Locomotor system - Videos and Explanation : Reflex Tone Superficial Deep Tendon Power Bulk Nutrition

1. GUIDE: DR Ameeth k
STUDENT:DR Ganesh

2. Includes the bones, muscles, tendons
and ligaments, skeletal system and all
that makes it move

5. WHY DO WE DO A MOTOR SYSTEM
EXAMINATION
▪ Cardinal symptoms and signs which
prompt a motor system examination:
1. Weakness
2. Imbalance
3. In-coordination
4. As a part of CNS examination

6. OUTLINE
• Muscle bulk ,Tone and Power
• Reflexes
• Posture and abnormal movements
• Coordination
• Stance and gait

7. 1. MUSCLE BULK
Bulk of muscle is assessed by
Inspection
Palpation
Measurement

8. INSPECTION
If there is wasting, find out whether it is
localised to
• One muscle
• Group of muscles
• Segment
• Whole limb
Features of wasted muscle/ atrophic
muscle
• Smaller in size
• Long term atrophy cause contracture.

11. PALPATION
Normal muscle is semi elastic to feel.
Atrophy muscle are soft initially, later the
fibrosis occurs and it feels firm.
Rubbery or doughy consistency occurs in
pseudo hypertrophy.
MEASUREMENT

12. 2. MUSCLE TONE
Defined as the degree of tension present in
a muscle at rest

13. MODIFIED ASHWORTH SCALE (MAS).
0 - No increase in muscle tone.
1 - Slight increase in muscle tone, manifested
by a catch and release or by minimal resistance
at the end of the range of motion.
2 - More marked increase in muscle tone
through most of the ROM, but affected part(s)
easily moved.
3 - Considerable increase in muscle tone,
passive movement difficult.
4 - Affected part(s) rigid in flexion or extension.

14. EXAMINATION OF TONE
UPPER LIMBS
▪ Flexion-extension movement at wrist & elbow
joint
▪ Supination pronation of forearm- PRONATOR
CATCH- in spasticity
▪ Hand dropping test- look for checking
movements
LOWER LIMBS
▪ Rolling of limbs-
▪ Passive flexion, extension of hip, knee & ankle
▪ Brisk flexion of knee joint upwards- heel slides /
leg rises
▪ Leg dropping test- normal checking movements

15. Support the elbow
with your left hand
Hold patient’s hand
as if shaking hands
Rapidly supinate and
pronate the arm
Use the same
technique on each arm
Always use the same
hand to assess
movement for the
patients right and left

16. While still
supporting the
elbow passively flex
and extend the
elbow
Use same
technique on both
arms
If tone is normal
there will be no
resistance to these
movements

18. ▪ PENDULOUSNESS OF LEGS- There will normally be a
swinging of the legs that progressively diminishes in
range and usually disappears after six or seven
oscillations
▪ In extrapyramidal rigidity, there is a decrease in
swing time but usually no qualitative change in the
response.
▪ In spasticity, there may be little or no decrease in
swing time, but the movements
are jerky and irregular- zigzag pattern

19. INCREASE OF TONE
Spasticity
Rigidity
Paratonia
Myotonia
DECREASE IN TONE

20. EXAMINATION OF POWER

22. MYOTOME
Spinal segments supplying skeletal muscle called
Myotome.
.C1/C2-Neck Flexion/ Extension
C4- Shoulder Elevation
C5- Shoulder Abduction
C6- Elbow Flexion/ Wrist Extension
C7- Elbow Extension/ Wrist Flexion/ Finger
Extension
C8- Finger Flexion
T1- Finger Abduction
L2- Hip Flexion
L3- Knee Extension
L4- Ankle Dorsi-flexion
L5- Great Toe Extension
S1- Ankle Plantar Flexion/ Ankle Eversion/ Hip
Extension
S2- Knee Flexion

23. MISLEADS
Extrapyramidal disease- rigidity/ bradykinesia
Hyperkinesia / ataxia
Speed – hypo/hyperthyroidism, depression
Motor Impersistence- apraxia
Loss/impairment of movement- pain, swelling,
spasm, fractures, dislocations, ankylosis.
▪ Variability in muscle power, size, gender, body
built affect examiners as well as patients
▪ Strength mismatch

