The effectiveness of allied health care in patients with ataxia: a systematic review

Differential Effects of Cerebellar Transcranial Direct Current Stimulation with Gait Training on Functional Mobility, Balance, and Ataxia Symptoms

Cerebellar transcranial direct current stimulation (ctDCS) has emerged as a promising, non-invasive, and safe neuromodulatory intervention capable of reducing ataxia symptoms and restoring cerebellum-motor connectivity. However, previous studies have only applied ctDCS in isolation, without association with specific training. This study aimed to assess the effect of ctDCS combined with gait training on functional mobility, balance, and symptoms and severity of ataxia. A randomized, triple-blind, sham-controlled, bi-center clinical trial was conducted with forty-four adults with cerebellar ataxia. Volunteers were randomized to receive five daily sessions of either real ctDCS (n = 11; 2 mA for 25 min) or sham ctDCS (n = 11) during gait training. Functional mobility, balance, and symptoms and severity of ataxia were assessed using the Time Up and Go test, the MiniBESTest, and the Scale for the Assessment and Rating of Ataxia (SARA), respectively, before and after the interventions. Both groups showed improvement in functional mobility, but there was no significant difference between the ctDCS and sham groups. However, the ctDCS group demonstrated significant improvements in cerebellar ataxia severity as reflected by SARA scores, particularly in tests of stance, sitting, speech disturbance, nose-finger test, and heel-shin slide test. Notably, no improvements were observed in balance. This study indicates that while ctDCS combined with gait training may improve specific symptoms of cerebellar ataxia, it does not significantly enhance overall functional mobility compared to sham treatment.

Ataxia-telangiectasia in Latin America: clinical features, immunodeficiency, and mortality in a multicenter study

Ataxia-telangiectasia (AT) is a rare genetic disorder leading to neurological defects, telangiectasias, and immunodeficiency. We aimed to study the clinical and immunological features of Latin American patients with AT and analyze factors associated with mortality. Referral centers from 9 Latin American countries participated in this retrospective cohort study, and 218 patients were included.  Median (IQR) ages at symptom onset and diagnosis were 1.0 (1.0-2.0)  and 5.0 (3.0-8.0) years, respectively. Most patients presented recurrent airway infections, which was significantly associated with IgA deficiency. IgA deficiency was observed in 60.8% of patients and IgG deficiency in 28.6%. T- and B-lymphopenias were also present in most cases. Mean survival was 24.2 years, and Kaplan-Meier 20-year-survival rate was 52.6%, with higher mortality associated with female gender and low IgG levels. These findings suggest that immunologic status should be investigated in all patients with AT.

Effectiveness and cost of integrated cognitive and balance training for balance and falls in cerebellar ataxia: a blinded two-arm parallel group RCT

Background

In patients with cerebellar ataxia (CA), dual-tasking deteriorates the performance of one or both tasks.

Objective

Evaluate the effects of 4 weeks of cognitive-coupled intensive balance training (CIBT) on dual-task cost, dynamic balance, disease severity, number of falls, quality of life, cognition and cost among patients with CA.

Methods

This RCT compared CIBT (Group 1) to single-task training (Group 2) among 32 patients with CA. The intervention included either dual-task (CIBT) or single-task training for 4 weeks followed by 6 months of unsupervised home exercises. Dual-task timed up-and-go test (D-TUG) assessed dual-task cost of the physical and cognitive tasks. Assessment time points included baseline 1 (Week 0:T1), baseline 2 (Week 6:T2), post-intervention (Week 10:T3), and follow-up (Week 34:T4).

Results

Compared to single-task training CIBT improved the dual-task cost of physical task [MD -8.36 95% CI (-14.47 to -2.36, p < 0.01), dual-tasking ability [-6.93 (-13.16 to -0.70); p = 0.03] assessed using D-TUG, balance assessed using the scale for the assessment and rating of ataxia (SARAbal) [-2.03 (-4.04 to -0.19); p = 0.04], visual scores of the SOT (SOT-VIS) [-18.53 (-25.81 to -11.24, p ≤ 0.01] and maximal excursion [13.84 (4.65 to 23.03; p ≤ 0.01] of the Limits of Stability (LOS) in the forward direction and reaction time in both forward [-1.11 (-1.42 to -0.78); p < 0.01] and right [-0.18 (0.05 to 0.31); p < 0.01] directions following 4 weeks of training. CIBT did not have any additional benefits in reducing the number of falls, or improving disease severity, quality of life and cognition. The mean cost of intervention and healthcare costs for 7 months was HKD 33,380 for CIBT group and HKD 38,571 for single-task training group.

Conclusion

We found some evidence to support the use of CIBT for improving the dual-tasking ability, dual-task cost of physical task and dynamic balance in CA. Future large fully-powered studies are needed to confirm this claim.

Clinical trial registration

https://clinicaltrials.gov/study/NCT04648501, identifier [Ref: NCT04648501].

Physical Activity and Fitness Levels of Individuals With Ataxia: A Cross-Sectional Study

OBJECTIVE

To investigate physical activity levels of individuals with ataxia and correlate fitness to ataxia severity.

DESIGN

An observational study SETTING: An outpatient ataxia clinic in a large, tertiary, urban hospital in the US.

PARTICIPANTS

Individuals with cerebellar ataxia (N=42).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE

Participants were classified as sedentary or physically active using the International Physical Activity Questionnaire-Short Form (IPAQ-SF). Maximal oxygen consumption (V̇o2max) as an indicator of fitness level was measured, and ataxia severity was determined by the Scale for the Assessment and Rating of Ataxia (SARA). Mixed effect models were used to correlate ataxia severity to fitness levels.

RESULTS

Most participants (28 out of 42) lived sedentary lifestyles, and these individuals had poor fitness levels (only 67.3% of their predicted measure). The main barriers to physical activity included lack of energy, lack of time, and fear of falling. There were no differences in age, sex, disease type, disease duration, ataxia severity, fatigue level, and medication use between sedentary and active groups. Measures of V̇o2max, maximal work, maximal heart rate, and anerobic threshold demonstrated statistically significant differences between groups whereas maximal respiratory rate and expired ventilation/carbon dioxide production were similar between groups. When adjusting for age, sex, functional mobility status, and disease duration, ataxia severity was inversely correlated with fitness level in the sedentary group. There was no relationship between ataxia severity and fitness level in the 14 individuals who were physically active.

CONCLUSIONS

Lower fitness levels were associated with more ataxia symptoms in the sedentary group. This relationship was not seen in individuals who were more active. Given the poor health outcomes associated with low fitness, physical activity should be encouraged in this population.

Assessment and tailored physical rehabilitation approaches in persons with cerebellar impairments targeting mobility and walking according to the International Classification of Functioning: a systematic review of case-reports and case-series

PURPOSE

Cerebellar impairment (CI) manifests from different etiologies resulting in a heterogenic clinical presentation affecting walking and mobility. Case-reports were reviewed to provide an analytical clinical picture of persons with CI (PwCI) to differentiate cerebellar and non-cerebellar impairments and to identify interventions and assessments used to quantify impact on walking and mobility according to the International Classification of Functioning, Disability and Health (ICF).

MATERIALS AND METHODS

Literature was searched in PubMed, Web Of Science and Scopus. Case-reports conducting physical rehabilitation and reporting at least one outcome measure of ataxia, gait pattern, walking or mobility were included.

RESULTS

28 articles with a total of 38 different patients were included. Etiologies were clustered to: spinocerebellar degenerations, traumatic brain injuries, cerebellar tumors, stroke and miscellaneous. The interventions applied were activity-based, including gait and balance training. Participation based activities such as tai chi, climbing and dance-based therapy had positive outcomes on mobility. Outcomes on body function such as ataxia and gait pattern were only reported in 22% of the patients.

