Multiple sclerosis (MS) is an immune-mediated disease that causes demyelination and degeneration within the brain and spinal cord. This may result in many impairments, including impaired ambulation, muscle weakness, abnormal tone, visual disturbances, decreased sensation, and fatigue. Rehabilitation helps patients with MS maximize independence by helping to manage and minimize impairments. Deficits seen in ambulation should be addressed to improve energy efficiency and reduce falls. Compensation through appropriate prescription of assistive devices, bracing, and wheelchairs will help improve safety. Rehabilitation can make a significant impact on achieving and maintaining quality of life and independence.
Key points
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Multiple sclerosis (MS) is an immune-mediated disease that causes demyelination and axonal degeneration within the brain and spinal cord.
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Impairments include impaired ambulation, muscle weakness, abnormal tone, visual disturbances, decreased sensation, and fatigue.
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Rehabilitation helps patients with MS maximize independence by helping to manage and minimize impairments.
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Deficits seen in ambulation should be addressed to improve energy efficiency and reduce falls.
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Compensation through appropriate prescription of assistive devices, bracing, and wheelchairs will help improve safety.
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Rehabilitation can make a significant impact on achieving and maintaining quality of life and independence.
Introduction
Multiple sclerosis (MS) is an immune-mediated disease that causes both demyelination and axonal degeneration within the brain and spinal cord. These pathologic changes in the nerves of the central nervous system (CNS) may cause many impairments, commonly including muscle weakness, increased tone, bladder dysfunction, cognitive impairment, visual impairment, sensory changes, and fatigue. One of the signature characteristics of MS is its predilection for affecting muscles and sensation innervated by the most caudal nerves: muscles and sensory structures of the feet, legs, and bladder. This is because of the cumulative impact of lesions throughout the CNS; nerve dysfunction is greatest over the longest pathways: those between the cortex and lower lumbo-sacral roots (the “cumulative impact” explanation).
There are currently a number of medications approved by the Food and Drug Administration (FDA) that can reduce the number of exacerbations and slow disease progression (disease-modifying treatments or DMTs) and one medication that may improve walking (dalfampridine [Ampyra]), none of them provide a cure. Rehabilitation aimed at maximizing patients’ current levels of function and increasing their overall independence is an important adjunct to DMTs in MS care.
Introduction
Multiple sclerosis (MS) is an immune-mediated disease that causes both demyelination and axonal degeneration within the brain and spinal cord. These pathologic changes in the nerves of the central nervous system (CNS) may cause many impairments, commonly including muscle weakness, increased tone, bladder dysfunction, cognitive impairment, visual impairment, sensory changes, and fatigue. One of the signature characteristics of MS is its predilection for affecting muscles and sensation innervated by the most caudal nerves: muscles and sensory structures of the feet, legs, and bladder. This is because of the cumulative impact of lesions throughout the CNS; nerve dysfunction is greatest over the longest pathways: those between the cortex and lower lumbo-sacral roots (the “cumulative impact” explanation).
There are currently a number of medications approved by the Food and Drug Administration (FDA) that can reduce the number of exacerbations and slow disease progression (disease-modifying treatments or DMTs) and one medication that may improve walking (dalfampridine [Ampyra]), none of them provide a cure. Rehabilitation aimed at maximizing patients’ current levels of function and increasing their overall independence is an important adjunct to DMTs in MS care.
Gait abnormalities
Patients with MS have a range of gait abnormalities, including decreased step length, decreased cadence, reduced joint movement, and increased variability of most gait parameters. These changes lead to decreased velocity, reduced endurance, increased metabolic costs, and reduced community ambulation. Even in those individuals with minimal disability (expanded disability status scale [EDSS] ≤3.5), analysis shows that persons with MS walk slower, with fewer, shorter, wider steps; have increased variability in time between steps; and spend more time in double support compared with controls.
Several types of abnormal gait patterns can arise as a result of MS; the specific pattern is dependent on the location of the lesions within the CNS. Some of the more common gait patterns are described in the following section and include spastic paresis, cerebellar ataxia, and sensory ataxia. Often a combination of patterns is seen.
