Approach to a Case of Ataxia

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Approach to a Case of Ataxia

7 Sep, 2:30 PM

[Music] good evening everyone this is dr brushali and i welcome you on behalf of medflex for this session on the approach to a case of ataxia so for today's session we have with us dr vinit banga he is the only neurologist in north india who has a double neuro intervention fellowship currently he is the associate director at the neurology and neurovascular intervention at blk max hospital delhi he has done his md in internal medicine with gold medal and later on he has done dm in neurology from delhi he subsequently went on to do fellowship in stroke medicine from royal melbourne hospital australia and masters in stroke medicine from dunawa university austria he also finished his fellowship in neuro intervention and stroke and also a fellowship in interventional neural radiology so that's an amazing amazing bio and experience that you have with you so i'll quickly stop my presentation and hand it over to you thank you so much uh for having me here and for giving me the opportunity and it's indeed a pleasure to come back again and again and speak uh about some of the topics i love and have been close to my heart and help the young minds in medical sciences and reignite the flame in them to pursue career in neurology or somehow help with their neurology patients so uh rather than so we will discuss an approach to a case of a taxi our approach to ataxia in general so uh when we talk about taxi atexia is atexia means there is a problem with the gate problem with the balance so we have to understand what exactly is the gate so a gate is a complex motor and mental skill when properly executed requires integration of many mechanisms one of which is locomotion locomotion balance motor control cognition and musculoskeletal function a series of rhythmical and alternating movements of the trunk and limb which result in forward progression of the center of gravity the first and the most complex motor skill that humans require is is walking is the gate it is the motor fingerprint of the individual and identification of the underlying disease can be done by observing the manner in which the gate is altered now coming on to the mechanisms of locomotion and balance there are three types of input one is the sensory input is there via visual or a properly receptive or a vestibular pathway the second is a cerebral central processing pathway and finally there is execution of movement which can be voluntary or involuntary through muscle effector responses so there has to be a sensory input there has to be cerebral central processing by the brain and then there has been there has to be a next execution which is actually important now coming on to the control centers like it's control the gate there are two types supraspinal and spinal the supraspinal ones i'll just uh elaborate uh each i'll not go into elaboration of each of them i'll just enumerate them subthalamic locomotor region dorsal and segmental fleet ponto pulper locomotor region cerebellar locomotor region and central pattern generators and spinal cord so supraspinal centers through many tracks have they have their influence on spinal cord which is the central pattern generator which in turn activates muscle but supraspinal centers actually controls the central pattern generator so whenever there is imbalance of the supraspinal center control to the spinal cord there is severe disease or atexia so you can see uh the mnemonics that have been written so how does that there are many neurotransmitters mainly acetylcholine and gaba these are the two main neurotransmitters responsible for the gate through prefrontal cortex so through medial globus pallidus and through subthalamic region they influence the quantum medullary reticular nuclei and subsequently the spinal cord so uh coming on to how how is the organization of these uh centers one is uh through cortex and basal ganglia are the higher centers of this cortical as i call them then there is brainstem regions which is uh then subsequently the spinal cord which is the central pattern generator and finally the effector muscles so this is how they work so they they have been many off and on splits there have been many sensory inputs so a lot of these actually uh come into play when you call when we somebody talks so it's it's it's a very complex uh thing uh gate or walking is a complex complex thing and involves a lot of structures a lot of neurotransmitters and lot of control now comparison of the gate terminology can be uh through uh either by a traditional or a modified pathology so i like the traditional once more which is the first thing that you do is a heel strike then there's foot flat then with stance heal of low law of acceleration with screening and finally deceleration so this is how the gate works now traditional phases of kit this is the first phase when your heel strikes begins with initial contact and ends with the foot flat and this is the second phase when the foot becomes flat after immediately after the heel strikes subsequently there is mid stance when is the point in which the body passes directly over the supporting activity then there is heal off the point following mid uh stance at which time the the heel of the reference extremity leaves the ground subsequently the stance phase which is the toe off as well so stance phase is divided