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Multimodal Mobility Assessment Predicts Fall Frequency and Severity in Cerebellar Ataxia. CEREBELLUM (LONDON, ENGLAND) 2023; 22:85-95. [PMID: 35122222 PMCID: PMC9883327 DOI: 10.1007/s12311-021-01365-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 02/01/2023]
Abstract
This cohort study aims to evaluate the predictive validity of multimodal clinical assessment and quantitative measures of in- and off-laboratory mobility for fall-risk estimation in patients with cerebellar ataxia (CA).Occurrence, severity, and consequences of falling were prospectively assessed for 6 months in 93 patients with hereditary (N = 36) and sporadic or secondary (N = 57) forms of CA and 63 healthy controls. Participants completed a multimodal clinical and functional fall risk assessment, in-laboratory gait examination, and a 2-week inertial sensor-based daily mobility monitoring. Multivariate logistic regression analyses were performed to evaluate the predictive capacity of all clinical and in- and off-laboratory mobility measures with respect to fall (1) status (non-faller vs. faller), (2) frequency (occasional vs. frequent falls), and (3) severity (benign vs. injurious fall) of patients. 64% of patients experienced one or recurrent falls and 65% of these severe fall-related injuries during prospective assessment. Mobility impairments in patients corresponded to a mild-to-moderate ataxic gait disorder. Patients' fall status and frequency could be reliably predicted (78% and 81% accuracy, respectively), primarily based on their retrospective fall status. Clinical scoring of ataxic symptoms and in- and off-laboratory gait and mobility measures improved classification and provided unique information for the prediction of fall severity (84% accuracy).These results encourage a stepwise approach for fall risk assessment in patients with CA: fall history-taking readily and reliably informs the clinician about patients' general fall risk. Clinical scoring and instrument-based mobility measures provide further in-depth information on the risk of recurrent and injurious falling.
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CRUZ GCD, ZONTA MB, MUNHOZ RP, MELLO NMD, MEIRA AT, NUNES MCDA, ARANHA NTG, CAMARGO CHF, LOPES NETO FDN, TEIVE HAG. Functionality and disease severity in spinocerebellar ataxias. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:137-144. [DOI: 10.1590/0004-282x-anp-2020-0580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/27/2021] [Indexed: 11/21/2022]
Abstract
ABSTRACT Background: Spinocerebellar ataxias (SCAs) are a group of neurodegenerative diseases characterized by deterioration of balance and functionality that tends to follow disease progression. There is no established link between formal clinical markers for severity and functional/balance scores that could guide rehabilitation teams. Objective: To evaluate the relationship between functional scales and ataxia severity in order to identify cutoff landmarks for functional loss and estimate the mean SARA (Scale for Assessment and Rating of Ataxia) score for the risk ratings for falls on the BBS (Berg Balance Scale). Methods: Consecutive patients with a molecular diagnosis of SCA (total 89: 31 with SCA2 and 58 with SCA3) were assessed for functionality FIM-ADL (Functional Independence Measure-activities of daily living and Lawton-IADL (instrumental activities of daily living), balance (BBS) and disease severity (SARA). Results: The main disability cutoff landmarks were that the need for supervision for FIM-ADL starts with 12 points on SARA and the need for supervision for Lawton-IADL starts with 14 points on SARA. The first items to require assistance were “expression” and “shopping”, respectively. At 20 points on SARA, patients were dependent on all FIM and Lawton items. The item with the greatest impact on distinguishing dependents from independents was “means of transport” in Lawton-IADL and the domain “locomotion” in FIM-ADL. The mean SARA score for patients classified as low risk in the BBS was 9.9 points, and it was 17.4 for medium risk and 25.2 for high risk. Conclusions: Analysis on the correlation between the severity of ataxia and functional scales can form an important guide for understanding the progression of functional dependence among individuals with SCAs.
