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Ersoy T, Kaya P, Hocaoglu E, Unal R. I-BaR: integrated balance rehabilitation framework. Front Neurorobot 2024; 18:1401931. [PMID: 39021504 PMCID: PMC11252086 DOI: 10.3389/fnbot.2024.1401931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 06/10/2024] [Indexed: 07/20/2024] Open
Abstract
Neurological diseases are observed in approximately 1 billion people worldwide. A further increase is foreseen at the global level as a result of population growth and aging. Individuals with neurological disorders often experience cognitive, motor, sensory, and lower extremity dysfunctions. Thus, the possibility of falling and balance problems arise due to the postural control deficiencies that occur as a result of the deterioration in the integration of multi-sensory information. We propose a novel rehabilitation framework, Integrated Balance Rehabilitation (I-BaR), to improve the effectiveness of the rehabilitation with objective assessment, individualized therapy, convenience with different disability levels and adoption of assist-as-needed paradigm and, with integrated rehabilitation process as whole, that is, ankle-foot preparation, balance, and stepping phases, respectively. Integrated Balance Rehabilitation allows patients to improve their balance ability by providing multi-modal feedback: visual via utilization of virtual reality; vestibular via anteroposterior and mediolateral perturbations with the robotic platform; proprioceptive via haptic feedback.
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Affiliation(s)
- Tugce Ersoy
- Department of Mechanical Engineering, Human-Centered Design Laboratory, Ozyegin University, Istanbul, Türkiye
| | - Pınar Kaya
- Department of Physiotherapy and Rehabilitation, Istanbul Medipol University, Istanbul, Türkiye
| | - Elif Hocaoglu
- Department of Electrical and Electronics Engineering, Living Robotics Laboratory, Istanbul Medipol University, Istanbul, Türkiye
- SABITA (Research Institute for Health Sciences and Technologies), Istanbul Medipol University, Istanbul, Türkiye
| | - Ramazan Unal
- Department of Mechanical Engineering, Human-Centered Design Laboratory, Ozyegin University, Istanbul, Türkiye
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Liu M, He J, Liu D, Hou M, Ma Y. Bibliometric and visualized analysis of dynamic balance and brain function using web of science and CiteSpace from 1995 to 2022. Heliyon 2024; 10:e24300. [PMID: 38293478 PMCID: PMC10824782 DOI: 10.1016/j.heliyon.2024.e24300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/05/2024] [Accepted: 01/05/2024] [Indexed: 02/01/2024] Open
Abstract
Purpose This study aims to explore the dynamic balance of human beings and investigate the relationship between functional structure as well as functional connectivity. Through a comprehensive bibliometric and visual analysis of the research literature from 1995 to 2022, we quantitatively display the development of the dynamic balance and brain structure as well as functional connection. Our objective is to present new trends and frontiers in the study of dynamic balance and brain function through bibliometrics software, providing valuable insights for future research in this domain. Methods The literature on dynamic balance, brain structure and functional connectivity between 1995 and 2022 was retrieved from the Web of Science database. We employed CiteSpace software to analyze various aspects, including the year of publication, journal, authors, keywords, institutions, countries, and references. Based on the analysis results, a co-reference map was generated to visually observe research hotspots and knowledge structures. Results A total of 1533 records were retrieved during the survey period (1995-2022), with a gradually increase in the number of annual publications. Notably, the data suggests a notable increase in publications between 2020 and 2021. The number of publications increased by 20 % from 2020 to 2021. The journal "Proceedings of the National Academy of Sciences (PNAS)" emerged as the most prolific journal. Among the cited authors, Deco and Gustavo ranked at the top. Key research terms in this field include "neural network", "functional connectivity", "dynamic", "model" and "brain". Particularly, the keyword "neural network" exhibited the strongest growth. The analysis of keywords cluster revealed the top 10 clusters of research themes. Oxford University stood out as the most productive institution, while the United States held the greatest influence with the highest number of publications and centrality. The reference cluster analysis further demonstrated the top 10 clusters in the literature. Conclusion Through the use of CiteSpace software, this study performed a comprehensive bibliometric and visual analysis of the Web of Science research literature on human dynamic balance and brain structural as well as functional connectivity over the past few decades. This may help researchers identify new perspectives on potential collaborators as well as collaborating institutions, hot topics, and research frontiers in the research field. The results provided an intuitive displayed overview of research trends, hotspots and frontiers in this field, facilitating a general understanding of its progression. Through unremitting efforts, it provides valuable guidance and reference for future research work.
