Cerebellar examination, gait and neuro presentation

• The cerebellar examination asks whether coordination, balance and tone are normal, and whether any abnormality is on one side, in the midline, or general.
• The key tests are gait and stance, finger-to-nose, rapid alternating movements, heel-to-shin, rebound, truncal balance, speech and nystagmus.
• A finger-nose or heel-shin abnormality points to an ipsilateral cerebellar lesion. ^[8]
• Sensory loss produces its own ataxia, which worsens when the eyes are closed (a positive Romberg test). ^[4]
• Parkinson disease produces a shuffling gait with small steps and little arm swing, whereas cerebellar ataxia is wide-based and reeling. ^[2][6]
• A careful screen of the whole nervous system (mental status, cranial nerves, motor, sensation, gait and reflexes) can be completed in about 4 minutes when the fundamentals only are needed. ^[1]
• A clear presentation leads with the most important finding, reports the abnormal and relevant negative findings, then ends with a summary and a differential.

By the end of this page you should be able to:

1. Set up and perform a cerebellar and coordination examination at the bedside in a reliable order.
2. Elicit and interpret finger-to-nose, heel-to-shin, dysdiadochokinesia, rebound, nystagmus, speech and truncal balance.
3. Recognise cerebellar, sensory-ataxic, parkinsonian, spastic and functional gait, and tell them apart.
4. Explain how the Romberg test separates impaired position sense from cerebellar disease.
5. Turn a list of neurological findings into a spoken or written presentation that ends in localisation and differential.

A cerebellar examination is part of every neurological examination. It asks whether coordination, tone, balance and speech are normal, and whether a problem lies in the cerebellum and its connections, in sensory pathways, or in motor pathways. The findings are best interpreted alongside the full neurological examination and localisation of disease, which is covered in its own MedGrasp topic; this page focuses on the cerebellar, gait and coordination components and on how to present them. NICE guidance reminds clinicians that neurological examination should be focused on the presenting problem and used to guide further assessment and referral rather than to reassure without reason. ^[9]

The eyes and ears do most of the work. By the time the formal testing begins you will already have seen the person walk in, sit down, reach for the cup and speak. Casual observation of posture, gait and the spontaneous use of the limbs colours everything that follows, so watch before you test. ^[1]

• Introduction and consent. Explain that you will test balance, coordination and gait, why, and that the person may steady themselves against you if needed. Confirm consent.
• Chaperone. Offer one when appropriate (intimate or sensitive aspects such as hip or pelvic exposure) and record the offer and response.
• Hand hygiene and safety. Clean your hands before and after. Stand so that you can catch the person if they sway, and clear the floor of obstacles. Do not test a person standing if you think they will fall; adapt (supine heel-shin, supported sitting balance).
• Exposure and position. The person should be able to stand, walk a clear distance and turn safely. Remove shoes if possible, and make sure the lighting is good. Have the person describe what they feel and see in their own words rather than prompting them.
• Environment and pace. A quiet room helps for speech testing. Test the apparently well side first for comparison, and do not rush; an ataxic person often performs worse when hurried.
• Screening. Where time is short, a problem-focused screen (mental status, cranial nerves, motor power, sensation, gait, reflexes) detects deficits in the major components; abnormal findings trigger a detailed examination of that component. ^[1]

Work in this order at the bedside. It groups the tests that need the person standing, then sitting, and it keeps the comparison between sides clean.

