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PHYSIOTHERAPY

ASSESSMENT IN
NEUROLOGY
Mohd Haidzir b Abd Manaf
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Introduction
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 The effectiveness of physiotherapy


treatment depends on our ability to
assess and analyze the main reasons
behind patient’s problems (Lennon &
Hastings, 1996)
 Principles of physiotherapy assessment
 Outcome measures in relation to the
physiotherapy assessment

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Principles of Physiotherapy
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Assessment
History Taking
 Details about the nature, severity,

frequency and pattern of the problem, as


well as past medical history
 Relieves symptoms, what previous

treatment or examinations has been


conducted and what other neurological
symptoms are experienced needs to be
collected.

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Principles of Physiotherapy
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Assessment
History Taking
 Difficulties patients may experience in

daily life as a consequences of their


movement problem.
 For example the impact upon social,

school, work life and impact upon social


relationship.
 There is a need to enquire about what

patients expect or hope the


physiotherapy can help with and what
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outcomes they anticipate.
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NEUROLOGICAL
INVESTIGATIONS
Skull and spinal X-rays
Imaging of the brain and spinal cord
Computed tomography: CT
Magnetic resonance imaging: MRI
Electroencephalography (EEG)
Electromyography and conduction studies
Peripheral nerve conduction

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Skull and spinal X-rays
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These show:
 fractures of the skull vault or base

 skull lesions (e.g. metastases, osteomyelitis,

Paget's disease, abnormal skull foramina, fibrous


dysplasia)
 enlargement or destruction of the pituitary fossa

- intrasellar tumour, raised intracranial pressure


 intracranial calcification - tuberculoma,

oligodendroglioma, wall of an aneurysm,


cysticercosis.
 Spinal X-rays show fractures, congenital bone

lesions (e.g. cysts), destructive


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metastasis) or spondylosis (degenerative
Imaging of the brain and
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spinal cord

 Brain CT is now widely available world-


wide and MRI is rapidly becoming a
standard test.

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Computed tomography: CT
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CT scanning demonstrates:
 cerebral tumours
 intracerebral haemorrhage and infarction
 subdural and extradural haematoma
 free blood in the subarachnoid space
(subarachnoid haemorrhage, see )
 lateral shift of midline structures and
displacement/enlargement of the ventricular
system
 cerebral atrophy
 spinal trauma (with CT myelography) PHT266
Magnetic resonance
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imaging: MRI
 The hydrogen nucleus is a proton whose
electrical charge creates a local electrical field.
 These protons are aligned by sudden strong
magnetic impulses.
 Protons are then imaged with radiofrequency
waves at right angles to their alignment.
 The protons resonate and spin, then revert to
their normal alignment. As they do so, images
are made at different phases of relaxation,
known as T1, T2, T2 'STIR', diffusion-weighted
imaging (DWI) and other sequences.
 From these sequences, referred to as different
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weightings, recorded images are compared.
Magnetic resonance
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imaging: MRI
Advantages of MRI
 distinguishes between brain white and

grey matter.
 Spinal cord and nerve roots are imaged

directly.
 Pituitary imaging.

 MRI has greater resolution than CT

(around 0.5 cm).


 No radiation is involved.

 Magnetic resonance angiography


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Magnetic resonance
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imaging: MRI
 Tumours, infarction, haemorrhage, clot, MS plaques,
posterior fossa, foramen magnum and spinal cord
are demonstrated well on MRI.
 Limitations of MRI are principally time and cost.
 Imaging one region takes about 20 minutes.
 Patients do need to cooperate.
 Claustrophobia is an issue but 'open' machines are
available.
 A general anaesthetic may be necessary.
 Patients with pacemakers or with metallic bodies in
the brain cannot be imaged. MR imaging for some
days after lumbar puncture frequently
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Electroencephalography
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(EEG)
 The EEG is recorded from scalp electrodes on
16 channels simultaneously.
 Its main value is in diagnosing epilepsy and

diffuse brain diseases.


 Videotelemetry, which combines EEG with

video, is valuable in assessment of 'attacks'


that are uncertain clinically.
Epilepsy
 Spikes, or spike-and-wave abnormalities, are

hallmarks of epilepsy, but it should be


emphasized that patients PHT266
with epilepsy often
Electroencephalography
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(EEG)
Diffuse brain disorders
 Recognizable slow-wave EEG abnormalities

appear in encephalitis, prion (Creutzfeldt-


Jakob) disease and metabolic states (e.g.
hypoglycaemia and hepatic coma

Brainstem death
 The EEG is isoelectric (flat), but is no longer

necessary to confirm brain death

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Electromyography and
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conduction studies
Electromyography
 A concentric needle electrode is inserted

into voluntary muscle.