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Affiliation(s)
- Mengjiao Liu
- Research Academy of Grand Health, Faculty of Sports Sciences, Ningbo University, Ningbo 315211, China
| | - Jian He
- Research Academy of Grand Health, Faculty of Sports Sciences, Ningbo University, Ningbo 315211, China
| | - Dongwei Liu
- School of Information Management and Artificial Intelligence, Zhejiang University of Finance and Economics, Hangzhou 310018, China
| | - Meijin Hou
- National Joint Engineering Research Center of Rehabilitation Medicine Technology, Fujian University of Traditional Chinese Medicine, Fuzhou 350108, China
- Key Laboratory of Orthopaedics and Traumatology of Traditional Chinese Medicine and Rehabilitation, Fujian University of Traditional Chinese Medicine, Fujian, China
| | - Ye Ma
- Research Academy of Grand Health, Faculty of Sports Sciences, Ningbo University, Ningbo 315211, China
- National Joint Engineering Research Center of Rehabilitation Medicine Technology, Fujian University of Traditional Chinese Medicine, Fuzhou 350108, China
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Charro PD, Santana LL, Seki KLM, Moro Junior N, Domingos JA, Christofoletti G. Motor and respiratory functions are main challenges to patients with multiple sclerosis. FISIOTERAPIA EM MOVIMENTO 2023. [DOI: 10.1590/fm.2023.36101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Abstract Introduction People with multiple sclerosis (MS) present wide and varied symptoms. Objective To investigate the impact of MS on subjects’ motor and respiratory functions. Methods One hundred one participants were enrolled in this study. The subjects had previous diagnosis of relapsing-remittent MS (n = 48) or presented no neurologic diseases (n = 53, control group). Assess-ments involved mobility (Timed Get Up and Go) and balance (Berg Balance Scale) tests. A force platform was used to evaluate postural stabilometry. Respiratory functions were assessed with a portable spirometer and a digital manovacuometer. Data analyses were carried out with Student´s t-tests, chi-square, and Pearson correlation index. Significance was set at 5%. Results Compared to control peers, participants with MS showed higher motor dysfunctions affecting mobility, balance, and postural stability. Spirometry indicated normal parameters for pulmonary flows and lung capacities in both groups. The manovacuometer, differently, pointed to a respiratory muscle weakness in 48% of participants with MS. Correlation analyses highlighted that respiratory functions are more associated to dynamic than to static motor tests. Conclusion Pathological changes in MS lead to motor dysfunction on mobility, balance and postural stability. Respiratory tests showed normal pulmonary flows and lung capacities in patients with MS, but with commitment of respiratory muscle strength. Respiratory functions were more impacted by dynamic tasks rather than static motor tasks.
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Gür E, Binkhamis G, Kluk K. Effects of multiple sclerosis on the audio-vestibular system: a systematic review. BMJ Open 2022; 12:e060540. [PMID: 35977771 PMCID: PMC9389089 DOI: 10.1136/bmjopen-2021-060540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/29/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Systematically investigate the effects of multiple sclerosis (MS) on the audio-vestibular system. METHODS Systematic review of literature investigating audio-vestibular conditions in persons with MS (PwMS) aged ≥18 years. PubMed, Scopus, NICE and Web of Science were searched. Randomised controlled trials, and cohort, case-control, observational and retrospective studies in English, published from 2000 to 21 November 2021, evaluated PwMS with at least one outcome (pure tone audiometry, auditory brainstem response, otoacoustic emissions, cortical auditory evoked potentials, functional MRI assessing auditory function, vestibular evoked myogenic potentials, videonystagmography, electronystagmography, posturography, rotary chair, gaps in noise, word discrimination scores, duration pattern sequence test), were included. Study selection and assessments of bias were independently conducted by two reviewers using the Risk of Bias Assessment Tool for Non-randomized Studies, Newcastle-Ottawa Scale (NOS) and the NOS adapted for cross-sectional studies. RESULTS 35 studies were included. Auditory function was evaluated in 714 PwMS and 501 controls, vestibular function was evaluated in 682 PwMS and 446 controls. Peripheral auditory function results were contradictory between studies; some found abnormalities in PwMS, and others found no differences. Tests of brainstem and central auditory functions were more consistently found to be abnormal in PwMS. Most vestibular tests were reported as abnormal in PwMS, abnormalities were either peripheral or central or both. However, quantitative analyses could not be performed due to discrepancies between studies in results reporting, test stimulus and recording parameters. CONCLUSIONS Although abnormal results on auditory and vestibular tests were noted in PwMS, specific effects of MS on the audio-vestibular system could not be determined due to the heterogeneity between studies that restricted the ability to conduct any quantitative analyses. Further research with consistent reporting, consistent stimulus and consistent recording parameters is needed in order to quantify the effects of MS on the auditory and vestibular systems. PROSPERO REGISTRATION NUMBER CRD42020180094.
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Affiliation(s)
- Evrim Gür
- Manchester Centre for Audiology and Deafness (ManCAD), School of Health Sciences, Ellen Wilkinson Building, The University of Manchester, Manchester, UK
| | - Ghada Binkhamis
- Manchester Centre for Audiology and Deafness (ManCAD), School of Health Sciences, Ellen Wilkinson Building, The University of Manchester, Manchester, UK
- Communication and Swallowing Disorders, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Karolina Kluk
- Manchester Centre for Audiology and Deafness (ManCAD), School of Health Sciences, Ellen Wilkinson Building, The University of Manchester, Manchester, UK
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Zhang S, Liu D, Tian E, Wang J, Guo Z, Kong W. Central vestibular dysfunction: don't forget vestibular rehabilitation. Expert Rev Neurother 2022; 22:669-680. [PMID: 35912850 DOI: 10.1080/14737175.2022.2106129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Vestibular rehabilitation (VR) is now a subject of active studies and has been shown to be effective for multiple vestibular disorders, peripheral or central. VR is a physical therapy that helps train the central nervous system to compensate for vestibular dysfunction. There is moderate to strong evidence that VR is safe and effective for the management of peripheral vestibular dysfunction. Nonetheless, the studies on how VR works on central vestibular dysfunction remains scanty. AREAS COVERED This article addressed the rehabilitation strategies and possible mechanisms, including how central vestibular function might improve upon rehabilitation. In addition, it provides some examples concerning the effect of VR on central vestibular dysfunction. EXPERT OPINION VR works on the vestibular system through repetition of specific physical exercises that activate central neuroplastic mechanisms to achieve adaptive compensation of the impaired functions. VR has become a mainstay in the management of patients with dizziness and balance dysfunction. Individualized VR programs are a safe and effective treatment option for a large percentage of patients with central vestibular disease reporting imbalance and dizziness. Exploration of various treatment strategies and possible mechanisms will help develop the best and personalized VR treatment for patients with central vestibular dysfunction.
