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Remember hand

hygiene before and

after every patient
Neurology Examination
Gait assessment
Exposing the patient
Ensure that the patients legs are exposed and clearly visible.
General Appearance/Inspection
All examinations begin with a general inspection of the patient and their immediate surroundings. This is done
from the end of the bed.
Abnormal posture e.g. hemiplegic positioning
Equipment assistive devices, mobility aids
Inspect lower limbs, comparing one side with the other
Muscle wasting or hypertrophy
Abnormal movements
Fasciculations - These are irregular contractions of small areas of muscle which have no
rhythmical pattern. If present with weakness and wasting, fasciculation indicates degeneration of
the lower motor neuron e.g. motor neuron disease.
Myoclonic jerks- brief, involuntary twitching of a muscle or a group of muscles
Other involuntary movements (dyskinesias) dystonia, chorea, athetosis, ballism, tics

dystonia- sustained muscle contractions cause twisting and repetitive movements or abnormal posture
chorea- 'dance-like' movements
athetosis- slow, involuntary, convoluted, writhing movements of the fingers, hands, toes, and feet and in some
cases, arms, legs, neck and tongue
Ballism- decrease in activity of the subthalamic nucleus of the basal ganglia, resulting in the appearance of
flailing, ballistic, undesired movements of the limbs.

Gait Exam
Ask patient to walk across the room, turn around quickly, and come back towards you:
o Veer off to one side = cerebellar dysfunction (e.g. disorder of left cerebellar hemisphere will cause
patient to fall to the left; diffuse disease affecting both cerebellar hemispheres will cause generalized
loss of balance)
Rate of Walking
o Loss of control of balance or speed = Parkinsons
o Slow moving 2o to pain or limited range of motion in joints = Degenerative joint disease
How do they hold their arms and legs?
o Loss of movement, evidence of contractures = post-stroke
Gait Disorders:
o Hemiplegia = foot is plantar flex and leg is swung in a lateral arc (Circumduction)- UMN lesion
o Spastic Paraparesis = scissors gait (seen in multiple sclerosis, UMN lesion)
o Parkinsons Disease = shuffling, hesitation, freezing, Festinating, propulsion, retropulsion

Cerebellar(ataxia gait) = wide-based (to avoid falling); staggering towards affected side
-wide-based with truncal instability and irregular lurching steps which results in lateral veering and if severe, falling.
This type of gait is seen in midline cerebellar disease. It can also be seen with severe lose of proprioception (sensory


Foot-Drop = high stepping gait due to damage to common peroneal nerve, which is injured by
trauma to head of the fibula
Proximal Myopathy = waddling gait
rolling gait in which the weight-bearing hip is not stabilized; it bulges outward with each step, while the opposite side of
the pelvis drops, resulting in alternating lateral trunk movements; due to gluteus medius muscle weakness,

Trendelenburgs gait = damaged superior gluteal nerve on contralateral side to hip dip.
During the stance phase, the weakened abductor muscles allow the pelvis to tilt down on the opposite side. To
compensate, the trunk lurches to the weakened side to attempt to maintain a level pelvis throughout the gait cycle.

Heel-to-Toe Walking:
Difficulty = midline cerebellar lesion, or in older patients (even in absence of neurological disease)
Walk on Toes:
Impossible with S1 lesion
Walk on Heels:
Impossible with L5 lesion causing foot-drop
Ask patient to squat and then stand up, or sit in a low chair and then stand
Impossible with L4 lesion
This tests for proximal myopathy
Ask patient to stand in one place with feet together: First with eyes open, then closed
Truncal ataxia = tendency to fall backwards = midline cerebellar lesion
Inability with eyes open or closed = cerebellar disease
Romberg Test - standing erect with feet together compare steadiness shown when eyes open with when
eyes closed. Marked unsteadiness with the eyes open is seen in cerebellar and vestibular dysfunction.
o Positive Test (loss of balance) = when unsteadiness increases with eye closure. Seen with impaired
Cerebellar Exam:
Generally, cerebellar lesions cause ipsilateral cerebellar signs. Bilateral cerebellar lesions will cause bilateral
signs and central cerebellar lesions can cause bilateral, asymmetrical signs.
General Inspection : CHAIR SAW
Hearing aid
Involuntary movement
Rash Skin (vasculitis, neurofibromas, caf au lait spots)
Abnormal posture or gait
Walking aid
Head and Neck:
Nystagmus jerky horizontal nystagmus towards side of the cerebellar lesion
Dysarthria difficulty with articulation e.g. jerky, slurring, explosive, loud, with irregular separation of
syllables (sign of diffuse cerebellar involvement). Ask patient to say British Constitution or West
Register Street:
Upper Limbs:
Ask patient to extend their arms to shoulder level out in front of them, palms upwards:
Upward drift = cerebellar lesion

Pronator drift (palms pronate)= contralateral pyramidal tract defect/ upper motor neuron lesion
Abnormalities more pronounced if hands tapped and/or eyes closed
Downward drift = lower motor neuron lesion
Ask patient to raise their arms quickly from their sides, and stop suddenly mid-motion:
Inability to stop = rebound = loss of coordination between agonist and antagonist muscle action
Test Tone
Nose-to-Finger Testing Ask patient to move their index finger between their nose and your finger, reposition
your finger after each touch; test both hands! Ensure patient must fully extend elbow to reach your finger
Past pointing = ipsilateral cerebellar disease
Intention tremor = ipsilateral cerebellar disease
Rapid Alternating Finger Movements Ask patient to touch the tip of each finger to the thumb of the same hand;
test both hands!
Inability (not fluid or accurate) = dysdiadochokinesis = ipsilateral cerebellar disease
Rapid Alternating Hand Movements Ask patient to rapidly and repeatedly touch the palm and then dorsal side
of one hand against the palm of the other hand; test both hands!
Inability (not fast or accurate) = dysdiadochokinesis = ipsilateral cerebellar disease
Lower Limbs:
Test Tone
Heel-to-Shin Testing Ask patient to move the heel of one foot up and down along the top of the other shin; test
both feet!
Inability (not fast or straight) = loss of coordination = ipsilateral cerebellar disease
Toe-to-Finger Testing Ask patient to lift the big toe up to touch your finger; test both feet!
Past pointing
Intention tremor
As above