A 46-year-old man received a course of quinolone-family antibiotics for puncture wound-related cellulitis. Cerebellar symptoms developed within 3 weeks of treatment, progressed over 6 months, and then became static. Seven years later, he received an individualized 12-week-long course of physical therapy to challenge his balance with high-level fall-inducing but safe dynamic activities. Outcome measures included the International Cooperative Ataxia Rating Scale, modified Dynamic Gait Index, instrumented gait analysis, and posturography. The total modified dynamic gait index score improved 4 points. Gait velocity increased and reached a meaningful clinically important difference threshold. Step length increased, and step width and toeing out decreased. Reaction times, movement velocities, and center of gravity excursions improved on the limits of stability test. He increased frontal and sagittal speed on the rhythmic weight shift test and became able to jump vertically and run with hand support on a treadmill. The results highlight the benefits of an individualized physical therapy program for a patient with chronic nonprogressive cerebellar deficits years after the original insult. Factors that may have contributed to the success of this case are the nonprogressive nature of the disorder, a harness system that allowed for sufficiently challenging repetitions, and the patient’s physically fit and disciplined characteristics.

IMPORTANCE:Patients with cancer experience increased falls risk secondary to oncological treatment and cancer-related sequelae. OBJECTIVE:Identifying diagnostically and prognostically accurate screening tool(s) for falls risk in populations with cancer is an important issue. DATA SOURCES:Screening tests were identified in PubMed and CINAHL. STUDY SELECTION:Two independent reviewers screened citations for inclusion. DATA EXTRACTION AND SYNTHESIS:Data extraction was performed by 1 reviewer and verified by a second. Tests were investigated for clinical utility, validity, diagnostic accuracy, and predictive capacity. Recommendations for screening measures were formulated using predetermined criteria. MEASURES:Falls risk screening tools were identified for populations with cancer. RESULTS:Of 532 articles screened, 24 articles were included. Fifty-five variations of screening measures were identified, of which 47 had sufficient clinical utility. Twenty measures contained data on diagnostic accuracy or predictive capacity. No screening measure met all criteria to be highly recommended for both ruling in and ruling out falls risk currently (diagnostic accuracy) or in the future (predictive capacity). History of falls demonstrated good diagnostic accuracy for ruling in immediate falls risk (specificity 98.9%, positive predictive value 84.6%). A negative falls history was highly indicative of lower future falls risk status (negative predictive value 82.5% to 90.1%). Fear of falling demonstrated accuracy for ruling out immediate risk for falls (negative predictive value 87.0%, sensitivity 88.7%). Strong predictive capacity was demonstrated with the Timed "Up & Go" (TUG) Standard (sensitivity 93% at ≤7.8 s, specificity 95% at ≥11.35 s). CONCLUSIONS:Based on these results, a history of falls plus either the TUG Standard for those with a history of falls or subjective report of fear of falling for those without a history of falls is recommended for risk screening in populations with cancer. RELEVANCE:Different screening tools are required for immediate versus future falls risk and are setting dependent.

Background Progressive supranuclear palsy (PSP) is a neurodegenerative condition, typically presenting with, but not limited to, impairments of postural instability, gait, and gaze stability. Purpose This case report describes the multifactorial assessment and rehabilitation of a patient with atypical PSP who has significant gaze deficits, asymmetrical stepping responses, trunk rigidity, and reduced posterior excursion on limits of stability. Case Description Evaluation utilized computerized gait and balance assessments, foot clearance analysis, a squat test, and a timed stepping test. The intervention included boxing, stepping tasks, and treadmill training each with eye movement challenges. A total of 15 hours of physical therapy was provided; 1 hour, 2 times a week. Outcomes Post-intervention improvements were noted subjectively, on eye-body coordination, and objectively, on limits of stability, foot clearance, and task performance (squats, timed stepping). Follow-up demonstrated some decline from posttest results; however, patient-reported adherence to the program was less than recommended. Conclusion A multifactorial rehabilitation program can improve balance, eye-body coordination, and strength in a high functioning patient with atypical PSP. Longitudinal randomized controlled studies are suggested to further investigate this interventional approach in high functioning individuals diagnosed with atypical PSP.