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Affiliation(s)
- Sulin Zhang
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China.,Institute of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Dan Liu
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - E Tian
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Jun Wang
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Zhaoqi Guo
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Weijia Kong
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China.,Institute of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China.,Key Laboratory of Neurological Disorders of Education Ministry, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei, China
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Auer F, Schoppik D. The Larval Zebrafish Vestibular System Is a Promising Model to Understand the Role of Myelin in Neural Circuits. Front Neurosci 2022; 16:904765. [PMID: 35600621 PMCID: PMC9122096 DOI: 10.3389/fnins.2022.904765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/11/2022] [Indexed: 12/27/2022] Open
Abstract
Myelin is classically known for its role in facilitating nerve conduction. However, recent work casts myelin as a key player in both proper neuronal circuit development and function. With this expanding role comes a demand for new approaches to characterize and perturb myelin in the context of tractable neural circuits as they mature. Here we argue that the simplicity, strong conservation, and clinical relevance of the vestibular system offer a way forward. Further, the tractability of the larval zebrafish affords a uniquely powerful means to test open hypotheses of myelin's role in normal development and disordered vestibular circuits. We end by identifying key open questions in myelin neurobiology that the zebrafish vestibular system is particularly well-suited to address.
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Affiliation(s)
| | - David Schoppik
- Departments of Otolaryngology, Neuroscience & Physiology, Neuroscience Institute, New York University Grossman School of Medicine, New York, NY, United States
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Grasso A, Poropat F, Kamagni Vodié T, Ghirardo S, Barbi E. How Age Matters in the Assessment of Vertigo in the Pediatric Emergency Department: A 10-Year Age-Stratified Etiology Survey. Pediatr Emerg Care 2022; 38:e43-e46. [PMID: 32947561 DOI: 10.1097/pec.0000000000002242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Vertigo is a relatively frequent cause for referral to the pediatric emergency department, and it is usually caused by benign or self-limiting etiology. However, it could be difficult to evaluate especially in the younger child and could also conceal serious illness as encephalitis or cerebellitis. Our survey collected in a 10-year period 757 children assessed in pediatric emergency department for vertigo and stratified this population for etiology and for group of age: younger than 6 years (113, 14.9%), between 7 and 12 years (251, 33.2%), and older than 12 years (393, 51.9%). In addition, associated signs and symptoms, evaluation by a neurologist or an otorhinolaryngologist, and instrumental investigations were recorded.We found that age is the most important variable to assess the possibility of a central nervous system disease as etiology cause of vertigo with a significant difference of incidence between the younger group (younger than 6 years, 23%) and older groups (3% and 1%; P < 0.001).This finding should reinforce the index of suspicion for a central nervous system illness as cause of vertigo in the preschool children with an accurate workup including evaluation by a neurologist or an otorhinolaryngologist and instrumental investigations as needed.
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García-Muñoz C, Casuso-Holgado MJ, Hernández-Rodríguez JC, Pinero-Pinto E, Palomo-Carrión R, Cortés-Vega MD. Feasibility and safety of an immersive virtual reality-based vestibular rehabilitation programme in people with multiple sclerosis experiencing vestibular impairment: a protocol for a pilot randomised controlled trial. BMJ Open 2021; 11:e051478. [PMID: 34810187 PMCID: PMC8609940 DOI: 10.1136/bmjopen-2021-051478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/22/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Vestibular system damage in patients with multiple sclerosis (MS) may have a central and/or peripheral origin. Subsequent vestibular impairments may contribute to dizziness, balance disorders and fatigue in this population. Vestibular rehabilitation targeting vestibular impairments may improve these symptoms. Furthermore, as a successful tool in neurological rehabilitation, immersive virtual reality (VRi) could also be implemented within a vestibular rehabilitation intervention. METHODS AND ANALYSIS This protocol describes a parallel-arm, pilot randomised controlled trial, with blinded assessments, in 30 patients with MS with vestibular impairment (Dizziness Handicap Inventory ≥16). The experimental group will receive a VRi vestibular rehabilitation intervention based on the conventional Cawthorne-Cooksey protocol; the control group will perform the conventional protocol. The duration of the intervention in both groups will be 7 weeks (20 sessions, 3 sessions/week). The primary outcomes are the feasibility and safety of the vestibular VRi intervention in patients with MS. Secondary outcome measures are dizziness symptoms, balance performance, fatigue and quality of life. Quantitative assessment will be carried out at baseline (T0), immediately after intervention (T1), and after a follow-up period of 3 and 6 months (T2 and T3). Additionally, in order to further examine the feasibility of the intervention, a qualitative assessment will be performed at T1. ETHICS AND DISSEMINATION The study was approved by the Andalusian Review Board and Ethics Committee, Virgen Macarena-Virgen del Rocio Hospitals (ID 2148-N-19, 25 March 2020). Informed consent will be collected from participants who wish to participate in the research. The results of this research will be disseminated by publication in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER NCT04497025.
