Paraneoplastic subacute cerebellar degeneration: functional improvement and the role of rehabilitation

Rehabilitation for a patient with anti-Yo antibody-positive paraneoplastic cerebellar degeneration caused by breast cancer: A case report and literature review

RATIONALE

Rehabilitation for paraneoplastic cerebellar degeneration (PCD) has been indicated as necessary. However, there are only a few reports on rehabilitation in PCD. We describe the course of physical and cognitive functions and activities of daily living (ADL) in a patient with PCD and examine the effect of rehabilitation, along with a review of relevant literature.

PATIENT CONCERNS

A 42-year-old woman experienced rapid deterioration in cerebellar symptoms and was unable to walk. The cerebellar symptoms improved after mastectomy, which was performed 3 months after the onset of symptoms. However, the cerebellar symptoms exacerbated 11 months after the onset of symptoms. She underwent immunotherapy because the level of anti-Yo antibodies was high, and anti-glutamic acid decarboxylase antibodies were detected.

DIAGNOSES

She was diagnosed with anti-Yo antibody-positive PCD caused by breast cancer.

INTERVENTIONS

Rehabilitation was performed preoperatively, postoperatively, and at 1 year after the onset of symptoms.

OUTCOMES

Her physical function and ADL improved after the surgery and at 1 year after the onset of symptoms. Finally, she regained the ability to walk between parallel bars supported with one hand and a walking frame.

LESSONS

Given the results of this case and the relevant literature, it appears that rehabilitation improves physical function and ADL after oncotherapy. Particularly, initiating treatment within three months of onset of symptoms may enable patients to walk without assistance.

Inpatient rehabilitation performance of patients with paraneoplastic cerebellar degeneration

OBJECTIVE

To evaluate the functional improvement of rehabilitation inpatients with paraneoplastic cerebellar degeneration.

DESIGN

Retrospective review.

SETTING

Referral-based hospitals.

PARTICIPANTS

Cancer rehabilitation inpatients (N=7) admitted to 3 different cancer centers with a diagnosis of paraneoplastic cerebellar degeneration.

INTERVENTION

Medical records were retrospectively analyzed for demographic, laboratory, medical, and functional data.

MAIN OUTCOME MEASURE

FIM.

RESULTS

All 7 patients were white women (median age, 62y). Primary cancers included ovarian carcinoma (n=2), small cell lung cancer (n=2), uterine carcinoma (n=2), and invasive ductal breast carcinoma (n=1). Mean admission total FIM score was 61±23.97. Mean discharge total FIM score was 73.6±29.35. The mean change in total FIM score was 12.6 (P=.0018). The mean length of rehabilitation stay was 17.1 days. The mean total FIM efficiency was .73. Of the 7 patients, 5 (71%) were discharged home, 1 (14%) was discharged to a nursing home, and 1 (14%) was transferred to the primary acute care service.

CONCLUSIONS

To our knowledge, this is the first study to demonstrate the functional performance of a group of rehabilitation inpatients with paraneoplastic cerebellar degeneration. Despite the poor neurologic prognosis associated with this syndrome, these patients made significant functional improvements in inpatient rehabilitation. When appropriate, inpatient rehabilitation should be considered. Further studies with larger sample sizes are needed.

A multidimensional physical therapy program for individuals with cerebellar ataxia secondary to traumatic brain injury: a case series

The purpose of this case series is to describe changes in impairments and activity limitations in three individuals with severe cerebellar ataxia from traumatic brain injury (TBI) who participated in a long-term, multidimensional physical therapy program. A secondary purpose is to document use of a climbing wall for these persons. Each of the individuals had a TBI, severe ataxia and was admitted to a transitional neuro-rehabilitation day treatment program. The first person, a 22-year-old, was 6 years post injury and had 127 individual physical therapy sessions over 12 months. The second person, a 16-year-old, was 5½ months post injury and had 187 individual therapy sessions over 19 months. The third person, a 20-year-old, was 6 months post injury and had 89 individual therapy sessions over 23 months. An integrative treatment approach was used, and the individuals participated in activities to minimize ataxia and improve mobility. Each of them made gains in coordination, balance, balance confidence, endurance and mobility. The three individuals with cerebellar ataxia participated in a long-term, individualized, multidimensional physical therapy treatment program, and made improvements in all areas of impairment and activity limitations. This study reinforces the need for long-term, multidimensional physical therapy for individuals with ataxia.

