How to measure balance in clinical practice. A systematic review of the psychometrics and clinical utility of measures of balance activity for neurological conditions

Virtual reality in the rehabilitation of patients with stroke: an integrative review

ABSTRACT Objective: To describe the intervention protocols to using commercial video games as virtual reality (VR) in rehabilitation of patients with stroke. Methods: Integrative review using the descriptors “rehabilitation”, “virtual reality exposure therapy” and “videogames” in the LILACS and PUBMED databases. Articles published from 2011 to 2018 were selected. Results: We found 1,396 articles, 1,383 were excluded and 13 were selected. Most of the articles were randomized clinical trials published in 2014 or later. The sample size varied from 5–47 adults, or adults and elders, with chronic stroke. The Nintendo Wii® was the most used video game system. The intervention happened two or three times a week, each session lasting from 30 to 60 minutes, over 2–12 weeks. Balance, upper limb motor functions, quality of life and daily living activities were the most common evaluated outcomes. The Fugl-Meyer Assessment, Berg Balance Scale, Timed Up and Go test, Barthel Scale and SF-36 were the most common outcome measurement tools. Conclusions: The studies indicated improvement in dynamic balance, upper limb motor function and quality of life after rehabilitation using VR. The VR was more effective than conventional treatments for the outcome of dynamic balance. Two studies did not find any changes in static balance and daily living activities. Physical aspects and quality of life were the outcomes most evaluated by the researchers; as were the population with chronic strokes and protocols of long duration and low intensity. Few studies targeted immediate VR effects, performance in daily living activities and social participation.

Environmental Styrene Exposure and Sensory and Motor Function in Gulf Coast Residents

BACKGROUND

Although styrene is an established neurotoxicant at occupational exposure levels, its neurotoxicity has not been characterized in relation to general population exposures. Further, occupational research to date has focused on central nervous system impairment.

OBJECTIVE

We assessed styrene-associated differences in sensory and motor function among Gulf coast residents.

METHODS

We used 2011 National Air Toxics Assessment estimates of ambient styrene to determine exposure levels for 2,956 nondiabetic Gulf state residents enrolled in the Gulf Long-term Follow-up Study, and additionally measured blood styrene concentration in a subset of participants 1 to 2 y after enrollment ([Formula: see text]). Participants completed an enrollment telephone interview and a comprehensive test battery to assess sensory and motor function during a clinical follow-up exam 2 to 4 y later. Detailed covariate information was ascertained at enrollment via telephone interview. We used multivariate linear regression to estimate continuous differences in sensory and motor function, and log-binomial regression to estimate prevalence ratios for dichotomous outcomes. We estimated associations of both ambient and blood styrene exposures with sensory and motor function, independently for five unique tests.

RESULTS

Those participants in the highest 25% vs. lowest 75% of ambient exposure and those in the highest 10% vs. lowest 90% of blood styrene had slightly diminished visual contrast sensitivity. Mean vibrotactile thresholds were lower among those in the highest vs. lowest quartile of ambient styrene and the highest 10% vs. lowest 90% of blood styrene ([Formula: see text] log microns; 95% CI: [Formula: see text], [Formula: see text] and [Formula: see text] log microns; 95% CI: [Formula: see text], [Formula: see text], respectively). The highest vs. lowest quartile of ambient styrene was associated with significantly poorer postural stability, and (unexpectedly) with significantly greater grip strength.

DISCUSSION

We observed associations between higher styrene exposure and poorer visual, sensory, and vestibular function, though we did not detect associations with reduced voluntary motor system performance. Associations were more consistent for ambient exposures, but we also found notable associations with measured blood styrene. https://doi.org/10.1289/EHP3954.

Effectiveness of backward walking training on balance performance: A systematic review and meta-analysis

BACKGROUND

Backward walking (BW) training is thought to impact balance performance through improving motor system proprioception and gait characteristic, but relevant evidence remains sparse and inconclusive.

OBJECTIVE

This study systematically reviewed and quantified the scientific evidence regarding the effectiveness of BW training on balance performance.

METHODS

Keyword and reference search on BW training interventions was conducted in six electronic databases (PubMed, Web of science, SPORTDiscus, CINAHL, Cochrane Library, and CNKI) for peer-reviewed articles published till November 2017. A standardized form was used to extract data from each selected article that met the pre-specified eligibility criteria. Meta-analysis was conducted to estimate the pooled effects of BW training on balance performance measures.

RESULTS

Eleven studies (nine randomized controlled trials and two pre-post studies) met the eligibility criteria and were included in the review. All studies reported some beneficial effects of BW training on balance performance. Compared to control, BW training was associated with a reduction in overall stability index score by 0.99 (95% CI = 0.37, 1.61; I² = 0.0%; fixed-effect model), medial-lateral stability index score by 0.95 (95% CI = 0.34, 1.57; I² = 0.0%; fixed-effect model), and anterior-posterior stability index score by 0.99 (95% CI = 0.37, 1.61; I² = 0.0%; fixed-effect model). Meanwhile, BW training was associated with an increase in open-eyes single leg standing duration by 0.91 s (95% CI = 0.29, 1.53; I² = 75.9%; random-effect model) in comparison to control.

CONCLUSIONS

BW training could serve as a potentially useful tool to improve balance performance among those with a high risk of fall. However, current evidence remains preliminary due to the small cohort of studies and possible learning effect in pre-post studies. Future work with larger scale and randomized experimental design is warranted to evaluate the effectiveness of BW training on balance performance across diverse population and disease subgroups, and elucidate the underlying biomechanical and neurological pathways.

Toward Accurate Clinical Spasticity Assessment: Validation of Movement Speed and Joint Angle Assessments Using Smartphones and Camera Tracking

OBJECTIVE

To investigate whether a three-dimensional (3-D) camera (Microsoft Kinect) and a smartphone can be used to accurately quantify the joint angular velocity and range of motion (ROM) compared to a criterion-standard 3-D motion analysis system during a lower limb spasticity assessment.

DESIGN

Observational, criterion-standard comparison study.

SETTING

Large rehabilitation center.

PARTICIPANTS

A convenience sample of 35 controls, 35 patients with a neurologic condition, and 34 rehabilitation professionals (physiotherapists and rehabilitation doctors) participated (N=104).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Modified Tardieu Scale was used to assess spasticity of the quadriceps, hamstrings, soleus, and gastrocnemius. Data for each trial were collected concurrently using the criterion-standard Optitrack 3-D motion analysis (3DMA) system, Microsoft Kinect, and a smartphone. Each healthy control participant was assessed by 1 health professional and each patient with a neurological condition was assessed by 3 health professionals. Spearman correlation coefficient and intraclass correlation coefficient with 95% confidence intervals were used to report the strength of the relationships investigated.

RESULTS

The smartphone and Microsoft Kinect demonstrated excellent concurrent validity with the 3DMA system. Overall, 74.8% of the relationships investigated demonstrated a very strong (≥0.80) correlation across all of the testing parameters. The Microsoft Kinect was superior to the smartphone for measuring joint start and end angle, the smartphone was superior for measuring joint angular velocity, and the 2 systems were comparable for measuring total joint ROM.

CONCLUSIONS

These findings provide preliminary evidence that user-friendly, low-cost technologies can be used to facilitate accurate measurements of joint angular velocity and angles during a lower limb spasticity assessment in a clinical setting.

