Physical therapy · 2025
Исследование сбалансированности восприятия и сбалансированности в неврологических расстройствах для целевых стратегий реабилитации.
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Cardini Rebecca, Torchio Alessandro, Aprile Irene, Turolla Andrea, Cattaneo Davide, Gervasoni Elisa
Аннотация
ВАЖНОСТЬ: У людей с неврологическими расстройствами (PwND) характерен дефицит баланса по конкретным задачам, что существенно влияет на их повседневную жизнь (ADLs). Однако связь между дефицитом баланса и АДЛ, измеряемая по результатам, о которых сообщают пациенты, плохо изучена, что ограничивает выбор конкретных статических и динамических задач, которые должны использоваться для подготовки к данной деятельности. ЦЕЛЬ: Цель исследования состояла в том, чтобы создать клиническую основу, увязывающую ADL, задачи и ресурсы для поддержки процесса принятия решений врачами при планировании ориентированной на достижение баланса деятельности по восстановлению PwND. DESIGN: Это было исследование наблюдения с поперечным сечением.Это исследование было посвящено изучению клинических контекстов, связанных с PwND. УЧАСТНИКИ: В этом исследовании участвовали люди, страдающие болезнью Паркинсона, инсультом или множественным склерозом (МС). EXPOSURE: В исследовании использовалась шкала " Виды деятельности - доверие к балансу " (ABC) для оценки результатов, сообщаемых пациентами, в целях оценки предполагаемого баланса в ходе ADL, а также шкала баланса Берга (BBS) и Индекс динамического баланса (DGI) для оценки статического и динамического баланса. ОСНОВНЫЕ РЕЗУЛЬТАТЫ И МЕРЫ: Для выявления значимых связей между АВС и ББС-ДГИ были использованы корреляции между Кендаллом и тау.Результаты исследования: В выборке было 299 человек с болезнью Паркинсона (n = 94), инсультом (n = 94) и MS (n = 111) с средним (межквартальным диапазоном) возрастом 63 (52,0-71,5) лет, причем все они имели умеренные и серьезные нарушения баланса. Умеренные корреляции (≥ 0,39) были обнаружены между динамическими и полудинамическими проблесковыми ADL на открытом воздухе с статическими и динамическими задачами, связанными с сенсорной ориентацией, и с использованием жильцовых и проприоцептивных систем. Кроме того, при разработке специальных реабилитационных мероприятий основное внимание следует уделять ограничениям стабильности - вертикали, предупредительной послеаварийной корректировке и стабильности походов.ВЫВОДЫ: Настоящее исследование устанавливает связи между конкретными АДЛ и задачами по обеспечению сбалансированности, обеспечивая клиническую основу для определения соответствующих сбалансированных ресурсов для реабилитации. Она предоставляет врачам структурированный подход к планированию ориентированного на конкретные задачи и ориентированного на потребности восстановления баланса для PwND с уделением особого внимания подготовке конкретных сбалансированных ресурсов в целях совершенствования ADL. СООТВЕТСТВИЕ: Это исследование представляет собой клиническую основу для оказания помощи клиническим специалистам в планировании ориентированной на конкретные задачи и ориентированной на потребности работы по восстановлению баланса для PwND, и в нем предлагается, какой баланс ресурсов следует подготовить для совершенствования конкретных ADL.
Оригинал публикации
Investigating Balance Perception and Balance Performance in Neurological Disorders for Targeted Rehabilitation Strategies.
IMPORTANCE: Task-specific balance deficits are common in people with neurological disorders (PwND), significantly affecting their activities of daily living (ADLs). However, the relationship between balance deficits and ADLs measured by patient-reported outcomes is poorly understood, thus limiting the selection of specific static and dynamic tasks to be used to train for a given activity.
OBJECTIVE: The aim of the study was to provide a clinical framework linking ADLs, balance tasks, and balance resources to support clinicians' decision-making when planning task-oriented balance rehabilitation for PwND.
DESIGN: This was an observational study with a cross-sectional design.
SETTING: This study examined clinical contexts involving PwND.
PARTICIPANTS: This study involved people with Parkinson disease, stroke, or multiple sclerosis (MS).
EXPOSURE: The study used the Activities-Specific Balance Confidence (ABC) Scale for patient-reported outcomes to assess perceived balance during ADLs, and the Berg Balance Scale (BBS) and Dynamic Gait Index (DGI) to evaluate static and dynamic balance.
MAIN OUTCOMES AND MEASURES: Kendall tau correlations (τ) were used to identify meaningful associations between ABC and BBS-DGI items, matching ADLs with specific balance tasks.
RESULTS: The study sample comprised 299 people with Parkinson disease (n = 94), stroke (n = 94), and MS (n = 111) with a median (interquartile range) age of 63 (52.0-71.5) years, all exhibiting moderate to severe balance impairments. Moderate correlations (τ ≥ 0.39) were found between dynamic and semi-dynamic challenging outdoor ADLs with static and dynamic tasks involving sensory orientation and the use of vestibular and proprioceptive systems. Moreover, stability limits-verticality, anticipatory postural adjustments, and stability in gait are the primary balance resources to consider when designing ad hoc rehabilitation interventions.
CONCLUSIONS: This study establishes associations between specific ADLs and balance tasks, offering a clinical framework to identify relevant balance resources for rehabilitation. It provides clinicians with a structured approach for planning task-oriented, needs-based balance rehabilitation for PwND, focusing on the training of specific balance resources to enhance ADLs.
RELEVANCE: This study provides a clinical framework to help clinicians in planning task-oriented and needs-based balance rehabilitation for PwND, suggesting which balance resources should be trained to improve specific ADLs.
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INTRODUCTION
Maintaining balance plays a critical role in the daily mobility of people with neurological disorders (PwND), impacting their ability to perform activities of daily living (ADLs) such as walking outside, taking stairs, getting in and out of a car, or moving through crowded areas. For this population, routine daily tasks can be immensely challenging, leading to reduced quality of life and limited social participation. 1–3 In people with multiple sclerosis (MS), 50% to 80% experience balance and gait dysfunctions, 4 which frequently interfere with their ADLs. 5 Similarly, over 60% of people with Parkinson disease (PD) exhibit balance deficits, reporting higher number of falls that severely impact their autonomy in ADLs and quality of life. 6 This percentage rises to around 80% in stroke survivors, resulting in decreased functional independence. 7 Balance deficits, whether in static or dynamic tasks, can stem from impairment in 1 of the underlying balance resources, defined as the neurophysiological mechanisms directly controlling a specific aspect of balance. 8 , 9 Horak et al have already developed a theoretical framework to identify resources underlying balance control so that specific rehabilitation approaches can be designed for different balance deficits. 1 , 8 However, there is a lack of information from patients on which impaired ADLs they want to improve on and, subsequently, which balance resources need to be trained. Patients’ engagement has evolved into a key discipline focused on understanding and integrating individual needs into the development, regulation, and delivery of new therapies and enhancing care. 10 This approach employs innovative frameworks to engage patients effectively and emphasizes collecting patient-reported outcomes (PROs) related to ADLs. This information provides insights into what truly matters to PwND and addresses unmet needs that may differ from those of clinicians. 11 , 12
However, the relationship between ADLs, measured by PROs, and tasks deficits remains poorly understood, hampering the ability to translate the perceived needs of patients into clinical practice. Therefore, understanding the relationship between how PwND perceive and assess their balance (balance perception) and their actual ability to maintain static and dynamic balance (balance performance) could lead to more personalized and effective treatment strategies to enhance the quality of life for this population. 1
Thus, the aim of this study was to provide a clinical framework able to link ADLs, tasks deficits, and balance resources to facilitate clinicians’ decision-making when planning a task-oriented balance rehabilitation for PwND.