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Ganapathy VS, James TT, Philip M, Kamble N, Bhattacharya A, Dhargave P, Pal PK. Anteroposterior Stability: A Determinant of Gait Dysfunction and Falls in Spinocerebellar Ataxia. Ann Indian Acad Neurol 2021; 24:518-523. [PMID: 34728944 PMCID: PMC8513964 DOI: 10.4103/aian.aian_1090_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/22/2020] [Accepted: 01/02/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Establishing an association between gait variability and direction specific balance indices may help in identifying the risk of falls in patients with spinocerebellar ataxia (SCA) which may help in developing an appropriate intervention. This study is intended to identify the association between balance and gait parameters especially gait variability in these patients. Methods: Patients with genetically confirmed SCA (n = 24) as well as controls (n = 24) who met the study criteria were recruited. Gait was assessed using the GAITRite system and balance was assessed using dynamic posturography (Biodex) to record direction-specific dynamic balance indices. Disease severity was assessed using international cooperative ataxia rating scale (ICARS). Results: The mean age of the SCA group (38.83 ± 13.03 years) and the control group (36.38 ± 9.09 years) were comparable. The age of onset of illness was 32 ± 10.62 years and duration of 5.67 ± 3.62 years. The mean ICARS was 45.10 ± 16.75. There was a significant difference in the overall balance index (OBI), anterior–posterior index (API), medial/lateral index (MLI) between SCA patients (4.56 ± 2.09, 3.49 ± 1.88, 2.94 ± 1.32) and the controls (2.72 ± 1.25, 2.08 ± 0.85, 1.85 ± 0.97). However, correlation was observed only between gait stability and balance parameters in API direction. Conclusions: There was an increased anteroposterior oriented balance deficit in patients with SCA, which was significantly correlating with the gait parameters. The balance training intervention may focus on improving anteroposterior direction to prevent falls and improving walking efficiency.
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Affiliation(s)
- V S Ganapathy
- National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Tittu T James
- National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Mariamma Philip
- National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Nitish Kamble
- National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Amitabh Bhattacharya
- National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Pradnya Dhargave
- National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Pramod Kumar Pal
- National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Konno KM, Zonta MB, Guimarães ATB, Camargo CHF, Munhoz RP, Raskin S, Ashizawa T, Teive HAG. Balance and physical functioning in Spinocerebellar ataxias 3 and 10. Acta Neurol Scand 2021; 143:458-463. [PMID: 33251611 DOI: 10.1111/ane.13384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/08/2020] [Accepted: 11/24/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Limitations of functional capacity and balance are common features of the natural history of spinocerebellar ataxias (SCA). However, their onset and progression patterns differ according to subtype. The aim of our study was to compare physical functionality and balance parameters in SCA10 and SCA3 patients, correlating with clinical variables. MATERIALS & METHODS Cross-sectional study evaluating ninety-five SCA patients (60 with SCA3 and 35 with SCA10) with validated scales for functional independence, balance and the severity of signs and symptoms. RESULTS The groups were similar in terms of age and gender, and results were adjusted for age at symptom onset. The SCA10 patients had better results for balance and functional independence (p < 0.007). They also had lower scores for disease severity (p < 0.0002) and the subitems gait (p < 0.0005), posture (p < 0.0021) and sitting balance (p < 0.0008). Symptom progression in both groups was similar for patients with a disease duration of up to ten years, but there was a more marked decline in SCA3 patients after this period. CONCLUSIONS We have shown that disease progression as assessed by balance and physical functioning is slower in SCA10 patients than SCA3 patients, particularly after 10 years of disease. These findings are important as they can help to characterize the disease, assisting in the development of new therapies and rehabilitation programs.
