TABLE 2183 Features of Tremor Types

PRONATOR DRIFT The pronator drift is tested by having the patient hold the arms outstretched with the palms upwards and the eyes closed. A positive finding results from turning or pronating the hand while the arm drift downwards. The pronator drift is a valuable screening tool for determining the presence of a subtle neurologic deficit and should be incorporated in the emergency examination of a conscious patient when any hemispheric lesion is suspected. A normal finding requires normal strength and motor functioning as well as normal proprioception mediated through the sensory fibers of the posterior columns.

GAIT AND STANCE Gait testing is an essential part of every neurologic examination. If the patient cannot stand, try to determine whether it is the result of weakness or of unsteadiness. If the patient can stand but is unsteady, note whether the patient tends to consistently fall in one direction, and whether the unsteadiness is increased with the eyes closed (Romberg's test).

The characteristic disorders of gait are:

1. Hemiplegic gait—circumduction of the leg with a stiff knee, scraping the floor.

2. Spastic paraplegic gait—slow, stiff movements, tilting of the pelvis and delayed flexion of hips.

3. Steppage gait—flopping feet, lifted too high, as with a foot drop.

4. Sensory ataxia—wide base, uneven steps, stamping.

5. Cerebellar—wide base, with irregularity, deviation or reeling, staggering or turning.

6. Parkinsonism (festinating)—stooped, with short steps, may accelerate, chasing center of gravity, or may have some degree of retropulsion, finding it difficult to stop when stepping backwards.

Chronic gait abnormalities can be detected by examining the soles of shoes for asymmetrical wear. Spasticity from hemiparesis results in increased wear of the toe of the shoe on the affected side. Midline cerebellar disease produces a widened stance and a wide-based gait. For cerebellar hemispheric lesions, the initial subtle finding may only be a difficulty in turning rapidly, especially if asymmetrical. Walking heel-to-toe may accentuate a subtle abnormality in coordination. Standing with the eyes closed and the feet together (Romberg test) requires normal position sense functioning as well as adequate strength in both legs. If a patient can stand with the feet together with the eyes opened but cannot do so with the eyes closed, this suggests a difficulty in proprioception or position sense (posterior columns). If this is not accomplished with the eyes opened or there is tendency to veer to one side on walking, the lesion is likely cerebellar or labyrinthine. When walking successively forwards and backwards with the eyes closed, movement in a direction perpendicular to the line of walking occurs in cerebellar hemispheric lesions. A progressive turning clockwise or counterclockwise (compass gait) occurs in labyrinthine lesions.

COORDINATION When possible, gait testing and performance of the Romberg test are important to assess complaints of incoordination. The finger-to-nose test, heel-to-shin test, and testing rapid alternating movements are valuable in assessing cerebellar function. In finger-to-nose and heel-to-shin testing, cerebellar lesions produce movements perpendicular to the line of movement. The rapid rhythmic cadence is disrupted in rapid alternating movements ( Tab.!®.. . .2.1.8-4.).

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