Chief Concern Series: Gait Problems Made Clear

Develop a clear approach to undifferentiated gait problems, from first hallway impressions to exam maneuvers that actually change decisions. Dr. Maebe O’Hare joins us to separate neuropathy, radiculopathy, and orthopedic causes, and to show where EMG, imaging, PT, and devices fit into the management of gait disorders.

• Watching the walk for rhythm, cadence, symmetry, stance and swing
• Using video to isolate limb and phase changes
• History clues that localize head versus legs
• Distinguishing neuropathic pain from radicular patterns
• Non-neurologic causes including osteoarthritis and deconditioning
• Sensory testing that matters for gait, including proprioception
• Romberg done right and when to stress it
• When EMG clarifies neuropathy versus nerve root disease
• Imaging for neurogenic claudication and focal deficits
• PT as diagnostic and therapeutic partner
• Choosing assistive devices and AFOs to reduce falls
• Setting expectations for neuropathic pain meds

Find all of our prior podcasts on your favorite podcast app, and you can always check out our website at theneurotransmitters.com

Chapters

• 0:00 Meet Maeve And Set The Stakes
• 2:55 Why Gait Complaints Get Misrouted
• 4:53 Watching The Walk: First Clues
• 7:17 Gait Cycle Basics And Video Use
• 10:28 Describe, Don’t Diagnose Too Fast
• 12:08 History Clues: Head Versus Legs
• 14:06 Non‑Neurologic Causes To Catch
• 16:30 High‑Yield History For Falls
• 18:18 Neuropathic Versus Radicular Pain
• 21:20 When Neuropathy Truly Alters Gait
• 23:01 Exam Fundamentals That Matter
• 26:22 Romberg Done Right
• 30:00 Stressing Sensory Systems
• 31:45 EMG: When It Helps
• 34:22 Imaging, PT, And Pacing Care
• 36:16 PT As Diagnostic And Therapy
• 38:24 Devices, AFOs, And Independence
• 41:00 Common Misses And Better Pathways
• 43:02 Pain Meds, Expectations, Education

Transcript

Michael Kentris: 0:04

Hello and welcome back to the Neurotransmitters. I'm your host, Dr. Michael Kentris, and I am joined again today by my co-host, Dr. Galena Geikman. Galena, how are you doing today?

SPEAKER_02: 0:16

I'm well, Michael. I'm so excited to be back and looking forward to another episode.

Michael Kentris: 0:22

Yes. So, you know, not to give away the topic too quickly, but when people are listening to podcasts, say on their their morning walk or when they're getting ready and moving around, this might be the perfect topic for them, would you say?

SPEAKER_02: 0:34

Yeah, you know, you pick up the podcast and you just walk into this topic.

Michael Kentris: 0:40

Yes. So we are joined by a very special co-host also. So Galena, would you go ahead and introduce them?

SPEAKER_02: 0:47

Of course. And I love what you've been saying, Michael, about, you know, this is really friends of the podcast and friends of ours. And Maeve O'Hare is no exception to that. She is one of our expert neuromuscular specialists here at the Brigham Women's Hospital in the Mass General Brigham System and one of the core faculty in neurology at Harbor Medical School. And she's 100% the first person I call when I need help with a neuromuscular patient or when I need to interpret those really thoughtful and detailed EMG reports that she sends to me. I'll reply back and say, wait, so what's actually going on here? Then she'll give me the lowdown. But thank you so much, Maeve, for being here and welcome. Well, thanks for having me. Maeve also led a wonderful session at the National Neurology Conference on an approach to the undifferentiated gate disorder. And it was in seeing this presentation that I really thought she'd be the perfect top, perfect speaker for this topic to really help us, you know, Michael and our listeners to, as you like to say, walk through the approach to what's going on with difficulty walking.

Michael Kentris: 1:58

This subject today is rife with puns. So I hope our listeners will forgive us.

SPEAKER_02: 2:02

So I guess we could just get started with actually the question I wanted to start with, May, was what are the what are the ways in which either patients are referred for this problem or that they talk about, you know, the difficulty with walking? I mean, I think I've heard lots of different things from patients. They don't necessarily say, I have trouble walking, they might say something else. But what are the types of reasons that a patient might come to see or to see their primary care provider before they're referred into us?

SPEAKER_04: 2:35

Yeah, so I think gait disorders can present, well, first of all, this is like probably one of the broadest topics in neurology, right? Because it it encompasses so much. But because gait is such a complex, you know, phenomenon that requires integration of so many different aspects of the nervous system. But broadly speaking, I think patients might um they might present very simply complaining of something's altered with their gait or they're they're walk they're they're not walking right. They feel they often might use the the term imbalance, feeling off balance. They might be falling, having issues with tripping, stumbling, falling. Um I think one of the really tricky parts is sometimes they might come to my clinic with a diagnosis that might not be accurate. So for example, they might get referred with neuropathy, which is like a pretty specific diagnosis. But what the patient really is trying to convey is that they the the sensation is altered in their feet and they feel like their balance is affected as a result. And so sometimes I try to take a step back and just fundamentally think, well, the problem is that they can't walk. Let's keep an open mind and take it from there. Trevor Burrus, Jr.

