Neuro Interventions Pt 1

what are the main considerations it terms of treating spasticity

• we can provide temporary reduction in spasticity, but no treatments that we apply can permenantly remove spasticity

• PT interventions can allow for more effective muscle stretch and increased ROM

• our goal is to help manage spasticity so we can do something in functional mobility easier

how long does our treatment for spasticity typically last?

30 minutes

what does evidence show regarding active movement based strategies to treat spasticity?

active movement based strategies have more support than passive strategies and include…

• resistance training

• LE ergometry training + FES

• NMES/FES

• task specific training

• mirror therapy as an adjunct to active rehab

these strategies address the movement system while also providing repetition, activation, and functional practice

what does evidence show regarding passive based strategies to treat spasticity?

these strategies need to be used with a purpose to create. window for active movement and include…

• stretching/ROM

• positioning and orthosis

• serial casting: best paired with botox

• TENS

• ESWT/vibration

• botox and medical managament: need to consider that botox helps diminish spasticity but also diminishes strength

what is the main clinical takeaways when it comes to spasiticty management?

1. ask whether it needs to be treated— it is not automatically the problem. identify how it affect movement, comfort, ROM, positioning, and functioning. does it limit those things or actually help promote them?

2. measure more than tone— the modified ashworth can describe resistance, but pair it with ROM, movement quality, motor control, gait/UE function, participation, and patient goals

3. match the intervention to the goal— use passive approaches strategically while prioritizing active interventions when teh goal is motor recovery and function

4. think multimodal— PT may be combined with FES, mirror therapy, orthotic management, botox, medications, or other modalities

5. reassess function— a reduction in spasticity does not guarantee better movement

what are sensory techniques for spasticity management?

E-stim, biofeedback, Tens

what is the role of TENS and NMES in reducing spasticity?

• use TENS for neuromodulation and NMES to produce a contraction

• both have moderate quality evidence for reducing post stroke spasticity

• best results when combined with active, task specific training. so we could do them before therapy to start priming the muscles.

what is the role of biofeedback in reducing spasticity?

provides real time visual or auditory feedback to reduce the H reflex excitability through operant conditioning

what are motor techniques for spasticity management?

LE ergometry, resistance training, stretching/loading, whole body vibration

discuss the role of resistance training in spasticity management

• purpose is to improve strength, motor control, and function

• repeated loading can module neural excitability and enhance reciprocal inhibition

• has moderate quality evidence

discuss the role of lower extremity ergometry training in spasticity management

• promotes rhythmic reciprocal movement and improves CV fitness and function

• the rhythmic movement enhances spinal reflex inhibition and sensorimotor input

• moderate quality evidence

discuss the role of whole body vibration in spasticity management

• provides mechanical vibration to stimulate neuromuscular responses and can reduce spasticity and improve balance and function

• actives muscle spindles, influences the spinal reflex excitability, and may enhance presynaptic inhibition

• grade A evidence

discuss the role of stretching in spasticity management

• help maintain ROM and tissue extensability and also support positioning and comfort

• decreases muscle stiffness and may reduce short term spasticity

• low quality evidence

discuss the role of dry needling in spasticity management

• reduces spasticiity and muscle stiffness and may improve ROM and short term function

• modulates local and spinal reflex activity and may disrupt trigger points and decrease abnormal muscle activity

• low quality evidence

*clinical pearl: Dr. Kraft said she would do dry needling, then stretching, then go into functional mobility if you are going to use these

what are the primary goals of positioning devices and resting splints for spasticity management?

• maintain available ROM

• support alignment and positioning

• improve comfort, hygeine, or ease of care

• limit secondary soft tissue shortening

what does the evidence say about positioning devices and resting splints and what are things we should consider for spasticity management?

• routine splinting is not supported for every patient and the benefit for preventing contracture is uncertain

• we should only use after individualized assessment when ROM or care is limited

• we need to monitor for skin, comfort, ROM, and function

• to be effective, splining needs to be done for a longer time and be combined with medical treatment (Baclofen or Botox)

• we need to pair it with active movement whenever possible

why and when would we use serial casting to treat spasticity?