into different things so first thing is the toe the point following heal off when the only row of the reference activity is in the contact of the so this is the time when uh only the toe of the reference extremity is in the contact and then there is a swing phase which is uh divided into an acceleration phase it begins with uh the two leaving the ground and continues until the mid swing and mid swing is uh when the extremity passes directly beneath the body or from the end of the acceleration to the beginning of deceleration and finally the deceleration phase it occurs after the mid swing when lip is decelerating in preparation for an heel strike so this is how it happens the first thing is heel strike then foot flat that mid stance then heal off and the toe off and if you modified the initial contact the loading response mid trans terminal stance and processing so this is how it is divided and there have been sub component of the swing phases so this is in total the gate cycle it's very important that you know about the gate cycle because this actually will tell us how does the gate actually malfunction so there are variables of gate which is the time or the temporal variable and the distance variable so both of these are important and provide essential quantitative information about the game now which are the factors like which effect these variables are age gender height shape and size of the bony components distribution of mass joint mobility muscle strength typing of clothing habit psychological status all of these are important these variables are the temporal variables are stance time single limb and double support time swing time stride and step time cadence and speed while the distance variables are stride length step length and degree of flow out so i'll i'll probably so if uh so there are two ways we can go about it we'll discuss about the gate a bit today and if the time permits we'll discuss we'll complete this today if the time doesn't permit we'll we can extend it to the next session so it's very important that we understand the gate very because before we go on to understand the problems of gate or a taxi it's very important that you know about the gate stance time is the amount of time that elapses during the stance phase of connectivity in a gate cycle a single support time is the amount of time that elapses during the period when one only one activity is on the supporting surface in a gate cycle double support time is exactly the opposite is amount of time spent both the feet on the ground during one gait cycle so percent of time spent in these and elderly persons because they find it difficult to balance so especially those patients have difficulty our balance disorders they have the double support time increases and as the double support time increases the speed of walking actually uh uh in also it's it's in reciprocal relationship with it so stride length is the linear distance from the heel strike of the one limb to the next heel strike of the same wing the step length is the linear distance from the heel strike of the one volume to the next heel strike of the opposite leg this is very well discriminated here the stride duration is the amount of time taken to accomplish one strike so stride duration and gate cycle duration are almost synonymous so they ask the same thing sometimes it will be speaking as spoken as strike duration and sometimes it will be spoken as gate cycle step duration it refers to the amount of the time spent during a single step and measurement usually is expressed as second first step cadence is the number of steps taken by a person per unit of time it is measured at number of steps per second or per minute walking velocity is it is the rate of the linear forward motion of the body which can be measured in meters or centimeter per second speed is referred to as slow free or fast free speed of the gate refers to the person's normal walking speed while slow and fast gate refers to the slower the faster version of the same uh average walking speed step width is the measure of the linear distance between midpoint of the heel of one foot and the same point on the other foot degree of flow out is depends the angle of the foot formed by each foot's line of progression and a line intersecting the center of the heel and the toe the angle of the men is about seven degree from the line of progression of each foot at free speed water this is the degree of toe the variables of gate in short step length stride length gait cycle the right gait cycle in the left kit cycle there then the center of gravity this path midway between the two hips few centimeters in front of s2 is your center of gravity and least energy consumption is if the center of gravity travels in straight line so this is how it is so these are how these athletes work it out so uh vertical displacement is the rhythmic up and down movement highest point is the mid stance lowest point comes when there is double support and the average displacement is around five centimeter the path is extremely smooth and sinusoidal curve the lateral displacement refers to the rhythmic side to side lateral limit is the midstance average displacement is again around five centimeters so overall displacement is in figure of eight movement of uh center of gravity as we see from uh the apv so stance faces when is the foot on the floor swing is when the foot is in the air stance time is the