Cerebellar ataxia and related Homoeopathic remedies

Dr Mansoora  K

Cerebellar ataxia results in a characteristic type of irregular, uncoordinated movement that can manifest itself in many possible ways, such as asthenia, asynergy, delayed reaction time, and dyschronometria.

CEREBELLAR  ATAXIA:
Although ataxia is not present with all cerebellar lesions, many conditions affecting the cerebellum do produce ataxia.

People with cerebellar ataxia may have trouble regulating the force, range, direction, velocity and rhythm of muscle contractions

Etiology:

• Developmental abnormality (hydrocephalus or hypoxia at birth)
• Traumatic brain injury.
• Stroke.
• Tumor or other space-occupying lesion.
• Infection (encephalitis)
• Demyelinating disease (Multiple sclerosis)
• Familial or hereditary disease (Friedreich’s ataxia)
• Degenerative disease
• Metabolic disease (myxoedema, Wilson’s disease)
• Vascular disease (vertebro-basilar artery insufficiency)
• Drug & alcohol intoxications.

Asthenia àabnormal physical weakness or lack of energy

Asynergyàabsence of coordination of organs or body parts that usually work together harmoniously

Dyschronometria is when a person can not accurately estimate the amount of time that has passed.

• Individuals with cerebellar ataxia could also display instability of gait,
• Difficulty with eye movements,
• Dysarthria,
• Dysphagia,
• Hypotonia , dysmetria and
• Dysdiadochokinesia: Impaired ability to perform rapid, alternating movements (i.e. diadochokinesia).
• Complete inability is called adiadochokinesia

Dysmetria (English: difficult to measure) refers to a lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye. It is a type of ataxia It is sometimes described as an inability to judge distance or scale.

People with cerebellar ataxia may initially present with poor balance, which could be demonstrated as an inability to stand on one leg or perform tandem gait

As the condition progresses, walking is characterized by a widened base and high stepping, as well as staggering and lurching from side to side.

Turning is also problematic and could result in falls.

As cerebellar ataxia becomes severe, great assistance and effort are needed in order to stand and walk.

Dysarthria an impairment with articulation, may also be present and is characterized by “scanning” speech that consists of slower rate, irregular rhythm and variable volume.

There may also be slurring of speech, tremor of the voice

There is overshooting with finger to nose testing, and heel to shin testing; thus, dysmetria is evident.

Impairments with alternating movements (dysdiadochokinesia), as well as dysrhythmia, may also be displayed.

There may also be tremor of the head and trunk (titubation) in individuals with cerebellar ataxia

The dysfunction of the vestibulocerebellum (flocculonodular lobe) impairs the balance and the control of eye movements.

This presents itself with postural instability, in which the person tends to separate his/her feet upon standing, in order to gain a wider base and to avoid titubation (bodily oscillations tending to be forward-backward ones).

The instability is therefore worsened when standing with the feet together, regardless of whether the eyes are open or closed. This is a negative Romberg’s test, or more accurately, it denotes the individual’s inability to carry out the test, because the individual feels unstable even with open eyes

Dysfunction of the spinocerebellum (vermis and associated areas near the midline) presents itself with a wide-based “drunken sailor” gait (called truncal ataxia),characterised by uncertain starts and stops, lateral deviations, and unequal steps.

As a result of this gait impairment, falling is a concern in patients with ataxia

Dysfunction of the cerebrocerebellum (lateral hemispheres) presents as disturbances in carrying out voluntary, planned movements by the extremities (called appendicular ataxia)

These include: intention tremor, peculiar writing abnormalities (large, unequal letters, irregular underlining); a peculiar pattern of dysarthria (slurred speech, sometimes characterised by explosive variations in voice intensity despite a regular rhythm). Inability to perform rapidly alternating movements, known as dysdiadochokinesia. inability to judge distances or ranges of movement. This is known as dysmetria and is often seen as undershooting, hypometria, or overshooting, hypermetria, the required distance or range to reach a target. This is sometimes seen when a patient is asked to reach out and touch someone’s finger or touch his or her own nose.

The rebound phenomenon, also known as the loss of the check reflex is also sometimes seen in patients with cerebellar ataxia.

For example, when a patient is flexing his or her elbow isometrically against a resistance.

When the resistance is suddenly removed without warning, the patient’s arm may swing up and even strike themselves. With an intact check reflex, the patient will check and activate the opposing triceps to slow and stop the movement.

