Early and delayed assessments of quantitative gait measures to improve the tap test as a predictor of shunt effectiveness in idiopathic normal pressure hydrocephalus

Masatsune Ishikawa, Shigeki Yamada, Kazuo Yamamoto, Masatsune Ishikawa, Shigeki Yamada, Kazuo Yamamoto

Abstract

Background: To improve the diagnostic performance of the cerebrospinal fluid (CSF) tap test (TT), early and delayed assessments of gait were performed after the removal of 30 ml of CSF in patients with probable idiopathic normal pressure hydrocephalus. Assessments of gait included the 3-m timed up and go test (TUG), and the 10-m walk in time (10Ti) and in step (10St) tests.

Methods: Quantitative data for the TUG, the 10Ti, and the 10St were obtained before CSF removal and on days 1 and 4 after removal of 30 ml CSF. CSF shunt surgery was performed in 61 patients within one month after the TT. The gait outcome was assessed 3 months after surgery. The area under the curve (AUC), sensitivity, specificity, and cutoff values were computed for the TUG, the 10Ti, and the 10St on day 1 and day 4 using receiver operating characteristic (ROC) curve analysis.

Results: The positive response rate in three measures on day 4 was equal to or higher than the values on day 1. Times were reduced significantly in the TUG and the 10mTi tests between baseline and both days 1 and 4 after TT. No significant differences were noted in the number of steps for the 10St test. The percent change in TUG on day 1 had the highest AUC value among all other variables (0.808). Although this was not statistically different from other variables in the TUG and the 10Ti, it had a good balance of high sensitivity (78.3%) and high specificity (80.0%), with a cutoff value of 11.3%. The change in the measured value in the day 1 TUG had the second highest AUC value at 0.770. The variables on day 4 tended to have high specificities of around 90%, although their sensitivities were low.

Conclusions: The percent change of TUG on day 1 showed the highest diagnostic accuracy. Delayed assessments on day 4 were not superior to those on day 1. Thus, the TUG on day 1 is useful as a simple quantitative measure for predicting shunt effectiveness.

Keywords: Aged population; Gait disturbance; Hydrocephalus; Tap test.

Figures

Fig. 1
Fig. 1
Number of patients showing a positive response to the three tests on days 1 and 4 after the tap test. The percentage of positive responses was comparable between day 1 and day 4 for the timed up and go (TUG) and the 10-m walk in time (10Ti) tests but significantly higher for the 10-m walk in step (10St) test at day 4. The number of patients was 61 on day 1 and 51 on day 4
Fig. 2
Fig. 2
Graphs showing the results for the three tests at baseline (before the tap test), and on day 1 and day 4 after the tap test. All measures decreased in value from baseline on day 1 and day 4. ANOVA revealed statistical significance for the TUG and the 10Ti, but not for the 10St. Post-hoc analysis indicated a significant decrease in time between the baseline and day 1, and between the baseline and day 4 in the TUG and the 10Ti tests, but not between day 1 and day 4. Values are mean ± confidence level
Fig. 3
Fig. 3
Receiver operating characteristic (ROC) curves and area under the curve (AUC) values on day 1 (solid lines) and day 4 (dotted lines). ROC curves for changes of measured values from baseline are left and ROC curves for percent changes are on the right. The AUC for TUG on day 1 was highest for both ROC curves
Fig. 4
Fig. 4
Positive response in any of three assessment measures. Positive response in any of three assessment measures on day1 (black line), day 4 (red line) or either day 1 or day 4 (blue line) showed high sensitivity but their specificities were low

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