Thread by @PearlsNeurology

#MedTwitter #neurotwitter #Neurotwitternetwork
It's time for another #tweetorial #twittorial!
Today's topic: Functional Gait Disorders
#FunctionalGait #FND #FMD #Gaitdisorders #Ataxia #MovDis #Medstudenttwitter #neuroresidents #neurology #movementdisorders #FNDHope
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Functional Gait disorders ("FGD" for the purpose of this #twittorial) are common and disabling, usually accompanied by other symptoms. FGD are challenging for the non #MovDis physician and it can difficult to determine #inconsistencies and #incongruencies during examination.
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A good approach is to identify #clinicalSigns to differentiate a #functional vs #organic cause

#Inconsistency is the variability in gait disorder severity over time.
#incongruency involves a combination of symptoms and sins not seen in organic disorders.
#distractibility
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Gait evaluation is important to determine the presence of these #clinical signs so... get a place with enough room to see the patient walk.
Identify any abnormal walking pattern: inability to walk in a straight line, scissoring or knee buckling, etc
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Some functional gait patterns we can identify are:
- #dystonic, #ataxic, #spastic, #weak, #antalgic, #parkinsonian, and #hemiparetic

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n.neurology.org/content/94/24/…

A detailed list of signs, including videos in the article below:

The rest of the examination is used to evaluate specific gait and balance tests to help reveal #inconsistencies and #incongruencies that may support a #functional etiology.

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#AtaxicGait can be #cerebellar, #sensory, #vestibular or #functional in origin.

Suggestive signs of an ataxic gait:
- variability in the base of support and stride
- inability to walk in straight line (sometimes with excessive arm swing)
- poor balance

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A common #Inconcistency in patients with #functionalgait disorder resembling ataxia is a much better balance than the one perceived by the patient and no history of falls even in spite of excessive truncal sway.

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#DystonicGait is characterized by an abnormal posturing of the trunk or the leg, usually present during casual gait (task specific). It can disappear while walking backwards or sideways
On #functional dystonic gait, abnormal posturing may disappear during casual walk.
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#SpasticGait or Scissoring: usually caused by spasticity of the adductor and calf muscles + muscle weakness and increased reflexes (spastic paraparesis). It persists while walking backwards
#functional etiology suggested by absence of spasticity, normal reflexes & no weakness
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In order to determine #weakness, assess muscle strength of quadriceps and gluteus muscles.
#Giveaway #weakness is suggestive of #functional etiology

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Limping or #antalgicGait of organic origin is consistently pesent. Usually history and examination reveal origin of the limp.
Functional antalgic gait has an inexplicable variability during dual tasks, tandem gait, walking with eyes closed or backward.

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In #parkinsonianGait: main features are #bradykinesia, #tremor and #rigidity. #FreezingOfGait (FOG) can be seen upon turning and/or gait initiation.
Inconsistent bradykinesia, rigidity, distractible tremor and incongruent pattern of FOG may suggest a functional etiology.

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In organic #hemiparetic gait, unilateral UMN lesion signs (spasticity and paresis) are always present.
Absence of #spasticity, #Giveaway weakness and positive #Hoover sign can be found in #functional etiology. Also, variability during exam is present

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Make sure to include the following in your gait assessment:
- Casual walk
- Tandem walk
- Romberg test (worsens vestibular, and sensory ataxia)
- Pull test
- Eyes closed
- Walk backwards, dual-task

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Keep in mind that organic gait disorders can also present inconsistencies during exam. #Pitfalls can be seen in dystonic gait (geste antagonist), chorea, levodopa-induce dyskinesia, other rare disorders like #DYT1,#DYT4 and frontal lobe dysfunction.

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In conclusion:
- #phenomenology first!
- Look for signs that may suggest functional etiology #distractibility, #inconsistency and #incongruency
- Look for other supportive signs since functional gait disorders are usually accompanied by other functional neurological symptoms.
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For more:
link.springer.com/article/10.100…
Inspired in the review: Functional Gait disorders: A great sign-based approach (videos Available)
n.neurology.org/content/94/24/…

This #twittorial is a brief overview with educational/board review purposes. Not intended as medical advise.
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