• we should use it to provide prolonged, low load positioning, increase PROM range, address muscle tension shortening, and improve alignment for positiont or function

• we should only use it when PROM is meaningfully restricted, loss of range affects positioning or function, a modifiable soft tissue component is present, and the patient can be safety monitored

• we should NOT use it for perventative ROM, only if a contracture is present and everyting else fails. and we need to combine it with botox which is done 2 weeks prior

what does evidence show the effects of serial casting are for PROM, spasticity, and function?

PROM: it can improve restricted ROM, but without maintenance, gains may diminish quickly

spasticity: tone may change in some patients but evidence for a direct anti-spasticity effect is inconsistent

function: ROM improvement does not guarantee functional gain therefore, we should always pair with with active, task specific rehab and also plan post cast positiong adn movement strategies to retain useful range

what is the process with going about putting on serial casting for spasticity management?

1. put on and take off in 24 hours to ensure they tolerate the pressure

2. second cast is on for a week and do ROM, joint mobs, and fucntional mobility

3. from here on they get a new cast every week so it can be adjusted with ROM gains

what are the principles for applying serial casting for spasticity management?

• cast at R1, not past it which provides a tolerable submax stretch

• protect bony prominences

• continue to cast as long as you are getting ROM gains

• reassess progress weekly, indluding rechecking skin, measuring ROM, repositioning only as tolerated

when should we avoid casting for spasticity management?

• unstable fracture or joint

• active infection or significant open would in the cast area

• severly compromised circulation

• uncontrolled medical insability that makes casting unsafe

• any condition in which safe skin/neurovascular monitoring cannot be ensured

when should we use extra precaution with casting for spasticity management?

• impaired sensation or peripheral neuropathy

• fragile skin/high pressure injury risk

• edema or fluctuating limb volume

• cognitive/behavior issues limiting symptom reporting or cast protection

• pain, autonomic dysreflexia risk, or other diagnosis-specific concerns

what should we be checking regularly with serial casting and when should we remove it/urgently reasess?

• check regularly for pain or increasing spasm, swelling and distal color/temp, capillary refill, new numbness/tingling, skin irritation

• remove if new neurovascular changes, persistent or escelating pain, new inability to bear weight, wet/cracked/softened/or damaged case, foul odor or drainage

discuss dynamic splinting for spasticity management?

• purpose: low load prolonged stretch, maintain or improve ROM, adjustable tension allows progressive positioning

• evidence shows it may improve ankle ROM but the evidence for reducing spasticity is limited. and it has a higher cost and lower adherance

• typical protocol is to begin 2-4 hours/day and then progress towards 6-8 hours, worn overnight, and then increasing tension as tolerated

what are the medical treatment options for spasticity?

• oral agents: used for generalized spasticity, most commonly Baclofen. however causes more system effects as it is used for widespread spasticity so you want to watch out for side effects, mainly grogginess

• intramuscular injection (Botox): used for focal spasticity to target specific muscles. its effects are temporary, typically lasting only 3-4 months and people also develop tolerance to it

• intrathecal interventions: used to deliver medications to the spinal cord to treat regional spasticity (larger regions or multiple muscles) or more severe spasticity. typically require a trial of oral agents before doing this

• dorsal rhizotomy: selectively cutting sensory nerve roots L2-S2. last resort!

what is PNF?

a specialized therapeutic approach that combines functionally based diagonal patterns of movement with techniques of neuromuscular facilitation to evoke motor responses for improved neuromuscular control and function

what are the 5 domains of PNF philosophy?

1. positive approach

2. functional approach

3. mobilization of reserves— everyone has the capacity to be a little better than they already are

4. treat the whole person

5. motor learning and motor control principles

what are the 5 main PNF concepts?

