Enhancing Balance and Coordination in Alcohol-Induced Cerebellar Ataxia: A Case Study

Introduction

Alcohol-induced cerebellar ataxia (ACA) is one of the most common types of acquired ataxias.¹ Acute effects of alcohol include gait instability, antero-posterior oscillations in Romberg’s test and dysarthria in various degrees. Two synaptic locations are most vulnerable to the acute effects of alcohol: the synapses on granule cells (GCs) and on Purkinje cells (PCs), which represent the cerebellar cortical output.² Chronic alcohol con-sumption leads to alcohol dependency, which causes cerebellar degeneration. The disease generally evolves over weeks or months, but it may also occur abruptly. However, a study showed that daily consumption of 150 g of alcohol for 10 years was associated with significant cerebellar atrophy on CT scan in 30% of patients.³

Gait and postural instability are hallmark cerebellar symptoms associated with chronic alcoholism. Characteristic gait disturbances include pronounced swaying, irregular steps, a compensatory short stride, broad-based stance, and reduced walking speed. Lower limb ataxia is frequently evident, particularly during heel-to-shin testing. In more advanced stages, patients may also exhibit upper limb ataxia and dysarthria. Gait impairment may gradually worsen over weeks to months or rapidly progress to a disabling stage, especially in cases involving malnutrition.⁴ The aim of physiotherapy in alcohol induced cerebellar ataxia is to alleviate the symptoms and explore the maximum functional capacity of patient. This case report is focused on exercise- based physiotherapy intervention in a patient with ACA.

Case Study

A 35-year-old male was admitted to the psychiatry ward with chief complaints of difficulty in walking and mood disturbances for several months. He had a history of alcohol use for about 10 years. Although he had undergone de-addiction treatment in the past, he resumed consuming alcohol after a period of recovery. Eight months ago, he was diagnosed with cerebellar ataxia secondary to cerebellar atrophy, along with alcohol dependence syndrome (ADS). He was re-admitted due to an increase in symptoms. The patient was referred for physiotherapy in view of gait imbalances. Prior to inclusion, written consent was obtained from the patient. Physiotherapy intervention was administered for a total of two weeks. He had been abstinent for the two weeks preceding the intervention.

Clinical findings

On examination, patient was conscious, cooperative and well oriented to time, place and person. He was moderately built and poorly nourished. Higher mental functions were evaluated using Montreal Cognitive Assessment (MoCA) scale which showed moderate cognitive impairment. Speech was scanning in nature. Tone was normal in all the extremities and reflexes were found diminished at knee and ankle bilaterally. The muscle power of major muscle groups in both the upper and lower limbs was 4 out of 5, as measured using the Medical Research Council (MRC) grading system. Sensations were intact and balance was observed to be good in sitting but severely impaired in standing. Berg Balance Scale was used to further assess the balance. Coordination was observed to be severely impaired. Right upper extremity was more affected than left. He performed the non-equilibrium tests with great difficulty and was unable to do equilibrium tests without support. The Comprehensive Coordination Scale (CCS) was used to assess coordination, in which he scored 51 out of 69. Romberg test and sharpened Romberg tests were positive. Dysdiadokokinesia was also noted. Gait analysis demonstrated lower limb ataxia, reduced gait speed, swaying to left side and a wide base of support. Patient was unable to walk independently and required at least one person’s support. Functionally, the patient was moderately dependent in performing activities of daily living (ADL) tasks.

Diagnostic assessment

The diagnosis of cerebellar ataxia secondary to cere-bellar atrophy and alcohol dependency syndrome was made by a registered medical practitioner. The alcohol dependency was confirmed using AUDIT questionnaire which is a valid and reliable tool developed by WHO to measure the level of alcohol consumption.⁵ The patient scored 24 out of 40 which indicates Alcohol Use Disorder (AUD).

Magnetic resonance imaging (MRI) of the brain sugg-ested mild prominence of sulcal spaces, basal cistern and ventricles. Diffuse cerebral atrophy and diffuse cerebellar involvement were seen and paleocerebellum was more involved than neocerebellum. Calcifications were seen in bilateral parietal lobes. Nerve conduction studies conducted to rule out other pathologies suggested normal conduction in both motor and sensory nerves of lower extremities.

Balance, coordination and gait were assessed using Berg Balance Scale (BBS), Comprehensive Coordination Scale (CCS) and Scale for Assessment and Rating of Ataxia (SARA), respectively. The patient scored 13 out of 56 on BBS, 51 out of 69 on CCS and 19 out of 40 on SARA when assessed before intervention.

The intervention included patient and family education, medical management and physiotherapy management. Pharmacologically, the patient received oral thiamine, lorazepam and baclofen. Counselling was provided for de-addiction. Physiotherapy intervention focused on improving balance, coordination and gait. The following activities were prescribed to the patient and progressively advanced based on the patient’s response.

Coordination exercises

Frenkel’s exercises were performed in supine position for lower extremities. Heel-to-shin and shin-to-toe exercises were performed on both limbs. In bedside sitting, rhythmic and alternate tapping of the hands and feet was performed with verbal and visual cues from the therapist. The activities were progressively increased in complexity and speed.