MATERIAL AND METHODS
Study Design, Participants, and Setting
This cross-sectional study is a secondary analysis of a multicenter prospective cohort study conducted to compare the risk of falls and to identify fall predictors in PwND. 13 , 14
We enrolled consecutive people with PD, stroke, and MS needing rehabilitation at 3 Italian centers. We excluded people with at least 1 of the following criteria: (1) cognitive impairment assessed with Mini-Mental State Examination (score < 21) 15 ; (2) major depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) 16 ; (3) severe joint or bone disorder, defined as impairments affecting balance and gait (based on clinical judgement); (4) aphasia, if it interfered with understanding of study objectives and self-administered tests; (5) relapses in the previous 3 months (MS); and (6) stroke <4 weeks before study entry.
The study was approved by the Istituto di Ricovero e Cura a Carattere Sceintifico (IRCCS) Fondazione Don Gnocchi ethics committee and all participants gave written informed consent.
Clinical Measurement and Data Collection
All examinations carried out were all done by experienced clinicians in each center trained for the assessment.
Activities of Daily Living
Participants were evaluated using the Activities-Specific Balance Confidence (ABC) Scale, a PRO measure assessing the perceived confidence in maintaining balance across various ADLs. The ABC Scale is a self-reported measure where patients rate their confidence in performing 16 different activities without losing balance or feeling unsteady. The scale ranges from 0% (no confidence) to 100% (complete confidence), with higher scores indicating greater confidence. This scale not only assesses balance but also provides insights into the psychological aspects of balance confidence, which can significantly influence a patient’s willingness to engage in daily activities. 17
Tasks Deficits
To assess balance deficits, 2 primary tools were used: the Berg Balance Scale (BBS) and the Dynamic Gait Index (DGI) Scale. The BBS is a widely recognized scale ranging from 0 (poor balance) to 56 (good balance). It evaluates an individual’s ability to maintain balance while performing 14 different tasks, such as standing on 1 leg, reaching forward, and turning to look behind. The detailed scoring provides nuanced insights into both static and dynamic balance capabilities. 18 The DGI ranges from 0 (poor performance) to 24 (good performance) and focuses on dynamic balance and mobility. It assesses an individual’s ability to adapt to changes in walking speed, stepping over obstacles, and respond to sudden movements. Together, these tools provide an evaluation of both static and dynamic balance, highlighting specific areas of impairment that can be addressed through targeted therapeutic interventions. 18
The combination of BBS and DGI scores enables a detailed understanding of a patient’s functional mobility, tasks deficits, and risk of falls, which is essential for developing personalized treatment plans.
Balance Resources
Postural control is considered a complex motor skill resulting from the interaction of multiple sensorimotor processes (balance resources). 19 Indeed, postural control involves integration of balance resources that underlie patients’ ability to stand, walk, and interact with the environment safely and efficiently. 8
According to Horak et al, 9 we classified the BBS and DGI items into 5 balance resources: (1) biomechanical constraints; (2) stability limits-verticality; (3) anticipatory postural adjustments (APAs); (4) sensory orientation; and (5) stability in gait, based on the system they refer to Figure 1 .
Balance Resources Adapted to Berg Balance Scale (BBS) and Dynamic Gait Index (DGI) Scale Assessment Scales. 9
Biomechanical constraints refer to all those movements involving the quality of foot support, postural alignment, ankle and hip strength, and the ability to rise from the floor, including BBS 1, BBS 2, and BBS 4. Stability limits-verticality refers to the internal representation of how far the body can move over its base of support before changing the support or losing balance and comprise measures of postural vertical perception and reaching limits. Therefore, this balance resource includes BBS 5, BBS 7, BBS 8, BBS 9, BBS 13, and BBS 14 items. Anticipatory postural adjustments are tasks involving the movement of the body center of mass in preparation for a postural transition, such as standing on toes, transitioning from sitting to standing, and shifting weight from leg to leg. This resource includes BBS 1, BBS 4, BBS 5, BBS 9, BBS 12, BBS 14, and DGI 8, which all refer to feedforward mechanisms. Sensory orientation resource identifies increased body sway when visual or somatosensory information is altered, including BBS 2, BBS 6, BBS 10, BBS 11, BBS 14, DGI 3, DGI 4, and DGI 5. Stability in gait evaluates balance during walking, including challenges like changing gait speed, head rotations, pivot turns, and stepping over obstacle, and therefore includes BBS 11 and all DGI items.
Data Analysis
Descriptive statistics were provided on the demographic and clinical variables for the whole sample and for the 3 subsamples separately. Since the data were not normally distributed, medians and interquartile range (IQR) were used as appropriate. Demographic and clinical variables were compared between PD, stroke, and MS using the Fisher exact test for categorical variables, and the Kruskal–Wallis test for continuous variables.
Kendall tau correlations ( τ ) were performed to identify meaningful associations between ABC and BBS–DGI items for the whole sample and for the 3 subsamples separately. Kendall τ was selected for its robustness as a non-parametric statistic, its suitability for ordinal data, and its lack of assumption regarding a normal distribution. These characteristics make it an appropriate measure for correlation analyses of ABC and BBS, DGI, particularly given their ordinal nature.
To control for multiple comparisons, we applied Holm–Bonferroni correction. Only correlations reaching statistical significance and demonstrating a moderate to strong association ( τ ≥ 0.39) were considered relevant for further analyses. 20 , 21 On the contrary, correlations that were either weak ( τ < 0.39) or not statistically significant were excluded to focus only on association that have clinical implications. Additionally, potential outliers affecting correlation analyses were examined, but none were observed to significantly influence the results.
This study conforms to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement (STROBE) guidelines 22 and reports the required information accordingly (see Suppl. Checklist ).
Role of the Funding Source
The funding sources played no role in study design, execution, administration, or dissemination.
RESULTS
Participants
The study sample comprised 299 people with PD ( n = 94), stroke ( n = 94), and MS ( n = 111) with a median (IQR) age of 63 (52.0–71.5) years. All 3 subsamples exhibited moderate to severe balance impairments resulting in reduced confidence in maintaining balance during ADL. ( Table 1 ). Five participants (1 with PD, 2 with stroke, and 2 with MS) and 12 (6 with PD, 5 with stroke, and 1 with MS) achieved a maximum score on the BBS and DGI, respectively.
Table 1 General Sample Characteristics a Clinical and Demographic Characteristics Overall, N = 299 b PD, N = 94 b Stroke, N = 94 b MS, N = 111 b
P
Age (y) 63 (52.0-71.5) 71.0 (66.0-76.8) 65.0 (58.0-73.0) 53.0 (45.0-61.5) <.001 Sex (F) 147/299 (49%) 33/94 (35%) 40/94 (43%) 74/111 (67%) <.001 DGI c 16.0 (11.0-20.0) 12.0 (8.0-17.0) 14.5(12.0-20.0) 19.0 (14.0-22.0) <.001 BBS c 43.0 (34.0-50.0) 44.0 (35.0-50.0) 40.0 (29.0-48.0) 44.0 (38.0-49.5) .044 ABC 52.5 (28.1-69.4) 58.1 (34.4-80.0) 46.3 (23.8-67.5) 51.3(35.9-65.6) .076
a
Abbreviations: ABC = Activities-Specific Balance Confidence Scale; BBS = Berg Balance Scale; DGI = Dynamic Gait Index; F = female; IQR = interquartile range; MS = multiple sclerosis; PD = Parkinson disease.
b
Median; n / N (%)
c
The score reported for BBS and DGI is the median (IQR) of the total score.