• normal movement and posture are dependent upon synergism with a balanced interaction of agonist and antagonist

• PFN philosophy utlizes motor control concepts and its stages of mobility, stability, controlled mobility, and motor skill development

• motor learning and motor recovery are critical components of the PNF concept in neuro rehab

• stronger segments of the body irradiate neural drive and muscular activation in to the more impaired sections

• PNF techniques should be implimented within the context of a functional therapeutic goal

what are the uses of PNF?

• PNF treatment has been used to increase flexiblity, strength, coordination, and functional patterns/mobility

• learning to relax muscles helps to increase range of motion and decrease spasticity

• build stability around a joint or body segment

• increase motor learning of the agonist thorugh facilitated repetition of an activity

• reverse the motor pattners to include the antagonist

what are the basic principles and procedures for PNF?

• manual contacts

• traction

• approximation

• stretch

• timing for emphasis

• maximal resistance

• verbal/auditory commands

• vision

• timing

• body position and mechanics

• patterns

discuss the PNF principle of manual contacts

• we don’t want our manual stimulation to be noxious so we use a lumbrical grip to stimulate the patients tactile cutaneous receptors and other pressure receptors

• the therapists hand should be placed over the agonist to apply presssure opposite the direction of motion and over the antagnoist to facilitate motion

discuss the PNF principles of traction and approximation

traction: opens the joint and provides elongation of soft tissues. it facilitates motor recruitment by activation of the stretch reflex

approximation closes the joint and provides compression through the trunk or extremsity. it promotes activation of antigravity muscles to enhance postural stabilization and weight bearing capacity

discuss the PNF principle of stretch

• uses the stretch stimulus where a pre-stretch occurs when the muscle is elongated from proximal to distal components of a specific pattern to facilitate motor recruitment and muscle contraction

• stretch stimulus applied in succession may summate motor unit excitation

• precaution: use the of the stretch reflex is not recommended during early stage of soft tissue healing or in the presence of flaccidity

discuss the PNF principle of timing

• timing is a sequencing of motions. normal timing provides continuous coordination motion until the taks is accomlished

• timing for emphasis involves changing the normal sequencing of motions to emphasize a particular muscle or desired activity

discuss the PNF principle of resistance

• the amount of resistance provided during an activity must be appropriate for the patients condition and the goal of the activity

• it elps facilitate muscle contraction to enhance motor control and learning

• it should match the patients effort to control a movement or stablize the body segment

• specific movement and purpose should determine optimal resistance against desired contraction

discuss the PNF principle of body position and mechanics

• the therapists body should be in line with the desired motion of force

• resistance comes from teh therapists body while the hands and arms stay comparatively relaxed

• proper therapist position and body mechanics achieves better movement facilitation and neuromuscular response

discuss the PNF principle of auditory stimulation

the verbal command tells the patient what to do and when to do it. it is divided into 3 parts… preparation, action, and correction

discuss the PNF principle of vision

• feedback from the visual sensory system can promote a more powerful contraction

• it helps the patient to guide correct position and motion

• visual feedback helps to modulate muscle force

• visual engagement enhances communication and helps to ensure cooperative interaction

discuss the PNF principle of patterns

patterns targeted in PNF are 3 dimensional synergistic mass movemtns that are the essential components of daily functional tasks

what are the scapular and pelvic patterns that occur naturally with cross body elevation and during gait?

• anterior elevation and posterior depression

• posterior elevation and anterior depression

what are the trunk patterns?

• flexion and side flexion

• extension and side flexion

what are the upper extremity diagonal PNF patterns?

D1 flexion: shoulder flexion, adduction, ER; forearm supination; wrist flexion, finger flexion

D1 Extension: shoulder extension, abduction, and IR; forearm pronation, wrist extension, finger extension

D2 flexion: shoulder flexion, abduction, and ER; forearm supination, wrist flexion, and finger extension

D2 extension: shoulder extension, adduction, and IR; forearm pronation; wrist extension, finger flexion

what are the lower extremity diagonal patterns?

