Stanley John Winser

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.

Balance outcome measures in cerebellar ataxia: a Delphi survey

Abstract Purpose: Choosing an appropriate outcome measure for the assessment of balance among people with cerebellar ataxia is currently challenging as no guidelines are available. There is a need for further investigation with clinical experts in order to derive a set of standardized outcome measures with high clinical utility. Methods: A two-round internet-based Delphi survey was considered. A steering committee was formed to guide the Delphi process. Neurologists and physiotherapists with clinical and research experience in cerebellar ataxia were identified as the expert group. Consensus among the experts for recommendation was set at 75%. Results: Thirty experts representing 10 countries agreed to participate. The response rate for the rounds were 87% and 96%, respectively. Forty-one relevant outcome measures were identified. The Berg Balance Scale (BBS), the Scale for the assessment and rating of ataxia (SARA), the Timed Up and Go test (TUG) were identified as the best outcome measures for use with at least 75% consensus among the experts. Conclusion: The recommended outcome measures (SARA, BBS and TUG) are available at no cost, require little equipment and are quick and easy to perform; however, formal psychometric testing of the BBS and TUG in people with cerebellar ataxia is warranted. Implications for Rehabilitation Currently, a wide range of outcome measures are available for the assessment of balance is people with cerebellar ataxia. Expert participants in this study identified the BBS, SARA and TUG as highly recommended for the assessment of balance. Formal psychometric property validation in people with cerebellar ataxia is required for the BBS and TUG.

Psychometric Properties of a Core Set of Measures of Balance for People With Cerebellar Ataxia Secondary to Multiple Sclerosis.

OBJECTIVE To examine the reliability, validity, and interpretability of 4 clinical measures in assessing the severity of balance dysfunction among people with cerebellar ataxia (CA) secondary to multiple sclerosis (MS). DESIGN Cross-sectional observation study. SETTING Outpatient clinics. PARTICIPANTS Consecutive participants with CA secondary to MS (N=60). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Balance was assessed and video recorded using the Berg Balance Scale (BBS), timed Up and Go (TUG) test, posture and gait subcomponent of the International Co-operative Ataxia Rating Scale (ICARS), and gait, stance, and sit subcomponents of the Scale for the Assessment and Rating of Ataxia (SARA). The videos were later used to estimate reliability. The Barthel Index, Expanded Disability Status Scale (EDSS), ICARS, and SARA were assessed, and disease duration was recorded. RESULTS Reliability was good for all 4 measures (intraclass correlation coefficient range, .95-.99). Internal consistency was moderate to good for all 4 measures (α range, .72-.94), with a moderate to good correlation between the measures of balance (Spearman ρ range, .72-.85) and poor to moderate correlation with disease severity (EDSS), functional independence (Barthel Index), and disease duration (Spearman ρ range, -.37 to .76). Minimal detectable change was derived for the BBS (3), posture and gait subcomponent of the ICARS (2), and gait, stance, and sit subcomponents of the SARA (2). Measures were able to discriminate between assistive walking device users and nonusers. CONCLUSIONS All 4 measures showed good reliability and acceptable validity; however, because of the item repetition in scoring of the posture and gait subcomponent of the ICARS and moderate construct, criterion, and convergent validity of the TUG, the BBS and gait, stance, and sit subcomponents of the SARA are recommended for balance assessment in clinical practice for people with CA secondary to MS.

Outcome measures in randomized controlled trials of neuropathic pain conditions: a systematic review of systematic reviews and recommendations for practice

Objectives:Neuropathic pain (NeP) is a prevalent, disabling, multidimensional condition with significant morbidity; however, there appears to be a variable approach in the use of outcome measures in NeP trials. A search of systematic reviews of interventional randomized-controlled trials for NeP was undertaken to investigate the range and types of outcome measures used to determine treatment effects. Methods:Keywords and MESH searches were conducted in 5 electronic databases from inception to January 31, 2012. Full-text English-language reviews based on various acute and chronic NeP conditions were included. Two independent reviewers screened papers for inclusion, extracted data, and assessed the quality of reviews. Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to critically appraise the reviews. Results:A total of 46 studies were identified: the majority of reviews (n=28/46, 61%) scored well on the PRISMA (PRISMA scores of 20-27/27). Change in levels or intensity of pain were used by the majority of studies as the primary outcome measure in intervention studies (n=40/46 studies, 87%). Few studies used a functional outcome measure as either a primary or secondary outcome measure (n=7/46, 15% of studies). Discussion:These results demonstrate that measures of pain are predominantly used in trials of NeP conditions and highlight the scant usage of functional outcome measures. The lack of standardization for the diagnostic criteria in NeP trials is also an issue that needs to be considered for future research and guideline development.

