Affordable, rapid methods for identifying mild Alzheimer’s disease (AD) are needed. A simple, brief performance-based test involving the learning of functional upper-extremity movements has been developed and is associated with AD pathology and functional decline. However, its specificity to AD relative to other neurodegenerative diseases that present with motor impairment is unknown. This study examined whether this novel test could distinguish between 34 participants diagnosed with mild AD (Clinical Dementia Rating Scale = 0.5–1) from 23 participants with mild-to-moderate Parkinson’s disease (PD) (Hoehn Yahr = 2–3) using Receiver Operating Characteristic analysis of secondary data from two separate clinical trials. Indicators of diagnostic accuracy demonstrated that the test identified participants with AD, who had worse scores than those with PD, suggesting it may be a viable screening tool for mild AD. Exploratory analyses with a control group (n=52) further showed that test scores were not sensitive to motor dysfunction.

Cues are commonly used to overcome the effects of motor symptoms associated with Parkinson’s disease. Little is known about the impact of cues on postural sway during transfers. The objective of this study was to identify if three different types of explicit cues provided during transfers of people with Parkinson’s disease results in postural sway more similar to healthy controls. This crossover study had 13 subjects in both the Parkinson’s and healthy control groups. All subjects completed three trials of uncued sit to stand transfers. The Parkinson’s group additionally completed three trials of sit to stand transfers in three conditions: external attentional focus of reaching to targets, external attentional focus of concurrent modeling, and explicit cue for internal attentional focus. Body worn sensors collected sway data, which was compared between groups with Mann Whitney U tests and between conditions with Friedman’s Tests. Sway normalized with modeling but was unchanged in the other conditions. Losses of balance presented with reaching towards targets and cueing for an internal attentional focus. Modeling during sit to stand of people with Parkinson’s disease may safely reduce sway more than other common cues.

Concussion-related brainstem injuries have received little attention in research, yet concussion-related symptoms, e.g. headache and postural instability, share a common neurological origin within the brainstem. As advanced neuroimaging techniques evolve, so do opportunities to better examine the underlying damage in the brainstem and its related white matter (WM) circuitry following an mTBI. PURPOSE: To examine the brainstem integrity in mTBI patients using advanced neuroimaging techniques. METHODS: T1-weighted and diffiusion-weighted MRI scans were performed on 13 mTBI participants within 14 days of their injuries and 3 individuals without history of brain injury. Diffusion images were acquired using a multishell high-definition fiber tracking sequence. The data were reconstructed using generalized q-sampling imaging, then a deterministic fiber tracking algorithm was applied to generate WM tract profiles indicating the quantitative anisotropy (QA) for the bilateral frontal, parietal, and occipital corticopontine tracts (CPT), the corticospinal tracts (CST), the corticoreticular tracts (CRT), and the middle cerebellar peduncle (MCP). Volumes of the midbrain, pons, medulla oblongata, and superior cerebellar peduncle were determined using Freesurfer v6. A two-sample t-test was used to determine between-group differences in the segmented brainstem structures. One-dimensional statistical parametric mapping was performed to compare WM tracts, and Hedge’s g was calculated to determine between-group effect size.RESULTS: QA values for the first 5% (caudal end) of the left CPT-F was significantly lower in the mTBI group (p = .021). Large effect sizes were found when comparing mTBI to control groups for overall tract QA for the right CPT-O and CPT-F, left and right CPT-P, CST, CRT, and MCP (g > 0.8), with the largest effect for the left CPT-F tract (g = 1.64). There were no significant differences between groups in the segmented brainstem volumes. CONCLUSION: Lower QA values in the caudal portion of the CPT-F indicate that WM near the brainstem may be susceptible to mTBI-related change despite a lack of effect on brainstem volume. Further research should investigate the brainstem after mTBI. Supported by NIH Grant R21 12973518

