Extended effects of a wearable sensory prosthesis on gait, balance function and falls after 26 weeks of use in persons with peripheral neuropathy and high fall risk-The walk2Wellness trial.

Background: We recently reported that individuals with impaired plantar sensation and high fall risk due to sensory peripheral neuropathy (PN) improved gait and balance function following 10 weeks of use of Walkasins®, a wearable lower limb sensory prosthesis that provides directional specific mechanical tactile stimuli related to plantar pressure measurements during standing and walking (RxFunction Inc., Eden Prairie, MN, United States). Here, we report 26-week outcomes and compare pre- and in-study fall rates. We expected improvements in outcomes and reduced fall rates reported after 10 weeks of use to be sustained. Materials and methods: Participants had clinically diagnosed PN with impaired plantar sensation, high fall risk (Functional Gait Assessment, FGA score < 23) and ability to sense tactile stimuli above the ankle at the location of the device. Additional outcomes included 10 m Gait Speed, Timed Up and Go (TUG), Four-Stage Balance Test, and self-reported outcomes, including Activities-Specific Balance Confidence scale and Vestibular Disorders Activities of Daily Living Scale. Participants tracked falls using a calendar. Results: We assessed falls and self-reported outcomes from 44 individuals after 26 weeks of device use; 30 of them conducted in-person testing of clinical outcomes. Overall, improvements in clinical outcomes seen at 10 weeks of use remained sustained at 26 weeks with statistically significant increases compared to baseline seen in FGA scores (from 15.0 to 19.2), self-selected gait speed (from 0.89 to 0.97 m/s), and 4-Stage Balance Test (from 25.6 to 28.4 s), indicating a decrease in fall risk. Non-significant improvements were observed in TUG and fast gait speed. Overall, 39 falls were reported; 31 of them did not require medical treatment and four caused severe injury. Participants who reported falls over 6 months prior to the study had a 43% decrease in fall rate during the study as compared to self-report 6-month pre-study (11.8 vs. 6.7 falls/1000 patient days, respectively, p < 0.004), similar to the 46% decrease reported after 10 weeks of use. Conclusion: A wearable sensory prosthesis can improve outcomes of gait and balance function and substantially decreases incidence of falls during long-term use. The sustained long-term benefits in clinical outcomes reported here lessen the likelihood that improvements are placebo effects. Clinical trial registration: ClinicalTrials.gov, identifier #NCT03538756.

Long-Term Use of a Sensory Prosthesis Improves Function in a Patient With Peripheral Neuropathy: A Case Report.

Background: Peripheral neuropathy (PN) can result in either partial or complete loss of distal sensation resulting in an increased fall risk. Walkasins® uses a shoe insert to detect the magnitude and direction of sway and sends signals to a leg unit that provides sensory balance cues. The objective of this case report is to describe the long-term influence of the Walkasins® lower limb sensory neuroprosthesis on balance and gait for an individual with diabetic PN. Case Description: A 51-year-old male with a 3-year history of PN and a 10-year history of type II diabetes mellitus was fitted bilaterally with Walkasins® and utilized them 8-10 hours/day for more than 2 years. Although, vibration and tactile sensation thresholds were severely impaired at his 1st metatarsophalangeal joint and the lateral malleolus bilaterally he could perceive tactile stimuli from the Walkasins® above the ankles. Outcomes: Following Walkasins® use, his Activities-specific Balance Confidence Scale (ABC) scores improved from 33 to 80%. His mean Vestibular Activities of Daily Living (VADL) scores decreased from 3.54 to 1. His Functional Gait Assessment (FGA) scores increased from 13/30 to 28/30 and his miniBESTest scores improved from 15/28 to 26/28. Gait speed increased from 0.23 to 1.5 m/s. The patient described a decrease in pain and cramping throughout his lower extremities and an increase in function. Discussion: Gait and balance improved with the use of the Walkasins® and participation in a wellness program. This improvement suggests that the use of sensory substitution devices, such as the Walkasins®, may replace sensory deficits related to gait and balance dysfunction experienced by patients with PN. Further research is needed to determine if other patients will have a similar response and what the necessary threshold of sensory function is to benefit from use of the Walkasins®.

