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Nervenheilkunde 2023; 42(01/02): 59-65
DOI: 10.1055/a-1928-4730
Schwerpunkt

Gangstörungen bei Schwindelerkrankungen

Übersicht zu Diagnostik und TherapieGait disorders in patients with vertigo and dizzinessDiagnostic and therapeutic approaches
Roman Schniepp
1   Neurologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München und Deutsches Schwindel- und Gleichgewichtszentrum (DSGZ)
,
Ken Möhwald
1   Neurologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München und Deutsches Schwindel- und Gleichgewichtszentrum (DSGZ)
,
Max Wuehr
1   Neurologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München und Deutsches Schwindel- und Gleichgewichtszentrum (DSGZ)
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ZUSAMMENFASSUNG

Einschränkungen der Gehfähigkeit sind bei Schwindelerkrankungen häufig und determinieren Funktionalität und Mobilität der Patienten. Stürze und deren psychische und körperliche Folgen sind zudem wichtige Einflussfaktoren für soziale Teilhabe und Lebensqualität.

Der vorliegende Übersichtsartikel informiert über die Möglichkeiten einer strukturierten Erfassung von Gangstörungsmustern bei Schwindel mit Nennung wichtiger differenzialdiagnostischer Aspekte. Zudem wird ein Konzept vorgestellt, mit dem Einschränkungen des Gehens in funktional relevante Bereiche unterteilt sind. Anhand dieses Konzepts werden im zweiten Teil des Artikels allgemeine Behandlungsoptionen der symptomatischen Therapie präsentiert. Diese umfassen neben physikalisch-medizinischen Basistherapien spezifischere Übungsformen des Gleichgewichts-, Koordinations- und Bewegungstrainings. In der Pharmakotherapie von Gangstörungen steht zumeist eine erkrankungsspezifische Zielsetzung im Vordergrund. Für die chronisch bilaterale vestibuläre Funktionsstörung bestehen zudem Ansätze der künstlichen Substitution bzw. Verstärkung.

ABSTRACT

Restrictions in the ability to walk are common in dizziness and determine the functionality and mobility of patients. Falls and their psychological and physical consequences are further important factors influencing social participation and quality of life.

The present review article therefore informs about the potentials of a structured assessment of gait patterns in dizziness with quoting important differential-diagnostic aspects. In addition, a concept of functional gait subdivisions is introduced. Based on this concept, general treatment options of symptomatic therapy are discussed in the second part of the article. These include basic therapies of physiotherapy. More specific training including balance, coordination, and locomotion trainings also complement gait therapy. In the pharmacotherapy of gait disorders, the focus is usually on a disease-specific objective. For chronic bilateral vestibular dysfunction, approaches of artificial substitution or amplification have also been developed.

Schlüsselwörter

Gangstörungen - Schwindel - Gleichgewichtssystem - Stürze

Key words

Gait disorders - dizziness - vertigo - vestibular system - falls


Publication History

Article published online:
13 February 2023

© 2023. Thieme. All rights reserved.

© Georg Thieme Verlag KG Stuttgart · New York
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  • Literatur

