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Background. Clinical practice for rehabilitation after mild traumatic brain injury (mTBI) is variable, and guidance on when to initiate physical therapy is lacking. Wearable sensor technology may aid clinical assessment, performance monitoring, and exercise adherence, potentially improving rehabilitation outcomes during unsupervised home exercise programs. Objective. The objectives of this study were to: (1) determine whether initiating rehabilitation earlier than typical will improve outcomes after mTBI, and (2) examine whether using wearable sensors during a home-exercise program will improve outcomes in participants with mTBI. Design. This was a randomized controlled trial. Setting. This study will take place within an academic hospital setting at Oregon Health & Science University and Veterans Affairs Portland Health Care System, and in the home environment. Participants. This study will include 160 individuals with mTBI. Intervention. The early intervention group (n = 80) will receive one-on-one physical therapy 8 times over 6 weeks and complete daily home exercises. The standard care group (n = 80) will complete the same intervention after a 6- to 8-week wait period. One-half of each group will receive wearable sensors for therapist monitoring of patient adherence and quality of movements during their home exercise program. Measurements. The primary outcome measure will be the Dizziness Handicap Inventory score. Secondary outcome measures will include symptomatology, static and dynamic postural control, central sensorimotor integration posturography, and vestibular-ocular-motor function. Limitations. Potential limitations include variable onset of care, a wide range of ages, possible low adherence and/or withdrawal from the study in the standard of care group, and low Dizziness Handicap Inventory scores effecting ceiling for change after rehabilitation. Conclusions. If initiating rehabilitation earlier improves primary and secondary outcomes post-mTBI, this could help shape current clinical care guidelines for rehabilitation. Additionally, using wearable sensors to monitor performance and adherence may improve home exercise outcomes., There is currently limited evidence supporting when rehabilitation for mild traumatic brain injury (mTBI) should be initiated, and as a result, clinical care guidelines for rehabilitation of mTBI lack consistency. [...]

Background. Freezing of gait (FOG) is one of the most disabling symptoms of Parkinson disease (PD). Different land-based rehabilitation approaches based on motor and cognitive strategies can be effective in treating FOG. Although there are data about the efficacy of aquatic therapy in ameliorating this phenomenon, no study has explored the combined effect of land-based therapies plus aquatic therapy in patients with PD who have FOG. Objective. The objective was to investigate the effectiveness of a multidisciplinary, intensive, motor-cognitive rehabilitation treatment (MIRT) in improving FOG and whether implementation with aquatic therapy (MIRT-AT) adds further benefits. Design. The design consisted of a single-blind, parallel-group, 1:1 allocation ratio, randomized trial. Setting. The Department of Parkinson Disease, Movement Disorders and Brain Injury Rehabilitation at 'Moriggia-Pelascini' Hospital (Gravedona ed Unid, Como, Italy) was used as the setting. Participants. Sixty hospitalized patients with PD who had FOG in Hoehn and Yahr stage 2 or 5-3 were included. Intervention. Sixty patients with PD + FOG were randomly assigned to 2 groups: 30 underwent a 4-week MIRT and 30 underwent a 4-week MIRT-AT. Measurements. The primary outcome measure was the Freezing of Gait Questionnaire; secondary- outcome measures were total Unified Parkinson Disease Rating Scale (UPDRS), UPDRS II, UPDRS III, Berg Balance Scale, Timed Up and Go Test, and 6-Minute Walk Test. These measures were assessed both at admission and discharge. Results. Participants in the 2 groups had similar age, sex distribution, Hoehn and Yahr stage, and most-affected side. At baseline, no difference in outcome measures was observed between the 2 groups. After treatment, a significant time effect was observed for all variables in both groups. No significant time x group interaction was observed. A betweengroup analysis showed nonsignificant differences between values at Tl and values at TO for all variables. Limitations. The limitations were the lack of a control group and follow-up. Conclusions. We showed that a multidisciplinary, intensive, and goal-based rehabilitation treatment, such as MIRT, improves FOG in patients with PD. Although aquatic therapy could be considered a useful approach for treating FOG, it does not add further benefits to this kind of motor-cognitive rehabilitation., I. Clerici, PT, Department of Parkinson's Disease, Movement Disorders and Brain Injury Rehabilitation, 'Moriggia-Pelascini' Hospital, Gravedona ed Uniti, Italy. R. Maestri, BME, Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri [...]

Background. Reactive balance control is often impaired poststroke. Studies addressing responses to laterally directed perturbations in this population are currently lacking. Given that stroke-related motor impairments are unilateral, a better understanding of reactive balance responses to these types of perturbations is critical. Objective. This study aimed to quantify differences in reactive balance control in response to laterally directed perturbations in people with chronic stroke, based on perturbation direction and ability to step with either limb. Design. This study used a cross-sectional design. Methods. Participants with chronic stroke (N = 19) were divided into groups representing their ability to step with either limb, based on performance on a reactive balance task in a baseline assessment. The preferred stepping limb was also identified during this assessment. Each participant then underwent a series of laterally directed perturbations on a motion platform. Behavioral measures were compared between platform direction and group. Results. Trials with extra steps, step initiation with the preferred limb, and crossover steps were more common with platform motion toward the preferred limb compared to the nonpreferred limb; the latter effect was only observed for participants with an impaired ability to step with either limb. Side-step sequences were more common in those able to step with either limb when the platform moved toward the preferred limb. Limitations. The participant sample was likely higher functioning than the general population of stroke survivors clue to equipment constraints. Additionally, participants may have developed strategies to use the platform's motion characteristics to aid with balance recovery. Conclusions. These findings provide an indication of responses to laterally directed perturbations in people with chronic stroke and may help inform strategies for improving reactive balance control during stroke rehabilitation., Falls are one of the most common medical complications post-stroke. (1-3) The ability to execute stepping reactions following a postural perturbation is crucial to preventing falls. (4-6) Reactive stepping may [...]