A Systematic Review of the Quality and Utility of Observer-Based Instruments for Assessing Medical Professionalism

BACKGROUND

Professionalism, which encompasses behavioral, ethical, and related domains, is a core competency of medical practice. While observer-based instruments to assess medical professionalism are available, information on their psychometric properties and utility is limited.

OBJECTIVE

We systematically reviewed the psychometric properties and utility of existing observer-based instruments for assessing professionalism in medical trainees.

METHODS

After selecting eligible studies, we employed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria to score study methodological quality. We identified eligible instruments and performed quality assessment of psychometric properties for each selected instrument. We scored the utility of each instrument based on the ability to distinguish performance levels over time, availability of objective scoring criteria, validity evidence in medical students and residents, and instrument length.

RESULTS

Ten instruments from 16 studies met criteria for consideration, with studies having acceptable methodological quality. Psychometric properties were variably assessed. Among 10 instruments, the Education Outcomes Service (EOS) group questionnaire and Professionalism Mini-Evaluation Exercise (P-MEX) possessed the best psychometric properties, with the P-MEX scoring higher on utility than the EOS group questionnaire.

CONCLUSIONS

We identified 2 instruments with best psychometric properties, with 1 also showing acceptable utility for assessing professionalism in trainees. The P-MEX may be an option for program directors to adopt as an observer-based instrument for formative assessment of medical professionalism. Further studies of the 2 instruments to aggregate additional validity evidence is recommended, particularly in the domain of content validity before they are used in specific cultural settings and in summative assessments.

Responsiveness and meaningful improvement of mobility measures following MS rehabilitation

Objective

To determine responsiveness of functional mobility measures, and provide reference values for clinically meaningful improvements, according to disability level, in persons with multiple sclerosis (pwMS) in response to physical rehabilitation.

Methods

Thirteen mobility measures (clinician- and patient-reported) were assessed before and after rehabilitation in 191 pwMS from 17 international centers (European and United States). Combined anchor- and distribution-based methods were used. A global rating of change scale, from patients' and therapists' perspective, served as external criteria when determining the area under the receiver operating characteristic curve (AUC), the minimally important change (MIC), and the smallest real change (SRC). Patients were stratified into 2 subgroups based on disability level (Expanded Disability Status Scale score ≤4 [n = 72], >4 [n = 119]).

Results

The Multiple Sclerosis Walking Scale–12, physical subscale of the Multiple Sclerosis Impact Scale–29 (especially for the mildly disabled pwMS), Rivermead Mobility Index, and 5-repetition sit-to-stand test (especially for the moderately to severely disabled pwMS) were the most sensitive measures in detecting improvements in mobility. Findings were determined once the AUC (95% confidence interval) was above 0.5, MIC was greater than SRC, and results were comparable from the patient and therapist perspective.

Conclusions

Responsiveness, clinically meaningful improvement, and real changes of frequently used mobility measures were calculated, showing great heterogeneity, and were dependent on disability level in pwMS.

[Characteristics of non-pharmacological interventions in the elderly with COPD. Smoking cessation, pulmonary rehabilitation, nutritional management and patient education]

Chronic obstructive pulmonary disease (COPD) is a respiratory disorder responsible for a high mortality and disability. People older than 65 years are more commonly affected than younger people and tend to present with more symptoms and a greater level of disability. Non-pharmacological interventions play an important role in the management of all patients with COPD and this is particularly true in the elderly. Given the improvement in quality of life and risk of hospitalization, smoking cessation should be promoted to patients of all ages. Increased physical activity is associated with reduced respiratory symptoms. Tests such as the "Short Physical Performance Battery" can be useful in frailer older people with COPD, while walking tests such as the 6-minute walk test are used as an assessment before pulmonary rehabilitation. Increased physical activity should be combined with nutritional management. Screening for undernutrition by questionnaire, body mass index and albumin quantification is recommended in the elderly. In case of undernutrition, oral supplementation seems to reduce the risk of re-admission. All these measures must be included in an education program adapted to the elderly comorbidities (hearing loss, isolation…).

Current state of balance assessment during transferring, sitting, standing and walking activities for the spinal cord injured population: A systematic review

CONTEXT

Comprehensive balance measures with high clinical utility and sound psychometric properties are needed to inform the rehabilitation of individuals with spinal cord injury (SCI).

OBJECTIVE

To identify the balance measures used in the SCI population, and to evaluate their clinical utility, psychometric properties and comprehensiveness.

METHODS

Medline, PubMed, Embase, Scopus, Web of Science, and the Allied and Complementary Medicine Database were searched from the earliest record to October 19/16. Two researchers independently screened abstracts for articles including a balance measure and adults with SCI. Extracted data included participant characteristics and descriptions of balance measures. Quality was evaluated by considering study design, sampling method and adequacy of description of research participants. Clinical utility of all balance measures was evaluated. Comprehensiveness was evaluated using the modified Systems Framework for Postural Control.

RESULTS

2820 abstracts were returned and 127 articles included. Thirty-one balance measures were identified; 11 evaluated a biomechanical construct and 20 were balance scales. All balance scales had high clinical utility. The Berg Balance Scale and Functional Reach Test were valid and reliable, while the mini-BESTest was the most comprehensive.

CONCLUSION

No single measure had high clinical utility, strong psychometric properties and comprehensiveness. The mini-BESTest and/or Activity-based Balance Level Evaluation may fill this gap with further testing of their psychometric properties.

Effects of orthopedic insoles on static balance of older adults wearing thick socks

BACKGROUND

The wearing of socks and insoles may affect the ability of the foot to detect tactile input influencing postural balance.

OBJECTIVES

The aim of this study was to investigate whether (1) thick socks adversely affected the elderly postural balance and (2) orthopedic insoles could improve the elderly postural balance while wearing thick socks.

STUDY DESIGN

Repeated-measures study design.

METHODS

In total, 14 healthy older adults were recruited. A monofilament test was conducted to evaluate foot plantar sensation with and without thick socks. Subjects then performed the Romberg tests under three conditions: (1) barefoot, (2) with socks only, and (3) with both socks and insoles. Postural balance was assessed by measuring the center of pressure movement during standing in each experimental condition.

RESULTS

Thick socks significantly decreased the monofilament score ( p < 0.001), suggesting reduction in ability to detect external forces. All center of pressure parameters increased significantly while wearing thick socks ( p < 0.017), implying reduction of postural stability. They then decreased significantly with the additional use of insoles ( p < 0.017).

CONCLUSION

Previous studies have documented the changes in plantar pressure distribution with the use of orthopedic insoles. This study further suggests that such changes in contact mechanics could produce some balance-improving effects, which appears not to have been reported earlier. Clinical relevance Wearing thick socks reduces plantar pressure sensitivity and increases postural sway which may increase risk of falls. Orthopedic insoles and footwear with similar design could potentially be a cost-effective method in maintaining postural balance when wearing thick socks.

Haptic-based perception-empathy biofeedback system for balance rehabilitation in patients with chronic stroke: Concepts and initial feasibility study

BACKGROUND

Most individuals have sensory disturbances post stroke, and these deficits contribute to post-stroke balance impairment. The haptic-based biofeedback (BF) system appears to be one of the promising tools for balance rehabilitation in patients with stroke, and the BF system can increase the objectivity of feedback and encouragement than that provided by a therapist.