24. TO AVOID MISLEADS
▪ The small hand muscles are best examined by
matching them against the examiner’s like muscle
▪ The gastrocnemius muscles are normally so
powerful it is virtually useless to examine them using
hand and arm strength
▪ Passive movements to assess range of motion are
necessary before strength evaluation

25. ▪ COMA
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful
stimulation
-any asymmetry of spontaneous or reflex movements
on the two sides.
▪ HEMIPLEGIA
-Absence of contraction of the facial muscles on one
side following pressure on the supraorbital ridge
-Dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg
when released

26. MUSCLES OF THE NECK
▪ Principal neck movements are flexion, extension
(retraction), rotation (turning), and lateral bending
(tilting, abduction)
▪ The spinal accessory nerve, along with the second,
third, and fourth cervical segments, supplies both
muscles
▪ SCM is a flexor and rotator of the head and neck;
the trapezius retracts the neck and draws it to one
side.

28. ▪ The neck flexion test consists of
measuring the time the supine patient can
keep the head raised with the chin on the
chest
▪ Most patients can keep their head in this
position for at least 1 minute
▪ Evaluation of myopathies and
neuromuscular junction disorders- cause
neck flexor or extensor weakness

31. THE GLENOHUMERAL JOINT
▪ Abduct- supraspinatus, deltoid, trapezius,
serratus anterior
▪ Adduct- pectoralis major, latismus dorsi
▪ Flexion- pectoralis major, anterior deltoid
▪ Extension-posterior deltoid, lattismus dorsi
▪ Internal rotation- subscapularis, teres major
▪ External rotation- infraspinatus, teres minor

32. Suprascapular nerve
C5,6
Contraction of the
muscle fibres
can be felt during
early stages of
abduction of the arm
SUPRASPINATUS

33. Axillary nerve C5,6
Abduction 15 to 90
degrees
The patient attempts
to abduct his arm
against resistance;
the contracting
deltoid can be seen
and palpated.
DELTOID

34. Lateral & medial
pectoral nerve
C5-T1 Contraction
of the muscle can be
seen and felt during
attempts to adduct
the arm against
resistance
PECTORALIS MAJOR

35. THE SCAPULA
▪ Elevate- upper fibers of trapezius, levator
scapulae
▪ Depression- lower fibers of trapezius, pectoralis
minor, subclavius
▪ Retraction- rhomboids, middle fibers of
trapezius
▪ Protraction- serratius anterior, pectoralis minor
▪ Examination of the rhomboids is important in
the differentiation of C5 radiculopathy from upper
trunk brachial plexopathy

36. Dorsal scapular nerve
C4/5
Retraction of scapula
The rhomboids can be
tested by having the
patient, with hand on
hip, retract the shoulder
against the examiner’s
attempt to push the
elbow forward
RHOMBOIDS

37. Long thoracic nerve- C5,7
Protraction of scapula
The patient pushes against a
wall with his arms extended
horizontally in front of him;
normally, the medial border
of the scapula remains close
to the thoracic wall.
SERRATIUS ANTERIOR

38. For demonstrating
winging of scapula due
to weakness in
trapezius
SWAN DIVE POSTURE

39. Thoracodorsal nerve, C6-8
Adducts, extends, medially
rotates shoulder
On adduction of the
horizontally and laterally
abducted arm against
resistance, the contracting
muscle fibers can be seen
and palpated.
LATTISMUS DORSI

40. Musculocutaneous nerve
C5,6
Flexion, supination
On attempts to flex the
forearm against
resistance, the
contracting biceps
muscle can be seen and
palpated
BICEPS BRACHII

41. Radial nerve C5,6
Flexion, supinator,
pronator
On flexion of the semi
pronated forearm
(thumb up) against
resistance, the
contracting muscle
can be seen and
palpated.
BRACHIORADIALIS

42. Cranial XI C2,3,4
Upper fibres- shrug
Middle fibres-retract
On retraction of the
shoulder against
resistance, the middle
fibres of the muscle can
be seen and palpated
TRAPEZIUS

43. Radial nerve C6,7,8
Extension of elbow joint
On attempts to extend
the partially flexed
forearm against
resistance,
TRICEPS

44. A. On attempts to supinate the extended forearm against
resistance, the contracting brachioradialis
B. supinate the flexed forearm against resistance, the
contracting biceps can be seen & palpated
C. On pronation of the forearm against resistance,
contraction of the Pronator Teres can be seen and
palpated.

