ataxia

What does *functional testing* consist of?

-Bed mobility and posture -Ability to move supine to sit -Maintaining a sitting posture -Sit to stand -Transfers -Maintaining a standing posture -Ambulation -Stairs -ADLs - Dress, groom, eat, toilet, etc.

Before intervention can begin, the therapist must synthesize the results of the assessment and the physical findings. What must we consider?

-What systems are involved? -What systems are intact? -Is sensation intact? -Is vision intact? -Is strength intact? -Is tone normal? -What cerebellar interference is present? -How can I modify the environment and tasks to make them easier? This information will assist in determining an intervention strategy that will work.

Intervention ideas that can help

-add an assistive device -add splints and orthotics -add bracing if possible -use power mobility -modify the household -change tasks and make ADLs easier

What might you observe in a client with ataxia during an assessment?

1. balance and equilibrium problems 2. muscle tone changes 3. dysmetria 4. movement decomposition 5. tremor 6. eye movements 7. dysarthria 8. dyssenergia

What Cerebellar Clinical testing is of importance for us to do?

1. functional testing 2. Finger to Nose Test 3. Alternating supination/pronation 4. Hand or finger tapping 5. Handwriting or drawing 6. Hold a static position (check for drift) 7. Resisted movements (check for rebound) 8. Heel to knee test 9. Foot or toe tapping 10. Sitting balance 11. Standing balance 12. Smooth pursuit 13. Saccades 14.Gaze evoked nystagmus 15. other clinical tests -gait analysis -reaching analysis -sensory testing -strength testing -endurance testing

What are classic characteristics of ataxia?

1. gathering the extremeties together (hands + arms close together; knees together)

those with lesions in the lateral hemispheres will have difficult with:

ADLs

Dysarthria

Difficulty in controlling the muscles (including the vocal cords!) that control speech. Speech is distorted, slurred, or difficult to understand. *sounds like they have a lazy tongue*, which can be interpreted as having cognitive problems.

_____ is a standardized cerebellar test. The scale measures 19 specific movements on an ordinal scale ranging from 0 (no ataxia) to 100 (most severe ataxia) Separated into: -posture and gait -limb movements -speech -oculomotor

ICAR (International Cooperative Ataxia Rating Scale) (note: this is a good test to do if youre doing research)

If sensation is NOT involved, what should we teach the clients?

*compensate* with either vision, or by conscious proprioception (concentrate on the activity at hand)

People with dysmetria cannot make appropriate anticipatory control movements & lack ability to dampen + control multi-joint activities. Therefore, what happens...

Movements of the shoulder thus become separated from movements of the elbow. Movements of the knee become separated from the hip

____ tests fewer items than the ICAR, therefore it is *less burdensome* for some clinicians to complete. It has better *construct* validity.

SARA (scale for assessment and rating of ataxia)

Dysmetria

a deficit in reaching a target (i.e. putting a cap on a pen) (do not give them a Styrofoam or paper cup!)

_______ is an incoordination or clumsiness of movements that is not the result of mm weakness

ataxia (it can affect gait, UE, LE, speech, and eye movements)

when the cerebellum is damaged specific, syndromes can result. These include: _____ These people are referred to PT and OT to assist with ___.

ataxia, muscle tone probs, and incoordination function

What tremor is exhibited in a patient with ataxia?

attention (the harder you try, the worse it gets) (NOTE: they can also get *postural* tremors. Although, People are unable to hold a posture against resistance, or are unable to stabilize an arm or leg on a stable trunk with or without resistance)

For those with ataxia, _____ is gone.

automaticity (have to think out each movement of my affected (right) arm)

The following are examples of ____ and ____ problems we will see in a client of ours with ataxia: -Increased postural sway -Delayed equilibrium reactions -Lack of response to environmental cues -Loss of motor learning about gait.

balance, equilibrium

Gaze evoked nystagmus involves therapist drawing a _____

capital "H" and asks the patient to follow it. Patient has to keep the head still. Observe for saccades at end of movement

Ataxia is most frequently caused by _____ damage. Cerebellum can be damaged by _____.

