Walking while talking--difficulties incurred during the initial stages of multiple sclerosis disease process

Exergames and Immersive Virtual Reality as a Novel Therapy Approach in Multiple Sclerosis: Randomised Feasibility Study

Background: Multiple sclerosis is a chronic, inflammatory, neurodegenerative autoimmune disease caused by myelin loss in the central nervous system, which leads to motor and non-motor problems. The main objective of this study was to explore whether an immersive virtual reality (IVR) exercise programme would be feasible as a form of physical therapy for people with MS (pwMS). Methods: 18 participants (13 women; 45.06 years) were assigned to an experimental group (EG, n = 8) and a control group (CG, n = 10). The EG took part in a twice-weekly IVR exergame physical therapy programme-ExeRVIEM programme. A randomised, single-blind clinical trial was conducted and was registered in clinicaltrials (NCT05870254). Results: The intervention was feasible and safe. The participants completed the programme with no adverse effects (no symptoms on the Simulator Sickness Questionnaire), high usability (System Usability Scale 90.31%), and outstandingly positive post-game experiences (Game Experience Questionnaire 3.10/4). In addition, the GE significantly improved several of their functional capacities: increased lower limb strength (Five Times Sit-to-Stand Test p = 0.042), improved functional mobility, and reduced fall risk (Timed Up and Go Test-simple p = 0.009; Timed Up and Go Test-cognitive p = 0.003). There were no statistically significant differences between the groups. Conclusions: The findings support that the use of exergames and IVR as physical therapy in pwMS is feasible and safe. Furthermore, there is the suggestion of possible benefits to participants' functional abilities, all of which position IVR as a promising tool for the rehabilitation of this neurodegenerative pathology affecting young adults.

Cognitive-motor dual task to reveal gait impairments in multiple sclerosis patients at an early stage: A systematic review

BACKGROUND

Multiple sclerosis can cause locomotor and cognitive impairments even at lower levels of disability, which can impact daily life. The cognitive-motor dual task is commonly used to assess everyday locomotion. Thus, this study aimed to examine the effect of cognitive-motor dual tasks on gait parameters among patients with multiple sclerosis in the early disease stages and to determine whether dual tasks could be used as a clinical test to detect locomotion impairments.

METHODS

A systematic search of five databases was conducted in May 2024. The population of interest was patients with multiple sclerosis with an Expanded Disability Status Scale score of 4 or less. The following outcome measures were examined: spatiotemporal and kinematic parameters. The Newcastle-Ottawa Scale was used to assess the quality of the studies.

FINDINGS

Eleven studies including 270 patients with multiple sclerosis and 221 healthy controls. Three spatiotemporal parameters were modified both in patients with multiple sclerosis and healthy controls during dual-task performance: gait speed, stride length and the double support phase. No spatiotemporal parameter was affected during dual-task performance in patients with multiple sclerosis alone.

INTERPRETATION

Dual-task performance could be useful for assessing gait impairments in patients with multiple sclerosis provided that assessments and protocols are standardized. Nevertheless, the spatiotemporal parameters did not allow discrimination between patients with multiple sclerosis at an early stage and healthy controls. Three-dimensional gait analysis during dual-task performance could be a useful approach for detecting early gait impairments in patients with multiple sclerosis, assessing their progression and adjusting rehabilitation programs.

Effects of wearing textured versus smooth shoe insoles for 12 weeks on gait, foot sensation and patient-reported outcomes, in people with multiple sclerosis: a randomised controlled trial

BACKGROUND

Innovative shoe insoles, designed to enhance sensory information on the plantar surface of the feet, could help to improve walking in people with Multiple Sclerosis.

OBJECTIVE

To compare the effects of wearing textured versus smooth insoles, on measures of gait, foot sensation and patient-reported outcomes, in people with Multiple Sclerosis.

METHODS

A prospective, randomised controlled trial was conducted with concealed allocation, assessor blinding and intention-to-treat analysis. Thirty ambulant men and women with multiple sclerosis (MS) (Disease Steps rating 1-4) were randomly allocated to wear textured or smooth insoles for 12 weeks. Self-reported insole wear and falls diaries were completed over the intervention period. Laboratory assessments of spatiotemporal gait patterns, foot sensation and proprioception, and patient-reported outcomes, were performed at Weeks 0 (Baseline 1), 4 (Baseline 2) and 16 (Post-Intervention). The primary outcome was the size of the mediolateral base of support (stride/step width) when walking over even and uneven surfaces. Independent t-tests were performed on change from baseline (average of baseline measures) to post-intervention.

RESULTS

There were no differences in stride width between groups, when walking over the even or uneven surfaces (P ≥ 0.20) at post-intervention. There were no between-group differences for any secondary outcomes including gait (all P values > 0.23), foot sensory function (all P values ≥ 0.08) and patient-reported outcomes (all P values ≥ 0.23).

CONCLUSIONS

In our small trial, prolonged wear of textured insoles did not appear to alter walking or foot sensation in people with MS who have limited foot sensory loss. Further investigation is needed to explore optimal insole design.

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN12615000421538).

Energy expenditure and perceived effort during uphill and downhill walking in people with multiple sclerosis

BACKGROUND

Walking on different slopes is a common daily activity for many ambulatory people with multiple sclerosis (pwMS) AIM: Investigate energy expenditure measures of walking on level, uphill and downhill slopes in pwMS.

DESIGN

Observational case-control study.

SETTING

Sheba Multiple Sclerosis Center, Tel-Hashomer, Israel.

POPULATION

Eighteen pwMS; 10 women and 8 men, aged 39.7 (SD=6.8), mean EDSS was 2.9 (SD=1.2) and 23 healthy adults; 8 women and 15 men, aged 37.1 (S.D.=5.3).

METHODS

Energy expenditure values were obtained via a metabolic device during four conditions: sitting, comfortable walking, uphill and downhill walking. Each walking trial, obtained on a treadmill, lasted 6-min and were separated by10-min recovery intervals.

