Balance impairment in people with multiple sclerosis: preliminary evidence for the Balance Evaluation Systems Test

When 'good' is not good enough: a retrospective Rasch analysis study of the Berg Balance Scale for persons with Multiple Sclerosis

Background

The Berg Balance Scale (BBS) is one of the most used tools to quantify balance in Persons with Multiple Sclerosis, a population at high risk of falling.

Aim

To evaluate the measurement characteristics of the BBS in Multiple Sclerosis through Rasch analysis.

Design

Retrospective study.

Setting

Outpatients in three Italian Rehabilitation centers.

Population

Eight hundred and fourteen persons with Multiple Sclerosis able to stand independently for more than 3 s.

Methods

The sample (N = 1,220) was split into one validating (B1) and three confirmatory subsamples. Following the Rasch analysis performed on B1, the item estimates were exported and anchored to the three confirmatory subsamples. After obtaining the same final solution across all samples, we studied the convergent and discriminant validity of the final BBS-MS using the EDSS, the ABC scale, and the number of falls.

Results

The base analysis on the B1 subsample failed the monotonicity, local independence, and unidimensionality requirements and did not fit the Rasch model. After grouping locally dependent items, the BBS-MS fitted the model (χ²₈ = 23.8; p = 0.003) and satisfied all requirements for adequate internal construct validity (ICV). However, it was mistargeted to the sample, given the striking prevalence of higher scores (targeting index 1.922) with a distribution-independent Person Separation Index sufficient for individual measurements (0.962). The B1 item estimates were anchored to the confirmatory samples with confirmation of adequate fit (χ² = [19.0, 22.8], value of ps = [0.015, 0.004]) and satisfaction of all ICV requirements for all subsamples. The final BBS-MS directly correlated with the ABC scale (rho = 0.523) and inversely with EDSS (rho = -0.573). The BBS-MS estimates significantly differed across groups according to the pre-specified hypotheses (between the three EDSS groups, between the ABC cut-offs, distinguishing 'fallers' vs. 'non-fallers', and between the 'low' vs. 'moderate' vs. 'high' levels of physical functioning; and, finally, between 'no falls' vs. 'one or more falls').

Conclusion

This study supports the internal construct validity and reliability of the BBS-MS in an Italian multicentre sample of persons with Multiple Sclerosis. However, as the scale is slightly mistargeted to the sample, it represents a candidate tool to assess balance, mainly in more disabled people with an advanced walking disability.

[Balance Evaluation Systems Test: German translation, cultural adaptation and preliminary results on psychometric properties]

BACKGROUND

The Balance Evaluation Systems Test (BESTest) evaluates balance ability and identifies affected systems associated with balance deficits.

OBJECTIVE

The primary objective was the translation and cultural adaptation of the BESTest into German. Secondary objective was the preliminary evaluation of psychometric properties of the BESTest.

METHOD

In accordance with international guidelines, the BESTest was translated and adapted by a 7-step process. To test the psychometric properties, persons with subjective or objective balance deficits were included. Internal consistency was evaluated by means of Cronbach's alpha. The criterion validity was tested by measuring the correlation with the Berg Balance Scale (BBS). Construct validity was examined using the Activities-Specific Balance Confidence (ABC-D) scale and the known groups methods (fallers versus non-fallers).

RESULTS

A total of 27 subjects were included in the testing of the psychometric properties. Cronbach's alpha was 0.95 for the total scale. The correlation of BESTest scores with those of the BBS revealed a Spearmen's ρ of 0.84 (p < 0.001) and 0.61 (p < 0.001) with those of the ABC‑D scale. Fallers and non-fallers showed a trend towards different BESTest scores (p = 0.057).

DISCUSSION

This paper provides a German translation of the BESTest authorized by the developer. Our preliminary results confirm reliability and validity.

Effect of Acupuncture on Sensorimotor Function and Mobility in Patients with Multiple Sclerosis: A Pilot Study

Introduction: Multiple sclerosis (MS) is a progressive disease of the central nervous system that can result in highly variable effects on mobility and sensorimotor function. Persons with MS (pwMS) often use complementary and alternative approaches, such as acupuncture, to address these symptoms. However, studies of acupuncture on these symptoms have been hindered by methodologic flaws, which have limited the ability to draw conclusions about its efficacy. The purpose of this study was to examine the feasibility of an acupuncture intervention on a wide range of sensorimotor and mobility measurements in pwMS. Methods: Using a randomized crossover design, subjects experienced acupuncture or a no treatment control condition twice weekly for 4 weeks, followed by a 4-week washout period, and then crossed over to the other condition for 4 weeks. Strength, sensation, spasticity, gait, and balance were measured for all subjects, both before and after each condition. Results: Seven of the 12 subjects who started the program completed all phases. No subjects experienced adverse effects. No statistically significant changes were observed in the gait or balance measures. Small statistically significant changes were observed in upper extremity strength. Sensation and spasticity were unaffected. Discussion: The variability of MS suggests that a wide array of testing procedures be utilized, however, this may have led to difficulty with completing all phases of the study. Acupuncture did not result in changes in mobility in pwMS. Some improvements in upper extremity strength were observed. It is unclear whether these changes represent the effect of acupuncture or the inherent variability of MS.

The effects of Baduanjin and yoga exercise programs on physical and mental health in patients with Multiple Sclerosis: A randomized controlled trial

OBJECTIVE

To discuss whether Baduanjin and yoga exercise interventions improve motor function, posture control, and relieving fatigue and depression in MS patients. And to explore whether practicing Baduanjin benefits MS patients more than yoga.

DESIGN

A prospective, randomized, controlled, three-arm trial comparing BDJ (n = 30), yoga (n = 30) and control group (n = 20).

SETTING

Jiangsu Provincial Corps Hospital.

