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Cited by 12Balance, Gait, and Falls PreventionMultiple Sclerosis Research StudiesStroke Rehabilitation and Recovery

The instrumented single leg stance test detects early balance impairment in people with multiple sclerosis

Open access
Berg-Hansen, Pål, Moen, Stine Marit, Klyve, Thomas Dahl, Gonzalez, Victor, Seeberg, Trine Margrethe, Celius, Elisabeth Gulowsen, Austeng, Andreas, Meyer, Frédéric·2023·Frontiers in Neurology
DOI 10.3389/fneur.2023.1227374PMC PMC10394643
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Abstract

Balance impairment is frequent in people with multiple sclerosis (pwMS) and affects risk of falls and quality of life. By using inertial measurement units (IMUs) on the Single Leg Stance Test (SLS) we aimed to discriminate healthy controls (HC) from pwMS and detect differences in balance endurance and quality. Thirdly, we wanted to test the correlation between instrumented SLS parameters and self-reported measures of gait and balance. Fifty-five pwMS with mild (EDSS<4) and moderate disability (EDSS≥4) and 20 HC performed the SLS with 3 IMUs placed on the feet and sacrum and filled the Twelve Item Multiple Sclerosis Walking Scale (MSWS-12) questionnaire. A linear mixed model was used to compare differences in the automated balance measures. Balance duration was significantly longer in HC compared to pwMS ( p < 0.001) and between the two disability groups ( p < 0.001). Instrumented measures identified that trunk stability (normalized mediolateral and antero-posterior center of mass stability) had the strongest association with disability (R 2 marginal 0.30, p < 0.001) and correlated well with MSWS-12 ( R = 0.650, p < 0.001). PwMS tended to overestimate own balance compared to measured balance duration. The use of both self-reported and objective assessments from IMUs can secure the follow-up of balance in pwMS.

AI snapshot

Written from the paper’s full text.

TL;DR

Instrumented Single Leg Stance Test (SLS) with three inertial measurement units discriminated healthy controls from people with multiple sclerosis (pwMS), including mild disability, mainly via balance duration and normalized trunk center-of-mass stability. Self-reported MSWS-12 correlated with measured balance duration, but pwMS tended to overestimate their own balance.

Key findings

  • Balance duration was significantly longer in healthy controls (HC) than in pwMS and differed between disability groups: HC least affected leg 54.2 ± 18.0 s, EDSS<4 38.5 ± 8.9 s, EDSS≥4 7.92 ± 6.52 s; group p < 0.001, effect size R² = 0.618.
  • Normalized mediolateral and antero-posterior center-of-mass stability had the strongest association with disability (R² marginal 0.30, p < 0.001) and correlated with MSWS-12 (R = 0.650, p < 0.001).
  • Time-to-peak, peak-to-balance, and peak-acceleration did not differ significantly between groups; raw RMS mediolateral and antero-posterior differed only between HC and EDSS≥4, while normalized RMS values also differentiated the two pwMS groups.
  • MSWS-12 mean was 52.2 (SD 22.7) overall, 37.5 (19.6) for EDSS<4 and 65.0 (17.1) for EDSS≥4 (p < 0.001); MSWS-Q5 was 3.0 (0.9), 2.4 (0.7), and 3.5 (0.8), respectively (p < 0.001 between disability groups). No significant test–retest change was found after a median 15-day rehabilitation stay (p = 0.485).

Methods

  • Participants performed the SLS with three IMUs on both feet and the sacrum, both legs tested twice alternating, with each trial stopped at 60 s; pwMS also completed the MSWS-12.
  • The paper reports 55 pwMS and 20 HC were available/performed testing, but due to IMU synchronization issues 41 pwMS and 15 HC were included in the present study; pwMS were divided into EDSS<4 and EDSS≥4 groups.
  • A linear mixed model compared SLS phases and stability measures between HC and pwMS groups, with Bonferroni correction; correlations with MSWS-12 and MSWS-Q5 were also examined.

