Clinical tests of standing balance: performance of persons with multiple sclerosis

The effect of cervical mobilization on joint position sense, balance and gait in patients with multiple sclerosis: a randomized crossover study

OBJECTIVE

To investigate the effect of cervical mobilization on joint position sense, balance and gait in multiple sclerosis (MS) patients.

METHODS

Sixteen MS patients received traditional rehabilitation and traditional rehabilitation+cervical mobilization treatments in different orders, 2 days a week for 4 weeks. For the cervical mobilization, joint traction and shifts with myofascial release techniques were applied. Joint position sense was evaluated from the bilateral knee and ankle joints with a digital goniometer, balanced with the Berg Balance Test (BBT), the Functional Reach Test, and gait with the Dynamic Gait Index (DGI) and the Timed 25-Foot Walk Test.

RESULTS

Improvements were determined in joint position sense, balance, gait with both treatment methods (p < 0.05). With the addition of cervical mobilization to traditional treatment, there was observed to be an increased effect carried over in knee joint position sense and BBT (p < 0.05). The BBT and DGI scores improved in the group applied with cervical mobilization following the washout period (p < 0.05).

CONCLUSIONS

Cervical mobilization could be effective in improving joint position sense, balance and gait, and accelerated improvements in a short time. The application of cervical mobilization could be a supportive treatment method to improve position sense, balance and gait in patients with MS.

Effect of melatonin intake on postural balance, functional mobility and fall risk in persons with multiple sclerosis: a pilot study

AIM

To assess the safety and the effect of a nocturnal melatonin (MEL) ingestion on postural balance, functional mobility and fall risk the following morning in adults with multiple sclerosis (MS).

METHODS

Fourteen adults with relapsing-remitting MS (RR-MS) (28.36 ± 6.81 years) were evaluated before and after nocturnal ingestion of MEL (6 mg) or placebo (PLA). Evaluations included a posturographic test of static bipedal postural balance with dual-task in eyes open (EO) and eyes closed conditions, and a clinical test of unipedal balance. The physical performance tests were: Timed Up and Go test (TUGT) (mobility), Four Square Step Test (FSST) (fall risk), and Timed 25-foot walk test (T25FWT) (walking speed). Cognitive performance [Montreal Cognitive Assessment (MoCA) and Simple Reaction Time (SRT) tests] and sleep quality [Spiegel's sleep questionnaire (SSQ)] were also assessed.

RESULTS

In EO condition, MEL decreased the posturographic parameters [center of pressure (CoP) sway area (CoPAr), CoP path length (CoPL) and CoPL in the mediolateral axis (CoPLX)] more than PLA by 15.82% (p = 0.0006), 12.48% (p  = 0.0004) and 14.25% (p = 0.0002), respectively. Durations of TUGT and FSST decreased following MEL session more than the PLA one by 14.52% (p = 0.017) and 19.85% (p = 0.0006), respectively. MEL increased the unipedal stance time, SSQ and MoCA scores more than PLA by 49.81% (p = 0.04), 32.21% (p = 0.004) and 11.87% (p = 0.008), respectively.

CONCLUSION

This pilot study showed that acute nocturnal MEL ingestion seems to be safe for enhancing postural balance, fun mobility and fall risk in RR-MS adults probably through improving sleep quality and cognitive function.

Association between the Hopkins Falls grading scale and motor function tests in patients with multiple sclerosis

Introduction

One of the main complications of multiple sclerosis (MS) is imbalance and walking problems that can lead to falls. This study investigated the association between a fall measurement scale called the Hopkins Falls Grading Scale (HFGS) and motor function tests in patients with MS.

Material and Methods

This cross sectional study was conducted using convenience sampling on 85 patients referred to the MS Association of Mashhad, Iran, in 2023. The HFGS examined falls during the past year and divided them into 4 degrees, and the function test included the timed 25 foot walk (T25FW) test and the timed up and go (TUG) test. Kruskal-Wallis test and Spearman's correlation coefficient were used for data analysis.

Results

A statistically significant association was obtained between HFGS and functional tests (T25FW and TUG) (for both P < 0.0001). A significant association was observed between the variables of age (P = 0.006), duration of the disease (P = 0.03), the use of mobility devices (P = 0.05), and HFGS.

Conclusion

Considering the association between HFGS and motor function tests in MS patients, clinical experts should pay attention to patients who have slower movement and evaluate them in terms of falling status when performing motor function tests.

The effect of hip abductor strengthening exercises on lower limb strength asymmetry and balance in women with multiple sclerosis: A randomized controlled clinical trial

INTRODUCTION

Patients with multiple sclerosis tend to use and move their body segments in an unbalanced way, which causes asymmetry of muscle strength, especially in the lower limbs. Among these muscles, the hip abductor muscles play a more important role in stabilizing the pelvis and maintaining balance. The purpose of this research was to investigate the effect of hip abductors exercises on lower limb strength asymmetry and balance in people with multiple sclerosis.

MATERIALS & METHODS

In this clinical trial with a pre-test-post-test design, 40 women with multiple sclerosis were purposefully selected and randomly divided into experimental and control groups. The experimental group performed hip abductor muscle strengthening exercises for 8 weeks and each session lasted 30 min. The control group did not receive any intervention and continued their daily activities. The strength of knee flexors and extensors, plantar-flexors and ankle dorsi-flexors was measured using a dynamometer. Static and dynamic balance was also evaluated using the stork test and timed get up and go test, respectively. ANCOVA test was used at a significance level of 0.05 to investigate the intergroup effects.

RESULTS

The results showed a significant decrease in the strength asymmetry of the knee extensor (P = 0.001) and knee flexor (P = 0.001) muscles in the experimental group. However, no significant difference was observed in the asymmetry of the strength of the ankle dorsi-flexor (P = 0.160) and plantar-flexor muscles (P = 0.698). The results also showed a significant improvement in static (P = 0.001) and dynamic balance (P = 0.001) in the experimental group.

DISCUSSIONS & CONCLUSIONS

Strengthening the hip abductors improves the symmetry of the strength of the knee extensor and flexor muscles. It also improves the balance of people with multiple sclerosis.

Impact of textured surfaces on the orthostatic balance of patients with multiple sclerosis

OBJECTIVE

To perform posturographic measurements with eyes open or closed using floor coverings with different textured surfaces to study postural control in patients with multiple sclerosis (MS).

METHODS

Static posturographic recordings were performed with eyes open and eyes closed on a forceplate with no covering (control condition) or covered by a textured mat with small pimples (height 2 mm) or large pimples (height 7 mm). Several posturographic variables were measured, focusing on displacements of the center of pressure (CoP) including the average velocity (Vav), the total length (L) of all displacements, and the surface (S) of the confidence ellipse. The recordings made with the textured mats were compared to the control condition with eyes open or closed. Then, the differences between the recordings made with large vs. small pimples on the one hand, and with eyes closed vs. open were calculated to assess the impact of pimple height or eye closure on posturographic measurements. Clinical assessment was based on the Expanded Disability Status Scale (EDSS) and its functional system (FS) subscores, the Modified Fatigue Impact Scale (MFIS), the Unipodal Stance test (UST), and the Timed Up-and-Go test (TUG).

RESULTS

Forty-six MS patients (mean EDSS score: 3.6) completed the study. Several posturographic variables, including Vav and L, deteriorated when measured on a textured mat, especially with large pimples and in eyes open condition. In contrast, no difference was found with small pimples and eyes closed, as compared to the control condition (no covering). The deleterious impact of pimple height on posturography correlated positively with the alteration of balance and gait clinically assessed by the UST and the TUG, and also with the MFIS physical and cerebral EDSS-FS subscores, and negatively with the cerebellar and brainstem subscores. On the other hand, the impact of eye closure on posturography was negatively correlated with the visual EDSS-FS subscore.

DISCUSSION

Static posturographic measurements made with different textured surfaces and visual conditions can be considered as a sensitive tool to measure "proprioceptive reserves". Actually, when cerebellar, brainstem, or visual functions are impaired, the resources of the sensory (proprioceptive) system, if preserved, can be recruited at a higher level and compensate for dysfunctions of other postural controls to maintain a satisfactory balance. In addition, this procedure of static posturographic examination can provide objective measurements correlated with clinical testing of balance and gait and could usefully complement EDSS scoring to assess disability affecting postural control and the risk of falling in MS patients.