Gait Patterns
Spastic paresis
Spastic paresis results from insufficient supraspinal recruitment of motor neurons in specific leg muscles during the gait cycle. Depending on which muscles are weak, limitations can be seen in stance or swing phase resulting in a variety of impairments including foot drop (ankle-foot weakness); knee hyperextension or hyperflexion; anterior, posterior, or lateral trunk lean; circumduction; and hip drop. The most common pattern in MS is asymmetric spastic paraparesis, but all patterns can be seen, including monoparesis, hemiparesis, and tetraparesis.
Ankle-foot weakness in its mildest and most common form, it is manifested by 2 characteristics:
- 1.
Weakness of ankle dorsiflexion (and sometimes associated weak push-off)
- 2.
Motor fatigue
Motor fatigue is greater weakness with greater duration of use and is also accounted for by the likelihood of increased sequential demyelinated regions encountered over the longest pathways in the CNS. This is caused by conduction block seen in partially demyelinated motor pathways over an extended period of activation, and may be associated with increase in body temperature or other causes. An easy assessment of this condition is to observe the wear pattern on the front of the sole of a shoe.
Cerebellar ataxia
Cerebellar ataxia occurs as a result of damage to the cerebellum or its connections and is characterized by incoordination, poor postural control, dysmetria, dysdiadochokinesia, and increased variability in stride length, as well as wide base of support and stooped trunk position.
Sensory ataxia
Sensory ataxia results from damage to the dorsal columns of the spinal cord that transmit proprioception, or from damage in the processing centers for afferent information, such as the thalamus or the parietal lobe. This gait is characterized by postural instability, heavy heel strikes, poor kinematics from lower limb joint position, and decreased gait velocity. This may be tested in clinic with the Romberg test: the patients with MS is asked to stand, feet together, and can do so with eyes open but not when closed. A more quantitative method of assessing posterior column function is with tibial nerve somatosensory evoked potentials (SEPs) (see the article by Kraft elsewhere in this issue for further exploration of this topic).
Weakness
Overall muscle force generated during a contraction is lower in patients with MS because of reduced central motor drive and consequent muscle recruitment, reduced muscle metabolic response, and muscle atrophy due to disuse. Strength training is known to promote neural adaptations, such as improved motor unit activation and synchronization of firing rates, both of which deteriorate rapidly with inactivity.
Strength training has been shown to be beneficial in several MS studies. Guitierrez and colleagues showed that an 8-week program of resistance training improved gait kinematics. The study found that resistance training facilitates positive changes in gait (specifically, longer strides), more time spent in swing phase, and less time in the stance and double-support phase. This study also showed improved toe clearance, which is a significant factor in decreasing falls. A trend toward improvement in the self-reported EDSS scale, which relies heavily on ambulation as a determinant of disability, was also documented. Kraft and colleagues found improved function, strength, and psychosocial well-being in a group of patients with MS after a 3-month course of strength training. DeBolt and McCubbin found that a home-based resistance program was well tolerated, caused no exacerbations in this population, and improved leg extension muscle power. This research demonstrates the critical importance of initiating an individualized home exercise program in a patient with MS. It is important that these patients are referred to physical therapy early on in their disease process to maximize strength and independence. Rehabilitation can make a significant impact on achieving and maintaining quality of life and independence.
Spasticity
Spasticity is commonly seen in the MS population. An increased level of tone is associated with higher levels of disability. Barnes and colleagues investigated the prevalence of spasticity in 68 subjects and identified that 97% had spasticity in at least one leg that was present at a clinically significant level in 47%.
There are several muscles that commonly interfere with ambulation in the MS population. Hypertonic plantarflexors cause the foot to point down, making toe clearance in the swing phase of gait difficult, resulting in “catching the toe” and falling. Increased spasticity in the quadriceps muscles makes bending the knee during the swing phase and advancing the leg difficult. Hip adductors are also commonly affected, creating a scissoring gait. Increased tone in the hamstrings makes it difficult for the knee to be fully extended at midstance, limiting leg swing advancement, and causing the patient to bear weight on a bent knee. This increases the risk for knee buckling and results in decreased weight bearing, shorter step length, and decreased stance time on the affected limb.
