SAN BEDA COLLEGE OF MEDICINE

NEUROLOGY:
BATCH 2019 A/Y 2015-2016 MINI OSCE REVIEWER

EXAMINATION OF CEREBELLUM: NEUROLOGICAL EXAMS AND THEORETICALS

A. Function of the Cerebellum peduncle, is CN VIII and the most ventral one, farthest
B. Anatomy of the Cerebellum from the peduncle, is CNVI.
C. Clinical Signs of Cerebellar Dysfunction - The Flocculondular lobe has the closest relation to the
D. Tests for Cerebellar Dysfunction vestibular nerve anatomically and phylogenetically.
E. Analysis of Patients and the four Cerebellar
Syndromes B. Cerebellar Peduncles
F. Summary of the Clinical Examination of Cerebellar - SCP –midbrain
Dysfunction  The major efferent peduncle, containing the
G. References brachium conjunctivum, is the superior peduncle.
- MCP- pons
 The corticopontocerebellar pathway runs in the
I. FUNCTION OF THE CEREBELLUM middle peduncle.
- ICP- medulla
- Cerebellum is responsible for coordination. To coordinate  Afferents of the olivary, vestibular, and dorsal
means to adjust the rate, range, force, and sequence of spinocerebellar systems and cerebellar efferents run
willed muscular contraction. through the inferior peduncle.
- The cerebellum receives both sensory and motor input
and coordinates motor activity, maintains equilibrium, **Remember the middLe peduncle by the L mnemonic:
and helps to control posture. In cerebellar disease look Largest, Lateralest, simpLest and phylogenetically Latest
for nystagmus, dysarthria, hypotonia, and ataxia.
- Fine tunes motor activity and assist with balance Largest by far of the peduncles, it conveys the Largest pathway
- Dysfuction results in loss of coordination and problems to the cerebellum; it constitutes the Largest part of the pons;
with gait. and ends in the Largest lobe of the cerebellum, the posterior
Ipsilateral control (Left side of cerebellum controls left lobe; and it is the simpLest peduncle in composition, conveying
side of the body) only one type of fiber, pontocerebellar fibers
- Musculoskeletal proprioceptors and other senses inform
the cerebellum about extremity position and movement,
joint angles, and the length of and tension on muscles and C. Flow of impulses
joints. From this information, the cerebellum coordinates
muscular contractions to produce steady volitional
movements and steady volitional postures.
- You cannot test for cerebellar dysfunction in a comatose
or paralyzed patient because they do not make willed D. Cortico-cerebello-cortical circuit
movements and maintains no willed postures. Cortex (precentral gyrus)  Midbrain  pons  decussate
pontomedullary junction  cerebellum (MCP)  synapse with
II. ANATOMY OF THE CEREBELLUM dentate nucleus  ascend back to the pons (SCP)  decussate
to the CL midbrain  synapse with red nucleus  thalamus 
A. Lobes of the cerebellum and their major source of cortex  CST
afferent fibers
- Anterior lobe (spinocerebellum / palleocerebellum) –
Spinocerebellar tract
- Posterior lobe (neocerebellum / cerebrocerebellum)
 In activating muscles for voluntary contractions, the
cerebrum communicates with the cerebellum via the
corticopontocerebellar pathway, which ends mainly in
the posterior lobe of the cerebellum.
- Flocculonodular lobe (archicerebellum /
vestibulocerebellum) – Vestibullocerebellar tract
- All lobes- Olivocerebellar tract

- Of the three CN attached along the pontomedullary

sulcus, the most dorsal one, closest to the inferior

SBCM 2019 SECTION A Page 1 of 6

 SAN BEDA COLLEGE OF MEDICINE
NEUROLOGY:
BATCH 2019 A/Y 2015-2016 MINI OSCE REVIEWER

E. Cerebellar Tracts
POSTERIOR SPINOCEREBELLAR TRACT
- Receives muscle joint information from the trunks and
lower limbs
- concern with tension of muscle tendons, and movements
of muscles and joints and is used by the cerebellum for
the coordination of limb movements and maintenance of
posture

CUNEOCEREBELLAR TRACT
- convey information from muscle spindles, tendon organs
and joint receptors of the upper limbs to the cerebellum.
- Conveys information of muscle joint sense to the
cerebellum.
- Some axons from the nucleus cuneatus enter the
cerebellum through the inferior cerebellar peduncle of the
same side.
- Fibers from this tract are known as the posterior external
arcuate fibers.

