11/13/24, 6\:57 PM Guide | Cerebellar examination

Cerebellar examination

Table of contents
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Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Ask the patient to sit on a chair, approximately one arm's length away.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

Clinical signs

Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology\:
Abnormal posture\: may indicate the presence of truncal ataxia.
Speech abnormalities\: slurred staccato speech is typical of cerebellar disease.
Scars\: may indicate previous neurosurgery (often di
Gait\: pay attention to the patient's gait as they enter the room and take a seat, noting any abnormalities (e.g. broad-based
gait in cerebellar pathology).
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Objects or equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Walking aids\: cerebellar disease often causes issues with balance (ataxia), resulting in patients using walking aids to steady
themselves.
Hearing aids\: hearing loss can be associated with pathology that may impact the cerebellum (e.g. acoustic neuroma
causing local cerebellar compression).
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications.
Observe the patient's posture
Ataxia
Ataxia is a neurological sign consisting of involuntary movements with an irregular oscillatory quality which interfere with
the normal smooth trajectory of movement. Ataxia can be truncal (a
limbs)\:
Truncal ataxia\: a
the cerebellar vermis and associated pathways (i.e. midline cerebellar lesions).
Appendicular ataxia\: a
ataxia is caused by damage to the cerebellar hemispheres (i.e. lateral cerebellar lesions).

Gait

Assess the patient's gait

Patients with cerebellar disease are at an increased risk of falls so make sure to remain close to the patient during the
assessment so that you are able to intervene if required.
Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying
attention to\:
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Stance\: a broad-based ataxic gait is typically associated with midline cerebellar pathology (e.g. a lesion in multiple sclerosis
or degeneration of the cerebellar vermis secondary to chronic alcohol excess).
Stability\: a staggering, slow and unsteady gait is typical of cerebellar pathology. In unilateral cerebellar disease, patients will
veer towards the side of the lesion.
Turning\: patients with cerebellar disease will

Tandem ('heel-to-toe') gait

Ask the patient to walk to the end of the examination room and back with their heels to their toes (known as 'tandem gait').
Heel-to-toe walking exacerbates underlying unsteadiness making it easier to identify more subtle ataxia.
Tandem gait is particularly sensitive at identifying dysfunction of the cerebellar vermis (e.g. alcohol-induced cerebellar
degeneration).
Assess gait
Cerebellar degeneration
Cerebellar degeneration involves the progressive loss of Purkinje cells in the cerebellum. It has a wide range of causes
including chronic alcohol abuse, nutritional de
diseases (e.g. multiple sclerosis, spinocerebellar ataxia).
Typical clinical features include\:
Broad-based ataxic gait
Truncal ataxia
Dysmetria (incoordination)
Nystagmus (abnormal eye movements)

Romberg's test

Romberg's test is used to assess for loss of proprioceptive or vestibular function (known as sensory ataxia). The test does not
assess cerebellar function and instead is used to quickly screen for evidence of sensory ataxia (i.e. non-cerebellar causes of
balance issues).
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Romberg's test is based on the premise that a patient requires at least two of the following three senses to maintain balance
whilst standing\:
Proprioception\: the awareness of one's body position in space.
Vestibular function\: the ability to know one's head position in space.
Vision\: the ability to see one's position in space.
Romberg's test involves removing the sense of vision by asking the patient to close their eyes. As a result, if the patient has a
de

Assessment

1. Position yourself within arms reach of the patient to allow you to intervene should they begin to fall.
2. Ask the patient to put their feet together and keep their arms by their sides (be aware that patients with truncal ataxia may
struggle to do this, however, this type of unsteadiness is not the same as a positive Romberg's sign).
3. Ask the patient to close their eyes.