The instrumented single leg stance test detects early balance impairment in people with multiple sclerosis

Balance impairment is frequent in people with multiple sclerosis (pwMS) and affects risk of falls and quality of life. By using inertial measurement units (IMUs) on the Single Leg Stance Test (SLS) we aimed to discriminate healthy controls (HC) from pwMS and detect differences in balance endurance and quality. Thirdly, we wanted to test the correlation between instrumented SLS parameters and self-reported measures of gait and balance. Fifty-five pwMS with mild (EDSS<4) and moderate disability (EDSS≥4) and 20 HC performed the SLS with 3 IMUs placed on the feet and sacrum and filled the Twelve Item Multiple Sclerosis Walking Scale (MSWS-12) questionnaire. A linear mixed model was used to compare differences in the automated balance measures. Balance duration was significantly longer in HC compared to pwMS (p < 0.001) and between the two disability groups (p < 0.001). Instrumented measures identified that trunk stability (normalized mediolateral and antero-posterior center of mass stability) had the strongest association with disability (R2 marginal 0.30, p < 0.001) and correlated well with MSWS-12 (R = 0.650, p < 0.001). PwMS tended to overestimate own balance compared to measured balance duration. The use of both self-reported and objective assessments from IMUs can secure the follow-up of balance in pwMS.

Combined effect of gender differences and fatiguing task on postural balance, functional mobility and fall risk in adults with multiple sclerosis: A preliminary study

AIM

To investigate the gender difference effect on postural balance, functional mobility, and fall risk after performing a fatiguing task in adults with multiple sclerosis (MS).

METHODS

Eleven women (30.91 ± 8.19 years) and seven men (30.29 ± 7.99 years) with relapsing-remitting MS performed a fatiguing task: three sets of the Five-repetition Sit-To-Stand Test (5-STST) were performed before and after the six-minute WalkTest (6MWT). Bipedal postural balance in eyes open and eyes closed conditions were assessed prefatigue (T0) and postfatigue (T3) using a force platform. Unipedal balance, functional mobility (Timed Up and Go Test), fall risk (Four Square Step Test) and fatigue [Visual Analogue Scale of Fatigue (VASF)] were assessed at T0 and T3. Heart rate (HR) and Rating of Perceived Exertion (RPE) were recorded before (only for HR), during and after the fatiguing task.

RESULTS

Compared to women, men showed an impairment of posturographic parameters [mean center of pressure (CoP) velocity (CoPVm) in both conditions (p < 0.05); CoP sway area (CoPAr) in both conditions (p < 0.01)], unipedal balance on the dominant leg (p <0.001), mobility (p<0.001) and an increased fall risk (p < 0.05). No gender differences were observed in 6MWT, 5-STST, HR, RPE, and VASF.

CONCLUSION

This preliminary study showed that fatiguing task negatively affected postural control, mobility and fall risk only in men. These gender differences were inconclusive but could be taken into account in postural balance rehabilitation programs for MS persons.

The effects of orthotics device on the balance control in multiple sclerosis patients: A systematic review and meta-analysis

BACKGROUND

Multiple sclerosis refers to a progressive autoimmune inflammatory disease in the central nervous system usually accompanied by balance disorder. Our systematic review aimed to investigate the effects of orthotic devices on balance control of multiple sclerosis patients.

METHODS

The search procedure was according to the population, intervention, comparison, and outcome (PICO) strategy. We looked into PubMed, Embase, ISI Web of Knowledge, and Scopus databases and included all studies published since 1980. Two researchers did the searches separately and evaluated the selected papers' quality based on the physiotherapy evidence database (PEDro) scale and Cochrane risk of bias tool. We did a meta-analysis to evaluate the interventions' effects on the balance factors.

RESULTS

We found nine studies, of which seven studies with 162 participants were included in our meta-analysis. Four studies investigated the effect of foot orthoses, one evaluated the effect of shoe modifications and four evaluated the effect of ankle foot orthoses. There was no significant immediate difference between the insole and control groups in center of pressure velocity change, C7 displacement, in both open and closed eyes conditions. Also, there was no significant immediate difference between ankle foot orthosis' intervention and control groups in center of pressure velocity and displacement changes in antero-posterior and medio-lateral directions, in both open and closed eyes conditions. We could not do a meta-analysis for shoe modification.

CONCLUSION

Few studies have assessed the effects of orthoses on balance control in multiple sclerosis patients. Studies on ankle foot and foot orthoses show inconsistent results. According to our meta-analysis, orthotic interventions do not seem to improve the balance of people with multiple sclerosis.

Comparing the effects of cognitive dual tasking on balance and gait motor performance in people with mild multiple sclerosis and healthy individuals

Background/Aims

People with multiple sclerosis show both cognitive and postural impairment, and various static and dynamic postural activities may be affected under conditions of cognitive distraction. The aim of this study was to determine the effects of cognitive dual tasking on the balance and gait motor performance of people with mild multiple sclerosis (Expanded Disability Status Scale score of 2.0 ± 1.3) and healthy people and to compare these two groups in terms of performing single and dual tasks.

Methods

People with mild multiple sclerosis (n=39) and healthy individuals (n=33) performed static balance tests (Romberg's Test, tandem stance test, single-legged stance test) and dynamic balance tests (Functional Reach Test, Four Square Step Test, Timed Up and Go Test, 10-Metre Walk Test), with and without a word list generation test (single and dual tasks). Independent t-tests were used to evaluate differences between the two groups, and paired t-tests were used for single or dual tasks for all static and dynamic tests. The magnitude of differences in tasks between measures was expressed as Cohen's d.

Results

Dual task effects were more evident during dynamic balance tests in participants with multiple sclerosis and healthy participants (specifically the Timed Up and Go Test and 10-Metre Walk Test) (P<0.001). There was a significant difference between both groups only in terms of static balance (P<0.001).

Conclusions

Dynamic balance and gait were shown to be more affected when performing the dual cognitive task than static balance in people with multiple sclerosis. Dual tasks should be included in diagnoses.

Static Balance Digital Endpoints with Mon4t: Smartphone Sensors vs. Force Plate

Static balance tests are conducted in various clinics for diagnosis and treatment adjustment. As a result of population aging, the accessibility of these tests should be increased, in the clinic, and for remote patient examination. A number of publications have already conducted static balance evaluations using the sensors embedded in a smartphone. This study focuses on the applicability of using smartphone-based balance assessment on a large scale while considering ease of use, safety, and reliability. The Mon4t^® app was used to acquire the postural motion using different smartphone devices, different smartphone locations, and various standing postures. The signals derived from the app were compared to the center of pressure displacement derived from a force plate. The results showed moderate to high agreement between the two methods, particularly at the tandem stance (0.69 ≤ r ≤ 0.91). Preliminary data collection was conducted on three healthy participants, followed by 50 additional healthy volunteers, aged 65+. The results demonstrated that the Mon4t app can serve as an accessible and inexpensive static balance assessment tool, both in clinical settings and for remote patient monitoring, which is key for enabling telehealth.

Postural Sway in Parkinson's Disease and Multiple Sclerosis Patients During Tasks With Different Complexity

Neurological diseases are associated with static postural instability. Differences in postural sway between neurological diseases could include "conceptual" information about how certain symptoms affect static postural stability. This information might have the potential to become a helpful aid during the process of finding the most appropriate treatment and training program. Therefore, this study investigated static postural sway performance of Parkinson's disease (PD) and multiple sclerosis (MS) patients, as well as of a cohort of healthy adults. Three increasingly difficult static postural tasks were performed, in order to determine whether the postural strategies of the two disease groups differ in response to the increased complexity of the balance task. Participants had to perform three stance tasks (side-by-side, semi-tandem and tandem stance) and maintain these positions for 10 s. Seven static sway parameters were extracted from an inertial measurement unit that participants wore on the lower back. Data of 47 healthy adults, 14 PD patients and 8 MS patients were analyzed. Both healthy adults and MS patients showed a substantial increase in several static sway parameters with increasingly complex stance tasks, whereas PD patients did not. In the MS patients, the observed substantial change was driven by large increases from semi-tandem and tandem stance. This study revealed differences in static sway adaptations between PD and MS patients to increasingly complex stance tasks. Therefore, PD and MS patients might require different training programs to improve their static postural stability. Moreover, this study indicates, at least indirectly, that rigidity/bradykinesia and spasticity lead to different adaptive processes in static sway.

Postural Control in Relapsing-Remitting Multiple Sclerosis

Introduction  Postural instability is considered one of the most disabling symptoms of relapsing-remitting multiple sclerosis (RRMS).

Objective  To evaluate postural control in patients with RRMS.

Method  A total of 79 individuals between 18 and 65 years old, of both genders, were distributed into an experimental group composed of patients with RRMS ( n  = 51) and in a control group composed by healthy individuals ( n  = 28). The evaluation consisted of anamnesis, Dizziness Handicap Inventory (DHI), visual vertigo analog scale (VVAS), and static posturography (Tetrax IBS).

