Move and improve - Move and improve - how coordinative training helps ataxiahow coordinative training helps ataxia
Ludger SchölsLudger Schöls
Department of Neurology and Department of Neurology and
Hertie-Institute for Clinical Brain ResearchHertie-Institute for Clinical Brain Research
University of TübingenUniversity of Tübingen
San Antonio, 16.03.2012
Ludger Schöls
has no relationships to disclose or list
Presenter disclosures
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?
Examples:
1) Motor use of new tools (Imamizu et al., 2000)
2) 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
Marr (1969) & Albus (1971): Cerebellum is the „motor learning machine“
Cerebellum is the place of motor learning
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
Cerebellar degeneration in ataxias
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 !!!
Which physiotherapy?
Concept of Doris Brötz (Tübingen):Active release of „fixed“ movement patternsTraning of static balanceTraining of dynamic balanceWhole body movementsFalling strategies and Steps to prevent fallingMovements to treat and prevent contracturesRather few exercises but frequent repetitions
Active coordinative training
Neurology 2009; 73:1823-1830
Study design
V1V1 V2V2 V3V3 V4V4 V5V5
W 0W 0 W 8W 8 W12W12 W20W20 W60W60
PPhhyyssiioo
Intrinsic Intrinsic control control
Follow Follow upup
LongtermLongterm
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)
Read out
GAS addresses indivudal goals in daily life selected by the patient
0: Stage at entry of study1: Less than expected2: Expected outcome3: Better outcome than expected4: Much better than expected
Goal attainment score (GAS)
Kiresuk et. al., 1994; Lawrence Erlbaum Associates Inc.
11
44
22
00
33
The BBS rates balance in aphysiotherapeutic examination14 items addressed • Sitting• Stance• Gait • Timed movements
Berg balance score (BBS)
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: 40Item 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)
SARA
Schmitz-Hübsch et. al., 2006; Neurology
Registration of three-dimensional movement trajectories by 41 reflecting markers using a VICON motion capture system with 10 infrared camerasAnalysis of complex whole body movmements for variability in room and time
1) Stance: sway is assessed as path length of the center of gravity while standing with feet together
2) Gait: Analysis of intra-limb coordination by the
angle-angle plots of the hip and knee joints temporal variability measure: vbt
3) Dynamic balance on a treadmill with sudden backward move
Computerized movement analysis
Ilg et al, Neurology 2009
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
Case S.T. - stance
48 year old kindergarten teacher
Idiopathic cerebellar ataxia
Disease duration 1.5 years
Physiotherapy before the study:
- Stabilisation exercises- Isometric training
Pre
Post
Case S.T. - gait
48 year old kindergarten teacher
Idiopathic cerebellar ataxia
Disease duration 1.5 years
Physiotherapy before the study:- Stabilisation exercises- Isometric training
Pre
Post
Case S.T. – complex movements
48 year old kindergarten teacher
Idiopathic cerebellar ataxia
Disease duration 1.5 years
Physiotherapy before the study:- Stabilisation exercises- Isometric training
Pre
Post
Case S.T. – stairs
48 year old kindergarten teacher
Idiopathic cerebellar ataxia
Disease duration 1.5 years
Physiotherapy before the study:- Stabilisation exercises- Isometric training
Pre
PostGoal attainment score0: Climbing stairs only with
banister1: Intermittend use of the banister2: No banister required for 2 steps
in both directions3: Staircase upwards without
banister 4: Staircase up and down without
banister
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 trainingIlg et al, Mov Disord 2010
Conclusions
Move and improve!Move and improve!
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
Thank you …
Matthis SynofzikMatthis Synofzik Winfried IlgWinfried Ilg Doris BrötzDoris Brötz
… and the dream team!
