Rehabilitation to Improve Gaze and Postural Stability in People With Multiple Sclerosis: A Randomized Clinical Trial.

BACKGROUND: People with multiple sclerosis (PwMS) frequently experience dizziness and imbalance that may be caused by central vestibular system dysfunction. Vestibular rehabilitation may offer an approach for improving dysfunction in these people. OBJECTIVE: To test the efficacy of a gaze and postural stability (GPS) retraining intervention compared to a strength and endurance (SAE) intervention in PwMS. METHODS: About 41 PwMS, with complaints of dizziness or history of falls, were randomized to either the GPS or SAE groups. Following randomization participants completed 6-weeks of 3×/week progressive training, delivered one-on-one by a provider. Following intervention, testing was performed at the primary (6-weeks) and secondary time point (10-weeks). A restricted maximum likelihood estimation mixed effects model was used to examine changes in the primary outcome of the Dizziness Handicap Inventory (DHI) between the 2 groups at the primary and secondary time point. Similar models were used to explore secondary outcomes between groups at both timepoints. RESULTS: Thirty-five people completed the study (17 GPS; 18 SAE). The change in the DHI at the primary time point was not statistically different between the GPS and SAE groups (mean difference = 2.33 [95% CI -9.18, 12.85]). However, both groups demonstrated significant improvement from baseline to 6-weeks (GPS -8.73; SAE -7.31). Similar results were observed for secondary outcomes and at the secondary timepoint. CONCLUSIONS: In this sample of PwMS with complaints of dizziness or imbalance, 6-weeks of GPS training did not result in significantly greater improvements in dizziness handicap or balance compared to 6-weeks of SAE training.

Characterizing gaze and postural stability deficits in people with multiple sclerosis.

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.

Control of Linear Head and Trunk Acceleration During Gait After Unilateral Vestibular Deficits.

OBJECTIVE: To use clinically available inertial measurement units to quantify the control of linear accelerations at the head and trunk during gait in different sensory conditions in individuals with unilateral vestibular loss. DESIGN: Observational study. SETTING: Outpatient research laboratory. PARTICIPANTS: Individuals (n=13; mean age, 47.6±13.7y; 69% women) 6 weeks after vestibular schwannoma resection surgery and vestibular healthy participants (n=16; mean age, 29.7±5.9y; 56% women). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Walking speed normalized, root mean square values of cranial-caudal, medial-lateral, and anterior-posterior directed linear accelerations at the head and the trunk while walking in 2 visual sensory conditions (eyes open and eyes closed). RESULTS: Linear mixed models for each root mean square value were fit on the effects of group, condition, and group by condition. The group by condition effect was used to examine the primary hypothesis that individuals with vestibular loss would experience greater change in triplanar root mean square values at the head and trunk from the eyes open to eyes closed condition compared with the vestibular healthy group. The group by condition effect was found to be significant at the head in the cranial-caudal (ß=0.39; P=.002), medial-lateral (ß=0.41; P<.001), and anterior-posterior (ß=0.43; P<.001) directions. The group by condition effect was also significant in the cranial-caudal (ß=0.39; P=.002), medial-lateral (ß=0.39; P<.001), and anterior-posterior (ß=0.23; P=.002) directions at the trunk. CONCLUSIONS: Participants who underwent vestibular schwannoma resection were more impaired in their ability to control accelerations at the head and trunk without visual sensory information than vestibular healthy participants. These impairments were detectable using clinically available inertial measurement units.

Turning Toward Monitoring of Gaze Stability Exercises: The Utility of Wearable Sensors.

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).

Rehabilitation to improve gaze and postural stability in people with multiple sclerosis: study protocol for a prospective randomized clinical trial.

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 .