Michael Kentris: 3:50

Yeah, I always find that's one of the hardest things is if someone does have a diagnosis when they get sent to you, it's it's very tempting to anchor onto that and not kind of do your own evaluation. Um that's I think an easy trap, especially if they've been seen by another neurologist. I know we're talking more about the primary care setting, but sometimes if it's another neurologist, we're like, well, they must have done a good job, right?

SPEAKER_04: 4:12

Right.

Michael Kentris: 4:13

Maybe maybe you have some disagreements with the assessment. So that can certainly happen.

SPEAKER_04: 4:17

Aaron Powell Yeah, this is kind of why Galena was mentioning we did this course at AAM this year, which was myself, a neuroPT, and a movement neurologist coming together to give this like talk together because we realized we all see these patients in different contexts and they get different and with different referral patterns. And it can be really tricky when patients get sent down the wrong pathway. So someone gets flagged as like Parkinson's disease, but truly they have like lumbar spinal stenosis, and just trying to think outside the box and take it back to basics, even for neurologists, is really important.

Michael Kentris: 4:53

One of the things, kind of starting from a fundamental perspective, I've have a little bit of a different training background. I'm a I'm a DO graduate, and so we had a lot of musculoskeletal type of stuff in our medical school, which I know is slightly atypical. I mean, there's some stuff that's maybe a little voodoo-y. But uh but as far as like gait analysis, I always think that that's something that gets underemphasized in a lot of medical school training. I mean, one of the things that kind of really stuck with me is that uh, you know, walking is basically a series of controlled falls. And if anything in that that cycle, that gate cycle goes off balance, it can obviously result in instability, falls, wobbliness, however the patient uh characterizes it. So as you said, we we have different referral patterns depending on if we're in a subspecialty practice or a general practice. But what what do you think is usually the the best place to start when you're getting these patients at your door?

SPEAKER_04: 5:47

I think so. The helpful part is that in our clinics we walk out to get our patients. So we literally are observing their gait from the very beginning, from the first moment that we meet them. And that is like my number one opportunity to see are they, you know, is there a clear pattern here? Is is the, you know, just like taking in as much as you can as that short walk, as we could take that short walk down the hallway. Um uh are they using any aids? Um, do they need support? Um, and using that as like the basics of like how I'm gonna start talking to them about it. But a lot of it comes down to just observations with the exam that will help put you on the right pathway.

SPEAKER_02: 6:31

I think you made such a key point, Michael, about gate analysis, because that really actually takes in the context that the gate may actually be different from like the sub, you know, sedary elements of the neurological exam. And that's something that I've always found interesting that I try to kind of think of that as a different part of the exam than testing strength, testing sensory change. I guess we're jumping a little ahead to the exam and we can always go back to the history, but for that aspect, Maeve, can you talk to us a little bit about a analysis kind of broadly defined? Like what are the components and how is that different from the initial, let's say, like phase dependent elements of the physical exam?

SPEAKER_04: 7:18

Yeah, exactly. So there, I think what you're you're kind of separating out is that we have our like um neuro exam, which includes, you know, motor, sensory, reflex, and all of those things are really key to getting an answer with a gait disorder. But then the the integration of all of that plus very higher cortical functions all comes together with gate, um, the gait cycle, which, you know, we're all used to looking at what normal gait looks like. Um and I think something I learned a lot from the neuroPT that I work with on the course that we did was just how to describe the components of the gait cycle. So there's, you know, and we don't need to get like too into the weeds here because you can really, really get very detailed with like various subcomponents of gait, but um there's, you know, phases where the foot is in contact with the ground, the stance, and then there's phases where the legs are swinging and that's a swing phase. But normally there's, you know, and there's elements of rhythm and cadence and speed and kind of symmetry. And those are all things that you may not be thinking about explicitly when you're looking at someone walk, but they do flag as abnormal when there's an abnormality. And so it's just a question of sometimes really paying attention and um seeing, you know, like which side, which side, which leg appears to be abnormal. What um, you know, what leg is the person favoring? What uh are they spending more time standing on one leg? Is there a problem with the movement of the leg when they're swinging it, you know, the other, you know, the other side of things? Um sorry, I'm not explaining that very well, but it's easier with videos. I think videos are really key here because um, and I use that a lot in my clinic where I I'll video someone's gait and then I can really slow it down and watch watch it on repeat so that I can really flag, oh, it actually looks like the problem is the left leg is a little bit stiff or it's the right toes are not clearing the ground properly. And you can um pick up those observations when you see the same cycle a couple of times.

