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 (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

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

W 0 V1 Intrinsic control P h y s i o W 8 V2 W12 V3 Follow up W20 V4 Longterm

Intervention:

4 week course with 3 physiotherapy sessions a week = 12 x physiotherapy per patient W60 V5

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

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

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 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

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

Pre 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) 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

Move and improve!

Thank you … … and the dream team!

Matthis Synofzik Winfried Ilg Doris Brötz