CONCLUSIONS

A comprehensive test battery to encompass the key features of a PwCI on different levels of the ICF is needed to manage heterogeneity. Measures on body function level should be included in interventions.

Use of the EXOPULSE Mollii for severe ataxia in an adult male 4 months after cardiac arrest

The EXOPULSE Mollii is designed to reduce spasticity through low-current electrical stimulation of major muscle groups. The effect on severe cerebellar ataxia has not been investigated. This case describes the use of the EXOPULSE Mollii in an adult male with severe cerebellar ataxia 4 months after cardiac arrest and ischaemic stroke. The patient used the suit in 15 of 19 possible sessions (78.9%). He improved in the sit-to-stand test, arm function test and 10 m walking test. He described improved visual focus, ability to speak and swallow. Improvements were maintained for 1 week after the last session. The EXOPULSE Mollii is relevant to consider in the early stages of inpatient rehabilitation for patients with severe ataxia, but further research is warranted.

Pharmacotherapy for the management of the symptoms of Machado-Joseph Disease

INTRODUCTION

Machado-Joseph disease or spinocerebellar ataxia type 3 (SCA3/MJD) is the leading cause of autosomal dominant ataxia worldwide. This is a slowly progressive, but very disabling disorder. Ataxia is the main clinical feature, but additional motor and non-motor manifestations may be found. Many of these manifestations are amenable to pharmacological treatments, which may impact the quality of life of affected subjects.

AREAS COVERED

Authors review available literature on both disease-modifying and symptomatic pharmacological therapies for SCA3/MJD. Discussion is stratified into motor (ataxic and non-ataxic syndromes) and non-motor manifestations. Ongoing clinical trials and future perspectives are also discussed in the manuscript.

EXPERT OPINION

Symptomatic treatment is the mainstay of clinical care and should be tailored for each patient with SCA3/MJD. Management of ataxia is still a challenging task, but relief (at least partial) of dystonia, pain/cramps, fatigue, and sleep disorders is an achievable goal for many patients. Even though there are no disease-modifying treatments so far, recent advances in understanding the biology of disease and international collaborations of clinical researchers are now paving the way for a new era where more clinical trials will be available for this devastating disorder.

Overview of the Clinical Approach to Individuals With Cerebellar Ataxia and Neuropathy

Increasingly, cerebellar syndromes are recognized as affecting multiple systems. Extracerebellar features include peripheral neuropathies affecting proprioception; cranial neuropathies such as auditory and vestibular; and neuronopathies, for example, dorsal root and vestibular. The presence of such features, which in and of themselves may cause ataxia, likely contribute to key disabilities such as gait instability and falls. Based on the evolving available literature and experience, we outline a clinical approach to the diagnosis of adult-onset ataxia where a combination of cerebellar and peripheral or cranial nerve pathology exists. Objective diagnostic modalities including electrophysiology, oculomotor, and vestibular function testing are invaluable in accurately defining an individual's phenotype. Advances in MRI techniques have led to an increased recognition of disease-specific patterns of cerebellar pathology, including those conditions where neuronopathies may be involved. Depending on availability, a stepwise approach to genetic testing is suggested. This is guided by factors such as pattern of inheritance and age at disease onset, and genetic testing may range from specific genetic panels through to whole-exome and whole-genome sequencing. Management is best performed with the involvement of a multidisciplinary team, aiming at minimization of complications such as falls and aspiration pneumonia and maximizing functional status.

Cerebellar Mutism Syndrome in Pediatric Neuro-oncology: A Multidisciplinary Perspective and Call for Research Priorities

Cerebellar mutism syndrome (CMS), also known as posterior fossa syndrome, occurs in a subset of children after posterior fossa tumor resection, most commonly medulloblastoma. Patients with this syndrome exhibit often transient, although protracted, symptoms of language impairment, emotional lability, cerebellar, and brainstem dysfunction. However, many patients experience persistent neurological deficits and lasting neurocognitive impairment. Historically, research and clinical care were hindered by inconsistent nomenclature, poorly defined diagnostic criteria, and uncertainty surrounding risk factors and etiology. Proposed diagnostic criteria include two major symptoms, language impairment and emotional lability, as proposed by the international Board of the Posterior Fossa Society in their consensus statement as well as other experts in this field. Risk factors most commonly associated with development of CMS include midline tumor location, diagnosis of medulloblastoma and specific tumor subtype, younger age at diagnosis, and preoperative language impairment. A proposed etiology of CMS includes disruption of the cerebellar outflow tracts, the cerebellar nuclei, and their efferent projections through the superior cerebellar peduncle. Treatment for CMS remains supportive. Herein, we present a comprehensive overview of CMS etiology, diagnosis, risk factors, clinical presentation, and clinical management. In addition, we identify essential multidisciplinary research priorities to advance diagnostics, prevention, and intervention efforts for patients with, or at risk for, development of CMS.

Effects of therapeutic exercise on disease severity, balance, and functional Independence among individuals with cerebellar ataxia: A systematic review with meta-analysis

BACKGROUND

Balance impairments are common in cerebellar ataxia. Exercises are beneficial in this population.

OBJECTIVE

Explore the benefits of therapeutic exercises on disease severity, balance and functional independence in cerebellar ataxia.

METHODS

Databases were searched from inception until July 2021. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale and the Newcastle-Ottawa Scale (NOS); and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

Twenty-six studies were included and eight studies of low to high PEDro methodological quality were meta-analyzed. 'Low' to 'moderate' GRADE quality evidence supports the use of therapeutic exercises to reduce disease severity, assessed using the Scale for the Assessment and Rating of Ataxia [weighted mean difference (WMD): -3.3; 95% confidence interval (95%CI): -3.7, -2.8; p < .01]; and improve balance, assessed using the Berg Balance Scale (WMD: 2.6; 95%CI: 1.1, 4.2; p < .01). The effect of therapeutic exercises on functional independence was insignificant (WMD: 1.6; 95%CI: -1.5, 4.6; p = .31).

CONCLUSION

Low to moderate evidence from studies of low to high methodological quality provides some support for therapeutic exercises for reducing disease severity among non-hereditary degenerative cerebellar ataxia and improving balance among acquired cerebellar ataxia. Exercises did not benefit functional independence. Additional studies of large sample size and high methodological quality are necessary to substantiate these findings.

Case Report: Late-Onset Autosomal Recessive Cerebellar Ataxia Associated With SYNE1 Mutation in a Chinese Family

Autosomal recessive cerebellar ataxia type 1 (ARCA-1), also known as autosomal recessive spinocerebellar ataxia type 8 (SCAR8), is caused by spectrin repeat containing nuclear envelope protein 1 (SYNE1) gene mutation. Nesprin-1, encoded by SYNE1, is widely expressed in various tissues, especially in the striated muscle and cerebellum. The destruction of Nesprin-1 is related to neuronal and neuromuscular lesions. It has been reported that SYNE1 gene variation is associated with Emery-Dreifuss muscular dystrophy type 4, arthrogryposis multiplex congenita, SCAR8, and dilated cardiomyopathy. The clinical manifestations of SCAR8 are mainly characterized by relatively pure cerebellar ataxia and may be accompanied by upper and/or lower motor neuron dysfunction. Some affected people may also display cerebellar cognitive affective syndrome. It is conventionally held that the age at the onset of SCAR8 is between 6 and 42 years (the median age is 17 years). Here, we report a pedigree with SCAR8 where the onset age in the proband is 48 years. This case report extends the genetic profile and clinical features of SCAR8. A new pathogenic site (c.7578del; p.S2526Sfs*8) located in SYNE1, which is the genetic cause of the patient, was identified via whole exome sequencing (WES).

Tai Chi for Dynamic Balance Training Among Individuals with Cerebellar Ataxia: An Assessor-Blinded Randomized-Controlled Trial

Objective: To evaluate the immediate and long-term effects of 12 weeks of Tai Chi training on dynamic balance and disease severity among individuals with cerebellar ataxia (CA).

