Objective: Discuss the importance of gait phenomenology in identifying Normal Pressure Hydrocephalus.

Background: Normal pressure hydrocephalus (iNPH) can present as a ‘magnetic gait’ but this gait disturbance can be easily attributed to other conditions such as neuropathy. NPH is a combination of clinical evaluation for tis triad of urinary incontinence, cognitive problems with a focus on the phenomenology of the gait and its historical progression which can reduce associated morbidity.^[1]

Method: We present an 82-year-old right-handed man with a history of progressive walking difficulty for 10 years attributed to long standing neuropathy diagnosis. He was admitted for worsening of his chronic progressive gait dysfunction. The spouse and patient report numerous falls over the last 3 years, to include 8 in the last 6 months. Symptoms manifested as a worsening sense of heavy legs and difficulty with unassisted walking, most notable over the last 12 months. The spouse expressed concern about dementia, noting bradyphrenia and apathy with resultant decline in quality of work. Review of systems elicited worsening intermittent urinary urgency and incontinence, most prominent over the last year. The patient underwent ‘up and go ‘gait testing with a certified physical therapist pre and post Lumbar puncture with removal of 40 cc CSF fluid.

Results: Gait time post LP was reduced approximately by 30%, and distance was improved by 40 feet. The phenomenology of gait improved with improved heel strike and ability to lift both legs without difficulty and decrease broad based gait.

Conclusion: In our case presentation the gait difficulty was attributed solely to neuropathy, while the phenomenology of his magnetic was not documented.  A careful examination of gait by a movement disorder neurologist and resident, supplemented by objective gait analysis by physical therapy before and after the lumbar puncture was paramount to accurately diagnose iNPH. ^{[1,2,3,4,5,6,7,8]} While iNPH diagnostic criteria is primarily focused on radiologic and bedside testing, employing a multidisciplinary approach utilizing physical therapy (rehab), in cases concerning for iNPH can potentially prevent the progression to disability in this complex disease process.

References: 1. RD, H., 2020. The Special Clinical Problem Of Symptomatic Hydrocephalus With Normal Cerebrospinal Fluid Pressure. Observations On Cerebrospinal Fluid Hydrodynamics. 2. Bräutigam K, Vakis A, Tsitsipanis C. Pathogenesis of idiopathic Normal Pressure Hydrocephalus: A review of knowledge. Journal of Clinical Neuroscience. 2019;61:10-13. doi:10.1016/j.jocn.2018.10.147. 3. Graff-Radford NR, Jones DT. Normal Pressure Hydrocephalus. Continuum (Minneap Minn). 2019;25(1):165-186. doi:10.1212/CON.0000000000000689 4. Relkin N, Marmarou A, Klinge P, Bergsneider M, Black PML. Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery. https://www.ncbi.nlm.nih.gov/pubmed/16160425. 5. Saper CB. The Emperor has no clothes. Ann Neurol. 2016;79(2):165-166. doi:10.1002/ana.24603 6. Jack CR Jr, Shiung MM, Gunter JL, et al. Comparison of different MRI brain atrophy rate measures with clinical disease progression in AD. Neurology. 2004;62(4):591-600. doi:10.1212/01.wnl.0000110315.26026.ef 7. Shprecher D, Schwalb J, Kurlan R. Normal pressure hydrocephalus: diagnosis and treatment. Curr Neurol Neurosci Rep. 2008;8(5):371–376. doi:10.1007/s11910-008-0058-2 8. Mori E, Ishikawa M, Kato T, et al. Guidelines for management of idiopathic normal pressure hydrocephalus: second edition. Neurol Med Chir (Tokyo). 2012;52(11):775-809. doi:10.2176/nmc.52.775

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