Objective: Identify the most reliable bedside screening test for lower extremity ataxia.

Background: Accurate identification of ataxia is critical for appropriate diagnosis and treatment. The heel-to-shin maneuver is widely taught for detection of ataxia in the lower extremities, but there is limited evidence supporting its sensitivity and reliability. We evaluated this and other commonly used tests of lower extremity ataxia to determine the best screening tool.

Method: We created a video survey of patients with and without ataxia performing lower extremity ataxia test maneuvers. This was distributed to healthcare providers who were asked to determine whether each maneuver demonstrated the presence of ataxia. The survey participants were from diverse training backgrounds, including movement disorder neurologists, other neurology faculty, mid-level neurology providers, neurology residents, non-neurology residents, non-neurology physicians, and medical students.

Results: 87 respondents completed the survey, including 20 movement disorders neurologists, 14 neurologists from other specialties, 8 non-neurologist physicians, 20 neurology residents, 8 non-neurology residents, 5 mid-level providers, and 12 medical students. Toe/heel tap was the best screening tool for the full cohort (sensitivity 86%, NPV 63%, LR- 0.15), then heel stomp (sensitivity 83%, NPV 55%, LR- 0.19) and extended heel-to-shin (sensitivity 80%, NPV 55%, LR- 0.21). Supine heel-to-shin performed poorly (sensitivity 62%, NPV 39%, LR- 0.40), but the least reliable test was toe tapping (sensitivity 31%, NPV 25%, LR- 0.74). When comparing only neurology faculty, extended heel-to-shin and toe/heel tap were the best screening tools, followed by heel stomp. Among all other respondents, toe/heel tap was the best screening tool, then heel stomp and toe rhythm tap.

Conclusion: Although heel-to-shin is the most widely taught maneuver for detecting lower extremity ataxia, our results suggest that toe/heel tap may be the most sensitive screening tool for providers of all healthcare backgrounds. As extended heel-to-shin and heel stomp also performed well, it is likely that combining multiple bedside screening tools would be the most effective approach to accurately detecting lower extremity ataxia.

References: [1] Brandsma R, Lawerman TF, Kuiper MJ, Lunsing RJ, Burger H, Sival DA. Reliability and discriminant validity of ataxia rating scales in early onset ataxia. Dev Med Child Neurol. 2017;59:427–432. [2] Schmitz-Hubsch T, Tezenas du Montcel S, Baliko L, et al. Reliability and validity of the International Cooperative Ataxia Rating Scale: a study in 156 spinocerebellar ataxia patients. Mov Disord Off J Mov Disord Soc. 2006;21:699–704. [2] Storey E, Tuck K, Hester R, Hughes A, Churchyard A. Inter-rater reliability of the International Cooperative Ataxia Rating Scale (ICARS). Mov Disord Off J Mov Disord Soc. 2004;19:190–192. [4] Yabe I, Matsushima M, Soma H, Basri R, Sasaki H. Usefulness of the Scale for Assessment and Rating of Ataxia (SARA). J Neurol Sci. 2008;266:164–166.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/detecting-lower-extremity-ataxia-toe-heel-tap-is-the-best-screening-tool/