Fatigue
We were the first to describe fatigue as a symptom of MS, and have identified it as the patents’ most common symptom, occurring in 77% of patients with MS. Exercises and ambulation should be spread throughout the day, and the time of day can be an important factor in the success of the patient’s exercise program. Patients with MS also report greater fatigue in warmer climates, because of heat sensitivity. Cooling jackets, increased hydration, fans, air conditioners, and showers are all important strategies to maintaining a cooler core temperature to help reduce this.
Balance
Many people with MS have poor balance, resulting in frequent falls. Balance requires the integration of 3 sensory systems, visual, somatosensory, and vestibular, which inform the body about where it is in space, as well as its direction of movement and relationship to the environment.
Visual system
The visual system provides information about how the body moves in its environment as well as allowing it to avoid obstacles. With proprioceptive deficits, vision can be used as a substitution to preserve balance.
Somatosensory system
This system provides the brain information regarding location of the body and limbs in space, pressure and force exertion, and direction of limb movement. Because of the “cumulative impact” (see earlier in this article) proprioception from the lower limbs is the most frequently involved afferent system in MS, and is the most common cause of imbalance in MS.
Vestibular system
The vestibular system coordinates eye and head movements and assists with balance. It is involved with ocular reflexes and a complex canal system that informs the brain about head position relative to gravity and angular/linear velocity. Vestibular disorders are associated with vertigo (an illusion of movement, a spinning sensation), imbalance, inability to maintain stable gaze during head movement, and gait ataxia.
Balance deficits
Balance during stance and gait requires central sensory integration of 3 sensory systems with suitable motor activity and sensorimotor changes that fluctuate based on body position, intention, and the environment. Central integration of sensory information in the cortex results in a coordinated motor output of the head, arms, legs, and trunk, and is used to control the center of mass in reaction to perturbations that are either self-generated in anticipation of movement or are caused externally. If there is interruption in this communication, balance deficits are often seen. In a 2010 literature review by Cameron and Lord, the mechanisms underlying imbalance in MS, such as changes in postural control, are likely primarily the result of slowed somatosensory conduction and impaired central integration, as opposed to being a result of cerebellar lesions.
Patients with MS demonstrate a decreased ability to stand still when compared with healthy controls, as evidenced by increased postural sway when their eyes are closed or base of support is decreased. Huisingaa and colleagues also found that patients with MS have increased sway in both the anterior/posterior and mediolateral directions. In MS, it is possible that poor integration of vestibular information and slowed somatosensory feedback lead to the increased sway variability.
Patients with MS demonstrate slowed and shortened movement when reaching or stepping forward toward their limits of stability, and they have decreased ability to control anterior/posterior sway in response to unanticipated balance disturbances and perturbations. Krishnan and colleagues uncovered the underlying impairments in anticipatory postural control showing that compared with healthy controls, patients with MS have decreased and delayed anticipatory postural adjustments (APAs), as well as an increased backward compensation of center of pressure (CoP) displacement when reaching. These delays in APAs could be attributed to poor information processing in the CNS, but research has also shown they could be the result of delayed somatosensory conduction in the spine.
Balance intervention
Studies have evaluated the efficacy of a variety of interventions for improving balance in patients with MS. Based on Cameron and Lord’s literature review, interventions related to sensory facilitation and dual-task practice are most effective. These specifically address the proprioceptive and central integration deficits that trigger imbalance and falls in patients with MS. Task-specific, dual-task training has been used in various neurologic patient populations to improve postural control and has been hypothesized to be effective in patients with MS. It is most effective when done in massed, variable, and random practice to promote neuroplasticity. Therapy that focuses on sensory facilitation and integration provides controlled sensory input from the vestibular, tactile, and proprioceptive systems. The retraining of sensory strategies may be an important way to recover both static and dynamic balance. Interventions specifically intended to improve balance or balance-related tasks show better results when compared with lower extremity strengthening or aerobic exercises.
