Cagayan State University

College of Medicine

Experiment 28:
CEREBELLAR FUNCTION TESTS

A Formal Written Report

Physiology Laboratory

In partial fulfillment of the requirements in

Doctor of Medicine

By: Group 4 - Section Med 1A

Cruz, Lunna-Sol
Davis, Glenda
Delos Santos, Jan Reeya Claire
Malazzab, Lyka Rose
Oñate, Terese
Raralio, Rainier
Tagulao, Aghios

May 2019
I. INTRODUCTION

The cerebellum plays a very important role in the control of posture and voluntary movements. It
unconsciously influences the smooth contraction of voluntary muscles and carefully coordinates their
actions, together with the relaxation of their antagonists. A great emphasis is placed on the fact that each
cerebellar hemisphere controls muscular movements on the same side of the body and that the
cerebellum has no direct pathway to the lower motor neurons but exerts its control via the cerebral
cortex and the brainstem.

The cerebellum is situated in the posterior cranial fossa and is covered superiorly by the tentorium
cerebelli. It is the largest part of the hindbrain and lies posterior to the fourth ventricle, the pons, and the
medulla oblongata (Fig. 28-1).

Figure 28.1 Sagittal section through the brainstem and the vermis of the cerebellum.

The cerebellum is somewhat ovoid in shape and constricted in its median part. It consists of two
cerebellar hemispheres joined by a narrow median vermis. The cerebellum is connected to the posterior
aspect of the brainstem by three symmetrical bundles of nerve fibers called the superior, middle, and
inferior cerebellar peduncles .

The cerebellum is divided into three main lobes: the anterior lobe, the middle lobe, and the
flocculonodular lobe. The anterior lobe may be seen on the superior surface of the cerebellum and is
separated from the middle lobe by a wide V-shaped fissure called the primary fissure (Figs. 28.2 and
28.3).
 Figure 28.2. The cerebellum. A: Superior view. B. Inferior view

The middle lobe (sometimes called the posterior lobe), which is the largest part of the
cerebellum, is situated between the primary and uvulonodular fissures. The flocculonodular lobe is
situated posterior to the uvulonodular fissure (Fig. 28.3). A deep horizontal fissure that is found along
the margin of the cerebellum separates the superior from the inferior surfaces; it is of no morphologic or
functional significance (Figs. 28.2 and 28.3).
 Figure 28.3. A. Flattened view of the cerebellar cortex showing the main cerebellar lobes, lobules, and
fissures. B. Relationship between the diagram in (A) and the cerebellum.

FUNCTIONS OF THE CEREBELLUM

The cerebellum receives afferent information concerning voluntary movement from the cerebral
cortex and from the muscles, tendons, and joints. It also receives information concerning balance from
the vestibular nerve and possibly concerning sight through the tectocerebellar tract. All this information
is fed into the cerebellar cortical circuitry by the mossy fibers and the climbing fibers and converges on
the Purkinje cells (Fig. 28.4).
 Figure 28.4. Functional organization of the cerebellar cortex, The arrows indicate the direction taken by the
nervous impulses.

The axons of the Purkinje cells project with few exceptions on the deep cerebellar nuclei. The
output of the vermis projects to the fastigial nucleus, the intermediate regions of the cortex project to the
globose and emboliform nuclei, and the output of the lateral part of the cerebellar hemisphere projects to
the dentate nucleus. A few Purkinje cell axons pass directly out of the cerebellum and end on the lateral
vestibular nucleus in the brainstem. It is now generally believed that the Purkinje axons exert an
inhibitory influence on the neurons of the cerebellar nuclei and the lateral vestibular nuclei. The
cerebellar output is conducted to the sites of origin of the descending pathways that influence motor
activity at the segmental spinal level. In this respect, the cerebellum has no direct neuronal connections
with the lower motor neurons but exerts its influence indirectly through the cerebral cortex and
brainstem.

Physiologists have postulated that the cerebellum functions as a coordinator of precise

movements by continually comparing the output of the motor area of the cerebral cortex with the
proprioceptive information received from the site of muscle action; it is then able to bring about the
necessary adjustments by influencing the activity of the lower motor neurons (Fig. 28.5).
 Figure 28.5. Cerebellum serving as a comparator.

This is accomplished by controlling the timing and sequence of firing of the alpha and gamma
motor neurons. It is also believed that the cerebellum can send back information to the motor cerebral
cortex to inhibit the agonist muscles and stimulate the antagonist muscles, thus limiting the extent of
voluntary movement.

CEREBELLAR AFFERENT FIBERS

Cerebellar Afferent Fibers From the Cerebral Cortex

The cerebral cortex sends information to the cerebellum by three pathways:
(1) the corticopontocerebellar pathway,
(2) the cerebro-olivocerebellar pathway, and
(3) the cerebroreticulocerebellar pathway.

