Volume 8, Issue 3 (Summer 2022)                   Caspian J Neurol Sci 2022, 8(3): 178-187 | Back to browse issues page


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Sedaghati P, Asgharzadeh G, Zarei H. Functional Balance Tests for Patients with Multiple Sclerosis: A Review Study. Caspian J Neurol Sci 2022; 8 (3) :178-187
URL: http://cjns.gums.ac.ir/article-1-549-en.html
1- Department of Corrective Exercises and Sports Injury, Faculty of Physical Education & Sport sciences, University of Guilan, Rasht, Iran
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Introduction
Multiple Sclerosis (MS) is a common inflammatory disease of the central nervous system [1, 2]. The number of patients with MS is increasing such that there are 2.5 million people affected by this disease globally [3]. In Iran, 15-30 in 100,000 people are suffering from this disease. Women are twice as likely to have MS as men [4]. A systematic review and meta-analysis in 2019 on the epidemiology of MS in Iran showed that the high prevalence of MS in Iran [5]. The age at onset of MS is 20-40 years and may occur from age 20 to 80 [6]. The main cause of MS is unknown. Immunological, genetic and environmental factors seem to be effective in its occurrence [7]. The symptoms of MS include fatigue, tremors and diplopia, gait and mobility problems, and poor balance, which can be exacerbated by decreased physical activity [8]. Among these factors, poor balance is associated with the increased risk of falling or even fear of falling, which reduces self-satisfaction and self-confidence, and cause dependency in performing daily activities of life [9]. Therefore, the importance of balance in increasing the quality of life of people with MS should not be neglected, because balance is the basic precondition for most activities of daily living [10]. 
Inability to maintain balance affects the simplest daily activities of Patients with MS (PwMS) such that simple activities such as standing and walking become challenging and prevent them from using the locomotor system [11]. Balance tests are used for the identification and classification of balance disorders and subsequently, evaluate the effect of exercise programs on motor function and balance in MS patients. Therefore, knowledge of balance tests used to evaluate MS patients is essential. 
Different studies use different tools and methods to measure the balance in different populations. Balance is measured quantitatively (quantitative posturography)or by functional tests [12]. The advantage of functional tests is that they require neither advanced and expensive equipment nor specialized and skilled staff for the interpretation and understanding of the outcome. The validity of these tests for assessing balance and their appropriateness for a particular group is very important. Therefore, in using these functional tests for balance, we should be very careful and have a clear understanding of the study group, because if the selected test is not appropriate for assessing the balance in a particular group, incorrect data can be reported. It is, therefore, important to determine what kind of functional tests could assess functional balance in PwMS. Studies have had a general look at the functional balance tests in PwMS; this general perspective can lead to more detailed and better knowledge of these tests to determine which of them provides more accurate data and have higher validity in functional evaluation of balance in PwMS. Therefore, this review study aims at compile functional balance tests in PwMS. 

Materials and Methods 
Search strategy

A search was conducted in eight databases of PubMed, Scopus, LILACS, CINAHL, CENTRAL (Cochrane Central Register of Controlled Trials), Web of Science, PEDro, and Google Scholar on studies published until November 2021. A manual search and a full review of the reference section of the found articles were also performed. Search was performed in databases using the following keywords: “balance control” or “center of pressure” or “balance” or “postural stability” or “postural balance” or “postural sway” or “stability” or “static balance” or “dynamic balance” and “functional tests” or “physical examination” or “functional performance tests” or “lower extremity tests” and “Multiple Sclerosis” or “MS” or “demyelinating diseases”. After searching, the titles and abstracts of articles were examined based on meeting inclusion criteria and relevance to the research objectives. 

Inclusion and exclusion criteria 
First, the titles and abstracts of found articles (descriptive studies in English or Persian on functional balance tests that were performed without advanced tools and methods to assess the balance in PwMS) were screened. Then, the articles’ full texts were examined according to the study variable (functional balance tests) and target population (PwMS). The final list of selected articles were re-checked to ensure that they were in line with the research objective. The studies that had not been conducted on PwMS, those with poor methodology, performed on other functional tests (physical fitness tests), used questionnaire to assess the balance in individuals, and those used laboratory tools that could not be classified as functional tests were excluded from the study. Figure 1 presents the flowchart diagram of screening process.

Exclusion criteria consisted of articles that had not used the statistical population of PwMS, articles in which the methodology was not well described, articles that were performed on other functional tests (physical fitness tests), articles that used questionnaire to assess the balance in these individuals, and articles that used precision laboratory tools and could not be classified as functional tests.