Limitations

  • The paper states BMI was higher in the least disabled pwMS, 13 patients used fampridine, and there was a relatively high dropout rate due to IMU synchronization issues from wrong settings; it also notes future studies could include validated fall-risk scales.
  • The paper states the short rehabilitation stay was heterogeneous and not specifically tailored to balance, and that the most disabled pwMS often never reached a stable balance phase, limiting strict conclusions.
  • Evident from the text: the HC sample size is inconsistent across sections—methods/Table 1 report 15 HC included, while the abstract and Table 2 label HC as n = 20.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.3389/fneur.2023.1227374

Cites

40 of 40 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

7 of 13 cited sources checked · 3 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    People with multiple sclerosis have a higher risk of falls than healthy peers, even in early phases of the disease.

    “PwMS have a higher risk of falls than healthy peers (5), even in early phases of the disease (6, 7).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [5] Mazumder, 2014, Falls in people with multiple sclerosis compared with falls in healthy controls, PLoS One source
    • cites [6] Coote, 2020, Falls in people with multiple sclerosis: risk identification, intervention, and future directions, Int J MS Care source
    • cites [7] Moen, 2011, Fractures and falls in patients with newly diagnosed clinically isolated syndrome and multiple sclerosis, Acta Neurol Scand Suppl source
  • Findingown data

    Peak-acceleration did not differ between HC and pwMS groups.

    “The peak-acceleration (Figure 1D) was neither different between the HC and pwMS groups.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Recordings from the initial anticipatory postural adjustment phases do not discriminate on a group level.

    “Recordings from the initial anticipatory postural adjustment phases do not discriminate on a group level but can give useful information on an individual level.”
    Quote in the paperSubstantial claim
  • Findingnone given

    The less disabled group showed the widest range of balance impairment.

    “The less disabled group showed the widest range of balance impairment and having a detailed analysis of the patients could potentially guide an individualized treatment.”
    Quote in the paperSubstantial claim
  • Findingown data

    Self-reported data from the MSWS-12 including question 5 on balance correlates well with balance duration.

    “Self-reported data from the MSWS-12 including question 5 on balance correlates well with balance duration, but pwMS tend to overestimate own balance.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 11
  • May combine two claims. 9
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The setup with three IMUs used on the SLS was similar to that used in the study of people with parkinsonism.

    “The setup with three IMUs used on the SLS was similar to that used in the study of people with parkinsonism (29).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [29] Bonora, 2017, Investigation of anticipatory postural adjustments during one-leg stance using inertial sensors: evidence from subjects with parkinsonism, Front Neurol source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Balance impairment affects approximately 75% of people with multiple sclerosis during the disease course.

    “Balance impairment affects approximately 75% of pwMS during the disease course (3) and is one of the most debilitating symptoms (4).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [3] Cattaneo, 2020, Factors influencing balance improvement in multiple sclerosis rehabilitation: a pragmatic multicentric trial, Ann Phys Rehabil Med source

      The Methods discuss balance deficits in people with MS, and the Results report outcomes for 150 rehabilitation participants, but neither gives a population prevalence. Searches for “75%,” balance-impairment prevalence, and impairment during the disease course found no passage supporting the approximately 75% figure. (LLM, conf=0.74)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The instrumented 30-s chair stand test was shown to predict risk of falls in people with multiple sclerosis.

    “The instrumented 30-s chair stand test was shown to predict risk of falls in pwMS (25).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [25] Tulipani, 2022, Evaluation of unsupervised 30-second chair stand test performance assessed by wearable sensors to predict fall status in multiple sclerosis, Gait Posture source

      The Results (ROC Analysis and Falls Classification; page unavailable) show that the instrumented 30-second chair stand test classified fall status in people with multiple sclerosis. The paper discusses its potential to screen for fall risk, but it classified existing faller status rather than demonstrating prediction of future falls. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Premisecitation

    Physilog inertial sensors have good technical capability compared to reference systems in healthy and clinical settings.