RESULTS

For both pwMS and healthy controls, the O2 rate and O2 cost was higher during uphill walking compared to level walking and lower during downhill walking compared with level walking. O2 rate and net O2 cost during uphill walking was lower in pwMS compared with the healthy controls. The most demanding effort was during uphill walking, with pwMS rating it more demanding compared with the healthy controls.

CONCLUSIONS

Perceived effort of walking on different slopes is not consistent with changes in the energy expenditure values in pwMS.

CLINICAL REHABILITATION IMPACT

pwMS describe the effort of walking on different slopes higher than normal, regardless of the energy expenditure values.

Cognitive-motor interference in people with mild to moderate multiple sclerosis, in comparison with healthy controls

BACKGROUND

Reduced motor and cognitive dual-task capacity is found to be more common among people with multiple sclerosis (MS), than among healthy populations. However, studies in larger samples of MS conducted using a more stringent methodology, which includes comparisons to healthy controls, are needed. Thus, the primary aim of this study was to explore the effects on motor and cognitive dual-tasking in people with mild to moderate overall MS-disability, in comparison to healthy controls. A second aim was to explore the differences in dual-task performance on a cognitive task between two motor tasks in people with mild to moderate MS and healthy controls.

METHODS

This case-control study evaluated dual-task performance of the motor tasks standing with eyes closed (hereafter standing) and walking and a cognitive task assessing selective executive functions (auditory-Stroop test). Fifty-five people with MS (mild MS, n = 28; moderate MS, n = 27), and 30 healthy controls participated. Standing and walking were assessed using wireless inertial measurement unit sensors (APDM). Standing (three 30 s trials) was measured using sway area and root mean square sway, while walking (2 min) was measured using speed, stride length, and step time. Auditory-Stroop was measured using accuracy and response time. During dual-task assessments, each subject was instructed to pay equal attention to both tasks. Statistical significance was considered if p < .05.

RESULTS

Instanding no significant within-group differences in the standing measures were found between single-task and dual-task performance. However, dual-task performance differed significantly between all groups (moderate MS > mild MS > healthy controls), except between mild and moderate MS in sway area. Inwalking, all groups slowed down speed and shortened stride length during dual-task condition compared to single-task condition. Moderate MS performed significantly poorer than mild MS and healthy controls in dual-task walking, but mild MS did not differ from healthy controls. In thecognitivetask only mild MS increased significantly in auditory-Stroop response time during walking. In healthy controls, the performance of auditory-Stroop was not affected by dual-tasking. Moderate MS had significantly longer response time in dual-task auditory-Stroop compared to the other groups, but no differences were observed between mild MS and healthy controls. Only mild MS had significantly longer response time during walking than during standing.

CONCLUSION

This study showed that cognitive-motor interference in people with MS is present also in the early phases of the disease. This was shown during dual-tasking with slower walking and a longer response time in the cognitive task compared to healthy controls. Moderate MS performed poorer in almost every aspect of the motor and cognitive assessments in dual-task condition, compared to mild MS and healthy controls. Furthermore, during standing, people with MS performed poorer in standing measures compared to healthy controls. Additionally, healthy controls showed no cognitive interference during motor tasks. The results suggest that standardized regular assessment of dual-tasking in MS care might increase the individual's knowledge of dual-task capacity and contribute to understanding of possible related consequences. However, feasible assessment equipment and specific motor-cognitive dual-task training interventions for people with MS need to be developed.

Cognitive-Motor Interference and Cortical Activation While Walking in Individuals With Multiple Sclerosis

The present study expands on current understanding of dual-task cognitive-motor interference, by including cortical activation measures to both traditional and ecologically valid dual-task paradigms. Fifteen individuals with multiple sclerosis and 14 control participants underwent mobility testing while wearing functional near-infrared spectroscopy. In the absence of increased prefrontal cortical activation, subjects with multiple sclerosis performed significantly worse on measures of cognition under both single- and dual-task conditions. These findings suggest that persons with multiple sclerosis may be unable to allocate additional cortical resources to cognition under dual-task conditions, leading to significant cognitive-motor interference and decrements in performance. This study is the first to investigate cortical activation across several commonly used and ecologically valid dual-task assessments.

Motoric cognitive risk syndrome in people with multiple sclerosis: prevalence and correlations with disease-related factors

Background:

The motoric cognitive risk (MCR) syndrome, defined as the coexistence of slow gait and subjective cognitive complaints, has as yet not been researched in people with multiple sclerosis (pwMS).

Objective:

To examine the prevalence of the MCR syndrome in pwMS and its association with disability, disease duration, perceived fatigue, and fear of falling.

Methods:

The study comprised 618 pwMS [43.7 (SD = 12.6) years, 61.7% females]. Gait speed was measured by the GAITRite™ electronic walkway (CIR Systems, Inc. Haverton, PA, USA). Cognitive status was defined according to the global cognitive score computed by the NeuroTrax™ cognitive battery (NeuroTrax Corporation, Medina, NY, USA). The sample was divided into four main groups: ‘normal’, ‘cognitively impaired’, ‘gait impaired’ or ‘MCR’. Perceived fatigue was assessed by the Modified Fatigue Impact Scale; fear of falling by the Falls Efficacy Scale International.

Results:

Sixty-three (10.2%) patients were diagnosed with MCR. The percentage of subjects categorized as MCR was 26.0% in severely disabled pwMS compared with 10.9%, 6.0%, and 4.6% in moderately, mildly and very mildly disabled pwMS, respectively. Subjects in the MCR group presented with elevated fatigue compared with patients classified as normal [49.7 (SD = 23.3) vs 26.5 (SD = 19.2), p < 0.001]. Fear of falling was significantly higher in the MCR and gait impairment groups compared with the cognitively impaired and normal groups.

Conclusions:

The current study corroborates the presence of MCR in pwMS. Nevertheless, future longitudinal research is warranted to better understand its application.

