Original Article J. Phys. Ther. Sci.

19: 183–188, 2007

Recovery Process of Gait Disturbance after
Ventriculo-Peritoneal Shunt in Patients with
Idiopathic Normal Pressure Hydrocephalus

MITSUAKI ISHII, PT1), ICHIRO AKIGUCHI, MD2)

1)Department of Physical Therapy, School of Health Science, Bukkyo University:

96 Murasakino Kita Hananobo, Kita, Kyoto 603-8301, Japan. Tel +81 75-491-2141,
E-mail: ishii@bukkyo-u.ac.jp
2)Center of Neurological and Cerebrovascular disease, Takeda Hospital

Abstract. To clarify the characteristics of the recovery process of gait disturbances after ventriculo-
peritoneal shunt (VP shunt) surgery in patients with idiopathic normal pressure hydrocephalus (iNPH), we
investigated three areas in two severely disabled patients: longitudinal changes of the severity of postural
instability of motor aspects of the Unified Parkinson’s disease Rating Scale (UPDRS); time taken in the
“timed up and go (TUG)” test; and the prevalence of freezing episodes and the severity of bradykinesia.
We also compared the computed tomography findings before and after VP shunt. Gait disturbances in the
early stage after VP shunt fall under the frontal gait disorder of Nutt’s classification or the mixed gait
apraxia of Liston’s classification. Disequilibrium clearly improved gradually after VP shunt, however, gait
ignition failure and hypokinesia showed no significant improvement in our study. In the early stage after
VP shunt, complementing disequilibrium using high-heeled shoes was highly effective at improving the
time taken in TUG. The improvements in radiographic findings were reported after VP shunt.
Key words: Idiopathic normal pressure hydrocephalus (iNPH), Gait disturbance, Ventriculo-peritoneal shunt

(This article was submitted Jan. 22, 2007, and was accepted Mar. 27, 2007)

INTRODUCTION gait disorder”4).

Idiopathic normal pressure hydrocephalus
(iNPH), first reported by Hakim and Adams et al., is
a specific syndrome that causes enlargement of
ventricles resulting from a blockage of the flow of
cerebrospinal fluid (CSF), and is characterized by
the clinical triad of gait disturbance, urinary
incontinence, and dementia. A shunt operation can
reverse the clinical features of iNPH in the early
stage of the disease1, 2).
At first, iNPH was called “treatable dementia”,
however, gait disturbance is usually the most
frequent symptom and is more reversible than the
other symptoms by shunt operation3). Thus, it has
been proposed that it be recognized as “treatable
It is important to understand the recovery process
of gait disturbance in order to establish
rehabilitation programs after shunt operations,
however, the process is still unclear. The purpose of
this study was to clarify the characteristics of the
recovery process of gait disturbance after
ventriculo-peritoneal shunt (VP shunt) in two
severely disabled patients with iNPH.
PATIENTS
Case 1 was a 79-year-old male; Case 2 was a 66-
year-old male. They were diagnosed as possible
iNPH according to the clinical triad characteristics
and radiographic findings, and were admitted for
184 J. Phys. Ther. Sci. Vol. 19, No. 3, 2007
Fig. 1. Magnetic resonance imaging scans before shunt operation.
Increased ventricular dilatation, increased sylvian fissures space,
and decreased superior convexity and medial subarachnoid space.
further examination and treatment (Fig. 1). From
the appearance of symptoms, a period of more than
6 months had passed. Based on a CSF tap test,
patients were diagnosed as probable iNPH and
underwent subsequent VP shunt5).
Preoperatively, both patients showed grade 4 gait
disturbance on the Japanese iNPH grading scale-
revised (JNPHGS-R), meaning it was impossible
for them to walk even with assistance5).
In frontal release signs, Case 1 was positive for
sucking reflex and Case 2 was positive for sucking
reflex, grasp reflex, palmomental reflex, Rossolimo
reflex and tonic plantar reflex. Evaluation of
bradykinesia showed frequent hesitations and
arrests in both patients. Mini-mental state
examination showed 10 points for Case 1 and 3
points for Case 2. In both patients, the severity of
urinary incontinence was grade 3 of the JNPHGS-
R, which meaning frequent incontinence5).
The shunt system employed a Medos adjustable
valve. The initial shunt pressure was set to 14
cmH2O in Case 1 and 20 cmH2O in Case 2. The
shunt pressure of Case 2 was altered to 17 cmH2O at
2 weeks and to 14 cmH 2 O at 8 weeks after VP
shunt.
METHODS
We investigated longitudinal changes in the
severity of postural instability of motor aspects of
Unified Parkinson’s disease Rating Scale (UPDRS)
after VP shunt. We confirmed the appropriateness
of this as an evaluation item for movement
disorders of iNPH in a previous study 6) . The
severity is graded on a scale of 0 to 4.
We also investigated longitudinal changes in the
time taken in the “timed up and go (TUG)” test with
two different methods: barefoot and with high-
heeled shoes. Patients with iNPH present posterior
instability in the standing position6). Thus, we used
high-heeled shoes to complement the posterior
instability.
The prevalence of freezing episodes and the
severity of bradykinesia were assessed. The
severity of bradykinesia was quantified using leg
agility by UPDRS scoring.
We compared the computed tomography findings
before and after VP shunt. The compared findings,
as specific findings in iNPH7), were ventricular
dilatation, periventricular lucency, sylvian fissures
space, superior convexity and medial subarachnoid
space, and focally dilated sulcus observed over the
convexity of the hemisphere.
RESULTS
In first week after VP shunt, both patients had
grade 3 of severity of postural instability of motor
aspects of UPDRS, meaning the patients fell
spontaneously. Case 1 improved to normal (no
reteropulsion), grade 0, within 5 weeks after VP
shunt. Case 2 improved to grade 1, the patient
recovered without assistance, although the
retropulsion was recorded 8 weeks after VP shunt
(Table 1).
Case 1 could perform TUG in high-heeled shoes
 185

