Computerized posturography is more sensitive than clinical Romberg Test in detecting postural control impairment in minimally impaired Multiple Sclerosis patients

The effect of balance, walking capacity, and fear of falling on the level of community integration in individuals with Multiple Sclerosis: A cross-sectional study

BACKGROUND

Social participation levels of individuals with Multiple Sclerosis (iwMS) are lower than those of healthy individuals.

OBJECTIVE

This study aimed to evaluate to which extent the walking capacity, balance, and fear of falling (FoF) affect the community integration levels of iwMS.

METHODS

Thirty-nine iwMS were evaluated for their participation levels [The Community Integration Questionnaire (CIQ)], walking capacity [The Six-Minute Walk Test (6MWT)], balance [Kinesthetic Ability Trainer (SportKAT®)], and FoF [The Modified Falls Efficacy Scale (MFES)]. Correlation and regression analyses were performed to detect the effects of SportKAT®, 6MWT, and MFES on CIQ.

RESULTS

CIQ scores were significantly correlated with 6MWT (p = .043) and MFES (p = .005) scores, while CIQ was not related with static (for two feet test p = .356, for right single-leg stance test p = .412, for left single-leg stance test p = .730) and dynamic balance (for clockwise test p = .097, for counterclockwise test p = .540) measured with the SportKAT®. It was found that CIQ could be predicted by 6MWT and MFES at the level of 16% and 25%, respectively.

CONCLUSION

FoF and walking capacity are associated with community integration in iwMS. Therefore, physiotherapy and rehabilitation programs of iwMS should be combined with treatment goals to increase community integration, balance, and gait and decrease the disability and FoF from an early stage. Comprehensive studies examining other factors that may impact participation in iwMS with different levels of disability are needed.

Could kyphotic posture disturb body balance in young healthy population?

BACKGROUND

Kyphosis is roughly a slight forward curvature of the spine. A slight kyphosis or posterior curvature is normal throughout the human body and is present in every individual. Hyperkyphotic is a kyphotic angle greater than 40° commonly measured on a lateral X-ray measured by the Cobb method between C7 and T12. Postural instability and loss of balance can result from shifting the center of mass beyond the support base's limits. Studies are showing that kyphotic posture affects the center of gravity and affects falls in the elderly, but there are limited studies on the effect of balance in young individuals.

OBJECTIVES

the correlation between the balance and thoracic kyphosis angle has been investigated.

METHODS

Forty-three healthy individuals over the age of 18 participated in the study. Participants who met the criteria were split into two groups based on their kyphosis angle. For measuring thoracic kyphosis, Flexi Curve is used. Objective evaluation of static balance was made with NeuroCom Balance Manager® static posturography device.

RESULTS

In terms of mean difference, there was no significant difference between the kyphotic and control groups in the balance measures, and there was no correlation between the kyphosis angle and balance measures, according to statistical analysis.

CONCLUSION

According to our study, no significant relationship was found between body balance and thoracic kyphosis in the young population.

Community-based postural control assessment in autistic individuals indicates a similar but delayed trajectory compared to neurotypical individuals

Autistic individuals exhibit significant sensorimotor differences. Postural stability and control are foundational motor skills for successfully performing many activities of daily living. In neurotypical development, postural stability and control develop throughout childhood and adolescence. In autistic development, previous studies have focused primarily on individual age groups (e.g., childhood, adolescence, adulthood) or only controlled for age using age-matching. Here, we examined the age trajectories of postural stability and control in autism from childhood through adolescents using standardized clinical assessments. In study 1, we tested the postural stability of autistic (n = 27) and neurotypical (n = 41) children, adolescents, and young adults aged 7-20 years during quiet standing on a force plate in three visual conditions: eyes open (EO), eyes closed (EC), and eyes open with the head in a translucent dome (Dome). Postural sway variability decreased as age increased for both groups, but autistic participants showed greater variability than neurotypical participants across age. In study 2, we tested autistic (n = 21) and neurotypical (n = 32) children and adolescents aged 7-16 years during a dynamic postural control task with nine targets. Postural control efficiency increased as age increased for both groups, but autistic participants were less efficient compared to neurotypical participants across age. Together, these results indicate that autistic individuals have a similar age trajectory for postural stability and control compared to neurotypical individuals, but have lower postural stability and control overall.

