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Hatton AL, Williams K, Chatfield MD, Hurn S, Maharaj JN, Gane EM, Cattagni T, Dixon J, Rome K, Kerr G, Brauer SG. Effects of wearing textured versus smooth shoe insoles for 12 weeks on gait, foot sensation and patient-reported outcomes, in people with multiple sclerosis: a randomised controlled trial. BRAIN IMPAIR 2023; 24:148-167. [PMID: 38167196 DOI: 10.1017/brimp.2022.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Innovative shoe insoles, designed to enhance sensory information on the plantar surface of the feet, could help to improve walking in people with Multiple Sclerosis. OBJECTIVE To compare the effects of wearing textured versus smooth insoles, on measures of gait, foot sensation and patient-reported outcomes, in people with Multiple Sclerosis. METHODS A prospective, randomised controlled trial was conducted with concealed allocation, assessor blinding and intention-to-treat analysis. Thirty ambulant men and women with multiple sclerosis (MS) (Disease Steps rating 1-4) were randomly allocated to wear textured or smooth insoles for 12 weeks. Self-reported insole wear and falls diaries were completed over the intervention period. Laboratory assessments of spatiotemporal gait patterns, foot sensation and proprioception, and patient-reported outcomes, were performed at Weeks 0 (Baseline 1), 4 (Baseline 2) and 16 (Post-Intervention). The primary outcome was the size of the mediolateral base of support (stride/step width) when walking over even and uneven surfaces. Independent t-tests were performed on change from baseline (average of baseline measures) to post-intervention. RESULTS There were no differences in stride width between groups, when walking over the even or uneven surfaces (P ≥ 0.20) at post-intervention. There were no between-group differences for any secondary outcomes including gait (all P values > 0.23), foot sensory function (all P values ≥ 0.08) and patient-reported outcomes (all P values ≥ 0.23). CONCLUSIONS In our small trial, prolonged wear of textured insoles did not appear to alter walking or foot sensation in people with MS who have limited foot sensory loss. Further investigation is needed to explore optimal insole design. CLINICAL TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry (ACTRN12615000421538).
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Affiliation(s)
- Anna L Hatton
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Katrina Williams
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Mark D Chatfield
- Centre for Health Sciences Research, The University of Queensland, Brisbane, Australia
| | - Sheree Hurn
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Jayishni N Maharaj
- School of Allied Health Sciences, Griffith University, Gold Coast, Australia
| | - Elise M Gane
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Thomas Cattagni
- Laboratory Movement, Interactions, Performance EA 4334, University of Nantes, Nantes, France
| | - John Dixon
- School of Health & Social Care, Teesside University, Middlesbrough, UK
| | - Keith Rome
- School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Graham Kerr
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Sandra G Brauer
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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The effects of orthotics device on the balance control in multiple sclerosis patients: A systematic review and meta-analysis. Mult Scler Relat Disord 2022; 66:104005. [PMID: 35839616 DOI: 10.1016/j.msard.2022.104005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 06/15/2022] [Accepted: 06/26/2022] [Indexed: 11/22/2022]
Abstract
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.
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Neuman RM, Shearin SM, McCain KJ, Fey NP. Biomechanical analysis of an unpowered hip flexion orthosis on individuals with and without multiple sclerosis. J Neuroeng Rehabil 2021; 18:104. [PMID: 34176484 PMCID: PMC8237473 DOI: 10.1186/s12984-021-00891-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 05/31/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Gait impairment is a common complication of multiple sclerosis (MS). Gait limitations such as limited hip flexion, foot drop, and knee hyperextension often require external devices like crutches, canes, and orthoses. The effects of mobility-assistive technologies (MATs) prescribed to people with MS are not well understood, and current devices do not cater to the specific needs of these individuals. To address this, a passive unilateral hip flexion-assisting orthosis (HFO) was developed that uses resistance bands spanning the hip joint to redirect energy in the gait cycle. The purpose of this study was to investigate the short-term effects of the HFO on gait mechanics and muscle activation for people with and without MS. We hypothesized that (1) hip flexion would increase in the limb wearing the device, and (2) that muscle activity would increase in hip extensors, and decrease in hip flexors and plantar flexors. METHODS Five healthy subjects and five subjects with MS walked for minute-long sessions with the device using three different levels of band stiffness. We analyzed peak hip flexion and extension angles, lower limb joint work, and muscle activity in eight muscles on the lower limbs and trunk. Single-subjects analysis was used due to inter-subject variability. RESULTS For subjects with MS, the HFO caused an increase in peak hip flexion angle and a decrease in peak hip extension angle, confirming our first hypothesis. Healthy subjects showed less pronounced kinematic changes when using the device. Power generated at the hip was increased in most subjects while using the HFO. The second hypothesis was not confirmed, as muscle activity showed inconsistent results, however several subjects demonstrated increased hip extensor and trunk muscle activity with the HFO. CONCLUSIONS This exploratory study showed that the HFO was well-tolerated by healthy subjects and subjects with MS, and that it promoted more normative kinematics at the hip for those with MS. Future studies with longer exposure to the HFO and personalized assistance parameters are needed to understand the efficacy of the HFO for mobility assistance and rehabilitation for people with MS.