Table 1. Longituginal changes of movement disorders

Weeks after VP shunt
Pre After
operation CSF tap 1 w 2w 3w 4w 5w 6w 7w 8w 9 w 10 w 11 w 12 w
Postural
Case 1 4 3 3 3 2 2 0 0 0
stability of
UPDRS
Case 2 4 4 3 3 3 3 2 2 2 1 1 1 1 1
motor aspect
Timed up and Case 1 Bare feet 66 60 34 23 21
go test (sec) High-heeled shoes 62 42 37 27 20 20
Case 2 Bare feet 156 180 142 109 90 64 70 46 37
High-heeled shoes 194 131 98 100 80 63 52 45 46 43 32

Fig. 2. Comparison of CT findings (Case 1). A: improved sylvian fissures space. B:

improved ventricular dilatation and periventricular lucency. C: improved space
between superior convexity and medial subarachnoid and focally dilated sulcus.

1 week after VP shunt, and in bare feet 2 weeks after
VP shunt. The time taken in TUG improved over
time within 5 weeks after VP shunt. The time taken
in high-heeled shoes shortened in comparison to
bare feet within 4 weeks after VP shunt. Case 2 was
able to perform this test in high-heeled shoes from 2
week after VP shunt, and from 4 weeks after VP
shunt in bare feet. The time improved over time
within 12 weeks after VP shunt. The time taken in
high-heeled shoes shortened in comparison to bare
feet within 11 weeks after VP shunt (Table 1).
In seven weeks for Case 1, and 12 weeks after VP
shunt for Case 2, severity of bradykinesia was
unchanged compared to pre-operation conditions in
both patients. Freezing episodes were shown
frequently during gait initiation, turning around, as
well as during walking through small passages.
Ventricular dilatation, periventricular lucency,
and the sylvian fissures space decreased in both
patients. The Evans index improved from 0.48 to
0.39 in Case 1 and from 0.42 to 0.38 in Case 2. The
superior convexity and medial subarachnoid space
increased in both patients. Case 1 also showed
decrease of the focally dilated sulcus (Figs. 2 and 3).
DISCUSSION
Gait disturbance and abnormal radiographic
186 J. Phys. Ther. Sci. Vol. 19, No. 3, 2007
Fig. 3. Comparison of CT findings (Case 2). A: improved sylvian fissures space. B:
improved ventricular dilatation and periventricular lucency. C: improved
space between superior convexity and medial subarachnoid.
findings were improved by VP shunt, and therefore,
they were diagnosed as definite iNPH. Similar
points in the recovery process of our two patients
were: 1) disequilibrium, which was severe in the
early stage and improved within several weeks after
VP shunt; 2) freezing episodes and severity of
bradykinesia, on the other hand, were unchanged; 3)
high-heeled shoes were effective within several
weeks after VP shunt; and 4) the difference of time
taken in TUG between bare feet and with high-
heeled shoes decreased over time and finally
disappeared.
We used the item of postural instability of motor
aspects of UPDRS as an index of disequilibrium.
Hydrocephalus can induce parkinsonism. Krauss et
al. reported that the prevalence of parkinsonism was
highest in elderly patients with iNPH8). In our
previous study, we investigated the characteristics
of movement disorders of NPH using motor aspects
of UPDRS. In comparison of pre- and post-shunt
operation, the grade of postural instability was
improved significantly6).
This is the first report of a quantitative assessment
of the recovery process of gait disturbance after VP
shunt in patients with iNPH. Our results may
indicate characteristics of the recovery process of
gait disturbance after VP shunt. However, only two
patients participated in our study. This is major
limitation of this study. Therefore, further research
is needed to clarify our findings.
It has been thought that iNPH is one of the causes
of higher-level gait disorders characterized by
disequilibrium, hypokinesia, and ignition failure9).
Gait disturbances in the early stage after VP shunt
fell under the frontal gait disorder of Nutt’s
classification or the mixed gait apraxia of Liston’s
classification10) (Tables 2 and 3). Disequilibrium
clearly improved gradually after VP shunt,
however, gait ignition failure and hypokinesia did
not improve significantly in our study. Therefore,
we presume that disturbed CSF absorption is related
to disequilibrium, and, according to Liston’s
classification9), affects the pre-motor area or its
connections. Our study also indicates that
decreased gait speed is greatly associated with
disequilibrium.
Knutsson et al. described that gait disturbances in
NPH is similar to gait apraxia (=ignition failure)11).
However, our study indicates that the main feature
of gait disturbance in iNPH is disequilibrium since
it improved after VP shunt but ignition failure did
not. Furthermore, Stolze et al. reported that gait
disturbance in iNPH is greatly associated with
disturbed dynamic equilibrium since external cues
 187

