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Cerebellar Examination OSCE Guide
Cerebellar Examination OSCE Guide
geekymedics.com /cerebellar-examination-osce-guide/
12/12/2012
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.
Introduction
Wash hands
Introduce yourself
Explain examination
Gain consent
General inspection
Around the bed – any mobility aids? (wheelchair / walking stick)
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Gait
2. Stability – can be staggering, often slow and unsteady – similar to a drunk person walking
In unilateral cerebellar disease the patient can veer towards the side of the lesion.
3. Tandem (‘heel to toe’) walking – ask the patient to walk in a straight line with their heels to their toes
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, not of cerebellar disease. Swaying with correction is not a positive result (although
this may occur in cerebellar disease). Falling without correction is abnormal and indicates the unsteadiness is due
to a sensory ataxia from lack of proprioception, rather than a cerebellar ataxia.
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Assess tandem ('heel to toe') gait
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Head
Speech
“British constitution”
“Baby hippopotamus”
Nystagmus
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 finger with their eyes.
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3. Move your finger throughout the various axes of vision.
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).
It is likely that detecting the presence or absence of nystagmus will be sufficient in the examination.
However, it can be characterised further: try to note the following:
The direction of the nystagmus. Most nystagmus has a fast phase and a slow phase (termed “jerk”
nystagmus). By convention, the direction of the nystagmus is defined by the direction of the fast phase. In
cerebellar lesions the direction is towards the side of the lesion.
If it is present on horizontal or vertical gaze
Whether it beats in a horizontal or vertical plane
Dysmetric saccades: hold your hand about 30cm to the side of your head. Ask the patient to look at your
hand, then back to your nose when you ask them to. Do this on both sides. This movement of the 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).
Impaired smooth pursuit: when the patient is tracking your finger, the eyes should move smoothly. In
cerebellar lesions, pursuit can be “jerky” or “saccadic” i.e. made up of lots of small movements (saccades)
added together.
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Assess for nystagmus
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Arms
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.
An inability to perform this test accurately (with past pointing or incoordination/dysmetria) may suggest cerebellar
pathology.
Patients’ may have an intention tremor – a terminal tremor that occurs as the finger approaches the target. Be
careful not to mistake an action tremor (which occurs throughout the movement) for an intention tremor.
Rebound phenomenon
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.
Positive test = Their arm shoots up above the position it originally was in ( this is suggestive of cerebellar disease).
Tone
2. Ask the patient to relax and allow you to fully control their arm.
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3. Move the arm’s muscle groups through their full range of movements.
In cerebellar disease, tone is meant to be reduced on the side of the lesion. However, reduced tone is a very
subjective phenomenon and tone can often can appear to be normal in cerebellar disease. It is advisable not to put
too much weight on this sign or the lack of it.
Dysdiadochokinesia
1. Demonstrate patting the palm of your hand with the back/palm of your other hand to the patient.
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.
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Assess for rebound phenomenon
Assess tone
Assess tone
Assess tone
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Assess tone
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Legs
Reflexes
In cerebellar disease the reflexes are described as ‘pendular’. This means less brisk and slower in rise and fall.
However, similar to reduced tone, this sign is very subjective and often reflexes appear to be normal in cerebellar
disease.
Co-ordination
Heel to shin test –“put your heel on your knee, run it down your shin, lift it off and repeat in a smooth motion”
In cerebellar disease, incoordination/dysmetria may be noted. (A note of caution: weakness, eg from an UMN lesion,
can also produce apparent incoordination of this movement. Therefore, ideally power should be assessed first).
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Assess lower limb co-ordination
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Wash hands
Summarise findings
Cranial nerves
Upper and lower limbs
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Perform appropriate imaging if indicated – e.g. CT / MRI
The mnemonic DANISH can help remind you of the key parts of the cerebellar exam:
Dysdiadochokinesia
Ataxia (gait and posture)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/Heel-shin test
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