Editor's Note: As introduced in part 1 of this article (November issue), "When patients present with tremors or ataxias, we commonly label these as Internal Wind and recognize the role of the cerebellum in such cases; however, we were never taught how to clinically assess Internal Wind."; This article continues Dr. Wolf's discussion of examinations specific to the cerebellum as a functional means to tracking Internal Wind.
Flexing the Tongue
The tongue is one of the most powerful muscles in the body and relies on the cerebellum for coordinated movement. The tongue is also an extremely strong muscle that doesn't easily fatigue. This means if the tongue is not functioning properly, it is highly suspect that the central nervous system is involved.
The cerebellum is highly sensitive to alcohol. Many people have likely witnessed the slurring of speech that occurs when someone becomes highly intoxicated. This is a direct consequence of a loss of cerebellar function, along with the sloshing of liquid as they fail to control the arm holding their cocktail.
Clinically, we can use the pronunciation of sound as a test for the cerebellum. Having a patient say famous tongue twisters such as, "Peter Piper picked a pack of pickled peppers,"; is a simple way of testing cerebellar control of tongue movement. Another way is to have the patient repeatedly pronounce sounds requiring different tongue positions, such as "pa-ka-ta.";
When assessing patients with concussions or traumatic brain injuries, these tests are very useful. Many patients with concussions report a slurring of speech that comes and goes depending on their level of cognitive fatigue.
Functional Testing
What, then, are useful functional tests for the cerebellum? In testing the upper limbs, several tests are useful. One is a simple finger-to-nose test with eyes closed. In this test, as the patient moves the index finger to the nose, you are looking for an overshooting of the finger; does it miss the nose and hit the face? You are also looking for any tremors.
Following that test, you can perform a finger-nose-finger test with eyes open, in which the patient touches their nose and then your finger. Move your finger into different quadrants (up/right, up/left, middle/right, middle/left, down/right, down/left, center). This test provides good evaluation of the coordination and accuracy of the arm being tested. You are comparing performance of the right arm and hand compared to the left arm and hand. You are also looking for tremors, which may only occur at the end range of motion, so make sure you hold your finger just far enough away from the patient so they have to fully extend their arm to reach it.
In testing the lower limbs, you can have the patient lie supine on the table and perform a heel tap test, whereby they take their right heel and tap it on the left kneecap 10 times, and then slide the heel from the kneecap to the big toe. You are assessing the coordination of the movement.
Then have the patient repeat with the left foot. You are looking for the accuracy of the heel hitting the kneecap each time, and the coordination of the slide from kneecap to toe.
Remember that testing for the cerebellum is ipsilateral. Poor coordination of the left arm or left leg may indicate dysfunction of the left cerebellum. When assessing gait, you want to look for a wide gait, or for a pulsion to the left or the right as the patient walks. In the case of a left cerebellar deficit, you would see a pulsion to the left.
Think of it like an arm-wrestling match. If the right cerebellum is functioning normally and the left is not, the right is going to win the arm-wrestling match and push the left side over.
This mechanism is also important to observe when performing Romberg's test for cerebellar function. In Romberg's test, the patient stands with their feet together and closes their eyes. If they start to fall over (you will want to catch them before they do), that is a positive Romberg's.
However, there is more to pay attention to here. Even if they don't fall over, the direction of initial sway can be an indication of poor cerebellar function. If the patient closes their eyes and immediately sways to the left, this may be an indication of a functional deficit of the left cerebellum; especially if you see other findings that corroborate this finding, such as pulsion to the left during gait, poor coordination of the left arm or leg or a tremor in the left arm.
Clinical value & Application
This is the essence of functional examination. Even in cases in which there is not an overt disease involved, there are methods to observe and assess dysfunction, functional imbalances and neurological decompensation that may be present and involved in the patient's presentation.
Assessing the cerebellum should be an important aspect of working with patients with neurological conditions – motor, cognitive and psychiatric; as well as any time Internal Wind is in the differential diagnosis.
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