Sensory ataxia:
The term sensory ataxia is employed to indicate ataxia due to loss of proprioception, the loss of sensitivity to the positions of joint and body parts.

This is generally caused by dysfunction of the dorsal columns of the spinal cord, because they carry proprioceptive information up to the brain.

In some cases, the cause of sensory ataxia may instead be dysfunction of the various parts of the brain which receive positional information, including the cerebellum, thalamus, and parietal lobes

Sensory ataxia presents itself with an unsteady “stamping” gait with heavy heel strikes, as well as a postural instability that is usually worsened when the lack of proprioceptive input cannot be compensated for by visual input.

Physicians can find evidence of sensory ataxia during physical examination by having the patient stand with his/her feet together and eyes shut. In affected patients, this will cause the instability to worsen markedly, producing wide oscillations and possibly a fall. This is called a positive Romberg’s test.

Worsening of the finger-pointing test with the eyes closed is another feature of sensory ataxia.

Also, when the patient is standing with arms and hands extended toward the physician, if the eyes are closed, the patient’s finger will tend to “fall down” and then be restored to the horizontal extended position by sudden muscular contractions

Vestibular ataxia:
The term vestibular ataxia is employed to indicate ataxia due to dysfunction of the vestibular system which in acute and unilateral cases is associated with prominent vertigo, nausea and vomiting

In slow-onset, chronic bilateral cases of vestibular dysfunction, these characteristic manifestations may be absent, and dysequilibrium may be the sole presentation.

Causes: The three types of ataxia have overlapping causes, and therefore can either coexist or occur in isolation.

Focal lesions
Any type of focal lesion of the central nervous system (such as stroke, brain tumour, multiple sclerosis) will cause the type of ataxia corresponding to the site of the lesion: cerebellar if in the cerebellum, sensory if in the dorsal spinal cord (and rarely in the thalamus or parietal lobe), vestibular if in the vestibular system (including the vestibular areas of the cerebral cortex).

Exogenous substances
Ethanol which is capable of causing reversible cerebellar and vestibular ataxia. various prescription drugs (e.g. most antiepileptic drugs have cerebellar ataxia as a possible adverse effect), Lithium level over 1.5mEq/L, cannabis ingestion and various other recreational drugs (e.g. ketamine, PCP or dextromethorphan, benzodiazepines. Exposure to high levels of methylmercury  through consumption of fish with high mercury concentrations

Radiation poisoning
Ataxia can be induced as a result of severe acute radiation poisoning with an absorbed dose of more than 30 Grays.

Vitamin B₁₂ deficiency
Vitamin B₁₂ deficiency may cause, among several neurological abnormalities, overlapping cerebellar and sensory ataxia

Hypothyroidism
Symptoms of neurological dysfunction may be the presenting feature in some patients with hypothyroidism. These include reversible cerebellar ataxia, dementia peripheral neuropathy  psychosis and coma. Most of the neurological complications improve completely after thyroid hormone  replacement therapy

Causes of isolated sensory ataxia
Peripheral neuropathies may cause generalised or localised sensory ataxia (e.g. a limb only) depending on the extent of the neuropathic involvement.

Spinal disorders of various types may cause sensory ataxia from the lesioned level below, when they involve the dorsal columns

Non-hereditary cerebellar degeneration
Non-hereditary causes of cerebellar degeneration include chronic ethanol abuse, head injury, paraneoplastic cerebellar degeneration, high altitude cerebral oedema, coeliac disease, normal pressure hydrocephalus and cerebellitis.

Hereditary ataxias
Hereditary disorders consisting of degeneration of the cerebellum and/or of the spine; most cases feature both to some extent, and therefore present with overlapping cerebellar and sensory ataxia, even though one is often more evident than the other.

Hereditary disorders causing ataxia include autosomal dominant ones such as spinocerebellar ataxia  episodic ataxia  and dentatorubropallidoluysian atrophy , as well as autosomal recessive disorders such as Friedreich’s ataxia  (sensory and cerebellar, with the former predominating) and Niemann Pick disease  ataxia-telangiectasia  (sensory and cerebellar, with the latter predominating), and abetalipoproteinaemia . An example of X-linked ataxic condition is the rare fragile X-associated tremor/ataxia syndrome.

Arnold-Chiari malformation (congenital ataxia)
Arnold-Chiari malformation is a malformation of the brain. It consists of a downward displacement of the cerebellar tonsils and the medulla through the foramen magnum , sometimes causing hydrocephalus as a result of obstruction of cerebrospinal fluid outflow.

