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HPIM 21e (Video V7-07) - 12992406
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HPIM 21e (Video V7-07) - 12992406
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https://cadmoreoriginalmedia.blob.core.windows.net/821edacd-2a7b-4db1-ab88-46b82cd01e72/HPIM2019e-2028439e-072920Coordination20and20Gait.mov?sv=2019-02-02&sr=c&sig=UVbuqRCDm9fLNbYr9ZCfQpNnCbqyRaxbAJwOeSlEodQ%3D&st=2025-07-18T23%3A22%3A02Z&se=2025-07-19T01%3A27%3A02Z&sp=r
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2022-07-07T00:00:00.0000000
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Language: EN.
Segment:0 .
Coordination and gait are somewhat artificial parts of the neurological examination in that they really are part of the function of many of the other systems that are otherwise examined. Put another way, in order to be coordinated, one has to have adequate motor function. We test motor separately. Has to have adequate sensory function. We test sensory function separately.
You have to have normal reflex function. We test those reflexes separately. But the fact is there are a group of disorders of the cerebellum and its connections which cause common neurological disturbances, which include gait disorder and discoordination of one sort or another. So in fact, it's useful for us to dissect it out of the regular neurological examination and consider it a separate category-- coordination and gait.
And that's what we're going to test now. We're really talking about disorders of the cerebellum and its connection. You remember the cerebellum is another little brain in the back. For a long time, we didn't really know what the cerebellum did. But it looks as though the cerebellum is very important in integrating functions of the cerebrum, the brain stem, and the spinal cord.
And not just motor functions, but probably cognitive functions as well. However, for practical purposes, the main disorders of the cerebellum and its connections involve coordination of the limbs and stance and gait. And that's what we routinely test in the neurological exam. Remember, the cerebellum sits in the back of the posterior fossa. It has fibers going toward it, which we'll call cerebellopedal fibers.
And we have fibers which are leaving, which we'll call cerebellofugal fibers. Anything in the cerebellum system, whether it be cerebrellopedal, cerebellofugal, or cerebellar, produce, essentially, an identical picture of ataxia. And that's what we're really looking for here. This ataxia can be axial. It can affect speech and axial structures, or it can be appendicular, out in the limbs.
And in fact, there is a sub-anatomy of the cerebellum, which distinguishes between structures which are in the midline and structures that are out away from the midline. When we tested the cranial nerves in fact, we already looked in part at the signs of cerebellar trouble, coordination problems associated with speech. And I won't repeat that in this context. Let's, rather, go to the limbs and stance and gait. Usually, patients with this kind of difficulty complain of discoordination, dropping things, falling.
Some of them will talk about weakness. But in actual fact, they're not talking about weakness. They're talking about discoordination. So how do we find these? Let's do a few tests of this in the upper extremities. Let's have you put your hands out here, Alan, out in front of you. When I'm actually doing the neurological examination, I often do it right after I'm testing for drift.
So you remember we turn the hands over, separate the fingers, and I say to the person, make believe you're holding a tray in your hands. Close your eyes. And I look for drift, and I see no drift. In order to save time, I'll say, now, keep your eyes closed. Close this hand and make a pointing finger. And touch that finger to the tip of your nose very accurately.
Good. Now, do it on the other side. Use the left hand. And now, faster. Back and forth as fast as you can. So we're going to try to stress the nervous system. You see he does that very accurately. Good. Open your eyes.
Make the pointing finger again on this side and touch my finger with it. And now touch your nose. Back and forth as fast as you can. I'm going to move the target. Good. Do it on the other side. This is known as the finger-nose-finger test for obvious reasons.
A person with cerebellar ataxia would have a side to side tremor of the movement, which would worsen as they got nearer and nearer the target. So I would say, point at my finger, and this is what you would see. Touch your nose. A little bit better. Closer to the target, worse. People can put their finger in their eye, have a terrible time controlling.
Touch my finger. Touch your nose. It's that's side to side terminal-looking tremor on action which is sometimes called cerebellar ataxia. By which we mean cerebellopedal, cerebellar, or cerebellofugal. The appearance of this tremor, this abnormality, this ataxic abnormality doesn't tell you whether it's cerebellopedal, cerebellar, or cerebellofugal.
