1. Elektroschwache und Kosmische Strings Move and improve -
Objektorientierte Partitionierungsstrategien und Architekturbewertung ...
:23:45
Elektroschwache und Kosmische Strings
Move and improve -
how coordinative training helps ataxia
Ludger Schöls
Department of Neurology and
Hertie-Institute for Clinical Brain Research
University of Tübingen
Bevor ich mit dem eigentlichen Vortrag beginne, möchte ich noch kurz das Projekt vorstellen, in das meine Arbeiten eingebettet sind:
Markus Quandt
San Antonio,
Carsten Schulz-Key

2. Physikalische Eigenschaften
Presenter disclosures
Ludger Schöls
has no relationships to disclose or list

3. Outline Cerebellum and motor learning
Does physiotherapy help in ataxias?
Which physiotherapy concept is successful?
A flash in the pan or longterm effects?

4. Cerebellum is the place of motor learning
Objektorientierte Partitionierungsstrategien und Architekturbewertung ...
:23:45
Cerebellum is the place of motor learning
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
Stadium 1: basaler Neocortex fronantal, temporal und occipital
Stadium 2:
Phases of [beta]-amyloidosis. Phase 1 is characterized by exclusively neocortical A[beta] deposits (Neocortex: black). Phase 2 shows additional allocortical A[beta] deposits (red arrows), phase 3 additional A[beta] deposits in diencephalic nuclei (red arrows) and the striatum (not shown), phase 4 additional A[beta] deposits in distinct brainstem nuclei (substantia nigra, red nucleus, central gray, superior and inferior collicle, inferior olivary nucleus, and intermediate reticular zone) (red arrows), and phase 5 in the cerebellum and additional brainstem nuclei (pontine nuclei, locus coeruleus, parabrachial nuclei, reticulo-tegmental nucleus, dorsal tegmental nucleus, and oral and central raphe nuclei) (red arrows).
Carsten Schulz-Key

5. Cerebellar degeneration in ataxias
Objektorientierte Partitionierungsstrategien und Architekturbewertung ...
:23:45
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
Stadium 1: basaler Neocortex fronantal, temporal und occipital
Stadium 2:
Phases of [beta]-amyloidosis. Phase 1 is characterized by exclusively neocortical A[beta] deposits (Neocortex: black). Phase 2 shows additional allocortical A[beta] deposits (red arrows), phase 3 additional A[beta] deposits in diencephalic nuclei (red arrows) and the striatum (not shown), phase 4 additional A[beta] deposits in distinct brainstem nuclei (substantia nigra, red nucleus, central gray, superior and inferior collicle, inferior olivary nucleus, and intermediate reticular zone) (red arrows), and phase 5 in the cerebellum and additional brainstem nuclei (pontine nuclei, locus coeruleus, parabrachial nuclei, reticulo-tegmental nucleus, dorsal tegmental nucleus, and oral and central raphe nuclei) (red arrows).
Carsten Schulz-Key

6. Which physiotherapy? But:
Objektorientierte Partitionierungsstrategien und Architekturbewertung ...
:23:45
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 !!!
Stadium 1: basaler Neocortex fronantal, temporal und occipital
Stadium 2:
Phases of [beta]-amyloidosis. Phase 1 is characterized by exclusively neocortical A[beta] deposits (Neocortex: black). Phase 2 shows additional allocortical A[beta] deposits (red arrows), phase 3 additional A[beta] deposits in diencephalic nuclei (red arrows) and the striatum (not shown), phase 4 additional A[beta] deposits in distinct brainstem nuclei (substantia nigra, red nucleus, central gray, superior and inferior collicle, inferior olivary nucleus, and intermediate reticular zone) (red arrows), and phase 5 in the cerebellum and additional brainstem nuclei (pontine nuclei, locus coeruleus, parabrachial nuclei, reticulo-tegmental nucleus, dorsal tegmental nucleus, and oral and central raphe nuclei) (red arrows).
Carsten Schulz-Key

7. Active coordinative training
Neurology 2009; 73:
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

8. Study design Physio Intrinsic control Follow up Longterm V1 V2 V3 V4
Intervention:
4 week course with 3 physiotherapy sessions a week
= 12 x physiotherapy per patient