The Effects of a Wearable Sensory Prosthesis on Gait and Balance Function After 10 Weeks of Use in Persons With Peripheral Neuropathy and High Fall Risk - The walk2Wellness Trial.

BACKGROUND: Sensory peripheral neuropathy (PN) is associated with gait, balance problems and high fall risk. The walk2Wellness trial investigates effects of long-term, home-based daily use of a wearable sensory prosthesis on gait function, balance, quality of life and fall rates in PN patients. The device (Walkasins®, RxFunction Inc., MN, United States) partially substitutes lost nerve function related to plantar sensation providing directional tactile cues reflecting plantar pressure measurements during standing and walking. We tested the null hypothesis that the Functional Gait Assessment (FGA) score would remain unchanged after 10 weeks of use. METHODS: Participants had PN with lost plantar sensation, gait and balance problems, an FGA score < 23 (high fall risk), and ability to sense tactile stimuli above the ankle. Clinical outcomes included FGA, Gait Speed, Timed Up&Go (TUG) and 4-Stage Balance Test. Patient-reported outcomes included Activities-Specific Balance Confidence (ABC) scale, Vestibular Disorders Activities of Daily Living Scale, PROMIS participation and satisfaction scores, pain rating, and falls. Evaluations were performed at baseline and after 2, 6, and 10 weeks. Subjects were not made aware of changes in outcomes. No additional balance interventions were allowed. RESULTS: Forty-five participants of 52 enrolled across four sites completed in-clinic assessments. FGA scores improved from 15.0 to 19.1 (p < 0.0001), normal and fast gait speed from 0.86 m/s to 0.95 m/s (p < 0.0001) and 1.24 m/s to 1.33 m/s (p = 0.002), respectively, and TUG from 13.8 s to 12.5 s (p = 0.012). Four-Stage Balance Test did not improve. Several patient-reported outcomes were normal at baseline and remained largely unchanged. Interestingly, subjects with baseline ABC scores lower than 67% (high fall risk cut-off) increased their ABC scores (49.9% to 59.3%, p = 0.01), whereas subjects with ABC scores above 67% showed a decrease (76.6% to 71.8%, p = 0.019). Subjects who reported falls in the prior 6 months (n = 25) showed a decrease in the number of fall-risk factors (5.1 to 4.3, p = 0.023) and a decrease in fall rate (13.8 to 7.4 falls/1000 days, p = 0.014). Four pre-study non-fallers (n = 20) fell during the 10 weeks. CONCLUSION: A wearable sensory prosthesis presents a new way to treat gait and balance problems and manage falls in high fall-risk patients with PN. TRIAL REGISTRATION: ClinicalTrials.gov (#NCT03538756).

Vestibular function assessment using the NIH Toolbox.

OBJECTIVE: Development of an easy to administer, low-cost test of vestibular function. METHODS: Members of the NIH Toolbox Sensory Domain Vestibular, Vision, and Motor subdomain teams collaborated to identify 2 tests: 1) Dynamic Visual Acuity (DVA), and 2) the Balance Accelerometry Measure (BAM). Extensive work was completed to identify and develop appropriate software and hardware. More than 300 subjects between the ages of 3 and 85 years, with and without vestibular dysfunction, were recruited and tested. Currently accepted gold standard measures of static visual acuity, vestibular function, dynamic visual acuity, and balance were performed to determine validity. Repeat testing was performed to examine reliability. RESULTS: The DVA and BAM tests are affordable and appropriate for use for individuals 3 through 85 years of age. The DVA had fair to good reliability (0.41-0.94) and sensitivity and specificity (50%-73%), depending on age and optotype chosen. The BAM test was moderately correlated with center of pressure (r = 0.42-0.48) and dynamic posturography (r = -0.48), depending on age and test condition. Both tests differentiated those with and without vestibular impairment and the young from the old. Each test was reliable. CONCLUSION: The newly created DVA test provides a valid measure of visual acuity with the head still and moving quickly. The novel BAM is a valid measure of balance. Both tests are sensitive to age-related changes and are able to screen for impairment of the vestibular system.

