Department of Neurology and
Hertie-Institute for Clinical Brain Research
San Antonio, 16.03.2012

Ludger Schöls has no relationships to disclose or list

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?

Marr (1969) & Albus (1971):
Cerebellum is the „motor learning machine“
Examples:
 Motor use of new tools
(Imamizu et al., 2000)
 Fast recalibration of internal motor programs
- e.g. saccadic adptation
(Barash et al., 1999)
- e.g. adaptation to new force fields
(Maschke et al, 2004)
- e.g. adaptation of anticipated motor prediction

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

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 !!!

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

i i
W 8 W12
V2 V3
Intervention:
4 week course with 3 physiotherapy sessions a week
= 12 x physiotherapy per patient

1. Goal attainment score (Patient)
2. Berg balance score (Physiotherapist)
3. Ataxia rating scale (Neurologist)
4. Movement analysis (Computer)

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
Kiresuk et. al., 1994;
Lawrence Erlbaum Associates Inc.

The BBS rates balance in a physiotherapeutic examination
14 items addressed
• Sitting
• Stance
• Gait
• Timed movements
Berg et. al., 1989; Physiotherapy Canada

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

1)
2)
3)
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
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

• 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

48 year old kindergarten teacher
Idiopathic cerebellar ataxia
Disease duration 1.5 years
-
-
Physiotherapy before the study:
Stabilisation exercises
Isometric training
Pre
Post

48 year old kindergarten teacher
Idiopathic cerebellar ataxia
Disease duration 1.5 years
-
-
Physiotherapy before the study:
Stabilisation exercises
Isometric training
Pre
Post

48 year old kindergarten teacher
Idiopathic cerebellar ataxia
Disease duration 1.5 years
-
-
Physiotherapy before the study:
Stabilisation exercises
Isometric training
Pre
Post

48 year old kindergarten teacher
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
Pre
Post

• 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

1)
2)
3)
4)
5)
6)
Physiotherapy is able to improve ataxia even in cerebellar degeneration
Active, coordinative training is a successful physiotherapy concept in ataxia
Effects are visible not only as a group mean but also on an individual basis
Effects persist over long term especially if a continuous training is performed
Patients with afferent ataxia do profit but cerebellar ataxia is likely to respond even better
Improvements meet individual goals in every day life

Matthis Synofzik
Doris Brötz