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Affiliation(s)
- Katia M. Konno
- Movement Disorders Unit Neurology Service Internal Medicine Department Hospital de Clínicas Curitiba Paraná Brazil
| | - Marise Bueno Zonta
- Movement Disorders Unit Neurology Service Internal Medicine Department Hospital de Clínicas Curitiba Paraná Brazil
- Neurological Diseases Group Postgraduate Program in Internal Medicine Internal Medicine Department Hospital de Clínicas Federal University of Paraná Curitiba Paraná Brazil
| | - Ana T. B. Guimarães
- Center for Biological and Health Sciences State University of Western Paraná Cascavel Paraná Brazil
| | - Carlos Henrique F. Camargo
- Neurological Diseases Group Postgraduate Program in Internal Medicine Internal Medicine Department Hospital de Clínicas Federal University of Paraná Curitiba Paraná Brazil
| | - Renato Puppi Munhoz
- Gloria and Morton Shulman Movement Disorders Centre Toronto Western HospitalUniversity of Toronto Toronto Ontario Canada
| | - Salmo Raskin
- Genetika ‐ Centro de Aconselhamento e Laboratório de Genética Curitiba Paraná Brazil
| | - Tetsuo Ashizawa
- Neuroscience Research Program Houston Methodist Neurological Institute and Research Institute Weill Cornell Medical College Houston Texas USA
| | - Helio A. G. Teive
- Movement Disorders Unit Neurology Service Internal Medicine Department Hospital de Clínicas Curitiba Paraná Brazil
- Neurological Diseases Group Postgraduate Program in Internal Medicine Internal Medicine Department Hospital de Clínicas Federal University of Paraná Curitiba Paraná Brazil
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Takeda T, Ikeda T, Tsutsumi T. The evaluation of gravitational recognition in patients with spinocerebellar degeneration using Listing's plane. Acta Otolaryngol 2019; 139:581-587. [PMID: 31107126 DOI: 10.1080/00016489.2019.1607975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: The thickness of Listing's plane accurately reflects gravitational recognition, constructed through the integration of visual, vestibular, and proprioceptive sensory input in the neural integrator of the central nervous system. Spinocerebellar degeneration (SCD) is a progressive degenerative disease mainly involving the cerebellum and brainstem that leads to destabilize the gravitational recognition, and may thicken thickening of Listing's plane. Objective: The aim of this study is to evaluate the gravitational recognition in response to positional change in patients with SCD, using the thickness of Listing's plane as a parameter. Materials and methods: In this prospective study, we evaluated the thickness of Listing's plane in 21 consecutive patients with SCD and 32 healthy subjects in the seated and supine positions, and investigated the association with other neuro-otological examinations (electronystagmography including caloric test and posturography). Results: We detected significant thickening of Listing's plane in SCD patients only when they were in the seated position. The thickness of Listing's plane correlated with neither the caloric response nor Romberg's ratio or the total center of the pressure path length. Conclusions and significance: The thickness of Listing's plane could be a useful parameter for assessing a gravity-oriented internal model in SCD patients.
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Affiliation(s)
- Takamori Takeda
- Department of Otolaryngology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takuo Ikeda
- Department of Otolaryngology, Tsudumigaura Medical Center for Children with Disabilities, Yamaguchi, Japan
| | - Takeshi Tsutsumi
- Department of Otolaryngology, Tokyo Medical and Dental University, Tokyo, Japan
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Santos LR, Teive HAG, Lopes Neto FDN, Macedo ACBD, Mello NMD, Zonta MB. Quality of life in individuals with spinocerebellar ataxia type 10: a preliminary study. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:527-533. [DOI: 10.1590/0004-282x20180077] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/07/2018] [Indexed: 11/22/2022]
Abstract
ABSTRACT Spinocerebellar ataxia type 10 (SCA10) is characterized by gait ataxia, dysarthria, nystagmus, epilepsy, reduced cognitive ability and depression, which lead to functional loss and behavioral changes. These signs gradually evolve and may interfere with the physical, emotional, and social aspects of quality of life (QoL). Objective: To assess the self-perception of quality of life and its association with disease duration, severity of ataxia, balance and functional independence. Methods: This study focused on the disease duration, ataxia severity (SARA), balance (Berg Balance Scale), functionality (FIM, Lawton IADL) and QoL (SF-36 v.2) of 15 individuals with SCA10. Results: The population sample consisted of eight females and seven males, with a mean age of 43.8 (± 8.2) years, mean age of symptom onset of 33.1 (± 8.9) years and mean disease duration of 9.8 (± 11.2) years. The mean Berg Balance Scale score was 47.2 (± 12), mean SARA score (n = 14) 11.5 (± 7.3), mean Lawton IADL score 20.4 (± 1.8) and mean FIM score 120.3 (± 5.4). Individuals with SCA10 had a greater impairment of QoL in the “role-physical” domain (p = 0.04). The longer the disease duration (p = 0.02), risk of falling (p = 0.04), severity of ataxia (p = 0.00) and functional dependence in activities of daily living (p = 0.03) and instrumental activities of daily living (p = 0.00), the worse the QoL was in the “physical functioning” domain, with a decrease of 1.62 points for each year of disease duration. Conclusion: In this sample, the greatest impairment of QoL in individuals with SCA10 was observed in “physical functioning” and “physical role”.