    “In general Physilog inertial sensors have good technical capability compared to reference systems in healthy and clinical settings (39, 40).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [39] Lefeber, 2019, Validity and reproducibility of inertial Physilog sensors for spatiotemporal gait analysis in patients with stroke, IEEE Trans Neural Syst Rehabil Eng source
    • cites [40] Zhou, 2020, Validation of an Imu gait analysis algorithm for gait monitoring in daily life situations, Annu Int Conf IEEE Eng Med Biol Soc source

      The Experimental Setup identifies Physilog 5 IMUs and an OptoGait reference system; the Abstract reports accurate stride-length and stride-time estimates from the IMU-based algorithm. But the study tested five healthy subjects, not a clinical population, and used the sensors’ raw data rather than validating the manufacturer’s gait-analysis software. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Single Leg Stance Test is widely used in elderly people and in people with neurological disorders, such as Parkinson's disease.

    “Single Leg Stance Test (SLS) is widely used in elderly (16) and in people with neurological disorders, such as Parkinson’s disease (17).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [16] Springer, 2007, Normative values for the Unipedal stance test with eyes open and closed, J Geriatr Phys Ther source
    • cites [17] Chomiak, 2015, The single-leg-stance test in Parkinson's disease, J Clin Med Res source

      The Introduction says the SLST has been widely used in the elderly but only “in some cases” in patients with Parkinson’s disease. This source supports use in Parkinson’s disease, the part linked to citation (17), but not the claim that it is widely used across people with neurological disorders. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    Normalized RMS antero-posterior was significantly different between HC and EDSS≥4, and between the two pwMS groups.

    “There were significant differences in the parameters normalized RMS mediolateral and normalized RMS antero-posterior between HC and EDSS≥4, and between the two pwMS group (Figures 2C,D).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Normalized RMS mediolateral was significantly different between HC and EDSS≥4, and between the two pwMS groups.

    “There were significant differences in the parameters normalized RMS mediolateral and normalized RMS antero-posterior between HC and EDSS≥4, and between the two pwMS group (Figures 2C,D).”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    MSWS-Q5 correlates with balance duration, but lower than MSWS-12 total.

    “There was a lower but still good correlation between MSWS-Q5 and balance duration.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    RMS mediolateral was significantly different only for HC compared to the moderate disability pwMS, but not between the two EDSS groups.

    “The parameters RMS mediolateral and RMS antero-posterior were significantly different only for HC compared to the moderate disability pwMS, but not between the two EDSS groups (Figures 2A,B).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    RMS antero-posterior was significantly different only for HC compared to the moderate disability pwMS, but not between the two EDSS groups.

    “The parameters RMS mediolateral and RMS antero-posterior were significantly different only for HC compared to the moderate disability pwMS, but not between the two EDSS groups (Figures 2A,B).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    There was a relatively high dropout rate due to synchronization issues.

    “There was a relatively high dropout rate due to syncronization issues, which was due to wrong setting of the IMUs.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Trunk stability in the balance phase was the best parameter in discriminating people with multiple sclerosis from healthy controls and between different disability groups.

    “Data recorded from IMUs revealed that trunk stability in the balance phase was the best parameter in discriminating pwMS from HC and between different disability groups.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The mild disability group had a significantly higher BMI compared to the moderate disability group and healthy controls (both p = 0.01).

    “The mild disability group had a significantly higher Body Mass index (BMI) compared to the moderate disability group and HC (both p = 0.01).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    There were no significant differences in age or gender distribution between healthy controls and people with multiple sclerosis, nor internally between the two disability groups.

    “There were no significant differences in age or gender distribution between the HC and pwMS, nor internally between the two disability groups.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Anticipatory postural adjustments are important in keeping the center of mass stable prior to a body perturbation, such as preparing to stand on one leg.

    “Anticipatory postural adjustments (APA) are important in keeping the center of mass stable prior to a body perturbation, such as preparing to stand on one leg (27).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27] Massion, 1992, Movement, posture and equilibrium: interaction and coordination, Prog Neurobiol source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The twelve item Multiple Sclerosis Walking Scale (MSWS-12) is shown to correlate with improvement after rehabilitation, especially in early phases of the disease.

