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NeuroRehabilitation 20 (2005) 8589


IOS Press

Beneficial effects of postural intervention on


prehensile action for an individual with ataxia
resulting from brainstem stroke
Mary Ellen Phillips Stoykova, Mark Stojakovicha and Jennifer A. Stevens a,b,
a

Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, IL, USA
Department of Physical Medicine & Rehabilitation, Northwestern University Feinberg School of Medicine, USA

Abstract. Primary objective: This paper examined the effectiveness of postural training on upper extremity performance in an
ataxic individual. The ataxia resulted from a brain stem stroke.
Research design: Before-after, single-subject experimental design.
Experimental intervention: Four-week course of postural training, comprised of three one-hour sessions/week.
Main outcomes and results: The patient demonstrated an increase in function of the ataxic limb, as evidenced by appreciable
increases in the Fugl-Meyer score and modest increases in the Postural Assessment Scale for Stroke Patients (PASS) score.
Conclusions: Improvement in postural control influences upper extremity function affecting the speed and accuracy of the
movement. We demonstrate the effectiveness of using postural training as an intervention towards reducing the effects of ataxia, a
movement coordination impairment for which relatively few therapeutic techniques have been specifically developed or evaluated.
Keywords: Ataxia, posture, brainstem stroke, rehabilitation

1. Introduction
Brainstem stroke accounts for twenty-five percent of
total stroke occurrence. Cardinal symptoms include
cranial nerve involvement, contralateral motor and/or
sensory deficits, and ipsilateral cerebellar signs. Other
typical symptoms may include double vision, pupil dilation, and paralysis of facial muscles. In comparison to cortical strokes, individuals who have suffered
a brainstem stroke have a higher incidence of dysphagia and dysarthria. Also, survival rate is significantly
lower. The clinical presentation of a brainstem stroke
is dependent on lesion site location, extent of damage
to cranial nerves, and the vascular integrity of nearby
structures. Clinical intervention is therefore highly individualized [16].
Address for correspondence: J.A. Stevens, Ph.D., now at Psychology Department, College of William & Mary, PO Box 8795,
Williamsburg, VA 23187-8795, USA. E-mail: jastev@wm.edu.

Ataxia, the inability to coordinate muscle activity during voluntary movement, also commonly results from brainstem stroke. Movement errors typical
of ataxia include timing errors, abnormal trajectories,
joint decomposition, inaccuracy in reaching the end
point, and delay in movement initiation. These deficits
in action are likely due to the inability to produce muscle torques that are appropriately counterbalanced with
joint interaction torques [2].
The evaluation of ataxia is based on the presentation
of overt behavioral deficits, many of which can be assessed for the arm using the upper extremity portion of
the Fugl-Meyer. For example, the finger-to-nose test
will demonstrate presence/absence of tremor, dysmetria, and postural stabilization [5]. Other tasks for assessing upper limb ataxia include alternating pronationsupination, finger to finger task, and tracing or drawing
on a predetermined pattern. These evaluation tasks,
which do have the ability to detect small motor changes,
are inappropriate to use as outcome measures or to

ISSN 1053-8135/05/$17.00 2005 IOS Press and the authors. All rights reserved

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M.E.P. Stoykov et al. / Postural intervention for ataxia

