Transcript No Slide Title

Changes in Vision, Balance, Gait, and Dizziness with Balance-Based Torso-Weighting:
A Case Report on a Woman with MS
Cynthia Gibson-Horn, PT Laurie Chaikin, OD, OTR/L, FCOVD
Background
Assessment
People with multiple sclerosis have numerous medical
impediments due to the unpredictable demyelination
in the brain, spinal cord, and optic nerve. Common
impairments affecting gait and or balance in MS are
disturbances in sensation, vision, and vestibular
function, as well as weakness, spasticity, ataxia and
fatigue.
Vision: impaired binocularity and tracking (see Vision table).
Posture: Leans posterior
ROM: Within normal limits
Strength: Trunk Abdominals 3/5; Back extension 3+/5;
bilateral hip flexion, 3+/5; bilateral hip extension 3/5;
Abduction Right 3/5, Left 4-/5; bilateral knee and ankles
4+/5.
Tone: WNL
Sensation: Light Touch diminished bilateral soles of feet,
position sense WNL, vibration duration was75% decreased at
the first metatarsal head and lateral malleoli.
Coordination: Dysmetria: Finger nose and heel shin were
mildly affected in EO and moderately affected in EC.
Disdiadochokinesis: WNL EO, 50% decreased in EC.
Gait: slow (see Gait and Balance table)
Balance: impaired (see Gait and Balance table and
SOT/COG)
Activities and Participation: limited (see Dizziness
Handicapped Inventory table).
Gait and vision are perceived as the most valuable
bodily functions regardless of whether patients have
had the disease for less than or greater than ten years.
Finding treatments that focus on improving vision and
gait impairments are important to patients’ quality of
life.
Balance-Based Torso-Weighting is an intervention that
begins with assessment of directional balance
impairment during standing in the Romberg position
with eyes open (EO) and eyes closed (EC). Anticipatory
and reactive control is assessed with trunk
perturbations. Small weights in ½ and ¼ pound
increments are strategically placed on the torso to
improve balance reactions.
References
•Gibson-Horn C. Balance-based torso-weighting in a patient with ataxia and multiple sclerosis: a case report. J Neurol Phys Ther. 2008;32:139146.
•Widener GL, Allen DD, Gibson-Horn C. Balance-based torso-weighting may enhance balance in persons with multiple sclerosis: preliminary
evidence. Arch Phys Med Rehabil. 2009;90:602-609.
•Widener GL, Allen DD, Gibson-Horn C. Randomized clinical trial of balance-based torso weighting for improving upright mobility in people with
multiple sclerosis. Neurorehabil Neural Repair. 2009;23(8):784-791.
•C Heesen, J Böhm, C Reich, J Kasper, M Goebel and SM Gold, Patient perception of bodily functions in multiple sclerosis: gait and visual
function are the most valuable. Mult Scer 2008 Aug:14 (7): 988-91
•Multiple Sclerosis The Questions You have - The Answers You Need, By: Rosalind C Kalb, PhD, Second Edition, 2000, New York: Demos, pp37-39.
ISBN: 1 888 799 43 9
Patient History
MC is a 49-year-old female diagnosed with MS nine
years prior after experiencing severe vertigo. She is
currently married and has a five-year-old daughter. She
was provided with BBTW in 2002.
In 2010 she was re-assessed to determine the
continued effects of BBTW both immediately and
short-term (4 months). Her goals were to improve
walking, balance, and dizziness.
Symptoms
Visual complaints were eye fatigue, reduced reading
time, loss of place when reading, blurred vision at near.
Nausea with eye movement.
MC noted instability with standing and walking. She
had spontaneous vertigo and disequilibrium induced by
motion and positional changes including lying down,
sitting, standing and walking in the dark or on uneven
surfaces. She denies falling but reports she stumbles,
staggers and side-steps to catch balance.
BBTW Assessment: Moderate trunk sway EO Romberg.
