LOWER LIMB EXAMINATION.pptx

NEUROLOGICAL EXAMINATION
OF LOWER LIMB
Speaker
Dr.Awdhesh Chaudhary
Moderator
Dr. Pankaj Kannauje
Dr. Ravindu

LUMBAR PLEXUS
T12,L1
L1
L2,L3
L2,L3,L4
L1,L2
L2,L3.L4

ANATOMY OF LOWER LIMB
• Lumbar Plexus: formed by the anterior rami (divisions) of
L1, L2, L3 and L4. It also receives contributions from
thoracic spinal nerve 12.
• Cords then combine together to form the six major
peripheral nerves:
1. Iliohypogastric Nerve (L1, T12)
• Motor: Internal oblique and transversus abdominis.
• Sensory: Posterolateral gluteal skin in the pubic region.
-Moore’s Clinically Oriented Anatomy

2. Ilioinguinal Nerve [L1]
• Motor: Internal oblique and transversus abdominis.
• Sensory: Skin on the upper middle thigh, over the root of
the penis and anterior scrotum, the skin over mons pubis
and labia majora.
3. Genitofemoral Nerve [L1, L2]
• Motor: Cremasteric muscle.
• Sensory:
– The genital branch innervates the skin of the anterior
scrotum or the skin over mons pubis and labia majora.
– The femoral branch innervates the skin on the upper
anterior thigh.

4. Lateral Cutaneous Nerve of the Thigh[L2,L3]:
• Sensory: Anterior and lateral thigh down to the level of
the knee.(no motor supply).
5. Obturator Nerve [L2, L3,L4]:
• Motor: obturator externus, pectineus, adductor longus,
adductor brevis, adductor magnus, gracilis.
• Sensory: Skin over the medial thigh.
6. Femoral Nerve [L2,L3,L4]
• Motor: Illiacus, pectineus, sartorius, all the muscles of
quadriceps femoris.
• Sensory: skin on the anterior thigh and the medial leg as
a saphenous nerve.

Sacral plexus
L4,L5,S1
L5,S1,S2
L4,L5,S1,S2,S3
S1,S2,S3
S2,S3,S4

Sacral plexus:
– formed by the anterior rami (divisions) of the S1, S2,
S3 and S4.
– Also receives contributions from L4 and L5.
• Spinal roots and trunk divide into several cords.
• Cords then combine together to form the five major
peripheral nerves:
1. Superior gluteal nerve [L4, L5, S1]
• Motor: gluteus minimus, gluteus medius and tensor
fascia lata
• Sensory: None

2. Inferior gluteal nerve[ L5, S1, S2]
• Motor: Innervates gluteus maximus.
• Sensory: None.
3. Sciatic Nerve [L4, L5, S1, S2, S3]
• When the sciatic nerve reaches the apex
of the popliteal fossa, it terminates
bifurcating into
– Tibial
– Common fibular nerves.

• Motor:
Tibial Portion – Innervates:
– all of the muscles in the posterior compartment of
the thigh, including the hamstring portion of
adductor magnus, except the short head of the
biceps femoris.
• When it becomes the tibial nerve, it
innervates:
– All the muscles in the posterior compartment of
the leg (superficial and deep)
– all muscles in the sole of the foot as medial plantar
nerve and lateral plantar nerve.

• Motor:
• Common Fibular Portion
– Innervates the short head of the biceps femoris.
– Then via its terminal branches, provide innervation
to:
Superficial fibular nerve: Innervates the muscles of
the lateral compartment of the leg.
Deep fibular nerve: Innervates the muscles of the
anterior compartment of the leg and extensor
digitorum brevis.

Sensory Functions of Sciatic nerve:
• Tibial Portion:
– Innervates the skin of the postero-lateral and
medial surfaces of the foot as well as the sole of
the foot.
• Common Fibular Portion:
– Innervates the skin on the antero-lateral surface
of the leg and the dorsal aspect of the foot.

4. Posterior Femoral Cutaneous Nerve: [S1, S2, S3}
• Motor: None
• Sensory: Skin on the posterior surface of the thigh and
leg and skin of the perineum.
5. Pudendal Nerve: [S2, S3, S4]
• Motor:
– Skeletal muscles in the perineum, the external
urethral sphincter, the external anal sphincter, levator
ani.
• Sensory: Penis and clitoris and most of the skin of the
perineum.

