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Suggest treatment for symptoms of truncal instability

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Posted on Fri, 22 May 2015
Question: Dear Dr. Saghafi,
Below are the youtube links where you could visit and see the videos for my mothers condition. The last link has 3-4 videos.
https://youtu.be/-YYYYgAGc
https://youtu.be/YYYY51qOQ
https://youtu.be/YYYYyFso
https://youtu.be/YYYYz-ad28

MRA of the head is scheduled for early next week.
Thanks and regards,
XXXX
doctor
Answered by Dr. Dariush Saghafi (23 hours later)
Brief Answer:
I will be looking at all the videos you have uploaded later this evening

Detailed Answer:
IN order to comply with the 24 hr network rule to turn around consultation requests I am answering you simply to let you know that since yesterday my hospital schedule has been extremely busy...my apologies.

But I will be reviewing all of your videos this evening. And giving you some opinions on what I'm seeing. I will also go back and review the notes to refresh my memory as to what I am looking at with your mum.

Cheers!
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi (2 hours later)
Dear Dr. Saghafi,
Perhaps this video that i had just uploaded might give you a better picture of my mothers condition. Below is the link for the same.
https://youtu.be/YYYYt3vDg
Best regards,
doctor
Answered by Dr. Dariush Saghafi (16 hours later)
Brief Answer:
Appears to have truncal instability

Detailed Answer:
Good morning Mr. XXXXXXX Thank you for your videos. I looked at them a number of times last evening and again this morning. It would be nice to be able to see more of your mother walking with someone else perhaps assisting her and for me to see more of her full body walking, turning and so forth. For example, on the video where you are assisting her walking the only I can really see is her face and upper body. That is because you are filming and helping her so she doesn't fall. Videos of subjects ambulating should always be done in an area that allows them to walk free and clearly of objects that they may have trouble navigating. It should also show full body shots and the legs and feet should be somewhat exposed, dress held up so that one can see the action of the knees, the hips, and the feet. This was difficult in your videos. Of course, I know you do not do this routinely so that's what I'm mentioning these details. Also, be sure to capture the subject while making turns so show steadiness and ability to go in the opposite direction.

Obviously I agree that her balance is poor but I cannot tell whether this could be due to a peripheral neuropathy or could it be a cerebellar problem. As you know the MRI of the brain was read as showing very little wrong except for what the reader called mild enlargement of the ventricles which is not unexpected for someone of your mother's age.

The other things I noticed from the videos you got of her is that she has good and symmetric movements in the legs and arms. This tells me that she does not have a stroke or strokelike illness present in the hemispheres of the brain. It is still possible that she could have a problem in her cerebellar pathways or the cerebellum itself could be shrinking....but again, the MRI did not suggest that this was the case. I did see in another MRI report the finding of a very small area of focal ischemia in the right basal ganglia. I do not believe this to be of any consequence to her style of gait which is very dysequilibric as opposed to demonstrating XXXXXXX weakness which would necessarily in the left face, arm, and leg for the location of this lesion.

I also did not see a PARKINSONIAN type of gait which would be considered a small steppage type of gait with a phenomenon known as festination where the patient "runs on their toes" as they continue to walk. She has a slowness about her but this is because she seems unsure of where to put her next step.

I did also review all her labs and cervical spine film report and noted that there is a bulging disk at C4/5 and C5/6 but this is of no consequence to her imbalance. Perhaps, she may be complaining of a bit of pain in the neck radiating down the right shoulder or upper arm...but other than that I don't see a problem.

In her labs the only thing I found significant (from a neurological point of view) was a low Vitamin D level. We don't use the same units as the laboratory where you had her analyzed, however, if I were to use the numbers they have there I would say that a good vitamin D level for your mother to have for neurological purposes should be above 60, perhaps 70-80 would be very nice for her. I don't know if this would really make a significant difference to the way she is walking but it certainly would put her vitamin D in a nice therapeutic range so that her bodily functions are well supported by this important nutrient. Otherwise, all other laboratory analyses seem to be quite adequate.

I'm sure her doctors have pointed out that her cholesterol is also high but this will not affect her gait but it is important to attend to this since it puts her at right for heart attacks and strokes.

Of all the labs I saw I thought it strange that I did not see any measurements of her blood sugar. There was no Hemoglobin A1C which is often obtained when considering diabetes in any individual but at the very least I would expect to see a glucose in serum in her electrolytes or other labs and I didn't see anything.

There is also an elevated White Count of 11,200 and this was surprising to me as well as a few numbers having to do with her red blood cell counts that seemed a bit high and one was low suggestive of some type of anemic condition even though the total red cell count and hematocrit seem to be normal. This is a question that a hematologist would be better equipped to answer. I only bring it to your attention...and especially the WBC count which is always suggestive of some type of infectious process. Perhaps, she had an upper respiratory illness of some sort that she had been battling at the time they drew her blood....her urine seemed to be free of infection or major abnormality. And certainly her videos did not suggest to me that she was in an infected or toxic state either...but again, just to draw your attention to these numbers that I witnessed.

I saw the results of her echocardiogram and doppler of the heart which was normal. As well, the doppler of her neck (in my opinion) does not require any further action for the moderate degree of plaque that seems to be present. If one wished to get an MRA of the neck to see whether it showed anything differently but the results do not suggest to me that she should be submitted for surgery of an endarterectomy or any such thing. The risk is much higher for a complication than the benefit would be to "clean" anything out so I would leave well enough alone in that department.

I expect you will be sending along another video or 2 based on my suggestions.

In the mean time I can tell you that just based upon what I saw on the video (and knowing nothing else about the patient) my initial thoughts on why she could be walking as she is would be:

1. Cerebellar stroke
2. Spinocerebellar degeneration (I don't see much ATAXIA)...just a lot of imbalance
3. Acoustic Neuroma
4. Peripheral neuropathy (some labs already completed for this but others not)
5. Normal Pressure Hydrocephalus
6. Bihemispheric stroke
7. Multi-infarct dementia

Your mother may benefit from a treatment called VESTIBULOTHERAPY. This is a form of physical therapy but it is where she is taught how to balance using her eyes and other senses to secure herself while standing or walking. She must be cooperative and she must practice the techniques intently in order for this to work but if you can find people where she is who are well versed in how to accomplish this, it can be very effective.

If this answer satisfactorily addresses your question then, I'd appreciate the favor of a HIGH STAR RATING with some written feedback on your part.

Also, CLOSING THE QUERY on your end (if there are no further comments) will be most helpful and appreciated so that this question can be transacted and archived expeditiously for further reference by colleagues as necessary.

Please keep me informed as to the outcome of your mum's situation by writing me at: bit.ly/drdariushsaghafi

All the best

The query has required a total of 183 minutes of physician specific time to read, research, analyze videos, and compile a return envoy to the patient.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Dariush Saghafi

Neurologist

Practicing since :1988

Answered : 2473 Questions

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Suggest treatment for symptoms of truncal instability

Brief Answer: I will be looking at all the videos you have uploaded later this evening Detailed Answer: IN order to comply with the 24 hr network rule to turn around consultation requests I am answering you simply to let you know that since yesterday my hospital schedule has been extremely busy...my apologies. But I will be reviewing all of your videos this evening. And giving you some opinions on what I'm seeing. I will also go back and review the notes to refresh my memory as to what I am looking at with your mum. Cheers!