RESEARCH QUESTION

Studies in skill science indicated that feedback or encouragement from a coach or trainer enhances motor learning effect. Nevertheless, the optimal BF system (or its concept) which would refine the interpersonal feedback between patients and therapist has not been proposed. Thus, the purpose of this study was to propose a haptic-based perception-empathy BF system which provides information regarding the patient's center-of-foot pressure (CoP) pattern to the patient and the physical therapist to enhance the motor learning effect and validate the feasibility of this balance-training regimen in patients with chronic stroke.

METHODS

This study used a pre-post design without control group. Nine chronic stroke patients (mean age: 64.4 ± 9.2 years) received a balance-training regimen using this BF system twice a week for 4 weeks. Testing comprised quantitative measures (i.e., CoP) and clinical balance scale (Berg Balance Scale, BBS; Functional Reach Test, FRT; and Timed-Up and Go test, TUG).

RESULTS AND SIGNIFICANCE

Post training, patients demonstrated marginally reduced postural spatial variability (i.e., 95% confidence elliptical area), and clinical balance performance significantly improved at post-training. Although the changes in FRT and TUG exceeded the minimal detectable change (MDC), changes in BBS did not reach clinical significance (i.e., smaller than MDC). These results may provide initial knowledge (i.e., beneficial effects, utility and its limitation) of the proposed BF system in designing effective motor learning strategies for stroke rehabilitation. More studies are required addressing limitations due to research design and training method for future clinical use.

Functional Reach, Depression Scores, and Number of Medications Are Associated With Number of Falls in People With Chronic Stroke

BACKGROUND

Falls are a common adverse event among people with stroke. Previous studies investigating risk of falls after stroke have relied primarily on retrospective fall history ranging from 6-12 months recall, with inconsistent findings.

OBJECTIVES

To identify factors and balance assessment tools that are associated with number of falls in individuals with chronic stroke.

DESIGN

Secondary analysis of a randomized clinical trial.

SETTING

Multisite academic and clinical institutions.

PARTICIPANTS

Data from 181 participants with stroke (age 60.67 ± 11.77 years, post stroke 4.51 ± 4.78 years) were included.

METHODS

Study participants completed baseline testing and were prospectively asked about falls. A multivariate negative binomial regression was used to identify baseline predictive factors predicting falls: age, endurance (6 minute walk test), number of medications, motor control (Fugl-Meyer lower extremity score), depression (Patient Health Questionnaire-9), physical activity (number of steps per week), and cognition (Mini Mental Status Exam score). A second negative binomial regression analysis was used to identify baseline balance assessment scores predicting falls: gait velocity (comfortable 10 Meter Walk), Berg Balance Scale (BBS), Timed Up and Go (TUG), and Functional Reach Test (FRT). Receiver operating characteristic (ROC) and area under the curve (AUC) were used to determine the cutoff scores for significant predictors of recurrent falls.

MAIN OUTCOME MEASUREMENT

The number of falls during the 42-week follow-up period.

RESULTS

Baseline measures that significantly predicted the number of falls included increased number of medications, higher depression scores, and decreased FRT. Cutoff scores for the number of medications were 8.5 with an AUC of 0.68. Depression scores differentiated recurrent fallers at a threshold of 2.5 scores with an AUC of 0.62. FRT differentiated recurrent fallers at a threshold of 18.15 cm with an AUC of 0.66.

CONCLUSIONS

Number of medications, depression scores, and decreased FRT distance at baseline were associated with increased number of falls. Increased medications might indicate multiple comorbidities or polypharmacy effect; increased depression scores may indicate psychological status; and decreased functional reach distance could indicate dynamic balance impairments.

LEVEL OF EVIDENCE

II.

Test-retest reliability of a balance testing protocol with external perturbations in young healthy adults

External perturbations are utilized to challenge balance and mimic realistic balance threats in patient populations. The reliability of such protocols has not been established. The purpose was to examine test-retest reliability of balance testing with external perturbations. Healthy adults (n=34; mean age 23 years) underwent balance testing over two visits. Participants completed ten balance conditions in which the following parameters were combined: perturbation or non-perturbation, single or double leg, and eyes open or closed. Three trials were collected for each condition. Data were collected on a force plate and external perturbations were applied by translating the plate. Force plate center of pressure (CoP) data were summarized using 13 different CoP measures. Test-retest reliability was examined using intraclass correlation coefficients (ICC) and Bland-Altman plots. CoP measures of total speed and excursion in both anterior-posterior and medial-lateral directions generally had acceptable ICC values for perturbation conditions (ICC=0.46 to 0.87); however, many other CoP measures (e.g. range, area of ellipse) had unacceptable test-retest reliability (ICC<0.70). Improved CoP measures were present on the second visit indicating a potential learning effect. Non-perturbation conditions generally produced more reliable CoP measures than perturbation conditions during double leg standing, but not single leg standing. Therefore, changes to balance testing protocols that include external perturbations should be made to improve test-retest reliability and diminish learning including more extensive participant training and increasing the number of trials. CoP measures that consider all data points (e.g. total speed) are more reliable than those that only consider a few data points.

Hand-Held Dynamometer is a Reliable Tool to Measure Trunk Muscle Strength in Chronic Stroke

INTRODUCTION

Patients with chronic stroke show atypical coordination of trunk movement and they find difficulty during bed mobility and transfer skills due to weakness of trunk muscles. Routine bedside clinical examination fails to quantify the trunk muscle strength in patients with stroke. Handheld dynamometer is widely administered to quantify the strength of extremities, but its reliability on testing the trunk muscles strength is limited.

AIM

This study aimed at examining the reliability of hand-held dynamometer to quantify the strength of trunk muscle groups in chronic stroke.

MATERIALS AND METHODS

This reliability study was conducted in outpatient clinical settings. Patients with chronic stroke aged between 30 and 80 years and an ambulatory capacity of 10-meter distance volunteered in the study. The strength of trunk flexors, extensors, rotators towards most and least affected sides and bilateral lateral flexors was examined by break test using hand-held dynamometer and the isometric strength was reported in pounds (lb.). These tests were carried out by two physical therapists independently at two time points and the assessment procedure was standardized. Pearson's correlation test was conducted to observe the reliability of dynamometer strength testing i.e., internal consistency of the measure and intra-class correlation coefficient (r).

RESULTS

Of the 85 study participants, 51 of them had most trunk involvement on the left side and 34 had it on the right side. This study showed an excellent intra-rater (0.88-0.98) and inter-rater (0.84-0.96) reliability of trunk muscle strength testing using hand-held dynamometer.

CONCLUSION

Hand-held dynamometer showed excellent intra and inter tester reliability to quantify the trunk muscle strength in patients with chronic stroke. So this tool can easily be administered in clinical and rehabilitation settings for diagnostic and prognostic purposes.

Comparison of the Mini-Balance Evaluations Systems Test with the Berg Balance Scale in relationship to walking speed and motor recovery post stroke

BACKGROUND

The Mini-BESTest is a recently developed balance assessment tool that incorporates challenging dynamic balance tasks. Few studies have compared the psychometric properties of the Mini-BESTest to the commonly used Berg Balance Scale (BBS). However, the utility of these scales in relationship to post stroke walking speeds has not been explored.