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Affiliation(s)
- Ross M. Neuman
- Walker Department of Mechanical Engineering, The University of Texas at Austin, 204 E Dean Keeton St, Austin, TX 78712 USA
| | - Staci M. Shearin
- UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Karen J. McCain
- UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Nicholas P. Fey
- Walker Department of Mechanical Engineering, The University of Texas at Austin, 204 E Dean Keeton St, Austin, TX 78712 USA
- UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
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Stolt M, Laitinen AM, Ruutiainen J, Leino-Kilpi H. Research on lower extremity health in patients with multiple sclerosis: a systematic scoping review. J Foot Ankle Res 2020; 13:54. [PMID: 32854741 PMCID: PMC7457257 DOI: 10.1186/s13047-020-00423-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/20/2020] [Indexed: 12/25/2022] Open
Abstract
Background Multiple sclerosis (MS) often affects ambulation and the function of the lower limbs. However, little is known about how much research has been conducted on lower extremity health in patients with MS. Objective To analyse empirical studies and their evidence on lower extremity health in patients with MS, in order to identify the need for future studies in key areas. Methods A systematic scoping review was conducted. A literature search of Medline (PubMed), CINAHL (EBSCO) and the Cochrane Library databases was performed. The search covered the period up to 15 January 2020 from the earliest records available. This led to the inclusion of 42 empirical articles. The data were analysed using content analysis and quantification techniques. Results The research on lower extremity health focused primarily on two main areas: gait and lower extremity muscle strength. Lower extremity health was assessed using a variety of methods, most of which consisted of objective physical tests and gait analysis. Patients with MS had many problems with the health of their lower extremities, which manifested in walking difficulties, balance problems, muscle weaknesses and spasticity. In the feet, pes cavus, claw toes, oedema and altered foot sensation were common. Conclusions MS affects lower limb and foot health, and these problems can affect patients’ daily lives. However, the extent of these problems is poorly understood, partly due to the dearth of research on lower limb and foot health. Therefore, further research is warranted in order to better understand the impact of MS on foot and lower limb health in everyday life.
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Affiliation(s)
- Minna Stolt
- Department of Nursing Science, University of Turku, 20014, Turku, Finland.
| | - Anne-Marie Laitinen
- Department of Nursing Science, University of Turku, 20014, Turku, Finland.,Turku University Hospital, Turku, Finland
| | - Juhani Ruutiainen
- Finnish Neuro Society, Masku, Finland.,Department of Neurology, University of Turku, Turku, Finland
| | - Helena Leino-Kilpi
- Department of Nursing Science, University of Turku, 20014, Turku, Finland.,Turku University Hospital, Turku, Finland
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Boes MK, Bollaert RE, Kesler RM, Learmonth YC, Islam M, Petrucci MN, Motl RW, Hsiao-Wecksler ET. Six-Minute Walk Test Performance in Persons With Multiple Sclerosis While Using Passive or Powered Ankle-Foot Orthoses. Arch Phys Med Rehabil 2018; 99:484-490. [DOI: 10.1016/j.apmr.2017.06.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/19/2017] [Indexed: 11/25/2022]
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Hatton AL, Dixon J, Rome K, Brauer SG, Williams K, Kerr G. 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. Trials 2016; 17:208. [PMID: 27098452 PMCID: PMC4839159 DOI: 10.1186/s13063-016-1337-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 03/18/2016] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Anna L. Hatton
- />School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
| | - John Dixon
- />Health and Social Care Institute, Teesside University, Middlesbrough, UK
| | - Keith Rome
- />Health and Rehabilitation Research Institute & School of Podiatry, AUT, Auckland, New Zealand
| | - Sandra G. Brauer
- />School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
| | - Katrina Williams
- />School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
| | - Graham Kerr
- />Institute of Health and Biomedical Innovation, QUT, Brisbane, Australia
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Castelli L, Stocchi L, Patrignani M, Sellitto G, Giuliani M, Prosperini L. We-Measure: Toward a low-cost portable posturography for patients with multiple sclerosis using the commercial Wii balance board. J Neurol Sci 2015; 359:440-4. [DOI: 10.1016/j.jns.2015.10.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 09/17/2015] [Accepted: 10/08/2015] [Indexed: 01/07/2023]
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Hatton AL, Hug F, Brown BCM, Green LP, Hughes JR, King J, Orgar EJ, Surman K, Vicenzino B. A study of the immediate effects of glycerine-filled insoles, contoured prefabricated orthoses and flat insoles on single-leg balance, gait patterns and perceived comfort in healthy adults. J Foot Ankle Res 2015; 8:47. [PMID: 26347802 PMCID: PMC4561414 DOI: 10.1186/s13047-015-0107-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/31/2015] [Indexed: 12/26/2022] Open