Background: As prevalence of cancer survivors continues to grow, physical therapists will play a major role in cancer rehabilitation. To meet growing educational needs for oncology physical therapy, the George Washington University DPT program developed an online elective course. Objectives: The purpose of this study was to explore student motivation for course enrollment, student self-perceived strengths and weaknesses in oncology physical therapy, and personal learning objectives. Design: Retrospective qualitative analysis. Methods: Pre and postcourse student narrative responses, based on self-reflection, were analyzed using a general inductive approach to identify themes. Results: Sixteen students enrolled in the course over 2 years. Students were interested in complex patient management and understood the effect of changing survival rates in future practice. Self-perceived strengths related to oncology physical therapy were rooted in communication skills, adaptability, compassion, and empathy. Students' perceived weaknesses and objectives ranged from oncological disease and treatment to safe physical therapy interventions. Students expressed concerns related to the emotional toll working with this population; they identified areas for future self-study. Conclusion: This course provided additional learning experiences in the management of patients with a cancer history. As adult learners, students identified learning objectives and explored topics in a supportive, self-directed learning environment. Educational needs related to oncological medical management and provision of safe and effective physical therapy interventions and psychosocial concerns expressed by our student group are similar to those of practicing clinicians. Qualitative analysis served as a useful tool to identify future course direction.

1Board Certified Neurological Clinical Specialist, Physical Therapist, Clinical Research Center, National Institutes of Health, Bethesda, MD 2Research Physical Therapist, Functional and Applied Biomechanics Laboratory, Clinical Research Center, National Institutes of Health, Bethesda, MD Correspondence: Earllaine Croarkin, PT, MPT, Clinical Research Center, National Institutes of Health, 10 Center Dr, MSC 1604, Bethesda, MD 20892 ([email protected]). The authors declare no conflicts of interest.

1Board Certified Neurological Physical Therapist, Clinical Research Center, National Institutes of Health, Bethesda, MD 2Associate Director, Center for Healthy Aging, National Council on Aging, Arlington, VA Correspondence: Earllaine Croarkin, PT, MPT, Clinical Research Center, National Institutes of Health, 10 Center Dr, Bethesda, MD 20892 ([email protected]). The authors declare no conflicts of interest.

1Clinical Supervisor, Maine Strong Balance Center, Scarborough, ME 2Physical Therapist, Clinical Research Center, National Institutes of Health, Bethesda, MD Correspondence: Sarah Kain, PT, DPT, Maine Strong Balance Center, Scarborough, ME 04074 ([email protected]). The authors declare no conflicts of interest.

National Institutes of Health, Clinical Research Center, Bethesda, MD Correspondence: Earllaine Croarkin, PT, MPT, NCS, National Institutes of Health, Clinical Research Center, 10 Center Dr, MSC 1604, Bethesda, MD 20892 ([email protected]). The author declares no conflicts of interest.

Background and Purpose: Balance impairments are prevalent in adult cancer survivors, leading to increased fall risk and reduced quality of life. To identify survivors in need of balance and fall interventions and to track change with intervention, health care providers need measures with sound psychometric properties and high clinical utility. The purpose of this systematic review was to identify reliable, valid, and clinically useful measures of balance impairments in adult cancer survivors. Secondary purposes were to obtain minimal detectable change of identified balance measures and to determine use of measures to evaluate fall risk. Methods: A systematic review was conducted to assess psychometric properties and clinical utility of balance measures identified from the literature search. Two reviewers in a team independently extracted data from articles and evaluated cumulative evidence for each balance measure using the Cancer EDGE Task Force Outcome Measure Rating Form. Results: The search located 187 articles, with 54 articles retained for quality assessment of balance measures. The Fullerton Advanced Balance Scale and gait speed were highly recommended (rated 4). Balance Evaluation Systems Test, Timed Up and Go, and Five Times Sit to Stand were recommended (rated 3). Limitations: Selection bias is possible. Samples and settings across reviewed studies were widely heterogeneous. Conclusions: We recommend 5 balance measures for use in adult cancer survivors. Future research with existing balance measures should establish norms, responsiveness, and predictive validity for fall risk, while expanding to focus on imbalance in midlife survivors. Patient-reported outcome measures are needed for cancer-related imbalance.

