What Causes Difficulty Standing And Walking For A Short Period Of Time?

Posted on Mon, 15 Dec 2014

Question: Hi - I'm a 58 year old female. For the past 2+ years I've been having difficulty standing and walking for any length of time/distance. This has been getting progressively worse. I now can only stand for about 5 minutes and can only walk 20_30 feet and that is with great pain and difficulty. I have other symptoms as well - numbness, pain, tingling in hands and feet, extreme fatigue, muscle weakness, urinary incontinence, lots of burning pain in legs as well as horrible and painful muscle spasms (mostly in legs and feet but sometimes in arms and around ribcage). I was diagnosed with diabetics 1 year ago but it is very well controlled with metformin and dietary changes. Highest A1c last fall was 7.3 and most recent was 6.6. Most recent and pressing issue is shortness of breath for the last 2 months getting much worse. Just to walk from one room to another leaves me breathless. Chest cat scan showed elevated right hemidiaphragm. White count and absolute neutrophils have been elevated for the past year and don't respond to antibiotics. Have had 7 instances of bronchitis in the past year. I get better on prednisone but as soon as I'm done, everything goes right back. I've had numerous MRI and have quite a lot of degeneration all down my spine. Last week I switched to a new neurologist at XXXXXXX university in St. XXXXXXX EMG showed bilateral neuropathy in legs. aldolace and CPK are both elevated. From everything I've read, I'm fearing muscular dystrophy. I don't see the neurologist again for 2 months but really need to find out before then. The waiting is horrible. I had a pulmonary function study yesterday and will see the criminology Monday to go over results.

Answered by Dr. Rakesh Madhyastha (7 hours later)

Brief Answer:
Peripheral neuropathy

Detailed Answer:
Hello

Thanks for the query

It looks like you have peripheral neuropathy, the cause of which is uncertain. Most often diabetics have peripheral neuropathy but not with a 1 year history of diabetes.

Here is how you should go about it

1. Repeated episodes of bronchitis needs further work up. Get a CT chest to rule out fibrosis of the lung
2. Get ACE levels done
3. I prefer Torsamide than Aldactone on my patients. Aldactone stands chance to increase potassium which might worsen your lower limb pain
4. For breathlessness I recommend you to get your heart examined with ECG and ECHO as well. A weak heart can also cause similar symptoms of lower limb swelling and breathlessness and often goes undiagnosed
5. I also recommend S creatinine to be done for renal failure for completetion.
56. Tab Pregaba is a fantastic drug for peripheral neuropathy, it will releive you of the neuropathic pain. I recommend that you get a lower spine CT scan to rule out nerve compression, especially because you feel tightness in the leg which is typical of a spinal cord involvement.

I must add here that pain in the lower limbs could be because of the swelling itself.
If I were to be your doctor I would have admitted you for evaluation as you have multiple issues and going through a lot of co morbid conditions.

I hope I was of help, if you have any further queries please get back to me

Regards

Above answer was peer-reviewed by : Dr. Raju A.T

Follow up: Dr. Rakesh Madhyastha (1 hour later)

Thank you for your response. I'll try to address each issue and hopefully you can get back with me.

Both of the neurologists that I've seen agree that the neuropathy would not be caused by the diabetis. I haven't had it that long and my glucose levels have not been high enough to warrant the kind of problems that I'm having.

Do you think this could be myotonic muscular dystrophy? It seems to fit everything I've read about it. I know it would need a muscle biopsy to confirm and I'm pretty sure my new neurologist is going to want one. He said he would if last week's labs came back positive, which they did.

I had a CT scan of chest (and noted that above) -- that is how we found out about the elevated hemidiaphragm. The CT scan did not show any abnormalities or signs of interstitial lung disease.

I had the Angiotensin Converting Enzyme done a year ago and it was low at <5 Reference is 8-53 U/L.

My primary care physician is carefully monotoring my potassium level since I started on the aldactone. So far, it has been fine.

My heart has checked out fine. I've had both ECK and ECHO done.

I've had a BMP done 8 times in the past year, including Creatininine, and each time it has been within normal range

None of the doctors have even talked about anything for treatment. They are all focused on diagnosis. I will ask them about Pregaba, I understand it's marketed as Lyrica in the US, correct?

I've had MRI of Lumbar, thoracic and cervical spine, brain and CAT scan chest -- am attaching the reports for you to look over.

Please respond with comments for the above. Do you think it might be myotonic muscular dystrophy? Please give me specific reasons why or why not?

I appreciate your input and this will help me proceed with my neurologist.

You mentioned that you would admit me -- what tests/procedures would you do as an inpatient that could not be done as an outpatient -- why would you admit? Just curious.

You didn't mention the elevated hemidiaphragm -- is that not a significant finding?

I'm anxious to hear back from you -- thank you!

Answered by Dr. Rakesh Madhyastha (10 hours later)

Brief Answer:
Not muscular dystrophy

Detailed Answer:
Hello

Thanks for getting back, I am sorry for the short delay in my response I just got back from the hospital.

