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Gait and Coordination, Study notes of Neurology

Look out for the following cerebellar signs in the examination sequence (DANISH):. • Dysdiadochokinesis. • Ataxia. • Nystagmus. • Intention tremor.

Typology: Study notes

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Document Owner: Clinical Skills/LK
Last Updated: May 2018
Clinical Examination Guide
Gait and Coordination
Components of examination
Introduction
General inspection and stability
Standing-Walking
Other cerebellar tests
Upper limb tone, reflexes, coordination
Lower Limb tone, clonus, reflexes, coordination
Look out for the following cerebellar signs in the examination sequence (DANISH):
Dysdiadochokinesis
Ataxia
Nystagmus
Intention tremor
Scanning dysarthria
Heel-shin test positivity
Introduction
Introduce yourself, confirm patient ID
Explain examination and gain consent. Ask about any pain. Ask patient to sit at edge of the bed
Gel hands
General inspection and stability
Look for truncal stability as the patient sits on edge of the bed.
Assess proximal weakness by asking patient to cross arms over their chest and rise to standing (without use of
arms)
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Document Owner: Clinical Skills/LK Last Updated: May 2018

Clinical Examination Guide

Gait and Coordination

Components of examination

  • Introduction
  • General inspection and stability
  • Standing-Walking
  • Other cerebellar tests
  • Upper limb – tone, reflexes, coordination
  • Lower Limb – tone, clonus, reflexes, coordination Look out for the following cerebellar signs in the examination sequence (DANISH):
  • Dysdiadochokinesis
  • Ataxia
  • Nystagmus
  • Intention tremor
  • Scanning dysarthria
  • Heel-shin test positivity

Introduction

  • Introduce yourself, confirm patient ID
  • Explain examination and gain consent. Ask about any pain. Ask patient to sit at edge of the bed
  • Gel hands

General inspection and stability

  • Look for truncal stability as the patient sits on edge of the bed.
  • Assess proximal weakness by asking patient to cross arms over their chest and rise to standing (without use of arms)

Page 2 of 3

Standing-Walking

With patient standing

  • Stance: On standing, look at the width of feet. Look for ataxia: could be cerebellar/motor/vestibular/proprioception
  • Proprioception: If steady, ask them to keep feet together and close their eyes. Dramatic difference with eyes closed = positive Romberg’s test
  • Gait: Look at width of base, height of step, arm swing, pattern of steps, ability to stop and turn, symmetry of movement
  • Heel to toe coordination: Ask patient to walk as if on a tightrope, to uncover subtle problems with proprioception/cerebellar ataxia
  • Ankle dorsiflexion: As patient to stand on heels. Difficulty may be due to weakness neuropathy or myopathy
  • Ankle plantarflexion: As patient to stand on toes

Other cerebellar tests

  • Eye Movements
    • Focus and follow my finger, whilst keeping your head still”
    • Move finger in exaggerated H shape to test all movements 0.5m from their face. Look for nystagmus
  • Dysarthria: “Repeat the phrase ‘baby hippopotamus ”. Listen for slurring of speech

Upper Limb

With patient lying on couch Tone

  • Ask patient to let arms go floppy
  • Move the elbow and wrist randomly with a mix of rotation, flexion and extension
  • Observe for any resistance e.g. clasp knife rigidity, lead pipe rigidity, cogwheel rigidity or reduced tone.
  • Compare each side Reflexes
  • Biceps C5/6: Patient elbow flexed, forearm across chest, strike biceps tendon over the top of your thumb
  • Triceps C7: Patient elbow flexed, hold patient’s wrist, strike triceps tendon above the elbow
  • Supinator C6: Patient hand in their lap, radial border up. Strike brachioradialis tendon proxomal to the radial styloid
  • Record tendon stretch reflexes as absent / reduced / normal / brisk Coordination
  • Resting tremor: “ Please raise your arms out in front of you ” Observe for tremor
  • Pronator Drift: “ Now, turn your hands over and keep them there, close your eyes ” Ideally wait 30s. An affected limb will pronate first, then drift down (mild upper motor neurone sign)
  • Bradykinesia: ” With both hands, please touch your thumb to each finger in turn, keep going ” Observe for maintenance of action and speed. Repeat opposite side
  • Dysdiadochokinesia: ” Hold your left hand out, tap it with your right hand, palm facing up then faced down, up,

down, as fast as you can ”. Look for inability to carry out accurate rapid repetitive alternating movements. Repeat

opposite side

  • Intention Tremor and Past pointing: “ With your right index finger, touch your nose, then my finger, then back to

your nose and repeat ”. Observe for past-pointing and tremor. Repeat opposite side