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Neurological disorders of gait, balance and posture: a sign-based approach

Nature Reviews Neurology volume 14, pages 183189 (2018) | Download Citation

Abstract

Neurological disorders of gait, balance and posture are both debilitating and common. Adequate recognition of these so-called disorders of axial mobility is important as they can offer useful clues to the underlying pathology in patients with an uncertain clinical diagnosis, such as those early in the course of neurological disorders. Medical teaching programmes typically take classic clinical presentations as the starting point and present students with a representative constellation of features that jointly characterize a particular axial motor syndrome. However, patients rarely present in this way to a physician in clinical practice. Particularly in the early stages of a disease, patients might display just one (or at best only a few) abnormal signs of gait, balance or posture. Importantly, these individual signs are never pathognomonic for any specific disorder but rather come with an associated differential diagnosis. In this Perspective, we offer a new diagnostic approach in which the presenting signs are taken as the starting point for a focused differential diagnosis and a tailored search into the underlying neurological syndrome.

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Author information

Affiliations

  1. Jorik Nonnekes is at the Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Rehabilitation, PO Box 9101, 6500 HB, Nijmegen, Netherlands.

    • Jorik Nonnekes
  2. Rianne J.M. Goselink and Bastiaan R. Bloem are at the Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, PO Box 9101, 6500 HB, Nijmegen, Netherlands.

    • Rianne J. M. Goselink
    •  & Bastiaan R. Bloem
  3. Evžen Růžička is at the Department of Neurology and Centre of Clinical Neuroscience, Charles University and General University Hospital, Katerinska 30, Praha 2, Czech Republic.

    • Evžen Růžička
  4. Alfonso Fasano is at the Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital and Division of Neurology, University of Toronto, 399 Bathurst Street, 7 Mc412, Toronto, Ontario M5T 3K9, Canada and at the Krembil Research Institute, 60 Leonard Avenue, Toronto, Ontario M5T 2S8, Canada.

    • Alfonso Fasano
  5. John G. Nutt is at the Department of Neurology, Oregon Health & Science University, Portland, Oregon 97239, USA.

    • John G. Nutt

Authors

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Contributions

J.N. and B.R.B. wrote the manuscript. All authors contributed substantially to discussions of the article content and to the review or editing of the article before submission.

Competing interests

The authors declare no competing financial interests.

Corresponding author

Correspondence to Jorik Nonnekes.

Supplementary information

Videos

  1. 1.

    Supplementary video S1

    Extreme broad-based gait in a man with spinocerebellar ataxia type 2. The authors affirm that the human research participant provided informed consent for publication of the images in Supplementary information (video) S1.

  2. 2.

    Supplementary video S2

    Variable base of support in spinocerebellar ataxia. Variable base of support (including a broadened stance width) in a man with spinocerebellar ataxia type 3, with a clear widening of the base of support during turning. The authors affirm that the human research participant provided informed consent for publication of the images in Supplementary information (video) S2.

  3. 3.

    Supplementary video S3

    Broad-based gait in sensory ataxia. Moderate broad-based gait in a woman with sensory ataxia due to diabetic neuropathy. The authors affirm that the human research participant provided informed consent for publication of the images in Supplementary information (video) S3.

  4. 4.

    Supplementary video S4a

    Effects of treatment on gait abnormalities. a | Broad-based gait in a man with normal-pressure hydrocephalus. The authors affirm that the human research participant provided informed consent for publication of the images in Supplementary information (video) S4a.

  5. 5.

    Supplementary video S4b

    Effects of treatment on gait abnormalities. b | A reduction in the width of the broadened base of support is evident after a spinal tap procedure that removed 35 ml of fluid. In this patient, instrumented gait analysis was used to quantify the effects of this intervention. The authors affirm that the human research participant provided informed consent for publication of the images in Supplementary information (video) S4b.

  6. 6.

    Supplementary video S5

    Narrow-based gait in Parkinson disease. Narrow-based gait in a man with idiopathic Parkinson disease. During long-standing disease (onset of symptoms 11 years ago), his gait has remained narrow-based. The authors affirm that the human research participant provided informed consent for publication of the images in Supplementary information (video) S5.

  7. 7.

    Supplementary video S6

    Narrow-based gait in spastic paraplegia. Narrow-based gait in a man with hereditary spastic paraplegia. The authors affirm that the human research participant provided informed consent for publication of the images in Supplementary information (video) S6.

  8. 8.

    Supplementary video S7

    Gait-scissoring in a functional gait disorder. Gait-scissoring in a woman with a functional gait disorder. This video comes from the collection of Prof Arthur van Gehuchten, a Belgian anatomist (1861–1914).

  9. 9.

    Supplementary video S8

    Gait-scissoring in chorea. Gait-scissoring in a woman with Huntington chorea, alternating with a compensatory wide-based and almost ataxic gait. Associated involuntary choreatic movements can also be seen in the limbs. The authors affirm that the human research participant provided informed consent for publication of the images in Supplementary information (video) S8.

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DOI

https://doi.org/10.1038/nrneurol.2017.178