Bridgett Piernik-Yoder, PhD, OTR UT Health Science Center at San Antonio Department of Occupational Therapy

 The information provided by speakers in any presentation made as part of the 2012 NAF Annual Membership Meeting is for informational use only.  NAF encourages all attendees to consult with their primary care provider, neurologist, or other health care provider about any advice, exercise, therapies, medication, treatment, nutritional supplement, or regimen that may have been mentioned as part of any presentation.  Products or services mentioned during these presentations does not imply endorsement by NAF.  I have no personal financial relationships with commercial interests relevant to this presentation to disclose

 Current evidence for rehabilitation intervention in the management of ataxia  Role of OT  Intervention approaches

Can rehabilitation intervention help ataxia?

 Ataxia results from a range of conditions  Rehabilitation interventions for neuromuscular conditions often address motor learning  Therapeutic gains may be mitigated by changes in a person’s condition  Variability in ataxia may make it difficult to control for differences

 16 patients with degenerative cerebellar ataxia  Participated in a 4-week therapy program, followed by 8-week home program  Experienced improvements in motor control and reduction of ataxia symptoms  Found those who maintained home program were more likely to retain gains  Therapy may result in gains but continuous therapy may be most beneficial Ilg, W., Synofzik, M., Brotz, D., Burkard, S., Giese, M., Schols, L. (2009). Intensive coordinative training improves motor performance in degenerative cerebellar disease. Neurology, 73, 1823–1830.

 3 individuals with ataxia from stroke  Completed a modified constraint-induced movement therapy protocol (CIMT)  Participants improved on several outcome measures  Specific measures of reach  Reported increased use of upper extremity  Intense motor therapy may be beneficial for some Richards, L., Senesac, C., McGuirk, T., Woodbury, M., Howland, D., Davis, S., Patterson, T. (2008). Response to intensive upper extremity therapy by individuals with ataxia from stroke. Topics in stroke rehabilitation, 15(3), 262 – 271.

 Examined outcome of postural training with an individual with ataxia due to stroke  Received four weeks of neuromuscular postural control intervention by an OT  Participant improved function of ataxic upper extremity yet still required assistance for all ADLs  Addressing postural control may be beneficial for some Stoykov, M. Stojakovich, M., Stevens, J. (2005). Beneficial effects of postural intervention on prehensile action for an individual with ataxia resulting from brainstem stroke. Neurorehabilitation, 20(2), 85 – 89.

 Intensive therapy has potential to improve motor function in some with ataxia  Mechanism for improvements is not clear  Create alternative neural pathways to better control movement  Rely on residual function  Non-specific therapeutic gains  Does clinical function translate to functional gains?

 Focus is dependent on goals of the client  Typical physical challenges  Decreased strength and endurance  Decreased proximal strength  Difficulty with multi-joint movements  Typical functional challenges  Home management tasks  Driving  Work and leisure occupations

Address skills to support function Daily “occupations” Adapt the task to support function Adapt the environment to support function Systems model of motor control

Skills Strength Activity tolerance or endurance Task Change the requirements of the task Adaptive equipment Environment Adaptations Social supports

 Addressing physical aspects  Addressing task performance  Utilizing adaptive equipment  Modifying the environment

 42 year-old female with ataxia resulting from MS  Pharmacological tx dampened magnitude of tremors  Identified self-care skills as greatest area of concern  Feeding – max assistance - UE, head and neck tremors worsen when bringing food or utensil to mouth  Grooming – max assistance  Bathing – max assist  Home management – difficulty with meal prep, dialing home phone  Dressing – satisfied with performance, had adapted style of clothing over time

 More difficulty with tasks that required multi-joint control  Strategies  Sliding hand across a surface to reach an object rather than reaching in space  Using a high-backed, firm chair during self-care activities  Resting elbow on table or counter for support  Stabilizing upper extremities against trunk or chin for activities that required hand function

 Strategies  Use of orthotics or wrist supports during self-care  Use of a tub bench with back support improved stability and conserved energy  Use of a bathing mitt and sliding mitt over body parts  Use of electric toothbrush reduced motor requirements  Use of an adaptive cutting board to assist with meal preparation  Started exclusively using a mobile phone with voice- dial

 Symptoms related to ataxia did not change  Focus of OT was environmental and adaptive strategies  Positioning  Movement patterns  Maximizing limb stability  Adaptive equipment

 Research shows that therapy can be beneficial in addressing some aspects of motor control  Focus of OT intervention is function  OT will address skills, task requirements, environment  Strategies will be aimed at supporting function, or daily “occupations”

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