Design: An assessor-blinded, two-arm, parallel-group randomized-controlled trial was conducted among 24 participants with CA. Participants were randomized to receive either Tai Chi intervention (n = 12) or usual care (n = 12). Dynamic balance was assessed using the Berg Balance Scale (BBS), Scale for the Assessment and Rating of Ataxia (SARA) balance sub-component of the SARA (SARAbal), Sensory Organization Test, and Limits of Stability test. Disease severity was assessed using the SARA and health-related quality of life using the EuroQol visual analog scale. Assessments were completed at baseline (week 0: T1), postintervention (week 12: T2), and at the end of the 24-week (week 36: T3) follow-up period.

Interventions: The 8-form Tai Chi exercise was delivered in 60-min sessions, three times a week for 12 weeks. Participants were asked to complete an unsupervised home Tai Chi exercise program over the next 24 weeks. Participants in the usual care control group completed all study measures but did not receive any intervention.

Results: Compared with the usual care control group, after 12 weeks of Tai Chi training, the experimental group demonstrated beneficial effects for dynamic balance assessed using the BBS (mean difference [MD]: 4, 95% confidence interval [CI]: −1.06 to 8.71) and the SARAbal (MD: −1.33, 95% CI: −2.66 to 2.33). The effect size ranged from small to large. The benefits gained were not sustained after 24 weeks during the follow-up assessment. Tai Chi did not benefit disease severity and health-related quality of life in this population.

Conclusion: Some evidence supports the immediate beneficial effects of 12 weeks of Tai Chi training on the dynamic balance among individuals with CA.

Australia New Zealand Clinical Trials Registry (ACTRN12617000327381).

A curtailed task for quantitative evaluation of visuomotor adaptation in the head-mounted display virtual reality environment

To accurately perform a goal-directed movement in continuously changing environments, it is unavoidable for individuals to adapt accordingly. The cerebellum has been known to be responsible for such process, specifically adaptation using sensorimotor information. As shown in previous studies, using HMD-VR technology in an experimental setting has similar advantages as in the real-world environment: researchers can manipulate the experimental environment, precisely control the experiments, and quantitatively analyze errors in real time. Moreover, the HMD-VR environment provides high immersiveness and embodiment which even enhance motor learning and increase engagement and motivation of individuals more than real-world environments do. In our HMD-VR-based task, the subjects were trained to adapt to a condition in which the visual information was artificially 20°clockwise rotated from the actual cursor movement. The subjects used a virtual reality tracker to move the cursor from a starting point to a target that appeared randomly at five locations, 20 cm from the starting point with an interval of 15°. Although no significant side effects were expected from experiencing the HMD-VR environment, we considered the appropriate number of trials for patients with cerebellar disease for future use in clinical settings. To examine the feasibility of our task for analysis of visuomotor adaptation pattern as shown in a real-world-based task, we created and compared two paradigms with a difference in the number of trials. As we expected, the results showed that the heading angle error decreased as the participants of both paradigms continued the task and that there was no significant difference between the two paradigms. Next, we applied our short task paradigm to patients diagnosed with cerebellar ataxia and age-matched controls for further examination of applicability to diagnosis and rehabilitation of the patients. As a result, we observed the distinguishable adaptation pattern of the patient group by using our paradigm. Overall, the results suggest that our paradigm is feasible to analyze the visuomotor adaptation pattern of healthy individuals and patients with cerebellar ataxia so may contribute to the clinical field.

Proposing a Core Outcome Set for Physical Activity and Exercise Interventions in People With Rare Neurological Conditions

Rare neurological conditions (RNCs) encompass a variety of diseases that differ in progression and symptoms but typically include muscle weakness, sensory and balance impairment and difficulty with coordinating voluntary movement. This can limit overall physical activity, so interventions to address this are recommended. The aim of this study was to agree a core outcome measurement set for physical activity interventions in people living with RNCs. We followed established guidelines to develop core outcome sets. Broad ranging discussions in a series of stakeholder workshops led to the consensus that (1) physical well-being; (2) psychological well-being and (3) participation in day-to-day activities should be evaluated in interventions. Recommendations were further informed by a scoping review of physical activity interventions for people living with RNCs. Nearly 200 outcome measures were identified from the review with a specific focus on activities or functions (e.g, on lower limb function, ability to perform daily tasks) but limited consideration of participation based outcomes (e.g., social interaction, work and leisure). Follow on searches identified two instruments that matched the priority areas: the Oxford Participation and Activities Questionnaire and the Sources of Self-Efficacy for Physical Activity. We propose these scales as measures to assess outcomes that are particularly relevant to assess when evaluating physical activity interventions mong people with RNCs. Validation work across rare neurological conditions is now required to inform application of this core outcome set in future clinical trials to facilitate syntheses of results and meta-analyses.

Pallidal degenerations and related disorders: an update

Neurodegenerative disorders involving preferentially the globus pallidus, its efferet and afferent circuits and/or related neuronal systems are rare. They include a variety of both familial and sporadic progressive movement disorders, clinically manifesting as choreoathetosis, dystonia, Parkinsonism, akinesia or myoclonus, often associated with seizures, mental impairment and motor or cerebellar symptoms. Based on the involved neuronal systems, this heterogenous group has been classified into several subgroups: "pure" pallidal atrophy (PPA) and extended forms, pallidonigral and pallidonigrospinal degeneration (PND, PNSD), pallidopyramidal syndrome (PPS), a highly debatable group, pallidopontonigral (PPND), nigrostriatal-pallidal-pyramidal degeneration (NSPPD) (Kufor-Rakeb syndrome /KRS), pallidoluysian degeneration (PLD), pallidoluysionigral degeneration (PLND), pallidoluysiodentate atrophy (PLDA), the more frequent dentatorubral-pallidoluysian atrophy (DRPLA), and other hereditary multisystem disorders affecting these systems, e.g., neuroferritinopathy (NF). Some of these syndromes are sporadic, others show autosomal recessive or dominant heredity, and for some specific gene mutations have been detected, e.g., ATP13A2/PARK9 (KRS), FTL1 or ATP13A2 (neuroferritinopathy), CAG triple expansions in gene ATN1 (DRPLA) or pA152T variant in MAPT gene (PNLD). One of the latter, and both PPND and DRPLA are particular subcortical 4-R tauopathies, related to progressive supranuclear palsy (PSP), corticobasal degeneration (CBD) and frontotemporal lobe degeneration-17 (FTLD-17), while others show additional 3-R and 4-R tauopathies or TDP-43 pathologies. The differential diagnosis includes a large variety of neurodegenerations ranging from Huntington and Joseph-Machado disease, tauopathies (PSP), torsion dystonia, multiple system atrophy, neurodegeneration with brain iron accumulation (NBIA), and other extrapyramidal disorders. Neuroimaging data and biological markers have been published for only few syndromes. In the presence of positive family histories, an early genetic counseling may be effective. The etiology of most phenotypes is unknown, and only for some pathogenic mechanisms, like polyglutamine-induced oxidative stress and autophagy in DRPLA, mitochondrial dysfunction induced by oxidative stress in KRS or ferrostasis/toxicity and protein aggregation in NF, have been discussed. Currently no disease-modifying therapy is available, and symptomatic treatment of hypo-, hyperkinetic, spastic or other symptoms may be helpful.