Background. The Berg Balance Scale (BBS) has several constraints--ceiling effect, low responsiveness, and uncertain predictability of falls--in neurological populations. The Mini-BESTest, which has not yet been validated in spinal cord [...]

Background. There is growing evidence for the positive effects of exercise training programs on balance control in Parkinson disease (PD). To be effective, balance training needs to be specific, progressive, and highly challenging. Little evidence exists, however, for how people with PD-related balance impairments perceive highly challenging and progressive balance training programs with dual-task components. Objective. The purpose of this study was to explore and describe perceptions of a highly challenging balance training program among people with mild to moderate PD. Design. This study was qualitative in nature. In-depth interviews were conducted with 13 individuals with mild to moderate PD who had participated in a highly challenging balance training program. Interview transcripts were analyzed using qualitative content analysis, with an inductive approach. Results. The analysis revealed 3 subthemes concerning participants' perceptions of highly challenging and progressive balance training: (1) movement to counter the disease, (2) dual-task training in contrast to everyday strategies, and (3) the struggle to maintain positive effects. The first subtheme reflects how physical activity was used as a short-term and long-term strategy for counteracting PD symptoms and their progression. The second subtheme incorporates the described experiences of being maximally challenged in a secure and supportive group environment, circumstances that stood in contrast to participants' everyday lives. The third subtheme describes participants' long-term struggle to maintain program effects on cognitive and physical function in the face of disease progression. Interpretation of the underlying patterns of these subthemes resulted in one overarching theme: training at the limits of balance capacity causes a rethinking motor and cognitive resources. Limitations. The findings of this study cannot be considered to reflect the beliefs of those with weaker or negative beliefs concerning physical activity or be transferred to those at more severe stages of the disease. Conclusions. Findings from this study suggest that being pushed to the limits of balance capacity provoked people with mild to moderate PD to rethink their individual motor and cognitive resources, a process that was further enabled by the PD-specific group setting., Parkinson disease (PD) is a degenerative neurological disease characterized by bradykinesia, resting tremor, rigidity, and progressive postural instability. (1) When compared with other neurodegenerative conditions, such as Alzheimer disease, a [...]

Background. Complex movement and balance impairments in people with Parkinson disease (PD) contribute to high fall risk. Comprehensive balance assessment is warranted to identify intrinsic fall risk factors and direct interventions. Objective. The purpose of this study was to examine the psychometric properties of 3 balance measures of a force platform (FP) system in people with PD. Methods. Forty-two community-dwelling individuals with idiopathic PD completed the testing protocol. Test-retest reliability was assessed for the Limits of Stability Test (LOS), Motor Control Test (MCT), and Sensory Organization Test (SOT). Intraclass correlation coefficients (ICC [2,1]) were calculated to determine test-retest reliability and minimal detectable change. Validity was assessed by comparing the FP measures with criterion gait and balance measures using Pearson product moment correlations. Multiple regression analyses examined the contribution of PD characteristics to FP measures. Results. All primary FP variables demonstrated excellent test-retest reliability (ICC=.78-.92). The SOT and LOS demonstrated fair to good correlations with criterion measures, whereas the MCT had fair correlations to balance measures only. Both SOT composite equilibrium and MCT average latency were moderately associated with disease severity. Limitations. This study's sample had a relatively small number of participants with a positive fall history, which may limit the generalizability of the findings. Conclusions. This study's findings provide support that FP measures are reliable and valid tests of balance impairment in people with PD. Disease severity was significantly associated with SOT and MCT measures, perhaps reflecting that these tests are meaningful indicators of decline in postural control with disease progression. Force platform measures may provide valuable quantitative information about underlying balance impairments in people with PD to guide therapeutic interventions for fall risk reduction., Parkinson disease (PD) is a prevalent neurodegenerative disorder affecting approximately 1 million people in the United States. (1) Individuals with PD experience injury-related falls, which decreases their quality of life [...]

Background. The Berg Balance Scale (BBS), Balance Evaluation Systems Test (BESTest), Mini-BESTest, and Brief-BESTest are useful in the assessment of balance. Their psychometric properties, however, have not been tested in patients with chronic obstructive pulmonary disease (COPD). Objective. This study aimed to compare the validity, reliability, and ability to identify fall status of the BBS, BESTest, Mini-BESTest, and the Brief-BESTest in patients with COPD. Design. A cross-sectional study was conducted. Methods. Forty-six patients (24 men, 22 women; mean age = 75.9 years, SD = 7.1) were included. Participants were asked to report their falls during the previous 12 months and to fill in the Activity-specific Balance Confidence (ABC) Scale. The BBS and the BESTest were administered. Mini-BESTest and Brief-BESTest scores were computed based on the participants' BESTest performance. Validity was assessed by correlating balance tests with each other and with the ABC Scale. Interrater reliability (2 raters), intrarater reliability (48-72 hours), and minimal detectable changes (MDCs) were established. Receiver operating characteristics assessed the ability of each balance test to differentiate between participants with and without a history of falls. Results. Balance test scores were significantly correlated with each other (Spearman correlation rho =.73-.90) and with the ABC Scale (rho =.53-.75). Balance tests presented high interrater reliability (intraclass correlation coefficient [ICC] =.85-.97) and intrarater reliability (ICC =.52-.88) and acceptable MDCs (MDC = 3.3-6.3 points). Although all balance tests were able to identify fall status (area under the curve = 0.74-0.84), the BBS (sensitivity=73%, specificity = 77%) and the Brief-BESTest (sensitivity = 81%, specificity=73%) had the higher ability to identify fall status. Limitations. Findings are generalizable mainly to older patients with moderate COPD. Conclusions. The 4 balance tests are valid, reliable, and valuable in identifying fall status in patients with COPD. The Brief-BESTest presented slightly higher interrater reliability and ability to differentiate participants' fall status., Chronic obstructive pulmonary disease (COPD) is one of the most prevalent chronic diseases among adults aged 60 years and older. (1) This respiratory disease is characterized by a progressive deterioration [...]

