Cost of Cerebellar Ataxia in Hong Kong: A Retrospective Cost-of-Illness Analysis

Cross-Cultural Translation and Validation of the Thai Version of the Scale for the Assessment and Rating of Ataxia (SARA-TH)

OBJECTIVE

To culturally adapt the original English Scale for the Assessment and Rating of Ataxia to Thai (SARA-TH) and to evaluate the reliability and validity of the SARA-TH in assessing ataxia in acute ischemic stroke or transient ischemic attack (TIA) patients, as assessed by three healthcare professionals.

METHODS

The SARA underwent translation and cross-cultural adaptation to Thai according to established guidelines. Reliability (e.g., internal consistency, intrarater reliability, interrater reliability) and validity (e.g., content validity, convergent validity) were assessed in a sample of 50 participants with ataxia after acute ischemic stroke or TIA. Spearman correlation analysis was used to examine the relationships between the SARA-TH and the Barthel Index (BI-TH), the National Institutes of Health Stroke Scale (NIHSS-TH), and the International Cooperative Ataxia Rating Scale (ICARS) to assess convergent validity. Interrater and intrarater reliability among experienced and novice neurologists, physiotherapists, and occupational therapists were assessed using weighted kappa.

RESULTS

The SARA-TH demonstrated good comprehension and exhibited no significant floor or ceiling effects. It showed excellent internal consistency (Cronbach's α≥0.776). Significant correlations were found between the SARA-TH score and the BI-TH score (rs=-0.743 to -0.665), NIHSS- TH score (rs=0.404-0.513), and ICARS score (rs=0.859-0.917). The intrarater reliability for each rater ranged from 0.724 to 1.000 (p<0.01), and the interrater reliability varied from 0.281 to 0.927 (p<0.01).

CONCLUSION

The SARA-TH has excellent internal consistency, validity, and intrarater reliability, as well as acceptable interrater reliability among health professionals with varying levels of experience. It is recommended for assessing ataxia severity in individuals following acute ischemic stroke or TIA.

Effectiveness and cost of integrated cognitive and balance training for balance and falls in cerebellar ataxia: a blinded two-arm parallel group RCT

Background

In patients with cerebellar ataxia (CA), dual-tasking deteriorates the performance of one or both tasks.

Objective

Evaluate the effects of 4 weeks of cognitive-coupled intensive balance training (CIBT) on dual-task cost, dynamic balance, disease severity, number of falls, quality of life, cognition and cost among patients with CA.

Methods

This RCT compared CIBT (Group 1) to single-task training (Group 2) among 32 patients with CA. The intervention included either dual-task (CIBT) or single-task training for 4 weeks followed by 6 months of unsupervised home exercises. Dual-task timed up-and-go test (D-TUG) assessed dual-task cost of the physical and cognitive tasks. Assessment time points included baseline 1 (Week 0:T1), baseline 2 (Week 6:T2), post-intervention (Week 10:T3), and follow-up (Week 34:T4).

Results

Compared to single-task training CIBT improved the dual-task cost of physical task [MD -8.36 95% CI (-14.47 to -2.36, p < 0.01), dual-tasking ability [-6.93 (-13.16 to -0.70); p = 0.03] assessed using D-TUG, balance assessed using the scale for the assessment and rating of ataxia (SARAbal) [-2.03 (-4.04 to -0.19); p = 0.04], visual scores of the SOT (SOT-VIS) [-18.53 (-25.81 to -11.24, p ≤ 0.01] and maximal excursion [13.84 (4.65 to 23.03; p ≤ 0.01] of the Limits of Stability (LOS) in the forward direction and reaction time in both forward [-1.11 (-1.42 to -0.78); p < 0.01] and right [-0.18 (0.05 to 0.31); p < 0.01] directions following 4 weeks of training. CIBT did not have any additional benefits in reducing the number of falls, or improving disease severity, quality of life and cognition. The mean cost of intervention and healthcare costs for 7 months was HKD 33,380 for CIBT group and HKD 38,571 for single-task training group.

Conclusion

We found some evidence to support the use of CIBT for improving the dual-tasking ability, dual-task cost of physical task and dynamic balance in CA. Future large fully-powered studies are needed to confirm this claim.

Clinical trial registration

https://clinicaltrials.gov/study/NCT04648501, identifier [Ref: NCT04648501].