Results  Patients with RRMS presented mild degree in the DHI and in the VVAS; in Tetrax IBS, they presented higher or lower values of the indices of general stability, weight distribution, synchronization of postural oscillation, fall risk, and frequency bands of postural oscillation in two, five or all eight sensory conditions, in relation to the control group. Vestibular, visual and/or somatosensory dysfunction of peripheral type (51.0%) prevailed over the central type. The RRMS group, with an expanded scale of disability status > 3 points, presented a higher fall risk than with a score ≤ 3 points ( p  = 0.003). There was a positive correlation of the Fall Risk Index with the total DHI Score (s = 0.380; p  = 0.006) and with the VVAS score (s = 0.348; p  = 0.012).

Conclusion  Patients with RRMS may present with inability to maintain postural control due to general instability, desynchronization and increased postural oscillation at frequencies that suggest deficiencies in the vestibular, visual, and somatosensory systems; as well as fall risk related to the state and intensity of functional disability and self-perception of the influence of dizziness on quality of life.

Modified Functional Reach Test: Upper-Body Kinematics and Muscular Activity in Chronic Stroke Survivors

Effective control of trunk muscles is fundamental to perform most daily activities. Stroke affects this ability also when sitting, and the Modified Functional Reach Test is a simple clinical method to evaluate sitting balance. We characterize the upper body kinematics and muscular activity during this test. Fifteen chronic stroke survivors performed twice, in separate sessions, three repetitions of the test in forward and lateral directions with their ipsilesional arm. We focused our analysis on muscles of the trunk and of the contralesional, not moving, arm. The bilateral activations of latissimi dorsi, trapezii transversalis and oblique externus abdominis were left/right asymmetric, for both test directions, except for the obliquus externus abdominis in the frontal reaching. Stroke survivors had difficulty deactivating the contralesional muscles at the end of each trial, especially the trapezii trasversalis in the lateral direction. The contralesional, non-moving arm had muscular activations modulated according to the movement phases of the moving arm. Repeating the task led to better performance in terms of reaching distance, supported by an increased activation of the trunk muscles. The reaching distance correlated negatively with the time-up-and-go test score.

Maximising Abilities, Negotiating and Generating Exercise options (MANAGE) in people with multiple sclerosis: A feasibility randomised controlled trial

OBJECTIVE

To investigate the feasibility and preliminary efficacy of a group self-management exercise and education program in people with multiple sclerosis.

DESIGN

Feasibility randomised controlled trial.

SETTING

Outpatient rehabilitation facility.

SUBJECTS

Twenty-three adults (age 48.6 (11.7) years) recruited from a Multiple Sclerosis Clinic register.

INTERVENTIONS

The intervention group undertook a 12-week group program incorporating behaviour change education, exercise and community integration. This was compared with a waitlist control group.

MAIN MEASURES

Feasibility was measured by recruitment, adherence and safety. Efficacy outcomes included measures of physical function (6-metre and 6-min walk, Functional Reach) and self-report questionnaires (fatigue, quality of life, exercise benefits and barriers) at baseline, 6, 12 and 24 weeks.

RESULTS

Of 74 individuals identified through the register, 48 (65%) were contacted and deemed eligible, and 23 (48%) agreed to participate. There was high adherence for attendance at education (57 of 72, 79%) and exercise (135 of 174, 78%) sessions. No adverse safety events occurred within the intervention sessions. Missed attendances at assessment sessions was high (5 to 8 participants missed at each time point) predominately due to health issues. The intervention group demonstrated positive changes in walking endurance, Functional Reach and fatigue, whereas the control had some reductions in walking speed and more perceived exercise barriers.

CONCLUSIONS

The MANAGE program appears feasible and safe for people with mild-to-moderate multiple sclerosis, with high adherence to exercise and education sessions. Future trials should consider strategies such as flexible scheduling or alternative methods of data collection to improve follow-up assessment attendance.

Alterations in Leg Muscle Glucose Uptake and Inter-Limb Asymmetry after a Single Session of tDCS in Four People with Multiple Sclerosis

Asymmetrical lower limb weakness is an early symptom and significant contributor to the progressive worsening of walking ability in people with multiple sclerosis (PwMS). Transcranial direct current stimulation (tDCS) may effectively increase neural drive to the more-affected lower limb and, therefore, increase symmetrical activation. Four PwMS (1 female, age range: 27–57) underwent one session each of 3 mA or SHAM tDCS over the motor cortex corresponding to their more-affected limb followed by 20 min of treadmill walking at a self-selected speed. Two min into the treadmill task, the subjects were injected with the glucose analog [¹⁸F]fluorodeoxyglucose (FDG). Immediately after treadmill walking, the subjects underwent whole-body positron emission tomography (PET) imaging. Glucose uptake (GU) values were compared between the legs, the spatial distribution of FDG was assessed to estimate glucose uptake heterogeneity (GUh), and GU asymmetry indices (AIs) were calculated. After tDCS, GU was altered, and GUh was decreased in various muscle groups in each subject. Additionally, AIs went from asymmetric to symmetric after tDCS in the subjects that demonstrated asymmetrical glucose uptake during SHAM. These results indicate that tDCS improved GU asymmetries, potentially from an increased neural drive and a more efficient muscle activation strategy of the lower limb in PwMS.

Long-Lasting Event-Related Beta Synchronizations of Electroencephalographic Activity in Response to Support-Surface Perturbations During Upright Stance: A Pilot Study Associating Beta Rebound and Active Monitoring in the Intermittent Postural Control

Movement related beta band cortical oscillations, including beta rebound after execution and/or suppression of movement, have drawn attention in upper extremity motor control literature. However, fewer studies focused on beta band oscillations during postural control in upright stance. In this preliminary study, we examined beta rebound and other components of electroencephalogram (EEG) activity during perturbed upright stance to investigate supraspinal contributions to postural stabilization. Particularly, we aimed to clarify the timing and duration of beta rebound within a non-sustained, but long-lasting postural recovery process that occurs more slowly compared to upper extremities. To this end, EEG signals were acquired from nine healthy young adults in response to a brief support-surface perturbation, together with the center of pressure, the center of mass and electromyogram (EMG) activities of ankle muscles. Event-related potentials (ERPs) and event-related spectral perturbations were computed from EEG data using the perturbation-onset as a triggering event. After short-latency (<0.3 s) ERPs, our results showed a decrease in high-beta band oscillations (event-related desynchronization), which was followed by a significant increase (event-related synchronization) in the same band, as well as a decrease in theta band oscillations. Unlike during upper extremity motor tasks, the beta rebound in this case was initiated before the postural recovery was completed, and sustained for as long as 3 s with small EMG responses for the first half period, followed by no excessive EMG activities for the second half period. We speculate that those novel characteristics of beta rebound might be caused by slow postural dynamics along a stable manifold of the unstable saddle-type upright equilibrium of the postural control system without active feedback control, but with active monitoring of the postural state, in the framework of the intermittent control.

A 1-Minute Re-warm Up at High-Intensity Improves Sprint Performance During the Loughborough Intermittent Shuttle Test

Although a 3- to 7-min re-warm up (RW) elicits performance and physiological benefits after half-time (HT), a time-efficient and feasible RW protocol is required for the use of an RW in the athletic setting. This study aimed to investigate the effect of a 1-min RW at high-intensity on the performance and physiological responses during the Loughborough Intermittent Shuttle Test (LIST). In a randomized and counterbalanced cross-over design, 12 male amateur intermittent team sports players (soccer, basketball, handball, and lacrosse; age, 22 ± 2 years; height, 1.70 ± 0.08 m; body mass, 65.1 ± 8.3 kg; body mass index, 22.4 ± 1.9 kg m⁻²; VO_2max, 53.5 ± 4.5 ml kg⁻¹ min⁻¹) performed the LIST. The LIST comprised two 45-min halves separated by a 15-min HT. Each half comprised repetitions of exercise cycles consisting of 3 × 20-m walking, 1 × 20-m maximal sprint, 3 × 20-m jogging, and 3 × 20-m running. During the HT, the participants were assigned to a control trial (CON; 15-min seated rest) or an RW trial (1-min running at 90% of the maximal oxygen uptake after a 14-min seated rest). Compared to the CON, the RW prevents reductions in sprint performance at the fourth and sixth periods of the LIST (fourth: 2.4%, p = 0.002, d = 1.68, sixth: 3.6%, p = 0.012, d = 1.74) and a decrement of gastrointestinal temperature during HT (0.5°C, p = 0.010, d = 1.41). Moreover, the RW decreased the electromyogram amplitude of maximal voluntary contraction (MVC) after HT (12%, p = 0.017, d = 1.12) without a decrease of maximal voluntary contraction force, suggesting an increased neuromuscular efficiency (9%, p = 0.048, d = 0.58). The RW also increased the mean heart rate in the initial part of the second half (4 bpm, p = 0.016, d = 0.38). In conclusion, the RW improved sprint performance, core temperature, muscle activation, and heart rate in the second half of the LIST. The findings suggest that the RW should be recommended for intermittent team sports players when longer RWs are not possible.