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Affiliation(s)
| | | | | | | | - Rocío Palomo-Carrión
- Department of Nursery, Physiotherapy and Occupational Therapy, University of Castilla-La Mancha, Toledo, Spain
- GIFTO, Physiotherapy Research Group, Toledo, Spain
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Psychometric Properties of Cognitive-Motor Dual-Task Studies With the Aim of Developing a Test Protocol for Persons With Vestibular Disorders: A Systematic Review. Ear Hear 2021; 41:3-16. [PMID: 31283530 DOI: 10.1097/aud.0000000000000748] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Patients suffering from vestibular disorders (VD) often present with impairments in cognitive domains such as visuospatial ability, memory, executive function, attention, and processing speed. These symptoms can be attributed to extensive vestibular projections throughout the cerebral cortex and subcortex on the one hand, and to increased cognitive-motor interference (CMI) on the other hand. CMI can be assessed by performing cognitive-motor dual-tasks (DTs). The existing literature on this topic is scarce and varies greatly when it comes to test protocol, type and degree of vestibular impairment, and outcome. To develop a reliable and sensitive test protocol for VD patients, an overview of the existing reliability and validity studies on DT paradigms will be given in a variety of populations, such as dementia, multiple sclerosis, Parkinson's disease, stroke, and elderly. DESIGN The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An extensive literature search on psychometric properties of cognitive-motor DTs was run on MEDLINE, Embase, and Cochrane Databases. The studies were assessed for eligibility by two independent researchers, and their methodological quality was subsequently evaluated using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). RESULTS AND CONCLUSIONS Thirty-three studies were included in the current review. Based on the reliability and validity calculations, including a static as well as dynamic motor task seems valuable in a DT protocol for VD patients. To evoke CMI maximally in this population, both motor tasks should be performed while challenging the vestibular cognitive domains. Out of the large amount of cognitive tasks employed in DT studies, a clear selection for each of these domains, except for visuospatial abilities, could be made based on this review. The use of the suggested DTs will give a more accurate and daily life representation of cognitive and motor deficiencies and their interaction in the VD population.
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Shin T, Ahn M, Kim J, Jung K, Moon C, Kim MD. Visual Dysfunction in Multiple Sclerosis and its Animal Model, Experimental Autoimmune Encephalomyelitis: a Review. Mol Neurobiol 2021; 58:3484-3493. [PMID: 33745114 DOI: 10.1007/s12035-021-02355-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/09/2021] [Indexed: 01/09/2023]
Abstract
Visual disabilities in central nervous system autoimmune diseases such as multiple sclerosis (MS) and its animal model, experimental autoimmune encephalomyelitis (EAE), are important symptoms. Past studies have focused on neuro-inflammatory changes and demyelination in the white matter of the brain and spinal cord. In MS, neuro-inflammatory lesions have been diagnosed in the visual pathway; the lesions may perturb visual function. Similarly, neuropathological changes in the retina and optic nerves have been found in animals with chronic EAE. Although the retina and optic nerves are immunologically privileged sites via the blood-retina barrier and blood-brain barrier, respectively, inflammation can occur via other routes, such as the uvea (e.g., iris and choroid) and cerebrospinal fluid in the meninges. This review primarily addresses the direct involvement of the blood-retina barrier and the blood-brain barrier in the development of retinitis and optic neuritis in EAE models. Additional routes, including pro-inflammatory mediator-filled choroidal and subarachnoid spaces, are also discussed with respect to their roles in EAE-induced visual disability and as analogues of MS in humans.
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Affiliation(s)
- Taekyun Shin
- College of Veterinary Medicine and Veterinary Medical Research Institute, Jeju National University, Jeju, 63243, Republic of Korea.