ANTERIOR SPINOCEREBELLAR TRACT III. CLINICAL SIGNS OF CEREBELLAR

- conveys information from muscle spindles, tendon organs, DYSFUNCTION
and joint receptor of the trunks and upper and lower
limbs A. Four Cardinal Cerebellar Signs
**especially in acute lesions

1. ATAXIA (= dystaxia)
- means “not ordered” or, as applied to the effect of
cerebellar lesions, “incoordinated” contractions of
muscles during volitional movements or during
volitionally sustained postures
- lacks coordination, with reeling (to move from side to
side as if you’re going to fall) and instability
- May be due to cerebellar dse, loss of position sense
or intoxication

2. TREMOR (intension tremor and postural)

- Postural, Positional or Static Type of action tremor
o The tremor of intentionally maintained head or
trunk posture or of a limb suspended in front of
the body
o appear when the affected part is actively
maintaining a posture.
o Resting (Static) Tremors =most prominent at rest
and may decrease or disappear with voluntary
movement

SBCM 2019 SECTION A Page 2 of 6

 SAN BEDA COLLEGE OF MEDICINE
NEUROLOGY:
BATCH 2019 A/Y 2015-2016 MINI OSCE REVIEWER

- Titubation - Cerebellar lesions result in nystagmus, dysmetria of

o unsteady oscillations of head and trunk saccades, jerky rather than smooth pursuit, slowness
characterized by a low-frequency oscillation of in initiating eye movements, and skew deviation.
around 3 Hz
Cerebellar nystagmus occurs preeminently during
- Intention, End-point, or Kinetic tremor
o tremor as a limb approaches a target volitional use of the eyes and thus is gaze evoked.
o absent at rest, appear with movement and often
get worse as the target gets closer C. Types of Gait
3. HYPOTONIA** 1. Developmental gaits: Automatic stepping of the newborn,
- The loose floppy joints and muscles; dec muscle tone cruising, toddler’s gait, and normal mature gait.
- Muscle tone- muscular resistance the Ex feels when 2. Spastic gaits: Hemiplegic gait, spastic diplegic gait, scissors
moving the pt’s resting extremity gait, crouch gait, paraplegic gait, and spastic-ataxic gait.2.
- Passively move the Pt’s extremities, inspect for rag-
3. Neuromuscular gaits: Lordotic waddling (myopathic) gait,
doll postures and a rag-doll gait, and look for
pride of pregnancy gait, Gower’s sign, unilateral and bilateral
pendulous MSRs.
4. ASTHENIA** foot-drop or step-page gait,heel-drop gait, flail-foot gait, and
- i.e. weakness, fatigability, and a reluctance to move toe-walking gait.
 Steppage Gait
B. Other Cerebellar Signs - Seen in foot drop.
 Dysarthria - Patients either drag the feet or lift them high, with
- uncoordinated, slurred speech, like any neurogenic knees flexed, and bring them down with a slap onto
disturbance of voice articulation the floor. They cannot walk on their heels.
- refers to a defect in the muscular control of the speech - Tibialis anterior and extensors are weak
apparatus (lips, tongue, palate, or pharynx). Words may 4. Sensory gaits: Hyperesthetic gait, radicular pain or antalgic
