Cerebellar examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This cerebellar examination OSCE guide provides a clear step by step approach to performing a focused cerebellar examination.
Confirm patient details – name / DOB
Achieve appropriate exposure
Ask if the patient has pain anywhere before you begin
Around the bed – note any mobility aids (e.g. wheelchair / walking stick)
Patient’s posture – note any truncal ataxia
Observe the patient’s normal gait:
1. Stance – a broad-based gait is noted in cerebellar disease
2. Stability – can be staggering, often slow and unsteady – similar to a drunk person walking
In unilateral cerebellar disease, the patient can veer towards the side of the lesion.
3. Tandem (‘heel to toe’) walking – 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 the function of the cerebellar vermis.
This is the first function to be lost in alcoholic cerebellar cortical degeneration.
4. Romberg’s test – ask the 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, not of cerebellar disease. Swaying with correction is not a positive result (although this may occur in cerebellar disease). Falling without correction is abnormal and indicates unsteadiness is due to a sensory ataxia from lack of proprioception, rather than a cerebellar ataxia.
Slurred, staccato speech is characteristic of cerebellar dysfunction.
Ask the patient to repeat the following phrases:
- “British constitution”
- “Baby hippopotamus”
1. Ask the patient to look straight ahead and examine the eyes in the primary position. Look for any abnormal movement such as nystagmus.
2. Ask the patient to keep their head still and follow your finger with their eyes.
3. Move your finger throughout the various axes of vision.
4. Look for multiple beats of nystagmus (a few beats at the extremes of gaze can be a normal variant and is termed physiological nystagmus).
It is likely that detecting the presence or absence of nystagmus will be sufficient in the examination. However, it can be characterised further by noting the following:
- The direction of the nystagmus. Most nystagmus has a fast phase and a slow phase (termed “jerk” nystagmus). By convention, the direction of the nystagmus is defined by the direction of the fast phase. In cerebellar lesions, the direction is towards the side of the lesion.
- If it is present on horizontal or vertical gaze
- Whether it beats in a horizontal or vertical plane
Other disturbances of gaze noted in cerebellar disease include:
- Dysmetric saccades: hold your hand about 30cm to the side of your head. Ask the patient to look at your hand, then back to your nose when you ask them to. Do this on both sides. This movement of the eyes should be quick and accurate. In cerebellar lesions, there will often be overshoot (i.e. the eyes will go too far past the target, then correct themselves back to the target).
- Impaired smooth pursuit: when the patient is tracking your finger, the eyes should move smoothly. In cerebellar lesions, pursuit can be “jerky” or “saccadic” i.e. made up of lots of small movements (saccades) added together.
Finger to nose test
1. Ask the patient to touch their nose with the tip of their index finger, then touch your fingertip.
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.
An inability to perform this test accurately (with past pointing or incoordination/dysmetria) may suggest cerebellar pathology.
Patients’ may have an intention tremor – a terminal tremor that occurs as the finger approaches the target. Be careful not to mistake an action tremor (which occurs throughout the movement) for an intention tremor.
Whilst the patient’s arms are still outstretched and 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.
3. When resistance is suddenly removed, a healthy patient’s limb normally moves a short distance in the desired direction and then rebounds (jerks back in the opposite direction)
An exaggerated version of the normal response is suggestive of spasticity.
The absence of rebound phenomenon is suggestive of cerebellar disease.
1. Support the patient’s arm by holding their hand and 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, tone is meant to be reduced on the side of the lesion. However, reduced tone is a very subjective phenomenon and tone can often can appear to be normal in cerebellar disease. It is advisable not to put too much weight on this sign or the lack of it.
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.
Knee-jerk (L3, L4)
In cerebellar disease, the reflexes are described as ‘pendular’. This means less brisk and slower in rise and fall. However, similar to reduced tone, this sign is very subjective and often reflexes appear to be normal in cerebellar disease.
Heel to shin test –“put your heel on your knee, run it down your shin, lift it off and repeat in a smooth motion”
In cerebellar disease, incoordination/dysmetria may be noted. (A note of caution: weakness, eg from an upper motor neurone lesion, can also produce apparent incoordination of this movement. Therefore, ideally, power should be assessed first).
To complete the examination…
Suggest further assessments and investigations
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 help remind you of the key parts of the cerebellar exam:
- Ataxia (gait and posture)
- Intention tremor
- Slurred, staccato speech
- Hypotonia/Heel-shin test
Dr Gemma Maxwell
Neurology Registrar (ST6)