  • 1 Wuehr M, Decker J, Schenkel F. et al Impact on daily mobility and risk of falling in bilateral vestibulopathy. J Neurol. 2022 https://link.springer.com/article/10.1007/s00415-022-11043-9
    PubMedGoogle Scholar
  • 2 Schlick C, Schniepp R, Loidl V. et al Falls and fear of falling in vertigo and balance disorders: A controlled cross-sectional study. J Vestib Res 2016; 25 5–6 241-51
    Google Scholar
  • 3 Lord S, Galna B, Verghese J. et al Independent domains of gait in older adults and associated motor and nonmotor attributes: validation of a factor analysis approach. J Gerontol A Biol Sci Med Sci 2013; 68 (07) 820-7
    CrossrefPubMedGoogle Scholar
  • 4 Brandt T. Vestibulopathic gait: you’re better off running than walking. Curr Opin Neurol 2000; 13 (01) 3-5
    CrossrefPubMedGoogle Scholar
  • 5 Jahn K, Strupp M, Schneider E. et al Differential effects of vestibular stimulation on walking and running. Neuroreport 2000; 11 (08) 1745-8
    CrossrefPubMedGoogle Scholar
  • 6 Schniepp R, Wuehr M, Neuhaeusser M. et al Locomotion speed determines gait variability in cerebellar ataxia and vestibular failure. Mov Disord 2012; 27 (01) 125-31
    CrossrefPubMedGoogle Scholar
  • 7 Schniepp R, Mohwald K, Wuehr M.. Key gait findings for diagnosing three syndromic categories of dynamic instability in patients with balance disorders. J Neurol 2020; 267: 301-308
    CrossrefPubMedGoogle Scholar
  • 8 Wuehr M, Schniepp R, Schlick C. et al Sensory loss and walking speed related factors for gait alterations in patients with peripheral neuropathy. Gait Posture 2014; 39 (03) 852-8
    CrossrefPubMedGoogle Scholar
  • 9 Dietrich H, Heidger F, Schniepp R. et al Head motion predictability explains activity-dependent suppression of vestibular balance control. Sci Rep 2020; 10 (01) 668
    CrossrefPubMedGoogle Scholar
  • 10 Jahn K, Deutschlander A, Stephan T. et al Supraspinal locomotor control in quadrupeds and humans. Prog Brain Res 2008; 171: 353-62
    CrossrefPubMedGoogle Scholar
  • 11 Kalla R, Deutschlander A, Hufner K. et al Detection of floccular hypometabolism in downbeat nystagmus by fMRI. Neurology 2006; 66 (02) 281-3
    Google Scholar
  • 12 Ilg W, Timmann D. Gait ataxia – specific cerebellar influences and their rehabilitation. Mov Disord 2013; 28 (11) 1566-75
    CrossrefPubMedGoogle Scholar
  • 13 Schniepp R, Schlick C, Pradhan C. et al The interrelationship between disease severity, dynamic stability, and falls in cerebellar ataxia. J Neurol 2016; 263 (07) 1409-17
    CrossrefPubMedGoogle Scholar
  • 14 Schniepp R, Mohwald K, Wuehr M. Gait ataxia in humans: vestibular and cerebellar control of dynamic stability. J Neurol 2017; 264 (Suppl. 01) 87-92
    CrossrefPubMedGoogle Scholar
  • 15 Dieterich M, Staab JP, Brandt T. Functional (psychogenic) dizziness. Handbook of clinical neurology 2016; 139: 447-68
    CrossrefPubMedGoogle Scholar
  • 16 Dieterich M, Staab JP. Functional dizziness: from phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness. Current opinion in neurology 2017; 30 (01) 107-13
    CrossrefPubMedGoogle Scholar
  • 17 Schniepp R, Wuehr M, Huth S. et al Gait characteristics of patients with phobic postural vertigo: effects of fear of falling, attention, and visual input. J Neurol 2014; 261 (04) 738-46
    CrossrefPubMedGoogle Scholar