OBJECTIVES

The purpose of this study was to compare the sensitivity and specificity of the Mini-BESTest and BBS to evaluate walking speeds in individuals with stroke.

DESIGN

A retrospective exploratory design.

METHODS

Forty-one individuals with chronic stroke were evaluated with the Mini-BESTest, BBS, and 10-meter self-selected walk test (10MWT). Based on their self-selected gait speeds (below or above 0.8 m/s), participants were classified as slow and fast walkers.

RESULTS

Significant linear correlations were observed between the Mini-BESTest vs. BBS (r = 0.72, p ≤ 0.001), Mini-BESTest vs. 10MWT (r = 0.58, p ≤ 0.001), and BBS vs. 10MWT (r = 0.30, p = 0.05). Independent t-tests comparing the balance scores for the slow and fast walkers revealed significant group differences for the Mini-BESTest (p = 0.003), but not for the BBS (p = 0.09). The Mini-BESTest demonstrated higher sensitivity (93%) and specificity (64%) compared to the BBS (sensitivity 81%, specificity 56%) for discriminating participants into slow and fast walkers.

CONCLUSIONS

The Mini-BESTest has a greater discriminative ability than the BBS to categorize individuals with stroke into slow and fast walkers.

A cross-sectional study comparing lateral and diagonal maximum weight shift in people with stroke and healthy controls and the correlation with balance, gait and fear of falling

Impaired balance is common post stroke and can be assessed by means of force-platforms measuring center of pressure (COP) displacements during static standing, or more dynamically during lateral maximum weight shift (MWS). However, activities of daily life also include diagonal MWS and since force platforms are nowadays commercially available, investigating lateral and diagonal MWS in a clinical setting might be feasible and clinically relevant. We investigated lateral and diagonal MWS while standing in patients with stroke (PwS) and healthy controls (HC), evaluated MWS towards the affected and the non-affected side for PwS and correlated MWS with measures of balance, gait and fear of falling. In a cross-sectional observational study including 36 ambulatory sub-acute inpatients and 32 age-matched HC, a force platform (BioRescue, RM Ingénierie, France) was used to measure lateral and diagonal MWS in standing. Clinical outcome measures collected were Berg Balance Scale and Community Balance and Mobility Scale (CBMS) for balance, 10-meter walk test (10MWT) for gait speed and Falls Efficacy Scale–international version for fear of falling. MWS for PwS towards the affected side was significantly smaller compared to HC (lateral: p = 0.029; diagonal-forward: p = 0.000). MWS for PwS was also significantly reduced towards the affected side in the diagonal-forward direction (p = 0.019) compared to the non-affected side of PwS. Strong correlations were found for MWS for PwS in the diagonal-forward direction towards the affected side, and clinical measures of balance (CBMS: r = 0.66) and gait speed (10MWT: r = 0.66). Our study showed that ambulatory sub-acute PwS, in comparison to HC, have decreased ability to shift their body weight diagonally forward in standing towards their affected side. This reduced ability is strongly related to clinical measures of balance and gait speed. Our results suggest that MWS in a diagonal-forward direction should receive attention in rehabilitation of ambulatory sub-acute PwS in an inpatient setting.

Altered postural control and stability in cirrhotic patients with minimal hepatic encephalopathy correlate with cognitive deficits

BACKGROUND & AIMS

Cognitive dysfunction in cirrhotic patients with minimal hepatic encephalopathy (MHE) is associated with falls. Alterations in postural control and stability could contribute to increase falls risk in these patients. We aimed to assess whether postural control and direction-specific limits of stability are altered in cirrhotic patients with MHE compared to patients without MHE and controls. We also assessed if alterations in postural control correlate with neurological impairment and/or blood biomarkers.

METHODS

Posturography analysis, attention Stroop test and bimanual and visuo-motor coordination tests were performed in 18 controls, 19 patients with cirrhosis without MHE and 17 with MHE, diagnosed by PHES. Posturography was assessed by NedSVE^® /IBV system under four sensory conditions. Limits of stability and rhythmic weight-shifting tests were also performed. Blood ammonia and serum interleukins were also measured. Falls were assessed after 12-24 months follow-up.

RESULTS

MHE patients show impaired balance, mainly on unstable surface with eyes open, with longer reaction and confinement times and lower success in Limits of Stability test compared to patients without MHE. Performance in attention and motor coordination tests correlated with most posturography parameters alterations. Logistic regression analysis shows that posturography parameters and bimanual coordination test are good predictors of falls.

CONCLUSION

Balance patterns and limits of stability in MHE patients are impaired compared to patients without MHE and controls. This seems to contribute to a higher falls risk. Attention and motor coordination deficits could contribute to balance impairment in patients with MHE.

Effects of phase proprioceptive training on balance in patients with chronic stroke

[Purpose] This study aimed to investigate the effect of phase proprioceptive training on balance in patients with chronic stroke. [Subjects and Methods] Participants included 30 patients with stroke who were randomly assigned to the proprioceptive training group (n=15) or control group (n=15). Participants in the proprioceptive training group underwent proprioceptive training and received general physical therapy each for a total of 20 thirty-minute sessions, five times per week, during a period of four weeks; the control group received general physical therapy for a total of 20 sixty-minute sessions, five times per week, during a period of four weeks. [Results] All participants were evaluated with the Berg Balance Scale, Timed Up and Go (TUG) test, and Activities-specific Balance Confidence (ABC) Scale instrument before and after intervention. After training, the differences in BBS, TUG, and ABC scores in the proprioceptive group were significantly greater than those in the control group. [Conclusion] In conclusion, proprioceptive training was effective on balance ability. Therefore, proprioceptive training may be efficient when combining general physical therapy with phase proprioceptive training for patients with impairments of balance. Further research is needed to investigate proprioceptive training methods.

Assessing postural balance in early Parkinson's Disease-validity of the BDL balance scale

BACKGROUND

There is a need for a valid assessment test of balance in early Parkinson's disease (PD).

OBJECTIVE

To validate the Bäckstrand Dahlberg Liljenäs Balance Scale (BDL), a test of balance performance constructed to assess mild to moderate balance disability due to neurological disease, for use in persons with early PD.

METHODS

Cross-sectional psychometric evaluation study from a convenience sample community-dwelling persons with PD (n = 28).

MAIN MEASURES

The BDL was validated using the Berg Balance Scale (BBS), the motor part of the Unified Parkinson's Disease Rating Scale (mUPDRS), the Timed Up and Go (TUG) and Timed Up and Go-cognition (CTUG). Correlations were calculated by Spearman's rank correlation coefficient (rho). Rasch analyses were used to test the internal construct of the BDL. The result from the BDL was compared to a healthy reference group.

RESULTS

The correlation between the BDL and the BBS (rho = 0.703) was high positive, while for mUPDRS (rho = -0.280), TUG (rho = -0.321) and CTUG (rho = -0.361) the correlations with the BDL were negligible to low negative. The Rasch analyses for the BDL showed a good distribution of the task difficulties with neither ceiling nor floor effect among individual measures. There was a significant difference (p = 0.03) in performance of the BDL between the PD group and the healthy reference group.

CONCLUSIONS

The BDL Balance Scale can be considered a valid clinical assessment test when evaluating balance training interventions in persons with early PD. It can be recommended as an outcome measure in clinical practice and in clinical research within this population.