time that the foot is on the floor and the time between the heel strike and the toe where swing time is the time that the foot is in the air and time too often he'll strike so cadence like this is in short what we have discussed so i'll just switch them faster so coming on to the gate disorders among the most frequent symptoms in neurology is ataxia so it's one of the major neurological problems especially more frequent in elderly but can be found in at any age there is more severe consequences fall with the risk of head trauma bone fracture or development of fear of falling with loss of mobility and independence and 30 of our deadly people actually suffer at least one first fall annually and 40 among those who are older than 80 years how do you evaluate it history is by weakness uh whether this patient is having some hemiparesis paraphrases any weakness of proximal or the distal muscle then we discuss about the slowness whether the patient has an extra phenomenal symptom in the form of small shuffling shallow steps difficulty in starting to work or in between standing like freezing there has there been any diagonal fluctuations in this and loss of balance such as sensory and cerebellar atexia which increase with darkness along narrow path and any history of fall such as due to tipping due to syncope during postural adjustments or due to pure poor balance then there are sensory symptoms and pain associated or if there are any bladder symptoms so we talk about weakness extrapyramidal symptoms atexia falls sensory symptoms and incontinence then the second thing that you need to so this is history so whenever you evaluate gate you ask you ask these questions ask the question whether there is any side of the body weak if not then if there is any slowness or any extra pyramidal syndrome if there is an imbalance whether it increases with darkness or on an uneven surfaces or during night or narrow pathways as there any misty or fall or any urinary structure incontinence the second thing you do is examine examine posture as well as like standing phase as well as the walking face so whenever you examine a patient standing you should know notices trunk posture posture reflexes as well as the stance when it works you should note how is he initiating what is he what is what how are his steps whether they are regular irregular what is his cadence what is the rhythm what is the length and then the trajectory and whether there's an associated trunk movements which is exercise or diminished or not then there's special menus such as heel toe walking roundwork station walking backwards then uh the usual motor examination that we do which is muscle tone pulse strength voluntary movement trunk movement leg movement tendon reflexes heal to shin test for uh cerebellar examination and then muscular skeletal examination so usually whenever somebody evaluates a person he should be evaluated walking in an open space for at least seven to ten meters and should also be in a turn should also be included at the mid distance one should also include his ability to rise from the chair with arm close standing capacity pull or push chest is a challenge station which we push or pull the person to know whether he can manage or balance it out and then turning in space and then ability to perform another cognitive or motor task like for example you tell the patient to walk while doing this hand movement or while doing some calculation so one of the pet site examination tool is the timed up and go test so what it does it records the time it takes a person from rise from the chair walk around three meters turn back and return to the chair and sit down so for example you are here you stand up go there come back and again back and sit on the chair so this is the time most adults can complete all of this in 10 seconds even the elderly adults can complete around 11 to 20 seconds but if it is more than 14 seconds the fall risk increases if it is more than 30 seconds then the patient needs a comprehensive evaluation it's a very easy test so how easy it is to tell the patient to get up go walk the three meters come back and sit down and notice a step step heights tight cadence everything and also the time so the time gate test is again it's it's in similar timed up and go test it's in the patient is asked to cover 30 feet distance if the patient uh covers this distance in less than 13 steps or less than 10 seconds is abnormal uh then there is trinity balance and mobility skill but out of this out of all these the my most favorite one and one of the most easiest tool is time up and go test this is what you i usually do in my opinion i would suggest you also start doing it as a routine practice now coming on to like different menus they are so their laboratory method such as motion capture system in which you use a camera which tracks and records the trajectories of light with reflective markers which are placed to the patient's skin provides information about joint stability gate physics and velocity uh coming on to force plates measure the resultant force generated by interaction of foot with the ground then electromyography equipment they can be many others now how frequent is ataxia so uh atexia is very frequent but then they can be different so we have learned in future that they have in the past that there have been a sensory input then that input goes to brain the brain processes it sends it back to spinal cord