Postural compensation for unilateral vestibular loss.

Postural control of upright stance was investigated in well-compensated, unilateral vestibular loss (UVL) subjects compared to age-matched control subjects. The goal was to determine how sensory weighting for postural control in UVL subjects differed from control subjects, and how sensory weighting related to UVL subjects' functional compensation, as assessed by standardized balance and dizziness questionnaires. Postural control mechanisms were identified using a model-based interpretation of medial-lateral center-of-mass body-sway evoked by support-surface rotational stimuli during eyes-closed stance. The surface-tilt stimuli consisted of continuous pseudorandom rotations presented at four different amplitudes. Parameters of a feedback control model were obtained that accounted for each subject's sway response to the surface-tilt stimuli. Sensory weighting factors quantified the relative contributions to stance control of vestibular sensory information, signaling body-sway relative to earth-vertical, and proprioceptive information, signaling body-sway relative to the surface. Results showed that UVL subjects made significantly greater use of proprioceptive, and therefore less use of vestibular, orientation information on all tests. There was relatively little overlap in the distributions of sensory weights measured in UVL and control subjects, although UVL subjects varied widely in the amount they could use their remaining vestibular function. Increased reliance on proprioceptive information by UVL subjects was associated with their balance being more disturbed by the surface-tilt perturbations than control subjects, thus indicating a deficiency of balance control even in well-compensated UVL subjects. Furthermore, there was some tendency for UVL subjects who were less able to utilize remaining vestibular information to also indicate worse functional compensation on questionnaires.

The effects of rotational platform training on balance and ADLs.

Patients with vestibular dysfunction complain of postural instability and disorientation long after the central compensation is thought to be complete. Previously it has been demonstrated that patients with unilateral vestibular loss who orient more to vertical have better perceived functional status. We proposed that performing balance training with surface perturbations at velocities that target the vestibular system would lead to increased reliance on vestibular information, and therefore improve function. The purpose of this study was to determine whether patients who train using repetitive platform perturbations at these vestibular dependent velocities demonstrate improved postural stability and greater functional abilities than patients who perform traditional balance therapy. Twelve subjects with chronic vestibular and balance dysfunction (age 58 ± 15 years; 3 males, 8 females) and 4 healthy control subjects (age 62 ± 23 years; 4 females) participated. Patients were randomized into 3 groups: clinical balance training (CBT n=3) and training with ramp platform perturbations (4 deg amplitude) either at vestibular (1, 2, 4 deg/sec; VESTIB n=6) or at non-vestibular velocities (0.5, 8, 16 deg/sec; Non-VESTIB n=3). The healthy control subjects completed training at vestibular velocities. Subjects' kinematic and kinetic responses to ramp rotational platform perturbations (0.5, 1, 2, 4, 8, 16 deg/sec at 6 deg amplitude), and scores on the Activities-specific Balance Confidence Scale (ABC), Dizziness Handicap Inventory (DHI), Vestibular Activities of Daily Living Scale (VADL) and Functional Gait Assessment (FGA) were compared before and after the 2 week, 3x/week training sessions. Control subjects demonstrated minimal change in orientation to vertical during platform rotations following training. The VESTIB group demonstrated greater improvements in orientation to vertical during ramp perturbations following training than the Non-VESTIB or CBT groups. Both the CBT and VESTIB groups demonstrated improvements on a composite clinical score incorporating the ABC, DHI, VADL, and FGA following training whereas the Non-VESTIB group did not demonstrate improvement. These preliminary results indicate that training using platform rotations may be an effective intervention for improving postural control following vestibular loss. Further research is needed to explore the efficacy of incorporating rotational platform training with clinical balance training.