Abstract
Background Footwear interventions are often prescribed to assist with the management of lower limb pain, injury and disease. Commercially available shoe insoles and orthoses are increasingly incorporating novel design features to alleviate foot and lower limb symptoms, but this may be at a cost to optimal functional performance. This study compared the immediate effects of wearing glycerine-filled insoles, contoured prefabricated orthoses, and flat insoles, on balance and gait measures. Methods Thirty healthy adults (17 men, 13 women; mean [SD] age: 24.3 [2.5] years) performed tests of single-leg standing with eyes open (Kistler force platform), star excursion balance test, and level-ground walking (GAITRite® walkway system), under three randomised conditions: wearing glycerine-filled insoles, prefabricated orthoses, and flat (control) insoles, within their own footwear. Centre of pressure movement (anterior-posterior and mediolateral range and standard deviation, total path velocity), star excursion balance test reach distance, and temporospatial gait variables were collected. Perceived comfort of the inserts was scored immediately after use on a 100 mm visual analogue rating scale. After trialling all inserts each participant ranked their level of comfort from least to most. Results Centre of pressure measures, star excursion balance test reach distance, or temporospatial gait variables did not differ between the three inserts (all P values >0.088). Significant between-condition differences were reported for comfort ranking (P = 0.031), but not rating scores (P = 0.638). Weak to moderate negative correlations (r values ranged between −0.368 and −0.406) were observed between visual analogue scale comfort rating for the flat insoles and prefabricated orthoses, star excursion balance test and gait measures. Conclusions Single-leg standing balance, star excursion balance test performance, and level-ground walking patterns in asymptomatic adults do not appear to differ when wearing glycerine-filled insoles, contoured prefabricated orthoses, or flat insoles. Perceived comfort may be related to the biomechanical or clinical effectiveness of novel footwear interventions, and requires further investigation. Importantly, these findings are specific to a healthy population and further research is needed to determine the long-term effects of glycerine-filled insoles in patients with known balance impairments.
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Affiliation(s)
- Anna L Hatton
- School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
| | - François Hug
- School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia ; Laboratory "Movement, Interaction, Performance" (EA 4334), University of Nantes, Nantes, France
| | - Brooke C M Brown
- School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
| | - Leon P Green
- School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
| | - Jacob R Hughes
- School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
| | - Jarrad King
- School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
| | - Emma J Orgar
- School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
| | - Kate Surman
- School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences, Therapies Building (84A), The University of Queensland, Brisbane, QLD 4072 Australia
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McLoughlin J, Barr C, Crotty M, Lord SR, Sturnieks DL. Association of Postural Sway with Disability Status and Cerebellar Dysfunction in People with Multiple Sclerosis: A Preliminary Study. Int J MS Care 2015; 17:146-51. [PMID: 26052260 DOI: 10.7224/1537-2073.2014-003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aims of this study were 1) to examine postural sway in the eyes open (EO) and eyes closed (EC) conditions in people with multiple sclerosis (MS) with moderate levels of disability compared with controls and 2) to examine relationships between postural sway and total Expanded Disability Status Scale (EDSS) scores, functional system subscores, and clinical measures of strength and spasticity in the MS group. METHODS Thirty-four people with moderate MS and ten matched controls completed measures of postural sway with EO and EC, knee extension and ankle dorsiflexion isometric strength, EDSS total score and subscores, and spasticity levels. RESULTS Participants with MS swayed significantly more with EO and EC and had reduced knee extension and ankle dorsiflexion strength compared with controls (P < .001). In the MS group, increased sway was associated with higher total EDSS scores and cerebellar function subscores, whereas increased sway ratio (EC/EO) was associated with reduced sensory function subscores. Postural sway was not significantly associated with strength or spasticity. CONCLUSIONS Participants with MS swayed more and were significantly weaker than controls. Cerebellar dysfunction was identified as the EDSS domain most strongly associated with increased sway, and sensory loss was associated with a relatively greater dependence on vision for balance control. These findings suggest that exercise interventions targeting sensory integration and cerebellar ataxia may be beneficial for enhancing balance control in people with MS.
