Movement System Diagnoses for Balance Dysfunction: Recommendations From the Academy of Neurologic Physical Therapy's Movement System Task Force

Movement System Diagnosis: A Consensus-Based Position for Pediatric Movement Specialists

PURPOSE

To offer a consensus for pediatrics clinicians, educators, and researchers on the use of movement system (MS) and review evidence that supports physical therapists (PTs) as movement experts.

SUMMARY OF KEY POINTS

This paper describes the MS and discusses how a MS diagnosis (Dx) can lead to most effective interventions and plans of care (POC) in pediatrics. Three cases illustrate using organized formulation of MS Dxs and how a MS Dx assists in choosing affective interventions for the POC.

CONCLUSIONS

Pediatric PTs are movement specialists designing individualized plans of care to meet functional goals in real world conditions. Using consistent terms to establish MS Dx will enable effective communication, and a foundation for interventions across the lifespan.

RECOMMENDATIONS

Adopting MS Dx framework will support and assist students of physical therapy, entry level and experienced clinicians, educators, and researchers with a critical decision-making process for formulating optimal family centered care.

Proactive modifications to walking stability under the threat of large, anterior or posterior perturbations

Biomechanically, falling after a walking perturbation may be influenced by: (1) the pre-perturbation state of mechanical stability (e.g., stability margins) and (2) the response to a perturbation (i.e., recovery skill). Walking stability margins must be modifiable to serve as a target for fall-prevention interventions. We investigated if neurotypical adults could proactively modulate pre-perturbation anteroposterior stability margins while walking. Eleven adults walked on a treadmill at three speeds with and without anterior and posterior perturbations. We measured stability margins anteriorly at mid-swing and posteriorly at foot strike for pre-perturbation steps. A repeated-measures factorial ANOVA evaluated main effects and interactions of walking speed (0.6, 0.8, 1.0 stats/s) and perturbation type (anterior, none, posterior). With posterior perturbation threats, the posterior stability margins were more positive at foot strike (p < 0.01) compared to trials without perturbations. With anterior perturbation threats, the anterior stability margins were not different at mid-swing compared to trials without perturbations (p > 0.05). With any perturbation threat, step lengths shortened (p < 0.01) and step rates increased (p < 0.01). Step width was not different (p > 0.11). At slow speeds with posterior perturbation threats, double-support time decreased (p = 0.04). Proactive modifications to stability margins are indeed possible in a neurotypical population. Consequently, anteroposterior stability margins may be a feasible target for fall-prevention interventions by targeting decreased step lengths or increased step rates within a given walking speed. We do not know the extent to which the observed effects have a meaningful effect on perturbation recovery.

Physical Therapy Management of Fall Risk in Community-Dwelling Older Adults: An Evidence-Based Clinical Practice Guideline From the American Physical Therapy Association - Geriatrics

APTA-Geriatrics, an Academy of the American Physical Therapy Association, appointed a guideline development group (GDG) to develop a clinical practice guideline (CPG) synthesizing the evidence for physical therapy management of fall risk in community-dwelling older adults. The GDG consisted of five physical therapists with clinical expertise in the management of fall risk in older adults and methodological expertise in evidence-based document development. The CPG includes a systematic review of existing literature, and stringent methodology developed by the American Physical Therapy Association to form the evidence-based recommendations. The CPG content, including methodology, recommendations and algorithm were externally reviewed by clinical providers and academicians with expertise in fall risk management for older adults. These recommendations are intended to assist physical therapists and physical therapist assistants who are engaged in fall risk management for community-dwelling older adults.

The Movement System and Diagnosis: Are We There Yet?

In the 29th Maley lecture, Phil McClure PT, PhD, FAPTA, shares a Perspective regarding the movement system and diagnosis. Despite declarations from the House of Delegates >10 years ago, the concept of a movement system has not been widely embraced in either education or practice. In this perspective, he offers critical analysis and 3 proposals that could potentially make the concept of a movement system more relevant and meaningful. The first is to operationally define the movement system, arguing that the current definition is too vague and not operational, and therefore not meaningful. The second is to intentionally separate the movement system from any specific diagnostic classification scheme which would allow the focus to remain on movement and movement analysis. He argues that diagnostic classification schemes require a biopsychosocial framework and that movement, while important, cannot be the only consideration. The third proposal is that diagnostic schemes must be developed by clinical scientists through appropriate research guided by sound theory, not by administrative or political process. He further argues that a greater focus on determining which patients are likely to be helped by physical therapists is necessary and offered the example of developing "appropriateness criteria" as a tool toward promoting value-based care. Achieving broad consensus around these proposals could unify our professional focus and assist toward the vision of optimizing movement to enhance the human experience.

European Portuguese version of the Mini-BESTest: a cross-cultural adaptation and psychometric measurements in individuals with sensorimotor impairments

PURPOSE

This study aimed to translate and cross-culturally adapt the Mini-BESTest into European Portuguese and to evaluate its psychometric properties in individuals with sensorimotor impairments.

