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292 Chapter 7: Nervous system

Rebound: Hands and arms outstretched, eyes closed, rolling (abduction-adduction of thumb with flexion–

push down each hand in turn, and look for rebound extension of the fingers). The tremor is improved with
(overshooting). action, but worse on concentration (ask the patient to
Finger-nose test: Intention tremor and past-pointing. count backwards from 100 in serial 7’s).

Dysdiadochokinesis: Tapping alternately with the pal- Speech: Monophonic, quiet. Tendency to peter out.

mar and dorsal aspects of the hand is poor. Tone: Cogwheel rigidity due to increased tone to-
Heel-shin test: Poorly performed, the patient is unable gether with tremor. Power, reflexes, sensation and co-

to keep heel on shin. ordination are normal.
Truncal ataxia: Also called central ataxia. Test the abil- Bradykinesia (slowness in movements) is noticeable

ity of the patient to sit on the edge of the bed with their when doing alternate hand tapping movements, or
arms crossed. touching the thumb to each finger in turn. Micro-
Gait:Wide-basedgait,withatendencytodrifttowards graphia (small, spidery handwriting).

the side of the lesion. Stopping and turning is difficult. Gaitandposture:Aflexedpositionwithheaddrooped,
If there is no obvious abnormality, ask the patient to shoulders and spine flexed, knees slightly flexed. Ini-
walk heel to toe. Even a mild cerebellar problem makes tiation of movement is impaired (hesitancy) with the
this very difficult. appearanceoffallingintowalking.Thegaitisslowand
shuffling with reduced arm swing. A festinating gait is
Causes include the following:
when the patient looks as though they are shuffling in
Multiple sclerosis

order to keep up with their centre of gravity, and then
Trauma

has difficulty in stopping and turning round.
Endocrine: Hypothyroidism.

Vascular: Cerebellar haemorrhage, cerebellar ischae-

mic stroke. Tremor
Drugs: Phenytoin, carbamazepine.

The three groups of tremor are distinguished by obser-
Metabolic: Alcohol (acute, reversible or chronic de-

vation (see Table 7.4).
generation)
Neoplastic: Tumour, paraneoplastic syndrome, e.g.

Gait
lung carcinoma
Congenital: Arnold–Chiari malformation, Friedre- Spastic gait: This is a sign of upper motor neurone

ich’s ataxia disease. The gait is stiff, one or both legs are kept
extended. If unilateral, the leg is swung out to the side
to move it forwards (circumduction). If bilateral, the
Extrapyramidal signs (Parkinsonism)
pelvis has to alternately tilt and the gait often becomes
Appearance: Expressionless face. Drooling saliva. scissor-like.Thepatientcanstandontip-toe,butoften

Resting tremor which is slow and classically pill- not on their heels.
Table 7.4 Types of tremor
Type of tremor Description Causes
Resting Pill-rolling Parkinsonism
Positional tremor (only appears when
hands and arms out-stretched)
Fine Physiological
Hyperthyroidism
Drugs: e.g. salbutamol, lithium, sodium valproate
Coarse Alcohol
Benign essential tremor (often familial)
Action (intention tremor and past-pointing) On purposeful movement Cerebellar