and spinal cord sensitive so if there is problem in any of these circuits for example this problem with sensory deficits this problem spinal cord which doesn't conduct the signals to brain or back if there has been problem with the brain in the form of an extra pyramidal disorder such as parkinson's or a stroke which leads to slowness or you know in order generation of the gait mechanisms or there's been psychogenic as well so uh stroke is one of the most common uh reasons for the atexia while parkinson's disease also is one of one of the common ones the other ones are less common such as neuropathy multiple sclerosis spinal disorder and the pain syndrome coming on to the anatomical classification done by net at all it may be classified the patient can be classified into two or three one is the low sensory motor level of gait disorders which can be subsequently divided into peripheral sensory and peripheral motor so peripheral sun theory is when once the patient has a sensory neuropathy which leads to sensory atexia when the patient is unsteady and uncoordinated while if the vestibular signal is not reaching the brain then it will be a vestibular taxi in which the patient is unsteady but breathing and visual atexia when the visual stimulus is not reaching the brain and the patient is tends to be temptative and a bit uncertain about what it's gonna do so uh low sensory motor level gait disorders may be sent sensory or motor peripheral sensory and peripheral motors if the patient has a myopathy or arthritis middle sensory motor level gate disorders can be because of spasticity such as hemiplegia or paraplegia or because of parkinson's which is an extra pyramidal disorder or cerebral atexia which can be due to problems with the cerebellum may be acquired in the right degenerative or acute toxic tumor then the final ones have the high sensory motor level gate disorders which are in the high up in the cortex which is the cautious gate the frontal lobe related gait disorders which can be because of cerebral vascular disorders or normal pressure hydrocephalus and can sometimes can be also found in patients who are just elderly and they have no other associated illness now system oriented classification can be peripherally originating or centrally originating peripherally alternating can be in the muscles or musculoskeletal system it can be in the joints muscles pains nerves sensory nervous system or proprioceptive system the centrally originating can be spinal pyramidal cerebellar extrapyramidal apraxia are unclassified so ah when we come to the abnormal gate according to the clinical characteristics this can be a division so we have discussed about the different classifications so it was the first was the anatomical class one is system oriented the third one is abnormal gate depending upon whether it is in peritectic gate or and the last one this normal gate classification which is according to the clinical structure system is characteristics which is one of the most commonly used classification now coming on to each of these gates so if it's very important that you know each of these gates and also know their origin so battling gate is when bait bearing at hip is not stabilized so whenever walking your hip your pelvis needs to be stable if it is not stable you will kind of weddle whenever person walks is there's been a bulge outwards with each step when the other side of the pelvis drops it's usually found in myopathies such as gluteus medius muscle weakness and muscular dystrophies coming on to the gate and the distal weakness which can be stupid for example you walk like this but in these patients because this distal muscle weakness or distal muscle issues a patient is not able to walk like this so he has to if he has to clear the ground he has to lift his head if lift his foot high up because he is not able to have any movements at the ankles needs so it can be due to digital anterolateral group which is peroneal muscle group which is in the form of foot drop or it can be due to uh the other steppage gates such as the entire solar entire footage now coming to slapping it slapping it is when somebody is not able to judge how far is the ground view below and this is due to proprioceptive sensory input dysfunction usually can it can be due to posterior group weakness can be due to weakness and plant reflection and like addiction difficulty in rolling the slower of the flu or sole of the floor and pushing off with the tip of the foot and the patient is unable to stand on the toe hemiparetic is usually due to um lesions above the forearm and magnum so the patient will walk like this so he is not able to because of stuff spasticity whenever we walk we have to keep flexing and extending all your limb so it's like this so if the patient is not able to do it so what we'll do this limb will go normal but this will be like this then this will be like this and then the patient will walk like this so the leg rotates in a semi circle and the patient becomes slow with decreased step length and increase term space then parabolic is when the patient has both illnesses for example he has a hemiparesis and then he has a spinal cord lesions so the patient walks as any scissor engage which is very commonly found so the patient because now both the legs are not able to flex now the patient will walk like this like this so this is like a scissor like because the patient is not able to clear