We read with attention the article by Benka Wallen et al. (1) The aim of their study was to examine the dimensionality of the Mini-BESTest, as well as the properties [...]

Background. The Mini-Balance Evaluation Systems Test (Mini-BESTest) is a clinical balance test comprising 14 items assumed to reflect the unidimensional construct 'dynamic balance.' Objective. The study objective was to examine the dimensionality of the test and the properties of each item and their interrelationships in elderly people with mild to moderate Parkinson disease (PD). Design. This was a cross-sectional study in a laboratory setting. Methods. A total of 112 participants (mean age=73 years) with idiopathic PD (Hoehn and Yahr stages 1-3) were assessed by physical therapists. Local independence among items was examined with Rasch modeling. Unidimensionality was tested by running a principal component analysis on the residuals. An exploratory factor analysis was used to examine the structure of the test, and a confirmatory factor analysis was used to evaluate the fit of the derived model. Results. The first residual component of the principal component analysis, with an eigenvalue of greater than 2, superseded the assumption of unidimensionality. After the omission of item 7 because of convergence problems, the exploratory factor analysis suggested that a 3-factor solution best fit the data. A confirmatory factor analysis demonstrated acceptable fit of the final model, although item 14 loaded poorly on its factor. Limitations. The sample size was on the lower end of what is generally recommended. Conclusions. This study could not confirm that the Mini-BESTest is unidimensional. Gait items were dispersed over all factors, indicating that they may reflect different constructs. Nonetheless, as there arguably is no clinical balance test superior to the Mini-BESTest today, we recommend using the total score for assessing gross balance in this population and individual items to identify specific weaknesses. Moreover, dual tasks should be assessed separately because they are an important aspect of balance control in people with PD, reflected in only one item of the test., Loss of balance control is a common and disabling complication in Parkinson disease (PD). (1) Several instruments for the assessment of balance are available, although none specifically target people with [...]

Background. Body-worn, inertial sensors can provide many objective measures of balance and gait. However, the objective measures that best reflect patient perception of mobility disability and clinician assessment of Parkinson disease (PD) are unknown. Objective. The purposes of this study were: (1) to determine which objective measures of balance and gait are most related to patient perception of mobility disability and disease severity in people with PD and (2) to examine the effect of levodopa therapy on these correlates. Design. This was an experimental correlation study. Methods. One hundred four people with idiopathic PD performed 3 trials of the Instrumented Stand and Walk Test (ISAW) in the 'on' and 'off' medication states. The ISAW consists of quiet standing (30 seconds), gait initiation, straight walking (7 m), and turning (180°), yielding 34 objective measures of mobility from body-worn inertial sensors. Patient perception of mobility disability was assessed with the Activities-specific Balance Confidence (ABC) scale and the mobility subscale of the Parkinson's Disease Questionnaire (PDQ-39). Disease severity was assessed with the Unified Parkinson's Disease Rating Scale, part III (motor UPDRS). Spearman correlations were used to relate objective measures of mobility to patient perception and disease severity. Results. Turning speed, gait speed, and stride length were most highly correlated to severity of disease and patient perception of mobility disability. The objective measures of mobility in the off-medication state were more indicative of patient perception of mobility disability and balance confidence compared with on-medication state measures. Limitations. Causation is an inherent problem of correlation studies. Conclusion. Physical therapists should evaluate mobility in people with PD in the off-medication state because the off-medication state is more related to disease severity and patient perception of mobility disability than the on-medication state mobility. Assessment and treatment of mobility in people with PD should target specific measures (ie, turning, gait speed, and stride length) because these measures best reflect patients' quality of life and balance confidence., Gait and balance impairments are common manifestations of idiopathic Parkinson disease (PD). These motor symptoms are debilitating, leading to decline in balance confidence (1) and self-perceived motor function. (2) Reduced [...]

Background. The Berg Balance Scale (BBS) is a balance measure commonly used for people with multiple sclerosis (MS). The Mini-BESTest is an alternative based on balance systems. Objective. The study objective was to compare the BBS and the Mini-BESTest for sensitivity to change, likelihood ratios for walking aid use and falls, and associations with clinical variables in people who have MS and are ambulatory. Design. This was a cohort study with measurements before and after exposure to 8 weeks of routine physical therapy intervention. Methods. For 52 participants who had a primary diagnosis of MS and who were independently mobile, with or without an aid, demographic details and a history of falls and near falls were collected. Participants completed the Mini-BESTest, Multiple Sclerosis Impact Scale-29, Multiple Sclerosis Walking Scale-12, BBS, Modified Fatigue Impact Scale, and Six-Minute Walk Test. Results. No participant started with a baseline Mini-BESTest maximum score of 28, whereas 38.5% (n=20) started with a baseline BBS maximum score of 56. Statistically significant changes in the Mini-BESTest score ([bar.X]=5.31, SD=3.5) and the BBS score ([bar.X]= 1.4, SD=1.9) were demonstrated. Effect sizes for the Mini-BESTest and the BBS were 0.70 and 0.37, respectively; standard response means for the Mini-BESTest and the BBS were 1.52 and 0.74, respectively. Areas under the receiver operating characteristic curves for the Mini-BESTest and the BBS were 0.88 and 0.77, respectively, for detecting mobility device use and 0.88 and 0.75, respectively, for detecting self-reported near falls. The Mini-BESTest had a higher correlation for each secondary measure than did the BBS. Limitations. This study involved a sample of convenience; 61% of the participants did not use a walking aid. The order of testing was not randomized, and fall status was obtained through retrospective recall. Conclusions. The Mini-BESTest had a lower ceiling effect and higher values on responsiveness tests. These findings suggest that the Mini-BESTest may be better at detecting changes in balance in people who have MS, are ambulatory, and have relatively little walking disability., Multiple sclerosis (MS) is a chronic, progressive disorder of the central nervous system that commonly affects young adults. (1,2) Many people with MS report balance problems. (3,4) Such balance impairments [...]