There is also research to support vestibular rehabilitation of patients with MS, with or without vestibular symptoms. Both Zeigelboim and colleagues and Pavan and colleagues showed that the use of vestibular exercises in treatment of patients with dizziness and relapsing-remitting MS was able to produce a small, significant change in balance and decreased disability via the Dizziness Handicap Inventory. Herbert and colleagues demonstrated in a single-blinded, randomized controlled trial that vestibular rehabilitation exercises were an effective tool to decrease fatigue, improve postural control, and reduce disability in patients with MS with or without dizziness. Patients performed a 6-week progressive vestibular rehabilitation program focused on standing and half-kneeling balance activities that also incorporated eye, head, and body movements. Herbert and colleagues hypothesized that because postural control and dizziness reflect central processing, further support is lent to the idea that impairments of central sensory processing also contribute to fatigue in patients with MS.
Recent preliminary research provides insight into potentially beneficial intervention strategies for balance training in patients with MS. An 8-week core exercise program was shown to improve balance and gait in 62% of a small sample of patients with MS. Preliminary research on the effect of therapeutic horseback riding and hippotherapy in patients with MS has shown potential for improved postural stability and gait, although further research is required. There is also promising research on the incorporation of the Nintendo Wii Fit in the prescription of balance exercise programs. Balance-based torso weighting, which involves small, subtle weighting of the trunk for improved upright mobility and to decrease ataxia, has also been researched. Studies have shown that this can be effective and demonstrates immediate improvements in gait velocity and functional activity. Overall, further study and research is needed to fully determine the best recommendations for effective balance interventions in patients with MS.
Falls
Falls are common in persons with MS, with 1-time fall prevalence reported retrospectively between 50.5% and 58.2% and prospectively between 52.0% to 63.0% in studies collecting information on fall prevalence greater than 2 months. Patients who have had 2+ falls demonstrate a prevalence retrospectively between 27.9% and 64.0%, and prospectively between 35.0% and 43.0%, indicating that the incidence of multiple falls in the MS population is extremely common.
Peterson and colleagues reported 50% of falls were injurious with 23% requiring medical care. Similar results were found by Matsuda and colleagues with 58.5% and 18.9% respectively. Another study by Matsuda and colleagues reported that 18.5% of fallers sought medical attention, whereas a study by Nilsagard and colleagues found a higher number of 26.6%. Cameron and colleagues found a smaller number of veterans with MS had injurious falls at 2.8%. Interestingly, Kasser and colleagues demonstrated that 81% of 1-time fallers reported injury, whereas recurrent fallers reported less injury at 47%. Differences in self-report were found in 1-time fallers, with falls more related to extrinsic environmental factors rather than the intrinsic disease-process–oriented falls found in recurrent fallers.
The study by Kasser and colleagues is not the only one to examine differences between 1-time fallers and recurrent fallers. Matsuda and colleagues also found significant differences in factors related to falling, suggesting that 1-time fallers are a distinct group from both nonfallers and recurrent fallers. However, across all groups, only 50.9% of people who fell reported discussing falls with a health care provider (HCP), and having an injurious fall or one requiring medical attention did not increase the likelihood of reporting these falls. Ninety-four percent of these reported falls were met with generalized fall-prevention strategy advice, suggesting that a more focused fall history discussion or individualized prevention strategies may increase the efficacy of fall reduction. For HCP to understand how to reduce falls, it is important to understand the multiple factors showed to be related to falls in MS ( Table 1 ).
