Lower Limb Neuro Exam Flashcards
What do you do after looking around the bed and general inspection (same as upper limb)?
assess patient’s gait
What are you looking for when assessing the patient’s gait?
- stance
- stability
- arm swing
- steps
- turning
What is a broad-based ataxic gait associated with?
midline cerebellar pathology e.g.
- lesion in multiple sclerosis
- degeneration of the cerebellar vermis secondary to chronic alcohol excess
What can stability suggest?
- staggering, slow and unsteady gait: cerebellar pathology
2. veer towards sign of lesion: cerebellar disease
What would an arm swing suggest?
absent or reduced in Parkinson’s disease (typically unilateral initially)
What are small, shuffling steps characteristic of?
Parkinson’s disease
What could high stepping indicate?
presence of foot drop
When would the turning maeouvere be hard?
cerebellar disease
What does tandem ‘heel-to-toe’ gait test?
exacerbates underlying unsteadiness making it easier to identify more subtle ataxia
What can tandem gait identify?
dysfunction of the cerbella rvermis (e.g. alcohol-induced cerbellar generation)
What would difficulty with heel to toe walking may suggest?
weakness of the flexors muscles of the leg or sensory ataxia
What is ataxic gait?
broad-based, unsteady and associated with either cerebellar pathology or sensory ataxia (e.g. vestibular or proprioceptive dysfunction)
How may patient walk in proprioceptive sensory ataxia?
- patients typically watch their feet intently to compensate for the proprioceptive loss
- if a cerebellar lesion is present the patient may veer to the side of the lesion
What would Parkinsonian gait be?
- small, shuffling steps, stooped posture and reduced arm swing (initially unilateral)
- will require several small steps to turn around
- gait appears rushed (festinating) and may get stuck (freeze)
- hand tremor may also be noticeable
How would high stepping gait show?
- unilateral or bilateral and is typically caused by foot drop (weakness of ankle dorsiflexion)
- patient also won’t be able to walk on their heel(s)
What does waddling gait look like?
shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk
What is waddling gait usually caused by?
commonly caused by proximal lower limb weakness (e.g. myopathy)
What is hemiparetic gait?
one leg held stiffly and swings round in an arc with each stride (circumduction)
What is hemiparetic gait usually associated with?
type of gait is commonly associated with individuals who have had a stroke
What is spastic paraparesis?
- similar to hemiparetic gait but bilateral, with both legs stiff and circumducting
- patient’s feet may be inverted and “scissor”
What is spastic paraparesis usually associated with?
hereditary spastic paraplegia
What test can be used to assess loss of proprioceptive or vestibular function (sensory ataxia)?
Romberg’s test
What does Romberg’s test not assess?
cerebellar function and instead is used to quickly screen for evidence of sensory ataxia (i.e. non-cerebellar causes of balance issues)
What does Romberg’s test based on?
need at least 2 of:
- Proprioception: the awareness of one’s body position in space.
- Vestibular function: the ability to know one’s head position in space.
- Vision: the ability to see one’s position in space
What does the Romberg test check?
if the patient has a deficit in proprioception or vestibular function they will struggle to remain standing without visual input
How is Romberg’s test carried out?
- Position yourself within arms reach of the patient to allow you to intervene should they begin to fall.
- Ask the patient to put their feet together and keep their arms by their sides (be aware that patients with truncal ataxia may struggle to do this, however, this type of unsteadiness is not the same as a positive Romberg’s sign).
- Ask the patient to close their eyes.
What is a positive Romberg’s signs?
Falling without correction is abnormal
What does positive Romberg’s test suggest?
ataxia is sensory in nature so there is a deficit of proprioceptive or vestibular function rather than cerebellar
What are possible causes of proprioceptive dysfunction?
- Joint hyper mobility e.g. EDS
- B12 deficiency
- Parkinson’s disease
- Aging (presbypropria)
What are causes of vestibular dysfunction?
- Vestibular neuronitis
2. Meniere’s disease
What is NOT a positive Romberg’s test?
swaying with correction is not a positive result and often occurs in cerebellar disease due to truncal ataxia
What muscle is stretched in ankle clonus?
gastrocnemius
What is spasticity associated with?
pyramidal tract lesions (e.g. stroke)
What is rigidity associated with?
extrapyramidal tract lesions (e.g. Parkinson’s disease)
How is tone affected in spasticity and rigidity?
both involve increased tone
What is spasticity dependent on?
velocity dependent
What does velocity dependent mean?
the faster you move the limb, the worse it is
What is clasp knife spasticity?
increased tone in the initial part of the movement which then suddenly reduces past a certain point
What is spasticity typically accompanied by?
weakness
What is rigidity dependent on?
velocity independent
What does velocity indepedent mean?
feels the same if you move the limb rapidly or slowly
What are two main types of rigidity?
- Cog wheel
2. Lead pipe
What is cogwheel rigidity?
involves a tremor superimposed on the hypertonia, resulting in intermittent increases in tone during movement of the limb
What is cogwheel rigidity associated with?
Parkinson’s disease
What is lead pipe rigidity?
involves uniformly increased tone throughout the movement of the muscle
What is lead pipe rigidity associated with?
neuroleptic malignant syndrome