D1 flexion: hip flexion, adduction, ER; knee flexion; ankle DF inversion, toe extension'

D1 extension: hip extension, abduction, IR; knee extension, ankle PF eversion, toe flexion

D2 flexion: hip flexion, abducion, IR; knee flexion, ankle DF eversion, toe extension

D2 extension: hip extension, adduction, and ER; knee extension, ankle PF inversion, toe flexion

what are the PNF techniques?

elongation (stretching) techniques

agonist (strengthening) techniques

antagonist (strengthening) techniques

what are the PNF stages of motor control?

• mobility: ability to initiate movement through a functional range requiring sufficient muscle strength and lack of tissue/joint restriction

• stability: ability to hold a position or posture with muscle contraction around a joint or body segment

• controlled mobility: ability to move around while maintaining a weight bearing posture or rotating limbs around a long axis

• skill: ability to consistently perform complex, functional tasks with stability and normal postural response

what are the primary and secondary impairments that PNF elongation techniaues treat?

primary: changes in muscle tone— hypertonicity and spasticity

secondary: tissue shortening and joint stiffness

what are the elongation (stretching) PNF techniques?

contract relax, hold relax, agonist contraction (active isolated stretch), hold relx with agonist contraction

discuss contract relax

• the therapist passively moves the limb or body segment, lengthening the range limiting muscle towards end range

• the patient is instructed to contract the pre-stretched lenghtened muscle concentrically against resistance. this is followed by passive limb movement from the therapist to elongate the range limiting muscle

• this is used to reduce stiffness, increase flexibility, and improve joint mobility

discuss hold relax

• the therapist passively moves the limb or body segment, lengthening the range limiting musle, stopping before pain provocation

• the patient is instructed to perform gentl isometric contraction of the pre stretched and lengthened muscle against resistance. this is followed by passive limb movement from the therapist to elongate the range limiting muscle

• may be used to reduce spasticity, icnrease joint mobility and reduce pain

discuss agonist contraction (active isolated stretch)

• the patient concentrically moves the limb or body segment lenghtening the range limiting muscle (antagonist)

• the patient is instructed to contract the (agonist) muscle concentrically and actively hold at end range of the range limiting muscle (antagonist)

• used to lengthen muscle and improve joint ROM

discuss hold relax with agonist contraction

• therapist passively moves the limb or body segment, lengthening the range limiting muscle, stopping before pain provocation

• the patient is instructed to perform gentle isometric contraction of the pre stretched and lengthened muscle against resistance. after several seconds of isometric contraction, the patient is instructed to relax the range limiting muscle and immediately activate the musct opposite. the therapist maintains the newly gained range for several seconds and repeats

what are the PNF techniques used to stabilization?

alternating isometrics

rhytmic stabalization

what are the PNF techniques for strength and coordination?

rhythmic initiation

repeated contraction

combination of isotonic contractions

slow (dynamic) reversals

replication (HRAM)

discuss alterating isometrics

• manual resistance is applied on one side of the body segment/limb followed immediatelly by resistance in the opposite direction, applied within a single plane with no rest periods between reversals

• it is used to build stability around the trunk or proximally at a limb

• this may be utilized in open or closed chain positions

• it is done uniplanar but you can switch the planes and resist flex/ext or side to side

discuss rhythmic stabilization

• isometric contraction of the agnoist and antagnoist without losing muscle tension including rotational forces

• used to increase strength and endurance and to promote stability around a joint or the torso

discuss rhythmic initiation

• rhythmic motion of the limb or body through the desired range, starting with passive motion, then targeting agonist activation through active assisted and active motion, and finally progresing to active resisted movement

• goals: provide sense of active movement, teach the motion, help the patient relax and coordinate movement, normalize the rate of motion by decreasing or increasing it

• traction may be applied at the beginning of active components to facilitate greater motor recruitment/muscle activation