Wilson’s disease
Wilson’s disease is an autosomal –recessive gene disorder whereby an alteration of the ATP7B gene results in an inability to properly excrete copper from the body. Copper accumulates in the nervous system and liver and can cause ataxia as well as other neurological and organ impairments.

Gluten ataxia
Gluten ataxia may be a form of gluten sensitivity. With gluten ataxia, damage takes place in the cerebellum, Gluten ataxia is the single most common cause of sporadic idiopathic ataxia.

Gluten ataxia is defined as sporadic cerebellar ataxia associated with the presence circulating antigliadin antibodies and in the absence of an alternative etiology for ataxia.

Gluten ataxia is an immune-mediated disease triggered by the ingestion of gluten in genetically susceptible individuals. Readily available and sensitive markers of gluten ataxia include anti-gliadin antibodies. Immunoglobulin A (IgA) deposits against transglutaminase 2 (TG2) in the small bowel and at extraintestinal sites are proving to be additional reliable and perhaps more specific markers of the whole spectrum of gluten sensitivity.

DIAGNOSIS:

• Neurological and medical history, including drug and toxin exposures.
• Family history of neurological problems
• Neurological and medical examinations
• Blood tests to rule out specific deficiencies and toxins
• Urine screen for mercury exposure
• Brain Imaging: Magnetic Resonance Image (MRI) or Computed Tomogram (CT)
• Possible neuroimaging of the spinal cord.
• Electrophysiologic testing (electromyography and nerve conduction velocity testing) if there are signs or symptoms of peripheral nerve dysfunction

The investigation may reveal a reversible cause of cerebellar dysfunction, such as vitamin E deficiency, Wilson’s disease, cerebellar dysfunction due to thyroid abnormalities, or cerebellar injury due to a toxin.

If no acquired cause of ataxia is found, or if the history suggests an inherited cerebellar disease, specific genetic testing is indicated. Examples include blood testing for Friedreich’s ataxia or any of the testable spinocerebellar ataxias (SCAs).

Imaging studies. A CT scan or MRI of your brain might help determine potential causes. An MRI can sometimes show shrinkage of the cerebellum and other brain structures in people with ataxia. It may also show other treatable findings, such as a blood clot or benign tumor, that could be pressing on your cerebellum.

TREATMENT:

There’s no treatment specifically for ataxia. In some cases, treating the underlying cause resolves the ataxia, such as stopping medications that cause it. In other cases, such as ataxia that results from chickenpox or other viral infections, it’s likely to resolve on its own.

Adaptive devices

Ataxia caused by conditions such as multiple sclerosis or cerebral palsy might not be treatable. In that case, recommend adaptive devices. They include:

• Hiking sticks or walkers for walking
• Modified utensils for eating
• Communication aids for speaking

Therapies

• Physical therapy to help coordination and enhance mobility
• Occupational therapy to help with daily living tasks, such as feeding self
• Speech therapy to improve speech and aid swallowing

Research has shown that transcranial magnetic stimulation may help improve gait and postural control in people with ataxia, but more research is needed. Some studies have indicated that aerobic exercise also may be beneficial for some people with idiopathic ataxic syndromes.

RUBRICS:

Kent’s repertory:

EXTREMITIES- Ataxia

EXTREMITIES- Incordination

BBCR:

SENSATIN AND COMPLAINTS- Incordination

Synthesis:

EXTREMITIES- Incordination

GENERALS- Locomotor ataxia

HEAD- Cerebellar disease

Murphy’s repertory:

Clinical–ataxia,cerebellar disease

Brain-cerebellar disease

THERAPEUTICS:

AGARICUS
Uncertain gait. Trembling. Neuralgia in locomotor ataxia.

Various forms of neuralgia and spasmodic affections, and neurotic skin troubles are pictured in the symptomatology of this remedy

Involuntary movements while awake,  cease during sleep; chorea, from simple motions and jerks of single muscles to dancing of whole body; trembling of whole body (twitching of muscles of face, Myg.)

ARGENTUM NITRICUM
Symptoms of inco-ordination, loss of control and want of balance everywhere, mentally and physically. Trembling, with general debility. Paraplegia Myelitis and disseminated sclerosis of brain and cord. Great weakness of lower extremities, with trembling; cannot walk with the eyes closed (Alum.). Walks and stands unsteadily, especially when he thinks himself unobserved.

