Subtle gait changes in patients with REM sleep behavior disorder

Many people with rapid eye movement (REM) sleep behavior disorder (RBD) have an underlying synucleinopathy, the most common of which is Lewy body disease. Identifying additional abnormal clinical features may help in identifying those at greater risk of evolving to a more severe syndrome. Because gait disorders are common in the synucleinopathies, early abnormalities in gait in those with RBD could help in identifying those at increased risk of developing overt parkinsonism and/or cognitive impairment. We identified 42 probable RBD subjects and 492 controls using the Mayo Sleep Questionnaire and assessed gait velocity, cadence, and stride dynamics with an automated gait analysis system. Cases and controls were similar in age (79.9±4.7 and 80.1±4.7, P=0.74), Unified Parkinson's Disease Rating Scale Part III (UPDRS) score (3.3±5.5 and 1.9±4.1, P=0.21) and Mini-Mental State Examination scores (27.2±1.9 and 27.7±1.6, P=0.10). A diagnosis of probable RBD was associated with decreased velocity (-7.9 cm/s; 95% confidence interval [CI], -13.8 to -2.0; P<0.01), cadence (-4.4 steps/min; 95% CI, -7.6 to -1.3; P<0.01), significantly increased double limb support variability (30%; 95% CI, 6-60; P=0.01), and greater stride time variability (29%; 95% CI, 2-63; P=0.03) and swing time variability (46%; 95% CI, 15-84; P<0.01). Probable RBD is associated with subtle gait changes prior to overt clinical parkinsonism. Diagnosis of probable RBD supplemented by gait analysis may help as a screening tool for disorders of α-synuclein.