Patient engagement and clinical feasibility of Augmented Reflection Technology for stroke rehabilitation

Abstract This paper evaluates the patient engagement and clinical feasibility of an Augmented Reflection Technology (ART) system for use in physical rehabilitation of the upper limb following stroke. In particular, TheraMem, an extension of the ART system, was assessed on its potential to engage patients in meaningful therapeutic exercise. Six patients participated in a total of 24 sessions of upper limb training using the system. Tailored support for patients performing the exercises was provided based on the severity and level of their impairment. Various configurations of the system were evaluated and adjusted to best match the therapeutic requirements and the patient’s preferences. All patients were able to successfully participate and complete the TheraMem intervention at a high level of engagement and motivation over the course of the therapy sessions.

Outcome measures for the assessment of balance and posture control in cerebellar ataxia

Abstract Background: Discrepancies exist in the use of outcome measures for the assessment of balance and postural control among people with cerebellar ataxia. There is a need to explore the spectrum of tools used in order to determine their utility. Objectives: The aims of this narrative review were to identify, categorize, and discuss outcome measures used for the evaluation of balance and postural control in cerebellar assessment and intervention, and to identify outcome measures which might relate to the localization of cerebellar lesion. Major findings: Electronic search of the evaluation of cerebellar interventions and identification or illustration of clinical features of problems relating to balance and postural control identified 45 outcome measures. Using the international classification of functioning, the outcome measures were categorized as: health condition-specific (n = 7), body structure and function level (n = 13), activity level (n = 25), and none at a participatory level. Accessibility, time required to perform, and psychometric property testing determined the utility of outcome measures. Frequency and amplitude of postural sway, and measures obtained from force plate testing were used to localize the cerebellar lesion. Conclusion: A wide range of outcome measures were used to assess balance and postural control deficits; none of the clinical tools appeared to localize cerebellar lesion. Health condition-specific outcome measures were used for cerebellar intervention trials and psychometric properties of outcome measures at an activity level were not tested among pure cerebellar lesions. Further investigation is warranted to streamline the utility and selection of outcome measures for clinical practice.

Ankle positions potentially facilitating greater maximal contraction of pelvic floor muscles : a systematic review and meta-analysis

Abstract Objectives: To evaluate the effect of ankle positions on pelvic floor muscles in women. Methods: Multiple databases were searched from inception-July 2017. Study quality was rated using the grading of recommendations, assessment, development, and evaluation system and the “threats to validity tool”. Results: Four studies were eligible for inclusion. Meta-analysis revealed significantly greater resting activity of pelvic floor muscles in neutral ankle position (−1.36 (95% CI −2.30, −0.42) p =  0.004) and induced 15° dorsiflexion (−1.65 (95% CI −2.49, −0.81) p =  0.0001) compared to induced 15° plantar flexion. Significantly greater maximal voluntary contraction of pelvic floor was found in dorsiflexion compared to plantar flexion (−2.28 (95% CI −3.96, −0.60) p =  0.008). Meta-analyses revealed no significant differences between the neutral ankle position and 15° dorsiflexion for either resting activity (0.30 (95% CI −0.75, 1.35) p =  0.57) or maximal voluntary contraction (0.97 (95% CI −0.77, 2.72) p =  0.27). Conclusion: Pelvic floor muscle-training for women with urinary incontinence could be performed in standing with ankles in a neutral position or dorsiflexion to facilitate greater maximal pelvic floor muscle contraction. As urethral support requires resting contraction of pelvic floor muscles, decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with urinary incontinence might potentially experience more leakage during exertion in a standing position. Implications for rehabilitation Pooled analyses revealed that maximal voluntary contraction of pelvic floor muscle is greater in induced ankle dorsiflexion than induced plantar flexion. As pelvic floor muscle strengthening involves achieving a greater maximal voluntary contraction, pelvic floor muscle training for women with stress urinary incontinence could be performed in standing either with ankles in a neutral position or dorsiflexion. Decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with stress urinary incontinence might potentially experience more leakage during exertion in a standing position. Women with stress urinary incontinence should be advised to wear flat shoes instead of high-heels and should be cautioned about body posture and ankle positions assumed during exercise and daily activities.