Effectiveness of Robotic Exoskeleton-Assisted Gait Training in Spinocerebellar Ataxia: A Case Report

Spinocerebellar ataxia (SCA) is a hereditary neurodegenerative disorder that presents as ataxia. Due to the decline in balance, patients with SCA often experience restricted mobility and a decreased quality of life. Thus, many studies have emphasized the importance of physiotherapies, including gait training, in SCA patients. However, few studies have examined the effectiveness of robotic gait training in SCA. Here, we report the therapeutic outcomes of exoskeleton-assisted gait training in a patient with SCA. A 23-year-old woman with SCA participated in a gait training program using a powered lower-limb robotic exoskeleton, ANGELLEGS. The 8-week training program consisted of standing training, weight-shifting exercises, and gait training. Several measures of general function, balance, gait, and cardiopulmonary function were applied before, after, and 4 weeks after the program. After the program, overall improvements were found on scales measuring balance and gait function, and these improvements remained at 4 weeks after the program. Cardiopulmonary function was also improved 4 weeks after the program. Robotic exoskeleton gait training can be a beneficial option for training balance, gait, and cardiopulmonary function in SCA.

Investigating the Clinical Significance and Research Discrepancies of Balance Training in Degenerative Cerebellar Disease: A Systematic Review

OBJECTIVE

The aims of this study were to understand the clinical significance of balance training in degenerative cerebellar disease and to analyze inconsistencies among published data.

DESIGN

Five databases were searched from inception to October 8, 2019. Cochrane guidelines informed review methods, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The Australian National Health and Medical Research Council Evidence Hierarchy, PEDro scale, and Joanna Briggs Institute Critical Appraisal Tools were used to evaluate methodological quality. Outcome measures examined included ataxia severity, gait speed, and balance.

RESULTS

Fourteen articles were identified that met inclusion criteria. The quality of evidence was moderate to high, with recent articles being of higher quality. Nine of 12 articles showed statistical improvements in ataxia severity (reduction ranging from 1.4 to 2.8 in the Scale for the Assessment and Rating of Ataxia points), three of eight showed statistical improvements in gait speed (average increase of 0.1 m/sec), and six of nine showed improvements in balance measures (average increase of 1.75 in Berg Balance Scale and 1.5 in Dynamic Gait Index).

CONCLUSION

Most studies showed statistical and clinically significant ataxia severity improvements in subjects who performed balance training. The amount of balance challenge and frequency of training were important factors in determining the extent of training benefit. Gait speed may also improve if walking exercises are included in the balance training, but more studies need to be conducted. Balance measures statistically improved with training, but these improvements did not meet criteria for clinical significance.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe the cause(s) of discrepancies in the literature regarding the benefits of balance training in degenerative cerebellar disease; (2) Determine if benefits from balance training are clinically meaningful for individuals with cerebellar degeneration; and (3) Understand the best practices gleaned from the current literature regarding balance training for these diseases.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Rehabilitation for ataxia study: protocol for a randomised controlled trial of an outpatient and supported home-based physiotherapy programme for people with hereditary cerebellar ataxia

INTRODUCTION

Emerging evidence indicates that rehabilitation can improve ataxia, mobility and independence in everyday activities in individuals with hereditary cerebellar ataxia. However, with the rarity of the genetic ataxias and known recruitment challenges in rehabilitation trials, most studies have been underpowered, non-randomised or non-controlled. This study will be the first, appropriately powered randomised controlled trial to examine the efficacy of an outpatient and home-based rehabilitation programme on improving motor function for individuals with hereditary cerebellar ataxia.

METHODS AND ANALYSIS

This randomised, single-blind, parallel group trial will compare a 30-week rehabilitation programme to standard care in individuals with hereditary cerebellar ataxia. Eighty individuals with a hereditary cerebellar ataxia, aged 15 years and above, will be recruited. The rehabilitation programme will include 6 weeks of outpatient land and aquatic physiotherapy followed immediately by a 24- week home exercise programme supported with fortnightly physiotherapy sessions. Participants in the standard care group will be asked to continue their usual physical activity. The primary outcome will be the motor domain of the Functional Independence Measure. Secondary outcomes will measure the motor impairment related to ataxia, balance, quality of life and cost-effectiveness. Outcomes will be administered at baseline, 7 weeks, 18 weeks and 30 weeks by a physiotherapist blinded to group allocation. A repeated measures mixed-effects linear regression model will be used to analyse the effect of the treatment group for each of the dependent continuous variables. The primary efficacy analysis will follow the intention-to-treat principle.

ETHICS AND DISSEMINATION

The study has been approved by the Monash Health Human Research Ethics Committee (HREC/18/MonH/418) and the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (2019/3503). Results will be published in peer-reviewed journals, presented at national and/or international conferences and disseminated to Australian ataxia support groups.

TRIAL REGISTRATION NUMBER

ACTRN12618000908235.

Balance and coordination training for patients with genetic degenerative ataxia: a systematic review

BACKGROUND AND PURPOSE

The group of genetic degenerative ataxias shares the same feature of gradual deterioration in balance and coordination. However, no cure is yet available for this group of disorders, while rehabilitation remains a cornerstone in the current therapy. This review aims to present a summary of the current knowledge of balance and coordination training in patients with inherited degenerative ataxia and to discuss the training effectiveness accordingly.

METHODS

A comprehensive search was performed in 5 electronic databases (i.e., Cochrane Library, PEDro, EMbase, PubMed and MEDLINE) to identify the related publications from January, 1999 to January, 2020. Methodological quality was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) grading system and the PEDro scale.

RESULTS

A total of 33 out of 515 studies met the eligibility criteria, and were categorized and discussed by their training methods including: (1) conventional physical/occupational therapy, (2) virtual reality/videogame-based training, and (3) adapted physical activity. Despite the substantial variation among included studies, most patients achieved significant improvement in the aspect of balance and coordination following individually-tailored rehabilitation programs. The effects of training showed a relative consistency regardless of the functional dependency level on admission.

CONCLUSIONS

Balance and coordination training, especially the conventional physical/occupational therapy, is able to improve the balance and coordinative function of patients with genetic degenerative ataxia, but more high-quality studies are needed to formulate recommendations for clinical practice.

Exercise and Physical Therapy Interventions for Children with Ataxia: A Systematic Review

The effectiveness of exercise and physical therapy for children with ataxia is poorly understood. The aim of this systematic review was to critically evaluate the range, scope and methodological quality of studies investigating the effectiveness of exercise and physical therapy interventions for children with ataxia. The following databases were searched: AMED, CENTRAL, CDSR, CINAHL, ClinicalTrials.gov, EMBASE, Ovid MEDLINE, PEDro and Web of Science. No limits were placed on language, type of study or year of publication. Two reviewers independently determined whether the studies met the inclusion criteria, extracted all relevant outcomes, and conducted methodological quality assessments. A total of 1988 studies were identified, and 124 full texts were screened. Twenty studies were included in the review. A total of 40 children (aged 5-18 years) with ataxia as a primary impairment participated in the included studies. Data were able to be extracted from eleven studies with a total of 21 children (aged 5-18 years), with a range of cerebellar pathology. The studies reported promising results but were of low methodological quality (no RCTs), used small sample sizes and were heterogeneous in terms of interventions, participants and outcomes. No firm conclusions can be made about the effectiveness of exercise and physical therapy for children with ataxia. There is a need for further high-quality child-centred research.

E-Survey of Current International Physiotherapy Practice for Children with Ataxia Following Surgical Resection of Posterior Fossa Tumour

Objective

To determine current international practice regarding physiotherapy input for children with ataxia following surgery for posterior fossa tumour. Design: An e-survey covering the following domains: participant demographics, treatment/ intervention, virtual training, intensity/timing of treatment, and aims and outcomes of physiotherapy management.

Participants

Physiotherapists involved in the management of children with ataxia following surgical resection of posterior fossa tumour. Participants were contacted via 6 key groups; Paediatric Oncology Physiotherapy Network (POPs), Association of Paediatric Chartered Physiotherapists (APCP), European Paediatric Neurology Society (EPNS), International Society of Paediatric Oncology (SIOP)-Europe Brain Tumour Group, Posterior Fossa Society (PFS), and Pediatric Oncology Special Interest Group (SIG) (American Physical Therapy Association).

Results

A total of 96 physiotherapists participated: UK (n =53), rest of Europe (n = 23), USA/ Canada (n = 10), and Australia/NZ (n = 10). The most common physiotherapy interventions used were balance exercises, gait re-education and proximal control activities. The most frequently used adjuncts to treatment were mobility aids and orthotics. Challenges reported regarding physiotherapy treatment were: reduced availability of physiotherapy input following discharge from the acute setting, lack of evidence, impact of adjuvant oncology treatment, and psychosocial impact.

Conclusion

This e-survey provides an initial scoping review of international physiotherapy practice in this area. It establishes a foundation for future research on improving rehabilitation of ataxia in this population.

Turkish version of Brief Ataxia Rating Scale

AIM

Our aim was to perform the Turkish-language adaptation of a practical ataxia rating scale for children.

METHODS

The Brief Ataxia Rating Scale was subjected to cultural adaptation following receipt of the requisite permissions. Thirty-six children aged 4-18 years followed-up with a diagnosis of ataxia were included in the study. Evaluation of each child was recorded on video. The video recordings were scored independently by nine observers (four physiotherapists, one pediatric neurologist, and four pediatricians). Intra-rater reliability was tested by the same video images being scored twice, at 15-day intervals, by a pediatric neurologist. Intraclass correlation coefficients were used for inter-rater and intra-rater reliability. The Scale for the Assessment and Rating of Ataxia was used for concurrent validity.

RESULTS

Good to excellent reliability was determined among the nine observers in terms of total scores with the intraclass correlation coefficient among the nine observers (intraclass correlation coefficient = 0.926; 95% CI: 0.885-0.956). Intra-rater reliability analysis results exhibited strong reliability in terms of scores elicited at two-week intervals (intraclass correlation coefficient = 0.967; 95% CI: 0.890-0.987, r = 0.97, p < 0.001). At concurrent validity analysis, a strong relation was determined between total Scale of the Assessment and Rating of Ataxia score and total Brief Ataxia Rating Scale score (r = 0.942, p < 0.001).

CONCLUSION

The Turkish-language adaptation of the Brief Ataxia Rating Scale is reliable and valid for application in children.Implications for RehabilitationThis study shows the reliability and validity of the Turkish language adaptation of brief ataxia rating scale in children.The scale being both practical and easily applicable to ataxic children will contribute to broadening its use in the pediatric age group in particular.

Effects of Physical Rehabilitation in Patients with Spinocerebellar Ataxia Type 7

Today, neurorehabilitation has become in a widely used therapeutic approach in spinocerebellar ataxias; however, there are scarce powerful clinical studies supporting this notion, and these studies require extension to other specific SCA subtypes in order to be able to form conclusions concerning its beneficial effects. Therefore, in this study, we perform for the first time a case-control pilot randomized, single-blinded, cross-sectional, and observational study to evaluate the effects of physical neurorehabilitation on the clinical and biochemical features of patients with spinocerebellar ataxia type 7 (SCA7) in 18 patients diagnosed with SCA7. In agreement with the exercise regimen, the participants were assigned to groups as follows: (a) the intensive training group, (b) the moderate training group, and (c) the non-training group (control group).We found that both moderate and intensive training groups showed a reduction in SARA scores but not INAS scores, compared with the control group (p < 0.05). Furthermore, trained patients exhibited improvement in the SARA sub-scores in stance, gait, dysarthria, dysmetria, and tremor, as compared with the control group (p < 0.05). No significant improvements were found in daily living activities, as revealed by Barthel and Lawton scales (p > 0.05). Patients under physical training exhibited significantly decreased levels in lipid-damage biomarkers and malondialdehyde, as well as a significant increase in the activity of the antioxidant enzyme PON-1, compared with the control group (p < 0.05). Physical exercise improved some cerebellar characteristics and the oxidative state of patients with SCA7, which suggest a beneficial effect on the general health condition of patients.

Current evidence for treatment with nusinersen for spinal muscular atrophy: a systematic review

Recent discovery of nusinersen, an antisense oligonucleotide drug, has provided encouragement for improving treatment of spinal muscular atrophy. No therapeutic options currently exist for this autosomal recessive motor neuron disorder. Nusinersen is developed for intrathecal use and binds to a specific sequence within the survival motor neuron 2 pre-messenger RNA, modifying the splicing process to promote expression of full-length survival motor neuron protein. We performed a MEDLINE and CENTRAL search to investigate the current evidence for treatment with nusinersen in patients with spinal muscular atrophy. Four papers were withheld, including two phase-3 randomized controlled trials, one phase-2 open-label clinical trial and one phase-1 open-label clinical trial. Outcome measures concerned improvement in motor function and milestones, as well as event-free survival and survival. Results of these trials are hopeful with significant and clinically meaningful improvement due to treatment with intrathecal nusinersen in patients with early- and later-onset spinal muscular atrophy, although this does not restore age-appropriate function. Intrathecal nusinersen has acceptable safety and tolerability. Further trials regarding long-term effects and safety aspects as well as trials including broader spinal muscular atrophy and age categories are required and ongoing.

Changes in standing stability with balance-based torso-weighting with cerebellar ataxia: A pilot study

Objectives

People with cerebellar ataxia have few options to improve the standing stability they need for function. Strategic placement of light weights on the torso using the balance‐based torso‐weighting (BBTW) method has improved stability and reduced falls in people with multiple sclerosis, but has not been tested in cerebellar ataxia. We examined whether torso‐weighting increased standing stability and/or functional movement in people with cerebellar ataxia.

Methods

Ten people with cerebellar ataxia and 10 matched controls participated in this single‐session quasi‐experimental pilot study. People with ataxia performed the Scale for the Assessment and Rating of Ataxia (SARA) prior to clinical testing. All participants donned inertial sensors that recorded postural sway; stopwatches recorded duration for standing and mobility tasks. All participants stood for up to 30 s on firm and foam surfaces with eyes open then eyes closed, and performed the Timed Up and Go (TUG) test. Light weights (0.57–1.25 kg) were strategically applied to a vest‐like garment. Paired t tests compared within‐group differences with and without BBTW weights. Independent t tests assessed differences from controls. All t tests were one‐tailed with alpha set at .05.

Results

Duration of standing for people with ataxia was significantly longer with weighting (p = .004); all controls stood for the maximum time of 120 s with and without weights. More severe ataxia according to SARA was moderately correlated with greater improvement in standing duration with BBTW (Pearson r = .54). Tasks with more sensory challenges (eyes closed, standing on firm surface) showed less body sway with weighting. Duration for the TUG was unchanged by torso‐weighting in people with ataxia.

Conclusion

Strategic weighting improved standing stability but not movement speed in people with ataxia. BBTW has potential for improving stability and response to challenging sensory conditions in this population. Future studies should further examine gait stability measures along with movement speed.

From Pathogenesis to Novel Therapeutics for Spinocerebellar Ataxia Type 3: Evading Potholes on the Way to Translation

Spinocerebellar ataxia type 3 (SCA3), also known as Machado-Joseph disease (MJD), is a neurodegenerative disorder caused by a polyglutamine expansion in the ATXN3 gene. In spite of the identification of a clear monogenic cause 25 years ago, the pathological process still puzzles researchers, impairing prospects for an effective therapy. Here, we propose the disruption of protein homeostasis as the hub of SCA3 pathogenesis, being the molecular mechanisms and cellular pathways that are deregulated in SCA3 downstream consequences of the misfolding and aggregation of ATXN3. Moreover, we attempt to provide a realistic perspective on how the translational/clinical research in SCA3 should evolve. This was based on molecular findings, clinical and epidemiological characteristics, studies of proposed treatments in other conditions, and how that information is essential for their (re-)application in SCA3. This review thus aims i) to critically evaluate the current state of research on SCA3, from fundamental to translational and clinical perspectives; ii) to bring up the current key questions that remain unanswered in this disorder; and iii) to provide a frame on how those answers should be pursued.

What is the best way to keep walking and moving around for individuals with Machado-Joseph disease? A scoping review through the lens of Aboriginal families with Machado-Joseph disease in the Top End of Australia

OBJECTIVES

Machado-Joseph disease (MJD) is the most common spinocerebellar ataxia worldwide. Prevalence is highest in affected remote Aboriginal communities of the Top End of Australia. Aboriginal families with MJD from Groote Eylandt believe 'staying strong on the inside and outside' works best to keep them walking and moving around, in accordance with six key domains that form the 'Staying Strong' Framework. The aim of this current study was to review the literature to: (1) map the range of interventions/strategies that have been explored to promote walking and moving around (functional mobility) for individuals with MJD and; (2) align these interventions to the 'Staying Strong' Framework described by Aboriginal families with MJD.

DESIGN

Scoping review.

DATA SOURCES

Searches were conducted in July 2018 in MEDLINE, EMBASE, CINAHL, PsychINFO and Cochrane Databases.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Peer-reviewed studies that (1) included adolescents/adults with MJD, (2) explored the effects of any intervention on mobility and (3) included a measure of mobility, function and/or ataxia were included in the review.

RESULTS

Thirty studies were included. Few studies involved participants with MJD alone (12/30). Most studies explored interventions that aligned with two 'Staying Strong' Framework domains, 'exercising your body' (n=13) and 'searching for good medicine' (n=17). Few studies aligned with the domains having 'something important to do' (n=2) or 'keeping yourself happy' (n=2). No studies aligned with the domains 'going country' or 'families helping each other'.

CONCLUSIONS

Evidence for interventions to promote mobility that align with the 'Staying Strong' Framework were focused on staying strong on the outside (physically) with little reflection on staying strong on the inside (emotionally, mentally and spiritually). Findings suggest future research is required to investigate the benefits of lifestyle activity programmes that address both physical and psychosocial well-being for families with MJD.

Spinocerebellar ataxias: prospects and challenges for therapy development

The spinocerebellar ataxias (SCAs) comprise more than 40 autosomal dominant neurodegenerative disorders that present principally with progressive ataxia. Within the past few years, studies of pathogenic mechanisms in the SCAs have led to the development of promising therapeutic strategies, especially for SCAs caused by polyglutamine-coding CAG repeats. Nucleotide-based gene-silencing approaches that target the first steps in the pathogenic cascade are one promising approach not only for polyglutamine SCAs but also for the many other SCAs caused by toxic mutant proteins or RNA. For these and other emerging therapeutic strategies, well-coordinated preparation is needed for fruitful clinical trials. To accomplish this goal, investigators from the United States and Europe are now collaborating to share data from their respective SCA cohorts. Increased knowledge of the natural history of SCAs, including of the premanifest and early symptomatic stages of disease, will improve the prospects for success in clinical trials of disease-modifying drugs. In addition, investigators are seeking validated clinical outcome measures that demonstrate responsiveness to changes in SCA populations. Findings suggest that MRI and magnetic resonance spectroscopy biomarkers will provide objective biological readouts of disease activity and progression, but more work is needed to establish disease-specific biomarkers that track target engagement in therapeutic trials. Together, these efforts suggest that the development of successful therapies for one or more SCAs is not far away.

[The correction of motor disorders by special physical exercises in patients with the late cerebellar ataxia]

AIM

The selection of special physical exercises for patients with late cerebellar ataxia based on the biomechanics of balance and gait and evaluation of the clinical effect of therapy.

MATERIAL AND METHODS

Twelve male patients with the diagnosis of late cerebellar ataxia were included in the study. The mean age was 49.33±8.80 years. The daily program of therapeutic exercises included training lessons with the exercise physician. The duration of training lessons was 25-30 minutes every day besides the independent task-repetitions 5-6 times a day during 12 days. To evaluate a clinical effect, the Scale for the assessment and rating of ataxia (SARA) was administered before the lessons and on the 12-th day of therapy.

RESULTS AND CONCLUSION

The authors developed the program of physical exercises for patients with late cerebellar ataxia based on the feeling of body weight and consecutive movements of the sole that were taken from techniques of classical dance steps. After 12 days of training, the total scores on SARA decreased (12.75±4.47 vs. 9.00±4.81, p<0.01) due to the decrease in the scores of gait (3.41±1.16 vs. 2.25±0.86, p<0.01) and stance (2.67±0.98 vs. 1.42±1.08, p<0.01). Therefore, special physical exercises are a necessary component of the therapy of late cerebellar ataxia.

Does integrated cognitive and balance (dual-task) training improve balance and reduce falls risk in individuals with cerebellar ataxia?

Frequent falls in people with cerebellar ataxia (CA) is a significant problem Therefore, an intervention that could improve balance and reduce the number of falls is of paramount importance from the patients' perspective. Combining cognitive training with physical training to improve balance is a new approach for reducing the risk of falls in patient populations who are at risk for falls. To determine if adding structured cognitive demands to conventional balance and coordination training we designed the Cognitive-coupled Intensive Balance Training (CIBT) program. We found that the more intensive and focused CIBT intervention reduced dual-task cost, improved balance, and reduced the number of falls in a sample of individuals with CA. We hypothesize that (1) CIBT will improve balance and reduce falls; and (2) CIBT will be a cost-effective treatment option for improving balance and reduce falls. To test these hypotheses, we propose conducting a randomized controlled trial (RCT) with economic evaluation . This paper reports the findings of our study testing the feasibility of the CIBT program, rationale for testing our hypothesis and an overview of our future study design to test the effectiveness and cost-effectiveness of the CIBT program.

Spinocerebellar ataxia

The spinocerebellar ataxias (SCAs) are a genetically heterogeneous group of autosomal dominantly inherited progressive disorders, the clinical hallmark of which is loss of balance and coordination accompanied by slurred speech; onset is most often in adult life. Genetically, SCAs are grouped as repeat expansion SCAs, such as SCA3/Machado-Joseph disease (MJD), and rare SCAs that are caused by non-repeat mutations, such as SCA5. Most SCA mutations cause prominent damage to cerebellar Purkinje neurons with consecutive cerebellar atrophy, although Purkinje neurons are only mildly affected in some SCAs. Furthermore, other parts of the nervous system, such as the spinal cord, basal ganglia and pontine nuclei in the brainstem, can be involved. As there is currently no treatment to slow or halt SCAs (many SCAs lead to premature death), the clinical care of patients with SCA focuses on managing the symptoms through physiotherapy, occupational therapy and speech therapy. Intense research has greatly expanded our understanding of the pathobiology of many SCAs, revealing that they occur via interrelated mechanisms (including proteotoxicity, RNA toxicity and ion channel dysfunction), and has led to the identification of new targets for treatment development. However, the development of effective therapies is hampered by the heterogeneity of the SCAs; specific therapeutic approaches may be required for each disease.

Incidence and prognostic factors of ataxia in children with posterior fossa tumors

Background

There is minimal literature specific to motor outcomes in children with posterior fossa tumors (PFTs) despite ataxia being a significant problem in this group. This study aims to report children's physical outcomes following management of PFT and determine which factors affect severity of ataxia and functional limitations.

Methods

Forty-two children aged between 5 and 17 and between 1 and 4 years following surgery for PFT were assessed using the Scale for the Assessment and Rating of Ataxia (SARA), the Brief Ataxia Rating Scale (BARS), and the mobility Pediatric Evaluation of Disability Inventory (PEDI) subscale to determine prevalence and severity of ataxia and a measure of physical function. Analysis was undertaken comparing impact of tumor location, tumor histology, adjuvant treatment, age at diagnosis, presence of preoperative ataxia, and presence of cerebellar mutism syndrome (CMS) on ataxia and physical function scores.

Results

Seventy-one percent of children demonstrated a SARA and BARS score greater than 2. A total of 48% of children had a PEDI-m score greater than 90. There was no correlation between age at diagnosis or preoperative ataxia and assessment scores. There was a significant difference in SARA/BARS and PEDI-mobility scores depending on tumor histology, tumor location, and presence of CMS.

Conclusions

A high proportion of children (>1 year) following surgery for PFT continue to present with ataxia. Higher ataxia and lower physical function scores were demonstrated in children with medulloblastoma and midline tumors and those diagnosed with CMS. The high prevalence of ataxia demonstrates the need for further research regarding rehabilitation management in this population.

Can pre-screening vestibulocerebellar involvement followed by targeted training improve the outcomes of balance in cerebellar ataxia?

Balance problems and frequent falls are common among clients with Cerebellar Ataxia (CA). CA is not a disease by itself but a collection of symptoms due to the involvement of cerebellum or its pathways. Presently the treatment for balance problems for CA is not standardized. Interventions available to improve balance are not specific to symptoms presentation. Functionally the cerebellum is divided into the spinocerebellum, vestibulocerebellum and corticocerebellum. Each functional zone has a distinct role in maintaining balance. Therefore, the presentation of symptoms will vary according to the functional zone involved. Pre-screening clients with CA for identifying the part of cerebellum involved will facilitate clinicians to provide tailor-made interventions for targeting specific symptoms for better outcomes. Pre-screening clients with CA according to the part of cerebellum involved is not in practice and our study will introduce this concept. We hypothesize pre-screening participants with spinocerebellar ataxia (SCA) for the involvement vestibulocerebellum followed by prescribing vestibulocerebellum targeted exercises will have better outcomes when compared to conventional balance training. We plan to conduct two related studies. In study 1 we will screen participants with CA for the involvement of vestibulocerebellum. In study 2, the effects of vestibulocerebellum targeted balance exercises on balance will be studied. We will assess the Subjective Visual Vertical (SVV) deviation and postural sway pattern to screen participants into people with and without vestibulocerebellar involvement. SVV deviation will be estimated using a computerized Subjective Visual Vertical (cSVV) device and postural sway pattern will be assessed using the limits of stability program of the Bertec© Balance system. The obtained SVV deviation scores will be used to derive at cut-off scores to discriminate clients with and without vestibulocerebellar involvement. The second study will test the treatment effects of conventional exercises plus vestibulocerebellum targeted exercises to improve balance by correcting SVV deviation in SCA with vestibulocerebellar involvement. The intervention is planned as 12 one-to-one sessions over three months period. Participants will be reassessed after the intervention and 3 months post-intervention. The findings of this cutting-edge research are extremely important to the clinicians, researchers and clients with SCA.

Cerebellar ataxia

The cerebellum plays an integral role in the control of limb and ocular movements, balance, and walking. Cerebellar disorders may be classified as sporadic or hereditary with clinical presentation varying with the extent and site of cerebellar damage and extracerebellar signs. Deficits in balance and walking reflect the cerebellum's proposed role in coordination, sensory integration, coordinate transformation, motor learning, and adaptation. Cerebellar dysfunction results in increased postural sway, hypermetric postural responses to perturbations and optokinetic stimuli, and postural responses that are poorly coordinated with volitional movement. Gait variability is characteristic and may arise from a combination of balance impairments, interlimb incoordination, and incoordination between postural activity and leg movement. Intrinsic problems with balance lead to a high prevalence of injurious falls. Evidence for pharmacologic management is limited, although aminopyridines reduce attacks in episodic ataxias and may have a role in improving gait ataxia in other conditions. Intensive exercises targeting balance and coordination lead to improvements in balance and walking but require ongoing training to maintain/maximize any effects. Noninvasive brain stimulation of the cerebellum may become a useful adjunct to therapy in the future. Walking aids, orthoses, specialized footwear and seating may be required for more severe cases of cerebellar ataxia.

Rehabilitation for a patient with anti-Yo antibody-positive paraneoplastic cerebellar degeneration caused by breast cancer: A case report and literature review

RATIONALE

Rehabilitation for paraneoplastic cerebellar degeneration (PCD) has been indicated as necessary. However, there are only a few reports on rehabilitation in PCD. We describe the course of physical and cognitive functions and activities of daily living (ADL) in a patient with PCD and examine the effect of rehabilitation, along with a review of relevant literature.

PATIENT CONCERNS

A 42-year-old woman experienced rapid deterioration in cerebellar symptoms and was unable to walk. The cerebellar symptoms improved after mastectomy, which was performed 3 months after the onset of symptoms. However, the cerebellar symptoms exacerbated 11 months after the onset of symptoms. She underwent immunotherapy because the level of anti-Yo antibodies was high, and anti-glutamic acid decarboxylase antibodies were detected.

DIAGNOSES

She was diagnosed with anti-Yo antibody-positive PCD caused by breast cancer.

INTERVENTIONS

Rehabilitation was performed preoperatively, postoperatively, and at 1 year after the onset of symptoms.

OUTCOMES

Her physical function and ADL improved after the surgery and at 1 year after the onset of symptoms. Finally, she regained the ability to walk between parallel bars supported with one hand and a walking frame.

LESSONS

Given the results of this case and the relevant literature, it appears that rehabilitation improves physical function and ADL after oncotherapy. Particularly, initiating treatment within three months of onset of symptoms may enable patients to walk without assistance.

Can rehabilitation improve the health and well-being in Friedreich's ataxia: a randomized controlled trial?

OBJECTIVE

To determine the effectiveness of a six-week rehabilitation programme followed by a home exercise programme for Friedreich's ataxia.

DESIGN

Randomized, delayed-start control single-blind trial.

SETTING

Outpatient rehabilitation centre.

SUBJECTS

Ambulant or non-ambulant individuals with Friedreich's ataxia.

INTERVENTION

Participants were randomized to a six-week outpatient rehabilitation programme, immediately (intervention group) or after a six-week delayed-start (control group). The rehabilitation was followed by a six-week home exercise programme.

MAIN MEASURES

The primary outcome was the Functional Independence Measure. Other measures included the Friedreich Ataxia Impact Scale and the Friedreich Ataxia Rating Scale. Outcomes were administered at baseline, 6, 12 and 18 weeks.

RESULTS

Of 159 individuals screened, 92 were excluded and 48 declined to participate. A total of 19 participants were enrolled in the study. There was no significant difference in Functional Independence Measure change from baseline to six weeks in the intervention group (mean ± standard deviation, 2.00 ± 3.16) as compared to the control group (0.56 ± 4.06). Change in the Friedreich Ataxia Impact Scale body movement subscale indicated a significant improvement in health and well-being in the intervention group compared to the control group ( P = 0.003). Significant within-group improvements in the Friedreich Ataxia Impact Scale and the motor domain of the Functional Independence Measure post-rehabilitation were not sustained post-home exercise programme.

CONCLUSION

Our study indicates that rehabilitation can improve health and well-being in individuals with Friedreich's ataxia; however, a larger study is required to have sufficient power to detect a significant change in the most sensitive measure of function, the motor domain of the Functional Independence Measure.

Ataxia-telangiectasia: recommendations for multidisciplinary treatment

Ataxia-telangiectasia is a rare, neurodegenerative, and multisystem disease, characterized by cerebellar ataxia, oculocutaneous telangiectasia, immunodeficiency, progressive respiratory failure, and an increased risk of malignancies. It demands specialized care tailored to the individual patient's needs. Besides the classic ataxia-telangiectasia phenotype, a variant phenotype exists with partly overlapping but some distinctive disease characteristics. This guideline summarizes frequently encountered medical problems in the disease course of patients with classic and variant ataxia-telangiectasia, in the domains of neurology, immunology and infectious diseases, pulmonology, anaesthetic and perioperative risk, oncology, endocrinology, and nutrition. Furthermore, it provides a practical guide with evidence- and expert-based recommendations for the follow-up and treatment of all these different clinical topics.

Rehabilitation for Individuals With Genetic Degenerative Ataxia: A Systematic Review

BACKGROUND

Treatment of genetic degenerative ataxia is currently based on symptom management and maintenance of function. However, utilization of rehabilitation is limited due to a lack of evidence supporting its efficacy.

OBJECTIVE

This systematic review evaluated rehabilitation interventions for individuals with genetic degenerative ataxia. In addition, long-term outcomes from rehabilitation and optimal duration and intensity of rehabilitation were examined.

METHODS

A comprehensive search of 4 databases (MEDLINE, CINAHL, PEDro, and Cochrane) identified randomized, nonrandomized controlled, and cohort studies published from inception through to January 2016. The studies included at least one measure examining function, ataxia, balance, or gait. Methodological quality was assessed with the Australian National Health and Medical Research Council (NHMRC) Hierarchy of Evidence and the randomized controlled trials were rated according to the PEDro scale.

RESULTS

Seventeen studies met eligibility criteria. Five randomized controlled trials were included; however, the majority were classified as level III-3 and IV studies. Of 292 participants included, 148 had autosomal dominant ataxia, and 85 had autosomal recessive ataxia. Rehabilitation interventions included coordination and balance training, multifaceted inpatient rehabilitation, a cycling regime, balance exercises with technology assisted biofeedback, respiratory muscle training, and treadmill training. Two studies examined adjuncts to rehabilitation. Fifteen of the 17 studies demonstrated a statistically significant improvement in at least 1 outcome measuring ataxia, function, gait, or balance. Less than half of the studies included assessment of long-term outcomes and follow-up time frames varied considerably.

CONCLUSION

There is consistent evidence that rehabilitation improves function, mobility, ataxia, and balance in genetic degenerative ataxia.

Current concepts in the treatment of hereditary ataxias

Hereditary ataxias (HA) represents an extensive group of clinically and genetically heterogeneous neurodegenerative diseases, characterized by progressive ataxia combined with extra-cerebellar and multi-systemic involvements, including peripheral neuropathy, pyramidal signs, movement disorders, seizures, and cognitive dysfunction. There is no effective treatment for HA, and management remains supportive and symptomatic. In this review, we will focus on the symptomatic treatment of the main autosomal recessive ataxias, autosomal dominant ataxias, X-linked cerebellar ataxias and mitochondrial ataxias. We describe management for different clinical symptoms, mechanism-based approaches, rehabilitation therapy, disease modifying therapy, future clinical trials and perspectives, genetic counseling and preimplantation genetic diagnosis.

Symptomatic management in multiple sclerosis

Multiple sclerosis (MS) is the commonest cause of disability in young adults. While there is increasing choice and better treatments available for delaying disease progression, there are still, very few, effective symptomatic treatments. For many patients such as those with primary progressive MS (PPMS) and those that inevitably become secondary progressive, symptom management is the only treatment available. MS related symptoms are complex, interrelated, and can be interdependent. It requires good understanding of the condition, a holistic multidisciplinary approach, and above all, patient education and empowerment.

Treatment of progressive multiple sclerosis: what works, what does not, and what is needed

Disease-modifying drugs have mostly failed as treatments for progressive multiple sclerosis. Management of the disease therefore solely aims to minimise symptoms and, if possible, improve function. The degree to which this approach is based on empirical data derived from studies of progressive disease or whether treatment decisions are based on what is known about relapsing-remitting disease remains unclear. Symptoms rated as important by patients with multiple sclerosis include balance and mobility impairments, weakness, reduced cardiovascular fitness, ataxia, fatigue, bladder dysfunction, spasticity, pain, cognitive deficits, depression, and pseudobulbar affect; a comprehensive literature search shows a notable paucity of studies devoted solely to these symptoms in progressive multiple sclerosis, which translates to few proven therapeutic options in the clinic. A new strategy that can be used in future rehabilitation trials is therefore needed, with the adoption of approaches that look beyond single interventions to concurrent, potentially synergistic, treatments that maximise what remains of neural plasticity in patients with progressive multiple sclerosis.

Consensus paper: management of degenerative cerebellar disorders

Treatment of motor symptoms of degenerative cerebellar ataxia remains difficult. Yet there are recent developments that are likely to lead to significant improvements in the future. Most desirable would be a causative treatment of the underlying cerebellar disease. This is currently available only for a very small subset of cerebellar ataxias with known metabolic dysfunction. However, increasing knowledge of the pathophysiology of hereditary ataxia should lead to an increasing number of medically sensible drug trials. In this paper, data from recent drug trials in patients with recessive and dominant cerebellar ataxias will be summarized. There is consensus that up to date, no medication has been proven effective. Aminopyridines and acetazolamide are the only exception, which are beneficial in patients with episodic ataxia type 2. Aminopyridines are also effective in a subset of patients presenting with downbeat nystagmus. As such, all authors agreed that the mainstays of treatment of degenerative cerebellar ataxia are currently physiotherapy, occupational therapy, and speech therapy. For many years, well-controlled rehabilitation studies in patients with cerebellar ataxia were lacking. Data of recently published studies show that coordinative training improves motor function in both adult and juvenile patients with cerebellar degeneration. Given the well-known contribution of the cerebellum to motor learning, possible mechanisms underlying improvement will be outlined. There is consensus that evidence-based guidelines for the physiotherapy of degenerative cerebellar ataxia need to be developed. Future developments in physiotherapeutical interventions will be discussed including application of non-invasive brain stimulation.

Treatment Options in Degenerative Cerebellar Ataxia: A Systematic Review

The etiology of cerebellar ataxia (CA) is heterogeneous and includes easily identified and often reversible causes (i.e., drug toxicity and vitamin B12 deficiency) as well as irreversible degenerative conditions. It is the latter that poses a significant therapeutic challenge for practitioners treating this population of patients. To date, there are no U.S. Food and Drug Administration-approved medications for the treatment of CA. The literature, consisting mostly of case reports, case series, and small clinical trials, is sparse and scattered. These studies are difficult to translate clinically because they often describe diverse study populations with various identified and unidentified genetic etiologies. In addition, the reported treatment duration is often brief, and it is uncertain whether any of these options provide substantially lasting benefits. In this article, we review published reports and studies to aid the practitioner counseling patients with degenerative ataxias.

Motor training in degenerative spinocerebellar disease: ataxia-specific improvements by intensive physiotherapy and exergames

The cerebellum is essentially involved in movement control and plays a critical role in motor learning. It has remained controversial whether patients with degenerative cerebellar disease benefit from high-intensity coordinative training. Moreover, it remains unclear by which training methods and mechanisms these patients might improve their motor performance. Here, we review evidence from different high-intensity training studies in patients with degenerative spinocerebellar disease. These studies demonstrate that high-intensity coordinative training might lead to a significant benefit in patients with degenerative ataxia. This training might be based either on physiotherapy or on whole-body controlled videogames (“exergames”). The benefit shown in these studies is equal to regaining one or more years of natural disease progression. In addition, first case studies indicate that even subjects with advanced neurodegeneration might benefit from such training programs. For both types of training, the observed clinical improvements are paralleled by recoveries in ataxia-specific dysfunctions (e.g., multijoint coordination and dynamic stability). Importantly, for both types of training, the retention of the effects seems to depend on the frequency and continuity of training. Based on these studies, we here present preliminary recommendations for clinical practice, and articulate open questions that might guide future studies on neurorehabilitation in degenerative spinocerebellar disease.