THEMEDPRACTICALEXAM.COM

CEREBELLAR EXAMINATION PROFORMA

I. Introduction & General Observation

  • Greeting & Consent: Briefly greet the patient, explain the procedure, and obtain consent.

  • Positioning: Ensure the patient is in a comfortable position (sitting or standing, as appropriate for the test).

  • Initial Observation (While patient is at rest or performing general tasks):

    • Any spontaneous involuntary movements (e.g., tremor, dyskinesia)?

    • Posture: Any abnormal posturing?

    • Speech: Is there dysarthria (slurred speech, scanning speech, staccato speech)?

    • Nystagmus: Observe eyes in primary gaze.

II. Assessment of Co-ordination

(A) Upper Limb Co-ordination

  1. Finger-Nose Test:

    • Instruction: "Please extend your arm out to the side, then touch the tip of your nose with your index finger, then return your arm to the side." (Demonstrate first).

    • Observation:

      • Dysmetria: Does the finger overshoot (hypermetria) or undershoot (hypometria) the target (nose)?

      • Intention Tremor: Is there a tremor that increases in amplitude as the finger approaches the nose?

      • Dyssynergia: Is the movement broken down into component parts rather than smooth?

      • Speed & Smoothness: Is the movement performed smoothly and at a consistent speed?

    • Repeat: Test each arm separately, several times. Note if closing eyes exaggerates the defect (suggests proprioceptive involvement rather than pure cerebellar).

  2. Finger-to-Finger Test (or Finger-to-Examiner's Finger Test):

    • Instruction: "Touch your nose, then touch my finger. I will move my finger."

    • Observation: Same as Finger-Nose Test, looking for dysmetria, intention tremor, dyssynergia.

  3. Dysdiadochokinesia (Rapid Alternating Movements):

    • Instruction: "Place your palms on your thighs, then rapidly turn them over to face up and down as fast as you can." (Demonstrate).

    • Observation:

      • Irregularity/Clumsiness: Is the rhythm irregular, or are movements clumsy and hesitant?

      • Slowness: Is there significant slowing of the movements?

      • Asymmetry: Compare both sides.

    • Repeat: Perform with both hands simultaneously and then each hand separately.

  4. Rebound Phenomenon:

    • Instruction: "Hold your arm up, flexed at the elbow, and make a fist. Now, pull your fist towards your shoulder, and don't let me stop you." (Apply resistance to the forearm). "Now, I will suddenly let go. Try to stop your arm from hitting yourself."

    • Observation: In cerebellar lesions, the patient may be unable to check the movement, causing the arm to "rebound" excessively, potentially hitting themselves.

  5. Past-Pointing Test:

    • Instruction: "Touch my finger with your index finger. Now, close your eyes, raise your arm straight up, and then bring it back down to touch my finger." (Examiner keeps their finger steady).

    • Observation: In cerebellar dysfunction, the patient's finger may consistently miss the target, usually deviating to the side of the cerebellar lesion (ipsilateral deviation).

(B) Lower Limb Co-ordination

  1. Heel-to-Shin Test (Heel-to-Knee Test):

    • Instruction: (Patient supine) "Place the heel of one foot on the opposite knee, then slowly slide it down along the shin to your ankle, and then lift it back up to the knee." (Demonstrate).

    • Observation:

      • Dysmetria: Does the heel overshoot or undershoot the knee or slip off the shin?

      • Ataxia: Is the movement clumsy, tremulous, or jerky?

      • Smoothness: Is the movement smooth and controlled?

    • Repeat: Test each leg separately, several times. Note if closing eyes exaggerates the defect (proprioceptive involvement).

III. Assessment of Gait & Stance

  1. Stance:

    • Observation: "Please stand with your feet close together." (Observe for stability).

    • Romberg's Test: "Now, please close your eyes."

      • Observation:

        • Positive Romberg's: Patient sways or falls significantly with eyes closed but is stable with eyes open (indicates sensory ataxia, i.e., dorsal column lesion, peripheral neuropathy).

        • Negative Romberg's with Ataxia: Patient is unstable with eyes open and closed (suggests cerebellar ataxia, as cerebellar ataxia is not compensated by vision).

  2. Gait:

    • Instruction: "Please walk normally across the room, turn, and come back."

    • Observation:

      • Broad-based: Is the stance wide?

      • Ataxic/Staggering: Is the gait unsteady, reeling, or drunken-like?

      • Asymmetry: Is one side worse?

      • Arm Swing: Is arm swing symmetrical and natural?

      • Truncal Titubation: Is there a rhythmic swaying of the trunk?

  3. Tandem Walking (Heel-to-Toe Walking):

    • Instruction: "Please walk in a straight line, placing the heel of one foot directly in front of the toes of the other, like walking on a tightrope."

    • Observation: Exaggerates subtle gait ataxia. Cerebellar lesions make this impossible or very difficult, with tendency to fall to the side of the lesion.

IV. Assessment of Other Cerebellar Signs

  1. Speech (Dysarthria):

    • Instruction: "Please say a long sentence like 'The quick brown fox jumps over the lazy dog' or 'British Constitution'."

    • Observation:

      • Scanning Speech: Excessively slow, deliberate, or separated syllables.

      • Staccato Speech: Each syllable pronounced separately with undue emphasis.

      • Explosive Speech: Sudden bursts of loudness.

  2. Nystagmus:

    • Instruction: "Follow my finger with your eyes. Do not move your head." (Move finger to extremes of horizontal and vertical gaze, holding for a few seconds).

    • Observation:

      • Presence and direction (horizontal, vertical, rotary).

      • Direction-changing nystagmus (central).

      • Gaze-evoked nystagmus (nystagmus that appears only when eyes are held in eccentric gaze).

  3. Hypotonia:

    • Assessment (Tone): During motor examination (especially passive movements of limbs), assess for reduced resistance to passive stretch, which can be a subtle sign of cerebellar dysfunction.

    • Pendular Reflexes: Elicit knee jerk (patellar reflex). In hypotonia, the leg may swing back and forth several times like a pendulum after the initial jerk.

Summary & Conclusion:

  • Positive Findings: Summarize any observed signs of dysmetria, dysdiadochokinesia, intention tremor, nystagmus, dysarthria, truncal titubation, or ataxic gait.

  • Lateralization: Note if findings suggest a unilateral cerebellar lesion (ipsilateral signs) or a bilateral/midline lesion.

  • Correlation: Briefly state how these findings correlate with the patient's history.