Cerebellar Afferent Fibers From the Spinal Cord

The spinal cord sends information to the cerebellum from somatosensory receptors by three
pathways:
(1) the anterior spinocerebellar tract,
(2) the posterior spinocerebellar tract, and
(3) the cuneocerebellar tract.

Table 28.1. THE AFFERENT CEREBELLAR PATHWAYS

 CEREBELLAR EFFERENT FIBERS

The entire output of the cerebellar cortex is through the axons of the Purkinje cells. Most of the
axons of the Purkinje cells end by synapsing on the neurons of the deep cerebellar nuclei. The axons of
the neurons that form the cerebellar nuclei constitute the efferent outflow from the cerebellum. A few
Purkinje cell axons pass directly out of the cerebellum to the lateral vestibular nucleus. The efferent
fibers from the cerebellum connect with the red nucleus, thalamus, vestibular complex, and reticular
formation.

Table 28.2. THE EFFERENT CEREBELLAR PATHWAYS

 OBJECTIVE:
This laboratory experiment aims to examine the functions of the cerebellum.

 TERMINOLOGIES:

 Ataxia – lack of voluntary coordination of muscle movements

 Dysarthria – difficult or unclear articulation of speech that is otherwise linguistically normal
 Dysdiadochokinesia – impaired ability to perform rapid, alternating movements
 Emboliform nuclei – anterior interposed nucleus that lies to the medial side of the nucleus
dentatus
 Fastigial nucleus – phyllogenetically oldest nucleus in the cerebellum which receives it
inputs from purkinje cells in the vermis
 Globose nucleus – one of the deep cerebellar nuclei; located medial to the emboliform
nucleus and lateral to the fastigial nucleus.
 Hypotonia – commonly known as floppy baby syndrome, is a state of low muscle tone, often
involving reduced muscle strength
  Nystagmus – eyes make repetitive, uncontrolled movements
 Purkinje cells – neurons located in the cerebellar cortex of the brain
 Red nucleus – pale pink, believed to be due to the presence of iron in at least two different
forms: hemoglobin and ferritin.
 Tentorium cerebelli – extension of the dura mater that separates the cerebellum from the
inferior portion of the occipital lobes.
 Tremor – involuntary, rhythmic, muscle contraction and relaxation involving oscillations or
twitching movements of one or more body parts.
 Vermis – located in the medial, corticonuclear zone of the cerebellum, which resides in the
posterior fossa of the cranium.

CLINICAL SIGNIFICANCE

Each cerebellar hemisphere is connected by nervous pathways principally with the same side of
the body; thus, a lesion in one cerebellar hemisphere gives rise to signs and symptoms that are
limited to the same side of the body.

SIGNS AND SYMPTOMS OF CEREBELLAR DISEASE

 Hypotonia
The muscles lose resilience to palpation. There is diminished resistance to passive
movements of joints. Shaking the limb produces excessive movements at the terminal joints. The
condition is attributable to loss of cerebellar influence on the simple stretch reflex.

 Postural Changes and Alteration of Gait

The head is often rotated and flexed, and the shoulder on the side of the lesion is lower
than on the normal side. The patient assumes a wide base when he or she stands and is often stiff
legged to compensate for loss of muscle tone. When the individual walks, he or she lurches and
staggers toward the affected side.

 Disturbances of Voluntary Movement (Ataxia)

The muscles contract irregularly and weakly. Tremor occurs when fine movements,
such as buttoning clothes, writing, and shaving, are attempted. Muscle groups fail to work
harmoniously, and there is decomposition of movement. When the patient is asked to touch the
tip of the nose with the index finger, the movements are not properly coordinated, and the finger
either passes the nose (past-pointing) or hits the nose. A similar test can be performed on the
lower limbs by asking the patient to place the heel of one foot on the shin of the opposite leg.

 Dysdiadochokinesia
 Dysdiadochokinesia is the inability to perform alternating movements regularly and
rapidly.Ask the patient to pronate and supinate the forearms rapidly. On the side of the cerebellar
lesion, the movements are slow, jerky, and incomplete.

 Disturbances of Reflexes
Movement produced by tendon reflexes tends to continue for a longer period of time than
normal. The pendular knee jerk, for example, occurs following tapping of the patellar tendon.
Normally,the movement occurs and is self-limited by the stretch reflexes of the agonists and
antagonists. In cerebellar disease, because of loss of influence on the stretch reflexes, the
movement continues as a series of flexion and extension movements at the knee joint; that is, the
leg moves like a pendulum.