Severe loss of balance and truncal ataxia in EC standing in
Romberg position. Perturbation testing revealed severe
posterior and lateral instability with moderate left lower
trunk loss of resistance to right forward rotation.
Treatment
MC was given a strategically weighted BalanceWear
garment with 1 ¾ pounds of weight to wear daily as much as
she wanted.
Results
Discussion
Visual skill
Pre BBTW
5/28/10
Visual acuity
20/20 right eye
with Best Correction
20/20-2 left eye
Horizontal tracking
Vertical tracking
Near phoria
(eye alignment)
Fixation Disparity*
Stereopsis
(depth perception)
Dizziness
Handicap
Inventory
With BBTW
5/28/10
Subjective
improvement in sense
of clarity
Multiple shifts
possible
Multiple times
up and down
9 exophoria
After 2 x unable
Dizzy
After 1x up unable
Dizzy
12 exophoria
0 to 4.3 more stable
4.3 to 8.6 sec. of arc,
cont. movement
400 seconds
(gross only)
Pre Intervention
05/27/10
40 seconds
(normal)
At Follow Up
Percent
Improvement
09/27/2010
Physical
20
8
60%
Emotional
22
12
45%
Function
24
18
25%
Total
66
38
62%
Gait and Balance
Assessments
Percent
Change
5/27/10
With
BBTW
5/27/10
TUG - 2 test average
9.4 sec
7.75 sec
18%
25 ft walk
2 test average
6.3 sec
5.55 sec
12%
Dynamic Gait Index
15/24
24/24
37.5%
HEP: Lower extremity strengthening, brock string to increase
convergence and horizontal and vertical eye movements.
MC wore the vest 8 hours per/day and performed her visual
exercises. Per report after 5.5 weeks she could do the EYE
exercises without the vest. She continued to wear the vest
for stability during daily activities. While on vacation she was
able to go on a gondola and also sailing which she attributed
to wearing the vest.
9/27/2010 Pre BBTW
Funding Source
No funding was received for this case report.
Pre BBTW
With the strategically weighted BalanceWear
Therapeutic Vest, MC demonstrated immediate positive
changes in many of her symptoms: dizziness, balance,
vision, and walking. Changes in body function were
attributed to changes in participation: MC could ride in a
gondola and go sailing while on vacation while wearing
the vest.
The initial balance difficulties were demonstrated in the
DGI and SOT 2-6 sensory, vestibular and visual conflict.
Vision testing revealed insufficient convergence, very
poor depth perception, and poor tracking skills that
further impacted her balance.
With BBTW, MC showed immediate improvement
toward normalization of the SOT and DGI. Additionally,
MC strategies on the SOT changed from using hip and
ankle strategies to primarily ankle while she wore the
vest. Her COG became consistent even though in both
conditions she leans toward the left side. In the nonweighted state her COG was slightly more posterior.
MC remarked that things in general looked clearer, and
she showed immediate ability to track with ease,
without impacting her balance. The immediate
improvements to normal-stereopsis and more stable
binocular findings typically require months of vision
therapy.
How can we explain this change? Each sensory system
transmits information about body motion: vestibular,
visual, proprioceptive, and cutaneous. Wearing the
weights on the trunk may provide augmented cutaneous
and proprioceptive input. Perhaps the additional input
improves capacity for attending to visual and vestibular
input.
Future Research
•Determine the prevalence and types of visual
coordination impairments seen in people with MS with
and with without optic neuritis.
•Investigate whether BBTW affects other patients with
dizziness, visual and vestibular dysfunction.
•What sensory impairments may predict positive
outcomes with BBTW.
Conclusion
MC had a positive outcome in vision and balance from
wearing the strategically weighted garment both
immediately and at a four-month follow-up.
Provided the BalanceWear vest for MC. Ms. Gibson-Horn
has a financial interest in Motion Therapeutics.
9/27/2010 With BBTW