Stand- und Ganganalyse bei Schwindel

Zusammenfassung

Bei etwa 1/3 der Patienten mit dem Leitsymptom Schwindel steht die Stand- und Gangunsicherheit dauerhaft im Vordergrund der Beschwerden. Dies betrifft insbesondere Patienten mit sensorischen Defiziten (vestibulär, somatosensorisch, visuell), neurodegenerativen Erkrankungen (zerebelläre Ataxie, Parkinson-Syndrome) und funktionellen Störungen (somatoformer und phobischer Schwindel). Zur Diagnosestellung ist eine strukturierte Erfassung der Defizite eine wichtige Voraussetzung. Dazu gehören im Bereich des Stehens und Gehens die Testung unter verschiedenen Bedingungen, also mit offenen und geschlossenen Augen, im Tandemstand, beim Gehen mit verschiedenen Geschwindigkeiten, beim Stehen und Gehen während eines kognitiven Dual task. Die qualitative Beurteilung kann sehr gut anhand der geschulten klinischen Beobachtung erfolgen, die durch etablierte Tests und Scores ergänzt wird (z. B. Timed-up-and-go Test). Apparative Methoden dienen vor allem (1) der Unterstützung der differentialdiagnostischen Einordnung mit Erfassung von Parametern, die der klinischen Beobachtung entgehen (z. B. 14 Hz Schwanken beim orthostatischen Tremor), (2) der Abschätzung des Sturzrisikos durch Quantifizierung relevanter Parameter (z. B. Schritt-zu-Schritt Variabilität) und (3) der Verlaufsbeurteilung mit oder ohne Intervention (z. B. Ganggeschwindigkeit und –variabilität nach Liquorablassversuch bei Normaldruckhydrozephalus). Die Methoden zur apparativen Testung entwickeln sich aktuell sehr dynamisch. Die für Schwindelpatienten wichtigsten Methoden sind die Stabilometrie/Posturografie mit Kraftmessplatten für die Erfassung der Körperschwankungen, Sensorteppiche für die Erfassung räumlicher und zeitlicher Schrittparameter und tragbare Sensoren für die Erfassung der Mobilität und Sturzfrequenz außerhalb der Klinik im Alltag. Ohne klinische Einordnung basierend auf Anamnese und klinischer Untersuchung haben die apparativen Zusatzuntersuchungen allerdings keinen Wert. Sie liefern aber – gezielt eingesetzt – sehr wertvolle Informationen über die individuellen Einschränkungen und können damit die Diagnostik und Therapieentscheidungen unterstützen.

Abstract

In about one third of patient with the chief complaint of vertigo and dizziness the instability of stance and gait is the leading symptom. This is in particular true for patients suffering from sensory deficits (vestibular, somatosensory, visual), from neurodegeneration (cerebellar ataxia, Parkinsonian syndromes), and from functional disorders (somatoform and phobic dizziness). To make a correct diagnosis, it is essential assessing all deficits in a structured manner. This includes tests of postural control and gait under different conditions, i.e. eyes open and closed, tandem stance, walking at different velocities, stance and gait during cognitive dual tasks. A qualitative assessment can easily be done by skilled clinical observation, complemented by established tests and scores (e.g. timed-up-and-go test). Instrumented stance and gait tests support (1) the differential diagnosis by providing parameters invisible for the clinical eye (e.g. 14 Hz sway in orthostatic tremor), (2) the estimation of the fall risk by quantification of relevant parameters (e.g. stride to stride gait variability), and (3) the assessment of the disease course with and without intervention (e.g. gait velocity and gait variability after spinal tap in normal pressure hydrocephalus). Methods for apparative testing currently develop rapidly and in a dynamic manner. Currently, the most relevant methods used in patients suffering from vertigo and dizziness are stabilometry/posturography with force plates for the quantification of body sway, sensor carpets for the assessment of spatial and temporal stride parameters, and wearable sensors for the assessment of mobility and fall frequency in daily life, outside the laboratory. Instrumented tests, however, are of no value without state of the art clinical workup based on the patient’s history and clinical bedside examination. Used with clear focus, laboratory tests for stance and gait deliver valuable information on the individual impairment, thus supporting diagnostics and therapeutic decisions.