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Affiliation(s)
- James McLoughlin
- Department of Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia (JM, CB, MC); and Neuroscience Research Australia (SRL, DLS) and School of Public Health and Community Medicine (JM, SRL, DLS), University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher Barr
- Department of Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia (JM, CB, MC); and Neuroscience Research Australia (SRL, DLS) and School of Public Health and Community Medicine (JM, SRL, DLS), University of New South Wales, Sydney, New South Wales, Australia
| | - Maria Crotty
- Department of Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia (JM, CB, MC); and Neuroscience Research Australia (SRL, DLS) and School of Public Health and Community Medicine (JM, SRL, DLS), University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen R Lord
- Department of Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia (JM, CB, MC); and Neuroscience Research Australia (SRL, DLS) and School of Public Health and Community Medicine (JM, SRL, DLS), University of New South Wales, Sydney, New South Wales, Australia
| | - Daina L Sturnieks
- Department of Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia (JM, CB, MC); and Neuroscience Research Australia (SRL, DLS) and School of Public Health and Community Medicine (JM, SRL, DLS), University of New South Wales, Sydney, New South Wales, Australia
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Ilett P, Lythgo N, Martin C, Brock K. Balance and Gait in People with Multiple Sclerosis: A Comparison with Healthy Controls and the Immediate Change after an Intervention based on the Bobath Concept. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2015; 21:91-101. [DOI: 10.1002/pri.1624] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 10/14/2014] [Accepted: 12/13/2014] [Indexed: 12/21/2022]
Affiliation(s)
- P. Ilett
- St Vincent's Health Melbourne; Melbourne Australia
- School of Physiotherapy; The University of Melbourne; Melbourne Australia
| | - N. Lythgo
- Discipline of Exercise Sciences, School of Medical Sciences; RMIT University; Melbourne Australia
| | - C. Martin
- Institute for Safety, Compensation and Recovery Research; Monash University; Melbourne Australia
| | - K. Brock
- St Vincent's Health Melbourne; Melbourne Australia
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Dorsiflexion assist orthosis reduces the physiological cost and mitigates deterioration in strength and balance associated with walking in people with multiple sclerosis. Arch Phys Med Rehabil 2014; 96:226-232.e1. [PMID: 25264109 DOI: 10.1016/j.apmr.2014.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 09/01/2014] [Accepted: 09/03/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the effect of wearing a dorsiflexion assist orthosis (DAO) on walking distance, physiological cost, fatigue, and strength and balance measures after a modified 6-minute walk test (6MWT) in people with multiple sclerosis (MS). DESIGN Randomized crossover trial. SETTING Hospital Movement Laboratory. PARTICIPANTS People with moderate MS and Expanded Disability Status Scale score of 3.7±0.7 (N=34; 26 women). INTERVENTIONS Modified 6MWT with and without a DAO worn on the weaker leg. MAIN OUTCOME MEASURES Distance walked, perceived fatigue, and the physiological cost of walking were compared between walking conditions. Pre- and postwalk changes in knee extensor and ankle dorsiflexor isometric strength and standing postural sway with eyes open and closed were compared between walking conditions. RESULTS There were no differences in distance walked or perceived fatigue between the 2 walking conditions. However, there was a reduced physiological cost of walking (P<.05), a smaller reduction in knee extensor strength (P<.05), and a smaller increase in standing postural sway with eyes open (P<.01) after walking while wearing the DAO compared with walking without wearing the DAO. CONCLUSIONS Despite not increasing walking distance or reducing perceived fatigue, the DAO reduced the physiological cost of walking and maintained knee strength and standing balance, which may have important implications for physical rehabilitation in people with MS. Further trials are required to determine whether the beneficial effects of wearing a DAO found here are maintained for longer periods.