| | - Meejung Ahn
- Department of Animal Science, College of Life Science, Sangji University, Wonju, 26339, Republic of Korea
| | - Jeongtae Kim
- Department of Anatomy, Kosin University College of Medicine, Busan, 43267, Republic of Korea
| | - Kyungsook Jung
- Functional Biomaterials Research Center, Korea Research Institute of Bioscience and Biotechnology, 181 Ipsin-gil, Jeongeup-si, Jeonbuk, 56212, Republic of Korea
| | - Changjong Moon
- Department of Veterinary Anatomy, College of Veterinary Medicine and BK21 Plus Project Team, Chonnam National University, Gwangju, 61186, Republic of Korea
| | - Moon-Doo Kim
- Department of Psychiatry, School of Medicine, Jeju National University, Jeju, 63241, Republic of Korea
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Cochrane GD, Christy JB, Motl RW. Comprehensive Clinical Assessment of Vestibular Function in Multiple Sclerosis. J Neurol Phys Ther 2021; 45:228-234. [PMID: 33867456 PMCID: PMC8187291 DOI: 10.1097/npt.0000000000000358] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Balance disorders and dizziness are common in people with multiple sclerosis (MS), suggesting dysfunction of the vestibular system. Evaluating how people with MS perform on objective clinical vestibular tools will help broaden understanding of vestibular function in MS. This cross-sectional study's goal was to complete a robust battery of vestibular-ocular reflex (VOR), dynamic visual acuity (DVA), subjective visual vertical (SVV), and cervical and ocular vestibular-evoked myogenic potential (c/oVEMP) tests in people with and without MS. METHODS Forty people with relapsing-remitting MS (Expanded Disability Status Scale [EDSS] ≤6.5) and 20 controls completed the vestibular testing battery. Results were compared between groups and correlations with EDSS scores were calculated. RESULTS People with MS were less able to visually cancel their VOR and showed a larger variance in response on SVV. EDSS significantly correlated with VOR cancellation, SVV variance, and DVA lines lost; linear regression showed that VOR cancellation and SVV variance significantly predicted EDSS. DISCUSSION AND CONCLUSION Vestibular functions requiring central integration of vestibular information, but not reflexive vestibular functions like VEMP, were impaired in people with MS and correlated with EDSS, suggesting that clinical evaluation of functions requiring central integration best evaluates MS-related vestibular dysfunction. Measures assessing central vestibular integration and not vestibular reflexes may be more sensitive to detecting vestibular deficits in people with mild to moderate MS.Video Abstract available for more insight from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A344).
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Affiliation(s)
- Graham D. Cochrane
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
- Medical Scientist Training Program, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer B. Christy
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert W. Motl
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, USA
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Allum JHJ, Rust HM, Lutz N, Schouenborg C, Fischer-Barnicol B, Haller V, Derfuss T, Kuhle J, Yaldizli Ö. Characteristics of improvements in balance control using vibro-tactile biofeedback of trunk sway for multiple sclerosis patients. J Neurol Sci 2021; 425:117432. [PMID: 33839367 DOI: 10.1016/j.jns.2021.117432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 03/27/2021] [Accepted: 03/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Previously, we determined that training with vibrotactile feedback (VTfb) of trunk sway improves MS patients' balance impairment. Here, we posed 5 questions: 1) How many weeks of VTfb training are required to obtain the best short-term carry over effect (CoE) with VTfb? 2) How long does the CoE last once VTfb training terminates? 3) Is the benefit similar for stance and gait? 4) Is position or velocity based VTfb more effective in reducing trunk sway? 5) Do patients' subjective assessments of balance control improve? METHODS Balance control of 16 MS patients was measured with gyroscopes at the lower trunk. The gyroscopes drove directionally active VTfb in a head-band. Patients trained twice per week with VTfb for 4 weeks to determine when balance control with and without VTfb stopped improving. Thereafter, weekly assessments without VTfb over 4 weeks and at 6 months determined when CoEs ended. RESULTS A 20% improvement in balance to normal levels occurred with VTfb. Short term CoEs improved from 15 to 20% (p ≤ 0.001). Medium term (1-4 weeks) CoEs were constant at 19% (p ≤ 0.001). At 6 months improvement was not significant, 9%. Most improvement was for lateral sway. Equal improvement occurred when angle position or velocity drove VTfb. Subjectively, balance improvements peaked after 3 weeks of training (32%, p ≤ 0.05). CONCLUSIONS 3-4 weeks VTfb training yields clinically relevant sway reductions and subjective improvements for MS patients during stance and gait. The CoEs lasted at least 1 month. Velocity-based VTfb was equally effective as position-based VTfb.
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Affiliation(s)
- J H J Allum
- Dept of Neurology, University of Basel Hospital, Basel, Switzerland; Dept of ORL, University of Basel Hospital, Basel, Switzerland.
