Balancing Acts: Why Coordination Matters for Everyone

Connect the dots for us: Juggling, acrobatics, knife throwing and walking the tightrope. What does it take to execute all these magnificent feats? Do you have it? We’ll give you a hint, it starts with a ‘c’ and ends with ‘-oordination’. Undoubtedly, the odds of our readers doubling as circus performers is next to none but coordination is assuredly an essential skill for all of us. For our patients living with ataxia, basic tasks quickly evolve into ‘big top’ acts, requiring mind-body gymnastics to accomplish what was once simple for them. Managing this lasting impairment after neurological injury is crucial to improving patients' quality of life and functional capacity. In this article we will journey to pull back the curtain on incoordination and decipher the best methods to approach it in the clinic.

Behind the Curtain: The Brain Structures That Shape Coordination

The cerebrum and the cerebellum. In latin, ‘brain’ and well… ‘little brain’. While its name may seem innocent enough, the cerebellum punches above its weight class for its role in coordination. This structure can be divided into 3 main regions that are responsible for unique aspects of functional coordination^1,2. 

1. Vestibulocerebellum: Also known as the flocculonodular lobe, this region is in charge of integrating incoming information from the vestibular nuclei to influence posture and eye movements.

2. Spinocerebellum: Referring to the vermis and paravermal regions, somatosensory information from the spinal cord and brain converge here to control ongoing gross movements.

3. Cerebrocerebellum: Making up the lateral portions of the cerebellum, these hemispheres connect with the motor and somatosensory cortices to influence voluntary motion coordination, planning and timing of sequential motion.

Additionally, we must recognize the role of sensation in coordination. Sensory ataxia can be related to the old saying ‘garbage in garbage out’. If the body is getting bad signals about the sensory information drawn from its distal regions there is no way for the central nervous system to interpret the static correctly. In all cases, using the best available medical information for patients in addition to our clinical findings is what will source ataxia to its root cause.

Hidden Signs Beyond Movement

For many patients, ataxia may be one of the first things that our trained eye notices even before we begin our formal evaluation process. Whether incoordination is apparent or not, it is certainly best practice to perform some form of a standardized measure to track the progression of ataxia in our patients. One such tool that we have at our disposal is the ‘Scale for Assessment and Rating of Ataxia’ also known as SARA³. This outcome measure incorporates functional movements from gait and balance with specific upper and lower extremity tests that can be tracked over time via a grading scale. Available on sites such as Shirley Ryan Ability Labs, this handout is a free print out to carry with you if you feel that it would be beneficial to your evaluation process. 

We like to remind new practitioners that you are also scientists! Performing a functional task that is salient to your patient’s life is a great way to objectively view ataxia. This can be as simple as having them reach for a paper towel out of a dispenser, folding a towel or kicking a ball. Counting attempts or putting a timer on these activities can be used to quantify and track the things that are really important to our patients. Additionally, if you have clinical reasoning to suspect ataxia, it might take more than low intensity tests to observe. In conditions where exertion is an inflammatory factor for symptoms, pushing your patient to complete a high functioning or intense task that requires coordinated movement can start to reveal true deficits.

Hidden Struggles: Beyond Gross Motor Incoordination

Unsurprisingly, especially in the world of neurological conditions, ataxia does not always present in its most obvious form. Motor ataxia affecting extremities or the trunk may be visible from across the room but speech or visual incoordination may not manifest so readily. While conducting a subjective interview or a vision screening we may pick up on these scanning speech or saccadic intrusions where there should not be. Signs and symptoms affecting these less obvious systems play just as big of a role in our patients quality of life that their gross movements do. While we can certainly work on these deficits during therapy sessions we would like to take this opportunity to remind you that healthcare is a team sport. Involving other members such as speech therapists to work on strategies to find words and help patients express themselves facilitates holistic recovery but can also be used to facilitate our treatment sessions. 

Restoring Rhythm: Evidence-Based Ways to Treating Ataxia

One of the best parts of our jobs is the ability to bring creativity into our treatment sessions. For treating ataxia, this continues to be true as we find ways to combine evidence based practice with salient activities in the clinic. From a 2014 systematic review, it has been found that biofeedback, torso weighting (using 1.5% of body weight) and multi segment coordination are all effective treatment methods for ataxia⁴. Fortunately, many of these intervention strategies can be applied very practically to our creative interventions that we perform with patients in the clinic using mirrors, ankle weights and complex movements. On the cutting edge, it has been hypothesized that asking patients to dual task by providing a cognitive load simultaneously with balance training could be an effective method to make improvements with cerebellar ataxia. While this is only a prospective treatment, it has found success with other neurological populations such as stroke and Parkinson’s disease⁵. 

Parting Words

So there it is, the troublesome world of ataxia unraveled before us. Its manifestations may be overt or elusive but both forms reflect upon a deeper disruption in the body's symphony of coordination. As clinicians, our role is to decode these patterns and respond with creativity grounded in evidence. Through thoughtful evaluation, interdisciplinary collaboration, and purposeful intervention, we help our patients reclaim agency in their movements and confidence in their daily lives. In the end, treating ataxia is not just a clinical task, it is a quiet act of restoring rhythm to the human experience.

References:

1. Lundy-Ekman L. Neuroscience: Fundamentals for Rehabilitation. 4th ed. Elsevier; 2013.

2. Hafiz S, De Jesus O. Ataxia. In: StatPearls. StatPearls Publishing; 2025. Accessed April 24, 2025. http://www.ncbi.nlm.nih.gov/books/NBK562284/

3. Scale for Assessment and Rating of Ataxia | RehabMeasures Database. May 7, 2015. Accessed April 24, 2025. https://www.sralab.org/rehabilitation-measures/scale-assessment-and-rating-ataxia

4. Marquer A, Barbieri G, Pérennou D. The assessment and treatment of postural disorders in cerebellar ataxia: a systematic review. Ann Phys Rehabil Med. 2014;57(2):67-78. doi:10.1016/j.rehab.2014.01.002

5. Winser S, Pang MYC, Rauszen JS, Chan AYY, Chen CH, Whitney SL. Does integrated cognitive and balance (dual-task) training improve balance and reduce falls risk in individuals with cerebellar ataxia? Med Hypotheses. 2019;126:149-153. doi:10.1016/j.mehy.2019.03.001

Disclaimer:

We are current Doctor of Physical Therapy (DPT) student sharing information based on our formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While we strive to provide accurate and up-to-date information, our knowledge is based on our current academic and clinical rotations and ongoing learning, not extensive clinical practice.