Outcomes After Weighted Lumbosacral Orthosis ( LSO) and Exercises in Patients with Progressive Cerebellar Ataxia
Sabrina Mele, PT, DPT
Good Shepherd Penn Partners, Philadelphia, PA
Ataxia manifests with a combination of gait instability, limb dyscoordination, impaired speech and gaze instability. Ataxia significantly impacts a person’s ability to independently function at
home, work or in the community. A strategically weighted lumbosacral orthosis (LSO) is a tool that can enhance the effects of balance exercises by improving function and safety in persons with
progressive cerebellar ataxia. The weighted LSO provides somatosensory input to optimize the efficacy of static and dynamic gaze stabilization and postural control exercises during outpatient
therapy. This poster will demonstrate improved outcomes using a weighted LSO to counterbalance postural control deficits in two patients with progressive cerebellar ataxia.
- A 59 year old female presented for outpatient physical therapy (OPPT) with a 5-year history
of progressive cerebellar ataxia. The patient’s baseline Sensory Organization Test (SOT)
score was 30%, which improved to 43% after completing a month of traditional postural
control exercises without the weighted LSO.
- Upon returning to OPPT 3 years later, the patient was fitted for a strategically weighted tria LSO and instructed in postural control and gaze stabilization exercises during 12-one hour therapy sessions.
- Outcomes included gait speed, Five Time Sit To Stand (FTSTS), SOT and 6MWT and were assessed at baseline (without the LSO), after 8 visits and after 12 visits.
- Patient was discharged from OPPT with a permanent weighted LSO with goal to progress wearing up to 10 hours per day, especially when standing or walking. Home exercise program included postural control and gaze stabilization exercises 3-5 times per day.
- A 69 year old male presented for outpatient physical therapy (OPPT) with a 10-year history of progressive cerebellar ataxia. Baseline SOT score was 29%, which improved to 32% upon completion of a month long balance program without the weighted LSO. Two years later, he returned to OPPT for 1 visit and scored a 40% on the SOT.
- Upon returning to OPPT seven years after the initial visit, the patient was fitted for a
strategically weighted trial LSO and instructed on postural control and gaze stabilization exercises during 10-one hour therapy sessions. Outcomes included gait speed, FTSTS, SOT, and 6MWT and were assessed at baseline (without the LSO), during same session (visit 1) and after 10 visits. Patient was discharged from OPPT with a permanent weighted LSO with goal to progress wearing up to 10 hours per day, especially when standing or walking. Home exercise program included postural control and gaze stabilization exercises 3-5 times per day.
Both cases demonstrated improvements in functional outcomes using static and dynamic
postural control and gaze stabilization exercises in combination with the strategically
weighted LSO. Due to the progressive nature of cerebellar ataxia, functional decline is
anticipated. However, introducing the weighted LSO during the second therapy course of
care was able to slow the progression of the functional deficits typically seen in this
diagnosis. During the same session and/or after 10-12 one-hour therapy sessions, the two
patients improved function and further functional deterioration was prevented to allow
return to baseline function. Additional research with a larger sample is needed to further
validate these findings.
1. Hadjivassiliou M., et al. Causes of progressive cerebellar ataxia: prospective evaluation of
1500 patients. J Neurol Neurosurg Psychiatry 2017;88:301–309
View the poster here: https://drive.google.com/open?id=1rqj0duq80obWVKcr2U3__INg-zp9SaGM
Four Months of Wearing a Balance Orthotic Improves Measures of Balance and Mobility Among a Cohort of Community-Living Older Adults.
To Be Published
Noah S1, C. Gibson-Horn2, & J.L. Vincenzo3
- 1University of California, Davis
- 2Motion Therapeutics, Oakland, Oxnard, California
- 3Department of Physical Therapy, University of Arkansas for Medical Sciences, Fayetteville
The Centers for Disease Control and Prevention estimated that there were 29 million falls and 7 million injuries in 2014 in the United States. Falls, decreased balance, and mobility disability are common in older adults and often result in loss of independence. Finding interventions to address these issues is important, as this age group is growing exponentially. Prior studies indicate balance and mobility can be improved by the balance-based torso-weighting (BBTW) assessment implemented through wear of a balance orthotic (BO). This study sought to determine the impact of wearing a BO on balance, mobility, and fall risk over time.
Methods: This quasiexperimental, 1-group pre-/posttest study investigated the effect of 4 months of daily wear (4 hours per day) of a BO on mobility, balance, and falls efficacy in 30 older adults living in a retirement community with limited mobility defined by a Short Physical Performance Battery (SPPB) score range between 4 and 9 out of a maximum of 12 points. Pre- and posttreatment tests included the Timed Up and Go (TUG), Functional Gait Assessment (FGA), Falls Efficacy Scale (FES), and SPPB. Participants received the BBTW assessment, consisting of individualized assessment of 3-dimensional balance loss, and treatment with a strategically weighted and fitted BO to control balance loss. The BO was worn twice a day for 2 hours (4 hours per day) for 4 months. Participants continued regular activity and no other interventions were provided. All posttests were conducted after 4 months and at least 8 hours after removal of the BO. Subitems from the SPPB (gait speed [GS], 5-time sit-to-stand [FTSST], and tandem stance time [TST]) were analyzed as separate outcome measures. Data were analyzed with paired t tests with a Bonferroni correction (SPPB, GS, FGA, and FES) when statistical assumptions were met. Data that did not meet the statistical assumptions of the paired t test (FTSST, TST, and TUG) were analyzed with Wilcoxon signed rank tests with a Bonferroni correction.