INTERVENTION

Eligible participants were randomized to a 24-week Baduanjin or yoga intervention, or a usual activity control group. Balance, posture control and trunk movement were measured with the Berg Balance Scale (BBS) and Trunk Impairment Scale (TIS). Fatigue was measured using the Fatigue Severity Scale (FSS) and depressive symptoms via the Zung Self-Rating Depression Scale (SDS).

RESULTS

For BBS and TIS, there were significant changes pre- to post- exercise in two exercise groups (P < 0.05), with greater increases in the Baduanjin exercise group (BDJ group). For the FSS, there were significant changes pre- to post- exercise in both the BDJ (P = 0.0292) and yoga groups (P = 0.0150). For the SDS, the pre- and post-exercise difference of the BDJ group was larger than the yoga group (P < 0.0001). On the other hand, we could not find any changes of the BBS, TIS, FSS, and SDS scores in the control group (p > 0.05).

CONCLUSION

The results suggest that practicing Baduanjin was more effective than yoga and that it is suitable for the MS patients.

Bridging the callosal gap in gait: corpus callosum white matter integrity's role in lower limb coordination

Bilateral coordination of the lower extremities is an essential component of mobility. The corpus callosum bridges the two hemispheres of the brain and is integral for the coordination of such complex movements. The aim of this project was to assess structural integrity of the transcallosal sensorimotor fiber tracts and identify their associations with gait coordination using novel methods of ecologically valid mobility assessments in persons with multiple sclerosis and age-/gender-matched neurotypical adults. Neurotypical adults (n = 29) and persons with multiple sclerosis (n = 27) underwent gait and diffusion tensor imaging assessments; the lower limb coordination via Phase Coordination Index, and radial diffusivity, an indirect marker of myelination, were applied as the primary outcome measures. Persons with multiple sclerosis possessed poorer transcallosal white matter microstructural integrity of sensorimotor fiber tracts compared to the neurotypical adults. Further, persons with multiple sclerosis demonstrated significantly poorer bilateral coordination of the lower limbs during over-ground walking in comparison to an age and gender-matched neurotypical cohort. Finally, bilateral coordination of the lower limbs was significantly associated with white matter microstructural integrity of the dorsal premotor and primary motor fiber bundles in persons with multiple sclerosis, but not in neurotypical adults. This analysis revealed that persons with multiple sclerosis exhibit poorer transcallosal microstructural integrity than neurotypical peers. Furthermore, these structural deficits were correlated to poorer consistency and accuracy of gait in those with multiple sclerosis. Together, these results, emphasize the importance of transcallosal communication for gait coordination in those with multiple sclerosis.

The relationship between plantar sensation and muscle onset during automatic postural responses in people with multiple sclerosis and healthy controls

BACKGROUND

Plantar sensation is critical for balance control in people with multiple sclerosis (PwMS). While previous research has described its impact on standing balance, the influence of plantar sensation during automatic postural responses (APRs) is not well understood in PwMS. The purpose of this study was to characterize the relationship between plantar sensation and APRs in PwMS and controls. A secondary aim was to determine whether the relationship between plantar sensation and APRs is different across PwMS and control groups.

METHODS

122 PwMS and 48 age-matched controls underwent forward and backward support-surface perturbations from stance. The onset of the tibialis anterior (TA) and medial gastrocnemius (MG) were the primary reactive balance outcome measures for backward and forward losses of balance, respectively. Plantar sensation was measured as the vibration sensation threshold (VT).

RESULTS

As expected, PwMS had significantly higher (i.e., worse) VT (p<0.001) and an increased MG and TA onset latency (TA: p<0.001, MG: p = 0.01) compared to the control group. A higher VT was related to increased MG (p<0.001) and TA latency (p<0.001) across all participants. However, no moderating effect of group (control or PwMS) was observed for the relationship between VT and muscle onset (MG: p = 0.14; TA: p = 0.34).

CONCLUSION

PwMS demonstrated poorer plantar sensation and delayed muscle onset during APRs compared to controls. Plantar sensation was also related to muscle onset after perturbations in all participants. Although this relationship was not moderated by group, this may be related to the lack of dynamic range of VT scores in controls. These results indicate that plantar sensation may be related to reactive balance and provides insight into a potential contributing factor of delayed automatic postural responses in people with MS.

Association between falls in Alzheimer disease and scores on the Balance Evaluation Systems Test (BESTest) and MiniBESTest

BACKGROUND AND PURPOSE

Alzheimer disease (AD) is the most common form of dementia and the sixth leading cause of death in the United States. Falls are associated with AD and can lead to injury. The Balance Evaluation Systems Test (BESTest) is a balance measure used in other neurological conditions to predict fall risk. The purpose of this study is to examine the relationship between MiniBestest, BESTest, and BESTest subsection scores and fall incidence among individuals with a diagnosis of mild AD.

METHODS

The study was a single centre, prospective, observational cohort study. Participants completed baseline questionnaires including a demographic form, a fall history questionnaire and the Barthel Index of Activities of Daily Living (ADLs). Balance and gait were assessed using the MiniBESTest and BESTest. After completing baseline assessment, participants were given monthly fall calendars to track falls for the next 12 months.

RESULTS

MiniBESTest total raw score for fallers was 13.4 out of 28 (SD = 3.6) and for non-fallers was 18.4 of out 28 (SD = 3.7). MiniBESTest total percentage score for fallers was 47.8% (SD = 12.8%) and for non-fallers was 65.5% (SD = 13.1%). BESTest total percentage scores for fallers was 58.2% (SD = 3.9%) and for non-fallers was 73.9% (SD = 7.9%). Subsections II-IV of the BESTest correlated with faller status.

DISCUSSION AND CONCLUSIONS

Among individuals with mild AD, fall status was associated with certain balance deficits on the BESTest including moving body outside base of support (subsection II), changing centre of mass (subsection III), and reacting to external perturbations (subsection IV). Future studies could explore differences between AD and other neurological conditions and how physical therapy could improve these areas to reduce fall risk.