• basically put the muscle in the opposite position, show passive mvmt into motion, then apply a quick stretch as you have them do the motion, then apply resistance against it

discuss repeated contractions

• therapist applies a brief stretch stimulus against the muscle contraction throughout the range of motion, increasing the spatial and temporal sumation of the motor unit recruitment in patients having poor motor control and/or hypotonicity

• used to improve AROM and strength and to modulate hypertonicity in the antagonist muscles via reciprocal inhibition

discuss slow reversal

• dynamic concentric contraction of the agonist (muscle or patterns) followed immediately by a concentric contraction of the antagnoist with no rest periods between reversals. amy include external resistance

• used for development of controlled AROM and to improve reciprocal timing with agonist and antagonist

• may add an isometric hold at end range of a patterns to enhance stability at end range

discuss combination of isotonic contraction

• active movement patterns against therapist resistance through a combination of concentric, static, and eccentric contractions without losing muscle tension

• used to improve motor control and strength

discuss replication (hold-relax active movement)

• therapist passively moves the patients limb to a target position, asking the patient to isometrically maintain the position, before returning the limb passively to the starting position. the patient is then asked to return the limb to the target

• goals: create kinesthetic awareness of movement patterns and reinforces senses of joint position

• may be helpful for individuals with sensory impairment

what are the outomes associated with hyptonia?

• slower to recover function

• increased hospitalization and rehab

• decreased functional independence

what is the LE motricity index?

0 no movement

9 palpable contraction in muscle, but no movement

14 visible movement, but not full range and not against gravity

19 full ROM against gravity but no resistance

25 full movement against gravity but weaker than the other side

33 normal power

what are the general principles for intervention of hypotonicity?

• attention to limb position is vital to maintain joint integrity

• positioning in bed and or chairs must be continuously monitored to support the shoulder joints, maintain lower limb alignments, and prevent over stretching of hypotonic muscles

what are hypotonia interventions?

1. treat proximal to distal

2. large BOS-small BOS

3. sensory stimulation and approximation

4. robotics to promote repetition

5. external supports— air splinting, therapist support, splinting, bracing

how can we promote motor return in hyptonia?

1. joint alignment

2. BW loading for approximation

3. muscle activation (automatic demands from functional tasks)

4. resistance: go back and do this after we get activation and start to build stability

what are the PNF techniques to address hyptonia?

improve muscle activation: rhythmic initiation, repeated contractions, replication

improve stability: alternating isometrics, rhythmic stablization, place and hold (yielding isometrics)

what is lateralopulsion?

• postural bias towards the CL side

• characterized by a passive or active lateral tilt with resistance to correction

• broader (contemporary) clinical term representing directional imbalance

what is pushers syndrome

• specific sub category with severe behavior manifestation of lateropulsion

• characterized by active and forceful pushing thorugh non paretic limbs towards the paretic hemibody

what is the incidence of pushers syndrome and lateral pulsion?

• lateral pulsion is clinically displayed in 41% of patients with stroke. 11.7% demonstrate severe behavior known as pushers syndrome

• there is a greater prevalence in R sided strokes

what will the patient demonstrate with pushers syndrome or lateral pulsion

• pushing towards the involved side

• decreased awareness of midline, typically about 15-18 degrees off

• strong extension with the uninvolved arm and leg

• resitance to postural correction towards midline bc they feel like you are pushing them off midline

what are the associated characteristics in those with pushers syndrome or lateral pulsion?

• most patients with PS have hemi spatial neglect and or sensory loss of the involved side seen in right sided lesions

• hemi spatial neglect and pushing is seen in 20%

• some patients present with aphasia and pushing behavior seen in left sided lesions

• damage to the thalamus, internal capsule, inferior parietal lobe, and superior temporal gyrus are associated with pushers syndrome

what is the clinical presentation in someone with pushing when sitting?