Longitudinal tracking of gait and balance impairments in cerebellar disease

Cerebellar damage typically results in ataxia and can be caused by stroke, tumor, or one of many forms of degenerative disease. Since few pharmacological options are available, most treatments rely heavily on rehabilitation therapy. Little data exist on methods for tracking the progression of ataxia, which is critical for assessing the efficacy of current and newly developing treatments. Here, we tracked the severity of ataxia, with a particular emphasis on gait and balance dysfunction, in a group of individuals with cerebellar damage using the International Cooperative Ataxia Rating Scale (ICARS) and several instrumented laboratory measures of gait and balance impairments over 1 year. We found that the ICARS was able to distinguish between subjects with static lesions and those with degenerative disorders, was sensitive to increases in ataxia severity occurring over 1 year, and correlated well with specific instrumented measures of gait in persons with cerebellar degeneration. These results suggest the ICARS is a valuable tool for clinicians and investigators to document and track long-term changes in gait and balance performance in individuals with cerebellar degenerative disorders.

Rehabilitation treatment options for a patient with paraneoplastic cerebellar degeneration

Paraneoplastic cerebellar degeneration is a neurologic syndrome associated with carcinoma. Medical management is limited to treatment of the underlying malignancy with excision, plasmapharesis, immunosuppression, or chemotherapy. We report on the case of a woman with paraneoplastic cerebellar degeneration who showed improvements in functional mobility after 3 wk of comprehensive inpatient rehabilitation. This case demonstrates the functional improvements of one patient with paraneoplastic cerebellar degeneration after intensive rehabilitation and describes the specific treatment interventions utilized.

Paraneoplastic cerebellar degeneration as the first manifestation of cancer

Paraneoplastic cerebellar degeneration (PCD) is a type of paraneoplastic syndrome that primarily affects women with gynecological cancers. Patients typically experience pancerebellar symptoms, including gait ataxia, dysarthria, nystagmus, and truncal and appendicular ataxia. We present the case of a 50-year-old woman with PCD and presumed ovarian cancer who initially complained of ataxia and dysarthria. PCD was diagnosed on the basis of her symptoms, diagnostic imaging, and laboratory work. PCD symptoms may precede the diagnosis of malignancy by months or years. Early diagnosis and treatment of these syndromes, including rehabilitation, may result in improvements in quality of life for this population of patients.

Paraneoplastic cerebellar degeneration as the first evidence of cancer: a case report

Paraneoplastic cerebellar degeneration (PCD) is the most frequently seen paraneoplastic syndrome affecting the brain. PCD is most commonly associated with cancers of the ovary, breast, and lung. The anti-Purkinje cell antibodies (anti-Yo) that specifically damage the Purkinje cells of the cerebellum are found in the patient's serum and cerebrospinal fluid. The typical presentation of PCD includes limb and truncal ataxia, often along with dysarthria. This report describes the case of a 47-year-old woman without significant medical history who developed new onset of unsteady gait, headache, and vertigo. The imaging studies suggested rhombencephalitis. The patient initially responded to corticosteroid treatment. Unfortunately, her gait ataxia worsened and she developed dysarthria, neither of which responded to increasing dosages of corticosteroids. Extensive imaging studies showed no evidence of tumor, but the patient was found to have positive anti-Yo antibodies and elevated cancer antigen 125 (CA-125). Pathology results from exploratory laparotomy revealed stage III C adenocarcinoma of the ovary. This case demonstrates that PCD may be the presenting symptom of an occult malignancy. The pathogenesis, diagnosis, and treatment of PCD, and its rehabilitation implications, are reviewed.

Anti-Yo positive paraneoplastic cerebellar degeneration associated with ovarian carcinoma: case report and review of the literature

Paraneoplastic cerebellar degeneration (PCD) is a rare nonmetastatic neurological complication in cancer patients. Anti-Yo is one of the anti-onconeural antibodies found in PCD patients. It is believed that anti-Yo occurs almost always in women and is most likely associated with gynecologic or breast cancers, although exceptions exist. Here we report a PCD patient with ovarian cancer having high-titer anti-Yo. The acute onset of her PCD symptoms mimicked that of a stroke. Her ovarian cancer tissue contained abundant plasma cells and lymphocytes. After a thorough review of the literature, we propose a schematic hypothesis for the autoimmune pathogenesis of PCD. Despite anecdotal case reports of neurological improvement with different combinations of treatment, including IVIg, there is still no definitely effective treatment for PCD. Further research on the pathogenesis of PCD may lead to more effective therapies.

Anti-tumour therapy in paraneoplastic neurological disease

Paraneoplastic neurological syndromes have attracted attention in recent years. Detection of auto-antibodies directed against CNS and PNS structures have suggested an autoimmune etiology. This review is based on reports from the past 10 years and summarizes the therapeutic results in 258 patients suffering from paraneoplastic neurological disease including paraneoplastic encephalomyelitis, sensory neuronopathy, cerebellar degeneration, motor neurone disease and stiff man syndrome. The results show that in some entities such as Lambert-Eaton syndrome successful treatment can be expected. In other syndromes such as subacute sensory neuronopathy or paraneoplastic cerebellar degeneration therapeutic success varies from 5 to 10%.