Exploring factors influencing physiotherapists' perceptions of measuring reactive balance following a theory-based multi-component intervention: a qualitative descriptive study

Purpose: Reactive balance is a critical consideration for mobility and fall avoidance, but is under-assessed among physiotherapists. The objective of this study was to explore factors influencing physiotherapist perceptions about measuring reactive balance upon completion of a 12-month theory-based, multi-component intervention to increase use of a measure of reactive balance.Methods: A qualitative descriptive approach was used. Semi-structured interviews were conducted with 28 physiotherapists treating adults with balance impairment in three urban Canadian rehabilitation hospitals that participated in the intervention. Interviews explored perceptions of reactive balance measurement and perceived changes in clinical behavior. Thematic analysis involved multiple rounds of coding, review and discussion, theme generation, and interpretation of findings through individual analysis and team meetings.Findings: Participants expressed contrasting views about integrating reactive balance measurement in their practice, despite consistent acknowledgement of the importance of reactive balance for function. Three themes were identified highlighting factors that mediated perceptions about measuring reactive balance: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Conclusions: The findings highlight that decision making for measuring reactive balance in rehabilitation settings is complex. There is a need for additional work to facilitate long-term implementation of clinical reactive balance measurement, such as refining patient criteria for administration, ensuring sufficient time to establish a trusting relationship, and developing and testing strategies to address physiotherapist fear.IMPLICATIONS FOR REHABILITATIONReactive balance is important for falls prevention and mobility, but is under-assessed among physiotherapists.This study identified three factors that influenced uptake of reactive balance measurement among physiotherapists in rehabilitation settings: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Knowledge of the identified factors may assist with design and use of reactive and other balance measurements.Strategies aimed at developing trusting relationships between physiotherapist and patient along with addressing physiotherapist fear could facilitate the uptake of clinical reactive balance measurement.

Falls in People with Multiple Sclerosis: Risk Identification, Intervention, and Future Directions

Falls are highly prevalent in people with multiple sclerosis (MS) and result in a range of negative consequences, such as injury, activity curtailment, reduced quality of life, and increased need for care and time off work. This narrative review aims to summarize key literature and to discuss future work needed in the area of fall prevention for people with MS. The incidence of falls in people with MS is estimated to be more than 50%, similar to that in adults older than 80 years. The consequences of falls are considerable because rate of injury is high, and fear of falling and low self-efficacy are significant problems that lead to activity curtailment. A wide range of physiological, personal, and environmental factors have been highlighted as potential risk factors and predictors of falls. Falls are individual and multifactorial, and, hence, approaches to interventions will likely need to adopt a multifactorial approach. However, the literature to date has largely focused on exercise-based interventions, with newer, more comprehensive interventions that use both education and exercise showing promising results. Several gaps in knowledge of falls in MS remain, in particular the lack of standardized definitions and outcome measures, to enable data pooling and comparison. Moving forward, the involvement of people with MS in the design and evaluation of programs is essential, as are approaches to intervention development that consider implementation from the outset.

Reactive Balance Adaptability and Retention in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis

Aim. To compare reactive balance in people with multiple sclerosis (MS) with healthy controls and to examine the ability of people with MS to adapt their reactive balance and retain training effects. Data Sources. Electronic databases (PubMed, EMBASE, PsychINFO) and reference lists of included articles from inception to February 25, 2019. Study Selection. Case-control and intervention studies that assessed reactive balance using mechanical perturbations in people with a confirmed diagnosis of MS. Results. Meta-analyses of 9 studies (n = 342) showed that people with MS have significantly worse reactive balance than healthy controls (standardized mean difference [SMD] 0.78, 95% CI 0.44-1.11, P < .0001, I² = 47%). Specifically, people with MS have greater center of mass displacements (SMD 0.41, 95% CI 0.05-0.77, P = .02, I² = 9%) and longer response times (MD (ms) 31.45, 95% CI 19.91-42.98, P < .0001, I² = 75%) in response to standing perturbations than healthy controls. Subsequent meta-analyses revealed training comprising repeated exposure to perturbations improved response times (P < .001) and training effects on response times could be retained for 24 hours (P < .001) in people with MS. Conclusions. Reactive balance assessments can highlight functional impairments related to falls in people with MS, and perturbation training can acutely improve reactive balance control and such improvements can be retained for 24 hours in this population. Systematic review registration number: CRD42019126130.

Reliability, Validity, and Responsiveness of the Mini-Balance Evaluation Systems Test in Ambulatory Individuals with Multiple Sclerosis

Purpose: The purpose of this study was to determine the reliability, validity, and responsiveness of the Mini-Balance Evaluation Systems Test (MBT) in persons with multiple sclerosis (pwMS). Method: A total of 32 pwMS completed a questionnaire on disease severity, the Activities-specific Balance Confidence Scale (ABC), and the MBT. The MBT was re-administered 1 week later. Results: The interrater and test-retest reliability of the total MBT and subscales were excellent. The standard error of measurement for the total MBT, calculated from test-retest and interrater reliability, respectively, was 1.32 and 1.07. The minimal detectable change (MDC) for the total MBT was 3.74; the MDC for the subscales ranged from 0.98 (sensory) to 2.38 (gait). The correlations between individual subscale scores and the total MBT, among subscales, and between the total MBT and disease severity and ABC were excellent. Correlations between the total MBT and age, MS type, and fall and imbalance histories were moderate. Disease severity and ABC scores were the strongest predictors of MBT score. No floor effects were found. Ceiling effects were found for two subscales, but not for the total MBT. Conclusions: The MBT is reliable and valid in pwMS. MDC values will facilitate assessing the effectiveness of treatment. Because ceiling effects were found for two subscales, but not the total MBT, it is recommended that clinicians administer the MBT in its entirety.