Action Muscle Nerve ,nerve root
FLEXION Iliopsoas Lumbar plexus, femoral,
L1,L2,L3
ADDUCTION Adductor longus /magnus/brevis Obturator , L2,L3,L4
ABDUCTION Gluteus medius & minimus Superior gluteal , L4,L5,S1
EXTENSION Guteus maximus Inferior gluteal, L5,S1,S2
EXTENSION Quadriceps femoris Femoral L2,L3,L4
FLEXION Hamstrings Sciatic L4,5,S1,S2
DORSIFLEXION Tibialis anterior Deep peroneal ,L4,L5.
PLANTARFLEXION Gastrocnemius &soleus Tibial, L5,S1,S2
EVERSION Peroneus longus and brevis Superficial peroneal, L5,S1
INVERSION Tibialis posterior Tibial , L5,S1
EXTENSION OF BIG TOE Extensor hallucis longus Deep peroneal, L5,S1
EXTENSION OF OTHERS Extensor digitorum longus and brevis Deep peroneal,L5,S1
FLEXION Flexor digitorum longus & flexor
hallucis longus
Tibial L5,S1

MUSCLES OF LOWER LIMB(anterior &posterior)

INTRODUCTION TO THE PATIENT
• Wash hands
• Introduce yourself
• Confirm patient details – Name/Age(DOB)/Sex
• Explain the examination
• Gain consent
• Expose patient appropriately
• Ask if the patient currently has any pain/discomfort

EXAMINATION OF MOTOR SYSTEM
• BULK
• TONE
• POWER
• LOOK FOR ANY ABNORMAL MOVEMENTS
• EXAMINATION OF COORDINATION AND GAIT ARE
CLOSELY RELATED TO MOTOR SYSTEM
• Before doing neurological examination, it is essential to
differentiate between neurological and non-neurological
disease.
DeJong’s Neurological Examination 7e

Motor Unit: Lowest echelon of motor activity.
Alpha motor neuron in spinal cord or brainstem ,its
axon, and all muscle fibres it innervates.

BULK
• INSPECTION
• PALPATION
• MEASUREMENTS
INSPECTION : Look down along axis symmetrically
• General appearance – any limb deformity or posturing?
• Scars
• Wasting of muscles
• Involuntary movements – dystonia/chorea/myoclonus
• Fasciculation – lower motor neuron lesions
• Tremor – Parkinson’s

PALPATION: Assess muscle bulk , contour and
consistency.
• Normal muscle: Semi-elastic and regains its shape at
once when compressed.
• Hypertrophy: Muscles are firm
• Pseudohypertropy: Hard muscle, may feel doughy or
rubbery.
• Atrophy: Soft and pulpy in consistency .

MEASUREMENTS OF BULK :
• Upper Limb: At 10 cm above and below olecranon
process.
• Lower Limb: At 18 cm above patella and 10 cm
below tibial tuberosity.
• Difference of 1 cm between limbs is normal.
• Muscle atrophy (amyotrophy) causes decrease in
muscle volume, usually accompanied by change in
shape or contour.

• Disease affecting, anterior horn cell, nerve roots,
peripheral nerve, muscle cause ATROPHY.
• Neuromuscular junction disorders do not cause
muscle atrophy.
• Atrophy may be due to:
– DISUSE OR INACTIVITY
– IMMOBILISATION
– TENDENOTOMY
– MUSCLE ISCHEMIA
– MALNUTRITION
– ENDOCRINE DISORDER: Hyperthyroidism , steroid
– NORMAL AGING

• NEUROGENIC ATROPHY:
– Diseases affecting any part of LMN.
– Weakness and wasting are comparable.
• MYOGENIC ATROPHY :
– Due to muscle disease.
– Weakness is disproportionally greater than wasting
.
• When a muscle appear wasted but not weak the cause
is likely to be non-neurogenic e.g. disuse or atrophy
related to arthritis.

• HYPERTROPHY:
– excessive use of muscles, or pathological.
– Not necessarily stronger than normal muscle
• PSEUDOHYPERTROPHY:
– enlargement is due to infiltration of muscle with fat and
connective tissue
– no increase in muscle fiber or number
– e.g. DMD.