SPEAKER_02: 9:32

Yeah, I think that was one of the things that I learned uh from from the course and from talking with you was the actual idea that when you look at it all together, it's hard to differentiate so much information. And I think it it taught me that you can like, you know, just stare at the right leg for a bit and then watch that cycle and then just stare at the left leg for a bit, and even just stare at a component of the cycle. And for me, it's actually making the note of even if there's consistency cycle to cycle, right? Because sometimes we uh think about like a for I mean it's not the only case, but something like a functional neurological disorder, like that gate will look different, potentially inconsistent. Um, again, I'm oversimplifying, that's not the only marker of it, but you know, seeing how those cycles change over time. And I can't emphasize enough the video point is it's kind of like the advice I've been given by neuroophthalmologists about eye movements. It's just like you're not gonna get it the first time, just you're mostly focusing on examining them the right way as you video it.

Michael Kentris: 10:35

I think those are those are all great points. And I think one of them, to your point, with doing this course with a neuroPT, one of the most valuable experiences I had as a medical student was spending a few weeks uh with physical therapists on a rehab rotation. And literally all we were doing was like walking patients. I shouldn't say all, but a large proportion of it was just that. Yeah, it's I kind of felt the same way when I was first learning about you know how to describe different kinds of movement disorders as a resident, where it's like you can see that something's kind of off, but you don't know the words to describe it properly. So a lot of it is kind of getting your mind to recognize what your eyes are seeing and uh putting that into a framework that makes sense from a kind of medical context.

SPEAKER_04: 11:22

And I I'll also just say I think it's much more helpful to use these broad descriptive terms than to try to snap someone into a bucket immediately. The gait analysis gets like pretty skimmed over in med school, right? So um you you end up with these sort of buckets that you know have abnormal gaits, like a Parkinsonian gate is shuffling stooped, or you know, multiple other adjectives you could apply. Sometimes patients get snapped into that category too quickly because there might be some shuffling characteristics to their gait, but maybe that's not all of it. Um and you know, a lot of things can make you shuffle, right? And so just trying to keep things broad and a little bit agnostic of the diagnosis when you're describing what you're seeing is I think really helpful.

SPEAKER_02: 12:08

Going back a little bit to uh what I mentioned about history, can you tell us, Mae, are there particular ways that patients will describe in their own words, their own chief concern, their difficulty with unsteadiness or with gait that clue you in potentially to one differ one diagnosis versus another?

SPEAKER_04: 12:28

That's a great question. I mean, honestly, you could talk about this all day, but I think um think one of the big differences that people describe is feeling that the problem is kind of up in their head versus down in their legs. So sometimes people f who have maybe say balance disorders that are related to things like polypharmacy or, you know, any kind of centrally acting meds, um, maybe some ataxia from like cerebellar problems, or even maybe kind of a hypoperfusion problem from like orthostatic hypotension, they'll often kind of be gesturing to their heads and be like, I feel off balance. Um whereas someone who's got like a problem with kind of sensory motor function in their legs will really locate it there. So that can be just like a good place to start. And then um I think it, you know, identifying whether there truly are problems with sensory and motor function will really take you down a different pathway very early on compared to if someone's really just complaining of pain or stiffness or um other things that are maybe there's a a differential beyond the nervous system.

Michael Kentris: 13:40

I think that's a great point. We tend to think as specialists about neurologic causes of gait problems, but there are many other causes that are kind of obliquely or perhaps not related at all. And a lot of times those are going to be hitting their primary care doctor before they get to us and possibly even fixed before they come to us. What would be some of the more common things that uh that people should look out for as far as like the non-neurologic causes?

SPEAKER_04: 14:05

Yeah, I uh well I think you know osteoarthritis is probably the biggest thing, you know, involving the knees, the hips. And then and this can sometimes get um, you know, maybe m mislabeled as neurologic because patients are complaining of um gait disorder or slowness or stiffness. Ultimately it's a um it's a it's a joint problem. Um and then there can be some kind of deconditioning that goes along with that. So in patients who have really bad hip disease, they'll get weakness of their hip abductors as well. And that can create an abnormal gait pattern where you get this swaying from side to side, the classic Trendalenberg gait. And so I see that in clinic as well. Um that gets kind of that gets labeled as you know, proximal weakness, maybe, where in reality the problem is primarily that they have intensely degenerated hips. Yeah.

SPEAKER_02: 15:05

Maver, are there particular go-to questions that you just love to ask on history? Because these are challenging histories to obtain. It's kind of like, you know, a headache history where you really have to like tease it out and be like the number and really they may be denying kind of the or or you know, randomizing the amount. So do you have teasing questions for uh gate uh difficulties that sometimes end up being high yield?

