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Cerebellar Ataxia - Case Study

An Incredible Journey

Maude Le Roux

Occupational Therapist

Abstract:

This report describes the case of a young boy with a medical diagnosis of cerebellar ataxia who progressed from needing a wheelchair to walking with hand held assistance after Tomatis training was added to a program of occupational and physical therapy. The boy had previously been discharged from an extensive therapy program for not making sufficient progress. The consultant concludes that adding Tomatis training to a two-hour program of occupational and physical therapy was responsible for the remarkable progress achieved.

Keywords: cerebellar ataxia, Tomatis Method, occupational therapy

Diagnosis:

Cerebellar ataxia refers to a condition of unsteadiness of gait. Causes of ataxia are varied. It may be caused, for example, by meningitis as in the case of SB.

SB has an unspecified diagnosis of either bacterial or viral meningitis. Bacterial meningitis is a serious infection of the fluid in the spinal cord and the fluid that surrounds the brain. It is most commonly caused by one of three types of bacteria: Haemophilus influenzae type b, Neisseria meningitidis, and Streptococcus pneumonia bacteria. Bacterial meningitis is considered more serious than viral meningitis as it can result in brain damage and even death. Viral meningitis is a relatively common but rarely serious infection affecting the fluid in the spinal cord and the fluid that surrounds the brain as well. Viral meningitis is caused by any of a number of different viruses, many of which are associated with other diseases. Mosquito-borne viruses can also cause viral meningitis. There is no specific treatment for viral meningitis, which is usually mild and clears up in a week.

Background Information:

SB is a young boy, born in 1994, who experienced an uncomplicated early childhood, played lacrosse, basketball and soccer. He contracted meningitis in September 2005, at the age of 10 years, 11 months. He was hospitalized from September 24, 2005 through October 4, 2005 and attended a rehabilitation center in Pennsylvania, USA, where he was diagnosed with resultant cerebellar ataxia. SB was treated as an outpatient from October 2005 through March 2006, when he transitioned to our program. After being discharged from the rehabilitation services (6 hours weekly including occupational therapy and physical therapy services) SB was seen for a joint occupational and physical therapy evaluation at our center, A Total Approach, on March 15, 2006.

Description of the Initial Evaluation:

At the time of the initial evaluation, SB was wearing a scopolamine patch for his consistent experience of vertigo/nausea. He required total assistance for toileting skills, though he was able to verbalize when he needed to go. He was being home schooled through his local school district and was wheelchair bound due to an unstable gait pattern with severe balance impediment. He experienced difficulty holding any utensils, handwriting, as well as manipulating any objects. His hands became shaky when contemplating fine motor tasks. SB used a 4-digit pattern loose grasp on a pencil, decreased web space, and decreased ulnar (one of the fore-arm bones) stabilization, using isolation at his elbow as a compensation for flexibility at his wrist and digits. He rubbed his eyes after visual tasks and experienced blurry vision after sustained reading. SB was unable to stand without support, walked with a two-hand assist or walker, fell easily, experienced difficulty throwing and catching, carrying objects, cutting, and pouring. He demonstrated poor trunk control overall and became fatigued quickly after motor output. SB was able to communicate very well, continued to maintain a number of friends, could control his frustration, was fully aware of social situations, and was generally in good humor. He was independent in upper body dressing, but required moderate assistance in lower body dressing. He showered while seated on a tub bench and needed help cutting and preparing his food.

Tomatis Consultant Impression:

Dr. Alfred Tomatis (1991) believed that the vestibular system, which was primarily affected in SB, is an integral part of the entire central nervous system. We also know from neuroscience (Castro et.al, 2002) that the auditory and vestibular system information is processed through the same cranial nerve, the vestibular-cochlear nerve, and is largely connected to the impact it has on the cerebellum. SB was struggling intensely to find a sense of balance, a sense of being “centered” and we needed to work on laterality through multiple systems, the integration of these systems being key to making a difference in his functional capacities.

Intervention:

SB completed three loops of Tomatis Training in combination with occupational and physical therapy exercises targeted specifically toward his unstable gait patterns, different gross motor transitions, such as sit-to-stand, four point kneeling, half kneeling, and also targeted toward the fine motor skills. Though some of the activities would have been standard practice procedures, similar to therapies that were completed prior at the rehab center, other activities were added that that would be considered to be more true of the field of Sensory Integration. In Sensory Integration we believe in working on all sensory systems together to create an effective adaptive response within the central nervous system. No active listening (filtered words) was completed during the first loop of 15 days, and it was decided to use a very gradual process of changing the precession and retard to be at about 5 and 50 on the last day. We started shifting the balance toward the right ear on the 8th day of his first loop. We introduced filters gradually from day five. After the first day in Tomatis training, SB commented to his mother that “his legs felt lighter”. After day three, he “seemed to have more energy and was able to walk 500 feet twice with his walker at home. By day five his mother commented that he appeared to have a “steadier gait”. After day 11, SB noted that he is now able to stop himself from falling, when he starts to fall. On day 12 the mother commented that Sam was now walking around the house independently without his walker. By the end of the 15 days, SB was not using the wheelchair anymore.