 Disturbances of Ocular Movement

Nystagmus, which is essentially an ataxia of the ocular muscles, is a rhythmical
oscillation of the eyes. It is more easily demonstrated when the eyes are deviated in a horizontal
direction. This rhythmic oscillation of the eyes may be of the same rate in both directions
(pendular nystagmus) or quicker in one direction than in the other (jerk nystagmus). In the
latter situation, the movements are referred to as the slow phase away from the visual object,
followed by a quick phase back toward the target. The quick phase is used to describe the form of
nystagmus. For example, a patient is said to have a nystagmus to the left if the quick phase is to
the left and the slow phase is to the right.The movement of nystagmus may be confined to one
plane and may be horizontal or vertical, or it may be in many planes when it is referred to as
rotatory nystagmus. The posture of the eye muscles depends mainly on the normal functioning of
two sets of afferent pathways.The first is the visual pathway whereby the eye views the object of
interest,and the second pathway is much more complicated and involves the labyrinths, the
vestibular nuclei, and the cerebellum.

 Disorders of Speech
Dysarthria occurs in cerebellar disease because of ataxia of the muscles of the
larynx.Articulation is jerky, and the syllables often are separated from one another. Speech
tends to be explosive, and the syllables often are slurred. In cerebellar lesions, paralysis and
sensory changes are not present.Although muscle hypotonia and incoordination may be
present, the disorder is not limited to specific muscles or muscle groups; rather, an entire
extremity or the entire half of the body is involved. If both cerebellar hemispheres are involved,
then the entire body may show disturbances of muscle action. Even though the muscular
contractions may be weak and the patient may be easily fatigued, there is no atrophy.

CEREBELLAR SYNDROMES

 Vermis Syndrome
The most common cause of vermis syndrome is a medulloblastoma of the vermis in
children. Involvement of the flocculonodular lobe results in signs and symptoms related to the
vestibular system. Since the vermis is unpaired and influences midline structures, muscle
incoordination involves the head and trunk and not the limbs.There is a tendency to fall forward
 or backward.There is difficulty in holding the head steady and in an upright position. There also
may be difficulty in holding the trunk erect.

 Cerebellar Hemisphere Syndrome

Tumors of one cerebellar hemisphere may be the cause of cerebellar hemisphere
syndrome.The symptoms and signs are usually unilateral and involve muscles on the side of the
diseased cerebellar hemisphere. Movements of the limbs, especially the arms,are
disturbed.Swaying and falling to the side of the lesion often occur. Dysarthria and nystagmus are
also common findings. Disorders of the lateral part of the cerebellar hemispheres produce delays
in initiating movements and inability to move all limb segments together in a coordinated manner
but show a tendency to move one joint at a time.

COMMON DISEASES INVOLVING THE CEREBELLUM

 Acute alcohol poisoning

One of the most common diseases affecting cerebellar function.This occurs as the result of
alcohol acting on GABA receptors on the cerebellar neurons.

 The following frequently involve the cerebellum:

 congenital agenesis or hypoplasia,trauma,
 infections,
 tumors,
 multiple sclerosis,
 vascular disorders such as thrombosis of the cerebellar arteries, and
 poisoning with heavy metals.

 The many manifestations of cerebellar disease can be reduced to two basic defects:
 Hypotonia and
 loss of influence of the cerebellum on the activities of the cerebral cortex

II. METHODOLOGY
A. Head
1. The subject was asked to speak random words to assess his speech.
2. The subject was asked to gaze upon the examiner to observe whether nystagmus is present or not.

B. Upper Limb (See Appendix for images)

1. Each arm of the subject was passively flexed and extended to assess the tone.
2. Point-to-point movement was assessed by asking the subject to fully extend each of his arm, then
touch his nose with a finger. This step was repeated with the subject’s eyes closed.
3. The examiner assessed the subject’s alternating movement by having the subject touch the pad of
her index finger with the pad of the subject’s index finger. Then the patient touches his or her
nose with the pad of the index finger. This step was repeated with the subject’s eyes closed.
 4. Fine motor skill was assessed by having the subject count the fingers of each of his arms using the
opposition of his corresponding thumb to the rest of his fingers. This step was repeated with the
subject’s eyes closed.
5. Another assessment for alternating movement was made by having the patient strike the
laboratory tables using his palm, then the dorsum of his hand alternately.
6. The examiner tested the subject’s rebound phenomenon by grasping the patient's right wrist. The
subject was asked to flex the right arm sharply, and the examiner suddenly let go.
7. Hand and eye coordination of the subject was tested by having him insert a thread through the
head of a needle.

