Neurology Complimentary Therapy

Published on December 12th, 2012 | by Lewis Potter

Cerebellar Examination – OSCE Guide

Cerebellar examination  frequently appears in OSCE’s. You’ll be expected to pick up the relevant clinical signs using your examination skills. This cerebellar examination OSCE guide provides a clear concise, step by step approach to examining the cerebellum, with an included video demonstration.

Introduction

Wash hands
Introduce yourself

Confirm patient details - name / DOB
Explain examination
Gain consent
Achieve appropriate exposure 
Ask if the patient has pain anywhere before you begin!

Gait
Observe the patients normal gait

Stance – a broad based gait is noted in cerebellar disease
Speed – often slow & unsteady – looks very similar to a drunk person walking
In unilateral cerebellar disease, there is deviation to the side of the lesion due to hypotonia 

 

Heel to toe

Ask the patient to walk in a straight line with their heels to their toes
This is a very sensitive test and will exaggerate any unsteadiness
It is particularly sensitive at assessing function of the cerebellar vermis
This is the first function to be lost in alcoholic cerebellar cortical degeneration

 

Romberg’s Test

How to do it?

 

Romberg’s test involves asking a patient to:

  1. Stand up with their feet close together & hands by their sides
  2. Close their eyes
  3. Keep as still as possible

You need to closely observe for signs the patient is losing balance
Make sure to be stood close to the patient when performing this test to prevent them falling

 

What’s a positive test?

A POSITIVE test is when the patient fails to maintain their balance with their eyes closed

 

What is it testing for?

It relies on the premise that a person requires at least 2 of the following 3 senses to balance:

  • Proprioception- the PNS & spinal cords dorsal columns monitor the bodies position in space
  • Vestibular function - the inner ear, vestibular nuclei & pathways into the cerebellum
  • Vision – visual feedback from the eyes to orientate the brain in space

The Romberg test therefore assesses the bodies sense of position (proprioception)

 

So what does a positive/negative result tell me about the pathology?
A positive test indicates the pathology is proprioceptive in origin – spinal cord / dorsal columns
A negative test in a patient with ataxia suggests the pathology is likely cerebellar in origin

Head
Speech

Staccato speech is characteristic of cerebellar dysfunction
It results in the individual pronouncing each syllable separately

 

Ask the patient to repeat the following phrases:

  • “British constitution”
  • “Baby hippopotamus”
  • “42 West Register street”

 

Nystagmus

1. Ask the patient to keep their head still & follow your finger with their eyes
2. Move your finger throughout the various axis of vision
3. Look for multiple beats of nystagmusa few can be a normal variant

Nystagmus at the extremes of gaze is normal & referred to as physiological nystagmus 

 

Other disturbances of gaze noted in cerebellar disease include:

  • Dysmetric saccades
  • Impaired smooth pursuit
Arms
Tone

1. Support the patients arm by holding their hand & elbow
2. Ask the patient to relax and allow you to fully control their arm
3. Move the arm’s muscle groups through their full range of movements 
4. Is the motion smooth or is there some resistance?
In cerebellar disease, there is often mild hypotonia (difficult to detect clinically)

 

Reflexes

Assess the patients upper limb reflexes, comparing left to right

1. Biceps(c5, c6) 
2. Triceps (c7) 
3. Supinator (c6) 

In cerebellar disease, there is often mild hyporeflexia

Co-ordination

Pronator drift

1. Ask patient to close eyes & place arms outstretched forwards with palms facing up

2. Observe the hands / arms for signs of pronation

If pronation occurs in one of the arms, it indicates contralateral UMN pathology

 

Finger to nose test

1. Ask patient to touch their nose with the tip of their index finger, then touch your finger tip

2. Position your finger so that the patient has to fully outstretch their arm to reach it

3. Ask them to continue to do this finger to nose motion as fast as they can manage

4. Move your finger, just before the patient is about to leave their nose,  to create a moving target (↑sensitivity)

An inability to perform this test accurately (past pointing/dysmetria) may suggest cerebellar pathology

 

Dysdiadokinesia

1. Demonstrate patting the palm of your hand with the back/palm of your other hand to the patient

2. Ask the patient to mimic this rapid alternating movement

3. Then have the patient repeat this movement on their other hand

An inability to perform this rapidly alternating movement (very slow/irregular) suggests cerebellar ataxia

Legs
Tone

Ask the patient to keep their legs fully relaxed and “floppy” throughout your assessment

Leg roll - roll the patients leg & watch the foot, it should flop independently of the leg
Leg lift – briskly lift leg off the bed at the knee joint, the heel should remain in contact with the bed

Reflexes

Knee jerk (L3,L4)
Ankle jerk (L5,S1)

 

Co-ordination

Heel to shin test -“run your heel down the other leg  from the knee & repeat in a smooth motion”

In cerebellar disease, a coarse side to side tremor of the leg/foot will be noted

To complete the examination…

Thank patient
Wash hands
Summarise findings

 

Say you would…
Perform a full neurological examination if indicated
Perform appropriate imaging if indicated - e.g. CT / MRI

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