MATERIAL AND METHODS

A cross-sectional cross-cultural adaptation and validation study was conducted according to the COSMIN guidelines and the STROBE statement. The study included 100 participants with sensorimotor impairments who were able to walk 6 m. Cronbach's alpha and item-total correlations were used to assess internal consistency. Interpretability was assessed by examining floor and ceiling effects and skewness. To investigate construct validity, Spearman correlation coefficients and Bland-Altman analysis were performed to compare the Berg Balance Scale and the Mini-BESTest Inter- and intra-rater reliability were assessed by calculating the ICC, SEM and MDC based on video recordings of the participants during the Mini-BESTest assessments.

RESULTS

The European Portuguese Mini-BESTest showed good internal consistency (Cronbach's α = 0.892) and no significant floor or ceiling effects. Excellent inter- and intra-rater reliability (ICC = 0.97) were also demonstrated, with MDC of 2.58 and 2.57, respectively. Furthermore, this instrument showed a significant correlation with the BBS (r = 0.902). Bland-Altman analysis showed small absolute differences.

CONCLUSION

The European Portuguese Mini-BESTest is comparable to the original English version in terms of validity and reliability and is therefore highly recommended for use by Portuguese-speaking professionals to assess postural control.

How should the margin of stability during walking be expressed to account for body size?

When expressing the margin of stability as a distance, it does not directly estimate the perturbation magnitude needed to change stability states. Additionally, it is unknown how body size may influence this measure. Therefore, we propose other expressions of stability margins, including that of an impulse, a change in center of mass velocity, and a scaled, unitless impulse. The purpose of this study was to determine the influence of body size on these margin expressions using walking data from children and adults. We anticipated that margins expressed as an impulse would have strong correlations with body mass and height, as well as large between-group differences. We predicted that scaling this impulse value would result in small correlations and between-group effect sizes. We calculated each stability margin at minimum lateral values and in the anteroposterior directions at mid-swing and foot strike. In the lateral direction, margins expressed as an impulse had strong correlations with body size (r≥0.58, p<0.01) and large between-group differences (|d|≥1.07, p<0.01). The other expressions did not have strong positive correlations (|r|≤0.20) or large between-group effects (|d|≤0.44). In the anteroposterior directions, impulse margins had strong correlations with body size (|r|≥0.83, p<0.01) and large between-group differences (|d|≥1.74, p<0.01). The scaled, unitless impulse margin was the only variable that resulted in small, non-significant differences (|r|≤0.22, p≥0.24) as well as small between-group effect sizes (|d|≤0.46, p≥0.22). We propose expressing stability margins as an impulse. If scaling is needed, we encourage using the scaled, unitless impulse.

Exploring the Nexus of lower extremity proprioception and postural stability in older adults with osteoporosis: a cross-sectional investigation

Background

Osteoporosis, characterized by reduced bone mass and micro-architectural deterioration, poses a significant public health concern due to increased fracture susceptibility. Beyond bone health, this cross-sectional study aimed to assess and compare lower extremity proprioception and postural stability in individuals with and without osteoporosis and to explore their correlation within the osteoporosis group.

Method

In this prospective cross-sectional study, 80 participants were divided into two groups: osteoporosis (n = 40) and control (n = 40). The demographic characteristics and clinical parameters of the participants were as follows: Age (years) - Osteoporosis group: 65.04 ± 4.33, Control group: 65.24 ± 4.63; Sex (%) - Osteoporosis group: Male 30%, Female 70%; Control group: Male 30%, Female 70%; Body mass index (kg/m2) - Osteoporosis group: 23.7 ± 3.2, Control group: 24.5 ± 4.6; T-score (Lumbar) - Osteoporosis group: -2.86 ± 1.23, Control group: 0.27 ± 0.58; T-score (hip) - Osteoporosis group: -2.28 ± 0.79, Control group: 0.68 ± 0.86. Joint Position Sense (JPS) at the hip, knee, and ankle was assessed using a digital inclinometer, and postural stability was measured using computerized force platforms.

Result

Osteoporosis participants exhibited higher errors in hip (5.63° vs. 2.36°), knee (4.86° vs. 1.98°), and ankle (4.46° vs. 2.02°) JPS compared to controls. Postural stability measures showed increased anterior-posterior sway (10.86 mm vs. 3.98 mm), medial-lateral sway (8.67 mm vs. 2.89 mm), and ellipse area (966.88 mm2 vs. 446.19 mm2) in osteoporosis participants. Furthermore, correlation analyses within the osteoporosis group unveiled significant positive associations between lower extremity proprioception and postural stability. Specifically, hip JPS exhibited a strong positive correlation with anterior-posterior sway (r = 0.493, p = 0.003), medial-lateral sway (r = 0.485, p = 0.003), and ellipse area (r = 0.496, p < 0.001). Knee JPS displayed a moderate positive correlation with anterior-posterior sway (r = 0.397, p = 0.012), medial-lateral sway (r = 0.337, p = 0.032), and ellipse area (r = 0.378, p < 0.001). Similarly, ankle JPS showed a moderate positive correlation with anterior-posterior sway (r = 0.373, p = 0.023), medial-lateral sway (r = 0.308, p = 0.045), and ellipse area (r = 0.368, p = 0.021).

