CEREBELLAR

DISORDERS
 INTRODUCTION

Cerebellum contributes to the balance and

coordination of voluntary movement.

Cerebellar Dysfunction or disorder

include:
• Postural unsteadiness
• Difficulty in coordinating movement
• Clumsiness experienced by individuals with
cerebellar dysfunction
 ETIOLOGY

The
• Familial or Hereditary disease
possible (e.g., Frederick's ataxia).
causes or • Space-occupying lesion,
diseases neoplastic or metastatic tumors.
affecting • Infection (e.g., encephalitis).
• Demyelinating disease (e.g.,
the multiple sclerosis)
cerebellum • Vascular: stroke
:
 ETIOLOGY

Developmen
tal Trauma:
Ataxic CP, Traumatic
Arnold- brain
Chiari
syndrome
injury

Drugs, Chronic
heavy alcoholis
metals m
BASIC CHARACTERISTICS OF CEREBELLAR SIGNS AND
SYMPTOMS

Errors in the planning and execution of movements, rather than paralysis or

involuntary movements.

If symptoms predominate in the trunk and legs, the lesion is near the midline;
if in the arms, the lesion is in the lateral hemispheres.

If only one side of the cerebellum is affected, the symptoms are unilateral
and ipsilateral to the lesion.

Many of the symptoms of cerebellar disease improve gradually with time if

the underlying disease process does not itself progress.

Almost all patients with cerebellar lesions have some type of gait
disturbance.

Speech disturbances occur only with bilateral damage.

The most severe disturbances are produced by lesions in the superior

cerebellar peduncle and the deep nuclei.
LOCALIZATION OF CEREBELLUM
DYSFUNCTION
 LOCALIZATION OF CEREBELLUM
DYSFUNCTION
1. Lesions of the
Archicerebellum/Flocculonodular
• Central vestibular symptoms: ocular dysmetria
(flutter like oscillations of eye), poor eye pursuit,
dysfunctional vestibular ocular reflex (VOR),
impaired eye-hand coordination.
• Gait and truncal ataxia: poor postural control
and orientation, wide-based gait.
• Patient lose their ability to stand or walk without
swaying or falling and tend to fall even when
sitting with their eyes open.
 LOCALIZATION OF CEREBELLUM
DYSFUNCTION

2. Lesions of the
Paleocerebellum/spinocerebellum
• Hypotonia: diminished resistance to passive
movement.
• Truncal ataxia: disequilibrium, static postural
tremor, increased sway, wide BOS and high guard
arm position. Posture worse with eyes closed,
narrow BOS (Romberg test for postural sway).
• Ataxic gait: unsteady, increased falls,
uneven/decreased step length, increased step width.
.
 LOCALIZATION OF CEREBELLUM
DYSFUNCTION
3. Lesions of Cerebrocerebellum/Neocerebellum

• Errors in direction, deviation from proper course, dysmetria,

dysdiadochokinesia, and intention tremor all may be present,
especially in movements of the upper extremities.
• The gait may actually be normal.
• Stretch reflexes and muscle tone are often diminished,
resulting in flabbiness.
• Dysarthric speech may occur with bilateral involvement and
can be pronounced.
• Dyssynergia: Impairments of multi-joint coordination,
movement sequences, complex motor tasks
• Errors in timing related to perceptual tasks.
 ADDITIONAL IMPAIRMENTS

It includes:
• Asthenia: generalized weakness.
• Hypotonia: especially in acute cerebellar lesions,
difficulty with postural control of proximal (axial)
muscles.
• Motor learning impairments: decreased
anticipatory control, feedback and learning delays.
• Cognition: deficits in information procession,
attention deficits.
• Emotional dysregulation: changes in emotional
behaviors.
• Nystagmus, Scanning (staccato), explosive, or
slurring speech.
COMMON COORDINATION
IMPAIRMENTS ASSOCIATED WITH
CEREBELLAR DYSFUNCTION
Asthenia Hypotonia

Asynergia
Hypermetria
Delayed reaction time

Dysarthria Hypometria

Dysdiadochokinesia
Nystagmus
Dysmetria

Dyssynergia Rebound phenomenon

• Intention (kinetic)
Gait disorders • Postural (static)
Tremor • Titubation (rhythmic
oscillations of head)
SUMMARY
CLINICAL ASSESSMENT & EVALUATION
CLINICAL ASSESSMENT & EVALUATION

1. Finger-to-finger and
2. Heel–to-shin test
finger to nose
• Ask patient to touch your • Ask the patient slide the
finger tip with his index heel of one foot straight
finger then touch his or down the top of the shin
her own nose. of other leg, from the
• You increase the knee down to the foot.
difficulty of this test by • Abnormal exam occurs
adding resistance to the when he/she is unable to
patient's movements or keep his/her foot on the
move your finger to shin. Difficulty placing
different locations. the heel illustrates the
Abnormality of this is dysmetric component of
called dysmetria. dysfunction.
CLINICAL ASSESSMENT & EVALUATION