Components of Standing Postural Control Evaluated in Pediatric Balance Measures: A Scoping Review

OBJECTIVE

To identify measures of standing balance validated in pediatric populations, and to determine the components of postural control captured in each tool.

DATA SOURCES

Electronic searches of MEDLINE, Embase, and CINAHL databases using key word combinations of postural balance/equilibrium, psychometrics/reproducibility of results/predictive value of tests, and child/pediatrics; gray literature; and hand searches.

STUDY SELECTION

Inclusion criteria were measures with a stated objective to assess balance, with pediatric (≤18y) populations, with at least 1 psychometric evaluation, with at least 1 standing task, with a standardized protocol and evaluation criteria, and published in English. Two reviewers independently identified studies for inclusion. There were 21 measures included.

DATA EXTRACTION

Two reviewers extracted descriptive characteristics, and 2 investigators independently coded components of balance in each measure using a systems perspective for postural control, an established framework for balance in pediatric populations.

DATA SYNTHESIS

Components of balance evaluated in measures were underlying motor systems (100% of measures), anticipatory postural control (72%), static stability (62%), sensory integration (52%), dynamic stability (48%), functional stability limits (24%), cognitive influences (24%), verticality (9%), and reactive postural control (0%).

CONCLUSIONS

Assessing children's balance with valid and comprehensive measures is important for ensuring development of safe mobility and independence with functional tasks. Balance measures validated in pediatric populations to date do not comprehensively assess standing postural control and omit some key components for safe mobility and independence. Existing balance measures, that have been validated in adult populations and address some of the existing gaps in pediatric measures, warrant consideration for validation in children.

Patient-reported questionnaires in MS rehabilitation: responsiveness and minimal important difference of the multiple sclerosis questionnaire for physiotherapists (MSQPT)

Background

The Multiple Sclerosis Questionnaire for Physical Therapists (MSQPT) is a patient-rated outcome questionnaire for evaluating the rehabilitation of persons with multiple sclerosis (MS). Responsiveness was evaluated, and minimal important difference (MID) estimates were calculated to provide thresholds for clinical change for four items, three sections and the total score of the MSQPT.

Methods

This multicentre study used a combined distribution- and anchor-based approach with multiple anchors and multiple rating of change questions. Responsiveness was evaluated using effect size, standardized response mean (SRM), modified SRM and relative efficiency. For distribution-based MID estimates, 0.2 and 0.33 standard deviations (SD), standard error of measurement (SEM) and minimal detectable change were used_. Triangulation of anchor- and distribution-based MID estimates provided a range of MID values for each of the four items, the three sections and the total score of the MSQPT. The MID values were tested for their sensitivity and specificity for amelioration and deterioration for each of the four items, the three sections and the total score of the MSQPT. The MID values of each item and section and of the total score with the best sensitivity and specificity were selected as thresholds for clinical change.

The outcome measures were the MSQPT, Hamburg Quality of Life Questionnaire for Multiple Sclerosis (HAQUAMS), rating of change questionnaires, Expanded Disability Status Scale, 6-metre timed walking test, Berg Balance Scale and 6-minute walking test.

Results

The effect size ranged from 0.46 to 1.49. The SRM data showed comparable results. The modified SRM ranged from 0.00 to 0.60. Anchor-based MID estimates were very low and were comparable with SD- and SEM-based estimates. The MSQPT was more responsive than the HAQUAMS in detecting improvement but less responsive in finding deterioration. The best MID estimates of the items, sections and total score, expressed in percentage of their maximum score, were between 5.4% (activity) and 22% (item 10) change for improvement and between 5.7% (total score) and 22% (item 10) change for deterioration.

Conclusions

The MSQPT is a responsive questionnaire with an adequate MID that may be used as threshold for change during rehabilitation of MS patients.

Trial registration

This trial was retrospectively (01/24/2015) registered in ClinicalTrials.gov as NCT02346279.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-017-0834-1) contains supplementary material, which is available to authorized users.

Perception and use of balance measures for stroke patients among physical therapists in South Korea

[Purpose] The purpose of this study looked into physical therapists’ perception and use of balance measures for stroke patients. [Subjects and Methods] Three hundred eighty two physical therapists who understood the purpose of this study, agreed on their participation in this study, were treating or treated stroke patients. A Cross-sectional study based on self-administered questionnaire that had a total of 41 questions was performed in South Korea. 382 questionnaires were used for analysis. [Results] Regarding the questions about their perception and of personal measures, 287 persons (75.1%) replied that Single Leg Stance test was the most useful. According to the data analysis on their use of balance measures, Single Leg Stance Test was used by 254 persons (66.5%, the highest percentage), Functional Reach Test by 199 (52.1%). Also, stepwise multiple regression analysis was conducted. As a result, the most influential factor was physical therapists’ perception of personal measures, and their use was also influenced by their comprehensive perception of measurement and their perception of balance factors. [Conclusion] This study revealed physical therapists’ perception and use of balance measures for stroke patients and showed that their perception of balance measures for stroke patients affected their use of personal measures.

Efficiency of physical therapy on postural imbalance after stroke: study protocol for a systematic review and meta-analysis

INTRODUCTION

Stroke frequently results in balance disorders, leading to lower levels of activity and a diminution in autonomy. Current physical therapies (PT) aiming to reduce postural imbalance have shown a large variety of effects with low levels of evidence. The objectives are to determine the efficiency of PT in recovering from postural imbalance in patients after a stroke and to assess which PT is more effective.

METHODS AND ANALYSIS

We will search several databases from inception to October 2015. Only randomised controlled trials assessing PT to recover from poststroke postural imbalance in adults will be considered.Outcome measures will be the Berg Balance Scale (BBS), the Postural Assessment Scale for Stroke (PASS), the 'weight-bearing asymmetry' (WBA), the 'centre of pressure' (COP) and the 'limit of stability' (LOS). WBA, COP and LOS are measured by a (sitting or standing) static evaluation on force plate or another device.Two independent reviewers will screen titles, abstracts and full-text articles, evaluate the risk of bias and will perform data extraction. In addition to the outcomes, measures of independence will be analysed. This study will aim at determining the effects of PT on the function (WBA, COP, LOS), the activity (BBS, PASS) and the independence of patients. Subgroup analyses will be planned according to the location of brain lesion (hemispheric, brainstem or cerebellum), the time since stroke (early, late, chronic), the PT (type, main aim (direct effect or generalisation), overall duration), the type of approaches (top-down or bottom-up) and the methodological quality of studies.

ETHICS AND DISSEMINATION

No ethical statement will be required. The results will be published in a peer-reviewed journal. This meta-analysis aims at managing the rehabilitation after postural imbalance by PT after a stroke.

TRIAL REGISTRATION NUMBER

Prospero CRD42016037966;Pre-results.

Comprehensive clinical sitting balance measures for individuals following stroke: a systematic review on the methodological quality

PURPOSE

The aim of this systematic review was to examine the psychometric properties of published clinical sitting measurement scales containing dynamic tasks in individuals following stroke.

METHOD

Databases, including Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, Cochrane, PubMed and Allied and Complementary Medicine Database (AMED) were searched from inception to December 2015. The search strategy included terms relating to sitting, balance and postural control. Two reviewers independently selected and extracted data from the identified articles and assessed the methodological quality of the papers using the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist.