General Sample Characteristics a
Abbreviations: ABC = Activities-Specific Balance Confidence Scale; BBS = Berg Balance Scale; DGI = Dynamic Gait Index; F = female; IQR = interquartile range; MS = multiple sclerosis; PD = Parkinson disease.
Median; n / N (%)
The score reported for BBS and DGI is the median (IQR) of the total score.
Kendall τ moderate correlations ( τ ≥ 0.39) between the ABC (ADLs) and BBS–DGI items (balance tasks) for the whole sample, with non-statistically significant correlations removed ( P > .05), are shown, respectively, in Table 2 and Figure 2 .
Table 2 Kendall τ Moderate Correlations ( τ ≥ 0.39) between ABC and BBS–DGI Items (Whole Sample) a ABC items BBS 9 BBS 11 BBS 12 BBS 13 BBS 14 DGI 6 DGI 8 ABC 3 0.39 b ABC 5 0.39 b 0.42 b ABC 6 0.39 b 0.39 b 0.40 b 0.40 b 0.45 b ABC 7 0.40 b 0.42 b ABC 11 0.39 b 0.41 b ABC 12 0.40 b 0.40 b 0.43 b ABC 13 0.40 b 0.39 b ABC 14 0.45 b 0.44 b 0.39 b ABC 15 0.39 b 0.39 b 0.45 b 0.43 b ABC 16 0.42 b
a
Abbreviations: ABC = Activities-Specific Balance Confidence Scale; ABC 3 = bending over to pick up a slipper from the front of a closet floor; ABC 5 = standing on tiptoes and reaching for something above his/her head; ABC 6 = standing on a chair to reach for something; ABC 7 = sweeping the floor; ABC 11 = walking up or down a ramp; ABC 12 = walking in a crowded mall where people rapidly walk past; ABC 13 = being bumped into people as they walk through the mall; ABC 14 = stepping onto or off an escalator while holding onto a railing; ABC 15 = stepping onto or off an escalator while holding onto parcels (so that they are not able to hold the railing); ABC 16 = walking outside on icy sidewalks; BBS = Berg Balance Scale; BBS 9 = picking up an object from the floor from a standing position; BBS 11 = 360° turn; BBS 12 = stepping while standing unsupported; BBS 13 = standing in tandem; BBS 14 = standing on one leg; DGI = Dynamic Gait Index Scale; DGI 6 = stepping over obstacle; DGI 8 = stairs.
b
P < .05, Holm–Bonferroni correction.
Kendall τ Moderate Correlations ( τ ≥ 0.39) between ABC and BBS–DGI Items (Whole Sample) a
Abbreviations: ABC = Activities-Specific Balance Confidence Scale; ABC 3 = bending over to pick up a slipper from the front of a closet floor; ABC 5 = standing on tiptoes and reaching for something above his/her head; ABC 6 = standing on a chair to reach for something; ABC 7 = sweeping the floor; ABC 11 = walking up or down a ramp; ABC 12 = walking in a crowded mall where people rapidly walk past; ABC 13 = being bumped into people as they walk through the mall; ABC 14 = stepping onto or off an escalator while holding onto a railing; ABC 15 = stepping onto or off an escalator while holding onto parcels (so that they are not able to hold the railing); ABC 16 = walking outside on icy sidewalks; BBS = Berg Balance Scale; BBS 9 = picking up an object from the floor from a standing position; BBS 11 = 360° turn; BBS 12 = stepping while standing unsupported; BBS 13 = standing in tandem; BBS 14 = standing on one leg; DGI = Dynamic Gait Index Scale; DGI 6 = stepping over obstacle; DGI 8 = stairs.
P < .05, Holm–Bonferroni correction.
Relationship between Activities of Daily Living (ADL), Balance Tasks, and Balance Resources in the Whole Sample. Abbreviations: ABC = Activities-Specific Balance Confidence Scale; ABC 3 = bending over to pick up a slipper from the front of a closet floor; ABC 5 = standing on tiptoes and reaching for something above his/her head; ABC 6 = standing on a chair to reach for something; ABC 7 = sweeping the floor; ABC 11 = walking up or down a ramp; ABC 12 = walking in a crowded mall where people rapidly walk past; ABC 13 = being bumped into people as they walk through the mall; ABC 14 = stepping onto or off an escalator while holding onto a railing; ABC 15 = stepping onto or off an escalator while holding onto parcels (so that they are not able to hold the railing); ABC 16 = walking outside on icy sidewalks; APAs = anticipatory postural adjustments; BBS = Berg Balance Scale; BBS 9 = picking up an object from the floor from a standing position; BBS 11 = 360° turn; BBS 12 = stepping while standing unsupported; BBS 13 = standing in tandem; BBS 14 = standing on one leg; DGI = Dynamic Gait Index Scale; DGI 6 = stepping over obstacle; DGI 8 = stairs.
All Kendall τ correlation values between all the ABC and the BBS–DGI items for the whole sample, with non-statistically significant correlations removed, are shown respectively in Supplementary Figure 1A . While only Kendall τ moderate correlations ( τ ≥ 0.39) between the ABC and the BBS–DGI items for the whole sample, with non-statistically significant correlations removed, are shown respectively in Supplementary Figure 1B .
In Figure 2 , the left part shows Kendall τ statistical correlations between ADLs (ABC items) and balance tasks (BBS and DGI items), while the right part represents the relationship between tasks deficits and balance resources based on clinical considerations.
Ten out of 16 ABC items, 5 out of 14 BBS items, and 2 out of 8 DGI items met the correlation criteria of τ ≥ 0.39. Due to weak correlation, several items of the balance assessment scales were excluded. Figure 2 suggests that the balance resources to be considered in planning rehabilitation for enhancing confidence in the ADLs are stability limits-verticality, APAs, sensory orientation, and stability in gait.
Kendall τ correlations between the ABC and BBS–DGI items for the 3 subsamples separately are shown, respectively, in Figure 3 with non-statistically significant correlations removed ( P > .05).
(A–C) Relationship Between Activities of Daily Living (ADLs), Balance Task, and Balance Resources in the 3 SubSamples. Abbreviations: ABC = Activities Balance Confidence Scale; ABC 1 = walking around the house; ABC 2 = walking up or down stairs; ABC 3 = bending over to pick up a slipper from the front of a closet floor; ABC 4 = reaching for a small can off a shelf at eye level; ABC 5 = standing on tiptoes and reaching for something above his/her head; ABC 6 = standing on a chair to reach for something; ABC 7 = sweeping the floor; ABC 8 = walking outside the house to a car parked in the driveway; ABC 9 = getting into or out of a car; ABC 10 = walking across a parking lot to the mall; ABC 11 = walking up or down a ramp; ABC 12 = walking in a crowded mall where people rapidly walk past; ABC 13 = being bumped into people as they walk through the mall; ABC 14 = stepping onto or off an escalator while holding onto a railing; ABC 15 = stepping onto or off an escalator while holding onto parcels (so that they are not able to hold the railing); ABC 16 = walking outside on icy sidewalks; APAs = anticipatory postural adjustments; BBS = Berg Balance Scale; BBS 1 = sitting to standing; BBS 2 = standing unsupported; BBS 4 = standing to sitting; BBS 5 = transfers; BBS 6 = standing unsupported with eyes closed; BBS 7 = standing unsupported with feet together; BBS 8 = reaching forward with outstretched arm while standing; BBS 9 = pick up an object from the floor from a standing position; BBS 10 = turning to look behind over left and right shoulders while standing; BBS 11 = turn 360°; BBS 12 = step while standing unsupported; BBS 13 = standing in tandem; BBS 14 = standing on one leg; DGI = Dynamic Gait Index; DGI 1 = gait level surface; DGI 2 = change gait speed; DGI 3 = gait with horizontal head turns; DGI 4 = gait with vertical head turns; DGI 5 = gait and pivot turn; DGI 6 = step over obstacle; DGI 7 = step around obstacle; DGI 8 = stairs; MS = multiple sclerosis; PD = Parkinson disease; ST = stroke.