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Affiliation(s)
| | | | | | | | | | - Marise Bueno Zonta
- Universidade Federal do Paraná, Brasil; Universidade Federal do Paraná, Brasil
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Abstract
The cerebellum plays an integral role in the control of limb and ocular movements, balance, and walking. Cerebellar disorders may be classified as sporadic or hereditary with clinical presentation varying with the extent and site of cerebellar damage and extracerebellar signs. Deficits in balance and walking reflect the cerebellum's proposed role in coordination, sensory integration, coordinate transformation, motor learning, and adaptation. Cerebellar dysfunction results in increased postural sway, hypermetric postural responses to perturbations and optokinetic stimuli, and postural responses that are poorly coordinated with volitional movement. Gait variability is characteristic and may arise from a combination of balance impairments, interlimb incoordination, and incoordination between postural activity and leg movement. Intrinsic problems with balance lead to a high prevalence of injurious falls. Evidence for pharmacologic management is limited, although aminopyridines reduce attacks in episodic ataxias and may have a role in improving gait ataxia in other conditions. Intensive exercises targeting balance and coordination lead to improvements in balance and walking but require ongoing training to maintain/maximize any effects. Noninvasive brain stimulation of the cerebellum may become a useful adjunct to therapy in the future. Walking aids, orthoses, specialized footwear and seating may be required for more severe cases of cerebellar ataxia.
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Affiliation(s)
- Jonathan F Marsden
- Department of Rehabilitation, School of Health Professions, University of Plymouth, Plymouth, United Kingdom.
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Amarante TRP, Takeda SYM, Teive HAG, Zonta MB. Impact of disease duration on functional status of patients with spinocerebellar ataxia type 2. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:773-777. [PMID: 29236819 DOI: 10.1590/0004-282x20170146] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/04/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To correlate disease duration in spinocerebellar ataxia type 2 (SCA2) with disease severity, balance and functionality. METHOD Sixteen SCA2 patients were analyzed for: disease duration, disease severity (SARA score), balance (Berg balance scale score) and functionality (FIM and Lawton scores). RESULTS Greater severity was correlated with worse functionality (Lawton: r = -0.0561, FIM: r = -0.6402) and balance (r = -0.7188). Longer disease duration was correlated with greater severity (p = 0.0002) and reduced functionality (FIM: p = 0.005; Lawton: p = 0.0402) and balance (p = 0.0036). A year increase in disease duration corresponded to a 0.8-point increase on the SARA scale, a 1.38-point decrease in FIM score, a 2.30-point decrease on the Berg balance scale and a 0.45-point decrease on the Lawton scale. CONCLUSION Longer disease duration in this series of SCA2 patients was correlated with greater disease severity, worse balance and greater functional dependency.
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Affiliation(s)
- Thiago R Padilha Amarante
- Universidade Federal do Paraná, Programa de Residência Integrada Multiprofissional em Cuidados Hospitalares - Saúde para Adultos e Idosos, Curitiba PR, Brasil
| | - Sibele Y M Takeda
- Universidade Federal do Paraná, Departamento de Prevenção e Reabilitação de Fisioterapia, Curitiba PR, Brasil
| | - Hélio A G Teive
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Curitiba PR, Brasil.,Universidade Federal do Paraná, Unidade dos Distúrbios do Movimento, Curitiba PR, Brasil
| | - Marise Bueno Zonta
- Universidade Federal do Paraná, Programa de Residência Integrada Multiprofissional em Cuidados Hospitalares - Saúde para Adultos e Idosos, Curitiba PR, Brasil
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Braga Neto P, Pedroso JL, Kuo SH, Marcondes Junior CF, Teive HAG, Barsottini OGP. Current concepts in the treatment of hereditary ataxias. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 74:244-52. [PMID: 27050855 DOI: 10.1590/0004-282x20160038] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 01/04/2016] [Indexed: 02/19/2023]
Abstract
Hereditary ataxias (HA) represents an extensive group of clinically and genetically heterogeneous neurodegenerative diseases, characterized by progressive ataxia combined with extra-cerebellar and multi-systemic involvements, including peripheral neuropathy, pyramidal signs, movement disorders, seizures, and cognitive dysfunction. There is no effective treatment for HA, and management remains supportive and symptomatic. In this review, we will focus on the symptomatic treatment of the main autosomal recessive ataxias, autosomal dominant ataxias, X-linked cerebellar ataxias and mitochondrial ataxias. We describe management for different clinical symptoms, mechanism-based approaches, rehabilitation therapy, disease modifying therapy, future clinical trials and perspectives, genetic counseling and preimplantation genetic diagnosis.
