Ataxia

Questions
Clinical approch with types
Assessment
Management
Reference

1. ATAXIA
BY: MITTAL JADAV

2. QUESTIONS
Q1-PT Mx for sensory ataxia. (2016) [5marks]
Q2-Ataxia (2015,2014) [5marks]
Q3-Mx of cerebellar ataxia. (2014) [5marks]
Q4-Describe different types of ataxia & write down
detail assessment of 25 year old pt with
cerebellar ataxia. (2013) [16marks]
Q5-Sensory ataxia. (2013, 2003) [5marks]

3. Q6-How will you differentiate cerebellar & sensory
ataxia? Write Mx of cerebellar ataxia. (2012)
[16marks]
Q7-Discuss evaluation & Mx of a pt with
cerebellar ataxia. (2011) [16marks]
Q8-Write about etiopathogenesis, pathology, C.F.
& PT Mx of a pt with cerebral ataxia. (2009)
[16marks]
Q9-What is ataxia? Write about C.F. & rehab. of a
pt with cerebellar ataxia. (2008) [16marks]

4. Q10-Cerebellar ataxia. (2006) [5marks]
Q11-Discuss assessment & Mx of a case of
cerebellar ataxia. (2006) [16marks]

5. CONTENTS
•Definition
•Types
[1] cerebellar ataxia
-definition
-types and symptoms
-etiology
-clinical features
-assessment
-management

6. [2] Sensory ataxia
-introduction
-cause
-assessment
-management
[3] Vestibular ataxia

7. DEFINITION
•“Ataxia” is a neurological sign & symptom
that consists of gross lack of coordination
of muscle movements.
•Ataxia is a non specific clinical
manifestation implying dysfunction of parts
of nervous system that coordinate
movement, such as the cerebellum.

8. TYPES
•1] Cerebellar
•2] Sensory
•3] Vestibular

9. [1] Cerebellar Ataxia
Definition
•It is a term used to describe certain
behavior like postural unsteadiness,
difficulty in coordinating movements &
clumsiness experienced by an individual
with cerebellar dysfunction.

10. Types & symptom manifestation
•Symptoms depends on cerebellar structures
which is affected & whether lesion is bilateral
or unilateral.
(a)Dysfunction of vestibulocerebellum:impairs
balance
& control of eye movements.
-with postural instability

11. -Negative Romberg’s test
~ the instability is worsened when standing
with the feet together, regardless of
whether the eyes are open or closed.
~ this is a negative Romberg’s test or
inability to carry out the test, because the
individual feels unstable even with open
eyes.

12. (b) Dysfunction of spinocerebellum: presents
•With a wide –based “drunken sailor” gait,
characterized by uncertain starts & stops,
lateral deviations, & unequal steps.
•This part of the cerebellum regulates body
& limb movements.
(c) Dysfunction of cerebrocerebellum:
presents with disturbances in carrying out
voluntary , planned movements.

13. •These include:
-intention tremor
-peculiar writing abnormalities (large,
unequal letters, irregular underlining);
-a peculiar pattern of dysarthria (slurred
speech, sometimes characterized by
explosive variations in voice intensity
despite a regular rhythm)

14. Etiology
•Developmental abnormality. Eg.
Hydrocephalus, Arnold Chiari
malformation.
•Trauma, focal lesion
•Stroke, tumor, infection
•Demyelinating disease like MS
•Degenerative disease
•Heriditary (Fredrich’s ataxia)

15. •Metabolic disease (B12 defficiency)
•Vascular disease
•Drug intoxication or exogenous substance
(ethanol causes reversible cerebellar &
vestibular ataxia)

16. Clinical presentation
•Hypotonia: decrease in muscle tone.
•Dysmetria: -loss of direction, extent,
force & timing of movements.
-It may be hypometria or
hypermetria.
•Dysdiadokokinesis:-inability to perform
rapid alteration movement eg. Supination
–pronation.

17. -movement appears slow &
quickly looses range & rhythm.
-it is a result of inappropriate
timing of muscle activity.
•Tremors: -intention tremors is often seen
& usually enhanced during terminal goal
oriented movt.
-they have a freq. of 3-5Hz.
-while maintaining posture,
postural tremor is seen.