guide treatment. Ataxia has also been evaluated using


kinematic measures [2,14].
There are relatively few studies examining occupational or physical therapy treatment techniques for
ataxia, and the treatments evaluated are quite varied.
For example, the effect of local ice application on reduction of cerebellar tremor for individuals with Multiple Sclerosis was investigated [1]. While the results indicated that cooling provided short-term tremor reduction, the approach has relatively small practical application in terms of long-term functional recovery gains.
Other treatments evaluated, although not systematically
studied, include distal limb weighting and postural control training [12].
Postural control strongly influences upper extremity
function affecting the speed and accuracy of the movement. Anticipatory postural control mechanisms shift
prior to arm movements in order to provide stability
by minimizing the disturbing forces resulting from the
moving extremity [10,15]. For stroke survivors with
movement incoordination, trunk control plays a necessary role in and is a significant predictor of successful
ADL performance and gait activity [9]. Some believe
that training in trunk control should precede upper extremity motor control training [7]. Focus on retraining
of postural control and postural reactions is a concept
intimately tied to Bobath treatment. Posture lies at the
seat of movement control as it provides the basis for
body positions and functional skills [4,11]. Indeed, infant studies indicate a significant impact of self-sitting
on the acquisition of reaching behaviors, demonstrating that prehensile movements are intimately tied to
postural stability [13].
Here, we present a case report of an individual with
severe upper limb ataxia and poor trunk control as the
consequence of a brainstem stroke. The article describes how arm movement improved after a four-week
course of postural training. To date, examination of the
direct effects of postural training on functional gains
in an individual with upper limb ataxia have not been
systematically investigated.

2. Method
2.1. Subject
The subject was a 68 year old, married female with
an unremarkable medical history. In January of 2000,
she suffered a hemorrhage of the left midbrain, a rare
location for a stroke [6,16]. Prior to stroke onset, the

subject complained of a headache and was given aspirin, then collapsed and became unconscious. Initial
MRI analysis revealed hemorrhage in the brain stem.
The lesion extended from the left lateral ventricle to
the superior cerebellar peduncle. There was no cortical
involvement.
The subject had an inpatient stay of four weeks and
remained in a coma during that time. When the subject emerged from her coma, she was transferred to a
nursing home. Symptoms observed following coma
emergence included a dense right hemiplegia, hyperreflexia, dysphagia, dysarthria, severe right hemianopsia, and dense right-sided sensory deficits. Additionally, the left (ipsilesional) side was extremely ataxic.
The subject received OT, PT, and speech therapy for
five months in the nursing home. Approximately a year
post-stroke, she was again admitted to an inpatient rehabilitation program for intensive therapies, which focused on family training in transfers, ADLs and communication strategies. After discharge, physical and
speech therapies were administered at home. At the
time of study, physical therapy intervention included a
maintenance program of standing with assistance, passive range of motion for the paretic side, and active
range for the non-paretic side. Speech therapy focused
on articulation. The subject was not receiving occupational therapy at the time of the study. Other than a
brief hospitalization due to a stress fracture, the subject
was medically stable. The subject was dependent in all
activities of daily living. A full-time caretaker provided
assistance with most ADLs. With the assistance of her
husband, she participated in activities outside the home
including investment club and going to restaurants and
movies. Time between stroke and participation in the
present intervention was approximately three years.
2.2. Assessments
Formal clinical evaluations included the FuglExtremity Motor Scale [8] and the Postural Assessment
Scale for Stroke Patients (PASS) [3]. The Fugl-Meyer
Upper Extremity Motor Scale is a well-known instrument that measures synergistic patterns and isolated
movement for individuals who have suffered a stroke.
We restricted our use of the test to the upper extremity
portion, which assesses a variety of multi-joint movement and grasp patterns of the upper limb. There are
four sub-scales including: 1) Upper extremity (measures proximal movement, 2) wrist, 3) hand, and 4)
coordination/speed. The maximum possible score for
these four categories combined is 66. The PASS is

