Psychometric properties of the Persian-version of the Activities-specific Balance Confidence scale and Fall Efficacy Scale-International in Iranian patients with multiple sclerosis

Fear of falling and common symptoms of multiple sclerosis: Physical function, cognition, fatigue, depression, and sleep - A systematic review

BACKGROUND

Fear of falling (FOF) is a common concern among persons with multiple sclerosis (MS) and affects the performance of their daily living activities. Falls may result in FOF, leading to worsening of symptoms of MS, physical deconditioning, and exposure to future falls. This may trigger a vicious cycle between FOF and falls. A better understanding of the relationship between FOF and symptoms of MS may be helpful to develop a conceptual model to guide fall prevention interventions.

OBJECTIVE

To synthesize the correlational and predictive relationships between FOF and common symptoms of MS.

METHODS

Databases including PubMed, Embase, Web of Science, Scopus, CINHAL, PsycINFO, and SPORTDiscuss were searched from inception to October 2023. Studies examining correlations and/or predictions between FOF and common MS symptoms that include measures of gait, postural control, fatigue, cognition, pain, sleep, depression, and anxiety were identified by two independent reviewers. Both reviewers also conducted the methodological quality assessment of the included studies.

RESULTS

Twenty-three studies with a total of 2819 participants were included in the review. Correlational findings indicated that increased FOF was significantly associated with greater walking deficits (lower gait speed, smaller steps), reduced mobility, and poorer balance. Increased FOF was also significantly correlated with higher cognitive impairments, more fatigue, sleep disturbances, and depression. Decreased gait parameters, reduced balance, lower physical functions, cognitive impairments, and sleep deficits were found as significant predictors of increased FOF.

CONCLUSION

Evidence indicates significant correlational and bidirectional predictive relationships exist between FOF and common MS symptoms. A comprehensive conceptual framework accounting for the interaction between FOF and MS symptoms is needed to develop effective falls prevention strategies.

Validity, reliability, and responsiveness of Persian version of mini-balance evaluation system test among ambulatory people with multiple sclerosis

BACKGROUND AND PURPOSE

Mini-Balance Evaluation Systems Test (mini-BESTest) is a widely used measure to assess balance impairments. This study aimed to assess the validity, reliability, responsiveness, and minimal clinically important change (MCIC) of the Persian mini-BESTest among ambulatory People with Multiple Sclerosis (PwMS).

METHODS

Fifty ambulatory PwMS participated in this study. Persian mini-BESTest validated against Berg Balance Scale (BBS) and Timed-Up and Go (TUG) with/without a cognitive task. To assess the reliability, the Persian mini-BESTest was re-administered for a sample of 30 participants after 1 week. Also, 32 PwMS were tested before and after a 4-week of balance and gait training to assess the responsiveness.

RESULTS

No floor/ceiling effect was found for the mini-BESTest total score. There were significant excellent correlations (p < .001) between mini-BESTest and BBS (r = 0.71), TUG (r = -0.76), and cognitive TUG (r = -0.73). No strong correlations were observed between the subscales (r = 0.37-0.55). Test-retest reliability and internal consistency of Persian mini-BESTest total score were excellent, with Intra-class Correlation Coefficient (ICC3,1 and Cronbach's alpha level of 0.89 and 0.80, respectively. The minimal detectable change was 4 points. The Persian mini-BESTest had acceptable responsiveness (AUC = 0.83), and MCIC was 5 points.

CONCLUSION

The Persian mini-BESTest is a valid, reliable, and responsive measure of balance performance in Iranian ambulatory PwMS.

Validity and reliability of the Persian version of the STarT musculoskeletal tool

BACKGROUND

The Subgrouping for Targeted Treatment (STarT) musculoskeletal (MSK) tool stratifies patients with MSK disorders (MSDs) into prognostic categories based on poor outcomes.

PURPOSE

This study aimed at investigating the validity and reliability of the Persian STarT MSK tool in people suffering from painful MSDs in Iran.

