CASE STUDY: SENSORY £ Differences from Cerebellar Ataxia ATAXIA § No Tremors § No Central Signs (EOM Normal, No Nystagmus, Etc.) Geoff Mosley, PT, NCS

£ Uncoordinated movement due to lack of peripheral sensation

£ Distinguishing characteristics: § Near normal coordination with visual guidance, but severe degradation when eyes are closed § Pseudoathetosis—writhing uncoordinated movement when visual guidance is absent

CASE STUDY: SENSORY £ Differences from cerebellar ataxia ATAXIA § No tremors § No central signs (EOM normal, no nystagmus, etc.) Geoff Mosley, PT, NCS

Sensory Ataxia Sensory Ataxia

£ Causes £ Case #1 § Peripheral neuropathies § 58 yom c multiple myeloma who had a decompressive ¢ Diabetic laminectomy for a spinal tumor (C7 to T12) ¢ Alcoholism § MMT mostly in 4/5 range except 3/5 range in ankles ¢ Metabolic and hip extensors § Dorsal column disease § Sensation was impaired below T4 distally, with ¢ Spinal cord injury (trauma, stenosis, spinal stroke) proprioception being especially impaired in both ¢ Vitamin deficiency (most commonly B12) ankles and feet (T4 ASIA D) ¢ Tabes dorsalis

Sensory Ataxia Sensory Ataxia

£ Case #1 £ Case #2 § Functionally he required mod-max assist for standing § 59 yom who suffered a STEMI, had syncopal episode and mod assist for transfers and ambulation with a and fell, causing C4-5 spinal cord compression and rolling walker 28’ syringomyelia. He initially transferred to rehab under another PT’s care but had sepsis and so went back to § Gait was ataxic with difficulty stepping accurately and one occasion of right knee buckling main hospital for 1 week for treatment. § MMT: decreased hand strength and dexterity, LEs 4 to § He also c/o back pain 7/10 and had low endurance 4+/5 x right hip and knee ext 4-/5 § He was able to propel a wheelchair 200+’ with UEs without assist § Sensation: Diminished in UEs especially hands, diminished in both LEs especially distally, proprioception included (C5 ASIA D)

1 Sensory Ataxia Sensory Ataxia

£ Case #2 £ Case #3 § Tone: 1+ to 2 spasticity in both UEs and LEs c right § 65 yom who had a right parietal lobe CVA. ankle clonus, Hoffman’s and Babinski positive bilat § 4+ to 5/5 x 3+/5 hip extensors and abductors § Transfers mod to max assist for “hop” pivot transfers bilaterally § Standing in bars pt leaned heavily forward at ankles and could not self correct even with cues (“ski jumper”) § Sensation: intact light touch but moderate impairment in § He walked in bars c max assist and knee blocking 9’, c proprioception on the left side poor knee control and inaccurate stepping § Balance: with standing pt had uncontrolled § He was able to operate power w/c c joystick control hyperextension of left knee and posterolateral LOB to and stand by assistance the left, but with hands on RW or other surface he could § Sitting tolerance was low and he used power tilt/recline maintain control (BBS: 5/56) to increase time up in w/c

Sensory Ataxia Sensory Ataxia

£ Case #3 £ All cases § Transfers were only min assist when using rolling walker § Treatment: but movement of left LE was awkward and unsafe ¢ Slow squats in parallel bars and duck walking in LiteGait to § Gait: he was able to amb 80’ with heavy reliance on encourage knee control—Focusing on avoiding knee arm support on RW and forward lean. Foot clearance hyperextension and buckling was variable and poor on the left and he needed cues ¢ Gait training in LiteGait focusing on smoothness and to keep from dragging his left leg. accuracy of step: target stepping, changing speeds while controlling COM and balance (quick wean from BWS) § In manual w/c he could propel using right limbs 100’ ¢ Use of LiteGait for balance/coordination tasks: cone and with supervision and cues due to mild left neglect box taps, kickball, perturbations—all with weaning of BWS to allow more natural balance and stepping strategies

Sensory Ataxia Sensory Ataxia

£ All cases £ Videos: ltgt5; IMG_0220; IMG_0222; IMG_0224; § Treatment: IMG_0250 ¢ Wean off BWS and onto assistive devices: rolling walker (platform walker initially for Case #2), off and on use of AFOs for foot/knee control; Case #2 used Litegait with pt facing out to allow use of RW ¢ Encourage active movement outside therapy: especially LE propulsion for manual w/c users (Case #1 and #3)

2 Sensory Ataxia Sensory Ataxia

£ All cases £ Outcomes: § Progression: Case #1 Case #2 Case #3

¢ Initial heavy use of LiteGait due to instability and safety Gait distance 160’ c RW 220’ c RW 220’ cRW concerns Gait assistance SBA to CGA (fatigue) SBA SBA ¢ Gradual weaning onto assistive devices for all patients as they were able Transfer assistance SBA to CGA c RW Min assist to stand, SBA c RW (fatigue) then SBA c RW for SPT ¢ Still used BWSGT once or twice a week to focus on pushing up speed and smooth out gait pattern (Case #2 amb 1000’ Balance Unable to maintains Able to maintain BBS: 29/56 at one point at speeds from 0.5 to 0.7 mph) UE support but knees standing balance s UE Still unsteady s UE were mostly stable support and min to support but could amb ¢ Case #2 dealt with increasing levels of spasticity and ankle and he could self mod challenges short distances in high clonus so physician was consulted to increase antispasmodics correct LOB guard c CGA regularly Discharge disposition Home with family; SNF awaiting further Home with wife started chemo p d/c neck sx (could have ¢ Case #3 was self limiting and so LiteGait was a good way went home c support to encourage distance and increased time on feet and home mods)