| Reason for Falls | Nilsagard et al, 2009 | Finlayson et al, 2006 | Matsuda et al, 2011 | Peterson et al, 2008 | Sosnoff et al, 2011 | Coote et al, 2012 | Nilsagard et al, 2009 | Kasser et al, 2011 | Cattaneo et al, 2002 | Prosperini et al, 2011 | Peterson et al, 2007 | Cattaneo et al, 2012 | D’Orio et al, 2012 | Cameron & Lord, 2010 | Matsuda et al, 2012 | Cameron et al, 2011 |
| Study focus | Accidental falls | Factors for falls | HCP response to falls | Injurious falls | Falls risk in MS | Falls using AD | Perceived fall risk | Falls in women | Factors for falls | Lesion site and falls | FoF falls | VTC in MS vs HS | Cognition and falls | Postural control | FoF & reasons for falls | Falls with injury |
| Balance deficits & postural control | (+) | (+) | (+) | (+) | (−) | (+) | (+) | (+) | (+) | (+) | (+) | |||||
| Age | (−) | (−) | (−) | (+) | (−) | (−) | (−) | (−) | (−) | (−) | ||||||
| Gender (F or M) | (−) | (+M) | (−) | (−) | (−) | (−) | (−) | (+F) | (−) | (+F) | ||||||
| Walking ability | (+) | (−) | (+) | (+) | (+) | (+) | (+) | |||||||||
| MS status (stable vs deteriorating) | (+) | (+) | (−) | (+) | (−) | (+) | (+) | (+) | (−) | |||||||
| Use of assisted device | (+) | (+) | (−) | (+) | (−) | (+) | (+) | (−) | ||||||||
| Cognition | (−) | (+) | (+) | (+) | (−) | (+) | ||||||||||
| FoF | (−) | (+) | (+) | (−) | (+) | |||||||||||
| Weakness/Fatigue | (−) | (+) | (+) | (+) | (+) | |||||||||||
| Spasticity | (+) | (+) | (+) | (+) | ||||||||||||
| Proproprioception | (+) | (+) | (−) | (+) | (+) | |||||||||||
| Bladder incontinence | (−) | (+) | (−) | (−) | (+) |
In addition to the findings in Table 1 , falls in patients with MS have been found to be associated with low economic status, infratentorial lesions, environmental factors, impaired central integration of afferent information, temperature, osteoporosis, and poor mental health. The relationship between falls and other factors, such as transfer ability, fall history, use of a wheelchair, ability in activities of daily living, and the role of vision has demonstrated variable results in previous studies. Accumulation of body impairments and medications have been studied but thus far have not been shown to be associated with increased risk for falls.
Fear of falling (FoF) is common in patients with MS, with studies indicating a range of 41.1% to 60.0% of fallers reporting FoF. However, FoF is not limited to fallers, as FoF is also reported in 25.9% to 68.0% of nonfallers. FoF can also lead to activity curtailment, as was shown in a study by Peterson and colleagues, in which 63.5% of both groups reported FoF and 82.6% of fallers and 46.6% of nonfallers limited their activity as a result. Activity curtailment related to FoF has been demonstrated in other studies with 42.9% to 8.8% and 27.7% to 71.4% of fallers and nonfallers reporting limiting their activity due to FoF respectively.
Few studies have looked at fall prevention and treatment of falls in MS. Finlayson and colleagues suggested a 12-hour discussion group entitled “Safe at Home BAASE,” focusing on increasing knowledge and skills for fall risk management and behavior modification to reduce fall risk. Results demonstrated participants reported gains in knowledge, skills, and behaviors to improve management of risk factors for falls. Cattaneo and colleagues studied groups of patients with MS receiving 12 sessions of motor balance training with and without emphasis on sensory balance training versus conservative therapy. Results showed both balance training groups significantly improved dynamic and static balance reducing falls. Coote and colleagues found a 10-week group class focused on balance and strength significantly reduced both the number of fallers and the number of falls. Further study for treatment and intervention is warranted because of the high number of falls reported in this population.
Common outcome measures in multiple sclerosis for ambulation and balance
Walking and balance limitations are some of the most visible and common manifestations of impairment in MS. Regular assessment of balance and walking with reliable and valid outcome measures helps direct patient care and intervention. The following sections describe common outcome measures used by physical therapists in the clinical setting to evaluate gait and balance.
Walking measures
12-item multiple sclerosis walking scale
The 12-item MS walking scale (MSWS-12) is a self-report measure of the impact of motor fatigue on walking. Nilsagard and colleagues found a cutoff score of 75 had a sensitivity of 52% and a specificity of 82% in predicting fallers versus nonfallers in 76 patients with MS; EDSS were scores 3.5 to 6.0. This study also found a test-retest intraclass correlation coefficient (ICC) of 0.94.