Results: Twenty-four subjects, average age 87 (5.7) years, completed the study. Paired t tests indicated that mean group scores on the SPPB, GS, and FGA significantly improved from pre- to posttests. The SPPB improved by 1.3 points (P = .001). GS improved by 0.09 m/s (P = .004) and both mean values improved beyond fall risk cutoffs. The FGA also improved by 2.6 points (P = .001). There were no significant changes in FES scores (P = .110). Wilcoxon signed rank tests indicated median group scores of the FTSST significantly improved from pre- to posttests by 7.4 seconds (P = .002) and median TUG times improved by 3.5 seconds (P = .004). There were no changes in TST (P = .117).
Conclusion: This study suggests that wearing a BO for 4 hours per day for 4 months results in improvements in functional assessments related to fall risk (SPPB, GS, FGA, TUG, and FTSST) in a group of older adult participants with limited mobility.
Short-term effect of BalanceWear therapy on mobility in older adults with mobility limitations.
Physical Therapy, June 23, 2016
J.L. Vincenzo1, C. Gibson-Horn2, & M. Gray3
- 1University of Arkansas, Office for Studies on Aging,University of Arkansas Medical Sciences Department of Kinesiology
- 2Motion Therapeutics, Oakland, CA
- 3Human Performance Lab, Office for Studies on Aging, University of Arkansas, Fayetteville
Mobility limitations are prevalent among older adults and are related to falls, morbidity, and mortality. BalanceWear Therapy (BWT) improves measures of mobility among people with multiple sclerosis but has not been studied in older adults. Therefore, the purpose of this investigation was to examine the effects of BWT on measures of mobility among older adults with limited mobility.
Methods: This study was a double-blind, randomized controlled trial of older adults recruited from senior living facilities. Adults aged 86.0 (6.1) years were randomized into a BWT, weighted orthotic (WG), group, n = 17, or a sham BWT, sham-weighted orthotic (SWG), group, n = 16. All participants wore the orthotic for 4 hours per day for 5 days. Mobility, measured by the Short Physical Performance Battery (SPPB), Timed Up and Go (TUG), gait speed (GS), and the Functional Gait Assessment (FGA), was recorded pre- and post intervention. Separate repeated analysis of variances were conducted for each variable to determine the intervention group (WG, SWG) by time (before, after) interaction effect.
Results: After a 5-day intervention of strategically weighted BWT intervention compared with a sham intervention, the SPPB improved 1.3 points in the WG, with no change in the SWG (P = .04). No between-group differences were observed for the TUG (P = .70), GS (P = .74), or FGA (P = .22).
Conclusion: A short-term BWT intervention resulted in improvements in mobility on the SPPB among older adults with limited mobility.
Balance-based torso-weighting intervention impact on functional mobility among older adults with impaired mobility – a pilot study.
CSM Presentation 2016
J.L. Vincenzo1, C. Gibson-Horn2, & M. Gray3
- 1University of Arkansas, Office for Studies on Aging,University of Arkansas Medical Sciences Department of Kinesiology
- 2Motion Therapeutics, Oakland, CA
- 3Human Performance Lab, Office for Studies on Aging, University of Arkansas, Fayetteville
Impaired postural control and functional mobility are prominent risk factors for falls among older adults. Balance-based torso-weighting (BBTW) is a non-exercise treatment intervention that results in same-day improvements in postural control and functional mobility among adults with multiple sclerosis but has not been studied among older adults with mobility impairments without progressive neurological diseases. We analyzed the effects of BBTW intervention on functional mobility among mobility impaired older adults.
Participants: Community-dwelling older adults from retirement facilities with mobility impairment defined by a short physical performance battery (SPPB) score of 4-9/12 but without cognitive or progressive neurological impairment participated. Eleven participants (n = 3 males, 8 females; age = 86.64 ± 4.13) served as a control group (CG) and 12 participants (n = 5 males, 7 females; age = 87.5 ± 6.45) were in the BBTW intervention group (BWG).
Methods: A non-randomized repeated measures study design to determine differences in functional mobility between groups after 6 months. The CG received no intervention. The BWG received BBTW 4 hours daily over 6 months. BBTW is an assessment and intervention used to identify patient specific directional balance loss during standing and perturbations and treat impairments by methodologically and strategically placing small variable weights (less than 1.5% body weight) on the torso inside a vest-like orthotic (BalanceWear®). Pre- and post-assessments of functional mobility included the SPPB and the timed up and go (TUG). Repeated measures analysis of variance (ANOVA) was used to analyze differences between groups from pre- to post-tests. Significance was set at α < .05.
Results: Repeated measures ANOVA indicated a significant group x time interaction for both functional mobility measures (p < .05, see table 1). Mean improvements in the measures exceeded clinically meaningful change in the SPPB [≥ 1 point] and TUG [≥ 4 s] in the BWG compared to the CG.
Conclusion: Among the older adults studied, 6 months of BBTW for 4 hours a day was beneficial in improving functional mobility when compared to a control group. Furthermore, Furthermore, the mean improvements are equivalent to or greater than defined clinically meaningful difference in the measures.