Instrumented Assessment of Motor Performance Fatigability During the 6-Min Walk Test in Mildly Affected People With Multiple Sclerosis

There are conflicting results regarding the changes in spatio-temporal gait parameters during the 6-min walk test (6MWT) as indicators of gait-related motor performance fatigability (PF) in people with Multiple Sclerosis (pwMS). To further analyze if gait-related motor PF can be quantified using instrumented gait analysis during the 6MWT, we investigated: (i) whether gait parameters recorded during the first or second minute were more stable and thus the better baseline to assess motor PF and (ii) if the minimum toe clearance (MTC) together with “classical” spatio-temporal gait parameters can be used to quantify motor PF in pwMS. Nineteen mildly affected pwMS [12 women/7 men; 47.8 ± 9.0 years; the Expanded Disability Status Scale (EDSS): 2.7 ± 1.0] and 24 healthy controls (HC; 15 women/9 men; 48.8 ± 7.6 years) completed the 6MWT equipped with inertial measurement units. Data were analyzed using the attractor method to compare the stability of gait parameters and, besides “classical” spatio-temporal gait parameters, the MTC was calculated as a potential new marker for motor PF in pwMS as this was shown in healthy older adults. It was found that (i) gait parameters were more stable in the second than in the first minute and (ii) gait-related motor PF could not be detected based on spatio-temporal gait parameters, including the MTC. Descriptive analysis indicated a decrease in MTC variability, which is assumed to be indicative for motor PF, toward the end of the 6MWT in some pwMS. Future studies should investigate gait parameters for the assessment of motor PF in pwMS recorded during more intense and/or longer walking protocols, taking the level of disability into account. Furthermore, using gait parameters recorded in the first minute of the 6MWT as a baseline for the assessment of motor PF should be avoided.

Longitudinal relationships between disability and gait characteristics in people with MS

Longitudinal data are vital in order to understand intra individual gait changes with the progression of multiple sclerosis (MS). Therefore, the primary aim of this study was to explore the relationship between changes in disability with changes in major spatio-temporal parameters of gait in people with MS (PwMS). PwMS (n = 83) completed two gait assessments performed at separate time points (M1, M2). For each individual, the absolute difference between the Expanded Disability Status Scale (EDSS) score, key spatio-temporal parameters of gait, Falls Efficacy Scale International (FES-I), and the 12-item Multiple Sclerosis Walking Scale (MSWS-12), were calculated. The mean time difference between M1 and M2 was 2.5 (SD = 1.7) years. At M2, PwMS presented with shorter strides, a wider base of support, increased perceived mobility difficulties and fear of falling compared with M1. According to the odds ratio (OR) analysis, the odds of experiencing an increase in the EDSS score was significantly higher once the MSWS-12 score increased at M2 compared with M1 (OR = 7.930, p = 0.004). This observation was highlighted specifically in people with mild-moderate MS (OR = 12.427, p < 0.001). The increase in the EDSS score was not associated with changes in key spatio-temporal parameters of gait. The present study provides a better understanding of gait and disease progression in PwMS, highlighting the significant role of the MSWS-12.

Reliability and validity of the modified Walking and Remembering Test in persons with multiple sclerosis

Cognitive dysfunction can adversely impact the walking ability of people with multiple sclerosis. However, valid and reliable standardized clinical tools to measure cognitive-motor interference or dual-tasking in people with multiple sclerosis remain lacking. This study evaluated the validity and reliability of the modified Walking and Remembering Test (mWART) in people with multiple sclerosis. Eleven adults (mean ± SD age, 51.1 ± 13.4 years) with multiple sclerosis (Expanded Disability Status Score, 2.0-6.0) and six adults (mean ± SD age, 41.5 ± 17.2 years) without multiple sclerosis were administered the mWART twice over a 2-week period. Participants were tested on gait and digit span length under single-task and dual-task conditions according to the mWART procedures over a 10-m walkway. intraclass correlation coefficient2,k were 0.961 for single-task gait velocity (P < 0.001), 0.968 for dual-task gait velocity (P < 0.001), 0.829 for single-task digit span (P = 0.004), and 0.439 for dual-task digit span (P = 0.154). Single-task gait velocity (P = 0.001) and dual-task gait velocity (P = 0.002) were able to discriminate between groups but dual-task costs were similar between participants with and without multiple sclerosis. Those with severe disability demonstrated the greater dual-task cost of gait velocity (P = 0.030). This study provides preliminary evidence of the mWART's validity and reliability in measuring dual-task performance in patients with multiple sclerosis with mild to severe disability. More research is required in more heterogeneous samples of persons with multiple sclerosis.

Walking with UAN.GO Exoskeleton: Training and Compliance in a Multiple Sclerosis Patient

BACKGROUND

Multiple sclerosis is a progressive neurodegenerative disease that affects myelin in the central nervous system. It is complex and unpredictable and occurs predominantly in young adults, causing increasing disability and a significantly lower quality of life. Recent studies investigated how rehabilitation training through the use of a robotic exoskeleton can influence walking recovery in patients with a serious neurological disease.

AIM

The purpose of this study was to analyze the first approach of a multiple sclerosis patient to a robotic exoskeleton for the lower limbs, in order to assess the effectiveness of the protocol on walking ability, adaptability of the device, level of appreciation, variations in parameters related to walking, and fatigue perception.

METHODS

This study was conducted on a 71-year-old male diagnosed with primary progressive multiple sclerosis since 2012, with an EDSS score of 6. The patient underwent a cycle of 10 sessions of treatment with the exoskeleton for the lower limbs, the UAN.GO, lasting 1 h 30 min. Pre- and post-treatment evaluations were carried out with the 6 min walking test, the Fatigue Severity Scale, the Short Form-36 Health Survey, and a Likert scale for review. During each session, blood pressure, heart rate, and peripheral saturation were monitored; in addition, the perception of fatigue by the Borg scale was studied.

