Today, just for laughs in a world where medicine and a few other subjects make us worry unnecessarily, a case history. (This is not based on an Elks Magazine column, but on a request for advice).
13 month old, ambidextrous WM presents with chief complaint of “something wrong with legs, ” noticed by his aunt. History obtained from caretakers, as the patient does not speak English.
HPI: Several weeks ago, the patient switched suddenly from four point locomotion on hands and knees to upright posture and ambulation on legs. His caretakers were pleased with this event and recorded his progress to share with interested parties. Upon viewing one recording in which the patient was hurrying to catch up with his mother, his aunt, who works in a health field, noted that “something is wrong with his legs.” There has been no sign that the patient is uncomfortable with his new choice. In fact he seems to revel in it and consistently pushes away the hands of those who attempt to support and assist him. He does not appear to be uncomfortable when he loses his balance and falls, which happens less and less frequently as he practices his new skill. Initially he reverted to 4 point locomotion when he seems eager to reach his destination, as if valuing speed over the upright posture. Of course this is an inference, because, as noted previously, the patient does not speak English (aphasia might also be considered). Now, however he chooses to ambulate in the upright position most of the time. He has also demonstrated increasingly frequent and increasingly more skilled ability in squatting and rising, picking things up and carrying them – and other more subtle indications that he is multitasking with his motor system while engaging in his new form of locomotion. And he is able to rise from sitting to the upright posture without holding using his hands or shifting to his knees, a skill that eludes many people who have used the upright posture for many years – a skill that some believe correlates well with life expectancy.
ROS: Of note and possible relevance is the fact that he is incontinent and as a result wears a bulky diaper and rubber pants.
PE: 1. Examination of the video in question reveals a small male at some distance from the camera. As he comes into clearer view it is evident that he is walking unsupported in bare feet on uneven ground. He uses gross motor groups of the trunk and hip to move his weight from one foot to the other, leaning from one side to the other as he unweights the new balancing leg to move it into the new planting position, slightly in advance of the weighted leg. His base is broad and his toes pointed outward. The aforementioned diaper and rubber pants may slightly exaggerate these two features. He also moves rapidly and since his build includes relatively short legs and large head, he appears a bit ungainly and off balance, as though he might topple over (prompting the aforementioned but usually spurned offers of help). His timing appears somewhat irregular, and he plants his feet without any finesse, leaving the observer with an overall impression of unsteadiness (recall Lurch, of the Adams Family).
2. Physical examination several weeks later and in the patient’s usual environment was remarkable for its normality. Neurological evaluation revealed a similar gait pattern, but with an appreciably narrowed base, and less outward deviation of the feet in forward motion (see supplemental video). He does remain aphasic, but responds appropriately to non-verbal accompaniments of speech (at times this leads to the conclusion that he understands some words, but unless the response occurs in a vacuum of other elements of communication this is hard to evaluate precisely).
Impression: Reversible gait dysfunction indicative of incomplete development of the cortico-cerebello-pontine pathways
Treatment plan: 1. Encourage patient to get on with getting older
2. Practice, practice, practice
(Video removed for privacy. Available on request to friends and family)