NEUROLOGIC EXAMINATIONAbnormalities 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 or

one Tibialis anterior and toe

extensors are weak

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 (retropulsion)

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 Flaccidity:

Lesion at the lower motor neuron system at any point from anterior horn cell to peripheral nerves

Paratonia: Lesion in both cerebral hemispheres.

Spasticity: lesion of the upper motor neuron of corticospinal

tract at any point from cortex to spinal tract

ASSESSING MOTOR SYSTEM Focus on:

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

strength) coordination

Body position 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

Muscle Bulk 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 Assessed best by

feeling the muscle’s resistance to passive stretch Persuade the patient to

relax Take one hand of the

patient while supporting the elbow

Flex and extend the patient’s fingers, wrist and elbow

Put the shoulder through moderate range motion

Tense patients show increased resistance

Muscle strength 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 examiner’s resistance

test flexion at the hip (L2, L3, L4 - iliopsoas) Examiner should place the hand on the patient’s

thigh and asking the patient to raise the leg against the examiner’s hand

Test adduction at the hips (L2, L3, L4 - adductors) The examiner places his hands firmly on the be

between the patient’s knees and asks the patient to bring both legs together

Abduction of the hips ( L4, L5, S1 – gluteus medius & minimus) Examiner places hands firmly on the bed outside the

patient’s knees and ask the patient to spread both legs against the hands

Test extension at the hips ( S1 – gluteus maximus) Have the patient push the posterior thigh down

against the examiner’s hand

Test extension at the knee (L2, L3, L4 – quadriceps) Support the knee in flexion and ask the patient to

straighten the leg against examiner’s hand Test flexion at the knee ( L4, L5, S1, S2 -

hamstrings) Place the patient’s 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 dorsiflexion ( L4, L5 – tibialis anterior) Test plantar flexion ( S1 – gastrocnemius &

sloeus)

COORDINATION Observe the patient’s 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 patient’s ability to maintain the upright position

Test for pronator drift Observe for the

position of the arm Tap the arms briskly

downward