This presentation from Wendy Hendrie looks at how health professionals can help people with MS cope with ataxia. It was presented at the MS Trust Annual Conference in November 2013.

1. Helping people with MS
cope with ataxia
Wendy Hendrie PhD MSc MCSP
Specialist Physiotherapist in MS
Norwich MS Centre

2. Two main approaches
• Rehabilitation
• Compensatory
 Mobility
 Upper limb
 Posture

3. Many systems responsible for movement quality
SENSORY
CEREBELLAR
VESTIBULAR
MOVEMENT
QUALITY
MOTOR
VISUAL
Deficits in one or more systems
ataxic symptoms

4. RESTORATIVE THERAPY
COMPENSATORY
STRATEGIES

5. Rehabilitation
• Some studies of rehab interventions have
shown improvements in gait, trunk control
and activities.
• Motor relearning may be possible in damaged
cerebellum?
• Very few studies in MS.

6. Rehabilitation
• Interventions
– Dynamic task practice
– Challenges to limits of stability
– Strengthening
– Flexibility
– PNF
– Treadmill training (not MS) + over-ground
training

7. No evidence in ataxia but may be useful…
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Yoga
T’ai Chi
Pilates
Horse riding
Hydrotherapy

8. Managing ataxia
Treatment of ataxic patients requires balance
between facilitation of improved control and
the recognition and acceptance of necessary
compensation which is essential for function.
Jon Marsden

9. Mobility
• Wide-based gait – difficulty placing feet
• Poor balance
• Frequent falls
• Prolonged sitting

10. Balance and Mobility Aids
• No studies have evaluated role of aids
• Case-by-case basis
• Rollators

11. Tendency to ‘fix’
posture (especially
if vestibular
problems).
May be dangerous
as lateral sidesteps to aid
balance is
impeded.

12. Balance and Mobility Aids
• Walking / trekking / Nordic poles – light tough
contact, more weight through lower limbs
• Difficult placing sticks / poles if person has
dysmetria or tremor
• Can weight all hollow mobility aids with sand /
ball-bearings

13. More strategies to improve mobility
• Visually guided stepping
- eyes and locomotor system work together during
walking
- rehearsal of intended placement of steps before
walking
- task-specific and short-lived
- ‘mindfullness’ of movement

14. Wobble cushion in
preparation for
walking cerebellar ataxia –
slow to start, slow
to stop – delay in
agonist/antagonist
initiation.

15. Axial weighting – vest or belt
• Use weights to increase
sensation through joints.
Increases feelings of
steadiness.
• To counteract forward or
backward lean.
• Reaching activities in
sitting.

16. Stabilise core, increase
proprioception / sensation
• Spinal stability wrap
(DM Orthotics)
• Lycra garments
• Support tights

17. Auditory feedback
• Study in people with MS (n=14).
• Rhythmic cueing via earpiece.
• Increased speed and step length but made
some people worse.

18. Keeping cool
• Damp T-shirt
• Cold drinks, meals, puddings
• Damp scarf or tea towel

19. Anecdotes……..

20. Strategies for the upper limb
• Manipulation of visual information
- tremor and dysmetria may improve if
movement not visually guided
- can work well in people with intention
tremor
- find the ‘quiet arc’ of movement

21. Central pick-up

22. Side pick-up, peripheral vision

23. Cooling
• 15 minutes of cooling
• use wine cooler over
forearm
• decrease in tremor
can last for up to 30
minutes (eating, ISC)

24. Wrist weighting
• Grade weight until
tremor diminished
enough for function
• Beware of making
tremor, instability,
weakness, fatigue or
rebound worse
• Up to 4lbs

25. Central pick-up, no aids

26. Central pick-up, weights

27. Equipment for eating
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Weighted cutlery / mugs
Neater-eater
Plate guard
Non-slip mats
Valved straws
Nosey cups

28. more ideas…..
• Overshoot and pick
up on return
• Easy target
• Improve sensation –
visual / touch
• Bag of different
objects / textures

29. Lycra garments
• May help with functional tasks
• Can be hot
• Can be difficult to put on
• Assess with two layers of Size B tubigrip

30. Central pick-up, tubigrip

31. Side pick-up, tubigrip

32. Posture - single joint move
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Simplify movement
Avoid rapid, multi-joint movements
Reduce number of moving joints
Stabilise
Slow movement

33. Standing frames

34. Windswept postures are unstable

35. Build a stable base

36. Unstable eating posture

37. ‘Normal’ eating posture

38. Using the toilet / commode

39. Postural case study
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49 year old lady with MS
Gross ataxia of trunk, head and upper limbs
Living at home
Refusing help with eating
Weight loss
Chest infection
Admitted to hospital

42. Just to make things difficult…..
• Mixed causes
• Reduced joint range
• Weakness
• Emotional impact
• Spasticity
• Cognitive problems
• Eye problems
• Weight loss
• Anxiety/fear
• Social stigma

43. In summary
• Deconditioning makes everything worse so
encourage activity!
• May need to use a variety of compensatory
interventions
• Check medication (especially anti-spasticity)
as muscle weakness may be contributing to
ataxia