RESULT

A comparison between the initial and final evaluations showed improvements in the walked distance at 6 MWT (T0 = 53 m/T1 = 61 m). There was a positive trend in saturation and heart rate values collected during each session. Further improvements were found by the Borg scale (T0 = 15/T1 = 11).

DISCUSSION

The data collected in this case report show promising results regarding the treatment of multiple sclerosis patients with the UAN.GO exoskeleton, with benefits on both motor performance and vital parameters.

Dual task training effects on gait and balance outcomes in multiple sclerosis: A systematic review

BACKGROUND

People with Multiple Sclerosis (PwMS) exhibit deteriorated balance and gait performance during dual task (DT) conditions. Impaired dual tasking is related to increased fall risk and lower quality of life in PwMS. While dual task interventions have proven effective in various patient populations, evidence is lacking to support the use of DT interventions to improve clinical measures of balance and gait in PwMS. Therefore, the purpose of this systematic review was to synthesize the effectiveness of DT intervention at improving balance and gait in PwMS.

METHODS

A systematic search was completed using CINHAL, PubMed and MEDLINE. Methodological quality, level of evidence and recommendations for included studies was assessed by two reviewers. Effect sizes with 95% confidence intervals comparing single and DT outcomes were calculated for all balance and gait variables.

RESULTS

Five randomized control trials (RCTs) were included for review. Of the 23 effect sizes calculated, three had 95% confidence intervals which did not pass zero and were therefore interpreted as strong. Due to inconsistent level one evidence of DT interventions being superior to single task balance and gait interventions a grade B recommendation was given.

CONCLUSION

There is inconsistent evidence supporting the use of DT interventions to improve clinical balance measures in PwMS. There is supportive evidence for the use of DT interventions to improve both single and DT gait speed. However, there was heterogeneity between interventions and dosage among RCTs. Despite multiple promising findings, DT interventions appear to have minimal impact on clinical balance and gait measures in PwMS.

Dual-Task Cost and Related Clinical Features in Patients With Multiple Sclerosis

This study aimed to investigate the dual-task cost of both motor and cognitive performances in patients with multiple sclerosis (PwMS) and in healthy controls and to determine their relationships with clinical features in PwMS. The participants performed motor tasks (postural stability, walking, and manual dexterity) and cognitive tasks (mental tracking and verbal fluency) under single- and dual-task conditions. The results showed that postural stability under dual-task conditions did not change, whereas walking and manual dexterity deteriorated, regardless of the concurrent cognitive task, in PwMS (median Expanded Disability Status Scale score: 1) and the healthy controls. Verbal fluency decreased during postural stability, whereas it increased during walking, and it was maintained during manual dexterity in both groups. Mental tracking did not change during walking; it declined during manual dexterity in both groups. Mental tracking during postural stability deteriorated in PwMS, while it did not change in the healthy controls. In general, dual-task costs were associated with baseline performances of tasks rather than clinical features. Therefore, baseline performances of both tasks should be increased for improving dual-task performance in PwMS.

The patients' perspective on the perceived difficulties of dual-tasking: development and validation of the Dual-task Impact on Daily-living Activities Questionnaire (DIDA-Q)

BACKGROUND

Everyday-life activities often require performing dual tasks (DT), with consequent possible occurrence of motor-cognitive or motor-motor interference. This could reduce quality of life, in particular in people with neurological diseases. However, there is lack of validated tools to assess the patients' perspective on DT difficulties in this population. Therefore, we developed the Dual-task Impact on Daily-living Activities-Questionnaire (DIDA-Q) and tested its psychometric properties in people with multiple sclerosis (PwMS).

METHODS

Items were generated based on existing scales, DT paradigms used in previous studies and the opinion of a multi-stakeholder group, including both experts and PwMS. Twenty DT constituted the preliminary version of the DIDA-Q which was administered to 230 PwMS. The psychometric properties of the scale were evaluated including internal consistency, validity and reliability.

RESULTS

Nineteen items survived after exploratory factor analysis, showing a three-factor solution which identifies the components mostly contributing to DT perceived difficulty (i.e., balance and mobility, cognition and upper-limb ability). The DIDA-Q appropriately fits the graded response model, with first evaluations supporting internal consistency (Cronbach's alpha=0.95), validity (70% of the hypotheses for convergent and discriminant constructs confirmed) and reliability (intraclass correlation coefficients=0.95) of this tool.

CONCLUSION

The DIDA-Q could be used in research and clinical settings to discriminate individuals with low vs. high cognitive-motor or motor-motor interference, and to develop and evaluate the efficacy of personalized DT rehabilitative treatments in PwMS.

Effect of a Combined Program of Strength and Dual Cognitive-Motor Tasks in Multiple Sclerosis Subjects

This study investigated the effects of a 24-week combined training program (CTP) based on strength exercises and cognitive–motor tasks performed concurrently in participants with multiple sclerosis. A randomized, controlled intervention study was carried out. In total, 31 subjects with a confirmed diagnosis of multiple sclerosis (14 men and 17 women) were stratified and randomized into an intervention group (17 subjects) and a control group (14 subjects). The intervention group completed three weekly training sessions for 24 weeks, while the control group pursued their normal daily activities. In this program, cognitive–motor tasks were completed at once (dual tasking). A 3D photogrammetry connected to a selective attention system designed for dual tasking while walking was used. Ground reaction forces were measured using two force plates, one for sit-to-stand testing, while the other was used for static force measurement. Postural equilibrium was examined using a stabilometric plate based for Romberg test assessment. The 24-week training program for multiple sclerosis patients improved their static peak force by 11% (p < 0 .05), their rate of force development by 36% (p < 0.05), and their balance (p < 0.05). Performance in daily activities such as walking or sitting-to-standing improved significantly in multiple sclerosis participants. CTP training was effective in reducing the dual-task costs of step length (48%) and walking velocity (54%), as compared to a matched control group.