Background. Balance confidence and fear of falling are factors associated with recurrent falls in people with Parkinson disease (PD). However, the accuracy for predicting falls on the basis of self-report measures has not been widely investigated. Objective. The study objectives were: (1) to compare the accuracy of the Activities-specific Balance Confidence Scale (ABC) and the Falls Efficacy Scale-International (FES-I) with that of the Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Functional Reach Test (FRT), and Timed 'Up & Go' Test (TUG) for predicting recurrent falls in people with PD and (2) to explore the ability of combinations of up to 3 tests to predict recurrent falls. Design. This was a prospective cohort study involving 225 people with PD. Methods. Participants were assessed with the ABC, FES-I, BBS, FRT, TUG, and DGI. Participants who reported 2 or more falls in the 12-month follow-up period were classified as recurrent fallers. Areas under the receiver operating characteristic curves were determined, and the Akaike information criterion was used to select the best predictive model. Results. Eighty-four participants (37.3%) were classified as recurrent fallers. Areas under the receiver operating characteristic curves for the ABC, FES-I, TUG, FRT, DGI, and BBS were 0.73, 0.74, 0.72, 0.74, 0.76, and 0.79, respectively. Two-test models provided additional discriminating ability compared with individual measures and had Akaike information criterion values similar to those of 3-test models, particularly the combination of the BBS with the FES-I. Limitations. The lack of an external validation sample was a limitation of this study. Conclusions. The ABC and FES-I demonstrated moderate accuracy in predicting recurrent falls and a predictive ability similar to that of performance-based balance measures, especially the FRT and the TUG. Two-test models showed performance similar to that of 3-test models, suggesting that a combination of 2 measures may improve the ability to predict recurrent falls in people with PD. Specifically, the combination of the BBS with the FES-I may be considered., Parkinson disease (PD) is one of the most common neurodegenerative diseases affecting elderly people and is a major cause of disability in this population. (1) One or more aspects of [...]

People with Parkinson disease (PD) who show freezing of gait also have dysfunction in cognitive domains that interact with mobility. Specifically, freezing of gait is associated with executive dysfunction involving response inhibition, divided attention or switching attention, and visuospatial function. The neural control impairments leading to freezing of gait have recently been attributed to higher-level, executive and attentional cortical processes involved in coordinating posture and gait rather than to lower-level, sensorimotor impairments. To date, rehabilitation for freezing of gait primarily has focused on compensatory mobility training to overcome freezing events, such as sensory cueing and voluntary step planning. Recently, a few interventions have focused on restitutive, rather than compensatory, therapy. Given the documented impairments in executive function specific to patients with PD who freeze and increasing evidence of overlap between cognitive and motor function, incorporating cognitive challenges with mobility training may have important benefits for patients with freezing of gait. Thus, a novel theoretical framework is proposed for exercise interventions that jointly address both the specific cognitive and mobility challenges of people with PD who freeze., Freezing of gait (FoG) is defined as a 'brief, episodic absence or marked reduction of forward progression of the feet despite the intention to walk.' (1(p734)) Approximately 26% of people [...]

Background. The correct identification of patients with Parkinson disease (PD) at risk for falling is important to initiate appropriate treatment early. Objective. This study compared the Fullerton Advanced Balance (FAB) scale with the Mini-Balance Evaluation Systems Test (Mini-BESTest) and Berg Balance Scale (BBS) to identify individuals with PD at risk for falls and to analyze which of the items of the scales best predict future falls. Design. This was a prospective study to assess predictive criterion-related validity. Setting. The study was conducted at a university hospital in an urban community. Patients. Eighty-five patients with idiopathic PD (Hoehn and Yahr stages: 1-4) participated in the study. Measurements. Measures were number of falls (assessed prospectively over 6 months), FAB scale, Mini-BESTest, BBS, and Unified Parkinson's Disease Rating Scale. Results. The FAB scale, Mini-BESTest, and BBS showed similar accuracy to predict future falls, with values for area under the curve (AUC) of the receiver operating characteristic (ROC) curve of 0.68, 0.65, and 0.69, respectively. A model combining the items 'tandem stance,' 'rise to toes,' 'one-leg stance,' 'compensatory stepping backward,' 'turning,' and 'placing alternate foot on stool' had an AUC of 0.84 of the ROC curve. Limitations. There was a dropout rate of 19/85 participants. Conclusions. The FAB scale, Mini-BESTest, and BBS provide moderate capacity to predict 'fallers' (people with one or more falls) front 'nonfallers.' Only some items of the 3 scales contribute to the detection of future falls. Clinicians should particularly focus on the item 'tandem stance' along with the items 'one-leg stance,' 'rise to toes,' 'compensatory stepping backward,' 'turning 360°,' and 'placing foot on stool' when analyzing postural control deficits related to fall risk. Future research should analyze whether balance training including the aforementioned items is effective in reducing fall risk., Approximately 60% of people with Parkinson disease (PD) fall at least once a year; 39% are considered recurrent 'fallers' with more than one fall. (1) Risk of hip fracture due [...]

