What are some of the key challenges in delivering rehabilitation for people with HCA? 

Delivering effective rehabilitation for people with hereditary cerebellar ataxia (HCA) is particularly challenging due to several factors. 

Many HCAs involve multisystem pathology, meaning that in addition to cerebellar dysfunction, individuals may experience impairments related to peripheral neuropathy, vestibular dysfunction, spasticity, muscle weakness and sensory loss. 

Clinical presentations are highly variable, even among those with the same diagnosis, requiring physiotherapists to individualise assessment and intervention. 

The degenerative nature of HCA adds further complexity, as rehabilitation goals and strategies must adapt over time to ongoing functional decline—being both proactive and reactive. 

Finally, cerebellar pathology itself impairs motor learning, which necessitates the tailoring of rehabilitation to optimise skill acquisition and retention. 

However, the best way to approach this is still not yet well understood. 

Sarah Milne will talk about using aquatic therapy to treat hereditary cerebellar ataxia in her invited presentation at APASC25.

What were the key findings from your multi-centre rehabilitation trial? 

We compared a 30-week goal-directed rehabilitation program to standard care. 

The program included six weeks of outpatient physiotherapy followed by 24 weeks of supported home exercise. 

Immediately after the outpatient rehabilitation, the rehabilitation group showed significant improvements in physical function, ataxia severity and balance. 

The gains in ataxia and balance were sustained at 30 weeks with the home exercise program, but physical functioning as measured by the motor domain of the Functional Independence Measure, was not. 

Why was aquatic physiotherapy included as part of the rehabilitation program, and what benefits does it offer for people with HCA? 

The rehabilitation program incorporated a significant aquatic component: each outpatient session included one hour of hydrotherapy in addition to one hour of land-based physiotherapy, three times per week. 

Aquatic physiotherapy offers several advantages for people with hereditary cerebellar ataxia. 

The properties of water allow training in a safe environment to challenge balance, work through full range of movement with whole body movements and practice movements and functional tasks that may be unsafe to practice on land. 

Immersion also provides resistance, which can be used to facilitate strengthening and postural control, in both people with mild and significant weakness. 

The supportive environment also allows for greater confidence and reduced fear of falling, and was complimentary to the land-based program which focused on rehabilitation in functional and postural activities up against gravity, as well as more precise, selective movements and control. 

What does this mean for physiotherapy practice? 

Rehabilitation works—but it needs to be tailored, goal-directed and sustained. 

Our findings support physiotherapy that focuses on coordination, balance and functional mobility, while also addressing the multi-system nature of HCA. 

While home exercise can help maintain gains, the intensity and therapist-led components of outpatient rehab appear critical for achieving meaningful improvements. 

Where is the field heading in the next five years? 

Now that we know rehabilitation works, the next step is to optimise it. 

We need to better understand the dosage, the mechanisms of improvement and which elements of rehabilitation are most impactful. 

It’s also essential that rehabilitation remains goal-directed, driven by people with HCA, feasible to complete and targeted to the presenting impairments. 

This means refining programs to be both effective and accessible, and continuing to build evidence for best practice across diverse populations and settings. 

What should physiotherapists take away from this research? 

Don’t underestimate the potential of rehabilitation. 

Even in progressive conditions like HCA, physiotherapy can improve function and quality of life. 

Be confident in prescribing and advocating for rehabilitation, and stay focused on tailoring care to individual needs—including cultural, environmental and psychosocial factors. 

>> Dr Sarah Milne MACP is the clinical research lead at Monash Health and the Friedreich ataxia clinic coordinator at the Murdoch Children’s Research Institute. Sarah has over 15 years of clinical experience working in rehabilitation and aquatic physiotherapy. 

>> Sarah will give an invited presentation titled ‘Understanding balance decline in hereditary cerebellar ataxia and the benefits of aquatic and land physiotherapy’ on Friday 24 October at 2:15 pm.

Click here for more information about APASC25.