GENERALISED
• Malignancy
• TB
• Thyrotoxicosis
• Advanced
myopathy/MND
PROXIMAL
• Muscular
dystrophy,
Inflammatory
Myopathy
• Myasthenia gravis
• MND, neuralgic
amyotrophy
• Neuronopathy/
plexopathy,
radiculopathy
DISTAL
• AHC: polio, MND,
syringomyelia, cord
tumors
• Anterior root:
cervical
spondylosis/
tumors
• Plexus lesions/
individual nerve
lesions
Wasting
Bickerstaff’s Neurological Examination, 6e

TONE
• Tone: Tension in relaxed muscle or resistance to passive
movement.
• Ask the patient to keep their legs fully relaxed and “floppy”
throughout your assessment.
 METHODS
1. Leg roll –
• Roll the patient’s shin and watch the foot – it should
flop independently of the leg- Normal or reduced tone.
• In hypertonic state –ankle and foot move all `all one piece’

2. Leg lift –
• Place both hands under knee , briskly flex joint with an
upward movement of hand– the heel should remain in
contact with the couch.
• When spastic, the leg raises all in one.
3.Passsive flexion and extension of Hip, knee, ankle.
4.Flex the hip and raise the lower limb until it forms more
than right angle at knee and allow it to fall.
5.With the flat of finger, flap calf muscle on each side

HYPOTONIA:
• muscles are lax, is found in LMN lesions, cerebellar disorders
and spinal shock.
• Common causes of hypotonia :
1.Lesion of motor side of reflex arc: anterior horn cell disease,
neuropathies, peripheral nerve injury.
2.Lesion of sensory side of reflex arc: neuropathies, tabes dorsalis,
herpes zoster
3.Combined motor and sensory lesion:
syringomyelia, cord or root compression, gross destruction of cord.
4.Lesions of muscle: myopathies, SMA, myasthenia gravis, periodic
paralysis.
5.Cerebellar lesions: ipsilateral hypotonia with prolong and
pendular reflex rather than loss.

TONE
CORD
Syringomyelia, cord/ root
compression, neurologic ‘shock’
SENSORY
Neuropathy, tabes dorsalis, herpes
zoster
CEREBELLAR
(ipsilateral hypotonia)
MOTOR
Myopathy, neuropathy, AHC disease
HYPOTONIA

HYPERTONIA
SPASTIC TYPE:
• Tone and resistance are greater in one group muscle than
antagonist, resistance is most at start of movement then it
suddenly overcome, producing clasp knife effect.
• Signs of pyramidal pathway lesion.
• It is velocity dependent(i.e. more noticeable with fast
movements).
• More evident in flexors and pronator of upper limb and
extensors and adductors in lower limb.

RIGIDITY:
• Seen in extrapyramidal lesions.
• It is not velocity dependent.
• Equal resistance in both agonist and antagonist at any point
i.e. plastic or lead pipe rigidity
• Antagonist and agonist contract alternately producing
cogwheel rigidity
• COGWHEEL RIGIDITY: Present only on first movement, feel
on wrist .
• PARATONIA(gegenhalten):
– seen in diffuse frontal lobe disease
– involuntary contraction of muscle when patient ask to relax and allow
movements
– Patient appear to actively opposing any movement at joint

SPASTIC
• One group of
muscles
• Clasp-knife/
supinator
catch
• UMN- flexors
UL, extensors
LL
• Velocity
dependent
PLASTIC/ RIGID
• Both groups
of muscles
• Lead pipe/
cog wheel
• Extra-
pyramidal
involvement
PARATONIA
• Resistance
increases in
proportion to
passive
movement
• Gegenhalten
• Diffuse
frontal lobe
disease
HYPERTONIA

CLONUS
• Sudden stretching of hypertonic muscle produces reflex
contraction.
• Sign of upper motor neuron lesions.
Ankle clonus:
• Position the patient’s leg so that the knee and ankle are slightly
flexed, supporting the leg with your hand under their knee, so
they can relax.
• Rapidly dorsiflex and partially evert the foot.
• Keep the foot in this position.
• Clonus is felt as rhythmical beats of dorsiflexion/plantarflexion.
(>5 is abnormal)
Patellar clonus:
• by sharply moving patella downward

POWER
• MRC scale for muscle power
• 0= No muscle contraction is visible
• 1= A Flicker or trace of contraction.
• 2= Active movement with gravity eliminated
• 3=Active movement against gravity
• 4-=Active movement against gravity and slight resistance(muscle can be broken by
using 1 finger)
• 4= Active movement against gravity and moderate resistance(muscle can be
broken by using 3 finger)
• 4+= Active movement against gravity and strong resistance(muscle can be broken
by whole hand firm push)
• 5 Full and normal power against resistance

• MRC scale is nonlinear.
• Patient who has 4/5 does not have mild or equivocal weakness but
has serious involvement.
• Examiner patient mismatch should be recognized
• By varying length of lever and the shortening of muscle permitted,
examiner may give or take mechanical advantage as necessary to
compensate for strength mismatch.
• Some clinician use grade 5-, 3-, 2-.
• 5- =borderline or equivocal weakness
• 3- =muscle can move against gravity but not through full range
• 2- = muscle can move with gravity eliminated but not through full
range
• Mayo clinic grades: more linear, five point scale, normal is zero, mild
weakness is -1, and total paralysis is -4.