45. THE WRIST
▪ Flexion- FCR, FCU
▪ Extension- ECRL,ECRB,ECU
▪ Adduction - ECU
▪ Abduction -ECRL,ECRB

47. FINGERS
▪ Flexion- FDS (flexes PIP) FDP (flexes DIP)
Interossei & lumbricals flex MCP and extend IP
joints
GRIP POWER
▪ Making a fist requires flexion of the fingers at
all joints (MCP,IP,Thumb)
▪ It is not very useful in assessing upper
extremity motor function
▪ Grip strength is unaffected by CST pathology
as finger and wrist flexors are not CST
innervated and are not likely to be weak with a
mild CST lesion

48. FDP-The patient resists attempts to extend the
distal phalanges while the middle phalanges
are fixed
FDS- The patient resists attempts to straighten
the fingers at the first Interphalangeal (IP) joint

49. EDC- With hand outstretched and IP joints held in extension, the
patient resists the examiner’s attempt to flex the fingers at the
(MCP) joints
Lumbricals & Interossei- Extension of the middle and distal
phalanges, the patient attempts to extend the fingers against
resistance while the MCP joints are fixed

50. THUMB MUSCLE
▪ Forearm muscle(extrinsic)- APL -EPL-
EPB-FPL
▪ Thenar muscle(intrinsic)- APB,OP,FLB
Palmar abduction by APL & APB muscles
Radial abduction by APL & EPB muscles
Opposition- OP,ODM

51. FPL- The patient resists attempts to extend the distal phalanx of the
thumb while the proximal phalanx is fixed
EPL- The patient attempts to resist passive flexion of the thumb at the IP
joint; the tendon can be seen and palpated.
EPB-The patient attempts to resist passive flexion of the thumb at the MCP
joint; the tendon can be seen and
palpated.

52. Radial abduction of the thumb.
The patient attempts to abduct the thumb in
the same plane as that of the palm; the
tendon of the APL can be seen and palpated
Palmar abduction of the thumb. The patient
attempts, against resistance, to bring the
thumb to a point vertically above its original
position.

53. Testing the grip
•C7, C8, T1
•Ask the patient to
squeeze two of your
fingers as hard
as possible and not let
them go. You should
normally have
difficulty removing
your fingers from the
patient's grip.
Test both grips
simultaneously with
arms extended or in
the lap.

54. MUSCLES OF ABDOMEN
▪ Rectus abdominis, pyramidalis, transverse abdominis & oblique (external &
internal)
▪ BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad
when the patient raises the head or attempts a sit-up

55. ABDOMINAL MUSCLES
T7-T12 intercostal
nerves
The recumbent patient
attempts to raise his
head against resistance
Flexors of spine also
involved

56. THE HIP JOINT
▪ Flexors- iliopsoas, rectus femoris, Sartorius,
tensor fascia lata
▪ Extensors- gluteus maximus
▪ Abductors- gluteus medius, minimus, TFL
▪ Adductors- adductor magnus,longus, brevis
▪ Internal/medial rotator- hip abductor muscles-
gluteus medius, minimus, TFL
▪ External/lateral rotator- gluteus maximus,
obturator internus & externus

57. Femoral nerve L2-4
The patient attempts to flex the
thigh against resistance; the knee
is flexed and the leg rests on the
examiner’s arm
With legs fixed they flex the trunk
and pelvis forward
Normal hip flexors cannot be
overcome by an examiner using
hand and arm strength from an
arm’s length away
LEG DRIFT- U/L CST lesion- flexed
hip, extended knee- 45 degree,
drift downward
FLEXORS OF THIGH

58. EXTENSORS OF THIGH
Inferior gluteal nerve L5-S2
The patient, lying prone with the leg
flexed at the knee, attempts to
extend the thigh against resistance;
Having the knee flexed minimizes any
contribution from the hamstrings
Lying in side & extending hip/ stand
upright from a stooped position
GOWERS MANEUVER- using his
hands to “climb up the legs”
Seen in muscular dystrophies with
marked weakness of hip extensors

