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General Rehabilitation

(Kiosk 1) Gegenhalten Syndrome: A Case Report of an Unfamiliar Phenomenon

Saturday, November 18, 2023
8:00 AM – 9:15 AM CT

    Primary Author(s)

  • Anam Purewal, MD (she/her/hers)

    Resident
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    Brooklyn, New York

    • Co-Author(s)

  • Jayne Ha, DO (she/her/hers)

    resident physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    brooklyn, New York

  • Jason Do, DO

    Resident Physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    333 Schermerhorn st, Apt 10P, New York

  • Simron Gill, MD (he/him/his)

    Resident Physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    New york, New York

  • Elver Ho, Other (he/him/his)

    Medical Student
    SUNY Downstate College of Medicine
    Brooklyn, New York

  • CN

    Chow Ng, MD

    Attending Physician
    New York Harbor Health Care System/ Brooklyn VA campus
    Jamaica, New York

  • SA

    Sanjeev Agarwal, MD

    Program Director
    SUNY Downstate Medical Center
    Brooklyn, New York

Case Diagnosis: Gegenhalten Syndrome in end-stage Alzheimer’s Disease

Case Description or Program Description: This is a 77-year-old male with a medical history of end-stage Alzheimer’s Disease and previous stroke with left-sided hemiparesis. Patient required total assistance for all activities of daily living. On examination, patient was AOx0, with tongue thrust, positive stepping and gasp reflexes, decreased passive range of motion in all joints, increased tone in all extremities, and severe spasticity with a Modified Ashworth Score of 3-4 in all four extremities.

Setting: Nursing home

Assessment/Results: Appropriate management emphasized decreasing complications including pressure ulcers, contractures, range of motion, and minimizing pain. We prescribed a Broda wheelchair with padding throughout (head, trunk, arm and leg rests), a nursing-led bedside exercise program, and educated his family to increase awareness about his condition.

Discussion (relevance): Gegenhalten, or oppositional paratonia, is a syndrome to describe a type of rigidity frequently seen in advanced dementias and is usually accompanied by emergence of primitive reflexes. Despite its ubiquity, awareness of this condition is low among clinicians, research data is scarce, and clinical guidelines are lacking. Paratonia is an involuntary variable resistance and varies depending on the speed of movement, the rigidity can be in any direction (has no pattern) and does not have exhibit clasp-knife phenomenon. The pathogenesis is hypothesized to be related to cortical and subcortical motor damage, impaired inhibition due to frontal lobe lesions, and possibly due to peripheral injury from accumulation of advanced glycation end-products in muscle collagen, resulting in tissue stiffness. Complications of this condition, most notably contractures from fixed posturing, lead to discomfort and decreased quality of life.

Conclusions: Gegenhalten Syndrome is a disease-state commonly seen in advanced dementias and is characterized by involuntary variable resistance that is velocity-dependent. There is no cure for this condition, so management should emphasize tertiary prevention, to decrease complications and maintain residual quality of life.