Walking assessment after lumbar puncture in normal-pressure hydrocephalus: a delayed improvement over 3 days

Abstract

OBJECTIVE The determination of gait improvement after lumbar puncture (LP) in idiopathic normal-pressure hydrocephalus (iNPH) is crucial, but the best time for such an assessment is unclear. The authors determined the time course of improvement in walking after LP for single-task and dual-task walking in iNPH. METHODS In patients with iNPH, sequential recordings of gait velocity were obtained prior to LP (time point [TP]0), 1-8 hours after LP (TP1), 24 hours after LP (TP2), 48 hours after LP (TP3), and 72 hours after LP (TP4). Gait analysis was performed using a pressure-sensitive carpet (GAITRite) under 4 conditions: walking at preferred velocity (STPS), walking at maximal velocity (STMS), walking while performing serial 7 subtractions (dual-task walking with serial 7 [DTS7]), and walking while performing verbal fluency tasks (dual-task walking with verbal fluency [DTVF]). RESULTS Twenty-four patients with a mean age of 76.1 ± 7.8 years were included in this study. Objective responder status moderately coincided with the self-estimation of the patients with subjective high false-positive results (83%). The extent of improvement was greater for single-task walking than for dual-task walking (p < 0.05). Significant increases in walking speed were found at TP2 for STPS (p = 0.042) and DTVF (p = 0.046) and at TP3 for STPS (p = 0.035), DTS7 (p = 0.042), and DTVF (p = 0.044). Enlargement of the ventricles (Evans Index) positively correlated with early improvement. Gait improvement at TP3 correlated with the shunt response in 18 patients. CONCLUSIONS Quantitative gait assessment in iNPH is important due to the poor self-evaluation of the patients. The maximal increase in gait velocity can be observed 24-48 hours after the LP. This time point is also best to predict the response to shunting. For dual-task paradigms, maximal improvement appears to occur later (48 to 72 hours). Assessment of gait should be performed at Day 2 or 3 after LP.

The effect of CSF drainage on ambulatory center of mass movement in idiopathic normal pressure hydrocephalus

“…In any case, clarifying the features of ambulatory COM movement in iNPH may help explain the patients' gait and balance disorders and elucidate the appropriate diagnostic and treatment strategies, which may include exercise therapy. Objective gait assessments in patients with iNPH have examined various gait parameters such as temporal and spatial parameters [4][5][6]8,10,[16][17][18][19], but the ambulatory COM movements in iNPH remain unclear.…”

Early and delayed assessments of quantitative gait measures to improve the tap test as a predictor of shunt effectiveness in idiopathic normal pressure hydrocephalus

“…This observation led us to study the clinical significance of delayed assessment for the prediction of shunt effectiveness. Recently, Schniepp et al reported a delayed improvement over 3 days after CSF removal [10]. Thus, the timing of assessment after CSF removal is an important issue in the tap test.…”

“…Williams et al reported that velocity, double support time, and cadence improve significantly after CSF drainage in patients with iNPH in assessments using an instrumented walkway [19]. Schniepp et al also reported an increase in walking speed in various tasks performed on the walkway [10]. They noted maximal improvements of dual task paradigms on days 2 and 3, and recommend that assessments of gait be performed on day 2 or day 3.…”

“…However, delayed improvement of symptoms is often observed. Recently, Schniepp et al [10] reported a maximal increase in gait velocity 24–48 h after the TT using quantitative measures of gait. Assessment of gait is performed using clinical grading scales in most studies.…”

The effects of cerebrospinal fluid tap-test on idiopathic normal pressure hydrocephalus: an inertial sensors based assessment

“…On the contrary, many other studies recommend examining patients performances since the second day after the CSF-TT [17,19,20,24]. Recently, Schniepp et al examined 24 iNPH patients employing sequential recordings of gait velocity from 1 h to 72 h [25]. The maximal increase was observed in single-tasking after 24 h to 48 h, whereas in dual-tasking after 48 h to 72 h. The low negative predictive value in screening patients for shunting of CSF-TT (37%) might also depend on post evaluations not acquired on the appropriate time point [25].…”