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