Óscar Diez Meleiro

1. Intentional
tremor
in the ataxic hand
Exposition of a real case.
Handfun Meeting 2013. Óscar Díez Meleiro.

2. What is ataxia?
• Disturbance in voluntary movement
• Muscles contrain irregularity and weakly.
• Intentional tremor, Coordination Impairment, disdiacocinesia,
dismetria, occular tremor.
• Discontinued movement
(1)(2)
Handfun Meeting 2013. Óscar Díez Meleiro.

3. How does the cerebellum
work?
Handfun Meeting 2013. Óscar Díez Meleiro.
Cerebellum
Cortex
Muscles,
tendons,
joints
Vestibular
nerve
Vision
Motor
Plan
Periphery
State
Normal
movement

4. What is intentional tremor?
• Rhythmical and oscillanting movement.
• Appears with actions.
• Two components: Nervous and mechanical.
(3)(4)(5)
Handfun Meeting 2013. Óscar Díez Meleiro.

5. PRESENTATION AND
TREATMENT OF A REAL CASE
Handfun Meeting 2013. Óscar Díez Meleiro.

6. Handfun Meeting 2013. Óscar Díez Meleiro.

7. Objective Measurements
Handfun Meeting 2013. Óscar Díez Meleiro.

8. Objective Measurements
• Spiral test
• Fugl-Meyer Scale
(Upper Extremity
Motor) :46/66
Handfun Meeting 2013. Óscar Díez Meleiro.

9. Handfun Meeting 2013. Óscar Díez Meleiro.
Main functional goal
Fill a glass of water and drink it. Spilling as little as
possible.
Why can’t the patient achieve this goal? Intentional
tremor
-Which are the worst enemies of intentional tremor?
Proximal stability and upper limb propioception.

10. Handfun Meeting 2013. Óscar Díez Meleiro.
Intentional
tremor
Not using of
Right Upper
Limb
Atrophy.
Proximal
hypotonia
Perceptive
deficiency

11. PHYSICAL TREATMENT
Handfun Meeting 2013. Óscar Díez Meleiro.

12. Eliminate cervical and
thoracic movement
dysfunctions
• Subjective vertical visual
line.
• Eyes-Head-Trunk
coordination.
• Decrease in nervous tension
(7)(8)(9)(10)
Handfun Meeting 2013. Óscar Díez Meleiro.

13. VISUAL TREATMENT
Handfun Meeting 2013. Óscar Díez Meleiro.

14. Activation of the right
scapular muscles with
function
Handfun Meeting 2013. Óscar Díez Meleiro.
• Increase Proximal
Stability.
• Decrease Mechanic
Component.
• Safety.
• Bimanual Coordination
(synchronization)

15. Handfun Meeting 2013. Óscar Díez Meleiro.

16. Handfun Meeting 2013. Óscar Díez Meleiro.
Bimanual coordination
Point a finger at

17. Handfun Meeting 2013. Óscar Díez Meleiro.
Grip and proximal stability

18. Handfun Meeting 2013. Óscar Díez Meleiro.
(11)(12)(13)(14)(15)

19. CHOR Contactual Hand-
Orientating Response
The CHOR facilitates:
• Midline orientation.
• ’Light touch contact’ as balance aid.
• Limp support and limb loading.
• Postural stabilisation for selective movement.
• Distal input improves proximal stability
(16)
Handfun Meeting 2013. Óscar Díez Meleiro.

20. CHOR
Handfun Meeting 2013. Óscar Díez Meleiro.

21. CHOR (16)(17)(18)(19)
Handfun Meeting 2013. Óscar Díez Meleiro.

22. Motor Re-learning
• Repeat without
repetition
• Imagining
• Active
participation
• Postural Control
• Memory
(20)(21)(22)(23)(24)
Handfun Meeting 2013. Óscar Díez Meleiro.

