Gait adaptability training improves obstacle avoidance and dynamic stability in patients with cerebellar degeneration

doi:10.1016/j.gaitpost.2014.04.190

Gait & Posture

Volume 40, Issue 1, May 2014, Pages 247-251

https://doi.org/10.1016/j.gaitpost.2014.04.190 Get rights and content

Highlights

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We examined the effects of gait adaptability training in patients with degenerative ataxia.
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Training was done on a treadmill projecting visual stepping targets and obstacles.
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Training improved obstacle avoidance during adaptive gait.
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Training also improved dynamic stability during obstacle avoidance.

Abstract

Balance and gait problems in patients with cerebellar degeneration lead to reduced mobility, loss of independence, and frequent falls. It is currently unclear, however, whether balance and gait capacities can be improved by training in this group of patients. Therefore, the aim of this study was to examine the effects of gait adaptability training on obstacle avoidance and dynamic stability during adaptive gait. Ten patients with degenerative cerebellar ataxia received 10 protocolized gait adaptability training sessions of 1 h each during 5 weeks. Training was performed on a treadmill with visual stepping targets and obstacles projected on the belt’s surface. As the primary outcome, we used an obstacle avoidance task while walking on a treadmill. We determined avoidance success rates, as well as dynamic stability during the avoidance manoeuvre. Clinical ratings included the scale for the assessment of ataxia (SARA), 10 m walking test, timed up-and-go test, berg balance scale, and the obstacle subtask of the emory functional ambulation profile (EFAP). Following the intervention, success rates on the obstacle avoidance task had significantly improved compared to pre-intervention. For successful avoidance, participants allowed themselves smaller stability margins in the sagittal plane in the (shortened) pre-crossing step. However, in the subsequent steps they returned to baseline stability values more effectively than before training. SARA scores and the EFAP obstacle subtask improved significantly as well. This pilot study provides preliminary evidence of a beneficial effect of gait adaptability training on obstacle avoidance capacity and dynamic stability in patients with cerebellar degeneration.

Introduction

Degenerative cerebellar ataxias are characterized by progressive disturbances in coordination, balance, and gait. Patients show an increased postural sway during stance and walking, which is omnidirectional, but greatest in anterior–posterior direction [1], [2]. Safe ambulation requires the ability to make gait adjustments dependent on environmental demands, such as stepping over uneven tiles. These step adjustments require a longer single leg stance phase. During avoidance of obstacles however, lateral instability is reported to be higher in ataxia patients due to a longer single-leg phase and simultaneous counter phase trunk movements, which are essential for obstacle crossing [2], [3]. All these factors contribute to a high risk of falling, with an incidence of falls up to 93% per year in patients with cerebellar degeneration, often accompanied with injuries and limitations in activities of daily living [4].

There are no pharmacologic treatments available at this moment that can provide sufficient symptomatic relief. As a result, physiotherapeutic interventions play an important role in the management of degenerative cerebellar ataxias, with improvements of balance, physical condition, and gait as main training goals [5]. As the cerebellum functions as a primary site for adaptation of limb movements and dynamic regulation of balance, and cerebellar patients are also known to have deficits in motor learning [6], [7], [8], the potential effectiveness of balance and gait training can be questioned. However, there is evidence of adaptation, functional motor retraining, and motor learning after cerebellar damage [9], [10], [11]. In addition, other studies suggest potential beneficial effects of physiotherapeutic interventions on balance, gait, upper limb functioning, and ataxia severity [5].

Since adjustment of gait patterns to the variable requirements of the environment is essential in daily life, gait adaptability training might be useful in improving walking and avoiding falls. This training modality has been reported to improve obstacle avoidance abilities and to reduce fall rates in healthy elderly. It was also found to ameliorate walking speed, step adjustments and balance in patients with stroke [12], [13], [14], [15]. The aim of this study was to examine the effects of gait adaptability training on an instrumented treadmill with visual cues on obstacle avoidance and dynamic stability in patients with degenerative cerebellar ataxia. We hypothesized that training would improve the participants’ ability to avoid sudden (physical) obstacles during walking on a treadmill, as well as dynamic stability during the obstacle crossing steps. We also expected these improvements to translate to better performance on a clinical overground walking test involving obstacle avoidance.

Section snippets

Subjects

We recruited ten male patients (age 61.4 ± 5.7 years, disease duration 8.5 ± 7.3 years) from the Department of Neurology of the Radboud University Nijmegen Medical Centre, seven diagnosed with sporadic adult-onset ataxia (SAOA), two patients with spinocerebellar ataxia type 6 (SCA6), and one with spinocerebellar ataxia type 3 (SCA3). Patients were included if they were diagnosed with degenerative cerebellar ataxia and no other causes for their symptoms were found. Exclusion criteria were the use of

Results

All patients completed the training and no adverse advents occurred.

Discussion

In this pilot study, we investigated the effect of gait adaptability training on obstacle avoidance and dynamic stability in patients with degenerative cerebellar ataxia. The training appeared to be feasible and was well appreciated by participants. After training, success rates on the obstacle avoidance task improved by 16%. Patients more frequently used a short step strategy to cross obstacles. In order to shorten the step in front of the obstacle, participants reduced their dynamic stability

Conflicts of interest

We have nothing to declare.

Acknowledgements

We are grateful to the participating patients and to Roland Loeffen for his technical support.

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View full text

Gait adaptability training improves obstacle avoidance and dynamic stability in patients with cerebellar degeneration

Highlights

Abstract

Introduction

Section snippets

Subjects

Results

Discussion

Conflicts of interest

Acknowledgements

Exp Neurol

Gait Posture

Hum Mov Sci

J Biomech

J Biomech

Trunk sway in patients with spinocerebellar ataxia

Mov Disord

Cerebellar ataxia: pathophysiology and rehabilitation

Clin Rehabil

Falls in spinocerebellar ataxias: results of the EuroSCA fall study

Cerebellum

The effectiveness of allied health care in patients with ataxia: a systematic review

J Neurol

Intact ability to learn internal models of arm dynamics in Huntington’s disease but not cerebellar degeneration

J Neurophysiol

Role of the cerebellum in the control and adaptation of gait in health and disease

Prog Brain Res

Hereditary cerebellar ataxia progressively impairs force adaptation during goal-directed arm movements

J Neurophysiol

Supervised learning of postural tasks in patients with poststroke hemiparesis, Parkinson’s disease or cerebellar ataxia

Exp Brain Res

Cerebellar stroke impairs temporal but not spatial accuracy during implicit motor learning

Neurorehabil Neural Repair