Developing an Instrumented Measure of Upper Limb Function in Friedreich Ataxia

Upper limb function for people with Friedreich ataxia determines capacity to participate in daily activities. Current upper limb measures available do not fully capture impairments related to Friedreich ataxia. We have developed an objective measure, the Ataxia Instrumented Measure-Spoon (AIM-S), which consists of a spoon equipped with a BioKin wireless motion capture device, and algorithms that analyse these signals, to measure ataxia of the upper limb during the pre-oral phase of eating. The aim of this study was to evaluate the AIM-S as a sensitive and functionally relevant clinical outcome for use in clinical trials. A prospective longitudinal study evaluated the capacity of the AIM-S to detect change in upper limb function over 48 weeks. Friedreich ataxia clinical severity, performance on the Nine-Hole Peg Test and Box and Block Test and responses to a purpose-designed questionnaire regarding acceptability of AIM-S were recorded. Forty individuals with Friedreich ataxia and 20 control participants completed the baseline assessment. Thirty individuals with Friedreich ataxia completed the second assessment. The sensitivity of the AIM-S to detect deterioration in upper limb function was greater than other measures. Patient-reported outcomes indicated the AIM-S reflected a daily activity and was more enjoyable to complete than other assessments. The AIM-S is a more accurate, less variable measure of upper limb function in Friedreich ataxia than existing measures. The AIM-S is perceived by individuals with Friedreich ataxia to be related to everyday life and will permit individuals who are non-ambulant to be included in future clinical trials.

The role of robotic gait training and tDCS in Friedrich ataxia rehabilitation: A case report

RATIONALE

Friedrich ataxia (FA) is the most common inherited neurodegenerative cerebellar ataxic syndrome. In patients with FA, physiotherapy is highly recommended to improve motor function outcome. Cerebellar transcranial direct current stimulation (tDCS) has been demonstrated to be effective in improving symptoms by modulating cerebellar excitability. Recently, robotic rehabilitation with Lokomat-Pro has been used to treat motor impairment in ataxic syndromes by "modulating" cortical plasticity and cerebello-motor connectivity.

PATIENT CONCERNS

A 29-year-old Italian male with FA, come to our Institute to undergo intensive rehabilitation training. He presented a moderate-to-severe spastic tetraparesis, brisk deep tendon reflexes, moderate dysarthria, occasional difficulty in speaking, and mild delay in swallowing. He was able to stand for at least 10 seconds in the natural position with constant support, and thus he used a wheelchair.

DIAGNOSIS

Tetraparesis in a young patient with FA.

INTERVENTIONS

The effects of a stand-alone robotic gait training with Lokomat-Pro preceded by cerebellar anodal tDCS (a-tDCS) versus Lokomat-Pro preceded by cathodal-tDCS (c-tDCS) are compared.

OUTCOMES

The coupled approach (i.e., tDCS and Lokomat) demonstrated better improvement in functional motor outcomes on the Scale for the Assessment and Rating of Ataxia (SARA).

LESSONS

Although only a single case is described, we found that the combined neuromodulation-neurorobotic approach could become a promising tool in the rehabilitation of cerebellar ataxias, possibly by shaping cerebello-cerebral plasticity and connectivity.

Retrospective study of the effects of inpatient rehabilitation on improving and maintaining functional independence in people with Friedreich ataxia

OBJECTIVES

To determine the effects of inpatient intervention for people with Friedreich ataxia (FRDA), and to identify whether improvements gained were sustained postdischarge.

DESIGN

This retrospective observational cohort study comprised people with FRDA admitted to inpatient rehabilitation.

SETTING

All participants in the study were referred by a specialist multidisciplinary FRDA clinic to inpatient rehabilitation.

PARTICIPANTS

From 2003 until 2010, people (N=29; men, n=17; women, n=12) with FRDA were admitted to rehabilitation, representing 42 admissions. On admission, 9 participants were ambulant and 33 participants were nonambulant.

INTERVENTIONS

Each participant was prescribed goal-related therapy on an individual basis by the multidisciplinary team, and this consisted of a range of treatment approaches.

MAIN OUTCOME MEASURE

The FIM was used to determine the efficacy of inpatient rehabilitation.

