Effects of the Use of Anchor Systems in the Rehabilitation of Dynamic Balance and Gait in Individuals With Chronic Dizziness of Peripheral Vestibular Origin: A Single-Blinded, Randomized, Controlled Clinical Trial

Influence of the anchor system on body sway in women affected and not affected by lymphedema secondary to breast cancer: A cross-sectional study

BACKGROUND

Postural control is an essential ability for functional independence modified by therapeutic approaches and morbidities secondary to breast cancer. The anchor system enables additional haptic perception of body position in front of the support base and can be used alone or in conjunction with sensorimotor training.

RESEARCH QUESTION

What is the influence of the anchor system, through different manual contacts on the upper limb, on body sway in women affected and not affected by lymphedema secondary to breast cancer treatment?

METHODS

Cross-sectional study involving 60 women homogeneously distributed to the group affected by lymphedema (GAL), with a mean age of 62.53 (SD = 12.54) years and upper limb volume difference (ULVD = Ipsilateral - Contralateral) of 636.21 (SD = 387.94) cm3, and group not affected by lymphedema (GNAL), with a mean age of 57.24 (SD = 11.43) years and ULVD of -8.91 (SD = 121.72) cm3. Baropodometry was used to assess body sway, through the presence and absence of the visual sense, associated with different manual contacts of the anchor system designated absence, simulation of use, unilateral and bilateral contact. The Shapiro-Wilk and Student's T-tests with Bonferroni Post-Hoc were used in the statistical analysis (p ≤ 0.05).

RESULTS

The GAL expressed non-significant values compared to the GNAL in the absence of visual sense and non-use of the anchor system. The unilateral contact of the anchor system on the preferred upper limb in the presence of the visual sense, and bilateral contact of the anchor system in the presence and absence of the visual sense promoted a significant reduction of body sway in both groups.

SIGNIFICANCE

In breast cancer survivors, the anchor system with bilateral contact effectively maintains postural control, regardless of the visual sense and the volume of the upper limb.

Effects of the Anchor System on Postural Balance of Women Undergoing Breast Cancer Treatment: A Clinical, Randomized, Controlled, and Crossover Trial

OBJECTIVE

Investigate the effects of multisensory training with and without the anchor system on breast cancer survivors' postural balance and self-efficacy of falls.

DESIGN

Clinical randomized, controlled, and crossover trial.

SETTING

Teaching, Research, and Assistance Center in Mastectomized Rehabilitation.

PARTICIPANTS

Eighty breast cancer survivors homogeneously distributed in the groups of adults and elderly affected, or not, by lymphedema.

INTERVENTIONS

Participants were randomized to multisensory training with and without the anchor system involving 3 sessions per week for 12 weeks. After the 4-week washout period, the remaining therapeutic intervention was applied.

MAIN OUTCOME MEASURES

The primary outcome was semi-static and dynamic balance as evaluated by baropodometry and Mini Balance Evaluation Systems Test, and the secondary outcome was self-efficacy of the fall episode as assessed by Falls Efficacy Scale - International in the pre-, post-immediate, and 4-week follow-up period.

RESULTS

Both therapeutic interventions caused positive and significant effects on postural balance and self-efficacy of falls in the immediate period. The multisensory training with the anchor system induced significant functional retention in the short term, related to the clinical effect of small to moderate variation.

CONCLUSIONS

Multisensory training with the anchor system is convenient for postural balance and self-efficacy for falls, regardless of age and upper limb volume, for breast cancer survivors.

Acute Effects of a Haptic Anchor System on Postural Sway of Individuals with Parkinson's Disease: A Preliminary Study

Some investigators have demonstrated that an anchor system can improve postural control in elderly persons during balance tasks, but none have reported on the use of this approach in individuals with Parkinson's disease (PD). Therefore, we aimed to evaluate the effect of an anchor system on postural sway in elderly individuals with (n = 13) and without (n = 14) PD. In this cross-sectional study, we measured postural sway with a force platform based on the Clinical Test of Sensory Interaction of Balance (CTSIB). We calculated center of pressure (COP) parameters, as a function of time, based on the ellipse sway area (cm²) and evaluated self-efficacy for postural control based on the degree of difficulty in each task. With the anchor system (i.e., handheld ropes attached to weights on the floor), we observed a significant reduction in the ellipse sway area in the semi-tandem position among individuals with PD (p = .04). For participants without PD, there was no significant difference in sway with or without the anchor system in all positions. Also, for participants with PD, there was an improvement in self-efficacy for postural control associated with the anchor system in several positions while there was only a self-efficacy improvement with the anchor system in the semi-tandem position for those without PD. Acute use of a haptic anchor system reduced postural sway in the semi-tandem position in individuals with PD, and the anchor system generally improved postural control self-efficacy for body sway in individuals with PD.

Effectiveness of virtual reality-based vestibular rehabilitation in patients with peripheral vestibular hypofunction

BACKGROUND

The rehabilitation of classical peripheral vestibular disorders is long and costly. Recently, interactive systems based on virtual reality (VR) technology have reduced the cost of vestibular rehabilitation therapy (VRT) and made the process more enjoyable. This study aims to investigate the effects of VR-based VRT in patients diagnosed with peripheral vestibular hypofunction (PVH).

