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Clinical Disorders of Balance, Posture and Gait
  1. ROGER BARKER

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    Clinical Disorders of Balance, Posture and Gait. Edited by: a m bronstein, t brandt, and m woollacott. (Pp 350; £85.00b). Published by Arnold, London 1996. ISBN 0340601450.

    This multiauthored book sets out to explore the neuroscientific basis, clinical examination, and evaluation of disorders of balance and locomotion. The book has an opening section on the organisation of the sensorimotor systems involved in balance, posture, and walking with particular reference to the vestibular system. This forms an essential basis for the rest of the book but is somewhat intimidating to the naive reader who may fail to get beyond discussions—for example, on the role of strategies or synergies in the control of posture in response to balance disturbances. This would, therefore, prevent the reader from entering the excellent section on clinical disorders of balance and gait, and the assessment of such patients, a section that will appeal to most general neurologists. In this section of the book we are entertained by some excellent chapters especially with respect to the diverse and sometimes devastating symptoms and signs of vestibular disorders and the range of different gait disorders that can now be distinguished. Such disorders include the well recognised isolated gait ignition failure as well as less widely known states such as those gathered under the rubric of subcortical disequilibrium states (including thalamic astasia). In addition, there are detailed discussions on the cautious gait and psychogenic disorders of gait and balance—cases of which abound in every neurological clinic. The classification and clinical features of different disorders of gait and balance are complemented by chapters on the analysis and investigation of such patients from an orthopaedic, neurological, and neuro-otological point of view. This serves not only to highlight a strength of this book—namely, the multidisciplinary approach, but also highlights the shortcomings of most neurological practices, which have limited access to specialist neuro-otological units. In most centres the patients are reviewed by non-specialist neurologists and ear, nose, and throat surgeons and then referred on to physiotherapists for treatment, as pharmacological treatments are generally not helpful. This aspect of the management of patients with gait or balance disorders is discussed in the three chapters forming section four of this book, in which the discussion concentrates on the psychological and physical approach to treatment.

    The book closes with a rather repetitive section on the specific problems of gait disorders and falls in elderly people—an important and often neglected area of medicine which will no doubt become more of an issue as the elderly population continues to grow. These chapters I found the most disappointing as they tended to be too wordy with little detail given to summary points—for example, in chapter 20 there is an eight page table on all the studies that have analysed the effects of medications on the risk of falls!

    Overall this book sets out to define and explore a much neglected area of neuroscience and clinical neurology and goes a long way to achieving this aim. The problem with a book such as this, however, is in trying to combine detailed technical accounts and models for the specialist while holding the interest of the neurologist. Ultimately the book has chapters of great value to the non-specialist neurologist, but these have to be looked for and the opening and closing sections of the book will scare off many possible readers. However, for those who are prepared to do battle with these chapters the rewards are worth seeking, because the book does give one of the best overviews on the control of posture, balance, and locomotion and with this comes an understanding of such disorders as camptocormia, otolith Tullio phenomenon, and Tumarrkin’s otolithic crisis.

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