Move and improve how coordinative training helps ataxia
Ludger Schöls
Department of Neurology and
Hertie-Institute for Clinical Brain Research
University of Tübingen
San Antonio, 16.03.2012
Presenter disclosures
Ludger Schöls
has no relationships to disclose or list
Outline
1)
Cerebellum and motor learning
2)
Does physiotherapy help in ataxias?
3)
Which physiotherapy concept is successful?
4)
A flash in the pan or longterm effects?
Cerebellum is the place of motor learning
Marr (1969) & Albus (1971):
Cerebellum is the „motor learning machine“
Examples:
1)
Motor use of new tools
2)
Fast recalibration of internal motor programs
- e.g. saccadic adptation
(Imamizu et al., 2000)
(Barash et al., 1999)
- e.g. adaptation to new force fields
(Maschke et al, 2004)
- e.g. adaptation of anticipated motor prediction
Cerebellar degeneration in ataxias
Regeneration of cerebellar function after focal lesions is well
established:
• e.g. after tumor or stroke
• limited regeneration if cerebellar nuclei are affected
Ataxias are degenerative diseases
• Degeneration is a generalized rather than a focal process
• No healthy regions left that can take over for affected parts
 Doubts that the cerebellum can still learn motor functions
with a degenerative ataxia
This matches with the experiences of some patients
that physiotherapy was not particular helpful to them
Which physiotherapy?
But:
Does that proof physiotherapy ot be ineffective?
If a pain killer does not help against high glucose levels
this does not mean that drugs are ineffective in diabetes
So: Which physiotherapy did not help?
• Vojta?
• Bobath?
• Isometric training?
• Massage / relaxation?
• Balance?
• Coordinative training?
Which physiotherapy concepts do help?
No physiotherapy concept had been evaluated in ataxia !!!
Active coordinative training
Neurology 2009; 73:1823-1830
Concept of Doris Brötz (Tübingen):
Active release of „fixed“ movement patterns
Traning of static balance
Training of dynamic balance
Whole body movements
Falling strategies and Steps to prevent falling
Movements to treat and prevent contractures
Rather few exercises but frequent repetitions
Study design
Intrinsic
control
P
h
y
s
i
o
Follow
up
Longterm
W0
W8
W12
W20
W60
V1
V2
V3
V4
V5
Intervention:
4 week course with 3 physiotherapy sessions a week
= 12 x physiotherapy per patient
Read out
1.
Goal attainment score (Patient)
2.
Berg balance score (Physiotherapist)
3.
Ataxia rating scale (Neurologist)
4.
Movement analysis (Computer)
Goal attainment score (GAS)
GAS addresses indivudal goals in
daily life selected by the patient
0: Stage at entry of study
1: Less than expected
2: Expected outcome
3: Better outcome than expected
4: Much better than expected
0
1
2
3
4
Kiresuk et. al., 1994;
Lawrence Erlbaum Associates Inc.
Berg balance score (BBS)
The BBS rates balance in a
physiotherapeutic examination
14 items addressed
•
Sitting
•
Stance
•
Gait
•
Timed movements
Berg et. al., 1989; Physiotherapy Canada
SARA
Scale for the assessment and rating of ataxia (SARA)
Higher scores indicate more severe problems
8 items, maximum sum score: 40
Item 1: Gait (8 points)
Item 2 Stance (6 points)
Item 3: Sitting (4 points)
Item 4: Speech (6 points)
Item 5: Finger chase (4 points)
Item 6: Finger pointing (4 points)
Item 7: Diadochokinesia (4 points)
Item 8: Heel-shin slide (4 points)
Schmitz-Hübsch et. al., 2006; Neurology
Computerized movement analysis
Registration of three-dimensional
movement trajectories by
41 reflecting markers using a
VICON motion capture system with
10 infrared cameras
Analysis of complex whole body
movmements for variability in room
and time
1)
2)
3)
Stance: sway is assessed as path length of the
center of gravity while standing with feet together
Gait: Analysis of intra-limb coordination by the
angle-angle plots of the hip and knee joints 
temporal variability measure: vbt
Dynamic balance on a treadmill with sudden
backward move
Results
• Improvement after training:
- 5.2 SARA points
~ progression of 2 – 4 years
• Goal attainment: 2.5
= more than expected
• Gait velocity, intra-limb
coordination, static and
dynamic balance all improved
• More benefit with
cerebellar rather than
afferent ataxia
• Persistent effects
after 8 weeks
but better with regular
training at home:
- 0.4 vs +1.0
Ilg et al, Neurology 2009
Case S.T. - stance
48 year old kindergarten teacher
Pre
Idiopathic cerebellar ataxia
Disease duration 1.5 years
Physiotherapy before the study:
Stabilisation exercises
Isometric training
Post
Case S.T. - gait
48 year old kindergarten teacher
Pre
Idiopathic cerebellar ataxia
Disease duration 1.5 years
Physiotherapy before the study:
Stabilisation exercises
Isometric training
Post
Case S.T. – complex movements
48 year old kindergarten teacher
Pre
Idiopathic cerebellar ataxia
Disease duration 1.5 years
Physiotherapy before the study:
Stabilisation exercises
Isometric training
Post
Case S.T. – stairs
48 year old kindergarten teacher
Pre
Idiopathic cerebellar ataxia
Disease duration 1.5 years
Physiotherapy before the study:
Stabilisation exercises
Isometric training
Goal attainment score
0: Climbing stairs only with banister
1: Intermittend use of the banister
2: No banister required for 2 steps
in both directions
3: Staircase upwards without
banister
4: Staircase up and down without
banister
Post
Longterm effects
• Even after 1 year SARA
was better than baseline
especially in the cerebellar
group
• Goal attainment: After 1
year still better than
expected
• Improvement in intra-limb
coordination persisted over
1 year in the cerebellar
group
• Patients performing
continuous exercises were
doing better than those
without training
Ilg et al, Mov Disord 2010
Conclusions
1)
Physiotherapy is able to improve ataxia even in
cerebellar degeneration
2)
Active, coordinative training is a successful
physiotherapy concept in ataxia
3)
Effects are visible not only as a group mean but also
on an individual basis
4)
Effects persist over long term especially if a
continuous training is performed
5)
Patients with afferent ataxia do profit but cerebellar
ataxia is likely to respond even better
6)
Improvements meet individual goals in every day life
Move and improve!
Thank you …
… and the dream team!
Matthis Synofzik
Winfried Ilg
Doris Brötz