Smartphone accelerometry to assess postural control in individuals with multiple sclerosis

BACKGROUND

Falls are a major health concern for people with Multiple Sclerosis (pwMS), and impaired postural control is an important predictor of falls. Lab-based technology to measure posture is precise but expensive, and clinical tests may not capture underlying impairments. An alternative solution is to leverage smartphone accelerometry as it is affordable, ubiquitous, and portable.

RESEARCH QUESTION

Can smartphone accelerometry measure postural control compared to a force plate and research grade accelerometer in pwMS, and can smartphone accelerometry discriminate between assisted device and non-assisted device users?

METHODS

27 pwMS (12 assisted device users, 15 non-assisted device users) stood on a force plate while holding a smartphone with an attached research grade accelerometer against their chest. Participants performed two, 30 s trials of: eyes open, eyes closed, semi-tandem, tandem, and single leg. Acceleration and center of pressure were extracted, and Root Mean Square (RMS) and 95 % confidence ellipse were calculated. Spearman's correlations were performed, and receiving operating characteristic (ROC) curves and the Area Under the Curve (AUC) were calculated.

RESULTS

There were moderate to high correlations between the smartphone and accelerometer for RMS (ρ = 0.85 - 1.0; p = 0.001 - <0.001) and 95 % area ellipse (ρ = 0.92 - 0.99; p = <0.001). There were weak to moderate correlations between the smartphone and force plate for RMS (ρ = 0.38 - 0.92; p = 0.06 - <0.001) and 95 % area ellipse (ρ = 0.69 - 0.90 p = 0.002 - <0.001). To discriminate between assisted device usage, ROC curves for smartphone outputs were constructed, the AUC was high and statistically significant (p < 0.001 - 0.02).

SIGNIFICANCE

There is potential to leverage smartphone accelerometery to measure postural control in pwMS. These finding provide preliminary results to support the development of a mobile health application to measure fall risk for pwMS.

The role of the dominant leg while assessing balance performance. A systematic review and meta-analysis

BACKGROUND

Good balance is a pre-requisite for various activities of daily life and sports. Physiotherapists thus regularly assess and train patient's balance capacities. In order to interpret the test results of unilateral balance tests, a comparison with normative data is common. In patients who had an injury or a surgery, the performance of the injured leg is often compared with performance of the non-injured leg. Nevertheless, it remains unclear if unilateral balance performance differs between the dominant and non- dominant legs. If so, this should take into consideration when interpreting test results.

RESEARCH QUESTION

This meta-analysis summarized the current evidence to determine if the balance performance of healthy adults was influenced by the leg's dominance.

METHODS

Articles were searched in PubMed, CINAHL, Cochrane and Embase. Data from studies meeting the pre-defined inclusion criteria were extracted in a standardized form. A meta-analysis was conducted using a random effect model.

RESULTS

Forty-six studies were included. Their data were allocated in 7 categories of balance tests. Significant differences between the dominant and the non-dominant legs were not found in any of the categories (surface stable, eyes open: -0.04, 95 % CI -0.12 to 0.05, surface stable eyes closed: -0.06, 95 % CI -0.22 to 0.11, surface unstable, eyes open: -0.15, 95 % CI -0.38 to 0.07, surface unstable, eyes closed: -0.06, 95 % CI -0.27 to 0.15, BESS (Balance Error Scoring System): 0.03, 95 % CI -1.09 to 1.14, SEBT (Star Excursion Balance Test)/YBT (Y Balance Test): 0.06, 95 % CI -0.04 to 0.16, jump: 0.04, 95 % CI -0.28 to 0.36).

SIGNIFICANCE

Results indicate that balance performance is not influenced by the leg's dominance. This means that performances of both legs can be used as reference. Evidence is strong for the one leg stance. However, future studies are needed to confirm our results for stabilization tasks after a jump landing.

Comparing the effects of vestibular rehabilitation with and without lavender oil scents as an olfactory stimulus on balance, fear of falling down and activities of daily living of people with multiple sclerosis: a randomized clinical trial

PURPOSE

To evaluate the effect of using lavender oil as an olfactory stimulus with vestibular rehabilitation (VR) on balance, fear of falling down, and activities of daily living of people with multiple sclerosis.

METHODS

Forty participants were randomly assigned into experimental and control groups. The experimental group did the VR exercises while smelling the lavender oil scents. The control group did the VR exercises without it. Both groups did the exercises in ten 45-min sessions. We assessed the participants with the timed up and go (TUG) test, Berg balance scale (BBS), fall efficacy scale - international (FES-I), and the 29-item multiple sclerosis impact scale (MSIS-29). We did the tests at the baseline and after the last exercise session.

RESULTS

The experimental group performed significantly better in the BBS (p = 0.007), TUG (p = 0.045), and FES-I (p = 0.016) tests as well as in the MSIS-29's psychological subscale (p = 0.034) than did the control group.

CONCLUSIONS

Using lavender oil as olfactory stimulus while doing the VR exercises can improve balance and reduce fear of falling down compared to doing the VR exercises without it in people with multiple sclerosis.Implications for rehabilitationIt seems that using lavender oil, as an olfactory stimulus, while doing vestibular rehabilitation exercises can improve balance and reduce fear of falling down in people with multiple sclerosis compared to doing the vestibular rehabilitation exercises without it.This treatment significantly alleviates the psychological effects of multiple sclerosis on daily life such as sleeping problems, feeling unwell, anxious, tense, depressed, etc.

Falls in older people with diabetes: Identification of simple screening measures and explanatory risk factors

AIMS

To identify risk factors for falls in older people with diabetes mellitus (DM) and to develop a low-cost fall risk screening tool.

METHODS

Older adults with DM (n = 103; age = 61.6 + 6.0 years) were recruited from diabetic clinics. Demographic, DM specific factors, lower limb strength and sensation, cognition, fear of falling, hand reaction time, balance, mobility and gait parameters were assessed using validated methods. Falls were prospectively recorded over six months.

RESULTS

Past falls and female gender were identified as significant predictors of falls: history of falls and female gender increased fall rates by 4.62 (95% CI = 2.31-9.27) and 2.40 (95% CI = 1.04-5.54) respectively. Fall rates were significantly associated with Diabetic Neuropathy scores, HbA1c level, contrast sensitivity, quadriceps strength, postural sway, tandem balance, stride length and Timed Up and Go Test times. A multi-variable fall risk tool derived using five measures, revealed that absolute risk for multiple falls increased from 0% in participants with zero or one factor to 83% in participants with all five risk factors.

CONCLUSIONS

Simple screening items for fall risk in people with DM were identified, with parsimonious explanatory risk factors. These findings help guide tailored interventions for preventing falls in DM.

Analysis of Postural Control in Sitting by Pressure Mapping in Patients with Multiple Sclerosis, Spinal Cord Injury and Friedreich's Ataxia: A Case Series Study

The postural control assessments in patients with neurological diseases lack reliability and sensitivity to small changes in patient functionality. The appearance of pressure mapping has allowed quantitative evaluation of postural control in sitting. This study was carried out to determine the evaluations in pressure mapping and verifying whether they are different between the three sample groups (multiple sclerosis, spinal cord injury and Friedreich’s ataxia), and to determine whether the variables extracted from the pressure mapping analysis are more sensitive than functional tests to evaluate the postural trunk control. A case series study was carried out in a sample of 10 adult patients with multiple sclerosis (n = 2), spinal cord injury (n = 4) and Friedreich’s ataxia (n = 4). The tests applied were: pressure mapping, seated Lateral Reach Test, seated Functional Reach Test, Berg Balance Scale, Posture and Postural Ability Scale, Function in Sitting Test, and Trunk Control Test. The participants with Friedreich’s ataxia showed a tendency to present a higher mean pressure on the seat of subject’s wheelchair compared to other groups. In parallel, users with spinal cord injury showed a tendency to present the highest values of maximum pressure and area of contact. People with different neurological pathologies and similar results in functional tests have very different results in the pressure mapping. Although it is not possible to establish a strong statistical correlation, the relationships between the pressure mapping variables and the functional tests seem to be numerous, especially in the multiple sclerosis group.