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Bulley C, Mercer TH, Hooper JE, Cowan P, Scott S, van der Linden ML. Experiences of functional electrical stimulation (FES) and ankle foot orthoses (AFOs) for foot-drop in people with multiple sclerosis. Disabil Rehabil Assist Technol 2014; 10:458-467. [PMID: 24796365 DOI: 10.3109/17483107.2014.913713] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE A constructivist phenomenological study explored impacts of ankle foot orthoses (AFOs) or functional electrical stimulation (FES) on people with foot-drop from multiple sclerosis (MS). METHOD Focus groups following topic guides were analysed using interpretative phenomenological analysis, with researcher reflexivity, participant verification and peer checking of analysis. Participants with sustained use of the devices (under 2 y) were invited from two quantitative studies that (a) investigated immediate FES effects (n = 12) and (b) compared habitual use of AFO (n = 7) or FES (n = 6). Two focus groups addressed AFO (n = 4) and FES (n = 6) experiences. RESULTS Similar numbers of positive and negative aspects were described for AFO and FES. Both reduced fatigue, improved gait, reduced trips and falls, increased participation, and increased confidence; greater balance/stability was reported for AFOs, and increased walking distance, fitness and physical activity for FES. Barriers to both included avoiding reliance on devices and implications for shoes and clothing; a non-normal gait pattern was reported for AFO, and difficulties of application and limitations in the design of FES. However, participants felt the positives outweighed the negatives. CONCLUSIONS Participants felt benefits outweighed the drawbacks for AFO and FES; greater understanding of user preferences and satisfaction may increase likelihood of usage and efficacy. Implications for Rehabilitation Interventions to reduce the impacts of foot-drop in people with multiple sclerosis (MS) are important to optimise physical activity participation and participation in life; they include ankle foot orthoses (AFOs) and functional electrical stimulation (FES). Research is lacking regarding user satisfaction and perceived outcomes, therefore, two separate focus groups were conducted from a constructivist phenomenological perspective to explore the impacts of AFOs (n = 4) and FES (n = 6) on people with foot-drop from MS. Some similar positive aspects of AFO and FES use were described, including reduced fatigue, improved gait and fewer trips and falls, while common barriers included finding the device cumbersome, uncomfortable, and inconvenient, with some psychological barriers to their use. On balance, the impacts of the devices on improving activities and participation were more important for participants than practical barriers, highlighting the importance of combining understanding of individual experiences and preferences with clinical decision-making when prescribing a device to manage foot-drop.
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Affiliation(s)
- Catherine Bulley
- a School of Health Sciences, Queen Margaret University , Edinburgh , UK
| | - Thomas H Mercer
- a School of Health Sciences, Queen Margaret University , Edinburgh , UK
| | | | - Paula Cowan
- c Kenilworth Medical Centre , Cumbernauld , UK
| | - Sasha Scott
- a School of Health Sciences, Queen Margaret University , Edinburgh , UK
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Paton JS, Thomason K, Trimble K, Metcalfe JE, Marsden J. Effect of a forefoot off-loading postoperative shoe on muscle activity, posture, and static balance. J Am Podiatr Med Assoc 2013; 103:36-42. [PMID: 23328851 DOI: 10.7547/1030036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND We investigated whether a forefoot off-loading postoperative shoe (FOPS) alters standing posture, ankle muscle activity, and static postural sway and whether any effects are altered by wearing a shoe raise on the contralateral side. METHODS Posture, ankle muscle activity, and postural sway were compared in 14 healthy participants wearing either a FOPS or a control shoe with or without a contralateral shoe raise. Participants were tested under different sensory and support surface conditions. Additionally, reductions in peak pressure under the forefoot while walking were assessed with and without a contralateral shoe raise to determine whether the FOPS continued to achieve its primary off-loading function. RESULTS Compared with the control condition, wearing a FOPS moved the center of pressure posteriorly, increased tibialis anterior muscle activity, and reduced ankle plantarflexor activity. These changes decreased when a contralateral shoe raise was added. No difference in postural sway was found between footwear conditions. Forefoot peak pressure was always reduced when wearing the FOPS. CONCLUSIONS The posterior shift in center of pressure toward and behind the ankle joint axis is believed to result in the increase in tibialis anterior muscle activity that now acts as the primary stabilizer around the ankle. Instability may, therefore, increase in patients with weak tibialis anterior muscles (eg, diabetic neuropathy) who need to wear offloading devices for ulcer management. We suggest that the addition of a contralateral shoe raise fitted with a FOPS may potentially be beneficial in maintaining stability while off-loading the forefoot in this patient group.
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Affiliation(s)
- Joanne S Paton
- School of Health Professions, Faculty of Health, Education, and Society, Plymouth University, Plymouth, England
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Dixon J, Hatton AL, Robinson J, Gamesby-Iyayi H, Hodgson D, Rome K, Warnett R, Martin DJ. Effect of textured insoles on balance and gait in people with multiple sclerosis: an exploratory trial. Physiotherapy 2013; 100:142-9. [PMID: 24070573 DOI: 10.1016/j.physio.2013.06.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 06/17/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To investigate the immediate effects of textured insoles on balance and gait in people with multiple sclerosis (MS), and to explore any effects after 2 weeks of wear. STUDY DESIGN Within-session repeated-measures design with an exploratory follow-up period. SETTING Hospital gait laboratory. PARTICIPANTS Forty-six individuals with MS (34 females, 12 males), with a mean (SD) age of 49 (7) years, who could walk 100m unassisted or using one stick/crutch. INTERVENTION Participants were tested wearing three types of insoles in a random order: control (smooth), Texture 1 (Algeos) or Texture 2 (Crocs™). Participants were allocated at random to wear one type of textured insoles for 2 weeks, after which they were retested. MAIN OUTCOME MEASURES Standing balance (centre of pressure excursions and velocity) was measured with eyes open and eyes closed on a Kistler force platform. Spatio-temporal parameters of gait were measured using a GAITRite system. RESULTS The textured insoles had no significant immediate effects on balance or gait, apart from an increase in anteroposterior sway range with eyes open for Texture 2 insoles [mean difference 4.5 (95% confidence interval 0.6 to 8.4)mm]. After 2 weeks, balance was not significantly different, but both types of textured insoles showed significant effects on spatio-temporal parameters of gait, with mean stride length increases of 3.5cm (Texture 1) and 5.3cm (Texture 2) when wearing the insoles. CONCLUSIONS After 2 weeks of wear, there were improvements in spatio-temporal parameters of gait. However, it is unclear whether this was a placebo effect or a learning effect.
