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June 2009KUWAIT MEDICAL JOURNAL 135Table 1: Demographic data and principal characteristics of 23 patientswith multiple sclerosisCharacteristics Cases n (%) Mean ± (SD)Age (years)Disease duration (years)EDSSTherapy with interferonClinical course of MS:Relapsing-remittingSecondary progressivePrimary progressiveProgressive relapsingDysarthriaCerebellar lesionBrainstem lesionPyramidal lesionSensory lesionBladder lesionMental lesion21 (91.3)21 (91.3)2 (8.7)——16 (69.7)14 (60.87)3 (13.1)17 (79.9)11 (73.9)2 (8.9)—EDSS : Expanded Disability Status Scale45.2 ± 7.616.8423 ± 5.82.3 ± 0.1balance training on static and dynamic conditionsand the somatosensory, visual and / or vestibularsystems by computerized dynamic posturographybefore and after rehabilitation program inmoderately disabled persons with MS in Kuwait.SUBJECTS AND METHODSA total of 23 female Kuwaiti patients with MSwere recruited for this study and selected fromthe out-patient clinic in the Physical Medicineand Rehabilitation Hospital, Kuwait. All patientswere evaluated clinically with a brief neurologicalexamination. All patients underwent image studiessuch as brain computed tomography or magneticresonance imaging to confirm their diagnosis.The diagnosis of MS is generally made by reviseddiagnostic criteria for multiple sclerosis [10] . Theassessment of neurological impairment of MS wasdone using the Kurtzke Expanded Disability StatusScale (EDSS) [11] . Formal consent was taken from allthe patients.Inclusion criteria were the following: (1)ambulatory patients with ability to ambulate 25 ftindependently; and (2) mild or moderate MS deficitsdefined by an EDSS of ≤ 2.3. Those with severe MS,severe spasticity or cognitive deficit, peripheralneuropathy or significant visual field problems wereexcluded. The patients gave informed voluntaryconsent to participate in the study according to theprotocol approved by the local ethics committeeand in accordance with the ethical standards of theHelsinki declaration.Balance functional impairment was done by usingthe BBS. The maximum score for this assessment is 56.Based on clinical experience, Berg et al contend thatscores below 45 indicate that someone is impaired,with an increased risk for falls [12] .Table 2: Mean ± SD of Berge Balance Scale and parameters of sensoryorganization test (SOT) before and after training in MS patientsParameters (mean ± SD)Berge Balance ScaleComposite Equilibrium Score %TotalSOT 1SOT 2SOT 3SOT 4SOT 5SOT 6Sensory analysis scores %SOM (somatosensory ratio)VIS (visual ratio)VEST (vestibular ratio)PREF (preference score)Beforetraining42.3 ± 4.849.5 ± 3.882.9 ± 7.174.2 ± 6.668.9 ± 12.955.2± 2.537.6 ± 2.746.7 ± 2.372.3 ± 1.868.6 ± 3.054.4 ± 9.450.0 ± 2.6Aftertraining51.4 ± 3.9*68.3 ± 4.2**87.1 ± 6.0*81.4 ± 8.7*83.0 ± 3.5*77.3 ± 5.4*62.4 ± 1.9*73.7 ± 3.3*93.1 ± 2.6*78.5 ± 2.5#66.9 ± 3.0#61.9 ± 9.3#p-value< 0.05< 0.001< 0.05< 0.05< 0.05< 0.05< 0.05< 0.05< 0.05The paired-sample Student’s t test, * = Significant, ** = Highlysignificant, # = non-Significant.The SOT was used for balance assessment. Itincluded six test conditions. The firstthreeconditionsinclude SOT 1 (eyes open), SOT 2 (eyes closed), SOT3 (sway-referenced vision with standing on a fixedplatform called static posturography. The secondthree conditions include SOT 4 (eyes open), SOT 5(eyes closed), SOT 6 (sway-referenced vision withstanding on a moving platform called dynamicposturography. Composite Equilibrium Score (CES%) was calculated that describes the overall level ofperformance under the six conditions. Scores rangefrom 0 to 100, with 0 representing a fall and 100representing perfect stability [9] .The sensory analysis scores represent the influenceof each sensory system on the individual’s stability,and quantify the relative difference in scores betweenconditions. The somatosensory ratio comparescondition 2 to condition 1 and measures posturalstability when vision is removed. The visual ratiocompares condition 4 to condition 1 and measuresthe ability of the visual system to function whensomatosensory input is altered by sway-referencing.The vestibular ratio compares condition 5 to condition1, assessing the stability of the individual when bothsomatosensory and visual input have been alteredby sway-referencing or eye closure, respectively. Avision preference score, an indication of whether theparticipant is overly reliant on visual information, isalso calculated using the ratio of the sum of conditions3 and 6 to the sum of conditions 2 and 5 [9] .All patients received complex training coursefor three months including visual feedback balancetraining (once weekly) by using computerizeddynamic posturography and conventional physicaltherapy (three times weekly). All patients wereevaluated in a study of postural stability by the BBS
136Effects of Visual Feedback Balance Training by Using Computerized Dynamic Posturography...June 2009Fig. 1: Represents dynamic posturography before treatment in MS patients (CES = 37%)and computerized dynamic posturography (CDP)before and three months after the training program.Statistical analysisStudy data were analyzed using the SPSS statisticalpackage. The paired-sample Student’s t test indicatesthe magnitudes of the differences of means betweenthe BBS, ES and SOT scores before and after treatmentin MS patients. A p-value of < 0.05 was consideredas significant. This study was approved by the hospitalethical committee.RESULTSTable 1 represents characteristics of patients withmultiple sclerosis. Table 2 shows results of BBS, CESand six tests conditions and sensory analysis scoresbefore as compared to results after training of MSpatients. Fig. 1 and 2 represent CDP before and aftertreatment in MS patients.There was statistically significant increase of mean(SD) of BBS after treatment (51.4 ± 3.9) as comparedwith results before training (42.3 ± 4.8) (p < 0.05). Therewas an increase of mean (SD) of CES after treatment(68.3 ± 4.2) as compared to results before training (49.5± 3.8, p < 0.001). Moreover, a statistically significantincrease was observed for the static and dynamicbalance after treatment as compared to results beforetraining (p < 0.05).According to the sensory analysis scores, a significantincrease was observed for the somatosensory ratioscore after treatment (93.1 ± 2.6) as compared to resultsbefore training (72.3 ± 1.8, p < 0.05). However , therewas a statistically non-significant difference in visualratio score, vestibular ratio score and preference scorebefore as compared with results after training (p >0.05). The data suggest that there is an impairment ofthe somatosensory system, rather than a specific lesionof vestibular and/or visual systems.
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