Helping people with MS cope with ataxia
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This presentation from Wendy Hendrie looks at how health professionals can help people with MS cope with ataxia. It was presented at the MS Trust Annual Conference in November 2013.
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Helping people with MS cope with ataxia
- 1. Helping people with MS cope with ataxia Wendy Hendrie PhD MSc MCSP Specialist Physiotherapist in MS Norwich MS Centre
- 2. Two main approaches • Rehabilitation • Compensatory Mobility Upper limb Posture
- 3. Many systems responsible for movement quality SENSORY CEREBELLAR VESTIBULAR MOVEMENT QUALITY MOTOR VISUAL Deficits in one or more systems ataxic symptoms
- 5. Rehabilitation • Some studies of rehab interventions have shown improvements in gait, trunk control and activities. • Motor relearning may be possible in damaged cerebellum? • Very few studies in MS.
- 6. Rehabilitation • Interventions – Dynamic task practice – Challenges to limits of stability – Strengthening – Flexibility – PNF – Treadmill training (not MS) + over-ground training
- 7. No evidence in ataxia but may be useful… • • • • • Yoga T’ai Chi Pilates Horse riding Hydrotherapy
- 8. Managing ataxia Treatment of ataxic patients requires balance between facilitation of improved control and the recognition and acceptance of necessary compensation which is essential for function. Jon Marsden
- 9. Mobility • Wide-based gait – difficulty placing feet • Poor balance • Frequent falls • Prolonged sitting
- 10. Balance and Mobility Aids • No studies have evaluated role of aids • Case-by-case basis • Rollators
- 11. Tendency to ‘fix’ posture (especially if vestibular problems). May be dangerous as lateral sidesteps to aid balance is impeded.
- 12. Balance and Mobility Aids • Walking / trekking / Nordic poles – light tough contact, more weight through lower limbs • Difficult placing sticks / poles if person has dysmetria or tremor • Can weight all hollow mobility aids with sand / ball-bearings
- 13. More strategies to improve mobility • Visually guided stepping - eyes and locomotor system work together during walking - rehearsal of intended placement of steps before walking - task-specific and short-lived - ‘mindfullness’ of movement
- 14. Wobble cushion in preparation for walking cerebellar ataxia – slow to start, slow to stop – delay in agonist/antagonist initiation.
- 15. Axial weighting – vest or belt • Use weights to increase sensation through joints. Increases feelings of steadiness. • To counteract forward or backward lean. • Reaching activities in sitting.
- 16. Stabilise core, increase proprioception / sensation • Spinal stability wrap (DM Orthotics) • Lycra garments • Support tights
- 17. Auditory feedback • Study in people with MS (n=14). • Rhythmic cueing via earpiece. • Increased speed and step length but made some people worse.
- 18. Keeping cool • Damp T-shirt • Cold drinks, meals, puddings • Damp scarf or tea towel
- 19. Anecdotes……..
- 20. Strategies for the upper limb • Manipulation of visual information - tremor and dysmetria may improve if movement not visually guided - can work well in people with intention tremor - find the ‘quiet arc’ of movement
- 21. Central pick-up
- 22. Side pick-up, peripheral vision
- 23. Cooling • 15 minutes of cooling • use wine cooler over forearm • decrease in tremor can last for up to 30 minutes (eating, ISC)
- 24. Wrist weighting • Grade weight until tremor diminished enough for function • Beware of making tremor, instability, weakness, fatigue or rebound worse • Up to 4lbs
- 25. Central pick-up, no aids
- 27. Equipment for eating • • • • • • Weighted cutlery / mugs Neater-eater Plate guard Non-slip mats Valved straws Nosey cups
- 28. more ideas….. • Overshoot and pick up on return • Easy target • Improve sensation – visual / touch • Bag of different objects / textures
- 29. Lycra garments • May help with functional tasks • Can be hot • Can be difficult to put on • Assess with two layers of Size B tubigrip
- 32. Posture - single joint move • • • • • Simplify movement Avoid rapid, multi-joint movements Reduce number of moving joints Stabilise Slow movement
- 33. Standing frames
- 34. Windswept postures are unstable
- 35. Build a stable base
- 38. Using the toilet / commode
- 39. Postural case study • • • • • • • 49 year old lady with MS Gross ataxia of trunk, head and upper limbs Living at home Refusing help with eating Weight loss Chest infection Admitted to hospital
- 42. Just to make things difficult….. • Mixed causes • Reduced joint range • Weakness • Emotional impact • Spasticity • Cognitive problems • Eye problems • Weight loss • Anxiety/fear • Social stigma
- 43. In summary • Deconditioning makes everything worse so encourage activity! • May need to use a variety of compensatory interventions • Check medication (especially anti-spasticity) as muscle weakness may be contributing to ataxia