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Affiliation(s)
- J Dixon
- Health and Social Care Institute, Teesside University, Middlesbrough, UK.
| | - A L Hatton
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - J Robinson
- Health and Social Care Institute, Teesside University, Middlesbrough, UK
| | - H Gamesby-Iyayi
- Health and Social Care Institute, Teesside University, Middlesbrough, UK
| | - D Hodgson
- Health and Social Care Institute, Teesside University, Middlesbrough, UK
| | - K Rome
- Health and Rehabilitation Research Institute, AUT University, Auckland, New Zealand
| | - R Warnett
- Department of Rehabilitation, James Cook University Hospital, Middlesbrough, UK
| | - D J Martin
- Health and Social Care Institute, Teesside University, Middlesbrough, UK
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Abstract
Multiple sclerosis (MS) is an immune-mediated disease that causes demyelination and degeneration within the brain and spinal cord. This may result in many impairments, including impaired ambulation, muscle weakness, abnormal tone, visual disturbances, decreased sensation, and fatigue. Rehabilitation helps patients with MS maximize independence by helping to manage and minimize impairments. Deficits seen in ambulation should be addressed to improve energy efficiency and reduce falls. Compensation through appropriate prescription of assistive devices, bracing, and wheelchairs will help improve safety. Rehabilitation can make a significant impact on achieving and maintaining quality of life and independence.
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Cameron MH, Nilsagård YE. Measurement and Treatment of Imbalance and Fall Risk in Multiple Sclerosis Using the International Classification of Functioning, Disability and Health Model. Phys Med Rehabil Clin N Am 2013; 24:337-54. [DOI: 10.1016/j.pmr.2012.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Krishnan V, Kanekar N, Aruin AS. Feedforward postural control in individuals with multiple sclerosis during load release. Gait Posture 2012; 36:225-30. [PMID: 22483546 DOI: 10.1016/j.gaitpost.2012.02.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 02/16/2012] [Accepted: 02/24/2012] [Indexed: 02/02/2023]
Abstract
The aim of the present study was to investigate the organization of anticipatory postural adjustments (APAs) in individuals with multiple sclerosis (MS) during self-initiated perturbation in the sagittal plane. Eleven individuals with MS and eleven age-and-gender matched healthy controls were asked to hold a 2.27 kg load in the extended arms and release it using fast arm abduction movements. Electrical activity of six leg and trunk muscles as well as displacements of the center of pressure (COP) were recorded. The results indicate that individuals with MS (1) demonstrate a reduced magnitude of APAs, (2) delayed latency of APAs and (3) smaller anticipatory COP displacement as compared to healthy control subjects. Moreover, in spite of individuals with MS being mildly affected, their balance capacity was significantly diminished. Thus, the outcome of this study demonstrates the underlying impairment in anticipatory postural control of individuals with MS and provides a background for development of rehabilitation strategies focused on balance restoration in this population.
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Affiliation(s)
- Vennila Krishnan
- Department of Physical Therapy, University of Illinois at Chicago, IL 60612, USA
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18
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Hatton AL, Dixon J, Rome K, Newton JL, Martin DJ. Altering gait by way of stimulation of the plantar surface of the foot: the immediate effect of wearing textured insoles in older fallers. J Foot Ankle Res 2012; 5:11. [PMID: 22546376 PMCID: PMC3431255 DOI: 10.1186/1757-1146-5-11] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 04/18/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence suggests that textured insoles can alter gait and standing balance by way of enhanced plantar tactile stimulation. However, to date, this has not been explored in older people at risk of falling. This study investigated the immediate effect of wearing textured insoles on gait and double-limb standing balance in older fallers. METHODS Thirty older adults >65 years (21 women, mean [SD] age 79.0 [7.1]), with self-reported history of ≥2 falls in the previous year, conducted tests of level-ground walking over 10 m (GAITRite system), and double-limb standing with eyes open and eyes closed over 30 seconds (Kistler force platform) under two conditions: wearing textured insoles (intervention) and smooth (control) insoles in their usual footwear. RESULTS Wearing textured insoles caused significantly lower gait velocity (P = 0.02), step length (P = 0.04) and stride length (P = 0.03) compared with wearing smooth insoles. No significant differences were found in any of the balance parameters (P > 0.05). CONCLUSIONS A textured insole worn by older adults with a history of falls significantly lowers gait velocity, step length and stride length, suggesting that this population may not have an immediate benefit from this type of intervention. The effects of prolonged wear remain to be investigated.
