Davide Cattaneo

Reliability of four scales on balance disorders in persons with multiple sclerosis

Purpose. Balance rehabilitation is an important component of the retraining program in people with multiple sclerosis (MS). Measuring balance is fundamental for an accurate assessment and therapy selection. The aim of this study was to compare interrater and test-retest reliability of the Berg Balance Scale, the Dynamic Gait Index, the Dizziness Handicap Inventory and the Activities-specific Balance Confidence. Method. A group of 25 persons were enrolled in the study. The group consisted of 8 males and 17 females, mean age 41.7 years (12.5 years, SD). The onset of pathology was 8.7 years (8.8 years SD) before the beginning of the study. To assess the test-retest reliability two consecutive assessments were collected by the same rater. To assess the inter-rater reliability persons were concurrently assessed by two raters. Results. The Intraclass Correlation Coefficients (ICCs) for interrater reliability ranged between 0.94 and 0.96. The ICCs for test-retest reliability ranged between 0.85 and 0.96. Conclusion. The inter-rater reliability of the instruments proved to be satisfactory. Lower but acceptable results were obtained for the test-retest paradigm. The data obtained in this study suggest that these scales are reliable tools for assessing balance function in persons suffering from MS.

Sensory impairments in quiet standing in subjects with multiple sclerosis.

Balance disorders and falls are frequently observed in subjects with multiple sclerosis (MS). Along with motor impairment, sensory disorders and integration deficits of sensory inputs lead to inadequate motor responses. The assessment of these sensory disorders in an every day tasks, such as upright stance, increases our knowledge of postural control in this pathology, thus promoting more effective treatments. The aim of the study was to describe sensory impairments and sensory strategies in different sensory conditions. A stabilometric assessment was carried out in a consecutive convenience sample of 53 subjects. The age of the sample was 52.7 (21.1) years; the onset of pathology was 27.20 (14.5) years before the assessment. Balance was assessed in six sensory conditions. The impact of pathology on balance control was shown by the high percentage of abnormal scores: 75% of subjects with MS showed abnormal scores even in the eyes open condition. The alteration of a single sensory input led to an increase of abnormal scores in up to 82% of subjects. Almost all subjects showed abnormal scores in the vestibular conditions where 22% of them fell. The pattern of the subjects’ performance in the six sensory conditions suggests that balance control may be more correlated to the number of reliable sensory inputs than the nature of the sensory input itself.

A systematic review of factors associated with accidental falls in people with multiple sclerosis: a meta-analytic approach:

Objective: To determine whether there are demographic, clinical, and instrumental variables useful to detect fall status of patients with multiple sclerosis. Data sources: PubMed and the Cochrane Library. Review methods: Eligible studies were identified by two independent investigators. Only studies having a clear distinction between fallers and non-fallers were included and meta-analysed. Odds ratios (ORs) and standard mean differences (SMDs) were calculated and pooled using fixed effect models. Results: Among 115 screened articles, 15 fulfilled criteria for meta-analyses, with a total of 2425 patients included. Proportion of fallers may vary from 30% to 63% in a time frame from 1 to 12 months. No significant publication bias was found, even though 12/15 studies relied on retrospective reports of falls, thus introducing recall biases. Risk factors for falls varied across studies, owing to heterogeneity of populations included and clinical instruments used. The meta-analytic approach found that, compared with non-fallers, fallers had longer disease duration (SMD = 0.14, p = 0.02), progressive course of disease (OR = 2.02, p < 0.0001), assistive device for walking (OR = 3.16, p < 0.0001), greater overall disability level (SMD = 0.74, p < 0.0001), slower walking speed (SMD = 0.45, p = 0.0005), and worse performances in balance tests (Berg Balance Scale: SMD = −0.48, p = 0.002; Timed up-and-go test, SMD = 0.31, p = 0.04), and force-platform measures (postural sway) with eyes opened (SMD = 0.71, p = 0.006) and closed (SMD = 0.83, p = 0.01), respectively. Conclusion: Elucidations regarding risk factors for accidental falls in patients with multiple sclerosis (PwMs) are provided here, with worse disability score, progressive course, use of walking aid, and poorer performances in static and dynamic balance tests strongly associated with fall status.

