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gait training in ataxia

gait training in ataxia

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Garima Gupta MPT Neurology

Indian Institute Of Rehabilitation Sciences New Delhi

Contents
◙ Standing and walking ◙ Role of cerebellum ◙ What is gait ataxia and its causes? ◙ Assessments of ataxia ◙ Specific scales for Ataxia and their validity & reliability ◙ Goals in Gait training in Ataxia ◙ Interventions and evidences. ◙ References

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Standing and Walking

Muscle power Postural sensibility

Central co-ordinating mechanism

Brain & Bannister’s clinical neurology 7th edition

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Role of cerebellum MOTOR CORTEX PERIPHERAL FEEDBACK MECHANISM CEREBELLUM 1/24/2010 Garima Gupta ISIC New Delhi 4 .

Role Of Cerebellum Cont…  Hence cerebellum acts as : Comparator Error correcting mech. 1/24/2010 Garima Gupta ISIC New Delhi 5 .

and adaptation of posture and locomotion through practice. Kennedy Krieger Institute and Department of Neurology. MD 21205. Morton SM. USA. dynamic regulation of balance. Baltimore.Role Of Cerebellum Cont…  The cerebellum is important for movement control and plays a particularly crucial role in balance and locomotion. ______________________________________________________________________ Cerebellar control of balance and locomotion. 1/24/2010 Garima Gupta ISIC New Delhi 6 . Bastian AJ.  Recent work suggests that it plays a role in the generation of appropriate patterns of limb movements. Johns Hopkins University School of Medicine.

equilibrium. ipsilateral limb movements. visually guided limb movements and the planning of those movement (lateral hemisphere and dentate nuclei) 1/24/2010 Garima Gupta ISIC New Delhi 7 . • control of complex. and locomotion (vermis and fastigial nuclei) • control of discrete.Role Of Cerebellum Cont… Medial cerebellum Intermediate Cerebellum Lateral Cerebellum • posture.

2000) ______________________________________________________________ Relative Contributions of Balance and Voluntary Leg-Coordination Deficits toCerebellar Gait Ataxia Susanne M. 2003. 130. (Cooper et al. 2004) while the control of goaldirected movements and perturbed or visually guided walking is influenced by the intermediate and lateral parts of the cerebellum. Specific influences of cerebellar dysfunctions on gait Heidrun Golla et al. Brain (2007).Role Of Cerebellum Cont…  Animal studies also confirmed the fact that the control of balance in stance and locomotion is dependent on the medial part of the cerebellum (Thach and Bastian. Morton1 and Amy J. 786^798 1/24/2010 Garima Gupta ISIC New Delhi 8 . Bastian J Neurophysiol 89: 1844–1856.

Steady on the right leg. d. 1/24/2010 Garima Gupta ISIC New Delhi 9 . Unsteady on the left leg. c. Ataxic gait. b.Ataxic Gait and position in standing & Gait a. Sways to the right in standing position.

1996. Morton and Bastian. 2004). or congenital Stroke Traumatic brain Metabolic disorders. increased step width and high variability of gait (Diener and Dichgans. Ataxia is a common sign in a variety of disorders. Some conditions displaying ataxia are inherited Insidious.Gait Ataxia Cerebellar ataxic gait is typically characterized by an instable stumbling walking path. 1/24/2010 Garima Gupta ISIC New Delhi 10 .

Cerebellar infarcts. hypoxia Dorsal spinal cord compression from vertebral fractures Alcohol Drug abuse Vestibular dysfunction may result in ataxia. 1/24/2010 Garima Gupta ISIC New Delhi 11 .

however. Possible mechanisms of recovery after central nervous system lesions may include: Neural sprouting. Substitution. These is. neighboring areas of the cerebellum can adapt or compensate for the impaired region. Vicarious functions. ____________________________________ Kathleen M Gill-Body et al Physical therapy 1997 1/24/2010 Garima Gupta ISIC New Delhi 12 .What are the bases for cerebellar recovery?? Recovery after cerebellar lesions or disease in humans is poorly documented. which suggests that if the cerebellum is not totally destroyed. strong evidence of recovery after cerebellar lesions in experimental animals. Functional reorganization.

dysphagia. 1/24/2010 Garima Gupta ISIC New Delhi 13 . musculoskeletal system(such as foot and spine deformities) Cranial nerves: ocular movements. ROM.Assessment History Systems review: cardiovascular system. spasticity may present later in the disease. visual field. hearing loss. Motor functions: symmetry. muscle strength. dysarthria. acuity deficits.