Functional gait assessment: concurrent, discriminative, and predictive validity in community-dwelling older adults.

BACKGROUND: The Functional Gait Assessment (FGA) is a reliable and valid measure of gait-related activities. OBJECTIVE: The purpose of this study was to determine the concurrent, discriminative, and predictive validity of the FGA in community-dwelling older adults. DESIGN: This was a prospective cohort study. METHODS: Thirty-five older adults aged 60 to 90 years completed the Activities-specific Balance Confidence Scale (ABC), Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Timed "Up & Go" Test (TUG), and Functional Gait Assessment (FGA) during one session. Falls were tracked by having participants complete a monthly fall calendar for 6 months. Spearman correlation coefficients were used to determine concurrent validity among the ABC, BBS, TUG, DGI, and FGA. To determine the optimum scores to classify fall risk, sensitivity (Sn), specificity (Sp), and positive and negative likelihood ratios (LR+ and LR-) were calculated for the FGA in classifying fall risk based on the published criterion scores of the DGI and TUG and for the FGA, TUG, and DGI in identifying prospective falls. Receiver operator curves with area under the curve were used to determine the effectiveness of the FGA in classifying fall risk and of the DGI, TUG, and FGA in identifying prospective falls. RESULTS: The FGA correlated with the ABC (r=.053, P<.001), BBS (r=.84, P<.001), and TUG (r=-.84, P<.001). An FGA score of

Vibrotactile tilt feedback improves dynamic gait index: a fall risk indicator in older adults.

The purpose of this study was to determine the effectiveness of vibrotactile feedback of body tilt in improving dynamic gait index (DGI) a fall risk indicator in community dwelling older adults. Twelve healthy elderly subjects (three males and nine females, age 79.7+/-5.4 yrs) were tested in an institutional balance rehabilitation laboratory to investigate changes between the feedback off and on conditions. Subjects were acutely exposed to a vibrotactile display that indicated the magnitude and direction of their body tilt from the vertical. DGI and mediolateral (ML) sway were determined during locomotion with, and without, vibrotactile tilt feedback (VTTF). All subjects were at risk for falls based on their initial DGI Score (range: 15-19, mean 17.4+/-1.56), which was taken with the vibratory stimulus turned off. Subjects learned to use the trunk tilt information from the vibrotactile feedback vest through 20-30 min of gait and balance training consisting of activities that challenged their balance. Subjects were then retested on the DGI. Statistically significant changes were demonstrated for the DGI total score while using the vibrotactile tilt feedback. DGI total scores improved from 17.1+/-0.4 to 20.8+/-0.3 (p<0.05). We conclude that vibrotactile tilt feedback improves both control of mediolateral sway during gait and dynamic gait index. Both are fall risk indicators for this population.

The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits.