In people with PD, 15 out of 16 ABC items, 13 out of 14 BBS items, and 5 out of 8 DGI items met the correlation criteria of τ ≥ 0.39. Figure 3A indicates that the balance resources to be considered in planning rehabilitation for enhancing confidence in the ADLs are biomechanical constraints, stability limits-verticality, APAs, sensory orientation, and stability in gait.
Regarding stroke, 15 out of 16 ABC items, 11 out of 14 BBS items, and 8 out of 8 DGI items met the correlation criteria of τ ≥ 0.39. Moreover, the balance resources to be considered in planning rehabilitation for enhancing confidence in the ADLs are biomechanical constraints, stability limits-verticality, APAs, sensory orientation, and stability in gait ( Figure 3B ).
With regard to MS, only 2 out of 16 ABC items and 2 out of 14 BBS items met the correlation criteria of τ ≥ 0.39 ( Figure 3C ). The plot indicates that the balance resources to be considered in planning rehabilitation for enhancing confidence in the ADLs are stability limits-verticality, APAs, and stability in gait.
All Kendall τ correlation values between all the ABC and the BBS–DGI items for the 3 subsamples, with non-statistically significant correlations removed, are shown, respectively, in Supplementary Figure 2A . While only Kendall τ moderate correlations ( τ ≥ 0.39) between the ABC and the BBS–DGI items for the 3 subsamples, with non-statistically significant correlations removed, are shown, respectively, in Supplementary Figure 2B .
DISCUSSION
This is the first study combining data on balance perception during ADLs and balance performance with Horak’s theoretical framework 8 , 9 to provide a new clinical framework for guiding clinicians to set up task-oriented balance rehabilitation for PwND. Our findings may help physical therapists to target the ADLs that patients find challenging and want to improve and to link that activity to the associated balance tasks and underlying balance resources, thus enabling the design of personalized rehabilitation treatment.
Dynamic and semi-dynamic challenging outdoor ADLs are correlated with static and dynamic tasks involving sensory orientation and the use of vestibular and proprioceptive systems. Moreover, other balance resources like stability limits-verticality, APAs, and stability in gait are the main balance resources to consider when designing ad hoc rehabilitation interventions.
Building on the importance of incorporating PROs to capture the patient’s perspective, we recognized that engaging participants is becoming increasingly relevant and essential to address unmet needs that may differ from those of clinicians. 23 Among PROs, in line with Moore et al, 24 the Activity-Specific Balance Confidence (ABC) Scale is commonly used to assess perceived balance during functional tasks involving both anticipatory and reactive postural control, significantly impacting PwND behaviors. 17 In literature, a moderate correlation between perceptive and performance balance scales is evidenced. 25 , 26 However, given the key role of PROs in detecting the main difficulties of PwND during their everyday life, 11 it appears crucial to focus on a single-item correlation analysis to identify specific ADLs deficits most closely associated with balance tasks. This emphasizes that specific activities often require the management of multiple tasks. For example, the activity of stepping onto or off an escalator while holding bags correlates with multiple tasks, such as 360° turn, stepping while standing unsupported, stepping over an obstacle, and stairs. All these tasks involve control of the center-of-body mass displacement on a narrow base of support, indicating which balance resources would be beneficial for improving that specific ADL.
Berg Balance Scale and DGI specific tasks provide a basis for identifying which balance resources should be used to plan a rehabilitation session. Dynamic tasks, such as stairs and stepping over an obstacle, are the most associated with ADLs and linked to stability limits-verticality, APAs, sensory orientation, and stability in gait balance resources. Conversely, static items (standing on 1 leg and standing in tandem) are less associated with ADLs. This highlights the complexity and the multidimensional nature of everyday life activities. Based on these findings, clinical implications can suggest a tailored rehabilitation plan aimed more at improving dynamic than static balance focusing on enhancing the balance resources above mentioned. This is also confirmed by a recent review by Tramontano et al 27 reporting that specific tasks focusing on postural stability, head and eyes movements during dynamic activities, and somatosensory integration and sensory orientation exercises are needed when planning balance rehabilitation in PwND.
Taken together, our results and existing evidence support the implementation of a rehabilitation program that targets these identified balance resources. This approach is likely to be a beneficial intervention for PwND, leading to significant improvements in reducing balance impairments during ADLs and providing clinicians with an effective method to address specific balance challenges. In this regard, the task-oriented approach emphasizes the practice of functional tasks in real-life contexts and plays a central role in promoting motor learning and enhancing the transferability of skills to everyday activities. 28 This is in line with a previous study reporting the need of goal-oriented functional exercises to improve specific balance deficits. 29
Notably, 2 of the 3 outcome measures used in this study (BBS and ABC) are part of the Core Set of Outcome Measures for Adults with Neurological Conditions. 24 To assess dynamic balance, we used DGI instead of Functional Gait Assessment (FGA). We acknowledge that the FGA was developed as a modification of the DGI to address ceiling effects and improve applicability to more complex gait tasks. However, the DGI still remains a widely used and validated tool in neurological papulations, particularly for assessing gait-related balance problems. 30–32 The widespread use of the Core Set in neurological rehabilitation increases the clinical relevance and applicability of our findings. The selection of well-established and clinically recommended tools strengthens the translation of research into practice, as good decision-making in rehabilitation begins with high quality outcome data.
Regarding both PD and stroke, we found many associations between ADLs and tasks deficits, emphasizing different aspects characterizing the pathologies.
In specific to PD, our analysis indicated that more dynamic tasks as gait on level surface, stepping while standing unsupported, stepping over an obstacle, and stairs are the most strongly correlated tasks with dynamic ADLs such as walking outside and sweeping the floor. These tasks reflect the most common symptoms of this condition, such as freezing and center-of-body mass management problems, 33 suggesting that exercises based on stability limits-verticality, APAs, sensory orientation, and gait stability should be also included in rehabilitation to help manage these symptoms. Our results are in line with previous studies 34 , 35 reporting that specific balance training improve postural instability in people with PD. The exercises included self-destabilization exercises where patients perform voluntary movements in static and dynamic conditions like shifting weight to toes and heels or bouncing a ball while walking (relying on APAs); exercises included tasks that externally induced destabilization of the center-of-body mass where patients maintain balance on unstable surfaces or when the therapist applies external perturbations; exercises of coordination between leg and arm movements during walking; and gait stability exercises such as walking while turning the head sideways and stepping over obstacle.
Regarding stroke, our analysis indicated that several tasks such as pick up an object from the floor, standing on 1 leg, and stairs are pathology-independent and associated to the same ADLs observed for PD. Conversely, other tasks such as 360° turn and standing unsupported are typical of people with stroke and are correlated with more static and semi-dynamic ADLs as standing on tiptoes and reaching for something and bending over to pick up a slipper from the front of a closet floor reflecting 1 of the most disabling symptoms of stroke that is center-of-body mass management problems. 36 The connections between balance tasks and balance resources depicted in Figure 3 suggest that balance rehabilitation for this population should focus on stability limits-verticality, APAs, sensory orientation, and gait stability. Previous studies 37 , 38 reported that balance rehabilitation including modification of base of support, maintaining balance while rotating head and trunk to right and left directions and weight shifting forward backward and side to side improve balance control in people with stroke.
