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Table 3: Standing Balance

Author Year
Country
Score
Research Design
Total Sample Size
 

 

Methods

 

 

Outcome

 

Standing Balance-Acute

 

 

 

 

Dobkin et al. 2006

USA

RCT

PEDro=2

N=146

 

 

Population: 146 individuals- 116 males and 30 females; 38 AIS, and 7 AIS D; level of injury: C5-L3; median age= 25y; time since injury= 1.03 months

 

Treatment: The control group had 12 weeks of over ground training. The experimental group participated in 12 weeks of body weight support treadmill training. The sessions were 1 hour long for 45-60 sessions. 5 times a week for 12 weeks

 

Outcome Measures: Berg Balance Scale

1.     There were no differences in balance between the overground training group and the body-weight supported treadmill training group.

 

 

Standing Balance-Chronic

Virtual Reality

 

 

 

Villiger et al. 2013

Switzerland

Pre-post

Level 4

N=14

 

Population: 14 individuals- 9 males and 5 females; chronic SCI; 2 AIS C and 12 AIS D; level of injury: C4-T12. mean age= 53y; median years post-injury= 4y

 

Treatment: Participants received 4-5 45-minute sessions of intensive virtual reality augmented training sessions per week for a total of 16-20 sessions.

 

Outcome Measures: Berg Balance Scale

1.     Significant increases were found for all patients in BBS (16.5% increase post treatment and 13% at follow up).
 

 

 

 

 

Sayenko et al. 2010

Canada, Japan

Pre-post

Level 4

N=6

 

Population: 6 participants- 5 males and 1 female; chronic SCI; 4 AIS C and 2 AIS D; level of injury: C4-T12; mean age= 41y; median years post-injury= 7y

 

Treatment: Patients participated in 3 60-minute visual feedback training sessions, totalling 12 sessions. During training, participants stood on a force platform and were asked to shift their center of pressure (COP) in the indicated directions as represented by a cursor on the monitor.

 

Outcome Measures: Static standing eyes open and closed as measured by COP displacement; Dynamic standing as measured by voluntary COP displacement.

1.     All participants showed substantial improvements in the scores, which varied between 236±94 and 130±14% of the initial values for different exercises.

2.     Improvements were all statistically significant for both eyes open and closed except mean velocity in the medial/lateral direction.

3.     The balance performance during training-irrelevant tasks was significantly improved: for example, the area inside the stability zone after the training reached 221±86% of the pre-training values.

 

 

 

 

Tamburella et al. 2013

Italy

Open-case study with retrospective matched controls

Level 4

N=18

 

Population: 18 individuals- 9 males and 9 females; chronic SCI; 6 AIS D; level of injury: T9-L5; mean age= 52y; median time since injury: 2.3y

 

Treatment: The control group participated in overground conventional rehabilitation including BWS standing and stepping on a treadmill and overground, balance exercises. The experimental group participated in 40 min of control group protocol and 20 min of specific vBFB (visual biofeedback task specific balance training). The sessions were 60 minutes long 5 times a week for a total of 8 weeks.

 

Outcome Measures: Berg Balance Scale, COP measures, Timed Up and Go (TUG)

1.     At T4, the experimental group saw an improvement in balance aned gait demonstrated by clinical and instrumental evaluation; the improvement was maintained at follow up examinations.

2.     In the experimental group, the enhancement in balance that existed at T1 preceded the improvement in gait, and significant correlations between the improvements in gait and balance were observed.

3.     In comparison with H data, vBFB treatment demonstrated a significant higher level of effecvtiveness than conventional rehab.

Standing Balance-Chronic

Body Weight Support

 

 

 

 

 

Alexeeva et al. 2011

USA

RCT

PEDro=7

Level 1

N=35

 

Population: 35 individuals- 30 males and 5 females; chornic SCI; 8 AIS C and 27 AIS D; level of injury: C2-T10. mean age= 38.5y; median years post injury= 4y

 

Treatment: Patients participated in a 13-week training program, with three 1 hour sessions per week. The PT group is a structured rehab program individualized for each participant. The TRK group consisted of body weight supported ambulation on a fixed track. The TM group involved body weight supported ambulation on a treadmill.

 

Outcome Measures: Tinetti Balance Scale

1.     All three training groups showed significant improvements in maximal walking speed, muscle strength, and psychological well-being.

