Questions Clinical approch with types Assessment Management Reference

1. ATAXIA
BY: MITTAL JADAV

2. QUESTIONS
Q1- PT Mx for sensory ataxia. (2016) [5marks]
Q2- Ataxia (2015,2014) [5marks]
Q3- Mx of cerebellar ataxia. (2014) [5marks]
Q4- Describe different types of ataxia & write down
detail assessment of 25 year old pt with
cerebellar ataxia. (2013) [16marks]
Q5- Sensory ataxia. (2013, 2003) [5marks]

3. Q6- How will you differentiate cerebellar & sensory
ataxia? Write Mx of cerebellar ataxia. (2012)
[16marks]
Q7- Discuss evaluation & Mx of a pt with
cerebellar ataxia. (2011) [16marks]
Q8- Write about etiopathogenesis, pathology, C.F.
& PT Mx of a pt with cerebral ataxia. (2009)
[16marks]
Q9- What is ataxia? Write about C.F. & rehab. of a
pt with cerebellar ataxia. (2008) [16marks]

4. Q10- Cerebellar ataxia. (2006) [5marks]
Q11- Discuss assessment & Mx of a case of
cerebellar ataxia. (2006) [16marks]

5. CONTENTS
• Definition
• Types
[1] cerebellar ataxia
-definition
- types and symptoms
- etiology
- clinical features
- assessment
- management

6. [2] Sensory ataxia
- introduction
- cause
- assessment
- management
[3] Vestibular ataxia

7. DEFINITION
• “Ataxia” is a neurological sign & symptom
that consists of gross lack of coordination
of muscle movements.
• Ataxia is a non specific clinical
manifestation implying dysfunction of parts
of nervous system that coordinate
movement, such as the cerebellum.

8. TYPES
• 1] Cerebellar
• 2] Sensory
• 3] Vestibular

9. [1] Cerebellar Ataxia
 Definition
• It is a term used to describe certain
behavior like postural unsteadiness,
difficulty in coordinating movements &
clumsiness experienced by an individual
with cerebellar dysfunction.

10.  Types & symptom manifestation
• Symptoms depends on cerebellar structures
which is affected & whether lesion is bilateral
or unilateral.
(a)Dysfunction of vestibulocerebellum :impairs
balance
& control of eye movements.
- with postural instability

11. - Negative Romberg’s test
~ the instability is worsened when standing
with the feet together, regardless of
whether the eyes are open or closed.
~ this is a negative Romberg’s test or
inability to carry out the test, because the
individual feels unstable even with open
eyes.

12. (b) Dysfunction of spinocerebellum: presents
• With a wide –based “drunken sailor” gait,
characterized by uncertain starts & stops,
lateral deviations, & unequal steps.
• This part of the cerebellum regulates body
& limb movements.
(c) Dysfunction of cerebrocerebellum:
presents with disturbances in carrying out
voluntary , planned movements.

13. • These include:
- intention tremor
- peculiar writing abnormalities (large,
unequal letters, irregular underlining);
- a peculiar pattern of dysarthria (slurred
speech, sometimes characterized by
explosive variations in voice intensity
despite a regular rhythm)

14. Etiology
• Developmental abnormality. Eg.
Hydrocephalus, Arnold Chiari
malformation.
• Trauma, focal lesion
• Stroke, tumor, infection
• Demyelinating disease like MS
• Degenerative disease
• Heriditary (Fredrich’s ataxia)

15. • Metabolic disease (B12 defficiency)
• Vascular disease
• Drug intoxication or exogenous substance
(ethanol causes reversible cerebellar &
vestibular ataxia)

16.  Clinical presentation
• Hypotonia: decrease in muscle tone.
• Dysmetria: - loss of direction, extent,
force & timing of movements.
-It may be hypometria or
hypermetria.
• Dysdiadokokinesis: -inability to perform
rapid alteration movement eg. Supination
– pronation.

17. - movement appears slow &
quickly looses range & rhythm.
- it is a result of inappropriate
timing of muscle activity.
• Tremors: - intention tremors is often seen
& usually enhanced during terminal goal
oriented movt.
-they have a freq. of 3-5Hz.
- while maintaining posture,
postural tremor is seen.

