Changes in Vision, Balance, Gait, and Dizziness with Balance-Based Torso-Weighting:

1
Changes in Vision, Balance, Gait, and Dizziness
with Balance-Based Torso-Weighting A Case Report
on a Woman with MS Cynthia Gibson-Horn, PT
Laurie Chaikin, OD, OTR/L, FCOVD

• Background
• People with multiple sclerosis have numerous
  medical impediments due to the unpredictable
  demyelination in the brain, spinal cord, and
  optic nerve. Common impairments affecting gait
  and or balance in MS are disturbances in
  sensation, vision, and vestibular function, as
  well as weakness, spasticity, ataxia and fatigue.
  
• Gait and vision are perceived as the most
  valuable bodily functions regardless of whether
  patients have had the disease for less than or
  greater than ten years. Finding treatments that
  focus on improving vision and gait impairments
  are important to patients quality of life.
• Balance-Based Torso-Weighting is an intervention
  that begins with assessment of directional
  balance impairment during standing in the Romberg
  position with eyes open (EO) and eyes closed
  (EC). Anticipatory and reactive control is
  assessed with trunk perturbations. Small weights
  in ½ and ¼ pound increments are strategically
  placed on the torso to improve balance reactions.
• References
• Gibson-Horn C. Balance-based torso-weighting in a
  patient with ataxia and multiple sclerosis a
  case report. J Neurol Phys Ther. 200832139-146.
• Widener GL, Allen DD, Gibson-Horn C.
  Balance-based torso-weighting may enhance balance
  in persons with multiple sclerosis preliminary
  evidence. Arch Phys Med Rehabil. 200990602-609.
• Widener GL, Allen DD, Gibson-Horn C. Randomized
  clinical trial of balance-based torso weighting
  for improving upright mobility in people with
  multiple sclerosis. Neurorehabil Neural Repair.
  200923(8)784-791.
• C Heesen, J Böhm, C Reich, J Kasper, M Goebel and
  SM Gold, Patient perception of bodily functions
  in multiple sclerosis gait and visual function
  are the most valuable. Mult Scer 2008 Aug14 (7)
  988-91
• Multiple Sclerosis The Questions You have - The
  Answers You Need, By Rosalind C Kalb, PhD,
  Second Edition, 2000, New York Demos, pp37-39.
  ISBN 1 888 799 43 9

Assessment Vision impaired binocularity and
tracking (see Vision table). Posture Leans
posterior ROM Within normal limits Strength
Trunk Abdominals 3/5 Back extension 3/5
bilateral hip flexion, 3/5 bilateral hip
extension 3/5 Abduction Right 3/5, Left 4-/5
bilateral knee and ankles 4/5. Tone
WNL Sensation Light Touch diminished bilateral
soles of feet, position sense WNL, vibration
duration was75 decreased at the first metatarsal
head and lateral malleoli. Coordination
Dysmetria Finger nose and heel shin were mildly
affected in EO and moderately affected in EC.
Disdiadochokinesis WNL EO, 50 decreased in
EC. Gait slow (see Gait and Balance
table) Balance impaired (see Gait and Balance
table and SOT/COG) Activities and Participation
limited (see Dizziness Handicapped Inventory
table). BBTW Assessment Moderate trunk sway EO
Romberg. Severe loss of balance and truncal
ataxia in EC standing in Romberg position.
Perturbation testing revealed severe posterior
and lateral instability with moderate left lower
trunk loss of resistance to right forward
rotation. Treatment MC was given a
strategically weighted BalanceWear garment with
1 ¾ pounds of weight to wear daily as much as she
wanted. HEP Lower extremity strengthening,
brock string to increase convergence and
horizontal and vertical eye movements. MC wore
the vest 8 hours per/day and performed her visual
exercises. Per report after 5.5 weeks she could
do the EYE exercises without the vest. She
continued to wear the vest for stability during
daily activities. While on vacation she was able
to go on a gondola and also sailing which she
attributed to wearing the vest.
Results