Clinical Relevance: BBTW may be an effective non-exercise intervention to improve functional mobility among mobility impaired older adults. It may be useful to explore a combined BBTW and exercise intervention to optimize and sustain the improvements in mobility.
Keywords: Balance-based torso-weighting, mobility, mobility-impaired, postural control, balance, older adults
Gait changes with balance-based torso-weighting in people with multiple sclerosis.
Physiotherapy Research International, June 14, 2014
Gorgas AM1, Allen DD, Gibson-Horn C.
- 1Physical Therapy Program, St. Poelten University of Applied Sciences, St. Poelten, Austria.
People with multiple sclerosis (PwMS) commonly have mobility impairments that may lead to falls and limitations in activities. Physiotherapy interventions that might improve mobility typically take several weeks. Balance-based torso-weighting (BBTW), a system of strategically placing light weights to improve response to balance perturbations, has resulted in immediate small improvements in clinical measures in PwMS, but changes in spatiotemporal gait parameters are unknown. The purpose was to investigate the effects of BBTW on gait parameters in PwMS and healthy controls.
METHODS: DESIGN: This study is a non-randomized controlled experiment.
PARTICIPANTS: This study included 20 PwMS and 20 matched healthy controls PROCEDURES: People with multiple sclerosis walked on an instrumented mat at their fastest speed for three trials each in two conditions: without BBTW then with BBTW. Healthy controls walked in both conditions at two speeds: their fastest speed and at velocities equivalent to their matched PwMS.
RESULTS: Averaged gait trials showed that, with BBTW, PwMS had significantly increased velocity (p = 0.002), cadence (p = 0.007) and time spent in single-limb support (p = 0.014), with decreased time in double-limb support (p = 0.004). Healthy controls increased velocity (p = 0.012) and cadence (p = 0.015) and decreased support base (p = 0.014) in fast trials with BBTW; at matched velocities, step length (p = 0.028) and support base (p = 0.006) were significantly different from PwMS. All gait variables in healthy controls at fast speeds were significantly different from PwMS walking at their fastest speeds.
DISCUSSION: All participants showed increases in gait velocity and cadence during fast walk with BBTW. Improvements in time spent in single-limb and double-limb support by PwMS with BBTW may reflect greater stability in gait. Future research might ascertain if these immediate improvements could enhance effectiveness of longer-term physiotherapy on functional mobility in PwMS.
Variability in postural control with and without balance-based torso weighting in people with multiple sclerosis and healthy controls.
Physical Therapy, June 5, 2014
Hunt CM1, Widener G2, Allen DD3.
- 1C.M. Hunt, BS, Graduate Program in Physical Therapy, University of California San Francisco/San Francisco State University, 1600 Holloway Ave, HSS 112, San Francisco, CA 94132 (USA).
- 2G. Widener, PT, PhD, Doctor of Physical Therapy Program, Samuel Merritt University, Oakland, California.
- 3D.D. Allen, PT, PhD, Graduate Program in Physical Therapy, University of California San Francisco/San Francisco State University.
BACKGROUND: People with multiple sclerosis (MS) have diminished postural control; center of pressure (COP) displacement varies more than in healthy controls. Balance-based torso-weighting (BBTW) can improve clinical balance and mobility in MS; exploration using both linear and nonlinear measures of COP may help determine if BBTW optimizes movement variability.
OBJECTIVE: Investigate effects of BBTW on people with MS and healthy controls during quiet standing. DESIGN: Quasi-experimental, comparing COP variability between groups, eye closure, and weighting conditions in the anterior-posterior and medial-lateral directions.
METHODS: 20 participants with MS and 18 healthy controls stood on a forceplate during four conditions: eyes open and closed, without and with BBTW. Linear measures of COP displacement included range and root mean square (RMS); nonlinear measures included approximate entropy (ApEn) and Lyapunov exponent (LyE). Three-way repeated-measure ANOVAs compared measures across groups and conditions. Association between weighting response and baseline nonlinear variables was examined. When significant, MS subgroups were created and compared.
RESULTS: MS and control groups had significantly different range, RMS, and ApEn values (range and RMS: p<.01; ApEn: p<.05); eyes open or closed conditions had significantly different range and RMS (range and RMS: p<.01). Change with weighting correlated with LyE (r=-.70) and ApEn (r=-.59). Two MS subgroups, with low and high baseline LyE, responded to BBTW in opposite directions (p<.003), with a significant main effect for weighting condition (p<.05), LyE medial-lateral direction only.
LIMITATIONS: Small samples, no identification of impairments related to LyE at baseline.
CONCLUSIONS: LyE may help differentiate subgroups that respond differently to BBTW. In both subgroups LyE values moved towards the average of healthy controls, suggesting that BBTW may help optimize movement variability in people with MS.
Balance-based torso-weighting results in fall reduction during sensory organization test for people with multiple sclerosis.
This abstract was submitted to the Consortium of Multiple Sclerosis Centers for their Annual Meeting, 2014. It was accepted as a podium presentation to be presented in Dallas TX on May 30, 2014.
Background: People with multiple sclerosis (MS) fall frequently. Balance-based torso-weighting (BBTW) can improve gait speed and increase time spent in single-limb support while walking. However, the association between BBTW and falls has not yet been examined in MS.
