ATAXIA DIAGNOSIS AND PHYSIOTHERAPY ASSESSMENT

1. CEREBELLAR ATAXIA
NITHIN NAIR

2. DIAGNOSTIC INVESTIGATIONS
• Haematology: CBC, Creatinine, Liver
Enzymes, Electrophoresis, ESR, CRP, TFT,
Vitamin B12, Cholestrol – helps to evaluate overall
health and detect a range of disorders inculding
infection and heavy metal poisoning

3. DIAGNOSTIC INVESTIGATIONS
• Urine tests: Urine analysis may suggest –
systemic abnormalities related to some forms
of ataxia. Wilson’s disease – screen 24 hrs
urine collection for copper.

4. DIAGNOSTIC INVESTIGATIONS
• Imaging studies: A computerized
tomography (CT) scan or Magnetic Resonance
Imaging (MRI) of brain may help to determine
potential causes.

5. DIAGNOSTIC INVESTIGATIONS
• Genetic testing: It is done to determine whether
a patient, particularly a child has the gene mutation
that causes one of the hereditary ataxic conditions.
Chromosomal studies are performed on peripheral
blood lymphocytes and cultured skin fibroblasts

6. DIAGNOSTIC INVESTIGATIONS
• Brainstem Auditory Potential (BAEP or BAER):
Helpful to determine the presence of intact
central pathways and may also provide some
information about central (brainstem)
projection pathways associated with hearing.

7. DIAGNOSTIC INVESTIGATIONS
• Lumbar Puncture: CSF analysis is helpful
primarily to determine the presence of
inflammatory diseases.

9. ASSESSMENT
• HISTORY: History taking needs following consideration –
 Duration (Acute, subacute, chronic)
 Symmetry
 Rate of progression (static, episodic, progressive)
 Associated features (headache, vomiting, dystonia/chorea,
proprioceptive dysfunction, visual deficits, auditory
involement)
 Medical history (infection, medications/intoxications,
environmental exposures)
 Family history (suggest genetic disorder – autosomal recessive
transmission/ autosomal dominant inheritence)

10. ASSESSMENT
• ON OBSERVATION
• PAIN ASSESSMENT
• ON EXAMINATION
HIGHER CENTRES (COGNITION, MEMORY,
ORIENTATION, SPEECH, PROBLEM SOLVING)
CRANIAL NERVES (II, III, IV, VI, VIII)
SENSORY ASSESSMENT
MOTOR ASSESSMENT (TONE, REFLEXES,
ROM, MUSCLE POWER, VCA, TREMOR)

11. ASSESSMENT
 BALANCE (BBS, FUNCTIONAL REACH TEST, TIMED UP
& GO, FRIEDREICH ATAXIA RATING SCALE)
 GAIT (DGI, OBSERVATIONAL GAIT ANALYSIS-SPEED,
SYMMETRY, LEVEL OF INDEPENDENCE)
 CO-ORDINATION (EQUILIBRIUM, NON-EQUILIBRIUM)
 CARDIOVASCULAR (SUBMAXIMAL GRADED EXERCISE
TESTING)
 FATIGUE (MODIFIED FATIGUE IMPACT SCALE)
 FUNCTION AND DISABILITY (FIM, BARTHEL INDEX)
 SPECIFIC SCALES (INTERNATIONAL COOPERATIVE
ATAXIA RATING SCALE, SCALE FOR ASSESSMENT
AND RATING OF ATAXIA)

12. TYPICAL CLINICAL TEST
• HYPOTONIA:
SPECIFIC TEST POSITIVE
MUSCLE PALPATION Reduced firmness
PASSIVE SHAKING OF
LIMBS
Moves through greater arc of
motion
HOLD OBJECTS WHILE
CONVERSING
Drops when distracted
VOL.FLEXION-EXTENSION
OF KNEE OR ELBOW
(SUPPORTED/UNSUPPORTED)
Ataxic when unsupported,
controlled when supported
FLEX ONE FINGER ONLY All fingers flex

