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CEREBELLUM & GAIT by Dr ROTO ROBO
1.
2. Cerebellum is the 2nd largest part of the brain occupying
the posterior cranial fossa beneath the tentorium cerebelli
belonging to a distributed sensori motor network designed
for coordination of willed muscular contractions and
maintenance of body balance.
11. In voluntary movement
› corrects motor irregularities
› compares motor “central” intentions to “peripheral
performance”
› controls ballistic movements
In posture and equilibrium
› cooperation with spinal cord, cortex and reticular
formation
Primarily inhibitory function
12. DYSARTHRIA
NYSTAGMUS
DYSTAXIA OF STATION AND GAIT
DYSTAXIA OF LIMB MOVEMENTS
.Dyssynergia (Decomposition of movements)
.Dysmetria
.Agonist - Antagonist incoordination
.Dysdiadochokinesia
.Rebound phenomenon
.Intention tremor
HYPOTONIA
13. SPEECH
Articulation is slow, ataxic, drawling, slurred, jerky
or explosive type.
Speech is scanning in nature.
14. Gaze evoked nystagmus
Hemispheric lesion – eyes at rest deviate 10-300
toward unaffected side,
on attempting to gaze elsewhere, eyes saccades
toward point of fixation
Slow component toward resting point
Cerebellopontine Angle Tumor – Nystagmus is coarse
on looking toward affected side and
fine & rapid on gazing to oppt side – BRUNS
NYSTAGMUS
15. May over or under - shoot target with attempts
at fixation ( ocular dysmetria )
In primary position, may see saccadic intrusions
(such as macro square – wave jerks ) or primary
nystagmus ( incl. vertical, esp up-beat nystagmus )
or periodic alternating nystagmus
rebound nystagmus can occur with contralateral-
beating nystagmus on return of eyes to primary
position after eccentric gaze evoked nystagmus
to one side
16.
17. STATION
Broad based stance
Swaying of body
Standing on one foot - falls on affected side
GAIT
Free walking–wide based,clumsy staggering,
lurching type of gait
Straight line walking
Tandem walking
18. Look for smoothness, accuracy,
oscillations, jerkiness.
Stops before or overshoots the
target
Intension tremor
FINGER TO FINGER TEST
(FingerTips in the Midline)
FINGER TO NOSE TEST
19. (DYSDIADOCHOKINESIA)
PRONATION AND
SUPINATION TEST
Uneven excurtion of
affected side hand
THIGH PATTING TEST
Slaps irregularly,slowly on
the affected hand
FINGER TAPPING TEST
.RAPID ALTERNATING MOVEMENT TEST
20. ARM PULLING TEST
(Holmes Rebound Test)
patient fails to check
arm’s flight
WRIST TAPPING TEST
Arm oscillates back and
forth and overshoots several
times
OVERSHOOTING AND CHECKING TESTS
21. PAST POINTING TESTS
Arm on the affected side deviate outwards
towards the side of lesion
Three types of drift of outstretched hands
1. Pyramidal drift( pronator or Barre’s sign)
Arm sinks downward and there is accompanying pronation
of the forearm.
2. Parietal drift
Arm usually rises and strays outward (updrift)
3. Cerebellar drift
Arm drifts mainly outward, either at the same level, rising
or less often sinking.
22. OTHER ADDITIONAL TESTS
Tapping in a circle
Spiral drawing test
Drawing line between two fixed points
Macrographia
23. HEEL-KNEE TEST
Heel overshoots the knee sideways and develops a rotary
oscillations as heel approaches the knee
While moving down the shin the heel oscillates from side to side.
HEEL TAPPING TEST
DRAWING A CIRCLE WITH THE LEG
24. Decrease in resistance to passive movement of muscles
related to depression of gamma motor neuron
activity
INSPECTION
At rest, assumes a floppy posture(rag doll appearance)
while walking, floppy sagging, loose jointed appearance.