• poor midline awarness/orientation

• trunk elongation on hemiplegic side of torso: shortened on involved side

• weight shifted towards hemiplegic side

• active pushing with instability (falls) towards the hemplegic side

what is the clinical presentation in someone with pushing when standing?

• poor midline awareness/orientation

• active pushing through uninvolved limbs in weight bearing positions

• asymmetric COM towards the hemiparetic LE with resistance to postural correction

• hemiparetic LE may flex/withdraw during active pushing

wha are the functional limitations seen with pushers syndrome?

• difficulty performing transfers in both directions

• minimal weight bearing on hemiplegic arm/leg to facilitate sensory input (through approximation and loading)

• abnormal postural control present significant safety concerns during all functional mobility and interventions

what are the prognosis and outcomes for pushers syndrome?

• 6 months post stroke, the PS symptoms had nearly complete recovered

• symptoms of PS were completely resolved by 6 weeks in 62% of pushers and 21% of patients still had signs of PS at 3 months

• their results also showed that patients with PS had a significantly longer length of stay

• in summary: pushing behavior will ikely resolve but recovery of funtional independent takes much longer

what are prognositc indicators of delayed recovery from pushers syndrome?

• right CVA: older age, greater admissions, limb placement error, lower cogntive FIM scores

• left CVA: older age, worse admission motor status, visuospatial neglect did not influence recovery from PS

how do we measure pushing behavior?

• scale of contraversive pushing: looks at spontaneous body posture in sitting and standing, use of the nonparetic extremities in sitting and standing, resistance to passive correction of tilted posture in sitting and standing

• Burke lateropulsion scale: looks as different functional mobility movements in supine, sitting, standing, transfers, and walking

why are those with pushers syndrome really hard to get research on?

it is a small percentage of people and most studies look at neuro OP which is more subacute and chronic patients where this is already resolved

what does literature show are the 5 main treatment modalities we can use to treat pushers syndrome?

• visual feedback: visues cues, mirrors, etc

• visual-somatosensory integration mirrors with reaching

• somatosensory cues- robotics

• brain stiimulation

• other balance exercises, acupuncutre, postural awareness

*conclusions: visual feedback alone is not enough and there is not enough evidence for brain stimulation

treating pushers syndrome is the one patient situation that goes against the integrated model in that ___________ to the unaffected side comes before ___________. so they are not treating in the linear progression.

excessive weight shift; midline alignment

what is the progression of treatment for pushers syndrome in sitting?

1. achieve midline posture (whout UE/LE support to take away the strong side thats pushing)

2. midline posture with UE/LE support

3. dynamic stability- starm small and progress watching for pushing. for ex, start with elbow prop on uninvolved side and advance to crossing involved leg over. feet should not be on the floor. then can have them sit up with a large ball uner uninvolved arm to work towards progressing to a hand prop. then can have the patient reach forward toward uninvolved side and the feet now start being on the floor

what are treatments we can use for pushers syndrome in sitting?

• mirror with tape down the middle

• elongate trunk on uninvolved side/short on hemi side

• inhibit active pushing through UE/LE

• re-introduce UE/LE using elbow to hand progression

• therapist positioning is important

• target placement is important

• sitting on wedge on the paretic side

what should we consider when trying to get someone up standing who has pushers dynrome?

• mini sit to stand

• high surface to decrease intensity

• therapist position

• target postural correction through LE positioning and loading

what should we consider when trying to do a lateral transfer in one who has pushers dynrome?

transferring away from the strong side may be easier bc they arent pushing against you but then it is a little less safe, increaseing loss of balance

what are treatments we can do for standing/gait treatment in those with pushers syndrome?

• consider uneven setup of parallel bars

• raised mat and keep arm on the table along a line

• cardiac walker so they can be stabalized but not push through hand but rather their forearms

• hip with target at tall table

• progress to midline as pushing behavior diminishes

• build stability in the static position and then progress towards dynamic mobility/gait

• tall kneeling positions

• quadruped

what are the 3 components contributing to subjective vertical?

visual-vertical on visual and vestibular information

haptic or tactile vertical: touch and pressure information from somatosensory receptors

postural vertical: direction of gravitational forces from gravireceptors

what are the causes of backwards disequalibrium?

