Gait and posture

Introduction
The examination of motor function, coordination, sensory function and reflexes is preceded by an examination of the patient’s gait and posture. This will give you an initial impression of motor function, coordination, balance, etc. The diagnostic physical examination, which includes the neurological examination, starts the moment the patient enters the consultation room. You will have already observed any clearly visible abnormalities in the patient’s posture and movements, but if you feel that based on the patient’s history and/or your first impression a complete neurological examination is necessary, more careful attention to the patient’s gait and posture will be required.

Procedure

• Ask the patient to undress. Underwear can usually be kept on.
• Have the patient stand in front of you in a position with adequate lighting.
  • Assess the patient’s posture and muscle contours. Look for signs of hypertrophy or atrophy. 
  • Assess whether there are any involuntary movements, for example fasciculations, tremors, choreiform movements.
• Ask the patient to walk across the room a few times.
  • Assess the width of the gait, the foot-floor contact pattern, arm swing and step length.
• Have the patient walk heel-to-toe (tandem gait). If necessary give a demonstration [Figure 35].
  • Assess the gait once more, and observe whether the patient wobbles.

Figure 35

• Have the patient walk on their heels and then on their toes.
• Ask the patient to stand on one leg (do not ask the patient to perform this task if you presume, based on the patient’s history or your first impression that this may be too taxing, for example in the case of a heart condition or severe hip arthritis).
  • Assess whether the patient is able to carry out these manoeuvres.
• Carry out Barré’s test (test for pronator drift) and Romberg’s test [Figure 36]:
  • Explain the test and the function of the test to the patient.
  • Have the patient stand with their feet close together.
  • Stand behind the patient with your arms positioned on either side of the patient without touching them.
  • Ask the patient to stretch out their arms in front with the palms facing upwards.
  • Instruct the patient to keep both palms at the same level positioned in front of them.
  • If the patient does not sway or fall with their eyes open, ask them to shut their eyes.
• Observe the patient during one minute and assess whether they lose balance or fall. Note the direction of falling or swaying.
• Assess whether one or both arms drop and whether the hand pronates.

Figure 36

Interpretation

• Muscle atrophy is seen:
  • after prolonged illness or malnutrition 
  •  in muscle diseases
  • after peripheral nerve damage
  • after damage to the corticospinal tract.

Asymmetric atrophy as the result of mononeuropathy, for example, is easier to spot than symmetric atrophy. The difference between left and right is clear. Symmetric atrophy, as seen with muscular diseases for example, can often only be detected at a later stage due to the absence of a reference point for comparison.

• There are various involuntary movements
  Fasciculations are random muscle contractions. They may be indicative of a motor neuron lesion (for example, poliomyelitis, amyotrophic lateral sclerosis), but can also be of no pathological significance. They should only be considered significant if they are accompanied by paresis and/or atrophy.
  Tremors are rhythmical oscillary movements usually seen in the hands, but may also be present in arms, legs or the head. They can be classified as follows:

1. resting (static) tremor
2. intention tremor
3. postural tremor.

1. Resting tremor can be a ‘physiological’ tremor which occurs for example with exertion and nervousness.

• The tremor may be hereditary (history).
• The tremor may be a senile tremor (6-10 muscle movements per second).
• The tremor may be a symptom of Parkinson’s disease (5 muscle movements per second). The tremor improves upon intentional movement.Note: in these cases the tremor becomes more obvious (with increased tremor amplitude) if the patient is tense.

2. Intention tremor only becomes apparent when the patient carries out an intentional movement, for example picking up a cup of coffee (refer to the coordination examination).

3. Postural tremor occurs if the patient has to maintain one position for a certain length of time (refer to the coordination examination).

Athetosis is a slow, tense, writhing movement, usually involving the arms or legs. 
Choreiform movements are rapid, jerky, sudden movements, usually involving the hands, arms or head.
Hemiballismus involves sudden large-amplitude flinging movements, usually of the arms.
The latter three involuntary movements mentioned above are seen in extrapyramidal diseases.

• The patient’s gait is influenced by the function of the cerebellum and the vestibular system, but also by lower limb proprioception. [Figure 35] shows the gait of a patient with a cerebellar condition compared with a normal gait when carrying out the heel-to-toe test.
• The foot-floor contact pattern. A condition involving the peroneal nerve can cause ‘foot drop’ when the patient walks, i.e. when the heel is placed on the ground the forefoot immediately slaps down onto the ground. If there is total loss of function in those muscles innervated by the peroneal nerve, a steppage gait may arise in which the toes first make contact with the ground, followed by the forefoot and finally the heel.
• The stride length may be reduced with Parkinson’s disease. With this condition, there is also noticeable reduction in arm swing during walking. If you observe a shorter stride length and reduced arm swing, ask the patient to stop suddenly and assess whether there is any sign of propulsion (i.e., coming to a sudden halt is difficult or impossible). 
• This test, also known as the tandem gait, is intended to investigate the function of the cerebellum, vestibular system and proprioception (the dorsal columns) (compare to gait).
• Walking on heels/toes allows you to examine the strength of the muscles that flex and extend the foot, which are supplied by the peroneal and tibial nerves. Standing on one leg examines the strength of the adductor muscles, which are supplied by the superior gluteal nerves.
• If, after closing their eyes, the patient sways during the Romberg’s test or if you have to catch the patient to prevent falling, the test is considered to be positive. The patient is able to maintain their balance using their eyes and visual system, but their proprioception (the dorsal columns) or vestibular system is not functioning properly. In the case of a cerebellar condition, the patient will sway but this does not become more pronounced when the patient shuts their eyes.
• If, when carrying out Barré’s test, one of the patient’s arms drops and pronates, the test is considered to be positive. This test is often used as a distraction manoeuvre during Romberg’s test. A positive Barré test indicates paresis of the arm. This type of paresis is often seen as a residual symptom of a stroke (CVA – Cerebral Vascular Accident) with motor function loss.