BACKGROUND:People with Multiple Sclerosis (PwMS) experience a wide range of symptoms that can alter function and limit activity and community participation. Symptoms including sensory changes, weakness, fatigue and others have been well documented. However, symptoms related to changes in vestibular related function, including gaze and postural stability have not been fully explored. While some recent studies have begun to provide insight into these deficits in PwMS and have explored the use of rehabilitation paradigms for their management, much remains unknown about the full extent of these deficits. Therefore, this study aimed to characterize the presence of gaze and postural stability deficits in measures across the World Health Organization International Classification of Functioning, Disability, and Health (WHO ICF) and to examine how deficits in domains of body structure and function and activity contribute to participation level limitations. METHODS:Baseline data from 41 PwMS (mean(SD) age = 53.9(11.2), 78% female) enrolled as part of a randomized clinical trial were used in this analysis. Measures of gaze and postural stability from the ICF domains of body structure and function (Vestibular ocular reflex [VOR] gain and postural sway area), activity (computerized dynamic visual acuity [cDVA] and MiniBEST test), and participation (Dizziness handicap inventory [DHI] and Activities Balance Confidence [ABC] scale) along with demographic data were used to characterize the sample. To explore relationships between ICF domains for gaze and postural stability, univariate correlations were performed between measures from each domain using Pearson's correlations. Separate multivariate regression models examined how measures from the body structure and function and activity domains contributed to the variance in the participation level outcomes. Variance explained by the models was quantified using R-squared statistic and contribution of the independent variables were quantified using the beta coefficient (p < 0.05). RESULTS:Correlation analysis demonstrated significant relationships in the postural stability measures across domains. Specifically, between postural sway area on a firm surface and MiniBEST test score (r = -.48;p < 0.01) and MiniBEST test score and ABC score (r = 0.5;p < 0.01). Significant correlations were also found between the gaze stability measures of horizontal and vertical VOR gain (r = .68;p < 0.001), horizontal VOR gain and dynamic visual acuity (r = .38;p = 0.02), and vertical VOR gain and dynamic visual acuity (r = .54;p < 0.001). Regression models assessing postural stability, found that only the MiniBEST score significantly contributed to the variance in ABC score (p = 0.01) and the full model explained 34% of the variance in ABC score. Regression modeling of gaze stability outcomes did not produce any variable that significantly contributed to the variance in DHI score and the full model explained 18% of the variance in DHI score. CONCLUSIONS:PwMS in this sample demonstrated deficits in gaze and postural stability across the domains of the WHO ICF compared to past samples of PwMS and healthy cohorts. Correlation between measures in the different domains were present, but no strong relationship between measures of body structure and function, activity and participation level outcomes were observed. This lack of relationship across the domains is likely contributed to the relatively small sample size, the high level of variability observed in the outcomes, and the diverse presentation often seen in PwMS.

Background and Purpose: Few tools are currently available to quantify gaze stability retraining exercises. This project examined the utility of a head-worn inertial measurement unit (IMU) to quantify head movement frequency, velocity, and amplitude during gaze stability exercises. Methods: Twenty-eight individuals with multiple sclerosis and complaints of dizziness or a history of falls were randomly assigned to either a strength and aerobic exercise (SAE) or gaze and postural stability (GPS) group. During a 6-week intervention, participants wore a head-mounted IMU 3 times (early, middle, and late). For aim 1, the frequency, mean peak velocity, and mean peak amplitude of head turns during equivalent duration components of group-specific exercises were compared using general linear models. For aim 2, the progression of treatment in the GPS group was examined using general linear regression models for each outcome. Results: Aim 1 revealed the GPS group demonstrated significantly greater velocity and amplitude head turns during treatment than the SAE group. The frequency of head turns did not significantly differ between the 2 groups. The aim 2 analyses demonstrated that the yaw and pitch frequency of head turns significantly increased during gaze stability exercises over the 6-week intervention. Velocity and amplitude of head turns during yaw and pitch gaze stability exercises did not significantly change. Discussion and Conclusions: A head-worn IMU during rehabilitation distinguished between groups. Furthermore, within the GPS group, the IMU quantified the progression of the frequency of head movements during gaze stability exercises over time. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A320).