C. Lower Limb (See Appendix for images)

1. The subject was asked to flex his leg while the examiner was holding his thigh. The subject was
also asked rapidly dorsiflex and partially evert the foot while the examiner was holding his leg.
This is to assess the overall tone of the subject’s lower limb.
2. The subject was asked to walk in the usual fashion across the room and back. This is to see
whether there is deviation from an imaginary straight line and to observe any abnormality in the
manner by which he walks.
3. The subject was asked to do tandem walking, where he walked a straight line in a heel-to-toe
manner. This is probably the most sensitive test of function of the vermis of the cerebellum.
4. Knee jerk was elicited in the subject to observe his cerebellar function. Under normal conditions,
his knee should not move in a pendular manner when the patellar tendon is tapped.
5. The subject was asked to gently tap his left knee using his right heel. Then, his right knee with his
left heel.
6. The subject was asked to draw a circle using each of his great toes.
7. Romberg’s test was conducted by asking the subject to stand erect with feet together and eyes
closed. In theory, a subject with normal physiology must be able to maintain his posture without
swaying or toppling over. It was also conducted while the subject’s eyes were open.
III. RESULTS AND DISCUSSIONS
Name: TAGULAO, AGHIOS RAFAEL Age: 21
Sex: MALE Occupation: Student
UPPER LIMB
CEREBELLAR NORMAL FINDINGS ABNORMAL FINDINGS
FUNCTION TESTS
TONE Patient’s shoulders are -increased tone:
moved back and forth
1. spasticity- found with
freely; rotated arm is
upper motor neuron injuries
dangled freely
and manifests as a marked
resistance to the initiation of
rapid passive movement
- This resistance gives
way and then there is
less resistance over
the remaining range
of motion (clasp-knife
phenomenon)

2. rigidity- increase in tone

that persists throughout the
passive range of motion
(lead pipe)

Paratonia- phenomenon in
which patient is essentially
unable to relax during
passive movement
-extreme paratonia is
common in patients with
dementia

Myotonia- slowness of
relaxation of muscles after a
voluntary contraction or a
contraction provoked by
 muscle percussion

Neuromyotonia- rare
condition of irritability of
the nerve where there is
persistent contraction

Hypotonia- decreased
muscle tone
FINGER- NOSE TEST The patient is able to place Clumsy and unsteady
the tip of his index finger to movements
the tip of his nose in a
smooth and single movement
without missing Dysmetria- errors in judging
distance and gauging the
distance, speed, power and
direction of movement
- Past pointing- a pointing
finger overshoots its
intended mark towards the
side of the cerebellar
damage.

Intention tremor- rhythmic,

alternating, oscillatory
movement of a limb as it
approaches a target

Appendicular ataxia- usually

caused by lesions of the
cerebellar hemispheres
which can affect the
coordination and movements
of extremities
 Incoordination often
worsens with eyes closed
(suggesting position sense
dysfunction)

FINGER-FINGER-NOSE The patient is able to place -same with FINGER- NOSE

TEST the tip of his index finger to TEST abnormal findings
the tip of his nose in a
smooth and single movement
without missing. Patient is
also able to touch the tip of
the examiner’s finger in a
single smooth movement.
COUNTING OF FINGERS Movement is fluid and Ataxia- unsteadiness or
accurate incoordination of limbs,
posture and gait. A disorder
of control of force and
timing of movements leading
to abnormality in speed,
range, rhythm, starting and
stopping

Intention tremor

Dysmetria

Dysdiadochokinesia-
impaired ability to perform
rapid, alternating
movements.
-usually caused by multiple
sclerosis in adults and
cerebellar tumors in
children
Complete inability is called
 adiadochokinesia
DYSDIADOCHOKINESIA The patient is able to move Inability to perform this
both hands at the same time rapidly alternating
(rapid pronation-supination)
at the same speed. movement (very slow/
irregular) suggests
cerebellar ataxia

Dysdiadochokinesia-
impaired ability to perform
rapid, alternating
movements.
-usually caused by multiple
sclerosis in adults and
cerebellar tumors in
children
Complete inability is called
adiadochokinesia
REBOUND When resistance is suddenly An exaggerated version of
PHENOMENON removed, a healthy patient’s the normal response is
limb normally moves a short suggestive of spasticity
distance in the desired
direction and then rebounds
( jerks back in the opposite The absence of the rebound
direction) phenomenon is suggestive of
cerebellar disease
THREADING A NEEDLE Act is carried smoothly and Ataxia- unsteadiness or
harmoniously incoordination of limbs,
posture and gait. A disorder
of control of force and
timing of movements leading
to abnormality in speed,
range, rhythm, starting and
stopping

Intention tremor

dysmetria
RESULTS OF UPPER LIMBS
EYES OPENED EYES CLOSED
RIGHT LEFT RIGHT LEFT
TONE NORMAL NORMAL X X
FINGER- NOSE TEST NORMAL NORMAL NORMAL NORMAL
FINGER-FINGER-NOSE NORMAL NORMAL NORMAL NORMAL
TEST
COUNTING OF FINGERS NORMAL NORMAL NORMAL NORMAL
DYSDIADOCHOKINESIA NORMAL NORMAL X X
REBOUND NORMAL NORMAL X X
PHENOMENON
THREADING A NEEDLE NORMAL NORMAL X X