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Affiliation(s)
- Anna L Hatton
- Health & Rehabilitation Research Institute, AUT University, Auckland, New Zealand.
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Alpini D, Berardino FD, Mattei V, Caputo D, Schalek P, Cesarani A. Characteristics of multiple sclerosis patient stance control disorders, measured by means of posturography and related to brainstem lesions. Audiol Res 2012. [PMID: 26557338 PMCID: PMC4630951 DOI: 10.4081/audiores.2012.e9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Balance disorders are commonly observed during the course of multiple sclerosis (MS). The aim of this study is to report characteristics of MS patient stance control disorders, measured by means of posturography and related to the brainstem lesions. Thirty-eight patients affected by MS, mildly to moderately disable according to Kurtzke's Expanded Disability Status Scale, underwent a complete clinical neurological and vestibular evaluation and brain MRI scanning. All patients were then tested on a static posturography platform (Tetrax, Israel) in four conditions: eyes open and eyes closed standing on a firm surface and on a foam pad. Clinical and/or magnetic resonance imaging evidence of brainstem involvement was observed in 55.3% of patients. When brainstem lesion was detected, Fourier analysis showed a typical pattern characterized by inversion of the 0–0.1 Hz and 0.1–0.25 Hz frequency bands. In conclusion, MS leads to pervasive postural disturbances in the majority of subjects, including the visuo-vestibular loops and proprioception involving vestibulo-spinal pathways in at least 55.3% of patients. Our results may also suggest the presence of Fourier inversion in patients with brainstem lesions.
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Affiliation(s)
- Dario Alpini
- Scientific Institute S. Maria Nascente, Don Carlo Cnocchi Foundation, Milan, Italy
| | - Federica Di Berardino
- Dipartimento di Scienze Chirurgiche Specialistiche, Università degli Studi di Milano, Milan, Italy
| | - Valentina Mattei
- Scientific Institute S. Maria Nascente, Don Carlo Cnocchi Foundation, Milan, Italy
| | - Domenico Caputo
- Scientific Institute S. Maria Nascente, Don Carlo Cnocchi Foundation, Milan, Italy
| | - Peter Schalek
- ENT Institute III Medical Faculty Charles University, Prague, Czech Republik
| | - Antonio Cesarani
- Dipartimento di Scienze Chirurgiche Specialistiche, Università degli Studi di Milano, Milan, Italy; ; Audiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Hawton A, Green C, Telford CJ, Wright DE, Zajicek JP. The use of multiple sclerosis condition-specific measures to inform health policy decision-making: mapping from the MSWS-12 to the EQ-5D. Mult Scler 2011; 18:853-61. [DOI: 10.1177/1352458511429319] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Walking impairment has a major influence on the quality of life of people with multiple sclerosis (MS). The Multiple Sclerosis Walking Scale (MSWS-12) assesses the impact of MS on walking ability from the patient’s perspective, but in its current form, is not amenable for use in many policy decision-making settings. Objectives: Statistical ‘mapping’ methods were used to convert MSWS-12 scores to EQ-5D health state values. Methods: The relationship between the measures was estimated using cohort data from people with MS in South West England. Regression analyses were conducted, estimation errors assessed, and predictive performance of the best models tested using longitudinal data. Results: Model performance was in line with that of other mapping studies, with the best-performing models being an ordinary least squares (OLS) model using MSWS-12 item scores, and an OLS model using the total MSWS-12 score and its squared term. Conclusions: A process has been described whereby data from a patient-reported outcome measure (MSWS-12) can be converted to (EQ-5D) health state values. These values may be used to consider the health-related quality of life of people with MS, to estimate quality adjusted life-years for use in effectiveness and cost-effectiveness analyses, and to inform health policy decisions.