HIP
• FLEXION :(L1-L3):
• Supine: patient is supine , attempt to
flex his thigh against resistance, knee is
flexed and and leg rest on examiner
arm.
• Sitting position: ask to flex hip, normal
hip flexor can not be overcome by
examiner`s arm and hand unless
examiner stand close and uses his body
weight to defeat hip flexors.

• TEST FOR MILD WEAKNESS
– Supine patient attempts to maintain both lower limb flexed at
hip and extended at knee, the leg is at about 45 degree angle
off the bed, feet apart.
– Drifting of leg rapidly towards bed compared to other leg
suggests corticospinal tract invovement (leg drift).

HIP EXTENSOR: L5-S2
• Patient lying prone:
– raise the flexed knee up from the
table against resistance (knee
flexion minimizes any contribution
from hamastring).
• Patient lying on side and extending
the hip
• Patient seated:
– trying to press raised knee as back
down as examiner holds it up.

•Marked weakness of hip extensors suggests muscular dystrophy.
•And Gower’s sign is positive.

HIP ADDUCTION :L5-S1
• Can be tested in
supine sitting or lying
down
• Attempt to adduct
leg in supine position
against resistance with
extended knee.

HIP ABDUCTION:L4-S1
• The supine patient attempts to move
the extended leg outward against
resistance, contraction of gluteus
medius and tensor faciae latae can be
patlpated.
• Ask patient to push your leg out .

INTERNAL/MEDIAL ROTATION AT HIP :
• Carried out by hip abductors(glutei medius
and minimus and tensor facie lata) with
some contribution from adductors.
• Patient is supine with knee extended and
patient is asked to rotate the foot medially
as if to touch big toe to the bed.
• Patient lying prone with leg flexed at knee,
attempt to carry foot laterally against
resistance.
• With unilateral cortico-spinal tract lesion
internal rotators are weak e.g. acute stroke.

EXTERNAL OR LATERAL ROTATOR OF
THIGH
• Muscles:
– gluteus maximus (primarly),
– obturator externous(Obturator nerve L3,L4)
– obturator internus (L5,S1,nerve to obturator
internus).
• Piriformis externally rotates extended thigh
but abduct the flexed thigh.
• It is tested by maneuvers similar to those for
testing internal rotation, but patient rotate
hip externally by attempting to carry the
foot medially against resistance with knee
flexed. DeJong’s Neurological Examination 7e

KNEE
Flexion (L4-S2) –hamstring (biceps femoris, semimembranosus,
semitendinosus), tested in prone, supine, sitting.
• Bend your knee and stop me from straightening it.
• Prone patient attempt to maintain flexion of leg while examiner
attempts to extend it.
• Weak knee flexor suggest pyramidal tract lesion.

Extension (L2-4):
Quadriceps femoris(powerful muscle).
• Sitting or supine position ,“kick out your leg”
• Quadriceps can be seen contacting or palpated
• Take mechanical advantage by holding leg near ankle.

Ankle
Dorsiflexion (L4,L5)
• “keep your legs flat on the bed, push your foot up towards
your face, don’t let me push it down “
• Powerful muscle, subtle weakness can some time be
detected by placing patient at maximum mechanical
disadvantage .
• Ask patient to “Walk on heel”
Plantarflexion (L5/S1/2) – “push down like on a pedal”
• Plantar flexor are among powerful muscle of body
• Ask patient “to stand on tip toes”.
Inversion (L5/S1) – “push your foot in against my hand”
Eversion (L5/S1) – “push your foot out against my hand”

Big toe
• Extension (L5) – “don’t let me push your big toe
down”
• Flexion: “don’t let me push your big toe up”