| | - H M Rust
- Dept of Neurology, University of Basel Hospital, Basel, Switzerland; Dept of ORL, University of Basel Hospital, Basel, Switzerland
| | - N Lutz
- Bern University of Applied Sciences, Department of Health Professions, Switzerland
| | - C Schouenborg
- Bern University of Applied Sciences, Department of Health Professions, Switzerland
| | | | - V Haller
- Dept of Neurology, University of Basel Hospital, Basel, Switzerland
| | - T Derfuss
- Dept of Neurology, University of Basel Hospital, Basel, Switzerland
| | - J Kuhle
- Dept of Neurology, University of Basel Hospital, Basel, Switzerland
| | - Ö Yaldizli
- Dept of Neurology, University of Basel Hospital, Basel, Switzerland
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Swanson CW, Richmond SB, Sharp BE, Fling BW. Middle-age people with multiple sclerosis demonstrate similar mobility characteristics to neurotypical older adults. Mult Scler Relat Disord 2021; 51:102924. [PMID: 33813095 DOI: 10.1016/j.msard.2021.102924] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/21/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical trials often report significant mobility differences between neurotypical and atypical groups, however, these analyses often do not determine which measures are capable of discriminating between groups. Additionally, indirect evidence supports the notion that some mobility impaired populations demonstrate similar mobility deficits. Thus, the current study aimed to provide a comprehensive analysis of three distinct aspects of mobility (walking, turning, and balance) to determine which variables were significantly different and were also able to discriminate between neurotypical older adults (OA) and middle-aged people with multiple sclerosis (PwMS), and between middle-aged neurotypical adults and PwMS. METHODS This study recruited 21 neurotypical OA, 19 middle-aged neurotypical adults, and 30 people with relapsing remitting MS. Participants came into the laboratory on two separate occasions to complete mobility testing while wearing wireless inertial sensors. Testing included a self-selected pace two-minute walk, a series of 180˚ and 360˚ turns, and a clinical balance test capturing a total of 99 distinct mobility characteristics. We determined significant differences for gait and turning measures through univariate analyses and a series of repeated measures analysis of variance in determining significance for balance conditions and measures. In determining discrimination between groups, the Area Under the Curve (AUC) was calculated for all individual mobility measures with a threshold of 0.80, denoting excellent discrimination. Additionally, a stepwise regression of the top five AUC producing variables was performed to determine whether a combination of variables could enhance discrimination while accounting for multicollinearity. RESULTS The results between neurotypical OA and middle-aged PwMS demonstrated significant differences for three gait and one turning variable, with no variable or combination of variables able to provide excellent discrimination between groups. Between middle-age neurotypical adults and PwMS a variety of mean and variability gait measures demonstrated significant differences between groups; however, no variable or combination of variables met discriminatory threshold. For turning, five 360˚ turn variables demonstrated significant differences and furthermore, the combination of 360˚ mean turn duration and variability of peak turn velocity were able to discriminate between groups. Finally, the majority of postural sway measures demonstrated significant group differences and the ability to discriminate between groups, particularly during more challenging balance conditions where participants stood on a compliant surface. CONCLUSION These results offer a comprehensive analysis of mobility differences and measures capable of discriminating between middle-age neurotypical adults and PwMS. Additionally, these results provide evidence that OA and middle-age PwMS display similar movement characteristics and thus a potential indicator of advanced aging from a mobility perspective.
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Affiliation(s)
- Clayton W Swanson
- Department of Health & Exercise Science, Colorado State University, Fort Collins, Colorado, USA
| | - Sutton B Richmond
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Benjamin E Sharp
- Department of Statistics, Colorado State University, Fort Collins, Colorado, USA
| | - Brett W Fling
- Department of Health & Exercise Science, Colorado State University, Fort Collins, Colorado, USA; Molecular, Cellular, and Integrative Neuroscience Program, Colorado State University, Fort Collins, Colorado, USA
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García-Muñoz C, Cortés-Vega MD, Hernández-Rodríguez JC, Palomo-Carrión R, Martín-Valero R, Casuso-Holgado MJ. Epley manoeuvre for posterior semicircular canal benign paroxysmal positional vertigo in people with multiple sclerosis: protocol of a randomised controlled trial. BMJ Open 2021; 11:e046510. [PMID: 33737443 PMCID: PMC7978251 DOI: 10.1136/bmjopen-2020-046510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Vestibular disorders in multiple sclerosis (MS) could have central or peripheral origin. Although the central aetiology is the most expected in MS, peripheral damage is also significant in this disease. The most prevalent effect of vestibular peripheral damage is benign paroxysmal positional vertigo (BPPV). Impairments of the posterior semicircular canals represent 60%-90% of cases of BPPV. The standard gold treatment for this syndrome is the Epley manoeuvre (EM), the effectiveness of which has been poorly studied in patients with MS. Only one retrospective research study and a case study have reported encouraging results for EM with regard to resolution of posterior semicircular canal BPPV. The aim of this future randomised controlled trial (RCT) is to assess the effectiveness of EM for BPPV in participants with MS compared with a sham manoeuvre. METHODS AND ANALYSIS The current protocol describes an RCT with two-arm, parallel-group design. Randomisation, concealed allocation and double-blinding will be conducted to reduce possible bias. Participants and evaluators will be blinded to group allocation. At least 80 participants who meet all eligibility criteria will be recruited. Participants will have the EM or sham manoeuvre performed within the experimental or control group, respectively. The primary outcome of the study is changes in the Dix Hallpike test. The secondary outcome will be changes in self-perceived scales: Dizziness Handicap Inventory and Vestibular Disorders Activities of Daily Living Scale. The sample will be evaluated at baseline, immediately after the intervention and 48 hours postintervention. ETHICS AND DISSEMINATION The study was approved by the Andalusian Review Board and Ethics Committee of Virgen Macarena-Virgen del Rocio Hospitals (ID 0107-N-20, 23 July 2020). The results of the research will be disseminated by the investigators to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04578262.
