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. Check out the cerebellar examination mark scheme here.
Confirm patient details – name / DOB
Achieve appropriate exposure
Ask if the patient has pain anywhere before you begin
Around the bed – any mobility aids? (wheelchair / walking stick)
Patient’s posture – truncal ataxia?
Patient’s appearance – signs of neglect (alcoholism? – an acquired cause of cerebellar 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 there is deviation to the side of the lesion due to hypotonia.
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 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.
Slurred staccato speech is characteristic of cerebellar dysfunction.
Ask the patient to repeat the following phrases:
- “British constitution”
- “Baby hippopotamus”
- “42 West Register street”
1. Ask the patient to keep their head still and follow your finger with their eyes.
2. Move your finger throughout the various axes of vision.
3. Look for multiple beats of nystagmus (a few can be a normal variant).
Nystagmus at the extremes of gaze is normal and referred to as physiological nystagmus.
Other disturbances of gaze noted in cerebellar disease include:
- Dysmetric saccades
- Impaired smooth pursuit
1. Ask the patient to close their eyes and place their arms outstretched forwards with palms facing up.
2. Observe the hands and arms for signs of pronation and drift.
A slow upward drift in one arm is suggestive of a lesion in the ipsilateral cerebellum.
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.
Positive test = Their arm shoots up above the position it originally was (this 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 you may note hypotonia.
Assess the patient’s 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.
Finger to nose test
1. Ask 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.
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 .
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.
Ask the patient to keep their legs fully relaxed and “floppy” throughout your assessment.
Leg roll – roll the patient’s leg and 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
In cerebellar disease you would expect to note hypotonia.
Knee jerk (L3,L4)
In cerebellar disease the reflexes are described as ‘pendular’ (e.g. the leg keeps swinging after you elicit the knee reflex).
Heel to shin test –“run your heel down the other leg from the knee and repeat in a smooth motion”
In cerebellar disease, a coarse side to side tremor of the leg or foot may be noted.
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