CAUSTICUM
Paralysis of single parts. Heaviness and weakness. Unsteadiness of muscles of forearm and hand. Numbness; loss of sensation in hands. Weak ankles. Cannot walk without suffering. Slow in learning to walk. Unsteady walking and easily falling.  Restless legs at night.  

COCCULUS
Trembling and pain in limbs. Arms go to sleep. One-sided paralysis; worse after sleep. Numb and unsteady.  Lower limbs very weak. Intensely painful, paralytic drawing. Limbs straightened out, painful when flexed.Within the sphere of action of Cocculus are many spasmodic and paretic affections, notably those affecting one-half of the body.

CONIUM MAC
The ascending paralysis it produces, ending in death by failure of respiration, shows the ultimate tendency of many symptoms produced in the provings, for which Conium is an excellent remedy, such as difficult gait, trembling, sudden loss of strength while walking, painful stiffness of legs, etc.Great debility in the morning in bed. Weakness of body and mind, trembling, and palpitation. Heavy, weary, paralyzed; trembling; hands unsteady; fingers and toes numb

GELSEMIUM
Centers its action upon the nervous system, causing various degrees of motor paralysis. General prostration. Dizziness, drowsiness, dullness, and trembling.  Paralysis of various groups of muscles about the eyes, throat, chest, larynx, sphincter, extremities, etc Muscular weakness. Complete relaxation and prostration. Lack of muscular co-ordination.  Loss of power of muscular contro. Excessive trembling and weakness of all limbs

HELODERMA
Numbness and trembling. Sensation as if walking on sponge, and as if feet were swollen. Staggering gait. Cock’s gait. When walking, lifts feet higher than usual, and puts down heel hard.  Feet cold as ice or burn. Stretching relieves pains in muscles and limbs

NITRIC ACID
Produce sclerotic contraction of nerve cells (syphilitic degeneration)and cause locomotor ataxia.Irritability,fulgirating pains,as they appear come suddenly and go suddenly.

ONOSMODIUM
Want of power of concentration and co-ordination. Vertigo, numbness and muscular prostration. Marked association of head and eye symptoms, with muscular tiredness and weariness. Tired and numb feeling in legs, popliteal spaces, and below knees. Staggering gait. Sidewalk seems too high. Great muscular weakness and weariness

PHOSPHORUS
Ataxia and adynamia. Ascending sensory and motor paralysis from ends of fingers and toes.Weakness and trembling, from every exertion. Can scarcely hold anything with his hands. Arms and hands become numb. Can lie only on right side. Restless, fidgety.

PICRIC ACID
Great weakness. Tired, heavy feeling all over body, especially limbs; worse, exertion. Acute descending paralysis.Prostration, weakness and pain of back, pins and needle sensation in extremities. Neurasthenia. [Oxal. ac.] Muscular debility. Myelitis with spasms and prostration

PLUMBUM MET
Locomotor ataxia. Bulbar paralysis. Important in peripheral affections. The points of attack for Plumbum are the neuraxons and the anterior horns. Symptoms of multiple sclerosis, posterior spinal sclerosis. Paralysis from overexertion of the extensor muscles in piano players. [Curare.]  Stinging and tearing in limbs, also twitching and tingling, numbness, pain or tremor.Pain in atrophied limbs alternates with colic. Loss of patellar reflex.

SULFONALUM
Ataxic movements, staggering gait; cold, weak, trembling; legs seem too heavy. Extreme restlessness; muscular twitchings. Knee-jerks disappear. Stiffness and paralysis of both legs. Anaesthesia of legs. incoordination

ZINCUM MET
Lameness, weakness, trembling and twitching of various muscles. Feet in continued motion; cannot keep still. Convulsions, with pale face. Transverse pains, especially in upper extremity. In chronic diseases with brain and spinal symptoms, trembling, convulsive twitching and fidgety feet are guiding symptoms

REFERENCES:

• Krishnadas K V; Textbook of Medicine; 5th ed
• Harrison’s Principles of Internal Medicine 19th ed
• Kent J T; Repertory of Homeopathic Materia Medica
• Boger Boenninghausen’s Characteristics and Materia Medica
• Schroyens F; Repertorium Homeopathicum Syntheticum
• Murphy N D; Homeopathic Medical Repertory
• Allen H C; Keynotes and Characteristics with Comparison
• Boericke W; Pocket Manual of Materia Medica
• www.homeobook.com