OBJECTIVE: Investigate the effects of BBTW on balance and fall frequency recorded by the sensory organization test (SOT) in people with MS.
METHOD: 51 people with MS with self-identified gait and balance difficulties (Disease Steps 1-4) completed the SOT on the SMART EquiTest® BalanceMaster twice in a single session, once without weights and a second time following placement of weights using the BBTW method. Data were collected as a part of an extensive testing protocol, generally lasting 3 to 5 hours, in which participants completed additional impairment and mobility testing with and without weights. A mandatory rest break followed BBTW assessment and weighting with additional breaks given as needed. Participant fatigue in two cases resulted in abbreviated testing. The SOT composite score (CS) recorded participants’ quiet standing for 3 trials in each of 6 conditions: eyes open (EO), eyes closed (EC), surround moving (EO), platform moving (EO), platform moving (EC) and platform and surround moving together (EO). The number of falls occurring in all trials of both no weight (NW) and weighted (WT) conditions were tallied. A fall was defined as touching the surround, taking a step, or being caught by an overhead harness. Paired t-tests compared participants’ CS and fall occurrence between conditions with alpha set at 0.05.
RESULTS: A statistically significant change (P=0.0001) occurred in mean (SD) CS from NW to WT trials, 50.9 (15.07) to 60.1 (14.88), respectively. A change of 8 points in the CS is considered a significant difference. Twenty-eight (55%) participants increased their CS by at least 8 points (range 8 to 38), 16 (31.4%) increased by 1 to 7 points, 1 had no change (2%) and 6 (11.8%) decreased their score (range -2 to -6). Fall occurrence differed between weighting conditions (P=0.02). There were 212 (60.7%) falls in the NW and 137 (39.3%) in the WT conditions. No correlation (r=0.014) was found between number of SOT falls and participant age.
CONCLUSION: A significant decline in fall number and an increase in CS occurred with BBTW during single testing session despite potential for fatigue. BBTW is a promising intervention that may lead to decreased falls when worn by people with MS.
Standing data disproves biomechanical mechanism for balance-based torso-weighting.
Archives of Physical Medicine and Rehabilitation, January, 2014
Crittendon A1, O'Neill D1, Widener GL2, Allen DD3.
- 1Graduate Program in Physical Therapy, University of California San Francisco/San Francisco State University, San Francisco, CA.
- 2Department of Physical Therapy, Samuel Merritt University, Oakland, CA.
- 3Graduate Program in Physical Therapy, University of California San Francisco/San Francisco State University, San Francisco, CA. Electronic address: email@example.com.
OBJECTIVE: To test a proposed mechanism for the effect of balance-based torso-weighting (BBTW) in people with multiple sclerosis (MS) and healthy controls. The mechanism to be tested is that application of light weights to the trunk may result in a biomechanical shift of postural sway in the direction of weighting, mechanically facilitating maintenance of the center of mass over the base of support.
DESIGN: Nonrandomized controlled trial.
SETTING: Motion analysis laboratory.
PARTICIPANTS: Participants with MS (n=20; average Expanded Disability Status Scale score, 4.1) and controls matched for sex, age, height, and weight (n=18).
INTERVENTION: Light weights strategically placed according to the BBTW protocol were applied to all participants after at least 3 walking trials and 10 seconds of quiet standing with feet together and eyes open and then eyes closed. Measures were repeated after weighting.
MAIN OUTCOME MEASURE: Forceplate center of pressure (COP) changes >1 standard error of measurement.
RESULTS: With BBTW, people with MS had larger maximum changes in COP than healthy controls in the left-right direction but not in the anterior-posterior direction. COP changes >1 standard error of measurement occurred in the same direction of weighting 20% of the time (95% confidence interval, 5-34), ranging from 10% to 28% across conditions and directions of postural sway. Direction of greatest weight placement did not match the direction of change in the average COP in most participants with MS or the healthy controls in eyes open or eyes closed conditions (P<.001).
CONCLUSIONS: If BBTW worked via a biomechanical shift of the center of mass, COP changes should match the direction of greatest weighting with BBTW. Our data allowed us to reject this hypothesis. Future research may explore alternative mechanisms of action underlying this intervention.
In-home measurement of the effect of strategically weighted vests on ambulation.
Annual International Conference of the IEEE Engineering in Medicine and Biology Society, Nov., 2013
Widener GL1, Widener G, Allen DD.
Strategically weighted vests are currently being used to treat patients with Parkinson's, Multiple Sclerosis, and ataxia. While studies have been conducted to demonstrate the effectiveness of these vests, there has been very little research into the mechanisms that give rise to the vest's results. This study demonstrates the ability to capture gait parameters from depth images in the home with sufficient sensitivity to support future investigation of the weighted vest intervention. The study also explores multiple metrics, using in-home gait sensing, to study a subject's ambulatory ability including gait mechanics, uncertainty in motion, and gait cadence. We then investigate the effects of these vests on a subject's ambulation by examining these metrics both before and after the vest is worn. While only four subjects were used, results are promising, showing a statistically significant and clinically significant change in many of these metrics as a result of the vest. The cases presented here concern two subjects, one with a "tight" gait caused by Progressive Supranuclear Palsy, and the second with an excessively "loose" gait due to Parkinson's disease. We show that in both subjects, using the vest immediately moved the metrics in a direction beneficial to the subject's clinical condition. This result concurs with clinical observations as measured using various clinical fall risk instruments.
