Neurology Cerebellar Exam

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 performing a focused examination to detect cerebellar pathology.

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!

General inspection

Around the bed - any mobility aids? (wheelchair / walking stick)

Patients posture - truncal ataxia? 

Patients appearance - signs of neglect (alcoholism? – an acquired cause of cerebellar ataxia)

Gait
Observe the patients normal gait looking especially for:

1. Stance - a broad based gait is noted in cerebellar disease

 

2. Stability - can be staggering and often slow & unsteady – can appear similar to a drunk person walking

In unilateral cerebellar disease, there is deviation to the side of the lesion due to hypotonia

 

 

3.   Tandem (‘Heel to toe’) walkingAsk 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

 

4. Romberg’s test – ask patient to put their feet together, keep their hands by their side and close their eyes (be ready to support them in case they are unsteady!)

This is a test of proprioception – a positive Romberg’s test indicates that the unsteadiness is due to a sensory ataxia (damage to dorsal columns of spinal cord) rather than a cerebellar ataxia

Head
Speech

Slurred 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
Pronator drift

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

2. Observe the hands / arm for signs of pronation / movement

A slow upward drift in one arm is suggestive of a lesion in the contralateral cerebellum

 

Rebound phenomenon

Whilst the patients arms are still outstretched & their eyes are closed:

1. Ask the patient to keep their arms in that position as you press down on their arm.

2. Release your hand

Positive test =  Their arm shoots up above the position it originally was (this is suggestive of cerebellar disease)

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 the reflexes are described as ‘pendular’ (e.g. the leg keeps swinging after you elicit the knee reflex)

 

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 

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

Patients may have an intention tremor – as they get closer to a target the tremor worsens at the endpoints of a deliberate movement 

 

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 including:

  • Cranial nerves
  • Upper and lower limbs

Perform appropriate imaging if indicated - e.g. CT / MRI

 

 

 

The mnemonic DANISH can remind you of the key parts of the cerebellar exam:

  • Dysdiadochokinesis
  • Ataxia (gait and posture)
  • Nystagmus
  • Intention tremor
  • Slurred, stacatto speech
  • Hypotonia/Heel-shin test

Tags: , ,


About the Author

Doctor. Gadget Fanatic. Internet Junkie.



Back to Top ↑