2.     A significant improvement in balance was seen for PT and TRK groups but not for participants in the TM group.

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data
 

 

 

Wu et al. 2012

USA

Repeated assessment with crossover

PEDro=4

Level 2

N=10

Population: 10 individuals- 8 males and 2 females; chronic SCI; all AIS D; level of injury: C2-T10; mean age= 47y; median time since injury=5y

 

Treatment: Group 1 underwent 4 weeks of assistance training then 4 weeks of resistance training. Group 2 underwent 4 weeks of resistance training first, then 4 weeks of assistance training. Resistance was provided by a cable-driven robotic locomotor training system. Sessions were 45 minutes long, 3 times a week for 8 weeks.

 

Outcome Measures: Berg Balance Scale.

1.     A significant improvement in walking speed and balance in humans with SCI was observed after robotic treadmill training using the cable-driven robotic locomotor trainer.
 

 

 

 

 

Buehner et al. 2012

USA

Prospective Cohort Study

Level 2

N=225

 

Population: 225 individuals- 167 males and 58 females; chronic SCI; 57 AIS C and 167 AIS D; level of injury was not specified; mean age= 42.5y; median time since injury= 2.45y

 

Treatment: NRN Locomotor Training Program consisting of manual-facilitated BWS standing and stepping on a treadmill and overground. Sessions included 1hr of treadmill training, 30 minutes overground assessment, and 15-30 minutes of community reintegration. Sessions were 5 days per week for non ambulators, 4 days per week for ambulators with pronounced assistance, and 3 days week for independent walkers.

 

Outcome Measures: Berg Balance Scale, AIS classification, lower extremity pin prick, light touch and motor scores, 10MWT, 6MWT

1.     Significant gains occurred in lower extremity motor scores.

2.     Final Berg Balance Scale scores and initial lower extremity motor scores were positively related.

3.     Although 70% of participants showed significantly improved gait speed after locomotor training, only 8% showed AIS category conversion.

 

 

 

 

 

Harkema et al. 2012

USA

Prospective Cohort Study

Level 2

N=196

 

Population: 169 individuals- 148 males and 48 females; chronic SCI; 66 AIS C and 130 AIS D; level of injury was not specified; mean age= 41y; median time since injury= 0.9y

 

Treatment: NRN Locomotor Training Program consisting of manual-facilitated BWS standing and stepping on a treadmill and overground. Sessions included 1hr of treadmill training, 30 minutes overground assessment, and 15-30 minutes of community reintegration. Sessions were 5 days per week for non ambulators, 4 days per week for ambulators with pronounced assistance, and 3 days week for independent walkers.

 

Outcome Measures: Berg Balance Scale, 6MWT, 10MWT

1.     Outcome measures at enrollment showed high variability between patients with AIS grades C and D.

2.     Significant improvement from enrollment to final evaluation was observed in balance and walking measures for patients with AIS grades C and D.

3.     The magnitude of improvement significantly differed between AIS groups for all measures.

4.     Time since SCI was not associated significantly with outcome measures at enrollment, but was related inversely to levels of improvement.

 

 

 

 

 

Lorenz et al. 2012

USA

Prospective Cohort Study

Level 2

N=337

 

 

Population: 337 participants- 255 males and 82 females; chronic SCI; 99 AIS C and 238 AIS D; level of injury: T10 or above; mean age= 40y; median time since injury= 1y

 

Treatment:  NRN Locomotor Training Program consisting of manual-facilitated BWS standing and stepping on a treadmill and overground. Sessions included 1hr of treadmill training, 30 minutes overground assessment, and 15-30 minutes of community reintegration. Sessions were 5 days per week for non ambulators, 4 days per week for ambulators with pronounced assistance, and 3 days week for independent walkers.

 

Outcome Measures: Berg Balance Scale, 6MWT, 10MWT.

1.    There was significant improvement on each outcome measure and significant attenuation of improvement over time.

2.    Patients varied significantly across groups defined by recovery status and American Spinal Injury Association Impairment Scale (AIS) grade at enrollment with respect to baseline performance and rates of change over time.

3.   Time since SCI was a significant determinant of the rate of recovery for all measures.

 

 

 

 

 

Behrman et al. 2012

USA

Prospective Cohort Study

Level 2

N=95

 

 

Population: 95 individuals- 75 males and 20 females; chronic SCI; 31 AIS C and 64 AIS D; level of injury= T11 or above; mean age= 43y; median time since injury= 1y; time since injury: <1 yr (n=47), 1-3 yrs (n=24), ³3 yrs (n=24).