59. ABDUCTION OF
THIGH AT HIP
Superior gluteal nerve L4-S1
TRENDELENBURG’S SIGN
Exacerbated pelvic swing
during the stance phase as
the pelvis on the side of the
swing leg drops downwards
Bilateral- pelvic waddle/
WADDLING GAIT

61. ADDUCTORS OF
THIGH AT THE HIP
Obturator nerve. L2-4
A.Magnus- Sciatic N carrying
L4/5
The recumbent patient
attempts to adduct the
extended leg against
resistance;
contraction of the
adductor muscles can be
seen and palpated

62. INTERNAL/MEDIAL
ROTATION
Superior gluteal nerve L4-S1
The patient, lying prone with the
leg flexed at the knee, attempts to
carry the foot laterally against
resistance, thus rotating the thigh
medially
G Medius inferior gluteal nerve
Rotate medially with flexed knee

63. THE KNEE JOINT
▪ Flexion- hamstring muscles (biceps
femoris, semimembranosus,
semitendinosus)
The hamstrings also act as powerful
hip extensors
▪ Extensors- Quadriceps femoris
(rectus femoris, vastus
lateralis,medialis,intermedius)

64. FLEXION AT THE KNEE
Sciatic nerve L5,S1 S2
The prone patient attempts to
maintain flexion of the leg while
the examiner attempts to extend
it;
the tendon of the biceps femoris
can be palpated laterally and the
tendons of the semimembranosus
and semitendinosus, medially.
LEG DRIFT /LEG SIGN OF BARRE
Prone, both knee flexed at 45
degree from horizontal, with CST
lesion involved leg will sink

65. EXTENSION AT KNEE
Femoral nerve L2-4
The supine patient
attempts to extend
the leg at the knee
against resistance;
contraction of the
quadriceps femoris
can be seen and
palpated.

66. The quadriceps is very powerful.
It is capable of generating as much as
1,000 pounds of force—three times
more than the hamstrings
The quadriceps is so powerful it is
nearly impossible to overcome in the
normal adolescent or adult except by
taking extreme mechanical advantage.
A sometimes useful technique for
testing knee extension is the
“BARKEEPER’S HOLD,” a hold usually
applied to the elbow to control

67. THE ANKLE JOINT
▪ Plantarflexion- gastrocnemius, soleus
▪ Dorsiflexion/extension- tibialis anterior
EDL, EHL
▪ Inversion- tibialis posterior (platarflexed),
tibialis anterior (dorsiflexed)
▪ Eversion- peronei longus, brevis, tertius,
EDL

68. PLANTARFLEXION
OF THE FOOT
Tibial nerve S1-S2
The patient attempts to plantarflex
the foot at the ankle joint against
resistance;
contraction of the gastrocnemius
and associated muscles can be
seen and palpated.
Patient stand on tiptoe

69. DERSIFLEXION/ EXTENSION
OF THE FOOT
Deep peroneal nerve L4-L5
The patient attempts to dorsiflex
the foot against resistance;
contraction of the tibialis anterior
can be seen and palpated.
Patient standing on heels raising
toe
STEPPAGE GAIT exaggerated
flexion at hip & knee to clear
ground
Audible double slap
Also in sensory ataxia

70. INVERSION OF THE
FOOT
Tibialis posterior.
Tibial nerve L5-S1
The patient attempts to raise
the inner border of the foot
against resistance;
the tendon of the tibialis
posterior can be seen and
palpated just behind the
medial malleolus.

71. EVERSION OF THE
FOOT
P longus, brevis- superficial
peroneal
nerve L5L5S1
P tertius- deep peroneal nerve
The patient attempts to raise the
outer border of the foot against
resistance;
the tendons of the peronei longus
and brevis can be seen and
palpated just above and
behind the lateral malleolus

72. MUSCLES OF FOOT & TOES
▪ The function of individual foot and toe
muscles is not as clearly defined as in the
hand
▪ Extension (dorsiflexion)- EDL, EDB, EHL,
EHB
▪ Flexion (plantarflexion)

73. DORSIFLEXION OF
TOES
Deep peroneal nerve L5-S1
On attempts to dorsiflex the
toes against resistance,
the tendons of the extensors
digitorum and hallucis
longus and the belly of the
extensor digitorum brevis
can be seen and palpated.

