Neurologic examination

GAIT & STATION

 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. 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.
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
 TESTING OF STATION
(EQUILIBRATORY COORDINATION)

• 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
• 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, Tandem Walking
and arm swing
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.
CEREBELLAR TESTING

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.
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.
CEREBELLAR TESTING
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.
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