Conclusion

These findings underscore the interplay between proprioceptive deficits, compromised postural stability, and osteoporosis, emphasizing the need for targeted interventions to improve fall prevention strategies and enhance the quality of life for individuals with osteoporosis.

A proposal for a universal physical therapy diagnostic concept

BACKGROUND

In Canada, as in other countries, the physical therapist (PT) must make a diagnosis to comply with direct access responsibilities. This means making a diagnosis is an entry-to-practice essential competency. However, there is no consensus across physical therapy practice domains and contexts regarding the diagnostic concept, i.e., the classification system, labelling and diagnostic format that should be used.

OBJECTIVE

To propose a universal diagnostic concept, one a PT could use regardless of their practice domain or context.

METHODS

The relevant scientific and grey literature (1986-2022) were searched and key information was synthesized.

RESULTS

Information from 194 retained documents (8506 identified) was synthesized to a list of seven essential criteria that were then used to develop a universal physical therapy diagnostic concept (PT-Dx-C). The PT-Dx-C format consists of three labels in the following order: (1) health problem, (2) primary impairment, and (3) primary activity limitation or participation restriction. Label definitions are those used by the World Health Organization. The specific health problem, impairment, and limitation or restriction making up the diagnosis are determined for each patient using valid tests and measures.

CONCLUSIONS

The PT-Dx-C is consistent with best practices and could be applied to all patients, in all PT practice domains and contexts. It reflects the PT's expertise in the human movement system and their unique contribution to health care. Furthermore, its use may allow for communication of the PT's conclusions in a manner that can be understood by others thereby facilitating collaborative practice.

Effects of exergaming on cognition, lower limb functional coordination, and stepping time in people with multiple sclerosis: a randomized controlled trial

PURPOSE

To compare the effects of exergaming versus conventional exercises on cognition, lower-limb functional coordination, and stepping time in people with multiple sclerosis (PwMS).

METHODS

Thirty-six PwMS were randomly assigned to either intervention (n = 18) or control (n = 18) group and received 18 training sessions during six weeks. The intervention group performed exergames that required multidirectional timed-stepping, weight-shifting, and walking while the control group performed conventional matched exercises. Trail making test (TMT part A, B; TMT-A, TMT-B, TMT B-A), six-spot step test (SSST), and choice stepping reaction time (CSRT-including reaction time (RT), movement time (MVT), and total response time (TRT)) were assessed pre- and post-intervention (short-term), and after three-month follow-up (mid-term).

RESULTS

The intervention group showed faster TMT-B (p = 0.003) and TMT B-A (p = 0.002) at post-intervention and faster SSST at both post-intervention (p = 0.002) and follow-up (p = 0.04). The CSRT components showed no between-group differences at post-intervention; however, at follow-up, the intervention group had lower TRT (p = 0.046) and MVT (p = 0.015). TMT-A and RT had no significant between-group differences.

CONCLUSIONS

In short-term, exergames led to more improvements in complex attention, executive function, and lower-limb functional coordination comparing to the matched conventional exercises. In mid-term, exergaming was more effective for improving stepping time and lower-limb functional coordination. However, the two approaches did not show any superiority over each other for improving simple attention and RT.Implications for rehabilitationWhen designed properly, exergames have great potential to improve attention and executive function of people with multiple sclerosis (PwMS), at least in the short-term.Exergames seem like an appropriate option for improving lower limb coordination and decreasing choice stepping response time among PwMS in the mid-term.Exergames do not have superiority in improving the choice stepping reaction time compared to their matched conventional treatment.

Functional Improvement and Satisfaction with a Wearable Hip Exoskeleton in Community-Living Adults

Demand for wearable devices and supportive technology is growing as these devices have the potential to enhance physical function and quality of life in users. The purpose of this study was to investigate usability and satisfaction after performing functional and gait exercise with a wearable hip exoskeleton in community-living adults. A total of 225 adults residing in the local community participated in this study. All participants performed 40 min of exercise once with a wearable hip exoskeleton in various environments. The EX1, which functions as a wearable hip exoskeleton, was used. Physical function was assessed before and after exercise with the EX1. After completing exercise with the EX1, the usability and satisfaction questionnaires were evaluated. Gait speed, timed up and go test (TUG), and four square step test (FSST) showed statistically significant improvements after exercise with the EX1 in both groups (p < 0.05). In the 6 min walking test (6MWT), a significant increase was observed in the middle-aged group (p < 0.05). In the short physical performance battery (SPPB), there was a significant improvement in the old-aged group (p < 0.05). On the other hand, positive results in usability and satisfaction were noticed in both groups. These results demonstrate that a single session of exercise with the EX1 was effective in improving physical performance of both middle- and old-aged adults, with positive feedback from most of the participants.