The cerebellum controls a lot of important functions including coordination of muscle function. Because of this, cerebellar disease leads to a number of specific clinical findings that can be seen in the cerebellar exam of a patient with disease.
Introduction to the Cerebellar Exam
The cerebellum coordinates unconscious regulation of balance, muscle tone, and coordination of voluntary movements. Therefore, cerebellar disease (including cerebellar stroke, cerebritis and metabolic insults) leads to clinical signs that occur throughout the body.
Signs of cerebellar disease, from head to foot
Causes enunciation of individual syllables: “the British parliament” becomes “the Brit-tish Par-la-ment.”
Fast phase toward side of cerebellar lesion.
Finger to nose & finger to finger test
Ask patient to fully extend arm then touch nose or ask them to touch their nose then fully extend to touch your finger. You increase the difficulty of this test by adding resistance to the patient's movements or move your finger to different locations. Abnormality of this is called dysmetria.
Rapid alternating movements
Ask patient to place one hand over the next and have them flip one hand back and forth as fast as possible (alternatively you can ask the patient to quickly tap their foot on the floor as fast as possible) if abnormal, this is called dysdiadochokinesia.
Rebound phenomenon (of Stewart & Holmes)
Have the patient pull on your hand and when they do, slip your hand out of their grasp. Normally the antagonists muscles will contract and stop their arm from moving in the desired direction. A positive sign is seen in a spastic limb where the exaggerated "rebound" occurs with movement in the opposite direction. However in cerebellar disease this response is completely absent causing to limb to continue moving in the desired direction. (Be careful that you protect the patient from the unarrested movement causing them to strike themselves.)
Heel to shin test
Have patient run their heel down the contralateral shin (this is equivalent the finger to nose test). Abnormal exam occurs when they are unable to keep their foot on the shin.
“Pendular” knee jerk, leg keeps swinging after knee jerk more than 4 times (4 or less is normal).
Gait (Acute Cerebellar Ataxia)
Acute cerebellar ataxia is a wide based and staggering gait. (See "Gaits" section to learn more about acute cerebellar ataxia and other gaits.)
They may fall to the side of the lesion
NOTE: patients with disease of the vermis and flocculonodular lobe will be unable to stand at all as they will have truncal ataxia–they may not be able to sit.
NOTE: THE ROMBERG TEST IS NOT A SIGN OF CEREBELLAR DISEASE.
It is a sign of a disturbance of proprioception, either from neuropathy or posterior column disease. The patient does not know where their joint is in space and so uses their eyes. In the dark or with eyes closed they have problems.
Historical Perspective of the Cerebellar Exam
Of historical interest is the “compass test” used prior to the days of CT scans and MRI's. To conduct this test, you have the patient close their eyes and take two steps forward and two steps back; patient will turn toward side of lesion. Of course they must be capable of standing in the first place with eyes closed.
Key Learning Points
- Learn the signs of cerebellar disease, from head to foot
- Learn the technique of the full cerebellar exam from our video
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