The Effect of Peripheral Neuropathy on Balance Performance in Community-Dwelling Adults with Type I Diabetes Mellitus

Purpose: Balance is affected by visual, somatosensory, proprioceptive, and vestibular input. Anything that alters one of these elements could potentially cause a decrease in postural stability. One disease which reduces the somatosensory input from the foot and ankles is diabetic neuropathy. The purpose of this study is to determine the correlation between Type I DM and balance performance, thereby adding to the current knowledge of postural control and the impact, if any, DM has on balance. Methods: Twenty-five volunteer subjects with Type I DM and 25 age-matched control subjects participated in the study. Semmes-Weinstein monofilaments were used to determine plantar sensation. Following this the Berg Balance Assessment was administered to assess functional balance performance. A Pearson Correlation multiple regression was used to determine the correlation between sensation, DM, and balance performance. Results: Significance was established between reduced sensation and decreased balance control in both the experimental and control groups. A significant correlation was also found between an increase in age and decreased sensation scores. Conclusion: Assessing the balance of all patients who are at risk for reduced sensation should be implemented as a screening procedure for determining any decrease in postural stability

Doctor of Philosophy in Rehabilitation Science

dissertationMultiple Sclerosis (MS) is a chronic, neurological disorder characterized by imbalance and falls. Accurate perception and integration of three sensory inputs - the vestibular, vision, and somatosensory, is critical to produce human gaze and posture orientation. In MS, demyelination of pathways within the brainstem and cerebellum adversely affect gaze and postural stability. However, the deficits and the psychometric properties of these measures remain less examined. Moreover, the benefits of training on gaze and postural stability are unknown in MS. This study examined the deficits in gaze stability, dynamic balance, and self-report measures in persons with MS as compared to controls; assessed the test-retest reliability and response stability of gaze stability, postural sway, and dynamic balance tests; and investigated the effects of training on gaze stability, galvanic-induced postural sway, dynamic balance, and self-report measures in persons with MS. We hypothesized that persons with MS will demonstrate deficits in gaze and postural stability; that study measures will demonstrate moderate to good reliability and acceptable response stability; and that persons with MS will demonstrate significant improvements after training. Nineteen persons with MS at fall-risk and 14 controls were recruited and the assessments were carried out on 2 occasions. The participants then completed a 2-week training followed by re-assessments. Persons with MS demonstrated significant differences in the gaze stability, dynamic balance, and self-report measures versus controls. In addition, significant inter-relationships were found. The majority of gaze stabilization measures demonstrated moderate while the postural sway and dynamic balance measures showed good reliability. The aVOR gain, FGA, and FSST showed SEM % <20 and MDD95% <20, suggesting acceptable response stability. After training, gaze stability was achieved by recruiting substitutive oculomotor strategies whereas postural stability was achieved by sway response adaptations. Consistent improvements in dynamic balance and self-report measures suggest clinically meaningful changes. Taken together, these findings support the study hypothesis and suggest that significant deficits in gaze and posture may be present in persons with MS. This highlights the utility of these assessments in fall-risk evaluations in persons with MS. Moreover, the different strategical mechanisms for improvements after training suggest the clinical value of a focused training intervention

Static and dynamic single leg postural control performance during dual-task paradigms

ABSTRACTCombining dynamic postural control assessments and cognitive tasks may give clinicians a more accurate indication of postural control under sport-like conditions compared to single-task assessments. We examined postural control, cognitive and squatting performance of healthy individuals during static and dynamic postural control assessments in single- and dual-task paradigms. Thirty participants (female = 22, male = 8; age = 20.8 ± 1.6 years, height = 157.9 ± 13.0 cm, mass = 67.8 ± 20.6 kg) completed single-leg stance and single-leg squat assessments on a force plate individually (single-task) and concurrently (dual-task) with two cognitive assessments, a modified Stroop test and the Brooks Spatial Memory Test. Outcomes included centre of pressure speed, 95% confidence ellipse, squat depth and speed and cognitive test measures (percentage of correct answers and reaction time). Postural control performance varied between postural control assessments and testing paradigms. Participants did not squat..

