Neuro Exam with focus on gait

Question 1

MCMC-SRG

Answer 1

Mental status
Cranial nerves
Muscle testing
Cerebellar signs
sensation
Reflexes
Gait

Question 2

Mental Status

Answer 2

• Coma: no sleep/wake
• PVS: + sleep/wake
• Minimally conscious: +tracking, episodes of awareness

Question 3

GOAT

Answer 3

• 100 point scale

- >75 on 2-3 consecutive days signifies out of post-traumatic amnesia

Question 4

Major Aphasic Syndromes

Answer 4

• Brocas: TC motor except no repetition
• TC motor: nonfluent with intact repetition
• Wernicke’s: TC sensory except no repetition
• TC sensory: fluent with intact repetition
• Paraphasias: word substitutions

Question 5

Treatment Arms

Answer 5

Medications
Therapy
Injections
Brace alternative medicine

Question 6

Decorticate vs. Decerebrate

Answer 6

• Decorticate: UE flexed, LE extended (arms to the coronary)

- Decerebrate: UE and LE extended

Question 7

Alcohol affect on Cerebellar Tests

Answer 7

Alcohol use preferentially affects the cerebellar vermis and thus leads to abnormalities in HTS with relatively preserved FTN.

Question 8

Romberg Test

Answer 8

• differentiates btw proprioception deficit and ataxia
• If loss of balance occurs only with eyes closed–> proprioception deficit
• Loss of balance with eyes open and closed–> cerebellar ataxia

Question 9

Spinal pathways

Answer 9

Dorsal Column: light touch, proprioception, vibration (crosses in brain stem)
Spinalthalamic pathway- pain/temperature (crosses at spinal cord in same level

Question 10

Brown Sequard Syndrome

Answer 10

Hemisection–> always trauma related (stab, gun shot)

Question 11

Reflexes

Answer 11

• graded 0-4
• Jendrassik maneuver (interlock fingers and pull apart)
• C5: biceps, brachioradialis
• C6: pronator
• C7: triceps
• L4: patellar
• L5: medial hamstring
• S1: achilles

Question 12

UMN signs

Answer 12

• clonus 4+
• Babinski, stimulus plantar suface
• Chaddock, stimulus lateral ankle
• Stransky, stimulus “flicking” out little toe
• Oppenheim, stimulus medial surface of tibia
• Hoffmans, contraction of thumb and index finger

Question 13

Dix Hallpike Test

Answer 13

• diagnosis BPPV
• should be fatigable (less nystagmus with repeated testing) and reversible (direction of nystagmus reverses with sitting up again.)

Question 14

Hoover Sign

Answer 14

• Assess for malingering
• “synergistic contraction”
• Patient supine and asked to raise one leg–> normally you should feel pressure in hand if patient is actively trying to life other leg
• caution in patients with strong hip muscles.

Question 15

Gower’s Sign

Answer 15

• Duchenne’s muscular dystrophy
• signifies weakness of proximal muscles
• patient uses hands to walk up from ground

Question 16

Beevor’s sign

Answer 16

• Implies spinal cord lesion between T6-T10
• Can be seens in T6-T10 SCI or motor neuron dz
• Patient supine, asked to attempt sit up–> belly button moves towards the level of injury (i.e. superiorly) due to weakness of the low ab muscles.

Question 17

Battle’s Sign

Answer 17

• Bruising over mastoid process

- Suggests basilar skull fractures and likely underlying brain injury

Question 18

“Gait is a reflex”

Answer 18

• Gait center/central pattern generator in lumbar spine

- Examples: newborns, cats with transected spinal cords, etc.

Question 19

Gait Definitions

Answer 19

• Gait cycle: heel strike to heel strike in SAME foot
• Step length: distance between heel strike of one foot to heel strike of other foot.
• Stride length: distance between heel strikes in the SAME foot (i.e. distance of the gait cycle)
• Cadence: #steps per time, step/minute
• Base of support lateral distance between the feet (wide vs. narrow base)

Question 20

Gait phases

Answer 20

8 functional phases

• 5 in stance (60%), 3 in swing (40%)
• 20% time in “double support” with both legs on the ground

***Remember 60-40-20

Question 21

Where is the center of gravity?