RESULTS

Consistent with the progressive nature of the condition, FIM scores, as measured on an annual basis preintervention, declined over time. However, FIM scores increased by a mean of 8.5 points during periods of inpatient rehabilitation and continued to increase by a mean of 2.0 points during the period immediately after rehabilitation. Results demonstrate these increases during and immediately after inpatient rehabilitation were significant (P<.001).

CONCLUSIONS

To the best of our knowledge, this study provides the first evidence that a period of inpatient rehabilitation reverses or halts the downward decline in function for people with FRDA. The benefits from this intervention continued during the period immediately after inpatient rehabilitation, indicating that these gains are more than just short-term achievements. Further exploration of intensity, type, and length of rehabilitation is required to ensure that the most appropriate rehabilitation is provided.

Articulatory kinematics in the dysarthria associated with Friedreich's ataxia

Electromagnetic articulography (EMA) was used to investigate the tongue kinematics in the dysarthria associated with Friedreich's ataxia (FRDA). The subject group consisted of four individuals diagnosed with FRDA. Five nonneurologically impaired individuals, matched for age and gender, served as controls. Each participant was assessed using the AG-200 EMA system during six repetitions of the tongue tip sentence Tess told Dan to stay fit and the tongue back sentence Karl got a croaking frog. Results revealed reduced speed measures (i.e., maximum acceleration / deceleration / velocity), greater movement durations and increased articulatory distances for the approach phases of consonant productions. The approach phase, involving movement up to the palate, was more affected than the release phase. It is suggested that deviant lingual kinematics could be the outcome of disturbances to cerebellar function, or possibly in combination with disturbances to upper motor neuron systems.

[Disability and occupational therapy in patients with Friedreich's ataxia]

Friedreich ataxia (FA) is a neurodegenerative disease characterized by a progressive course resulting in severe disability. The occupational therapy (OT) is aimed to facilitate task performance by improving relevant performing skills or developing and teaching compensatory strategies to overcome lost performances. This study was aimed to investigate the role of OT in FA subjects carried out with sequential treatments performed during a scheduled time period. Neurological deficits, physical performances, and quality of life were evaluated with appropriate outcome measures in 10 subjects with FA who underwent three different in-hospital rehabilitation periods in one year. The baseline evaluation was performed at the beginning of the rehabilitation treatment and the final one at the end. The observed long-lasting stability of the neurological deficits and the increased functional independence of FA subjects may be considered a remarkable outcome indicating that sequential OT treatments may contribute to limit the progression of disability and maintain the participation in the everyday activities. OT and neuromotor rehabilitation may contribute to recover common abilities of FA patients representing the correct approach to the management of the disease.

Evaluation of neuropsychological functions in patients with Friedreich ataxia before and after cognitive therapy

Friedreich ataxia (FA) is a neurodegenerative disease characterized by progressive nervous system damage resulting in severe disability. Cognitive functions and mood disorders in FA have been studied little and with conflicting results. The aim of this study was to investigate cognitive functions and mood disorders in FA subjects and the role of cognitive rehabilitation therapy (sequential treatments) performed during a scheduled study period. The executive functions of 24 subjects with FA were evaluated over one year during three separate periods of in-hospital rehabilitation. The neuropsychological evaluations performed before and after cognitive therapy did not reveal differences in the mean test scores of the MMSE, the Rey 15-item Memorization Test for long-term memory, Raven's Colored Progressive Matrices, the Phonemic Verbal Fluency Test, the Symbol Digit Modalities Test, or the Zung scale. The mean scores of the Stroop color-word interference task and of the Rey 15-item Memorization Test for short-term memory were increased at the final evaluation. This finding of long-lasting stability of neuropsychological test scores is noteworthy, as it suggests that one-year cognitive rehabilitation therapy (sequential treatments) may at least contribute to reducing cognitive decline. A cognitive rehabilitation therapy in addition to the conventional neuromotor rehabilitation treatment may improve the management of subjects with FA.