Interpretation

Falling without correction is abnormal and referred to as a positive Romberg's sign. This indicates unsteadiness is due to
sensory ataxia (i.e. a de
dysfunction include joint hypermobility (e.g. Ehlers-Danlos syndrome), B12 de
as presbypropria). Causes of vestibular dysfunction include vestibular neuronitis and Ménière's disease.
Swaying with correction is not a positive result and often occurs in cerebellar disease due to truncal ataxia.
Perform Romberg's test

Speech

Assess speech by asking the patient to repeat the following phrases\:
" B r i t i s h c o n s t i t u t i o n"
" B a b y h i p p o p o t a m u s"
Cerebellar lesions can cause ataxic dysarthria which can present in a number of ways\:
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Scanning speech (also known as staccato speech)\: words are broken down into separate syllables, often separated by
pauses and spoken with varying volume.
Slurred speech\: patients are often mistaken for being intoxicated as a result.
Scanning and slurred speech often occur in combination (often referred to as "slurred staccato speech").
Assess the patient's speech

Eyes

Nystagmus

cerebellar pathology.
Nystagmus involves repetitive, involuntary oscillation of the eyes and can be either physiological (i.e. benign) or associated with
Assessment
When assessing for nystagmus, begin by asking the patient to report any double vision (diplopia) if they experience it during
the assessment. Diplopia may suggest the presence of strabismus which can be associated with some cerebellar syndromes
(e.g. vestibulocerebellar syndrome).
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
3. Move your
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).
Describing nystagmus
Detecting the presence or absence of nystagmus will be su
characterised further by assessing the following\:
Direction of nystagmus\: most nystagmus has a fast phase and a slow phase (termed “jerk” nystagmus). By convention, the
direction of the nystagmus is de
of the lesion.
Direction of gaze\: note if nystagmus is present on horizontal or vertical gaze.
Plane of nystagmus\: note if nystagmus beats in a horizontal or vertical plane.
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Other gaze disturbances

Other disturbances of gaze that are associated with cerebellar disease include dysmetric saccades and impaired smooth
pursuit.
Dysmetric saccades
1. Position your hand approximately 30cm to the side of your head.
2. Ask the patient to look at your hand, then back to your nose. Repeat this assessment on both sides.
The movement of the patient's 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). This overshoot and subsequent correction are
known as dysmetric saccades.
Impaired smooth pursuit
When the patient is tracking your
pursuit can be “jerky” or “saccadic”( i.e. made up of lots of small movements).
Observe for nystagmus

Upper limbs

Finger-to-nose test

Assessment
The
1. Position your
2. Ask the patient to touch their nose with the tip of their index
3. Ask the patient to continue to do this
Interpretation
When patients with cerebellar pathology perform this task they may exhibit both dysmetria and intention tremor\:
Dysmetria\: refers to a lack of coordination of movement. Clinically this results in the patient missing the target by
over/undershooting.
Intention tremor\: a broad, coarse, low-frequency tremor that develops as a limb reaches the endpoint of a deliberate
movement. Clinically this results in a tremor that becomes apparent as the patient's
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to mistake an action tremor (which occurs throughout the movement) for an intention tremor.
The presence of dysmetria and intention tremor is suggestive of ipsilateral cerebellar pathology.
Assess co-ordination

Rebound phenomenon

Rebound phenomenon is a re
suddenly removed.
Assessment
1. Ask the patient to close their eyes and position their arms outstretched in front of them.
2. Explain to the patient that you are going to apply some downward resistance on each arm and that they should try to
maintain the current position of their arms as you apply that resistance.
3. Push downwards on one of the patient's forearms and then immediately remove the resistance.
4. Observe the movement of the limb being assessed.
Interpretation
In healthy individuals, when the resistance is removed the limb will usually move a short distance upwards (i.e. the direction
the patient was pushing towards to maintain limb position) before antagonist muscles contract and move the limb back to the
original position. This is the normal re
An exaggerated version of rebound phenomenon is suggestive of spasticity (e.g. stroke a
A complete absence of the phenomenon, caused by a failure of the antagonist muscles to contract, is suggestive of cerebellar
disease.
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Assess for rebound phenomenon

