Neurologic examinationGAIT & STATION

• 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. Difficulty getting out a chair and initiating movement, for example, would be consistent with Parkinson’s Disease. On the other hand, lack of balance and a wide based gait would suggest a cerebellar disorder.

GAIT TESTING

Ask the patient to:

Walk across the room, turn and come back Walk heel-to-toe in a straight line Walk on their toes in a straight line Walk on their heels in a straight line Hop in place on each foot Do a shallow knee bend Rise from a sitting position

• Cerebellar ataxia is not ameliorated by visual orientation• Have the patient stand in one place. This is a test of

balance, incorporating input from the visual, cerebellar, proprioceptive, and vestibular systems. If they are able to do this, have them close their eyes, removing visual input. This is referred to as the Romberg test. Loss of balance suggests impaired proprioception.

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

TESTING OF STATION (EQUILIBRATORY COORDINATION)

• Ask the patient to stand from a chair, walk across the room, turn, and come back towards you. Pay particular attention to: – Difficulty getting up from a chair: Can the patient easily arise

from a sitting position? Problems with this activity might suggest proximal muscle weakness, a balance problem, or difficulty initiating movements.

– Balance: Do they veer off to one side or the other as might occur with cerebellar dysfunction? Disorders affecting the left cerebellar hemisphere (as might occur with a stroke or tumor) will cause patient’s to fall to the left. Right sided lesions will cause the patient to fall to the right. Diffuse disease affecting both cerebellar hemispheres will cause a generalized loss of balance.

– Rate of walking: Do they start off slow and then accelerate, perhaps losing control of their balance or speed (e.g. as might occur with Parkinson’s Disease)? Are they simply slow moving secondary to pain/limited range of motion in their joints, as might occur with degenerative joint disease? etc.

– Attitude of Arms and Legs: How do they hold their arms and legs? Is there loss of movement and evidence of contractures (e.g. as might occur after a stroke)?

• Heel to Toe Walking: Ask the patient to walk in a straight line, putting the heel of one foot directly in front of the toe of the other. This is referred to as tandem gait and is a test of balance. Realize that this may be difficult for older patients (due to the frequent coexistence of other medical conditions) even in the absence of neurological disease.

Normal posture, step size, and arm swing

Tandem Walking

Hemiplegic Gait  Parkinsonian Gait 

Steppage Gait  Retropulsion 

CEREBELLAR TESTING

• The 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.

• Specifics of Testing: There are several ways of testing cerebellar function. 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. Gait testing, an important part of the cerebellar exam.

Finger to nose testing: – With the patient seated, position your index finger at a point in space in front of

the patient. – Instruct the patient to move their index finger between your finger and their

nose. – Reposition your finger after each touch. – Then test the other hand.

Interpretation: The patient should be able to do this at a reasonable rate of speed, trace a straight path, and hit the end points accurately.  Missing the mark, known as dysmetria, may be indicative of disease.

Rapid Alternating Finger Movements: – Ask the patient to touch the tips of each finger to the thumb of the same hand. – Test both hands. Interpretation: The movement should be fluid and accurate.  Inability to do this, known as dysdiadokinesia, may be indicative of cerebellar disease.

CEREBELLAR TESTING

Evaluation of cerebellar function. While the examiner holds his finger at arm's length from the patient, the patient touches her nose and then touches the examiner's finger. After several sequences, the patient is asked to repeat the exercise with her eyes shut. A patient with a cerebellar disorder tends to overshoot the target.

Rapid Alternating Hand Movements: – Direct the patient to touch first the palm and then the dorsal side of

one hand repeatedly against their thigh. – Then test the other hand. Interpretation: The movement should be performed with speed and accuracy.  Inability to do this, known as dysdiadokinesia, may be indicative of cerebellar disease.

Heel to Shin Testing: – Direct the patient to move the heel of one foot up and down along the

top of the other shin. – Then test the other foot. Interpretation: The movement should trace a straight line along the top of the shin and be done with reasonable speed.

CEREBELLAR TESTING

Rapid Alternating Movements

Heal Shin Test 

The Romberg test. Have the patient stand still with heels and toes together. Ask the patient to close her eyes and balance herself. If the patient loses her balance, the test is positive.

THE END