It tells you there's something wrong with the connections between the cerebellar system and the rest of the nervous system. Let's do a few other tests that sometimes you find-- one will find to be quite useful here. This is called the mirror test. Point your finger at my finger, but don't touch it. Very close, though. Come right to it.
And imitate my movements now. Ready? Go everywhere I go. You'll notice that he has a little bit of overshoot. You see how that goes by and comes back if I go real quickly? Somebody with cerebellar ataxia-- again, this takes experience-- has more than normal.
And so you say follow my finger, you see this. This is often called dysmetria, the inability to measure distances normally. And in fact, dysmetria is probably one of the key features of cerebellar trouble. A nice, little way of trying to decide whether the problem with coordination is cerebellar of the kind we've just talked, or whether it's extrapyramidal, Parkinsonism, or whether it's weakness, supranuclear weakness, somebody who's got weakness because of a stroke or multiple sclerosis, a good way of doing this is to use an old test that Miller Fisher, a great strokologist from Boston here, I think invented, or at least popularized.
Hold your hand out like this. And what I'd like you to do is touch on that first fold. And I'd like you to tap as fast as you can. Nice, big movements. Look at me. As fast as you can. Faster. He does that quite well. This is often quite a useful test.
Thank you. What you might see in a person with these three kinds of disorders, all of which could cause a coordination problem, is that if they had pyramidal tract disease, weakness from, let's say, multiple sclerosis, what you might see is an accurate but slow movement. So you'd say, come on. Go faster. The person's saying, I'm going as fast as I can.
I just can't do it any faster. If it's extrapyramidal, Parkinsonism, what you notice is that the first movement is good, but then it sort of sticks and they get stuck and can't move it any further. And if it's cerebellar, they're fast but inaccurate. So this test, the finger tapping test, I find to be quite helpful. A lot of people, I think, administer it incorrectly and ask people to tap.
And the patients tend to tap at the end. That's too easy. We have to make the test hard enough so that we can bring out the abnormality. Here's another one. Make believe you're screwing a light bulb into the ceiling as fast as you can. These are called rapid alternating movements. Let's see you do it on the other side.
Faster. You're a right-hander? See there's a slight difference between his dominant and non-dominant hand? Not much. Rapid alternating movements deteriorate, fragment, in people with cerebellar ataxia. Irregular, very much like the speech that I described when we talked about the cranial nerves.
It would be wrong emphasis on individual syllables would be sort of a cerebellar kind of speech. This is a cerebellar kind of movement. Another way of doing that is to do the following. I'd like you to slap on your knee over and back, over and back. Fast, though. As fast as you can. Faster, faster, faster.
And the other side. One hand at a time is fine. OK. It's too hard to do two. Perfect. Those are rapid alternating movements. By the way, just as an aside, all of these tests were basically discovered and invented by one man, a man named Gordon Holmes, who was an English neurologist very interested in the cerebellum.
And in fact, his paper on the cerebellum, which is in the journal Brain, published in the 1930s, I think has never been improved upon. Basically, all of these tests that you've just seen here-- the finger-nose-finger test, rapid alternating movements, the mirror test-- he basically invented or described all of these tests to try to recognize cerebellar ataxia and separate it from other kinds of movement disorder problems of one sort or another.
Those are all good tests for the upper extremity. Let's do a couple for the lower extremity. Let's have you land on your back here for a minute. So we have somebody in bed in a hospital. You can't get them up and walk. What's the surrogate for that? Well, let me have you put this heel on that knee. And what you ought to do is put the leg up like that. Put them in the position you want.
And what I'd like you do is pick it up and put it down a few times, right on the knee very accurately. Faster. What you would see in cerebellar ataxia is an inaccuracy, a rapid kind of inaccuracy in making that movement. And now what I'd like you do is run that heel up and down your shin. What you'd see in cerebellar ataxia is that side to side tremor that we saw on the upper extremity, but this time in the lower extremity.
Lie down all relaxed. And lastly, what we do with cerebellar disease is we test for tone. And a good way of testing for tone in a person who's lying is to say, just relax completely. Act like you're going to sleep. And let me do all the work. And you grab the leg above the knee and just give it a quick jerk and drop it.
