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NeuroRehabilitation 20 (2005) 85–89
IOS Press

Beneficial effects of postural intervention on
prehensile action for an individual with ataxia
resulting from brainstem stroke
Mary Ellen Phillips Stoykova, Mark Stojakovicha and Jennifer A. Stevens a,b,∗


Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, IL, USA
Department of Physical Medicine & Rehabilitation, Northwestern University Feinberg School of Medicine, USA

Abstract. Primary objective: This paper examined the effectiveness of postural training on upper extremity performance in an
ataxic individual. The ataxia resulted from a brain stem stroke.
Research design: Before-after, single-subject experimental design.
Experimental intervention: Four-week course of postural training, comprised of three one-hour sessions/week.
Main outcomes and results: The patient demonstrated an increase in function of the ataxic limb, as evidenced by appreciable
increases in the Fugl-Meyer score and modest increases in the Postural Assessment Scale for Stroke Patients (PASS) score.
Conclusions: Improvement in postural control influences upper extremity function affecting the speed and accuracy of the
movement. We demonstrate the effectiveness of using postural training as an intervention towards reducing the effects of ataxia, a
movement coordination impairment for which relatively few therapeutic techniques have been specifically developed or evaluated.
Keywords: Ataxia, posture, brainstem stroke, rehabilitation

1. Introduction
Brainstem stroke accounts for twenty-five percent of
total stroke occurrence. Cardinal symptoms include
cranial nerve involvement, contralateral motor and/or
sensory deficits, and ipsilateral cerebellar signs. Other
typical symptoms may include double vision, pupil dilation, and paralysis of facial muscles. In comparison to cortical strokes, individuals who have suffered
a brainstem stroke have a higher incidence of dysphagia and dysarthria. Also, survival rate is significantly
lower. The clinical presentation of a brainstem stroke
is dependent on lesion site location, extent of damage
to cranial nerves, and the vascular integrity of nearby
structures. Clinical intervention is therefore highly individualized [16].
∗ Address for correspondence: J.A. Stevens, Ph.D., now at Psychology Department, College of William & Mary, PO Box 8795,
Williamsburg, VA 23187-8795, USA. E-mail:

Ataxia, the inability to coordinate muscle activity during voluntary movement, also commonly results from brainstem stroke. Movement errors typical
of ataxia include timing errors, abnormal trajectories,
joint decomposition, inaccuracy in reaching the end
point, and delay in movement initiation. These deficits
in action are likely due to the inability to produce muscle torques that are appropriately counterbalanced with
joint interaction torques [2].
The evaluation of ataxia is based on the presentation
of overt behavioral deficits, many of which can be assessed for the arm using the upper extremity portion of
the Fugl-Meyer. For example, the finger-to-nose test
will demonstrate presence/absence of tremor, dysmetria, and postural stabilization [5]. Other tasks for assessing upper limb ataxia include alternating pronationsupination, finger to finger task, and tracing or drawing
on a predetermined pattern. These evaluation tasks,
which do have the ability to detect small motor changes,
are inappropriate to use as outcome measures or to

ISSN 1053-8135/05/$17.00 © 2005 – IOS Press and the authors. All rights reserved

Other than a brief hospitalization due to a stress fracture.14]. / Postural intervention for ataxia guide treatment. trunk control plays a necessary role in and is a significant predictor of successful ADL performance and gait activity [9]. physical therapy intervention included a maintenance program of standing with assistance. and speech therapy for five months in the nursing home. married female with an unremarkable medical history. physical and speech therapies were administered at home. The maximum possible score for these four categories combined is 66. There are relatively few studies examining occupational or physical therapy treatment techniques for ataxia. The subject had an inpatient stay of four weeks and remained in a coma during that time. Method 2. the approach has relatively small practical application in terms of long-term functional recovery gains. severe right hemianopsia. which assesses a variety of multi-joint movement and grasp patterns of the upper limb.15]. and the treatments evaluated are quite varied. we present a case report of an individual with severe upper limb ataxia and poor trunk control as the consequence of a brainstem stroke. Anticipatory postural control mechanisms shift prior to arm movements in order to provide stability by minimizing the disturbing forces resulting from the moving extremity [10. and active range for the non-paretic side. Indeed. Time between stroke and participation in the present intervention was approximately three years. The subject received OT. she participated in activities outside the home including investment club and going to restaurants and movies.16].86 M. Assessments Formal clinical evaluations included the FuglExtremity Motor Scale [8] and the Postural Assessment Scale for Stroke Patients (PASS) [3]. For stroke survivors with movement incoordination. she was again admitted to an inpatient rehabilitation program for intensive therapies. With the assistance of her husband. Here. When the subject emerged from her coma. she was transferred to a nursing home. In January of 2000. the effect of local ice application on reduction of cerebellar tremor for individuals with Multiple Sclerosis was investigated [1]. dysphagia. The PASS is . A full-time caretaker provided assistance with most ADLs. There are four sub-scales including: 1) Upper extremity (measures proximal movement.2. PT. ADLs and communication strategies. Focus on retraining of postural control and postural reactions is a concept intimately tied to Bobath treatment. Some believe that training in trunk control should precede upper extremity motor control training [7]. The subject was dependent in all activities of daily living. Other treatments evaluated. While the results indicated that cooling provided short-term tremor reduction. The lesion extended from the left lateral ventricle to the superior cerebellar peduncle. 2. Symptoms observed following coma emergence included a dense right hemiplegia. although not systematically studied. she suffered a hemorrhage of the left midbrain.E. 2) wrist.11].1. dysarthria. passive range of motion for the paretic side. Stoykov et al. hyperreflexia. The Fugl-Meyer Upper Extremity Motor Scale is a well-known instrument that measures synergistic patterns and isolated movement for individuals who have suffered a stroke. To date. The article describes how arm movement improved after a four-week course of postural training. Posture lies at the seat of movement control as it provides the basis for body positions and functional skills [4.P. Prior to stroke onset. Ataxia has also been evaluated using kinematic measures [2. a rare location for a stroke [6. and 4) coordination/speed. Subject The subject was a 68 year old. The subject was not receiving occupational therapy at the time of the study. We restricted our use of the test to the upper extremity portion. There was no cortical involvement. the subject complained of a headache and was given aspirin. Initial MRI analysis revealed hemorrhage in the brain stem. the subject was medically stable. examination of the direct effects of postural training on functional gains in an individual with upper limb ataxia have not been systematically investigated. demonstrating that prehensile movements are intimately tied to postural stability [13]. Approximately a year post-stroke. At the time of study. Postural control strongly influences upper extremity function affecting the speed and accuracy of the movement. infant studies indicate a significant impact of self-sitting on the acquisition of reaching behaviors. Speech therapy focused on articulation. Additionally. include distal limb weighting and postural control training [12]. and dense right-sided sensory deficits. For example. then collapsed and became unconscious. which focused on family training in transfers. the left (ipsilesional) side was extremely ataxic. 2. After discharge. 3) hand.