DISCUSSION OF UPPER LIMBS

Testing for cerebellar function is the basis of the coordination exam. The subtests target
appendicular musculature, controlling of the limbs and axial musculature of posture and gait.
The assessment of cerebellar functions will depend on the normal functioning of other systems.
Motor control of the cerebellum as well as sensory input from somatic, visual and vestibular
senses are important to cerebellar function.
The part of cerebellum which is usually involved in coordination of limb movements,
control of balance and skilled voluntary movement is the lateral zone of the cerebellar
hemisphere, also called cerebrocerebellum/ neocerebellum/ pontocerebellum. Damage to this
part typically causes problems in skilled voluntary and planned movements which can cause
errors in the force, direction, speed and amplitude of movements. In addition to these functions
the cerebellar vermis also receives visual input from the superior colliculus and is involved in
coordinating eye movements
Cerebellar function test for the upper limbs of the subject is overall normal. No apparent
disability is observed.
TESTS FOR ATAXIA AND DYSMETRIA
 FINGER-TO-NOSE TEST AND FINGER-FINGER-NOSE TEST

The finger-to-nose test and finger-finger-nose test involve flexion and extension around a
joint. The patient must switch between the opposing muscles like the biceps and triceps brachii
to move their finger from the target to their nose. Coordinating these movements involves the
motor cortex communicating with the cerebellum through the pons and feedback through the
thalamus to plan the movements. Visual cortex information is also part of the processing that
occurs in the cerebrocerebelluum while it is involved in guiding movements of the finger.
RAPID ALTERNATING MOVEMENTS
 RAPID PRONATION-SUPINATION AND COUNTING FINGERS

Rapid, alternating movements are tested for both upper and lower extremities. All of these
rapid alternations require planning from the cerebrocerebellum to coordinate movement
commands that control the coordination.
 REBOUND RESPONSE/ PHENOMENON

The subtests that address appendicular musculature and therefore the lateral regions of the
cerebellum begin with a check for tremor. In rebound response, the arms are automatically
brought back to the extended position. The extension of the arm is an ongoing motor process and
the tap or push on the arms presents a change in the proprioceptive feedback, the cerebellum
compares the cerebral motor command with proprioceptive feedback and adjusts the descending
input to correct. The red nucleus sends an additional signal to the Lower motor neuron for the
arm to increase contraction momentarily to overcome the change and regain the original position.
TEST FOR COORDINATION
 THREADING A NEEDLE

Fine motor skill/ dexterity such as threading a needle is the coordination of small muscles, in
movements- usually involving the synchronization of hands and fingers with the eyes. Lack of
limb coordination is usually cause by a damage to the lateral hemisphere of the cerebellum.

Name: RARALIO, RAINIER Age: 22

Sex: MALE Occupation: Student
LOWER LIMBS
CEREBELLAR NORMAL FINDING ABNORMAL FINDING
FUNCTION TEST

TONE Slight tautness in the muscle. Hypertonia – increased tone;

Resistance offered to passive patient’s muscles resist the
movements done by the passive movements
examiner is normal.
Hypotonia – decreased tone;
movements are free and the
joints can be hyperextended
*impaired check and
 rebound

GAIT normal posture and Lesion in mid-cerebellum:

coordinated arm movements movements are in all
directions

Lesion in lateral cerebellum:

staggering/falling are toward
the side of the lesion

WALK ALONG Patients can walk in a Subject deviates to one or

STRAIGHT LINE straight manner without the other side and takes a
deviating from the straight zigzag course like that of a
line. drunk

TANDEM WALK Smooth, continuous rhythm Subject deviates to one or

the other side and takes a
zigzag course like that of a
drunk

Patients will spread their

legs apart to widen the base
of support, may stagger
when they walk (severe
cases), and falls toward one
or both sides while
performing heel-toe walk.

Caused by midline lesions of

the cerebellum (vermis)

KNEE-HEEL TEST Normal force and rhythm of Abnormal force and rhythm
movements of movements

KNEE JERK Hyperactive reflex – Absence or decreased

concomitant adduction of hyperactive reflex known as
the ipsilateral thigh Westphal’s sign.

