NEUROLOGIC EXAMINATION

Abnormalities of Gait & Posture

ABNORMALITIES OF GAIT & POSTURE

Spastic Hemiparesis Scissors Gait Steppage Gait Parkinsonian Gait Cerebellar ataxia Sensory ataxia

SPASTIC HEMIPARESIS
Observed in corticospinal tract lesion in stroke Cause poor control of flexor muscles during swing phase Affected arm:

Flexed immobile held close to the side elbow, wrists and interphalangeal joints flexed

SPASTIC HEMIPARESIS CONT.

Affected leg:

Extension spastic Ankle plantar flexed and inverted Patients may drag toe, circle leg stiffly outward and forward ( circumduction) Lean trunk to contralateral side to clear affected leg during walking

SCISSORS GAIT

Observed in spinal cord disease Cause bilateral lower extremity spasticity, adductor spasm & abnormal proprioception Gait is stiff Patients advance leg slowly & thighs tend cross forward on each other at each step Steps are short Appear as walking on water

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 the feet down with a slap on the floor Appear as waling up stairs Cannot walk on their heels May involve in both legs

PARKINSONIAN GAIT
Seen in Basal Ganglia defects of Parkinson disease Posture is stooped with flexion of head, arms, hips and knees Steps are short and shuffling with involuntary hastening (festination) Arm swings are decreased Postural control is poor

CEREBELLAR ATAXIA
Observed in disease of cerebellum or tracts Gait is staggering, unsteady, wide based with exaggerated difficulty on turns Patients cannot stand steadily with feet together whether eyes are open or closed Cerebellar signs are present:

Nystagmus Dysmetria Intension tremor

SENSORY ATAXIA
Observed in loss of position sense in the legs ( polyneuropathy or posterior column damage) Gait is unsteady ad wide based ( feet wide apart) 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 Watch ground for guidance when walking With eyes closed they cannot stand steadily with feet together and the staggering gait gets worsen

DISORDERS OF MUSCLE TONE

Rigidity:

Lesion at the Basal Ganglia system

Lesion at the lower motor neuron system at any point from anterior horn cell to peripheral nerves Lesion in both cerebral hemispheres. lesion of the upper motor neuron of corticospinal tract at any point from cortex to spinal tract

Flaccidity:

Paratonia:

Spasticity:

ASSESSING MOTOR SYSTEM

Focus on:

Body position Involuntary movements Characteristics of muscles ( bulk, tone and strength) coordination

Body position

Muscle Bulk

Observe the patients body movement during movement and at rest

Involuntary movements
watch for tremors, tics, fasciculations Note their;

location, quality, rate, rhythm, amplitude Relation to posture, activity, fatigue, emotion and other factors

Inspect the size and contours of muscles Do muscles look flat or concave Do muscles suggest atrophy Is the process unilateral or bilateral Is it distal or proximal Attend particularly to hands, shoulders and thighs

Muscle Tone

Muscle strength

Assessed best by feeling the muscles resistance to passive stretch

Persuade the patient to relax Take one hand of the patient while supporting the elbow Flex and extend the patients fingers, wrist and elbow Put the shoulder through moderate range motion Tense patients show increased resistance

Assess for paresis, paralysis, plegia, hemiparesis, hemiplegia & quadriplegia

Ask patient to move actively against the examiners resistance If muscles are weak to overcome the resistance test against the gravity along with gravity eliminated

SCALE FOR GRADING MUSCLE STRENGTH

METHODS FOR TESTING MAJOR MUSCLE

GROUPS

Test flexion ( C5, C6 - biceps) and extension (C6, C7, C8 - triceps) at the elbow:

Ask patient to pull and push against your hand

Test extension at the wrist (C6, C7, C8, radial nerve extensor carpi radialis longus & brevis)

Ask the patient to make a fist and resist when the examiner pulls down

Test the grip (C7, C8, T1)

Ask the patient to squeeze two of the examiners fingers as hard as possible and not to let them go

Test opposition of the thumb (C8, T1, median nerve )

The patient should try to touch the tip of the little finger with the thumb, against the examiners resistance

test flexion at the hip (L2, L3, L4 - iliopsoas)

Examiner should place the hand on the patients thigh and asking the patient to raise the leg against the examiners hand The examiner places his hands firmly on the be between the patients knees and asks the patient to bring both legs together

Test adduction at the hips (L2, L3, L4 - adductors)

Abduction of the hips ( L4, L5, S1 gluteus medius & minimus)

Examiner places hands firmly on the bed outside the patients knees and ask the patient to spread both legs against the hands Have the patient push the posterior thigh down against the examiners hand

Test extension at the hips ( S1 gluteus maximus)

Test extension at the knee (L2, L3, L4 quadriceps)

Support the knee in flexion and ask the patient to straighten the leg against examiners hand Place the patients leg so that the knee is flexed with the foot resting on the bed. Ask the patient to keep the foot down as the examiner try to straighten the leg

Test flexion at the knee ( L4, L5, S1, S2 - hamstrings)

Test dorsiflexion ( L4, L5 tibialis anterior) Test plantar flexion ( S1 gastrocnemius & sloeus)

COORDINATION

Observe the patients performance in;

Rapid alternating movements Point to point movements Gait and other related body movements Standing in specific ways

Rapid alternating movement

Observe the speed, rhythm and smoothness of movements

Point to point movement

Finger to nose test Heel to shin test

Gait

Walk across the room

Balance, swinging of the arms & posture

Tandem walking ( walk heel to toe) Walk on toes and heels Hop Do a swallow knee bend

Stance

The Romberg test

Observe the patients ability to maintain the upright position

Test for pronator drift

Observe for the position of the arm Tap the arms briskly downward