What you'd see with increased tone is that you'd pick that up and the heel comes off the bed. That's what you'd see with spasticity. What you'd see in cerebellar disease is decreased tone. And in fact, if you just looked at a person lying in bed who had decreased tone in their hips, their legs would be out like that. The fact that he holds his legs like this means that there is tone in his legs, which intorts his legs like that, so his feet are straight.
So if you look at that and you see the tone. You say, aha, decreased tone. This test-- we just did the heel-knee-shin test-- is abnormal. And then finally, stand up. And stand at the side here. We're going to test tone in the upper extremities, looking for cerebellar trouble. And I'm going to swing your arms like this.
I'd like you to close your eyes and just let me do all the work. Just let your arms go. You see when I let go, they swing maybe one or two movements, forward and back. Let me get up next to you. If you were to do me and I had cerebellar ataxia, I would look like this. Be this long pendulum before I would stop, because I was actually hypotonic.
So with that, I think we're going to take a walk, and we're going to have a look at gait and stance. And that will be the end of our cerebellar examination. Now, Alan, I'd like to test your gait. Let's just have you walk up and back, naturally as you can. Turn a sharp left and come right back. Perfect. Do it one more time, just the same way, normal gait.
We're looking at his arms, actually, more than we're looking at legs. We're looking to see if he swings his arms naturally, makes normal, natural movements. Good. Now, walking back, walk on your heels like that. Good. Perfect. Now, this is a stress gait.
This will bring out a movement disorder in the arms if there is one, which of course, he doesn't have. And toes. Perfect. Also, perfect. And now, let's walk heel to toe, like a tight rope. This is the ultimate stress gait. And again, his arms are not doing anything strange. He does that very well.
One more time. Perfect. So he has a perfectly normal stance and gait. So let me now show you a couple of what might look like abnormal gaits. Since Alan's gait is really normal, you're not seeing anything abnormal. What kinds of things you're going to look for. So here I am walking up and down.
And if you look carefully, you're going to notice that my right arm is not swinging normally. You notice that now? See, if you obsess about the legs, you'll not notice that my right arm is not swinging normally. Then you might add to that that my posture becomes somewhat flexed. See, I'm bent a little forward here. I'm still swinging my left side.
I'm bent slightly forward. And then now you begin to see a tremor of my right hand. And it begins to become obvious that this is Parkinsonism, isn't it? And now you see when I turn, it takes me more than one or two steps to make that turn. And now, it's becoming very obvious that this is Parkisonism. What you've just seen is sort of time lapse over what would be, really, years of gradual development.
Another one that you might see is a person with a subtle hemiparesis where one foot is catching and one arm is flexed. They don't have that flexed posture in the tremor of the Parkinsonism, but not using that right side. Holding it in a flexed posture. If you make it worse, it's more obvious. The leg becomes circumducted, that right leg. It has to turn around to get around there.
Now, here's another one that you will commonly see. And that's somebody who's spastic in both legs. Here's a mild example of it. They're circumducting both legs. This is the kind of thing you'd see in somebody who had cervical spondylosis, perhaps, squeezing their spinal cord. Here's a gait that would be characteristic of cerebellar ataxia. Wide-based, unbalanced.
The person wants to keep their legs apart. And it looks a little like acute alcohol intoxication, doesn't it? And that's what cerebellar gait looks like. Holding the legs wide apart, not putting them together. Sometimes you can see a movement disorder during gait that you didn't notice when the person was sitting on the table. You notice that there is chorea of my right arm.
And this might get much worse with a stress gait. I try to walk heel to toe. It gets much, much worse. Or on my heels. See all that funny movement disorder of one arm? And then, you might see something very, very peculiar, something that looks like this.
Notice I'm crossing one leg over another, which actually produces a situation which some of the time I'm actually standing on one foot. Of course, the nervous system would never do that, would it? If the nervous system were broken, it would never want to try to stand on one foot. That's more difficult. So this is the kind of gait you would see in somebody who is putting on a gait disorder.
Charcot called this astasia-abasia. It means the gait without a base at all. It's the opposite of cerebellar ataxia. So some of these are very bizarre, odd gaits that certainly couldn't be due to a real organic neurological disease. So you can see that watching someone walk is incredibly important in understanding the overall neurological examination.