23. Results
Handfun Meeting 2013. Óscar Díez Meleiro.

24. Results
• Fugl-Meyer Scale
(Upper Extremity
Motor) : 55/66
Handfun Meeting 2013. Óscar Díez Meleiro.

25. Bibliography
Handfun Meeting 2013. Óscar Díez Meleiro.
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Disorder Society on Tremor. Ad Hoc Scientific Committee. Mov Disord;13
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University Press, pp 37-84. En: Fahn S, Jankovic J (Eds). (2007). Principles
and practice of Movement Disorders. Churchill Livingston Elsevier.

26. Handfun Meeting 2013. Óscar Díez Meleiro.
5. Deuschland G. Bergman H. Pathophysiology of Nonparkinsonian Tremors.
Movement Disorders.2002.17, Suppl. 3. p S41–S48
6. Shumway –Cook, A. Woollacoott, Mh. Normal reach, grasp and manipulation
(Cap. 16). Motor Control. Translating research into clinical practice. Theory and
practical applications. Lippincott. Williams-Wilkins; Philadelphia, 2001-2007:
443-467
7. P.M. Davies. Pasos a seguir. 2ª ed. Madrid: Editorial Médica Panamericana.
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8. Bettina Paeth Rohlfs. “Experiencias con el Concepto Bobath. 2ª ed. Madrid:
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precision and whole-hand visually guided grasping in humans. European Journal of
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contributions to the online control of inmediate and delayed grasping: A TMS
aproach. Neuropsicology (2009); 47: 1553-1562.

27. Handfun Meeting 2013. Óscar Díez Meleiro.
11. Daneaul JF, Carignan B, Duval C. Finger tremor can be voluntarily reduced
during a tracking task. Brain Research 1370. (2011) 164-174
12. Richard L. Senesac L. et al. Response to Intensive Upper Extremity Therapy by
Individuals with Ataxia from Stroke. Top Stroke Rehabil 2008;15(3):262–271
13. Park J; Lewis M.M; Huang X.; Latash M.L. Effects of olivo-ponto-cerebellar
atrophy (OPCA) on finger interaction and coordination. Clinical Neurophysiology.
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14. Winter J.M. et al. Effects of Mobilization and Tactile Stimulation on Chronic
Upper-Limb Sensorimotor Dysfunction After Stroke. Archives of Physical
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15. Sleimen-Malkoun et al. Bimanual training in stroke: How do coupling
and symmetry-breaking matter? BMC Neurology. 2011. 11.11
16.Recovery of upper limb function, en Bobath Concept. Theory and Clinical
Practice in Neurological Rehabilitation. Raine, Meadows, Lynch-Ellerington.
Wiley-Blackwell. 2010. Oxford (United Kingdom) P 154-158.

28. Handfun Meeting 2013. Óscar Díez Meleiro.
17. Werring D. Improving hand motor control after stroke. J Neurol Neurosurg Psychiatry. 2009. 80:
586
18. Hird JS, Landers DM, Thomas JR, Horan JJ. Physical practice is superior to mental practice in
enhancing cognitive and motor task performance. Journal of Sport and Exercise Psychology 1991;
13:281-293.
19. Mackrous, Isabelle Proteau, Luc. Specificity of practice results from differences in movement
planning strategies. Source: Experimental Brain Research; Nov2007, Vol. 183 Issue 2, p181-193, 13p.
20. Proteau, Luc; Carnahan, Heather. What Causes Specificity of Practice in a Manual Aiming
Movement: Vision Dominance or Transformation Errors?, Journal of Motor Behavior, Sep2001, Vol.
33 Issue 3, p226.
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77(8):811-5.
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23. Isawa J, Criscimagna Hemminger S; Shadmer R. Cerebellar Contributions to Reach Adaptation
and Learning Sensory Consequences. The Journal of Neuroscience, 2012 • 32(12):4230–4239.
24. Martin CL et al. Effectiveness of physiotherapy for adults with cerebellar dysfunction: a
systematic review. Clinical Rehabilitation 2009; 23: 15–26.

29. Thanks!
Handfun Meeting 2013. Óscar Díez Meleiro.
http://neurorehabilitacion.wordpress.com
neurorehabilitacionblog@gmail.com