18. •Movement: decomposition: -difficulty in
performing movt. In one smooth pattern &
may perform the movt. In a sequence of
steps.
-movt.
become separated into individual
components.

19. •Ataxic gait ( gait disturbance): -also
known as staggering gait/ reeling gait/
drunkards gai
-characterized by:-
~ uneven step length
~ irregular width of the walking
base.
~rhythm is absent
~ feet are lifted to high

20. •Scanning speech/ Dysarthria: -it is a
motor speech disorder resulting from
neurological injury, characterized by poor
articulation
-it is due to some disorder in the N.
system, which hinders control over, the
tongue, throat, lips or lungs.
-swallowing problems (dysphagia)
are often present.
-cranial N. that control these muscles
include the Ⅴ,Ⅶ,Ⅸ,Ⅹ,Ⅻ.

21. •Asthenia:-generalized weakness of the
involved side of the body
-complains of heaviness,
excessive effort & early onset of fatigue.
-caused due to loss of
cerebellar facilitation to the motor cortex
which in turn could reduce the activity of
the spinal motor neurons during voluntary
movt.

22. •Rebound phenomena: -eg, the pt with
his elbow fixed, flex it against resistance.
When the resistance is suddenly released
the pt’s forearm flies upwards & may hit
his face or sh.
•Nystagmus (central nystagmus): -
occurs as a result of either normal or
abnormal processes not related to the
vestibular organ.

23. •-eg. Lesions of the midbrain or cerebellum
can result in up beat & down beat
nystagmus.

24. ASSESSMENT

25. [A] Personal database
•Name
•Age
•Gender
•Address
•Occupation
•C/C

26. [B] HISTORY
[C] INVESTIGATION
•CT scan , MRI
-Cerebellar atrophy
-cerebellar tumor
-cerebellar infarction
-tonsilar invagination & hydroceplaus
-Arnold Chiari malformation

27. [C] On Observation
•General observation
-postural tremor, tone (hypotonic), gait (ataxic),
external appliances (walking aids), nystagmus
•Posture
-sit with an increased thoracic kyphosis & forward
head.
-sit with hyperlordosis due to abdominal muscle
weakness.
-stand with a wide BOS.

28. •Involuntary movt. Presence
•Gait

29. [E] On Examination
•Vitals
•Higher function examination
or
Examination of communication & cognitive
skills
-may exhibit delirium ( restlessness,
irritability, tremors, confusion, disorientation or
hallucination) dementia or short term memory
problems in pt’s with alcoholic CD (Coeliac
diesease).

30. -may experience dysarthria
•Sensory examination
-superficial
-deep
-cortical
-pt with CD may demonstrate impaired
proprioception & vibration & therefore
often require vision to perform motor
tasks.

31. •Motor examination
-muscle power/ MMT
~Asthenia (generalized muscle
weakness)
~Need arm support to rise from floor or a
chair due to L.L. or trunk weakness.
-Tone: Hypotonia in the ipsilateral side
-ROM examination & flexibility

32. -Presence of specific signs
~ cerebellar signs: ataxia, tremors,
nystagmus, postural imbalance
•Reflex examination
-decreased DTR or pendular due to
hypotonia
-normal righting reflexes
-delayed or absent protective extension &
equilibrium reactions.

33. •Coordination & bal. ass.
-predict risk of fall
~ intention tremors
~ UL & LL coordination problems
~ positive Rebound test
~ dysdiadokinesia (inability to maintain
rhythm range when foot-tapping or in
supination or pronation)

34. ~ dysmetria (undershooting or
overshooting target during finger to nose &
finger to examiner’s finger tests)
~ movement decomposition (inability to
move smoothly while performing ADL)
~ Difficulty learning new motor tasks due to
cognitive impairment.