Anybody who can walk must walk. You must make them walk up and down. And over time, you'll learn to be able to evaluate these gaits for subtle abnormalities which will help you make your neurological examination complete. I would say that there's no examination which is complete without a good examination of the patient's gait.
Language: ES.
Segment:0 .
Segment:0 .
Coordination and gait are somewhat artificial parts of the neurological examination in that they really are part of the function of many of the other systems that are otherwise examined. Put another way, in order to be coordinated, one has to have adequate motor function. We test motor separately. Has to have adequate sensory function. We test sensory function separately.
You have to have normal reflex function. We test those reflexes separately. But the fact is there are a group of disorders of the cerebellum and its connections which cause common neurological disturbances, which include gait disorder and discoordination of one sort or another. So in fact, it's useful for us to dissect it out of the regular neurological examination and consider it a separate category-- coordination and gait.
And that's what we're going to test now. We're really talking about disorders of the cerebellum and its connection. You remember the cerebellum is another little brain in the back. For a long time, we didn't really know what the cerebellum did. But it looks as though the cerebellum is very important in integrating functions of the cerebrum, the brain stem, and the spinal cord.
And not just motor functions, but probably cognitive functions as well. However, for practical purposes, the main disorders of the cerebellum and its connections involve coordination of the limbs and stance and gait. And that's what we routinely test in the neurological exam. Remember, the cerebellum sits in the back of the posterior fossa. It has fibers going toward it, which we'll call cerebellopedal fibers.
And we have fibers which are leaving, which we'll call cerebellofugal fibers. Anything in the cerebellum system, whether it be cerebrellopedal, cerebellofugal, or cerebellar, produce, essentially, an identical picture of ataxia. And that's what we're really looking for here. This ataxia can be axial. It can affect speech and axial structures, or it can be appendicular, out in the limbs.
And in fact, there is a sub-anatomy of the cerebellum, which distinguishes between structures which are in the midline and structures that are out away from the midline. When we tested the cranial nerves in fact, we already looked in part at the signs of cerebellar trouble, coordination problems associated with speech. And I won't repeat that in this context. Let's, rather, go to the limbs and stance and gait. Usually, patients with this kind of difficulty complain of discoordination, dropping things, falling.
Some of them will talk about weakness. But in actual fact, they're not talking about weakness. They're talking about discoordination. So how do we find these? Let's do a few tests of this in the upper extremities. Let's have you put your hands out here, Alan, out in front of you. When I'm actually doing the neurological examination, I often do it right after I'm testing for drift.
So you remember we turn the hands over, separate the fingers, and I say to the person, make believe you're holding a tray in your hands. Close your eyes. And I look for drift, and I see no drift. In order to save time, I'll say, now, keep your eyes closed. Close this hand and make a pointing finger. And touch that finger to the tip of your nose very accurately.
Good. Now, do it on the other side. Use the left hand. And now, faster. Back and forth as fast as you can. So we're going to try to stress the nervous system. You see he does that very accurately. Good. Open your eyes.
Make the pointing finger again on this side and touch my finger with it. And now touch your nose. Back and forth as fast as you can. I'm going to move the target. Good. Do it on the other side. This is known as the finger-nose-finger test for obvious reasons.
A person with cerebellar ataxia would have a side to side tremor of the movement, which would worsen as they got nearer and nearer the target. So I would say, point at my finger, and this is what you would see. Touch your nose. A little bit better. Closer to the target, worse. People can put their finger in their eye, have a terrible time controlling.
Touch my finger. Touch your nose. It's that's side to side terminal-looking tremor on action which is sometimes called cerebellar ataxia. By which we mean cerebellopedal, cerebellar, or cerebellofugal. The appearance of this tremor, this abnormality, this ataxic abnormality doesn't tell you whether it's cerebellopedal, cerebellar, or cerebellofugal.
It tells you there's something wrong with the connections between the cerebellar system and the rest of the nervous system. Let's do a few other tests that sometimes you find-- one will find to be quite useful here. This is called the mirror test. Point your finger at my finger, but don't touch it. Very close, though. Come right to it.
