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Gait and Coordination

Gait requires the coordinated functioning of many neuroanatomical systems, including the motor cortex and corticospinal tracts, peripheral neurons and muscles, the basal ganglia, the cerebellum, the vestibular system and the visual and proprioceptive sensory afferents. Therefore, gait may be disturbed in the context of a wide variety of neurological disorders and gait testing is a good overall screening device. Every attempt should be made to have patients walk, even if some effort and support are needed to prevent their falling. Conditions such as arthritis and back pain may interfere with evaluation of the neurological aspects of gait. While engaged in natural gait, the patientís overall posture, arm-swing, width of stance, springiness, length of stride, and balance are observed.

Hopping or standing on one leg may provide further useful information. The patient should walk on his or her toes and heels so that distal lower extremity muscle strength can be assessed. Tandem gait, or walking heel-to-toe along a straight line, may be done forward and backward principally to test midline cerebellar function. The Romberg test is fairly sensitive for determining the status of the patients proprioceptive pathways from the lower extremities. Results may also be positive with vestibular impairment. The patient is asked first to stand with his or her feet together and the arms extended out in front and eyes open. If imbalance is increased when the eyes are closed, this is a positive result. Caution must be exercised to prevent the patient from falling.

Coordination of the individual limbs may be affected by lesions of the cerebellum and its connections, weakness, alterations of sensory input with certain neuropathies, and rarely cortical lesions in the absence of weakness. Limb ataxia and dysmetria, which is a difficulty in achieving a precise movement toward a specific target with a tendency to overshoot, should be sought in the upper extremities using the finger-nose-finger test, in which the patient is asked to alternately touch the examinerís finger while in motion, then his or her nose, and back to the examinerís finger, and so on.

An analogous test for the lower extremities is the heel-knee-shin test, in which the patient slides his or her heel, with the toes pointing upward, smoothly up and down the front of the shin between the knee and ankle.

Intention tremor, which is usually a sign of a cerebellar efferent lesion, is also looked for during these tests. It consists of an oscillating movement perpendicular to the line of motion that increases in amplitude as the goal is approached. Distal fine movements are influenced not only by cerebellar function but also by strength, muscle tone, and, to a certain degree, by sensory input. Useful tests to assess this are to have the patient tap the index finger on the most distal thumb creases as rapidly as possible, describe small circles continuously on the back of the hand with the second and third fingers, rapidly alternate touching of the thumb to each of the other fingers, and tap a foot on the floor with the heel planted against the examinerís hand while the patient is supine. When interpreting the results of these tests, normal right-left differences must be taken into account. When the ability to perform rapid alternating movements is impaired, this is referred to as dysdiadochokinesia.

Spastic-Stiff-legged, scissoring, may walk on toes.

Cause or main example: Paraparesis due to upper motor neuron lesions.

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