35. [H] Special Test
•Romberg’s test : The extent of the sway
envelope when standing with about 4
inches between the feet can be 12˚ in the
sagittal plane & 16˚ in the frontal plane.
[I] PFD

36. MANAGMENT
•There is no specific treatment.
•Physical therapy proves to be effective in
reducing the pt’s difficulties.
•Some amount of recovery takes place
within 3 months without any treatment.

37. PT Mx
1) Psychological support
•Maintain a non threatening interaction
•Give positive reinforcement
•Gain confidence of the pt
•pt should not be isolated
•Family & care giver advice

38. 2) Improve relaxation
•Relaxed passive motion
•General rocking movt.
•Relaxed positioning
•Deep breathing ex.
•Yoga therapy
•Medication
•PNF technique
•Massage
•Relaxation techniques

39. 3) Active general ex.
•AROM ex. & other free ex.
•Mat ex.
•Reaching activities
•Spot marching
•Gymball activites
•Weight shifting ex.s

40. 4) Balance ex.
•Weight shifting
•Alteration in the complexity of the activity,
speed & duration
•Increased amplitude of movement
•Training of complex dual task
•Balance board ex., gymball activities,
tampoline activities
•Progress by giving external pertubations
•Distract attention by speaking during ex.

41. 5) Gait training
•Lengthen stride length
•Concentrate on heel to toe pattern
•Improve arm swing
•Parallel bar activities
•Walk on printed foot prints
•Marching on spot with arm swing
•Waling n straight line
•Walking in circle
•Walking sideways with outstretch hand.

42. 6) Reduce fatigue
•Modification of task, breaking into
component parts
•Pacing of ex. Speed & rate
•Proper rest periods
•Complex activities are broken down to
simpler parts.
•Ex. which requires minimum energy
expenditure are used.
•Over ex. Is avoided.

43. 7) Strengthening exercise
•Simple pendular ex. for very weak
muscles.
•Assisted & resisted ex.
•Theraband ex. To improve eccentric &
concentric control
•Muscle energy technique

44. 8) Ataxia management
•Promote accuracy of limb movt.s by using aids,
cues & feedback.
•Combined activities of the trunk & limbs to
improve coordination, balance & automaticity of
movt.
•Frenkels ex.
•Small wt. cuffs, ankle & wrist bands can be used
during activities to increase awareness of the
limbs.
•Wt. bearing ex. of UL & LL

45. 9) Functional training
•Development of problem solving skills
•Transfer training
•Training of ADL activities
•Environmental modifications & architectural
changes.
•AFO
•Recreational activities –ballroom dancing,
treadmill walking, throwing ball in the basket.
•Sit to stand

46. 10) Tremor Mx
•Wt bearing ex.
•Push ups
•Use weighted utensils & weighted canes
11) For bed ridden pt’s
•Skin care advice
•Respiratory & cardiac care
•Aerobic training with recumbent cycling

47. 12) Family & pt education
13) Home ex. Program

48. [2] Sensory Ataxia
INTRODUCTION
•Ataxia due to loss of proprioception.
CAUSE
•By dysfunction of dorsal columns of spinal cord.
•May also due to dysfunction of various parts of
brain, which receive positional information,
including cerebellum, thalamus & parietal lobes.

49. ASSESSMENT
[A] Personal database
[B] History
[C] Ix
[D] On observation
-Gait: ~ unsteady “stomping” gait with heavy
heel strikes.
~ Postural instability that worsens when
lack of proprioceptive input cannot be
compensated by visual input, s/a in poorly lit
envt.s.

50. [E] On examination
[F] Reflex examination
[G] Co-ordination & balance
-worsening of finger-pointing test with eyes
closed.
[H] Special test
-positive Romberg’s test
[I] PFD

51. MANAGEMENT
•More focus on
~ gait & bal. Mx

52. [3] Vestibular Ataxia
•It is employed to indicate ataxia due to
dysfunction of vestibular system, which in
acute & unilateral cases is associated with
prominent vertigo, nausea & vomiting.
•In slow-onset, chronic b/l cases of
vestibular dysfunction, these characteristic
manifestations may be absent &
disequilibrium may be the sole
presentation.

53. REFERENCE
•Glady Samuel Raj –nero.
•Assessment formate