EDSS
The EDSS is a 0- to 10-point scale in which walking is measured in the middle range from 4.5 to 7.5 using need for assistive device and maximum distance walked up to 500 m as measures. The EDSS is useful for assessing disease severity; however, it is only marginally useful in assessing walking performance because many researchers have found a bimodal frequency distribution in which the middle ranges are not as well represented. Historically, the EDSS demonstrates poor psychometric properties with low sensitivity, poor reliability, and low responsiveness to change.
Hauser ambulation index
The Hauser ambulation index (HAI) is a 10-point scale (0 = no impairment to 9 = confinement to wheelchair) dependent on need for an assistive device and the time to walk 25 feet. In one study by Cattaneo and colleagues, the HAI was not able to distinguish between fallers and nonfallers. This scale has demonstrated high inter-rater and intra-rater reliability at ICC of 0.96 and 0.93, respectively, but has demonstrated low responsiveness to change with an effect size of 0.2.
Modified functional walking categories
The modified functional walking categories (MFWC) is a categorical scale from 1 (physiologic walker) to 6 (unlimited community walker) that focuses on the skills necessary for home and community ambulation, including the ability to negotiate curbs, crowded environments, stairs, and uneven terrain in the community. It also addresses levels of supervision needed for walking within and outside of the home and home mobility with and without a wheelchair. In a 2011 study by Kempen and colleagues, a specific cutoff gait speed was found for each level of community walking on the MFWC using 10-minute walk test (10MWT) (unlimited community walker [cw] = 1.63 m/s, least-limited cw = 1.35 m/s, most-limited cw = 1.04 m/s, unlimited household walker = .48 m/s).
6MWT and 2MWT
In a study by Goldman and colleagues, the 6MWT demonstrated excellent intra-rater ICC of 0.95 and inter-rater reliability with an ICC of 0.91 in 40 patients with EDSS of 0 to 6.5 (20 controls). Patients with MS demonstrated reduced 6MWT distances compared with controls and 6MWT distance was reduced with increasing disability. Learmonth and colleagues established the minimal detectable change (MDC) to be 76.2 m with a standard error of measurement (SEM) to be 27.48 m. In a study by Wetzel and colleagues, 6MWT performance was found to differ significantly between patients with MS with mild (EDSS <4 = 402.4 m) and moderate (EDSS 4.0–6.5 = 193.7 m) disability. They found that decreased balance confidence and lower extremity power were correlated with increased risk for disability, as patients with MS were not able to reach the 350-m threshold required for even a single-task community ambulation. Because of the possible constraints on patients with MS due to fatigue, the 2MWT test may be more feasible than the 6MWT in patients with MS. However, the reliability of the 2MWT has not yet been reported.
Six-spot step test
In the 6-spot step test (6SST), the patient is instructed to walk as fast as possible while kicking blocks out of marked circles with the same foot alternating between using the medial and lateral side of the foot around a rectangular field 1 m wide × 5 m in length. The 6SST is scored by calculating the mean time of 4 runs (2 runs with each foot). The 6SST demonstrated excellent test-retest reliability with an ICC of 0.95 and was strongly correlated with the Timed 25-ft Walk (T25FW) with a Spearman’s r of 0.80.
Gait speed measures
10MWT
The 10MWT has demonstrated excellent reproducibility in a study with an ICC of 0.92 with the smallest percentage difference needed to detect genuine change of –23% or +30% change in time for the 10MWT. There is little consensus among studies on what constitutes a minimally important clinical difference (MICD), with some studies showing an increase of 0.17 m/s or a decrease of 0.12 m/s, or a change of 0.26 m/s in speed verses a change in time of 28% as meaningful. One study reported a strong correlation of r = 0.95 when comparing maximal speed of the 10MWT and the 6MWT.
