Chaptr 8 gaitdisturbance.docVIP

Chapter 8: Gait Disturbance Barbara Scherokman, MD, FAAN, FACP; Patrick C. Alguire, MD, FACP I. CASE HISTORIES Case 8-1. A 58-year-old man with a history of hypertension awoke on the day of admission with a moderate global headache and inability to walk due to imbalance. He denies previous difficulty walking, double vision, dizziness, leg weakness, and numbness of his feet. On examination he has a wide-based gait and is unable to tandem walk. The remainder of his examination is normal.? 1. Where would you localize his neurologic problem?2. What are the likely etiologies?3. What would be your first step in evaluating this patient? Case 8-2. A 70-year-old woman presents with difficulty with her balance and several falls over the past six months. This came on gradually and has gotten somewhat worse. She has a history of hypertension and diabetes, which have been treated with medications over the past year. She denies double vision and leg weakness but admits to numbness of both feet that has gradually gotten worse over the past several months. At times she becomes lightheaded when getting up from a seated position. On examination she has evidence of cataracts. She has a slightly wide-based gait, turns on three steps, and is able to tandem walk if she looks at her feet. She has a Romberg sign and a moderate stocking-distribution decrease in pain, vibration, and position sensation.? 1. What part or parts of the nervous system could be implicated in causing her gait disorder? 2. What measures could be taken to help improve her gait? II. DISORDERS A normal gait is a very complex and fluid set of movements. The arms move synchronously with the opposite leg, the ankles nearly touch, and the heel strikes first. A normal gait requires the integration of the following systems: visual, vestibular, auditory, cerebellar, basal ganglia, sensory, and muscular. An abnormality in any one of the systems can cause a problem with gait and can lead to falls. Gait disturbance is a ver