Quality assessment and data extraction
Risk of bias was evaluated by two reviewers using the Newcastle-Ottawa Scale (NOS) for cross-sectional studies Error! Hyperlink reference not valid.based on Herzog et al.’s [13] form. Quality of studies was classifiedError! hyperlink reference not valid. as very good (9-10 stars), good (7-8 stars), satisfactory (5-6 stars), and unsatisfactory (0-4 stars). Data from studies were extracted independently by researchers which included: the name of functional test, validity, reliability, description of functional tests, and quality based on NOS (Table 1).


Exclusion criteria consisted of articles that had not used the statistical population of PwMS, articles in which the methodology was not well described, articles that were performed on other functional tests (physical fitness tests), articles that used questionnaire to assess the balance in these individuals, and articles that used precision laboratory tools and could not be classified as functional tests. 

Results
The initial search in online databases yielded 456 titles. Manually searching and reviewing the resources led to the finding of 10 more titles. After removing duplicates, 301 articles were remained. After checking the titles and abstracts of articles, 76 articles were removed and 225 were selected for examining the full texts. Finally, 21 articles that evaluated the functional balance of PwMS were selected for review (Figure 1). Based on results of NOS, studies that were systematically reviewed had desirable qualities: 10 study (40%) had very good quality; 8 studies (32%) had good quality, and 7 studies (28%)had satisfactory quality. Therefore, the articles that were systematically reviewed in this study had very good to satisfactory quality. By careful examination of the tests used to assess the functional balance of PwMS, it was found that studies had used 6 tests to assess static balance, 13 tests to assess dynamic balance, and 6 multi-item tests to assess functional balance in PwMS. The test results are detailed in Table 1.