COSMIN for quality rating systematic reviews on psychometric properties

Abstract This commentary reports on the application and our views on the advantages, disadvantages and recommendations on the use of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN), a quality rating tool for systematic reviews on psychometric properties.

Effectiveness of Pelvic Floor Muscle Training Alone and in Combination With Biofeedback, Electrical Stimulation, or Both Compared to Control for Urinary Incontinence in Men Following Prostatectomy: Systematic Review and Meta-Analysis

Background The efficacy of pelvic floor muscle training (PFMT) alone and in combination with biofeedback (BFB), electrical stimulation (ES), or both for urinary incontinence in men following prostatectomy is inconclusive. Purpose The purpose of this study was to determine whether PFMT works well alone or in combination with BFB, ES, or both in comparison with a control. Data Sources The databases Ovid Medline, EMBASE, CENTRAL, Scopus, and Web of Science, and the specialized register of the Citroen Incontinence Review Group were searched from study inception to August 2017. Abstract proceedings from urological meetings, including the European Association of Urology and the American Urological Association, were also searched. Study Selection Randomized controlled trials that compared PFMT alone and PFMT with ES, BFB, or both and no treatment, placebo, or sham were included in the review. Data Extraction, Synthesis, and Quality Two independent reviewers completed data extraction and quality appraisal. The Grading of Recommendations, Assessment, Development, and Evaluation tool was used for quality appraisal. Meta-analysis was done with software used for preparing and maintaining Cochrane reviews. Limitations Methodological flaws in the included studies limited internal validity. Conclusions PFMT alone, PFMT plus BFB and ES, and PFMT plus ES were more effective than the control for urinary incontinence following prostatectomy. The effect of PFMT plus BFB on postprostatectomy incontinence remains uncertain.

Can pre-screening vestibulocerebellar involvement followed by targeted training improve the outcomes of balance in cerebellar ataxia?

Balance problems and frequent falls are common among clients with Cerebellar Ataxia (CA). CA is not a disease by itself but a collection of symptoms due to the involvement of cerebellum or its pathways. Presently the treatment for balance problems for CA is not standardized. Interventions available to improve balance are not specific to symptoms presentation. Functionally the cerebellum is divided into the spinocerebellum, vestibulocerebellum and corticocerebellum. Each functional zone has a distinct role in maintaining balance. Therefore, the presentation of symptoms will vary according to the functional zone involved. Pre-screening clients with CA for identifying the part of cerebellum involved will facilitate clinicians to provide tailor-made interventions for targeting specific symptoms for better outcomes. Pre-screening clients with CA according to the part of cerebellum involved is not in practice and our study will introduce this concept. We hypothesize pre-screening participants with spinocerebellar ataxia (SCA) for the involvement vestibulocerebellum followed by prescribing vestibulocerebellum targeted exercises will have better outcomes when compared to conventional balance training. We plan to conduct two related studies. In study 1 we will screen participants with CA for the involvement of vestibulocerebellum. In study 2, the effects of vestibulocerebellum targeted balance exercises on balance will be studied. We will assess the Subjective Visual Vertical (SVV) deviation and postural sway pattern to screen participants into people with and without vestibulocerebellar involvement. SVV deviation will be estimated using a computerized Subjective Visual Vertical (cSVV) device and postural sway pattern will be assessed using the limits of stability program of the Bertec© Balance system. The obtained SVV deviation scores will be used to derive at cut-off scores to discriminate clients with and without vestibulocerebellar involvement. The second study will test the treatment effects of conventional exercises plus vestibulocerebellum targeted exercises to improve balance by correcting SVV deviation in SCA with vestibulocerebellar involvement. The intervention is planned as 12 one-to-one sessions over three months period. Participants will be reassessed after the intervention and 3 months post-intervention. The findings of this cutting-edge research are extremely important to the clinicians, researchers and clients with SCA.