METHODS

In this study, a VR-based VRT program that utilized Sony Playstation®4 VR Head Mounted Display was applied to 25 patients (between 18-60) diagnosed with PVH. PVH was diagnosed by evaluating the patients' clinical histories, the findings in the "Micromedical Technologies VisualEyes Spectrum" videonystagmography (VNG) and the "Micromedical Aqua Stim" model bithermal water caloric tests. VR-based VRT program was applied to the patients for 4 weeks, 2 sessions per week, 8 sessions in total. Each session lasted around 30 to 40 min. All patients underwent the Dizziness Handicap Inventory (DHI), Sensory Organization Test (SOT), Adaptation Test (ADT), Limits of Stability (LOS), and Rhythmic Weight Shift (RWS) before, after, and 8-week follow-up of the VRT program. In addition, the Cybersickness Survey was applied to the patients at the end of the VR-based VRT session every week.

RESULTS

The DHI mean scores of the patients were 54.60, 19.20, and 16.84, respectively, before, just after, and at the 8-week follow-up VRT (p < 0.001). The mean SOT composite score of the patients was obtained as 58.08 before VRT; 77.16 after VRT and 76.40 at 8-week after VRT (p < 0.000). On the other hand, the values in the 'movement velocity' and "direction control" parameters of the patients in LOS and RWS showed a significant improvement after VRT compared to before VRT (p < 0.000). From before VRT to 8 weeks after VRT, the patient's oscillation averages in the 'toes up' and 'toes down' positions in ADT reduced progressively (p < 0.000).

DISCUSSION

This study demonstrates that implementing a VR-based VRT protocol may be an efficient option to improve posture stability and the quality of life in patients with PVH. In addition, VR-based vestibular rehabilitation therapy has shown to be effective for PVH patients in the mid-term.

Three days of beam walking practice improves dynamic balance control regardless of the use of haptic anchors in older adults

Balance deficits during walking increase the risk of falls in older adults. Providing haptic information through anchors improves dynamic balance control, but the benefits of practicing with anchors during walking need to be evaluated. We investigated the effect of practice with haptic anchors in the beam walking task in older adults. Twenty-five older adults participated in this study divided into 0% (G0, practice without the anchors) and 50% (G50, practice with the haptic anchors in 50% of the trials) groups. With the anchors, participants held in each hand a cable with a mass of 0.125 kg affixed to the end of the cable that contacted the ground. They walked and kept the anchors in contact with the ground such that they dragged them. Participants increased the distance walked on the beam and reduced the trunk angular acceleration after training, but this effect was independent of the anchors. The use of haptic anchors during beam walking training did not significantly affect older adults' performance and dynamic balance control. Both groups showed improvements in the post-test and 24-hr retention conditions, indicating that older adults can learn to adapt their gait to more challenging contexts.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association

Background:

Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises.

Methods:

These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence.

Results:

Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes.

Discussion:

Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction.

Limitations:

The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction.

Disclaimer:

These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.

Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369).

Stabilization demands of walking modulate the vestibular contributions to gait

Stable walking relies critically on motor responses to signals of head motion provided by the vestibular system, which are phase-dependent and modulated differently within each muscle. It is unclear, however, whether these vestibular contributions also vary according to the stability of the walking task. Here we investigate how vestibular signals influence muscles relevant for gait stability (medial gastrocnemius, gluteus medius and erector spinae)-as well as their net effect on ground reaction forces-while humans walked normally, with mediolateral stabilization, wide and narrow steps. We estimated local dynamic stability of trunk kinematics together with coherence of electrical vestibular stimulation (EVS) with muscle activity and mediolateral ground reaction forces. Walking with external stabilization increased local dynamic stability and decreased coherence between EVS and all muscles/forces compared to normal walking. Wide-base walking also decreased vestibulomotor coherence, though local dynamic stability did not differ. Conversely, narrow-base walking increased local dynamic stability, but produced muscle-specific increases and decreases in coherence that resulted in a net increase in vestibulomotor coherence with ground reaction forces. Overall, our results show that while vestibular contributions may vary with gait stability, they more critically depend on the stabilization demands (i.e. control effort) needed to maintain a stable walking pattern.

Trunk balance control during beam walking improves with the haptic anchors without the interference of an auditory-cognitive task in older adults

BACKGROUND

Prior studies have shown that older adults reduced trunk acceleration when walking on a balance beam with haptic inputs provided by anchors; however, it is unknown whether these benefits would remain in the presence of a concurrent cognitive task.

RESEARCH QUESTION

This study aimed to evaluate the effect of a cognitive task on balance control when using the anchors while walking on a balance beam in older adults.

METHODS

Thirty older adults participated in this study. They walked on a balance beam under four conditions combining haptic inputs (with and without anchors) and a cognitive task (present and absent). The anchors consisted of a flexible cable with a small load (125 g) attached at the end contacting the ground. Participants held one anchor in each hand and dragged the loads over the ground while walking. In the cognitive task, participants silently counted the number of times they heard a target number within a series of random numbers and provided their response at the end of each trial. Trunk acceleration and normalized step speed were assessed.

RESULTS

The anchors reduced the normalized step speed and the trunk acceleration amplitude in the frontal plane when walking on the beam. The cognitive task also diminished the normalized step speed in the beam walking. The use of the anchors did not influence the cognitive task performance.

SIGNIFICANCE

Even on a balance beam in the presence of a cognitive task, haptic anchors were able to reduce trunk acceleration in older adults to improve balance control. The cognitive task did not affect the use of haptic anchors.