Finger-to-finger and finger to Heel–to-shin test

nose
CLINICAL ASSESSMENT & EVALUATION

3. Rebound phenomenon
• Inability to stop forceful movements after resistive
stimulus removed, patient unable to stop sudden limb
motion
• Flex the patients elbow. Ask the patient to keep their
arm in that position as you pull away, when you release
the arm, the arm will hit the patient's body.
• A positive sign is seen in a spastic limb where the
exaggerated "rebound" occurs with movement in the
opposite direction. With cerebellar involvement, patient
is unable to stop the motion, and the limb will move
suddenly when the resistance is removed.
 4. DYSDIADOCHOKINESIA:

Rapid Rapid loss

Impaired ability to Irregular
perform rapid pronation of range
alternating movement movements and
/supination
rhythm
CLINICAL ASSESSMENT & EVALUATION

4. Test for rapid 5. Romberg test for

alternating movement
• Impaired ability to perform
rapid, alternating movements i.e.
dysdiadochokinesia.
• Complete inability is called
adiadochokinesia.
• Ask the patient to tap the palm of
one hand with the fingers of the
other, then rapidly turn over the
fingers and tap the palm with the
back of them, repeatedly. i.e.
supination and pronation
• (alternatively you can ask the
patient to quickly tap their foot
on the floor as fast as possible).
postural sway
• This test is performed in standing
to test balance.
• Subjects are asked to stand with
both feet together and arms at
sides, first with EO and then with
EC for 10-20 seconds.
• If okay with EO but sways with
EC then positive Romberg.
CLINICAL ASSESSMENT & EVALUATION

If Romberg test is +, then this test is performed. Inability to

perform this test indicates vestibular impairments.
CLINICAL ASSESSMENT & EVALUATION

6. Past pointing test

●
Pt. made to sit with hands up &
index finger extended
●
Examiner raises his both index
fingers in front of patient
●
Pt. asked to touch examiner’s
fingers with EO and then EC
●
If patient cannot perform task
smoothly then test is positive i.e.
movement beyond the target
 EXAMINATION
Muscle strength, tone.

Range of motion.

Coordination.
Balance: determine abnormalities of
postural control and balance.

Gait: determine abnormalities

of gait (ataxic gait).

Motor function: determine

abnormalities of motor learning.

Functional status.
Endurance and fatigue level: fatigue
is common with dysmetric patients.
PHYSICAL THERAPY MANAGEMENT

The most commonly

Cerebellar Disorder
commonly treated by
the physiotherapist is
“Cerebellar Ataxia”

GOALS
THERAPEUTIC MANAGEMENT:

Therapy directed
at promoting:

Functional
postural stability
balance and gait

Accuracy of
limb movements
 MAIN PRINCIPLES OF TRAINING

Exercises should be practiced consciously at first and then

followed by automatic exercise activities

Exercises should progress from simple to complex

Activities should be practiced first with EO and later with

EC
After achieving proximal tone and stabilization, the coordinated
movement of the distal segments should be considered

Compensation methods and supportive aids and

equipment should be employed when necessary

Appropriate home exercise program and sports activities

PHYSICAL THERAPY MANAGEMENT

Eye-head Stability Dynamic postural

coordination exercises: control exercises:
exercise: Use of wt-bearing Weight shifting,
Slow head postures, use of rocking, moving in
thera band, weights and out of postures
movements with
(ankle and wrist or movement
visual fixation;
cuffs), weighted transitions such as
active eye and supine to sit, sit to
waist belts and
head movements. walkers to decrease stand and scooting.
ataxic movements.
Balance training: compensatory training/safety
important. Standing balance and gait activities.
Static balance: single limb stance, Clock reach, Body
circles, Eyes tracking
Dynamic balance: Dynamic walk, Heel to toe etc.
Gait training: walking on two narrow lines, tandem
gait, backward gait, slowed down gait (soldier's
gait), stopping and turning in response to sudden
directions, flexion, extension and left-right rotations
of the head.
Hydrotherapy: water provides graded resistance, decreases
ataxic movements and postural instability. Practice static
and dynamic postural control in sitting and standing.
Swimming and shallow water calisthenics
Improves strength , endurance and reduce fatigability.
Proprioceptive training
Plyometric exercises, balance
board and mini trampoline
exercises. Vibration and suit
therapy are also used to
improve proprioception,
posture and movement. PNF,
rhythmic stabilization, slow
reversal techniques. Yoga and
other body-awareness exercises
may also be included.
Coordinatio Use of supportive
Motor learning aids
n exercises: strategies: low Use of supportive
PNF patterns, stimulus environment devices enables the
(closed environment) patient to function more
Frenkel's ideal; focus on easily within his present
exercises, ball practice and
functional level. In cases
of severe ataxia,
gymnastics to repetition; distributed suspending weights from
practice (endurance the extremities and the
promote may be low) use of weighted walkers
balance can be preferred
11. Supportive aids: In
cases which restorative
physical treatment
applications are insufficient,
use of supportive devices
enables the patient to
function more easily within
his present functional level.