13. TYPICAL CLINICAL TEST
• ASTHENIA
SPECIFIC TEST POSITIVE
MAINTAIN ARM IN 90°
POSITION OF FLEXION OR
ABDUCTION
Arm(s) tire quickly
MAXIMAL RESISTED
MUSCLE CONTRACTION FOR
MAJOR MUSCLE GROUPS
Weaker on involved side or
unable to work against
resistance
REPEATED SUBNMAXIMAL
MUSCLE CONTRACTIONS –
RISING ON TOES, PUSHUPS,
SQUEEZING TENNIS BALL
Tires quickly

14. TYPICAL CLINICAL TEST
• BALANCE AND POSTURAL CONTROL
SPECIFIC TEST POSITIVE
OBSERVATION-
STANDING POSTURE
Feet apart, trunk flexed slightly,
needs to hold for stability,
postural tremor of legs
HOLD LIMB AGAINST
PULL OF GRAVITY
Postural tremor
NUDGE CLIENT
UNEXPECTEDLY WHEN
SITTING OR STANDING
Loses balance
STAND ON ONE FOOT OR
WALK BACKWARD
Loses balance

15. TYPICAL CLINICAL TEST
• DYSMETRIA
SPECIFIC TESTS POSITIVE
FLEX ARMS TO 90°, QUICKLY
ELEVATE OVERHEAD AND THEN
RETURN TO 90° POSITION
Not able to resume 90° position
without initial error
PUT PEG IN A HOLE, TRACE CIRCLE
WITH PENCIL, TRACE CIRCLE ON
FLOOR WITH GREAT TOE, SLIDE
HEEL DOWN SHIN SLOWLY, PLACE
FEET ON WALKERS WHEN WALKING
Intention tremor, undershoots or
overshoots target
THERAPIST RESISTS CLIENT’S
ELBOW FLEXION AND RELEASES
UNEXPECTEDLY
Arm rebounds

16. TYPICAL CLINICAL TEST
SPECIFIC TESTS POSITIVE
MARCH TO CADENCE Unable to follow rhythm
WALK ON HEELS OR TOES Loses balance and rhythm
WALK CLOCKWISE AND
COUNTERWISE
Stumbles in one direction
WALK ON UNEVEN GROUND Cannot compensate and stumbles
OBSERVATION- TYPICAL GAIT
PATTERN
Slow, stumbles easily, not rhythmical,
step length irregular
GAIT DISTUBANCE

17. TYPICAL CLINICAL TEST
• DYSDIADOCHOKINESIA
SPECIFIC TESTS POSITIVE
TAP HAND ON KNEE OR
TOES ON FLOOR
Rapidly loses rhythm and range
WALK AS FAST AS
POSSIBLE
Gait become impaired when fast
OBSERVATION –ADL’S Unable to brush teeth, stir food...

18. TYPICAL CLINICAL TEST
• MOVEMENT DECOMPOSITION:
SPECIFIC TESTS POSITIVE
SUPINE- CLIENT TOUCHES
HEEL TO OPPOSITE KNEE
Movement broken into separate
phases – does not flow
OBSERVATION – TYPICAL
MOVEMENT
Activity appears as if in a slow
motion – mechanical like a
puppet

19. TYPICAL CLINICAL TEST
• OCULOMOTOR PERFORMANCE
TYPES PROCEDURE
SMOOTH PURSUIT
(MOVING TARGET)
Sit Head still Follow pen tip with⇨ ⇨
eyes Test in all movement planes⇨
and directions Vary speed.⇨
SACCADES
(STATIONARY TARGET)
Verbally promted Client alternately⇨
fixes gaze on a pen tip and the
examiner’s nose Vary target⇨
locations Observe for dysmetria⇨
GAZE EVOKED NYSTAGMUS Client maintains gaze in variety of
locations including near end ranges of
lateral gaze Observe for nystagmus⇨

20. REFERENCE....
Neurological Rehabilitation - Darcy
Umphred (5th
and 6th
edition)
Neurorehabilitation (Neurogen) – Dr.
VC Jacob
Text book of Neurology – Navneet
kumar