Different Effects of Transcranial Direct Current Stimulation on Leg Muscle Glucose Uptake Asymmetry in Two Women with Multiple Sclerosis

Asymmetrical lower limb strength is a significant contributor to impaired walking abilities in people with multiple sclerosis (PwMS). Transcranial direct current stimulation (tDCS) may be an effective technique to enhance cortical excitability and increase neural drive to more-affected lower limbs. A sham-controlled, randomized, cross-over design was employed. Two women with MS underwent two 20 min sessions of either 3 mA tDCS or Sham before 20 min of treadmill walking at a self-selected speed. During walking, the participants were injected with the glucose analogue, [¹⁸F] fluorodeoxyglucose (FDG). Participants were then imaged to examine glucose metabolism and uptake asymmetries in the legs. Standardized uptake values (SUVs) were compared between the legs and asymmetry indices were calculated. Subject 2 was considered physically active (self-reported participating in at least 30 min of moderate-intensity physical activity on at least three days of the week for the last three months), while Subject 1 was physically inactive. In Subject 1, there was a decrease in SUVs at the left knee flexors, left upper leg, left and right plantar flexors, and left and right lower legs and SUVs in the knee extensors and dorsiflexors were considered symmetric after tDCS compared to Sham. Subject 2 showed an increase in SUVs at the left and right upper legs, right plantar flexors, and right lower leg with no muscle group changing asymmetry status. This study demonstrates that tDCS may increase neural drive to leg muscles and decrease glucose uptake during walking in PwMS with low physical activity levels.

Choose your words wisely: Optimizing impacts on standardized performance testing

BACKGROUND

The OPTIMAL theory of motor learning identifies motivational (enhanced expectancies, EE, and autonomy support, AS) and attentional (an external attentional focus, EF) factors that affect motor performance and learning [1]. One implication of this theory is that standardized clinical and laboratory assessments of physical capacity and motor performance that do not incorporate optimizing conditions may underestimate true maximal capabilities. The influence of "optimized" conditions on a clinical-applied test of balance control was examined with healthy participants. Given the motor performance benefits of optimized conditions predicted by the OPTIMAL theory, it was hypothesized that providing participants with information that induced EE, provided them with AS, and promoted their use of EF would reduce balance errors and postural sway.

METHODS

We used as an exemplar assessment, the Balance Error Scoring System (BESS), and center-of-pressure (COP) velocity measurements of postural sway. Participants performed under two different conditions, separated by two days: an optimized (EE, AS, and EF) condition and a control ("neutral") condition, with sample-wide order counterbalancing. In each condition, participants performed three stances (double-leg, single-leg, and tandem) on two support surfaces (firm and foam). Stance order was participant-determined in the optimized condition and, for the control condition, yoked to a participant in the optimized condition.

RESULTS

Participants committed fewer balance errors in the optimized condition than in the control condition (p < .001) and their resultant COP velocity in the optimized condition was lower than that in the control condition (p = .004). BESS scores were correlated with resultant COP velocity (r = .593, p < .001).

SIGNIFICANCE

Our results demonstrated the impact of implementing optimized, as opposed to "neutral" control, conditions for better insight into balance capabilities in normal and challenging situations. Practitioners' roles in mediating test situations and using subtle wording to promote optimized performance may have consequential impacts on motor assessment outcomes.

Test-Retest Reliability and Response Stability of Gaze Stabilization, Postural Sway, and Dynamic Balance Tests in Persons with Multiple Sclerosis and Controls

Background:

Psychometric properties of tests that assess the angular vestibulo-ocular reflex (aVOR) and vestibulospinal reflex function are currently unknown. This study investigated the test-retest reliability and response stability of gaze stabilization, postural sway, and dynamic balance measures in persons with multiple sclerosis (MS) and controls.

Methods:

Nineteen adults with MS and 14 controls performed passive horizontal head impulses, quiet standing, and dynamic balance tests on two separate occasions. Gaze stabilization measures included aVOR gain, number of compensatory saccades (CSs) per head rotation, CS latency, and gaze position error. Postural sway included sway amplitude and total sway path. Dynamic balance measure included the Functional Gait Assessment. Intraclass correlation coefficient, standard error of measurement (SEM, SEM%), and minimal detectable difference at 95% confidence level were calculated.

Results:

Test-retest reliability for aVOR gain, CSs per head rotation, and gaze position error was moderate and for each postural sway and dynamic balance measure was good. Low error (SEM, SEM%) for aVOR gain, CS latency, postural sway, and dynamic balance variables and low minimal detectable difference values for aVOR gain and Functional Gait Assessment scores were seen, suggestive of acceptable response stability.

Conclusions:

These results support the utility of some of the gaze and postural measures for examination and treatment efficacy purposes in people with MS.

Somatosensory impairments in patients with multiple sclerosis: association with dynamic postural control and upper extremity motor function

Purpose: We planned this study to bring attention to the somatosensory impairments in patients with multiple sclerosis (PwMS) and to investigate relationship of somatosensory impairments with dynamic postural stability and upper extremity motor function.Methods: Seven males and 23 females, 30 patients with mean EDSS 2.9 (SD = 1.4), aged between 18 and 65 years (mean = 41.43 ± 14.90 years) were included in this clinical study. Light touch sensorial assessment was made with Semmes Weinstein monofilament test and proprioception by distal proprioception test. Hand strength was measured by the Jamar dynamometer, fine motor skill was examined with nine-hole peg test, functional reach test in sitting and standing position was applied. Nottingham Extended Activities of Daily Living Scale (NEADLS) was used to measure everyday activities.Results: We found a negative and moderate correlation between FRT in standing and light touch of the middle of the heel (right: -0.515), metatarsal bone (right r: 0.453, left r: -0.426), and medial of the foot (right r: -0.462). There was a negative and moderate correlation between NEADLS and light touch of the metatarsal bone (right r: -0.564, left r: -0.472), medial of the foot (right r: -0.531, left r: -0.479), and lateral of the foot (right r: -0.526). We found a positive and moderate correlation between proprioception of the ankle (right r: 0.421 left r: 0.588) and NEADLS.Conclusions: We found impairment in light touch and proprioception and, associations between sensorial functions and dynamic postural stability in PwMS. Also impaired sensorial functions cause dependent patients in daily living activities. In the assessment of balance and falling risk, independency in daily living activities; foot light touch and proprioception sense should be taken into account, hence it may provide guidance in planning rehabilitation programmes.Abbreviations: MS: multiple sclerosis; PwMS: patients with multiple sclerosis; VAS: visual analogue scale; FRT: functional reach test; 9-HPT: Nine-hole peg test; EDSS: The Expanded Disability Status Scale; NEADLS: Nottingham Extended Activities of Daily Living Scale.

Hair cortisol concentration, cognitive, behavioral, and motor impairment in multiple sclerosis

Multiple sclerosis (MS) is an autoimmune neurodegenerative disease that is characterized by the demyelinated inflammatory processes that occur within the central nervous system. Hypothalamus-pituitary-adrenal axis (HPA axis) dysfunctions have been associated with the triggering or increase in MS symptoms. We thus aimed at evaluating motor and behavioral functions, planning skills, processing speed, and their relationship with stress through measuring hair cortisol concentration from patients with MS. The sample was composed of 40 volunteers that were clinically diagnosed with MS, along with 33 healthy adults. Evaluations included: Clinical Evaluation Form, Mini-Mental State Exam, Hamilton Depression Rating Scale, Multiple Sclerosis Functional Composite Measure, Expanded Disability Status Scale, Berg Balance Scale, Perceived Stress Scale, Zoo Map task, and a hair sample to analyze cortisol levels in the last 30 days. MS patients showed highly elevated hair cortisol levels in comparison to the control group (p = 0.048). All groups presented some degree of depressive and anxiety symptoms, aside from considerable perceived stress levels. The MS group presented deficits in gait, balance, manual skills and processing speed, and this was particularly so in individuals with moderate impairments when compared to control group (p < 0.001). Individuals with MS spent less time planning on ZooMap1 (p = 0.024) and made more mistakes (p < 0.001). No correlation was found between hair cortisol and the symptoms we assessed. However, depressive symptoms and anxiety were related to perceived stress, and higher hair cortisol suggests a change in levels in the HPA axis in MS. Nevertheless, future studies will be necessary to further understand how basal hair cortisol is related to MS symptoms.

Postural control deficits in people with Multiple Sclerosis: A systematic review and meta-analysis

BACKGROUND

Multiple sclerosis (MS) is a neurological condition that can affect the postural stability of the individual and predispose falls in this population.

METHODS

A systematic literature search identified case-control studies investigating differences in postural control across a diversity of task conditions, with the exception of gait, between people with MS and healthy controls. Meta-analysis was conducted where a variable was presented by four or more studies.

