Improved Sway Velocity and Directional Balance ImprovementIn Two Individuals With Spinocerebellar Ataxia With Balance-Based Torso-Weighting

Cynthia Gibson-Horn PT, Susan Perlman MD

MethodsAbstract

Background

Results

ConclusionsReferences

OBJECTIVE: To determine immediate and short-term impact of application of Balance-Based Torso-Weighting (BBTW) and BalanceWear® Therapy (BWT) on sway patterns in patients with spinocerebellar ataxia (SCA). BACKGROUND: Patients with SCA exhibit impairments in balance and mobility impairments which often result in falls. BBTW demonstrated immediate improvement in gait and balance in MS studies. BWT involves the patient wearing BalanceWear®; incorporating targeted weighted sensory inputs which are strategically placed to augment neuro-sensory information. DESIGN/METHOD: Sway velocity, direction, and magnitude were measured with ADPM sensors placed posteriorly at the lumbosacral junction before and after BBTW immediately and after either 3 or 10 days of BWT with two individuals with midline cerebellar atrophy confirmed by MRI.PRIMARY OUTCOME MEASURES: SwayRESULTS: In Patient 1, a 46 year old woman with a 12 year history of a slowly progressive cerebellar syndrome with upper motor neuron features the composite score (CS) was reduced from 95 to 49 m/s immediately from pre-BBTW to post-BBTW. Patient 1 wore the BWT for 18 hours over two days and was retested 15 hours after BWT. On day three; her CS was reduced from 95 to 24 m/s and direction of sway improved. In Patient 2, a 72 year old woman with a 6 year history of a slowly progressive, idiopathic, cerebellar syndrome the composite score (CS) of sway velocity improved from 98 to 71 m/s from pre-BBTW to post-BBTW same session. Patient 2 wore BWT 10 hours each day for 10 days. On day 11 she was retested without BWT. Her CS was reduced from 98 to 68 m/s. Her directional imbalance improved. CONCLUSION: Application of BBTW and BWT may be beneficial in reducing sway and improving directional stability in patients with SCA. More research is indicated in this patient population, where minimal information is available for symptom management of falls and mobility challenges.

©Cynthia Gibson–Horn MTI 2015 Printed by

Balance-Based Torso-Weighting ProtocolPatient stood with their feet in the Romberg position •Observation of body sway •Resistive Rotations and Perturbations applied at upper and lower torso

• Anterior• Posterior• Lateral

•Small Weighted TSIs were applied strategically in BalanceWear to improve the loss of balance and alleviate the rotational asymmetry found in the BBTW (3-5)

Patient was instructed to wear BalanceWear for 8 hours per/day and remove BalanceWear the night before retesting on either day 3 or 11

Measurement: Clinical Test of Sensory Integration of Balance (CTSIB)•One Opal movement monitor with triaxial accelerometers, gyroscopes, and magnetometers was applied at the LS junction •Patient stood with their arms at their side in a comfortable position•Verbal instructions given according to the APDM protocol

• Before the BBTW protocol• With TSI’s wearing BalanceWear day one • Without BalanceWear

•Eyes open, hard surface•Eyes closed, hard surface Sensor •Eyes open, foam surface•Eyes closed, foam surface.

Postural disorders in cerebellar ataxia are a major cause of imbalance and falls.(1) Large sway velocities are associated with falls in the elderly (2) and may also result in falls in people with SCA. (2) Balance-Based Torso-Weighting (BBTW) is a new treatment for balance and gait impairment. BBTW is associated with improving balance and gait in several studies in people with MS.(3-5) During BBTW patient-specific directional static and dynamic imbalance is identified in all planes of movement while the patient stands in the Romberg position. Perturbations are tested and rated from no loss [0] to loss in all direction equaling a fall [48]. BalanceWear Therapy (BWT) involves obtaining a customized balance orthosis the patient wears with strategically placed targeted somatosensory stimulating inputs (TSIs) in the form of small weights titrated to improve three dimensional control of balance in the Romberg position and dynamically. This case report series is the first to demonstrate the use of APDM motion sensors on sway and directional loss of balance in Clinical Test of Sensory Integration of Balance (CTSIB) in people with cerebellar ataxia and BalanceWear Therapy (BWT).The CTSIB protocol helps determine which sensory system (visual, somatosensory, or vestibular) a subject relies on to maintain balance.(6) APDM has further bolstered the quality of the test by instrumenting it with Mobility Lab™ software..

BalanceWear Therapy was successful in improving postural control; velocity and direction of imbalance immediately, same session in two patients with SCA. In the short-term when BalanceWear was removed there appeared to be carryover in ability on the CTSIB. Future research should involve testing twice on the APDM to account for learning and on greater numbers of individuals with SCA to determine if falls and risk decreases, and mobility improves over time.

1. Marquer A, Barbieri G, Perennou D. The assessment and treatment of postural disorders in cerebellar ataxia: a systematic review (2014). Annals of Physical and Rehabilitation Medicine 57(2):67-78.

2. Muir J, Kiel D, Hannan M, Magaziner J, Rubin C. Dynamic parameters of balance which correlate to elderly persons with a history of falls (2013) 8(8) e70566.

3. Gorgas AM, Widener GL, Gibson-Horn C, Allen DD. Gait changes with balance-based torso-weighting in people with multiple sclerosis (2014). Physiother Res Int 20(1):45-53.

4. Hunt CM, Widener G, Allen DD. Variability in postural control with and without balance-based torso-weighting in people with multiple sclerosis and healthy controls (2015). Phys Ther 94(10):1489-1498.

5. Widener GL, Allen DD, Gibson-Horn C. Randomized clinical trial of balance-based torso weighting for improving upright mobility in people with multiple sclerosis (2009). Neurorehabil Neural Repair 23(8):784-791

6. Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction of balance. Suggestion from the field (1986). Phys Ther 66(10):1548-1550. 

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Sway Scores Improve with BalanceWear Therapy

Sway Direction Improve With BalanceWear Therapy

Patient 1 Patient 2

Scores in the green range are normal

0

20

40

60

80

100

120

Pat 1 Pat 2

Before BWT

With BWT

After BWT

Sway Velocity Normal Sway Velocity Toward Normal Normal

DX Age BWT

Patient 1 SCA 46 3 days

Patient 2 SCA 72 10 days

Demographicsm/sec

Sway Reduction Associated

with Decreased Fall Risk (2)

TSI’s areIndividual specific,

based on each person’s

balance loss