The sensitivity and specificity of the balance evaluation systems test-BESTest in determining risk of fall in stroke patients

BACKGROUND

Balance disorders cause disability in stroke and increase risk of falls. The Balance Evaluation Systems Test (BESTest), examines balance, determines parameters causing balance disorders, provides information on risk factors for falls.

OBJECTIVE

To investigate the sensitivity and specificity of the BESTest in determining the risk of falls in stroke patients.

METHODS

Fifty patients with chronic stroke were included in the study. Balance was assessed using BESTest, Berg Balance Scale (BBS), Activity Specific Balance Confidence scale (ABC) and Biodex-BioSway Balance System. To examine the content validity of BESTest, the relationship between BESTest and other balance assessment methods was examined. The internal consistency reliability of BESTest was evaluated by Cronbach's α coefficient. Analysis of receiver operating characteristics (ROC) was performed to determine cut-off point, sensitivity and specificity.

RESULTS

BESTest, BBS, ABC and Biodex-BioSway Balance System results of faller stroke patients were worse than that of non-faller (p <0.05). Internal consistency of BESTest was found to be Cronbach's α = 0.960. The BESTest value of area under curve (AUC) was 0.844, with a cut-off point of 69.44%, a sensitivity of 75% and a specificity of 84.6% (p < 0.01).

CONCLUSION

BESTest is reliable and valid with high sensitivity and specificity in determining the risk of fall in stroke patients.

Experiences of people with stroke and multiple sclerosis and caregivers of a community exercise programme involving a healthcare-recreation partnership

Purpose: To explore perceptions of people with neurological conditions and their caregivers of the health benefits of a group, task-oriented community-based exercise programme incorporating a healthcare-recreation partnership.Materials and methods: Descriptive qualitative study. Individuals with balance and mobility deficits from a neurological condition, and their caregivers, were interviewed on completion of a group, task-oriented community-based exercise programme incorporating a healthcare-recreation partnership. A thematic analysis was performed.Results: Nine people post-stroke, and four people with multiple sclerosis (MS) (n = 13; 54% male) and 12 caregivers (83% spouses) participated. Two themes emerged. One theme indicated that the programme fosters diverse, interrelated health benefits. Participants described experiences of improved balance, strength, and confidence that translated to improved everyday functioning and social participation. Benefits were reinforced through repeated programme registration. A second theme indicated that caregivers experience challenges and diverse benefits related to the programme. Transportation and programme cost were primary challenges. Caregivers described emotional health benefits from assisting participants during classes and observing participants improvement over time.Conclusions: Group, task-oriented community-based exercise programmes incorporating a healthcare-recreation partnership may yield health benefits for exercise participants and caregivers. Results can guide programme evaluation, the nature and timing of education about such programmes, and efforts to address cost and transportation issues.Implications of rehabilitationStroke and multiple sclerosis commonly cause balance and mobility limitations that can result in physical inactivity and further deterioration in health.Group, task-oriented community-based exercise programmes in which rehabilitation professionals train and support fitness instructors to deliver the exercise programme in community centres may increase access to exercise participation for this group.Study results suggest by improving balance and mobility, these programmes help increase independence in activities of daily living and social and leisure participation, while improving caregiver mental health and decreasing the need for caregiver assistance.Rehabilitation professionals can use findings to inform patient education, and support programme implementation and referral.

A theory-based multi-component intervention to increase reactive balance measurement by physiotherapists in three rehabilitation hospitals: an uncontrolled single group study

BACKGROUND

Most implementation interventions in rehabilitation, including physiotherapy, have used passive, non-theoretical approaches without demonstrated effectiveness. The goal of this study was to improve an important domain of physiotherapy practice - reactive balance measurement - with a targeted theory-based multi-component intervention developed using the Theoretical Domains Framework. The primary objective was to determine documented reactive balance measure use in a 12-month baseline, during, and for three months post- intervention.

METHODS

An uncontrolled before-and-after study was completed with physiotherapists at three urban adult rehabilitation hospitals in Ontario, Canada. The 12-month intervention included group meetings, local champions, and health record modifications for a validated reactive balance measure. The primary outcome was the proportion of records with a documented reactive balance measure when balance was assessed pre-, during- and post-intervention. Secondary outcomes were changes in use, knowledge, and confidence post-intervention, differences across sites, and intervention satisfaction.

RESULTS

Reactive balance was not measured in any of 211 eligible pre-intervention records. Thirty-three physiotherapists enrolled and 28 completed the study. Reactive balance was measured in 31% of 300 eligible records during-intervention, and in 19% of 90 eligible records post-intervention (p < 0.04). Knowledge and confidence significantly increased post-intervention (all p < 0.05). There were significant site differences in use during- and post-intervention (all p < 0.05). Most participants reported satisfaction with intervention content (71%) and delivery (68%).

CONCLUSIONS

Reactive balance measurement was greater among participants during-intervention relative to the baseline, and use was partially sustained post-intervention. Continued study of intervention influences on clinical reasoning and exploration of site differences is warranted.

Test-Retest Reliability, Validity, and Minimal Detectable Change of the Balance Evaluation Systems Test to Assess Balance in Persons with Multiple Sclerosis

BACKGROUND

Individuals with multiple sclerosis (MS) have balance deficits that result in falls. Balance tests developed for older adults do not discriminate between fallers and nonfallers with MS. The Balance Evaluation Systems Test (BESTest) identifies body systems contributing to imbalance/fall risk. This study evaluated the test-retest reliability and construct validity of the BESTest to assess balance in individuals with MS, compared the diagnostic accuracy of the BESTest and Berg Balance Scale (BBS), and investigated the minimal detectable change of the BESTest in this population.

METHODS

Twenty individuals with MS were recruited. Age, onset of disease, and fall history were obtained. The following measures were used: Expanded Disability Status Scale, University of Illinois at Chicago Fear of Falling Measure, BESTest, and BBS. Twelve participants were retested to determine test-retest reliability of the BESTest.

