Assessment of postural balance in multiple sclerosis patients

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1 Atteya et al. The Egyptian Jounal of Neuology, Psychiaty and Neuosugey (2019) 55:7 The Egyptian Jounal of Neuology, Psychiaty and Neuosugey RESEARCH Open Access Assessment of postual balance in multiple scleosis patients Abdulalim Atteya 1, Abee Elwishy 1, Nimeen Kishk 2, Rania Shehata Ismail 2* and Rania Badawy 1 Abstact Backgound: Distubance of balance and falls ae commonly obseved in people with multiple scleosis (MS). Objectives: The aim of this study is to assess the postual balance in patients with MS by using clinical and instumental methods and to specify the most diection of balance instability among MS patients using Biodex stability system (BSS). Methods: Fifty ambulatoy individuals with MS [42 elapsing-emitting (RRMS) and 8 seconday pogessive (SPMS)] wee evaluated fo balance using quantitative Beg balance scale (BBS) and BSS. Twenty healthy voluntees wee selected as a contol goup. Results: Thee was a statistically significant diffeence between the patient and contol goups assessed by BBS. Moeove, patients with SPMS had wose postual balance when compaed with RRMS. Accoding to BSS, MS goup showed moe sway in the thee limits of stability (mediolateal, antoposteio, and oveall) when compaed to the contol goup. The least stability level was obseved in mediolateal diection in the patient goup. The degee of tilt was highe in SPMS than RRMS as egad the thee limits of stability. The BBS was significantly negatively coelated with age, Expanded Disability Status Scale (EDSS), duation of illness, and the Biodex tilt. Also, thee wee positive significant coelation between age, EDSS scoe, and the duation of illness of the disease with paametes of BSS (mediolateal, antoposteio, and oveall). Conclusion: BSS was significantly coelated with clinical balance measuement scale using BBS in MS patients. Moeove, BSS can povide moe objective, quantitative measues of postual imbalance. Keywods: MS, Balance, Beg balance scale, Biodex stability system Intoduction Multiple scleosis is one of the most fequent neuological diseases in young adults and its pevalence shows a heteogeneous distibution among counties [1, 2]. Lack of balance and falls ae among the most disabling symptoms of multiple scleosis and may affect about 75% of patients ove the couse of the disease [3]. Balance impaiment educes mobility and independence, leads to falls and injuies, impacts upon oveall quality of life [4]. Imbalance in multiple scleosis (MS) emains incuable with majo buden on the society [5]. Deficiency in any one of the multiple sensoy o moto mechanisms of the postual system can poduce damatic effects on postual stability and moto * Coespondence: aniashehata.neuo@yahoo.com 2 Neuology Depatment, Faculty of Medicine, Caio Univesity, Caio, Egypt Full list of autho infomation is available at the end of the aticle pefomance. Numeous factos including biometic factos, physiological functions, cognitive pocessing, visual feedback, and ceebella activity have shown to influence postual sway [6]. Clinical tests usually ate balance pefomance on a set of moto tasks. Scoing is based on the sum of odinal item scoes. Ideally, an evaluation of postual balance should include clinical scales that ae pactical, sensitive, selective, eliable, and valid. Although some clinical scales ae easy and elatively quick to use, they ae hampeed by thei vaiable execution [7, 8]. The Biodex stability system (BSS) was used to assess the paticipant s dynamic balance. It is used fo both assessment and taining of the dynamic balance, and dynamic limits of stability. It focuses on the popioceptive neuomuscula mechanisms that appea to affect both dynamic joint and postual stabilities [9, 10]. The Autho(s) Open Access This aticle is distibuted unde the tems of the Ceative Commons Attibution 4.0 Intenational License ( which pemits unesticted use, distibution, and epoduction in any medium, povided you give appopiate cedit to the oiginal autho(s) and the souce, povide a link to the Ceative Commons license, and indicate if changes wee made.