Gait Parameters With And Without Balance-Based Torso-Weighting In People With Multiple Sclerosis.
Int. Journal of MS Care, Winter, 2011
Anna-Maria Gorgas1, Gail L. Widener2, Diane D. Allen1
- 1Graduate Program in Physical Therapy, University of California, San Francisco/San Francisco State University, San Francisco, CA
- 2Department of Physical Therapy, Samuel Merritt University, Oakland, CA
Up to 85% of people with multiple sclerosis (MS) show balance and gait impairments. Balance-based torso-weighting (BBTW), a novel intervention in which patients wear light weights on the trunk, has effected immediate improvements in balance and gait in people with MS. In this study, we examined gait parameters with and without BBTW.
Methods: Eighteen volunteers (ages 25–68 years)
Participated: 14 with MS (Expanded Disability Status Scale [EDSS] score equivalent 2–6, 10 with EDSS ≤ 3) and 4 controls. Participants walked across a 24-foot GaitRite instrumented gait mat three times “as fast as they could safely.” After being weighted using a BBTW protocol (weights 0.75–2.75 pounds, average 0.92% body weight), participants repeated the walking trials. Paired t tests compared velocity, step parameters, and cadence with and without weighting.
Results: In people with MS, mean velocity and percentage of gait cycle in single (SLS) and double (DLS) limb support showed statistically significant results with a mean (SD) velocity of 182.3 (27.6) cm/sec for the weighted trials and 177.5 (26.4) cm/sec for the nonweighted trials. SLS averaged 41.2% (1.4%) with weights and 40.8% (1.4%) without weights; DLS averaged 17.2% (2.9%) with versus 17.9% (2.9%) without weights. Cadence, step length, and step width showed no significant difference between the two conditions. Without weights, none of the variables were significantly different between people with MS and controls.
Discussion: The increase in velocity in our sample was not considered clinically significant at less than 3%, but the change confirms previous studies recording velocity improvement with BBTW in people with MS with more significant gait impairments (average unweighted fast-walk velocity 110 cm/sec). In addition, our data provide insight regarding the gait parameters that change along with velocity (SLS, DLS) in people with MS who show no difference from controls at baseline. The evidence indicates that BBTW can affect gait parameters in people with MS that may be associated with improved balance.
Randomized clinical trial of balance-based torso weighting for improving upright mobility in people with multiple sclerosis.
Neurorehabilitation and Neural Repair, Oct., 2009
Widener GL1, Allen DD, Gibson-Horn C.
- 1Department of Physical Therapy, Samuel Merritt University, Oakland, USA.
BACKGROUND: Torso weighting has sometimes been effective for improving upright mobility in people with multiple sclerosis, but parameters for weighting have been inconsistent.
OBJECTIVE: To determine whether balance-based torso weighting (BBTW) has immediate effects on upright mobility in people with multiple sclerosis.
METHODS: This was a 2-phase randomized clinical trial. In phase 1, 36 participants were randomly assigned to experimental and control groups. In phase 2, the control group was subsequently randomized into 2 groups with alternate weight-placement. Tests of upright mobility included: timed up and go (TUG), sharpened Romberg, 360-degree turns, 25-foot walk, and computerized platform posturography. Participants were tested at baseline and again with weights placed according to group membership. In both phases, a physical therapist assessed balance for the BBTW group and then placed weights to decrease balance loss. In phase 1, the control group had no weights placed. In phase 2, the alternate treatment group received standard weight placement of 1.5% body weight.
RESULTS: People with BBTW showed a significant improvement in the 25-foot walk (P = .01) over those with no weight, and the TUG (P = .01) over those with standard weight placement. BBTW participants received an average of 0.5 kg, less than 1.5% of any participant's body weight.
CONCLUSION: BBTW can have immediate advantages over a nonweighted condition for gait velocity and over a standardized weighted condition for a functional activity in people with multiple sclerosis (MS) who are ambulatory but have balance and mobility abnormalities.
Balance-based torso-weighting may enhance balance in persons with multiple sclerosis: preliminary evidence.
Widener GL1, Widener G, Allen DD.
- 1Department of Physical Therapy, Samuel Merritt University, Oakland, USA.
OBJECTIVE: To determine whether weight placed on the trunk in response to directional balance loss would enhance function and stability in people with multiple sclerosis (MS).
DESIGN: Quasi-experimental study in which subjects served as their own controls.
SETTING: Research laboratory.
PARTICIPANTS: Subjects (N=16) age 20 to 65 years with MS recruited through the Northern California Chapter of the National Multiple Sclerosis Society.
INTERVENTIONS: Balance-based torso-weighting where up to 1.5% body weight was placed in a garment on the trunk. Subjects were tested at baseline and then in randomly ordered balance-based torso-weighting and nonweighted garment conditions.
MAIN OUTCOME MEASURES: Sharpened Romberg, eyes open (SREO) and Sharpened Romberg, eyes closed, computerized dynamic platform posturography (CDPP), Timed Up & Go (TUG), and 25-foot timed walk.