BACKGROUND: Current clinical balance assessment tools do not aim to help therapists identify the underlying postural control systems responsible for poor functional balance. By identifying the disordered systems underlying balance control, therapists can direct specific types of intervention for different types of balance problems. OBJECTIVE: The goal of this study was to develop a clinical balance assessment tool that aims to target 6 different balance control systems so that specific rehabilitation approaches can be designed for different balance deficits. This article presents the theoretical framework, interrater reliability, and preliminary concurrent validity for this new instrument, the Balance Evaluation Systems Test (BESTest). DESIGN: The BESTest consists of 36 items, grouped into 6 systems: "Biomechanical Constraints," "Stability Limits/Verticality," "Anticipatory Postural Adjustments," "Postural Responses," "Sensory Orientation," and "Stability in Gait." METHODS: In 2 interrater trials, 22 subjects with and without balance disorders, ranging in age from 50 to 88 years, were rated concurrently on the BESTest by 19 therapists, students, and balance researchers. Concurrent validity was measured by correlation between the BESTest and balance confidence, as assessed with the Activities-specific Balance Confidence (ABC) Scale. RESULTS: Consistent with our theoretical framework, subjects with different diagnoses scored poorly on different sections of the BESTest. The intraclass correlation coefficient (ICC) for interrater reliability for the test as a whole was .91, with the 6 section ICCs ranging from .79 to .96. The Kendall coefficient of concordance among raters ranged from .46 to 1.00 for the 36 individual items. Concurrent validity of the correlation between the BESTest and the ABC Scale was r=.636, P<.01. LIMITATIONS: Further testing is needed to determine whether: (1) the sections of the BESTest actually detect independent balance deficits, (2) other systems important for balance control should be added, and (3) a shorter version of the test is possible by eliminating redundant or insensitive items. CONCLUSIONS: The BESTest is easy to learn to administer, with excellent reliability and very good validity. It is unique in allowing clinicians to determine the type of balance problems to direct specific treatments for their patients. By organizing clinical balance test items already in use, combined with new items not currently available, the BESTest is the most comprehensive clinical balance tool available and warrants further development.

Learning effects of repetitive administrations of the sensory organization test in healthy young adults.

OBJECTIVES: To evaluate the learning effect of multiple administrations of the Sensory Organization Test (SOT) on performance and to begin to establish clinical meaningful change scores for the SOT. DESIGN: Descriptive case series. SETTING: University-affiliated clinic. PARTICIPANTS: Healthy young adults (6 men, 7 women; mean age, 24+/-4y). INTERVENTION: All subjects performed the standardized SOT using the SMART EquiTest 5 times over a 2-week period, and 1 month later. MAIN OUTCOME MEASURE: Composite and individual SOT test condition standardized equilibrium scores. RESULTS: Test-retest reliability (intraclass correlation coefficient model 2,3) of the composite (.67) and equilibrium score (range, .35-.79) were fair to good. Repeated-measures analysis of variance revealed a significant (P<.05) increase in the composite and equilibrium scores for conditions 4, 5, and 6 over the 5 sessions that plateaued after the third session, and were retained at 1 month. The 95% confidence interval for the composite score change from session 1 to session 4, the plateau of the learning effect, was 3.9 to 8.1. CONCLUSIONS: Although the findings of this study would indicate that multiple baseline measures are desirable for the more challenging conditions, a composite change of greater than 8 points would indicate change due to rehabilitation.

Physical therapy for central vestibular dysfunction.

OBJECTIVE: To determine if vestibular physical therapy (PT) leads to improved functional outcomes in people with central vestibular dysfunction. DESIGN: Retrospective case series. SETTING: Outpatient PT clinic. PARTICIPANTS: Forty-eight patients with central vestibular dysfunction met the criteria for inclusion in this retrospective chart review. The 48 patients were divided into various subgroups including central vestibulopathy, cerebellar dysfunction, stroke, mixed central and peripheral vestibulopathy, and posttraumatic central disorders. INTERVENTION: Patients were treated with a custom-designed PT program for a mean of 5 visits over an average of 5 months. MAIN OUTCOME MEASURES: Patients completed the Activities-Specific Balance Confidence Scale, the Dizziness Handicap Inventory (DHI), the Dynamic Gait Index, the Timed Up & Go test, and the Five Times Sit-to-Stand (FTSTS) Test. RESULTS: Significant differences were demonstrated between initial evaluation and discharge in each of the assessment measures for the entire group. Post hoc tests were performed to determine if there was a significant difference in any of the assessment measures by diagnosis. Central vestibular diagnostic subgroup was shown to affect pre- to postintervention differences in the functional and disability measures (P< or =.05). With the exception of the FTSTS, effect sizes of change due to PT intervention were greater in those persons with severe disability at baseline as determined by a DHI score of more than 60. CONCLUSIONS: Patients with central vestibular dysfunctions improved in both subjective and objective measures of balance after PT intervention. Persons with cerebellar dysfunction improved the least.

Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the Five-Times-Sit-to-Stand Test.

BACKGROUND AND PURPOSE: People with balance disorders are characterized as having difficulty with transitional movements, such as the sit-to-stand movement. A valid and feasible tool is needed to help clinicians quantify the ability of people with balance disorders to perform transitional movements. The purpose of this study was to describe the concurrent and discriminative validity of data obtained with the Five-Times-Sit-to-Stand Test (FTSST). The FTSST was compared with the Activities-specific Balance Confidence Scale (ABC) and the Dynamic Gait Index (DGI). SUBJECTS AND METHODS: Eighty-one subjects without balance disorders and 93 subjects with balance disorders were recruited for the study. Each subject was asked to stand from a 43-cm-high chair 5 times as quickly as possible. The ABC and DGI scores were recorded. RESULTS: Subjects with balance disorders performed the FTSST more slowly than subjects without balance disorders. Discriminant analysis demonstrated that the FTSST correctly identified 65% of subjects with balance dysfunction, the ABC identified 80%, and the DGI identified 78%. The ability of the FTSST to identify subjects with balance dysfunction was better for subjects younger than 60 years of age (81%). DISCUSSION AND CONCLUSION: The FTSST displays discriminative and concurrent validity properties that make this test potentially useful in clinical decision making, although overall the ABC and the DGI are better than the FTSST at discriminating between subjects with and subjects without balance disorders.

The sensitivity and specificity of the Timed "Up & Go" and the Dynamic Gait Index for self-reported falls in persons with vestibular disorders.

The purpose of this study was to determine the sensitivity and specificity of the Timed "Up & Go" (TUG) and Dynamic Gait Index in identifying self-reported fallers among persons with vestibular dysfunction. One hundred three patient charts were included from a tertiary vestibular physical therapy practice. The patients ranged in age from 14-90 years and had vestibular diagnoses, falls reported in the patient chart, and completed the TUG and/or the Dynamic Gait Index (DGI). Thirty-one persons reported falling one or more times in the previous 6 months during their initial assessment. Persons who took longer than 13.5 seconds to perform the TUG test were 3.7 times more likely to have reported a fall in the previous 6 months. Those persons with scores less than or equal to 18 on the DGI were 2.7 times (p = 0.03) more likely to have reported a fall in the previous 6 months. The sensitivity of the DGI at 18 or less was 70% and the specificity was 51%. People who scored greater than 11.1 seconds on the TUG were 5 times (p = 0.001) more likely to have reported a fall in the previous 6 months. Sensitivity (80%) and specificity (56%) were calculated for TUG scores of greater than 11.1 seconds. The TUG and the DGI appear to be helpful in identifying fall risk in persons with vestibular dysfunction. Slower scores on the TUG (> 11.1 seconds) and lower scores on the DGI (18) correlated with reports of falls in persons with vestibular dysfunction.

Reliability, internal consistency, and validity of data obtained with the functional gait assessment.

BACKGROUND AND PURPOSE: The Functional Gait Assessment (FGA) is a 10-item gait assessment based on the Dynamic Gait Index. The purpose of this study was to evaluate the reliability, internal consistency, and validity of data obtained with the FGA when used with people with vestibular disorders. SUBJECTS: Seven physical therapists from various practice settings, 3 physical therapist students, and 6 patients with vestibular disorders volunteered to participate. METHODS: All raters were given 10 minutes to review the instructions, the test items, and the grading criteria for the FGA. The 10 raters concurrently rated the performance of the 6 patients on the FGA. Patients completed the FGA twice, with an hour's rest between sessions. Reliability of total FGA scores was assessed using intraclass correlation coefficients (2,1). Internal consistency of the FGA was assessed using the Cronbach alpha and confirmatory factor analysis. Concurrent validity was assessed using the correlation of the FGA scores with balance and gait measurements. RESULTS: Intraclass correlation coefficients of.86 and.74 were found for interrater and intrarater reliability of the total FGA scores. Internal consistency of the FGA scores was.79. Spearman rank order correlation coefficients of the FGA scores with balance measurements ranged from.11 to.67. DISCUSSION AND CONCLUSION: The FGA demonstrates what we believe is acceptable reliability, internal consistency, and concurrent validity with other balance measures used for patients with vestibular disorders.