Discussion 
The purpose of the present study was to review the functional balance tests in PwMS to determine what kind of balance tests are suitable for assessing static, dynamic, and functional (from the perspective of postural control systems) balance in PwMS. Twenty-five articles were found that had examined the functional balance in PwMS using 25 tests; 6 static balance tests, 13 dynamic balance tests, and 6 multi-item balance tests. 
In general, the purpose of static balance tests is to evaluate three sensory systems (visual, vestibular, and somatosensory) that have a major role in postural control. Different tests use different methods to evaluate each of these systems, but it is necessary to consider the target population; some of these tests may not be able to accurately assess the static balance in a population. The test conditions may be either too hard to be performed by a target population or too easy and may not accurately assess their static balance. Various methods have been used in PwMS for evaluating each sensory systems. In some tests, the patient is asked to be in heel-to-toe position [14], stand on one leg [12], or be in a tandem stance (right foot in front of the left foot) [15]. There were some studies that examined the balance in all three mentioned states together in different sensory states [12, 16]. 
The central nervous system is impaired in PwMS [34], any sensory systems with a role in postural control may be impaired [35]. Therefore, to assess balance in this population, it is better to use static balance tests that are separately conducted to examine the sensory systems so that the therapist could have more detailed information about the involvement of these systems in PwMS. Single-leg stance test, Balance Error Scoring System (BESS) test, and steady stance test are some tests that separately evaluate the sensory systems of PwMS. Therefore, this test battery seems to provide more accurate information about the static balance of PwMS. One of the complexities of functional tests is that they can be manipulated. In reviewing 6 static balance tests, we found that one test had been used differently in multiple articles. Some studies had considered the standing time as a balance score for the patient, while other studies considered the number of errors in 30 or 20 seconds as the score of static balance. Therefore, extreme care should be taken in comparing and interpreting the balance performance in different populations. 
Reviewing the dynamic balance tests for PwMS, we found that the tests had not been performed under sensory system manipulation; all had been performed in a state where the somatosensory system was available. Dynamic balance tests can further assess neuromuscular coordination and locomotor control [36]. One method for assessing the neuromuscular system and the locomotor control is the gait test. Several gait tests had been used to assess gait speed, neuromuscular coordination, and the control system of PwMS [23, 26, 27, 28, 33]. Among the gait tests, some take into account the low extremity muscle endurance, such as the 6-minute walk test [27], or 10-meter and 12-meter walk tests aimed to examine the muscle strength of the lower limbs and individual speed [23, 26, 27, 28, 33]. There were also some gait tests to assess the cognitive system and locomotor function in PwMS [24, 29, 31]. Since one of the reasons for reduced locomotor function and falling is the dysfunction of the cognitive system [37], some dynamic balance tests for PwMS are designed to assess this system. It seems that all dynamic balance tests have the same validity and reliability in evaluating the locomotor function of PwMS, but the Six-spot step test, timed up and go test, and figure-of-8 hop test not only evaluate the locomotor function, but also challenge the cognitive system. These tests provide more valuable data about the dynamic balance of PwMS.
Multi-item balance tests are functional tests that postural control components using several items. These tests are selected with respect to the target population. One of these tests for PwMS was the Berg Balance Scale [20]. It is the most commonly used clinical test that has many items similar to the Tinetti test [38]. This scale, however, has some limitations such as not assessing the reactive postural control (e.g., response to a disturbance) [39], poor responsiveness [40, 41], only 53% sensitivity (number of correctly detected falls) and ceiling effect [40]. This test cannot be used to assess the balance function of active PwMS, those with high motor activity. The Dynamic Gait Index was another multi-item test for PwMS [17]. It measures a person’s ability to adapt to changes in environment, speed and head position while walking. This test has been designed based on a large number of gait adjustments that should occur when walking indoor and outdoor, and is the most challenging gait test for PwMS [42]. However, it is not superior to other scales in predicting the risk of falling in terms of properties [42]. The most recent multi-item test for balance assessment is the Fullerton Advanced Balance Scale [21]. This test is able to identify various balance problems and examines the systems that may be involved in these problems (e.g., sensory, musculoskeletal, and neuromuscular). This test uses more difficult static and dynamic balance items to avoid being influenced by the ceiling effect when used by more active patients. It is also more sensitive when is used to assess the effectiveness of an intervention [21]. If the purpose of balance test is to identify and treat the causes of balance impairment, it is important to examine a number of balance control tasks. The balance evaluation systems test (BESTest) is an example of a balance test with different tasks. This test was introduced by Horak et al. [43]. The test uses 6 main tasks to assess the posture control: Biomechanical constraints, stability limits, anticipatory postural adjustments, sensory orientation, postural responses, and gait stability. This test emphasizes the importance of these tasks in evaluation of balance [43]. The systems approaches in the clinical balance assessment seek to identify impaired components and mechanisms in balance control. Understanding the strategies used by the central nervous system to control the balance is important for the systematic analysis of balance impairment that affect each patient. This test can also help identify the causes of balance impairment. The framework of postural control system is useful in selecting tests to assess the balance and effectiveness of therapeutic interventions [44]. This framework is based on the need for evaluation of each component and case-by-case treatment [43]. Therefore, it seems that the BESTest is a better test to assess the balance in PwMS since it provides a complete review of posture control components. 
This review study used a systematic search method but lacked quantitative evaluation of articles; therefore, the quality of the study depends on the quality of reviewed articles. Although most of the reviewed articles had been published in reputable international journals with acceptable quality, the necessary precautions should be taken in generalizing the results. Moreover, only articles in English and Persian were reviewed; there may be other relevant articles in other languages. Considering these limitations, it seems that future studies in this field should examine the quality of articles. 

Conclusion 
There were 25 tests to evaluate the functional balance of PwMS which include static balance, dynamic balance and multi-item balance tests. Single-leg stance test, the BESS, and steady stance test is a test battery that can separately evaluate the sensory systems involved in balance and can provide more accurate data about the static balance of PwMS. The six-spot step test, timed up and go test, and figure-of-8 hop test not only can evaluate the locomotor function, but also challenge the cognitive system and provides more valuable data about the dynamic balance of PwMS. Finally, the BESTest seems to be a better multi-item test to assess the balance of PwMS and examine the postural control components.

Ethical Considerations
Compliance with ethical guidelines

Since this is a review study, there was no need for ethical approval. The principles in writing the article were observed according to the COPE regulations.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
Conceptualization and Resources: All authors; Methodology and Investigation: Gita Asgharzadeh and Hamed Zarei; Writing-original draft, Writing-review & editing, Supervision: Parisa Sedaghti and Hamed Zarei; Funding Acquisition: Gita Asgharzadeh. 

Conflict of interest
The authors declared no conflict of interest.


Acknowledgements
The authors would like to thank the head of the Faculty of Physical Education & Sport Sciences, University of Guilan, Iran.


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Type of Study: Review | Subject: Special
Received: 2022/07/12 | Accepted: 2022/07/19 | Published: 2022/07/1

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