SPEAKER_04: 15:34

That's a great question. I I think um uh one thing you know, as neurologists we're usually obsessed with is the tempo and the time course and like when did you first notice it? When were you walking normally? When did this begin? And like really asking like in a million different ways what what were the beginnings, the origins, the evolution of this? Because that will, you know, beyond localization, that will really help you clear, you know, clear yourself into the diagnosis. And also kind of the acuity and the how how how urgent this referral might be. I think falls are very important to ask about. And I usually try to ask about the most recent fall, if someone's falling frequently, so that I can really understand what happened, what what was the context of one fall, rather than saying generally when you fall, what happens? You know, it's helpful to say what was the last fall? What were you doing? Like had you just stood up, you know, what was the environment? And and getting like as much detail as you can about one fall. That's sometimes high yield. And then some some sort of questions are just sort of like I said, like any disorder of the sensory function, motor function, the presence or absence of pain, those things are all really important to to find out about as well.

Michael Kentris: 16:55

Something I found, and I'm curious about your experience, is that I'll ask, because a lot of a lot of these patients are going to be on the older side of things, and you know, there's a bit of pride sometimes associated with not being able to walk properly. And so I find that a lot of, again, here in the Midwest at least, a lot of people tend to minimize their symptoms. And so if I ask about falls, I'll say, no, I haven't fallen. And then I'll ask, like, well, have you almost fallen? And you find out, like, yes, they caught themselves on the sofa or on the wall, and like they would have gone down if they'd been in a larger space. And it was just luck that they haven't fallen so far. Or, you know, their spouse will throw them under the bus and say, like, you know, it's like, I caught you. You would have fallen if I hadn't been there.

SPEAKER_04: 17:40

Exactly, yeah.

Michael Kentris: 17:41

Something else you mentioned that I thought was interesting, and I I find it's a useful thing to differentiate out is the pain as well. And obviously there's a lot of different kinds of pain, but uh what are the the characteristics of pain that make you think of more of a neurologic issue versus say like a musculoskeletal or spinal type of issue?

SPEAKER_04: 18:00

Aaron Powell Yeah, great question. So I think so the kind of neurologic causes of pain that would affect gait, what I'm really thinking of are problems with the peripheral nerves or problems with nerve roots. So peripheral neuropathy can be extremely painful. Um, and patients will often use terms like, you know, burning, pain, or kind of hypersensitivity. Um, or they'll have like bizarre phenomena because they've lost sensation in their feet. Um, they almost like have these sensory hallucinations where they're like, oh, no matter what I do, it feels like my sock is bunched up in my in my shoe, or I got rocks in my shoe, got sand in my shoe, like my feet feel wet. These kind of like weird sensory phenomena often go along with kind of neuropathic pain symptoms. Um, and so usually kind of the distribution of that is fairly obvious because most forms of peripheral neuropathy begin in the feet. And so it'll be this kind of symmetric presentation in the feet. And then the disorders of nerve roots, or you know, any kind of problem with the kind of particularly the lumbosacral nerve roots, which, you know, L5, S1 are the nerve roots that really control a lot of the sensation and motor function of the feet and are important for gait. Disorders of nerve roots are really painful as well, and that pain is usually feels different in that it has this radiating quality. So we um generally refer to that as ridicular pain, or sometimes the term sciatica is used, but a pain that feels like it it's originating kind of in the back or in the buttock and radiating into the leg or into the thigh or even all the way down the leg. That's very suggestive of a nerve root problem. The other thing that's very suggestive of nerve root kind of impingement to me is a very positional nature of pain. So it's pain that's worse if someone's lying down. Or standing up, or they they have certain positional triggers for it, or um the classic neurogenic claudication where the pain is provoked by walking a certain distance and then alleviated by leaning forward or you know just sitting down and having a rest. So those are all the things that would make me think about um either neuropathy on one hand or ridiculopathy on the other. And I will say patients who are experiencing these kind of painful sensory phenomena usually just use the term neuropathy. They might not relate things to their kind of lumbosacral spine nerve root region. So that's why when someone says, comes into my clinic complaining of neuropathy, I'm always trying to keep an open mind as to what the actual etiology is.

Michael Kentris: 20:48

Those are all great points. One thing I, and again, I'm just curious for your anecdotal opinion, that um you know neuropathy obviously is one of our more common diagnoses that we see in the neurology clinic. And we're talking about people who are in trouble walking. At what point do most neuropathies, if we're saying like our traditional, you know, small fiber diabetic type neuropathy, when how severe does that have to be before we start seeing that affecting gait for most people?