METHODS

A total of 593 subjects with painful MSDs including neck, shoulder, low back, knee, and multisite pain received and completed the STarT MSK tool, visual analog scale (VAS), EuroQol five-dimensions three-levels questionnaire (EQ-5D-3 L), short form-36 health survey questionnaire (SF-36), and Örebro musculoskeletal pain screening questionnaire (ÖMPSQ) in the first visit. To examine test-retest reliability, 234 patients completed the STarT MSK tool 2 days after the initial visit.

RESULTS

In this study, 139 (23.5%), 266 (44.9%), and 188 (31.7%) participants were classified as low-, medium-, and high-risk groupings for poor outcomes, respectively. Spearman's correlation coefficient showed a strong relationship among Persian STarT MSK tool and EQ-5D-3 L (-0.78), SF-36 (-0.76), and OMPSQ (0.70). The results of known-group validity indicated that this tool could distinguish among the participants in different risk subgroups based on the scores of the ÖMPSQ, VAS, SF36, and EQ-5D-5 L (p < .001). No ceiling and floor effects were observed. Cronbach's alpha and intra-class correlation coefficient (ICC2,1) were acceptable (0.71) and excellent (0.98), respectively.

CONCLUSION

The Persian version of STarT MSK tool has shown to be a valid and reliable instrument to stratify people with painful MSDs into low-, medium-, and high-risk subgroups based on persistent pain disability.

Perturbation-based Balance Training to improve postural responses and falls in people with multiple sclerosis: a randomized controlled trial

PURPOSE

To determine the effects of Perturbation-based Balance Training (PBT) on postural responses and falls in people with multiple sclerosis (PwMS) and compare the results with conventional balance training (CBT).

MATERIALS AND METHODS

Thirty-four PwMS were randomized to receive 4 weeks of PBT or CBT. Latency of postural responses to external perturbations, Timed-Up-and-Go (TUG), 10-meter-walk (10MW), Berg Balance Scale (BBS), and Activities-specific Balance Confidence Scale (ABC) were measured at baseline and post-training. Also, the proportion of fallers and fall rate were assessed at a 3-month follow-up.

RESULTS

The latency of postural responses significantly decreased in PBT compared to CBT. TUG, 10MW, BBS, and ABC, at post-training, and relative risk of falls and fall rate at 3-month follow-up had no statistically significant between-group differences.

CONCLUSIONS

The results show that PBT is at least as effective as CBT in improving balance and decreasing falls, while it has superiority over CBT whenever the clinicians mainly aim to improve reactive balance strategies. Future studies with a larger sample size are warranted to complement the results of this study.Implication for rehabilitationPerturbation-based Balance Training is at least as effective as conventional balance training (CBT) in improving proactive postural control in people with multiple sclerosis (PwMS).Perturbation-based Balance Training has superiority over CBT in improving reactive postural control in PwMS.Perturbation-based Balance Training has no superiority over CBT in improving fall-related outcomes.

Relationship between fear of falling and fall risk among older patients with stroke: a structural equation modeling

BACKGROUND

With reduced balance and mobility, older patients with stroke are more susceptible to fear of falling (FOF). A maladaptive form of FOF can cause excessive activity restriction, poor balance, and recurrent falls, forming a self-reinforcing vicious cycle. This study applied and adapted the FOF model to investigate the interaction between FOF and fall risk in older stroke patients.

METHODS

A cross-sectional study was conducted among 302 older stroke patients aged 60 and over. All participants were invited to complete the FOF, fall risk, physical activity, and balance tests, which were measured by the Falls Efficacy Scale International (FES-I), Self-Rated Fall Risk Questionnaire (FRQ), the long-form International Physical Activity Questionnaire (IPAQ-LF) and the Four-Stage Balance Test (FSBT) respectively. Data were analyzed using structural equation modeling.