RESULTS: Significant improvement (P<.014) was found with SREO in the balance-based torso-weighting compared with nonweighted conditions. CDPP eyes open and TUG showed improvements (P<.03) from baseline to balance-based torso-weighting and nonweighted conditions.
CONCLUSIONS: Improved performance in a group of adults with MS was seen when light weights were placed on the torso to counteract balance loss. Placement of weights may have the potential to produce immediate improvements in balance in this population.
Balance-based torso-weighting in a patient with ataxia and multiple sclerosis: a case report.
Journal of Neurologic Pphysical Therapy,, Sept., 2008
- 1Samuel Merritt College, USA.
OBJECTIVE: The use of external body weights, although controversial, is occasionally employed to improve balance or mobility in patients with ataxia or tremor. This case report describes the effect of torso-weighting to counteract directional balance loss in a woman with relapsing/remitting multiple sclerosis.
CASE DESCRIPTION: Clinical examination of a 40-year-old woman after multiple sclerosis exacerbation revealed loss of balance in the posterior direction during quiet standing as well as loss of dynamic balance in the posterior and lateral directions. The patient's standing posture was with her trunk posterior to her pelvis. She exhibited decreased strength in both extremities and trunk, diminished sensation in the right lower extremity and palms, and an unstable ataxic gait. Difficulty with walking and severe fatigue and dizziness were also reported. Standing balance and alignment were examined during (1) quiet standing with eyes open and eyes closed, (2) transitional movements, and (3) multidirectional trunk perturbations. The patient demonstrated a loss of balance and alignment in the posterior direction in all tests.
INTERVENTION: Based on balance examination results, the patient was fitted with a 0.5-lb vest containing 1.5-lb of additional weight placed anteriorly on the torso at the level of the umbilicus. Progressive balance, gait, and functional activities were repeated both with and without weighting the torso over six weeks.
OUTCOME: Immediately on weighting, the patient demonstrated less sway in quiet standing, increased stability when perturbed, improved body alignment, and less ataxia during gait. The patient was able to accomplish more challenging activities with better balance while weighted. Functional improvement in walking and improved control during balance activities were demonstrated in later treatment sessions without weighting.
CONCLUSION: Placing small amounts of weight asymmetrically on the torso, based on directional loss of balance and alignment, seemed to assist this patient in maintaining balance during static and dynamic activities. Additional research may help determine whether this intervention is applicable to others with directional losses of balance, ataxia, or multiple sclerosis to improve balance control.
Balance based torso weighting shows immediate and long-term functional improvement in a woman with multiple sclerosis: the results of an ABA single subject study.
Journal of the American Physical Therapy Association, June 8, 2005
Gail Widener; Cynthia Gibson-Horn
Physical Therapy, Samuel Merritt College, Oakland, CA
UNIQUE: Placing weight on the bodies of people with ataxia to improve function and balance is controversial. In the past, large amounts of weight have been used and were typically placed on the shoulders, waist, or distal extremities. People with Multiple Sclerosis (MS) often have ataxia that affects their ability to balance and move. There is a paucity of information about the effects of placing minimal weight on the trunk to counteract balance dysfunction.
PURPOSE: This single subject study was designed to evaluate changes in function, both immediate and long-term, from placing minimal amounts of weight on the torso of a woman with MS.
FOUNDATION: Balance based torso weighting (BBTW) is an examination and treatment method in which small amounts of weight are placed on the trunk based on the person's balance dysfunction. The added weight may activate more automatic postural control mechanisms either through increased sensory feedback and/or biomechanical alteration of the center of mass.
DESCRIPTION: An ABA design with pre-intervention (baseline), intervention and post-intervention phases was used. Data was collected weekly for each four week phase. The Timed Up and Go test (TUG), Berg Balance Scale (BBS) and a timed 360 degree turn were used to determine the effect of BBTW. During the intervention phase the subject was asked to wear the torso weight at least one hour per day while continuing with their normal daily activities. No additional treatment was given. Testing was performed without torso weighting except during the intervention phase in which it was completed both weighted and unweighted. Subject: The subject was a 267 pound female with primary progressive MS diagnosed in 1998. She presented with ataxic movements of her trunk. After the baseline period, BBTW was performed and revealed a balance dysfunction that was most pronounced in the posterior direction. Two pounds of weight (0.75% body weight) was distributed anteriorly and laterally, on both sides, that stabilized her excessive trunk movement during quiet stance (Romberg position) and improved her balance dysfunction.
OBSERVATIONS: The subject reported liking the torso weight and wearing it ten hours a day. She noted an increase in steadiness, improved activity level along with an increase in fatigue. Objectively, the TUG, BBS and timed turn all showed improvements during the four week intervention phase compared to baseline. This improvement was maintained in the post-inervention phase. For example, TUG scores changed from a mean of 37.48 sec. in the baseline phase to a mean of 30.73 sec. and 29.73 sec. in the intervention and post-intervention phases, respectively. Performance was further enhanced to a mean of 26.08 sec. while wearing the torso weight during the intervention phase.
CONCLUSIONS: Small amounts of torso weight improved both immediate and long-term performance with this subject with an ataxic presentation. More research is needed to evaluate the use of strategically placed light weights to improve function in individuals with balance dysfunction.
FUNDING SOURCE: This work was supported by a Faculty Development Grant from Samuel Merritt College.
