Case Presentation

(Cerebellar Stroke)
By Gregory Ong PT Student
Hello!
I am Gregory Ong,
a Year-3 Physiotherapy student
from SIT.
Today’s presentation will be about
my experience with a patient who
has cerebellar stroke.

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Presentation Outline
▫ Patient Clinical Presentation
▫ Cerebellar Stroke
▫ Literature Review
▫ Treatment Plan
▫ Reflection

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1 Patient Clinical
Presentation
Patient Profile

Name: Mr H Age: 73 Years Old

Living Arrangement:
1-bedroom studio apartment with 50 y/o daughter
Care Arrangement:
Self-care as daughter is working 
Premorbid Functional Status:
Independent in ADLs and community ambulant without aid
Lifestyle:
Retired. Goes to Bishan Park every morning for exercise,
visits temple and buys own meals

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What Happened?
Admitted to
Sustained a Raffles Transferred
head injury Hospital for to AMKH for
from a fall on acute rehabilitation
2 May 2020 management

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Main Issues in AMKH

1. Cerebellar Intracranial Hemorrhage,

complicated by Intraventricular Hemorrhage
and hydrocephalus
• Was on External Ventricular Drainage (EVD) and
Right frontal Ventriculoperitoneal Shunt (VP shunt)

2. Acute delirium secondary to Urinary Tract Infection

• Disoriented to time and place
• Memory impairment

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ICF Model

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ICF Model

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ICF Model

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ICF Model

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ICF Model

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ICF Model

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2 Cerebellar Stroke
Symptoms and Impairments
Functions of the Cerebellum
“Air Traffic Controller” of the Body

• Maintaining Balance
Integrates inputs from the sensory systems (vestibular, somatosensory and visual),
spinal cord and other parts of the brain. Closely related to vestibular system. Fine-
tunes motor movement to maintain upright posture.
• Coordination of Movements (Including Eye Movements)
Timing of muscle actions to allow smooth movement of the body.
• Motor Learning
Formation of muscle memory for movements that are practiced repeatedly
• Speech
Poor coordination of muscles of speech production

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Signs and Symptoms of Cerebellar Stroke
Signs Symptoms
• Ataxia (heel-shin test) • Loss of balance
• Dysmetria (finger-to-nose test) • Difficulty performing fine motor skills
• Dysdiadochokinesia (Flipping hand, • Speech difficulty
tapping foot quickly) • Gait incoordination
• Dysarthria (Slurred speech) • Nausea/Vomiting
• Headaches

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3 Literature Review
Physiotherapy Interventions for Postural Control and
Ataxia
Current Evidence For Improving Balance After
Stroke
1) Limited evidence of physical therapy on balance after stroke: A systematic
review and meta-analysis (Hugues et al., 2019)
• 145 studies about various physiotherapy interventions for improving balance.
Ranging from functional task-training to assistive devices.

Conclusion:
“Functional task-training associated with musculoskeletal intervention and/or
cardiopulmonary intervention and sensory interventions seemed to be immediately
effective in improving balance or postural stability respectively.” (Hugues et al., 2019)

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Current Evidence For Improving Balance After
Stroke
2) Rehabilitation interventions for improving balance following stroke: An overview of
systematic reviews (Arienti et al., 2019)
• 51 systematic reviews about various physiotherapy interventions for improving balance after
stroke

Conclusion:
“…limited evidence that rehabilitation interventions, including exercise therapy, repetitive task
training, physical fitness training, care-mediated exercise, virtual therapy and use of unstable
support surfaces, may be beneficial for people with balance impairment after stroke, but further
research is necessary to be confident in this finding.”

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Evidence For Improving Walking Coordination
After Stroke
3) Interventions for coordination of walking following stroke: Systematic review
(Hollands et al., 2012)
• 33 studies about four types of interventions: task specific walking practice, ankle foot
orthoses, functional electrical stimulation, auditory cues

Conclusion:
“The results of this review indicate that interventions involving auditory cueing and task-
specific practice of walking may positively influence gait coordination after stroke.”