the ground he has to keep his leg straight so he will go like this so this is like scissor so we call it scissoring it the consonant gate is when the patient walks slowly with slow step lengths slow height and stoop posture and a combination of echinacea impaired posterior reflexes dystonia rigidity and trevor so the patient walks very slowly with difficulty in initiation so with and the patient starts as as he starts walking the patient will start flexing forward you'll start gaining the speed and the patient will eventually tend to fall if not stopped now there can be episodic disturbances in parkinsonian disorders such as freezing the patient suddenly stops working and there can be partial instability due to these kids so two types of uh these intermittent problems one is the freezing and the other one is fascination freezing can freezing is mostly short it's usually less than taken 10 seconds and really more than 30 seconds it is intermittent it feels that the patient is glued to the ground it's not able to move forward is not able to move backward is not able to move sidewards and then you give them certain stimuli and your starts walking so this is what freezing is and then they can be shuffling forward they can be trembling there can be complete immobility so whenever there is freezing freezing can be complete like the patient is not able to move at all and uh if the patient sometimes can be just like this like he's moving like this he's moving like this but he's not able to walk he's like moving at the same place or the patient is just glued to the surface so it's more common in the off space then the first initiation is when the patient works with very very small short lengths forwards coming on to the toxic kit uh it is characteristic by unsteadiness and insecurity in security because the patient tends to have imbalance the incoordination is the problem either because of cerebral or the vestibular or the sensory system the patient used to have a white base for example normal the patient will walk like this the atexic patient will walk like this if it is due to one of these etiologies so vestibular ataxia due to disorders of the vestibule and the sensory inputs doesn't reach the brain from the pesticide it causes wearing it separation will start it will be a bit of uh unpredictable type of hunger and the patient will be very cautious because they tend to find it very difficult to predict the movement so we have to predict every moment when you walk the patient stand on a white base and walk with instability staggering and pronounce laters the latest speeds if you make the patient run it's very important then this lateral sway actually updates and the patient doesn't have a tiger and consistent unilateral tendency in central vestibular signal sensory ataxia disorders of the deep sensation from the lower extremities especially the posterior column this one dysfunction sorry the patient has a wide base it strikes up irregular length and the sleep sometimes the feet will be slapping and these patients tend to have imbalance especially more in the night because one of these stimulus the vestibular sensory and the visual if one system is not working the other has to supplement if you tell the patient to close his eye or walk on an uneven surface then the vestibular then the visual stimulus goes so if the patient has sensory atexia he'll kind of he'll kind of decompensate as i would say so cerebellar ataxia is a major system of lesion of cerebellar hemisphere it's ipsilateral extremity in case of unilateralism the patient has a white paste and irregular cadence it's completely unpredictable and equilibrium is unimpaired the falls are relatively rare because the patient is able to manage and this is how we differentiate cerebellar versus sensory attacks it's very important and you need to read this and uh just keep it in your heart because this is one of the very commonly asked questions in in the viva as well as in the exams now this kinetic gate is especially in those patients who have dyskinesias like korea athetosis the patient seems to be dancing so it's like irregular the cadence is irregular the gate characteristic will not be consistent it will be so till now whatever you spoke the gate characteristic will remain same throughout the gate because the disorder is there in this the gate characteristics varies with each walk coming on to dystonic it isn't after type of in this timing it is kind of taking it the patient has a dystonic posturing and either it appears during walking or it appears during rest so the posture and the motions propagate from lower extremity to the other muscles and mobile dystonia and athetosis then there is frontal lobe dysfunction of the gate in three conditions frontal discipline ignition failure and frontal gate disorder so these are the three conditions when frontal lobe dysfunction is there so frontal discolorium is what we known as aprxicate the patient doesn't know patient knows how can it be done but it will not be able to do when you tell him to do so the patient doesn't haven't started agency freezing or shuffling it's normally seen in early people this normal rhythm of work and food claims but slightly wide base and short stride an isolated gate ignition failure is the when the patient finds it very difficult to begin walking this problem with the initiation it can also be found in patients of parkinson's but it is if there