I will address all your questions one by one

1. I do not think it is muscular dystrophy because it is predominantly seen as wasting of the muscles certainly not limited to the lower limbs alone. More over the other neurological issues like increased sleep and defect in cognition is not present in you. One more thing is that these patients have a positive family history. Muscle biopsy can be the next for of investigation as all other things are done.
2. Diaphragm will be elevated in a film taken during expiration. It is not of much value
3. Lyrica is the correct trade name for Pregabalin
4. I would have admitted you because OPD basis investigation is slow and takes a long time to come to conclusion. Once the patient is admitted he will be seen daily and more time is spent with the patient. Its just a way I prefer to function in patients who havent had a conclusion of the diagnosis in a long time.

I hope I was of help, if you have any further queries please get back to me

Regards

Above answer was peer-reviewed by : Dr. Ashwin Bhandari

Follow up: Dr. Rakesh Madhyastha (1 hour later)

Yes, very helpful. Thank you.

I have had extreme fatigue as well and fall asleep with very little warning. Loss of muscle strength is also in hands and arms.and I have had some cognitive issues with inattention, inability to complete tasks and stay focused, memory issues, etc. No family history that I know of. Does that completely eliminate the possibility?

I have wondered about the inpatient diagnosis and why they haven't suggested that. However, I am a single parent so that would be problematic. Perhaps that is why. At this point I would be willing to be admitted if I thought they could make a diagnosis. I'm so tired of not knowing and frustrated that there is no treatment started.

So, do you agree that a muscle biopsy should be the next step?

The raised diaphragm could also be seen on a chest tray and cervical MRI, all taken within the last 6 months. Should there be something done to rule it out for sure like an ultrasound or spectroscopy?

Did you have a chance to look at the MRI reports that I sent?

Thank you for your input!

Answered by Dr. Rakesh Madhyastha (9 hours later)

Brief Answer:
Yes, Biopsy would be the next step

Detailed Answer:
Hello

Thanks for getting back

Here is what I suggest should be the next step

1. Muscle biopsy should be the next step, there is no doubt about it. Muscular dystophy is possible even without family history. However to be more convinced about muscular dystrophy I would want to clinically examine you.
2. Inpatient diagnosis is something what I follow, many doctors prefer outpatient diagnosis but I feel it is more laborious and irritating to the patients.
3. Right sided elevated diaphragm- I recommend that the doctor should clinically examine you. If chest expansion is equal bilaterally and air entry is also equal then we can forget about the MRI finding.

I have gone through your MRI report. Thanks for attaching it. Its good that you have undergone operation for it.

Regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Rakesh Madhyastha (19 minutes later)

Thank you. I will see the pulmonoligst on Monday. Is there anything specific I should ask him to check? I may have more questions for you after that. You've been Very helpful. Thank you

Answered by Dr. Rakesh Madhyastha (5 minutes later)

Brief Answer:
Follow up

Detailed Answer:
Hello

Here is what I think you should ask him

1. How long does he think you should be on oral steroids?
2. Is it possible to be on long acting inhalation bronchodilators instead?
3. Do you think the breathlessness is of cardiac origin as well?
4. Pulmonary function test to see for reversibility
5. Please confirm the elevation of the diaphragm with him, clinical examination of it is the best way to go about it

You can get back to me, I will be happy to help you out. You could send the query straight to me by starting your answer as TO Dr Rakesh Madhyastha

Wishing you good health

Regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Rakesh Madhyastha (2 days later)

Hello - I saw the pulmonologist today. My metylcholine challenge test showed that I do have asthma. They put me on a symbiocort inhaler twice a day. If that doesn't improve the cough and shortness of breath, he will discontinue the lisinopril that I take for blood pressure.

I'm having a sniff test done on Wednesday to evaluate for elevated hemidiaphragm.

After taking it for about a month, the aldactone has finally started to work. I've lost 20 pounds in water weight this week and feel so much better. I'm having blood drawn tomorrow for electrolytes and potassium.

He is concerned about my o2 level at night so I'm wearing a pulse ox meter tonight.if it's low, will they put me on o2 at night? That seems extreme to me.

I haven't heard anything back from the neurologist yet.

Comments or suggestions? Thanks

Answered by Dr. Rakesh Madhyastha (12 hours later)

Brief Answer:
ABG is a better option

Detailed Answer:
Hello

Thanks for getting back

1. It is true that Lisinopril causes cough,most often it is dry cough not associated with breathlessness or tiredness.
2. I would want to check your arterial blood gas in the morning to see for oxygen levels and also for carbon dioxide retention. Please ask them if it is possible to do an ABG as well. High carbon dioxide retention warrants for a CPAP machine in the night
3. Please let me know the results of the sniff test

I am happy you are being further evaluated. I am of the belief that along with testing, symptomatic relief is also of utmost importance because that's what every patient has come to the doctor for in the first place

Regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar