CEREBELLAR
DISORDERS
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Cerebellar control of movement
• Primary function is regulation of movement, postural
control & muscle tone
• Functions as comparator & error correcting mechanism
• Performs the planning, sequencing & timing of complex
movement pattern
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• Controls the ongoing movement particularly the timing &
strength of the co contraction, relaxation & contraction of
agonist, antagonist, prime movers & fixator muscles
• Clinical consequences of cerebellar lesions are ipsilateral
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Movement disorders of the cerebellum
Hypotonia
Asthenia
Ataxia
Gait disturbances
Balance & equilibrium disorders
Dysmetria
Rebound phenomenon
Disdiadokokinesia
Movement decomposition
Tremor
Inco-ordination
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Hypotonia
• Decrease in muscle tone due to decrease in
excitation from the cerebellar deep nuclei to the
region of the brain that excite alpha & gamma
motor neuron
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Asthenia
• Generalized weakness of the involved side of the body
• Complains of heaviness, excessive effort for simple
effort and early onset of fatigue
• Caused due to loss of cerebellar facilitation to the
motor cortex which in turn could reduce the activity
of the spinal motor neurons during voluntary
movement
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Ataxia
• Classic sign of cerebellar lesion
• Appears in the trunk, extremities, head, mouth &
tongue
• Refers to lack of order of movement or sequence of
movement
• Most often associated with gait disturbances
• Multijoint movement patterns are more affected than
the single joint movement
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Gait disturbances
• Ataxic gait/ staggering gait/ reeling gait/ drunkards
gait
• Characterized by
• Uneven step length
• Irregular width of the walking base
• Rhythm is absent
• Feet are lifted too high
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Balance and equilibrium
• Severe disturbances in stance & gait but almost never
fall
• Presence of postural tremor and sway
• Looses balance easily
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Dysmetria
• Loss of direction, extent, force & timing of movements
• It may be hypometria or hypermetria
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Disdiadokokinesia
• Inability to perform rapid alternating movement E.g.
supination pronation
• Movement appears slow & quickly looses range & rhythm
• It is a result of inappropriate timing of muscle activity
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Movement decomposition
• Difficulty in performing movement in one smooth
pattern & may perform the movement in a sequence of
steps
• Movement becomes separated into individual components
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Tremor
• Intention tremor is often seen and usually enhanced
during terminal goal oriented movt.
• They have a frequency of 3-5 hz
• While maintaining posture, postural tremor is seen
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Inco-ordination
• Specific test
• Equilibrium & non equilibrium test
Dysarthria
• Dysarthria is a motor speech disorder resulting from
neurological injury, characterized by poor articulation
• It is due to some disorder in the NS, which hinders
control over, the tongue, throat, lips or lungs.
• Swallowing problems (dysphagia) are often present
• Cranial nerves that control these muscles include the
trigeminal nerve's motor branch (V), the facial nerve
(VII), the glossopharyngeal nerve (IX), the vagus
nerve (X), and the hypoglossal nerve (XII).
• Spastic (resulting from bilateral damage to the upper motor
neuron),
• Flaccid (resulting from bilateral or unilateral damage to the
lower motor neuron),
• Ataxic (resulting from damage to cerebellum),
• Unilateral UMN (presenting milder symptoms than bilateral
UMN damage),
• Hyperkinetic and hypokinetic (resulting from damage to
parts of the basal ganglia, such as in Parkinsonism),
• Mixed (where symptoms of more than one type of
dysarthria are present).
ATAXIA
Definition
• Ataxia is a neurological sign and symptom that consists
of gross lack of coordination of muscle movements.
• Ataxia is a non-specific clinical manifestation implying
dysfunction of parts of NS that coordinate movement,
such as the cerebellum
Types
• Cerebellar
• Sensory
• Vestibular
CEREBELLAR ATAXIA
Definition of cerebellar ataxia
• It is a term used to described certain behavior like
postural unsteadiness, difficulty in co coordinating
movements & clumsiness experienced by an individual
with cerebellar dysfunction
Types of symptom manifestation
• Symptoms depends on cerebellar structures which is
affected, & whether lesion is bilateral or unilateral.
• Dysfunction of vestibulocerebellum impairs balance &
control of eye movements.
• With postural instability
• The instability is therefore worsened when standing with the
feet together, regardless of whether the eyes are open or
closed. This is a negative Romberg's test, or inability to carry
out the test, because the individual feels unstable even with
open eyes.
• Dysfunction of spinocerebellum presents
• with a wide-based "drunken sailor" gait,
characterised by uncertain starts and stops, lateral
deviations, and unequal steps.
• This part of the cerebellum regulates body and limb
movements.
• Dysfunction of cerebrocerebellum presents
with disturbances in carrying out voluntary,
planned movements. These include:
• intention tremor
• peculiar writing abnormalities (large, unequal letters,
irregular underlining);
• a peculiar pattern of dysarthria (slurred speech,
sometimes characterised by explosive variations in
voice intensity despite a regular rhythm).
Etiology
• Developmental abnormality e.g. Hydrocephalus, Arnold
Chiari Malformation
• Trauma, focal lesion
• Stroke, tumour, infection
• Demyelinating disease like MS
• Degenerative disease
• Heriditary (Fredriech’s ataxia)
• Metabolic disease (B12 defficiency)
• Vascular disease
• Drug intoxication or exogenous substance (ethanol causes
reversible cerebellar & vestibular ataxia)
Clinical presentation
• Hypotonia
• Dysmetria
• Dysdiadokokinesis
• Tremor
• Movement decomposition
• Ataxic gait
• Scanning speech
• Asthenia
• Rebound phenomena
• Dysarthria/ scanning speech
• Nystagmus (Central nystagmus)
Treatment of ataxia
• There is no specific treatment
• Physical therapy proves to be effective in reducing the
patients difficulties
• Some amount of recovery takes place within 3 months
without any treatment
PT assessment
• History
• General observation of patient
• postural tremor, tone (hypotonic), gait (ataxic), external appliances (wailking
aid), nystagmus
• Posture
• Sit with an increased thoracic kyphosis & forward head
• Sit with hyperlordosis due to abdominal muscle weakness
• Stand with a wide base of support
• Examination of communication & cognitive skills
• May exhibit delirium (restlessness, irritability, tremors, confusion,
disorientation or hallucination), dementia or short-term memory problems in
patients with alcoholic CD
• May experience dysarthria
• Sensory evaluation
• Motor evaluation- muscle power
• Asthenia (generalized muscle weakness)
• Need arm support to rise from floor or a chair due to lower
limb or trunk weakness
• Tone – hypotonia in the ipsilateral side
• ROM & flexibility
• Reflex integrity -
• Decreased DTR or pendular due to hypotonia
• Normal righting reflexes
• Delayed or absent protective extension & equilibrium reactions
• Sensory integrity
• Patients with CD may demonstrate impaired proprioception &
vibration & therefore often require vision to perform motor
tasks
• Presence of cerebellar signs- ataxia, tremor,
nystagmus, postural imbalance
• Co ordination & balance assessment- predict risk of fall
• Intention tremors
• UL & LL coordination problems
• Positive Rebound Test
• Dysdiadochokinesia (inability to maintain rhythm range when foot-tapping or
in supination or pronation)
• Dysmetria (undershooting or overshooting target during finger-to-nose &
finger-to-examiner’s finger tests)
• Movement decomposition (inability to move smoothly while performing ADL)
• Difficulty learning new motor tasks due to cognitive impairment
• Romberg’s test: The extent of the sway envelope when standing
with about 4 inches between the feet can be 12o in the sagittal
plane and 16o in the frontal plane.
Investigations
• CT scan, MRI
• Cerebellar atrophy
• Cerebellar tumour
• Cerebellar infarction
• Tonsilar invagination & hydrocephalus
• Arnold chiari malformation
PT management
• Psychological support
• Maintain a non threatening interaction
• Give positive reinforcement
• Gain confidence of the patient
• Patient should not be isolated
• Family & care giver advice
• Improve relaxation
• Relaxed passive motion
• General rocking movement
• Relaxed positioning
• Deep breathing exercise
• Yoga therapy
• Meditation
• PNF technique
• Massage
• Relaxation techniques
• Active general exercise
• AROM ex & other free ex
• Mat exercises
• Reaching activities
• Spot marching
• Gymball activities
• Weight shifting exercises
• Balance exercise
• Weight shifting
• Alteration in the complexity of the activity, speed & duration
• Slowly withdraw external control
• Increase amplitude of movement
• Training of complex dual task
• Balance board exercise, Gymball activities, Trampoline
activities
• Progress by giving external perturbations
• Distract attention by speaking during exercise
• Gait training
• Lengthen stride length
• Concentrate on heel to toe pattern
• Improve arm swing
• Parallel bar activities
• Walk on printed foot prints
• Marching on spot with arm swing
• Walking in straight line
• Walking in circle
• Walking sideways with outstretch hand
• Reduce fatigue
• Modification of task, breaking into component parts
• Pacing of exercise speed & rate
• Proper rest periods
• Complex activities are broken down to simpler parts
• Exercise which requires minimum energy expenditure are used
• Over exercise is avoided
• Strengthening exercise
• Simple pendular exercise for very weak muscles
• Assisted & resisted exercise
• Theraband exercise to improve eccentric & concentric control
• Muscle energy technique
• Ataxia management
• Promote accuracy of limb movements by using aids, cues &
feedback
• Combined activities of the trunk & limbs to improve co
ordination, balance & automaticity of movement
• Frenkels exercise
• Small weight cuffs, ankle & wrist bands can be used during
activities to increase awareness of the limbs
• Weight bearing exercise of UL & LL
• Functional training
• Development of problem solving skills
• Transfer training
• Training of ADL activities
• Environmental modifications & architectural changes
• Ankle foot orthosis
• Recreational activities- ballroom dancing, treadmill walking,
throwing ball in the basket
• Sit to stand exercise
• Tremor management
• Weight bearing exercise
• Push ups
• Use weighted utensils & weighted canes
• As discussed for ataxia
• For bed ridden patients
• Skin care advice
• Respiratory & cardiac care
• Aerobic training with recumbent cycling
• Family & patient education
• Home exercise program
Sensory ataxia
• Ataxia due to loss of proprioception
• Caused by dysfunction of dorsal columns of spinal cord
• May also due to dysfunction of various parts of brain which
receive positional information, including cerebellum,
thalamus, & parietal lobes
• Presents with
• unsteady "stomping" gait with heavy heel strikes
• postural instability that worsens when lack of proprioceptive input
cannot be compensated by visual input, s/a in poorly lit environments.
• Positive Romberg's test
• Worsening of finger-pointing test with eyes closed
Vestibular ataxia
• It is employed to indicate ataxia due to dysfunction of
vestibular system, which in acute and unilateral cases
is associated with prominent vertigo, nausea and
vomiting
• In slow-onset, chronic bilateral cases of vestibular
dysfunction, these characteristic manifestations may
be absent, and disequilibrium may be the sole
presentation.
