Cerebellar OSCE Examination

1. Introduction
2. General Inspection
3. Speech
4. Eye Movements
5. Upper Limb Coordination
6. Lower Limb Coordination
7. Gait and Romberg’s Test
8. Completing the Examination
9. Quiz

Wash your hands thoroughly before approaching the patient, as good hygiene reduces the risk of healthcare-associated infection.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient’s details taking 3 points of identification; usually full name, date of birth and NHS/hospital number.

Obtain consent for the examination, ensuring to explain what it will entail. A clear explanation is particularly helpful here, as the cerebellar examination involves several unfamiliar coordination tasks the patient will need to follow.

Position the patient sitting comfortably, ideally on the edge of the bed or in a chair so that you can later observe their gait. Ensure there is enough space and a clear path for the patient to walk safely.

Expose the patient’s arms and legs appropriately so that movement and tone can be assessed.

Ask the patient whether they are in any pain before you begin, and enquire whether they feel steady on their feet, as some manoeuvres carry a risk of falls.

Begin with a general inspection of the patient and their surroundings, as this often gives valuable clues before any formal testing is performed. If the patient walks into the room, watch how they move from the outset, since a broad-based or unsteady gait may be apparent long before you formally test walking.

Look at the patient themselves for an abnormal posture or a tendency to lean or list to one side, which may reflect truncal ataxia (instability of the trunk). Observe for any obvious involuntary movements of the head or limbs and note whether the patient appears alert and comfortable or distressed.

Look around the bedside for mobility aids such as a walking stick, frame or wheelchair, which suggest the patient has difficulty with balance and walking. The presence of these aids hints at the severity of any ataxia before you have even started.

Note any prescriptions or medications, as several drugs are associated with cerebellar dysfunction. Long-term phenytoin use and chronic alcohol excess are classic causes of cerebellar degeneration, while lithium toxicity can produce an acute cerebellar syndrome.

It is helpful to keep the broad causes of cerebellar disease in mind throughout, as the pattern of signs helps to localise the problem. Common causes include stroke (ischaemic or haemorrhagic) affecting the posterior circulation, multiple sclerosis, posterior fossa tumours, chronic alcohol misuse, drug toxicity, and inherited conditions such as the spinocerebellar ataxias and Friedreich’s ataxia. As a rule, a unilateral lesion such as a stroke or tumour causes limb signs on the same side, a point we return to throughout the examination.

Assessing speech early is sensible, as cerebellar pathology characteristically affects the coordination of the muscles of articulation, producing dysarthria.

The classic cerebellar speech pattern is scanning or staccato speech, in which words are broken into separate syllables that are spoken with abnormal, irregular emphasis. This arises because the cerebellum can no longer smoothly coordinate the rate, rhythm and force of the muscles used in speaking.

To test for this, ask the patient to repeat phrases that demand rapid, coordinated articulation. Commonly used examples are ‘baby hippopotamus’ and ‘British constitution’. A patient with cerebellar disease will often struggle to produce these smoothly, with the syllables becoming slurred or fragmented.

The cerebellum plays an important role in coordinating eye movements, so abnormalities here are a useful sign of cerebellar pathology.

Ask the patient to keep their head still and follow your finger with their eyes only. Move your finger through the cardinal positions of gaze in an ‘H’ shape, watching carefully for nystagmus.

Nystagmus is an involuntary rhythmic eye movement. Cerebellar dysfunction can impair gaze holding, producing sustained gaze-evoked nystagmus, and can make smooth pursuit jerky. In gaze-evoked nystagmus the fast phase may change with the direction of gaze; its direction alone is not a dependable rule for deciding which cerebellar hemisphere is affected. Interpret the eye findings alongside limb coordination, gait and other neurological signs. Concordant limb dysmetria provides a stronger clue to sidedness.

It is worth remembering that a few beats of nystagmus at the extremes of gaze can be physiological and normal, so look for sustained nystagmus within the normal range of eye movement. Also note any difficulty with smooth pursuit, where the eyes move in a jerky, ‘broken’ fashion rather than tracking the target smoothly.

While testing eye movements, you may also notice saccadic abnormalities, in which the rapid movements the eyes make to jump between targets are inaccurate and either overshoot or undershoot. This is another manifestation of the cerebellum’s loss of fine control over movement, in this case applied to the eyes rather than the limbs.

Preview the Cerebellar OSCE Examination quiz