74. PRONATOR DRIFT (BARRE’S SIGN)
▪ Upper extremity outstretched to front, palms up,
eyes closed, hold for 20-30 seconds
▪ Normally palm flat,elbow straight, if any
deviation its similar bilaterally
▪ Slight pronation, without downward drift, of the
dominant arm (pseudodrift) is not abnormal
▪ In mild CST lesion- pronation of hand, flexion of
the elbow (due to weakness of CST innervated
muscles i.e extensors,supinators abductors)
▪ Similarly leg drift

75. With mild drift, there is slight pronation of the hand and slight
flexion of the elbow on the abnormal side.
With more severe drift, there is more prominent pronation and
obvious flexion of the elbow, and there may be downward drift of the
entire arm

76. Cerebellar disease may cause drift to some
degree, but the movement is outward and
usually slightly upward.
▪ In parietal lobe lesions, there may be “updrift,”
with the involved arm rising overhead without
the patient’s awareness
▪ Other useful maneuvers include examination of
forearm roll, finger roll, and rapid alternating
movements
▪ Thumb rolling was more sensitive (88%) than
pronator drift (47%), forearm rolling (65%), or
index finger rolling (65%)

77. UPDRIFT due to a parietal lobe
lesion with loss of position sense ARM ROLL TEST

78. REFLEX
Stretch reflex
• This is a basic reflex present in the
spinal cord
• Stimulus: muscle stretch
• Response: contraction of the muscle
• Receptors: stretch receptors located
in the muscle spindle

80. • REFLEX LEVEL
• Biceps jerk C56
• Supinator jerk C56
• Triceps jerk C78
• Knee jerk L34
• Ankle jerk S12

81. SUPERFICIAL REFLEXES
•CORNEAL
• Superficial abdominal reflex
• Flexor plantar reflex

83. GRADING
0 absent;
1 present but diminished;
2 normal;
3 increased(brisk)
4 markedly hyperactive, pathologic, often with
extra beats or accompanying sustained clonus.
5 for the patient with extreme spasticity and clonus.

84. •A technique involving
isometric contraction of
other muscles for up to
10 seconds that may
increase reflex activity.
•Tell the patient to pull just
before you strike the tendon
REINFORCEMENT

85. THE UPPER LIMBS
1. The Biceps Jerk (C5 6):-
• Relax the forearm on examiner’s hand.
• Place the forefinger gently on the biceps tendon and then strikes the
finger with the hammer.
• Normal response -flexion of elbow and visible contraction of biceps
seen.

86. 2. THE SUPINATOR JERK(C5, C6):-
• Relax the forearm on patient’s body at pronation state. Strike the
lower end of radious about 5 cm above the wrist.
• Watch the movement of forearm and finger.
• Contraction of brachioradialis and flexion of elbow results.
• Also slight flexion of finger may occur

87. 3. THE TRICEPS JERK(C7, C8):-
• By holding the patients hand, draw the arm across the trunk
and allow it to lie loosely in the new position.
• Then strike the triceps tendon 5 cm above elbow.
• Extension of elbow and visible contraction of triceps seen.

88. WATERNBERG SIGN-
• The patient supinate his hand slightly flexing the fingers.
• The examiner pronate his hand and links his similarly flexed finger
with patient’s.
• Both then flex their finger further against each others resistance.
• Normally the thumb extends, though the terminal phalanx may flex
slightly.
• In pyramidal tract lesion, the thumb adduct and flexed strongly.

89. THE LOWER LIMBS
1. The Knee Jerk(L3-L4):-
• Patient supine, flex the knee 60ᵒ by placing the forearm under the
knee to be tested.
• Strike the patellar tendon midway between its origin and insertion.
• Extension of knee and visible contraction of quadriceps seen.
• It can also be done with patient in high sitting on bed and leg
hanging at edge

90. WESTPHAL SIGN - Absence of patellar
reflex
INVERTED PATELLAR REFLEX
•Tapping causes contraction of hamstrings
and flexion of knee
•Lesion in efferent limb

91. 2. THE ANKLE JERK(S1):-
• Patient in supine position, hip externally rotated, slightly flex the
knee (medial malleolus facing upward), dorsiflex the ankle by examiner
as to stretch the achillis tendon.
• Strike the tendon on posterior surface.
• The calf contracts and moves ankle.
• The plantarflexion of foot can be felt by the hand of examiner.
• Alternative method:- ask the patient to kneel on the chair so that the
ankle are hanging loose over the edge. Then strikes the achillis tendon.