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Citations
• Hugues, A., Di Marco, J., Ribault, S., Ardaillon, H., Janiaud, P., Xue, Y., ... & Bernal, P. H. (2019).
Limited evidence of physical therapy on balance after stroke: A systematic review and meta-
analysis. PloS one, 14(8).
• Arienti, C., Lazzarini, S. G., Pollock, A., & Negrini, S. (2019). Rehabilitation interventions for
improving balance following stroke: An overview of systematic reviews. PloS one, 14(7).
• Hollands, K. L., Pelton, T. A., Tyson, S. F., Hollands, M. A., & van Vliet, P. M. (2012). Interventions
for coordination of walking following stroke: systematic review. Gait & Posture, 35(3), 349-359.

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4 Treatment Plan
Integration of Evidence Into Treatment Plan

Problems Strategy

Decreased Postural Control • Functional task training (Hugues et al., 2019)

• Unstable surfaces (Arienti et al., 2019)

Impaired Gait • Task-specific walking training

• Auditory cueing (Hollands et al., 2012)

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Components of Postural Control

The Central Nervous System

Vestibular System (CNS) integrates sensory input
from the:
• Vestibular System
• Visual System

te m ry
• Somatosensory System
Vis

Sys senso
ual

In order to produce adequate motor

Sys

ato

output to maintain a controlled and

Som
te m

upright posture.

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Relationship of Cerebellum to Vestibular Organs

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Postural Control Training Approach
1. Force-use remaining vestibular inputs to train it (train hard as much as
possible)
• Alter visual input: close eyes, reduce lighting, exercise in busy environment with
moving stimuli, head movements
• Alter somatosensory input: unstable surface, decrease base of support (feet together, tandem)

2. Using somatosensory and visual inputs to substitute impaired vestibular

inputs (make it easier if it is too hard)
• Increase visual input: exercise in front of mirror, train in environment with reduced moving stimuli
• Increase somatosensory input: remove shoes

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Functional Task Training
Static Balance Exercises: Stand unsupported feet together/semitandem/tandem
(eyes open/closed)

Dynamic Balance Exercises: Standing/sitting on unstable surfaces (eyes open/closed),

figure of 8 walking, marching on the spot, alternate foot stepping on
stool

Weight Shift Exercises: https://www.youtube.com/watch?v=b9B-TxzmKfQ

Mock stairs: Practice stair climbing technique with walking aid

Obstacle course: Practice how to negotiate kerbs/steps/ramps with walking aid

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Unstable Surfaces
Performing sitting and/or standing activities on:
• Foam Board
Examples of activities:
• Upper limb movement (shoulder flexion,
horizontal abduction/adduction)
• Wobble Board • Reach and throw beanbags
• Throwing and catching small ball
• Turning trunk side-to-side
• Balance Discs

• Gym Ball

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Task-Specific Walking Training

Parallel Bar: Weight shifting exercises, increasing step length

Walking Aid: Practice correct usage of walking aid (3-point or 2-point gait)

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Auditory Cueing

Rhythmic cues: Walking to the beat of music or metronome to establish

consistent pace

Counting out loud: Count the steps “1, 2, 3” when practicing 3-point gait

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Progression

Walking Practice
Postural Control Gait Training at With Suitable Aid
Training Parallel Bar Crossing
Kerb/Obstacles
Stair Climbing

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Patient’s Progress
Improved postural control (standing balance):
• Reduced postural sway during dynamic standing tasks
• Reduced leaning to one side when walking

Improvements in gait:
• Able to take bigger steps when walking i.e. less shuffling
• Improved regulation of gait speed. Initially walking at a inconsistent
pace, will speed up suddenly.
• Able to use walking aid correctly with verbal prompting of steps. Initially
carrying walking aid and not following sequence of 3-point gait pattern.

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5 Reflection
What Went Well

• Built rapport with patient

• Explain the purpose behind each exercise

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Challenges and Areas For Improvement

• Prioritization of patient’s impairments

• Flexibility in modifying exercises based on patient’s

response

• Knowing how much to push the patient to in order to

maximize recovery

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 Thank You!
Hope you have enjoyed the
presentation.
Any comments/questions?

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