CALDERON, GARCIA, HARDIN, MANABAT, SOLIS 1 of 4

GAIT AND STATION

2.3-A August 11, 2014

PLM CM Dr. Guzman

Legend: normal text lecture/old trans; Bates italics; transers notes red text

THE NEUROLOGIC EXAM

Steps in the Diagnosis of Neurologic Diseases: 1. Mental Status Exam 2. Gait and Station* 3. Cranial Nerves 4. Motor System 5. Coordination 6. Reflexes 7. Sensation 8. Head and Neck 9. Spine and Skin

*On Bates, this part was included in The Motor System (See next section: Coordination)

CEREBELLAR TESTING o Cerebellum: Fine tunes motor activity and assists

with balance. Dysfunction results in a loss of coordination and problems with gait. The left cerebellar hemisphere controls the left side of the body and vice versa.

o For the screening exam, using one modality will suffice. If an abnormality is suspected or identified, multiple tests should be done to determine whether the finding is durable. That is, if the abnormality on one test is truly due to cerebellar dysfunction, other tests should identify the same problem.

o Gait testing is an important part of the cerebellar exam.

COORDINATION

Coordination of muscle movement requires the integration of the following areas of nervous system function:

1. Motor system: for muscle strength 2. Cerebellar system (also part of the motor

system): for rhythmic movement and steady posture

3. Vestibular system: for balance and for coordinating eye, head, and body movements

4. Sensory system: for position sense

To assess coordination, observe the patients performance in:

1. Rapid alternating movements 2. Point-to-point movements 3. Gait and other related body movements 4. Standing in specified ways/ Stance

RAPID ALTERNATING MOVEMENTS

Dysdiadochokinesis: one movement cannot be followed quickly by its opposite, and movements are slow, irregular, and clumsy; seen in cerebellardisease

Upper motor neuron weakness and basal ganglia disease may also impair rapid alternating movements, but not in the same manner.

Using Arms/ Hands

From Bates

Show the patient how to strike one hand on the thigh, raise the hand, turn it over, and then strike the back of the hand

down on the same place.

Urge the patient to repeat these alternating movements as rapidly as possible.

Observe the speed, rhythm, and smoothness of the

movements.

Repeat with the other hand. The nondominant hand often performs somewhat less well.

Alternative: From Lecture

Direct the patient to touch first the palm and then the dorsal side of one hand against their thigh.

Ask patient to repeat this movement as fast and accurate as

possible

Test the other hand

Using Fingers

From Bates

Show the patient how to tap the distal joint of the thumb with the tip of the index finger, again as rapidly as possible.

Observe the speed, rhythm, and smoothness of the

movements. The nondominant side often performs less well.

Alternative: From Lecture

Ask the patient to touch the tips of each finger to the thumb of the same hand.

Test fingers on both hands.

Using Legs

Ask the patient to tap your hand as quickly as possible with

the ball of each foot in turn.

Note any slowness or awkwardness. The feet normally perform less well than the hands.

POINT-TO-POINT MOVEMENTS

Finger-to-Nose Test (Arms)

Ask the patient to touch your index finger and then his or her nose alternately several times.

Move your finger about so that the patient has to alter

directions and extend the arm fully to reach it.

Observe the accuracy and smoothness of movements, and watch for any tremor. Normal Result: patients movements

are smooth and accurate

Now hold your finger in one place so that the patient can touch it with one arm and finger outstretched.

Ask the patient to raise the arm overhead and lower it again

to touch your finger.

After several repeats, ask the patient to close both eyes and try several more times.

Repeat on the other side. Normal Result: a person can

touch the examiners finger successfully with eyes open or closed. These maneuvers test position sense and the

functions of both the labyrinth and the cerebellum.

An intention tremor may appear toward the end of the movement.

In cerebellar disease, movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction.

Dysmetria: If the finger initially overshoots its mark, but finally reaches it fairly well

Past pointing: repetitive and consistent deviation to one side, which worsens with eyes closed; suggests cerebellar or vestibular disease

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS 2 of 4

GAIT AND STATION

2.3-A August 11, 2014

PLM CM Dr. Guzman

Heel-to-Shin Test (Legs)

Ask the patient to place one heel on the opposite knee, and then run it down the shin to the big toe.