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Affiliation(s)
- Pedro Braga Neto
- Center of Health Sciences, Universidade Estadual do Ceará, Fortaleza, CE, Brazil
| | - José Luiz Pedroso
- Departmento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Sheng-Han Kuo
- Department of Neurology, Columbia University, New York, NY, United States
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Lee BH, Park JO, Kim HS, Suk KS, Lee SY, Lee HM, Yang JH, Moon SH. Spinal sagittal balance status affects postoperative actual falls and quality of life after decompression and fusion in-situ surgery in patients with lumbar spinal stenosis. Clin Neurol Neurosurg 2016; 148:52-9. [PMID: 27398622 DOI: 10.1016/j.clineuro.2016.06.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/20/2016] [Accepted: 06/20/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES It has been reported that good spinal sagittal alignment reduces the risk of fall and positive sagittal balance is the radiographic parameter that is most highly correlated with adverse health outcomes. However, no reports have demonstrated a change in risk of falling in patients with lumbar spinal stenosis (LSS) according to sagittal balance status. PATIENTS AND METHODS From September 2013 to October 2014, 141 patients who underwent lumbar spine surgery, including decompression and fusion in-situ for LSS, were enrolled in this study. Based on sagittal balance status, patients were divided into sagittal balance (SB) and sagittal imbalance (SI) groups. Four functional mobility tests were used to evaluate the risk of falling, and a fall diary, Oswestry disability index (ODI), and the Euro-QoL 5D(EQ-5D) visual analogue scale (VAS) were utilized to assess clinical improvement. RESULTS The mean patient age was 70.1 years in the SB group (N=46) and 70.9 years in the SI group (N=95) (not significant). The mean C7PL was 7.9mm in the SB group and 66.1mm in the SI group preoperatively (p<0.05). Among the four functional tests, only postoperative SMT and STS improved significantly in the SB group (p<0.05). Patients in the SI group showed significantly improved scores for all four functional tests during postoperative follow-up (p<0.05), but their performance was still worse than patients in the SB group. Average number of falls per individual during the follow-up period was 1.1±2.5 in the SB group and 1.9±3.2 in the SI group (p<0.05). There was a significant difference in the distribution of non-fallers and fallers (single and multiple fallers) between the two groups postoperatively(p<0.05). ODI and the EQ-5D VAS showed greater improvement in the SB group than the SI group. Multiple regression analysis revealed that sagittal balance during follow-up significantly affected ODI, EQ-VAS, functional mobility tests. (p<0.05). CONCLUSION Therefore, when fusion surgery is planned in patients with LSS, careful consideration of sagittal balance status might be important to attain better surgical and functional outcomes and decrease the incidence of actual falls after surgical treatment.
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Affiliation(s)
- Byung Ho Lee
- Department of Orthopedic Surgery, Catholic-Kwandong University College of Medicine, Incheon, Republic of Korea
| | - Jin-Oh Park
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hak-Sun Kim
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Soo Suk
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Yoon Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hwan-Mo Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Ho Yang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seong-Hwan Moon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Local Stability of the Trunk in Patients with Degenerative Cerebellar Ataxia During Walking. THE CEREBELLUM 2016; 16:26-33. [DOI: 10.1007/s12311-016-0760-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Oliveira LAS, Rodrigues EDC, Sancho AG, Mainenti MRM, Vigário PDS, Lopes AJ, Lemos T. Functional capacity, cardiorespiratory fitness and quality of life in spinocerebellar ataxia: Implications for rehabilitation. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2015. [DOI: 10.3109/21679169.2015.1072244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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