REFLEX AND REFLEX ARC
• DTR
• SUPERFICIAL REFLEX

REFLEXES
EXAGGERATED/
BRISK
• UMN
• Increase in
reflexogenic
zone
• Spread of
reflex to
nearby
muscles
• Crossed
extension
REDUCED
• LMN
• Initial Spinal ‘
shock’
• Extreme
rigidity/
spasticity/
contracture
CLONUS
• Ill
sustained
• Well
sustained
NORMAL

REFLEX
Deep tendon reflexes(DTR)
• Ensure the patient’s lower limb is completely relaxed.
• Hold at the end of the tendon hammer handle and allow
gravity to aid a good swing.
• If a reflex appears absent: Make sure the patient is fully
relaxed and then perform a reinforcement manoeuvre.
• Ask the patient to hook their hands together in a monkey
grip and try to pull them apart, while you hit the tendon.
-Bickerstaff’s Neurological Examination, 6e

GRADING OF REFLEX
• By convention the deep tendon reflexes are graded as
follows:
• 0 = no response; always abnormal
• 1+ = a slight but definitely present response; may or may
not be normal
• 2+ = a brisk response; normal
• 3+ = a very brisk response; may or may not be normal
• 4+ = a tap elicits a repeating reflex (clonus); always
abnormal.

KNEE JERK (L3,L4),FEMORAL NERVE
• Hold knee with one palm and then stuck tendon lightly ,watch the
movement of lower leg and quadriceps
• Absence of patellar reflex is known as Westphal’s sign.
• Inverted patellar reflex: Lesion of nerve supplying quadriceps, cord
lesion at L3, L4.

ANKLE JERK:(S1),MEDIAL POPLITEAL
• Patient’s leg should be externally rotated and slightly
flexed at knee, dorsiflex the foot with other hand.
• For left leg, move to other side of the bed.
• Observe for movement of foot and contraction of calf.
• Also called as Achilles or triceps surae reflex.

PLANTAR REFLEX(S1):
• Position the patient such that knee is slightly flexed and thigh is
externally rotated, outer aspect of foot resting on couch, explain
that sole will be scratched and ask him to try to let foot remain
loose.
• Outer aspect of foot is firmly stroked with blunt point such as key or
end of hammer.
• Stimulator should move forward and then curved inward toward
middle metatarso-phalangeal joint .
• Observe the great toe.
• Normal result = Flexion of the great toe and flexion of the other toes
• Abnormal (Babinski sign) = Extension of the great toe and spread of
the other toes – upper motor neuron lesion

• True- Extension of big toe (MTP and IP), fanning of other
toes
• Minimal- contraction of hamstrings and tensor faciae
latae
• Crossed extensor- bilateral response (bilateral cerebral/
cord disease)
BABINSKI REFLEX

BABINSKI REFLEX
Fallacies:
• Pes cavus/ deformity of great toe.
• Normal extensor response in children up to 12 months of age.
• Identify anxiety, painful stimulus causing a withdrawal.
• Callosities of sole/ S1 neuropathy
• Post ictal / deep anaesthesia/ deep sleep/ coma/ electroconvulsive
therapy
• Hypoglycemia/ alcohol intoxication/ narcosis

Superficial reflex of lower extremities
Cremastric reflex :(L1-L2):
• elicted by stroking or lightly scratching or pinching the skin of upper
inner aspect of thigh
• response: contraction of cremastric muscle with elevation
homolateral testicle
Anal reflex :(S2-S5):
• contraction of external anal sphincter in response to stroking or
piercing the skin or mucous membrane in perianal region
Bulbocavernous reflex:
• related to anal reflex both causes contraction of external anal
sphincter but in BCR ,stimulus is delivered to glans penis or clitoris
• Response is best palpated with gloved finger in the rectum
• Useful for assessing integrity of cauda equina , lower sacral root and
conus medullaris.

SENSORY SYSTEM
Modality of sensation to be tested :
• 1.pain, light touch, temperature: extoceptive
sensation
• 2. position sense, passive movement, vibration
and deep pain:proprioceptive
• 3.stereognosis, graphaesthesia and two point
discrimination.
• 4. Visceral or interoceptive.