In specific to MS, our analysis shows that semi-dynamic and dynamic balance tasks are significantly associated with ADLs. Specifically, only 2 correlations were found between balance in ADLs (stepping on or off an escalator and sweeping the floor and performance balance in tasks; 360° turn and pick up an object from the floor). The limited correlations observed may be due to the presence of ceiling effects, high variability, and heterogeneity in the clinical presentation of MS, which manifests with a wide range of symptoms and phenotypes. 39
Our results emphasize that stability limits-verticality, APAs, and stability in gait are crucial balance resources to prioritize in rehabilitation planning for improving balance confidence during ADLs in people with MS. Our findings are in line with a previous study 40 reporting an improvement in balance skills in people with MS after a task-oriented balance treatment taking into consideration the above-mentioned resources. These treatments focused on improving both motor and sensory strategies including exercises regarding the postural alignment, the ability to detect the position and movements of the center of mass, the ability to explore the limits of stability, and axial and postural anticipatory strategies and exercises in eyes-closed condition, using foam pads under the feet and using modified lenses, along with tasks to improve balance during head, eye, and head-eye movements. Other studies 41 , 42 reported an improvement in balance in people with MS after a balance rehabilitation consisting in standing dynamic balance exercises as sit-to-stand, standing with eyes open or closed while narrowing the base of support progressively, walking forward, eyes open or closed, backward, sideways, along a line, and around cones. The alignment with previous studies 40–43 validates the efficacy of task-oriented dynamic balance treatments that integrate stability limits-verticality, APAs, and stability in gait exercises.
Limitations
The study has several limitations. Firstly, the study population was not selected based on a population-based approach. Secondly, the study recruited a sample of patients who were seeking rehabilitation services, which may limit the external validity of the study results. Thirdly, we did not assess any important factors such as cognitive functions that they may have affected the accuracy of completing the ABC questionnaire. Fourthly, other PROs investigating the capacity of performing daily activities could be a suggestion for further analysis to assess people with neurological conditions.
Although few participants achieved the maximum total score for BBS and DGI, respectively, several items achieved the maximum score for both performance scales, biasing the correlations between ADLs and balance tasks. Another limitation is that the selected balance measures do not assess reactive balance deficits. The use of the Mini-Balance Evaluation System Test (Mini-BEST test) would allow both to assess reactive balance and better link tasks and balance resource and also to reduce ceiling effects in specific for people with PD. On the same line, the use of the FGA might have been more appropriate to reduce ceiling effects and to provide more sound data due to its good psychometric properties as reported in the clinical practice guidelines. 24
Finally, among balance resources, stability in gait may already embrace other domains, such as sensory orientation and APAs.
CONCLUSIONS
Our study shows that specific ADLs are closely associated with particular balance tasks. These findings collectively underscore the importance of adopting a comprehensive and personalized approach to balance rehabilitation. This approach should include tailored treatments that address symptom variability in individuals with MS, comprehensive balance training to enhance functional abilities in people with PD, and a multifaceted strategy aimed at improving stability and postural control in stroke survivors.
Supplementary Material
Maintaining balance plays a critical role in the daily mobility of people with neurological disorders (PwND), impacting their ability to perform activities of daily living (ADLs) such as walking outside, taking stairs, getting in and out of a car, or moving through crowded areas. For this population, routine daily tasks can be immensely challenging, leading to reduced quality of life and limited social participation. 1–3 In people with multiple sclerosis (MS), 50% to 80% experience balance and gait dysfunctions, 4 which frequently interfere with their ADLs. 5 Similarly, over 60% of people with Parkinson disease (PD) exhibit balance deficits, reporting higher number of falls that severely impact their autonomy in ADLs and quality of life. 6 This percentage rises to around 80% in stroke survivors, resulting in decreased functional independence. 7 Balance deficits, whether in static or dynamic tasks, can stem from impairment in 1 of the underlying balance resources, defined as the neurophysiological mechanisms directly controlling a specific aspect of balance. 8 , 9 Horak et al have already developed a theoretical framework to identify resources underlying balance control so that specific rehabilitation approaches can be designed for different balance deficits. 1 , 8 However, there is a lack of information from patients on which impaired ADLs they want to improve on and, subsequently, which balance resources need to be trained. Patients’ engagement has evolved into a key discipline focused on understanding and integrating individual needs into the development, regulation, and delivery of new therapies and enhancing care. 10 This approach employs innovative frameworks to engage patients effectively and emphasizes collecting patient-reported outcomes (PROs) related to ADLs. This information provides insights into what truly matters to PwND and addresses unmet needs that may differ from those of clinicians. 11 , 12
However, the relationship between ADLs, measured by PROs, and tasks deficits remains poorly understood, hampering the ability to translate the perceived needs of patients into clinical practice. Therefore, understanding the relationship between how PwND perceive and assess their balance (balance perception) and their actual ability to maintain static and dynamic balance (balance performance) could lead to more personalized and effective treatment strategies to enhance the quality of life for this population. 1
Thus, the aim of this study was to provide a clinical framework able to link ADLs, tasks deficits, and balance resources to facilitate clinicians’ decision-making when planning a task-oriented balance rehabilitation for PwND.
MATERIAL AND METHODS
Study Design, Participants, and Setting
This cross-sectional study is a secondary analysis of a multicenter prospective cohort study conducted to compare the risk of falls and to identify fall predictors in PwND. 13 , 14
We enrolled consecutive people with PD, stroke, and MS needing rehabilitation at 3 Italian centers. We excluded people with at least 1 of the following criteria: (1) cognitive impairment assessed with Mini-Mental State Examination (score < 21) 15 ; (2) major depression (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) 16 ; (3) severe joint or bone disorder, defined as impairments affecting balance and gait (based on clinical judgement); (4) aphasia, if it interfered with understanding of study objectives and self-administered tests; (5) relapses in the previous 3 months (MS); and (6) stroke <4 weeks before study entry.
The study was approved by the Istituto di Ricovero e Cura a Carattere Sceintifico (IRCCS) Fondazione Don Gnocchi ethics committee and all participants gave written informed consent.
Clinical Measurement and Data Collection
All examinations carried out were all done by experienced clinicians in each center trained for the assessment.
Activities of Daily Living
Participants were evaluated using the Activities-Specific Balance Confidence (ABC) Scale, a PRO measure assessing the perceived confidence in maintaining balance across various ADLs. The ABC Scale is a self-reported measure where patients rate their confidence in performing 16 different activities without losing balance or feeling unsteady. The scale ranges from 0% (no confidence) to 100% (complete confidence), with higher scores indicating greater confidence. This scale not only assesses balance but also provides insights into the psychological aspects of balance confidence, which can significantly influence a patient’s willingness to engage in daily activities. 17
Tasks Deficits
To assess balance deficits, 2 primary tools were used: the Berg Balance Scale (BBS) and the Dynamic Gait Index (DGI) Scale. The BBS is a widely recognized scale ranging from 0 (poor balance) to 56 (good balance). It evaluates an individual’s ability to maintain balance while performing 14 different tasks, such as standing on 1 leg, reaching forward, and turning to look behind. The detailed scoring provides nuanced insights into both static and dynamic balance capabilities. 18 The DGI ranges from 0 (poor performance) to 24 (good performance) and focuses on dynamic balance and mobility. It assesses an individual’s ability to adapt to changes in walking speed, stepping over obstacles, and respond to sudden movements. Together, these tools provide an evaluation of both static and dynamic balance, highlighting specific areas of impairment that can be addressed through targeted therapeutic interventions. 18
The combination of BBS and DGI scores enables a detailed understanding of a patient’s functional mobility, tasks deficits, and risk of falls, which is essential for developing personalized treatment plans.
