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Physiotherapy management of cerebellar ataxia
Transcript of Physiotherapy management of cerebellar ataxia
What does our PAP consist of
During Semester 3, we missed some information about Ataxia so we decided to fill in the gap :
What is cerebellar ataxia ?
There are 3 types of ataxia (lack of coordination):
Isabelle Gontard, Caroline Hiensch, Lisa Zinkwe
Course material to teach 2nd year ESP student :
A didactic course manual
A Powerpoint presentation for a class of 1.40 h
We based the course material on a literature review where our research question was : What is the best evidence for
What causes those lesions to the cerebellum / cerebellar pathways ?
What our review taught us
The general recommendations based on our review
3. Use validated ataxia-specific scales :
- For research
- For multiprofessional communication
Review your knowledge of the cerebellum
The symptoms :
1. Limb movement disorder (general dyscoordination, tonus abnormality, dysmetria, tremor)
2. Postural and gait disorders (unstable inefficient gait)
3. Oculomotor deficit
4. Dysarthria & dysphagia
5. Cognitive and Affective deficits
Functions of the cerebellum:
Coordination of voluntary movements
Maintainance of balance
Muscle tone tuning
1. Cerebral Vascular Accidents (mostly affecting the cerebellar posterior-inferior arteries)
2. Immune disorders (mostly multiple sclerosis)
3. Tumors in the posterior fossa
4. Traumatic brain injury in the cerebellar region
5. Autosomal recessive cerebellar ataxias are a group of ataxias (ACARs) such as Friedreich's ataxia.
6. Autosomal dominant ataxias also called SpinoCerebellar Ataxias (SCAs)
7. Development disorders affecting the cerebellum (Chiari malformation, Cerebellar hypoplagia)
8. Intoxications mostly due to alcohol (such as in the Wernicke-Korsakoff syndrome)
The interventions that lower quality evidence tends to deter:
For lack of evidence despite many attempts:
For lack of evidence + possible adverse effects:
Mobility aid with strong weight bearing on UE
The interventions that lower quality evidence
tends to encourage :
Strength & flexibility
Gait training : treadmill and /or over ground
Cold therapy to reduce tremor
In the absence of good quality evidence to guide our physiotherapy practice we can consider the following clues.
- Pronation/Supination test (dysdiadochokinesia)
- Finger-Nose test (dysmetria & intention tremor)
- Look for typical ataxic signs in tandem walk / gait
- Romberg test (differential diagnosis)
Overall, we now know there is:
- Limited good quality evidence about the effectiveness of physiotherapy for ataxia
- Limited poor quality evidence to choose between different treatment options
- No scientific data about the use of other non specific assessment tools
- Scientifically approved grading scales specific to ataxia
The rating scales (clinimetrics) :
SARA – Scale for the assessment and rating of ataxia
ICARS – International cooperative ataxia rating scale
FARS – Friedreich’s ataxia rating scale
Non ataxia specific functional assessment tools:
Dynamic gait index
It is important for physiotherapist to know about ataxia because it is a misunderstood disorder common among neurological patients:
- Ataxia is present in at least :
20 % of stroke patients
40 % of MS patients
10 % of TBI patients
- Specific ataxic syndromes have a higher prevalence than well known diseases such as Huntington's and motor neuron diseases .
(Lawrence 2001, Kraft 1986, Levin 1990)
Estimate: 10 000 adults affected in the UK (Cassidy et al. 2005)
We defined 8 different categories of etiologies for ataxia :
6 RCTs about physiotherapy interventions
5 scientific articles about rating scales
Our research question was very general.
We have a limited amount of articles.
(5 assessment and 6 intervention)
The assessment part of our review only covers scales specific to ataxic syndromes and we did not evaluate these articles systematically.
: Focus on working around ataxia since the cerebellum function itself most likely will not improve with physiotherapy
Treatment choice :
Favor the tools available to physiotherapists which received some scientific evidence
: Use the ataxia specific scales, as well as, functional scales not specific to ataxia
should focus on the long term effect of physiotherapy compared to no treatment before focusing on the comparison between treatment options.
1. Confirming your patient has ataxia and which signs are prevalent
2. Evaluate your patient's functional level
Keep in mind your role is to help the patient, not to treat ataxia.
1. Sensory disorders
2. Cerebellar disorders
is a typical sign of ataxia. What does it mean ?
1.Difficulty performing symetrical actions with both arms
2. Difficulty maintaining a constant force during an action
A lesion to the right cerebellar hemisphere will cause ataxic signs on the :
1. Right arm
2. Left arm
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Thank you for your attention
Time for your questions
(very short term)
- the effectiveness of physiotherapy compared to no treatment for cerebellar ataxia (any etiology)
- the effectiveness of specific physiotherapy treatments compared to standard physiotherapy for cerebellar ataxia (any etiology)
- the validity, responsiveness and reliability of clinimetrical tools used to assess cerebellar ataxia (any etiology)