Coordination tests: 1/24/2010 Garima Gupta ISIC New Delhi 14 .Deep tendon reflexes and superficial reflexes: decrease or absent. Sensory integrity: sensory neuropathy may present. Positive babinski: later in disease.

unequal step length. Balance measures: Functional reach test. Timed “Up and Go”. Earllaine Croarkin Volume 87 Number 12 Physical Therapy 1/24/2010 Garima Gupta ISIC New Delhi 15 . decreased velocity etc… ______________________________________________ Presentation and Progression of Friedreich Ataxia and Implications for Physical Therapist Examination Joyce R Maring.  Gait assessment: wide base of support. Timed Up and Down stairs test and measurement of static standing. Pediatric balance scale.

Posture and gait disturbance ii. Oculomotor disorder 1/24/2010 Garima Gupta ISIC New Delhi 16 . Speech disorder iv.Composite Performance Measures A. Kinetic functions iii. International Cooperative Ataxia Rating Scale: 100 point scale 10-15 mins Domains: i.

B. Peripheral nervous system 5. Lower limb coordination 4. Upright stability 1/24/2010 Garima Gupta ISIC New Delhi 17 . Neurologic examination 1. Activities of daily living III. Bulbar 2. Upper limb coordination 3. Friedreich’s Ataxia Rating Scale: 30 mins Domains: I. Functional staging of ataxia II.

Inherited Ataxia Clinical Rating Scale G. Functional Ataxia Scoring Scale E. Ataxia Clinical Rating Scale D.C. Northwestern University Disability Scale _________________________________________________ Presentation and Progression of Friedreich Ataxia and Implications for Physical Therapist Examination Joyce R Maring. Inherited Ataxia Progression Scale F. Earllaine Croarkin Volume 87 Number 12 Physical Therapy 1/24/2010 Garima Gupta ISIC New Delhi 18 .

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+/. or Valsalva maneuvers Absent Only if bilateral vestibulopathy Cerebelllar Sensory Sometimes present Absent Limb paresthesia or numbness Ataxia worse in the dark May be present with brainstem involvement Absent or rare Present Present 1/24/2010 Garima Gupta ISIC New Delhi 20 .noise. or waxing and waning may be worse with head movements. constant.History Vertigo Vestibular Present ++ Paroxysmal.

History Vestibular Cerebelllar Sensory Cerebellar signs •Tremor •Ataxia Absent Present •Dysmetria •Dysynergia •Dysdiadoch okinesis •Dysarthria •Titubation •Impaired eye pursuit Nystagmus Often present Often present acutely central type peripheral type Peripheral proprioceptive Absent Absent sensory deficit Romberg's test May be Absent present if there is a bilateral vestibulo pathy 1/24/2010 Garima Gupta ISIC New Delhi Absent Absent Present Present 21 .

Once the patient is on established home exercise program ongoing clinical evaluation with changes in the home program as needed. Maintaining or improving patient’s ability to continue to participate in all environmental contexts for as long as possible. Prolonging locomotor skills. Patient and family education about the effect of disease progression on function and life style.Gait Training In Ataxia Goals: Minimize disability. deformity and pain. 1/24/2010 Garima Gupta ISIC New Delhi 22 . potential therapeutic interventions and realistic expectation about those interventions.

Balance exercises 6. Aerobic fitness and treadmill training 8. Proximal muscle stabilization exercises & Pre gait training 2. Maintenance of biomechanical alignment 1/24/2010 Garima Gupta ISIC New Delhi 23 . Body weight supported treadmill training 9. Stretching exercises 4. Vestibular Rehabilitation 7. Coordination exercises 5. Strengthening exercises 3.Interventions 1.

