Know this gait, memorize it. It is NOT a Parkinsonian gait.
Here is what you need to know about the gait presentation in Normopressure hydrocephalus (NPH):
The gait changes are often subtle and progress as NPH progresses because of the changes in the brains ventricular tissues eventually compromising the sensory-motor tracts.
Early gait changes, MILD, may show a cautious gait. Steps length and stride length may be slowed and shortened. The gait may begin to show signs of being deliberate and calculated, less fluid and free. The appearance of unsteadiness or balance challenges may prevail. Once simple environmental obstacles may now present as challenges, things like curbs, stairs, weaving between tables in restaurants or wide open spaces where there is nothing to grasp onto for stability. Weakness and tiredness of the legs may also be part of the complaint, although examination discloses no paresis or ataxia. (Ropper) A walking aid such as a cane may add comfort but often appears to be rarely used.
As the gait changes progress into the more MODERATE to ADVANCED, the walking aids used often progress into quad walkers. Wheelchairs are needed in more difficult places or when fatigue is growing factor. As the gait challenges progress, the careful observer will note a more obvious reduction in step and stride length, a head down posture, less dual tasking engagement during gait execution, slowed walking speed, reduced foot-floor clearance, shuffling gait (keeping the feet more engaged to the ground, this can be a Parkinsonian-type gait mis-read, there will be no tremor or rigidity), searches for stable external cues (reaching for railings, a kind arm or hand, touching walls etc), widening of the feet (broad based stance), and fears of falling backward.
In the most ADVANCED gait impairments, the fear of falling can become too great. There may even be an inability to engage sit-stand-walk motor patterns and the fatigue of the limbs may be too advanced to even stand let along walk. This stage is referred to as Hydrocephalic astasia-abasia (Ropper).
Normopressure Hydrocephalus is a serious issue if left unrecognized and untreated. NPH must be diagnosed early on since a delay in reducing the pressure on the cortical tissues can lead to permanency of disease and dysfunction. According to Poca there can be a wide range of successes and failures in symptom remediation, but there is clearly a time dependency on early diagnosis. Thus, clearly recognizing any early gait changes and behaviors prior to advancing incontinence and mental decline is paramount.
Dr. Shawn Allen, … one of “the gait guys”
Some of the above was inspired and summarized by this great article, from the Boston Globe.
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