Cerebellar examination Flashcards
What do you inspect?
Abnormal posture (standing position)
Scars
Walking aids
Hearing aids
What are the two types of ataxia and what do they indicate?
Truncal ataxia - proximal muscles - damage to cerebellar vermis
Appendicular ataxia - muscles of arms and legs - damage to cerebella hemishperes
What are the dimensions of the cerebellar exam?
Gait
Rombergs
Speech
Eyes
Upper limbs
Lower limbs
What does Danish stand for?
Dysdiadochokinesia
Ataxia (gait and posture)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/heel-shin test
What do you look for when assessing gait?
Stance (broad based?)
Stability (staggering? slow?)
Turning
How can you exacerbate subtle unsteadiness?
Heel-toe walking, this is said to indeintify dysfunction of the cerebellar vermis
What are the clinical features of cereballar degeneration?
Broad-based ataxic gait
Truncal ataxia
Dysmetria (incoordination)
Nystagmus (abnormal eye movements)
Why do we perform rombergs test?
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.
How to interpret rombergs?
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))
How do you assess speech?
“British constitution”
“Baby hippopotamus”
Looking for staccato or slurred speech
How do you assess nystagmus?
Double vision?
Any nystagmus whilst looking straight ahead?
Any nyastagmus at extremes of gaze during H pattern?
How do you describe nystagmus?
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)
How do you assess upper limbs?
Tone
Coordination (finger nose test, rebound phenomena, dysdiadochokinesia)
What would hypotonia indicate?
ipsilateral cerebellar lesion
What would cerebellar pathology demonstrate on the finger nose test?
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)
How do you interpret the rebound response?
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.
How to interpret dysdiadochokinesia?
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.
How do you examine the lower limbs?
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)
Further assessments?
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).
Summary
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)
Here is a sample marking scheme
Notice they want you to look for:
resting tremor
fine finger movements