be nasal, slurred, or indistinct. Causes include motor gait, nocturnal flipping- hand gait in an adult and a flipping-
lesions of the central or peripheral nervous system, hand gait in a retarded child, a sensory ataxia or tabetic gait,
parkinsonism, and cerebellar disease. and a blind person’s gait.
 Nystagmus  Cerebellar Ataxia
- Uncoordinated / rhythmic oscillations of the eyes - Gait is staggering, unsteady, wide-base with
has both slow and fast movements, but is defined by its exaggerated difficulty on turns
fast phase - Patients cannot stand steadily with feet together,
 Pendular Nystagmus - coarse oscillations without whether eyes are open or closed
quick and slow components.  Sensory Ataxia
 Left-beating nystagmus - i.e. eyes jerk quickly to the - Caused by loss of position sense in the legs
patient’s left and drift back slowly to the right. - Unsteady and wide-based gait
 Scanning Speech. - They watch the ground for guidance when walking
- Pt’s voice varies from a low volume to a high volume as if - They can stand steadily with feet together when eyes
scanning from peak to peak. are open, but not when closed (+) Romberg
 Dysmetria 5. Basal ganglia gaits: Marche à petit pas, parkinsonian gait,
- Pt frequently undershoots or overshoots the target festinating gait, en bloc or pedestal turning, choreiform gait,
because of failure to control, or meter, the muscular spastic-athetoid gait, equinovarus dystonic gait, dromedary or
contractions that set the distance (finger to nose test) tortipelvis dystonic gait.
 Dysdiadochokinesia  Parkinsonian Gait
- dystaxia-dysmetria of rapid alternating, movements; - Caused by basal ganglia defects of Parkinsonism
incoordination of muscular contractions during rapid - Stooped posture, flexed head, arms, hips, knees
alternating movements (pronation- supination test –aka - Patients are slow getting started
free hand test, thigh patting, finger tapping test). - Short, shuffling steps with festination (involuntary
- Thigh patting test is more used than the free hand test hastening)
because this produces audible alternating sounds. - Patients turned around stiffly
- The finger tapping test could be made audible with the 6. Cerebral gaits: Marche à petit pas, dancing bear, and the
use of cassette tapes. signs of the gait variously named an apraxic gait, frontal gait,
 The cerebellar Pt may experience mild asthenia, i.e., ignition failure gait, and progressive primary freezing gait.
weakness, fatigability, and a reluctance to move. The 7. Psychiatric gaits: Astasia-abasia gait of hysteria, gaits of
feedback pathway that connects the cerebellar cortex depression and agitated depression, schizophrenic gaits,
with the cerebral motor cortex might explain the asthenia. Tourette’s syndrome gait, and hyperactive child gait.
Destruction of the pathway might alter the output of the
cerebral motor cortex.
 Effects of cerebellar lesions on eye movements
- in testing, make sure EX and Pt have same eye level