Background. The Balance Evaluation Systems Test (BESTest) is a relatively new balance assessment tool. Recently, the Mini-BESTest and the Brief-BESTest, which are shortened versions of the BESTest, were developed. Objective. The purpose of this study was to estimate interrater and intrarater-interoccasion reliability, internal consistency, concurrent and convergent validity, and floor and ceiling effects of the 3 BESTests and other related measures, namely, the Berg Balance Scale (BBS), Functional Gait Assessment (FGA), and Activities-specific Balance Confidence (ABC) Scale, among patients with total knee arthroplasty (TKA). Design. This was an observational measurement study. Methods. To establish interrater reliability, the 3 BESTests were administered by 3 independent raters to 25 participants with TKA. Intrarater-interoccasion reliability was evaluated in 46 participants with TKA (including the 25 individuals who participated in the interrater reliability experiments) by repeating the 3 BESTests, BBS, and FGA within 1 week by the same rater. Internal consistency of each test also was assessed with Cronbach alpha. Validity was assessed in another 46 patients with TKA by correlating the 3 BESTests with BBS, FGA, and ABC. The floor and ceiling effects also were examined. Results. The 3 BESTests demonstrated excellent interrater reliability (intraclass correlation coefficient [ICC] [2,1] =.96-.99), intrarater-interoccasion reliability (ICC [2,1] =.92-.96), and internal consistency (Cronbach alpha=.96-.98). These values were comparable to those for the BBS and FGA. The 3 BESTests also showed moderate-to-strong correlations with the BBS, FGA, and ABC (r=.35-.81), thus demonstrating good concurrent and convergent validity. No significant floor and ceiling effects were observed, except for the BBS. Limitations. The results are generalizable only to patients with TKA due to end-stage knee osteoarthritis. Conclusions. The 3 BESTests have good reliability and validity for evaluating balance in people with TKA. The Brief-BESTest is the least time-consuming and may be more useful clinically., Total knee arthroplasty (TKA) has become a common surgical intervention in the treatment of severe osteoarthritis (OA) of the knee joint. Both scientific research and clinical observations support the use [...]

This perspective article will discuss the potential role of body-worn movement monitors for balance and gait assessment and treatment in rehabilitation. Recent advances in inexpensive, wireless sensor technology and smart devices are resulting in an explosion of miniature, portable sensors that can quickly and accurately quantify body motion. Practical and useful movement monitoring systems are now becoming available. It is critical that therapists understand the potential advantages and limitations of such emerging technology. One important advantage of obtaining objective measures of balance and gait from body-worn sensors is impairment-level metrics characterizing how and why functional performance of balance and gait activities are impaired. Therapy can then be focused on the specific physiological reasons for difficulty in walking or balancing during specific tasks. A second advantage of using technology to measure balance and gait behavior is the increased sensitivity of the balance and gait measures to document mild disability and change with rehabilitation. A third advantage of measuring movement, such as postural sway and gait characteristics, with body-worn sensors is the opportunity for immediate biofeedback provided to patients that can focus attention and enhance performance. In the future, body-worn sensors may allow therapists to perform telerehabilitation to monitor compliance with home exercise programs and the quality of their natural mobility in the community. Therapists need technological systems that are quick to use and provide actionable information and useful reports for their patients and referring physicians. Therapists should look for systems that provide measures that have been validated with respect to gold standard accuracy and to clinically relevant outcomes such as fall risk and severity of disability., The use of technology to quantify mobility in physical therapy has lagged behind other rehabilitation specialties, such as cardiac and musculoskeletal specialties. This lag in use of technology is due [...]

Background. The Balance Evaluation Systems Test (BESTest) is a new clinical balance assessment tool, but it has never been validated in patients with subacute stroke. Objective. The purpose of this study was to examine the reliability and validity of the BESTest in patients with subacute stroke. Design. This was an observational reliability and validity study. Methods. Twelve patients participated in the interrater and intrarater reliability study. Convergent validity was investigated in 70 patients using the Berg Balance Scale (BBS), Postural Assessment Scale for Stroke (PASS), Community Balance and Mobility Scale (CB&M), and Mini-BESTest. The receiver operating characteristic curve was used to calculate the sensitivity, specificity, and accuracy of the BESTest, Mini-BESTest, and BBS in classifying participants into low functional ability (LFA) and high functional ability (EIFA) groups based on Fugl-Meyer Assessment motor subscale scores. Results. The BESTest showed excellent intrarater reliability and interrater reliability (intraclass correlation coefficient= .99) and was highly correlated with the BBS (Spearman r=.96), PASS (r=.96), CB&M (r=.91), and Mini-BESTest (r=.96), indicating excellent convergent validity. No floor or ceiling effects were observed with the BESTest. In contrast, the Mini-BESTest and CB&M had a floor effect in the LFA group, and the BBS and PASS demonstrated responsive ceiling effects in the HFA group. In addition, the BESTest showed high accuracy as the BBS and Mini-BESTest in separating participants into HFA and LFA groups. Limitation. Whether the results are generalizable to patients with chronic stroke is unknown. Conclusion. The BESTest is reliable, valid, sensitive, and specific in assessing balance in people with subacute stroke across all levels of functional disability., Balance control is a complex integration of multiple systems, including sensory and motor systems, sensorimotor integration, and high-level premotor processing--all of which can be affected following stroke. (1) Laboratory studies [...]

Background. Balance is a composite ability requiting the integration of multiple systems. The Balance Evaluation Systems Test (BESTest) and 2 abbreviated versions (the Mini-BESTest and the Brief-BESTest) are balance assessment tools that target these systems. To date, no normative data exist for any version of the BESTest. Objective. The purpose of this study was to determine the age-related normative scores on the BESTest, Mini-BESTest, and Brief-BESTest for Canadians who are healthy and 50 to 89 years of age. Design. A cross-sectional study design was used. Methods. Seventy-nine adults who were healthy and aged 50 to 89 years (mean age=68.9 years; 50.6% women) participated. Normative scores were reported by age decade. Results. Mean BESTest scores were 95.7 (95% confidence interval [CI]=94.497.1) for adults who were aged 50 to 59 years, 91.4 (95% CI=89.8-93.0) for those who were aged 60 to 69 years, 85.4 (95% CI=82.5-88.2) for those who were aged 70 to 79 years, and 79.4 (95% CI =74.3- 84.5) for those who were aged 80 to 89 years. Similar results were obtained for the Mini-BESTest and the Brief-BESTest, and all 3 tests showed statistically significant differences in scores among the age cohorts. Limitations. Because only adults who were 50 to 89 years of age were tested, there are still no normative data for people outside this age range. Also, the scores presented may not be generalizable to all countries. Conclusions. These normative data enhance the clinical utility of the BESTest, Mini-BESTest, and Brief-BESTest by providing clinicians with reference points to guide treatment., Approximately one third of people who live in the community and are more than 65 years of age fall each year. (1) Falls are associated with increased morbidity and mortality [...]