Effects of Vestibular Rehabilitation Using the Dizziness Handicap Inventory

Vertigo, which may be caused by a variety of problems, is a significant symptom in patients with vestibular disorders. The Dizziness Handicap Inventory is a disease-specific questionnaire used to measure how vertigo affects an individual\u27s quality-of-life. This study assessed patient outcomes following vestibular rehabilitation, using the Dizziness Handicap Inventory. Forty-nine former patients of a vestibular rehabilitation program participated in a phone survey following vestibular rehabilitation. Subjects answered the Dizziness Handicap Inventory based on how they . felt before and after they had received physical therapy intervention. Patient outcomes were assessed by comparing Dizziness Handicap Inventory total and sub-scores before and after physical therapy intervention using the Sign test at the .05 alpha level. Statistically significant improvements in Dizziness Handicap Inventory total and sub-scores were determined following vestibular rehabilitation. A significant difference in score change was determined in 57% of the patients. The significant improvement in scores demonstrated that following vestibular rehabilitation, patient perceived outcomes improved. The Dizziness Handicap Inventory demonstrated to be useful to assess patient outcomes and can assist in making treatment goals and outcomes more patient focused and measurable

Using visual stimuli to enhance gait control

Gait control challenges commonly coincide with vestibular dysfunction and there is a long history in using balance and gait activities to enhance functional mobility in this population. While much has been learned using traditional rehabilitation exercises, there is a new line of research emerging that is using visual stimuli in a very specific way to enhance gait control. For example, avatars can be created in an individualized manner to incorporate specific gait characteristics. The avatar could then be used as a visual stimulus to which the patient can synchronize their own gait cycle. This line of research builds upon the rich history of sensorimotor control research in which augmented sensory information (visual, haptic, or auditory) is used to probe, and even enhance, human motor control. This review paper focuses on gait control challenges in patients with vestibular dysfunction, provides a brief historical perspective on how various visual displays have been used to probe sensorimotor and gait control, and offers some recommendations for future research

The Effect of Peripheral Neuropathy on Balance Performance in Community-Dwelling Adults with Type I Diabetes Mellitus

Purpose: A common complication of Diabetes Mellitus (DM) is peripheral neuropathy, which may decrease sensory input. The purpose of this study is to determine the correlation between decreased sensation and balance performance. Methods: Fifty subjects, 25 experimental with Type I DM and 25 control, were recruited from the community. Sensory response was tested with Semmes-Weinstein Monofilaments, and the Berg Balance Measure to assess balance performance. The Pearson correlation and Multiple Regression were performed to study the relationship between DM and balance. Results: Significance was established between age and 4.31 monofilament response score and the dependent variable, Berg Balance Score. The monofilament score contributed the greatest amount to the prediction equation with a positive beta coefficient of .662; with a higher amount of responses to the monofilament, a higher score on the Berg balance scale can be predicted. Age contributes to the prediction equation to a lesser degree with a negative beta coefficient; as age increases, the Berg balance score is predicted to decrease. Conclusion: Based on the assumption that neuropathy leads to decreased balance, and that diminished balance increases an individual\u27s risk of falling, our results have shown that the Berg Balance Assessment, used in conjunction with the monofilaments, would be clinically useful in screening a patient with DM for risk of falls

ADVANCES IN BALANCE AND BIOFEEDBACK MEASUREMENT: THE CASE FOR HEALTH-BASED, POSTURAL SERIOUS GAMES

Health games are increasingly seen as a means to address issues from therapy and rehabilitation. Yet, as a transformative technology, rarely have such games been explored or exploited to assist research into pathologies. Serious games for research (SGR) to uncover pathologies would allow clinicians to develop new differential diagnostics while providing a positive experience for the subject. This paper is not about game design; nevertheless it presents an outlook to considerations that could be taken forward when developing health-based SGRs for pathomechanics, etiopathogenesis and biofeedback. This work relates to preliminary studies on balance challenges manifested in pathologies of the central nervous system. As technology advancements seek to augment human sensory contact between virtual and real worlds this may impact on how virtual environments are used and designed in future. As a consequence heightened sensory (or lack of thereof) may result in falls, for example users with vestibular disorder – because postural stability is a key aspect of motor ability that allows individuals to sustain and maintain the desired physical position of their body Here, our investigation is specific to functional correspondence of the incidental properties in human body sway between healthy subjects and subjects with dyslexia. Our early results suggest postural sway between healthy subjects and those with mild disorders can be distinguished