RESULTS

The BESTest demonstrated strong test-retest reliability (intraclass correlation coefficient [3,1] = 0.98 [95% CI, 0.91-0.99], P = .01) and was highly correlated with the BBS (r = 0.94, P = .01). The BBS had poor accuracy to identify fallers. Using a score of 81%, the BESTest had moderate sensitivity (0.89) to identify fallers. The standard error of the measurement for the BESTest was 4.16 points, which translates into a minimal detectable change of 9.7% [90% CI] to 11.5% [95% CI].

CONCLUSIONS

The BESTest demonstrates excellent test-retest reliability and diagnostic utility as a measure of functional balance in persons with moderate MS. A change in BESTest score of at least 10% may indicate a true change in balance performance in this population.

Bipedal hopping timed to a metronome to detect impairments in anticipatory motor control in people with mild multiple sclerosis

BACKGROUND

People with mild multiple sclerosis (MS) often report subtle deficits in balance and cognition but display no measurable impairment on clinical assessments. We examined whether hopping to a metronome beat had the potential to detect anticipatory motor control deficits among people with mild MS (Expanded Disability Status Scale ≤ 3.5).

METHODS

Participants with MS (n = 13), matched controls (n = 9), and elderly subjects (n = 13) completed tests of cognition (Montreal Cognitive Assessment (MoCA)) and motor performance (Timed 25 Foot Walk Test (T25FWT)). Participants performed two bipedal hopping tasks: at 40 beats/min (bpm) and 60-bpm in random order. Hop characteristics (length, symmetry, variability) and delay from the metronome beat were extracted from an instrumented walkway and compared between groups.

RESULTS

The MS group became more delayed from the metronome beat over time whereas elderly subjects tended to hop closer to the beat (F = 4.52, p = 0.02). Delay of the first hop during 60-bpm predicted cognition in people with MS (R = 0.55, β = 4.64 (SD 4.63), F = 4.85, p = 0.05) but not among control (R = 0.07, p = 0.86) or elderly subjects (R = 0.17, p = 0.57). In terms of hopping characteristics, at 60-bpm, people with MS and matched controls were significantly different from the elderly group. However, at 40-bpm, the MS group was no longer significantly different from the elderly group, even though matched controls and elderly still differed significantly.

CONCLUSIONS

This new timed hopping test may be able to detect both physical ability, and feed-forward anticipatory control impairments in people with mild MS. Hopping at a frequency of 40-bpm seemed more challenging. Several aspects of anticipatory motor control can be measured: including reaction time to the first metronome cue and the ability to adapt and anticipate the beat over time.

Spotlight on postural control in patients with multiple sclerosis

Multiple sclerosis (MS) is a disease that heavily affects postural control, predisposing patients to accidental falls and fall-related injuries, with a relevant burden on their families, health care systems and themselves. Clinical scales aimed to assess balance are easy to administer in daily clinical setting, but suffer from several limitations including their variable execution, subjective judgment in the scoring system, poor performance in identifying patients at higher risk of falls, and statistical concerns mainly related to distribution of their scores. Today we are able to objectively and reliably assess postural control not only with laboratory-grade standard force platform, but also with low-cost systems based on commercial devices that provide acceptable comparability to gold-standard equipment. The sensitivity of measurements derived from force platforms is such that we can detect balance abnormalities even in minimally impaired patients and predict the risk of future accidental falls accurately. By manipulating sensory inputs (dynamic posturography) or by adding a concurrent cognitive task (dual-task paradigm) to the standard postural assessment, we can unmask postural control deficit even in patients at first demyelinating event or in those with a radiologic isolated syndrome. Studies on neuroanatomical correlates support the multifactorial etiology of postural control deficit in MS, with the association with balance impairment being correlated with cerebellum, spinal cord, and highly ordered processing network according to different studies. Postural control deficit can be managed by means of rehabilitation, which is the most important way to improve balance in patients with MS, but there are also suggestions of a beneficial effect of some pharmacologic interventions. On the other hand, it would be useful to pay attention to some drugs that are currently used to manage other symptoms in daily clinical setting because they can further impair postural controls of patients with MS.

The ability of clinical balance measures to identify falls risk in multiple sclerosis: a systematic review and meta-analysis

Objective:

To determine the ability of clinical measures of balance to distinguish fallers from non-fallers and to determine their predictive validity in identifying those at risk of falls.

Data sources:

AMED, CINAHL, Medline, Scopus, PubMed Central and Google Scholar. First search: July 2015. Final search: October 2017.

Review methods:

Inclusion criteria were studies of adults with a definite multiple sclerosis diagnosis, a clinical balance assessment and method of falls recording. Data were extracted independently by two reviewers. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 scale and the modified Newcastle–Ottawa Quality Assessment Scale. Statistical analysis was conducted for the cross-sectional studies using Review Manager 5. The mean difference with 95% confidence interval in balance outcomes between fallers and non-fallers was used as the mode of analysis.

Results:

We included 33 studies (19 cross-sectional, 5 randomised controlled trials, 9 prospective) with a total of 3901 participants, of which 1917 (49%) were classified as fallers. The balance measures most commonly reported were the Berg Balance Scale, Timed Up and Go and Falls Efficacy Scale International. Meta-analysis demonstrated fallers perform significantly worse than non-fallers on all measures analysed except the Timed Up and Go Cognitive ( p < 0.05), but discriminative ability of the measures is commonly not reported. Of those reported, the Activities-specific Balance Confidence Scale had the highest area under the receiver operating characteristic curve value (0.92), but without reporting corresponding measures of clinical utility.

Conclusion:

Clinical measures of balance differ significantly between fallers and non-fallers but have poor predictive ability for falls risk in people with multiple sclerosis.