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Affiliation(s)
| | | | | | - Rocio Palomo-Carrión
- Department of Nursery, Physiotherapy and Occupational Therapy, Universidad de Castilla-La Mancha, Toledo, Spain
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15
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Inojosa H, Schriefer D, Trentzsch K, Klöditz A, Ziemssen T. Visual Feedback and Postural Control in Multiple Sclerosis. J Clin Med 2020; 9:jcm9051291. [PMID: 32365769 PMCID: PMC7288335 DOI: 10.3390/jcm9051291] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 01/07/2023] Open
Abstract
As people with multiple sclerosis (pwMS) manifest heterogeneous demyelinating lesions that could affect somatosensory or vestibular ways, visual stimulus as feedback could be especially relevant to achieve postural control. This has clinical importance for the development of preventive measures and rehabilitation therapies in order to avoid falls and accidents in this group. In our study, we objectively evaluated the influence of visual feedback on the stabilization of balance in pwMS versus healthy controls (HC) and its potential utility in clinical evaluation. Static posturography tests were performed in 99 pwMS and 30 HC. Subjects stood on a force platform with open and closed eyes. During this procedure, three balance parameters were obtained for both vision conditions: average sway, average speed, and average speed of sway. Neurostatus-Expanded Disease Disability Score (EDSS) and Multiple Sclerosis Functional Composite (MSFC) were performed in parallel as well. A two-way mixed repeated measures ANCOVA, controlling for sex and age, was performed to evaluate the effect of vision, MS diagnosis, and the interaction of both in static posturography parameters. The difference between both closed and open eyes conditions was calculated for each parameter and further analyzed according to MS-relevant clinical variables. The magnitude of the vision effect differed between pwMS and HC as a significant interaction between the vision and the MS diagnosis in the delineated area (p < 0.001) and average speed of sway (p = 0.001) was seen. These parameters had a greater increase in pwMS than in HC after closing eyes. For the average sway, a significant main effect of vision was present (p = 0.047). Additionally, the differences obtained between open and closed eyes conditions assessed with the delineated area and average speed of sway were moderately correlated to the assessed clinical tests EDSS (r = 0.405 and r = 0.329, respectively) and the MSFC (r = −0.385 and r = −0.259, respectively). In our study, pwMS were more dependent of visual feedback than HC to maintain postural control. This easy and short evaluation by static posturography could support the development of targeted preventive measures and interventions in pwMS.
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16
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Selgrade BP, Meyer D, Sosnoff JJ, Franz JR. Can optical flow perturbations detect walking balance impairment in people with multiple sclerosis? PLoS One 2020; 15:e0230202. [PMID: 32155225 PMCID: PMC7064213 DOI: 10.1371/journal.pone.0230202] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 02/24/2020] [Indexed: 12/04/2022] Open
Abstract
People with multiple sclerosis (PwMS) who exhibit minimal to no disability are still over twice as likely to fall as the general population and many of these falls occur during walking. There is a need for more effective ways to detect preclinical walking balance deficits in PwMS. Therefore, the purpose of this study was to investigate the effects of optical flow perturbations applied using virtual reality on walking balance in PwMS compared to age-matched controls. We hypothesized that susceptibility to perturbations–especially those in the mediolateral direction–would be larger in PwMS compared to controls. Fourteen PwMS and fourteen age-matched controls walked on a treadmill while viewing a virtual hallway with and without optical flow perturbations in the mediolateral or anterior-posterior directions. We quantified foot placement kinematics, gait variability, lateral margin of stability and, in a separate session, performance on the standing sensory organization test (SOT). We found only modest differences between groups during normal, unperturbed walking. These differences were larger and more pervasive in the presence of mediolateral perturbations, evidenced by higher variability in step width, sacrum position, and margin of stability at heel-strike in PwMS than controls. PwMS also performed worse than controls on the SOT, and there was a modest correlation between step width variability during perturbed gait and SOT visual score. In conclusion, mediolateral optical flow perturbations revealed differences in walking balance in PwMS that went undetected during normal, unperturbed walking. Targeting this difference may be a promising approach to more effectively detect preclinical walking balance deficits in PwMS.
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Affiliation(s)
- Brian P. Selgrade
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, NC, United States of America
| | - Diane Meyer
- UNC Healthcare, UNC Center for Rehabilitation Care, Chapel Hill, NC, United States of America
| | - Jacob J. Sosnoff
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, IL, United States of America
| | - Jason R. Franz
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, NC, United States of America
- * E-mail:
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17
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Cofré Lizama LE, Bastani A, van der Walt A, Kilpatrick T, Khan F, Galea MP. Increased ankle muscle coactivation in the early stages of multiple sclerosis. Mult Scler J Exp Transl Clin 2020; 6:2055217320905870. [PMID: 32110431 PMCID: PMC7016311 DOI: 10.1177/2055217320905870] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/30/2019] [Accepted: 01/21/2020] [Indexed: 01/20/2023] Open
Abstract
Background Neural damage at early stages of multiple sclerosis (MS) can subtly affect gait muscle activation patterns. Detecting these changes using current clinical tools, however, is not possible. We propose using muscle coactivation measures to detect these subtle gait changes. This may also help in identifying people with MS (PwMS) that may benefit from strategies aimed at preventing further mobility impairments. Objective We aimed to determine if coactivation of ankle muscles during gait is greater in PwMS with Expanded Disability Status Scale (EDSS) score <3.5. A secondary aim is to determine whether coactivation increases are speed dependent. Methods For this study 30 PwMS and 15 healthy controls (HC) walked on a treadmill at 1.0 m/s, 1.2 m/s and 1.4 m/s. Electromyography was recorded from the tibialis anterior (TA), soleus (SO) and lateral gastrocnemius (LG). The coactivation index was calculated between SO/TA and LG/TA. Ankle kinematics data were also collected. Results Compared with HC, PwMS exhibited significantly greater SO/TA and LG/TA coactivation, which was greater during early stance and swing phases (p < .01). Speed did not affect coactivation except during early stance. Ankle kinematic changes were also observed. Conclusion PwMS exhibited greater ankle muscles coactivation than controls regardless of the speed of walking. These changes in muscle activation may serve as a biomarker of neurodegeneration occurring at early stages of the disease.