To our knowledge. which is important for postural alignment as well as reduction of pain. treatment included practice in maintaining an unsupported sitting posture. Intervention The subject received one-hour occupational therapy sessions in the clinic three times a week for four consecutive weeks. They are assessed both statically and dynamically. the subject scored a 35 out of a possible score of 66 on the Fugl-Meyer Upper Extremity Motor Scale. The scores on the Fugl-Myer indicate greater isolated control of proximal and distal musculature. She scored 0 on the Barthel ADL index both before and after the treatment. Moreover. Occupational therapists traditionally use compensatory techniques such as minimizing the degrees of freedom via external support (e. receives assistance in all ADLs. Upper extremity activity and pos- . Results and discussion Baseline scores were taken before the first day of postural intervention. she reported greater comfort in sitting and was able to sit for longer periods in her wheelchair without discomfort. sitting. it is likely that postural training facilitated improved anticipatory control. a consid- 87 erable gain of 18 points.3. and standing. 2. Moreover. Currently.E. The subject reported that she was able to attend her investment club meetings. During the first two weeks. the subject initially scored a 2 out of a possible 36. 4. On the ataxic left upper extremity. A neuromuscular approach to postural control was initiated. the subject reported greater comfort while sitting. The discrepancy between increases in FuglMeyer score and unchanged Barthel index scores indicate that the successful performance of low-level activities such as precede activities for daily living and must remain a focus for physical and occupational therapists alike. Additionally. On the PASS. Also. 1. the therapist recommended a lumbar support to use while the subject was in the wheel chair.g. The D1 pelvic pattern includes anterior elevation and posterior depression of the pelvis. however. after intervention. The subject also was instructed in scapular strengthening exercises while sitting supported in the wheel chair. As the client gained the ability to achieve unsupported sitting. However. there is no consensus on how to treat upper limb ataxia. an activity she thoroughly enjoyed. The subject still suffers from severe ataxia and. the increases in Fugl-Meyer occurred as a result of postural intervention highlight postural stability as a critical component stage in the functional recovery process for an individual with ataxia. / Postural intervention for ataxia a clinical scale designed to assess static and dynamic postural control in individuals with stroke. thus. The paralyzed right upper extremity had no active movement and could not perform any of the movements on the Fugl-Meyer scale. Caregiver training included instructions in facilitating sitting balance and trunk strengthening exercises. Stoykov et al. which afforded better quality of limb movement. this is the first study demonstrating quantifiable gains in functional recovery in the ataxic individual following a controlled course of postural intervention. this case study illustrated how neuromuscular postural control intervention resulted in improved upper extremity movement. dynamic trunk exercises including trunk flexion and reaching to the left while weight shifting were also attempted. Mobilization of the pelvis in the D1 direction facilitated a more symmetrical pattern during sitting. A lumbar support provided enhanced somatosensory feedback about the subject’s position in space. Upper extremity strengthening may also be attempted.rolling and reverse rolling from the less affected (left) side were performed with gradually decreased assistance from the therapist. Following the four-week intervention. score of 7 out of a possible 36. Conclusion In summary. In order to strengthen the trunk. Verbal and tactile cures were provided to the subject as she practiced sitting without support. Additionally. perhaps a longer course of training. Three postural activities are assessed including lying.P. it assisted the subject in maintaining an anterior pelvic tilt.M. strengthening alone will not resolve the coordination decrement between the muscle and joint interaction torques. the subject had attained a score of 53 out of a possible 66 on the Fugl-Meyer. and introduction of postural training at an earlier stage in the recovery process may have greater effect of performance improvement. The results of both assessments are presented in Fig. The subject was still dependent in all activities of daily living due to complete paralysis of the right side. resting forearms on table while performing an activity) or distal weighting. 3. However. Sessions began with passive range of motion of the pelvis in the D1 diagonal in side lying [17]. The PASS score increased by 5 points with an overall.