Clinical measures of balance in people with type two diabetes: A systematic literature review

Approximately 422 million people have diabetes mellitus worldwide, with the majority diagnosed with type 2 diabetes mellitus (T2DM). The complications of diabetes mellitus include diabetic peripheral neuropathy (DPN) and retinopathy, both of which can lead to balance impairments. Balance assessment is therefore an integral component of the clinical assessment of a person with T2DM. Although there are a variety of balance measures available, it is uncertain which measures are the most appropriate for this population. Therefore, the aim of this study was to conduct a systematic review on clinical balance measures used with people with T2DM and DPN. Databases searched included: CINAHL plus, MEDLINE, SPORTDiscus, Dentistry and Oral Sciences source, and SCOPUS. Key terms, inclusion and exclusion criteria were used to identify appropriate studies. Identified studies were critiqued using the Downs and Black appraisal tool. Eight studies were included, these studies incorporated a total of ten different clinical balance measures. The balance measures identified included the Dynamic Balance Test, balance walk, tandem and unipedal stance, Functional Reach Test, Clinical Test of Sensory Interaction and Balance, Berg Balance Scale, Tinetti Performance-Oriented Mobility Assessment, Activity-Specific Balance Confidence Scale, Timed Up and Go test, and the Dynamic Gait Index. Numerous clinical balance measures were used for people with T2DM. However, the identified balance measures did not assess all of the systems of balance, and most had not been validated in a T2DM population. Therefore, future research is needed to identify the validity of a balance measure that assesses these systems in people with T2DM.

Psychometric properties of Brief-Balance Evaluation Systems Test (Brief-BESTest) in evaluating balance performance in individuals with chronic stroke

OBJECTIVE

To examine the psychometric properties of the Brief-Balance Evaluation Systems Test (Brief-BESTest) in individuals with chronic stroke.

MATERIALS AND METHODS

This was an observational study with repeated measurements involving 50 participants with chronic stroke [mean (SD) age: 59.2 (7.3) years]. Each participant with stroke was evaluated with the Brief-BESTest, Berg balance scale (BBS), Postural Assessment Scale for Stroke Patients (PASS), Fugl-Meyer Motor Assessment (FMA), Chedoke-McMaster Stroke Assessment (CMSA), Montreal Cognitive Assessment (MoCA), and Geriatric Depression Scale (GDS). Two raters (rater 1 and 2) provided the Brief-BESTest scores of the first 27 participants independently to establish inter-rater reliability. After 15 min of rest, the same 27 participants were evaluated with the Brief-BESTest again by rater 1 to establish intra-rater reliability. The Brief-BESTest scores of the stroke group were also compared with those of the control group [n = 27, mean (SD) age: 56.7 (7.7) years].

RESULTS

The Brief-BESTest had no substantial floor and ceiling effects, good intra-rater (ICC _2,1 = 0.974) and inter-rater (ICC _2,1 = 0.980) reliability and internal consistency (Cronbach's alpha = 0.818). The minimal detectable change at 95% confidence level was 2 points. The Brief-BESTest showed moderate to very strong correlations with other balance (BBS and PASS) and motor impairment (FMA, CMSA) measures (r_s = .547-.911, p < .001), thus revealing good concurrent and convergent validity. Its correlation with measures that evaluated other constructs was weaker (MoCA: r_s = .437, p = .002) or non-significant (GDS: r_s  = -0.152, p = .292), thus showing good discriminant validity. Good known-groups validity was established, as the Brief-BESTest was effective in distinguishing participants with stroke from controls (cutoff score: <18, area under curve: 0.942), and individuals with stroke who required assistive device for their outdoor mobility from those who did not (cutoff score <14, area under curve: 0.810).

CONCLUSIONS

The Brief-BESTest has good reliability and validity in assessing balance function in individuals with chronic stroke.

Lower Endurance and Strength of Core Muscles in Patients with Multiple Sclerosis

Background

Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system associated with a variety of symptoms and functional deficits. Balance impairment is a common concern in patients with MS. Core muscle stabilization is considered a main component of balance. The strength and endurance of core muscles have not been compared between patients with MS and healthy people. The objective of this study was to compare core muscle strength and endurance between ambulatory patients with MS and a healthy group.

Methods

Thirty-three patients with MS with Expanded Disability Status Scale scores ranging from 1.0 to 4.5 and 33 matched healthy people participated in this cross-sectional group comparison study. The primary outcome measure was endurance of core muscles assessed by functional endurance tests, and the secondary outcome was isometric strength of core muscles assessed using a dynamometer.

Results

Patients with MS had lower performance on endurance tests (P < .001) and strength tests (P < .05) compared with the control group.

Conclusions

These results show decreased core muscle strength and endurance in ambulatory individuals with MS compared with a matched control group. Future studies are required to assess how core muscle impairment affects balance and how it would be affected by rehabilitation and exercise programs.

Characterising community exercise programmes delivered by fitness instructors for people with neurological conditions: a scoping review

A scoping review was conducted to characterise evaluations of community-based exercise programmes (CBEPs) delivered by fitness instructors to people with neurological conditions. Literature published from 1946 to April 2014 in MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and the grey literature were searched. Search terms included community, programme, exercise, adult, brain disease and spinal cord disease. Two reviewers independently screened titles and abstracts for inclusion. One author reviewed full-text articles to evaluate eligibility. Studies were included if the study objective was to evaluate an exercise programme, the programme was community-based and delivered by fitness instructors, exercise participants were ≥18 years of age and had a neurological condition, and a full-text article was available and written in English. After reviewing 1785 titles and abstracts, 18 (1.01%) articles describing 15 studies were included in the review. One author completed data abstraction from the included studies. A second reviewer independently verified the extracted data for accuracy. Exercise programmes most commonly included people with stroke (47%) and Parkinson's disease (40%), incorporated a stand-alone (80%), multi-component (20%), group (67%), individual (20%) and combined format (13%), strength training (40%) and functional/task-oriented training (40%), reported a minimum walking requirement (67%), and involved a healthcare professional (HCP) with various roles (53%), including training (27%), advising and supporting (33%). The most commonly examined participant outcomes were health-related quality of life (60%) and functional balance (47%). More research is needed to develop CBEPs targeting individuals with low ambulatory function and multiple neurological conditions, to develop recommendations for the involvement of HCPs in CBEPs and document their involvement, and to evaluate system-level outcomes such as cost, healthcare utilisation and impact on caregivers. The findings support a number of considerations to guide future research into CBEPs delivered by fitness instructors for individuals with neurological conditions.