Balance Resources
Postural control is considered a complex motor skill resulting from the interaction of multiple sensorimotor processes (balance resources). 19 Indeed, postural control involves integration of balance resources that underlie patients’ ability to stand, walk, and interact with the environment safely and efficiently. 8
According to Horak et al, 9 we classified the BBS and DGI items into 5 balance resources: (1) biomechanical constraints; (2) stability limits-verticality; (3) anticipatory postural adjustments (APAs); (4) sensory orientation; and (5) stability in gait, based on the system they refer to Figure 1 .
Balance Resources Adapted to Berg Balance Scale (BBS) and Dynamic Gait Index (DGI) Scale Assessment Scales. 9
Biomechanical constraints refer to all those movements involving the quality of foot support, postural alignment, ankle and hip strength, and the ability to rise from the floor, including BBS 1, BBS 2, and BBS 4. Stability limits-verticality refers to the internal representation of how far the body can move over its base of support before changing the support or losing balance and comprise measures of postural vertical perception and reaching limits. Therefore, this balance resource includes BBS 5, BBS 7, BBS 8, BBS 9, BBS 13, and BBS 14 items. Anticipatory postural adjustments are tasks involving the movement of the body center of mass in preparation for a postural transition, such as standing on toes, transitioning from sitting to standing, and shifting weight from leg to leg. This resource includes BBS 1, BBS 4, BBS 5, BBS 9, BBS 12, BBS 14, and DGI 8, which all refer to feedforward mechanisms. Sensory orientation resource identifies increased body sway when visual or somatosensory information is altered, including BBS 2, BBS 6, BBS 10, BBS 11, BBS 14, DGI 3, DGI 4, and DGI 5. Stability in gait evaluates balance during walking, including challenges like changing gait speed, head rotations, pivot turns, and stepping over obstacle, and therefore includes BBS 11 and all DGI items.
Data Analysis
Descriptive statistics were provided on the demographic and clinical variables for the whole sample and for the 3 subsamples separately. Since the data were not normally distributed, medians and interquartile range (IQR) were used as appropriate. Demographic and clinical variables were compared between PD, stroke, and MS using the Fisher exact test for categorical variables, and the Kruskal–Wallis test for continuous variables.
Kendall tau correlations ( τ ) were performed to identify meaningful associations between ABC and BBS–DGI items for the whole sample and for the 3 subsamples separately. Kendall τ was selected for its robustness as a non-parametric statistic, its suitability for ordinal data, and its lack of assumption regarding a normal distribution. These characteristics make it an appropriate measure for correlation analyses of ABC and BBS, DGI, particularly given their ordinal nature.
To control for multiple comparisons, we applied Holm–Bonferroni correction. Only correlations reaching statistical significance and demonstrating a moderate to strong association ( τ ≥ 0.39) were considered relevant for further analyses. 20 , 21 On the contrary, correlations that were either weak ( τ < 0.39) or not statistically significant were excluded to focus only on association that have clinical implications. Additionally, potential outliers affecting correlation analyses were examined, but none were observed to significantly influence the results.
This study conforms to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement (STROBE) guidelines 22 and reports the required information accordingly (see Suppl. Checklist ).
Role of the Funding Source
The funding sources played no role in study design, execution, administration, or dissemination.
RESULTS
Participants
The study sample comprised 299 people with PD ( n = 94), stroke ( n = 94), and MS ( n = 111) with a median (IQR) age of 63 (52.0–71.5) years. All 3 subsamples exhibited moderate to severe balance impairments resulting in reduced confidence in maintaining balance during ADL. ( Table 1 ). Five participants (1 with PD, 2 with stroke, and 2 with MS) and 12 (6 with PD, 5 with stroke, and 1 with MS) achieved a maximum score on the BBS and DGI, respectively.
Table 1 General Sample Characteristics a Clinical and Demographic Characteristics Overall, N = 299 b PD, N = 94 b Stroke, N = 94 b MS, N = 111 b
P
Age (y) 63 (52.0-71.5) 71.0 (66.0-76.8) 65.0 (58.0-73.0) 53.0 (45.0-61.5) <.001 Sex (F) 147/299 (49%) 33/94 (35%) 40/94 (43%) 74/111 (67%) <.001 DGI c 16.0 (11.0-20.0) 12.0 (8.0-17.0) 14.5(12.0-20.0) 19.0 (14.0-22.0) <.001 BBS c 43.0 (34.0-50.0) 44.0 (35.0-50.0) 40.0 (29.0-48.0) 44.0 (38.0-49.5) .044 ABC 52.5 (28.1-69.4) 58.1 (34.4-80.0) 46.3 (23.8-67.5) 51.3(35.9-65.6) .076
a
Abbreviations: ABC = Activities-Specific Balance Confidence Scale; BBS = Berg Balance Scale; DGI = Dynamic Gait Index; F = female; IQR = interquartile range; MS = multiple sclerosis; PD = Parkinson disease.
b
Median; n / N (%)
c
The score reported for BBS and DGI is the median (IQR) of the total score.
General Sample Characteristics a
Abbreviations: ABC = Activities-Specific Balance Confidence Scale; BBS = Berg Balance Scale; DGI = Dynamic Gait Index; F = female; IQR = interquartile range; MS = multiple sclerosis; PD = Parkinson disease.
Median; n / N (%)
The score reported for BBS and DGI is the median (IQR) of the total score.
Kendall τ moderate correlations ( τ ≥ 0.39) between the ABC (ADLs) and BBS–DGI items (balance tasks) for the whole sample, with non-statistically significant correlations removed ( P > .05), are shown, respectively, in Table 2 and Figure 2 .
Table 2 Kendall τ Moderate Correlations ( τ ≥ 0.39) between ABC and BBS–DGI Items (Whole Sample) a ABC items BBS 9 BBS 11 BBS 12 BBS 13 BBS 14 DGI 6 DGI 8 ABC 3 0.39 b ABC 5 0.39 b 0.42 b ABC 6 0.39 b 0.39 b 0.40 b 0.40 b 0.45 b ABC 7 0.40 b 0.42 b ABC 11 0.39 b 0.41 b ABC 12 0.40 b 0.40 b 0.43 b ABC 13 0.40 b 0.39 b ABC 14 0.45 b 0.44 b 0.39 b ABC 15 0.39 b 0.39 b 0.45 b 0.43 b ABC 16 0.42 b
a
Abbreviations: ABC = Activities-Specific Balance Confidence Scale; ABC 3 = bending over to pick up a slipper from the front of a closet floor; ABC 5 = standing on tiptoes and reaching for something above his/her head; ABC 6 = standing on a chair to reach for something; ABC 7 = sweeping the floor; ABC 11 = walking up or down a ramp; ABC 12 = walking in a crowded mall where people rapidly walk past; ABC 13 = being bumped into people as they walk through the mall; ABC 14 = stepping onto or off an escalator while holding onto a railing; ABC 15 = stepping onto or off an escalator while holding onto parcels (so that they are not able to hold the railing); ABC 16 = walking outside on icy sidewalks; BBS = Berg Balance Scale; BBS 9 = picking up an object from the floor from a standing position; BBS 11 = 360° turn; BBS 12 = stepping while standing unsupported; BBS 13 = standing in tandem; BBS 14 = standing on one leg; DGI = Dynamic Gait Index Scale; DGI 6 = stepping over obstacle; DGI 8 = stairs.
b
P < .05, Holm–Bonferroni correction.