OBJECTIVE:To assess the costs, health gains, and cost-effectiveness of operative versus nonoperative treatment of calcaneal fractures over a 5-year time horizon from both US societal and payer perspectives.METHODS:The societal perspective analysis included both direct medical costs and costs for missed work, whereas the health care payer perspective analysis included only direct medical costs associated with treatment and complications. A decision tree simulation model was developed to estimate the direct medical and indirect costs (2018 US$) and quality-adjusted life-years (QALYs) for treatment of patients sustaining intra-articular calcaneal fractures fixed with an extensile lateral approach. Direct medical costs were obtained from a large US health care system in Utah, Intermountain Healthcare, and indirect costs from the literature. Utility and probability parameters were also derived from the literature. Parameter uncertainty was explored using both one-way and probabilistic sensitivity analysis.RESULTS:From a US societal perspective, operative treatment costs less ($35,110 vs. $39,870) and yielded more QALYs (3.89 vs. 3.51) over 5 years compared with nonoperative treatment. At a willingness-to-pay threshold of $50,000 per QALY, operative fixation had an 89% probability of being cost-effective. From a health care payer perspective, operative management remained cost-effective as the incremental cost-effectiveness ratio is below the willingness-to-pay threshold of $50,000/QALY.CONCLUSION:From both US societal and health care payer perspectives, operative treatment of displaced intra-articular calcaneal fractures utilizing an extensile lateral approach is cost-effective at commonly accepted willingness-to-pay thresholds compared with nonoperative treatment over a 5-year time horizon. Patient variability may impact cost-effectiveness and should be explored in future research.LEVEL OF EVIDENCE:Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Patients with surgical fixation of ankle and/or hindfoot fractures often experience decreased range of motion and loss of function following surgery and postsurgical immobilization, yet there is minimal evidence to guide care for these patients. Objectives To assess whether manual therapy may provide short-term improvements in range of motion, muscle stiffness, gait, and balance in patients who undergo operative fixation of an ankle and/or hindfoot fracture. Methods In this multisite, double-blind randomized clinical trial, 72 consecutive patients who underwent open reduction internal fixation of an ankle and/or hindfoot fracture and were receiving physical therapy treatment of exercise and gait training were randomized to receive either impairment-based manual therapy (manual therapy group) or a sham manual therapy treatment of light soft tissue mobilization and proximal tibiofibular joint mobilizations (control group). Participants in both groups received 3 treatment sessions over 7 to 10 days, and outcomes were assessed immediately post intervention. Outcomes included ankle joint range of motion, muscle stiffness, gait characteristics, and balance measures. Group-by-time effects were compared using linear mixed modeling. Results There were no significant differences between the manual therapy and control groups for range of motion, gait, or balance outcomes. There was a significant difference from baseline to the final follow-up in resting gastrocnemius muscle stiffness between the manual therapy and control groups (−47.9 N/m; 95% confidence interval: −86.1, −9.8; P = .01). There was no change in muscle stiffness for the manual therapy group between baseline and final follow-up, whereas muscle stiffness increased in the control group by 6.4%. Conclusion A brief course of manual therapy consisting of 3 treatment sessions over 7 to 10 days did not lead to better short-term improvement than the application of sham manual therapy for most clinical outcomes in patients after ankle and/or hindfoot fracture who were already being treated with exercise and gait training. Our results, however, suggest that manual therapy might decrease aberrant resting muscle stiffness after ankle and/or hindfoot surgical fixation. Level of Evidence Therapy, level 2. J Orthop Sports Phys Ther 2019;49(5):310–319. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8864

Background The use of vestibular rehabilitation principles in the management of gaze and postural stability impairments in people with multiple sclerosis (PwMS) has shown promise in pilot work completed in our lab and in a recently published randomized clinical trial (RCT). However, further work is needed to fully quantify the gaze and postural impairments present in people with multiple sclerosis and how they respond to rehabilitation. Methods/design The study is a single blind RCT designed to examine the benefit of a gaze and postural stability (GPS) intervention program compared to a standard of care (SOC) rehabilitation program in dizzy and balance impaired PwMS. Outcomes will be collected across the domains of body structure and function, activity, and participation as classified by the World Health Organization International Classification of Functioning, Disability, and Health (ICF). Our primary outcomes are the Dizziness Handicap Inventory (DHI) and the Functional Gait Assessment (FGA). Secondary outcomes include other measures of gaze and postural stability, fatigue, and functional mobility. Participants who are interested and eligible for enrollment will be consented prior to completing a baseline assessment. Following the baseline assessment each participant will be randomized to either the GPS or SOC intervention group and will complete a 6 week treatment period. During the treatment period, both groups will participate in guided exercise 3x/week. Following the treatment period participants will be asked to return for a post-treatment evaluation and again for a follow-up assessment 1 month later. We anticipate enrolling 50 participants. Discussion This study will be an innovative RCT that will utilize gaze and postural stability metrics to assess the efficacy of vestibular rehabilitation in PwMS. It will build on previous work by examining measures across the ICF and improve the current evidence base for treating PwMS. Trial registration ClinicalTrials.gov, May 29th 2018, NCT03521557 .

Objectives: To determine whether 12-week home-based exergame step training can improve stepping performance, gait and complementary physical and neuropsychological measures associated with falls in Parkinson's disease. Design: A single-blinded randomised controlled trial. Setting: Community (experimental intervention), university laboratory (outcome measures). Subjects: Sixty community-dwelling people with Parkinson's disease. Interventions: Home-based step training using videogame technology. Main measures: The primary outcomes were the choice stepping reaction time test and Functional Gait Assessment. Secondary outcomes included physical and neuropsychological measures associated with falls in Parkinson's disease, number of falls over sixmonths and self-reported mobility and balance. Results: Post intervention, there were no differences between the intervention (n=28) and control (n=25) groups in the primary or secondary outcomes except for the Timed Up and Go test, where there was a significant difference in favour of the control group (P=0.02). Intervention participants reported mobility improvement, whereas control participants reported mobility deteriorationbetween-group difference on an 11-point scale=0.9 (95% confidence interval: -1.8 to -0.1, P=0.03). Interaction effects between intervention and disease severity on physical function measures were observed (P=0.01 to P=0.08) with seemingly positive effects for the low-severity group and potentially negative effects for the high-severity group. Conclusion: Overall, home-based exergame step training was not effective in improving the outcomes assessed. However, the improved physical function in the lower disease severity intervention participants as well as the self-reported improved mobility in the intervention group suggest home-based exergame step training may have benefits for some people with Parkinson's disease.