RESULTS

Fourteen clinical sitting measurement scales (39 papers) containing dynamic tasks met the inclusion criteria and various measurement properties were evaluated. The methodological quality of the majority of the included studies was rated as poor to fair using the COSMIN checklist, with common limitations including small sample size and inappropriate use of statistical methods.

CONCLUSIONS

This review was unable to identify measures with sufficient psychometric properties to enable recommendation as preferred tools. However, measures were identified that warrant further specific psychometric investigations to fulfil requirements for a high quality measure. Implications for Rehabilitation Fourteen clinical sitting balance scales containing dynamic tasks are available to measure sitting balance with individuals following stroke. No single scale has sufficient psychometric properties to enable recommendation as a preferred tool for measuring sitting balance with stroke survivors. Use of a balance scale or dedicated sitting balance measure containing static and dynamic sitting items should be utilised to monitor progress for individuals following stroke with more severe deficits.

Dynamic Balanced Reach: A Temporal and Spectral Analysis Across Increasing Performance Demands

Standing balanced reach is a fundamental task involved in many activities of daily living that has not been well analyzed quantitatively to assess and characterize the multisegmental nature of the body's movements. We developed a dynamic balanced reach test (BRT) to analyze performance in this activity; in which a standing subject is required to maintain balance while reaching and pointing to a target disk moving across a large projection screen according to a sum-of-sines function. This tracking and balance task is made progressively more difficult by increasing the disk's overall excursion amplitude. Using kinematic and ground reaction force data from 32 young healthy subjects, we investigated how the motions of the tracking finger and whole-body center of mass (CoM) varied in response to the motion of the disk across five overall disk excursion amplitudes. Group representative performance statistics for the cohort revealed a monotonically increasing root mean squared (RMS) tracking error (RMSE) and RMS deviation (RMSD) between whole-body CoM (projected onto the ground plane) and the center of the base of support (BoS) with increasing amplitude (p < 0.03). Tracking and CoM response delays remained constant, however, at 0.5 s and 1.0 s, respectively. We also performed detailed spectral analyses of group-representative response data for each of the five overall excursion amplitudes. We derived empirical and analytical transfer functions between the motion of the disk and that of the tracking finger and CoM, computed tracking and CoM responses to a step input, and RMSE and RMSD as functions of disk frequency. We found that for frequencies less than 1.0 Hz, RMSE generally decreased, while RMSE normalized to disk motion amplitude generally increased. RMSD, on the other hand, decreased monotonically. These findings quantitatively characterize the amplitude- and frequency-dependent nature of young healthy tracking and balance in this task. The BRT is not subject to floor or ceiling effects, overcoming an important deficiency associated with most research and clinical instruments used to assess balance. This makes a comprehensive quantification of young healthy balance performance possible. The results of such analyses could be used in work space design and in fall-prevention instructional materials, for both the home and work place. Young healthy performance represents "exemplar" performance and can also be used as a reference against which to compare the performance of aging and other clinical populations at risk for falling.

Minimal Clinically Important Difference of Berg Balance Scale in People With Multiple Sclerosis

OBJECTIVE

To identify the minimal clinically important difference (MCID) to define clinically meaningful patient's improvement on the Berg Balance Scale (BBS) in people with multiple sclerosis (PwMS) in response to rehabilitation.

DESIGN

Cohort study.

SETTING

Neurorehabilitation institute.

PARTICIPANTS

PwMS (N=110).

INTERVENTIONS

This study comprised inpatients and outpatients who participated in research on balance and gait rehabilitation. All received 20 rehabilitation sessions with different intensities. Inpatients received daily treatments over a period of 4 weeks, while outpatients received 2 to 3 treatments per week for 10 weeks.

MAIN OUTCOME MEASURES

An anchor-based approach using clinical global impression of improvement in balance (Activities-specific Balance Confidence [ABC] Scale) was used to determine the MCID of the BBS. The MCID was defined as the minimum change in the BBS total score (postintervention - preintervention) that was needed to perceive at least a 10% improvement on the ABC Scale. Receiver operating characteristic curves were used to define the cutoff of the optimal MCID of the BBS discriminating between improved and not improved subjects.

RESULTS

The MCID for change on the BBS was 3 points for the whole sample, 3 points for the inpatients, and 2 points for the outpatients. The area under the curve was .65 for the whole sample, .64 for inpatients, and .68 for outpatients.

CONCLUSIONS

The MCID for improvement in balance as measured by the BBS was 3 points, meaning that PwMS are likely to perceive that as a reproducible and clinically important change in their balance performance.

Balance and mobility assessment for ruling-out the peripheral neuropathy of the lower limbs in older adults

The peripheral neuropathy of the lower limbs (PNLL) is an important cause of balance and mobility impairment in older adults. The nerve conduction study (NCS) is the gold standard for PNLL diagnosis. Aim of this work is to establish the sensitivity (Sn) and the specificity (Sp) of the balance and mobility examination for the PNLL in older adults. This study consecutively recruited 72 participants (>65years) who accessed to the clinical neurophysiology outpatient clinic for suspected PNLL. Participants were given the NCS and four clinical tests. Mobility was evaluated by the Timed Up and Go (TUG) test, the Performance Oriented Mobility Assessment (POMA) and the de Morton Mobility Index (DEMMI). In addition the Clinical Evaluation of Static Upright Stance (CELSIUS) scale was developed for a selective evaluation of static balance. Based on the NCS, 36% of participants had PNLL. The CELSIUS scale (cutoff: 19.5/24), the TUG test (cutoff: 9.6s) and the DEMMI scale (cutoff: 17.5/19) have high Sn (0.92÷0.96), but low Sp (0.28÷0.43) for the PNLL in the older adult. POMA scale (cutoff: 14.5/16) has low Sn (0.73), but acceptable Sp (0.85). In addition, CELSIUS, DEMMI and TUG negative likelihood ratios are 0.13, 0.17 and 0.12, respectively. Balance and mobility examination have high sensitivity for PNLL. CELSIUS score>19/24, DEMMI score>17/19 or TUG time≤9.6s substantially reduce PNLL likelihood. These clinical measures are thus recommended for ruling-out PNLL in the older adult.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Posturography using the Wii Balance Board™: A feasibility study with healthy adults and adults post-stroke

BACKGROUND

Posturography systems that incorporate force platforms are considered to assess balance and postural control with greater sensitivity and objectivity than conventional clinical tests. The Wii Balance Board (WBB) system has been shown to have similar performance characteristics as other force platforms, but with lower cost and size.

OBJECTIVES

To determine the validity and reliability of a freely available WBB-based posturography system that combined the WBB with several traditional balance assessments, and to assess the performance of a cohort of stroke individuals with respect to healthy individuals.

METHODS

Healthy subjects and individuals with stroke were recruited. Both groups were assessed using the WBB-based posturography system. Individuals with stroke were also assessed using a laboratory grade posturography system and a battery of clinical tests to determine the concurrent validity of the system. A group of subjects were assessed twice with the WBB-based system to determine its reliability.

RESULTS

A total of 144 healthy individuals and 53 individuals with stroke participated in the study. Concurrent validity with another posturography system was moderate to high. Correlations with clinical scales were consistent with previous research. The reliability of the system was excellent in almost all measures. In addition, the system successfully characterized individuals with stroke with respect to the healthy population.