Changes in Multidigit Synergies and Their Feed-Forward Adjustments in Multiple Sclerosis

The authors explored the changes in multidigit synergies in patients with multiple sclerosis (MS) within the framework of the uncontrolled manifold hypothesis. The specific hypotheses were that both synergy indices and anticipatory synergy adjustments prior to the initiation of a self-paced quick action would be diminished in the patients compared to age-matched controls. The MS patients and age-matched controls (n = 13 in both groups) performed one-finger and multifinger force production tasks involving both accurate steady-state force production and quick force pulses. The patients showed significantly lower maximal finger forces and a tendency toward slower force pulses. Enslaving was increased in MS, but only in the lateral fingers (index and little). Indices of multifinger synergies during steady-state force production were lower in MS, mainly due to the lower amount of intertrial variance that did not affect total force. Anticipatory synergy adjustments were significantly delayed in MS. The results show that MS leads to significant changes in multidigit synergies and feed-forward adjustments of the synergies prior to a quick action. The authors discuss possible contributions of subcortical structures to the impaired synergic control.

Relationship between gait initiation and disability in individuals affected by multiple sclerosis

This study analyzes how multiple sclerosis (MS) does affect one of the most common voluntary activities in life: the gait initiation (GI). The main aim of the work is to characterize the execution of this task by measuring and comparing relevant parameters based on center of pressure (COP) patterns and to study the relationship between these and the level of expanded disability status scale (EDSS). To this aim, 95 MS subjects with an average EDSS score of 2.4 and 35 healthy subjects were tested using a force platform during the transition from standing posture to gait. COP time-series were acquired and processed to extract a number of parameters related to the trajectory followed by the COP. The statistical analysis revealed that only a few measurements were statistically different between the two groups and only these were subsequently correlated with EDSS score. The correlation analysis underlined that a progressive alteration of the task execution can be directly related with the increase of EDSS score. These finding suggest that most of the impairment found in people with MS comes from the first part of the COP pattern, the anticipatory postural adjustments (APAs). The central nervous system performs APAs before every voluntary movement to minimize balance perturbation due to the movement itself. Gait Initiation's APAs consist in some ankle muscles contractions that induce a backward COP shift to the swing limb. The analysis here performed highlighted that MS affected patients have a reduced posterior COP shift that reveals that the anticipatory mechanism is impaired.

Detection of postural sway abnormalities by wireless inertial sensors in minimally disabled patients with multiple sclerosis: a case-control study

Background

Common clinical neurological exams can be insensitive to balance and mobility impairment at the early stages of multiple sclerosis (MS) and may not correspond with patient reports. Instrumented measurement of standing postural sway with inertial motion sensors may provide sensitive measures of balance impairment and better correspond with patient reports.

Methods

While wearing wireless inertial sensors, 20 subjects with MS – Expanded Disability Status Scale of less than 3.0 and a Timed 25 Foot Walk of 5 sec or less – and 20 age- and sex-matched control subjects stood with eyes open and eyes closed on a foam surface. Forty-six outcome measures of postural sway were derived. A stepwise logistic regression model determined which measures of instrumented sway provide independent predictors of group status. Subjects with MS also completed the Activities-Specific Balance Confidence (ABC) scale and the 12-Item MS Walking Scale (MSWS-12) as measures of subject-reported balance and mobility impairment.

Results

The regression model identified medio-lateral sway path length and medio-lateral range of sway acceleration amplitude, each in the eyes-open condition, as the only two significant independent predictors to differentiate subjects with MS from those without MS (model chi-squared = 34.55, p < 0.0001): accuracy = 87.5 %, positive likelihood ratio = 6 (2.09–17.21), negative likelihood ratio = 0.12 (0.03–0.44). Range of sway acceleration amplitude significantly correlated with both ABC (Spearman’s r = −0.567, p = 0.009) and MSWS-12 scores (Spearman’s r = −0.590, p = 0.006).

Conclusions

Postural sway abnormalities in subjects with MS who are minimally disabled were detected using wireless inertial sensors and may signify a superior sensitivity to identify balance impairment prior to developing clinically evident disability or impaired gait speed. Further study is needed to confirm the clinical significance and predictive value of these objectively identified balance impairments.

Anticipatory and compensatory postural adjustments in individuals with multiple sclerosis in response to external perturbations

Deficit in balance control is a common and often an initial disabling symptom of multiple sclerosis (MS). The aim of the study was to investigate the organization of anticipatory and compensatory postural adjustments in individuals with MS dealing with external perturbations. Ten individuals with MS and ten age-and-gender matched healthy controls were exposed to external perturbations applied at the shoulder level. The perturbations were either predictable or unpredictable as subjects stood with eyes open or closed. Electrical activity of six leg and trunk muscles as well as displacements of the center of pressure (COP) were recorded and quantified within the time intervals typical of anticipatory (APAs) and compensatory (CPAs) postural adjustments. Individuals with MS demonstrated delayed anticipatory onsets of muscle activity and smaller anticipatory COP displacements as compared to healthy control subjects. The deficiency of the APAs was associated with increased displacements of the COP during the balance restoration phase. The results demonstrate the underlying impairment in anticipatory postural control of individuals with MS. The study outcome provides a background for development of rehabilitation strategies focused on balance restoration in people with MS.

