Original Article
Influences of visual and supporting surface conditions on standing postural control and correlation with walking ability in patients with post-stroke hemiplegia
J. Phys. Ther. Sci. 27: 1323–1327, 2015
Nanami Okawara1, 2)*, Shigeru Usuda2) 1) Public
Nanokaichi Hospital: 643 Nanokaichi, Tomioka, Gunma, Japan School of Health Sciences, Gunma University: 3-39-22 Showa, Maebashi, Gunma, Japan
2) Graduate
Abstract. [Purpose] To quantify the influence of visual and under-foot-surface conditions on standing balance in patients with post stroke hemiplegia and examine associations of this ordinal score with somatosensory disturbance and walking ability. [Subjects] Sixty-six patients with post-stroke hemiplegia. [Methods] Standing balance was tested in 4 conditions (firm floor or foam rubber surface with eyes open or eyes closed) for 30 s per condition and scored using a 5-category ordinal scale. The accuracy of the standing balance score to distinguish patients above/below cut-offs for the timed up-and-go test (14 s) and functional ambulation category (4) was determined. [Results] Standing balance score was correlated with sensory impairments (tactile and vibration perception) and walking ability (up-and-go and functional ambulation category). The standing balance score distinguished patients with up-and-go times ≤14 and >14 s with moderate sensitivity and specificity, and distinguished patients with functional ambulation category 14 s, and FAC 14 s is because of the differences of the standing balance test and TUG. The standing balance test measures static balance, whereas the TUG test requires dynamic balance and walking17). Some patients who had a TUG time >14 s had a high score on the standing balance test. Balance incorporates many systems including stability limits, postural responses, sensory organization, and gait stability26); thus, therapists need to be able to differentiate the contribution of the different underlying systems to balance problems and fall risk. Hence, therapists need to perform a comprehensive balance test for all post-stroke patients. The limitations of this study are that the balance test used measures only static standing balance and is therefore
1327 insufficient to inform clinical decision-making. Patients with post-stroke hemiplegia have multiple motor or sensory impairments; therefore balance impairments should be assessed using a comprehensive tool such as the Balance Evaluation System Test26). Likewise, a computerized force platform is commonly used to measure standing balance19); however, this equipment is expensive and not readily available in clinics. However, the static standing balance test used in the present study involves standing with eyes closed or open on a firm surface or foam rubber, is easy and safe to use and does not require any special or expensive equipment. As our results indicate standing balance ordinal score is correlated with sensory disturbance and walking ability, analysis of the pattern of instability among the 4 conditions provides therapists insight regarding which sense a person is dependent on to maintain stability2). A follow-up intervention study assessing the validity and reliability of this ordinal score system in clinical settings as well as efficacy as an outcome measurement for evaluating patients’ performance should be performed. ACKNOWLEDGEMENTS This study was supported by the Hidaka Hospital and Day Service Center of the Hidaka-kai Group. We sincerely appreciate Hiroyuki Gokan for his supervision and the staff of the Hidaka Hospital and Day Service Center of the Hidaka-kai Group for their cooperation. Finally, we are grateful to all the participants. REFERENCES 1) Horak FB, Nashner LM, Diener HC: Postural strategies associated with somatosensory and vestibular loss. Exp Brain Res, 1990, 82: 167–177. [Medline] [CrossRef] 2) Shumway-Cook A, Horak FB: Assessing the influence of sensory interaction of balance. Suggestion from the field. Phys Ther, 1986, 66: 1548–1550. [Medline] 3) Bonan IV, Colle FM, Guichard JP, et al.: Reliance on visual information after stroke. Part I: Balance on dynamic posturography. Arch Phys Med Rehabil, 2004, 85: 268–273. [Medline] [CrossRef] 4) Bonan IV, Yelnik AP, Colle FM, et al.: Reliance on visual information after stroke. Part II: Effectiveness of a balance rehabilitation program with visual cue deprivation after stroke: a randomized controlled trial. Arch