Hydrotherapy 13.Newer concepts in training of gait ataxia 15.Biofeedback 12. Home exercises  1/24/2010 Garima Gupta ISIC New Delhi 24 .10.Weight bearing ex’s & gait training in parallel bar 11. Adaptive devices: Walker / Cane  Power scooter  Wheel chair 14.

1/24/2010 Garima Gupta ISIC New Delhi 25 .  Prone  Forearm supported prone lying  Reaching and B/L and U/L weight bearing activities and weight shifting activities.Proximal muscle stabilization exercises & Gait training :  To improve postural stability.

Half kneeling weight transfer and reach outs. Kneeling position weight transfer and reach outs. Quadruped position weight transfer and reach outs. Standing 1/24/2010 Garima Gupta ISIC New Delhi 26 .

1/24/2010 Garima Gupta ISIC New Delhi 27 . Standing in a 1st with wide BOS gradual narrow BOS parallel bar Placing foot forward on marked point. Arm swing with foot placement. Reduce support & gait with assistive devise. Gradual increase in step length & distance walked.

May 1997 1/24/2010 Garima Gupta ISIC New Delhi 28 . described proprioceptive neuromuscular facilitation including resistive exercises to help improve strength. but no research studies of the efficacy of PNF for patients with cerebellar disorders have been reported.Strengthening exercises: For hip and shoulder muscles – posture and functional use of arms and legs. coordination.trunk control and helps to reduce pain from scoliosis PNF techniques like rhythmic stabilization can promote trunk stabilization. low weights. Number 5 . ________________________________________ **Physical Therapy . Kabat. and gait. For trunk and low back muscles. balance.** Avoid over fatigue Low repetition. with rest period in between. endurance. in 1955. Volume 77 .

1/24/2010 Garima Gupta ISIC New Delhi 29 . In wheel chair bound patient: hamstring and hip flexor stretching is beneficial to prevent contractures.Stretching exercises: Gasrtocnemius/soleus and foot arch : for foot deformities such as pes cavus. Stretching of spinal musculature is beneficial to tightened muscles as a result of scoliosis.

Coordination exercises:  All the coordination test can be used as the treatment exercises to improve coordination. direction and force. by speaking during the performance) 1/24/2010 Garima Gupta ISIC New Delhi 30 . withdrawal of external cues & guidance. Reduce the attentional demands of action to encourage the automaticity (eg.  complexity can be increases by varying: Support condition Timing constraints Environmental context  Closing eyes. increasing the amplitude of movement. altering the speed.

 Improve postural control using visual and vestibular inputs.Cervico ocular reflex 1/24/2010 Garima Gupta ISIC New Delhi 31 . * VOR.Balance exercises: What is the rational for balance exercise? :  Promote use of VOR & COR* for gaze stability.Vestibulo ocular reflex COR.  Promote use of saccadic eye movements for gaze stability.  Promote VOR cancellation  Improve ability to use somatosensory and vestibular inputs for postural control.  Improve postural control using all sensory inputs.  Improve ability to use vestibular and visual inputs for postural control.

slow/self paced head movements.Exercises : Visual fixation. Visual fixation at various speeds. simple static background. EO. slow and fast head movements. Visual fixation. complex static and dynamic background 1/24/2010 Garima Gupta ISIC New Delhi 32 .

EO and EC . firm and padded surface 1/24/2010 Garima Gupta ISIC New Delhi 33 . feet together. arms crossed Semi tandem stance with EC continuously . EO/EC. arms closed to body. head movements Semi tandem stance.Static stance.

wide turns. EO/EC. firm/ foam surfaces Walking sideways/backward. slow/ fast head movements Gait with progressively narrowed BOS.Gait with narrow BOS. EO. sharp turns bending and reaching activities 1/24/2010 Garima Gupta ISIC New Delhi 34 . March in place.

67(2-A):219-223 Decreased ataxia and improved balance after vestibular rehabilitation 1/24/2010 Garima Gupta ISIC New Delhi 35 .Vestibular Rehabilitation:  Cawthoren first describe the concept in 1944. Increase the static and dynamic postural stability .  Based on central mechanisms of neuro plasticity known as adaptation.  The VR exercises seek to Improve the vestibulovisual interaction during cephalic movement. familiarization and substitution for obtaining vestibular compensation . _________________________________________ Helen S.Head & Neck surgery Vol 130.4:418-425 2004 Vestibular Rehabilitation Arq Neuropsiquiatr 2009. Reduce individual sensitivity to cephalic movement. Cohen Otolaryngology.