Identification of Gait Unbalance and Fallers Among Subjects with Cerebellar Ataxia by a Set of Trunk Acceleration-Derived Indices of Gait

This study aimed to assess the ability of 25 gait indices to characterize gait instability and recurrent fallers among persons with primary degenerative cerebellar ataxia (pwCA), regardless of gait speed, and investigate their correlation with clinical and kinematic variables. Trunk acceleration patterns were acquired during the gait of 34 pwCA, and 34 age- and speed-matched healthy subjects (HS_matched) using an inertial measurement unit. We calculated harmonic ratios (HR), percent recurrence, percent determinism, step length coefficient of variation, short-time largest Lyapunov exponent (sLLE), normalized jerk score, log-dimensionless jerk (LDLJ-A), root mean square (RMS), and root mean square ratio of accelerations (RMSR) in each spatial direction for each participant. Unpaired t-tests or Mann-Whitney tests were performed to identify significant differences between the pwCA and HS_matched groups. Receiver operating characteristics were plotted to assess the ability to characterize gait alterations in pwCA and fallers. Optimal cutoff points were identified, and post-test probabilities were calculated. The HRs showed to characterize gait instability and pwCA fallers with high probabilities. They were correlated with disease severity and stance, swing, and double support duration, regardless of gait speed. sLLEs, RMSs, RMSRs, and LDLJ-A were slightly able to characterize the gait of pwCA but failed to characterize fallers.

Validity of balance measures in cerebellar ataxia: A prospective study with 12-month follow-up

INTRODUCTION

Balance deficits are common in cerebellar ataxia. Determining which balance outcome measures are psychometrically strong for this population remains an unmet need.

OBJECTIVE

Evaluate the validity and responsiveness of two clinic-based balance measures [Berg Balance Scale (BBS) and balance sub-component of the Scale for the Assessment and Rating of Ataxia (SARA-bal)] and two laboratory-based balance measures [Sensory Organization Test (SOT) and Limits of Stability (LOS)] in cerebellar ataxia.

DESIGN

Prospective cohort study.

SETTING

Institutional study assessing 40 participants with cerebellar ataxia at baseline, 6, and 12 months.

MAIN OUTCOME MEASURES

Balance was assessed using the BBS, SARA-bal, SOT, and LOS; disease severity was assessed using the SARA; and Patients' Global Impression of Change (PGIC) was used to estimate responsiveness to disease progress at 6 and 12 months.

RESULTS

BBS and SARA-bal (Spearman's correlation coefficient, ρS = -0.89, p < 0.01) demonstrated strong criterion validity. Convergent validity was moderate to high (ρS range:-0.75 to 0.92) and external validity was low (ρS range:-0.75 to 0.11). Composite SOT scores (SOT-COM; ρS=0.29, p<0.01) and maximal excursion (MXE-LOS) in the forward (F) and right (R) directions of the LOS (ρS = 0.18, p < 0.01) demonstrated moderate to low criterion and convergent validity. The area under the receiver operating characteristic curve (AUC_ROC ) and its effect size (standard response mean [SRM]) for categorizing 'stable' and 'worsened' patients at 6 and 12 months were satisfactory for the BBS (AUC_ROC :0.75; SRM-Stable:1.06; SRM-Worsened:1.16), SARA-bal (AUC_ROC :0.76; SRM-Stable:0.86; SRM-Worsened:0.85), and MXE-LOS(R) (AUC_ROC :0.29; SRM-Stable:0.41; SRM-Worsened:1.39).

CONCLUSION

BBS and SARA-bal have moderate to strong criterion and convergent validity and adequate responsiveness to balance changes. Both laboratory-based measures (SOT and LOS) demonstrated a high floor effect. The SOT-COM and MXE-LOS(R) demonstrated moderate to low criterion validity, with only the MXE-LOS(R) displaying adequate responsiveness to balance changes after 6 and 12 months. This article is protected by copyright. All rights reserved.

Effects of therapeutic exercise on disease severity, balance, and functional Independence among individuals with cerebellar ataxia: A systematic review with meta-analysis

BACKGROUND

Balance impairments are common in cerebellar ataxia. Exercises are beneficial in this population.

OBJECTIVE

Explore the benefits of therapeutic exercises on disease severity, balance and functional independence in cerebellar ataxia.

METHODS

Databases were searched from inception until July 2021. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale and the Newcastle-Ottawa Scale (NOS); and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

Twenty-six studies were included and eight studies of low to high PEDro methodological quality were meta-analyzed. 'Low' to 'moderate' GRADE quality evidence supports the use of therapeutic exercises to reduce disease severity, assessed using the Scale for the Assessment and Rating of Ataxia [weighted mean difference (WMD): -3.3; 95% confidence interval (95%CI): -3.7, -2.8; p < .01]; and improve balance, assessed using the Berg Balance Scale (WMD: 2.6; 95%CI: 1.1, 4.2; p < .01). The effect of therapeutic exercises on functional independence was insignificant (WMD: 1.6; 95%CI: -1.5, 4.6; p = .31).

CONCLUSION

Low to moderate evidence from studies of low to high methodological quality provides some support for therapeutic exercises for reducing disease severity among non-hereditary degenerative cerebellar ataxia and improving balance among acquired cerebellar ataxia. Exercises did not benefit functional independence. Additional studies of large sample size and high methodological quality are necessary to substantiate these findings.