2 Atteya et al. The Egyptian Jounal of Neuology, Psychiaty and Neuosugey (2019) 55:7 Page 2 of 5 The aim of this study wee to assess the postual balance in patients with MS by using clinical and instumental methods and to detemine the diffeences in the diections of tilt of the instumental method (Biodex stability system) which may help in the ehabilitation pogams of the patients. Subjects and methods This case-contol study was conducted on 50 patients with multiple scleosis eithe elapsing-emitting multiple scleosis (RRMS) o seconday pogessive multiple scleosis (SPMS) (mean age = ± 7.7 yeas, M:F = 16:34) diagnosed accoding to McDonald s citeia 2017 [11], ecuited fom outpatient clinic of Faculty of Medicine, Caio Univesity. Expanded Disability Status Scale (EDSS) of these patients is < 5. Patients with RRMS wee being in emission peiod (at least 2 months afte last elapse). Twenty healthy voluntees wee selected as a contol goup matching in age, gende, weight, and height to patients. Infomed witten consent was obtained fom paticipants and the study was appoved by the ethical committee of Depatment of Physical Theapy fo Neuomuscula Disodes and its Sugey, Faculty of Physical Theapy, Caio Univesity. Registation numbe (NO:P.T.REC/010/001075). Excluded fom this study ae patients with cognitive impaiments (MMSE 24) [12], patients with skeletal defomities in lowe limbs, diabetes mellitus, as well as patients with visual and intenal ea dysfunction. Patients wee subjected to (a) complete geneal and neuological examination including EDSS [13]. (b) Clinical assessment of balance using Beg balance scale (BBS) which consists of 14 standadized sub-tests scoed on 5-point scales (0 4), with a maximum scoe of 56 (the best pefomance) examining individuals ability to sit, stand, each, maintain single-leg stance, and tun [14]. Scoes less than 45 wee consideed as falle [15]. (c) Instumental assessment of balance using BSS. The system supplies with data egading the balance of the tested subject. This data include anteoposteio (AP) stability index, mediolateal (ML) stability index, and oveall stability index. The smalle the amount of the sway, the lowe the numeical value of these indices will be [16]. Statistical methods Data was analyzed using SPSS vesion 21. Numeical data will be expessed as mean and standad deviation. Fequency and pecentage fo qualitative data, student t test will be used to compae the diffeence between two means of quantitative vaiables among patients and contols, chi-squae test will be used to compae qualitative vaiables, and coelation was done using Speaman ank coefficient to study the elation between numeic vaiables. Paied t test was used to compae two means in the same patients; level of significant was at Results Geneal chaacteistics of the subjects Patient goup Fifty patients with multiple scleosis (16 males and 34 females) wee included in this goup. Thei mean age was ± 7.7 yeas, mean weight was ± kg, mean height was ± 7.5 cm, and mean body mass index (BMI) was ± 4.16 kg/m 2. Contol goup Twenty healthy voluntee subjects (7 males and 13 females) wee included. Thei mean age was 29.9 ± 4.81 yeas, mean weight was 78.9 ± kg, mean height was ± 8.91 cm, and mean BMI was ± 6.81 kg/m 2. Thee was no statistically significant diffeence between both goups egading age, gende, weight, height, and BMI ( > 0.05). Clinical chaacteistics of patients Patient goup consisted of 50 patients, 42 (84%) had RRMS and 8 (16%) patients had SPMS. The mean values of the age, weight, height, BMI, duation of illness, and EDSS wee epesented in (Table 1). Clinical assessment of the balance using Beg balance scale test In patient goup, thee wee 39 (78%) subjects concened as non-falles (scoe between 56 and 45 in BBS accoding to Riddle and Statfod [18], while 11 (22.0%) subjects wee concened as falles (scoe less than 45). In the contol goup, all subjects wee detected as non-falle (100%). Thee was significant diffeence between both goups ( = 0.027). Also, thee was a significant diffeence between RRMS and SPMS egading BBS scoe ( = 0.001). Table 1 Demogaphic and clinical data of patient subgoups RRMS (n = 42) SPMS (n =8) P value Mean SD ± Mean SD ± Age (yeas) Weight (kg) Height (cm) a BMI (kg/m 2 ) a Duation of illness a EDSS , a

