Neurology Examination (cerebellar and gait examination) Dr. Bandar Al Jafen, MD Assistant Professor Consultant Neurologist and Epileptologist King Saud University, Riyadh

CO-ORDINATION WHAT TO DO Arms Finger-nose test Dysdiadochokinesis Legs Heel – shin test The finger –nose test The heel-shin test

Cerebellar Examination and Coordination Hemisphere Dysfunction Dysmetria on Finger-Nose-Finger Testing* Irregularly-Irregular Tapping Rhythm* Dysdiadochokinesis* Hypotonia* Impaired Heel-Knee-Shin* Falls to Side of Lesion* Nystagmus (Variable Directions) * All Deficits are Ipsilateral to the side of the lesion

Midline Dysfunction Truncal Ataxia Titubation Ataxic Speech Gait Ataxia Acute Ataxia (unsteady Gait) Chronic Ataxia (wide-based, steady Gait)

WHAT IT MEANS Unilateral inco-ordination – ipsilateral cerebellar syndrome. Bilateral inco-ordination – bilateral cerebellar syndrome. Truncal ataxia, gait ataxia, without limb inco-ordination – midline cerebellar syndrome. Unilateral cerellar syndrome – common causes: demyelination, vascular disease; rare causes: trauma, tumour or abscess. Bilateral cerebellar syndrome – common causes: drugs (anti-convulsants), alcohol, demyelination, vascular disease; rare causes: hereditary cerebellar degenerations, paraneoplastic disorders, hypothyroidism. Midline cerebellar syndrome: lesion of the cerebellar vermis – causes as for bilateral cerebellar syndrome.

The Neurological Examination Gait Observe Different Aspects of Gait Arm Swing Base of Gait Heel Strike Time Spent on Each Leg Posture of Trunk Toe Walking Heel Walking Tandem Walking

GAIT Always examine patient's gait. It is a co-ordinated action requiring integration of sensory and motor functions. The gait may be the only abnormality on examination. The most commonly seen are: hemiplegic, parkinsonian, ataxic and unsteady gaits. Romberg's test is conveniently performed after examination the gait. This is a simple test primarily of joint position sense. Ask the patient to walk Ensure you are able to see the arms and legs adeguately. Is the gait symmetrical? Gait can usually be divided into symmetrical and asymmetrical even though the symmetry is not perfect. If symmetrical: Look at the size of paces Small or normal? If small paces: Look at the posture and arm swing Stooped with reduced armswing – parkinsonian (may be difficult to start and stop – festinant). Upright with marked armswing – marche a' petits pas.

If normal paces: Look at the lateral distance between the feet normal widely separated - broad based Legs unco-ordinated – cerebellar Crossing over, toes dragged – scissoring. Look at the knees knees lifted high – high-stepping. Look at the pelvis and shoulders marked rotation of pelvis and shoulder –waddling. Look at the whole movement disjointed as if forgotten how to walk, patient frequently appears rooted to pot – apraxic. bizarre, elaborate and inconsistent – functional. If asymmetrical Is the patient in pain? yes – painful or antalgic gait. Look for a bony deformity orthopaedic gait.

Does one leg swing out to the side? yes – hemiplegic gait. Look at the knee heights normal one knee lifts higher – foot drop. Ask the patient to walk as if on a tight – rope (demonstrate) if patient fall consistently – unsteady may fall predominantly to one side. Ask the patient to walk on his heels (demonstrate) If unable to – foot drop. Ask the patient to walk on his toes (demonstrate) If unable - weakness of gastrocnemius. Parkinsonian: indicates basal ganglion dysfunction – common causes: Parkinson's disease, major tranquillisers. Scissoring: indicates spastic paraparesis – common causes: cerebral palsy, multiple scelrosis, cord compression. Sensory ataxia: indicates loss of joint position sense (Romberg's positive) – common causes: peripheral neuropathy, posterior column loss (see below). Cerebellar ataxia: veers towards side of lesion – common causes: drugs (e.g. phenytoin), alcohol, multiple sclerosis, cerebrovascular disease.

Non-neurological gaits Waddling gait: indicates weak or ineffective proximal muscles – common causes: proximal myopathies, bilateral cogenital dislocation of the hip. Apraxic gait: indicates the cortical integration of the movement is abnormal, usually with frontal lobe pathology – common causes: normal pressure hydrocephalus, cerebrovascular disease. Hemiplegic: unilateral upper motor neurone lesion – common causes: stroke, multiple sclerosis. Foot drop: common causes – unilateral: common peroneal palsy, pyramidal lesion, L5 radiculopathy. Bilateral: peripheral neuropathy. Non-neurological gaits Painful gait: common causes:arthritis, trauma – usually obvious. Orthopaedic gait: common causes: shortened limb, previous hip surgery, trauma.