is an isolated gate ignition failure then it's type 1 frontal gate and not parkinsonian then the frontal gate disorder can be found in vascular parkinson's normal pressure hydrocephalus it's in it causes moderate to severe disease and this freezing of gate is usually found in frontal get disorder and then there can be slowness because of sub-particle disease this is how we differentiate parkinsonian versus a normal pressure hydro plus gate cautious state of elderly like these are the parameters that the stance time the swing time will increase the arm swing will decrease the patient will have an increased step width and a decreased stride length the patient will be cautious psychogenic again is similar to dyskinetic gait it will be out of you normal out of out of line unusual pattern it will not fit into a pattern it will be too much of variation and the patient usually have a psychiatric features present now how do we treat it i'll rather not discuss too much if the patient is then you need to give anti-spasmodic drugs uh suggest zanidine or if it is a local spasticity inject botulism toxin if it's in spinal cord disorder then give intra ethical backlog and pump non-medical is by giving them physiotherapy activation of spinal insular spinal gait receptors in parkinson's we give uh levodopa amended in we have discussed it later and we gave a lot of gait training as a day and we we push the patients to walk as as much as long possible as long as possible in advance stage we know that the divo dopa controls it but sometimes the deep brain stimulation is actually helps in uh dyskinetic gait deep brain stimulation also helps especially in globus pallidus internals for uh dystonic gate you can give baclofen anticoagulants and anti-epileptic gates so this is all about it i i i think the lecture has been quite long and i've tried to cover everything it might be possible that some things are discussed a bit fast so i would like you all of you to give me suggestion if you want something to be discussed in particular something that needs more focus on if you want to become me if you want me to come up with the case and show you the videos which is a bit difficult on this platform because it requires a lot of consent taking uh if you want that to happen how to approach it so like you need to know this is in in brief approach to a gate disorder that i have discussed we can discuss about each of these ataxias and future or we can discuss about someone that the majority wants to discuss thank you very much thank you for that session uh for the audience members i would request please put your queries in the comment section or you can click on raise and as well we have a question by dr hari how common is vitamin deficiency causing ataxia is thiamine effective vitamin d deficiency doesn't directly cause vitamin d i he has vitamin d and it can cause sensory atexia but assets not very common b12 deficiency is more common causing ataxia than thymine deficiency okay thank you i hope dr hari that answered your question i think today there are less questions when when somebody when people ask less questions there are only two reasons for it one is they didn't get it or they understood everything i think today it's the first thing probably it is a very complicated uh subject and to discuss about gate in a single lecture is a very difficult task for that so yes how is vitamin b12 deficiency diagnosed can be diagnosed so the classical presentation of vitamin b2 b2 deficiencies subacute combined degeneration in which there is myelopathy plus there is neuropathy so these patients they tend to present with both the signs of myelopathy as well as the neuropathy so to examine these patients will have a positive bromberg sign they'll have absent angle absent ankle reflex and they'll have a brisk knee reflex which will not fit into neuropathy so it will be the knee reflex knee reflex is a sign of uh myelopathy while absent ankle reflex with normal design of neuropathy so they kind of present with both so these patients they tend to present with the findings suggestive of sensory ethics all right true thank you so much subaru is saying in next session please discuss the cases also i'll try to do that i'll try to bring in some videos in which we will discuss about the patients and the cases okay great so we'll what we'll try to do is we'll uh uh try to get some videos of the patients having atexia and then we will discuss each one of them right great uh so i hope dr subrah will see you in the next session like you requested and suggested we'll be having a few videos in the next session uh i think there are no more questions so yes thank you so much sir thank you for this session and we hope to see you soon again as for audience members thank you so much for joining us today


Patients with Ataxia suffer from balance impairments, which limit their functional range and decrease their quality of life. The difficulty of ambulation is related to the patients' motor impairments since their steps may be staggered and lack a clear cadence. Brain tumours, chemical toxicity, infection, stroke, and degenerative disorders are only a few of the many reasons of cerebellar ataxia. Join us LIVE as Dr. Vinit Banga, the Chief of Neurovascular Intervention at the B.L. Kapoor Memorial Hospital in Delhi, discusses the diagnosis, investigations, and therapy of ataxia.


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