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3-A
August 11, 2014
PLM CM

GAIT AND STATION

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.

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

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

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GAIT AND STATION

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.

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

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

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GAIT AND STATION

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

Picture

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

Type
Description

Normal

Spastic hemiparesis/
Hemiplegic gait

Normal posture, step size, and arm swing

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

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 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.

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

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GAIT AND STATION

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

Retropulsion

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

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

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

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