SPEAKER_04: 21:18

This is a really good question. And I think it's like it's actually something that's come up in clinical practice quite a bit. Um because especially in a context where you have maybe competing diagnoses and you're trying to figure out, well, what's really affecting the gate, and someone has this sort of mild diabetic neuropathy, I think it's fair to question like, is this really affecting the gait? I think the the times when peripheral neuropathy really definitely affects the gate is where there's a loss of proprioception. So a problem with joint position sense manifesting as like, you know, not knowing where your feet are in space, that can clearly affect your gait. And so that's one piece. And then the other is like weakness. If someone has really advanced peripheral neuropathy to the point that it's causing them to have weakness of their ankle dorsiflexion, um, that that's going to impact gait as well. But a pure small fiber type neuropathy where you might just have pain, um kind of hypersensitivity, altered pinprick and temperature sensation, that wouldn't really affect gait in a major way, other than making it painful to walk, but it shouldn't affect the mechanics of gait. So yeah, I think it's a great point.

Michael Kentris: 22:40

Yeah, because I I find that's exactly what I wind up with is I I have someone in their you know, 70s, they've got spinal stenosis, you know, prior L5S1, laminectomy, infusion, mild diabetic neuropathy. It's like, and now they're having you know some balance traumas. Like, well, it's probably all of these.

SPEAKER_04: 23:02

All of the above.

SPEAKER_01: 23:04

Right.

SPEAKER_04: 23:04

Exactly.

SPEAKER_02: 23:06

Yeah. Maeve, I know that we're all neurologists on the call here, but thinking of our non-neurology friends who might be listening, can you walk through the exam in a little bit more detail and just share your kind of best approach to strength testing in these patients and actually sensory testing, like how do you sense vibration or proprioception and kind of like contrasting that with the small fiber testing just to review those elements and then you can get to maybe any bonus maneuvers for gait.

SPEAKER_04: 23:39

Okay, perfect. Okay, so we already talked about sort of the gait cycle and and analyzing that and observing that. And then when you get the patient sort of sitting or lying down in your office to do the more detailed neural exam, um I think um I usually start out with sort of moving the arms and legs around to feel tone. Um is there kind of a spasticity or like tightness to the tone or rigidity that might suggest something like Parkinson's disease if they're really rigid and stiff throughout? Um, and then and then I and then I test um strength. So for strength testing, this is sort of something that like I think we as neurologists get more and more comfortable with knowing like what normal strength is because we do it so many times a day. But it's important to disambiguate someone who's limited due to pain versus someone who's truly weak, like they they're not giving you any resistance to the movement because they can't. So I I'll often be questioning patients during it, like, is that if someone is having a hard time flexing their hips up, I'm like, is that painful for you, or they're just you know, or is it truly like a weakness, like you're not able to make the movement? And I test um like each muscle group individually. And then I'll, you know, for the sensory exam, I think the sensory exam is sort of like off-putting, maybe for maybe many non-neurologists, because there's so many components to it, and you know, you want to make it a useful exercise and not kind of a waste of time. And so uh you usually I think it's good to think about small fiber modalities of sensory function, so pin precursor or temperature, and then large fiber, so joint position sense and vibration sense, and maybe pick one of each and just check, check that. So you could use a tiny pin and I'll pick an area that I know sensation is normal for. So I'll I'll just show them what a pin feels like on their forehead, and then I'll just say, okay, this is a hundred percent. You feel that sharp sensation, we're gonna call that a hundred percent sharp. And then I'll move to the foot and say, Does it feel a hundred percent? It's either a yes or no. Um, I think you can get really into the weeds with, can you do it again? 99%, or you know, um, maybe especially if you like check an area that's like a slightly calloused, and then you're so I'm really just trying to get a very broad sense of like, is there a problem with that modality of sensation? And then I'll move on to check some large fiber function. So especially for gait, we're particularly interested in problems with joint position sense. So holding the toe um on its sides, not not on the top and bottom, because that's giving them way too much extra information to work with, but holding it on its sides and then just moving it very, very small movements and telling someone before you start, this is up, this is down, can you tell the difference? And then having them close their eyes and say, now where is it? Now, now, now, now, and then have them, you do it at least five times to get a sense of whether they're guessing or not. Um, and then the other great test for proprioception is the Romberg test where we have patients stand up, feet together, look straight ahead, and see are they able to keep their balance in that position, and then have them close their eyes and see if they start to sway. Which indicates that once you've removed the visual inputs, they're really struggling to maintain balance um from proprioception alone.

Michael Kentris: 27:14

You know, I find the the Romberg is one of the more misunderstood tests.

SPEAKER_04: 27:19

Yeah.

Michael Kentris: 27:19

So I see a lot of places teach it with like the arms outstretched like you're doing prone or drift simultaneously. And I always have to tell people, it's like, no, no, we don't need to do that at the same time. So I'm just curious. When do you consider a Romberg to be positive? And do you have gradations of positivity? Like I've seen people write, you know, with sway or positive or just absent or negative, you know. What are what are your thoughts on the Romberg assessment?