Phys Med Rehabil, 2004, 85: 274–278. [Medline] [CrossRef] 5) Anacker SL, Di Fabio RP: Influence of sensory inputs on standing balance in community-dwelling elders with a recent history of falling. Phys Ther, 1992, 72: 575–581, discussion 581–584. [Medline] 6) Cohen H, Blatchly CA, Gombash LL: A study of the clinical test of sensory interaction and balance. Phys Ther, 1993, 73: 346–351, discussion 351–354. [Medline] 7) Wrisley DM, Whitney SL: The effect of foot position on the modified clinical test of sensory interaction and balance. Arch Phys Med Rehabil, 2004, 85: 335–338. [Medline] [CrossRef] 8) Madureira MM, Takayama L, Gallinaro AL, et al.: Balance training program is highly effective in improving functional status and reducing the
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risk of falls in elderly women with osteoporosis: a randomized controlled trial. Osteoporos Int, 2007, 18: 419–425. [Medline] [CrossRef] Ricci NA, de Faria Figueiredo Gonçalves D, Coimbra AM, et al.: Sensory interaction on static balance: a comparison concerning the history of falls of community-dwelling elderly. Geriatr Gerontol Int, 2009, 9: 165–171. [Medline] [CrossRef] van der Linden MH, van der Linden SC, Hendricks HT, et al.: Postural instability in Charcot-Marie-Tooth type 1A patients is strongly associated with reduced somatosensation. Gait Posture, 2010, 31: 483–488. [Medline] [CrossRef] Yu J, Jung J, Cho K: Changes in postural sway according to surface stability in post-stroke patients. J Phys Ther Sci, 2012, 24: 1183–1186. [CrossRef] Okawara N, Usuda S: Influence of visual and surface conditions on standing postural control in patients with post-stroke hemiplegia. Rigakuryouhou Kagaku, 2014, 29: 33–38 (in Japanese). [CrossRef] Kim D, Ko J, Woo Y: Effects of dual task training with visual restriction and an unstable base on the balance and attention of stroke patients. J Phys Ther Sci, 2013, 25: 1579–1582. [Medline] [CrossRef] Lee YJ, Park J, Lee D, et al.: The effects of exercising on unstable surface on the balance ability of stroke patients. J Phys Ther Sci, 2011, 23: 789–792. [CrossRef] Chino K, Sonoda S, Domen K, et al.: Stroke Impairment Assessment Set (SIAS): a new evaluation instrument for stroke patients. Jpn J Rehabil Med, 1994, 31: 495–495. Fugl-Meyer AR, Jääskö L, Leyman I, et al.: The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med, 1975, 7: 13–31. [Medline] Di Fabio RP, Badke MB: Relationship of sensory organization to balance function in patients with hemiplegia. Phys Ther, 1990, 70: 542–548. [Medline] Brunnstrom S: Movement Therapy in Hemiplegia. Ney York: Harper & Row Publications.1970, pp 1–30. Podsiadlo D, Richardson S: The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc, 1991, 39: 142–148. [Medline] Holden MK, Gill KM, Magliozzi MR: Gait assessment for neurologically impaired patients. Standards for outcome assessment. Phys Ther, 1986, 66: 1530–1539. [Medline] Collins S, Visscher P, De Vet HC, et al.: Reliability of the Semmes Weinstein Monofilaments to measure coetaneous sensibility in the feet of healthy subjects. Disabil Rehabil, 2010, 32: 2019–2027. [Medline] [CrossRef] Martina IS, van Koningsveld R, Schmitz PI, et al.: Measuring vibration threshold with a graduated tuning fork in normal aging and in patients with polyneuropathy. European Inflammatory Neuropathy Cause and Treatment (INCAT) group. J Neurol Neurosurg Psychiatry, 1998, 65: 743–747. [Medline] [CrossRef] Merkies IS, Schmitz PI, van der Meché FG, et al. The Inflammatory Neuropathy Cause and Treatment (INCAT) Group: Reliability and responsiveness of a graduated tuning fork in immune mediated polyneuropathies. J Neurol Neurosurg Psychiatry, 2000, 68: 669–671. [Medline] [CrossRef] Andersson AG, Kamwendo K, Seiger A, et al.: How to identify potential fallers in a stroke unit: validity indexes of 4 test methods. J Rehabil Med, 2006, 38: 186–191. [Medline] [CrossRef] Niam S, Cheung W, Sullivan PE, et al.: Balance and physical impairments after stroke. Arch Phys Med Rehabil, 1999, 80: 1227–1233. [Medline] [CrossRef] Horak FB, Wrisley DM, Frank J: The Balance Evaluation Test (BESTest) to differentiate balance deficits. Phys Ther, 2009, 89: 484–498. [Medline] [CrossRef] Tsang CS, Liao LR, Chung RC, et al.: Psychometric properties of the MiniBalance Evaluation Systems Test (Mini-BESTest) in community-dwelling individuals with chronic stroke. Phys Ther, 2013, 93: 1102–1115. [Medline] [CrossRef]