Timed 25-foot walk
In patients with MS and EDSS 5.0 to 6.5, Learmonth and colleagues found the reliability of the timed 25-foot walk (T25FW) to be ICC of 0.94 with an MCD of 12.6 seconds and the standard error of measurement to be 4.56 seconds. Multiple studies report a more than 20% change in time on the T25FW as a clinically meaningful difference in gait speed.
30MWT
The 30MWT has demonstrated excellent reproducibility with ICC of 0.93. The smallest percentage difference needed to detect genuine change varies with disability status (−14% to +17% change in time in those with EDSS ≤4 vs –38% to +60% for EDSS >4), with those with less disability demonstrating smaller performance changes for meaningful differences.
Balance measures
Activities-specific balance confidence
The activities-specific balance confidence (ABC) scale is a 16-item self-report measure in which patients rate their percent of balance confidence (0%–100%) in performing several functional activities. It was validated in people with mild to moderate MS with high ICC of 95 and was able to distinguish multiple fallers from nonfallers, but not from single fallers. Cattaneo and colleagues also validated the ABC’s test-retest reliability at 0.92 with the standard error of measurement of 7.14. In another study by Cattaneo and colleagues, a score of 40% was identified as a cutoff for risk of falls with a sensitivity of 65% and specificity of 77%.
Balance evaluation systems test
This clinical balance assessment tool of 36 items examines different functional balance control systems for a comprehensive balance evaluation. In a small study (n of 13 patients with MS and 13 healthy controls) by Jacobs and Kasser, subjects with MS exhibited significantly lower scores on the balance evaluation system test (BESTest) than controls, which also correlated with peak CoP displacements on leaning and postural response tasks and step velocity during step initiation but not to anticipatory postural reactions. The regression models demonstrated that the BESTest can provide 86% of the sensitivity to identify fallers and 95% of the specificity to identify nonfallers.
Berg balance scale
The Berg balance scale (BBS) is a classic balance outcome measure composed of 14 items designed to assess static balance and fall risk. In patients with MS EDSS of 5.0 to 6.5, Learmonth and colleagues found the reliability of the BBS to be ICC of 0.96 with an MCD of 7 points and the standard error of measurement to be 3 points. In one study by Cattaneo and colleagues, the inter-rater reliability was 0.96 with test-retest reliability at 0.96 with the standard error of measurement ranging between 1.48 and 1.51. In another study by Cattaneo and colleagues, a score of 44 was identified as a cutoff for risk of falls with poor sensitivity of 40% but good specificity of 90%, indicating the BBS better identifies nonfallers correctly.
Dizziness handicap inventory
The dizziness handicap inventory (DHI) is a 25-item self-assessment designed to evaluate the self-perceived effects of dizziness on daily function. In one study by Cattaneo and colleagues, test-retest reliability was found with an ICC of 0.90. In another study by Cattaneo and colleagues, a score of less than 59 was identified as a cutoff for risk of falls with a sensitivity of 50% and specificity of 74%.
Dynamic gait index
The dynamic gait index (DGI) is an 8-item ambulation assessment to measure dynamic balance. The DGI has demonstrated good inter-rater reliability with an ICC of 0.98 and intra-rater reliability from 0.76 to 0.98 in patients with MS EDSS of 2.0 to 6.0. In another study, inter-rater reliability was 0.94 with test-retest reliability at 0.85. In 2006, Cattaneo and colleagues, also found that a score less than 12 was the cutoff for risk of falls with poor sensitivity of 45% but moderate to good specificity of 80%, indicating the DGI identifies nonfallers better than fallers.
Timed up and go
The timed up and go (TUG) is a short test designed to assess walking, transfers, and fall risk. In patients with MS EDSS of 5.0 to 6.5, Learmonth and colleagues found the reliability of the TUG to be ICC of 0.97 with an MCD of 10.6 seconds and the standard error of measurement to be 3.81 seconds. Similar findings were reported by Nilsagard and colleagues, with an ICC of 0.91 for test-retest reliability. The smallest percentage difference needed to detect genuine change was approximately a –24% or +31% change in time for the TUG. However, in a study by Cattaneo and colleagues, no cutoff scores were established for falls, as the TUG was not able to discriminate between fallers and nonfallers.
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