A multi-modal virtual reality treadmill intervention for enhancing mobility and cognitive function in people with multiple sclerosis: Protocol for a randomized controlled trial

BACKGROUND

Gait and cognitive impairments are common in individuals with Multiple Sclerosis (MS) and can interfere with everyday function. Those with MS have difficulties executing cognitive tasks and walking simultaneously, a reflection of dual-task interference. Therefore, dual-task training may improve functional ambulation. Additionally, using technology such as virtual reality can provide personalized rehabilitation while mimicking real-world environments. The purpose of this randomized controlled trial is to establish the benefits of a combined cognitive-motor virtual reality training on MS symptoms compared to conventional treadmill training.

METHODS

This study will be a single-blinded, two arm RCT with a six-week intervention period. 144 people with MS will be randomized into a treadmill training alone group or treadmill training with virtual reality group. Both groups will receive 18 sessions of training while walking on a treadmill, with the virtual reality group receiving feedback from the virtual system. Primary outcome measures include dual-task gait speed and information processing speed, which will be measured prior to training, one-week post-training, and three months following training.

DISCUSSION

This study will provide insight into the ability of a multi-modal cognitive-motor intervention to reduce dual-task cost and to enhance information processing speed in those with MS. This is one of the first studies that is powered to understand whether targeted dual-task training can improve MS symptoms and increase functional ambulation. We anticipate that those in the virtual reality group will have a significantly greater increase in dual-task gait speed and information processing speed than those achieved via treadmill training alone.

Time matters: Early-phase multiple sclerosis is accompanied by considerable impairments across multiple domains

Impairments across multiple domains are a disabling consequence of multiple sclerosis (MS). Originating from preventive medical strategies, the “time matters”-perspective has become a focal point when treating MS. In particular, early detection of physical and cognitive deficits, along with deficits in patient-reported outcomes seems crucial to further optimize both pharmacological and non-pharmacological MS treatment strategies. Therefore, this topical review investigates the level of impairments across multiple domains (physical function, cognitive function, and patient-reported outcomes) in the early stage of MS (⩽5 years since diagnosis, including clinically isolated syndrome (CIS)), when compared to matched healthy controls. Even at early disease stages, studies show impairments corresponding to 8%–34% and small-to-large numerical effect sizes (0.35–2.85) in MS/CIS patients across domains. This evidence call for early screening programs along with early interventions targeting the multiple impaired domains. This further highlights the importance of preventive initiatives preserving and/or restoring physical and cognitive reserve capacity if possible.

Design, Development, and Testing of an App for Dual-Task Assessment and Training Regarding Cognitive-Motor Interference (CMI-APP) in People With Multiple Sclerosis: Multicenter Pilot Study

Background

Dual tasking constitutes a large portion of most activities of daily living; in real-life situations, people need to not only maintain balance and mobility skills, but also perform other cognitive or motor tasks at the same time. Interest toward dual-task training (DTT) is increasing as traditional interventions may not prepare patients to adequately face the challenges of most activities of daily living. These usually involve simultaneous cognitive and motor tasks, and they often show a decline in performance. Cognitive-motor interference (CMI) has been investigated in different neurological populations, but limited evidence is present for people with multiple sclerosis (MS). The use of computerized tools is mandatory to allow the application of more standardized assessment and rehabilitation intervention protocols and easier implementation of multicenter and multilanguage studies.

Objective

To describe the design and development of CMI-APP, an adaptive and interactive technology tablet-based app, and to present the preliminary results of a multicenter pilot study involving people with MS performed in several European centers for evaluating the feasibility of and adherence to a rehabilitation program based on CMI-APP.

Methods

CMI-APP includes user-friendly interfaces for personal data input and management, assessment of CMI, and DTT. A dedicated team developed CMI-APP for Android tablets above API level 14 (version 4.0), using C# as the programming language and Unity and Visual Studio as development tools. Three cognitive assessment tests for working memory, information processing speed, and sustained attention and four motor assessment tests for walking at different difficulty levels were implemented. Dual cognitive-motor tasks were performed by combining single cognitive and motor tasks. CMI-APP implements exercises for DTT involving the following 12 cognitive functions: sustained attention, text comprehension, verbal fluency, auditory discrimination, visual discrimination, working memory, information processing speed, auditory memory, visual memory, verbal analog reasoning, visual analog reasoning, and visual spatial planning, which can be performed during walking or stepping on the spot. Fifteen people with MS (mean age 52.6, SD 8.6 years; mean disease duration 9.4, SD 8.4 years; mean Expanded Disability Status Scale score 3.6, SD 1.1) underwent DTT (20 sessions). Adherence to the rehabilitation program was evaluated according to the percentage of performed sessions, perceived exertion during the training (Borg 15-point Ratings of Perceived Exertion [RPE] Scale), and subjective experience of the training (Intrinsic Motivation Inventory [IMI]).

Results

The adherence rate was 91%. DTT was perceived as “somewhat difficult” (mean RPE Scale score 12.6, SD 1.9). IMI revealed that participants enjoyed the training and felt that it was valuable and, to some extent, important, without feelings of pressure. They felt competent, although they did not always feel they could choose the exercises, probably because the therapist chose the exercises and many exercises had few difficulty levels.

Conclusions

CMI-APP is safe, highly usable, motivating, and well accepted for DTT by people with MS. The findings are fundamental for the preparation of future large-sample studies examining CMI and the effectiveness of DTT interventions with CMI-APP in people with MS.

The ability of the instrumented tandem walking tests to discriminate fully ambulatory people with MS from healthy adults

BACKGROUND

People with multiple sclerosis (PwMS) experience walking and balance deficits at the initial phases of the disease, even when classified as only minimally disabled. Complex balance tasks, such as tandem walking, are probably more sensitive in detecting mild balance difficulties compared to the standard traditional tests in this population.

RESEARCH QUESTION

The aim was to investigate different types of 3-meter tandem walking tests in fully ambulatory PwMS.