Background. The Mini-Balance Evaluation Systems Test (Mini-BESTest) is a new balance assessment, but its psychometric properties have not been specifically tested in individuals with stroke. Objectives. The purpose of this study was to examine the reliability and validity of the Mini-BESTest and its accuracy in categorizing people with stroke based on fall history. Design. An observational measurement study with a test-retest design was conducted. Methods. One hundred six people with chronic stroke were recruited. Intrarater reliability was evaluated by repeating the Mini-BESTest within 10 days by the same rater. The Mini-BESTest was administered by 2 independent raters to establish interrater reliability. Validity was assessed by correlating Mini-BESTest scores with scores of other balance measures (Berg Balance Scale, one-leg-standing, Functional Reach Test, and Timed 'Up & Go' Test) in the stroke group and by comparing Mini- BESTest scores between the stroke group and 48 control participants, and between fallers (≥ 1 falls in the previous 12 months, n=25) and nonfallers (n=81) in the stroke group. Results. The Mini-BESTest had excellent internal consistency (Cronbach alpha =.89 -.94), intrarater reliability (intraclass correlation coefficient [3,1]=.97), and interrater reliability (intraclass correlation coefficient [2,1] =.96). The minimal detectable change at 95% confidence interval was 3.0 points. The Mini-BESTest was strongly correlated with other balance measures. Significant differences in Mini-BESTest total scores were found between the stroke and control groups and between fallers and nonfallers in the stroke group. In terms of floor and ceiling effects, the Mini-BESTest was significantly less skewed than other balance measures, except for one-leg-standing on the nonparetic side. The Berg Balance Scale showed significantly better ability to identify fallers (positive likelihood ratio=2.6) than the Mini-BESTest (positive likelihood ratio = 1.8). Limitations. The results are generalizable only to people with mild to moderate chronic stroke. Conclusions. The Mini-BESTest is a reliable and valid tool for evaluating balance in people with chronic stroke., Stroke is a major cause of disability and global disease burden. (1) Dysfunction in balance control is one of the most common physical impairments observed after stroke. (2,3) Compromised balance [...]

Background. The newly developed Brief-Balance Evaluation System Test (Brief-BESTest) may be useful for measuring balance and predicting falls in individuals with Parkinson disease (PD). Objectives. The purposes of this study were: (1) to describe the balance performance of those with PD using the Brief-BESTest, (2) to determine the relationships among the scores derived from the 3 versions of the BESTest (ie, full BESTest, Mini-BESTest, and Brief-BESTest), and (3) to compare the accuracy of the Brief-BESTest with that of the Mini-BESTest and BESTest in identifying recurrent fallers among people with PD. Design. This was a prospective cohort study. Methods. Eighty participants with PD completed a baseline balance assessment. All participants reported a fall history during the previous 6 months. Fall history was again collected 6 months (n=51) and 12 months (n=40) later. Results. At baseline, participants had varying levels of balance impairment, and Brief-BESTest scores were significantly correlated with Mini-BESTest (r=.94, P Limitations. The sample included primarily individuals with mild to moderate PD. Also, there was a moderate dropout rate at 6 and 12 months. Conclusions. All versions of the BESTest were reasonably accurate in identifying future recurrent fallers, especially during the 6 months following assessment. Clinicians can reasonably rely on the Brief-BESTest for predicting falls, particularly when time and equipment constraints are of concern., Falls are common among people with Parkinson disease (PD). A retrospective study demonstrated that 38.3% of individuals with PD fell since being diagnosed and 67% of fallers fell more than [...]

Background. Recently, a new tool for assessing dynamic balance impairments has been presented: the 14-item Mini-BESTest. Objective. The aim of this study was to compare the psychometric performance of the Mini-BESTest and the Berg Balance Scale (BBS). Design. A prospective, single-group, observational design was used in the study. Methods. Ninety-three participants (mean age=66.2 years, SD=13.2; 53 women, 40 men) with balance deficits were recruited. Interrater (3 raters) and test-retest (1-3 days) reliability were calculated using intraclass correlation coefficients (ICCs). Responsiveness and minimal important change were assessed (after 10 sessions of physical therapy) using both distribution-based and anchor-based methods (external criterion: the 15-point Global Rating of Change [GRC] scale). Results. At baseline, neither floor effects nor ceiling effects were found in either the Mini-BESTest or the BBS. After treatment, the maximum score was found in 12 participants (12.9%) with BBS and in 2 participants (2.1%) with Mini-BESTest. Test-retest reliability for total scores was significantly higher for the Mini-BESTest (ICC=.96) than for the BBS (ICC=.92), whereas interrater reliability was similar (ICC=.98 versus .97, respectively). The standard error of measurement (SEM) was 1.26 and the minimum detectable change at the 95% confidence level (MDC95) was 3.5 points for Mini-BESTest, whereas the SEM was 2.18 and the MDC95 was 6.2 points for the BBS. In receiver operating characteristic curves, the area under the curve was 0.92 for the Mini-BESTest and 0.91 for the BBS. The best minimal important change (MIC) was 4 points for the Mini-BESTest and 7 points for the BBS. After treatment, 38 participants evaluated with the Mini-BESTest and only 23 participants evaluated with the BBS (out of the 40 participants who had a GRC score of ≥ 3.5) showed a score change equal to or greater than the MIC values. Limitations. The consecutive sampling method drawn from a single rehabilitation facility and the intrinsic weakness of the GRC for calculating MIC values were limitations of the study. Conclusions. The 2 scales behave similarly, but the Mini-BESTest appears to have a lower ceiling effect, slightly higher reliability levels, and greater accuracy in classifying individual patients who show significant improvement in balance function., Body balance relies on feedback circuits fed by the input from different receptors, including somatosensory, labyrinthine, and visual. (1) These inputs have to be adequately integrated in the central nervous [...]