CONCLUSIONS

The WBB-based posturography system exhibited excellent psychometric properties and sensitivity for identifying balance performance of individuals with stroke in comparison with healthy subjects, which supports feasibility of the system as a clinical tool.

A comparison between the Static Balance Test and the Berg Balance Scale: validity, reliability, and comparative resource use

Objective:

Within a sample of acute post-stroke patients, to compare the score on the Berg Balance Scale and the Static Balance Test for validity, inter-rater reliability, and the expenditure of time.

Design:

Prospective, intra-individual, cross-sectional evaluation study.

Setting:

Acute stroke unit of a university hospital in Germany.

Participants:

A total of 53 patients with acute stroke who did not have other pathology affecting their balance.

Main outcome measure:

For intra-individual comparisons of the Berg Balance Scale and the Static Balance Test, Pearson correlation coefficients were calculated. For inter-rater reliability, Bland Altman plots were drawn and the corresponding mean difference and limits of agreement were calculated.

Results:

The Static Balance Test took three to five minutes; the Berg Balance Scale 20–30 minutes. There was a high correlation between the scores on the Berg Balance Scale and the Static Balance Test (r = 0.91). For the Berg Balance Scale, the mean difference between the two raters was 0.13 and the limits of agreement were small (–0.25; 0.51). For the Static Balance Test, the mean difference between the two raters was −0.02 and also the limits of agreement (–0.06; 0.02) were even smaller than for the Berg Balance Scale. Both scales showed excellent inter-rater reliability.

Conclusion:

The Static Balance Test was compared with the Berg Balance Scale and turned out to be equally valid, more reliable, and takes much less time. For the moment, the scale can be recommended for the use in acute stroke care, especially for the daily routine therapy.

Recommendations for a core outcome set for measuring standing balance in adult populations: a consensus-based approach

BACKGROUND

Standing balance is imperative for mobility and avoiding falls. Use of an excessive number of standing balance measures has limited the synthesis of balance intervention data and hampered consistent clinical practice.

OBJECTIVE

To develop recommendations for a core outcome set (COS) of standing balance measures for research and practice among adults.

METHODOLOGY

A combination of scoping reviews, literature appraisal, anonymous voting and face-to-face meetings with fourteen invited experts from a range of disciplines with international recognition in balance measurement and falls prevention. Consensus was sought over three rounds using pre-established criteria.

DATA SOURCES

The scoping review identified 56 existing standing balance measures validated in adult populations with evidence of use in the past five years, and these were considered for inclusion in the COS.

RESULTS

Fifteen measures were excluded after the first round of scoring and a further 36 after round two. Five measures were considered in round three. Two measures reached consensus for recommendation, and the expert panel recommended that at a minimum, either the Berg Balance Scale or Mini Balance Evaluation Systems Test be used when measuring standing balance in adult populations.

LIMITATIONS

Inclusion of two measures in the COS may increase the feasibility of potential uptake, but poses challenges for data synthesis. Adoption of the standing balance COS does not constitute a comprehensive balance assessment for any population, and users should include additional validated measures as appropriate.

CONCLUSIONS

The absence of a gold standard for measuring standing balance has contributed to the proliferation of outcome measures. These recommendations represent an important first step towards greater standardization in the assessment and measurement of this critical skill and will inform clinical research and practice internationally.

Clinical evaluation of balance in hemiparetic adults: a systematic review

Introduction Hemiparesis is a common post-stroke impairment often associated with balance deficits. Standardized instruments for balance assessment may be useful in identifying individuals at risk of falling and evaluating intervention outcomes. Objectives To identify instruments with adequate psychometric properties and clinical application to assess balance in hemiparetic cases within the scope of physiotherapy and to verify tools most frequently used in studies that evaluated the effects of therapeutic interventions in order to improve the balance of hemiparetic patients. Methods A search was conducted in the Medline, Lilacs, PEDro, and Web of Science databases by two independent researchers, who selected and analyzed studies that evaluated the reliability and validity of balance assessment instruments and intervention results. Results and discussion The Berg Balance Scale was the most frequently used instrument in the intervention studies. Nine single-task tests (timed up and go, functional reach test, step test, four-square step test, side step test, supported standing balance, standing arm raise, static tandem standing, and weight shifting) and six multiple-task tests (Berg balance scale, Brunel balance assessment, Fugl-Meyer Assessment/balance section, mini balance evaluation systems test, and postural assessment scale for stroke patients) demonstrated adequate psychometric properties and clinical applications to assess balance in hemiparetic individuals. Conclusions The Berg Balance Scale had the most widely studied psychometric properties and was the most frequently used scale in the intervention studies. Further studies are required to validate and adapt other instruments for the Brazilian population.

Physiotherapy for human T-lymphotropic virus 1-associated myelopathy: review of the literature and future perspectives

Human T-lymphotropic virus 1 (HTLV-1) infection may be associated with damage to the spinal cord – HTLV-associated myelopathy/tropical spastic paraparesis – and other neurological symptoms that compromise everyday life activities. There is no cure for this disease, but recent evidence suggests that physiotherapy may help individuals with the infection, although, as far as we are aware, no systematic review has approached this topic. Therefore, the objective of this review is to address the core problems associated with HTLV-1 infection that can be detected and treated by physiotherapy, present the results of clinical trials, and discuss perspectives on the development of knowledge in this area. Major problems for individuals with HTLV-1 are pain, sensory-motor dysfunction, and urinary symptoms. All of these have high impact on quality of life, and recent clinical trials involving exercises, electrotherapeutic modalities, and massage have shown promising effects. Although not influencing the basic pathologic disturbances, a physiotherapeutic approach seems to be useful to detect specific problems related to body structures, activity, and participation related to movement in HTLV-1 infection, as well as to treat these conditions.

Fear of falling in people with chronic obstructive pulmonary disease

BACKGROUND

Increased fear of falling (FOF) has been associated with impaired physical function, reduced physical activity and increased fall risk in older adults. Preliminary evidence suggests that individuals with chronic obstructive pulmonary disease (COPD) may have an increased FOF. This study aims to compare the level of FOF in people with COPD with healthy controls, and to determine the associations between FOF and measures of physical function, physical activity and fall risk in COPD.

METHODS

FOF was assessed in 40 participants with COPD and 25 age- and gender-matched controls using the Falls Efficacy Scale-International (FES-I). Physical function was evaluated using quadriceps hand-held dynamometry, the Berg Balance Scale and the Six-minute Walk Test. Associations between FOF, physical activity and fall risk were evaluated using the Physical Activity Scale for the Elderly and the Falls Risk in Older People - Community Setting. Pearson's correlation coefficient and stepwise multivariate linear regression were used.

RESULTS

Individuals with COPD (mean ± SD; age: 71 ± 8 years, FEV1: 45 ± 16 %pred) had higher FOF compared to controls (FES-I: 25.0 ± 7.9 vs 20.2 ± 5.2, p=0.01). Higher FOF was associated with lower quadriceps strength (p=0.02) and an impaired balance (p < 0.01); these explained 26% of the FOF variance. Reduced levels of physical activity (p=0.01) and a higher fall risk (p < 0.01) were associated with an increased FOF in COPD.

CONCLUSION

People with COPD have a higher FOF compared to the healthy peers, which is related to lower quadriceps muscle strength, impaired balance, lower levels of physical activity and an increased fall risk.