RESULTS

Forty-three studies of people with a mean Expanded Disability Status Scale (EDSS) of 1.0 to 6.0 were included. Seven conditions of assessment and 105 individual measurement variables relating to postural control were included. Quiet stance was the only condition (11 studies) possessing sufficient data to contribute to meta-analysis in terms of centre of pressure path length (SMD = 1.04, 95% CI {0.86-1.22}, p < 0.001), medio-lateral velocity (SMD = 1.35, 95% CI {0.77-1.92}, p < 0.001) and 95% confidence ellipse (SMD = 0.83 95% CI {0.59-1.08}, p < 0.001).

RESULTS

indicate that regardless of task complexity or sensory condition, people with MS display considerable deficits in postural control in comparison to healthy controls.

CONCLUSIONS

The large number of variables and lack of standardisation of reporting makes data synthesis challenging, however, people with MS display considerable deficits in postural control compared to healthy controls regardless of task condition or complexity.

Balance, gait, and falls in multiple sclerosis

Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) and the most widespread nontraumatic cause of disability in young adults around the world. MS occurs in people of all ages, races, and ethnicities. MS is characterized by clinical symptoms resulting from lesions in the brain, spinal cord, or optic nerves that can affect balance, gait, and fall risk. Lesions accumulate over time and occur in different areas of the CNS causing symptoms that include weakness, spasticity, and fatigue, as well as changes in sensation, coordination, vision, cognition, and bladder function. Thus, it is not surprising that imbalance, gait dysfunction, and falls are common in people with MS. The overwhelming majority have abnormalities of postural control and gait even early in the disease course. In all, 50-80% have balance and gait dysfunction and over 50% fall at least once each year. Balance dysfunction in MS is conceptualized as three interrelated problems: decreased ability to maintain position, limited and slowed movement towards limits of stability, and delayed responses to postural displacements and perturbations. In addition, functional balance performance may be affected by impaired dual-task integration. Walking changes in MS include reduced gait speed, impaired walking balance, and reduced walking-related physical activity. Falls in people with MS are associated with injuries, reduced participation, and increased fear of falling. A wide and growing range of rehabilitation and medical interventions are available to address the changes in balance, gait, and fall risk associated with MS.

Mii-vitaliSe: a pilot randomised controlled trial of a home gaming system (Nintendo Wii) to increase activity levels, vitality and well-being in people with multiple sclerosis

OBJECTIVES

While the health and well-being benefits of physical activity are recognised, people with multiple sclerosis (MS) often face greater barriers than the general population. The Nintendo Wii potentially offers a fun, convenient way of overcoming some of these. The aim was to test the feasibility of conducting a definitive trial of the effectiveness and cost-effectiveness of Mii-vitaliSe; a home-based, physiotherapist-supported Nintendo Wii intervention.

DESIGN

A single-centre wait-list randomised controlled study.

SETTING

MS service in secondary care.

PARTICIPANTS

Ambulatory, relatively inactive people with clinically confirmed MS.

INTERVENTION

Thirty participants were randomised to receive Mii-vitaliSe either immediately (for 12 months) or after a 6-month wait (for 6 months). Mii-vitaliSe consisted of two supervised Nintendo Wii familiarisation sessions in the hospital followed by home use (Wii Sports, Sports Resort and Fit Plus software) with physiotherapist support and personalised resources.

OUTCOMES

Included self-reported physical activity levels, quality of life, mood, self-efficacy, fatigue and assessments of balance, gait, mobility and hand dexterity at baseline, 6 and 12 months. Interviews (n=25) explored participants' experiences and, at study end, the two Mii-vitaliSe facilitators' experiences of intervention delivery (main qualitative findings reported separately).

RESULTS

Mean (SD) age was 49.3 (8.7) years, 90% female, with 47% diagnosed with MS <6 years ago and 60% new to active gaming. The recruitment rate was 31% (95% CI 20% to 44%). Outcome data were available for 29 (97%) at 6 months and 28 (93%) at 12 months. No serious adverse events were reported during the study. Qualitative data indicated that Mii-vitaliSe was well-received. Mean Wii use across both groups over the initial 6-month intervention period was twice a week for 27 min/day. Mean cost of delivering Mii-vitaliSe was £684 per person.

DISCUSSION

Mii-vitaliSe appears acceptable and a future trial feasible and warranted. These findings will inform its design.

TRIAL REGISTRATION

ISRCTN49286846.

Somatosensory impairment and its association with balance limitation in people with multiple sclerosis

BACKGROUND

Somatosensory impairments are common in multiple sclerosis. However, little data are available to characterize the nature and frequency of these problems in people with multiple sclerosis.

OBJECTIVE

To investigate the frequency of somatosensory impairments and identify any association with balance limitations in people with multiple sclerosis.

METHODS

The design was a prospective cross-sectional study, involving 82 people with multiple sclerosis and 30 healthy controls. Tactile and proprioceptive sensory acuity were measured using the Rivermead Assessment of Somatosensory Performance. Vibration duration was assessed using a tuning fork. Duration for the Timed Up and Go Test and reaching distance of the Functional Reach Test were measured to assess balance limitations. The normative range of sensory modalities was defined using cut-off points in the healthy participants. The multivariate linear regression was used to identify the significant predictors of balance in people with multiple sclerosis.

RESULTS

Proprioceptive impairments (66.7%) were more common than tactile (60.8%) and vibration impairments (44.9%). Somatosensory impairments were more frequent in the lower limb (78.2%) than the upper limb (64.1%). All sensory modalities were significantly associated with the Timed Up and Go and Functional Reach tests (p<0.05). The Timed Up and Go test was independently predicted by the severity of the neurological lesion, Body Mass Index, ataxia, and tactile sensation (R2=0.58), whereas the Functional Reach test was predicted by the severity of the neurological lesion, lower limb strength, and vibration sense (R2=0.49).

CONCLUSIONS

Somatosensory impairments are very common in people with multiple sclerosis. These impairments are independent predictors of balance limitation.

Reliability and Concurrent Validity of the Narrow Path Walking Test in Persons With Multiple Sclerosis

BACKGROUND AND PURPOSE

About 90% of people with multiple sclerosis (PwMS) have gait instability and 50% fall. Reliable and clinically feasible methods of gait instability assessment are needed. The study investigated the reliability and validity of the Narrow Path Walking Test (NPWT) under single-task (ST) and dual-task (DT) conditions for PwMS.

METHODS

Thirty PwMS performed the NPWT on 2 different occasions, a week apart. Number of Steps, Trial Time, Trial Velocity, Step Length, Number of Step Errors, Number of Cognitive Task Errors, and Number of Balance Losses were measured. Intraclass correlation coefficients (ICC2,1) were calculated from the average values of NPWT parameters. Absolute reliability was quantified from standard error of measurement (SEM) and smallest real difference (SRD). Concurrent validity of NPWT with Functional Reach Test, Four Square Step Test (FSST), 12-item Multiple Sclerosis Walking Scale (MSWS-12), and 2 Minute Walking Test (2MWT) was determined using partial correlations.

RESULTS

Intraclass correlation coefficients (ICCs) for most NPWT parameters during ST and DT ranged from 0.46-0.94 and 0.55-0.95, respectively. The highest relative reliability was found for Number of Step Errors (ICC = 0.94 and 0.93, for ST and DT, respectively) and Trial Velocity (ICC = 0.83 and 0.86, for ST and DT, respectively). Absolute reliability was high for Number of Step Errors in ST (SEM % = 19.53%) and DT (SEM % = 18.14%) and low for Trial Velocity in ST (SEM % = 6.88%) and DT (SEM % = 7.29%). Significant correlations for Number of Step Errors and Trial Velocity were found with FSST, MSWS-12, and 2MWT.

DISCUSSION AND CONCLUSIONS

In persons with PwMS performing the NPWT, Number of Step Errors and Trial Velocity were highly reliable parameters. Based on correlations with other measures of gait instability, Number of Step Errors was the most valid parameter of dynamic balance under the conditions of our test.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A159).

Static balance according to hip joint angle of unsupported leg during one-leg standing

[Purpose] This study aimed to determine static balance according to hip joint angle of the unsupported leg during one-leg standing. [Subjects and Methods] Subjects included 45 healthy adult males and females in their 20s. During one-leg standing on the non-dominant leg, the position of the unsupported leg was classified according to hip joint angles of point angle was class. Static balance was then measured using a force plate with eyes open and closed. The total length, sway velocity, maximum deviation, and velocity on the mediolateral and anteroposterior axes of center of pressure were measured. [Results] In balance assessment with eyes open, there were significant differences between groups according to hip joint angle, except for maximum deviation on the anteroposterior axis. In balance assessment with eyes closed, there were significant differences between total length measurements at 0° and 30°, 60° and between 30° and 90°. There were significant differences between sway velocity measurements at 0° and 30° and between 30° and 90°. [Conclusion] Thus, there were differences in static balance according to hip joint angle. It is necessary to clearly identify the hip joint angle during one-leg standing testing.