 The amplified recording is viewed on an

oscilloscope and heard through a


speaker.
Three main features are seen:
 normal interference pattern

 denervation and reinnervation

 myopathic, myotonic or myasthenic


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Peripheral nerve
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conduction
 Four measurements are of principal value in
diagnosis of neuropathies and nerve entrapment:
1. mean nerve (motor and sensory) conduction
velocity
2. distal motor latency
3. sensory action potentials
4. muscle action potentials.
 These measurements differentiate between
axonal and demyelinating damage and also
determine whether the process is focal or
diffuse. PHT266
16 Assessing Impairment
Neurological impairments can be
assessed in terms of their presence
and severity.
Typical body functions that need to be
assessed in the neurological patient
are:
1. Joints
2. Muscles
3. Movements
4. sensations PHT266
Cognitive function
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 Orientation in time and place, recall of


recent and distant events (memory, level of
intellect, language and speech/cerebral
dominance, other disorders of skilled
function, e.g. apraxia)

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Mental state, attitude, insight
Orientation
Score one point for each correct answer:
What is the: time, date, day, month, year? 5 points
Maximum:

What is the name of: this ward, hospital, district, 5 points


town, country?
Registration

Name three objects only once. Score up to a 3 points


maximum of 3 points for each correct repetition.
Repeat the objects until the patient can repeat
them accurately (in order to test recall later).

Attention and calculation

Ask the patient to subtract 7 from 100 and then 7 5 points


from the result four more times.
Score 1 point for each correct subtraction
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Mental state, attitude, insight
Orientation
Score one point for each correct answer:
Language

Score 1 point for each of two simple objects 2 points


named (e.g. pen and a watch)
Score 1 point for an accurate repetition of the 1 point
phrase: 'No ifs, ands or buts'
Give a 3-stage command, scoring 1 point for each 3 points
part correctly carried out; e.g.
Write 'Close your eyes' on a blank piece of paper 1 point
and ask the patient to follow the written
command. Score 1 point if the patient closes the
eyes.
Ask the patient to write a sentence. 1 point

Draw a pair of intersecting pentagons with each 1 point


side approximately 1 inch long.

19 TOTAL MAXIMUM SCORE PHT266 30 POINTS


Joint function
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 Evaluation of the passive range of


movement (shortening and contractures)
 Reliable measurements – using a
goniometer (Macdermid et al, 2000)

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Motor system
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 Upper limbs:  Thorax and abdomen:


 Wasting and  Respiration
fasciculation  Thoracic and
 Posture of arms: drift,
abdominal muscles
rebound, tremor  Abdominal reflexes
 Tone: spasticity or
 Cremasteric reflexes
extrapyramidal rigidity  Lower limbs:
 Power: 0-5 scale
 Wasting and
 Tendon reflexes: + or
fasciculation
++ normal; +++  Tone, power and
increased: 0 absent
tendon reflexes
with reinforcement
 Plantar responses
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Muscle Function
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Muscle strength
2. Scale of muscle strength (MRC UK, 1878)
Grade
0 No muscular activity
1 Minimal contraction of muscle but
insufficient to move a joint
2 Contraction of muscle sufficient to move
a joint but not to oppose gravity
3 Muscle contraction sufficient to move a
joint against gravity but not against
4 physical resistance sufficient to move a
Muscle contraction
joint against gravity but against
mild/moderate physical resistance
5 Normal power, that is muscular
contraction sufficient to resist firm
resistance. PHT266
Muscle Function
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Muscle strength
2. Grip strength and pinch strength using
hand dynamometer (Bohannon &
Andrews, 1987)
3. Equipment to measure muscle strength

(static or isometric) and power


(isokinetic)

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Muscle function
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Muscle Size
2. Decrease or increase in muscle bulk
( atrophy or hypertrophy).
3. Tape measure – measuring limb

circumference
4. Ultrasound imaging – reliable

measurement

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Muscle function
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Muscle tone
 Assessed by passively moving the limbs

or trunk through the normal range of


movement whilst the patient remains
relaxed

1. Normal
2. Increased – hypertonic due to spasticity or
rigidity
3. Decreased - hypotonic
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Muscle function
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Muscle tone
 Depend on the velocity of the movement
Grade Modified Ashworth Scale of muscle Spasticity
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 when the affected part is
moved in flexion or extension.
1+ Slight increase in muscle tone, manifested by a
catch, followed by minimal resistance through the
remainder (less than half) of the range of movement