The influence of footwear on timed balance scores of the modified clinical test of sensory interaction and balance.

OBJECTIVES: To determine if timed balance scores on the modified Clinical Test of Sensory Interaction and Balance (CTSIB) were affected by shoe wear in patients with balance and vestibular disorders and to determine if there is a difference in correlation with the Sensory Organization Test (SOT) or in the sensitivity or specificity based on footwear. DESIGN: Prospective correlational trial. SETTING: Outpatient clinic. PARTICIPANTS: Thirty persons (mean age, 63+/-17 y) currently undergoing vestibular physical therapy (PT). INTERVENTION: All subjects completed the modified CTSIB with their shoes on and off at the end of a PT session; 16 of them (53%) also completed the SOT on the same day. MAIN OUTCOME MEASURES: Scores on the modified CTSIB and SOT. RESULTS: No difference existed between scores on the modified CTSIB with shoes on versus off. Similar correlation was found between the modified CTSIB performed with the shoes on and off and SOT scores. The sensitivity and specificity of the modified CTSIB was similar with shoes on and off. CONCLUSIONS: The modified CTSIB can be performed with or without shoes, with no difference expected in patient score or test sensitivity or specificity.

Is perception of handicap related to functional performance in persons with vestibular dysfunction?

OBJECTIVE: The purpose of this study was to determine if scores between 0 and 30 (mild), 31 and 60 (moderate), and 61 and 100 (severe) on the Dizziness Handicap Inventory (DHI) differentiated a person's functional abilities. STUDY DESIGN: Retrospective case series. SETTING: Tertiary balance outpatient center. PATIENTS: Patients (n = 85; mean age, 61 years) with a variety of vestibular diagnoses participated. INTERVENTIONS: Patients completed the DHI, the Dynamic Gait Index (DGI), the 5 times sit to stand test (FTSST), the Activities-specific Balance Confidence (ABC) scale, gait speed, and the Timed "Up & Go" (TUG) during the same session. Reported numbers of falls within the last 4 weeks were recorded. MAIN OUTCOME MEASURES: The DGI, FTSST, ABC, gait speed, TUG, and gait speed were compared among DHI groups. RESULTS: Significant differences were identified using an analysis of variance between DHI groups on the DGI, the FTSST, ABC, and number of falls (p < 0.05). A significant difference was found between DHI groups (mild vs. severe and moderate vs. severe) on the DGI (p < 0.05) with greater DHI scores exhibiting more impaired walking. The FTSST was different between DHI groups mild and severe and DHI groups moderate and severe (p < 0.05), with slower FTSST scores with higher DHI scores. Reported falls were higher among the severe DHI group and the other 2 DHI groups (p < 0.05). All 3 DHI groupings were different from each other on the ABC (p < 0.001). CONCLUSION: Patients who perceive a greater handicap as a result of dizziness demonstrate greater functional impairment than patients who perceive less handicap from dizziness.

The effect of foot position on the modified clinical test of sensory interaction and balance.