Visual fixation on a moving target – Gaze Stability 5. Active eye head movement between two stationary targets 3.Head coordination ex’s protocol1.Gaze stability Eye. Visual fixation on a moving target 4. Visual fixation on stationary target 2. Imaginary visual fixation _____________________________ Kathleen M Gill-Body et al Physical therapy 1997 1/24/2010 Garima Gupta ISIC New Delhi 36 .

 Ear.  Ear. Cawthorne’s head exercises.Eye coordination exercises.body coordination exercises. _________________________________ Guidelines from Michigan Ear Institute 1/24/2010 Garima Gupta ISIC New Delhi 37 .

reflecting a 50 watt increase in maximum work load.Aerobic fitness: Case report: Patient’s with FRDA may improve aerobic fitness by participating in stationary cycling for 20 to 25 mins at 70% to 85% of their maximum heart rate. Peak VO2 increased 27% and peak ventilation increased 21%. Total exercise time increased 5 mins. In addition. _______________________________________ Endurance exercise training in friedreich ataxia .70:786-788 1/24/2010 Garima Gupta ISIC New Delhi 38 .75Kg weight loss. Large increase in cardiorespiratory and work measure demonstrated clinically important physiologic adaptation to aerobic conditioning in this patient. the patient experienced a 4. Archive Physical medical rehabilitation 1989.

Both individuals demonstrated gains in all parameters over initial baseline and subsequent phases. _________________________________________________ Treadmill training for ataxic patients: a single-subject experimental design Clinical Rehabilitation 2008.22:234. with performance increases ranging from 26% to 233% when first and last assessments were compared. but intervention withdrawal produced deceleration of performance gains. 1/24/2010 Garima Gupta ISIC New Delhi 39 . Gains in walking speed were not significantly better during intervention. Three 20-minute treadmill training sessions each week with progression in velocity and step length.05). Significantly superior effects of treadmill training over baseline conditions on cadence were detected (P < 0.Treadmill training: A woman (25 years) and a man (53 years) with chronic ataxia due to head trauma.

The repetitive training of a complete gait cycle enables a more appropriate pattern of sensory input associated with the different phases of gait to stimulate the locomotor pattern. 1/24/2010 Garima Gupta ISIC New Delhi 40 .Body weight supported treadmill training: BWST has several advantages: The body-weight support harness allows a progressive increase in the demands for postural control The treadmill allows systematic control and progression of the speed at which walking is performed. locomotor training using BWST allows the therapist to provide manual assistance to help the patient simulate a more normal walking pattern. In addition.

Body weight supported treadmill training: 1/24/2010 Garima Gupta ISIC New Delhi 41 .

Robert Price. but the intensity and duration of training required for functionally significant improvements may be prolonged.  Locomotor training using BWS on a treadmill in conjunction with over ground gait training may be an effective way to improve ambulatory function in individuals with severe cerebellar ataxia. Vicki Stevens. _______________________________________________________ Locomotor Training Using Body-Weight Support on a Treadmill in Conjunction With Ongoing Physical Therapy in a Child With Severe Cerebellar Ataxia Kristin Cernak. Locomotor training using BWS on a treadmill was continued 5 days a week for 4 months at home. Anne Shumway-Cook Volume 88 Number 1 Physical Therapy 1/24/2010 Garima Gupta ISIC New Delhi 42 . Locomotor training using a BWS system both on the treadmill and during over ground walking was implemented 5 days a week for 4 weeks in a clinic.

4:25 Garima Gupta ISIC New Delhi 43 . _________________________________________________________ 1/24/2010 A rehabilitation tool for functional balance using altered gravity and virtual reality Lars IE Oddsson et al Journal of NeuroEngineering and Rehabilitation 2007.  This restriction may limit the full advantage of unload of gait training.  BWS training there is absence of associated postural adjustments(APAs).Newer Approach:  Some researches says that BWS treadmill do not sufficiently challenge the balance function as it provide the support with harness.

