Demystifying Diagnosis of Gait Impairment: NPH and Beyond (Podcast)

The symptom triad of gait disorders, cognitive difficulties and urinary incontinence can be helpful in diagnosing normal pressure hydrocephalus (NPH), but much remains unknown about the condition, which affects 8.4 million people over age 80 around the world. Among key questions are how NPH develops in the first place and the role of genetics.

A recent systematic literature review of NPH genetics by Cleveland Clinic researchers found that the genes identified so far tend to be endothelial cell expressed, says neurologist James Liao, MD, PhD. More research will be needed to identify others and to better understand the interplay between genetics and environment.

“The motivation is really to help better define what NPH is, because there’s actually some debate in the literature and in the field about whether NPH is a distinct condition or some final common pathway of other neurodegenerative conditions,” says Dr. Liao. “One way to answer that is to do genetic testing and find genes that are associated with NPH and show that NPH has a different genetic pattern or profile than other neurodegenerative conditions.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Liao, who specializes in movement disorders, discusses NPH and other topics pertaining to gait impairment, including:

• The varied causes of gait changes
• The treatability of some disorders
• Roles of the patient’s medical history and physical exam
• Exercise and Parkinson’s disease
• Augmented reality (AR) and gait freezing

Click the podcast player above to listen to the 30-minute episode now, or read on for an edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

This activity has been approved for AMA PRA Category 1 Credit™ and ANCC contact hours. After listening to the podcast, you can claim your credit here.

Excerpt from the podcast

Podcast host Glen Stevens, DO, PhD: Talk a little bit about augmented reality or other options that you have for treatment or evaluation of patients.

James Liao, MD: Augmented reality is a pretty cool technology. It’s a way to display images in glasses, and the images are displayed as if they are objects in the real world. The headset has a transparent lens. You’re looking at the real world, and the technology is able to, say, add a ball that’s floating in space. And if you move around, it knows where your head is, it knows where your eyes are. So it can draw the ball to be stationary in space. The big tech companies all have some prototype of this. And here at Cleveland Clinic, we have several projects that involve AR. In one of them, we used AR to draw visual cues on the ground.

For some people with Parkinson’s who have freezing gait, the freezing behavior gets better if there are just lines on the ground oriented correctly that people are walking over. There is even a laser light attachment that you can get for your cane or your walker.

Dr. Stevens: I’ve seen that, right, where it draws a line [and] they step over it.

Dr. Liao: For some reason, having that visual thing on the ground changes your cognitive strategy of walking, and it prevents you from freezing. The AR technique is basically a fancier way to do that. It’s a little bit more flexible. [The lines] don’t have to be straight — they can be colorful, they can adapt, they can appear only when necessary. We developed a study for this and showed that circular visual cues that appear on the ground when people are frozen reduce the duration of freezes, and they reduce how often freezes happen. There’s a little bit more to it than that, but to my knowledge, that’s the first study that shows that visual cues from an AR headset actually directly reduce freezing metrics.