  • 18 Schniepp R, Huppert A, Decker J. et al Fall prediction in neurological gait disorders: differential contributions from clinical assessment, gait analysis, and daily-life mobility monitoring. J Neurol 2021; 268 (09) 3421-34
    CrossrefPubMedGoogle Scholar
  • 19 Schniepp R, Wuehr M, Schlick C. et al Increased gait variability is associated with the history of falls in patients with cerebellar ataxia. J Neurol 2014; 261 (01) 213-23
    CrossrefPubMedGoogle Scholar
  • 20 Schlick C, Rasoul A, Wuehr M. et al Gait variability predicts a subset of falls in cerebellar gait disorders. J Neurol 2017; 264 (11) 2322-4
    Google Scholar
  • 21 Schniepp R, Huppert A, Decker J. et al Multimodal Mobility Assessment Predicts Fall Frequency and Severity in Cerebellar Ataxia. Cerebellum. 2022 https://link.springer.com/article/10.1007/s12311-021-01365-1
    PubMedGoogle Scholar
  • 22 Schniepp R, Schlick C, Schenkel F. et al Clinical and neurophysiological risk factors for falls in patients with bilateral vestibulopathy. J Neurol 2017; 264 (02) 277-83
    CrossrefPubMedGoogle Scholar
  • 23 Schniepp R, Möhwald K, Wuehr M. Symptomatische Behandlungsoptionen chronischer, neurologischer Gangstörungen. Fortschritte der Neurologie Psychiatrie 2021; 89 (05) 243-53
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane database of systematic reviews. 2015: 1
    PubMedGoogle Scholar
  • 25 David EK, Kathleen MG-B, Stephen WP. et al Vestibular rehabilitation: useful but not universally so. Otolaryngology—Head and Neck Surgery 2003; 128 (02) 240-50
    CrossrefPubMedGoogle Scholar
  • 26 Herdman SJ. Role of vestibular adaptation in vestibular rehabilitation. Otolaryngology—Head and Neck Surgery 1998; 119 (01) 49-54
    CrossrefPubMedGoogle Scholar
  • 27 Michel L, Laurent T, Alain T. Rehabilitation of dynamic visual acuity in patients with unilateral vestibular hypofunction: earlier is better. European Archives of Oto-Rhino-Laryngology 2020; 277 (01) 103-13
    CrossrefPubMedGoogle Scholar
  • 28 Krebs DE, Gill-Body KM, Riley PO. et al Double-blind, placebo-controlled trial of rehabilitation for bilateral vestibular hypofunction: preliminary report. Otolaryngology—Head and Neck Surgery 1993; 109 (04) 735-41
    CrossrefPubMedGoogle Scholar
  • 29 Wayne PM, Krebs DE, Wolf SL. et al Can Tai Chi improve vestibulopathic postural control?. Archives of physical medicine and rehabilitation 2004; 85 (01) 142-52
    PubMedGoogle Scholar
  • 30 McGibbon CA, Krebs DE, Parker SW. et al Tai Chi and vestibular rehabilitation improve vestibulopathic gait via different neuromuscular mechanisms: preliminary report. BMC neurology 2005; 05 (01) 1-12
    CrossrefPubMedGoogle Scholar
  • 31 Huang H-W, Nicholson N, Thomas S. Impact of Tai Chi exercise on balance disorders: a systematic review. American journal of audiology 2019; 28 (02) 391-404
    CrossrefPubMedGoogle Scholar
  • 32 Milne SC, Corben LA, Georgiou-Karistianis N. et al Rehabilitation for individuals with genetic degenerative ataxia: a systematic review. Neurorehabilitation and Neural Repair 2017; 31 (07) 609-22
    CrossrefPubMedGoogle Scholar
  • 33 Ilg W, Schatton C, Schicks J. et al Video game-based coordinative training improves ataxia in children with degenerative ataxia. Neurology 2012; 79 (20) 2056-60
    CrossrefPubMedGoogle Scholar