DRAW A CIRCLE Patient can properly draw a Patient cannot properly

closed circle draw a circle
 ROMBERG’S SIGN Patient can maintain Loss of balance
balance

DISCUSSIONS
MUSCLE TONE
Muscle tone is the continuously maintained state of slight tension or tautness in the
healthy muscles even when they appear to be at rest. It is usually discussed in terms of
hypertonicity, hypotonicity, or dystonia. HYPERTONIA is an increase in tone which occurs in
lesions of upper motor neurons and extrapyramidal systems. HYPOTONIA is a decrease in tone
which is commonly seen in lower motor neuron disease and cerebellar lesions. DYSTONIA is a
movement disorder in which a person's muscles contract uncontrollably.
GAIT
Gait refers to the manner, style, or pattern of walking. It is dependent on the same
vestibular, proprioceptive, and integrative systems as stance and balance. However, it requires
direction from the central gait mechanism in the frontal lobes, basal ganglia, brain stem, and
descending motor systems.
four common forms of abnormal gait seen in neurological conditions:
 Spastic (hemiplegic) Gait
o Knee cannot be flexed and foot is not properly lifted off the ground as patient is
instructed to walk on a narrow base. As a result, patient drags his/her foot on the
ground and tends to describe a semicircle with the affected leg.
 Stamping Gait
o Patient raises each foot suddenly and brings it down on the ground with a thump
o Usually Seen in sensory ataxia
 Drunken or reeling gait
o Also an ataxic gait
o Seen in cerebellar lesions
o Characterized by a clumsy, and zigzagging-like gait of a drunkard as the patient is
instructed to walk on a broad base with his/her feet apart
o Ataxia is equally severe whether the eyes are closed or open
 Festinant Gait
o Seen in Parkinson’s disease
o Characterized by slow-paced walking and short shuffling steps, and uncontrolled
acceleration while walking
o Inability to stop when patient is pushed forward or pushed back
WALKING ALONG STRAIGHT LINE / TANDEM WALK
To bring out abnormalities in gait and balance, ask the patient to do more difficult
maneuvers. Test tandem gait by asking the patient to walk a straight line while touching the heel
of one foot to the toe of the other with each step.
Patients with truncal ataxia caused by damage to the cerebellar vermis or associated
pathways will have particular difficulty with this task, since they tend to have a wide-based,
unsteady gait, and become more unsteady when attempting to keep their feet close together. To
bring out subtle gait abnormalities or asymmetries, it may be appropriate in some cases to ask the
patient to walk on their heels, their toes, or the insides or outsides of their feet, to stand or hop on
one leg, or to walk upstairs.
KNEE-HEEL TEST
The KNEE-HEEL TEST or heel-to-shin test is a test of lower limb coordination and
position sense, often performed to assess the integrity of the cerebellum. This test assesses the
accuracy of heel placement. Note if the heel is not pushed down the shin without smoothly and
accurately. Any Inability to perform this test properly may indicate possible cerebellar trauma
or ataxia.
KNEE JERK TEST
Knee-jerk reflex, also called patellar reflex, sudden kicking movement of the lower leg
in response to a sharp tap on the patellar tendon, which lies just below the kneecap. The sharp tap
on the tendon slightly stretches the quadriceps, the complex of muscles at the front of the upper
leg. In reaction these muscles contract, and the contraction tends to straighten the leg in a kicking
motion. Exaggeration or absence of the reaction suggests that there may be damage to the central
nervous system. Westphal's sign is the clinical correlate of the absence or decrease of patellar
reflex or knee jerk.
Clinical significance of westphal’s sign in determining neurological disorders or disease:
 receptor damage, peripheral nerve disease, involving the dorsal(sensory) columns of the
spinal cord and cerebellar lesions
 lesions present within the motor cortex of the brain or the pyramidal tracts which it
combined with muscular spasms
 complete interruption of sensory and/or motor impulse transmission in the femoral nerve

ROMBERG’S SIGN TEST

The Romberg’s Sign Test is an appropriate tool to diagnose sensory ataxia, a gait
disturbance caused by abnormal proprioception involving information about the location of the
joints. It is also proven to be sensitive and accurate means of measuring the degree of
disequilibrium caused by central vertigo, peripheral vertigo and head trauma. It is used to
demonstrate the effects of posterior column disease upon human upright postural control.
Posterior column disease involves selective damaging of the posterior column, known as tabes
dorsalis neurosyphilis. The Romberg test is used for the clinical assessment of patients with
disequilibrium or ataxia from sensory and motor disorders.

IV. CONCLUSION
The cerebellum functions in motor control by coordinating movements including those
involving precise and accurate movements. Damage in the cerebellum manifests itself as
problems with fine movement, equilibrium and posture. The tests performed serve to examine
each function of the cerebellum—balance,coordination, and proprioception(knowing where the
parts of the body are without the need of sight)—in a non-clinical setting by using tests that are
used as part of a physician's screening. It by no means is intended to provide an accurate
diagnosis. After each test there will be information about what is considered normal as well as
some signs that could relate to problems with the cerebellum If the cerebellum is lesioned or
otherwise affected, some form of ataxia is likely. What exactly goes wrong depends upon which
part of the cerebellum is affected. When the vestibulocerebellum (flocculonodular lobe) is
affected, this manifests in problems with balance and control of eye movements. Dysfunction of
the spinocerebellum (vermis and paravermis) causes people to walk widely, and imbalanced with
unequal steps, as if they are drunk. The cerebrocerebellum (lateral parts of the hemispheres) is
involved in the accurate timing and planning out of movements, so when something is wrong
there it can cause tremors, unequal writing, slurred speech, inability to rapidly alter movements,
undershooting or overshooting movement, and more.