Balanced based torso weighting: a demonstration of the immediate impacts on temporal, spatial, and gait kinematics in a woman with a parietal stroke.
Journal of Geriatric Physical Therapy, June 11, 2005
Cynthia Gibson-Horn1; Sandra Radtka2
- 1Physical Therapy, Rehab Without Walls, San Jose, CA
- 2Graduate Program in Physical Therapy, University of California/San Francisco State University, San Francisco, CA
UNIQUE: Decreased postural control after stroke can adversely affect walking velocity, stride length, cadence, and gait kinematics. While weighting the body has been shown to improve function in those with ataxia, there is little information on balance-based, specific placement of small amounts of weight to counteract dysfunction in individuals post-stroke.
PURPOSE: The purpose of this case study was to determine the immediate effects of Balance-Based Torso Weighting (BBTW) on temporal, spatial, and gait kinematics with a patient post-stroke.
FOUNDATION: Postural control is a necessary foundation of smooth, controlled movement. Stability is often influenced by one's ability to anticipate or react to the environment. BBTW initially involves examination of anticipatory and reactive postural control. Once a balance dyfunction is determined, small amounts of weight (1-2% body weight) are strategically placed on the trunk to counteract the identfied dysfunction.
DESCRIPTION: The patient was diagnosed with a right parietal cerebral vascular accident(CVA) six weeks prior to the evaluation. Her past medical history was significant for a previous left sided stroke, hypertension, headaches, depression, and long-term past cocaine abuse. The physical therapy evaluation included measurement of range of motion, strength, tone, balance, mobility, and weight. The patient weighed 145 pounds. The most pronounced problems were strength, balance, mobility, and gait. Anticipatory and reactive balance testing revealed a right posterior lateral balance dyfunction. A one-half pound vest was weighted with an additional one-half pound, placed in the left anterior lower pocket of a vest. The patient was retested and had less posterior lateral balance dysfunction. The patient was tested with and without BBTW with motion analysis during forward ambulation.
OBSERVATIONS: Baseline characteristics revealed the patient ambulated with an average walking velocity of 59 cm/sec (normal is 124.8), with a stride length of 70 cm (normal is 149 cm), and a cadence of 98 steps per minute (normal is 100 steps per min). Step length on the right was 35.4 cm and the left was 35.8 cm (normal is 65 cm). In the BBTW condition the patient ambulated with an average walking velocity of 80 cm/sec, with a stride length of 96 cm, and a cadence of 99.3 steps per minute. The right step length increased to 49.8 cm and the left to 47.7 cm. In addition, gait kinematics improved bilaterally. On the right side, she showed improved pelvic obliquity closer toward normal during stance, reduced pelvic tilt toward normal in stance and swing, hip adduction closer toward normal in mid to late stance and intial swing, hip flexion/extension at normal for stance and swing, hip rotation closer toward normal during stance, but reduced knee flexion during mid to terminal stance. On the left side, the patient showed improved pelvic obliquity toward normal in midstance, increased hip adduction toward normal during midstance, improved knee flexion during terminal stance and swing, and improved plantar flexion during terminal stance, but had excessive pelvic rotation in the BBTW condition.
CONCLUSIONS: BBTW appeared to have an immediate beneficial impact on temporal, spatial, and gait kinematics with this subject with a right parietal CVA. Treating the trunk may have provided the proximal stability needed for the distal mobility changes seen in this subject. Further research is indicated to evaluate BBTW with individuals with CVA to investigate whether the location of the brain injury influences weight placement. Electromyography to investigate if the muscles fire differently would also be interesting.
Curry Durborow, PT, DPT; Valerie Malizzia, PT, DPT. Impact of the Balance-Based Torso-Weighting System on Balance, Gait, Vestibular-ocular Function and Symptom. Self-Report in an Individual with Vestibular Dysfunction. Purpose, Introduction, Case Description, Outcome Measure, Interventions, Outcomes, Findings Discussion, and Future Considerations.
Certificate of Recognition Research Publication Award presented to Gail Widener and co-authors Cynthia Gibson-Horn and Diane Allen for Randomized Clinical Trial of Balance-Based Torso Weighting for Improving Upright Mobility in People with Multiple Sclerosis. Published in Neurorehabilitation and Neural Repair Vol. 23, No. 8, 2009.
Peer Reviewed, Invited Presentations
Askari, Hasan. Immediate and significant reduction in fall risk in patients with peripheral neuropathy, treated with BalanceWear® Therapy: A Case Series.AAN Washington DC., April 2015.
Gibson-Horn C, Horn K, Widener G, Allen D. Balance-Based Torso-Weighting Results In Fall Reduction During Sensory Organization Test For People With Multiple Sclerosis. Podium Presentation, AAN, April 2015.
Gibson-Horn C, Perlman S. Improved Sway Velocities and Directional Balance Improvement in Two Individuals with Spinocerebellar Ataxia with Balance-Based Torso-Weighting: A Case Series Report. Poster, AAN, April 2015.
Duborow, C. Emerging Technology for the Treatment of Dizziness and Imbalance. One-hour presentation. April 2015 at the Hershey Neuroscience program.
Widener GL, Horn K, Gibson-Horn C, Allen DD. Fall Reduction and Functional Improvement with Balance-Based Torso-Weighting in People with Multiple Sclerosis. CSM, Indianapolis, IN, Feb 2015.