Orthopedic shoes improve gait in Friedreich's ataxia: a clinical and quantified case study

Our aim was to evaluate with modern tools the efficacy of orthopedic shoes on gait disorders in Friedreich's ataxia. The case of a 26-year-old woman with Friedreich's ataxia is described. She mainly complained of fatigability, ankle instability, frequent falls and pain. Impairments involved a cerebellar syndrome, a proprioceptive deficit, an upper motor neurone syndrome and osteoarticular deformities. Gait disabilities included ataxia and requirement of a cane. Handicap concerned outings, altering quality of life. Orthopedic shoes combined with physical therapy were prescribed. Assessment of treatment was planned after one month. Self-assessment by the patient was noted. Clinical assessment was provided by physical examination and clinical gait analysis supported by video. Quantified assessment was performed with a Gaitrite system recording spatiotemporal gait parameters. Our results demonstrated that orthopedic shoes improved gait disorders in this patient with Friedreich's ataxia. Pain decreased, walking distance increased, falls were less frequent, going out became possible, stability was better, speed, step length and cadence increased. Both clinical and quantified assessment confirmed functional improvement felt by the patient. In conclusion complete medical and social assessment determines quality of prescription in physical and rehabilitation medicine.

Presentation and progression of Friedreich ataxia and implications for physical therapist examination

Friedreich ataxia, although rare, is the most prevalent inherited ataxia. Recent insight into the disease pathogenesis is creating new hope for effective therapies. The purposes of this update are: (1) to review the etiology, presentation, and progression of Friedreich ataxia and (2) to describe a comprehensive physical therapist examination emphasizing valid and reliable performance measurements associated with disease progression. Early identification of individuals with Friedreich ataxia and precise characterization of impairments and functional limitations gain importance as new drug therapies are considered.

[Diagnosis of a Friedreich's ataxia: contribution of electrophysical explorations]

The monitoring of scoliosis treatment can lead to discover its cause.

CASE REPORT

A 16-year-old patient was allowed in Center of Functional Rehabilitation for intensive orthopaedic treatment of a severe scoliosis. Electrophysiological explorations carried out within the framework of the monitoring of this treatment detected an axonal neuropathy with sensitive prevalence, whose association with clinical signs made it possible to diagnose Friedreich's disease, then confirmed by molecular biology.

CONCLUSION

Electrophysiological examination is useful in a Rehabilitation Center within the framework of the monitoring of the treatment proposed, more especially as it can make it possible to direct a diagnosis.

Rehabilitation management of Friedreich ataxia: lower extremity force-control variability and gait performance

We describe the rehabilitation management during a 12-month period of a 14-year-old female with Friedreich ataxia. Interventions included task-oriented bimanual reaching activities, functional strengthening, and gait training using a walker featuring tension-controlled wheels and a reverse-braking system. Her physical status was assessed with the Nine-Hole Peg Test, single limb stance time, manual muscle testing, self-reported falls, isometric force control testing, and 3-dimensional gait analysis in a motion-capture laboratory. Although measures of the patient's Nine-Hole Peg Test, single limb stance time, and manual muscle testing reflected minimal changes, her gait speed decreased by 69.4%. However, the force-control targeting of her dominant knee extensors showed a 43.7% increase in force variability that was concomitant with her decline in gait performance. The decrement of her initial gait speed was reduced to 42.9% on replacing the wheeled walker with the U-Step Walking Stabilizer at the end of the intervention period. Although the patient's gait remained significantly impaired, extended use of the U-Step Walking Stabilizer modestly improved her gait performance, and her rate of falls decreased from 10 to 3 per month. Our observations suggest that use of force-control testing as proxy measures of ataxia and tension-controlled gait aids show promise in the management of Friedreich ataxia and merit further investigation.

Endurance exercise training in Friedreich ataxia

The purpose of this case study was to determine whether a patient with Friedreich ataxia (FA) would experience a clinically significant physiologic adaptation to aerobic endurance training. A 38-year-old man with FA underwent graded exercise testing with collection of expired gases on a bicycle ergometer before and after training, to determine maximum work capacity and oxygen consumption. Training consisted of 27 electrocardiographically monitored exercise sessions on the ergometer, each for 20 to 25 minutes at a workload adjusted to achieve an exercising heart rate equal to 70% to 85% of his pretest maximum, preceded and followed by a stretching routine. Large increases in cardiorespiratory and work measures demonstrated clinically important physiologic adaptations to aerobic conditioning in this patient. Peak VO2 increased 27% and peak ventilation increased 21%. Total exercise time increased five minutes, reflecting a 50-watt increase in maximum workload. In addition, the patient experienced a 4.75-kg weight loss. A medically supervised endurance training program can increase aerobic work capacity and promote weight loss in patients with FA who can pedal a bicycle at training level intensities.