Balance exercises

In the sitting position, trunk movements were facilitated in all directions, followed by trunk rotations. Progression was made by performing the movements with eyes closed and reducing base of support (BOS) by taking feet together and crossing the arms. Perturbation training was given in all directions and was progressed from eyes open to eyes closed. Sit to stand training was given initially with hand support and later without support. Standing without support was encouraged and timings were noted. Progression was done from wide base to narrow base with feet together. Tandem stance was performed from wide base to narrow base with minimal support and verbal cueing. Marching in place was done with two hand support initially, and then progressed to one hand support. Star excursion activity was performed in the second week of intervention.

Gait training

Forward walking was practiced within the ward with the support of one person. The base of support was gradually reduced by having the patient walk in a straight line. Progression was made by increasing the speed of walking. Assistance was reduced slowly and gradually. Backward walking and sideways walking were performed. An obstacle course was set up by placing objects on the floor, and the patient was instru-cted to navigate through it without falling.

All the exercises were performed for a total of 35-40 minutes twice daily, once under the supervision of a therapist and another under the supervision of a family member. The patient and family were counseled for a home exercise program.

The outcome measures employed to evaluate the prog-ress were Berg Balance Scale (BBS), Comprehensive Coordination Scale (CCS) and Scale for Assessment and Rating of Ataxia (SARA). The measurements were recorded pre-intervention and post two weeks.

Over the period of two weeks, patient showed impro-vement in the walking ability and ability to perform ADL. Balance during standing and walking showed notable improvement. On the BBS, the patient initially scored 13 (indicating a high fall risk), which improved to 28 (indicating a medium fall risk), out of a total score of 56. Coordination was assessed using the CCS, where the patient’s score improved from 51 to 60, out of a total of 69 over a period of two weeks. Gait impairment was evaluated using the SARA, where the score improved from 19 to 14 out of 40, indicating a reduction in ataxia (Table 1).

The goal of physiotherapy was to improve the walking capacity and facilitate functional independency. In the present case, physiotherapy exercises for two weeks enabled the patient diagnosed with alcohol induced cerebellar ataxia to improve balance, coordination and gait, thereby improving the activities performed in daily living. A systematic review and meta- analysis conducted in 2023 concluded that therapeutic exercises are beneficial in improving balance among patients with acquired cerebellar ataxia but do not significantly enhance functional independence.⁶ It was also observed that there is only low to moderate level of evidence available for this intervention. Elshafey MA et al., conducted a randomized controlled trial on 40 children affected with cerebellar ataxia in which intervention group received core stability program in addition to the standard physical therapy program.⁷ The study concluded that the intervention group showed significant improvements in ataxia severity, balance, and coordination compared to the control group.

The patient in the present case was encouraged to perform exercises with family supervision. Research demonstrates that home balance exercise program for six weeks proved to be beneficial in improving locomotor functions in people with cerebellar ataxia.⁸ Another study was conducted to evaluate the long-term benefits of coordination training in degenerative cerebellar disease. They assessed motor performance and ADLs one year after four weeks of intensive coordination training. The results demonstrated that, despite a gradual decline in motor performance and an increase in ataxia symptoms, the improvements in motor performance persisted.⁹

Exercises have shown to improve motor functions through adaptive plasticity and cortical reorganization. A systematic review reported that exercises help in improving cerebellar dysfunction in adults, through the mechanism of neuroplasticity.¹⁰ Neuroplasticity occurs with an increase in the production of neurotrophins that generate changes in cell growth and signaling. The main neurotrophins involved in the process are glial cell derived neurotrophic factor (GDNF), nerve growth factor (NGF), neurotrophin 3 (NT3), neurotrophin 4 (NT4) and brain-derived neurotrophic factor (BDNF). Physical exercises have shown to increase the production of these neurotrophic factors leading to an improvement in motor as well as cognitive functions.¹¹

Clinical implications

The findings of this study suggest that targeted physical therapy interventions, including coordination, balance, and gait training exercises, can provide measurable improvements in patients with cerebellar ataxia. A randomized controlled trial explored the benefits of specific coordination exercises on cerebellar ataxia.¹² The study found that exercises like finger tapping, heel-to-shin tasks, and alternating hand movements improved motor control and coordination. These exercises engage both the motor cortex and cerebellar regions of the brain, helping to retrain impaired pathways. Evidence reports that balance training utilizing both static and dynamic postural tasks significantly improved balance and reduced fall risk in individuals with cerebellar ataxia.¹³ Training typically includes tasks such as standing on one leg, heel-to-toe walking, and use of stability balls or balance boards. Targeted rehabilitation is effective in reducing fall risk and improving daily activities which is commonly associated with cerebellar ataxia.¹⁴

The intervention successfully improved the intended parameters but had a few limitations. The long-term effects of the exercises could not be evaluated, and patient compliance was poor initially. However, adherence improved overtime after multiple sessions of counseling. The effect of poor compliance might have altered the overall outcomes. Future studies with long term follow-up can be performed to determine the carry over effects of exercise on cerebellar ataxia.

Conclusion

This case report suggests that exercise-based physiotherapy interventions can be beneficial in improving balance, coordination, and gait impairment associated with ACA.

Conflict of Interest

Nil