• Discussion
• With the strategically weighted BalanceWear
  Therapeutic Vest, MC demonstrated immediate
  positive changes in many of her symptoms
  dizziness, balance, vision, and walking. Changes
  in body function were attributed to changes in
  participation MC could ride in a gondola and go
  sailing while on vacation while wearing the vest.
• The initial balance difficulties were
  demonstrated in the DGI and SOT 2-6 sensory,
  vestibular and visual conflict. Vision testing
  revealed insufficient convergence, very poor
  depth perception, and poor tracking skills that
  further impacted her balance.
• With BBTW, MC showed immediate improvement toward
  normalization of the SOT and DGI. Additionally,
  MC strategies on the SOT changed from using hip
  and ankle strategies to primarily ankle while she
  wore the vest. Her COG became consistent even
  though in both conditions she leans toward the
  left side. In the non- weighted state her COG was
  slightly more posterior.
• MC remarked that things in general looked
  clearer, and she showed immediate ability to
  track with ease, without impacting her balance.
  The immediate improvements to normal-stereopsis
  and more stable binocular findings typically
  require months of vision therapy.
• How can we explain this change? Each sensory
  system transmits information about body motion
  vestibular, visual, proprioceptive, and
  cutaneous. Wearing the weights on the trunk may
  provide augmented cutaneous and proprioceptive
  input. Perhaps the additional input improves
  capacity for attending to visual and vestibular
  input.
• Future Research
• Determine the prevalence and types of visual
  coordination impairments seen in people with MS
  with and with without optic neuritis.
• Investigate whether BBTW affects other patients
  with dizziness, visual and vestibular
  dysfunction.
• What sensory impairments may predict positive
  outcomes with BBTW.
• Conclusion
• MC had a positive outcome in vision and balance
  from wearing the strategically weighted garment
  both immediately and at a four-month follow-up.

Visual skill Pre BBTW 5/28/10 With BBTW 5/28/10
Visual acuity with Best Correction 20/20 right eye 20/20-2 left eye Subjective improvement in sense of clarity
Horizontal tracking After 2 x unable Dizzy Multiple shifts possible
Vertical tracking After 1x up unable Dizzy Multiple times up and down
Near phoria (eye alignment) 12 exophoria 9 exophoria
Fixation Disparity 4.3 to 8.6 sec. of arc, cont. movement 0 to 4.3 more stable
Stereopsis (depth perception) 400 seconds (gross only) 40 seconds (normal)
Dizziness Handicap Inventory Pre - Intervention 05/27/10 At Follow Up 09/27/2010 Percent Improvement
Physical 20 8 60
Emotional 22 12 45
Function 24 18 25
Total 66 38 62
Gait and Balance Assessments Pre BBTW 5/27/10 With BBTW 5/27/10 Percent Change
TUG - 2 test average 9.4 sec 7.75 sec 18
25 ft walk 2 test average 6.3 sec 5.55 sec 12
Dynamic Gait Index 15/24 24/24 37.5
Patient History MC is a 49-year-old female
diagnosed with MS nine years prior after
experiencing severe vertigo. She is currently
married and has a five-year-old daughter. She was
provided with BBTW in 2002. In 2010 she was
re-assessed to determine the continued effects of
BBTW both immediately and short-term (4 months).
Her goals were to improve walking, balance, and
dizziness. Symptoms Visual complaints were eye
fatigue, reduced reading time, loss of place when
reading, blurred vision at near. Nausea with eye
movement. MC noted instability with standing and
walking. She had spontaneous vertigo and
disequilibrium induced by motion and positional
changes including lying down, sitting, standing
and walking in the dark or on uneven surfaces.
She denies falling but reports she stumbles,
staggers and side-steps to catch balance.
9/27/2010 Pre BBTW
Funding Source No funding was received for this
case report.
Provided the BalanceWear vest for MC. Ms.
Gibson-Horn has a financial interest in Motion
Therapeutics.
9/27/2010 With BBTW