Background. The Balance Evaluation Systems Test (BESTest) and Mini-BESTest are clinical examinations of balance impairment, but the tests are lengthy and the Mini-BESTest is theoretically inconsistent with the BESTest. Objective. The purpose of this study was to generate an alternative version of the BESTest that is valid, reliable, time efficient, and founded upon the same theoretical underpinnings as the original test. Design. This was a cross-sectional study. Methods. Three raters evaluated 20 people with and without a neurological diagnosis. Test items with the highest item-section correlations defined the new Brief-BESTest. The validity of the BESTest, the Mini-BESTest, and the new BriefBESTest to identify people with or without a neurological diagnosis was compared. Interrater reliability of the test versions was evaluated by intraclass correlation coefficients. Validity was further investigated by determining the ability of each version of the examination to identify the fall status of a second cohort of 26 people with and without multiple sclerosis. Results. Items of hip abductor strength, functional reach, one-leg stance, lateral push-and-release, standing on foam with eyes closed, and the Timed 'Up & Go' Test defined the Brief-BESTest. Intraclass correlation coefficients for all examination versions were greater than .98. The accuracy of identifying people from the first cohort with or without a neurological diagnosis was 78% for the BESTest versus 72% for the Mini-BESTest or Brief-BESTest. The sensitivity to fallers from the second cohort was 100% for the Brief-BESTest, 71% for the Mini-BESTest, and 86% for the BESTest, and all versions exhibited specificity of 95% to 100% to identify nonfallers. Limitations. Further testing is needed to improve the generalizability of findings. Conclusions. Although preliminary, the Brief-BESTest demonstrated reliability comparable to that of the Mini-BESTest and potentially superior sensitivity while requiring half the items of the Mini-BESTest and representing all theoretically based sections of the original BESTest., Injuries resulting from falls contribute to decreased health status and increased mortality, particularly for individuals of advanced age or with chronic disease. (1) In addition, falls are linked to a [...]

Background. Little is known about the effects of use of a cane on balance during perturbed gait or whether people with Parkinson disease (PD) benefit from using a cane. Objectives. The purpose of this study was to evaluate the effects of cane use on postural recovery from a slip due to repeated surface perturbations in individuals with PD compared with age- and sex-matched individuals who were healthy. Design. This was a prospective study with 2 groups of participants. Methods. Fourteen individuals with PD (PD group) and 11 individuals without PD (control group) walked across a platform that translated 15 cm rightward at 30 cm/s during the single-limb support phase of the right foot. Data from 15 trials in 2 conditions (ie, with and without an instrumented cane in the fight hand) were collected in random order. Outcome measures included lateral displacement of body center of mass (COM) due to the slip and compensatory step width and length after the perturbation. Results. Cane use improved postural recovery from the first untrained slip, characterized by smaller lateral COM displacement, in the PD group but not in the control group. The beneficial effect of cane use, however, occurred only during the first perturbation, and those individuals in the PD group who demonstrated the largest COM displacement without a cane benefited the most from use of a cane. Both PD and control groups gradually decreased lateral COM displacement across slip exposures, but a slower learning rate was evident in the PD group participants, who required 6, rather than 3, trials for adapting balance recovery. Limitations. Future studies are needed to examine the long-term effects of repeated slip training in people with PD. Conclusions. Use of a cane improved postural recovery from an unpracticed slip in individuals with PD. Balance in people with PD can be improved by training with repeated exposures to perturbations., Failure to recover from a trip or slip during gait is one of the most common reasons for falls in people with Parkinson disease (PD). (1,2) Previous studies demonstrated normal [...]

Background and Purpose. A nontraditional form of exercise recently applied for patients with Parkinson disease (PD) is boxing training. The primary purpose of this case series is to describe the effects of disease severity and duration of boxing training (short term and long term) on changes in balance, mobility, and quality of life for patients with mild or moderate to severe PD. The feasibility and safety of the boxing training program also were assessed. Case Descriptions. Six patients with idiopathic PD attended 24 to 36 boxing training sessions for 12 weeks, with the option of continuing the training for an additional 24 weeks (a seventh patient attended sessions for only 4 weeks). The 90-minute sessions included boxing drills and traditional stretching, strengthening, and endurance exercises. Outcomes were tested at the baseline and after 12, 24, and 36 weeks of boxing sessions (12-, 24-, and 36-week tests). The outcome measures were the Functional Reach Test, Berg Balance Scale, Activities-specific Balance Confidence Scale, Timed 'Up & Go' Test, Six-Minute Walk Test, gait speed, cadence, stride length, step width, activities of daily living and motor examination subscales of the Unified Parkinson Disease Rating Scale, and Parkinson Disease Quality of Life Scale. Outcomes. six patients completed all phases of the case series, showed improvements on at least 5 of the 12 outcome measures over the baseline at the 12-week test, and showed continued improvements at the 24- and 36-week tests. Patients with mild PD typically showed improvements earlier than those with moderate to severe PD. Discussion. Despite the progressive nature of PD, the patients in this case series showed short-term and long-term improvements in balance, gait, activities of daily living, and quality of life after the boxing training program. A longer duration of training was necessary for patients with moderate to severe PD to show maximal training outcomes. The boxing training program was feasible and safe for these patients with PD., Parkinson disease (PD) is a progressive neurodegenerative disorder that is characterized by tremors, postural rigidity, bradykinesia, and postural instability. (1) These motor signs can have detrimental effects on balance, mobility, [...]

