Neurology ExaminationGait assessment

Exposing the patientEnsure that the patient’s legs are exposed and clearly visible.

General Appearance/InspectionAll examinations begin with a general inspection of the patient and their immediate surroundings. This is done from the end of the bed.

Abnormal posture – e.g. hemiplegic positioning Equipment – assistive devices, mobility aids

Inspect lower limbs, comparing one side with the other Asymmetry Muscle wasting or hypertrophy Abnormal movements –

Tremor Fasciculations - These are irregular contractions of small areas of muscle which have no

rhythmical pattern. If present with weakness and wasting, fasciculation indicates degeneration of the lower motor neuron e.g. motor neuron disease.

Myoclonic jerks- brief, involuntary twitching of a muscle or a group of muscles Other involuntary movements (dyskinesias) – dystonia, chorea, athetosis, ballism, tics

dystonia- sustained muscle contractions cause twisting and repetitive movements or abnormal posture chorea- 'dance-like' movements athetosis- slow, involuntary, convoluted, writhing movements of the fingers, hands, toes, and feet and in some

cases, arms, legs, neck and tongue Ballism- decrease in activity of the subthalamic nucleus of the basal ganglia, resulting in the appearance of

flailing, ballistic, undesired movements of the limbs.

Gait Exam

Ask patient to walk across the room, turn around quickly, and come back towards you: Balance

o Veer off to one side = cerebellar dysfunction (e.g. disorder of left cerebellar hemisphere will cause patient to fall to the left; diffuse disease affecting both cerebellar hemispheres will cause generalized loss of balance)

Rate of Walkingo Loss of control of balance or speed = Parkinson’so Slow moving 2o to pain or limited range of motion in joints = Degenerative joint disease

How do they hold their arms and legs?o Loss of movement, evidence of contractures = post-stroke

Gait Disorders:o Hemiplegia = foot is plantar flex and leg is swung in a lateral arc (Circumduction)- UMN lesiono Spastic Paraparesis = scissors gait (seen in multiple sclerosis, UMN lesion)o Parkinson’s Disease = shuffling, hesitation, freezing, Festinating, propulsion, retropulsiono Cerebellar(ataxia gait) = wide-based (to avoid falling); staggering towards affected side

Remember hand hygiene

before and after every

patient contact

-wide-based with truncal instability and irregular lurching steps which results in lateral veering and if severe, falling. This type of gait is seen in midline cerebellar disease. It can also be seen with severe lose of proprioception (sensory ataxia)

o Foot-Drop = high stepping gait due to damage to common peroneal nerve, which is injured by trauma to head of the fibula

o Proximal Myopathy = waddling gaitrolling gait in which the weight-bearing hip is not stabilized; it bulges outward with each step, while the opposite side of the pelvis drops, resulting in alternating lateral trunk movements; due to gluteus medius muscle weakness,

o Trendelenburg’s gait = damaged superior gluteal nerve on contralateral side to hip dip.During the stance phase, the weakened abductor muscles allow the pelvis to tilt down on the opposite side. To compensate, the trunk lurches to the weakened side to attempt to maintain a level pelvis throughout the gait cycle.

Heel-to-Toe Walking: Difficulty = midline cerebellar lesion, or in older patients (even in absence of neurological disease)

Walk on Toes: Impossible with S1 lesion

Walk on Heels: Impossible with L5 lesion causing foot-drop

Ask patient to squat and then stand up, or sit in a low chair and then stand Impossible with L4 lesion This tests for proximal myopathy

Ask patient to stand in one place with feet together: First with eyes open, then closed Truncal ataxia = tendency to fall backwards = midline cerebellar lesion Inability with eyes open or closed = cerebellar disease Romberg Test - standing erect with feet together– compare steadiness shown when eyes open with when

eyes closed. Marked unsteadiness with the eyes open is seen in cerebellar and vestibular dysfunction. oPositive Test (loss of balance) = when unsteadiness increases with eye closure. Seen with impaired

proprioception

Cerebellar Exam:

Generally, cerebellar lesions cause ipsilateral cerebellar signs. Bilateral cerebellar lesions will cause bilateral signs and central cerebellar lesions can cause bilateral, asymmetrical signs.

General Inspection : CHAIR SAW Consciousness Hearing aid Asymmetry Involuntary movement Rash Skin (vasculitis, neurofibromas, café au lait spots) Scars Abnormal posture or gait Walking aid

Head and Neck: Nystagmus – jerky horizontal nystagmus towards side of the cerebellar lesion Dysarthria – difficulty with articulation e.g. jerky, slurring, explosive, loud, with irregular separation of

syllables (sign of diffuse cerebellar involvement). Ask patient to say “British Constitution” or “West Register Street”:

Upper Limbs: Ask patient to extend their arms to shoulder level out in front of them, palms upwards:

Upward drift = cerebellar lesion Pronator drift (palms pronate)= contralateral pyramidal tract defect/ upper motor neuron lesion Abnormalities more pronounced if hands tapped and/or eyes closed Downward drift = lower motor neuron lesion

Ask patient to raise their arms quickly from their sides, and stop suddenly mid-motion: Inability to stop = rebound = loss of coordination between agonist and antagonist muscle action

Test ToneNose-to-Finger Testing – Ask patient to move their index finger between their nose and your finger, reposition your finger after each touch; test both hands! Ensure patient must fully extend elbow to reach your finger

Past pointing = ipsilateral cerebellar disease Intention tremor = ipsilateral cerebellar disease

Rapid Alternating Finger Movements – Ask patient to touch the tip of each finger to the thumb of the same hand; test both hands!

Inability (not fluid or accurate) = dysdiadochokinesis = ipsilateral cerebellar diseaseRapid Alternating Hand Movements – Ask patient to rapidly and repeatedly touch the palm and then dorsal side of one hand against the palm of the other hand; test both hands!

Inability (not fast or accurate) = dysdiadochokinesis = ipsilateral cerebellar disease

Lower Limbs:Test ToneHeel-to-Shin Testing – Ask patient to move the heel of one foot up and down along the top of the other shin; test both feet!

Inability (not fast or straight) = loss of coordination = ipsilateral cerebellar diseaseToe-to-Finger Testing – Ask patient to lift the big toe up to touch your finger; test both feet!

Past pointing Intention tremor

Gait: As above