V. ANSWERS TO QUESTIONS:

1. Name the organs responsible for equilibrium.

Along with hearing, the inner ear is responsible for encoding information about
equilibrium (the sense of balance), which it does in the vestibule and semi-circular canals.

2. Name the vestibular apparatus.

The vestibular apparatus (or vestibular system) consists of two structures of the bony
labyrinth of the inner ear, the vestibule and the semi-circular canals, and the structures of the
membranous labyrinth contained within them.

3. Name the three types of cerebellum phylogenetically.

PHYLOGENETIC ANATOMICAL ROLE

DENOMINATION PARTS

Archicerebellum Flocculonodular The archicerebellum (also known as vestibulocerebellum)

lobe regulates balance and eye movements. It
receives vestibular input from both the semicircular
 (and immediately canals and from the vestibular nuclei, and sends fibres
adjacent vermis) back to the medial and lateral vestibular nuclei. It also
receives visual input from the superior colliculi and from
the visual cortex (the latter via the pontine nuclei, forming
a cortico-ponto-cerebellar pathway).
Lesions of the vestibulocerebellum cause disturbances of
balance and gait.
Paleocerebellum Vermis and The paleocerebellum (also known as spinocerebellum)
intermediate parts regulates body and limb movements. It
of the receives proprioception input from the dorsal columns of
hemispheres the spinal cord (including the spinocerebellar tract) and
("paravermis") the trigeminal nerve, as well as from visual and auditory
systems. It sends fibres to deep cerebellar nuclei which in
turn project to both the cerebral cortex
(via midbrain and thalamus) and the brain stem
(via reticular formation in the pons, and vestibular
nuclei in the medulla oblongata), thus providing
modulation of descending motor systems.
The spinocerebellum contains sensory maps as it receives
data on the position of various body parts in space: in
particular, the vermis receives fibres from the trunk and
proximal portions of limbs, while the intermediate parts of
the hemispheres receive fibres from the distal portions of
limbs.
The spinocerebellum is able to elaborate proprioceptive
input in order to anticipate the future position of a body
part during the course of a movement, in a "feed forward"
manner.
Neocerebellum, Lateral parts of The neocerebellum (also known as pontocerebellum or
Pontocerebellum the hemispheres cerebrocerebellum) is involved in planning movement
and evaluating sensory information for action. It
receives input exclusively from the cerebral cortex
(especially the parietal lobe) via the pontine nuclei (in
the pons, forming cortico-ponto-cerebellar pathways)
and dentate nucleus (in the cerebellum), and sends fibres
mainly to the ventrolateral thalamus (in turn connected to
motor areas of the premotor cortex and primary motor
area of the cerebral cortex) and to the red nucleus (in turn
connected to the inferior olivary nucleus). The
neocerebellum is involved in planning movement that is
about to occur and has purely cognitive functions as well.

4. Name the nucleus of the cerebellum.

The fastigial nucleus is the most medially located of the cerebellar nuclei. It receives
input from the vermis and from cerebellar afferents that carry vestibular, proximal
somatosensory, auditory, and visual information. It projects to the vestibular nuclei and the
reticular formation.

The interposed nuclei comprise the emboliform nucleus and the globose nucleus. They
are situated lateral to the fastigial nucleus. They receive input from the intermediate zone and
from cerebellar afferents that carry spinal, proximal somatosensory, auditory, and visual
information. They project to the contralateral red nucleus (the origin of the rubrospinal tract).

The dentate nucleus is the largest of the cerebellar nuclei, located lateral to the
interposed nuclei. It receives input from the lateral hemisphere and from cerebellar afferents that
carry information from the cerebral cortex (via the pontine nuclei). It projects to the contralateral
red nucleus and the ventrolateral (VL) thalamic nucleus.

The vestibular nuclei are located outside the cerebellum, in the medulla. Hence, they are
not strictly cerebellar nuclei, but they are considered to be functionally equivalent to the
cerebellar nuclei because their connectivity patterns are identical to the cerebellar nuclei. The
vestibular nuclei receive input from the flocculonodular lobe and from the vestibular labyrinth.
They project to various motor nuclei and originate the vestibulospinal tracts.