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Orthopedic problems such as foot deformities and scoliosis are often treated with orthoses or surgery and may result in a temporary improvement in function.Maintenance of biomechanical alignment: Maintaining biomechanical alignment is an important therapeutic consideration. 1/24/2010 Garima Gupta ISIC New Delhi 45 .

 Orthopedic shoes improve gait in Friedreich’s ataxia: a clinical and quantified case study __________________________________________________ C. GOULIPIAN. The patient suffered from: Pain on soles and dorsal side of toes.44:93-8 1/24/2010 Garima Gupta ISIC New Delhi 46 . with an estimated 400 m walking distance Falls happening many times per day Ankle sprains occurring once a week. Orthopedics shoe: Case report: This study reports the case of a 26-year-old woman with FA. BENSOUSSAN et al EUR J PHYS REHABIL MED 2008. its rating was 70/100 mm on the visual analogue pain scale Fatigability. when walking with Standard shoes. L.

Avoid friction 1/24/2010 Garima Gupta ISIC New Delhi 47 . Impairments: Equinovarus . Hallux valgus. Orthopedic shoe to improve stability and hold the foot deformities.  Rehabilitation program: To maintain ankle ROM and balance. Claw toes.

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Biofeedback :
 Sensory information can be augmented by using a biofeedback (BF)

system.  Visual, acoustic, and tactile BF systems have been used successfully to improve stance balance in subjects lacking vestibular, visual, and somatosensory information.

____________________________________________________________

Effects of practicing tandem gait with and without vibrotactile in subjects with unilateral vestibular loss. Marco Dozzaa et al. J Vestib Res. 2007 ; 17(4): 195–204.

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Hydrotherapy :
 In early rehabilitation, hydrotherapy can be used to increase alertness by using

Halliwick techniques or stimulating the input by using Watsu with lots of movement and turbulence.  A hydrotherapy advantage in this patient group is the ease of handling in the water in comparison to handling on dry land.

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Adaptive Devices : 1/24/2010 Garima Gupta ISIC New Delhi 51 .

1/24/2010 Garima Gupta ISIC New Delhi 52 .

1/24/2010 Garima Gupta ISIC New Delhi 53 .

Some people use lateral stepping strategies to prevent falling.The use of reverse – break system walker has been reported to reduce fall frequency. for these people walker may reduce ambulatory safety. 1/24/2010 Garima Gupta ISIC New Delhi 54 .

_________________________________________________________ Retraining of functional gait through the reduction of upper extremity weight bearing in chronic cerebellar ataxia Internal rehabilitation medicine 1987 1/24/2010 Garima Gupta ISIC New Delhi 55 ..•Some researches says that the use of upper extremity as weight bearing may impede the improvement of balance in gait training. •Brandt et al suggested progressively increasing body instability to activate “ sensori motor rearrangement”.

Power scooter 1/24/2010 Garima Gupta ISIC New Delhi 56 .

 Automatic spinal program over take the control. suppressing the misleading false cerebellar inflow. March 15. Neurol Sci.  Task oriented training. 254(1-2)2007 Auditory feedback control for improvement of gait in patients with multiple sclerosis __________________________________________________________ 1/24/2010 Garima Gupta ISIC New Delhi 57 .29(1):34-42 Locomotor training and virtual reality – based balance training for an individual with multiple sclerosis: a case report  J.2:117-124 2004 Rehabilitation management of fridreich ataxia: LE force control variability & gait performance  Neurology 2006 Jan 24.  Neurorehabilitation & neural repair 18.  Virtual reality  Auditory feedback  cerebellar stroke with speed dependent gaot ataxia Stroke journal.Newer concepts for gait training in Ataxia:  Motor control theory (Dynamic Action Theory).  Walk as fast as possible. Treatment showed 3 fold improvement in gait velocity and 2 fold improvement in stride length and single leg support time improved.66(2):178-81 Virtual reality cues for improvement of gait in patients with multiple sclerosis  J Neurol Phy Ther 2005 Mar.

