults with falls of gait imbalance: an under-recognized problem in the inner city

INTRODUCTION

Recent reports suggest that vitamin D deficiency is both under-recognized and undertreated in the geriatric population. In particular, older adults with unexplained pain, falls, and gait disorders often may have osteomalacia from vitamin D deficiency. Currently, older adults are not screened for vitamin D status even when clinical skin suggest deficiency. Our pilot study determined the vitamin D status in older, inner city community adults with features suggestive of vitamin D deficiency.

METHODS

The study was prospective and observational. Community-dwelling adults (> 60 years) from our ambulatory clinic or in-patient geriatric program, with features compatible with vitamin D deficiency (history of falls, gait imbalance, unexplained musculoskeletal pain, and/or fractures), were enrolled. IRB approval and signed informed consents were obtained. Following a history and physical exam, blood samples for vitamin D assay and routine chemistries were obtained. Additional information was collected on age, gender, race, dairy product intake, calcium and/or vitamin D supplement use, weekly sunlight exposure, season of exam (May-October vs. November-April), prior falls and fractures, musculoskeletal pain, and gait disturbances.

RESULTS

Data were obtained from 48 patients (32F and 16M), mean age of 79 +/- 9 (SD) years (range 60-95). Seventy-seven percent of enrollees had gait disturbances, 77% had a history of falls, 29% had previous fractures and 6% had unexplained pain; 79% consumed milk daily, 25% took calcium supplements and 21% used vitamin D supplements (in a multivitamin or calcium supplement). Self-reported weekly exposure to sunlight ranged from 0 to 42 hours (clothing amount was highly variable). Fifty-four percent of this sample had sub-normal vitamin D status (serum vitamin D < 20 ng/mL). Patient age (P = 0.2287), gender (P=0.9270), exposure to sunlight (P=0.3493), season (P=0.573), and dairy intake (P = 0.735) were not associated with vitamin D status. However, 80% of vitamin D supplement users versus 37% of non-users had normal vitamin D status (P = 0.029) and 75% of calcium supplement users versus 36% of non-users had normal vitamin D status (P = 0.042). A logistic regression model determined that the use of vitamin D or calcium supplements decreased the risk of low vitamin D status by 94% and 93% (P = 0.009 and P = 0.010, respectively).

CONCLUSION

In this pilot study of older adults with gait imbalance and falls, vitamin D deficiency (< 20 ng/mL) was observed in 54% of patients tested and previously unrecognized. Higher serum vitamin D levels appeared related to the use of vitamin D (in multivitamin or calcium supplements) suggesting that deficiency may be preventable and easily treated. As vitamin D deficiency is associated with substantial disability, the need for increased awareness to screen and prevent this disorder is evident.