Multiple Sclerosis
Table 4: Tests Used for the Specific Assessment of Balance and Prediction of Falling in Multiple Sclerosis Test Method
Purpose
Berg Balance Test
Details of Assessments Included
Measures ability to balance. Subjects are challenged to maintain balance with narrowing base of support, starting seated and
Modified Clinical Examines postural sway in Test for Sensory 4 conditions. Interaction on Balance
progressing to one leg standing. Measures weight shifting, turning and reaching. The highest score is 56 points. A score of 45 usually separates fallers from non-fallers. Patient’s balance is examined with their eyes open or closed while being rocked on a moving platform, which has either a firm or a foam surface. Composite sway is the mean sway speed averaged over the 4 conditions.
100% Limits of Maximum angle a person of Ability of patients to shift their Stability Test
a given height can sway the centre of pressure from a centre body over the feet without losing balance and taking a step.
Tinetti Two separate sections Performance
Overall Mobility Assessment (POMA)
measuring balance and gait. 9 tests including sitting, rising, standing and turning; maximum score 16. Gait: elements of a
point to 8 targets placed around the centre of pressure: front, sides, back and 4 diagonal points.
Balance: patient is asked to complete
Equipment Needed, Validity of Data, Time to Perform and Cost
Minimal equipment needed.
Minimal cost. Advantages/Disadvantages
Good reliability has been established in studies on the elderly but not in MS.40
High cost of
Test–retest reliability was high for
equipment needed. standing on a firm surface with eyes open or closed.42
Patient-perceived
imbalance correlated poorly with assessment of postural stability.43
Requires a Balance Moderate test–retest reliability of
Master instrument and movement time to targets and experienced operator. path length to targets.42 20–30 minutes
to complete. High cost.
Chair, stopwatch, 15-inch walkway. 15 minutes to complete.
patient’s gait are observed over 7 tests: Low cost. step length, symmetry, continuity, path, walking stance; maximum score 12.
facets of gait. Performance is graded on a scale of 0–3. The neurologist or technician observes the patient performing tasks that include walking at different speeds for fixed time periods, walking while their head is turned and ability to avoid obstacles while walking. The DGI has been shown to be a reliable and valid method, the results of which are inversely correlated with results from a timed walk over a 6.1m distance.28
The TUGT was primarily designed as a means of assessing the risk of falling in the elderly, but it also addresses wider aspects of mobility.29–34
The TUGT method is a useful assessment of mobility but evaluation in MS patients has been limited.35,36
This timed test requires subjects to rise from an armchair, walk three metres, return and sit down as quickly as they are able. Subjects with higher scores were generally less mobile and at greater risk of falling. A study of 413 community-dwelling and 78 institutionalised elderly women showed that reduced levels of physical activity and residence in an institution were strongly associated with poorer performance on the TUGT (p
The T25FT is often used
as a stand-alone test of mobility (see Table 3). As a measure of mobility it is limited in scope, as it only gauges walking speed and not other specific characteristics of gait or balance. The T25FT is an integral part of the MSFC test, which was discussed above under methods for general assessment of disability in MS.37,38
Patients are instructed to walk as quickly as possible between marked circles in a rectangular floor area measuring 1x5m
66
In addition to the five preliminary tests listed by the consensus group, the Six Spot Step Test (SSST) has recently been used to assess MS patients.39
following diagonal paths and knocking wooden blocks out of each circle using the same foot (see Figure 1). A study in Denmark and The Netherlands of 151 patients with MS showed that the SSST performed better than the T25FW in terms of dynamic range, floor effect and discriminatory power. It was suggested by the authors that this might be a better test to use as part of the MSFC described above, but further research is required.
There are many more tests of mobility that have been used for limited numbers of investigations in MS patients (see Table 3). The choice of test usually depends on investigator preference or established practice at each treatment centre. A simple alternative to these tests is observation in a controlled clinical setting; however, this approach requires experience and a thorough understanding of normal and abnormal gait and has poor inter-rater reliability.4
Given the
multiplicity of test methods available, it may be necessary to establish new guidelines that recommend particular methods and attempt to standardise assessments used at different treatment centres and in clinical trials.
Methods for the Assessment of Balance and Prediction of Falling in Multiple Sclerosis Several different tests have been used in MS patients to specifically assess balance or assess it as part of a wider determination of mobility (see Table 4). Some of these tests, such as the Berg Balance Test, require no special equipment. The patient completes a questionnaire and is then asked to make a number of defined movements while initially sitting and then moving to a standing position and then finally balancing on one leg.40
Results using this method showed that use of an EUROPEAN NEUROLOGICAL REVIEW
Inter- and intra-rater reliability good to excellent when evaluated in Parkinson’s disease patients; limited data available for use in MS.41
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