3 Atteya et al. The Egyptian Jounal of Neuology, Psychiaty and Neuosugey (2019) 55:7 Page 3 of 5 Compaison between patient and contol goups as egad the stability indices of BSS Thee wee significant diffeences between patient and contol goup as egad the thee limits of stability mediolateal, anteoposteio, and oveall ( = 0.001, 0.005, and 0.002) espectively as shown in (Table 2). Compaison between the deviation (tilt) in anteoposteio and mediolateal diection in patient goup By using Biodex stability system (BSS), the mediolateal and antoposteio diections cutoff values in the patient goup wee 1.79 and 2.26 espectively (as egad the contol cutoff values). The least stability level was obseved in mediolateal diection in the patient goup (p value = 0.001) (Table 3). Compaison between the patient subgoups (RRMS and SPMS) as egad stability indices of BSS The degee of tilt was highe in SPMS than RRMS as egad the thee limits of stability mediolateal, anteoposteio, and oveall ( = 0.009, 0.001, and 0.003) espectively. The elation between BBS and BSS In MS patients, the falle goup showed moe significant deviation than non-falle goup in the thee diections (anteoposteio, mediolateal, and oveall) ( = 0.002, 0.001, and 0.001) espectively as shown in (Table 4). Coelation between BBS and the patient data The Beg balance scale (BBS) was significantly negatively coelated with age, EDSS, duation of illness, and the Biodex tilt in the thee diffeent diections (mediolateal, antoposteio, and oveall). Also, thee wee positive coelation between BBS and weight, height and BMI. This is shown in (Table 5). Coelation between the BSS and the patients data Thee wee positive significant coelation between age, EDSS scoe, and the duation of illness of the disease with paametes of BSS (mediolateal, antoposteio, and oveall). Also, thee was a negative coelation Table 2 Compaison between patient and contol goups as egad the stability indices of BSS BSS Patient goup (n = 50) Contol goup (n = 20) P Mean ± SD Degee/second value ML 1.83 ± ± a AP 2.16 ± ± a OA 2.75 ± ± a Table 3 Compaison between anteoposteio and mediolateal tilt in patient goup ML insignificant tilt ML significant tilt P value AP insignificant tilt a AP significant tilt 1 17 N.B. The mediolateal and antoposteio diections cutoff values in the patient goup wee 1.79 and 2.26 espectively (as egad the contol cutoff values) between weight, height, BMI, and BBS with the paametes of BSS (Table 6). Discussion In patients with MS, balance deficits and the associated fea of falling esult in significant declines in thei mobility and activity levels, deceased social contact [17]. Balance assessment is necessay fo multiple scleosis subjects in ehabilitation settings. It helps establishing appopiate teatment goals. Also, it is impotant to incease awaeness of fall isk and to assign appopiate assistive devices [18, 19]. BBS is used as sceening tool fo balance poblems in people with MS [20]. Assessment of balance by BBS test evealed significant diffeence between patient and contol goups in the pesent study. This was in ageement with Finlayson and colleagues. Finlayson et al. [21] and Nilsagad et al. [22] found that the balance impaiment can be associated with inceased isk of fall in MS patients when measuing by BBS. On the othe hand, Fjeldstad and colleagues [20] epoted that BBS measues mainly the static balance and does not povide significant infomation about dynamic functions. In contast to the pesent study, Findling and colleagues [23] found that the use of clinical balance potocols (BBS) did not identify any balance abnomalities. This may be attibuted to the sample of patients chosen in that study as they wee minimally impaied MS patients with EDSS scoes less than 3. Accoding to the cuent study, thee was a significant diffeence between RRMS and SPMS goups as egad BBS scoe. Thee was moe instability found in SPMS goup than RRMS goup. In ageement with the pesent Table 4 Compaison between falles and non-falles as egad the degee of tilt in the limits of the stability of BSS BSS Non falle (n = 39) Falle (n = 11) P Mean ± SD Degee/second value ML 1.73 ± ± a AP 1.85 ± ± a OA 2.42 ± ± a

4 Atteya et al. The Egyptian Jounal of Neuology, Psychiaty and Neuosugey (2019) 55:7 Page 4 of 5 Table 5 Coelations between BBS and the patients data Coelation coefficient () of BBS P value Age a Weight a Height BMI a EDSS a Duation of illness a BSS ML a AP a OA a BMI Body mass index, EDSS Expanded Disability Status Scale, BSS Biodex stability system, ML mediolateal, AP antoposteio, OA oveall study, Soyue and colleagues [19] found that patients with MS epot wose postual balance and inceased isk of falls when compaed with healthy contols. This is moe significant fo those with pogessive foms of MS athe than the elapsing emitting fom of MS. Instumental measues of balance may be moe sensitive than common clinical tests fo documenting both deficits and impovements in balance, even in minimally impaied patients with MS [24]. Accoding to the cuent study, assessment with the Biodex stability system (BSS) evealed that the MS goup demonstated geate postual sway in the thee limits of stability compaed with healthy contol goup. The least stability level was obseved in mediolateal diection. Also, the SPMS goup showed moe instability than the RRMS goup in all tilting diections. Moeove, thee