SBCM 2019 SECTION A Page 3 of 6

 SAN BEDA COLLEGE OF MEDICINE
NEUROLOGY:
BATCH 2019 A/Y 2015-2016 MINI OSCE REVIEWER

ROMBERG TEST
1. Have the patient stand still with heels and toes together.
2. Ask the patient to close her eyes and balance herself.
Closing the eyes removes visual input.
(+) Romberg = The patient loses balance, when eyes are closed
(hindi na alam ng tao kung nasan siya, kasi sarado na ang
mata)
 Loss of balance suggests impaired proprioception.
 In disease of the cerebellum:
Steppage gait Cerebellar gait Sensory ataxia Parkinsonian gait
o Lateral lobe, falling is toward the affected side
o Frontal lobe, falling is to the opposite side
IV. TESTS FOR CEREBELLAR DYSFUNCTION o Midline or vermis, falling indiscriminately

GAIT TESTING
- First notice how the Pt rises and the steadiness of the
vertical posture.
- Instruct the patient to walk across the room, then turn,
and come back.
2) Ask the patient to stand from a chair, walk across the room,
Observe posture, balance, movements of the legs, irregular
strides, lack of heel-to-toe, unsteadiness, a wide-based gait, turn, and come back towards you. Pay particular attention to:
overplay of involuntary movements, and lack of or excessive Difficulty getting up from a chair:
arm swinging. Notice whether the Pt turns  Problems with this activity might suggest proximal muscle
- by Stepping around freely or rotates on the spot, en bloc, weakness, a balance problem, or difficulty initiating
with tiny steps. movements.
- Walk heel to toe in a straight line, a.k.a tandem walking to
Balance:
test for balance.
 Ask the patient to walk in a straight line, putting the  Do they veer off to one side or the other as might occur
heel of one foot directly in front of the toe of the with cerebellar dysfunction?
other  Dysfunction of a cerebellar hemisphere will cause the
 This may be difficult for older patients (due to the patient to fall to the same side.(e.g. tumor on L
frequent coexistence of other medical conditions) cerebellum – patient will tend to fall to the L)
even in the absence of neurological disease  Diffuse disease affecting both cerebellar hemispheres will
- Test triceps surae strength and balance by having the Pt
cause a generalized loss of balance.
walk on the balls of the feet and then on the heels. Walk
on toes, then on heels. Rate of walking:
 May reveal distal muscular weakness in the legs.  Do they start off slow and then accelerate, perhaps losing
 Hop in place on each foot in turn (if the patient is control of their balance or speed?
not too ill).  Are they simply slow moving secondary to pain / limited
 Involves the proximal and distal muscles of the legs range of motion in their joints, as might occur with
 Rising from a sitting position without arm support
degenerative joint disease? etc.
and stepping up on a sturdy stool.
Attitude of Arms and Legs:
 Proximal muscular weakness (pelvic girdle and
legs)  How do they hold their arms and legs?
 Is there a loss of movement and evidence of contractures?
- Symptomatic cerebellar lesions universally impair the gait (e.g. after stroke)
and stance. To compensate for unsteadiness of stance and
gait, the cerebellar Pt assumes a broad-based stance and
- If the Pt rises, stands, and walks completely normally,
a broad-based gait, just as a toddler does before gaining
then, in all probability, the Pt’s motor system is
coordination, or an elderly Pt does after losing some.
- Finally, request a deep knee bend. Ask a child to run and completely intact. If the Pt’s motor system is completely
hop. Throughout, note how well the Pt comprehends and intact, then, in all probability, the sensory system is
executes the commands. Retarded, demented, psychotic, completely intact. If the Pt follows all commands promptly
and passive-aggressive or oppositional Pts require and well, with no confusion or hesitancy, then in all
constant coaxing. probability the Pt’s mental state and sensorium are intact.
With motor, sensory, and mental functions intact, then, in
STANCE
Cerebellar ataxia is not improved by visual orientation all probability, the Pt’s nervous system is intact.
1) Have the patient stand in one place. - A normal gait requires the integrity of vast circuits of the
 This is a test of balance, incorporating input from the PNS and CNS: circuits that underlie the willing of
visual, cerebellar, proprioceptive, and vestibular systems. movements and the antigravity, supporting, and righting
reflexes; circuits that coordinate the rate, regularity, and
force of the muscular contractions; circuits that generate

SBCM 2019 SECTION A Page 4 of 6

 SAN BEDA COLLEGE OF MEDICINE
NEUROLOGY:
BATCH 2019 A/Y 2015-2016 MINI OSCE REVIEWER

reciprocal limb actions; and circuits that mediate touch,

proprioception, and vision

THE OVERSHOOTING TEST (aka REBOUND) OF THE UPPER

EXTREMITIES
 Arm displacement test
- Starting point: pt with eyes closed, arms outstretched
- Ex: -“I am going to tap your arms. Hold them still. Don’t let
me budge them.” The Ex strikes the back of the Pt’s wrist
a sharp blow, strong enough to displace the arm.
- Response: The normal subject’s arm returns quickly to its RAPID ALTERNATING MOVEMENTS
initial positionPRONATOR DRIFT. The cerebellar Pt’s ARM
arm oscillates back and forth: it overshoots several times 1. Show the patient how to strike one hand on the thigh, raise
the hand, turn it over, and then strike the back of the hand
down on the same place
2. Ask the patient to do it as rapidly as possible. Observe the
speed, rhythm, and smoothness of the movements.
3. Repeat with the other hand. The non- dominant hand often
performs somewhat less well.