SPEAKER_04: 27:50

Oh yeah. I mean, it it's it is hard because, you know, there's um so I'll say to start out with, if someone can't just stand upright with their feet together and look straight ahead with their eyes open and keep their balance, then you can't really proceed with the Romberg because there's probably something else that's affecting their balance. And we're not going to be able to remove other sensory inputs and figure out is this truly a proprioceptive problem. But if someone is like good with that part and they're standing up and they look great, eyes and eyes open, feet together, then and then you get them to close their eyes and they start swaying. Um, I think you're you're absolutely right. There's like a range of how much someone can sway. Some people, they're gonna go way over and it's kind of scary to watch. Um, try not to let it get that far. Like I don't want someone to fall on me. But if someone's swaying slightly, usually I'll like uh give them, you know, a minute in that position or 30 seconds to see if they kind of write themselves. Because everyone feels a little bit off when they first start doing it. Um and people will often like start saying, Oh, I feel I feel off balance. I'm swaying, aren't I? Because they're nervous because they're seeing a neurologist for the first time and they're like, they're they're stressed about like how their performance is looking. And so I'm like, no, no, you look good, you look good, and try to reassure them and see if I can settle them into it. And then if they're if they um stop swaying and sort of, you know, steady themselves, then I call that a negative Romberg.

Michael Kentris: 29:24

Okay. I'm probably not doing my Rombergs long enough then.

SPEAKER_04: 29:28

Well, yeah, I think you're supposed to do it for quite a while. I know, yeah, we don't we don't have enough time. But um the the other thing that you can do that I I read about in one of um our, you know, myself and Golina's mentors, Marty Samuels textbooks, he does a stressed Romberg, or he did um this kind of stressed form of the Romberg, where if you think about the components of the sensory system that are contributing to balance, we have you know the visual input, so like seeing where you are in space, proprioception, which is what we're really interested in, um, kind of a sensory function perspective, and where you can feel where your feet are in space. And then there's this whole complicated vestibular system where your ears are telling, you know, your inner ear is giving you a lot of information about where you are in space. So the point of the rhomberg is we remove the visual input. We're left with just vestibular and proprioception. And if there's a problem with proprioception, um, you'll start to sway. And what Marty did was um stress the vestibular system as well during the Romberg. So make it more complicated for the patient by having them shake their heads side to side with their eyes closed. And then sometimes you'll bring out a proprioceptive problem more so because you're sort of downgrading another sensory element that's contributing to balance.

SPEAKER_02: 30:45

Maeve, I didn't know that, but I'm so glad you mentioned Marty Samuels because he used to tell the stories of how patients will tell you on their history, if you're really listening, that they've had a positive Romberg. And often it's that when they close their eyes in the shower, that's when things get really off. And so it's I always kind of joke that you know, Allah Samuels, the shower is the Romberg machine. Yes. Where the patient will say, Oh, I can't take showers anymore, or I've changed how I do it, or I'm sitting or I'm holding on. And I have to say, I heard another very interesting patient, patient experience portrayal of the Romberg, which is a gentleman I saw who said to me that he doesn't fall, he doesn't sway, everything's okay, except in church when they stand up to pray, and at the end the priest asked them to close their eyes and raise their hands to the ceiling. He consistently falls now.

SPEAKER_01: 31:39

No.

SPEAKER_02: 31:40

This is a very, very distressing experience. But I looked at him and I said, Oh, thank you, Sarai. But you've given me another story to add to the, you know, the um kind of functional Romberg testing out in the real world.

SPEAKER_04: 31:52

Exactly. Yeah. I mean, the other thing as well is like just lighting. So like if someone's just walking in dim lighting, this is why, well, there's probably a lot of reasons why people fall in the middle of the night, but that's one of the big ones is that you're removing the visual aids that help people maintain their balance. And so any kind of sensory problems come to the fore.

SPEAKER_02: 32:14

So, Maeve, you're a neuromuscular specialist. So is the answer just EMG for everyone?

SPEAKER_04: 32:23

I would say no. I think if um so when is an EMG helpful? I think um an EMG can help with identifying problems with the peripheral nervous system that might be contributing to gait disorder. But certainly I I don't think it's helpful in every single patient. Like Michael was mentioning, someone with sort of like a mild, small fiber predominant diabetic neuropathy. And by small fiber predominant, I mean really it's just like they have pain and sensitivity, but their motor and sensory function is otherwise pretty good. First of all, we might not pick much up on an EMG. And second of all, even if we do show some mild neuropathy, like is that really the cause of their gait disorder? So I'd that I would caveat the EMG with that. But if someone has um clear-cut um sensory or motor problems with their, you know, legs, and you really think this is what's contributing to their gait disorder, an EMG is probably going to be pretty helpful in number one, defining is this a peripheral neuropathy, or is it alternatively, as I mentioned, like could it be a problem with the nerve roots? And what's the severity and what are what's the characteristics? Is this like a axonal or demyelating, which helps us in neurology clinic because we're, you know, we have a totally different differential for both of those subtypes of neuropathy? Or is, you know, is the EMG totally normal? And then you have to think beyond the peripheral nervous system, could it be a spinal cord problem? So I think EMG is really helpful in those situations. So I would say any identifiable sensory motor deficits that you think are contributing to the gait disorder, EMG could really help figure that part out.

Michael Kentris: 34:05

And I assume if we're thinking like nerve roots or spinal issues, we're looking at some imaging as well in those select cases.

SPEAKER_04: 34:13

Exactly. Yeah. So if we got that history that I described earlier where someone is having, you know, that kind of radiating shooting pain or that classic neurogenic claudication where they can only walk so far before they have to stop and rest or change posture, then I would image their lumbar spine.

Michael Kentris: 34:32

And I know, you know, I think we're all practicing here in the US. And so insurance for a lot of people, getting MRIs, especially of the lumbar spine, can be challenging. And so if they haven't, I usually find that if if they don't have documented like uh like a focal weakness or some sort of, as you said, some sort of physical impairment, then getting it approved without a preceding course of physical therapy for X number of weeks is nigh impossible.

SPEAKER_04: 35:00

Yeah, that's it, that's a good point. I I have to say I haven't run into that problem a ton, but it's possibly just the selection bias that, you know, like whoever I'm seeing in my clinic, they've already kind of gone down those pathways. But um the yeah, I think I think that's actually reasonable though as well, right? Because a lot of ridiculopathy symptoms do get better with physical therapy and conservative measures. And really, you know, maybe a significant proportion of these patients don't require imaging um if they have less than six weeks of symptoms or and there's as you said, if there's no like sensory or motor deficit on the on their physical exam.

Michael Kentris: 35:38

Yeah. I know I've had a a couple older gentlemen that I go to church with who have come up to me and asked me, like, uh, Mike, you know, I'm having trouble with this this back pain. And I was like, well, how long has it been there? You know, and it, you know, it sounds like your classic kind of L5S1's the Attica kind of picture. And they're like, well, it's only been a few weeks, you know, do the physical therapy. And, you know, they're like, they're out they're out there talking to spine surgery, and I'm just like, whoa, whoa, whoa.

SPEAKER_03: 36:02

Yeah, exactly. That's the last thing you want. Yeah.

Michael Kentris: 36:05

And, you know, the most of them they both got markedly better. I mean, did it go away entirely? No. But are they thinking about spine surgery anymore? Also, no. Which kind of brings me to a second line of question. So let's say we've got this person with an undifferentiated gay disorder. They've only seen their family doc yet, they're like, maybe it's a little bit of this, a little bit of that. Is there any situation where physical therapy is the wrong choice?

SPEAKER_04: 36:30

Yeah, that's a great question. I actually think a lot of patients ask me that question because they're worried. You know, they're like, I wanted to see you first. Like it's to give me the all-clear. There's really nothing I can think of that PT is gonna worsen, you know, espe people are worried about neuropathy worsening with um physical therapy, which, you know, like mechanistically, that just doesn't really make sense and it wouldn't be a concern. So yeah, I I usually say just, you know, within reason, obviously you're trying, you're not trying to like um, you know, put yourself in a ton of pain by pushing through a bunch of exercises. But within reason, staying active, mobile, and like engaging with physical therapy is usually the right move to regardless of the diagnosis.

Michael Kentris: 37:18

Um, I would say a lot of physical therapists know more about gait than a lot of physicians do, unless you spend a lot of time specifically studying it. It's just not something part of like standard medical curriculums, like we were saying earlier.

SPEAKER_04: 37:31

Yeah. Especially like any PT with kind of neurospecific experience, they're gonna be the expert on gait analysis and they're gonna help they're gonna be diagnostically helpful as well, as well as therapeutically helpful, because they can help figure out is a problem to do with um sensory function, motor function, tone, or is this more orthopedic? You know, they'll they'll actually be often if you have a conversation, they'll they'll be really helpful.

SPEAKER_02: 37:58

Also found to your point, Maeve, about them being both diagnostic and therapeutic is like physical therapies who I really rely on when I think about augmenting the quality of life for the patient. Because sometimes you go through this diagnostic process and you know, we we give ourselves a pat on the back, okay, great, sensory, like you know, ataxia related to large fiber neuropathy, boom, done, right? And we have the diagnosis. But then the question becomes, how do we manage it? And if there's a pain component, maybe we start to take on a little bit of the pain management for the neuropathic component. But in addition, I will often talk to patients. I'll have the the Walker talk as I call it, which is sort of discussing, you know, what would be the utility of a desistive device and could it be helpful? And I personally don't, you know, fit patients for that, but I rely on my physical therapy colleagues to think about whether uh, you know, assistive device is broadly defined, but can you give us just a quick comment on what those might be or or perhaps how you talk to patients about them to try to persuade them that it could actually be helpful for maintaining their independence?

SPEAKER_04: 39:05

Yeah, I I probably um similar to you in that I really rely on physical therapy to make the assessment of like the safety with a device because some patients, you know, a walker is not the right move and it might even increase their fall risk, you know, depending on different factors. So I I usually try to have a conversation with the PT that the patient is working with and say, like, do you think um a uh like a cane or a walker would be helpful here or not? Do you think this is something that's remediable with strengthening or balance training? I think I'm maybe more prescriptive when it comes to like very focal motor deficits. Like if someone has like a foot drop and they're catching, they're clearly just catching their toes and they're tripping and falling as a result. Then I um then I talked to the patient. About using, you know, an assistive device like an ankle foot orthotic and AFO to keep the, you know, the foot raised. And that um patients often are really, really hesitant about pursuing an AFO because it c comes with a lot of kind of connotations, negative connotations of disability. But I try to, you know, emphasize that this is like a safety measure is it's really going to help maintain your independence and ability to get around without putting you at an increased full risk or at least reducing your full risk. And so, yeah.

Michael Kentris: 40:37

Those are all great points. Any other things that you say? I mean, obviously a lot of these treatments and further diagnostic investigations are going to be very dependent on what your initial assessment shows, and there's a lot of different rabbit trails to go down. But what's the one thing that you see missing most often in the assessments or thought processes that you wish people would catch on?

SPEAKER_04: 40:58

I think I'm always very appreciative when someone has come to my clinic and they've tried some physical therapy. And then I am appreciative, but I understand the limitations when someone has been recognized as having, you know, sensory motor problems and had kind of some initial workup for that with like an AMG and some imaging of the, you know, lumbar spine or higher in the spine as appropriate, depending on the pattern of symptoms. So I find that really helpful. But I think that that's tough maybe for a generalist to achieve in every patient, especially because the other point that we're trying to make with this whole conversation is it's important to keep an open mind as to the differential diagnosis and think about orthopedic and non-neurologic and kind of medication-related causes of gait disorders, as well as the more clear-cut diagnoses that we've discussed.

SPEAKER_02: 41:52

I think one thing I'll add that to sorry to jump in is just around neuropathic pain management. Because I think it's super helpful if someone has tried something, if the nature and characteristics of the pain fit a neuropathic picture. And one, they haven't been, you know, suffering for many months waiting for you. They've been on maybe a dose of something or maybe a lower dose of something. And then you can feel both you have a little bit of therapeutic information. How do they do with it to helps you even potentially diagnostically, you know, did their pain respond to a neuropathic agent? But also gives you something that you can do in terms of increasing the dose or or trying alternatives. But I find that sometimes on history, almost their response to some of these medications can be helpful into cluing me into what's going on.

SPEAKER_04: 42:40

Yeah, and I'll just say one additional piece to that, just to push back slightly, is just um sometimes there's a little bit of confusion about what neuropathic pain medications can achieve. So patients sometimes are prescribed them just for numbness and tingling. When it's, you know, things like gabapentin help with neuropathic pain and they reduce the intensity of pain in not all patients, unfortunately, but they do not help with the loss of sensation or the, you know, that kind of altered sensation. And so they're they're and they're only going to have side effects in that scenario. So just to make sure that we're treating with neuropathic pain meds, we're always treating pain and not just kind of nonspecific sensory symptoms.

Michael Kentris: 43:25

That's a great point.

SPEAKER_02: 43:27

Yeah, great point about expectation setting too in education. Well, Maeve, it's been so wonderful to have you on the show, just sharing your wisdom, walking the talk, as they say, talking, walking the talk. Yeah. And uh I feel like I could learn so much more from you, and hopefully we'll be able to chat more about this at other time. But any final words, anything, anything else to share?

SPEAKER_04: 43:53

Oh gosh, I can't think of anything snappy to say. I was thinking of run out of puns. But uh, thanks for having me. This has been amazing.

Michael Kentris: 44:01

Any projects that you'd like to plug or anything you're working on presently?

SPEAKER_04: 44:05

Well, we're doing kind of uh a streamlined version of this talk at the full AAM conference of the the kind of gate disorder talk that I mentioned earlier. Um that's what I'm working on right now.

SPEAKER_01: 44:16

But um It's awesome.

SPEAKER_02: 44:19

So if you want more, yeah, catch uh catch MAVE in in November.

Michael Kentris: 44:24

Awesome.

SPEAKER_02: 44:24

All right.

Michael Kentris: 44:26

Uh Galena, any final words today before we all sign off?

SPEAKER_02: 44:30

No, just thank you again, Michael. Thank you again, MAVE. Thanks to everyone for listening. And if we are addressing chief concerns that you like, let us know. And if we're missing chief concerns you want to hear more about, let us know as well.

Michael Kentris: 44:44

Find all of our prior podcasts on your favorite podcast app, and you can always check out our website at theneurotransmitters.com. Thank you all for listening again, and we'll talk to you again really soon.

SPEAKER_04: 44:58

Thank you.