SB was in his first week of a four-week break period when we received a frantic call from his father. During the first loop we decided to leave on the vestibular patch as it was a medical intervention and we did not feel comfortable making this decision. Because SB was making so many tremendous changes, his parents decided to remove the patch at their own risk. SB seemed to have taken a turn for the worse and was unstable again, feeling very nauseated. We recommended that the family go to their physician and we gave them a therapeutic CD of modulated music of Mozart, a system designed by occupational therapist Sheila Frick (Hall and Case-Smith, 2007). Within two days, SB was back on track and without his vestibular patch, needing no more of this medical support, and only reported this to their doctor at a follow up visit after completing Tomatis training.

During the second loop (eight days), we focused more on the lower frequencies with smaller bursts into the higher frequencies and used the same gradual process on precession and retard, although we started to work more vigorously on laterality on day three. SB’s profile continued to gradually progress; he started walking more independently on outside unstable surfaces without his walker. His reading (introduced on the third day) actively over the microphone also improved steadily with each day.

By loop three (another eight days), the focus was completely shifted to walking. SB’s gait pattern was irregular and he required handheld assist to walk without his walker. His stability and fluidity were improving steadily day after day. We used higher frequencies more vigorously during this loop and, by the end of the loop, SB was walking with handheld assist over unstable surfaces inside and outside buildings.

Results of the Tomatis Listening Test:

SB’s Tomatis Listening Test (TLT) taken before the first loop of Tomatis training indicated a superimposed bone conduction pattern in his left ear, with an underactive air conduction curve. A similar pattern was observed in his right ear with the exception of a mingling of the two curves around 1500 Hz. SB was hearing “ringing” in his right ear and exhibited several spatialization errors in his right ear. His TLT upon returning for his second loop showed the air conduction on both left and right ear to now superimpose the bone conduction in the lower frequencies, with intermingling in the mid frequencies. Bone conduction continued to superimpose in the higher frequencies. No more spatialization errors were noted. Post testing after completion of his third loop, indicated intermingling of the air and bone conduction curves in both his left and right ears, although there was still some superimposing of the bone over the air curve in the very high frequencies. The ringing in his ears was “more silent” in his right ear by the end of the third loop and SB did not complain of ringing in his right ear again.

The functional results of the Tomatis program have been reported above. The success of the more natural air conduction curves in both ears in the lower and mid frequencies correlated very well with the motor changes we have observed during his treatment period.

Conclusion:

SB came to Tomatis training after having undergone much intensive therapy based on a diagnosis of cerebellar ataxia. He arrived with a very unstable gait pattern, needing a wheelchair, and only walking with a walker when supervised. At the time, SB had very little sense of laterality and his position related to center of gravity; he wore a vestibular patch to prevent nausea. When he exited our program after three loops of Tomatis training, he was walking with hand held assistance and with no need for the wheelchair. SB played Lacrosse before the onset of his illness and one of his goals was to be able to string the head of his lacrosse stick again, which he was able to do, though still at slow speed. He was eating and writing with utensils and he did not experience the blurriness of vision during reading at this time. Since SB had experienced multiple occupational and physical therapies intensively on a daily basis prior to coming to our center, we have to conclude that what made the real difference in this young man’s life was the Tomatis program.

Our results with SB support Tomatis’s belief that the vestibular system is integral to the functioning of the central nervous system (Sollier, P, 2005). Given that these results demonstrate the robustness of the Tomatis Method of sound stimulation as a means of strengthening balance and coordination in the context of a complex condition such as cerebellar ataxia, we recommend that Tomatis training be added to the traditional treatment options for this condition.

References:

Tomatis, Alfred A, (1991), The Conscious Ear, New York, Station Hill Press, Inc.

Sollier, P, (2005), Listening For Wellness, California, The Mozart Center Press.

Perlman, SL (2000) Cerebellar Ataxia. Current Treatment Options in Neurology 2 (3) 215-224.

Hall L. & Case-Smith, J. (2007). The effect of sound-based intervention on children with sensory processing disorders and visual-motor delays. American Journal of Occupational Therapy, 61 (2), 209-215. (This study was completed on the Therapeutic Listening Program, designed by Sheila M. Frick, OTR. It was one of her CD’s that were used during the first 4 week break from Tomatis training. More information on her work can be obtained at www.vitallinks.net )

Castro, A, PhD, Merchut, M, MD, FACP, Neafsey, E, PhD, Wurster, Robert, PhD (2002), Neuroscience, An Outline Approach, Missouri, Mosby Press.

Author:

Maude Le Roux is an occupational therapist who directs and owns a pediatric private practice in Glen Mills, PA in the USA.  – July 2007

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