    “The twelve item Multiple Sclerosis Walking Scale (MSWS-12) (30), a self-reported questionnaire on walking ability in MS, is shown to correlate with improvement after rehabilitation, especially in early phases of the disease (31).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] Baert, 2014, Responsiveness and clinically meaningful improvement, according to disability level, of five walking measures after rehabilitation in multiple sclerosis: a European multicenter study, Neurorehabil Neural Repair source

  • May combine two claims.

    Premisecitation

    EDSS is the most frequently used disability measure in people with multiple sclerosis, but has major limitations, and does not specifically measure balance problems.

    “Expanded Disability Status Scale (EDSS) (10) is the most frequently used disability measure in pwMS, but has major limitations, and does not specifically measure balance problems (11).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [11] Cohen, 2012, Disability outcome measures in multiple sclerosis clinical trials: current status and future prospects, Lancet Neurol source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    There was a relatively high number of participants in each group allowing for meaningful statistical calculations.

    “There was also a relatively high number of participants in each group allowing for meaningful statistical calculations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    There was no significant difference in disease duration between the two disability groups.

    “There was no significant difference in disease duration between the two disability groups.”
    Quote in the paperNot a substantial claim
19 of 19

  • The paper relies on this without support.

    The participants excluded due to synchronization issues did not differ systematically from included participants in ways that could affect the results.

    “There were, however, no systematic differences between the sensored and included participants in the study that might have affected the results.”
1 of 1

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Raw acceleration RMS is labeled with normalized units

    Minor

    The methods define raw RMS from acceleration and say that only the normalized values are divided by duration. Table 2 nevertheless labels raw RMS in m/s3, the units that would result after division by seconds, rather than acceleration units of m/s2.

  • Gender comparison is both significant and nonsignificant

    Minor

    Table 1 reports p < 0.001 for the gender comparison between controls and pwMS, while the results explicitly say there was no significant difference.

  • Normalized RMS does not distinguish controls from all patients

    Minor

    The discussion claims differences between controls and all pwMS, but Table 2 gives p = 1.000 for the control-versus-mild-disability comparison for both normalized RMS measures.

  • Table 2 uses the wrong healthy-control sample size

    Minor

    The methods state that 15 healthy controls were included after synchronization failures, but Table 2 labels the healthy-control results as n = 20.

4 of 4

Cites

Flagged first, then by citations

2 of the 42 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Berg-Hansen, P., Moen, S. M., Klyve, T. D., Gonzalez, V., Seeberg, T. M., Celius, E. G., Austeng, A., & Meyer, F.
Affiliations
  • Oslo University Hospital (NO)
  • University of Oslo (NO)
ORCID
Venue
Frontiers in Neurology
Publisher
Frontiers Media SA
Published
2023-07-19
Volume
14
Pages
1227374-1227374
ISSN
1664-2295 (ISSN-L)
DOI
10.3389/fneur.2023.1227374
PMC
PMC10394643
OpenAlex
W4384827578
Semantic Scholar
3c8e0123abc147560341ac9379cb37f1dbaf456f
Cited by
12
References
42
Citations by year
2026: 4 · 2025: 5 · 2024: 3
FWCI
6.99
Type
journal article
Language
en
Open access
Licence
Locations
  • Frontiers in Neurology (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • NORA - Norwegian Open Research Archives (submittedVersion, cc-by)
Funders
  • Norges Teknisk-Naturvitenskapelige Universitet
  • Universitetet i Oslo
  • Norges Forskningsråd (270791)
Topics
  • Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Balance, Gait, and Falls Prevention
  • Health Sciences › Medicine › Pathology and Forensic Medicine › Multiple Sclerosis Research Studies
  • Health Sciences › Medicine › Rehabilitation › Stroke Rehabilitation and Recovery
Keywords
multiple sclerosis, balance disorders, single-leg stance test, inertial measurement unit, core stability, center of mass stability, MSWS-12, disability severity, fall risk

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