M.E.P. Stoykov et al. / Postural intervention for ataxia

a clinical scale designed to assess static and dynamic


postural control in individuals with stroke. Three postural activities are assessed including lying, sitting, and
standing. They are assessed both statically and dynamically.
2.3. Intervention
The subject received one-hour occupational therapy
sessions in the clinic three times a week for four consecutive weeks. A neuromuscular approach to postural control was initiated. During the first two weeks,
treatment included practice in maintaining an unsupported sitting posture. Sessions began with passive
range of motion of the pelvis in the D1 diagonal in
side lying [17]. The D1 pelvic pattern includes anterior
elevation and posterior depression of the pelvis. Mobilization of the pelvis in the D1 direction facilitated
a more symmetrical pattern during sitting. In order to
strengthen the trunk,rolling and reverse rolling from the
less affected (left) side were performed with gradually
decreased assistance from the therapist. Verbal and tactile cures were provided to the subject as she practiced
sitting without support. As the client gained the ability
to achieve unsupported sitting, dynamic trunk exercises
including trunk flexion and reaching to the left while
weight shifting were also attempted. Additionally, the
therapist recommended a lumbar support to use while
the subject was in the wheel chair. A lumbar support
provided enhanced somatosensory feedback about the
subjects position in space. Also, it assisted the subject
in maintaining an anterior pelvic tilt, which is important for postural alignment as well as reduction of pain.
The subject also was instructed in scapular strengthening exercises while sitting supported in the wheel chair.
Caregiver training included instructions in facilitating
sitting balance and trunk strengthening exercises.

3. Results and discussion


Baseline scores were taken before the first day of
postural intervention. On the ataxic left upper extremity, the subject scored a 35 out of a possible score of 66
on the Fugl-Meyer Upper Extremity Motor Scale. The
paralyzed right upper extremity had no active movement and could not perform any of the movements on
the Fugl-Meyer scale. On the PASS, the subject initially scored a 2 out of a possible 36. Following the
four-week intervention, the subject had attained a score
of 53 out of a possible 66 on the Fugl-Meyer, a consid-

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erable gain of 18 points. The PASS score increased by


5 points with an overall, score of 7 out of a possible 36.
The results of both assessments are presented in Fig. 1.
The subject was still dependent in all activities of
daily living due to complete paralysis of the right side.
She scored 0 on the Barthel ADL index both before and
after the treatment. However, after intervention, she reported greater comfort in sitting and was able to sit for
longer periods in her wheelchair without discomfort.
The subject reported that she was able to attend her
investment club meetings, an activity she thoroughly
enjoyed. The discrepancy between increases in FuglMeyer score and unchanged Barthel index scores indicate that the successful performance of low-level activities such as precede activities for daily living and must
remain a focus for physical and occupational therapists
alike. Moreover, the increases in Fugl-Meyer occurred
as a result of postural intervention highlight postural
stability as a critical component stage in the functional
recovery process for an individual with ataxia. Currently, there is no consensus on how to treat upper limb
ataxia. Occupational therapists traditionally use compensatory techniques such as minimizing the degrees
of freedom via external support (e.g. resting forearms
on table while performing an activity) or distal weighting. Upper extremity strengthening may also be attempted, however, strengthening alone will not resolve
the coordination decrement between the muscle and
joint interaction torques.

4. Conclusion
In summary, this case study illustrated how neuromuscular postural control intervention resulted in improved upper extremity movement. The scores on the
Fugl-Myer indicate greater isolated control of proximal and distal musculature. Additionally, the subject
reported greater comfort while sitting. The subject still
suffers from severe ataxia and, thus, receives assistance
in all ADLs. However, it is likely that postural training facilitated improved anticipatory control, which afforded better quality of limb movement. Moreover,
perhaps a longer course of training, and introduction of
postural training at an earlier stage in the recovery process may have greater effect of performance improvement.
To our knowledge, this is the first study demonstrating quantifiable gains in functional recovery in the
ataxic individual following a controlled course of postural intervention. Upper extremity activity and pos-

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M.E.P. Stoykov et al. / Postural intervention for ataxia

Fig. 1. Increases in Mayer and PASS scores with an ataxic limb following four weeks of postural intervention.

tural control are interconnected, and both should be


assessed prior to intervention [9]. The PASS may be
utilized specifically for individuals demonstrating difficulties with trunk control. The goals of postural training are varied and may include: (1) preventing and remediating impairments, (2) to develop postural strategies (3) stabilizing upper limb movement and (4) incorporate postural control into activities of daily living.
Due to the severity of the ataxia in our subject, we were

unable to incorporate activities of daily living into her


intervention. However, our case illustrates the strong
relationship between postural control and manipulation
skill.
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