# Exercise as it relates to Disease/The effects of coordination training on cerebellar disease

This article is a critical analysis of the paper: "Intensive coordinative training improves motor performance in degenerative cerebellar disease”$_1$

## What is the background to this research?

The cerebellum plays a strong functional role in motor control as well as motor learning$_2$. Degenerative cerebellar diseases, including cerebellar ataxia and multiple system atrophy, share several distinctive features post onset including ocular degeneration, dysarthria, as well as progressive gait and limb ataxia$_3$.
Exercise is noted as the primary intervention for individuals with degenerative cerebellar disease. Exercise programs are proven to effect gait in relation to walking accuracy, speed, and dynamic balance. Improvement in these areas is particularly important in individuals with cerebellar disease as they act to improve mobility, and as a result, reduce falls risk which is highly prevalent in sufferers$_4$.

## Where is this research from?

The article was drawn from “Neurology,” a journal by the American Academy of Neurology. Neurology is recognised as the most widely used and highly cited peer-reviewed neurology journal.
The primary author of this article, Dr. Winfried Ilg, has been involved in 78 research items including 1 project, 44 articles and 25 full texts all pertaining to ataxia and other degenerative diseases$_1$.
The article is recognised as unbiased, providing Class III evidence. This is determined by the evidence pertaining to the opinions respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Ilg’s co-authors are also involved in research aligning with his studies of degenerative diseases, providing a wealth of knowledge and experience to the article$_1$.

## What kind of research was this?

The study undertaken was a case report, in which the target population is monitored in relation to a specific outcome.
As empirical inquiries, case reports provide natural, real world insight into certain populations and analysis of the events, conditions and outcomes pertaining to the study. Case reports are often avenues into further research, with evidence becoming stronger the more the outcomes are tested. They are becoming increasingly popular due to the ease in which they can be conducted, as well as their cost-effective nature$_5$.
Whilst this is the case, there is debate as to their validity, particularly in relation to the teaching of evidence based medicine. Evidence based medicine aims to optimise decision making by utilising evidence from reliable and well-conducted research$_5$. Therefore, data collated from case reports is not recognised as valid within these constructs.

## What did the research involve?

The study included 16 patients with progressive ataxia due to cerebellar degeneration (n = 10) or degeneration of afferent pathways (n = 6). Each patient underwent an intensive four-week coordinative training program to assess improvements in motor performance and reduction in ataxia symptoms. To ensure a holistic approach, parameters were measured on four occasions; 8 weeks prior to the program, immediately before the program, immediately after the program, and 8 weeks after the program$_1$.

## What were the results?

The four-week intensive program elicited significant improvement in motor performance and reduction of ataxia symptoms. Greater improvements were seen in patients with predominant cerebellar ataxia than patients with afferent ataxia in aspects of gait such as velocity, lateral sway and intra-limb coordination. These measures were all recorded in relation to the Scale for the Assessment and Rating of Ataxia (SARA) and the International Cooperative Ataxia Rating Scale (ICARS)$_1$.
Clinical Ataxia Scores for Study Participants :
| | SARA | SARA | SARA | SARA | ICARS | ICARS | ICARS | ICARS |
| Patient | E1 | E2 | E3 | E4 | E1 | E2 | E3 | E4 |
| C1 | 11 | 17 | 13 | 13.5 | 37 | 52 | 33 | 38 |
| C2 | 11.5 | 13.5 | 6 | 7 | 36 | 43 | 24 | 26 |
| C3 | 15 | 15 | 9 | 6.5 | 45 | 43 | 29 | 23 |
| C4 | 11 | 13.5 | 9.5 | 10 | 36 | 43 | 26 | 34 |
| C5 | 14 | 14.5 | 10 | 11 | 42 | 44 | 32 | 36 |
| C6 | 13.5 | 14 | 8.5 | 9.5 | 40 | 43 | 25 | 25 |
| C7 | 20 | 24.5 | 19 | 16.5 | 55 | 56 | 49 | 44 |
| C8 | 11 | 11.5 | 8.5 | 9 | 41 | 41 | 31 | 30 |
| C9 | 16.5 | 17 | 13 | 12 | 45 | 48 | 39 | 37 |
| C10 | 12.5 | 12.5 | 8 | 9.5 | 34 | 34 | 25 | 34 |
| A1 | 15.5 | 14 | 12 | 11 | 37 | 44 | 32 | 32 |
| A2 | 21 | 23 | 16.5 | 16.5 | 57 | 54 | 43 | 50 |
| A3 | 15 | 12.5 | 8 | 13 | 44 | 38 | 26 | 39 |
| A4 | 23 | 19 | 16 | 17 | 59 | 44 | 41 | 44 |
| A5 | 24 | 20 | 17 | 16 | 62 | 52 | 45 | 47 |
| A6 | 18 | 17 | 14 | 17.5 | 51 | 44 | 37 | 39 |

## Critique/analysis

The study design utilised creates a holistic analysis of each individuals baseline results and subsequent improvement post intervention. A comparison of results was conducted (E1 to E2, E2 to E3, E2 to E4 and E3 to E4) as a means of analysing each measure. This allowed for acknowledgement of individual disease progression and recognition of intervention based improvement. Individuals were also measured in comparison to internationally recognised ataxia rating scales. Through a thorough analysis of both pre and post-intervention results, in association with internationally recognised standards, the results within the article present with little bias and strong validity. Reliability and validity are furthered by the nature of the evidence presented (Class III), which utilises leading authorities in the subject area.
Whilst this is the case, the sample population within the study is small, utilising only 16 participants. A small sample population poses questions as to how applicable the concepts are to the greater population. Thus, it can be inferred that further research must be conducted as a means of consolidating the current results. Effects over a longer period should also be measured, taking into account the likelihood of individuals maintaining coordinative training post intervention.

## Practical Advice

As is supported by varying research articles and authors, coordinative and exercise training elicit positive results in relation to improving gait, balance and mobility in individuals with degenerative cerebellar diseases. Therefore, in association with an exercise physiologist, individuals suffering from cerebellar disease should regularly engage in exercise and coordination based programs, thus increasing functional movement ability.
Coordination Exercises - Physiotherapy

## Further research/relevant information

For further information surrounding Cerebellar Disease and the role of coordinative training/exercise please utilise the links below:
Cerebellar Disease
Exercise and Cerebellar Ataxia
Physical Medicine and Rehabilitation

## References

1. Ilg W, Synofzik M, Brotz D, Burkard S, Giese M, Schols L. Intensive coordinative training improves motor performance in degenerative cerebellar disease. Neurology. 2009;73(22):1823-1830.
2. Manto M, Bower J, Conforto A, Delgado-García J, da Guarda S, Gerwig M et al. Consensus Paper: Roles of the Cerebellum in Motor Control—The Diversity of Ideas on Cerebellar Involvement in Movement. The Cerebellum. 2011;11(2):457-487.
3. Ciolli L, Krismer F, Nicoletti F, Wenning G. An update on the cerebellar subtype of multiple system atrophy. Cerebellum & Ataxias. 2014;1(1):1-3.
4. Keller J, Bastian A. A Home Balance Exercise Program Improves Walking in People With Cerebellar Ataxia. Neurorehabilitation and Neural Repair. 2014;28(8):770-778.
5. Sayre J, Toklu H, Ye F, Mazza J, Yale S. Case Reports, Case Series – From Clinical Practice to Evidence-Based Medicine in Graduate Medical Education. Cureus. 2017;9(8):154.