  • 34 Keller JL, Bastian AJ. A home balance exercise program improves walking in people with cerebellar ataxia. Neurorehabilitation and neural repair 2014; 28 (08) 770-8
    CrossrefPubMedGoogle Scholar
  • 35 Wang R-Y, Huang F-Y, Soong B-W. et al A randomized controlled pilot trial of game-based training in individuals with spinocerebellar ataxia type 3. Scientific reports 2018; 08 (01) 1-7
    Google Scholar
  • 36 Ayvat E, Onursal Kılınç Ö. et al The effects of exergame on postural control in individuals with ataxia: A rater-blinded, randomized controlled, cross-over study. The Cerebellum 2022; 21 (01) 64-72
    CrossrefPubMedGoogle Scholar
  • 37 Missaoui B, Thoumie P. Balance training in ataxic neuropathies. Effects on balance and gait parameters. Gait & posture 2013; 38 (03) 471-6
    CrossrefPubMedGoogle Scholar
  • 38 Missaoui B, Thoumie P. How far do patients with sensory ataxia benefit from so-called “proprioceptive rehabilitation”?. Neurophysiologie Clinique/Clinical Neurophysiology 2009; 39 4–5 229-33
    CrossrefPubMedGoogle Scholar
  • 39 Taveggia G, Villafañe JH, Vavassori F. et al Multimodal treatment of distal sensorimotor polyneuropathy in diabetic patients: a randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 2014; 37 (04) 242-52
    CrossrefPubMedGoogle Scholar
  • 40 Holmberg J, Karlberg M, Harlacher U. et al Treatment of phobic postural vertigo. Journal of neurology 2006; 253 (04) 500-6
    CrossrefPubMedGoogle Scholar
  • 41 Whitney SL, Jacob RG, Sparto PJ. et al Acrophobia and pathological height vertigo: indications for vestibular physical therapy?. Physical Therapy 2005; 85 (05) 443-58
    CrossrefPubMedGoogle Scholar
  • 42 Huppert D, Strupp M, Rettinger N. et al Phobic postural vertigo. Journal of neurology 2005; 252 (05) 564-9
    CrossrefPubMedGoogle Scholar
  • 43 Strupp M, Magnusson M. Acute unilateral vestibulopathy. Neurologic clinics 2015; 33 (03) 669-85
    CrossrefPubMedGoogle Scholar
  • 44 Strupp M, Dlugaiczyk J, Ertl-Wagner BB. et al Vestibular disorders: diagnosis, new classification and treatment. Deutsches Ärzteblatt International 2020; 117 (17) 300
    PubMedGoogle Scholar
  • 45 Beck R, Günther L, Xiong G. et al The mixed blessing of treating symptoms in acute vestibular failure – evidence from a 4-aminopyridine experiment. Experimental neurology 2014; 261: 638-45
    CrossrefPubMedGoogle Scholar
  • 46 Gunther L, Beck R, Xiong G. et al N-acetyl-L-leucine accelerates vestibular compensation after unilateral labyrinthectomy by action in the cerebellum and thalamus. PLoS One 2015; 10 (03) e0120891
    CrossrefPubMedGoogle Scholar
  • 47 Lindner M, Gosewisch A, Eilles E. et al Ginkgo biloba extract EGb 761 improves vestibular compensation and modulates cerebral vestibular networks in the rat. Frontiers in Neurology 2019; 10: 147
    CrossrefPubMedGoogle Scholar
  • 48 Strupp M, Zwergal A, Feil K. et al Pharmacotherapy of vestibular and cerebellar disorders and downbeat nystagmus: Translational and back-translational research. Annals of the new York Academy of Sciences 2015; 1343 (01) 27-36
    CrossrefPubMedGoogle Scholar
  • 49 Strupp M, Zingler VC, Arbusow V. et al Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. New England Journal of Medicine 2004; 351 (04) 354-61
    CrossrefPubMedGoogle Scholar
  • 50 Goudakos JK, Markou KD, Franco-Vidal V. et al Corticosteroids in the treatment of vestibular neuritis: a systematic review and meta-analysis. Otology & Neurotology 2010; 31 (02) 183-9