Tai Chi for Dynamic Balance Training Among Individuals with Cerebellar Ataxia: An Assessor-Blinded Randomized-Controlled Trial

Objective: To evaluate the immediate and long-term effects of 12 weeks of Tai Chi training on dynamic balance and disease severity among individuals with cerebellar ataxia (CA).

Design: An assessor-blinded, two-arm, parallel-group randomized-controlled trial was conducted among 24 participants with CA. Participants were randomized to receive either Tai Chi intervention (n = 12) or usual care (n = 12). Dynamic balance was assessed using the Berg Balance Scale (BBS), Scale for the Assessment and Rating of Ataxia (SARA) balance sub-component of the SARA (SARAbal), Sensory Organization Test, and Limits of Stability test. Disease severity was assessed using the SARA and health-related quality of life using the EuroQol visual analog scale. Assessments were completed at baseline (week 0: T1), postintervention (week 12: T2), and at the end of the 24-week (week 36: T3) follow-up period.

Interventions: The 8-form Tai Chi exercise was delivered in 60-min sessions, three times a week for 12 weeks. Participants were asked to complete an unsupervised home Tai Chi exercise program over the next 24 weeks. Participants in the usual care control group completed all study measures but did not receive any intervention.

Results: Compared with the usual care control group, after 12 weeks of Tai Chi training, the experimental group demonstrated beneficial effects for dynamic balance assessed using the BBS (mean difference [MD]: 4, 95% confidence interval [CI]: −1.06 to 8.71) and the SARAbal (MD: −1.33, 95% CI: −2.66 to 2.33). The effect size ranged from small to large. The benefits gained were not sustained after 24 weeks during the follow-up assessment. Tai Chi did not benefit disease severity and health-related quality of life in this population.

Conclusion: Some evidence supports the immediate beneficial effects of 12 weeks of Tai Chi training on the dynamic balance among individuals with CA.

Australia New Zealand Clinical Trials Registry (ACTRN12617000327381).

Assessment of gait and balance impairment in people with spinocerebellar ataxia using wearable sensors

OBJECTIVE

To explore the use of wearable sensors for objective measurement of motor impairment in spinocerebellar ataxia (SCA) patients during clinical assessments of gait and balance.

METHODS

In total, 14 patients with genetically confirmed SCA (mean age 61.6 ± 8.6 years) and 4 healthy controls (mean age 49.0 ± 16.4 years) were recruited through the Massachusetts General Hospital (MGH) Ataxia Center. Participants donned seven inertial sensors while performing two independent trials of gait and balance assessments from the Scale for the Assessment and Rating of Ataxia (SARA) and Brief Ataxia Rating Scale (BARS2). Univariate analysis was used to identify sensor-derived metrics from wearable sensors that discriminate motor function between the SCA and control groups. Multivariate linear regression models were used to estimate the subjective in-person SARA/BARS2 ratings. Spearman correlation coefficients were used to evaluate the performance of the model.

RESULTS

Stride length variability, stride duration, cadence, stance phase, pelvis sway, and turn duration were different between SCA and controls (p < 0.05). Similarly, sway and sway velocity of the ankle, hip, and center of mass differentiated SCA and controls (p < 0.05). Using these features, linear regression models showed moderate-to-strong correlation with clinical scores from the in-person rater during SARA assessments of gait (r = 0.73, p = 0.003) and stance (r = 0.90, p < 0.001) and the BARS2 gait assessment (r = 0.74, p = 0.003).

CONCLUSION

This study demonstrates that sensor-derived metrics can potentially be used to estimate the level of motor impairment in patient with SCA quickly and objectively. Thus, digital biomarkers from wearable sensors have the potential to be an integral tool for SCA clinical trials and care.

Establishing a second-generation artificial intelligence-based system for improving diagnosis, treatment, and monitoring of patients with rare diseases

Patients with rare diseases are a major challenge for healthcare systems. These patients face three major obstacles: late diagnosis and misdiagnosis, lack of proper response to therapies, and absence of valid monitoring tools. We reviewed the relevant literature on first-generation artificial intelligence (AI) algorithms which were designed to improve the management of chronic diseases. The shortage of big data resources and the inability to provide patients with clinical value limit the use of these AI platforms by patients and physicians. In the present study, we reviewed the relevant literature on the obstacles encountered in the management of patients with rare diseases. Examples of currently available AI platforms are presented. The use of second-generation AI-based systems that are patient-tailored is presented. The system provides a means for early diagnosis and a method for improving the response to therapies based on clinically meaningful outcome parameters. The system may offer a patient-tailored monitoring tool that is based on parameters that are relevant to patients and caregivers and provides a clinically meaningful tool for follow-up. The system can provide an inclusive solution for patients with rare diseases and ensures adherence based on clinical responses. It has the potential advantage of not being dependent on large datasets and is a dynamic system that adapts to ongoing changes in patients' disease and response to therapy.