Note the smoothness and accuracy of the movements.

Repetition with the patients eyes closed tests for position sense.

Repeat on the other side.

Normal result: movement should trace a straight line along the top of the shin and be done with reasonable speed.

In cerebellar disease, the heel may overshoot the knee and then oscillate from side to side down the shin.

When position sense is lost, the heel is lifted too high and the patient tries to look. With eyes closed, performance is poor.

GAIT TESTING

Ability to stand and walk normally is dependent on input from several systems, including: visual, vestibular, cerebellar, motor, and sensory.

The precise cause(s) of the dysfunction can be determined by identifying which aspect of gait is abnormal and incorporating this information with that obtained during the rest of the exam.

o Ex 1. Difficulty getting out a chair and initiating movement would be consistent with Parkinsons Disease

o Ex 2. Lack of balance and a wide based gait would suggest a cerebellar disorder

Ask the patient to: 1. Walk across the room, turn and come back 2. Walk heel-to-toe in a straight line 3. Walk on their toes in a straight line 4. Walk on their heels in a straight line 5. Hop in place on each foot 6. Do a shallow knee bend 7. Rise from a sitting position

1. Walk across the room, turn, and come back towards you

Pay particular attention to: o Balance

- Left-sided cerebellar lesions (e.g. d/t stroke or tumor): patient falls to the left

- Right sided lesions: patient falls to the right - Diffuse disease affecting both hemispheres:

generalized loss of balance o Rate of walking:

If they start off slow then accelerate, perhaps losing control of their balance or speed may occur with Parkinsons Disease

o If they are slow moving secondary to pain/limited range of motion in their joints may occur with degenerative joint disease

o Attitude of Arms and Legs: includes how they hold their arms and legs, loss of movement, and evidence of contractures (e.g. as might occur after a stroke)

Ataxia: presence of a gait that lacks coordination, with reeling and instability; may be due to cerebellar disease, loss of position sense, or intoxication.

2. Walk heel-to-toe in a straight line

a.ka. tandem walking

A test of balance

May reveal an ataxia not previously obvious

May be difficult for older patients (due to the frequent coexistence of other medical conditions) even in the absence of neurological disease.

3&4. Walk on their toes, then on their heels

Sensitive tests for plantar flexion (toes) and dorsiflexion of the ankles (knees), as well as for balance.

May reveal distal muscular weakness in the legs

Inability to heel-walk is a sensitive test for corticospinal tract damage.

5. Hop on place on each foot in turn (if patient is not too ill)

Involves the proximal and distal muscles of the legs

Requires both good position sense and normal cerebellar function.

Difficulty may be due to weakness, lack of position sense, or cerebellar dysfunction

6. Do a shallow knee bend on each leg in turn

Support the patients elbow if you think the patient is in danger of falling.

Difficulty in doing a shallow knee bend suggests proximal weakness (extensors of the hip), weakness of the quadriceps (the extensor of the knee), or both

7. Rise from a sitting position without arm support

Difficulty getting up from a chair: might suggest proximal muscle weakness (involving pelvic girdle and legs), a balance problem, or difficulty initiating movements.

This, and stepping up on a sturdy stool are more suitable tests than hopping or knee bends when the patients are old or less robust.

STANDING/ STANCE

Cerebellar ataxia is NOT ameliorated by visual orientation

The following two tests can often be performed concurrently. They differ only in the patients arm position and in what you are assessing.

According to Doc Guzman, tumayo raw sa medyo gilid para masalo yung patient sakaling matumba palikod or paharap

The Romberg Test

This is a test of balance, incorporating input from the visual, cerebellar, proprioceptive, and vestibular systems.

Mainly a test of position sense (proprioception)

Ask patient to stand with feet together and eyes open

If patient is able to do this, ask him/her to close both eyes for 30 to 60 seconds without support.

Note the patients ability to maintain an upright posture.

Normally only minimal swaying occurs.

(+) Romberg sign: patient stands fairly well with eyes open but loses balance when they are closed (impaired

proprioception)

In ataxia from dorsal column disease and loss of position sense, vision compensates for the sensory loss.

In cerebellar ataxia, the patient has difficulty standing with feet together whether the eyes are open or closed.