Sitting unsupported. Knee walking with walker and without walker 4. 2. Standing balance: ● Feet apart ● Feet together ● Split stance ● Weight shifting ● Stepping without assistive device 1/24/2010 Garima Gupta ISIC New Delhi 58 .Home exercise: Balance 1. High kneeling with bench for upper-extremity support 3.

Gait ● Treadmill with harness ● Gait with 4-wheeled walker ● Gait with U-Step walker Strength 1.Mobility 1. Progressive resistive exercises for core and extremities 1/24/2010 Garima Gupta ISIC New Delhi 59 . Transfers ● Wheel to chair and back ● Wheelchair to floor ● Floor to wheelchair ● Sit to stand and back to sitting 3. Crawling on forearms ● On extended arms 2.

Brain (2007). Earllaine Croarkin Volume 87 Number 12 Physical Therapy Decreased ataxia and improved balance after vestibular rehabilitation Helen S. Clinical Neuroanatomy Richard S. 4th edition. 130. 7th edition. Cerebellar control of balance and locomotion. USA.References:         Principle of internal medicine: Harrison16th edition.Kennedy Krieger Institute and Department of Neurology.4:418-425 2004 Garima Gupta ISIC New Delhi 60 1/24/2010 . Cohen Otolaryngology. Johns Hopkins University School of Medicine.. Morton SM. Baltimore. Specific influences of cerebellar dysfunctions on gaitHeidrun Golla et al.Head & Neck surgery Vol 130. Snell 6th Edition Physical rehabilitation assessment & management. Vol II Brain & Bannister’s clinical neurology. MD 21205. Bastian AJ. 786^798 Presentation and Progression of Friedreich Ataxia and Implications for Physical Therapist Examination Joyce R Maring.

Kristin Cernak. GOULIPIAN.  Orthopedic shoes improve gait in Friedreich’s ataxia: a clinical and quantified case study C. Archive Physical medical rehabilitation 1989.22:234. Vicki Stevens. Robert Price.70:786-788  Treadmill training for ataxic patients: a single-subject experimental design. L.  Locomotor Training Using Body-Weight Support on a Treadmill in Conjunction With Ongoing Physical Therapy in a Child With Severe Cerebellar Ataxia. Anne Shumway-Cook Volume 88 Number 1 Physical Therapy  Retraining of functional gait through the reduction of upper extremity weight bearing in chronic cerebellar ataxia Internal rehabilitation medicine 1987  Cerebellar stroke with speed dependent gaot ataxia Stroke journal. Clinical Rehabilitation 2008.44:93-8 1/24/2010 Garima Gupta ISIC New Delhi 61  .67(2-A):219-223  Endurance exercise training in friedreich ataxia .References cont… Vestibular Rehabilitation Arq Neuropsiquiatr 2009. BENSOUSSAN et al EUR J PHYS REHABIL MED 2008.

Neurol Sci. Marco Dozzaa et al. 2007 .29(1):34-42 Locomotor training and virtual reality – based balance training for an individual with multiple sclerosis: a case report J.ewac. Morton and Amy J. Garima Gupta ISIC New Delhi 62 1/24/2010 . Jneurol Sci 2007 Mar 15. EWAC Medical http://www.2:117-124 2004 Rehabilitation management of fridreich ataxia: LE force control variability & gait performance Neurology 2006 Jan 24. Bastian J Neurophysiol 89: 1844–1856.Baram Y. Hydrotherapy in adult neurology By Johan Lambeck PT.References cont…        Neurorehabilitation & neural repair 18.Miller A. 2003. 17(4): 195–204.254 (1-2):90-4 Relative Contributions of Balance and Voluntary Leg-Coordination Deficits to Cerebellar Gait Ataxia Susanne M. March 15.66(2):178-81 Virtual reality cues for improvement of gait in patients with multiple sclerosis J Neurol Phy Ther 2005 Mar. J Vestib Res.com Effects of practicing tandem gait with and without vibrotactile in subjects with unilateral vestibular loss. 254(1-2)2007 Auditory feedback control for improvement of gait in patients with multiple sclerosis.

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