Gibson-Horn C. Balance-Based Torso-Weighting In People with Ataxia. NAF Annual
Conference, Las Vegas, March 2014 and Detroit 2012.
Vivian, A. Gibson-Horn, C. Impact of the Balance-Based Torso-Weighting System on Falls, Gait Speed, and Gait Quality in an Individual with Multiple Sclerosis: A case Report. Poster presentation at CPTA Annual Conference, Oakland CA, Oct 2014.
Widener GL, Horn K, Gibson-Horn C, Allen DD. Fall Reduction During the Sensory Organization Test with and Without Balance-Based Torso-Weighting in People with Multiple Sclerosis. Oct. 10, 2014, Cleveland, OH. Podium presentation at the CPTA Annual Conference, Oct 24, 2014, Oakland CA.
Fridolfsson J, Gibson-Horn C, Widener G. Balance-Based Torso Weighting for Enhancing Functional Mobility in a Child with Ataxia from a Traumatic Brain Injury: a case report. Poster Presentation at CPTA Annual Conference, Oakland, California, Oct 24, 2014.
Wallace C. Abbott, C. Gibson-Horn C, and Skubic M. In-Home Measurement of Effect of Strategically Weighted Vests on Ambulation. Paper presentation, IEEE in Japan July 2013.
Allen DD, Gorgas AM, Gibson-Horn C, Widener GL. People with Multiple Sclerosis Show Improved Gait with Balance-Based Torso Weighting. American Academy of Neurology Annual Conference, New Orleans, LA, April 2012. CMSC-ACTRIMS Annual meeting San Diego, CA, May 30-June 2 and the APTA Section on Research Retreat August 3, 2012.
Durborow, C. Impact of the Balance Based Torso Weighting System on Balance, Gait, Vestibular-ocular Function and Symptom Self-Report in an Individual with Vestibular Dysfunction. CSM 2012.
Lazaro R, Tanasescu M, Widener G, Burke-Doe A. The Immediate Effects of Torso Weighting on Balance and Functional Measures of People with Parkinson’s Disease. World Confederation of Physical Therapy (WCPT) Scientific Meeting, Amsterdam, Netherlands, June 2011
APTA Combined Section Meeting Poster Presentation: Balance-Based Torso-Weighting® is effective in Improving Function in a Randomized Clinical Trial of People with Multiple Sclerosis, February 2008
Widener GL, Allen DD, Gibson-Horn, C. Balance-based Torso-Weighting is Effective in Improving Function in a Randomized Clinical Trial of People with Multiple Sclerosis. CSM of the APTA, Boston, MA, February 2007.
California APTA Conference Podium Presentation: Balance-Based Torso Weighting®: Results of a RCT, September 2007
Widener, GL, Allen, DD, Gibson-Horn. Consortium of Multiple Sclerosis Centers Annual Meeting Presentation: Updates on Balance-Based Torso-Weighting and Use with Patients. , C. Balance-based. torso weighting® may enhance postual controls in persons with multiple sclerosis: a pilot study, June 2007.
Gibson-Horn C, Widener GL. Balance-Based Torso-Weighting Improves Balance and Mobility in MS. CMSC Annual Meeting, Scottsdale AZ, May 2006
Consortium of Multiple Sclerosis Centers Annual Meeting Podium Presentation: Balance-Based Torso-Weighting® Improves Postural Control and Function in Persons with Multiple Sclerosis: A Review of the Evidence and the abstract is highlighted with a small presentation at the first International Rehabilitation Dinner, June 2006.
III Step Conference: Linking Movement Science and Intervention – Poster: Balance Based Torso-Weighting® Improves Postural Control and Function in Persons with Multiple Sclerosis, July 2005.
Physical Therapy Association National Convention – Podium Presentation: Balanced Based Torso-Weighting® Demonstrates Immediate Improvement in a Woman With a Parietal CVA; Poster: Balance Based Torso Weighting® shows Immediate and Long Term Functional Improvement in a Woman with Multiple Sclerosis: The Results of an ABA Design Single Subject Study, June 2005.
Gibson-Horn C, Radtka S. Balanced-Based Torso Weighting: A Demonstration of the Immediate Impacts on Temporal, Spatial, and Gait Kinematics in a Woman With a Parietal Stroke. Platform Presentation, Annual Conference and Exposition of the APTA, Boston, MA, June 2005
Gibson-Horn C, Widener GL. Balance-Based Torso Weighting Improves Postural Control and Function in Persons with Multiple Sclerosis. III Step Conference, Salt Lake City, Utah, July 2005.
Conducted presentations at National, State and Local professional associations such as the Physical Therapy Association National Convention and medical education institutions, 2003-2004
Duborow, C. Stroke outcomes and benefits of BalanceWear Therapy. Pennsylvania Neuroscience. October 2015.
Vincenzo, J. Improved Physical Performance in Elderly with BalanceWear. American Congress of Physical Medicine. October 2015.
Grants Awarded to Validate the Balance-Based Torso –Weighting® Method
National Institutes of Health Grant, 2010 – 2013.
California PT Fund
Samuel Merritt Faculty Grants (Two separate grants)
National MS Society 2004 (#PP1052)