Balance Impairments in People with Early-Stage Multiple Sclerosis: Boosting the Integration of Instrumented Assessment in Clinical Practice

The balance of people with multiple sclerosis (PwMS) is commonly assessed during neurological examinations through clinical Romberg and tandem gait tests that are often not sensitive enough to unravel subtle deficits in early-stage PwMS. Inertial sensors (IMUs) could overcome this drawback. Nevertheless, IMUs are not yet fully integrated into clinical practice due to issues including the difficulty to understand/interpret the big number of parameters provided and the lack of cut-off values to identify possible abnormalities. In an attempt to overcome these limitations, an instrumented modified Romberg test (ImRomberg: standing on foam with eyes closed while wearing an IMU on the trunk) was administered to 81 early-stage PwMS and 38 healthy subjects (HS). To facilitate clinical interpretation, 21 IMU-based parameters were computed and reduced through principal component analysis into two components, sway complexity and sway intensity, descriptive of independent aspects of balance, presenting a clear clinical meaning and significant correlations with at least one clinical scale. Compared to HS, early-stage PwMS showed a 228% reduction in sway complexity and a 63% increase in sway intensity, indicating, respectively, a less automatic (more conscious) balance control and larger and faster trunk movements during upright posture. Cut-off values were derived to identify the presence of balance abnormalities and if these abnormalities are clinically meaningful. By applying these thresholds and integrating the ImRomberg test with the clinical tandem gait test, balance impairments were identified in 58% of PwMS versus the 17% detected by traditional Romberg and tandem gait tests. The higher sensitivity of the proposed approach would allow for the direct identification of early-stage PwMS who could benefit from preventive rehabilitation interventions aimed at slowing MS-related functional decline during neurological examinations and with minimal modifications to the tests commonly performed.

Enhancement of balance, and mobility in individuals with multiple sclerosis using visual cue guided multidirectional step training - A pilot study

BACKGROUND

Individuals with multiple sclerosis (MS) often experience limitations in mobility due to impairment of gait and balance. Rehabilitation approaches to improve balance and mobility in individuals with MS are limited. We have developed a novel visual cue guided multi-direction step (MDS) training method to improve balance and mobility in individuals with MS.

OBJECTIVE

To examine the effect of MDS training on balance, gait, and mobility in individuals with MS.

METHODS

Five individuals with relapsing- remitting MS participated in the 4-week training involving stepping in eight directions in response to a visual cue. Balance, gait, and mobility were assessed before and after training.

RESULTS

Training related improvements were seen in the limits of stability (p< .05), spatial and temporal gait parameters (p<.05), and performance of the Tinetti Mobility Assessment (p=.001), 10-Meter Walk test (p<.001), and Four-Square Step test (p<.002).

CONCLUSION

Balance, gait, and mobility in individuals with MS could be improved after 4 weeks of visual cue guided multi-direction stepping training. Outcomes from this feasibility study could help to refocus conventional rehabilitation strategies aimed at aiding individuals with MS to achieve maximal independence in mobility.

Association of posturography with clinical measures in balance rehabilitation of ataxic patients

The assessment of balance includes posturography measures and clinical balance tests in individuals with ataxia. Although both advantages and disadvantages of these assessments have been stated, no relationship between them in individuals with ataxia has been shown in the literature. The aim of this cross-sectional study was to investigate the relationships between commonly used clinical balance tests and posturography measures in ataxic individuals. The study included a total of 42 patients (mean age: 33.90 ± 8.75 years) with different diagnoses causing ataxia. The sensory organization test (SOT), limits of stability (LOS), unilateral stance and rhythmic weight shift (RWS) tests in computerized dynamic posturography and the clinical balance tests of Berg Balance Scale (BBS), International Cooperative Ataxia Rating Scale (ICARS) and timed up and go (TUG) test were used to assess balance. The Spearman correlation test was used to evaluate the relationships between the clinical balance tests and posturography variables. Moderate and strong correlations were found between the ICARS, BBS and TUG scores and Unilateral Stance sway velocity, directional control parameter of RWS and LOS (P < 0.01-0.05). The ICARS and BBS scores were correlated with the SOT-Composite Equilibrium Score (P < 0.01-0.05). The results of this study suggest the use of both posturography and clinical balance tests in the rehabilitation of ataxic individuals with mild-moderate balance impairment, because posturography variables determine the underlying cause of imbalance and clinical tests evaluate balance in functional activities.

Selected Tools for Assessing the Risk of Falls in Older Women

Methods

Fifty-five females were examined (May 2018-June 2019). Stabilographic examinations were performed with eyes open (EO) and closed (EC). An analysis of variance (ANOVA) and Spearman rank correlation were performed to determine the relationships and differences between the above tests.