Analysis of Sideline Concussion Screening Tools in an Athletic Setting

This paper serves as a primer to healthcare professionals of the now and future of sideline screening for concussion. In the past decade, significant research into sports-related concussions has expanded understanding of what is as a very complex injury. As the definition of concussion has evolved, the impact they have is put into perspective. As more research into the short- and long-term effects of concussions brings to light the effects of continuing to participate after suffering a concussion, the importance of keeping concussed athletes off the field is now understood as a potential life or death situation. With the dangers of continuing to play after concussion becoming apparent there has been a renewed emphasis on tools and/or techniques that screen for symptoms of concussion. Some of the most widespread include, but are not limited to, the Standardized Assessment for Concussion (SAC), the Balance Error Scoring System (BESS), the Sideline Concussion Assessment Tool 3rd Edition (SCAT3) and King-Devick Test (KDT). This paper will explore the benefits, limitations, and implementation of each of these assessment tools. A crucial part of improving rates of concussion recognition is to look at what has been developed based on the most current understanding of concussions. As more attention has been drawn to the potential dangers of concussions and repeated sub-concussive blows there has been a surge in funding and studies regarding current and developing technique’s and tools. This paper examines tools recently implemented or under development and explores their potential benefits, limitations and availability. These include Vestibular-Ocular Motor Screening (VOMS), force plate balance testing and blood tests for proteins associated with injury to the brain. The paper concludes with a discussion of the benefits, limitations and reliability of each test. Recommendations are made for developing a sideline concussion screening protocol

Reflex control of the spine and posture: a review of the literature from a chiropractic perspective

OBJECTIVE: This review details the anatomy and interactions of the postural and somatosensory reflexes. We attempt to identify the important role the nervous system plays in maintaining reflex control of the spine and posture. We also review, illustrate, and discuss how the human vertebral column develops, functions, and adapts to Earth's gravity in an upright position. We identify functional characteristics of the postural reflexes by reporting previous observations of subjects during periods of microgravity or weightlessness. BACKGROUND: Historically, chiropractic has centered around the concept that the nervous system controls and regulates all other bodily systems; and that disruption to normal nervous system function can contribute to a wide variety of common ailments. Surprisingly, the chiropractic literature has paid relatively little attention to the importance of neurological regulation of static upright human posture. With so much information available on how posture may affect health and function, we felt it important to review the neuroanatomical structures and pathways responsible for maintaining the spine and posture. Maintenance of static upright posture is regulated by the nervous system through the various postural reflexes. Hence, from a chiropractic standpoint, it is clinically beneficial to understand how the individual postural reflexes work, as it may explain some of the clinical presentations seen in chiropractic practice. METHOD: We performed a manual search for available relevant textbooks, and a computer search of the MEDLINE, MANTIS, and Index to Chiropractic Literature databases from 1970 to present, using the following key words and phrases: "posture," "ocular," "vestibular," "cervical facet joint," "afferent," "vestibulocollic," "cervicocollic," "postural reflexes," "spaceflight," "microgravity," "weightlessness," "gravity," "posture," and "postural." Studies were selected if they specifically tested any or all of the postural reflexes either in Earth's gravity or in microgravitational environments. Studies testing the function of each postural component, as well as those discussing postural reflex interactions, were also included in this review. DISCUSSION: It is quite apparent from the indexed literature we searched that posture is largely maintained by reflexive, involuntary control. While reflexive components for postural control are found in skin and joint receptors, somatic graviceptors, and baroreceptors throughout the body, much of the reflexive postural control mechanisms are housed, or occur, within the head and neck region primarily. We suggest that the postural reflexes may function in a hierarchical fashion. This hierarchy may well be based on the gravity-dependent or gravity-independent nature of each postural reflex. Some or all of these postural reflexes may contribute to the development of a postural body scheme, a conceptual internal representation of the external environment under normal gravity. This model may be the framework through which the postural reflexes anticipate and adapt to new gravitational environments. CONCLUSION: Visual and vestibular input, as well as joint and soft tissue mechanoreceptors, are major players in the regulation of static upright posture. Each of these input sources detects and responds to specific types of postural stimulus and perturbations, and each region has specific pathways by which it communicates with other postural reflexes, as well as higher central nervous system structures. This review of the postural reflex structures and mechanisms adds to the growing body of posture rehabilitation literature relating specifically to chiropractic treatment. Chiropractic interest in these reflexes may enhance the ability of chiropractic physicians to treat and correct global spine and posture disorders. With the knowledge and understanding of these postural reflexes, chiropractors can evaluate spinal configurations not only from a segmental perspective, but can also determine how spinal dysfunction may be the ultimate consequence of maintaining an upright posture in the presence of other postural deficits. These perspectives need to be explored in more detail