1. Gait (observational). Ask the person to walk a few metres away, turn briskly and walk back. Watch the moment they start (any delay?), the stride (length and width), the arm swing (symmetric and present?), and the turn (controlled or unsteady?). Repeat with heel walking, toe walking and tandem (heel-to-toe) gait. Do not ask someone to tandem walk if they are already unsteady; observe natural walking instead.
2. Stance and Romberg. With the person standing, feet together and arms at the sides if they can do so safely, watch the sway. Then ask them to close their eyes for a few seconds. A person who sways only, or markedly more, with the eyes closed has impaired position sense in the lower limbs. ^[4] In cerebellar disease the person usually tries to stand with the feet apart, as close together as possible without falling, and only then closes the eyes. ^[4] Stand close enough to prevent a fall.
3. Trunk and head. Sitting, ask the person to bring the arms forward and hold them there; watch for titubation (a nodding or tremor of the head and trunk) and for back-and-forth swaying of the trunk (truncal ataxia). Look also at the eyes for nystagmus and at the head and neck for scars.
4. Speech. Ask the person to repeat short, awkward phrases such as "baby hippopotamus" or "British Constitution" and a short sentence. Listen for slurring, a staccato (explosive) rhythm and scanning speech, in which each syllable is separated and prosody is lost. ^[8]
5. Eye movements. Look for nystagmus (its direction, amplitude and whether it is present at rest or only on gaze), saccadic dysmetria (overshoot or undershoot when the eyes move to your target) and diplopia. Nystagmus with the fast phase toward the side of the cerebellar lesion is typical of cerebellar disease. ^[3]
6. Tone in the upper limbs. With the eyes closed, support the person's forearms and ask them to keep the arms outstretched and steady while you push lightly downward on the forearms. If the arms overshoot on repositioning, rebound (loss of check) is present: the antagonists failed to brake the movement. ^[8] Note globally decreased tone (hypotonia) and, separately, spasticity, rigidity or lead-pipe tone. ^[3][5]
7. Rapid alternating movements (dysdiadochokinesia). Test the better side first. Ask the person to put one hand over the other and flip it over and back repeatedly at increasing speed, for about 5 seconds, then repeat on the other side. A jerky, irregular performance that breaks down with speed is dysdiadochokinesia. ^[8] The same can be tested by rapid thumb-to-index tapping. ^[2]
8. Finger-to-nose. Test the better side first, with vision allowed. Ask the person to touch their own nose, then your finger held at arm's length, then their nose again. Watch for dysmetria (overshooting or undershooting the target) and an intention tremor that worsens as the target is approached. Finger-to-nose dysmetria points to an ipsilateral cerebellar lesion. ^[8]
9. Lower limb tone. Test the patellar reflex on both sides, taking the weight of the leg and asking the person to relax. A pendular reflex, in which the leg swings back and forth like a pendulum with more than 4 swings, suggests hypotonia from cerebellar disease. ^[8]
10. Heel-to-shin. Test the better side first. Ask the person to place one heel on the opposite knee and run it steadily down the shin, then lift the foot and tap your hand, and repeat as fast as possible. Watch for clumsiness, wavering off the bone and inability to keep to the line. ^[8]
11. Record. Write the gait pattern, the accuracy of each movement for each limb, tone, speech, nystagmus and Romberg, and then go back and re-examine any abnormal movement once more before documenting the level and the side.

A normal result is steady gait with a normal base and arm swing, stable stance with no sway even with the eyes closed, accurate finger-to-nose and heel-to-shin on both sides, smooth rapid alternating movements, clear and normally phrased speech, no nystagmus and normal tone without rebound. Write these negatives down; they are half of the presentation.

Ataxia, a reeling, wide-based gait, is the archetypal sign. ^[3] Other signs that may accompany it include decomposition of movement (inability to sequence fine acts), dysarthria, dysdiadochokinesia, dysmetria, decreased tone, nystagmus with the fast phase toward the side of the lesion, scanning speech and an intention or postural tremor (high amplitude, low frequency) that appears as the target is approached. ^[3] Speech may be slow, slurred, staccato (explosive) or scanning, with syllables separated and prosody lost. ^[8] Eye findings include horizontal, vertical or rotary nystagmus. ^[3] A unilateral lesion produces ipsilateral incoordination and nystagmus to that side; midline (vermis) lesions particularly affect stance and gait. ^[3]

Rebound (loss of check) is tested in the arms and indicates that the antagonists cannot brake a sudden change in position. ^[8] Pendular reflexes (more than 4 swings of the leg) and hypotonia point to cerebellar disease. ^[3][8] Dysdiadochokinesia, dysmetria and finger-to-nose abnormality on one side point to an ipsilateral cerebellar lesion. ^[8]