Results

The results of the TUG correlate with the overall stability index (OSI) EO (r = 0.314), medial-lateral stability index (MLSI) EO (r = 0.297), and fall risk index (FRI6-2; r = 0.435) in stabilographic examinations and the FRT (r = −0.399). The results of the modified Unterberger test correlate with MLSI EO (r = 0.276), OSI EC (r = 0.310), and MLSI EC (r = 0.378). There are statistically significant differences between faller and nonfaller groups in TUG (p = 0.0068), FRT (p = 0.001), and MLSI EO (p = 0.0118).

Conclusions

The modified Unterberger test and TUG can be considered effective in functional FR assessment in older women. Using at least two different functional tests may improve the assessment of FR.

Quantitative assessment of postural instability in spinocerebellar ataxia type 3 patients

Objective

Spinocerebellar ataxia type 3 (SCA3) is one of the most common hereditary neurodegenerative diseases, with balance instability as main symptom. Balance quantification is crucial for evaluating the efficacy of therapeutic interventions. However, balance evaluation in SCA3 is often subject to bias. Here, we aimed to quantitatively evaluate postural instability and investigate the relationship between postural instability and clinical characteristics in SCA3 patients.

Methods

Sixty‐two SCA3 patients and 62 normal controls were recruited, and their postural balance was measured using a posturographic platform. Principal component analysis was performed as data reduction to identify postural instability factors. Multivariable linear regression was used to investigate potential risk factors for postural instability and to explore whether postural instability predicts the severity and progression of ataxia in SCA3 patients.

Results

We found SCA3 patients experience postural instability characterized by significant impairment in static and dynamic stability. The condition without visual feedback was the most sensitive measure in differentiating SCA3 from controls. Regression analyses revealed that ataxia severity predicted both static (P = 0.014) and dynamic stability (P = 0.001). Likewise, along with expanded CAG repeats (P < 0.001), both static (P < 0.001) and dynamic stability (P < 0.001) predicted ataxia severity, but not ataxia progression.

Interpretation

Our findings demonstrate the validity of using the Pro‐kin system for assessing postural instability in SCA3 patients. This type of quantitative assessment of balance dysfunction can contribute to clinical trials and balance rehabilitation in SCA3 patients.

Visual Feedback and Postural Control in Multiple Sclerosis

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.

Dalfampridine to Improve Balance in Multiple Sclerosis: Substudy from a Randomized Placebo-Controlled Trial

This was a substudy of a randomized, double-blind, placebo-controlled trial originally designed to explore the effect of dalfampridine on information processing speed (2013-002558-64 EU Clinical Trials Register) in patients with multiple sclerosis (MS). A total of 120 patients were originally randomized in a 2:1 ratio to receive dalfampridine 10 mg or placebo twice daily for 12 weeks. Here, we sought to explore the effect of dalfampridine on static balance in single-task and dual-task conditions in a subgroup of 41 patients. They underwent static posturography in quiet standing (single-task) and while performing the Stroop test (dual-task) at randomization (baseline), after 12 weeks and after a 4-week wash-out period. Baseline characteristics of active group (n = 27) did not differ from those of placebo group (n = 14). Dalfampridine treatment was associated with better balance control than placebo in both single-task (F = 4.80, p = 0.034) and dual-task (F = 6.42, p = 0.015) conditions, with small-to-moderate effect sizes (Cohen's f2 = 0.122-0.162). The beneficial effect of dalfampridine was not retained 4 weeks after its discontinuation. The rate of accidental falls per month did not differ between the two groups (p = 0.12). Our preliminary findings suggest that dalfampridine can be considered a potential option to treat balance impairment due to MS. Larger sample sizes are needed to verify if the beneficial effect of dalfampridine on balance can be translated into a reduced risk of accidental falls.

Balance Testing in Multiple Sclerosis-Improving Neurological Assessment With Static Posturography?