RESULTS

The mean age of the respondents was 68.62 ± 7.62 years; 8.94% reported a high level of FOF, and 18.21% reported a moderate level of FOF. The structural equation model showed that FOF was directly associated with fall risk (β=-0.38, p < 0.001), and was indirectly associated with fall risk via physical activity (β=-0.075, p < 0.05) and balance ability (β=-0.123, p < 0.05). Depression (β=-0.47, p < 0.001), fall history (β=-0.13, p < 0.05), and female sex (β=-0.16, p < 0.05) affected FOF, while anxiety was not associated with FOF.

CONCLUSIONS

The increased risk of falling in older stroke patients results from a maladaptive FOF affected by depression, fall history, poor balance ability, and limited physical activity. Our results suggest that greater attention should be paid to FOF during stroke recovery and fall prevention. A multifaced intervention program encompassing physiological and psychological factors should be designed to address FOF and prevent falls.

A systematic review and meta-analysis of the measurement properties of concerns-about-falling instruments in older people and people at increased risk of falls

BACKGROUND

The 16-item Falls Efficacy Scale International (FES-I) is widely used to assess concerns-about-falling. Variants include 7-item Short FES-I, 30-item Iconographical Falls Efficacy Scale (Icon FES) and 10-item short Icon FES. No comprehensive systematic review and meta-analysis has been conducted to synthesise evidence regarding the measurement properties of these tools.

OBJECTIVES

To conduct a systematic review and meta-analysis of the measurement properties of four FES-I variants.

METHODS

MEDLINE, Embase, CINAHL Plus, PsycINFO and Web of Science were searched systematically and articles were assessed for eligibility independently. The methodological quality of eligible studies was assessed using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist. The quality of measurement properties was assessed using COSMIN criteria for good measurement properties. Where possible, meta-analysis was conducted; otherwise, narrative synthesis was performed. Overall certainty of evidence was rated using a modified Grading of Recommendations, Assessment, Development and Evaluation system approach.

RESULTS

The review included 58 studies investigating measurement properties of the four instruments. There was high-quality evidence to support internal consistency, reliability and construct validity of all instruments. Moderate- to high-certainty evidence suggests one-factor structure of FES-I with two underlying dimensions, one-factor structure of Short FES-I and two-factor structure of Icon FES. There was high-certainty evidence to support the responsiveness of FES-I, with further research needed for the other instruments.

CONCLUSION

There is evidence for excellent measurement properties of all four instruments. We recommend the use of these tools with healthy older people and people at a greater risk of falls due to conditions that might affect mobility and balance.

Studies in the Falls Efficacy Scale-International for patients with cervical compressive myelopathy: Reliability, validity, and minimum clinically important difference

CONTEXT

Patients with cervical compressive myelopathy (CCM) often complain of body balance problems, such as fear of falling and bodily unsteadiness. However, no accepted patient-reported outcome measures (PROMs) for this symptomatology exist. The Falls Efficacy Scale-International (FES-I) is one of the most widely used PROMs for evaluating impaired body balance in various clinical fields.

OBJECTIVE

To examine reliability, validity, and minimum clinically important difference (MCID) of the FES-I for the evaluation of impaired body balance in patients with CCM.

METHODS

Patients who underwent surgery for CCM were retrospectively reviewed. The FES-I was administered preoperatively and at 1 year postoperatively. Further, cJOA-LE score (subscore for lower extremities in the Japanese Orthopaedic Association score for cervical myelopathy) and stabilometric data, obtained at the same time points of the FES-I administration, were analyzed. Reliability was examined through internal consistency with Cronbach's alpha. Convergent validity was studied using correlation analysis. The MCID was estimated using anchor- and distribution-based methods.

RESULTS

Overall, 151 patients were included for analysis. Cronbach's alpha coefficient was the acceptable value of 0.97 at both baseline and 1 year postoperatively. As for convergent validity, the FES-I had significant correlations with the cJOA-LE score and stabilometric parameters both at baseline and 1 year postoperatively. The MCID calculated using anchor- and distribution-based methods was 5.5 and 10, respectively.