And imitate my movements now. Ready? Go everywhere I go. You'll notice that he has a little bit of overshoot. You see how that goes by and comes back if I go real quickly? Somebody with cerebellar ataxia-- again, this takes experience-- has more than normal.
And so you say follow my finger, you see this. This is often called dysmetria, the inability to measure distances normally. And in fact, dysmetria is probably one of the key features of cerebellar trouble. A nice, little way of trying to decide whether the problem with coordination is cerebellar of the kind we've just talked, or whether it's extrapyramidal, Parkinsonism, or whether it's weakness, supranuclear weakness, somebody who's got weakness because of a stroke or multiple sclerosis, a good way of doing this is to use an old test that Miller Fisher, a great strokologist from Boston here, I think invented, or at least popularized.
Hold your hand out like this. And what I'd like you to do is touch on that first fold. And I'd like you to tap as fast as you can. Nice, big movements. Look at me. As fast as you can. Faster. He does that quite well. This is often quite a useful test.
Thank you. What you might see in a person with these three kinds of disorders, all of which could cause a coordination problem, is that if they had pyramidal tract disease, weakness from, let's say, multiple sclerosis, what you might see is an accurate but slow movement. So you'd say, come on. Go faster. The person's saying, I'm going as fast as I can.
I just can't do it any faster. If it's extrapyramidal, Parkinsonism, what you notice is that the first movement is good, but then it sort of sticks and they get stuck and can't move it any further. And if it's cerebellar, they're fast but inaccurate. So this test, the finger tapping test, I find to be quite helpful. A lot of people, I think, administer it incorrectly and ask people to tap.
And the patients tend to tap at the end. That's too easy. We have to make the test hard enough so that we can bring out the abnormality. Here's another one. Make believe you're screwing a light bulb into the ceiling as fast as you can. These are called rapid alternating movements. Let's see you do it on the other side.
Faster. You're a right-hander? See there's a slight difference between his dominant and non-dominant hand? Not much. Rapid alternating movements deteriorate, fragment, in people with cerebellar ataxia. Irregular, very much like the speech that I described when we talked about the cranial nerves.
It would be wrong emphasis on individual syllables would be sort of a cerebellar kind of speech. This is a cerebellar kind of movement. Another way of doing that is to do the following. I'd like you to slap on your knee over and back, over and back. Fast, though. As fast as you can. Faster, faster, faster.
And the other side. One hand at a time is fine. OK. It's too hard to do two. Perfect. Those are rapid alternating movements. By the way, just as an aside, all of these tests were basically discovered and invented by one man, a man named Gordon Holmes, who was an English neurologist very interested in the cerebellum.
And in fact, his paper on the cerebellum, which is in the journal Brain, published in the 1930s, I think has never been improved upon. Basically, all of these tests that you've just seen here-- the finger-nose-finger test, rapid alternating movements, the mirror test-- he basically invented or described all of these tests to try to recognize cerebellar ataxia and separate it from other kinds of movement disorder problems of one sort or another.
Those are all good tests for the upper extremity. Let's do a couple for the lower extremity. Let's have you land on your back here for a minute. So we have somebody in bed in a hospital. You can't get them up and walk. What's the surrogate for that? Well, let me have you put this heel on that knee. And what you ought to do is put the leg up like that. Put them in the position you want.
And what I'd like you do is pick it up and put it down a few times, right on the knee very accurately. Faster. What you would see in cerebellar ataxia is an inaccuracy, a rapid kind of inaccuracy in making that movement. And now what I'd like you do is run that heel up and down your shin. What you'd see in cerebellar ataxia is that side to side tremor that we saw on the upper extremity, but this time in the lower extremity.
Lie down all relaxed. And lastly, what we do with cerebellar disease is we test for tone. And a good way of testing for tone in a person who's lying is to say, just relax completely. Act like you're going to sleep. And let me do all the work. And you grab the leg above the knee and just give it a quick jerk and drop it.
What you'd see with increased tone is that you'd pick that up and the heel comes off the bed. That's what you'd see with spasticity. What you'd see in cerebellar disease is decreased tone. And in fact, if you just looked at a person lying in bed who had decreased tone in their hips, their legs would be out like that. The fact that he holds his legs like this means that there is tone in his legs, which intorts his legs like that, so his feet are straight.