• CNS lesion

• PNS lesion—imbalances ankle DF/PF often seen in parkinsons

• prolonged supine position

• fear avoidance

what are characteristics of backwards disequalibrium?

• posterior position of the COm with respect to the BOS in the standing and sitting predisposing subjects to backward falls

• axial and limb rigidity

• mismatch between subjective vertical and body vertical

what is pshychomotor disadaptation syndrome (PDS)

• when someone is fearful of falling so they subconsciously push themselves back

• result of psychomatic causes

• characteristics include: backwards disequalibrium, cautious gait with wide BOS, fearful to forward trunk flexion in sit, fearful in moving sit from stand, fear of falling-grabbing for support

what are ways that we can help facilitate better transfers in someone who has backwards disequalibrium?

• if they are actively pushing through their feet, then take them away. but if not, then allow their feet to touch the floor for stability

• getting someone to be able to lean forward with feet on teh floor and forearms on legs is a good position to calm down the retropulsion

what are the outcome measures we can use for backwards disequalibrium?

mini mootr scale

scale of retropulsion

backwards disequalibrium test

what are the 5 primary components of treatment for backwards disequalibrium?

1. standing with back against the wall with heels touching the wall to prevent them from going backward and give positional feedback

2. practicing moving from sitting to standing

3. practice moving from standing to sitting

4. walking with continuous forward stepping

5. stepping backward

what are motor learning considerations for treating ataxia?

• impaired error based learning: individuals with cerebellar dysfunction have difficulty detecting and correcting movement errors so we should increase external feedback

• constant practice: use constant practice conditions to improve acquisition and retention

• high repetition is necessary

• provide frequent knowledge of results and performance to improve awareness and performance

• compensation strategies: incorporate visual cueing, pacing, and safety strategies when appropriate

hwo does cerebeallar damage change coordination?

• difficulty scaling force and timing

• poor multijoint coordination

• impaired error detection and correction

how should treatment change for ataxia?

• begin in stable positions

• practice accurate, isolate movements

• provide frequent external feedback

• progress from single to multi joint tasks

• transition to functional activities and gait

what is the treatment progression for ataxia?

1. supine

2. sitting

3. standing

4. dynamic balance

5. gait

what are evidence based interventions for treating ataxia?

1. therapeutic exercise: high intesnity, taks specific practice

2. body weight supported treadmill training: gait speed, endurance, adaptability

3. coordination training: balance, UE/LE coordination

4. balanced torso weighting: reduce sway in selected patients. however, could end up making them worst off once its removed

5. vibrotactile feedback: augmented feedback during HEP

6. gaming/VR: increase dosage and engagement

what is our clinical interpretation and the treatment implication for various evaluation findings seen with ataxia?

• dysmetria: poor force scaling so treat with targeted reaching, graded accuracy training

• truncal instability: poor proximal control so treat with core stability and sitting/standing balance

• dysdiadiochokinesia: difficutly with recoprocal movement so treat with alternating movement practice

• poor error adaptation: reduced cerebellar motor learning so treat with constant practice with frequent KR/KP

• force regulation deficits: overshooting/undershooting so treat with graded reaching and object manipulation

• gait ataxia: dynamic instability so treat with BWSTT, overground gait, and balance challenge

• hypotonia: reduced postural support so treat with postural activation and endurance training

• frequent falls: high fal lrisk so treat with task specific balance and environment modification

what are motor control activities we can use to build towards a functional progression in the LE with ataxia?

1. core stability via briding, single leg bridge, and weight shifting

2. functional training/proximal stability via tall kneeling, half kneeling, floor to kneeling, and fal recovery

3. progression to gait via static gait, stepping accuracy, AD progression, and overground gait