    CrossrefPubMedGoogle Scholar
  • 51 Karlberg ML-Å, Magnusson M. Treatment of acute vestibular neuronitis with glucocorticoids. Otology & Neurotology 2011; 32 (07) 1140-3
    CrossrefPubMedGoogle Scholar
  • 52 Goudakos JK, Markou KD, Psillas G. et al Corticosteroids and vestibular exercises in vestibular neuritis: single-blind randomized clinical trial. JAMA Otolaryngology–Head & Neck Surgery 2014; 140 (05) 434-40
    CrossrefPubMedGoogle Scholar
  • 53 Fishman JM, Burgess C, Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database of Systematic Reviews 2011: 5
    PubMedGoogle Scholar
  • 54 Leong K-J, Lau T, Stewart V. et al Systematic review and meta-analysis: effectiveness of corticosteroids in treating adults with acute vestibular neuritis. Otolaryngology–Head and Neck Surgery 2021; 165 (02) 255-66
    CrossrefPubMedGoogle Scholar
  • 55 Schniepp R, Wuehr M, Neuhaeusser M. et al 4-aminopyridine and cerebellar gait: a retrospective case series. J Neurol 2012; 259 (11) 2491-3
    CrossrefPubMedGoogle Scholar
  • 56 Strupp M, Schüler O, Krafczyk S. et al Treatment of downbeat nystagmus with 3, 4-diaminopyridine: a placebo-controlled study. Neurology 2003; 61 (02) 165-70
    Google Scholar
  • 57 Spiegel R, Kalla R, Classen J. et al Aminopyridine treatment in a patient with bilateral vestibular failure and cryptogenic downbeat nystagmus. J Neuroophthalmol 2012; 32 (02) 190
    CrossrefPubMedGoogle Scholar
  • 58 Kalla R, Strupp M. Aminopyridines and acetyl-DL-leucine: new therapies in cerebellar disorders. Current neuropharmacology 2019; 17 (01) 7-13
    CrossrefPubMedGoogle Scholar
  • 59 Schniepp R, Strupp M, Wuehr M. et al Acetyl-DL-leucine improves gait variability in patients with cerebellar ataxia-a case series. Cerebellum Ataxias 2016; 03: 8
    CrossrefPubMedGoogle Scholar
  • 60 Feil K, Adrion C, Boesch S. et al Safety and efficacy of acetyl-DL-leucine in certain types of cerebellar ataxia: the ALCAT randomized clinical crossover trial. JAMA network open 2021; 04 (12) e2135841-e
    CrossrefPubMedGoogle Scholar
  • 61 Van de Warrenburg B, Van Gaalen J, Boesch S. et al EFNS/ENS Consensus on the diagnosis and management of chronic ataxias in adulthood. European journal of neurology 2014; 21 (04) 552-62
    CrossrefPubMedGoogle Scholar
  • 62 Zesiewicz TA, Greenstein P, Sullivan KL. et al A randomized trial of varenicline (Chantix) for the treatment of spinocerebellar ataxia type 3. Neurology 2012; 78 (08) 545-50
    CrossrefPubMedGoogle Scholar
  • 63 Botez M, Young SN, Botez T. et al Treatment of heredo-degenerative ataxias with amantadine hydrochloride. Canadian journal of neurological sciences 1991; 18 (03) 307-11
    CrossrefPubMedGoogle Scholar
  • 64 Botez M, Botez-Marquard T, Elie R. et al Amantadine hydrochloride treatment in heredodegenerative ataxias: a double blind study. Journal of Neurology, Neurosurgery & Psychiatry 1996; 61 (03) 259-64
    CrossrefPubMedGoogle Scholar
  • 65 Filla A, De Michele G, Orefice G. et al A double-blind cross-over trial of amantadine hydrochloride in Friedreich’s ataxia. Canadian journal of neurological sciences 1993; 20 (01) 52-5
    CrossrefPubMedGoogle Scholar
  • 66 Ristori G, Romano S, Visconti A. et al Riluzole in cerebellar ataxia: a randomized, double-blind, placebo-controlled pilot trial. Neurology 2010; 74 (10) 839-45