Local ice application in therapy of kinetic limb . The PASS may be utilized specifically for individuals demonstrating difficulties with trunk control. Schwecht. M. Konig. L. Albrecht. Stoykov et al.P. W. Erasmus and N.E.88 M. 1. Pollman D. References [1] H. Increases in Mayer and PASS scores with an ataxic limb following four weeks of postural intervention. However.P. (2) to develop postural strategies (3) stabilizing upper limb movement and (4) incorporate postural control into activities of daily living. tural control are interconnected. The goals of postural training are varied and may include: (1) preventing and remediating impairments. and both should be assessed prior to intervention [9]. Due to the severity of the ataxia in our subject. we were unable to incorporate activities of daily living into her intervention. our case illustrates the strong relationship between postural control and manipulation skill. / Postural intervention for ataxia Fig. Parag.

446–462. 189–205. Jaasko. Trunk control as an early predictor of comprehensive activities of [10] [11] [12] [13] [14] [15] [16] [17] 89 daily living function in stroke patients. Pelissier. Human Movement Science 22 (2003). Myers. G. The post-stroke hemiplegic patient. Archives of Physical Medicine and Rehabilitation 77 (1996). Morasso. Baltimore. Adult Hemiplegia: Evaluation and Treatment..F. Baltimore.L. Hsueh and C. Kong. Journal of Motor Behavior 24 (1992). L.Y. Fugl-Meyer. pp. J. Neurological Rehabilitation: Optimizing Human Performance. Validation of a standardized assessment of postural control in stroke patients: The Postural Assessment Scale for Stroke Patients (PASS). in: Occupational Therapy for Physical Dysfunction. J. Williams & Wilkins.R. Functional outcome in brainstem stroke patients after rehabilitation. William Heinemann Medical Books: London. Mazaux and M. de Seze. T. in: Occupational Therapy for Physical Dysfunction. Martin. B. V. Shepard. 1995. (4th ed.M. 1013–1016. Mancardi and C. L. Keating and W. Scandinavian Journal of Rehabilitation Medicine 7 (1975). De Seze. M. K. Dogerty and H. Movement preparation. Kaminski and S. Clinical characteristics of patients with brainstem strokes admitted to a rehabilitation unit. K. Bobath. 1995. The effects of stance configuration and target distance on reaching I. Foley. / Postural intervention for ataxia [2] [3] [4] [5] [6] [7] [8] [9] ataxia. Perennou. Simpkins.G.P. Stroke 30 (1999)..A. Maryland.M. Clinical assessment of positive treatment effects in patients with multiple sclerosis. Debelleix. Proprioceptive neuromuscular facilitation approach. Bastian. Archives of Physical Medicine and Rehabilitation 82 (2001). Leyman. Williams & Wilkins.A. L.E. 13–31. Villy. 2626– 2630. S.E. Barat. P. Cerebellar ataxia. 1066– 1073. C. 1862–1868. Sanguineti. P. Benaim. T. Self-sitting and reaching in 5. Wiart. Baratto.S.). P. Experimental Brain Research 136 (2001). C.L. 492– 509.R. Trombly. Voss. Hsieh. C. Stroke 33 (2002). 210–220. ed.J. Rehabilitation of postural disturbances of hemiplegic patients by using trunk control retraining during exploratory exercises. Woollacott. Brichetto. Solaro. B. J. Teasell. Stoykov et al. Abnormal control of interaction torques across multiple joints. I.T. Cerebellar ataxia: Quantitative assessment and cybernetic interpetation. 194– 8-month old infants: The impact of posture and its development on early eye-hand coordination. 1995. Carr and R. 793–800. Propriocepitve Neuromuscular Facilitation: Patterns and Techniques. ed. Motor Control Theory and Practical Implication. 1990. 474–498.A. R. Thach.A.H. T. Shumway-Cook and M. Rochat. M.J. X. M. A.G. Ionta and B. 439–446. Rousseaux and J. Sheu. D. Neurodevelopmental (Bobath) Treatment.H. J. . Williams & Wilkins. Myers. Bon-Saint-Come. 1998. pp. C.P. M. G. Nervenarzt 69 (1998). Chua and K. Archives of Physical Medicine and Rehabilitation 83 (2002). Butterworth-Heinemann: Massachusetts.A. I: A method for evaluation of physical performance. Journal of Neurophysiology 76 (1996). 1985.J. Wang. A. C. D. Levit. A.I. Steglind. Olsson and S. A. Finestone.H. Trombly. Willliams & Wilkins. N. Joseph. L.K.