Gait, coordination and abnormal movements

Published on 09/04/2015 by admin

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Last modified 22/04/2025

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Gait, coordination and abnormal movements

When examining gait and coordination, the results must be interpreted in the light of any motor or sensory findings in the rest of the examination. Patients with significant weakness or posterior column sensory loss will have some loss of coordination. There may be additional incoordination, and assessment of this is difficult and is based on a judgement as to whether the incoordination is disproportionate to the weakness or sensory loss.

Gait

Ask the patient to walk and observe whether the gait is broadly symmetrical. If it is symmetrical, look at the posture – stooped or erect; the step size – normal or shortened; the distance between the feet – normal, wide-based or scissoring; how high the knees are lifted – normal or high-stepping gait; the arm swing – normal or reduced; and if there are any abnormal movements. If the gait is asymmetrical, look at whether this is due to pain (antalgic gait), an orthopaedic problem, such as a shortened limb, or weakness (a hemiplegic gait or unilateral foot drop).

Heel–toe walking

Ask the patient to walk placing their heel directly in front of their toe. This is normally done relatively easily. This is a sensitive test for ataxia.

Romberg test

This is a test primarily of posterior column sensation. Ask the patient to stand with the feet close together. Once balanced, tell the patient to close the eyes. If the patient is steady with eyes open but falls with eyes closed, the Romberg test is positive. If the patient is unable to stay still with the eyes open then the test cannot be completed.

Coordination

In testing coordination, look for smoothness and accuracy of movement. The standard manoeuvres used for bed-side testing are finger–nose coordination (Fig. 1), fast repeated movements and heel–shin testing (Fig. 2). Other parts of the examination afford an opportunity to observe coordination, for example the way the patient gets dressed and undressed and does up buttons.

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Fig. 1 The finger–nose test.

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Fig. 2 The heel–shin test.

Finger–nose coordination

Hold out your finger about 50 cm in front of the patient’s face. Ask the patient to touch your finger with his or her finger and then touch the nose. Ask the patient to repeat this (Fig. 1).

Repeated movements

Ask the patient to tap one hand on the back of the other. Then ask the patient to tap the same spot first with the palm of the hand and then quickly turning the hand over to touch with the dorsum of the hand. When this is done slowly and clumsily, it is referred to as dysdiadokokinesia. Listen out for the ‘slappy’ sound it produces.

Heel–shin testing

Ask the patient to lift the heel up and put it on the opposite knee and then run it accurately down the front of the shin (Fig. 2).

Other repeated movements

There are several other movements used, though not primarily as a test of coordination. Fast movements, particularly relatively simple ones, may be slowed in extrapyramidal and upper motor neurone lesions. Movements that are often tested are: rapidly bringing the index finger and thumb together; pronation and supination of the wrist; tapping a finger on a table; and foot tapping, as if listening to fast music. In upper motor neurone lesions, these movements are slow and deliberate, and in extrapyramidal disease, the movements start slowly, becoming slower and smaller in amplitude.

Abnormal movements and posture

The diagnosis of patients with movement disorders is primarily syndromic and depends on the clinical classification of their movement disorder. There is considerable overlap between the movements and classification of some movements can be difficult, and in some patients this is a subject of dispute between experts (Fig. 3). However, the most common types of abnormal posture and movement are relatively easily identified.

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Fig. 3 Types of abnormal movement.

Abnormal posture

The patient can have an abnormal posture as part of a generalized movement disorder, for example the stooped posture of a patient with Parkinson’s disease, with arms flexed and an immobile face. The abnormal posture may be the only abnormality, such as in focal dystonia where agonist and antagonist muscles co-contract and maintain an abnormal position. The most common focal dystonia is torticollis or cervical dystonia (p. 92).

Abnormal movements

Tremor

Tremor is a rhythmical movement that can be described in terms of:

image amplitude – fine, moderate and coarse
image frequency – measured in Hertz
image the situations in which it occurs – rest, position, action or on intention.

Some tremors have a particular character, such as the ‘pill-rolling’ tremor of Parkinson’s disease. Examination of tremor aims to distinguish these features. Observe patients at rest; they may need to be distracted to bring out the rest tremor – ask them to say the months of the year backwards or count down from 100. Ask the patient to hold the hands out in the positions (Fig. 4). Observe to see if the tremor develops (postural tremor). Test finger–nose coordination – the tremor can appear as the finger moves (action tremor) or increase as it gets closer to the target (intention tremor). Asking the patient to draw an Archimedes spiral (Fig. 5) is a useful way to document a tremor.

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Fig. 4 Classification of tremor.

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Fig. 5 Archimedes spiral.

Rest tremor is commonly seen in extrapyramidal disease, and intention tremor as part of cerebellar syndromes (p. 63).

Dystonia, chorea, athetosis and ballismus

These abnormal movements have considerable overlap and can be usefully thought of as a spectrum rather than distinct entities (see Fig. 3).

Dystonia, described above, is associated with abnormal posture but may also be associated with slow movement or may occur during a particular movement. It is described by its distribution (focal or generalized) and whether it is related to one action (e.g. writing, as in writer’s cramp) when it is a task-specific dystonia.

Chorea is a fidgety, semi-purposeful movement that can vary in amplitude of movement and frequency of occurrence. Patients are often adept at hiding it by converting some of the abnormal movements into apparently intentional movements. Its causes are discussed on page 93.

Athetosis refers to a more distal writhing movement. It is almost always seen in association with chorea, which is used instead so the term has gone out of fashion.

Ballismus is a much more dramatic movement (it means throwing) where the limbs are thrown about violently. They are usually unilateral – hemiballismus.

Tics

These are relatively stereotyped movements, often affecting the face (blink or grimace) or hands.

Gait, coordination and abnormal movements

image Abnormalities in coordination need to be interpreted in the light of any motor or sensory deficits.
image Classification of abnormal movements depends on description using specialized terms. Even experts disagree…

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