    CrossrefPubMedGoogle Scholar
  • 67 Muth C, Teufel J, Schöls L. et al Fampridine and acetazolamide in EA2 and related familial EA: A prospective randomized placebo-controlled trial. Neurology: Clinical Practice 2021; 11 (04) e438-e4
    PubMedGoogle Scholar
  • 68 Staab JP. Chronic subjective dizziness. CONTINUUM: Lifelong Learning in Neurology 2012; 18 (05) 1118-41
    PubMedGoogle Scholar
  • 69 Popkirov S, Stone J, Holle-Lee D. Treatment of persistent postural-perceptual dizziness (PPPD) and related disorders. Current treatment options in neurology 2018; 20 (12) 1-11
    CrossrefPubMedGoogle Scholar
  • 70 Trinidade A, Goebel JA. Persistent postural-perceptual dizziness – a systematic review of the literature for the balance specialist. Otology & Neurotology 2018; 39 (10) 1291-303
    CrossrefPubMedGoogle Scholar
  • 71 Axer H, Finn S, Wassermann A. et al Multimodal treatment of persistent postural-perceptual dizziness. Brain and Behavior 2020; 10 (12) e01864
    CrossrefPubMedGoogle Scholar
  • 72 Dlugaiczyk J, Wuehr M, Straka H. Electrical Stimulation of Vestibular Endorgans. In: Fritzsch B, editor. The Senses: A Comprehensive Reference. Oxford: Elsevier; 2022
    Google Scholar
  • 73 Guyot JP, Perez Fornos A. Milestones in the development of a vestibular implant. Curr Opin Neurol 2019; 32 (01) 145-53
    CrossrefPubMedGoogle Scholar
  • 74 Guinand N, Van de Berg R, Cavuscens S. et al Restoring Visual Acuity in Dynamic Conditions with a Vestibular Implant. Front Neurosci 2016; 10: 577
    CrossrefPubMedGoogle Scholar
  • 75 Fornos AP, van de Berg R, Armand S. et al Cervical myogenic potentials and controlled postural responses elicited by a prototype vestibular implant. J Neurol 2019; 266 (Suppl. 01) 33-41
    CrossrefPubMedGoogle Scholar
  • 76 Chow MR, Ayiotis AI, Schoo DP. et al Posture, Gait, Quality of Life, and Hearing with a Vestibular Implant. N Engl J Med 2021; 384 (06) 521-32
    CrossrefPubMedGoogle Scholar
  • 77 Wuehr M, Decker J, Schniepp R. Noisy galvanic vestibular stimulation: an emerging treatment option for bilateral vestibulopathy. J Neurol 2017; 264 (01) 81-6
    CrossrefPubMedGoogle Scholar
  • 78 Keywan A, Wuehr M, Pradhan C. et al Noisy Galvanic Stimulation Improves Roll-Tilt Vestibular Perception in Healthy Subjects. Front Neurol 2018; 9(83)
    Google Scholar
  • 79 Schniepp R, Boerner JC, Decker J. et al Noisy vestibular stimulation improves vestibulospinal function in patients with bilateral vestibulopathy. J Neurol 2018; 265 (Suppl. 01) 57-62
    CrossrefPubMedGoogle Scholar
  • 80 Iwasaki S, Yamamoto Y, Togo F. et al Noisy vestibular stimulation improves body balance in bilateral vestibulopathy. Neurology 2014; 82 (11) 969-75
    CrossrefPubMedGoogle Scholar
  • 81 Wuehr M, Nusser E, Decker J. et al Noisy vestibular stimulation improves dynamic walking stability in bilateral vestibulopathy. Neurology 2016; 86 (23) 2196-202
    CrossrefPubMedGoogle Scholar
  • 82 Keywan A, Dietrich H, Wuehr M. Subliminal Passive Motion Stimulation Improves Vestibular Perception. Neuroscience 2020; 441: 1-7
    CrossrefPubMedGoogle Scholar
  • 83 Keywan A, Yassin G, Jahn K. et al Subliminal conditioning of vestibular perception generalizes within otolith organs. J Neurol 2022; 269: 5258-5261
    CrossrefPubMedGoogle Scholar