Effect of transcutaneous electrical nerve stimulation on pain, function, and quality of life in fibromyalgia: a double-blind randomized clinical trial

BACKGROUND

Fibromyalgia is a common chronic pain condition that has a significant impact on quality of life and often leads to disability. To date, there have been few well-controlled trials assessing the utility of nonpharmacological treatment modalities such as transcutaneous electrical nerve stimulation (TENS) in the management of pain and improvement in function in individuals with fibromyalgia.

OBJECTIVES

The purpose of this study will be to complete a long-term, multicenter study to assess the effects of TENS in women with fibromyalgia.

DESIGN

This will be a phase II randomized, double-blind, placebo-controlled, multicenter clinical trial.

PARTICIPANTS

Three hundred forty-three participants with fibromyalgia will be recruited for this study.

INTERVENTION

Participants will be randomly assigned to 1 of 3 groups: the intervention (TENS), placebo, or no treatment. After completing the randomized period, all participants will receive the intervention for 1 month. The participants will be asked to use TENS at the highest tolerable level for at least 2 hours daily during physical activity.

MEASUREMENTS

The primary outcome will be pain with movement, with secondary outcomes assessing functional abilities, patient-reported outcomes, and quantitative sensory testing.

LIMITATIONS

Because having participants refrain from their typical medications is not practical, their usage and any change in medication use will be recorded.

CONCLUSIONS

The results of this study will provide some of the first evidence from a large-scale, double-blind, placebo-controlled trial on the effectiveness of TENS on pain control and quality-of-life changes in patients with fibromyalgia.

Evaluation of trunk stability in the sitting position using a new device

The purpose of this study was to evaluate trunk stability in seated elderly and young individuals using a new device that inclines a seat while tracking the center of pressure (CoP). We evaluated the locus of CoP, locus length, locus length per second, enveloped area, root mean square area, and locus length per unit area (LNG/AREA). LNG/AREA, which reflects postural adjustments controlled by the spinal proprioceptive reflexes of the lower limbs, was not significantly different between young and elderly individuals. Our device measured trunk stability without influence from the lower extremities, which explains why LNG/AREA did not significantly differ between young and elderly individuals. These findings indicate that the new device can be used to quantify dynamic trunk stability.

Clinimetric properties of sitting balance measures for children with cerebral palsy: a systematic review

Assessment of sitting balance in children and youth with cerebral palsy (CP) is critical in order to design appropriate interventions to enhance activities and participation. This systematic review synthesized research evidence on the reliability, validity, responsiveness to change, and clinical utility of sitting balance measures for children and youth with CP. A two-tiered search in August 2012 using nine peer-reviewed electronic databases yielded nine articles with relevant information on seven clinical measures. Four of seven clinical measures: the Pediatric Reach Test (PRT), Sitting Assessment for Children with Neuromotor Dysfunction (SACND), Segmental Assessment of Trunk Control (SATCo), and Trunk Control Measurement Scale (TCMS), demonstrate acceptable overall applicability (at least one study supporting clinical utility, reliability, and validity) and are thus recommended for use in practice. Ongoing research on responsiveness to change, however, is warranted to support validity for outcomes measurement.

Using the systems framework for postural control to analyze the components of balance evaluated in standardized balance measures: a scoping review

OBJECTIVE

To identify components of postural control included in standardized balance measures for adult populations.

DATA SOURCES

Electronic searches of MEDLINE, EMBASE, and CINAHL databases using keyword combinations of postural balance/equilibrium, psychometrics/reproducibility of results/predictive value of tests/validation studies, instrument construction/instrument validation, geriatric assessment/disability evaluation, gray literature, and hand searches.

STUDY SELECTION

Inclusion criteria were measures with a stated objective to assess balance, adult populations (18y and older), at least 1 psychometric evaluation, 1 standing task, a standardized protocol and evaluation criteria, and published in English. Two reviewers independently identified studies for inclusion. Sixty-six measures were included.

DATA EXTRACTION

A research assistant extracted descriptive characteristics and 2 reviewers independently coded components of balance in each measure using the Systems Framework for Postural Control, a widely recognized model of balance.

DATA SYNTHESIS

Components of balance evaluated in these measures were underlying motor systems (100% of measures), anticipatory postural control (71%), dynamic stability (67%), static stability (64%), sensory integration (48%), functional stability limits (27%), reactive postural control (23%), cognitive influences (17%), and verticality (8%). Thirty-four measures evaluated 3 or fewer components of balance, and 1 measure-the Balance Evaluation Systems Test-evaluated all components of balance.

CONCLUSIONS

Several standardized balance measures provide only partial information on postural control and omit important components of balance related to avoiding falls. As such, the choice of measure(s) may limit the overall interpretation of an individual's balance ability. Continued work is necessary to increase the implementation of comprehensive balance assessment in research and practice.

The reliability of the Leeds Movement Performance Index (LMPI): a new tool for neurological physiotherapy

BACKGROUND

Measuring movement performance in people with neurological damage requires a tool that reflects physiotherapy assessment and clinical reasoning. The Leeds Movement Performance Index (LMPI) was previously developed by a group of neurological physiotherapists to fulfill these requirements.

OBJECTIVE

To assess the reliability of the LMPI for use in neurological physiotherapy practice.

METHODS

Twelve senior neurological physiotherapists were trained to use the LMPI and then asked to measure the movement performance of five patients whose movement had been previously video-recorded for this purpose. A retest session was completed after two weeks. Data were analysed to establish internal and external reliability.

RESULTS

Internal reliability was assessed using Cronbach's alpha coefficient, applied to the entire scale (0.862) and to each item (range 0.795-0.892). External (inter-rater) reliability was assessed by a calculation of the intraclass correlation coefficient for scores awarded by multiple raters (0.959), with individual item reliability ranging from 0.874 to 0.968. External (test-retest) reliability was assessed by calculating the Spearman's rank correlation coefficient between scores obtained on two testing occasions (0.792) with values of individual items ranging from 0.397 to 0.674. A variance components analysis partitioned variance into components arising from between-patient variability (55.2%) between-therapist variability (7.8%) and between-testing variability (2.8%).

CONCLUSIONS

RESULTS indicate that the LMPI is a reliable measurement tool when used by senior neurological physiotherapists.

Progression of posturographic findings after acquired brain injury

OBJECTIVE

To study the characteristics of balance performance in a sample of patients with increasing postural instability after acquired brain injury (ABI) and to establish the clinical utility of a new computerized posturographic system (NedSVE/IBV).

METHODS

This study included 108 patients with ABI divided into five groups from minimal to severe postural impairment. All patients were assessed with the NedSVE/IBV system and with traditional balance measures. Posturographic analyses included the modified clinical test of sensory interaction on balance, the limits of stability and the weight-shifting test. Sensitivity to detect changes and reproducibility were evaluated in 63 patients who were followed-up for 6 months and in 20 patients who were evaluated on two separate occasions during the same week, respectively.

RESULTS

The patients showed reduced stability limits, abnormal postural responses and an increased reliance on visual input with differences in intensity directly related to their degree of balance impairment. Posturographic study showed excellent convergent validity, reproducibility and sensitivity to detect changes.

CONCLUSION

The data suggests that, regardless of the intensity of postural instability, there is a common mechanism of sensory processing to maintain balance after ABI. The NedSVE-IBV system is a valid tool to quantify balance after ABI.