What is the primary treatment for a patient presenting with a bizarre gait due to sensory ataxia?

Treatment of Sensory Ataxia with Bizarre Gait

The primary treatment for sensory ataxia involves addressing the underlying spinal cord or peripheral nerve pathology, combined with prescription of assistive devices and structured balance training programs to reduce fall risk and improve functional mobility. 1, 2

Diagnostic Workup Before Treatment

Before initiating treatment, confirm the diagnosis and identify the underlying cause:

• Obtain MRI of the cervical and thoracic spine (with or without contrast depending on suspected etiology) to evaluate the dorsal columns for compressive myelopathy, B12/copper deficiency, tabes dorsalis, or other spinal cord pathology 1, 2
• Distinguish sensory from cerebellar ataxia clinically by performing a Romberg test—sensory ataxia dramatically worsens with eye closure, while cerebellar ataxia does not significantly change 1, 2, 3
• Look for associated findings including sensory loss, hyporeflexia, and absence of cerebellar signs (no nystagmus, dysmetria, or intention tremor) 2, 4

Primary Treatment Approach

1. Address the Underlying Cause

• Treat the specific spinal cord or peripheral nerve pathology identified on imaging or laboratory testing (e.g., vitamin B12 supplementation for deficiency, decompression for myelopathy, treatment of neurosyphilis) 1, 5
• Recognize that some causes are progressive and treatment-resistant, such as chronic idiopathic ataxic neuropathy, which may not respond to immunosuppressants or plasmapheresis 6

2. Assistive Devices and Orthotics

• Prescribe and properly fit assistive devices (canes, walkers) to improve stability and reduce fall risk—this is a Class I, Level A recommendation from the American Heart Association 1, 2
• Ensure proper fitting as this maximizes benefit and safety 2

3. Balance Training Programs

• Provide structured balance training programs for all patients with poor balance, low balance confidence, fear of falls, or documented fall risk—this is a Class I, Level A recommendation 1, 7
• Focus training on compensatory strategies that minimize the complexity of movements, such as teaching patients to avoid rapid multijoint movements and instead make slower, single-joint movements 3
• Emphasize visual compensation techniques since patients with sensory ataxia rely heavily on vision to compensate for proprioceptive loss 1, 2

Special Considerations

Movement Strategy Modifications

• Teach patients to reduce movement complexity by minimizing the number of moving joints simultaneously, as sensory ataxia results from inability to coordinate relative muscle activity and adjust for interaction torques 3
• Encourage slower, more deliberate movements limited to single joints when possible 3

Vestibular Complications

• Screen for concurrent bilateral vestibulopathy in patients with unexpectedly severe balance impairment, as this can aggravate sensory ataxia and may benefit from specific vestibular rehabilitation 8

Common Pitfalls to Avoid

• Do not mistake sensory ataxia for cerebellar ataxia, as this leads to diagnostic delays and inappropriate workup—always perform a Romberg test 4, 2
• Do not focus solely on brain imaging when sensory ataxia is suspected; spinal cord evaluation is essential 1, 5
• Do not overlook treatable causes such as vitamin deficiencies or compressive myelopathy that require specific interventions beyond symptomatic management 1