5. What is dysdiadochokinesia? Examples.

Dysdiadochokinesia (DDK) is the medical term used to describe difficulty performing

quick and alternating movements, usually by opposing muscle groups. DDK is not a disease
itself, but rather a symptom of an underlying health problem.

DDK is often seen as a symptom of multiple sclerosis or other cerebral conditions, such
as: Friedreich’s ataxia and ataxic dysarthria (a speech disorder).

6. What is intentional tremor and resting tremor?

Intention tremor is produced with purposeful movement toward a target, such as lifting
a finger to touch the nose. Typically the tremor will become worse as an individual gets closer
to their target.

Resting tremor occurs when the muscle is relaxed, such as when the hands are resting on
the lap. With this disorder, a person’s hands, arms, or legs may shake even when they are at rest.
Often, the tremor only affects the hand or fingers. This type of tremor is often seen in people
with Parkinson’s disease and is called a “pillrolling” tremor because the circular finger and
hand movements resemble rolling of small objects or pills in the hand.

7. What is tetany?

Tetany is a state of hyperexcitability of the central and peripheral nervous systems that
results from abnormally reduced concentrations of ions (i.e., Ca2+, Mg2+, or H+ [alkalosis]) in
the fluid bathing nerve cells.
 8. What is Romberg’s sign?

Romberg’s Sign is a diagnostic sign of tabes dorsalis and other diseases of the
nervous system consisting of a swaying of the body when the feet are placed close together
and the eyes are closed.

9. Name the two ascending spinocerebellar tracts.

Ventral spinocerebellar tract

• transmits unconscious proprioceptive information to the cerebellum
• is concerned with coordinated movement and posture of the entire lower extremity
• receives input from muscle spindles, GTOs, and pressure receptors
• is a crossed tract

Dorsal spinocerebellar tract

• transmits unconscious proprioceptive information to the cerebellum
• receives input from muscle spindles, GTOs, and pressure receptors
• is involved in fine coordination of posture and the movement of individual muscles of
the lower extremity
• is an uncrossed tract

10. What is dysmetria?

Dysmetria is a condition in which there is improper measuring of distance in muscular

acts; disturbance of the power to control the range of movement in muscular action.
11. What is nystagmus?

Nystagmus is a rhythmic oscillation of the eyes, analogous to a tremor in other parts of

the body. It is the rapid, rhythmic, repetitious, and involuntary eye movements.

12. What is tinnitus?

Tinnitus is the perception of sound within the human ear (“ringing of the ears”) when no
external sound is present.

13. What is the receptor in the semicircular canals and otolith organs?

Semicircular canal system (kinetic labyrinth)

 detects and responds to angular acceleration and deceleration of the head. It contains hair
cells receptors which are embedded in the cupulae of the cristae ampullare and are
bathed in endolymph. The hair cells also contain one kinocilium and many stereocilia
and are innervated by bipolar cells of the vestibular ganglion (Scarpa ganglion).

Maculae of the utricle and saccule (“otolith organ”)

 are two patches of sensory epithelium consisting of supporting cells and hair cells
receptors which are structurally similar to those of the cristae ampullares and are
 embedded in the gelatinous otolithic membrane, which contains calcareous otolith
crystals.

14. How is the cerebellum connected to the brain stem?

The cerebellum is situated in the posterior cranial fossa and is covered superiorly by the
tentorium cerebelli. The cerebellum is connected to the posterior aspect of the brainstem by three
symmetrical bundles of nerve fibers called the superior, middle, and inferior cerebellar
peduncles.

15. Which nucleus of the cerebellum is concerned with coordination? Name the tract
connecting this to the cortex.

The dentate nucleus caries information important for coordination of limb movements.
The rubrospinal tract originates from the dentate nucleus passing the thalamic nuclei,
continuously ascend to the internal capsule to the corona radiata and finally, to the primary motor
cortex.
16. Mention some abnormal gaits.
APPENDIX

A. TEST FOR TONE (UPPER LIMBS)

Right and left upper limbs

B. FINGER-NOSE TEST
Right and left upper limbs; eyes opened
 Right and left upper limbs; eyes closed

C. FINGER-FINGER-NOSE TEST
Right and left upper limbs; eyes opened
 Right and left upper limbs; eyes closed

D. COUNTING OF FINGERS

Right and left upper limbs; eyes opened

 Right and left upper limbs; eyes closed

E. Dysdiadochokinesia

Right and left upper limbs

F. REBOUND PHENOMENON
Right and left upper limbs

G. THREADING A NEEDLE
Right and left upper limbs
H. TEST FOR TONE (LOWER LIMBS)
Right and left lower limbs

I. GAIT
J. WALK ALONG A STRAIGHT LINE

K. TANDEM WALK
L. KNEE-JERK

M. KNEE-HEEL TEST

N. DRAW A CIRCLE TEST

O. ROMBERG’S SIGN
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