Effect of kinesio taping on standing balance in subjects with multiple sclerosis: A pilot study\m{1}

OBJECTIVE The aim of this study was to assess the effect of Kinesio Taping on body stability in subjects with MS. STUDY DESIGN Non controlled intervention study in a Rehabilitation Unit. INTERVENTION A consecutive convenience sample of 15 individuals with multiple sclerosis was assessed. Kinesio Tex Tape was applied directly to the skin of both calves and kept for the next two days. MAIN OUTCOME MEASURES Clinical and stabilometric assessments were performed at baseline, immediately after application of the tape and the day after its removal. To control for learning effect 10 subject with multiple sclerosis were tested repeatedly under the same conditions without tape. RESULTS No statistically or clinically relevant differences were observed among conditions in the mediolateral plane. In the AP plane Friedmans ANOVA showed statistically significant differences between baseline and taping condition with respect to length of sway. A trend towards statistically relevant differences were found also with respect to mean sway and velocity of sway. No learning effect was found for repeated testing within the no treated group. CONCLUSIONS These preliminary results suggest that the use of ankle taping may be useful in immediately stabilising body posture.

Robot-based rehabilitation of the upper limbs in multiple sclerosis: feasibility and preliminary results.

OBJECTIVE To make a preliminary evaluation of the feasibility of a robot-based rehabilitation protocol for the improvement of upper limb motor co-ordination in a group of patients with multiple sclerosis. PATIENTS AND METHODS Seven patients with multiple sclerosis underwent a training protocol of 8 sessions. During each session patients performed reaching movements toward virtual targets presented on a screen, by moving the handle of a robot, which generated resistive and disturbing forces. Each subject was evaluated before and after the treatment by means of clinical and instrumental tests. RESULTS After the 8-session treatment, all patients significantly improved the velocity, linearity and smoothness of their reaching movements. Moreover, this amelioration was also present in other kinds of movement, not executed during the sessions. Results on the Nine-Hole Peg Test showed a clinically relevant improvement in the treated arm of 4 out of 7 patients, suggesting also a transfer of the therapy effect to tasks more related to activities of daily living. CONCLUSION The preliminary results of this pilot study suggest that robot therapy can be applied to patients with multiple sclerosis in a clinical setting and may be beneficial for reduction of the upper limb motor co-ordination deficit.

Quantitative assessment of upper limb motor function in Multiple Sclerosis using an instrumented Action Research Arm Test.

BackgroundArm impairment in Multiple Sclerosis (MS) is commonly assessed with clinical scales, such as Action Research Arm Test (ARAT) which evaluates the ability to handle and transport smaller and larger objects. ARAT provides a complete upper limb assessment, as it considers both proximal arm and hand, but suffers from subjectivity and poor sensitivity to mild impairment. In this study an instrumented ARAT is proposed to overcome these limitations and supplement the assessment of arm function in MS.MethodsARAT was executed by 12 healthy volunteers and 21 MS subjects wearing a single inertial sensor on the wrist. Accelerometers and gyroscopes signals were used to calculate the duration of each task and its sub-phases (reaching, manipulation, transport, release and return). A jerk index was computed to quantify movement smoothness. For each parameter, z-scores were calculated to analyze the deviation from normative data. MS subjects were clinically assessed with ARAT score, Nine-Hole Peg test (9HPT) and Fahn Tremor Rating Scale (FTRS).ResultsARAT tasks executed by MS patients were significantly slower (duration increase: 70%) and less smooth (jerk increase: 16%) with respect to controls. These anomalies were mainly related to manipulation, transport and release sub-movements, with the former showing the greatest alterations. A statistically significant decrease in movement velocity and smoothness was also noticed in patients with normal ARAT score. Z-scores related to duration and jerk were strongly correlated with ARAT rating (r < -0.80, p < 0.001) and 9HPT (r < -0.75, p < 0.001) and were significantly different among MS sub-groups with different levels of arm impairments (p < 0.001). Moreover, Z-score related to manipulation-phase jerk was significantly correlated with the FTRS rating of intention tremor (r = 0.84, p < 0.001).ConclusionsThe present study showed that the proposed method is able to discriminate between control and MS groups and to reveal subtle arm alterations not detectable from ARAT score. Validity was shown by high correlations between instrumental variables and clinical ratings. These results suggested that instrumented ARAT could be a valid quick and easy-to-use method for a sensitive quantification of arm function in MS. Inclusion of finger-mounted sensors could complement present findings and provide further indications about hand function in MS.

Unilateral and bilateral upper limb dysfunction at body functions, activity and participation levels in people with multiple sclerosis.

