- Published on
Symptoms and Signs -Differential Diagnosis of Propulsive Gait
Propulsive gait is defined by a stooping, rigid posture, wherein the patient's head and neck are inclined forward, flexed and stiffened arms are positioned away from the body, fingers are extended, and knees and hips are rigidly bent. As the body shifts its center of gravity forward during walking, it impairs balance by causing increasingly rapid, short, shuffling steps with involuntary acceleration (festination) and lack of control over forward motion (propulsion) or backward motion (retropulsion).
Propulsive gait is a key indicator of advanced Parkinson's disease, caused by the gradual deterioration of the ganglia, which are mainly responsible for the motility of smooth muscles. Due to the gradual development of this symptom and the often incorrect attribution of its effects to ageing, propulsive gait often remains undiagnosed or unreported until it severely impairs mobility.
Historical Background and Physical Assessment
Request information from the patient regarding the first onset of his gait disability and any recent exacerbation. Because he may have memory impairments, having ascribed the gait to "old age" or disease processes, you may be able to get information from family members or friends, particularly those who have limited contact with the patient.
Obtain a comprehensive drug history, including the specific type and dosage of the prescription. Request information from the patient regarding the use of tranquilizers, particularly phenothiazines. Particular attention should be given to the dosage if he is aware of his Parkinson's disease and has been using levodopa, since an overdose might lead to an immediate worsening of signs and symptoms. Assuming Parkinson's disease is not a confirmed or suspected diagnosis, inquire with the patient about any instances of acute or regular exposure to carbon monoxide or manganese.
Initiate the physical examination by assessing the patient's reflexes and sensorimotor function, observing any atypical patterns of response.
Medical etiology
Parkinson's disease. Early on, the distinctive and enduring propulsive gait initiates as a shuffle. A slowing of the gait occurs as the condition advances. The primary indicators of the disease include gradual muscle stiffness, which can manifest as either uniform (lead-pipe rigidity) or jerky (cogwheel rigidity); impairing movement; and a subtle tremor that starts in the fingers, intensifies during periods of stress or worry, and diminishes with intentional movement and sleep. Besides the gait, akinesia usually results in a monotonous voice, excessive salivation, a mask-like appearance, a stooped posture, and difficulty speaking, difficulty swallowing, or both. Seldom, it also induces oculogyric crises or blepharospasm.
Drugs.
Pharmacological agents such as phenothiazines, other antipsychotics (particularly haloperidol, thiothixene, and loxapine), and occasionally metoclopramide and metyrosine might cause propulsive gait and potentially other extrapyramidal symptoms. Such effects are often transient, vanishing within a few weeks following the cessation of treatment.
Carbon monoxide poisoning
A propulsive gait often manifests many weeks following acute carbon monoxide poisoning. History of symptoms includes muscular rigidity, choreoathetoid motions, widespread seizures, myoclonic jerks, masklike facial expressions, and dementia.
Manganese poisoning.
Prolonged over exposure to manganese can lead to a gradual, often irreversible, propulsive gait. Common initial symptoms include excessive tiredness, muscular weakness and stiffness, dystonia, resting tremor, choreoathetoid movements, a mask-like appearance, and alterations in personality. Specific occupational groups susceptible to manganese poisoning include welders, railroad workers, miners, steelworkers, and pesticide handlers.
Points of Special Consideration
The patient's gait and resulting motor impairment may hinder his ability to carry out routine activities of daily living. Provide suitable support to him while also fostering his autonomy, self-sufficiency, and self-assurance. It is recommended that the patient and his family allocate sufficient time for these activities, particularly walking, as he is especially prone to falls as a result of festination and impaired balance. To ensure safety, it is important to encourage the patient to continue walking and to remain by his side while he is walking, particularly if he is
in unknown or rough terrain. It may be necessary to direct him to a physical therapist for targeted exercise therapy and retraining of his gait.
Clinical Counseling for Patients
Suggest to the patient and his family to provide sufficient time for walking in order to prevent falls. Educate the patient on the proper use of assistive devices, if deemed suitable.
Guidelines for Pediatrics
Propulsive gait, often accompanied by intense tremors, commonly manifests in juvenile parkinsonism, an uncommon genetic disorder. Additional, while uncommon, potential causes include Hallervorden-Spatz disease and kernicterus.