Effects of Peripheral Vestibular Dysfunction on Dynamic Postural Stability Measured by the Functional Reach Test and Timed Up and Go Test

OBJECTIVE

To investigate the influence of vestibular function on dynamic postural stability assessed by the functional reach test (FRT) and the timed up and go test (TUG).

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

The FRT and TUG were performed in 399 patients with dizziness. The effects of peripheral vestibular dysfunction assessed by the caloric test and cervical vestibular evoked myogenic potentials (cVEMPs) to air-conducted sound (500 Hz, tone burst) on the results of FRT and TUG were analyzed.

RESULTS

Neither FRT nor TUG scores showed significant differences in relation to the results of the caloric test ( P > .3). The FRT scores in patients who showed abnormal cVEMP responses on both sides were significantly smaller than those in patients who showed normal cVEMP responses ( P < .01). The TUG scores in patients who showed abnormal cVEMP responses on both sides were significantly greater than those in patients who showed normal cVEMP responses ( P < .05).

CONCLUSION

The vestibulo-spinal reflex mediated by the saccule and its afferents is one of the factors that influence the maintenance of dynamic postural stability as measured by FRT and TUG.

Use of Nintendo Wii Balance Board for posturographic analysis of Multiple Sclerosis patients with minimal balance impairment

Background

The Wii Balance Board (WBB) has been proposed as an inexpensive alternative to laboratory-grade Force Plates (FP) for the instrumented assessment of balance. Previous studies have reported a good validity and reliability of the WBB for estimating the path length of the Center of Pressure. Here we extend this analysis to 18 balance related features extracted from healthy subjects (HS) and individuals affected by Multiple Sclerosis (MS) with minimal balance impairment.

Methods

Eighteen MS patients with minimal balance impairment (Berg Balance Scale 53.3 ± 3.1) and 18 age-matched HS were recruited in this study. All subjects underwent instrumented balance tests on the FP and WBB consisting of quiet standing with the eyes open and closed. Linear correlation analysis and Bland-Altman plots were used to assess relations between path lengths estimated using the WBB and the FP. 18 features were extracted from the instrumented balance tests. Statistical analysis was used to assess significant differences between the features estimated using the WBB and the FP and between HS and MS. The Spearman correlation coefficient was used to evaluate the validity and the Intraclass Correlation Coefficient was used to assess the reliability of WBB measures with respect to the FP. Classifiers based on Support Vector Machines trained on the FP and WBB features were used to assess the ability of both devices to discriminate between HS and MS.

Results

We found a significant linear relation between the path lengths calculated from the WBB and the FP indicating an overestimation of these parameters in the WBB. We observed significant differences in the path lengths between FP and WBB in most conditions. However, significant differences were not found for the majority of the other features. We observed the same significant differences between the HS and MS populations across the two measurement systems. Validity and reliability were moderate-to-high for all the analyzed features. Both the FP and WBB trained classifier showed similar classification performance (>80%) when discriminating between HS and MS.

Conclusions

Our results support the observation that the WBB, although not suitable for obtaining absolute measures, could be successfully used in comparative analysis of different populations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-017-0230-5) contains supplementary material, which is available to authorized users.

Quantification of postural stability in minimally disabled multiple sclerosis patients by means of dynamic posturography: an observational study

BACKGROUND

Multiple Sclerosis (MS) is a widespread progressive neurologic disease with consequent impairments in daily activities. Disorders of balance are frequent and equilibrium tests are potentially useful to quantify disability and to verify treatment effectiveness. The fair sensitivity of the widely used not-perturbed tests to detect balance disturbances in MS patients have prompted the development of mechatronic systems capable to impose known equilibrium perturbations, in order to challenge the balance control and, consequently, to better assess the level of impairment. We sought to clarify whether the proposed perturbed-test is capable to discriminate healthy subjects from patients with MS, even in mild or in the absence of clinically evident balance disturbances.

METHODS

We assessed balance performances of 17 adults with MS and 13 age-matched healthy controls (HC) using both perturbed (PT) and not-perturbed (NPT) postural tests by means of a 3 Degree Of Freedom (DOF) rotational mechatronic platform. Participants stood barefoot on the platform in standing position and their center of pressure (CoP) was gathered by using a pressure matrix. Each trial lasted 30 s and was carried out with and without visual stimuli. Several postural indices were computed for each trial. Correlations between postural indices and clinical scales were analyzed.

RESULTS

No significant differences were found between groups for all indices when subjects performed NPTs. Conversely, significant differences in postural indices between MS and HC emerged during PTs. Additionally, PTs revealed significant differences between patients without any cerebellar impairment (cerebellar EDSS subscore equal to 0) and HC. The discrimination capability of PTs was confirmed by the ROC analysis. No significant change of the selected metrics occurred in HC when NPTs were performed with eyes closed, while indices presented a significant worsening in MS subjects.

CONCLUSIONS

Not-perturbed tests showed lower sensitivity than perturbed ones in the identification of equilibrium impairments in minimally disabled MS patients. However, not-perturbed tests allow to better evaluate the influence of visual flow disturbances on balance control in MS. In conclusion, our findings proved that the use of the novel tests based on a 3DOF mechatronic device represents an effective tool to investigate early balance disturbances in MS.

A disturbed processing of graviceptive pathways may be involved in the pathophysiology of balance disorders in patients with multiple sclerosis

The purpose of this study was to determine the relationship between perception of verticality and balance disorders in multiple sclerosis patients. We evaluated patients and healthy controls. Patients were divided into two groups according to their risk of fall, with or without risk of fall, measured by a Dynamic Gait Index scale. Graviceptive perception was assessed using the subjective visual vertical test. Patients with risk of fall showed worse perception than those without risk of fall, p < 0.001. Misperception of verticality was correlated with the dynamic gait index scores (p < 0.001), suggesting that the larger the error for verticality judgment, the greater risk for falling. Considering that the perception of verticality is essential for postural control, our results suggested that the disturbed processing of graviceptive pathways may be involved in the pathophysiology of balance disorders in these patients.

Effects of Pilates-Based Core Stability Training in Ambulant People With Multiple Sclerosis: Multicenter, Assessor-Blinded, Randomized Controlled Trial

BACKGROUND

Pilates exercise is often undertaken by people with multiple sclerosis (MS) who have balance and mobility difficulties.

OBJECTIVES

The primary aim of the study was to compare the effects of 12 weeks of Pilates exercises with relaxation on balance and mobility. Secondary aims were: (1) to compare standardized exercises with relaxation and (2) to compare Pilates exercises with standardized exercises.

METHODS

A multicenter, assessor-blinded, randomized controlled trial was conducted. Participants with Expanded Disability Status Scale scores of 4.0 to 6.5 were randomly allocated to groups receiving 12 weeks of Pilates exercises, standardized exercises, or relaxation. Assessments were undertaken at baseline and weeks 12 and 16 (primary outcome measure: 10-Meter Timed Walk Test [10MTW]).

RESULTS

One hundred participants (mean age=54 years, 74% female) were randomized to study groups. Six participants relapsed (withdrew from the study), leaving 94 participants for intention-to-treat analysis. There was no significant difference in mean 10MTW measurements between the Pilates and relaxation groups. At 12 weeks, there was a mean reduction of 4.2 seconds for the standardized exercise group compared with the relaxation group (95% confidence interval [relaxation group minus standardized exercise group measurements]=0.0, 8.4) and a mean reduction of 3.7 seconds for the Pilates group compared with the standardized exercise group (95% confidence interval [Pilates group minus standardized exercise group measurements]=-0.4 to 7.8). At 16 weeks, mean 10MTW times for the standardized exercise group remained quicker than those for the Pilates and relaxation groups, although the differences were nonsignificant. There were no significant differences between the Pilates and relaxation groups for any secondary outcome measure.

LIMITATIONS

In this study, therapists were limited to a standardized basket of exercises that may have affected the study outcomes. Furthermore, choosing measures such as posturography to assess balance, accelerometry to assess walking, or a specific trunk assessment scale might have been more responsive in detecting changes in outcome.

CONCLUSION

Participants did not improve significantly, either in the short term or at the 4-week follow-up, on the 10MTW after 12 weeks of Pilates exercises compared with 12 weeks of relaxation.