Parkinson disease is a slowly progressive disorder of resting tremor, rigidity, slow and decreased movement (bradykinesia) and, eventually, gait and postural instability. ^[6] Gait is characteristic: the person has difficulty starting, turning and stopping; shuffles with short steps; holds the arms flexed at the waist; and swings the arms little or not at all. Steps may inadvertently quicken while stride length shortens (festination). ^[6] Masked facies, infrequent blinking and loss of facial expression support the diagnosis. ^[6] Postural instability that appears at onset, rather than later, should make you consider alternative diagnoses. ^[6]

Impaired joint position and vibration sense in the lower limbs (large-fibre sensory loss in the dorsal columns or peripheral nerves) makes the person place each foot under visual control. The gait is wide-based and careful, with the person looking down at the placement of the feet. The Romberg test is positive: the person stands with feet together while steady with the eyes open, but sways or falls when the eyes are closed. ^[4] Very rarely, bilateral severe vestibular loss produces the same picture. ^[4] Pseudoathetosis (involuntary writhing of a limb, used to find its position when position sense is lost) may also be seen. ^[4] Weakness is not the cause: the problem is not enough information about where the limbs are.

Upper motor neurone disease produces spasticity (clasp-knife increase in tone, often with cogwheel rigidity in the basal ganglia disorders). ^[5] The spastic leg does not bend at the knee and is swung outward in a rowing or circumducting motion to clear the toe; both legs crossing the central walking line (scissoring) may be seen. ^[2] A hemiparetic gait after a unilateral upper motor neurone lesion combines a flexed, pronated arm with a stiff, extended, circumducted leg and a plantarflexed foot. A unilateral problem such as this, with normal arm swing lost on one side, points to the contralateral motor pathway rather than to a single cerebellar hemisphere.

In a functional neurological presentation the signs are not consistently present and are not reproducible in a way that fits an anatomical pathway. ^[7] Two positive signs are useful: a person who reports marked plantar-flexion weakness in bed yet can walk on tiptoes normally, and the Hoover sign (downward pressure felt under the heel of the "paralyzed" leg when the opposite leg is lifted against resistance in a supine person). ^[7] A tremor that changes or disappears when the person is distracted, for example by copying a rhythmic movement with the unaffected hand, is also suggestive. ^[7] These are clinical findings to be stated plainly; they are not a reason to stop looking for organic disease.

Present in this order, whether speaking or writing. Examiners remember the first sentence and the last.

1. One-line header. "This is a (age)-year-old (person) with (the complaint that brought them)."
2. Most important finding first. State the pattern now, not at the end: "There is a left cerebellar syndrome," "There is a parkinsonian gait," or "The gait and coordination are normal."
3. Abnormal finding in a sentence. Give the sign, the side and one example of how you elicited it: "Finger-to-nose and heel-to-shin are inaccurate on the left, with ipsilateral intention tremor."
4. Relevant negatives. Say the ones that change the differential: cranial nerves intact, no sensory level, normal power, no Romberg sway, eye movements without nystagmus, speech clear.
5. Summary in one sentence. Say where the problem is and what it is not: "The findings localise to the left cerebellar hemisphere and its connections."
6. Differential in one or two sentences. Two or three plausible causes, ordered by likelihood and danger, not a textbook list.
7. Plan (when presenting to a senior). One or two practical next steps: imaging, bloods, review timing.

Written notes use the same order but shorter: "Gait wide-based, reeling, R Romberg negative; speech scanning; nystagmus fast phase L; LL/UL tone decreased with rebound and finger-nose dysmetria L; heel-shin dysmetric L; pendular reflex > 4 swings on L. Differential: L cerebellar hemisphere lesion (vascular, inflammatory, neoplastic); sensory ataxia less likely (Romberg negative, vibration preserved). Needs MRI posterior fossa and urgent vascular assessment." Only abbreviations you have already explained (R, L, UL, LL) are allowed, and only one or two per line of speech.

Negatives carry weight: "The cranial nerves are intact to the testing I performed" is more useful than "CN intact" without expansion. If you could not test something, say so and state what you did instead.

The following patients are invented and illustrative. All details are fictional.

Illustrative normal (invented patient). Spoken: "Oliver, 23, a medical student, here with a sore throat. When he walked in, his gait was normal and steady. On examination his stance is stable with no sway, even with the eyes closed; finger-to-nose, rapid alternating movements and heel-to-shin are accurate and brisk on both sides; tone is normal with no rebound; the patellar reflexes are normal and not pendular; speech is clear; and there is no nystagmus. In summary, there is no cerebellar, sensory or motor incoordination, and gait and coordination are normal."

