Center IMT - Integrative Manual Therapy and Diagnostics

Significant Functional Gains Using Integrative Manual Therapy with a Patient Diagnosed with Cerebellar Ataxia and Peripheral Demyelination

Author: Susan J. Leger PT

Abstract: This article is about a 27 year old female diagnosed at age 5 with Cerebellar Ataxia, and further diagnosed at age 25 with peripheral nerve demyelination, who stood independently for the first time since age 3 after (15) hours of Integrative Manual Therapy (IMT). The patient walked with a rolling walker independently after 60 hours of IMT.

Key Words: Ataxia, Peripheral Nerve Demyelination, Functional Rehabilitation, NDT

Introduction: This 27 year old female was referred by the out patient physical therapy director at Sheppard Spinal Center (Atlanta, Georgia), where the patient had been receiving traditional physical therapy, with a Bobath (1,2) emphasis, routinely for many years.

Developmentally, this patient had walked at an appropriate age, however, her gait never improved past the new toddler stage. By age 3 she was unable to stand by herself, and within 2 more years she was given the diagnosis of Cerebellar Ataxia. She spent the rest of her life wheelchair bound. Two years ago her motor skills began to further diminish and her Neurologist from Emory gave her the additional diagnosis of peripheral nerve demyelination.

Evaluation: Her mother brought her for her evaluation. They had the following two goals for treatment: improve safety during sliding transfers (patient was unable to transfer safely and fell frequently); improve sitting balance in her electric wheelchair (patient was unable to maintain a safe erect posture consistently).

The evaluation revealed that the patient required moderate assistance for a sliding transfer to same height surfaces and maximum assistance if the surface heights were not equal. The patient was unable to lie supine due to severe vertigo and subsequent nausea and vomiting if placed horizontal. Bilateral eye nystamus was constant. Bilateral hand and finger movements resembled athetosis. Hips and feet locked in a windswept position to the right.

Treatment: The patient came for therapy averaging once a week for a three hour session for eight months, a total of 24 sessions. She received IMT for a descended sacrum, tethered spinal cord, descended brain stem, compression at the cranial base, improving circulation in the brain and neural tissue tension.

Structural techniques used included Muscle Energy and ‘Beyond’ Technique (3,4), Myofascial Release (5), Biologic Analogs (6,7), Cranial Therapy (8), Silent Dialoging (9), Advanced Strain and Counterstrain (10), Compression Syndromes (8,11), Advanced Neural Tissue Tension Techniques (12), Immune Deficiency Motility and Disruption of Membrane Technique (8,11), progressive resistance strengthening exercise program, foot orthoses, and Reflex Ambulation Therapy (10).

She also received functional rehabilitation of Neurodevelopmental Treatment (NDT) (1,2), motor coordination and control postural training on a ball and on a mat, along with gait training at the end of each three hour session. The parents were given one hour of homework to do with their daughter every other day that included Strain and Counterstrain (12), Synchronizers (6,7), Neurofascial Process (13), Reflex Ambulation Therapy (10), gait training, NDT ball therapy (1,2), and progressive resistive strengthening exercises.

Outcome: By the end of each three-hour session the following improvements were noted:

The patient was able to tolerate supine for 5 minutes without vertigo; she was able to sit with side and back support improved; nystagmus reduced; the patient was able to perform sliding transfers with standby assist only.
The patient was able to sit without side and back support with minimal assistance for 3 minutes; she was able to tolerate supine indefinitely without vertigo.
The patient was able to sit with side and back support erect and independent for 30 minutes; her nystagmus was nearly gone; she was able to tolerate supine with vertigo no longer an issue; sliding transfers were independent; she performed sit to stand with moderate assistance.
The patient was able to sit with side and back support erect and independent for two hours; she performed sit to stand independent (from hi/lo table at chair height to standing with no assist for one minute); she was able to perform stand to sit with moderate assist to unlock knees and lower.
The patient was also able to sit without side and back support with standby assistance for 15 minutes; she was able to perform sit to stand and stand to sit independent (lowering not fully controlled).
The patient was able to sit without side and back support without assistance for 10 minutes, and with standby assistance for 30 minutes; she was also able to perform sit to stand and stand to sit controlled and independent.
The patient was able to sit without side and back support without assistance for 30 minutes; the patient’s gait improved to maximum assistance with a rolling walker 15 feet.
The patient presented with improved gait where she required maximum assistance with a rolling walker and was able to ambulate 30 feet times 3; her standing endurance improved to 10 minutes at a counter, with pain in left hip her limiting factor.
The patient was able to ambulate with moderate assistance and rolling walker 30 feet times 3; she was able to stand at home up to 20 minutes in kitchen, with limiting factor of right hip pain.
The patient was able to ambulate with moderate assistance and rolling walker 50 feet; she reported that she was progressing in her daily walking program; the patient was standing at home up to 30 minutes in kitchen and at bathroom sink, with limiting factor low back pain.
The patient ambulated with moderate assistance and rolling walker 50 feet; she reported walking daily as home program; patient reported falling twice at home and confidence temporarily low; she was standing at home up to 30 minutes in kitchen and at bathroom sink, with limiting factor low back pain.
The patient was ambulating with minimum assistance and rolling walker 40 feet; she was still walking daily as home program; the patient reported standing at home up to 30 minutes in kitchen and at bathroom sink; she was cruising along cabinet to the left with minimal assistance and to the right with moderate assistance; patient was sitting without side and back support independent.
Patient was performing fully independent transfers from any typical heights to another; she was ambulating with minimal assistance and rolling walker 50 feet; she was walking daily as home program; the patient was standing at home up to 30 minutes in kitchen and at bathroom sink, with limiting factor right ankle pain.
The patient was ambulating with standby assistance on straight away, and moderate assistance for corners and doors, with rolling walker 100 feet; she was standing at home up to 30 minutes in kitchen and at bathroom sink, with limiting factor low back pain.
The patient was ambulating with standby assistance on straight away, and moderate assistance for corners and doors, with rolling walker 100 feet; she was standing at home up to 30 minutes at any stable surface to lean on; patient also reported cruising along furniture with minimal assistance to the right or the left.
The patient was ambulating with hands held in front 30 feet; she also ambulated with standby assistance on straight away, and minimal assistance for corners and doors, with rolling walker 100 feet.
The patient ambulated with standby assistance on straight away and for corners, and minimal assistance for opening doors, with rolling walker 100 feet.
The patient ambulated with left hand held to the side 15 feet; patient also ambulated on straight away with rolling walker independent for 30 feet, and minimal assistance for corners and doors, with rolling walker 100 feet.
Patient ambulated on straight away and corners with rolling walker independent for 70 feet, and minimal assistance for doors, with rolling walker 100 feet; curbs with rolling walker require maximum assistance.
The patient ambulated over curbs with rolling walker require moderate assistance; patient was able to stand and cruise home surfaces independently and painfree for up to 30 minutes.
Patient ambulated over curbs with rolling walker requiring minimum assistance.
Patient was able to ambulate over curbs with rolling walker and required standby assistance.
At this point, the patient moved out of state at this point and has not made further appointments.

Discussion: It is evident that the IMT program made a significant impact on this client’s level of function. The IMT was coupled with the functional progression of NDT and progressive resistive strengthening, however the functional approach alone had not proven to make any impact. In fact during the last two years this client was receiving consistent functional training at Sheppard Spinal Center from highly trained Physical Therapists; she was documented as regressing.

It is probable that the imperative diagnostics for this client was the descended complex, inferior brainstem entrapment, and the protections around the cerebellum. The focus on treating the breakdowns of self leading to the need for these protections was essential for allowing for the changes to occur.

It is probable that family support and home intervention played a significant role in this patient’s improvement. It is also probable that therapy blocked in three-hour intervals, allowed for continuity between IMT treatments, functional therapy and home training, and contributed to the therapeutic gains.

References

5. Weiselfish-Giammatteo, S. © 1998. Integrative Manual Therapy For The Upper and Lower Extremities, Introducing Synergic Pattern Release With Strain and Counterstrain Technique and Muscle Energy and ‘Beyond’ Techinique for the Peripheral Joints. Burkley, CA: North Atlantic Books

12. Weiselfish-Giammatteo, S. © 199?. Advanced Assessment and Treatment Of Neural Tissue Tension Techniques. Bloomfield, CT: Dialogues in Contemporary Rehabilitation

13. Weiselfish-Giammatteo, S. © 199?. Integrative Diagnostics In Applied Psychosynthesis. Bloomfield, CT: Dialogues in Contemporary Rehabilitation