Background. Compensatory stepping and grasping reactions are prevalent responses to sudden loss of balance and play a critical role in preventing falls. The ability to execute these reactions effectively is impaired in older adults. Objective. The purpose of this study was to evaluate a perturbation-based balance training program designed to target specific age-related impairments in compensatory stepping and grasping balance recovery reactions. Design. This was a double-blind randomized controlled trial. Setting. The study was conducted at research laboratories in a large urban hospital. Participants. Thirty community-dwelling older adults (aged 64-80 years) with a recent history of falls or self-reported instability participated in the study. Intervention. Participants were randomly assigned to receive either a 6-week perturbation-based (motion platform) balance training program or a 6-week control program involving flexibility and relaxation training. Measurements. Features of balance reactions targeted by the perturbation-based program were: (1) multi-step reactions, (2) extra lateral steps following anteroposterior perturbations, (3) foot collisions following lateral perturbations, and (4) time to complete grasping reactions. The reactions were evoked during testing by highly unpredictable surface translation and cable pull perturbations, both of which differed from the perturbations used during training. Results. Compared with the control program, the perturbation-based training led to greater reductions in frequency of multi-step reactions and foot collisions that were statistically significant for surface translations but not cable pulls. The perturbation group also showed significantly greater reduction in handrail contact time compared with the control group for cable pulls and a possible trend in this direction for surface translations. Limitations. Further work is needed to determine whether a maintenance program is needed to retain the training benefits and to assess whether these benefits reduce fall risk in daily life. Conclusion. Perturbation-based training shows promise as an effective intervention to improve the ability of older adults to prevent themselves from falling when they lose their balance., The devastating consequences of falls in older adults have been well documented, and much work has aimed to develop effective fall prevention interventions. (1,2) Exercise involving a balance component appears [...]

Background. Current clinical balance assessment tools do not aim to help therapists identify the underlying postural control systems responsible for poor functional balance. By identifying the disordered systems underlying balance control, therapists can direct specific types of intervention for different types of balance problems. Objective. The goal of this study was to develop a clinical balance assessment tool that aims to target 6 different balance control systems so that specific rehabilitation approaches can be designed for different balance deficits. This article presents the theoretical framework, interrater reliability, and preliminary concurrent validity for this new instrument, the Balance Evaluation Systems Test (BESTest). Design. The BESTest consists of 36 items, grouped into 6 systems: 'Biomechanical Constraints,' 'Stability Limits/Verticality,' 'Anticipatory Postural Adjustments,' 'Postural Responses,' 'Sensory Orientation,' and 'Stability in Gait.' Methods. In 2 interrater trials, 22 subjects with and without balance disorders, ranging in age from 50 to 88 years, were rated concurrently on the BESTest by 19 therapists, students, and balance researchers. Concurrent validity was measured by correlation between the BESTest and balance confidence, as assessed with the Activities-specific Balance Confidence (ABC) Scale. Results. Consistent with our theoretical framework, subjects with different diagnoses scored poorly on different sections of the BESTest. The intraclass correlation coefficient (ICC) for interrater reliability for the test as a whole was .91, with the 6 section ICCs ranging from .79 to .96. The Kendall coefficient of concordance among raters ranged from .46 to 1.00 for the 36 individual items. Concurrent validity of the correlation between the BESTest and the ABC Scale was r=.636, P Limitations. Further testing is needed to determine whether: (1) the sections of the BESTest actually detect independent balance deficits, (2) other systems important for balance control should be added, and (3) a shorter version of the test is possible by eliminating redundant or insensitive items. Conclusions. The BESTest is easy to learn to administer, with excellent reliability and very good validity. It is unique in allowing clinicians to determine the type of balance problems to direct specific treatments for their patients. By organizing clinical balance test items already in use, combined with new items not currently available, the BESTest is the most comprehensive clinical balance tool available and warrants further development., Balance deficits are one of the most common problems treated by physical therapists. Therapists need to identify who has a balance problem and then decide the best approach to rehabilitation. [...]

This article introduces a new framework for therapists to develop an exercise program to delay mobility disability in people with Parkinson disease (PD). Mobility, or the ability to efficiently navigate and function in a variety of environments, requires balance, agility, and flexibility, all of which are affected by PD. This article summarizes recent research identifying how constraints on mobility specific to PD, such as rigidity, bradykinesia, freezing, poor sensory integration, inflexible program selection, and impaired cognitive processing, limit mobility in people with PD. Based on these constraints, a conceptual framework for exercises to maintain and improve mobility is presented. An example of a constraint-focused agility exercise program, incorporating movement principles from tai chi, kayaking, boxing, lunges, agility training, and Pilates exercises, is presented. This new constraint-focused agility exercise program is based on a strong scientific framework and includes progressive levels of sensorimotor, resistance, and coordination challenges that can be customized for each patient while maintaining fidelity. Principles for improving mobility presented here can be incorporated into an ongoing or long-term exercise program for people with PD., Most people who are diagnosed with Parkinson disk ease (PD) do not consult with a physical therapist until they already have obvious mobility problems. However, it is possible that a [...]

'Neuromuscular Electrical Stimulation After Total Joint Arthroplasty: A Critical Review of Recent Controlled Studies,' by Kittelson AJ, Stackhouse SK, and Stevens-Lapsley JE, was published in the European Journal of Physical [...]

'The Bilateral Movement Condition Facilitates Maximal but Not Submaximal Paretic-Limb Grip Force in People With Post-Stroke Hemiparesis,' by DeJong SL and Lang CE, was published online in Clinical Neurophysiology on [...]