cerebellar, BI, CVA, MS, & end-stage alcoholism

Ataxia can occur as a result of damage to _____ input and output structures.

cerebellum (thalamus, vestibular nucleus, and a result of sensory neuropathy)

people with cerebellar lesions require _____. Why?

compensation, little to NO neuroplasticity exists in the cerebellum. *cerebellar lesions tend to worsen over time and with normal aging processes* --> compensation can assist with this!

movement decomposition may be a ____ strategy that reduces the complexity of the multijointed movement.

compensatory

Clients with dysmetria cannot control what? How do we test for Dysmetria?

direction, extent, force, or timing of limb movement (Sudden release of force by examiner (as in a MMT) can lead to extreme movement) use the finger to nose test

The problem with the muscle tone changes is the inability to stabilize a limb thus making ____ movements nearly *impossible*. How do we counter this?

distal, support part of the limb (the rest should move quite appropriately)

In isolation, cerebellar lesions generally produce _______;however, lesions are seldom in isolation. Patients can correct this with ______ to the task at hand, but when attention is diverted, the limbs get weak.

hypotonicity, attention (Think about having to concentrate on holding on to your baby the whole time you carry it. If you meet a stranger who wants to admire that baby and distracts you, you would drop it!)

Adiadochokinesia

inability to make rapid, alternating movements of a limb and seems to reflect abnormal agonist-antagonist muscle control

dysdiadochokinesia

inability to perform rapid alternating movements --> loss of range and rhythm

Connections to motor systems are ________. Connections with the cortex and other brain structures are ______. Damage to the cerebellum affects the motor control on the ________ side of the body. How does the cerebellum communicate with the rest of the brain?

ipsilateral, contralateral, ipsilateral, through 3 sets of nuclei

Specific interventions to do with Ataxia: 1. Reduce the number of ____ the pt needs to control. 2. reduce the ___ of the movement ^^How do we do this? through _____

joints, speed strength and endurance training

What 3 groups are lesions in the cerebellum placed into, depending on where the damage occurs?

midline lateral hemispheres posterior

For the Finger to Nose Test, make sure the test requires movement at ___ joint

more than one (people with ataxia tend to move more normally when they limit movement to only one joint)

for interventions with ataxia, consider _____ intense, _____ duration programs as well as: -gait and balance interventions -aerobic conditioning -resistance training

more, longer

dyssynergia

movement decomposition -performed as a sequence of parts rather than a single smooth movement - *stop and make adjustments* throughout the movement

Eye movement deficits seen in patients with ataxia are: _____ How do we test for this?

nystagmus, impaired ability to smoothly track objects, and abnormal VOR ask them to track moving objects and to fixate on objects while turning their heads back and forth (so, VOR and VOR cancel)

In the *lateral hemispheres*, the ___ side controls the right and vice versa. lesions here contribute to what? ___ This portion of the cerebellum also controls the movement to ________ targets.

right, limb ataxia, dysarthria, and hypokinesia visual

the cerebellum controls movement by collecting _____ ____ ____ such as *limb position, balance, info, and vision + synthesizes them together to control movement by sending nerve transmissions down motor nerve _____.

sensory nerve inputs, outputs

Newer research is showing that ataxia *can be managed*, but because of ______ motor learning time, it may take much more ____ than originally thought

slower, time

the cerebellum plays in important role in movements which require careful _____ and interaction of many muscles: maintaining posture, walking, eating, playing musical instruments, tracking movements with the eyes, etc. Those with *cerebellar damage* may still be able to ____, gesture and eat, but movements may appear _____ and clumsy

timing, walk, difficult

lesions in the *midline* cause _____. The tremor *disappears partially* or completely when an affected person is walking or sitting. This portion of the cerebellum controls ____ and is preferentially involved in gait and stance. WILL have *difficulty* with what?

titubation (staggering), trunk ataxia, and orthostatic tremor equilibrium standing still, walking, and higher level gait

The *posterior lobes* (Flocculonodular, Archicerebellum) have multiple synapses and tracts to form the ______ system. Bc of this, lesions here cause what? ____

vestibular, balance and equilibrium disruptions, as well as vestibulo-oculo-motor, and VOR disruptions