In disease of the cerebellum: o lateral lobe, falling is toward the affected side o frontal lobe, falling is to the opposite side o midline or vermis, falling indiscriminately

Test for Pronator Drift

Pronator drift: pronation of one forearm

It is both sensitive and specific for a corticospinal tract lesion originating in the contralateral hemisphere.

Ask patient to stand for 20 to 30 seconds with both arms straight forward, palms up, and with eyes closed.

Instructing the patient to keep the arms up and eyes shut, tap the arms briskly downward. The arms normally return

smoothly to the horizontal position. This response requires muscular strength, coordination, and a good sense of

position.

Normal response: able to hold arm position well

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS 3 of 4

GAIT AND STATION

2.3-A August 11, 2014

PLM CM Dr. Guzman

A person who cannot stand may be tested for a pronator drift in the sitting position.

Downward drift of the arm with flexion of fingers and elbow may also occur.

In loss of position sense: there is sideward or upward drift, sometimes with searching, writhing movements of the

hands; patient may not recognize the displacement and, if told to correct it, does so poorly

In cerebellar incoordination: the arm returns to its original position but overshoots and bounces

ABNORMALITIES OF GAIT AND POSTURE

Picture Type Description

Normal Normal posture, step size, and arm swing

Spastic hemiparesis/ Hemiplegic gait

Seen in corticospinal tract lesion in stroke, causing poor control of flexor muscles during swing phase.

Affected arm is flexed, immobile, and held close to the side, with elbow, wrists, and interphalangeal joints flexed.

Affected leg extensors spastic; ankle plantarflexed and inverted.

Patients may drag toe, circle leg stiffly outward and forward (circumduction), or lean trunk to contralateral side to clear affected leg during walking.

Ayon sa na-search ko, hemiparesis if one side of the body is weak but not paralyzed or is partially paralyzed, and hemiplegia if one side of the body is paralyzed; sa Bates kasi hemiparesis yung ginamit, pero sa lecture, hemiplegic gait yung picture

Steppage gait

Seen in foot drop, usually secondary to peripheral motor unit disease

Patients either drag the feet or lift them high, with knees flexed, and bring them down with a slap onto the floor, thus appearing to be walking up stairs

They cannot walk on their heels.

May involve one or both legs

Tibialis anterior and toe extensors are weak.

Scissors gait

Seen in spinal cord disease, causing bilateral lower extremity spasticity, including adductor spasm, and abnormal proprioception.

Gait is stiff and steps are short

Patients advance each leg slowly, and the thighs tend to cross forward on each other at each step.

Patients appear to be walking through water

Seen in all spasticity disorders, most commonly cerebral palsy

Parkinsonian gait

Seen in the basal-ganglia defects of Parkinson disease

Posture is stooped, with flexion of head, arms, hips, and knees. Patients are slow getting started.

Fesination: steps are short and shuffling, with involuntary hastening

Arm swings are decreased

Patients turn around stifflyall in one piece. Retropulsion: if postural control is poor

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS 4 of 4

GAIT AND STATION

2.3-A August 11, 2014

PLM CM Dr. Guzman

Cerebellar Gait/ Ataxia

Seen in disease of the cerebellum or associated tracts.

Gait is staggering, unsteady, and wide based, with exaggerated difficulty on turns.

Patients cannot stand steadily with feet together, whether eyes are open or closed.

Other cerebellar signs are present such as dysmetria, nystagmus, and intention tremor.

From the internet : accompanied by swaying of the trunk

Sensory Ataxia

Seen in loss of position sense in the legs (with polyneuropathy or posterior column damage).

Gait is unsteady and wide based.

Patients throw their feet forward and outward and bring them down, first on the heels and then on the toes, with a double tapping sound.

Exhibits positive Rombergs sign; staggering gait worsens with eyes closed

Retropulsion

Internet source (UF): retropulsion in Parkinsons disease is the force that contributes to loss of balance in a backwards or posterior direction.

Occurs due to a worsening of postural stability and an associated loss of postural reflexes

A big contributor to falls in Parkinsons disease

Some video demonstrations here: http://library.med.utah.edu/neurologicexam/html/gait_abnormal.html