Pin-prick sensation:
• Assesses spinothalamic tracts.
• Use sharp pin with rounded head, with the shaft of
pin long enough to allow the examiner`s index finger
and thumb to slide downward on impact.
• Always start from impaired sensation to normal
sensation.
• If sensation is reduced peripherally, assess from a
distal point and move proximally to identify
‘stocking’ sensory loss (peripheral neuropathy).
• If necessary, keep going all the way up the leg and
truck until normal sensation is felt. This may reveal a
“sensory level”, which is suggestive of a spinal lesion

Light touch sensation:
• Assesses dorsal/posterior columns and spinothalamic
tracts.
• The patient’s eyes should be closed for this assessment.
• Touch the patient’s sternum with the cotton wool wisp to
confirm they can feel it.
• Ask the patient to say “yes” when they are touched.
• Using a wisp of cotton wool, gently touch the skin (don’t
stroke)
• Assess each of the dermatomes.
• Compare left to right, by asking the patient if it feels the
same on both sides

Vibration sensation
• Assesses dorsal / posterior columns
1. Ask patient to close their eyes.
2. Tap a 128 Hz tuning fork.
3. Place onto patient’s sternum/clavicle and confirm
patient can feel it buzzing.
4. Ask patient to tell you when they can feel it on their
foot and to tell you when it stops buzzing.
5. Place onto the distal phalanx of the great toe.
6. If sensation is impaired, continue to assess more
proximally – e.g. proximal phalanx.

Proprioception :
• Dorsal / posterior columns
• Hold the distal phalanx of the great toe by its sides
• Demonstrate movement of the toe “upwards” and
“downwards” to the patient (while they watch)
• Then ask patient to close their eyes and tell you if you
are moving the toe up or down.
• If the patient is unable to correctly identify direction
of movement, move to a more proximal joint.
• (big toe > ankle > knee > hip)

Sterognosis
• Ability of recognizing object purely from feel of its
shape and size.
• Test object must be familiar and easily identifiable.
• It is defective if touch and position sense are defective.
Graphaesthesia
• Ability to recognize letter or number written on skin
with a blunt point.
• If peripheral sensation is lost it will also lost but if it is
absent in intact peripheral nerve it suggest parietal
cortical lesion .

Two point discrimination:
• Ability to detect that a stimulus consist of two blunt
point when they are simultaneously applied.
• Normal ability to distinguish the two points from one
varies in different body parts, on finger it should be
possible to differentiate less than 5 mm ,but on dorsum
of foot separation of 5 cm may be required.
• Depends on integrity of light touch: When light touch is
normal, impaired two point discrimination suggests
parietal lesion.

• Co-ordination:
requires both motor and sensory intact
• Purpose of test :
1. cerebellar dysfunction,
2. proprioceptive defeciency
• Heel to shin test –“put your heel on your knee, run it
down your shin, lift it up and repeat”
• An inability to perform this test may suggest loss
of motor strength, proprioception or a cerebellar
disorder.

• Gait
• • Abnormal gaits:
• · Hemiplegia: the foot is plantar flexed and the leg is swung in a lateral arc
• · Spastic paraparesis: scissors gait
• · Parkinson's: starting hesitation, shuffling, freezing, festination
• pro/retropulsion
• · Cerebellar: drunken wide-based or reeling on a narrow base gait; staggers
• towards side of cerebellar lesion
• · Posterior column lesion: clumsy slapping down of the feet on a broad base
• · Footdrop: high stepping gait
• · Proximal myopathy: waddling gait
• · Prefrontal lobe (apraxic): feet appear glued to floor when erect, but move
• more easily when the patient is supine
• · Hysterical: characterised by a bizarre, inconsistent gait

MUSCLE OF ANTERIOR AND POSTERIOR COMPARTEMENT OF LEG

• Romberg’s test
• Ask the patient to stand with their feet
together and eyes closed
• Observe the patient (ideally for 1 minute)
• Positive test – loss of balance (swaying
without correction/falling over) – this suggests
a sensory ataxia (proprioceptive deficit)
• It’s important to stand close by the patient
during this test to stop them falling over!

• Gait
• 1. Ask patient to walk to the end of the
• room & back – assess speed, symmetry
• ,balance and arm swing
• 2. Tandem (heel-to-toe) gait – ask to walk
• in a straight line heel-to-toe – an
• abnormal heel-to-toe test may suggest
• weakness, impaired proprioception or a
• cerebellar disorder
• 3. stand on heel then on toes walking:
• testing distal power. toes (L4/5) & heels
• (S1)

Question :right side body movement is
controlled by ?
• 1.left cerebral hemisphere only
• 2.left cerebral hemisphere and left cerebellar
hemisphere
• 3.right cerebral and left cerebellar hemisphere
• 4.left cerebral and right cerebellar hemisphere

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