Neurology - Topic 4 - Cerebellar Syndrome Examination

I'm now going to briefly show how to assess the cerebellum or features of a cerebellar syndrome I once again I would recommend at all times you've obviously had a conversation with the patient and you can pick up certain things but the gate I must emphasize more than anything else so I've shown on a number of occasions in this video that how to examine a normal gait but I'm going to talk it to now a person who doesn't obviously have a cerebellar syndrome but what you're looking for on how to examine it and head through to its end so once again Peter thank you very much for coming I'm going to examine your walk and I'm going to talk at the students through this as we go along okay so if you wouldn't mind walking as far as the pillar they're turning around slowly and then half way I'm half way back just stop okay and then I want you to walk heel to toe as before so a bit more slowly this time you could don't mind if you could walk towards the pillar please so as he walks I'm looking for the the width of the gate it's called a broad-base gate in cerebellar syndrome as if someone's had drunk too much and when they turn they have to turn on an axis like that because they're always fearful they're going to fall over now the next thing you look for is you ask the patient to stop at this time it's crucially important as I've said before you're going to ask them to heel to toe walk again so could you try that now if someone has a bad cerebellar syndrome or a severe one I should say there's no way they'll be able to this they'll take one or two steps and they'll be falling all over the place like this so don't push it as I keep saying the next thing you do as always is stand on the toes and on the heels it won't be relevant here but what will be relevant and is very important is the Romberg sign once more so can you put your feet tightly close together at this time I must remind you again that vision vestibular system and posterior columns keep you up in space when your feet are tightly closed together and you ask them to close their eyes if the posterior columns or the vestibular system are afflicted in any way the patient or the person will fall over note this is not part of the cerebellar syndrome an urban myth if you will or a medical medically urban myth that the cerebellum do deficit for the cerebellum cause of Romberg's positive syndrome it does not now it can look like it you must reassure the patients I often do this over there here I'm here they feel unsteady you say I'm here I'm here and reassure them and then just step away for a long enough to say it's actually negative so you must give the patient confidence when you're doing that the next thing you do then thanks Pierre is is you ask the patient to relax be a bit more comfortable and when you're examining the cerebellum like most of the neurology system when you're thinking through it you start from head to toe now I'm going to ask you to look straight ahead and you look at my finger here okay now what I'm looking for here from the side is the patient's looking at me and I'm looking at the eye movements now at rest at thing called square wave jerks tiny little jerkiness of the eyes can occur in the cerebellar syndrome so I look rather closely and a lot of students tend to say there are no square wave jerks that pupils are equal etc and and they haven't actually looked so you must take your time you must breathe easy particularly examination situations so you look very closely and then another fault our students tend to make is when they say has pursuit movements if you could follow my finger please they do it like this too quick nobody can do that it looks like nystagmus all the time so what I'm looking for is look at my finger not too close to the patient either I hope and I ask the patient to keep their head still and follow my finger and most patients can keep their head still you don't need to put your hand all over the way any thought and what I'm looking for here is flick enos of the eyes or nystagmus clearly Peter doesn't have any now very slowly look at the speed it's very important I come over here maybe I'm going even too slowly and I tend to go left and right just to get a feel for it at the extremes of gauge you can get a few little bits of nystagmus tends to be over interpreted by the less experienced and then if you keep your head still you go up a head still and you can have up gaze and down gaze nystagmus but horizontal nystagmus tends to be more suggestive of a cerebellar problem the cerebellum air also can influence speech and you one gets difficulty with articulation called dysarthria but dysarthria can read you two problems easier lips your tongue your palate and you have to rule those things out first so what I tend to do learning from people more experience than I I tend to ask them patients to say can you repeat the following fairly clearly and Padgett ibly obviously can you go okay so I know the lips and lip function is reasonably okay then I asked you to go Tata Tata Tata Tata as you can imagine that's Tung and then I want you okay so you know the palace's is fine so put that together it's Buttercup buttercup buttercup and I was taught to me by a very eminent neurologist in London so if that's all clear and the patient still has difficulty with the enunciation or with articulation then you can say well I wonder if this is a cerebellar syndrome and you look for the full package of course things don't come wrapped in full packages as we see in their textbooks but you put them all together the next thing I tend to do is ask the patient hold our hands out in front of them and I'm not looking for drift here as you see in stroke but what I ask the patient is close their eyes now what happens in cerebellar syndrome is the loss of control are superimposed control and motor and sensory function tends to lead to a kind of a drifting type situation so there's a rebound is what a rebound is what I'm looking for here so I'm going to tap when your hands Peter try and keep it in the same position I'm not going to tell you which one though so rather aggressively you note that his hand goes down and up and back into its original position in a rebound situation sometimes the patient is in quite sure where they where the hand is so that I tap hard like that and you go a few little over swings and that could happen in cerebellar syndrome and then if you open your eyes I'm now going to move air continuing and ask you to I'm going to tip the tip touch the tip of your finger and ask you to touch the tip of your nose very accurately okay and now to touch my finger and your nose and hold it and now my finger and your nose and my finger now a lot of people tend then and run back to your nose I'm going to try and catch them out but a lot of people tend to inappropriately move left to right and the patient's all over the place and you're all over the place and it's not a question of catching someone else it's a question of depth what you're trying to get is can they judge depth and so I now ask you to touch my finger and your nose and I move away and then back so if there's passed pointing someone's cerebellum will miss then go past it or when they come to the finger they're just not quite sure and they'll start to go come towards me and they'll get an intention tremor as they come to touch my finger so we're looking for path pointing intention tremor an excessive rebound I asked the patient's any must give clear instructions it's critical because once you clear clearly a chance I tell patients clearly what's going on they will cooperate very well so can you put both palms out like that and you could put your right hand on your left palm and then a big turn over a little slightly exaggerated here like that and then back and forth back now we get quicker and quicker and again it is doing it perfectly right the normal way should be like this but if someone has a deficit in the cerebellum their coordination will be reduced and they find they can't quite get it and they'll actually turn one hand on top of the other and that's called dis dire doko can easier and then if you swap over and you get quick and quicker and that's another sign of cerebellar syndrome or a deficit a problem with the cerebellum the other features you look for are a loss of tone but in my experience it's not really that obvious patients with cerebellar syndromes tend to have hypotonia hard to pick up I think and as you can imagine with the reflexes as we see later on and when you tap a reflex the response going to the brain isn't as clear cut so you tap the reflex it should go up and down obviously but in a cerebellar syndrome what tends to happen is you hope and the you get a pendulum reflex a slight over swing and that's again because the loss of control from cerebellum is saying where is the reflex where is the lemon space at this time and once you finish that you thank the patient is always and ask them to sit down you

Channel: UCD Medicine

Views: 391,407

Keywords: neurology, tubridy, medicine, cerebellar, syndrome, examination, UCD, neuro, education

Id: xEI4_St8qUU

Length: 8min 50sec (530 seconds)

Published: Mon Jan 07 2013