wee significant diffeences between falles and non-falles as egad BSS Table 6 Coelation between BSS paametes (mediolateal, anteoposteio, and oveall) and the patients data ML AP OA Age Weight Height BMI EDSS Duation of illness BBS a a a ML mediolateal, AP antoposteio, OA oveall a a a a a a a a a assessment in the thee diections of tilt. Fjeldstad and colleagues [20] found that thee was a significant diffeence between the MS and healthy contol goups fo both static and dynamic balance using BBS and Neuo- Com SMART Balance Maste. They found a significant coelation between the postual assessments using the standad BBS and appoximately 70% of all tests pefomed with the NeuoCom balance tests fo the MS goup. Moeove, Findling and colleagues [23] epoted significant balance changes in MS patients compaed to healthy subjects on a nomal suface in both anteoposteio and mediolateal diection, while standing on two legs with eyes opened. Also, they found significant diffeences fo angula ange velocity in the mediolateal diection. Futhemoe, Sosnoff and colleagues [24] found that falle subjects exhibited inceased sway velocity in the ML diection with eyes opened moe than the anteoposteio diection compaed to non-falle subjects. This was in ageement with the pesent esults. The cuent study findings ae contay to Cattaneo and colleagues [25] who found that the patients in MS goup showed moe instability than the healthy subjects in anteoposteio diection moe than mediolateal diection. Accoding to the pesent esults, the possibility of falling accoding to the BBS and BSS assessment inceases in olde patients, patients with highe scoe of EDSS, and those with inceased duation of illness. This was in accodance with Sosnoff and colleagues [24] who obseved that people with MS who ae olde, walk slowe, and have wose balance and deceased walking enduance ae at a geate isk of falls. Also, Pospeini and colleagues [3] found that falles had a longe disease duation and wose EDSS and had lowe BBS scoes than non-falles. Accoding to Nilsagad and colleagues [22], they found that thee wee significant diffeences between falles and non-falles with egad to EDSS and fo each degee of inceased EDSS scoe, the odds of falling wee doubled. Fom all pevious esults, we conclude that BSS was significantly coelated with clinical balance measuement scale using BBS in MS patients. Moeove, BSS can povide moe objective, quantitative measues of postual imbalance. This may help in applying the suitable ehabilitation pogam of the patients. Abbeviations BBS: Beg balance scale; BSS: Biodex stability system; EDSS: Expanded Disability Status Scale; MS: Multiple scleosis; RRMS: Relapsing-emitting multiple scleosis; SPMS: Seconday pogessive multiple scleosis Acknowledgements The authos acknowledge subjects fo thei paticipation and coopeation in this study. Funding This eseach eceived no specific gant fom any funding agency in the public, commecial, o not-fo-pofit sectos.

5 Atteya et al. The Egyptian Jounal of Neuology, Psychiaty and Neuosugey (2019) 55:7 Page 5 of 5 Availability of data and mateials The datasets geneated and/o analyzed duing the cuent study ae not publicly available due to cuent Caio Univesity egulations & Egyptian legislation but ae available fom the coesponding autho on easonable equest and afte institutional appoval. Authos contibutions AA, NK, and AE contibuted in eseach idea, data acquisition, data analysis, and intepetation. RS contibuted in data analysis, intepetation, and manuscipt witing and eviewing. RB contibuted in data acquisition, data analysis, and intepetation.all authos ead and appoved the final manuscipt. Ethics appoval and consent to paticipate The aim and pocedues of the study wee explained to evey paticipant and an infomed consent was obtained befoe being enolled in the study. The study was appoved by the ethical committee of Depatment of Physical Theapy fo Neuomuscula Disodes and its Sugey, Faculty of Physical Theapy, Caio Univesity. (NO:P.T.REC/010/001075). (12/10/2015). Consent fo publication Not applicable. Competing inteests The authos declae that we have no competing inteests (financial and nonfinancial). We declae that the eseach was conducted in absence of any commecial elationships that could be constucted as a potential conflict of inteest. Publishe s Note Spinge Natue emains neutal with egad to juisdictional claims in published maps and institutional affiliations. Autho details 1 Depatment of Physical Theapy fo Neuomuscula Disode and its Sugey, Faculty of Physical Theapy, Caio Univesity, Caio, Egypt. 2 Neuology Depatment, Faculty of Medicine, Caio Univesity, Caio, Egypt. 12. Tombaugh TN, McIntye NJ. The mini-mental state examination: a compehensive eview. J Am Geiat Soc. 1992;40(9): Kutzke JF. 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