92. SUPERFICIAL REFLEXES
The Abdominal Reflexes

93. THE CREMASTERIC REFLEX-
• The patient lies supine, with the lower limbs in a
slightly abducted and externally rotated position.
• With the handle of the knee hammer, lightly stroke
the upper and inner aspects of thigh from below
upwards.
• The normal response is an immediate contraction of
cremaster muscle that pulls the ipsilateral testis.
THE ANAL REFLEX:-
• Lightly scratch the perianal skin which contract the
external sphincter muscle

94. THE PLANTAR REFLEX
• Position the patient so that knee is slightly
flexed, and thigh externally rotated.
• The foot is rest on the couch. Ask the patient to
let the foot remain closed.
• The outer aspect of sole is then firmly stroked
with the blunt point end of knee hammer.
• Then curve the stimulus towards the middle
MTP
• Do the stimulation slowly and allow yourself
time to see what is happening.
• Normally great toe flex at the MTP
• At the same time other toe will flex and close
together.

96. Voluntary withdrawal rarely causes
dorsiflexion of the ankle, and there is
usually plantar flexion of the toes (reflex
v/s voluntary withdrawal)
▪ Occasionally, withdrawal makes it
impossible to be certain whether the toe
was truly extensor or not (equivocal
plantar responses)
▪ Some patients have no elicitable plantar
response, in which case the plantars are
said to be mute or silent

97. FRONTAL RELEASE SIGNS
▪ GRASP/FORCED GRASPING REFLEX- stimulation of skin
of palmar surface between thumb & forefinger
▪ PALMOMENTAL REFLEX- contraction of the mentalis and
orbicularis oris muscles causing wrinkling of the skin of
the chin with slight retraction in response to scratching or
stroking the palm of the ipsilateral hand (thenar
eminence)
▪ SNOUT- is puckering and protrusion of the lips in
response to pressing firmly backward on the philtrum of
the upper lip
▪ SUCK- stimulation of the perioral region is followed by
sucking movements of the lips, tongue, and jaw
▪ ROOTING- when the lips, mouth, and even head deviate
toward a tactile stimulus delivered beside the
mouth/cheek

101. COORDINATION
To assess coordination, observe the
patient's performance in:
•Rapid alternating movements
•Point-to-point movements
•Gait and other related body
movements
•Standing in specified ways

102. NONORGANIC WEAKNESS
▪ HOOVER (AUTOMATIC WALKING)
SIGN absence of the expected
associated movement
- flexion/extension counter movement
(hip)
- adduction/adduction (hip)
- abduction/abduction (hip)
▪ Muscle tone is normal/ decreased &
usually vary from time to time

103. GAIT
•Walk across the room or down the hall, then turn,
and come back. Observe posture, balance, swinging
of the arms, and movements of the legs.
•Walk heel-to-toe in a straight line (tandem
walking).
•Walk on the toes, then on the heels
•Hop in place on each foot in turn
•Do a shallow knee bend, first on one leg, then on
the other.
•Rising from a sitting position without arm support
and stepping up on a sturdy stool.

104. GAIT CYCLE
Stance Phase
(60%)
Heel strike
Foot flat
Midstance
Push-of
Swing Phase
(40%)
Acceleration
Midswing
Deceleration

106. EXAMINATION OF STATION
Patient asked to stand with feet closely
together.
Stand with eyes open and eyes closed.
One foot at a time
On toes and heels
Tandem with one heel in front of other.
Light push.

107. Cerebellar disease there is broad base and
swaying.
Lesion in the vermis – swaying on backward,
forward and either side.
Hemispheric lesion / unilateral vestibular
disease patient
sways or falls towards affected side OR
There may be tilting of the head towards the
involved side with chin rotated towards sound
side.
Patient will lose balance more easily when
pushed towards involved side.

