Pemeriksaan Keseimbangan dan KoordinasiCoordination Coordination is evaluated by testing the patient's ability to perform rapidly alternating and point-to- point movements correctly. Rapidly Alternating Movement Evaluation Ask the patient to place their hands on their thighs and then rapidly turn their hands over and lift them off their thighs. Once the patient understands this movement, tell them to repeat it rapidly for 10 seconds. Normally this is possible without difficulty. This is considered a rapidly alternating movement. Dysdiadochokinesis is the clinical term for an inability to perform rapidly alternating movements. Dysdiadochokinesia is usually caused by multiple sclerosis in adults and cerebellar tumors in children. Note that patients with other movement disorders (e.g. Parkinson's disease) may have abnormal rapid alternating movement testing secondary to akinesia or rigidity, thus creating a false impression of dysdiadochokinesia. Point-to-Point Movement Evaluation Finger to Finger Next, ask the patient to extend their index finger and touch their nose, and then touch the an abnormal. Normally this movement remains accurate when the eyes are closed. The heel to shin test is a measure of coordination and may be abnormal if there is loss of motor strength. Dix-Hallpike test .examiner's outstretched finger with the same finger. An inability to perform this motion in a relatively rapid cadence is abnormal. ask the patient to continue with their eyes closed. With the patient lying supine. proprioception or a cerebellar lesion. Repeat and compare to the other hand. Ask the patient to go back and forth between touching their nose and examiner's finger. asymmetric heel to shin test is highly suggestive of an ipsilateral cerebellar lesion. If motor and sensory systems are intact. Once this is done correctly a few times at a moderate cadence. Dysmetria is the clinical term for the inability to perform point-to-point movements due to over or under projecting ones fingers. Next have the patient perform the heel to shin coordination test. instruct him or her to place their right heel on their left shin just below the knee and then slide it down their shin to the top of their foot. Have them repeat this motion as quickly as possible without making mistakes. Have the patient repeat this movement with the other foot. a central nervous system (CNS) dysfunction is indicated. The patient's head is then rotated by approximately 45 degrees. Downbeating nystagmus indicates that the vertigo is in the anterior semicircular canal of the tested side.The Dix-Hallpike test or Nylen-Barany test is a diagnostic maneuver used to identify benign paroxysmal positional vertigo (BPPV). There are several key characteristics of a positive test: Latency of onset (usually 5-10 seconds) Torsional (rotational) nystagmus. The patient's eyes are then observed for about 45 seconds as there is a characteristic 5-10 second period of latency prior to the onset of nystagmus. During a positive test. Upon sitting after a positive maneuver the direction of nystagmus should reverse for a brief period of time. Multiple repetition of the test will result in less and less nystagmus. If no torsional nystagmus occurs but there is upbeating or downbeating nystagmus. Reversal. If rotational nystagmus occurs then the test is considered positive for benign positional vertigo. This extension may either be achieved by having the clinician supporting the head as it hangs off the table or by placing a pillow under their upper back. The clinician helps the patient to lie down backwards quickly with the head held in approximately 20 degrees of extension. the fast phase of the rotatory nystagmus is toward the affected ear. Upbeating nystagmus indicates that the vertigo is present in the posterior semicircular canal of the tested side. Upbeating or downbeating nystagmus. which is the ear closest to the ground. Home devices are available to assist in the performance of the Dix-Hallpike Maneuver for patients with a diagnosis of BPPV. The Dix-Hallpike test is performed with the patient sitting upright with the legs extended. Fatigable nystagmus. The direction of the fast phase is defined by the rotation of the top of the eye. . either clockwise or counter-clockwise. Gait Gait is evaluated by having the patient walk across the room under observation. and the eyes are examined again to see if reversal occurs. Also. hopping in place on each foot should be performed. then on their toes only. Be certain to note the amount of arm swinging because a slight decrease in arm swinging is a highly sensitive indicator of upper extremity weakness. Gross gait abnormalities should be noted. Normally. it makes benign positional vertigo a less likely diagnosis and CNS involvement should be considered. and finally on their heels only. The nystagmus may come in paroxysms and may be delayed by several seconds after the maneuver is performed. Pendular Reflexes Pendular reflexes are not brisk but involve less damping of the limb movement than is usually observed when a deep tendon reflex is elicited. If the test is negative. Next ask the patient to walk heel to toe across the room.To complete the test. Pendular reflexes are best observed when the patient's lower legs are allowed to hang and swing freelly off the end of an examining table. the patient is brought back to the seated position. Patients with cerebellar injury may have a knee jerk that swings forwards and backwards several times. . these maneuvers possible without too much difficulty. A normal or brisk knee jerk would have little more than one swing forward and one back. weakness. These causes must be excluded before the unbalance can be attributed to a cerebellar lesion. Abnormalities in heel to toe walking (tandem gait) may be due to ethanol intoxication.Walking on heels is the most sensitive way to test for foot dorsiflexion weakness. Heel to toe walking is highly useful in testing for ethanol inebriation and is often used by police officers in examining potential "drunk drivers". Tandem gait . vertigo and leg tremors. Most elderly patients have difficulty with tandem gait purportedly due to general neuronal loss impairing a combination of position sense. while walking on toes is the best way to test early foot plantar flexion weakness. poor position sense. strength and coordination. Therefore. the results are not definitive. Neurologists sometimes ask patients to walk in a straight line using tandem gait as a test to help diagnose ataxia. More recently.Tandem gait is a gait (method of walking or running) where the toes of the back foot touch the heel of the front foot at each step. because sufferers of these disorders will have an unsteady gait. However. the test has been shown to greater reflect somatosensory function . Fukuda Test The "stepping test" was first developed by Fukuda as a test of vestibular function. especially truncal ataxia. because many disorders or problems can cause unsteady gait (such as vision difficulties and problems with the motor neurons or associative cortex). inability to walk correctly in tandem gait does not prove the presence of ataxia. To achieve balance. In the low back pain patient. visual confirmation of position. The doctor observes for any rotation that takes place. perform the Romberg test by having the patient stand still with their heels together. arms outstretched and wearing ear muffs. the test is positive. a positive test is likely a reflection of either faulty kinesthetic sense or faulty tonic lumbar reflexes.The test is performed by having the patient stand with eyes closed. If the patient loses their balance. 2. a person requires 2 out of the following 3 inputs to the cortex: 1. Rotation of 30 degrees or more is considered a positive test. non-visual confirmation of position (including proprioceptive and . Ask the patient to remain still and close their eyes. Romberg Test Next. The significance of the test is that it suggests the presence of either faulty kinesthetic sense or tonic neck reflexes (or both). The patient marches in place at the pace of a brisk walk while keeping the eyes closed. and 3.edu/courseware/neurosurgery/coordination. To conclude the gait exam.vestibular input).html . This is a positive Romberg. observe the patient rising from the sitting position. and is able to maintain balance with their eyes open. Note gross abnormalities. then this is indicative of pathology in the proprioceptive pathway. if a patient loses their balance after standing still with their eyes closed.med. http://edinfo. Therefore. a normally functioning cerebellum.nyu.
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