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Affiliation(s)
- L Eduardo Cofré Lizama
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Andisheh Bastani
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Anneke van der Walt
- Department of Neurosciences, Alfred Health, Central Clinical School, Monash University, Melbourne, Australia
| | - Trevor Kilpatrick
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - Fary Khan
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.,Australian Rehabilitation Research Centre, Royal Melbourne Hospital, Melbourne, Australia.,Department of Rehabilitation Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Mary P Galea
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.,Australian Rehabilitation Research Centre, Royal Melbourne Hospital, Melbourne, Australia.,Department of Rehabilitation Medicine, Royal Melbourne Hospital, Melbourne, Australia
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Effectiveness of Vestibular Training for Balance and Dizziness Rehabilitation in People with Multiple Sclerosis: A Systematic Review and Meta-Analysis. J Clin Med 2020; 9:jcm9020590. [PMID: 32098162 PMCID: PMC7074243 DOI: 10.3390/jcm9020590] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/08/2020] [Accepted: 02/08/2020] [Indexed: 12/30/2022] Open
Abstract
Postural instability and dizziness are commonly observed in people with multiple sclerosis (PwMS). The aim of this systematic review was to evaluate the evidence for the use of vestibular rehabilitation, in comparison with other exercise interventions or no intervention, to treat balance impairments and dizziness in PwMS. An electronic search was conducted by two independent reviewers in the following databases: MEDLINE (Pubmed), Scopus, the Physiotherapy Evidence Database (PEDro), Web of Science (WOS), Lilacs, CINHAL and the Cochrane Database of Systematic Reviews (CDSR). A quality assessment was performed using the PEDro scale and the Cochrane Risk of Bias Tool. When possible, the data were pooled in a meta-analysis (95%CI). This systematic review followed the PRISMA guideline statement and was registered in the PROSPERO database (CRD42019134230). Seven studies were included, with a total of 321 participants analysed. Compared with no intervention, vestibular rehabilitation was more effective for balance development (SMD = 2.12; 95% CI = 0.49, 3.75; p = 0.01; I2 = 89%) and dizziness symptoms improvement (SMD = −17.43; 95% CI = −29.99, −4.87; p= 0.007; I2= 66%). Compared with other exercise interventions, improvements in favour of the experimental group were observed, but statistical significance for the differences between groups was not reached.
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19
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Capone F, Capone G, Motolese F, Voci A, Caminiti ML, Musumeci G, Di Lazzaro V. Spinal cord dysfunction contributes to balance impairment in multiple sclerosis patients. Clin Neurol Neurosurg 2019; 184:105451. [DOI: 10.1016/j.clineuro.2019.105451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 07/01/2019] [Accepted: 07/17/2019] [Indexed: 10/26/2022]
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Callesen J, Cattaneo D, Brincks J, Kjeldgaard Jørgensen ML, Dalgas U. How do resistance training and balance and motor control training affect gait performance and fatigue impact in people with multiple sclerosis? A randomized controlled multi-center study. Mult Scler 2019; 26:1420-1432. [DOI: 10.1177/1352458519865740] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Despite a shared purpose of improving functional capacity, the principles of progressive resistance training (PRT) and balance and motor control training (BMCT) are fundamentally different. Objectives: To investigate the effects of PRT and BMCT on gait performance and fatigue impact in people with multiple sclerosis (PwMS). Methods: A multi-center, single-blinded, cluster-randomized controlled trial with two intervention groups (PRT and BMCT) and a control group (CON). The interventions lasted 10 weeks. A total of 71 participants with impaired mobility (Timed 25-Foot Walk (T25FW) > 5 seconds or Six Spot Step Test (SSST) > 8 seconds) were enrolled. Primary outcomes were the T25FW and the SSST. Fatigue impact, self-perceived gait function, 6-minute walk, balance, and muscle strength were secondary outcomes. Results: In total, 83% completed the study. The primary comparisons showed that BMCT, but not PRT, improved T25FW, SSST, and self-perceived gait function when compared to CON. Secondary comparisons showed that BMCT improved SSST more than PRT, while T25FW did not differ. Both BMCT and PRT reduced the fatigue impact. Finally, the effect of BMCT was superior to PRT on dynamic balance, while PRT was superior to BMCT on knee extensor muscle strength. Conclusion: BMCT, but not PRT, was superior to CON in improving gait performance, while both BMCT and PRT reduced fatigue.
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Affiliation(s)
- Jacob Callesen
- Department of Rehabilitation and Health Promotion Research, Faculty of Health Science, VIA University College, Aarhus N, Denmark/ Section for Sport Science, Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - John Brincks
- Department of Rehabilitation and Health Promotion Research, Faculty of Health Science, VIA University College, Aarhus N, Denmark
| | | | - Ulrik Dalgas
- Section for Sport Science, Department of Public Health, Aarhus University, Aarhus, Denmark
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