Directed Neurological Examination

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In examining a patient with complaints regarding gait and balance, sitting balance is first evaluated. If an inability to sit upright is found, profound imbalance or weakness is suggested. The examiner should check to see whether titubation (rhythmical tremor or shaking of the trunk and head) is present, suggesting cerebellar disease, or whether there is a tendency to lean progressively in one direction, suggesting hemiparesis or basal ganglia disease. To make sitting balance more challenging and to bring out subtle abnormalities, the clinician should ask the subject to sit on the examining table with the arms and legs not touching any support surface.

Next, the ability to arise from a chair should be tested. This maneuver tests the patient's strength and anticipatory postural responses. The physician should check to see whether the patient can arise and if he or she can organize rising appropriately (brings the feet under the body, leans forward, and uses the arms to push). If the patient is unable to rise without pushing himself off the chair, proximal muscle weakness or impaired central recruitment of force is suggested, as in Parkinson's disease.

Standing unaided, which tests static balance, should then be evaluated. The examiner should determine whether the patient can stand without assistance or whether titubation or excessive sway is present, indicating cerebellar disease. The distance between the feet should be noted, because feet placed wide apart suggest problems with lateral stability (seen in patients with cerebellar disease, multi-infarct state, or proprioceptive loss). Furthermore, the presence of any discrepancy between standing with the eyes open and with the eyes closed (Romberg's sign) should be determined because this finding may indicate defective proprioception. Balancing on one foot is a more stringent test of static balance, and all healthy individuals should generally be able to manage this task for 10 seconds.

Finally, the gait should be examined. Gait initiation reveals the integrity of locomotor synergies. Abnormalities that should be sought include delays of seconds (freezing) and delays with a series of small steps (start hesitation) on the initiation of gait. These are common signs of frontal lobe, subcortical white matter, and basal ganglia lesions.

Once gait has started, the examiner should check to see whether the maintenance of stepping is disturbed by passage through narrow spaces, distractions, or turns. Changes in gait speed and stride length are nonspecific indicators of gait and balance disturbances. Speed slows and steps shorten in most disorders of gait and balance or in patients with perceived postural insecurity. y Occasionally, gait is not slowed in proportion to postural instability, for example, in those with progressive supranuclear palsy, indicating difficulties with perception, attention, or judgment. The distance between the feet while walking (gait base) is an indicator of lateral stability. Typically, the base narrows as a patient changes from standing to walking. As with the standing base, a widened base during walking generally indicates sensory, cerebellar, or frontal lobe dysfunction. Head movements during walking may offer a clue to vestibular function. Patients with diminished or absent vestibular function often try to minimize head movements while walking, giving them a stiff appearance. Asking the patient with a vestibular disorder to rotate the head while walking causes the gait to become ataxic.

The cadence of gait is important because it is an indicator of motor coordination. Steps should be regular and symmetrical. In certain disorders, they may be dysmetric, choreic, dystonic, parkinsonian, hemiparetic, or spastic, thereby disturbing the normal free movements of stepping and altering gait cadence. Observation of arm swing can identify a variety of motor function problems. Involuntary movements often appear in the arms during walking, particularly dystonia, chorea, and rest tremor. Unilaterally decreased arm swing is common in early parkinsonism and mild hemiparesis. Decreased arm swing does not always have a neurological explanation because musculoskeletal disorders can induce changes as well.

Turning or pivoting while walking is more posturally demanding than walking straight ahead, and abnormalities may emerge during turning that are inapparent during straight walking. Widening of the base only during turns or taking an extra one or two short steps during turning to maintain balance may be the earliest sign of cerebellar ataxia. "En bloc" turns (in which the head, torso, and legs turn together as a rigid unit rather than in sequence beginning with the head and followed in turn by the shoulders and then the hips and legs) suggest parkinsonism or caution. With more severe imbalance, en bloc turns are associated with slow, small steps, and the patient may freeze during turning in the so-called turn hesitation that is very typical of patients with parkinsonism and frontal lobe gaits.

Tandem walking tests lateral stability and should be observed because it is a sensitive indicator of cerebellar and vestibular dysfunction. Finally, the process of pushing the patient to the side and pulling him backward (with the examiner maintaining a position to keep the patient from falling) tests reactive postural responses. These responses may be deficient in patients with basal ganglia disease or frontal or subcortical lesions.

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