Background: Balance problems can severely limit the quality of life for people with Multiple Sclerosis (pwMS) already in the early stages of the disease. PwMS are usually assessed with the Expanded Disability Status Scale (EDSS), which includes a Romberg test for assessing balance. As the EDSS assessments are subjective to the examining neurologist, the postural stability of pwMS could be objectively quantified by implementing static posturography to detect balance problems and address preventive medical care. Methods: In this cross-sectional study, we added static posturography to the neurological EDSS examination in pwMS and healthy subjects to determine how this technique could supply additional information during the evaluation of the cerebellar functional system of the neurostatus EDSS as clinical outcome already in early disease stages. Static posturography was performed with subjects standing on a force platform while outcome variables such as delineated area, average speed and average sway were obtained. Unpaired t-test as well as (Welch's) analysis of variance (ANOVA) with pairwise post-hoc comparisons according to Games-Howell were used. Spearman rank correlations were implemented to study associations of balance outcomes with EDSS-associated outcomes. Results: A total of 99 pwMS (mean age: 35.01 years; EDSS median: 2.0, 68.69% females) and 30 healthy subjects (mean age: 34.03 years; 70% females) were enrolled. PwMS had worse performances in the three evaluated balance parameters than the healthy group (all p < 0.001). Even patients without postural instability as documented in the Romberg test score of the EDSS assessment showed significantly worse outcome regarding the delineated area [+1.97 cm², 95%-CI (0.61-3.34); p = 0.002] vs. healthy controls. Similar results were observed for the comparison between pwMS with normal cerebellar function EDSS-systems and healthy subjects. There were significant correlations with the EDSS, cerebellar function score and Romberg test for the delineated area and average speed (r's ranging from 0.330 to 0.537, p < 0.001). Conclusions: Static posturography can complement neurological assessment of EDSS as an objective and quantitative test, especially for MS patients in early stages of the disease.

The relationship between trunk position sense and postural control in ataxic individuals

BACKGROUND

The proprioceptive system plays a role in the maintenance of postural control more than the visual and vestibular systems in ataxic patients with postural control disorders, but the relationship between trunk proprioception and postural control has not been sufficiently investigated yet. This relationship can provide a different perspective to the ataxia rehabilitation.

RESEARCH QUESTION

This study aimed to examine the relationship between trunk position sense and postural control in ataxic individuals by comparing them to healthy individuals.

METHODS

Twenty ataxic and 20 healthy individuals were included. The Sensory Organization Test, Limits of Stability Test, and Unilateral Stance Test in the Computerized Dynamic Posturography and Berg Balance Scale were used to evaluate postural control. The Baseline Digital Inclinometer (Norwalk, CA, USA) measured trunk position sense.

RESULTS

It was found that repositioning error degree of the trunk position sense was higher in ataxic individuals than in healthy individuals, including scores of clinical and objective tests in postural control evaluation: they were lower in ataxic individuals (p < 0.05). As a result, trunk position sense was associated with almost all evaluated parameters, including sensory integration, postural sway, limits of stability, and functional balance (p < 0.05).

SIGNIFICANCE

The impairment of postural control, which is the most important cause of activity and participation limitations in ataxic patients, is not only affected by motor disorders, but by sensory disturbances. Our study demonstrated that impairment of the trunk position sense in ataxic individuals was higher than that of healthy individuals, and affected the different components of postural control.

Static postural control disturbances among the different multiple sclerosis phenotypes: A Neurocom Balance Manager® evaluation study

BACKGROUND

The computerized stabilometric platform can be used and privileged over clinical scales, as self-administered questionnaires to asses postural control and balance evaluation in Multiple sclerosis (MS). Aim of our study was to evaluate static postural control assessed by Neurocom Balance Manager® through the modified Clinical Test of Sensory Interaction on Balance (mCTSIB) in relapsing-remitting MS (RRMS), progressive MS (PMS) and CIS, compared to healthy controls (HC).

METHODS

We screened MS patients consecutively referring to our MS Center at University of Catania, during July 2013-June 2014 diagnosed as CIS, RRMS and PMS. All MS patients underwent clinical and neurological evaluations and a complete postural exam by Neurocom Balance Manager® in order to evaluate Center of Pressure (COP), through mCTSIB. We evaluated the following parameters: Total Path Length-open eyes (TPL-OE), Total Path Length-closed eyes (TPL-CE), Sway Area-open eyes (SA-OE), Sway Area-closed eyes (SA-CE), Mean sway velocity-open eyes (MSV-OE), Mean sway velocity-closed eyes (MSV-CE). Additionally, patients were tested by Berg balance scale (BBS) for balance and Barthel Index (BI) for disability outcomes.

RESULTS

Out of 170 MS patients assessed for eligibility, 163 met the inclusion/exclusion criteria and were finally enrolled. All balance parameters were found more impaired in MS group compared to controls and CIS. Moreover, no differences in terms of balance assessment were found between HC and CIS. The correlation analysis showed that BBS was strongly associated to SA-OE, SA-CE, TPL-OE and MSV-OE. We also found a correlation between BI and SA-CE.

CONCLUSION

Our study revealed significant differences among HCs, CIS and MS. MS, especially PMS, exhibit the worst balance performances especially in EC trials. The higher correlation between balance parameters, especially sway area, and BBS score confirmed the reliability and sensibility of mCTSIB assessment in evaluating static postural control in MS patients.