OBJECTIVES: To determine whether there was a difference in the timed scores on a modified version of the Clinical Test of Sensory Interaction and Balance (CTSIB) with the feet apart versus feet together and to correlate modified CTSIB scores with Sensory Organization Test (SOT) scores. DESIGN: Prospective correlational study. SETTING: Outpatient clinic. PARTICIPANTS: Thirty patients (mean age, 58+/-17 y) with vestibular dysfunction who were undergoing vestibular therapy. INTERVENTIONS: Subjects completed the modified CTSIB with their feet together and feet apart at the end of a vestibular therapy session. Subjects also completed the SOT on the same day. MAIN OUTCOME MEASURES: Modified CTSIB scores (feet together, feet apart) and SOT scores. RESULTS: Modified CTSIB scores were slightly lower when performed with feet together as compared with feet apart. However, no statistically significant difference existed between scores on the modified CTSIB with feet together versus feet apart using the Wilcoxon signed-rank test (P<.05). The modified CTSIB correlated more strongly with SOT scores when performed with feet together than with feet apart using the Spearman rho. CONCLUSIONS: Scores on the modified CTSIB performed with the feet together did not differ from scores on the modified CTSIB performed with the feet apart. In persons with vestibular disorders, the CTSIB done with the feet together correlated more closely with the SOT.

Reliability of the dynamic gait index in people with vestibular disorders.

OBJECTIVE: To examine the interrater reliability of the Dynamic Gait Index (DGI) when used with patients with vestibular disorders and with previously published instructions. DESIGN: Correlational study. SETTING: Outpatient physical therapy clinic. PARTICIPANTS: Subjects included 30 patients (age range, 27-88y) with vestibular disorders, who were referred for vestibular rehabilitation. INTERVENTIONS: Subjects' performance on the DGI was concurrently rated by 2 physical therapists experienced in vestibular rehabilitation to determine interrater reliability. MAIN OUTCOME MEASURES: Percentage agreement, kappa statistics, and the ratio of subject variability to total variability were calculated for individual DGI items. Kappa statistics for individual items were averaged to yield a composite kappa score of the DGI. Total DGI scores were evaluated for interrater reliability by using the Spearman rank-order correlation coefficient. RESULTS: Interrater reliability of individual DGI items varied from poor to excellent based on kappa values (kappa range,.35-1.00). Composite kappa values showed good overall interrater reliability (kappa=.64) of total DGI scores. The Spearman rho demonstrated excellent correlation (r=.95) between total DGI scores given concurrently by the 2 raters. CONCLUSION: DGI total scores, administered by using the published instructions, showed moderate interrater reliability with subjects with vestibular disorders. The DGI should be used with caution in this population at this time, because of the lack of strong reliability.

The effect of age on vestibular rehabilitation outcomes.

OBJECTIVE: The purpose of the retrospective chart review was to compare vestibular rehabilitation outcomes in young versus older adults. STUDY DESIGN: Retrospective matched design. METHODS: Twenty-three persons with vestibular disorders aged 20 to 40 years were matched by gender, vestibular diagnosis, and vestibular function test results to 23 older adults aged 60 to 80 years. The patients were treated with a custom-designed physical therapy exercise program. Patients completed the Dizziness Handicap Inventory, the Activities-Specific Balance Confidence (ABC) scale, and the Dynamic Gait Index; number of falls; and rated the severity of their dizziness. The two-sample test, the Mann-Whitney test, and McNemar's test for correlated proportions were used to determine whether there was a difference in scores between the two age groups at the beginning and end of physical therapy. RESULTS: During the initial evaluation, older adults reported having statistically greater space and motion discomfort and more severe symptoms on a scale of 0 to 100. Younger adults had more impaired DGI scores and a higher proportion of caloric testing abnormalities. After rehabilitation, overall improvement was seen in both the younger and older populations. There were no statistical differences between the two groups on the DHI, the DGI, reported symptoms at discharge, or number of falls. When only the complete matched-pair data were analyzed, there were no statistically significant differences between the age groups in the proportion of patients demonstrating clinical improvement. CONCLUSION: Age does not significantly influence the beneficial effects of vestibular rehabilitation for persons with vestibular disorders.