Propulsive gait is defined by a stooping, rigid posture, wherein the patient's head and neck are inclined forward, flexed and stiffened arms are positioned away from the body, fingers are extended, and knees and hips are rigidly bent. As the body shifts its center of gravity forward during walking, it impairs balance by causing increasingly rapid, short, shuffling steps with involuntary acceleration (festination) and lack of control over forward motion (propulsion) or backward motion (retropulsion).
Propulsive gait is a key indicator of advanced Parkinson's disease, caused by the gradual deterioration of the ganglia, which are mainly responsible for the motility of smooth muscles. Due to the gradual development of this symptom and the often incorrect attribution of its effects to ageing, propulsive gait often remains undiagnosed or unreported until it severely impairs mobility.
Historical Background and Physical Assessment
Request information from the patient regarding the first onset of his gait disability and any recent exacerbation. Because he may have memory impairments, having ascribed the gait to "old age" or disease processes, you may be able to get information from family members or friends, particularly those who have limited contact with the patient.
Obtain a comprehensive drug history, including the specific type and dosage of the prescription. Request information from the patient regarding the use of tranquilizers, particularly phenothiazines. Particular attention should be given to the dosage if he is aware of his Parkinson's disease and has been using levodopa, since an overdose might lead to an immediate worsening of signs and symptoms. Assuming Parkinson's disease is not a confirmed or suspected diagnosis, inquire with the patient about any instances of acute or regular exposure to carbon monoxide or manganese.
Initiate the physical examination by assessing the patient's reflexes and sensorimotor function, observing any atypical patterns of response.
Medical etiology
Parkinson's disease. Early on, the distinctive and enduring propulsive gait initiates as a shuffle. A slowing of the gait occurs as the condition advances. The primary indicators of the disease include gradual muscle stiffness, which can manifest as either uniform (lead-pipe rigidity) or jerky (cogwheel rigidity); impairing movement; and a subtle tremor that starts in the fingers, intensifies during periods of stress or worry, and diminishes with intentional movement and sleep. Besides the gait, akinesia usually results in a monotonous voice, excessive salivation, a mask-like appearance, a stooped posture, and difficulty speaking, difficulty swallowing, or both. Seldom, it also induces oculogyric crises or blepharospasm.
Drugs.
Pharmacological agents such as phenothiazines, other antipsychotics (particularly haloperidol, thiothixene, and loxapine), and occasionally metoclopramide and metyrosine might cause propulsive gait and potentially other extrapyramidal symptoms. Such effects are often transient, vanishing within a few weeks following the cessation of treatment.
Carbon monoxide poisoning
A propulsive gait often manifests many weeks following acute carbon monoxide poisoning. History of symptoms includes muscular rigidity, choreoathetoid motions, widespread seizures, myoclonic jerks, masklike facial expressions, and dementia.
Manganese poisoning.
Prolonged over exposure to manganese can lead to a gradual, often irreversible, propulsive gait. Common initial symptoms include excessive tiredness, muscular weakness and stiffness, dystonia, resting tremor, choreoathetoid movements, a mask-like appearance, and alterations in personality. Specific occupational groups susceptible to manganese poisoning include welders, railroad workers, miners, steelworkers, and pesticide handlers.
Points of Special Consideration
The patient's gait and resulting motor impairment may hinder his ability to carry out routine activities of daily living. Provide suitable support to him while also fostering his autonomy, self-sufficiency, and self-assurance. It is recommended that the patient and his family allocate sufficient time for these activities, particularly walking, as he is especially prone to falls as a result of festination and impaired balance. To ensure safety, it is important to encourage the patient to continue walking and to remain by his side while he is walking, particularly if he is
in unknown or rough terrain. It may be necessary to direct him to a physical therapist for targeted exercise therapy and retraining of his gait.
Clinical Counseling for Patients
Suggest to the patient and his family to provide sufficient time for walking in order to prevent falls. Educate the patient on the proper use of assistive devices, if deemed suitable.
Guidelines for Pediatrics
Propulsive gait, often accompanied by intense tremors, commonly manifests in juvenile parkinsonism, an uncommon genetic disorder. Additional, while uncommon, potential causes include Hallervorden-Spatz disease and kernicterus.
0 Comments