Background: There has been limited research on upper limb dysfunction in people with multiple sclerosis (PwMS). Objective: The objective of this paper is to study unilateral and bilateral upper limb dysfunction at different International Classification of Functioning (ICF) levels according to overall disability in PwMS. Methods: A total of 105 PwMS (16 with EDSS<4 (mild); 17 with EDSS 4–5.5 (moderate); 37 with EDSS 6–6.5 (severe); 35 with EDSS>6.5 (severe non-ambulant)) were recruited from two rehabilitation centers and assessed in a cross-sectional study. Results: The whole sample showed a diminished sensory function (median (first/third interquartile)) score of 3 (2/3) on the Monofilament Test and a reduced strength 91 (76/100) points on the Motricity Index (Body-Function level). Sensory dysfunction did not increase with higher EDSS while strength decreased from 100 (86/100) in the mild subgroups to 91 (80/100) points in the severe subgroup. All showed diminished dexterity, scoring 0.28 peg/s (0.17/0.35) on the Nine-Hole Peg Test (NHPT) (activity level). Score was better for the mild (0.38 (0.35/0.46)) peg/s compared to the severe subgroup (0.28 (0.17/0.35)). Sixty-eight percent, 44% and 75% of PwMS showed bilateral disorders in sensation, strength and dexterity, respectively. The Community Integration Questionnaire (participation level) showed a 35% reduction in home activities, even among PwMS with EDSS<4. Conclusion: This study showed uni-/bilateral upper limb abnormalities at all ICF levels increasing with the overall disability.

Concepts of Motor Learning Applied to a Rehabilitation Protocol Using Biofeedback to Improve Gait in a Chronic Stroke Patient: An A-B System Study With Multiple Gait Analyses

Objective. The impact of electromyographic biofeedback (EMG BFB) applied during functional gait activities and employed in accord with theories on motor learning was investigated in a chronic hemiplegic patient. Methods. A single-subject A-B design was used. EMG BFB was applied to the triceps surae during gait. A rehabilitation program with a fading frequency of BFB application and an increasing variability in the task training was implemented. Responses to the rehabilitation program were documented via multiple quantitative gait analyses, performed during a baseline, treatment, and at follow-up 6 weeks after the end of treatment. Results.From baseline to end of treatment, there were significant changes in ankle power at push-off, both in amplitude and timing, as well as onset of ankle power at push-off relative to heel strike of the healthy leg. There was a significant increase in gait velocity, step length of the healthy side, stride length, and stride frequency. At follow-up, changes were still significantly different from baseline and the patient had reduced the use of the cane in activities of daily living. Conclusions. BFB appears to have been effective in promoting positive changes in gait in this pilot study. The rehabilitation protocol also appeared to be effective in promoting learning and the incorporation of trained activities into daily activities.

Emerging evidence-based physical rehabilitation for Multiple Sclerosis - Towards an inventory of current content across Europe

In Europe, theoretical approaches to physical therapy and rehabilitation in multiple sclerosis often appear significantly different. While there is general agreement that rehabilitation plays an important role in maintaining and improving function in persons with multiple sclerosis, no consensus exists on what may be the most effective approach to achieve the best possible functionality within an individuals limitations.The objective of this paper is to initiate an analysis of currently applied physical interventions for people with multiple sclerosis throughout Europe during inpatient or outpatient rehabilitation programs. A study of the content of rehabilitation may show presently performed treatment methods revealing the basic considerations that nowadays guide clinicians implicitly or explicitly in the treatment of persons with multiple sclerosis. Following this first step, comparative studies can be set up.

The virtual time to contact in the evaluation of balance disorders and prediction of falls in people with multiple sclerosis

Purpose: The purpose of the study was to compute Virtual Time to Contact (VTC) from stabilometric assessment to study balance impairments in people with multiple sclerosis (PwMS). To this purpose we assessed the ability of VTC to discriminate between balance skills of PwMS and healthy subjects (HS), among sensory conditions and between fallers and non fallers. Methods: VTC was calculated to characterize balance performance in 47 PwMS and 13 HS in four different sensory conditions during quiet standing. Main Outcome Measures were VTC, Number of falls, Berg Balance Scale and Dynamic Gait Index. Results: The results showed that VTC was able to discriminate between PwMS and HS (p < 0.0001) and between challenging sensory conditions (p < 0.0001), no relevant information was added by VTC in the detection of subjects prone to falls. Conclusion: VTC provides unique information with respect to balance control because it takes into account the relationship between centre of mass (CoM) and the borders of base of support (BoS). VTC proved to be a valid descriptor of balance performance in PwMS highlighting balance disorders in this population of subjects, however models for falls prediction have to be improved. Implications for Rehabilitation Given the high prevalence of balance disorders in MS balance control and fall frequency should be routinely assessed. VTC appears to be useful in assessing upright balance in different sensory conditions. The adjunction of stabilometric evaluation did not improve ability of clinical scales to detect subjects prone to fall.