A 38‐year‐old woman complained of a gait disorder, which began at the age of 33 and was characterized by episodes of sudden gait arrest. In addition, she manifested since childhood a series of movements as shoulder shrug, head tilts, and facial grimaces, frequently associated with guttural vocalizations, poorly inhibited on demand. These movements increased immediately after pregnancy, when gait dysfunction and obsessive‐compulsive behaviors (OCBs) also appeared. While walking, the patient reported an urge to stop, as if to hit or move something with her foot. This could be suppressed by the patient, although, in association with the increase of an uncomfortable sensation, described as an inner tension. This uncomfortable feeling disappeared after the patient stopped again. Her gait arrests could also manifest repeatedly in clusters. Brain MRI and laboratory tests, including serum antistreptolysin 0, streptozyme, transferrin, ferritin, copper, ceruloplasmin, and acanthocytes, were normal. All symptoms improved with risperidone therapy (2 mg/day, with a follow‐up of 6 months).
Which clinical condition cannot underlie a paroxysmal gait dysfunction?
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Freezing of gait (FoG)
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Paroxysmal dyskinesia
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Gait apraxia
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Tourette's syndrome (TS)
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Psychogenic disorder
Unlike clinical conditions, such as gait apraxia, which permanently affects ability to walk, few neurological disorders cause episodic gait dysfunction. Of these, FoG, mainly observed in parkinsonism, is the most frequent.1 Less‐common disorders include psychogenic disorders, paroxysmal dyskinesias, and episodic ataxias.2 Episodic gait abnormalities induced by tics (e.g., tripping, “blocking” of gait, and hip movements) have been also reported.3 Our patient fulfilled criteria for diagnosis of TS.4 Phenomenological aspects of her gait dysfunction could resemble FoG, from which, however, differed for the absence of alternate trembling of the legs, increase in cadence with decrease in step length, and subjective feeling of feet being glued to the floor.1 On the contrary, she complained of an urge to stop. The need to move her legs as if to hit or move something with her foot could suggest an OCB. The interpretation of gait arrests as tics was based on the feeling of inner tension, consisting with a typical premonitory urge,5, 6 that she experienced when she tried to suppress them, and the relief of this sensation after she stopped again, when gait arrests could manifest repeatedly in clusters.4 There were no features suggestive of alternative phenomenological diagnoses, such as psychogenic gait abnormality7 or stereotypies.8
Notably, risperidone therapy (level of evidence A, according to European Society for the Study of Tourette syndrome [ESSTS] guidelines)9 was effective on all symptoms, including gait dysfunction.
Author Roles
(1) Research Project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript: A. Writing of the First Draft, B. Review and Critique.
G.R.: 1A, 1B, 1C, 3A
D.M.: 1B, 3A
G.L.: 1A, 3B
Disclosures
Funding Sources and Conflicts of Interest: The authors report no sources of funding and no conflicts of interest.
Financial Disclosures for previous 12 months: The authors declare that there are no disclosures to report.
Supporting information
A video accompanying this article is available in the supporting information here.
Video S1. Segment 1: The patient shows gait arrests resembling “freezing,” mainly involving the right leg alone or both legs at the same time, associated with extension of both upper limbs. During these arrests, she also manifests startle‐like axial movements, bending forward of her trunk, side‐to‐side head tilts, leg jerking, and kicking. Segment 2: While the patient is sitting at rest on the couch, multiple motor tics are observed, including right shoulder shrug, head flicks, head tilts, facial grimacing, arm stretching, truncal sideways jerks, sudden hip flexion, and adduction. In both segments, the patient was instructed to relax and not to suppress tics. She reported an internal tension pushing her to make those movements.
Relevant disclosures and conflicts of interest are listed at the end of this article.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
A video accompanying this article is available in the supporting information here.
Video S1. Segment 1: The patient shows gait arrests resembling “freezing,” mainly involving the right leg alone or both legs at the same time, associated with extension of both upper limbs. During these arrests, she also manifests startle‐like axial movements, bending forward of her trunk, side‐to‐side head tilts, leg jerking, and kicking. Segment 2: While the patient is sitting at rest on the couch, multiple motor tics are observed, including right shoulder shrug, head flicks, head tilts, facial grimacing, arm stretching, truncal sideways jerks, sudden hip flexion, and adduction. In both segments, the patient was instructed to relax and not to suppress tics. She reported an internal tension pushing her to make those movements.