Thanks for your remarks GCoe.

Yes I read the Lenfeldt article. It seems that an article by Stolze in 2001 hinted at some form of Frontal Lobe dysfunction may be implicated in PD. :

"Secondly, the fact that external cues are not helpful in improving gait in normal pressure hydrocephalus raises the hypothesis that a lack of internal cues from the basal ganglia to drive the supplementary motor area and motor cortex via the ventrolateral thalamus [23] may play a minor part in the hypokinetic gait disorder in normal pressure hydrocephalus. Hypokinesia, freezing, and balance disturbance are often seen after frontal cortex lesions. Such gait disorders due to structural lesions of the frontal lobes and their connections have also been called "frontal dysequilibrium". [40] As the basal ganglia loop is projecting to the frontal cortex this may explain some of the symptomatic overlap of hypokinesia in Parkinson's disease and normal pressure hydrocephalus. Balance is not exclusively regulated at the supraspinal level. It may also be abnormal after disturbances of corticobulbar fibres and subsequent disturbance of brainstem related posture and balance systems. Thus primary frontal damage, lesion of frontocerebellar pathways, or lesioned corticocortical fibres projecting to the frontal cortex are more likely to cause the condition" - from:
Comparative analysis of the gait disorder of normal pressure hydrocephalus and Parkinson's disease. Journal of Neurology, Neurosurgery and Psychiatry March 01, 2001 | Stolze, H; Kuhtz-Buschbeck, J P; Drucke, H; Johnk, K; Illert, M; Deuschl, G

I understand this to mean that perhaps the problem is not in the BG itself (as in PD) which could influence the SMA, but rather in the SMA itself or some other area of the frontal lobe or its pathways.

Another interesting read was this article which in differentiating the gait of PD and NPH states that PD is more likely to have unilateral symptoms, (Kuba, et al. 2002) whereas with my patient clearly has more hypokinesia on his left side, especially as gait breaks down.

Also, my patient has responded somewhat to cueing that the Stolze article asserts does not work in NPH patients (in general of course). So, my patient seems to have a mix of the 2. His neurologist is convinced he has NPH and not PD b/c PD meds did not help, the shunt did, and he has the definitive mild cog and incontinence issues associated with NPH.

Thanks for your input. I will reexamine his HEP and also try a treadmill if he can get over the fear factor.

I'll try to keep you updated.

Jeremy