Schlüsselwörter

Ganganalyse - Gangstörung - Neurodegeneration - Posturografie - Vestibuläre Störung

Keywords

gait analysis - gait disorder - neurodegeneration - posturography - vestibular deficit

• Literatur

• 1 Jahn K, Kressig RW, Bridenbaugh SA et al. Dizziness and unstable gait in old age. Dtsch Arztebl Int 2015; 112: 387-393
• 2 Wuehr M, Pradhan C, Novozhilov S et al. Inadequate interaction between open- and closed-loop postural control in phobic postural vertigo. J Neurol 2013; 260: 1314-1323
• 3 Schniepp R, Wuehr M, Huth S et al. Gait characteristics of patients with phobic postural vertigo: effects of fear of falling, attention, and visual input. J Neurol 2014; 261: 738-746
• 4 Deandrea S, Lucenteforte E, Bravi F et al. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology 2010; 21: 658-668
• 5 Homann B, Plaschg A, Grundner M et al. The impact of neurological disorders on the risk for falls in the community dwelling elderly: a case-controlled study. BMJ 2013; 3: e003367
• 6 Helmchen C, Machner B, Lehnen N et al. Current state of diagnostic management of acute vertigo: a survey of neurologists in Germany. J Neurol 2014; 261: 1638-1640
• 7 Strupp M, Hüfner K, Sandmann R et al. Central oculomotor disturbances and nystagmus: a window into the brainstem and cerebellum. Dtsch Arztebl Int 2011; 108: 197-204
• 8 Eid E, Dastan S, Heckmann JG. Acute dizziness in rural practice: Proposal of a diagnostic procedure. J Neurosci Rural Pract 2015; 6: 272-276
• 9 Okumura T, Horii A, Kitahara T et al. Somatosensory shift of postural control in dizzy patients. Acta Otolaryngol 2015; 135: 925-930
• 10 Hong SK, Park JH, Kwon SY et al. Clinical efficacy of the Romberg test using a foam pad to identify balance problems: a comparative study with the sensory organization test. Eur Arch Otorhinolaryngol 2014; [doi]
• 11 Cohen HS, Sangi-Haghpeykar H, Ricci NA et al. Utility of stepping, walking, and head impulses for screening patients for vestibular impairments. Otolaryngol Head Neck Surg 2014; 151: 131-136
• 12 Munnings A, Chisnall B, Oji S et al. Environmental factors that affect the Fukuda stepping test in normal participants. J Laryngol Otol 2015; 129: 450-453
• 13 Jahn K, Heinze C, Selge C et al. Gait disorders in geriatric patients. Classification and therapy. Nervenarzt 2015; 86: 431-439
• 14 Manckoundia P, Perennou D, Pfitzenmeyer P et al. Backward disequilibrium in the elderly: review of symptoms and proposition of a tool for quantitative assessment. Rev Med Interne 2007; 28: 242-249
• 15 Obermann M. Chronic dizziness and vertigo from a neurologists' perspective. Dtsch Med Wochenschr 2013; 138: 269-274
• 16 Chetana N, Jayesh R. Subjective visual vertical in various vestibular disorders by using a simple bucket test. Indian J Otolaryngol Head Neck Surg 2015; 67: 180-184
• 17 Cohen HS, Kimball KT. Usefulness of some current balance tests for identifying individuals with disequilibrium due to vestibular impairments. J Vestib Res 2008; 18: 295-303
• 18 Krafczyk S, Tietze S, Swoboda W et al. Artificial neural network: a new diagnostic posturographic tool for disorders of stance. Clin Neurophysiol 2006; 117: 1692-1698
• 19 Brandt T, Strupp M, Novozhilov S et al. Artificial neural network posturography detects the transition of vestibular neuritis to phobic postural vertigo. J Neurol 2012; 259: 182-184
• 20 Schniepp R, Wuehr M, Pradhan C et al. Nonlinear variability of body sway in patients with phobic postural vertigo. Front Neurol 2013; 4: 115
• 21 Querner V, Krafczyk S, Dieterich M et al. Patients with somatoform phobic postural vertigo: the more difficult the balance task, the better the balance performance. Neurosci Lett 2000; 285: 21-24
• 22 Wuehr M, Kugler G, Schniepp R et al. Balance control and anti-gravity muscle activity during the experience of fear at heights. Physiol Rep 2014; 2: e00232
• 23 Allum JH, Tang KS, Carpenter MG et al. Review of first trial responses in balance control: influence of vestibular loss and Parkinson's disease. Hum Mov Sci 2011; 30: 279-295
• 24 Jahn K, Zwergal A, Schniepp R. Gait disturbances in old age: classification, diagnosis, and treatment from a neurological perspective. Dtsch Arztebl Int 2010; 107: 306-316
