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
Explain examination
Gain consent
Achieve appropriate exposure 
Ask if patient has any 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 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:

  • Stand up with their feet close together & hands by their sides
  • Close their eyes
  • Keep 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)
The Romberg test is therefore used to distinguish the cause of ataxia in patients presenting to clinic

 

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

Speech can often be affected in cerebellar disease
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

Ask the patient to keep their head still & follow your finger with their eyes
Move your finger throughout the various axis of vision
Look for multiple beats of nystagmusa few can be a normal variant
Other disturbances of gaze seen in cerebellar disease include:

  • Dysmetric saccades
  • Impaired smooth pursuit
Arms
Tone

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

 

Reflexes

In cerebellar disease mild hyporeflexia is often noted

  • Biceps (c5, c6) 
  • Triceps (c7) 
  • Supinator (c6) 

 

Co-ordination

Pronator Drift 
Ask patient to hold out arms outstretched in front of them with palms facing upwards
Tell them to close their eyes
Watch the arms / hands for drift – the hand characteristically drifts into pronation in a positive test

Finger to Nose 
Ask patient to touch their nose, then the tip of your finger in a repetitive fashion
Move your finger around and to the extremes of their reach
Look for poor co-ordination – e.g. missing their nose or missing your finger
Look for intention tremor – most noticeable at the extremes of their reach

Dysdiadokinesia 
Ask patient to tap their palm with the other hand
Then tell them to start alternating between the palm and back of their hand as they tap
Then ask them to do it as fast as they can
In cerebellar diseases dysdiadokinesia is noted (inability to perform rapidly alternating movements)

Legs
Tone

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, heel should remain in contact with the bed

Reflexes

Knee Jerk (L3,L4)
Ankle (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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