The Neurological

Examination – Part 1

Stance, Gait and Coordination

• After a precise anamnesis (including personal
and familial history, as well as life and work
conditions), with variability from case to case,
the neurological examination is based on
evaluation of:
Particular stance; Examination of reflexes;

Gait; Vegetative issues;

Coordination; Sensibility;

Active motility; Cranial nerves;

Involuntary movements; Speech disorders;

Passive mobility; Psychological state.

• The neurological examination must aim
towards identifying:
– The supposed level of the lesion (either cortical,
subcortical, spinal, peripheral or mixed);
– Localization, and if possible, the type of lession
(either focal or diffuse);
– The lesion’s effect (whether there is any mass
effect or not);
– The most likely etiology (vascular, degenerative,
inflammatory, immunological, neoplastic, toxic/
metabolic or traumatic).
• Particular stance:
• 1. the “swan neck deformity” in radial
neuropathy (Saturday night palsy).
• 2. The ulnar claw hand in ulnar neuropathy
• 3. The median nerve palsy
• 4. Peroneal palsy
• 5. Torticolis
• 6. Spastic hemiparesis
• 7. Parkinson’s disease
• The upright posture can be affected by:

– Paralysis;
– Muscle tone modifications;
– Involuntary movements;
– Cerebellar dysfunctions;
– Vestibular dysfunctions;
– Profound sensibility issues.
• Gait disorders

– Common presentation of neurological disease;

– Prevalence increases with age;

– Normal gait requires integration and coordination

of the central and peripheral nervous systems + a
functional musculoskeletal system;
Gait
Locomotion = the
generation and
maintenance of
rhythmic stepping

Equilibrium = the
ability to keep the
body upright and
maintain balance
 …however,

Subcortical

Cortical Peripheral

Gait
disorders
• For both stance and gait it is necessary to:
– Observe the patient in standing position;
– Observe the patient’s posture at rest, as it may
reveal different disease process;
– It is ideal that the patient is examined barefoot;
– It might be necessary to ask the patient to walk
during the examination – sufficient room should
be taken into consideration;
– One of the most important aspects to notice is
whether the patient can walk at normal speed
without limping.
• Walking on tiptoe and walking on the heels:
– Useful for evaluation of the strength of the calf
muscles and toe extensors;
– If the plantar flexors are only mildly weak, the
patient will still be able to walk on tiptoe, but will
not be able to raise himself or herself on tiptoe
while standing on one leg, or hop repeatedly on
one foot (10 times in a raw).
• The tightrope walk (heel to toe walk):
– Is a very sensitive test of equilibrium and gait
stability;
– The patient has to place one foot firmly in front of
the other, at first while looking at the floor, then
while looking straight ahead, and finally while
looking at the ceiling;
– Heel to toe walking should be possible under all of
these conditions.
• The Romberg Test:
– The patient is asked to stand with the feet
together and parallel and with eyes closed for at
least 20 seconds.
– This should be accomplished easily (negative
Romberg sign).
– If the patient experiences presents signs of
affected equilibrium, we call it a “positive
Romberg”.
• 1. Positive Romberg – cerebellar type:
– The tendency to fall is not influenced by the
closing of the eyes. If the anterior vermis is
affected, the tendency to fall will be forward,
whereas in posterior vermis lessions there is a
tendency to fall backwards. In cerebellar
hemisphere lesions, the patient will experience
falling towards the affected cerebellar
hemisphere.
• 2. Positive Romberg – vestibular type:
– The patient tends to fall towards the side of the
affected vestibular side; closing of the eyes
increases the misbalance;
• 3. Positive Romberg – tabetic type
– Is present in lesions of the profound sensibility.
– The tendency to fall is in all directions.
• 3. Coordination
• Basically, coordination problems are
represented by:
– Dysmetria (detour from the proposed trajectory)
– Hypermetria (exceeding the target)
– Disdiadochokinesia (inability in performing quick
and contrary movements).
• Diadochokinesis is the ability to carry out
rapid alternating movements, like pronation
and supination of the forearm;

• If abnormaly slow, these movements are

called bradydiadochokinesia;

• If irregular, disdiadochokinesia on either one

or both sides, is usually associated with
paresis, extrapiramidal disease or cerebellar
affectation.
• During the postural test, the patient is asked
to extend both arm horizontally in front, in
supination position, with eyes closed.

• The so called pronator drift, the involuntary

sinking by pronating of one arm indicates
motor hemiparesis of central origin (stroke).

• Conjugate deviation of both hand on one side

suggests an ipsilateral lesion of either the
labyrinth or the cerebellum.
• Arm rolling test implies rapidly rotating the
forearms around each other in front of the
trunck.

• Mild hemiparesis may be evidenced this way.

• Take-Home Messages!

Stance

Gait

Coordination
 Bibliography and Suggested Further Reading:

1. Mummenthaler M, Mattle H, Eds. 4th ed. Neurology. Georg Thieme Verlag 2004;
pp. 13-5, 28-9;
2. Jones H. Royden, Hreib K. Clinical Neurologic Evaluation. In: Royden JH,
Srinivasan J, Allam GJ, Baker RA, Eds. 2nd ed. Netter’s Neurology. Philadelphia:
Elsevier Saunders2012; pp. 16-8;
3. Leegwater-Kim J. Gait Disorders. In: Royden JH, Srinivasan J, Allam GJ, Baker RA,
Eds. 2nd ed. Netter’s Neurology. Philadelphia: Elsevier Saunders2012; pp. 280-6;
4. Lowenstein HD, Martin JB, Hauser SL. Approach to the Patient with Neurologic
Disease. In: Hauser SL, Josephson SA, Eds. 2nd ed. Harrison’s Neurology in Clinical
Medicine: McGraw-Hill Medical 2010; p. 9.

Images used from the references mentioned above +

• https://aneskey.com/radial-neuropathy-saturday-night-palsy/
• http://www.ehealthstar.com/conditions/guyons-canal-syndrome
• http://www.msunites.com/multiple-sclerosis-ms-symptoms-foot-drop/
• http://stanfordmedicine25.stanford.edu/the25/hand.html
• http://lacolonnevitaletahiti.over-blog.com/mot-de-la-semaine-n-22-torticolis
• http://nursingcrib.com/case-study/cerebral-palsy-cp/3/
• Apetauerova D. Medication-Induced Movement Disorders. In: Royden JH, Srinivasan J, Allam GJ,
Baker RA, Eds. 2nd ed. Netter’s Neurology. Philadelphia: Elsevier Saunders2012; p. 338.
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