Influences of visual and supporting surface conditions on standing postural control and correlation with walking ability in patients with post-stroke hemiplegia
J. Phys. Ther. Sci. 27: 1323–1327, 2015
Nanami Okawara1, 2)*, Shigeru Usuda2) 1) Public
Nanokaichi Hospital: 643 Nanokaichi, Tomioka, Gunma, Japan School of Health Sciences, Gunma University: 3-39-22 Showa, Maebashi, Gunma, Japan
2) Graduate
Abstract. [Purpose] To quantify the influence of visual and under-foot-surface conditions on standing balance in patients with post stroke hemiplegia and examine associations of this ordinal score with somatosensory disturbance and walking ability. [Subjects] Sixty-six patients with post-stroke hemiplegia. [Methods] Standing balance was tested in 4 conditions (firm floor or foam rubber surface with eyes open or eyes closed) for 30 s per condition and scored using a 5-category ordinal scale. The accuracy of the standing balance score to distinguish patients above/below cut-offs for the timed up-and-go test (14 s) and functional ambulation category (4) was determined. [Results] Standing balance score was correlated with sensory impairments (tactile and vibration perception) and walking ability (up-and-go and functional ambulation category). The standing balance score distinguished patients with up-and-go times ≤14 and >14 s with moderate sensitivity and specificity, and distinguished patients with functional ambulation category 14 s, and FAC 14 s is because of the differences of the standing balance test and TUG. The standing balance test measures static balance, whereas the TUG test requires dynamic balance and walking17). Some patients who had a TUG time >14 s had a high score on the standing balance test. Balance incorporates many systems including stability limits, postural responses, sensory organization, and gait stability26); thus, therapists need to be able to differentiate the contribution of the different underlying systems to balance problems and fall risk. Hence, therapists need to perform a comprehensive balance test for all post-stroke patients. The limitations of this study are that the balance test used measures only static standing balance and is therefore
1327 insufficient to inform clinical decision-making. Patients with post-stroke hemiplegia have multiple motor or sensory impairments; therefore balance impairments should be assessed using a comprehensive tool such as the Balance Evaluation System Test26). Likewise, a computerized force platform is commonly used to measure standing balance19); however, this equipment is expensive and not readily available in clinics. However, the static standing balance test used in the present study involves standing with eyes closed or open on a firm surface or foam rubber, is easy and safe to use and does not require any special or expensive equipment. As our results indicate standing balance ordinal score is correlated with sensory disturbance and walking ability, analysis of the pattern of instability among the 4 conditions provides therapists insight regarding which sense a person is dependent on to maintain stability2). A follow-up intervention study assessing the validity and reliability of this ordinal score system in clinical settings as well as efficacy as an outcome measurement for evaluating patients’ performance should be performed. ACKNOWLEDGEMENTS This study was supported by the Hidaka Hospital and Day Service Center of the Hidaka-kai Group. We sincerely appreciate Hiroyuki Gokan for his supervision and the staff of the Hidaka Hospital and Day Service Center of the Hidaka-kai Group for their cooperation. Finally, we are grateful to all the participants. REFERENCES 1) Horak FB, Nashner LM, Diener HC: Postural strategies associated with somatosensory and vestibular loss. Exp Brain Res, 1990, 82: 167–177. [Medline] [CrossRef] 2) Shumway-Cook A, Horak FB: Assessing the influence of sensory interaction of balance. Suggestion from the field. Phys Ther, 1986, 66: 1548–1550. [Medline] 3) Bonan IV, Colle FM, Guichard JP, et al.: Reliance on visual information after stroke. Part I: Balance on dynamic posturography. Arch Phys Med Rehabil, 2004, 85: 268–273. [Medline] [CrossRef] 4) Bonan IV, Yelnik AP, Colle FM, et al.: Reliance on visual information after stroke. Part II: Effectiveness of a balance rehabilitation program with visual cue deprivation after stroke: a randomized controlled trial. Arch Phys Med