Treatment of walking disorders
Last reviewed: 23.04.2024
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Treatment of walking disorders
In the treatment of walking disorders, measures aimed at treating the underlying disease are crucial. It is important to identify and correct all additional factors that can affect walking, including orthopedic disorders, chronic pain syndromes, affective disorders. It is necessary to limit the intake of medications that can worsen walking (for example, sedatives).
Non-pharmacological treatment of walking disorders
Important is therapeutic gymnastics, aimed at training the skills of initiating walking, turning, maintaining balance, etc. Recognition of the main defect allows to develop a way of its compensation by connecting the stored systems. For example, you can recommend a set of special exercises of Chinese gymnastics "tai chi", developing postural stability. With multisensory insufficiency, correction of visual and auditory function, training of the vestibular apparatus, and also improvement of illumination, including at night, are effective.
Part of the patients have effective methods of correcting the step with the help of visual landmarks or rhythmic auditory commands, walking training on a treadmill (with special support), etc. Regular physical activity allows to prevent the consequences of mobility limitation (muscle atrophy from inactivity, osteoporosis, reduction of compensatory possibilities of the cardiovascular system), which close the vicious circle and complicate the subsequent rehabilitation. To significantly improve the quality of life of patients, educational programs that teach them how to move are able to avoid falls, fall injuries, how to use orthopedic devices (various crutches, walkers, special shoes, adaptations, corrective posture, etc.).
Drug treatment for walking disorders
Drug therapy depends on the etiology of walking disorders. The best results are achieved with the treatment of Parkinson's disease with dopaminergic agents. Under the influence of levodopa, the step length and walking speed in patients with Parkinson's disease increase significantly, especially in the early stages of the disease, when walking disorders are more dependent on hypokinesia and rigidity in the limbs. As the disease progresses in connection with the growth of postural instability, axial motor disorders, which are more dependent on nedophaminergic mechanisms and relatively resistant to levodopa, the effectiveness of treatment is reduced. When pouring out during the "turn-off" period, measures aimed at increasing the duration of the "inclusion" period-dopamine receptor agonists, catechol-O-methyltransferase inhibitors-are effective. With comparatively rare pouring in the period of "inclusion", a decrease in the dose of levodopa may be required, which can be compensated for by increasing the dose of the dopamine receptor agonist, adding an MAO inhibitor of type B or amantadine, learning to overcome palliation, training walking using visual landmarks and rhythmic auditory signals, psychopathological changes (primarily with the help of antidepressants). Long-term follow-up of patients with Parkinson's disease who started treatment with levodopa or pramipexole has shown that earlier use of levodopa is associated with a lower risk of palliation. It was also noted that early and long-term use of MAO inhibitors type B reduces the frequency of palliation, and also contributes to their correction if they have already developed. The correction of orthostatic hypotension may be important. Preparations of levodopa may be useful in other diseases accompanied by Parkinson's syndrome (for example, in vascular parkinsonism or multisystem atrophy), but in this case their effect is at best mild and temporary. Some cases of improvement of congestion and other walking disorders, resistant to levodopa, under the influence of inhibitors MAO type B (selegiline and rasagiline), as well as amantadine are described.
Correction of chorea, dystonia, myoclonia and other extrapyramidal hyperkinesis can improve walking, however, appropriate antidiskinetic drugs should be administered with caution, given the possible negative effects. For example, in patients with Huntington's disease, neuroleptics can weaken hyperkinesis, but contribute to a deterioration in mobility due to the increase in bradykinesia and sedation - in this situation, the drug of choice is amantadine. In the dystonia of the lower limbs, local treatment with botulinum toxin can be effective.
Reduction of spasticity (with the help of muscle relaxants or injections of botulinum toxin), for example, in patients with infantile cerebral palsy, can greatly facilitate walking. However, in patients who have suffered a stroke, an increase in tonus in the muscles of the shin can have a compensatory value and its elimination with antispastic agents can make walking difficult. Therefore, the use of antispastic drugs should focus not so much on reducing muscle tone, but on increasing the mobility of patients and accompanied by physical methods of rehabilitation. In patients with severe lower spastic paraparesis (eg, after spinal trauma) or coarse spastic hemiparesis, the continuous intrathecal administration of baclofen using a special pump can improve the locomotor function.
Medical treatment of primary (integrative) disorders of walking remains insufficiently developed. According to Japanese neurologists, the severity of violations of the initiation of walking in vascular and certain degenerative brain lesions can be reduced with the help of the noradrenaline precursor - L-threo-3,4-dihydroxyphenylserine (L-DOPS), which also corresponds to experimental data on the activating influence of noradrenergic tracts on spinal generator mechanisms. A number of studies have shown the efficacy of amantadine blocking NMDA-glutamate receptors in patients with discirculatory (vascular) encephalopathy with frontal dysbasia, resistant to levodopa preparations. In the presence of signs of aprakticheskogo defect drug was ineffective.
In patients with cognitive impairment and dementia, their correction can (primarily due to increased attention and concentration) help to improve mobility and improve the effectiveness of rehabilitation methods, but this aspect of the effectiveness of tools that improve cognitive functions remains poorly understood. In the presence of an irrational fear of falling, selective serotonin reuptake inhibitors can be effective, especially in combination with curative gymnastics and rational psychotherapy.
[Surgical treatment of walking disorders
Surgical treatment of walking disorders can include orthopedic interventions, spinal cord decompression with spondylogenic cervical myelopathy, shunting operations with normotensive hydrocephalus, and stereotactic operations in patients with extrapyramidal syndromes. In patients with Parkinson's disease, improvement in walking can be achieved by deep stimulation of the brain with the introduction of electrodes into the subthalamic nucleus. It is also shown that stimulation of the outer segment of the pale ball improves walking, while stimulation of the inner segment of the pale sphere (which usually improves other manifestations of parkinsonism) can worsen it. The low-frequency stimulation of the pedunculopontine nucleus is the most promising from the point of view of improving walking, however, to date, its effectiveness is shown only in a small sample of patients with Parkinson's disease. In generalized and segmental muscular dystonia (both idiopathic and multi-systemic degeneration, for example, in Gallervorden-Spatz disease), a pronounced effect with a significant improvement in walking can be achieved with the help of bilateral stimulation of the medial segment of the pale sphere.