Thread by @MedinaRiojaMD

Higher-Level Gait Disorders (HLGD): a brief overview.
🚶🧠🦵

#Neuro #Neurotwitter #Neurology #Gait #Movement #Teaching

1/🧵

"It is likely possible to learn more about neurologic status from watching a patient walk than from any other single procedure, and observation of gait should always be part of a neurologic examination."
🧐🧠🥸

2/🧵

Gait is a sensory-motor function, which needs the adequate interaction between major systems for:

1⃣ Generating force
2⃣ Orientation in space
3⃣ Refine force
4⃣ Collate and interpret sensory information; select and modify motor programs

3/🧵
Gait in a "nutshell" (sort of) 👇

An easy-to-approach classification of these systems was published in 2013 and divided systems in:

1⃣ Lower
2⃣ Middle
3⃣ Higher

4/🧵

Back to the topic, what are HLGD?

"Term used for locomotor and balance difficulties that cannot be explained by peripheral motor, sensory, pyramidal, cerebellar or basal ganglia lesions."
🧐🤔

5/🧵

There are a multitude of terms which are part of HLGD

🥇 Gait apraxia
🥈 Frontal ataxia
🥉 Marche a petits pas
🍀 Lower-half parkinsonism/vascular parkinsonism (VaP)?*

*Most of these patients do not have VaP, but Leukoaraiosis-associated HLGD

6/🧵

*For more information on what IS and what is NOT VaP I suggest the following articles by the amazing @AlbertoEspay

7/🧵

Clinical features 🏥
1⃣ Anterior/frontal HLGD

- Most Fx
- Freezing of the gait (FOG)
- Small Steps
- Disequilibrium

8/🧵

Clinical features🏥
2⃣ Posterior HLGD

- Abnormalities in the spatial real perception
- The sense of postural vertical may be disturbed
- Distorsions of enviroment and body maps are present

9/🧵

What about Gait Apraxia? Adequate term?🧐

- Limb apraxia, not associated with gait and balance dysfx 🤔
- Limb apraxia 🟰 dominant parietal lesions
- HLGD/Gait apraxia most fx associated with bilateral medial frontal lesions 🧠

Apraxia and Gait Apraxia not same concepts

10/🧵

🚨 Basic Balance-locomotor circuits

1⃣ Shaded structures and connections are "hypothetically" affected in anterior or frontal HLGD

2⃣ The parietal, temporal and occipital lobes are hypothetically responsible for posterior HLGD

11/🧵

HLGD can be one of the most difficult entities to understand and evaluate. This 🧵is based on a great paper by Nutt J, MD and serves as a brief intro to these disorders.
Let's not forget that HLGD are syndromes and an accurate evaluation may lead to the final diagnosis.

12/12

Sources:
1.- Mov Disord. 2013 Sep 15;28(11):1560-5.
doi: 10.1002/mds.25673.
2.- Campbell W. DeJong’s The Neurologic Examination. 8th Edition,2019.
3.- J Mov Disord. 2017 Jan;10(1):1-17.
doi: 10.14802/jmd.16062
4.- Mov Disord. 2015 Jun;30(7):886-94.
doi: 10.1002/mds.26263.

More sources:
5.- Parkinsonism Relat Disord. 2022 Jan;94:132-134.
doi: 10.1016/j.parkreldis.2021.12.008.
6.- Arq Neuropsiquiatr. 2022 May;80(5 Suppl 1):42-52. doi: 10.1590/0004-282X-ANP-2022-S118.

More and more sources:
7.- Continuum (Minneap Minn). 2022 Jun 1;28(3):750-780. doi: 10.1212/CON.0000000000001124.
8.- Phys Ther. 2003 Dec;83(12):1119-25