Rehabil, 2004, 85: 274–278. [Medline] [CrossRef] 5) Anacker SL, Di Fabio RP: Influence of sensory inputs on standing balance in community-dwelling elders with a recent history of falling. Phys Ther, 1992, 72: 575–581, discussion 581–584. [Medline] 6) Cohen H, Blatchly CA, Gombash LL: A study of the clinical test of sensory interaction and balance. Phys Ther, 1993, 73: 346–351, discussion 351–354. [Medline] 7) Wrisley DM, Whitney SL: The effect of foot position on the modified clinical test of sensory interaction and balance. Arch Phys Med Rehabil, 2004, 85: 335–338. [Medline] [CrossRef] 8) Madureira MM, Takayama L, Gallinaro AL, et al.: Balance training program is highly effective in improving functional status and reducing the
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risk of falls in elderly women with osteoporosis: a randomized controlled trial. Osteoporos Int, 2007, 18: 419–425. [Medline] [CrossRef] Ricci NA, de Faria Figueiredo Gonçalves D, Coimbra AM, et al.: Sensory interaction on static balance: a comparison concerning the history of falls of community-dwelling elderly. Geriatr Gerontol Int, 2009, 9: 165–171. [Medline] [CrossRef] van der Linden MH, van der Linden SC, Hendricks HT, et al.: Postural instability in Charcot-Marie-Tooth type 1A patients is strongly associated with reduced somatosensation. Gait Posture, 2010, 31: 483–488. [Medline] [CrossRef] Yu J, Jung J, Cho K: Changes in postural sway according to surface stability in post-stroke patients. J Phys Ther Sci, 2012, 24: 1183–1186. [CrossRef] Okawara N, Usuda S: Influence of visual and surface conditions on standing postural control in patients with post-stroke hemiplegia. Rigakuryouhou Kagaku, 2014, 29: 33–38 (in Japanese). [CrossRef] Kim D, Ko J, Woo Y: Effects of dual task training with visual restriction and an unstable base on the balance and attention of stroke patients. J Phys Ther Sci, 2013, 25: 1579–1582. [Medline] [CrossRef] Lee YJ, Park J, Lee D, et al.: The effects of exercising on unstable surface on the balance ability of stroke patients. J Phys Ther Sci, 2011, 23: 789–792. [CrossRef] Chino K, Sonoda S, Domen K, et al.: Stroke Impairment Assessment Set (SIAS): a new evaluation instrument for stroke patients. Jpn J Rehabil Med, 1994, 31: 495–495. Fugl-Meyer AR, Jääskö L, Leyman I, et al.: The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med, 1975, 7: 13–31. [Medline] Di Fabio RP, Badke MB: Relationship of sensory organization to balance function in patients with hemiplegia. Phys Ther, 1990, 70: 542–548. [Medline] Brunnstrom S: Movement Therapy in Hemiplegia. Ney York: Harper & Row Publications.1970, pp 1–30. Podsiadlo D, Richardson S: The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc, 1991, 39: 142–148. [Medline] Holden MK, Gill KM, Magliozzi MR: Gait assessment for neurologically impaired patients. Standards for outcome assessment. Phys Ther, 1986, 66: 1530–1539. [Medline] Collins S, Visscher P, De Vet HC, et al.: Reliability of the Semmes Weinstein Monofilaments to measure coetaneous sensibility in the feet of healthy subjects. Disabil Rehabil, 2010, 32: 2019–2027. [Medline] [CrossRef] Martina IS, van Koningsveld R, Schmitz PI, et al.: Measuring vibration threshold with a graduated tuning fork in normal aging and in patients with polyneuropathy. European Inflammatory Neuropathy Cause and Treatment (INCAT) group. J Neurol Neurosurg Psychiatry, 1998, 65: 743–747. [Medline] [CrossRef] Merkies IS, Schmitz PI, van der Meché FG, et al. The Inflammatory Neuropathy Cause and Treatment (INCAT) Group: Reliability and responsiveness of a graduated tuning fork in immune mediated polyneuropathies. J Neurol Neurosurg Psychiatry, 2000, 68: 669–671. [Medline] [CrossRef] Andersson AG, Kamwendo K, Seiger A, et al.: How to identify potential fallers in a stroke unit: validity indexes of 4 test methods. J Rehabil Med, 2006, 38: 186–191. [Medline] [CrossRef] Niam S, Cheung W, Sullivan PE, et al.: Balance and physical impairments after stroke. Arch Phys Med Rehabil, 1999, 80: 1227–1233. [Medline] [CrossRef] Horak FB, Wrisley DM, Frank J: The Balance Evaluation Test (BESTest) to differentiate balance deficits. Phys Ther, 2009, 89: 484–498. [Medline] [CrossRef] Tsang CS, Liao LR, Chung RC, et al.: Psychometric properties of the MiniBalance Evaluation Systems Test (Mini-BESTest) in community-dwelling individuals with chronic stroke. Phys Ther, 2013, 93: 1102–1115. [Medline] [CrossRef]