PASSIVE MOVEMENT
Increased range of joint exertion
PENDULOUS MUSCLE STRECH REFLEXES
Leg swings to and fro several times
25. A: Lateral or Hemispheric syndrome
B: Midline or Vermis(Rostral vermis) syndrome
C :Caudal Vermis(Flocculonodular) syndrome
A+B+C :Pancerebellar syndrome
26. Hemisphere Appendicular ataxia Stroke(Bleed,infarct)
Tumor(Astrocytoma)
Abscess,multiple
sclerosis.
Vermis Gait Ataxia Alcoholic
degeneration,
midline tumor
Flocculonodular lobe Nystagmus,extra
ocular movement
abnormality
Tumors(astrocytoma
,medulloblastoma,
ependymoma
Pancerebellar All of The Above Drugs,Toxins,
paraneoplastic
Site of lesion manifestation cause
27. GAIT CYCLE-
period between successive points at which
heel of the same foot strikes the ground.
1. STANCE PHASE -
foot in contact with the ground, occupies 60-65 %
of the cycle.
2. SWING PHASE -
Begins when toes leave the ground.
DOUBLE LIMB SUPPORT -
Both feet are in contact with the ground,
occupies 20-25% of the walking cycle.
28.
29. 1. Initial Contact
› The moment when the foot contacts the ground, heel strike (heel
strike)
2. Loading response
› The weight is rapidly transferred onto the outstretched limb, the
first period of double-limb support (foot flat)
3. Midstance
› The body progresses over a single, stable limb
4. Terminal Stance
› Progression over the stance limb continues. The body moves
ahead of the limb and weight is transferred onto the forefoot
5. Pre-Swing
› A rapid unloading of the limb occurs as weight is transferred onto
the forefoot (toe-off)
30.
31. 1. Initial swing
› The thigh begins to advance as the foot comes up from
the floor.
2. Midswing
› The thigh continues to advance as the knee begins to
extend; the foot clears the ground.
3. Terminal Swing
› The knee extends; the limb prepares to contact the
ground for Initial Contact.
32.
33. Parameters to measure & characterize gait:
1. Step length -Distance advanced by one foot
compared to the position of the other
2. Stride length -Sum of two consecutive step lengths
or the distance advanced by one foot compared to
its prior position
3. Step time –Time between heel strike of one foot
to the subsequent heel strike of the contralateral
foot
4. Stride time –time for a full gait cycle
5. Average Gait velocity - Stride length divided by
stride time
34.
35. 1. ANTIGRAVITY SUPPORT-
Provided by righting & antigravity reflexes.
Postural reflexes depend on afferent, vestibular,
somatosensory(Proprioceptive & Tactile) & visual impulses,
which are integrated in spinal cord, brainstem & basal
ganglia
2. STEPPNG-
Integrated in spinal-midbrain-diencephalic levels.
Elicited by contact of sole with a flat surface & shifting of
center of gravity- first laterally onto one foot, allowing other
to raised, then forward, allowing the body to move onto the
advancing foot.
36. 3. EQUILIBRIUM- Involves maintenance of balance in
relation to gravity & to the direction of movement in
order to retain a vertical posture.
Shifting of Center of gravity ,with activity of highly
sensitive postural & righting reflexes, both
peripheral(stretch reflex) & central (vestibulocerebellar
reflex).
4. PROPULSION- Provided by forward & slightly to one
side & permitting the body to fall a certain distance
before being checked by support of the leg.
Both forward & alternating lateral movements must
occur.
37.
38. • Wide base,
• unsteadiness,
• irregularity of steps,
• lateral veering.
Steps are uncertain, some short & long, pt compensate
these problem by shortening his steps & shuffling, referred
to as “Reeling or Drunken gait”
Causes-
multiple sclerosis, cerebellar tumors - medulloblastoma,
stroke, cerebellar degeneration
39.
40. “Disturbances in the sensory input to the cerebellum”
corrective effects of the Visual system
Steppage gait - walks with unusually high steps.
Throws out her foot & slams it down on floor in order to increase
proprioceptive feedback.