108. EXAMINATION OF GAIT
Width of the base- normally medial malleoli
should pass within about 2 inches of each other
during stride phase.
Asymmetry of toe lift- foot drop.
Stride length- shortened stride length may be
early evidence of bifrontal or extra pyramidal
disease.
Decreased arm swing on one side may be
early indicator of Hemiparesis or hemi
parkinsonism.
Tandem walking

109. ANATOMICAL ASPECTS OF GAIT
• Neuroanatomical structures responsible
for equilibrium and locomotion -
1. Brainstem (subthalamic, midbrain)
2. Cerebellar locomotor regions project
through descending reticulospinal
pathways from the pontomedullary
reticular formation into ventromedial
spinal cord.

110. • Prefrontal cortex - modulates
midbrain and cerebellar locomotor
regions
• Parietal cortex - integrates sensory
inputs indicating position
and orientation in space, the
relationship to gravitational forces, the
speed and direction of movement.
• Cerebellum - modulates the rate,
rhythm, amplitude, and force of
stepping.

116. FREEZING OF GAIT is even more common in
some of the
Parkinson's-related neurodegenerative disorders.
Progressive supra nuclear palsy
multiple-system atrophy
cortico basal degeneration.
These patients frequently present with axial
stiffness, postural instability, and a shuffling gait
while lacking the characteristic pill-rolling tremor of
Parkinson's disease.

117. CAUTIOUS GAIT (SENILE GAIT)
Older patients
Abbreviated stride, lowered centre of mass,
slow velocity, short steps, wide base.
No difficulty in foot-floor clearance, no
shuffle, no difficulty with initiation of gait, no
freezing.
“walking on icy/ slippery surface”
An adaptation to perceived postural threat
Age related degeneration of sensory apparatus
Physical therapy

118. SPASTIC GAIT (STIFF LEGGED GAIT)
A hemiparetic posture with arms flexed,
adducted and internally rotated.
Plantar flexion of the foot on the affected side
(equinus deformity).
Holds arm tightly by side, rigid and flexed
while walking. No arm swing.
circumduction and hip hike, dragging and
shuffling of the feet
Upper motor neuron signs in physical
examination.

119. compromise of corticospinal
command and over activity of spinal
reflexes.
SPINAL CORD CAUSES
Myelopathy from cervical spondylosis
Demyelinating disease and trauma
hereditary spastic paraplegia
structural lesion -tumor or spinal
vascular malformation.

120. MYOPATHIC (WADDLING) GAIT
Weakness of hip girdle muscle.
Myopathy and muscular dystrophy.
Pronounced lordosis in case of weak hip flexors.
Trendelenberg’s sign - an abnormal drop of pelvis
on the side of swing leg due to hip abductor
weakness.
Bilateral weakness cause an exaggerated pelvic
swing resulting inn waddling gait.

121. PSYCHOGENIC GAIT DISORDER
Some patients with extreme anxiety or phobia walk
with exaggerated caution with abduction of the
arms, as if walking on ice.
Odd gyrations of posture
wastage of muscular energy (astasia-abasia),
extreme slow motion,
dramatic fluctuations over time may be observed
in patients with somatoform disorders and
conversion reaction.

122. APRAXIC GAIT
• Impaired ability to plan and execute sequential
movements due bilateral frontal lobe disease
• Normal pressure hydrocephalus
• Alzheimer’s disease
• Binswanger’s disease
Seen in:
• Difficulty in initiating gait- ‘feet glued to the
ground’
• Short and shuffling steps but is not
maintained-walking stops after one or several
steps are taken, repeats itself
• Upright posture with normal swing

123. DYSTONIC GAIT
• Childhood-onset primary torsion dystonia -
sustained abnormal posturing of the foot
(typically plantar flexion and inversion) on
attempting to run.
• Walking forward or backward or even running
backward may be normal at an early stage.
• Early stages - tonic extension of the great toe
(striatal toe) when walking.
• Birdlike (peacock) gait - excessive flexion of
the hip and knee and plantar flexion of the foot
in a during the swing phase.

124.  DEJONGS NEUROLOGICAL EXAMINATION
 HARRISONS TEXTBOOK OF MEDICINE

125. THANK YOU