BackgroundDisorders of posture, gait, and balance in Parkinson's disease (PD) are common and debilitating. This MDS-commissioned task force assessed clinimetric properties of existing rating scales, questionnaires, and timed tests that assess these features in PD.MethodsA literature review was conducted. Identified instruments were evaluated systematically and classified as recommended, suggested, or listed. Inclusion of rating scales was restricted to those that could be used readily in clinical research and practice.ResultsOne rating scale was classified as recommended (UPDRS-derived Postural Instability and Gait Difficulty score) and 2 as suggested (Tinetti Balance Scale, Rating Scale for Gait Evaluation). Three scales requiring equipment (Berg Balance Scale, Mini-BESTest, Dynamic Gait Index) also fulfilled criteria for recommended and 2 for suggested (FOG score, Gait and Balance Scale). Four questionnaires were recommended (Freezing of Gait Questionnaire, Activities-specific Balance Confidence Scale, Falls Efficacy Scale, Survey of Activities, and Fear of Falling in the Elderly-Modified). Four tests were classified as recommended (6-minute and 10-m walk tests, Timed Up-and-Go, Functional Reach).ConclusionWe identified several questionnaires that adequately assess freezing of gait and balance confidence in PD and a number of useful clinical tests. However, most clinical rating scales for gait, balance, and posture perform suboptimally or have been evaluated insufficiently. No instrument comprehensively and separately evaluates all relevant PD-specific gait characteristics with good clinimetric properties, and none provides separate balance and gait scores with adequate content validity for PD. We therefore recommend the development of such a PD-specific, easily administered, comprehensive gait and balance scale that separately assesses all relevant constructs. (c) 2016 International Parkinson and Movement Disorder Society

ABSTRACT Frequently, clinical balance outcome measures are limited by floor or ceiling effects and provide insufficient resolution to determine subtle deficits. Detailed assessment of postural control obtained through posturography may be cost‐prohibitive or logistically infeasible in some clinical settings. Two‐dimensional (2D) motion analysis may provide a clinically feasible means of obtaining detailed quantification of balance deficits. Forty‐five participants aged 18–80 years, with and without Parkinson disease, performed the Push and Release (PR) test, sit‐to‐stand (STS), and timed single leg stance (SLS). Performance was captured simultaneously using a three‐dimensional (3D) (10‐camera laboratory‐based 3D motion capture system and 3D motion analysis software) and 2D (two commercially available video cameras and 2D motion analysis software) system. Agreement was excellent between 2D and 3D systems for all outcomes of the PR and SLS (intraclass correlation coefficients [ICC 2,1 ] 0.96–0.99, 95% CIs 0.92–0.98 to 0.99–1.0), and ranged from fair to excellent for STS outcomes (ICC 2,1 0.59–0.93, 95% CIs 0.36–0.75 to 0.87–0.96). Test–retest reliability (ICC 3,1 0.89–1.0, 95% CIs 0.76–0.96 to 1.0–1.0) and inter‐rater reliability (ICC 2,1 0.77–1.0, 95% CIs 0.61–0.87 to 1.0–1.0) of the 2D obtained outcomes were excellent. A technology package of commonly available video cameras and 2D motion analysis software was a valid and reliable method for quantifying outcomes of postural control tasks in people with a range of balance abilities. Two‐dimensional analysis can be used in clinical practice to provide balance assessments as a cost‐effective alternative to 3D motion capture. Anat Rec, 299:1165–1173, 2016. © 2016 Wiley Periodicals, Inc.

The motor skill required to decrease the variability in muscle force steadiness can be challenging. The purposes of this study were to determine whether muscle force steadiness improved following repeated trials and whether the number of trials varied for healthy younger adults, healthy older adults, and older adults who have fallen to obtain stable muscle force steadiness measures. Sixty participants performed 30 concentric and eccentric contractions of the knee extensors on an isokinetic dynamometer. Each group had significant improvements in muscle force steadiness and obtained stable measures within six to nine trials. Healthy younger and older adults, and older adults who have fallen, can improve muscle force steadiness. These findings provide a framework for methodological approaches when testing steadiness in varying populations.