CONCLUSION

FES-I is a reliable and valid PROM to evaluate body balance problems for the CCM population. The established thresholds of MCID can help clinicians recognize the clinical significance of changes in patient status.

Balance ability and all-cause death in middle-aged and older adults: A prospective cohort study

Objective

The present study aimed to explore the relationship between balance ability and all-cause death in middle-aged and elderly people and to provide a basis for formulating a balanced training plan for middle-aged and older people in China.

Methods

Based on data from the China Health and Retirement Longitudinal Study (CHARLS) carried out in the years 2011, 2013, 2015, and 2018, 18,888 participants aged 45 years and above were included. Cox proportional hazard models were designed to evaluate the effect of balance ability on death events.

Results

The present study found that there was an association between balance ability and death among middle-aged and older people. Multivariate Cox proportional hazard regression model analysis showed that the risk of death decreased by 10% (HR = 0.90,95% CI: 0.85-0.95) for every second increase in balance ability. With balance ability <10 s as the reference group, the adjusted HRs were 0.61 (0.44-0.85) among middle-aged and elderly people. The death density of balance ability of <10 s was 73.87 per thousand person-years higher than that of ≥10 s. There was no interaction between balance ability and chronic disease, overweight, and obesity (P > 0.05).

Conclusion

The risk of all-cause death in middle-aged and older people increased with the decrease in balance ability and showed no statistical significance between chronic disease, overweight, and obesity, as corroborated by the present study.

Quantifying lower extremity inter-segmental coordination variability during walking in people with multiple sclerosis with high and low fear of falling

BACKGROUND

Fear of falling (FOF) is associated with gait disturbances in people with multiple sclerosis (PwMS). However, previous studies mostly assessed FOF-related changes in gait patterns of PwMS using spatio-temporal gait parameters. Considering the complex nature of gait control, investigation of the higher order properties of the human movement system, particularly inter-segmental coordination variability may provide valuable information about underlying deficits in motor control patterns in PwMS with different levels of FOF. Therefore, the purpose of this study was to clarify the differences in lower extremity inter-segmental coordination variability between healthy controls and PwMS with high and low FOF.

METHODS

This cross-sectional study examined gait patterns of 40 PwMS and 20 age-and-sex-matched healthy controls during treadmill walking at a preferred walking speed for 3 min. The falls efficacy scale-international questionnaire was used to stratify PwMS into high and low FOF subgroups. Variability in coordinative relationships between shank-thigh and foot-shank segments was determined using deviation phase (DP), which is the average standard deviation calculated from all points of the ensemble continuous relative phase (CRP) curve during the stance and swing phases of gait.

RESULTS

DP values for shank-thigh (p = 0.005 and p < 0.001, respectively) and foot-shank inter-segmental relationships (p < 0.001) during the stance phase as well as for foot-shank inter-segmental relationships during the swing phase (p = 0.03) were significantly greater in PwMS with high FOF compared to those with low FOF and healthy controls. In addition, both groups of PwMS with high and low FOF indicated greater shank-thigh DP values compared to healthy controls during the swing phase (p < 0.001 and p = 0.002, respectively).

CONCLUSION

The findings suggest unsteadiness in neuromuscular organization during walking in PwMS with high FOF. Rehabilitative interventions targeting impairments in lower extremity inter-segmental coordination and FOF may be useful to improve walking and reduce risk of falls in PwMS with high FOF.

The Chinese Short Version of the Activities-Specific Balance Confidence Scale: Its Validity, Reliability, and Predictive Value for Future Falls in Community-Dwelling Older Adults

Purpose

To examine the reliability and validity of the Chinese short version of the Activities-specific Balance Confidence scale (ABC-6), and its predictive value for prospective falls in community-dwelling older adults.

