This document describes a case study on using physiotherapy to treat severe tremor. The patient had multiple sclerosis with sensitive ataxia and severe left arm tremor. The physiotherapy treatment plan focused on teaching the patient about their condition, sensory stimulation like textures and movements, mirror therapy, and bilateral/unilateral coordination exercises with an emphasis on minimizing rocking movements. The conclusions were that the treatment improved movement quality but did not significantly improve activities of daily living or function, and more research is needed on physiotherapy for tremor patients.

1. Physiotherapy in severe tremor. A case study
#HandFun13

2. What´s tremor?
• Part
of
ataxia…or
not
Res6ng
tremor
│ Postural
tremor
│ Cine6c
tremor
inac6vity
Essen6al
tremor
Movement
&
target
│
│
Sensi6ve
Ataxia
→ Inten6onal
&
Postural
tremor
Del
Val,
2004

3. What do we know about tremor?
Neurons of these structures
are capable of genera?ng
oscilla?ng & rhythmic
ac?vity
MacAuley,
2000
Cor6cospinal
via?

4. Treatment in Tremor
• Botulinum
toxin
(e.
Ia)(Demetrios,2013)
• Drugs
(Propranolol,
Topiramate,
Atenolol,
Alprazolam,
Gabapen6ne)
(Zesiewic,
2013)
• Deep
Brain
s6mula6on
• Physical Therapy:
• Resistance
training
(Sequeira,
2012)
• Weight
proximal
/
distal
(mcGruder,
2003)
• robo6c
exoskeleton/
wearable
orthosis
(Rocon,
2007)
• Differents
physical
therapies
methods.
LOW
EVIDENCE

5. Case
• MS
progressive
2004
• Sensi6ve
Ataxia
&
severe
Tremor
in
le`
arm.
• Last
interven6on
for
tremor
was
botulinum
Toxin.
• EDSS:6
• Fa6gue
• MSQoL
• WHIGET
Tremor
Ra6ng
Scale
• Tremor
ac6vi6es
of
ADL
ques6onnaire
• Assessment
of
tremor
related
hándicap
ques6onnaire.
• Ataxia
Scale

6. Case
• Mingazzini
• Finger-­‐nose
• 9
Hole
Peg
Test

8. Pre-­‐treatment
Unilateral Bilateral

9. Physiotherapy…..ideas?
• Teaching
illnes
• Sensi6ve
S6mula6on
• Mirror
Therapy
• Bilateral
Movement
Hipothesys & objec?ves
• Normal
movement
imaging
for
a
bad
cor6cal
image
• Posterior
spinal
cord
symptoms
need
sensi6ve
&
propiocep6ve
treatment
• Short
Term
objec6ves:
how
is
my
tremor?
• Medium
Term
objec6ves:
I´m
moving
with
less
tremor.
• Long
Term
objec6ves:
My
ADL
with
less
tremor

10. Teaching illnes
(same strategy of
Packer,T)
• How
does
my
tremor
work?
Let´s
ROCK!
• Posturology
&
tremor
• Strategies
• Benefits
if
i
work
my
tremor
• ADL
&
tremor
• Changing
behavior
• Biofeedback
Sensi?ve treatment
• Textures
• Propiocep6ve
mobiliza6ons
• Objec6ve:
Generate
new
sensi6ve
inputs
in
somatosensorial
cortex
• NO
ROCK
&
ROLL

11. Mirror Therapy
• Create
new
movement
cortex
input
• No
Rock&Roll

12. Bilateral/Unilateral/Coordina?on movement
• Sensi6ve
&
Motor
control
therapy
• No
rock
as
posible
• Repe66ve
&
short
movements
• Without
func6on.
Just
feel
&
move

13. and… fine movement?

14. Conclusions & objec?ves…
-­‐ Only
qualita6ve
improvements.
-­‐ This
protocol
not
improve
ADL
&
func6on,
only
movement.
-­‐ Short
&
medium
term
objec6ves:
move
with
tremor.
-­‐ Need
more
pa6ents
with
tremor!
-­‐ Inclusion
criteria:
-­‐ Tremor
(Medium
&
Severe)
-­‐ Exclusion
criteria
-­‐ Not
Parkinson
tremor
&
¿Rubral
tremor?

15. @mirallesfisio
mirallesfisio@gmail.com
ROCK
&
ROLL