Targeting Dynamic Balance in Falls-Prevention Interventions in Multiple Sclerosis: Recommendations from the International MS Falls Prevention Research Network

Balance deficits are common in people with multiple sclerosis (MS) and are associated with past and future falls. People with MS tend to fall during activities of daily living and recreation that involve transitions between body positions and during walking and turning. The evident deficits in dynamic balance may be partly due to impairment in the collection or integration of sensory inputs or the execution of appropriate movements in moments of distraction. There is growing evidence that dynamic balance is modifiable and that improvements in dynamic balance are associated with reduction in falls. Consequently, it is imperative that balance measures be appropriate to capture changes in components of dynamic balance. There are numerous ways to measure dynamic balance. When selecting the appropriate dynamic balance measure for an MS falls-prevention trial, the inclusion criteria and content of intervention will inform the choice of measure. The International MS Falls Prevention Research Network (IMSFPRN) suggests that measures of dynamic balance be included as an outcome measure for use in falls-prevention trials.

Systematic review of the psychometric properties of balance measures for cerebellar ataxia

OBJECTIVE

To review systematically the psychometric properties of balance measures for use in people with cerebellar ataxia.

DATA SOURCES

Medline, AMED, CINAHL, Web of Science and EMBASE were searched between 1946 and April 2014.

REVIEW METHODS

Two reviewers independently searched data sources. Cerebellar-specific and generic measures of balance were considered. Included studies tested psychometric properties of balance measures in people with cerebellar ataxia of any cause. Quality of reported studies was rated using the Consensus Based Standards for the selection of health status Measurement INstruments (COSMIN) checklist.

RESULTS

Twenty-one articles across which 16 measures had been tested were included for review. Using the COSMIN, quality of methodology in studies investigating psychometric properties of generic balance measures (n=10) was rated predominantly as 'poor'. Furthermore, responsiveness has not been tested for any generic measures in this population. The quality of studies investigating psychometric properties of balance sub-components of the cerebellar-specific measures (n=6) ranged from 'poor' to 'excellent'; however, Minimally Clinically Important Difference has not been determined for these cerebellar-specific measures.

CONCLUSION

The Posture and Gait (PG) sub-component of the International Cooperative Ataxia Rating Scale (ICARS) demonstrates the most robust psychometric properties with acceptable clinical utility.

Gait impairment and optimizing mobility in multiple sclerosis

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.

The clinical relevance of force platform measures in multiple sclerosis: a review

Balance impairment and falls are frequent in patients with multiple sclerosis (PwMS), and they may occur even at the earliest stage of the disease and in minimally impaired patients. The introduction of computer-based force platform measures (i.e., static and dynamic posturography) has provided an objective and sensitive tool to document both deficits and improvements in balance. By using more challenging test conditions, force platform measures can also reveal subtle balance disorders undetectable by common clinical scales. Furthermore, posturographic techniques may also allow to reliably identify PwMS who are at risk of accidental falls. Although force platform measures offer several theoretical advantages, only few studies extensively investigated their role in better managing PwMS. Standardised procedures, as well as clinical relevance of changes detected by static or dynamic posturography, are still lacking. In this review, we summarized studies which investigated balance deficit by means of force platform measures, focusing on their ability in detecting patients at high risk of falls and in estimating rehabilitation-induced changes, highlighting the pros and the cons with respect to clinical scales.

A Systems Perspective on Postural and Gait Stability: Implications for Physical Activity in Aging and Disease

Postural instability, falls, and fear of falling that accompany frailty with aging and disease form major impediments to physical activity. In this article we present a theoretical framework that may help researchers and practitioners in the development and delivery of intervention programs aimed at reducing falls and improving postural stability and locomotion in older individuals and in those with disability due to disease. Based on a review of the dynamical and complex systems perspectives of movement coordination and control, we show that 1) central to developing a movement-based intervention program aimed at fall reduction and prevention is the notion that variability can play a functional role and facilitate movement adaptability, 2) intervention programs aimed at fall reduction should focus more on coordination and stability boundary measures instead of traditional gait and posture outcome variables, and 3) noise-based intervention techniques using stochastic resonance may offer external aids to improve dynamic balance control.

Is the BESTest at its best? A suggested brief version based on interrater reliability, validity, internal consistency, and theoretical construct

BACKGROUND

The Balance Evaluation Systems Test (BESTest) and Mini-BESTest are clinical examinations of balance impairment, but the tests are lengthy and the Mini-BESTest is theoretically inconsistent with the BESTest.

OBJECTIVE

The purpose of this study was to generate an alternative version of the BESTest that is valid, reliable, time efficient, and founded upon the same theoretical underpinnings as the original test.

DESIGN

This was a cross-sectional study.

METHODS

Three raters evaluated 20 people with and without a neurological diagnosis. Test items with the highest item-section correlations defined the new Brief-BESTest. The validity of the BESTest, the Mini-BESTest, and the new Brief-BESTest to identify people with or without a neurological diagnosis was compared. Interrater reliability of the test versions was evaluated by intraclass correlation coefficients. Validity was further investigated by determining the ability of each version of the examination to identify the fall status of a second cohort of 26 people with and without multiple sclerosis.

RESULTS

Items of hip abductor strength, functional reach, one-leg stance, lateral push-and-release, standing on foam with eyes closed, and the Timed "Up & Go" Test defined the Brief-BESTest. Intraclass correlation coefficients for all examination versions were greater than .98. The accuracy of identifying people from the first cohort with or without a neurological diagnosis was 78% for the BESTest versus 72% for the Mini-BESTest or Brief-BESTest. The sensitivity to fallers from the second cohort was 100% for the Brief-BESTest, 71% for the Mini-BESTest, and 86% for the BESTest, and all versions exhibited specificity of 95% to 100% to identify nonfallers. Limitations Further testing is needed to improve the generalizability of findings.

CONCLUSIONS

Although preliminary, the Brief-BESTest demonstrated reliability comparable to that of the Mini-BESTest and potentially superior sensitivity while requiring half the items of the Mini-BESTest and representing all theoretically based sections of the original BESTest.