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Affiliation(s)
- A Hawton
- Health Economics Group, PenCLAHRC, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UK
| | - C Green
- Health Economics Group, PenCLAHRC, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UK
| | - CJ Telford
- Health Economics Group, PenCLAHRC, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UK
| | - DE Wright
- Centre for Health & Environmental Statistics, University of Plymouth, Plymouth, UK
| | - JP Zajicek
- Clinical Neurology Research Group, Peninsula College of Medicine and Dentistry, University of Plymouth, Plymouth, UK
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Dixon J, Gamesby H, Robinson J, Hodgson D, Hatton AL, Warnett R, Rome K, Martin D. The Effect of Textured Insoles on Gait in People with Multiple Sclerosis: An Exploratory Study. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2011. [DOI: 10.1002/pri.521] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- John Dixon
- School of Health and Social Care; Teesside University; Borough Road Middlesbrough TS1 3BA UK
| | - Helen Gamesby
- School of Health and Social Care; Teesside University; Borough Road Middlesbrough TS1 3BA UK
| | - Jonathan Robinson
- School of Health and Social Care; Teesside University; Borough Road Middlesbrough TS1 3BA UK
| | - David Hodgson
- School of Health and Social Care; Teesside University; Borough Road Middlesbrough TS1 3BA UK
| | | | - Rosie Warnett
- Department of Rehabilitation; James Cook University Hospital; Middlesbrough UK
| | - Keith Rome
- Division of Rehabilitation and Occupation Studies; AUT University; Auckland New Zealand
| | - Denis Martin
- School of Health and Social Care; Teesside University; Borough Road Middlesbrough TS1 3BA UK
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Cattaneo D, Ferrarin M, Jonsdottir J, Montesano A, Bove M. The virtual time to contact in the evaluation of balance disorders and prediction of falls in people with multiple sclerosis. Disabil Rehabil 2011; 34:470-7. [DOI: 10.3109/09638288.2011.608144] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Cameron MH, Lord S. Postural control in multiple sclerosis: implications for fall prevention. Curr Neurol Neurosci Rep 2010; 10:407-12. [PMID: 20567946 DOI: 10.1007/s11910-010-0128-0] [Citation(s) in RCA: 199] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
People with multiple sclerosis (MS) often have poor postural control, which likely underlies their increased risk of falls. Based on several studies of balance and gait in MS, it appears that the primary mechanisms underlying the observed changes are slowed somatosensory conduction and impaired central integration. This review of the published research on balance, gait, and falls in people with MS demonstrates that people with MS have balance impairments characterized by increased sway in quiet stance, delayed responses to postural perturbations, and a reduced ability to move toward their limits of stability. These impairments are likely causes of falls in people with MS and are consistent with the reduced gait speed, as well as decreased stride length, cadence, and joint movement, observed in most studies of gait in MS. Based on these findings, we identify several factors that may be amenable to intervention to prevent falls in people with MS.
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Affiliation(s)
- Michelle H Cameron
- Department of Neurology, Oregon Health and Science University, CR120, Portland, OR 97239, USA.
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Spatiotemporal and Kinematic Effect of Peroneal Nerve Stimulation Versus an Ankle-Foot Orthosis in Patients With Multiple Sclerosis: A Case Series. PM R 2009; 1:604-11. [DOI: 10.1016/j.pmrj.2009.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Revised: 03/27/2009] [Accepted: 04/08/2009] [Indexed: 11/22/2022]
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Cattaneo D, Jonsdottir J. Sensory impairments in quiet standing in subjects with multiple sclerosis. Mult Scler 2008; 15:59-67. [PMID: 18845654 DOI: 10.1177/1352458508096874] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Balance disorders and falls are frequently observed in subjects with multiple sclerosis (MS). Along with motor impairment, sensory disorders and integration deficits of sensory inputs lead to inadequate motor responses. The assessment of these sensory disorders in an every day tasks, such as upright stance, increases our knowledge of postural control in this pathology, thus promoting more effective treatments. The aim of the study was to describe sensory impairments and sensory strategies in different sensory conditions. A stabilometric assessment was carried out in a consecutive convenience sample of 53 subjects. The age of the sample was 52.7 (21.1) years; the onset of pathology was 27.20 (14.5) years before the assessment. Balance was assessed in six sensory conditions. The impact of pathology on balance control was shown by the high percentage of abnormal scores: 75% of subjects with MS showed abnormal scores even in the eyes open condition. The alteration of a single sensory input led to an increase of abnormal scores in up to 82% of subjects. Almost all subjects showed abnormal scores in the vestibular conditions where 22% of them fell. The pattern of the subjects' performance in the six sensory conditions suggests that balance control may be more correlated to the number of reliable sensory inputs than the nature of the sensory input itself.
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Affiliation(s)
- D Cattaneo
- LaRiCE: Gait and Balance Disorders Laboratory, Department of neurorehabilitation, Don Gnocchi Foundation I.R.C.C.S., Milano, Italy.
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Postural control during kneeling. Exp Brain Res 2008; 187:395-405. [DOI: 10.1007/s00221-008-1308-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Accepted: 02/07/2008] [Indexed: 10/22/2022]
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