Patients and Methods

A total of 391 community older adults completed the prospective study. Internal consistency reliability, test-retest reliability, structural validity and discriminant validity were analyzed. To determine the accuracy of ABC-6 total score in predicting falls, a receiver operating characteristic curve analysis was performed, and comparisons with the Activities-specific Balance Confidence scale (ABC-16) and Berg Balance Scale (BBS) were made.

Results

Excellent internal consistency (Cronbach’s α = 0.938) and test-retest reliability (ICC=0.964, 95% CI: 0.947–0.977) were found for the ABC-6. Exploratory factor analysis suggested that ABC-6 had a one-factor structure (explained variance, 68.30%). The optimal cutoff value, sensitivity and specificity of ABC-6 to distinguish fallers from non-fallers was ≤ 60.00%, 70.83% and 84.26%, respectively, and there was no significant difference in the predictive value among the ABC-6, ABC-16, and BBS.

Conclusion

The Chinese version of the ABC-6 scale was a valid and reliable tool for measuring self-perceived balance confidence in community-dwelling older adults, and can be used as an effective assessment tool to predict future falls.

Effects of Virtual Reality vs Conventional Balance Training on Balance and Falls in People With Multiple Sclerosis: A Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of virtual reality (VR)-based vs conventional balance training on the improvement of balance and reduction of falls in people with multiple sclerosis (PwMS).

DESIGN

Single-blinded, randomized, controlled trial.

SETTING

Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences.

PARTICIPANTS

PwMS (N=39), randomized into VR (n=19) and control (n=20) groups.

INTERVENTION

The VR group performed exergames using Kinect, while the control group accomplished conventional balance exercises. Both groups received 18 training sessions for 6 weeks.

MAIN OUTCOME MEASURES

Limits of stability, timed Up and Go (TUG) test, and 10-m walk tests with and without cognitive task and their dual-task costs (DTCs), Berg Balance Scale, Multiple Sclerosis Walking Scale-12, Fall Efficacy Scale-International, Activities-specific Balance Confidence Scale, and fall history were obtained pre- and post intervention and after a 3-month follow-up.

RESULTS

At both post intervention and follow-up, TUG^cognitive and DTCs on the TUG were significantly lower and the 10-m walk^cognitive was significantly higher in the VR group. At follow-up, reaction time and the number of falls demonstrated significant differences favoring the VR group, whereas the directional control revealed significant difference in favor of the control group (P<.05). The other outcomes showed no statistically significant difference at post intervention or follow-up.

CONCLUSIONS

Both the VR-based and conventional balance exercises improved balance and mobility in PwMS, while each acted better in improving certain aspects. VR-based training was more efficacious in enhancing cognitive-motor function and reducing falls, whereas conventional exercises led to better directional control. Further studies are needed to confirm the effectiveness of recruiting VR-based exercises in clinical settings.

Fear of falling and falls in people with multiple sclerosis: A literature review

INTRODUCTION

Fear of falling (FOF) is a widespread problem affecting about 60% of people with multiple sclerosis (pwMS). Inflammatory lesions in the brain that are caused by the disease result in gait deficits and increase the risk of fall. Falls induce fear of falling and trigger a vicious circle, which in turn increases the likelihood of falling. Objective of this review was to provide an overview of existing research on the effects of FOF and therapy options in multiple sclerosis.

METHODS

A systematic search at Web of Science and PubMed was conducted. The search included the terms (fear of falling) OR (concern about falling) OR (fall anxiety) AND (multiple sclerosis).

RESULTS

In included studies, FOF was measured by different instruments. The Falls Efficacy Scale-International (FES-I) was the most frequently used instrument for pwMS. Patients with a higher FOF score fell more frequently, had lower walking speed, shorter stride length, larger ellipse sway area and a more severe disability. At present, therapeutic offers exist mainly in the field of physiotherapy. For reducing FOF, assisted vibration (d_z = 0.68), VR (d_z =0.87) and bicycle training (d_z = 1.23) were the most effective methods.