Illustrative cerebellar (invented patient). Spoken: "Aisha, 58, has had unsteadiness for five days. She walks with a wide-based, reeling gait and cannot do tandem walking. Speech is scanning, with each syllable separated. On the left, finger-to-nose and heel-to-shin are dysmetric with an intention tremor, rapid alternating movements are jerky, tone is reduced, rebound is present and the patellar reflex is pendular with five swings. Nystagmus is present with the fast phase to the left. The Romberg test is negative and vibration and position sense are intact. In summary, there is a left cerebellar syndrome, localising to the left cerebellar hemisphere and its connections. The likely causes are a vascular event in the posterior circulation, an inflammatory lesion or, less commonly, a mass. She needs urgent neuroimaging."

Illustrative sensory ataxia (invented patient). Spoken: "Tariq, 46, has pins and needles in his feet and unsteadiness in the dark. Gait is wide-based and careful; he watches where he puts each foot. Romberg is positive: he is steady with his eyes open but sways and almost falls when he closes them. Vibration and joint position sense are absent at the ankles and reduced at the knees; finger-to-nose is accurate. His cerebellar and motor examinations are otherwise normal. In summary, there is a sensory ataxia from large-fibre sensory loss, below the knees; the likely causes are a peripheral neuropathy or a posterior column lesion. He needs nerve conduction studies and, if indicated, spinal imaging."

Illustrative Parkinson (invented patient). Spoken: "Mrs Green, 71, has slowed over the past year. Gait is shuffling with short steps; arm swing is markedly reduced on both sides, the arms held flexed at the waist; there is difficulty starting and turning; steps sometimes quicken. There is resting tremor of the right hand, rigidity with cogwheeling and bradykinesia. In summary, there is a parkinsonian syndrome, with postural instability not yet prominent. The likely diagnoses are idiopathic Parkinson disease, or Parkinson-plus syndromes if there are early red flags. She needs a specialist review and, later, brain imaging if the presentation is atypical."

• Calling any unsteadiness "cerebellar ataxia": sensory ataxia, vestibular disease, weakness and functional disorders each have their own pattern, and the Romberg test helps separate them.
• Testing finger-to-nose only once and only on one side. Test the better side first and compare.
• Letting the person see your target while also testing eye-head coordination; observe both with and without vision.
• Missing nystagmus by looking only straight ahead: look at rest and in each direction of gaze, and note the fast phase.
• Reporting "CN intact" or "cerebellar signs present" without saying which test, which limb and which side.
• Pressing so hard during rebound that the person cannot help but overshoot; the push should be light, on the forearm.
• Forgetting to guard during stance and Romberg; a person with a positive Romberg will fall.
• Documenting tone without distinguishing hypotonia, spasticity and rigidity; they localise to different systems.
• Skipping speech and gait: a reeling gait and scanning speech are often the first clues.
• Over-calling functional signs before excluding structural disease; state them as clinical findings, not as a conclusion from exclusion.

• The cerebellar examination tests coordination, tone, balance, gait, speech and eye movements.
• A wide-based reeling gait points to cerebellar ataxia; a shuffling short-stepped gait with little arm swing points to Parkinson disease.
• Finger-to-nose and heel-to-shin dysmetria, and dysdiadochokinesia, on one side point to an ipsilateral cerebellar lesion.
• Rebound (loss of check), hypotonia and pendular reflexes (more than 4 swings) reflect cerebellar hypotonia.
• Scanning, staccato or slurred dysarthria, and nystagmus with the fast phase toward the side of the lesion, support a cerebellar cause.
• Romberg positive with eyes closed points to impaired position sense; in cerebellar disease the feet are placed apart before the eyes close.
• Sensory ataxia is careful, wide-based, visually guided gait with preserved strength.
• Functional signs include variability, walking on tiptoes despite weak plantar flexion, Hoover sign and tremor that disappears with distraction.
• Present abnormal findings first, then the nerve-by-nerve or system-by-system report, then a summary, then the differential.
• State the negatives that matter and write enough to prove each part was tested.