Balance and Gait Problems

Abstract

73-year-old gentleman was referred to Neurology outpatient clinic by his General Practitioner for gait and balance issues. Patient reported a 3 year history of difficulty mobilising due to leg weakness, as well as his problems with balance. He also mentioned memory problems, which was corroborated by his wife. His symptoms had progressively worsened over the years. He also complained of proximal limb weakness, worse on the left, long standing urinary problems (urgency with occasional “incidents”), intermittent faecal incontinence and lower back pain, not-radiating to his legs. He also reported significant weight loss despite a good appetite. His swallowing had become of some concern recently as well due to occasionally choking. His symptoms seemed to worsen as the day progressed (aggravated by fatigue/exertion). On examination he had a broad based gait, decreased power in legs, with a grade of 4/5 on the right and 3/5 on the left. There was some loss of dexterity in his hands when picking up small things (coins, pencil etc.) but muscle strength seemed normal. There were increased reflexes in lower extremities and normal reflexes in upper extremities. He had bilateral nystagmus with diplopia in lateral position. There was also finger/nose and finger/finger ataxia with dysmetria and intention tremor. He struggled to drink (choked on examination) but soft palate and tongue moved well. His speech seemed slurred/dysarthric, but according to his family it had not progressed recently. His jaw jerk was increased. There was no facial asymmetry (no ptosis or facial drooping).