CONCLUSION

It is advisable to develop therapies that incorporate both physical and psychological aspects in neurorehabilitation, like in a cognitive behavioral therapy. Moreover, FOF monitoring should be integrated into the clinical routine.

Effectiveness of Physical Therapy Interventions in Reducing Fear of Falling Among Individuals With Neurologic Diseases: A Systematic Review and Meta-analysis

OBJECTIVE

To summarize the effectiveness of physical therapy interventions to reduce fear of falling (FOF) among individuals living with neurologic diseases.

DATA SOURCES

PubMed, Physiotherapy Evidence Database, Scopus, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health, and SportDiscuss were searched from inception until December 2019.

STUDY SELECTION

Clinical trials with either the primary or secondary aim to reduce FOF among adults with neurologic diseases were selected.

DATA EXTRACTION

Potential articles were screened for eligibility, and data were extracted by 2 independent researchers. Risk of bias was assessed by the Cochrane Risk of Bias tool for randomized controlled trials and the National Institutes of Health Quality Assessment Tool for pre-post studies. A meta-analysis was performed among trials presenting with similar clinical characteristics. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to rate the overall quality of evidence.

RESULTS

Sixty-one trials with 3954 participants were included in the review and 53 trials with 3524 participants in the meta-analysis. The included studies presented, in general, with a low to high risk of bias. A combination of gait and balance training was significantly more effective compared with gait training alone in reducing FOF among individuals with Parkinson disease (PD) (mean difference [MD]=11.80; 95% CI, 8.22-15.38; P<.001). Home-based exercise and leisure exercise demonstrated significant improvement in reducing FOF over usual care in multiple sclerosis (MS) (MD=15.27; 95% CI, 6.15-24.38; P=.001). No statistically significant between-groups differences were reported among individuals with stroke and spinal cord injury. The overall quality of evidence presented in this review ranges from very low to moderate according to the assessment with the GRADE approach.

CONCLUSIONS

Gait with lower limb training combined with balance training is effective in reducing FOF in individuals with PD. Also, home-based or leisure exercise is effective among individuals with MS. However, because of several limitations of the included studies, further research is needed to examine the effectiveness of FOF intervention among individuals with neurologic diseases.

Responsiveness and clinically meaningful changes for the Persian versions of the multiple sclerosis walking scale-12 and the modified fatigue impact scale following balance and gait rehabilitation in people with multiple sclerosis

Background and Purpose: The Multiple sclerosis walking scale-12 (MSWS-12) and the Modified Fatigue Impact Scale (MFIS) are two popular outcome measures applied widely for assessing self-perceived walking ability and fatigue in people with multiple sclerosis (PwMS). The present study aimed to examine responsiveness and clinically meaningful changes for the Persian versions of the MSWS-12 and the MFIS following balance and gait rehabilitation in PwMS.Methods: Fifty-eight PwMS completed the Persian versions of the MSWS-12 and the MFIS before and after 4 weeks of balance and gait rehabilitation. Also, a 7-point global rating scale as an external criterion of change was completed at the post-intervention evaluation. The area under the receiver operating characteristics curve (AUC) and the correlation analysis were used to assess the responsiveness. In addition, the minimally clinically important change (MCIC) was measured to determine clinically meaningful changes following rehabilitation.Results: The AUC values for the Persian MSWS-12 and MFIS were 0.74 and 0.73, respectively. There were good to excellent correlations between the global rating scale of change and the Persian MSWS-12 (Gamma = 0.77) also MFIS (Gamma = 0.80) change scores (p = .001). Moreover, the MCICs of 7.5 and 4 points were obtained for the Persian MSWS-12 and MFIS, respectively.Conclusion: The Persian versions of the MSWS-12 and the MFIS were responsive outcome measures for monitoring changes in walking and fatigue after balance and gait rehabilitation in PwMS. The calculation of MCIC values would enhance the interpretation of changes in clinical and research settings.