Three-Month Test-Retest Reliability of Center of Pressure Motion During Standing Balance in Individuals with Multiple Sclerosis

BACKGROUND

Balance impairment and an increased rate of falls are commonly reported in individuals with multiple sclerosis (MS). Force platform-generated center of pressure (COP) metrics have previously been recommended as an outcome measure to quantify balance deficits and distinguish between fallers and nonfallers in MS. Information is limited regarding the preservation of postural control in individuals with MS over extended time frames in the absence of an intervention. This report examines the test-retest reliability and magnitude of change of COP motion during standing balance over 3 months.

METHODS

Twenty individuals with MS and a history of falling underwent testing on two occasions 3 months apart in the absence of an intervention. On both occasions, participants completed two 30-second trials of three conditions: eyes open, eyes closed, and eyes open with concurrent cognitive challenge (dual task). Measures of COP area, velocity, and temporal structure were calculated and included in the reliability analysis.

RESULTS

The COP metrics displayed fair-to-excellent reliability over 3 months without an intervention. Reliability was maintained across the three commonly used balance conditions.

CONCLUSIONS

These results offer insight into the reliability of COP measures over a 3-month period in MS and can inform the use of COP metrics for future study design (eg, sample size estimates) and balance outcome assessment during randomized controlled trials and fall-prevention studies in individuals with MS.

The effects of prolonged wear of textured shoe insoles on gait, foot sensation and proprioception in people with multiple sclerosis: study protocol for a randomised controlled trial

BACKGROUND

Many people with multiple sclerosis experience problems with walking, which can make daily activities difficult and often leads to falls. Foot sensation plays an important role in keeping the body balanced whilst walking; however, people with multiple sclerosis often have poor sensation on the soles of their feet. Wearing a specially designed shoe insole, which enhances plantar sensory information, could help people with multiple sclerosis to walk better. This study will explore whether long-term wear of a textured insole can improve walking in people with multiple sclerosis.

METHODS

A prospective randomised controlled trial with two parallel groups will be conducted aiming to recruit 176 people with multiple sclerosis living in the community (Brisbane, Australia). Adults with a clinical diagnosis of multiple sclerosis, Disease Steps score 1-4, who are ambulant over 100 m and who meet specific inclusion criteria will be recruited. Participants will be randomised to a smooth control insole (n = 88) or textured insole (n = 88) group. The allocated insole will be worn for 12-weeks within participants' own footwear, with self-report wear diaries and falls calendars being completed over this period. Blinded assessors will conduct two baseline assessments and one post-intervention assessment. Gait tasks will be completed barefoot, wearing standardised footwear only, and wearing standardised footwear with smooth and textured insoles. The primary outcome measure will be mediolateral base of support when walking over even and uneven surfaces. Secondary measures include spatiotemporal gait parameters (stride length, stride time variability, double-limb support time, velocity), gait kinematics (hip, knee, and ankle joint angles, toe clearance, trunk inclination, arm swing, mediolateral pelvis/head displacement), foot sensation (light touch-pressure, vibration, two-point discrimination) and proprioception (ankle joint position sense). Group allocation will be concealed and all analyses will be based on an intention-to-treat principle.

DISCUSSION

This study will explore the effects of wearing textured insoles over 12-weeks on gait, foot sensation and proprioception in people with multiple sclerosis. The study has the potential to identify a new, evidence-based footwear intervention which has the capacity to enhance mobility and independent living in people with multiple sclerosis.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000421538 . Registered 4 May 2015.

Effects of motor-motor and motor-cognitive tasks on balance in patients with multiple sclerosis

BACKGROUND

Dual tasking is frequently impaired in Multiple Sclerosis (MS), substantially impairing quality of life (QoL). We aimed to examine the effects of motor-motor and motor-cognitive tasks on balance in highly mobile patients with relapsing-remitting MS (RRMS), with mild disability.

METHODS

Thirty-eight patients and 34 controls were included. Steady Stance Test (SST), Berg Balance Scale (BBS) and Activities-specific Balance Confidence Scale (ABC) were used to evaluate the balance. Expanded Disability Status Scale (EDSS), Mini-mental State Examination (MMSE), Beck Depression Inventory (BDI) and Fatigue Impact Scale (FIS) were used to evaluate disability, cognitive impairment, depression and fatigue, respectively.

RESULTS

BBS and ABC scores were significantly different between the groups. Also, balance was significantly impaired in patients. Eyes-open left single stance test was the most efficient test to reveal the balance impairment in RRMS patients independent of dual-task. Physical component of FIS affected this test independent of age and BMI. Visual input significantly increased the stance durations in majority of SST, especially in tough stance positions with reduced balance area. However, visual input during dual-tasking impaired the balance. In addition, eyes-closed left tandem stance test with MM dual task significantly improved the balance in patients. BBS was significantly correlated with EDSS(r: -0.336), ABC(r: 0.688), FIS physical subgroup(r: -0.614) and FIS social subgroup(r: -0.475).

CONCLUSION

Dual-tasking improves balance and increases QoL in patients with RRMS. Eyes closed balance treatment with motor-dual task could be beneficial.

A comparison of linear and nonlinear stability parameters in different clinical forms of multiple sclerosis

Background

Multiple sclerosis (MS) is one of the neurological diseases that affect the ability of subjects to stand and walk. The stability of MS subjects has been evaluated in various studies, mostly based on linear approach. Based on this approach it is controversial weather stability of MS subjects differ from normal or not. Therefore, the aim of this study was to evaluate stability in three groups of MS subjects (spastic, ataxic and ataxic-spastic) using both linear and non-linear approaches.

Method

Seventeen healthy and 36 subjects with MS participated in this study. The MS group presenting with spastic, ataxic and ataxic-spastic (each group consisted of 12 subjects) participated in the study. The stability of the subjects was evaluated using Kistler force plate. The difference between stability of the subjects was evaluated using the Multi Analysis of Variance and significant value was set at P < 0.05.

Result

There was a significant difference in the mean value of Approximate Entropy (ApEn) in anterior-posterior direction between normal (0.66 ± 0.13) and ataxic (0.85 ± 0.12) and ataxic-spastic (0.90 ± 0.12) subjects (P < 0.05) and no difference between normal and spastic groups (0.76 ± 0.13). The results of both linear and nonlinear approaches confirmed that both ataxic and ataxic-spastic subjects had more instability than normal subjects. Although, the mean values of stability parameters increased in spastic compared to normal, the difference was not statistically significant.

Conclusion

Subjects with ataxic and ataxic-spastic MS disorder had difficulty in controlling their stability during quiet standing. The results of this study also confirmed that spasticity of muscles surrounding the hip and knee joints did not influence standing stability in patients with spastic MS.

The effects of the Nintendo™ Wii Fit on gait, balance, and quality of life in individuals with incomplete spinal cord injury

PURPOSE

To assess the effects of virtual reality using the NintendoTM Wii Fit on balance, gait, and quality of life in ambulatory individuals with incomplete spinal cord injury (iSCI).

RELEVANCE

There is a need for continued research to support effective treatment techniques in individuals with iSCI to maximize each individual's potential functional performance.

SUBJECTS

Five males with a mean age of 58.6 years who had an iSCI and were greater than one-year post injury.

METHODS

An interrupted time series design with three pre-tests over three weeks, a post-test within one week of the intervention, and a four-week follow up. Outcome measures: gait speed, timed up and go (TUG), forward functional reach test (FFRT) and lateral functional reach test (LFRT), RAND SF-36. Intervention consisted of one-hour sessions with varied games using the Nintendo Wii Fit twice per week for seven weeks. Survey data was also collected at post-test. Results There were statistically significant changes found in gait speed and functional reach. The changes were also maintained at the four-week follow up post-test. Survey reports suggested improvements in balance, endurance, and mobility with daily tasks at home.

CONCLUSION

All subjects who participated in training with the NintendoTM Wii Fit demonstrated statistically significant improvements in gait speed and functional reach after seven weeks of training. Given the potential positive impact that the NintendoTM Wii Fit has on functional reach and gait speed in patients with iSCI, physical therapists may want to incorporate these activities as part of a rehabilitation program.

Biomechanical Analysis of a Dynamic Stability Test System to Evoke Sway and Step Recovery

This paper reports on the dynamic analysis and experimental validation of a method to perturb the balance of subjects in quiet standing. Electronically released weights pull the subject's waist through a specified displacement sensed by a photoelectric sensor. A dynamic model is derived that computes the force applied to the subject as a function of waist acceleration. This model accurately predicts the acceleration of mock subjects (suspended masses) with high repeatability. The validity and simplicity of this model suggest that this method can provide a standard for provocation testing on stable surfaces. Proof-of-concept trials on human subjects demonstrate that the device can be used with a force platform and motion tracking and that the device can induce both sway and step recoveries in healthy male adults.