From the Department of Rehabilitation (J.N.), Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre of Expertise for Parkinson & Movement Disorders; Department of Rehabilitation (J.N.), Sint Maartenskliniek, Nijmegen, the Netherlands; Department of Neurology and Centre of Clinical Neuroscience (E.R., T.S.), First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic; Department of Neurology (S.G.R.), The University of Maryland School of Medicine, Baltimore, MD; Department of Neurology (B.R.B.), Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, the Netherlands; andNational Institute of Neurological Disorders and Stroke (M.H.), Bethesda, MD.
Neurology. 2020 Jun 16;94(24):1093-1099. doi: 10.1212/WNL.0000000000009649. Epub 2020 Jun 1.
Functional gait disorders are common in clinical practice. They are also usually disabling for affected individuals. The diagnosis is challenging because no single walking pattern is pathognomonic for a functional gait disorder. Establishing a diagnosis is based not primarily on excluding organic gait disorders but instead predominantly on recognizing positive clinical features of functional gait disorders, such as an antalgic, a buckling, or a waddling gait. However, these features can resemble and overlap with organic gait disorders. It is therefore necessary to also look for inconsistency (variations in clinical presentation that cannot be reconciled with an organic lesion) and incongruity (combination of symptoms and signs that is not seen with organic lesions). Yet, these features also have potential pitfalls as inconsistency can occur in patients with dystonic gait or those with freezing of gait. Similarly, patients with dystonia or chorea can present with bizarre gait patterns that may falsely be interpreted as incongruity. A further complicating factor is that functional and organic gait disorders may coexist within the same patient. To improve the diagnostic process, we present a sign-based approach-supported by videos-that incorporates the diverse clinical spectrum of functional gait disorders. We identify 7 groups of supportive gait signs that can signal the presence of functional gait disorders. For each group of signs, we highlight how specific clinical tests can bring out the inconsistencies and incongruencies that further point to a functional gait disorder.
功能性步态障碍在临床实践中很常见。它们通常也会使受影响的个体丧失能力。由于没有单一的步态模式是功能性步态障碍的特征性表现，因此诊断具有挑战性。诊断的建立不是主要基于排除器质性步态障碍，而是主要基于识别功能性步态障碍的阳性临床特征，如疼痛步态、足内翻或鸭步。然而，这些特征可能与器质性步态障碍相似并重叠。因此，还需要寻找不一致性（临床表现的变化不能与器质性病变相协调）和不协调性（症状和体征的组合与器质性病变不一致）。然而，这些特征也存在潜在的陷阱，因为在有肌张力障碍步态或步态冻结的患者中可能会出现不一致性。同样，有肌张力障碍或舞蹈病的患者可能会出现奇异的步态模式，这些模式可能会被错误地解释为不协调性。一个进一步使情况复杂化的因素是，功能性和器质性步态障碍可能同时存在于同一患者中。为了改善诊断过程，我们提出了一种基于征象的方法——通过视频支持——纳入了功能性步态障碍的广泛临床谱。我们确定了 7 组支持性步态征象，这些征象可以提示功能性步态障碍的存在。对于每组征象，我们强调特定的临床检查如何揭示进一步指向功能性步态障碍的不一致性和不协调性。
