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