 

Treatment: NRN Locomotor Training Program consisting of manual-facilitated BWS standing and stepping on a treadmill and overground. Sessions included 1hr of treadmill training, 30 minutes overground assessment, and 15-30 minutes of community reintegration. Sessions were 5 days per week for non ambulators, 4 days per week for ambulators with pronounced assistance, and 3 days week for independent walkers.

 

Outcome Measures: Berg Balance Scale, 6MWT, 10MWT

1.     Individuals classified within each of the 4 phases of the NRS were functionally discrete, as shown by significant differences in the mean values of balance, gait speed, walking endurance, and the variability of these measurements was significantly reduced by NRS classification.

2.     The magnitude of improvements in these outcomes was also significantly different among phase groups.

 

 

 

 

 

Fritz et al. 2011

USA

Pre-post

Level 4

N=15

 

Population: 15 individuals- 11 males and 4 females; incomplete chronic SCI; Lower functioning group: 10 individuals- 8 males and 2 females; mean age= 38.5y; time since injury: 6.6y; AIS lower extremity score= 24;

Higher functioning group: 5 individuals- 3 males and 2 females; mean age= 50.4y; time since injury= 5.7y; AIS lower extremity score= 44

 

Treatment: Participants received intensive mobility training (IMT) in activities that encouraged repetitive, task specific training of the lower extremities. IMT combines BWSTT, balance exercises, muscle strengthening, coordination and range of motion in a massed intensive therapy. Sessions were 3 hours a day for 3-5 days per week for a total of 10 weeks.

 

Outcome Measures:  Berg Balance Scale, Dynamic Gait Index (DGI)

1.     Individuals in the higher functioning ISCI group (BBS score ≥45 and gait speed ≥0.6m/s) spent more time in the intensive therapy on average than individuals in the lower functioning ISCI group.

2.     Effect sizes were comparable for changes in balance and mobility assessments between the lower and higher functioning groups, with the largest effect sizes observed for the DGI.

 

 

 

 

 

 

Musselman et al. 2009

Canada

Case Series

Level 4

N=4

 

Population: 4 participants- 2 males and 2 females; all AIS C; level of injury: C5-L1; mean age: 44.5y; Gender: median time since injury= 2.7y

 

Treatment: Initial 3 months BWSTT by all 4 patients. Patients 1, 2 received 3 months skills training, followed by 3 months BWSTT. Patients 3, 4 received the training in reverse order. Sessions were 1 hour long, 5 days a week for 3 months.

 

Outcome measures: Berg Balance Scale, Modified Emory Functional Ambulation Profile, 10MWT, 6MWT, Activities- specific Balance Confidence Scale.

1.     Overall improvements in walking speed met or exceeded the minimal clinically important difference for individuals with iSCI (> or = 0.05 m/s), particularly during the skill training phase (skill training: median=0.09 m/s, IQR=0.13; BWSTT: median=0.01 m/s, IQR=0.07).

2.     Walking endurance, obstacle clearance, and stair climbing also improved with both types of intervention. Three of the 4 patients had retained their gains at follow-up (retention of walking speed: median=92%, IQR=63%).

3.     The findings suggest that skill training was effective in this small group of individuals.

Standing Balance

Acute (< 6 months) SCI

There was one lower quality RCT that compared BWSTT (experimental group) vs. over ground gait training (control group) in acute (<8 weeks post-injury) incomplete SCI (N=146, N=45 at 6 months; AIS C=38, AIS D=7, 12 weeks of training) (Dobkin et al., 2006) (Table 3). There were no significant differences in balance scores following training between the two groups. However, there was a large median difference between baseline and 6-months post-training in both groups, indicating that for people who were able to walk at six months (N=45), both types of interventions resulted in considerable improvements in balance scores.

Chronic (> 1 year) SCI

Virtual Reality

There were 3 trials that assessed standing balance in people with chronic incomplete SCI using virtual reality (VR) (N=38, AIS C=6, AIS D=20, Table 3). Two studies performed similar VR interventions consisting of standing on a force plate and performing task specific exercises while the center of pressure (COP) position signal was used for visual biofeedback for 4 and 8 weeks respectively (Sayenko et al., 2010; Tamburella et al., 2013). Pre-post studies support the feasibility and reported positive effects on balance function using this approach (Sayenko et al., 2010; Villiger et al. 2013). In the study by Tamburella et al, participants were randomized to receive active training with or without the visual biofeedback. After 8 weeks of training, only the experimental group showed significant improvements in BBS (Baseline= 26.0±10.69 to post-training=41.0±7.8) and Timed Up and Go test (Baseline=21.70±10.70 to post-training=15.22±6.14) (Tamburella et al., 2013).

