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Nonpharmacological Interventions in Degenerative Cerebellar Ataxia: A Systematic Review
Divyani Garg1, Jacob Yomtoob2, Puneet Opal2
1Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
Background:
A comprehensive synthesis of nonpharmacological interventions (NPI) in degenerative cerebellar ataxia will clarify their efficacy and inform clinical practice and trial design in a field with limited therapeutic options.
Methods:
A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review was conducted (PROSPERO CRD42025649802). PubMed/MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane CENTRAL were searched from inception to April 16, 2025. Randomized and nonrandomized interventional studies evaluating rehabilitation, speech therapy, noninvasive neuromodulation (repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation [tDCS]), virtual reality, vibration therapy, biofeedback-based, assistive devices, and complementary approaches were included. Methodological quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. Given substantial clinical and methodological heterogeneity, findings were consolidated narratively.
Results:
A total of 100 studies met inclusion criteria. Structured physical therapy, rTMS, and tDCS demonstrated statistically significant short-term reductions in ataxia severity (measured using Scale for the Assessment and Rating of Ataxia [SARA] or International Cooperative Ataxia Rating Scale [ICARS]). Improvements were most consistent in axial domains, including gait and postural control. Limited mechanistic studies reported restoration of cerebellar inhibitory modulation, increased cerebellar-frontal connectivity, and enhanced regional perfusion following tDCS. Evidence for speech therapy, virtual reality-based rehabilitation, vibration therapy and complementary approaches was limited. Across all modalities, durability beyond the short-term remained unclear.
Conclusions:
NPI may confer short-term symptomatic and functional benefits in degenerative cerebellar ataxia, particularly in axial motor domains, supported by the largest evidence for structured rehabilitation followed by neuromodulation, although heterogeneous. Future multicenter, biomarker-informed trials are required to define optimal dosing, durability and stage-specific therapeutic strategies.