• 25 Schniepp R, Wuehr M, Schlick C et al. Increased gait variability is associated with the history of falls in patients with cerebellar ataxia. J Neurol 2014; 261: 213-223
• 26 Wuehr M, Schniepp R, Ilmberger J et al. Speed-dependent temporospatial gait variability and long-range correlations in cerebellar ataxia. Gait Posture 2013; 37: 214-218
• 27 Schniepp R, Wuehr M, Neuhaeusser M et al. Locomotion speed determines gait variability in cerebellar ataxia and vestibular failure. Mov Disord 2012; 27: 125-131
• 28 Wuehr M, Schniepp R, Schlick C et al. Sensory loss and walking speed related factors for gait alterations in patients with peripheral neuropathy. Gait Posture 2014; 39: 852-858
• 29 Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas 2013; 75: 51-61
• 30 Kugler G, Huppert D, Schneider E et al. How acrophobia impairs visual exploration and gait. Nervenarzt 2013; 84: 1233-1237
• 31 Wrisley DM, Kumar NA. Functional gait assessment: concurrent, discriminative, and predictive validity in community-dwelling older adults. Phys Ther 2010; 90: 761-773
• 32 Hogue JD. Office Evaluation of Dizziness. Prim Care 2015; 42: 249-258
• 33 Choi JH, Seo JD, Choi YR et al. Exercise-induced downbeat nystagmus in a Korean family with a nonsense mutation in CACNA1A. Neurol Sci 2015; 36: 1393-1396
• 34 Schniepp R, Wuehr M, Huth S et al. The gait disorder in downbeat nystagmus syndrome. PloS One 2014; 9: e105463
• 35 Wuehr M, Schniepp R, Pradhan C et al. Differential effects of absent visual feedback control on gait variability during different locomotion speeds. Exp Brain Res 2013; 224: 287-294
• 36 Wuehr M, Schniepp R, Schlick C et al. Sensory loss and walking speed related factors for gait alterations in patients with peripheral neuropathy. Gait Posture 2014; 39: 852-858
• 37 Mori S, Matsui T, Kuze B et al. Cerebellar-induced locomotion: reticulospinal control of spinal rhythm generating mechanism in cats. Ann N Y Acad Sci 1998; 860: 94-105
• 38 Jahn K, Deutschlander A, Stephan T et al. Supraspinal locomotor control in quadrupeds and humans. Progr Brain Res 2008; 171: 353-362
• 39 Jahn K, Deutschlander A, Stephan T et al. Brain activation patterns during imagined stance and locomotion in functional magnetic resonance imaging. NeuroImage 2004; 22: 1722-1731
• 40 Brandt T, Strupp M, Benson J. You are better off running than walking with acute vestibulopathy. Lancet 1999; 354: 746
• 41 Schniepp R, Kugler G, Wuehr M et al. Quantification of gait changes in subjects with visual height intolerance when exposed to heights. Front Hum Neurosci 2014; 8: 963
• 42 Schniepp R, Wuehr M, Huth S et al. Gait characteristics of patients with phobic postural vertigo: effects of fear of falling, attention, and visual input. J Neurol 2014; 261: 738-746
• 43 Kressig RW, Herrmann FR, Grandjean R et al. Gait variability while dual-tasking: fall predictor in older inpatients?. Aging Clin Exp Res 2008; 20: 123-130
• 44 Brandt T, Kugler G, Schniepp R et al. Acrophobia impairs visual exploration and balance during standing and walking. Ann N Y Acad Sci 2015; 1343: 37-48
• 45 Lord S, Galna B, Verghese J et al. Independent domains of gait in older adults and associated motor and nonmotor attributes: validation of a factor analysis approach. J Gerontol Series A, Biol Sci Med Sci 2013; 68: 820-827
• 46 Pradhan C, Wuehr M, Neuhaeusser M et al. Multi-variate gait data analysis: comparison between healthy adults of different age groups. J Neurosci Neuroengineering 2013; 2: 542-549
• 47 Pradhan C, Wuehr M, Akrami F et al. Automated classification of neurological disorders of gait using spatio-temporal gait parameters. J Electromyography Kinesiology 2015; 25: 413-422
• 48 Beauchet O, Allali G, Annweiler C et al. Gait variability among healthy adults: low and high stride-to-stride variability are both a reflection of gait stability. Gerontology 2009; 55: 702-706
• 49 Evitt CP, Quigley PA. Fear of falling in older adults: a guide to its prevalence, risk factors, and consequences. Rehabilitation Nursing 2004; 29: 207-210
• 50 Schniepp R, Wuehr M, Neuhaeusser M et al. 4-aminopyridine and cerebellar gait: a retrospective case series. J Neurol 2012; 259: 2491-2493
• 51 Schniepp R, Wuehr M, Ackl N et al. 4-Aminopyridine improves gait variability in cerebellar ataxia due to CACNA 1A mutation. J Neurol 2011; 258: 1708-1711