2 More marked increase in muscle tone through most


of the range of movement, but affected part easily
moved
3 Considerable increase in muscle toe, passive
movement difficult
4 Affected part rigid in flexion or extension
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Muscle function
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Muscle tone – rigidity


 Increased in tone throughout the whole range of the
passive movement
 Lead pipe – agonist and antagonist muscles
 Cogwheel rigidity a regular intermittent break in tone is felt
throughout the whole range of movement
Grade Unified Parkinson’s Disease Rating System Scale
(Lang & Fahn, 1989)
0 Rigidity absent
1 Rigidity slight or detectable only when activated by
mirror or other movements
2 Mild to moderate rigidity
3 Marked rigidity but full range of motion easily achieved
4 Severe rigidity range of motionPHT266
achieved with difficult
Muscle functions
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 Co-ordination
 Integration of sensory feedback with
motor output of sufficient strength
 Involuntary contractions, involuntary
movement reactions, control of
voluntary movement functions and
involuntary movement functions.

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Deep Tendon Reflexes
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 Involuntary contractions or tendon


reflexes are increased in UMNL and
decreased in LMNL
 6 reflexes can be tested using this
grading system
 Ankle, knee, biceps, supinator, triceps
Grade Grading of reflexes (Fuller, 1999)
0 absent
and
±
finger reflexes
Present but only with reinforcement
1+ Present but depressed
2+ Normal
3+ Increased
4+ Clonus PHT266
Biceps (C5, C6)
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 The patient's arm should be partially


flexed at the elbow with the palm down.
 Place your thumb or finger firmly on the
biceps tendon.
 Strike your finger with the reflex
hammer.
 You should feel the response even if you
can't see it.

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Triceps (C6, C7)
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 Support the upper arm and let the


patient's forearm hang free.
 Strike the triceps tendon above the
elbow with the broad side of the
hammer.
 Ifthe patient is sitting or lying down, flex
the patient's arm at the elbow and hold it
close to the chest.

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Brachioradialis (C5, C6)
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 Have the patient rest the forearm on the


abdomen or lap.
 Strike the radius about 1-2 inches above
the wrist.
 Watch for flexion and supination of the
forearm.

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Knee (L2, L3, L4)
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 Have the patient sit or lie down with the


knee flexed.
 Strike the patellar tendon just below the
patella.
 Note contraction of the quadraceps and
extension of the knee.

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Ankle (S1, S2)
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 Dorsiflex the foot at the ankle.


 Strike the Achilles tendon.
 Watch and feel for plantar flexion at the
ankle.

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Clonus
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 If the reflexes seem hyperactive, test for


ankle clonus: ++
 Support the knee in a partly flexed
position.
 With the patient relaxed, quickly
dorsiflex the foot.
 Observe for rhythmic oscillations.

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Plantar Response
(Babinski)
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 Stroke the lateral aspect of the sole of


each foot with the end of a reflex
hammer or key.
 Note movement of the toes, normally
flexion (withdrawal).
 Extension of the big toe with fanning of
the other toes is abnormal. This is
referred to as a positive Babinski.

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Balance Task
1 Sitting to standing
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2 Standing unsupported
 Traditionally – 3 Sitting unsupported
good, fair , poor 4 Standing to sitting
5 Transfer
 Validated
6 Standing with eyes closed
measure – Berg 7 Standing with feet together
Balance Scale 8 Reaching forward with
outstretched arm
 The Functional
9 Retrieving object from floor
Reach Test 10 Turning to look behind
11 Turning 360º
12 Placing alternate foot on stool
13 Standing with one foot in front
14 Standing
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Co-ordination
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 Control of voluntary functions refers to


the patient’s ability to co-ordinate
movements.
 Dysdiadochokinesia – inability to tap and
turn over the hand

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Co-ordination
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Finger-nose test  Intention tremor –


 Tremor and ataxia when the
 Touch therapist’s patient’s finger
finger with the shows a tremor
index finger and on approaching
then touch his the target finger.
nose  Dysmetria –
 Make the patient overshoot
movement faster the target
 Moving the
 Action tremor –
finger(target) intention tremor
+ dysmetria
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Co-ordination
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Heel-shin test
 Line supine

 Move one heel from the knee down the

sharp anterior edge of the shin.


 Inability suggest ataxia

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Sensory Function
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Proprioception
Joint position sense
 Sensory function for detecting and

identifying the relative position of body


parts whilst the patient has his eyes
closed
 Distal joint are tested before proximal

joints.
 The patient is asked in what direction

the joint is moved.