METHODS

This observational case-control study included 50 participants; 25 PwMS, 17 women and 8 men, aged 35.2 (S.D = 8.6) and 25 healthy subjects, 18 women and 7 men, aged 34.3 (S.D = 6.1). The 3-meter tandem walk tests were performed during a single session. Each subject completed a sequence of 3 consecutive tests under 3 different task conditions: normal tandem walking, backward tandem walking and cognitive tandem walking. Tandem walking tests were evaluated via three small, lightweight axial wearable accelerometers (APDM, Oregon, USA).

RESULTS

The mean EDSS for the MS group was 1.6 (S.D = 0.6) indicating minimal disability. PwMS walked slower and at a slower pace, with a prolonged double support and decreased swing phase compared to healthy subjects in normal and backward conditions. In contrast, during the cognitive task, non-significant differences were found in gait measures between the PwMS and the healthy controls. Significant differences were found between task conditions for all participants. All reduced their walking speed and walked at a slower pace in both the cognitive and backward conditions compared to the normal tandem walk condition. However, non-significant scores were found for the condition X group factor.

SIGNIFICANCE

The study provides new insights into the 3-meter tandem walk test. Findings should improve evaluation and training of dynamic balance in fully ambulatory PwMS.

Cognitive-motor interference in persons with multiple sclerosis during five upper limb motor tasks with different complexity

BACKGROUND

Cognitive-motor interference in multiple sclerosis has been well examined during walking, but not during upper limb (UL) performance.

OBJECTIVES

To examine the dual-task cost (DTC) in persons with multiple sclerosis (pwMS) and healthy controls (HC) in various type and complexity of UL motor tasks.

METHOD

In total, 30 pwMS without major UL impairment and 30 HC performed five different UL tasks, in single condition and combined with the phonemic word list generation task. The percent change in performances was evaluated by the motor, cognitive, and combined DTC. The motor tasks consisted of four unimanual (sustained hand grip strength, box-and-block test, Purdue pegboard test, finger tapping task) and one bimanual task (Purdue pegboard test). Group and task differences were analyzed with unpaired and paired t-tests, respectively, and overall effect with a multivariate analysis of variance.

RESULTS

The motor DTC ranged between 10% (Purdue pegboard bimanual) and 35% (box-and-block test). The cognitive DTC ranged between -8% (finger tapping test) and +21% (bimanual Purdue pegboard). The magnitude of the combined DTC did not differ significantly between pwMS and HC in any task.

CONCLUSION

DTC is influenced by the complexity of the UL task, but was not significantly different between HC and cognitive intact, but mildly motor disabled pwMS.

Perspectives on walking from people with multiple sclerosis and reactions to video self-observation

Purpose: People with multiple sclerosis (MS) rank walking among the most challenging aspects of their condition. A greater understanding of people's perspectives concerning their walking may help to prioritize walking outcomes and strategies for optimizing walking. The purpose was to explore perceptions of walking in people with MS and to describe their reactions after observing themselves walk on video.Materials and methods: An interpretive thematic analysis study using face-to-face, semi-structured interviews was conducted with 14 people who self-identified a change in their walking due to MS. Participants were video-recorded walking and watched their video during the interview.Results: Four themes were identified: "awareness," "acceptance," "constant change," and "increased effort." People with MS develop awareness of how their walking performance looks and awareness of constantly-changing internal factors and external factors which impact their walking. Awareness of change in fatigue, temperature, terrain, and the use of aids in particular are perceived relevant to walking and to impact the effort required to walk. People with MS also describe differences in their acceptance of how others view their walking and the changes related to walking. An analogy with a marionette performing describes how people perceive walking as no longer automatic; instead walking requires the person to consciously pull the strings to walk. An increase in both the physical and cognitive effort is required to walk and an awareness and acceptance of a variety of changes in oneself and the lived world may help or hinder walking. People with MS are willing to watch themselves walk on video and are not surprised by what they observe.Conclusions: People with MS develop a learned self-awareness with variable levels of acceptance about their walking function and what it looks like. The perceptions on walking from persons with MS suggest that focusing on reducing the effort to walk and minimizing the constantly-changing variables may help to optimize walking.Implications for rehabilitationPeople with multiple sclerosis are challenged by the increased effort and constant change required to walk in their day-to-day lives.A focus on minimizing both the effort to walk and the changing variables (i.e., fluctuating symptoms and environmental factors) is warranted.People with multiple sclerosis develop a learned awareness of how they walk and how their walking looks.Acceptance of loss of walking function is variable.Video self-observation is a feasible tool which warrants further exploration for enhancing acceptance of walking function and accommodating strategies.

Cognitive-motor interference during gait in patients with Multiple Sclerosis: a mixed methods Systematic Review

BACKGROUND

Cognitive-motor interference (CMI) has been proposed as a valid marker of daily life impairment in Multiple Sclerosis (MS). The heterogeneity and scarce number of studies regarding CMI in MS has hampered the synthesis of the existing evidence. The present systematic review employed a mixed methods approach with the aim of identifying and describing variables under which CMI is particularly useful to assess patients with MS.

RESULTS

MS patients showed significant CMI. The motor variables that were most sensitive in detecting significant CMI were velocity (m/s), cadence (steps/min), and double support (% gait cycle), which was also specific for MS. Among the cognitive tasks, Alternate Alphabet and Serial Subtracting 7 s were sensitive, whereas Verbal Fluency were both sensitive and specific to CMI in MS.

CONCLUSIONS

CMI should be assessed in MS with a standardised dual task such as the Verbal Fluency task while walking, with measurements of the double support time and the effect on the cognitive task. The clinical usefulness of CMI in the assessment of patients with MS is discussed.

Exploring cognitive motor interference in multiple sclerosis by the visual Stroop test

BACKGROUND

The dual task paradigm (the simultaneous performance of motor and cognitive task) is used in a laboratory setting to evaluate walking impairments that affect patients' daily lives. Although promising, it is poorly standardized and neither the cognitive task nor the motor task have been validated in a matched healthy control group (HC) for multiple sclerosis (MS).