Tone

Assessment
Assess tone in the muscle groups of the shoulder, elbow and wrist on each arm, comparing each side as you go\:
1. Support the patient's arm by holding their hand and elbow.
2. Ask the patient to relax and allow you to fully control the movement of their arm.
3. Move the muscle groups of the shoulder (circumduction), elbow (
full range of movements.
4. Feel for abnormalities of tone as you assess each joint (e.g. hypotonia).
Interpretation
Hypotonia can be caused by an ipsilateral cerebellar lesion. However, the ability to detect reduced muscle tone is highly
subjective and in many cases, tone can feel 'normal' in cerebellar disease. As a result, it is advisable not to put too much weight
on this sign or the lack of it.
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Assess tone

Dysdiadochokinesia

Dysdiadochokinesia is a term that describes the inability to perform rapid, alternating movements, which is a feature of
ipsilateral cerebellar pathology.
Assessment
1. Ask the patient to place their left palm on top of their right palm.
2. Then ask them to turn over their left hand and touch the back of it onto their right palm.
3. Now ask them to return their left hand to the original position (left palm on right palm).
4. Ask the patient to now repeat this sequence of movements as fast as they are able until you tell them to stop. It is often
useful to demonstrate the sequence of movements to the patient to aid understanding.
5. Observe the speed and
6. Repeat the assessment with the other hand.
Interpretation
Patients with cerebellar ataxia may struggle to carry out this task, with their movements appearing slow and irregular. The
presence of dysdiadochokinesia suggests ipsilateral cerebellar pathology.
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Assess for dysdiadochokinesia

Lower limbs

Although tone can be re-assessed in the lower limbs, it is often not required in a cerebellar OSCE exam if you have already
comprehensively assessed tone in the upper limbs.
Assessment
Brie
1. With the patient lying on the examination couch, roll each leg to assess tone in the muscles responsible for the rotation of
the hip.
2. Lift each knee briskly o
tone, the knee should rise whilst the heel remains in contact with the bed (the heel will typically lift o
increased tone).
Interpretation
Hypotonia can be caused by an ipsilateral cerebellar lesion. However, the ability to detect reduced muscle tone is highly
subjective and in many cases, tone can feel 'normal' in cerebellar disease. As a result, it is advisable not to put too much weight
on this sign or the lack of it.

Re

Assess the knee-jerk re
Explain to the patient that you are now going to assess their re
useful to show the patient the tendon hammer at this stage).
For each of the re
Make sure to hold the tendon hammer handle at its end to allow gravity to aid a good swing.
If a re
patient to clench their teeth together whilst you simultaneously tap the tendon.
Assessment
1. Remove the weight from the patient's lower limb by either supporting it or asking the patient to hang their legs over the side
of the bed. Ensure the patient’s lower limb is completely relaxed before assessing the deep tendon re
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2. Tap the patellar tendon with the tendon hammer (making sure to hold the tendon hammer handle at its end to allow gravity
to aid a good swing).
3. If a re
Interpretation
In cerebellar disease, re
, which means less brisk and slower in their rise and fall. However,
similar to reduced tone, this sign is very subjective and often re
Assess re

Heel-to-shin test

Assessment
The heel-to-shin test is a convenient method of assessing lower limb co-ordination\:
1. Ask the patient to place their left heel on their right knee and then run it down their shin in a straight line.
2. Then ask them to return their left heel to the starting position over the right knee.
3. Now ask them to repeat this sequence of movements in a smooth motion until you tell them to stop.
4. Repeat the assessment with the right heel on the left leg.
Interpretation
Dysmetria (i.e. incoordination) whilst attempting to perform this task is suggestive of ipsilateral cerebellar pathology.
A note of caution\: weakness (e.g. from an upper motor neuron lesion) can also produce apparent incoordination of this
movement. As a result, power should be assessed before any diagnostic conclusions are drawn.
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