Kendall τ Moderate Correlations ( τ ≥ 0.39) between ABC and BBS–DGI Items (Whole Sample) a
Abbreviations: ABC = Activities-Specific Balance Confidence Scale; ABC 3 = bending over to pick up a slipper from the front of a closet floor; ABC 5 = standing on tiptoes and reaching for something above his/her head; ABC 6 = standing on a chair to reach for something; ABC 7 = sweeping the floor; ABC 11 = walking up or down a ramp; ABC 12 = walking in a crowded mall where people rapidly walk past; ABC 13 = being bumped into people as they walk through the mall; ABC 14 = stepping onto or off an escalator while holding onto a railing; ABC 15 = stepping onto or off an escalator while holding onto parcels (so that they are not able to hold the railing); ABC 16 = walking outside on icy sidewalks; BBS = Berg Balance Scale; BBS 9 = picking up an object from the floor from a standing position; BBS 11 = 360° turn; BBS 12 = stepping while standing unsupported; BBS 13 = standing in tandem; BBS 14 = standing on one leg; DGI = Dynamic Gait Index Scale; DGI 6 = stepping over obstacle; DGI 8 = stairs.
P < .05, Holm–Bonferroni correction.
Relationship between Activities of Daily Living (ADL), Balance Tasks, and Balance Resources in the Whole Sample. Abbreviations: ABC = Activities-Specific Balance Confidence Scale; ABC 3 = bending over to pick up a slipper from the front of a closet floor; ABC 5 = standing on tiptoes and reaching for something above his/her head; ABC 6 = standing on a chair to reach for something; ABC 7 = sweeping the floor; ABC 11 = walking up or down a ramp; ABC 12 = walking in a crowded mall where people rapidly walk past; ABC 13 = being bumped into people as they walk through the mall; ABC 14 = stepping onto or off an escalator while holding onto a railing; ABC 15 = stepping onto or off an escalator while holding onto parcels (so that they are not able to hold the railing); ABC 16 = walking outside on icy sidewalks; APAs = anticipatory postural adjustments; BBS = Berg Balance Scale; BBS 9 = picking up an object from the floor from a standing position; BBS 11 = 360° turn; BBS 12 = stepping while standing unsupported; BBS 13 = standing in tandem; BBS 14 = standing on one leg; DGI = Dynamic Gait Index Scale; DGI 6 = stepping over obstacle; DGI 8 = stairs.
All Kendall τ correlation values between all the ABC and the BBS–DGI items for the whole sample, with non-statistically significant correlations removed, are shown respectively in Supplementary Figure 1A . While only Kendall τ moderate correlations ( τ ≥ 0.39) between the ABC and the BBS–DGI items for the whole sample, with non-statistically significant correlations removed, are shown respectively in Supplementary Figure 1B .
In Figure 2 , the left part shows Kendall τ statistical correlations between ADLs (ABC items) and balance tasks (BBS and DGI items), while the right part represents the relationship between tasks deficits and balance resources based on clinical considerations.
Ten out of 16 ABC items, 5 out of 14 BBS items, and 2 out of 8 DGI items met the correlation criteria of τ ≥ 0.39. Due to weak correlation, several items of the balance assessment scales were excluded. Figure 2 suggests that the balance resources to be considered in planning rehabilitation for enhancing confidence in the ADLs are stability limits-verticality, APAs, sensory orientation, and stability in gait.
Kendall τ correlations between the ABC and BBS–DGI items for the 3 subsamples separately are shown, respectively, in Figure 3 with non-statistically significant correlations removed ( P > .05).
(A–C) Relationship Between Activities of Daily Living (ADLs), Balance Task, and Balance Resources in the 3 SubSamples. Abbreviations: ABC = Activities Balance Confidence Scale; ABC 1 = walking around the house; ABC 2 = walking up or down stairs; ABC 3 = bending over to pick up a slipper from the front of a closet floor; ABC 4 = reaching for a small can off a shelf at eye level; ABC 5 = standing on tiptoes and reaching for something above his/her head; ABC 6 = standing on a chair to reach for something; ABC 7 = sweeping the floor; ABC 8 = walking outside the house to a car parked in the driveway; ABC 9 = getting into or out of a car; ABC 10 = walking across a parking lot to the mall; ABC 11 = walking up or down a ramp; ABC 12 = walking in a crowded mall where people rapidly walk past; ABC 13 = being bumped into people as they walk through the mall; ABC 14 = stepping onto or off an escalator while holding onto a railing; ABC 15 = stepping onto or off an escalator while holding onto parcels (so that they are not able to hold the railing); ABC 16 = walking outside on icy sidewalks; APAs = anticipatory postural adjustments; BBS = Berg Balance Scale; BBS 1 = sitting to standing; BBS 2 = standing unsupported; BBS 4 = standing to sitting; BBS 5 = transfers; BBS 6 = standing unsupported with eyes closed; BBS 7 = standing unsupported with feet together; BBS 8 = reaching forward with outstretched arm while standing; BBS 9 = pick up an object from the floor from a standing position; BBS 10 = turning to look behind over left and right shoulders while standing; BBS 11 = turn 360°; BBS 12 = step while standing unsupported; BBS 13 = standing in tandem; BBS 14 = standing on one leg; DGI = Dynamic Gait Index; DGI 1 = gait level surface; DGI 2 = change gait speed; DGI 3 = gait with horizontal head turns; DGI 4 = gait with vertical head turns; DGI 5 = gait and pivot turn; DGI 6 = step over obstacle; DGI 7 = step around obstacle; DGI 8 = stairs; MS = multiple sclerosis; PD = Parkinson disease; ST = stroke.
In people with PD, 15 out of 16 ABC items, 13 out of 14 BBS items, and 5 out of 8 DGI items met the correlation criteria of τ ≥ 0.39. Figure 3A indicates that the balance resources to be considered in planning rehabilitation for enhancing confidence in the ADLs are biomechanical constraints, stability limits-verticality, APAs, sensory orientation, and stability in gait.
Regarding stroke, 15 out of 16 ABC items, 11 out of 14 BBS items, and 8 out of 8 DGI items met the correlation criteria of τ ≥ 0.39. Moreover, the balance resources to be considered in planning rehabilitation for enhancing confidence in the ADLs are biomechanical constraints, stability limits-verticality, APAs, sensory orientation, and stability in gait ( Figure 3B ).
With regard to MS, only 2 out of 16 ABC items and 2 out of 14 BBS items met the correlation criteria of τ ≥ 0.39 ( Figure 3C ). The plot indicates that the balance resources to be considered in planning rehabilitation for enhancing confidence in the ADLs are stability limits-verticality, APAs, and stability in gait.
All Kendall τ correlation values between all the ABC and the BBS–DGI items for the 3 subsamples, with non-statistically significant correlations removed, are shown, respectively, in Supplementary Figure 2A . While only Kendall τ moderate correlations ( τ ≥ 0.39) between the ABC and the BBS–DGI items for the 3 subsamples, with non-statistically significant correlations removed, are shown, respectively, in Supplementary Figure 2B .
DISCUSSION
This is the first study combining data on balance perception during ADLs and balance performance with Horak’s theoretical framework 8 , 9 to provide a new clinical framework for guiding clinicians to set up task-oriented balance rehabilitation for PwND. Our findings may help physical therapists to target the ADLs that patients find challenging and want to improve and to link that activity to the associated balance tasks and underlying balance resources, thus enabling the design of personalized rehabilitation treatment.
Dynamic and semi-dynamic challenging outdoor ADLs are correlated with static and dynamic tasks involving sensory orientation and the use of vestibular and proprioceptive systems. Moreover, other balance resources like stability limits-verticality, APAs, and stability in gait are the main balance resources to consider when designing ad hoc rehabilitation interventions.
