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 • • Nystagmus • Intention • Scanning • 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)

Document Owner: Clinical Skills/LK Last Updated: May 2018 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/ • 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 • : “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 • : ”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 • 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

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Lower Limb

Tone • Try to keep patient relaxed, ask them to stay floppy • Roll each leg in turn – the foot should rotate loosely. Look for any sign of foot flop. Compare each side • Sharply lift each knee slightly and let it drop to the couch – in hypertonia the foot will lift off bed. Compare each side • Check for clonus by flexing and supporting the knee. After rotating the foot a couple of times, pull foot back briskly to dorsiflex the ankle. Observe for ankle jerk. Up to 3-4 beats is normal. Compare each side

Reflexes • Knees: Bend patient’s knee and support their weight. Strike the patellar tendon. Note L3/4 reflex to be absent/reduced/normal/brisk. • Ankles: Bend patient’s knee and place ankle dorsiflexed resting on the other shin. Strike Achilles tendon. Note L5/S1 reflex • Plantars: Using your thumbnail/end of tendon hammer, start at the lateral aspect of heel, sharply draw nail up lateral border to the little toe and across to big toe. Observe for plantar flexion the toes as a normal response. Dorsiflexion of hallux and abduction (fanning) of other toes = positive Babinski sign (UMN)

Coordination • Ask patient to rub their heel down the shin from knee to ankle of the opposite leg, lift foot up and back to knee, forming a triangle. Perform a few times. Repeat opposite leg

Conclusion

• Thank patient, ask them to get dressed, report/record findings

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