9. Read out Goal attainment score (Patient)
Objektorientierte Partitionierungsstrategien und Architekturbewertung ...
:23:45
Read out
Goal attainment score (Patient)
Berg balance score (Physiotherapist)
Ataxia rating scale (Neurologist)
Movement analysis (Computer)
Stadium 1: basaler Neocortex fronantal, temporal und occipital
Stadium 2:
Phases of [beta]-amyloidosis. Phase 1 is characterized by exclusively neocortical A[beta] deposits (Neocortex: black). Phase 2 shows additional allocortical A[beta] deposits (red arrows), phase 3 additional A[beta] deposits in diencephalic nuclei (red arrows) and the striatum (not shown), phase 4 additional A[beta] deposits in distinct brainstem nuclei (substantia nigra, red nucleus, central gray, superior and inferior collicle, inferior olivary nucleus, and intermediate reticular zone) (red arrows), and phase 5 in the cerebellum and additional brainstem nuclei (pontine nuclei, locus coeruleus, parabrachial nuclei, reticulo-tegmental nucleus, dorsal tegmental nucleus, and oral and central raphe nuclei) (red arrows).
Carsten Schulz-Key

10. Goal attainment score (GAS)
Objektorientierte Partitionierungsstrategien und Architekturbewertung ...
:23:45
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 1 2 3 4
Stadium 1: basaler Neocortex fronantal, temporal und occipital
Stadium 2:
Phases of [beta]-amyloidosis. Phase 1 is characterized by exclusively neocortical A[beta] deposits (Neocortex: black). Phase 2 shows additional allocortical A[beta] deposits (red arrows), phase 3 additional A[beta] deposits in diencephalic nuclei (red arrows) and the striatum (not shown), phase 4 additional A[beta] deposits in distinct brainstem nuclei (substantia nigra, red nucleus, central gray, superior and inferior collicle, inferior olivary nucleus, and intermediate reticular zone) (red arrows), and phase 5 in the cerebellum and additional brainstem nuclei (pontine nuclei, locus coeruleus, parabrachial nuclei, reticulo-tegmental nucleus, dorsal tegmental nucleus, and oral and central raphe nuclei) (red arrows).
Kiresuk et. al., 1994;
Lawrence Erlbaum Associates Inc.
Carsten Schulz-Key

11. Berg balance score (BBS)
Objektorientierte Partitionierungsstrategien und Architekturbewertung ...
:23:45
Berg balance score (BBS)
The BBS rates balance in a
physiotherapeutic examination
14 items addressed
Sitting
Stance
Gait
Timed movements
Stadium 1: basaler Neocortex fronantal, temporal und occipital
Stadium 2:
Phases of [beta]-amyloidosis. Phase 1 is characterized by exclusively neocortical A[beta] deposits (Neocortex: black). Phase 2 shows additional allocortical A[beta] deposits (red arrows), phase 3 additional A[beta] deposits in diencephalic nuclei (red arrows) and the striatum (not shown), phase 4 additional A[beta] deposits in distinct brainstem nuclei (substantia nigra, red nucleus, central gray, superior and inferior collicle, inferior olivary nucleus, and intermediate reticular zone) (red arrows), and phase 5 in the cerebellum and additional brainstem nuclei (pontine nuclei, locus coeruleus, parabrachial nuclei, reticulo-tegmental nucleus, dorsal tegmental nucleus, and oral and central raphe nuclei) (red arrows).
Berg et. al., 1989; Physiotherapy Canada
Carsten Schulz-Key

12. SARA Scale for the assessment and rating of ataxia (SARA)
Objektorientierte Partitionierungsstrategien und Architekturbewertung ...
:23:45
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)
Stadium 1: basaler Neocortex fronantal, temporal und occipital
Stadium 2:
Phases of [beta]-amyloidosis. Phase 1 is characterized by exclusively neocortical A[beta] deposits (Neocortex: black). Phase 2 shows additional allocortical A[beta] deposits (red arrows), phase 3 additional A[beta] deposits in diencephalic nuclei (red arrows) and the striatum (not shown), phase 4 additional A[beta] deposits in distinct brainstem nuclei (substantia nigra, red nucleus, central gray, superior and inferior collicle, inferior olivary nucleus, and intermediate reticular zone) (red arrows), and phase 5 in the cerebellum and additional brainstem nuclei (pontine nuclei, locus coeruleus, parabrachial nuclei, reticulo-tegmental nucleus, dorsal tegmental nucleus, and oral and central raphe nuclei) (red arrows).
Schmitz-Hübsch et. al., 2006; Neurology
Carsten Schulz-Key

13. 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
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

14. 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

15. 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
Pre
Post

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

17. 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

18. Case S.T. – stairs Pre 48 year old kindergarten teacher
Idiopathic cerebellar ataxia
Disease duration 1.5 years
Physiotherapy before the study:
Stabilisation exercises
Isometric training
Pre
Post
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

19. 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
Patients performing
continuous exercises were
doing better than those
without training
Ilg et al, Mov Disord 2010

20. Conclusions Move and improve!
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!

21. Thank you … … and the dream team!
Matthis Synofzik
Winfried Ilg
Doris Brötz