APPROACH TO THE PATIENT

WITH DIFFICULT IN WALKING

(HEMIPLEGIA)

COMPLIED BY DR ZAR CHI WAI LINN

DIFFICULTY IN WALKING
 WALKING DIFFICULTY

NEUROPATHY NEUROMUSCULAR MYOPATHY

JUNCTION

CNS PNS
(UMNL) (LMNL)

BRAIN SPINAL CORD

CEREBRAL CORTEX EXTRAPYRIMIDAL

CEREBELLUM BASAL GANGLIA

 WALKING DIFFICULTY

NEUROPATHY NEUROMUSCULAR MYOPATHY

JUNCTION

CNS PNS
(UMNL) (LMNL)

BRAIN SPINAL CORD

CEREBRAL CORTEX EXTRAPYRIMIDAL

CEREBELLUM BASALGANGLIA
 WALKING DIFFICULTY

NEUROPATHY NEUROMUSCULAR MYOPATHY

JUNCTION

CNS PNS
(UMNL)
(LMNL)
ANTERIOR HORN CELL
BRAIN SPINAL CORD
REDICULOPATHY

PLEXOPATHY
CEREBRAL CORTEX EXTRAPYRIMIDAL
MONONEUROPATHY

CEREBELLUM BASALGANGLIA MONONEURITIS MULTIPLEX

 DIFFICULT IN WALKING

• Nerve?

• Muscle ?

• Neuro -Mascular Junction?

 NEUROPATHY

• CNS ?
• PNS?
 CNS

• Brain : Hemiplegia?
• Spinal cord : Quadriplegia?
• Cerebeller lesion
• Basal ganglia lesion
 PNS
• Flaccid paraplegia ?

• Peripheral neuropathy? Sensory (Glove and stocking)/Motor/Mixed

• Rediculopathy ?

• Plexopathy?

• Mononeuropathy?

• Mononeuritis Multiplex ?
NEUROPATHY
INSPECTION
 LOOK FOR BEDSIDE CLUES:

ankle-foot orthosis (AFO)s may point towards foot drop.

A catheter bag may imply a spastic paraparesis.

Crutches suggest that upper limbs are strong.

Look around the bedside for a wheelchair, or walking aids.

 INSPECT THE LIMBS CAREFULLY:
• General muscle bulk – look for wasting, fasciculations, and particularly at the
intrinsic muscles of the hand. If wasting is present, consider the distribution e.g.
symmetrical and distal or localized to a specific nerve. Pseudohypertrophy of the
calf suggests a dystrophy.

• Check for deformities such as contractures, pes cavus (suggesting a hereditary

sensorimotor neuropathy or polio) or Charcot’s joints (consistent with a sensory
neuropathy).

• Look at limb posture e.g. wrist drop of a radial nerve palsy, clawing of the hand
due to ulnar nerve palsy.

• Look for muscle biopsy scars (often deltoid, triceps, or lateral quadriceps) or
spinal procedure.
NEXT
WHAT DO YOU THINK?
HOW DO YOU START
THE EXAMINATION?
• If the patient can walk, start by Rhombergs Test
 WALKING DIFFICULTY

NEUROPATHY NEUROMUSCULAR MYOPATHY

JUNCTION

CNS PNS
(UMNL) (LMNL)

BRAIN SPINAL CORD

PYRIMIDAL EXTRAPYRIMIDAL

BASALGANGLIA
HEMIPLEGIC CEREBELLUM
GAIT
HEMIPLEGIC GAIT
Written by Dr Sarah Kennedy

Be familiar with the NICE stroke algorithm (https://www.nice.org.uk/guidance/CG68) and the Bamford
classification of stroke and the CHA2DS2Vasc and HASBLED scoring systems and the National Institutes of
Health Stroke Scale.
IMPORTANT CLINICAL
SIGNS
CLONUS
HYPERREFLEXIA
EXTENSOR PLANTER
RESPONSE
UPPER LIMB
IF THE WEAKNESS IS
VASCULAR ONSET
PRESENTATION
 WITH REGARDS TO AETIOLOGY:

The pulse was regular,

there was (no) carotid bruit or cardiac murmur/prosthetic sounds or
evidence of diabetic fingerprick marks or tar staining.
 WITH REGARDS TO COMPLICATIONS: 

There was (no) DVT, pressure sores, catheter, NG tube

The patient had good/reduced function of the left hand.
INVESTIGATIONS FOR STROKE:
INVESTIGATIONS FOR STROKE:
INVESTIGATIONS FOR STROKE:
MANAGEMENT OF STROKE:
MANAGEMENT OF STROKE:
MANAGEMENT OF STROKE:
GOOD LUCK