Cerebellar examination

Question 1

What do you inspect?

Answer 1

Abnormal posture (standing position)

Scars

Walking aids

Hearing aids

Question 2

What are the two types of ataxia and what do they indicate?

Answer 2

Truncal ataxia - proximal muscles - damage to cerebellar vermis

Appendicular ataxia - muscles of arms and legs - damage to cerebella hemishperes

Question 3

What are the dimensions of the cerebellar exam?

Answer 3

Gait

Rombergs

Speech

Eyes

Upper limbs

Lower limbs

Question 4

What does Danish stand for?

Answer 4

Dysdiadochokinesia

Ataxia (gait and posture)

Nystagmus

Intention tremor

Slurred, staccato speech

Hypotonia/heel-shin test

Question 5

What do you look for when assessing gait?

Answer 5

Stance (broad based?)

Stability (staggering? slow?)

Turning

Question 6

How can you exacerbate subtle unsteadiness?

Answer 6

Heel-toe walking, this is said to indeintify dysfunction of the cerebellar vermis

Question 7

What are the clinical features of cereballar degeneration?

Answer 7

Broad-based ataxic gait

Truncal ataxia

Dysmetria (incoordination)

Nystagmus (abnormal eye movements)

Question 8

Why do we perform rombergs test?

Answer 8

Assesses loss of proprioceptive or vestibular function.

Does not assess cerebellar function - simply it checks for non-cerebellar causes of balance issues.

By removing vision, you are forced to use proprioceptive and vestibuoar function to keep balance.

Question 9

How to interpret rombergs?

Answer 9

Falling without correction is abnormal and referred to as a positive Romberg’s sign.

Due to sensory ataxia (joint hypermobility (e.g. Ehlers-Danlos syndrome), B12 deficiency, Parkinson’s disease and ageing (known as presbypropria))

Question 10

How do you assess speech?

Answer 10

“British constitution”

“Baby hippopotamus”

Looking for staccato or slurred speech

Question 11

How do you assess nystagmus?

Answer 11

Double vision?

Any nystagmus whilst looking straight ahead?

Any nyastagmus at extremes of gaze during H pattern?

Question 12

How do you describe nystagmus?

Answer 12

Direction (fast phase = direction) (direction is toward the side of the lesion in cerebellar pathology)

Direction of gaze when nystagmus started

Plane of nystagmus (horizontal or vertical)

Question 13

How do you assess upper limbs?

Answer 13

Tone

Coordination (finger nose test, rebound phenomena, dysdiadochokinesia)

Question 14

What would hypotonia indicate?

Answer 14

ipsilateral cerebellar lesion

Question 15

What would cerebellar pathology demonstrate on the finger nose test?

Answer 15

Dysmetria (refers to a lack of coordination of movement. Clinically this results in the patient missing the target by over/undershooting.)

Intention tremor (Clinically this results in a tremor that becomes apparent as the patient’s finger approaches yours)

Question 16

How do you interpret the rebound response?

Answer 16

An exaggerated version of rebound phenomenon is suggestive of spasticity (e.g. stroke affecting the cerebrum).

A complete absence of the phenomenon, caused by a failure of the antagonist muscles to contract, is suggestive of cerebellar disease.

Question 17

How to interpret dysdiadochokinesia?

Answer 17

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.

Question 18

How do you examine the lower limbs?

Answer 18

Tone (hypotonia if ipsilateral cerbellar lesion)

Knee reflex (cereballar pathology produces a pendular reflex)

Heel-shin test (look for dysmetria, remember weakness may cause false results - so check power first)

Question 19

Further assessments?

Answer 19

Full neurological examination including the cranial nerves and the upper and lower limbs.

Neuroimaging (e.g. MRI head): if there are concerns about space-occupying lesions or demyelination.

Formal hearing assessment (including pure tone audiometry): if there are concerns about vestibulocochlear nerve function (e.g. acoustic neuroma).

Question 20

Summary

Answer 20

General inspection

Posture / gait (Sitting, standing, rombergs, gait heel-toe)

Nystagmus

Speech

Upper limbs (tone, rebound, finger-nose, dysdiadochokinesia)

Lower limbs (Tone, reflex, foot tapping, heel-shin)

Question 21

Here is a sample marking scheme

Answer 21

Notice they want you to look for:

resting tremor

fine finger movements