 The evaluation of tremor and ataxia in rehabilitation should include a description of the clinical signs, an assessment of the severity of the problem as well as the impact of these symptoms on the daily functioning of the person with MS with regard to personal care, domestic activities and participation in the community.
While quantitative measures are important in the evaluation of therapies for tremor and ataxia in MS, a statistically significant change on a measure is not necessarily clinically significant, nor meaningful for the individual. For example, on a scale of improvement for tremor there may be a statistical improvement but this may not be compatible with the person’s subjective experience. For this reason, it is important to assess the impact of tremor and ataxia on daily functioning.
 Studies on the efficacy of neurorehabilitation (or physiotherapy) in ataxia and tremor are limited. Most studies have included relatively small numbers of subjects with various methodological designs. The Cochrane Collaboration (see right) conducted a review of therapies for ataxia and tremor in MS that included pharmacological and non-pharmacological treatments. The review included three comparative studies on neurorehabilitation. No standardised outcome measures were used across the studies.
Although some did show promising results, the authors reported that there is not enough evidence to suggest that rehabilitation provides sustained improvement in ataxia or tremor.
The Cochrane Library is a collection of databases that contain high-quality, independent evidence to inform healthcare decision-making. Cochrane reviews represent the highest level of evidence on which to base clinical treatment decisions. In addition to Cochrane reviews, The Cochrane Library provides other sources of reliable information, from other systematic review abstracts, technology assessments, economic evaluations and individual clinical trials – all the current evidence in one single environment.
www.cochrane.org |
While physiotherapy for tremor and ataxia can be associated with short-term gains that are difficult to maintain over time, there are components of rehabilitation that can help. The techniques described here can be useful for some people, but do not resolve tremor or ataxia completely. The aim is that the symptoms are more under control, thus, improving functioning to varying degrees.
Activities of daily living
Goal setting in rehabilitation of more severe tremor and ataxia symptoms may focus on the basic activities of daily living (ADLs) consisting of these self-care tasks:
● Bathing
● Dressing and undressing
● Eating
● Transferring from bed to chair, and back
● Continence
● Using the toilet
● Walking (not confined to a bed)
Instrumental activities of daily living are not necessary for fundamental functioning, but enable the individual to live independently within a community:
● Light housework
● Preparing meals
● Taking medications
● Shopping for groceries or clothes
● Using the telephone
● Managing money
Occupational therapists also evaluate other areas of ADLs when completing patient assessments. These include 10 areas of ADLs that are generally optional in nature, and can be evaluated by various other rehabilitation or healthcare professionals:
●Care of others (including selecting and supervising caregivers)
● Care of pets
● Child rearing
● Communication device use (for example a computer)
● Community mobility
● Financial management
● Health management and maintenance
● Meal preparation and cleanup
● Safety procedures and emergency responses
● Shopping |
Immobilisation uses splints and braces across a joint to stabilise it in one position. This reduces the random movement caused by tremor. Positioning of the brace depends on the action that needs to be performed. A brace can be used at the ankle or foot to provide stability in standing, or applied to the wrist, hand or arm for eating, writing and other similar tasks. Immobilisation can also be achieved by using the arm to brace the affected limb during the tremor or to hold an affected arm close to the body which can sometimes be useful to gain motion control.
Orthoses made using a Lycra™-based stretch fabric to achieve a close fit have also been suggested as helpful in some cases. Although there is no specific evidence from MS clinical trials, it is believed that the close fit gives increased pressure on certain muscle groups and improves proprioception leading to better awareness of the affected part of the body.
However, a controlled trial is required.
Weighting is based on the theory that more muscles will be used to stabilise a distant point in the body, such as the hands, when a heavier object is involved. The limb itself, or the object being used, can be weighted (some people find either weighting the limb or the object works better for them). Items such as weighted eating utensils, cups and writing instruments are available commercially. Hands-free or voice-activated devices are also available.
Adaptive equipment or assistive devices can be used in the home or workplace to make performing many activities easier and safer. Examples include large handles on doors and cooking utensils, zippers rather than buttons on clothing and non-slip pads under plates. The purpose of these aids and modifications is to help the person to continue performing activities that he or she likes or needs to perform as independently as possible.
Goal setting
Goals in rehabilitation should be person-specific and focused on the activities of daily life (ADLs – see left). The rehabilitation team must assess, together with the individual and their family, the sorts of activities the individual performs or would like to perform throughout the day.
Most often, these activities involve personal hygiene, eating, communicating, for example using a keyboard, taking care of the household, moving about and carrying objects, and participation in some leisure pursuit.
The rehabilitation team must understand from the person what the priorities are and ensure that goals are realistic and attainable. Goals should be clearly defined, measurable, realistic in the therapist’s view and meaningful for the person.
|