18. • Movement: decomposition: - difficulty in
performing movt. In one smooth pattern &
may perform the movt. In a sequence of
steps.
- movt.
become separated into individual
components.

19. • Ataxic gait ( gait disturbance): - also
known as staggering gait/ reeling gait/
drunkards gai
- characterized by:-
~ uneven step length
~ irregular width of the walking
base.
~rhythm is absent
~ feet are lifted to high

20. • Scanning speech/ Dysarthria: -it is a
motor speech disorder resulting from
neurological injury, characterized by poor
articulation
- it is due to some disorder in the N.
system, which hinders control over, the
tongue, throat, lips or lungs.
- swallowing problems (dysphagia)
are often present.
- cranial N. that control these muscles
include the Ⅴ,Ⅶ,Ⅸ,Ⅹ,Ⅻ.

21. • Asthenia: - generalized weakness of the
involved side of the body
- complains of heaviness,
excessive effort & early onset of fatigue.
- caused due to loss of
cerebellar facilitation to the motor cortex
which in turn could reduce the activity of
the spinal motor neurons during voluntary
movt.

22. • Rebound phenomena: - eg, the pt with
his elbow fixed, flex it against resistance.
When the resistance is suddenly released
the pt’s forearm flies upwards & may hit
his face or sh.
• Nystagmus (central nystagmus): -
occurs as a result of either normal or
abnormal processes not related to the
vestibular organ.

23. • - eg. Lesions of the midbrain or cerebellum
can result in up beat & down beat
nystagmus.

24. ASSESSMENT

25. [A] Personal database
• Name
• Age
• Gender
• Address
• Occupation
• C/C

26. [B] HISTORY
[C] INVESTIGATION
• CT scan , MRI
- Cerebellar atrophy
- cerebellar tumor
- cerebellar infarction
- tonsilar invagination & hydroceplaus
- Arnold Chiari malformation

27. [C] On Observation
• General observation
- postural tremor, tone (hypotonic), gait (ataxic),
external appliances (walking aids), nystagmus
• Posture
- sit with an increased thoracic kyphosis & forward
head.
- sit with hyperlordosis due to abdominal muscle
weakness.
- stand with a wide BOS.

28. • Involuntary movt. Presence
• Gait

29. [E] On Examination
• Vitals
• Higher function examination
or
Examination of communication & cognitive
skills
- may exhibit delirium ( restlessness,
irritability, tremors, confusion, disorientation or
hallucination) dementia or short term memory
problems in pt’s with alcoholic CD (Coeliac
diesease).

30. - may experience dysarthria
• Sensory examination
- superficial
- deep
- cortical
-pt with CD may demonstrate impaired
proprioception & vibration & therefore
often require vision to perform motor
tasks.

31. • Motor examination
- muscle power/ MMT
~Asthenia (generalized muscle
weakness)
~Need arm support to rise from floor or a
chair due to L.L. or trunk weakness.
- Tone: Hypotonia in the ipsilateral side
- ROM examination & flexibility

32. - Presence of specific signs
~ cerebellar signs: ataxia, tremors,
nystagmus, postural imbalance
• Reflex examination
- decreased DTR or pendular due to
hypotonia
- normal righting reflexes
- delayed or absent protective extension &
equilibrium reactions.

33. • Coordination & bal. ass.
- predict risk of fall
~ intention tremors
~ UL & LL coordination problems
~ positive Rebound test
~ dysdiadokinesia (inability to maintain
rhythm range when foot- tapping or in
supination or pronation)

34. ~ dysmetria (undershooting or
overshooting target during finger to nose &
finger to examiner’s finger tests)
~ movement decomposition (inability to
move smoothly while performing ADL)
~ Difficulty learning new motor tasks due to
cognitive impairment.