Building on the importance of incorporating PROs to capture the patient’s perspective, we recognized that engaging participants is becoming increasingly relevant and essential to address unmet needs that may differ from those of clinicians. 23 Among PROs, in line with Moore et al, 24 the Activity-Specific Balance Confidence (ABC) Scale is commonly used to assess perceived balance during functional tasks involving both anticipatory and reactive postural control, significantly impacting PwND behaviors. 17 In literature, a moderate correlation between perceptive and performance balance scales is evidenced. 25 , 26 However, given the key role of PROs in detecting the main difficulties of PwND during their everyday life, 11 it appears crucial to focus on a single-item correlation analysis to identify specific ADLs deficits most closely associated with balance tasks. This emphasizes that specific activities often require the management of multiple tasks. For example, the activity of stepping onto or off an escalator while holding bags correlates with multiple tasks, such as 360° turn, stepping while standing unsupported, stepping over an obstacle, and stairs. All these tasks involve control of the center-of-body mass displacement on a narrow base of support, indicating which balance resources would be beneficial for improving that specific ADL.
Berg Balance Scale and DGI specific tasks provide a basis for identifying which balance resources should be used to plan a rehabilitation session. Dynamic tasks, such as stairs and stepping over an obstacle, are the most associated with ADLs and linked to stability limits-verticality, APAs, sensory orientation, and stability in gait balance resources. Conversely, static items (standing on 1 leg and standing in tandem) are less associated with ADLs. This highlights the complexity and the multidimensional nature of everyday life activities. Based on these findings, clinical implications can suggest a tailored rehabilitation plan aimed more at improving dynamic than static balance focusing on enhancing the balance resources above mentioned. This is also confirmed by a recent review by Tramontano et al 27 reporting that specific tasks focusing on postural stability, head and eyes movements during dynamic activities, and somatosensory integration and sensory orientation exercises are needed when planning balance rehabilitation in PwND.
Taken together, our results and existing evidence support the implementation of a rehabilitation program that targets these identified balance resources. This approach is likely to be a beneficial intervention for PwND, leading to significant improvements in reducing balance impairments during ADLs and providing clinicians with an effective method to address specific balance challenges. In this regard, the task-oriented approach emphasizes the practice of functional tasks in real-life contexts and plays a central role in promoting motor learning and enhancing the transferability of skills to everyday activities. 28 This is in line with a previous study reporting the need of goal-oriented functional exercises to improve specific balance deficits. 29
Notably, 2 of the 3 outcome measures used in this study (BBS and ABC) are part of the Core Set of Outcome Measures for Adults with Neurological Conditions. 24 To assess dynamic balance, we used DGI instead of Functional Gait Assessment (FGA). We acknowledge that the FGA was developed as a modification of the DGI to address ceiling effects and improve applicability to more complex gait tasks. However, the DGI still remains a widely used and validated tool in neurological papulations, particularly for assessing gait-related balance problems. 30–32 The widespread use of the Core Set in neurological rehabilitation increases the clinical relevance and applicability of our findings. The selection of well-established and clinically recommended tools strengthens the translation of research into practice, as good decision-making in rehabilitation begins with high quality outcome data.
Regarding both PD and stroke, we found many associations between ADLs and tasks deficits, emphasizing different aspects characterizing the pathologies.
In specific to PD, our analysis indicated that more dynamic tasks as gait on level surface, stepping while standing unsupported, stepping over an obstacle, and stairs are the most strongly correlated tasks with dynamic ADLs such as walking outside and sweeping the floor. These tasks reflect the most common symptoms of this condition, such as freezing and center-of-body mass management problems, 33 suggesting that exercises based on stability limits-verticality, APAs, sensory orientation, and gait stability should be also included in rehabilitation to help manage these symptoms. Our results are in line with previous studies 34 , 35 reporting that specific balance training improve postural instability in people with PD. The exercises included self-destabilization exercises where patients perform voluntary movements in static and dynamic conditions like shifting weight to toes and heels or bouncing a ball while walking (relying on APAs); exercises included tasks that externally induced destabilization of the center-of-body mass where patients maintain balance on unstable surfaces or when the therapist applies external perturbations; exercises of coordination between leg and arm movements during walking; and gait stability exercises such as walking while turning the head sideways and stepping over obstacle.
Regarding stroke, our analysis indicated that several tasks such as pick up an object from the floor, standing on 1 leg, and stairs are pathology-independent and associated to the same ADLs observed for PD. Conversely, other tasks such as 360° turn and standing unsupported are typical of people with stroke and are correlated with more static and semi-dynamic ADLs as standing on tiptoes and reaching for something and bending over to pick up a slipper from the front of a closet floor reflecting 1 of the most disabling symptoms of stroke that is center-of-body mass management problems. 36 The connections between balance tasks and balance resources depicted in Figure 3 suggest that balance rehabilitation for this population should focus on stability limits-verticality, APAs, sensory orientation, and gait stability. Previous studies 37 , 38 reported that balance rehabilitation including modification of base of support, maintaining balance while rotating head and trunk to right and left directions and weight shifting forward backward and side to side improve balance control in people with stroke.
In specific to MS, our analysis shows that semi-dynamic and dynamic balance tasks are significantly associated with ADLs. Specifically, only 2 correlations were found between balance in ADLs (stepping on or off an escalator and sweeping the floor and performance balance in tasks; 360° turn and pick up an object from the floor). The limited correlations observed may be due to the presence of ceiling effects, high variability, and heterogeneity in the clinical presentation of MS, which manifests with a wide range of symptoms and phenotypes. 39
Our results emphasize that stability limits-verticality, APAs, and stability in gait are crucial balance resources to prioritize in rehabilitation planning for improving balance confidence during ADLs in people with MS. Our findings are in line with a previous study 40 reporting an improvement in balance skills in people with MS after a task-oriented balance treatment taking into consideration the above-mentioned resources. These treatments focused on improving both motor and sensory strategies including exercises regarding the postural alignment, the ability to detect the position and movements of the center of mass, the ability to explore the limits of stability, and axial and postural anticipatory strategies and exercises in eyes-closed condition, using foam pads under the feet and using modified lenses, along with tasks to improve balance during head, eye, and head-eye movements. Other studies 41 , 42 reported an improvement in balance in people with MS after a balance rehabilitation consisting in standing dynamic balance exercises as sit-to-stand, standing with eyes open or closed while narrowing the base of support progressively, walking forward, eyes open or closed, backward, sideways, along a line, and around cones. The alignment with previous studies 40–43 validates the efficacy of task-oriented dynamic balance treatments that integrate stability limits-verticality, APAs, and stability in gait exercises.
Limitations
The study has several limitations. Firstly, the study population was not selected based on a population-based approach. Secondly, the study recruited a sample of patients who were seeking rehabilitation services, which may limit the external validity of the study results. Thirdly, we did not assess any important factors such as cognitive functions that they may have affected the accuracy of completing the ABC questionnaire. Fourthly, other PROs investigating the capacity of performing daily activities could be a suggestion for further analysis to assess people with neurological conditions.
Although few participants achieved the maximum total score for BBS and DGI, respectively, several items achieved the maximum score for both performance scales, biasing the correlations between ADLs and balance tasks. Another limitation is that the selected balance measures do not assess reactive balance deficits. The use of the Mini-Balance Evaluation System Test (Mini-BEST test) would allow both to assess reactive balance and better link tasks and balance resource and also to reduce ceiling effects in specific for people with PD. On the same line, the use of the FGA might have been more appropriate to reduce ceiling effects and to provide more sound data due to its good psychometric properties as reported in the clinical practice guidelines. 24
Finally, among balance resources, stability in gait may already embrace other domains, such as sensory orientation and APAs.
CONCLUSIONS
Our study shows that specific ADLs are closely associated with particular balance tasks. These findings collectively underscore the importance of adopting a comprehensive and personalized approach to balance rehabilitation. This approach should include tailored treatments that address symptom variability in individuals with MS, comprehensive balance training to enhance functional abilities in people with PD, and a multifaceted strategy aimed at improving stability and postural control in stroke survivors.
Supplementary Material