Table 2. Nutt’s classification of higher-level gait disorders (Nutt et al. Neurology 1993)
Nutt’s classification Previous terms Lesion
Cautious gait Senile gait
Isolated gait ignition failure Gait apraxia Frontal lobe, white matter
connections and BG
Subcortical disequilibrium Astasia-abasia, Thalamic astasia Mid brain, BG, thalamus
Frontal disequilibrium Frontal ataxia Frontal lobe and white matter
connections
Frontal gait disorder Frontal lobe and white matter
BG: basal ganglia.

Table 3. Liston’s classification of higher-level gait disorders (Liston et al. Age and Aging 2003)
Type Clinical feature Gait alters Cadence alters Site of lesion
with visual cues with auditory cues
Ignition apraxia Gait ignition failure, Yes Yes SMA, BG or connections
shuffling, freezing
Equilibrium apraxia Poor balance and falls No No PMA or connections

Mixed gait apraxia Gait ignition failure, Yes Yes SMA, GB or connections
shuffling, freezing, and SMA, BG or connections
poor balance and falls
SMA: supplementaly motor area.
PMA: premotor area.
BG: basal ganglia.

were less effective at raising the gait ability in iNPH
compared to Parkinson’s disease12). Blomsterwall
et al. reported that (1) the preoperative backward
velocity correlated with time and number of steps
needed to walk 10 m and the time taken in TUG,
and (2) postoperative reduction of backward
velocity correlated with improvement in time
needed for TUG13).
Gait disturbance in iNPH is characterized by petit
pas gait, magnetic gait, and broad based gait.
Further, it has been reported that CSF removal
produced good results in petit pas gait compared
with magnetic gait and broad based gait14). Our
study indicates that disequilibrium improved
remarkably compared with ignition failure and
hypokinesia. Thus, we assume that petit pas gait is
greatly associated with postural instability.
It is thought that the recovery of gait disturbance
depends on the improvement of CSF absorption by
VP shunt. However, we believe that rehabilitative
intervention is an important treatment option for our
patients because (1) the patients were elderly, (2)
severe gait disturbances remained in the early stage
after VP shunt, (3) several weeks were necessary for
recovery from disequilibrium to reach roughly
steady gait, (4) several months had passed since the
appearance of symptoms, and (5) in the recovery
process, without rehabilitative intervention, there
might be delayed recovery of gait ability due to
disuse and increased risk of fall.
Although the neurological mechanism is unclear,
the recovery of disequilibrium after VP shunt was
delayed in Case 2 compared to Case 1. Thus, the
effective term of high-heeled shoes in Case 2 was
longer than in Case 1.
The similarity of the recovery process of our
patients suggests that different rehabilitative
interventions are needed in each stage after VP
shunt. In the early stage after VP shunt,
complementing disequilibrium, such as by using
high-heeled shoes, is necessary. As Blomsterwall et
al. have stated, patients with iNPH present with
backward shift of center of gravity13). We assumed
that this leads to decreased joint moment of ankle
plantar flexion in the mid to terminal stance phase
of walking, since forward shift of vector of ground
188 J. Phys. Ther. Sci. Vol. 19, No. 3, 2007
reaction force is insufficient. As a result, ankle
power in the terminal stance phase may decrease.
In fact, electromyographic study has shown that
patients with iNPH presented the regularly
premature and low activation of the calf muscles11).
High-heeled shoes may decrease the backward shift
of gravity center, and increase joint moment of
ankle plantar flexion in mid to terminal stance phase
of walking. However, future study using kinetic
analysis is needed to clarify this.
It has been proposed that the external cues may
compensate for disturbed motor programming12).
Disturbed balance regulation and motor
programming are involved in the clinical features of
iNPH. However, in our patients, a key feature of
iNPH in the early stage after VP shunt was balance
regulation disorder. Therefore, these patients would
not be expected to benefit from external cues
without complement of disequilibrium.
Our study also suggests that, in the several weeks
after VP shunt, rehabilitative intervention for
freezing episodes and hypokinesia is needed.
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