So if you look at that and you see the tone. You say, aha, decreased tone. This test-- we just did the heel-knee-shin test-- is abnormal. And then finally, stand up. And stand at the side here. We're going to test tone in the upper extremities, looking for cerebellar trouble. And I'm going to swing your arms like this.
I'd like you to close your eyes and just let me do all the work. Just let your arms go. You see when I let go, they swing maybe one or two movements, forward and back. Let me get up next to you. If you were to do me and I had cerebellar ataxia, I would look like this. Be this long pendulum before I would stop, because I was actually hypotonic.
So with that, I think we're going to take a walk, and we're going to have a look at gait and stance. And that will be the end of our cerebellar examination. Now, Alan, I'd like to test your gait. Let's just have you walk up and back, naturally as you can. Turn a sharp left and come right back. Perfect. Do it one more time, just the same way, normal gait.
We're looking at his arms, actually, more than we're looking at legs. We're looking to see if he swings his arms naturally, makes normal, natural movements. Good. Now, walking back, walk on your heels like that. Good. Perfect. Now, this is a stress gait.
This will bring out a movement disorder in the arms if there is one, which of course, he doesn't have. And toes. Perfect. Also, perfect. And now, let's walk heel to toe, like a tight rope. This is the ultimate stress gait. And again, his arms are not doing anything strange. He does that very well.
One more time. Perfect. So he has a perfectly normal stance and gait. So let me now show you a couple of what might look like abnormal gaits. Since Alan's gait is really normal, you're not seeing anything abnormal. What kinds of things you're going to look for. So here I am walking up and down.
And if you look carefully, you're going to notice that my right arm is not swinging normally. You notice that now? See, if you obsess about the legs, you'll not notice that my right arm is not swinging normally. Then you might add to that that my posture becomes somewhat flexed. See, I'm bent a little forward here. I'm still swinging my left side.
I'm bent slightly forward. And then now you begin to see a tremor of my right hand. And it begins to become obvious that this is Parkinsonism, isn't it? And now you see when I turn, it takes me more than one or two steps to make that turn. And now, it's becoming very obvious that this is Parkisonism. What you've just seen is sort of time lapse over what would be, really, years of gradual development.
Another one that you might see is a person with a subtle hemiparesis where one foot is catching and one arm is flexed. They don't have that flexed posture in the tremor of the Parkinsonism, but not using that right side. Holding it in a flexed posture. If you make it worse, it's more obvious. The leg becomes circumducted, that right leg. It has to turn around to get around there.
Now, here's another one that you will commonly see. And that's somebody who's spastic in both legs. Here's a mild example of it. They're circumducting both legs. This is the kind of thing you'd see in somebody who had cervical spondylosis, perhaps, squeezing their spinal cord. Here's a gait that would be characteristic of cerebellar ataxia. Wide-based, unbalanced.
The person wants to keep their legs apart. And it looks a little like acute alcohol intoxication, doesn't it? And that's what cerebellar gait looks like. Holding the legs wide apart, not putting them together. Sometimes you can see a movement disorder during gait that you didn't notice when the person was sitting on the table. You notice that there is chorea of my right arm.
And this might get much worse with a stress gait. I try to walk heel to toe. It gets much, much worse. Or on my heels. See all that funny movement disorder of one arm? And then, you might see something very, very peculiar, something that looks like this.
Notice I'm crossing one leg over another, which actually produces a situation which some of the time I'm actually standing on one foot. Of course, the nervous system would never do that, would it? If the nervous system were broken, it would never want to try to stand on one foot. That's more difficult. So this is the kind of gait you would see in somebody who is putting on a gait disorder.
Charcot called this astasia-abasia. It means the gait without a base at all. It's the opposite of cerebellar ataxia. So some of these are very bizarre, odd gaits that certainly couldn't be due to a real organic neurological disease. So you can see that watching someone walk is incredibly important in understanding the overall neurological examination.
Anybody who can walk must walk. You must make them walk up and down. And over time, you'll learn to be able to evaluate these gaits for subtle abnormalities which will help you make your neurological examination complete. I would say that there's no examination which is complete without a good examination of the patient's gait.
Language: ES.
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