**PRONATOR DRIFT -Px should stand for 20-30sec with both

arms straight forward, palms up, and eyes closed. Tap the
arms briskly downward. It is both sensitive and specific for a
corticospinal tract lesion originating in the contralateral
hemisphere. Downward drift of the arm with flexion of fingers FINGER
and elbow may also occur. 1. Show the patient how to tap the distal joint of the thumb
 Holmes rebound test with the tip of the index finger, again as rapidly as possible.
- Starting point: Pt’s arms extended out front Observe the speed, rhythm, and smoothness of the
- Ex: grasp pt’s wrists (held in place), pull them down, movements.
sudden release grip
- Response: The normal arm will fly upward a small
distance, checks and rebound, and quickly resume the
resting position. The cerebellar Pt specifically overshoots
by flying upward a greater distance and then overshoots
the up and down position several times.
 Arm pulling test
- Starting point: Pt arm is flexed Interpretation for both arm and finger:
- Ex: Ex pulls hard against the Pt’s flexed arm The movement should be fluid and accurate; if otherwise it is
- Response: When the Ex suddenly releases the Pt’s arm, dysdiadochokinesia
the cerebellar Pt fails to check the arm’s flight.
TESTS FOR LEG DYSTAXIA
 HEEL TO SHIN TEST
- Starting point: pt supine or sitting; pt to place one heel
precisely on the opposite knee; hold the heel to the knee
few seconds; Pt to run the heel in a straight line precisely
down the shin
- Response: observe positional tremor (while holding the
heel to the knee). The cerebellar Pt misses the spot
(dysmetria) and taps dysrhythmically (dysdiadochokinesia)
- Note the smoothness and accuracy of the movements.
FINGER TO NOSE TEST - Repetition with the patient’s eyes closed tests for position
1. Ask the patient to touch your index finger and then his or sense. Repeat on the other side
her nose alternately several times.
 HEEL TAPPING
- To enlist the Pt’s best effort, say, “Move your finger in and
- Starting point: pt supine or sitting; pt to place one heel
place the tip of your finger exactly on the tip of your nose.
precisely on the opposite knee; Pt to place one heel over
Don’t miss!”
the other shin and to tap the shin with the heel as rapidly
2. Move your finger about so that the patient has to alter
as possible on one spot
directions and extend the arm fully to reach it. Observe the
- Response: observe positional tremor (while holding the
accuracy and smoothness of movements, and watch for any
heel to the knee). The cerebellar Pt misses the spot
tremor.
(dysmetria) and taps dysrhythmically (dysdiadochokinesia)
Interpretation: The patient should be able to do this at a
reasonable rate of speed, trace a straight path, and hit the end
points accurately. Missing the mark or overshooting the target,
known as dysmetria, may be indicative of cerebellar disease.

SBCM 2019 SECTION A Page 5 of 6

 SAN BEDA COLLEGE OF MEDICINE
NEUROLOGY:
BATCH 2019 A/Y 2015-2016 MINI OSCE REVIEWER

V. ANALYSIS OF PATIENTS AND THE  By means of the single pyramidal decussation,

FOUR CEREBELLAR SYNDROMES cerebral hemisphere controls volitional movements
on the contralateral side of the body.
 By means of double crossing pathways in conjunction
with the pyramidal decussation, one cerebellar
hemisphere ultimately coordinates muscular
contractions on the ipsilateral side of the body.

VI. SUMMARY OF THE CLINICAL

EXAMINATION OF CEREBELLAR
DYSFUNCTION

- Rostral vermis syndrome

 results from alcoholism and nutritional deficiency.
- Caudal vermis syndrome
 implies a midline cerebellar neoplasm, usually a
medulloblastoma, ependymoma, or astrocytoma.
- Cerebellar hemisphere syndrome
 comes from an acute destructive lesion, most likely an
infarct, hemorrhage, neoplasm, abscess, or trauma.
- Pancerebellar syndrome
 requires a lesion that affects the entire cerebellum,
and, therefore, usually results from vitamin
deficiencies, toxic or metabolic, demyelinating,
immune mediated, paraneoplastic, or hereditary or
non-hereditary degenerative ataxias.
 presents the most difficulty in differential diagnosis
because the causative agents span the ocean of
possibilities.
 Intermittent pancerebellar signs suggest a metabolic
disorder with intermittent flare-ups, disclosed by
measuring amino acids and organic acids, or a
demyelinating disorder, such as multiple sclerosis.
 The fairly common vascular lesions that affect the
distribution of only one cerebellar artery are relatively VII. REFERENCES AND AUTHORS
th
easy to diagnose.  DeMyer’s Neurologic Examination 6 Edition
th
- final warning: A mass lesion in the cerebellum or  Bates’ Guide to Physical Examination and History Taking 11
Edition by Lynn S. Bickley
posterior fossa is always a danger. It may cause the th
 Clinical Neuroanatomy 7 Edition by Richard Snell
posterior fossa contents to herniate upward through the
tentorial notch or downward through the foramen AUTHORS
magnum or directly compress the medullary respiratory Francisco, Tricia (Editor)
Gozun, Zara
center
Inocencio, Marie Pompei
- “Cerebral hemisphere lesions cause contralateral motor
signs, whereas cerebellar hemisphere lesions cause VIDEO
ipsilateral motor signs.” Abu, Reigna
Amer, Salih
Bagsit, Mitzi

SBCM 2019 SECTION A Page 6 of 6