Answer 21

***Remember 2-2

2 inches anterior to S2 vertebrae

When ambulating, COG moves in a sinusoidal pattern in horizontal and vertical planes.

Question 22

What is inman’s gait determinants?

Answer 22

Serve to minimize movement of COG to make gait as energy efficient as possible.

Question 23

What are Inman’s 6 determinants of gait?

Answer 23

***Know that are 3 at hip, 2 at knee, 1 at foot/ankle

• Pelvic rotation, pelvic tilt, lateral displacement of pelvis (only one which displaces COG in horizontal plane)
• Knee flexion in stance/early knee flexion, knee mechanisms (i.e. KE, PF, supination at terminal stance/pre-swing)
• Ankle/foot mechanisms (i.e. controlled plantarflexion after heel strike)

Question 24

Antalgic gait

Answer 24

• “limping”

- decreased stance time on affected leg

Question 25

What are the 4 compensations to clear an abnormal limb which is “functionally longer” through swing phase?

-May be due to drop foot, PF spasticity, stiff knee, leg length difference, pelvic drop, etc.

Answer 25

1. Circumduction
2. Steppage gait- increase hip and knee flexion
3. Hip hike- lifting of hip/trunk to clear leg in swing phase
4. Vaulting- elevating on toes of sound limb

Question 26

What are the 2 causes of foot slapping after heel strike?

Answer 26

• Proprioception deficits (pt usually has difficulty ambulating in the dark)
• Mild weakness of dorsiflexors (tibialis anterior)

Question 27

What are the 2 main causes of knee hyperextension/ Genu Recurvatum?

Answer 27

• quadriceps/hamstring weakness–> knee snaps back to avoid falling forward??
• foot drop/plantar flexion contracture–> plantarflexion a/w knee extension

***may also be seen in ACL deficit knees or ligamentous instability–> hyper-extend at the knee

Question 28

What type of contraction generates most force?

Answer 28

Fast eccentric

***Eccentric is lengthening, concentric is shortening

Question 29

What are the 2 main categories of pathologic gait?

Answer 29

• Neurologic

- Musculoskeletal

Question 30

What are the 5 types of neurologic pathologic gaits?

Answer 30

• parkinsons
• myopathic
• ataxic
• spastic diplegia
• hemiplegic

Question 31

What are the 3 types of msk pathologic gaits?

Answer 31

• hip disorders
• knee disorders
• ankle/foot disorders

Question 32

Pakinson gait

Answer 32

• hypokinectic
• forward flexed
• decreased arm swing
• shuffling
• fenestrating- increased speech w/ increased distance
• difficulty initiating gait and turning
• “freezing” episodes
• often improve with a metronome (clapping, beat)
• may assess postural stability (retropulsion)

Question 33

Myopathic gait

Answer 33

• Waddling
• Due to proximal weakness–> hip abduction and hip extension are weak
• “Trendenlenberg-Weight shift”
• hyperlordosis for hip stability

Question 34

Ataxic gait

Answer 34

• Due to pathology of cerebellum
• Wide base of support
• truncal unsteadiness–> “titubation”
• Unable to do tandem gait
• Variable leg placement, appears uncoordinated

Question 35

Spastic Diplegic

Answer 35

• Narrow base
• “scissoring” due to adductor spasticity
• “walking through water”–> difficult to advance limb
• Equinovarus (turns in) feet with decreased/absent heel strike
• Often a/w increased hip and knee flexion as well

Question 36

Hemiplegic gait

Answer 36

• Circumduction of involved leg during swing phase
• decreased arm swing on involved side- often held in flexion synergy
• Slow with decreased step length
• Decreased/absent heel strike on involved side
• Often with genu recurvatum (knee hyperextension) on involved side during stance phase
• Decreased knee flexion during swing phase–> circumduct

Question 37

Trendelenburg gait

Answer 37

-Due to gluteus medius weakness/dysfunction

Question 38

Knee Disorders

Answer 38

-Painful knee ***

Question 39

Ankle/Foot disorders