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Sensory system
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 First,
ask whether feeling in the limbs, face and
trunk is entirely normal
 Posterior columns:
 Vibration (using a 128 Hz tuning fork)
 Joint position
 Light touch
 2-point discrimination (normal: 0.5 cm finger tips, 2
cm soles)
 Spinothalamic tracts:
 Pain:
use a split orange-stick or a sterile pin
 Temperature: hot or cold tubes

 If sensation is abnormal, chart areas involvedPHT266


proprioception
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Romberg’s Test
 Patient is asked to stand with the feet

together for a few seconds.


 Make sure patients that they will be

caught if they fall


 If the patient falls with the eyes closed

then the test is positive

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Touch
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 The sensory Pinprick test


function of touch  Gently touches the
involves sensing skin with the pin or
surfaces and their back end and asks
textures and the patient
qualities. whether it feels
 Pinprick test and sharp or blunt
light touch test Light touch test
 Both test should be  Dabbing a piece of
demonstrated to cotton wool on an
the patient first. area of skin
 Both test begin
distally and then
move proximally PHT266
Temperature
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 Two tubes – cold and hot water


 Patient’s eyes closed
 Begin distally
 Aiming to test each dermatome and
each main nerve

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46 Assessing Activities
Observation of gait
Assessment of gait
Global measures of activity limitations

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Observation of gait
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 Symmetry
 Duration of swing and stance phases
 Muscle activation around ankle, knees,
hips and trunk, arm swing, trunk
rotation, balance and speed.

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Parkinson's disease
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 There is muscular  Gait becomes festinant


rigidity throughout (hurried) in small rapid
extensors and flexors. steps.
 Power is preserved  There is particular
but walking slows. difficulty initiating
 The pace shortens to movement and turning
a shuffle; its base quickly.
remains narrow.  Retropulsion describes
 Falls occur. small backward steps,
taken involuntarily
 A stoop and
when a patient is
diminished arm
halted.
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swinging become
Cerebellar ataxia
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 In disease of the  In disease confined


lateral cerebellar to cerebellar
lobes stance becomes midline structures
broad-based, unstable (the vermis) the
and tremulous. trunk becomes
 Ataxia describes this unsteady without
imperfect control. limb ataxia.
 Walking tends to veer  There is a tendency
towards the more to fall backwards or
affected cerebellar sideways - truncal
lobe. ataxia.
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Sensory ataxia
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 Peripheral sensory  This ataxia is made


lesions (e.g. worse by removal of
polyneuropathy,) additional sensory
cause ataxia because input (e.g. vision) and
there is loss of the is worse in the dark.
sense of joint position  First described in
- proprioception. sensory ataxia of
tabes dorsalis, this is
 Broad-based, high-
the basis of Romberg's
stepping, stamping
test.
gait develops.
 Ask the patient to
close the eyes while
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standing: observe
Lower limb weakness
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 When weakness is  Weakness of proximal


distal, each leg must lower limb muscles
be lifted over (e.g. in polymyositis or
obstacles. muscular dystrophy)
 When ankle leads to difficulty in
dorsiflexors are weak, rising from sitting or
such as in a common squatting.
peroneal nerve palsy,  Once upright, the
each foot, returns to patient walks with a
the ground with a waddling gait, the
visible and audible pelvis being ill-
slap. supported by each
lower
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limb as it carries
Gait apraxia
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 With frontal lobe  This is gait apraxia - a


disease (e.g. tumour, failure of the skilled act
hydrocephalus, of walking.
infarction), the  Shuffling small steps
acquired skill of (marche à petits pas),
walking becomes difficulty initiating
disorganized. walking (gait ignition
 Leg movement is failure) or undue
normal when sitting hesitancy may
or lying but initiation predominate.
and organization of  Urinary incontinence
walking fail. and dementia are often
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Observation of gait
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Hemiplegia
 Foot drop

 Lateral leg swing

 High step

 Hip hitch during swing phase (as)

 Hyperextended knee, ↓hip extension,

drop of the affected shoulder

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Observation of gait
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Spastic paraparesis Waddling gait


 Cerebral palsy,  Marked rotation of

multiple sclerosis, the pelvis and


spinal cord shoulders
compression,  Proximal muscles
 Scissoring gait weakness
 ↑flexion and

adduction of the hips


 ↑flexion of the knees

 Dragging of the toes


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Assessment Tools
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 Modified Rivermead Mobility Index


 Barthel Index
 Motor Assessment Scale
 Functional Independence Measurement
 Berg Balance Scale

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