OBJECTIVE

Our aim was to set up a standardized instrument to evaluate cognitive motor interference in MS using the interference test par excellence: the stroop colour word test (SCWT).

METHODS

Patients with MS and HC underwent 3D gait analysis with a dual task protocol, using the SCWT as a cognitive task. Gait performance impairment during the dual task was evaluated by dual task cost (DTC). A MANOVA was used to verify the effect of status (MS, HC) on DTC, calculated for the spatiotemporal parameter of the gait.

RESULTS

In MS, the DTC was higher for the following gait parameters: speed (p = .013), cadence (p = .004), stride time (p = .005) stance phase (p < .001), and swing phase duration (p = .032).

CONCLUSION

DTC is present in MS and HC, but the motor cost in MS is higher. The present work provides a useful and validated basis for future studies about cognitive motor interference in MS.

Balancing the Demands of Two Tasks: An Investigation of Cognitive-Motor Dual-Tasking in Relapsing Remitting Multiple Sclerosis

BACKGROUND

People with relapsing remitting multiple sclerosis (PwRRMS) suffer disproportionate decrements in gait under dual-task conditions, when walking and a cognitive task are combined. There has been much less investigation of the impact of cognitive demands on balance.

OBJECTIVES

This study investigated whether: (1) PwRRMS show disproportionate decrements in postural stability under dual-task conditions compared to healthy controls, and (2) dual-task decrements are associated with everyday dual-tasking difficulties. The impact of mood, fatigue, and disease severity on dual-tasking was also examined.

METHODS

A total of 34 PwRRMS and 34 matched controls completed cognitive (digit span) and balance (movement of center of pressure on Biosway on stable and unstable surfaces) tasks under single- and dual-task conditions. Everyday dual-tasking was measured using the Dual-Tasking Questionnaire. Mood was measured by the Hospital Anxiety & Depression Scale. Fatigue was measured via the Modified Fatigue Index Scale.

RESULTS

No differences in age, gender, years of education, estimated pre-morbid IQ, or baseline digit span between groups. Compared with controls, PwRRMS showed significantly greater decrement in postural stability under dual-task conditions on an unstable surface (p=.007), but not a stable surface (p=.679). Balance decrement scores were not correlated with everyday dual-tasking difficulties or fatigue. Stable surface balance decrement scores were significantly associated with levels of anxiety (rho=0.527; p=.001) and depression (rho=0.451; p=.007).

CONCLUSIONS

RRMS causes dual-tasking difficulties, impacting balance under challenging conditions, which may contribute to increased risk of gait difficulties and falls. The relationship between anxiety/depression and dual-task decrement suggests that emotional factors may be contributing to dual-task difficulties. (JINS, 2018, 24, 247-258).

Texting while walking differently alters gait patterns in people with multiple sclerosis and healthy individuals

BACKGROUND

In recent times, increasing safety concerns have been associated with the use of mobile phones by pedestrians. In particular, texting has been shown to significantly alter gait patterns. However, no specific investigations have been performed on people with Multiple Sclerosis (pwMS), who are already characterized by gait dysfunctions caused by the disease.

OBJECTIVE

To assess the existence of possible alterations in spatio-temporal parameters of gait in pwMS when simultaneously texting on a smartphone and walking.

METHODS

Fifty-four pwMS (mean age 40.5 ± 10.5) and 40 age-matched unaffected individuals were tested in two conditions: walking, and walking while texting on a smartphone. Spatio-temporal parameters of gait were assessed using a wearable accelerometer located on the lower back.

RESULTS

Texting induces reduction of gait speed, stride length and cadence in both groups, but such changes were smaller in magnitude in pwMS. An increase of stance and double support and reduction of swing phase were observed in pwMS only.

CONCLUSIONS

Texting alters gait patterns of pwMS differently from unaffected individuals, probably due to a different prioritization of the task, which appears to take into account the motor and sensory impairments associated with the disease by favoring the motor task.

Smoothness of gait detects early alterations of walking in persons with multiple sclerosis without disability

In people with Multiple Sclerosis (pwMS) with little or no signs of disability, early detection of walking impairments represents a challenging issue, as simple gait metrics (e.g. speed, cadence, stride length, etc.) may not significantly differ from those of healthy individuals. In this study, we aimed to assess the existence of possible differences in spatial-temporal parameters and smoothness of gait measures (assessed through Harmonic Ratio, HR) obtained from trunk accelerations between 50pwMS without disability (Expanded Disability Status Scale score =1) and 50 age-matched healthy controls. The results show no differences in terms of gait velocity, stride length, stance/swing and double support phases duration, while HR in the direction of motion was significantly lower in pwMS (2.92 vs. 3.67, p<0.001), thus indicating a less smooth gait. The study of trunk accelerations through calculation of HR represents a fast, non-intrusive technique that allows early identification of anomalies in gait patterns of pwMS in absence of disability.

Relationship of Obesity With Gait and Balance in People With Multiple Sclerosis

OBJECTIVE

The aim of this study was to examine the relationship of obesity with walking and balance in people with multiple sclerosis.

DESIGN

This was a cross-sectional study performed at the Multiple Sclerosis Center, Sheba Medical Center, Israel. Four hundred thirty-six people with multiple sclerosis were divided into obese (n = 178) and normal-weight (n = 258) groups. Spatiotemporal parameters of gait, 2-Minute Walk test, 6-Minute Walk test, Timed Up and Go test, Timed 25-Foot Walk test, Multiple Sclerosis Walking Scale self-reported questionnaire, and posturography measures were determined.