Background: Balance deficits are a common morbidity following treatment for breast cancer. Accurate assessment of balance following breast cancer treatments is essential in identifying deficits and risk for falls along with planning rehabilitation strategies.Purpose: This systematic review identifies balance outcome measures for use with women treated for breast cancer that possess strong psychometric properties and are clinically useful. Methods: Multiple electronic databases were searched from February to July 2014. The review included studies of outcome measures for assessing balance that met the following criteria: Reported psychometric properties, clinically feasible methods, adults (preferably female), published between January 1, 1995, to July 31, 2014, in the English language. Each outcome measure was reviewed and rated independently by two reviewers. A single Cancer EDGE Task Force Outcome Measure Rating Form was completed for each balance measure, and a recommendation was made using the 4-point Breast Cancer EDGE Task Force Rating Scale.Results: Of the original 683 articles found, 36 were included in this review. None of the balance outcome measures reviewed merited the highest rating of 4, strongly recommended. The Fullerton Advanced Balance (FAB) Scale and Timed Up and Go (TUG) were rated 3, recommended for clinical use. Six outcome measures were rated 2B, unable to recommend at this time. Six outcome measures were rated 2A, unable to recommend at this time.Conclusions: This review demonstrates that there is a lack of research evidence supporting the psychometric properties of outcome measures for balance in breast cancer survivors. No studies have examined cutoff scores of balance assessment tools for detecting fallers in breast cancer survivors. Future research is necessary to identify self-reported outcome measures for assessing balance and fall risks, and to differentiate tools specifically for different practice settings throughout the continuum of cancer survivorship.

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a complication commonly involving extremities characterized by dysthesias. Given the predilection towards diminished proprioceptive feedback, balance and gait deficits often result, leading to an increase in falls risk. To date there is no published evidence to support the use of orthotics in the treatment of balance dysfunction secondary to CIPN. Purpose: This report describes custom foot orthotics with a closed cell foam overlay to improve postural stability and mobility in CIPN. Case Description: An individual experiencing progressive balance dysfunction was provided orthotics when standard interventions were not effective. Expectations were that improved joint contact via midfoot compression and improved bony alignment would alter proprioceptive feedback throughout the kinetic chain and result in greater postural stability. Finding a cosmetically appealing shoe to provide sufficient tactile cues and support, without undue pressure challenged clinical decision making. Outcome Measures: Computerized dynamic posturography and accelerometry were used to measure postural sway. Three conditions (barefoot, shoes only, and shoe plus orthotics) were tested to differentiate effects of orthotics and shoes. With orthotic use measures of sway velocity and area improved as did his ability to stand unassisted. Timed Up and Go and gait speed measures also improved.

Nearly one-third of older adults experience a fall every year. Balance and gait deficits are among the most important risk factors of falls. Cancer and associated interventions used to cure it challenge systems responsible for maintaining balance control. Older individuals diagnosed with cancer are more likely to develop impairments and disability and are at a slightly higher risk of falls. An improved understanding of age-related changes in balance control and increased knowledge of screening tools that identify those at risk for falls can help lower fall risk.

BACKGROUND AND PURPOSE:The purpose of this study was to describe gait parameters in children and adolescents with a diagnosis of Friedreich ataxia (FA) and examine the relationship between disease severity, measured by the Friedreich Ataxia Rating Scale (FARS) and gait parameters. The study examined whether FARS scores can discriminate between those who walk independently and those who require assistance.METHODS:Thirty-eight children (aged 5-11 years) and adolescents (aged 12-17 years) with genetically confirmed FA were divided into two groups based on locomotor status: group 1, subjects who were able to walk independently, and group 2, subjects who required assistance for walking. Temporal and spatial gait parameters were collected using the Stride Analyzer computerized foot switch system and compared with age-matched normative data. The FARS was used to measure disease severity. Correlation coefficients and the Mann-Whitney U test of differences were used to evaluate associations and discern differences between groups.RESULTS:In subjects with FA, gait parameters of velocity and cadence were slower and stride length was shorter compared with age-matched children without disabilities. These parameters were significantly correlated with FARS score (r = 0.696, 0.667, 0.537; respectively, all P values <0.001). Total FARS scores were correlated with locomotor status (ç value r = 0.623; P < 0.01) and could categorize subjects into groups based on independent walking or need for assistance, 73% and 87% of the time, respectively.DISCUSSION AND CONCLUSION:Subjects with FA exhibited specific abnormal gait characteristics relative to age-matched individuals. Disease severity, as measured by the FARS, was associated with gait velocity, stride length, and cadence. FARS scores can be used to categorize subjects by locomotor status and may be a useful screening tool to identify those requiring assistance.

