Birnbaum MA 1,2 , Brock K 1 , Clark R 3 , Hill K 2

1. Assessment of balance following stroke: feasibility of using a Wii Balance Board to quantify postural control and performance in patients with lateropulsion Birnbaum MA1,2, Brock K1, Clark R3, Hill K2 1St. Vincent’s Hospital, Melbourne2Curtin University, Perth 3Australian Catholic University, Melbourne • Funding: St. Vincent’s Hospital • Melbourne Research Endowment Fund

2. Background Lateropulsion= Altered perception of body verticality (Perennou et al 2008) (Karnath 2007)

3. Background •  length of stay (30 days longer in one study) • functional level at discharge • (Clark E et al 2012; Danells et al 2004; Babyaret al 2008) (Broetz and Karnath 2005) (Davies 1985)

4. Background Measures of lateropulsion • Reliable and valid measures needed to develop effective treatments • Ordinal scales: e.g. Burke Lateropulsion Scale & Scale of Contraversive Pushing • Ordinal nature may be problematic • Potentially reduces scales’ sensitivity to change • ?Relationship with specific kinematic and kinetic measures of postural control

5. Background • Nintendo Wii Balance Board • Centre of pressure (COP) • Comparable data to force platform • Test retest reliability established • (Bower et al 2014; Clark R et al 2010; Clark R et al 2011; Holmes et al 2012; Scaglioni-Solano et al 2014)

6. Aim • To investigate the feasibility of using a WBB as a measure of balance in people with lateropulsion following stroke • To develop and refine standardised testing procedures

7. Participants • Inclusion: • Diagnosis of acute stroke • Between one to twelve weeks post stroke • Presence of lateropulsion (Burke Lateropulsion Scale ≥ 2) • Able to follow one stage command with gesture • Tolerate 20 minute physiotherapy session • Able to provide informed consent • Exclusion: • Pre existing co morbidity limiting mobility in community • Weight > 112 kgs

8. Instrumented Measures • Wii Balance Board COP Measures Standing measures if: Sitting measures if:

9. Technology tasks in sitting 2 1 • Shift weight to non-paretic side • Shift weight to paretic side • Sitting eyes closed • Arm raise test • Reaching sideways • Picking up object from behind • Picking up object from floor 10 seconds test duration / test

10. Technology tasks in standing 1 • Shift weight to non-paretic leg • Shift weight to paretic leg • Standing eyes closed • Turning head while standing • Forward reachStanding feet together • Picking up object from floor 2

11. COP Measures • Types of COP information available: • Path length • Anteroposterior or mediolateral amplitude • Anteroposterior or mediolateral COP movement variability NOT SYMMETRY

12. Procedures • Recruited day seven or when able to maintain sitting as described • Trained assessors • Physiotherapists with >5 years post-graduate experience and >2 years experience in areas of rehabilitation or neurology 20 minute rest Clinical and impairment measures Instrumented Measures day 1 day 2 day 15 day 14

13. Clinical Measures • Lateropulsion • Burke Lateropulsion Scale & Scale of Contraversive Pushing • Postural control • Postural Assessment Scale for Stroke patients (PASS) (Benaim et al 1990) • Active motor control • Stroke Rehabilitation Assessment of Movement Instrument (Wang et al 2002) • Sensation • Sensory section of Fugl-Meyer Assessment(Sullivan et al 2011) • Neglect • Catherine BergegoScale(Azouviet al 1996) • Visual fields • Confrontation visual field examination • Functional ability • Functional Independence Measure (motor domain)(Dodds et al 1993)

14. Analysis • Feasibility • Participant retention • Compliance with assessment procedures • Wii Balance Board-derived COP data • Visually by graphing performance over four occasions

15. Results • Participants (n = 10) • Age (years) Mean 65.6 (SD 13.4) Time since stroke (days) Mean 26.3 [16-44 range] • Males 4 (40%) • Left side hemiparesis 7 (70%) • FIM Motor (day 1) Mean 32 (range 21-56) • Severity of lateropulsion (day 1) Range 3 – 13 (max 17) • Mild 7 • Moderate 2 • Severe 1 SD – standard deviation; D1 – Day 1; max – maximum

16. Results • Participant retention • 100% • Compliance with assessment procedures • 30% completed all assessment items • Predominantly due to participant fatigue • No major adverse events or falls • Missing data • All participants completed sit with arm support task • Greater missing data from those individuals with lower functional levels

17. Results Example 1: Sitting without arm Participant A

18. Results Example 1: Sitting without arm Participant B

19. Results Example 2: Standing without support Participant A – Unable Participant B

20. Conclusion Key Practice Points • Feasible using a reduced number of tasks and test duration (3-5 seconds) • May capture useful information about balance in individuals with lateropulsion • Fatigue should be taken into account Results from this pilot study have informed a larger longitudinal measurement study currently underway

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