Balance assessment in Multiple Sclerosis and cerebellar ataxia: rationale, protocol and demographic data

A core set of standardized balance measures are required for use in rehabilitation among people with multiple sclerosis (MS) and cerebellar ataxia. An earlier systematic review and Delphi survey identified the Berg Balance Scale (BBS), the Timed Up and Go test (TUG), Posture and Gait sub-component of the International Co-operative Ataxia Rating Scale (PG of ICARS) and the gait, sitting and stance sub-components of the Scale for the Assessment and Rating of Ataxia (SARA Bal) as suitable balance measures. This study aims to estimate the reliability, validity and interpretability of these measures. This study will recruit 60 participants with multiple sclerosis with secondary cerebellar involvement across four centres in New Zealand and the United States of America. Participants will be assessed and videotaped performing the BBS, TUG, SARA Bal and PG of ICARS by trained physiotherapists. Barthel Index, Expanded Disability Status Scale (EDSS), Disease duration, ICARS and SARA will also be assessed to determine validity. A second assessment to determine reliability will be conducted by assessors watching the video-recording. Data collection is in progress, 44 samples have been collected and the demographic data are presented. The findings of this study will recommend a core set of reliable, valid and interpretable measures that are suitable for clinical practice and research for the assessment of balance among adults with MS and cerebellar ataxia. Minimal Clinically Important Difference (MCID) and cut-off scores to predict the use of assistive walking device will be established

Outcome measures for the assessment of balance and postural control in Cerebellar Ataxia: a narrative review

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

COSMIN for quality rating systematic reviews on psychometric properties

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 and cost of integrated cognitive and balance training for balance and falls in cerebellar ataxia: a blinded two-arm parallel group RCT

BackgroundIn patients with cerebellar ataxia (CA), dual-tasking deteriorates the performance of one or both tasks.ObjectiveEvaluate the effects of 4 weeks of cognitive-coupled intensive balance training (CIBT) on dual-task cost, dynamic balance, disease severity, number of falls, quality of life, cognition and cost among patients with CA.MethodsThis RCT compared CIBT (Group 1) to single-task training (Group 2) among 32 patients with CA. The intervention included either dual-task (CIBT) or single-task training for 4 weeks followed by 6 months of unsupervised home exercises. Dual-task timed up-and-go test (D-TUG) assessed dual-task cost of the physical and cognitive tasks. Assessment time points included baseline 1 (Week 0:T1), baseline 2 (Week 6:T2), post-intervention (Week 10:T3), and follow-up (Week 34:T4).ResultsCompared to single-task training CIBT improved the dual-task cost of physical task [MD −8.36 95% CI (−14.47 to −2.36, p < 0.01), dual-tasking ability [−6.93 (−13.16 to −0.70); p = 0.03] assessed using D-TUG, balance assessed using the scale for the assessment and rating of ataxia (SARAbal) [−2.03 (−4.04 to −0.19); p = 0.04], visual scores of the SOT (SOT-VIS) [−18.53 (−25.81 to −11.24, p ≤ 0.01] and maximal excursion [13.84 (4.65 to 23.03; p ≤ 0.01] of the Limits of Stability (LOS) in the forward direction and reaction time in both forward [−1.11 (−1.42 to −0.78); p < 0.01] and right [−0.18 (0.05 to 0.31); p < 0.01] directions following 4 weeks of training. CIBT did not have any additional benefits in reducing the number of falls, or improving disease severity, quality of life and cognition. The mean cost of intervention and healthcare costs for 7 months was HKD 33,380 for CIBT group and HKD 38,571 for single-task training group.ConclusionWe found some evidence to support the use of CIBT for improving the dual-tasking ability, dual-task cost of physical task and dynamic balance in CA. Future large fully-powered studies are needed to confirm this claim.Clinical trial registrationhttps://clinicaltrials.gov/study/NCT04648501, identifier [Ref: NCT04648501]

Table_1_Effectiveness and cost of integrated cognitive and balance training for balance and falls in cerebellar ataxia: a blinded two-arm parallel group RCT.DOCX

BackgroundIn patients with cerebellar ataxia (CA), dual-tasking deteriorates the performance of one or both tasks.ObjectiveEvaluate the effects of 4 weeks of cognitive-coupled intensive balance training (CIBT) on dual-task cost, dynamic balance, disease severity, number of falls, quality of life, cognition and cost among patients with CA.MethodsThis RCT compared CIBT (Group 1) to single-task training (Group 2) among 32 patients with CA. The intervention included either dual-task (CIBT) or single-task training for 4 weeks followed by 6 months of unsupervised home exercises. Dual-task timed up-and-go test (D-TUG) assessed dual-task cost of the physical and cognitive tasks. Assessment time points included baseline 1 (Week 0:T1), baseline 2 (Week 6:T2), post-intervention (Week 10:T3), and follow-up (Week 34:T4).ResultsCompared to single-task training CIBT improved the dual-task cost of physical task [MD −8.36 95% CI (−14.47 to −2.36, p ConclusionWe found some evidence to support the use of CIBT for improving the dual-tasking ability, dual-task cost of physical task and dynamic balance in CA. Future large fully-powered studies are needed to confirm this claim.Clinical trial registrationhttps://clinicaltrials.gov/study/NCT04648501, identifier [Ref: NCT04648501].</p

Balance outcome measures in cerebellar ataxia: a Delphi survey

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

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