Friedreich ataxia, although rare, is the most prevalent inherited ataxia. Recent insight into the disease pathogenesis is creating new hope for effective therapies. The purposes of this update are: (1) to review the etiology, presentation, and progression of Friedreich ataxia and (2) to describe a comprehensive physical therapist examination emphasizing valid and reliable performance measurements associated with disease progression. Early identification of individuals with Friedreich ataxia and precise characterization of impairments and functional limitations gain importance as new drug therapies are considered.

Objective: To determine reliability of and relationships between a force control task and the standardized nine-hole peg test (9HPT) in the dominant upper limb of healthy participants. Design: Prospective test-retest model including comparisons to 9HPT. Setting: Rehabilitation research clinic. Participants: 10 healthy, normal volunteers between 10 and 18 (mean, 13.7) years (6 men, 4 women). Interventions: Not applicable. Main Outcome Measures: Force control task: Biodex dynamometer isometric tracking task, at 25% of maximal voluntary contraction (MVC), measuring mean torque and calculating target accuracy ratio (accuracy ratio = target torque/mean torque) and coefficient of variation (CV) of elbow flexion and extension over time. Coordination task: 9HPT completion speed. Results: There was no significant test-retest difference in 9HPT speed (20.3±1.42s, 20.1±1.45s). There was no significant test-retest difference in mean torque of elbow flexion (6.47±4.47ft-lb, 6.53±4.39ft-lb) or of elbow extension (5.97±4.80ft-lb, 5.95±4.70ft-lb). There was no significant test-retest difference in accuracy ratio of elbow flexion (1.02±0.15, 1.05±.015) or of elbow extension (1.05±0.16, 1.04±0.10). There was no significant test-retest difference in CV of elbow flexion (6.48±6.00, 5.12±4.61) or of elbow extension (11.35±12.37, 8.84±10.24). There was significant positive correlation between 9HPT and CV (elbow flexion: r=.713, P=.021; elbow extension: r=.707, P=.022). Conclusions: Measurement of an isometric tracking task at 25% of MVC in normal children and adolescents can yield reliable results that correlate with the 9HPT. In this study, the CV of force control was more closely associated with ability to perform the 9HPT than accuracy ratio. Further study will compare these results to a group of age-matched subjects with Friedreich’s ataxia to help determine sensitivity and selectivity of various force control measures and to compare findings in dominant and nondominant limbs.

INTRODUCTION:Tests of upper-extremity motor function used for people following a stroke have been described, but reliability and validity (psychometric properties) of measurements obtained with these tests have not been consistently established. This investigation was performed: (1) to review literature relative to upper-extremity motor function testing during rehabilitation following a stroke, (2) to develop selection criteria for identifying these tests in the literature, and (3) to rate the tests relative to their psychometric properties.METHOD:Literature searches were done using 2 databases. Reports of 4 psychometric properties were sought: interrater reliability, test-retest reliability, convergent validity or concurrent validity, and predictive validity.RESULTS:Nine tests met the inclusion criteria of having psychometric properties reported in the literature. No test had evidence for all 4 psychometric properties. Only the Nine-Hole Peg Test was supported by 3 out of 4 properties. Most tests had 2 properties supported. Concurrent validity or convergent validity was most frequently described; test-retest reliability was least frequently described.CONCLUSIONS:More complete psychometric support is needed for upper-extremity motor function tests applied following a stroke. The absence of psychometric support, however, does not mean that a test has no value. Clinicians are cautioned not to generalize psychometric evidence.

1Ms Ruppert is currently an undergraduate student at Loyola University. She collected data and wrote the first draft of this paper during a summer internship. She was supported by funds supplied by the Bristol-Meyers Squibb Corporation during her internship at the National Institutes of Health. 2Mrs Croarkin is currently a Neurological Clinical Specialist for the Physical Therapy Section of the Warren G. Magnuson Clinical Center at the National Institutes of Health. She is responsible for the concept and review of the paper.

Osteopenia is defined as a reduction in bone mass. It is commonly known to occur in elderly people or women who are postmenopausal due to hormonal imbalances. This condition, however, can result because of many other factors, such as poor nutrition, prolonged pharmacological intervention, disease, and decreased mobility. Because patients with cancer experience many of these factors, they are often predisposed to osteopenia. Currently, patients with cancer are living longer and leading more fulfilling lives after treatment. Therefore, it is imperative that therapists who are responsible for these patients understand the risk factors for osteopenia and their relevance to a patient with cancer.