While walking, watches her feet and keep an eye on floor
Difficulty is even worse walking backward
Romberg’s sign
Loss of tendon reflexes
Features of Peripheral neuropathy
41.
42.
43. • Hemiparetic Posture - arm flexed,
adducted, internally Rotated & Leg
extended.
• Equinus deformity.
• With each step pt tilt pelvis upward
on involved side to aid in lifting toe
off the floor & may swing entire
Extremity around semi circle from
hip ( Circumduction ).
• Both Stance and swing phase -
shortened
44. Causes–
Congenital spastic diplegia (Little’s disease,
cerebral palsy),
Chronic myelopathies (multiple sclerosis, cervical
spondylosis)
Characteristic tightness of Hip adductors causing
adduction of the thighs, so that knee may cross,
one in front of other, with each step (scissors gait)
Pt walk on abnormally narrow base with stiff
shuffling gait, dragging both legs, scraping the toes.
45. Steps are short & slow.
Marked compensatory swag of trunk away from
side of advancing leg.
Shuffling, scraping sound together with worn areas
at toes or shoes – are characteristic
Equinus position of feet & heel cord shortening
often cause pt to walk on tip toe.
46. • Disorder cause involvement of both corticospinal
& proprioceptive pathways ( eg. Vit - B 12
deficiency, Multiple Sclerosis) resulting in gait that
has features of both spasticity and ataxia.
• Ataxic component may be either cerebellar or
sensory. In vit-B 12 deficiency, it is predominently
sensory & in multiple sclerosis – both component.
• In amyotrophic lateral sclerosis – b/L foot drop,
spasticity result in spastic ataxic gait described
as jiggling or Bobbing with tremulous, bouncing,
up & down body movement
47. • Festinating gait – Pt is stooped, head & neck
forward & knees flexed, upper extremities are
flexed at shoulders, elbows & wrist but fingers are
usually extended.
• Gait is slow, stiff & shuffling. pt walks with small
mincing steps.
• Difficulty walking may be one of earliest symptom.
• Impaired postural reflexes lead to tendency to
fall forward (propulsion) which pt tries to avoid by
walking with increasing speed but with very short
steps.
48.
49. Resemble that of parkinsonism but lacks rigidity
& bradykinesia.
Locomotion is slow, pt walks with very short,
mincing, shuffling & some what irregular footsteps.
Cause-
- Normal Pressure Hydrocephalus ,
- multi – infarct dementia,
- normal elderly person.
50. Seen in extensive cerebral lesions – Frontal lobes,
NPH, neoplasm, Binswanger’s disease, pick disease.
Pt cannot carry out purposeful movement with legs
& feet such as making circle etc.
In rising, standing & walking there is difficulty in
initiating movement & automatic sequence of
component movement is lost.
Gait – slow, shuffling with short steps.
51. Greatest difficulty is in initiating walking, making
small, feeble, stepping movement with minimal
forward progress, eventually unable to lift feet
from floor, as if they were stuck or glued down –
magnet gait, gait Ignition Failure,
start hesitation.
52. More or less similar to gait apraxia.
Characterized by slightly flexed posture, short,
shuffling steps, inability to integrates & coordinate
lower extremity movement to accomplish normal
ambulation.
Disorder of frontopontocerebellar fibres.
53. • Occur with weakness of Hip girdle muscles,
eg. myopathy, muscular dystrophy.
• Hip abducter muscles vital in stabilizing pelvis
while walking.
• Trendelenburg’s sign is abnormal drop of pelvis
on side of swing leg due to hip abducter
weakness, when weakness is bilateral – exaggerated
pelvis swing that result in waddling gait.
• Pt walk with broad base, exaggerated rotation of
pelvis, rolling or throwing hips from side to side
with every step to shift weight of body.
54.
55. Seen in older patient who
have no neurological
disease. but are uncertain
of their balance & posture
reflexes.
Velocity slows, steps
shortens , base widens.