35. [H] Special Test
• Romberg’s test : The extent of the sway
envelope when standing with about 4
inches between the feet can be 12˚ in the
sagittal plane & 16˚ in the frontal plane.
[I] PFD

36. MANAGMENT
• There is no specific treatment.
• Physical therapy proves to be effective in
reducing the pt’s difficulties.
• Some amount of recovery takes place
within 3 months without any treatment.

37. PT Mx
1) Psychological support
• Maintain a non threatening interaction
• Give positive reinforcement
• Gain confidence of the pt
• pt should not be isolated
• Family & care giver advice

38. 2) Improve relaxation
• Relaxed passive motion
• General rocking movt.
• Relaxed positioning
• Deep breathing ex.
• Yoga therapy
• Medication
• PNF technique
• Massage
• Relaxation techniques

39. 3) Active general ex.
• AROM ex. & other free ex.
• Mat ex.
• Reaching activities
• Spot marching
• Gymball activites
• Weight shifting ex.s

40. 4) Balance ex.
• Weight shifting
• Alteration in the complexity of the activity,
speed & duration
• Increased amplitude of movement
• Training of complex dual task
• Balance board ex., gymball activities,
tampoline activities
• Progress by giving external pertubations
• Distract attention by speaking during ex.

41. 5) Gait training
• Lengthen stride length
• Concentrate on heel to toe pattern
• Improve arm swing
• Parallel bar activities
• Walk on printed foot prints
• Marching on spot with arm swing
• Waling n straight line
• Walking in circle
• Walking sideways with outstretch hand.

42. 6) Reduce fatigue
• Modification of task, breaking into
component parts
• Pacing of ex. Speed & rate
• Proper rest periods
• Complex activities are broken down to
simpler parts.
• Ex. which requires minimum energy
expenditure are used.
• Over ex. Is avoided.

43. 7) Strengthening exercise
• Simple pendular ex. for very weak
muscles.
• Assisted & resisted ex.
• Theraband ex. To improve eccentric &
concentric control
• Muscle energy technique

44. 8) Ataxia management
• Promote accuracy of limb movt.s by using aids,
cues & feedback.
• Combined activities of the trunk & limbs to
improve coordination, balance & automaticity of
movt.
• Frenkels ex.
• Small wt. cuffs, ankle & wrist bands can be used
during activities to increase awareness of the
limbs.
• Wt. bearing ex. of UL & LL

45. 9) Functional training
• Development of problem solving skills
• Transfer training
• Training of ADL activities
• Environmental modifications & architectural
changes.
• AFO
• Recreational activities – ballroom dancing,
treadmill walking, throwing ball in the basket.
• Sit to stand

46. 10) Tremor Mx
• Wt bearing ex.
• Push ups
• Use weighted utensils & weighted canes
11) For bed ridden pt’s
• Skin care advice
• Respiratory & cardiac care
• Aerobic training with recumbent cycling

47. 12) Family & pt education
13) Home ex. Program

48. [2] Sensory Ataxia
 INTRODUCTION
• Ataxia due to loss of proprioception.
CAUSE
• By dysfunction of dorsal columns of spinal cord.
• May also due to dysfunction of various parts of
brain, which receive positional information,
including cerebellum, thalamus & parietal lobes.

49. ASSESSMENT
[A] Personal database
[B] History
[C] Ix
[D] On observation
- Gait: ~ unsteady “stomping” gait with heavy
heel strikes.
~ Postural instability that worsens when
lack of proprioceptive input cannot be
compensated by visual input, s/a in poorly lit
envt.s.

50. [E] On examination
[F] Reflex examination
[G] Co-ordination & balance
- worsening of finger- pointing test with eyes
closed.
[H] Special test
- positive Romberg’s test
[I] PFD

51. MANAGEMENT
• More focus on
~ gait & bal. Mx

52. [3] Vestibular Ataxia
• It is employed to indicate ataxia due to
dysfunction of vestibular system, which in
acute & unilateral cases is associated with
prominent vertigo, nausea & vomiting.
• In slow-onset, chronic b/l cases of
vestibular dysfunction, these characteristic
manifestations may be absent &
disequilibrium may be the sole
presentation.

53. REFERENCE
• Glady Samuel Raj – nero.
• Assessment formate