Body Weight Support Training (BWST)

There were 4 trials that measured standing balance in incomplete SCI following body-weight supported treadmill training. One good quality RCT (Alexeeva et al., 2011), and three studies of level 4 evidence (Musselman et al., 2009; Fritz et al., 2011; Wu et al., 2012) utilized BWST in addition to various interventions such as treadmill, over ground, physical therapist (PT) skills training or a combination of these. After 8 weeks of training, PT skills training resulted in greater balance improvements than BWSTT and BWST on a track (Alexeeva et al., 2011). Small to medium effect sizes for the BBS (0.31-0.67) were reported when BWST was combined with 10 days of intensive mobility training (Fritz et al., 2011). An overall improvement in BBS was found when combining 8 weeks of BWSTT with resistance or assistance but no significant difference between the 2 interventions was reported (Wu et al., 2012).

Four level 4 evidence pre-post trials from the same clinical setting spanning reported significant improvements in balance scores following a program of 3-5 days per week of treadmill- progressing to overground-based BWST (NRN protocol; Behrman et al., 2012; Buehner et al., 2012; Harkema et al., 2012; Lorenz et al., 2012). In addition, this data set demonstrated that the Berg Balance Scale scores were significantly correlated to the severity of injury (Lorenz et al., 2012). Among the pre-post studies, effect sizes were generally small for interventions involving BWST regardless if they were combined with other types of therapy when assessed using the BBS (d=0.18-0.47) with the exception of 1 case-control trial (d=0.88) (Musselman et al., 2009).

There are some drawbacks of measuring balance with only functional outcomes. A ceiling effect was observed in BBS scores of SCI participants receiving BWST with assistance and resistance (Wu et al., 2012). Only one trial was able to use predictable and unpredictable perturbations to assess balance reactions after kayak ergometry training (Bjerkefors et al., 2007). Nonetheless, functional measures are quick, cost effective and easy to apply in both the research and clinical setting and have the added benefit of being validated for the SCI population (Lemay and Nadeau, 2009). It would be optimal that when assessing balance, where feasible, reactions to sudden movements are included in order to give a more comprehensive understanding of balance capacity in persons with SCI.

CONCLUSION

Only preliminary recommendations can be made from the results of this review as there are relatively few studies that provide information on specific balance outcomes in SCI. Early balance training does not appear to enhance the effects of standard physical therapy in either sitting or standing balance. In people with chronic SCI who cannot stand, sitting balance can be improved with both static and dynamic task specific training. For participants with lower severity injuries (e.g., AIS C and D), BWS over ground training combined with physiotherapist-led task-specific exercises and feedback appear to be more effective to improve standing function than BWSTT alone.

There is Level 2 evidence (Dobkin et al. 2006) that there were no differences in balance whether participants engaged in overground training or Body-weight supported treadmill training, but the participants that completed either training and were able to walk made considerable progress in balance.

There is Level 4 evidence (Sayenko et al., 2010; Tamburella et al., 2013) that visual field feedback training leads to substantial improvements in static and dynamic standing eyes open and closed scores, and improvements in balance performance during training-irrelevant tasks.

Tamburella et al. found that the visual biofeedback task specific balance training group saw improvements in balance and gait, and that it demonstrated a significantly higher level of effectiveness than conventional rehabilitation.

There is one study with Level 1 evidence (Alexeeva et al., 2011) and 3 studies with Level 4 evidence (Musselman et al., 2009; Fritz et al., 2011; Wu et al., 2012) that found that BWSTT in addition to Physical Therapy resulted in greater balance improvements than BWSTT alone. Wu et al. found non-significant differences in balance when combining BWSTT with resistance or assistance training.

There is Level 4 evidence (Behrman et al., 2012; Buehner et al., 2012; Harkema et al., 2012; Lorenz et al., 2012) that treadmill and overground based BWST leads to improvements in balance scores.

There is level 1 evidence (Harvey et al., 2011) that task-specific sitting balance exercises for an additional 3 weeks in acute SCI resulted in no difference on balance outcomes.