RESULTS

Compared with normal-weight patients, obese subjects walked significantly slower [98.7 (SD, 29.2) m/s vs. 106.4 (SD, 29.2) m/s; P = 0.01], with shorter step lengths [54.8 (SD, 11.6) cm vs. 58.1 (SD, 10.7) cm; P = 0.003] and a wider step width [12.1 (SD, 3.7) cm vs. 10.9 (SD, 4.6) cm; P = 0.01]. Furthermore, the obese group walked a shorter distance on the 6-Minute Walk test [378.2 (SD, 145.5) m vs. 426.1 (SD, 129.8) m; P ≤ 0.001] and slower on the Timed 25-Foot Walk test [9.0 (SD, 8.0) seconds vs. 7.2 (SD, 2.4) seconds; P = 0.006] and the Timed Up and Go test [9.2 (SD, 6.3) seconds vs. 10.0 (SD, 6.1) seconds; P = 0.002]. No significant differences between groups were noted in the Multiple Sclerosis Walking Scale self-reported questionnaire and postural control measures.

CONCLUSION

Obesity affects walking but not postural control in people with multiple sclerosis despite the level of neurological disability.

Reliability and Concurrent Validity of the Narrow Path Walking Test in Persons With Multiple Sclerosis

BACKGROUND AND PURPOSE

About 90% of people with multiple sclerosis (PwMS) have gait instability and 50% fall. Reliable and clinically feasible methods of gait instability assessment are needed. The study investigated the reliability and validity of the Narrow Path Walking Test (NPWT) under single-task (ST) and dual-task (DT) conditions for PwMS.

METHODS

Thirty PwMS performed the NPWT on 2 different occasions, a week apart. Number of Steps, Trial Time, Trial Velocity, Step Length, Number of Step Errors, Number of Cognitive Task Errors, and Number of Balance Losses were measured. Intraclass correlation coefficients (ICC2,1) were calculated from the average values of NPWT parameters. Absolute reliability was quantified from standard error of measurement (SEM) and smallest real difference (SRD). Concurrent validity of NPWT with Functional Reach Test, Four Square Step Test (FSST), 12-item Multiple Sclerosis Walking Scale (MSWS-12), and 2 Minute Walking Test (2MWT) was determined using partial correlations.

RESULTS

Intraclass correlation coefficients (ICCs) for most NPWT parameters during ST and DT ranged from 0.46-0.94 and 0.55-0.95, respectively. The highest relative reliability was found for Number of Step Errors (ICC = 0.94 and 0.93, for ST and DT, respectively) and Trial Velocity (ICC = 0.83 and 0.86, for ST and DT, respectively). Absolute reliability was high for Number of Step Errors in ST (SEM % = 19.53%) and DT (SEM % = 18.14%) and low for Trial Velocity in ST (SEM % = 6.88%) and DT (SEM % = 7.29%). Significant correlations for Number of Step Errors and Trial Velocity were found with FSST, MSWS-12, and 2MWT.

DISCUSSION AND CONCLUSIONS

In persons with PwMS performing the NPWT, Number of Step Errors and Trial Velocity were highly reliable parameters. Based on correlations with other measures of gait instability, Number of Step Errors was the most valid parameter of dynamic balance under the conditions of our test.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A159).

Impaired sweating responses to a passive whole body heat stress in individuals with multiple sclerosis

Multiple sclerosis (MS) is an autoimmune disease that affects the central nervous system (CNS), disrupting autonomic function. The aim of this study was to test the hypothesis that individuals with MS have blunted control of thermoregulatory reflex increases in sweat rate (SR) and cutaneous vasodilation compared with controls during a passive whole body heat stress (WBH). Eighteen individuals with relapsing-remitting MS and 18 healthy controls (Con) participated in the study. Core temperature (T_core), skin temperature, heart rate, arterial blood pressure (10-min intervals), skin blood flow (laser-Doppler flux, LDF), and SR were continuously measured during normothermic baseline (34°C water perfusing a tube-lined suit) and WBH (increased T_core 0.8°C via 48°C water perfusing the suit). Following WBH, local heaters were warmed to 42°C, inducing peak cutaneous vasodilation at the site of LDF collection. Cutaneous vascular conductance (CVC) was calculated as the ratio of LDF to mean arterial pressure and expressed as a percentage of peak achieved during local heating. Individuals with MS had attenuated SR responses to WBH (ΔSR from baseline: Con, 0.65 ± 0.27; MS, 0.42 ± 0.17 mg·cm^-2·min^-1, P = 0.003), whereas Δ%CVC_42C from baseline was similar between groups (Con, 42 ± 16%; MS, 38 ± 12%, P = 0.39). SR responses were blunted as a function of T_core in MS (interaction: group × T_core, P = 0.03), of which differences were evident at ΔT_core 0.7°C and 0.8°C (P < 0.05). No interaction was observed in Δ%CVC_42C Taken together, the findings show MS blunts sweating responses, whereas control of the cutaneous vasculature is preserved, in response to WBH.NEW & NOTEWORTHY This study is the first to assess the reflex control of the thermoregulatory system in individuals living with multiple sclerosis (MS). The novel findings are twofold. First, attenuated increases in sweat rate in subjects with MS compared with healthy controls were observed in response to a moderate increase (0.8°C) in core temperature via passive whole body heat stress. Second, it appears the reflex control of the cutaneous vasculature is preserved in MS.

Gait Characteristics in Adolescents With Multiple Sclerosis

BACKGROUND

Multiple sclerosis is a progressive autoimmune disease of the central nervous system. A presentation of multiple sclerosis before age18 years has traditionally been thought to be rare. However, during the past decade, more cases have been reported.

PATIENT DESCRIPTION

We examined gait characteristics in 24 adolescents with multiple sclerosis (12 girls, 12 boys). Mean disease duration was 20.4 (S.D. = 24.9) months and mean age was 15.5 (S.D. = 1.1) years. The mean expanded disability status scale score was 1.7 (S.D. = 0.7) indicating minimal disability. Outcomes were compared with gait and the gait variability index value of healthy age-matched adolescents.

RESULTS

Adolescents with multiple sclerosis walked slower with a wider base of support compared with age-matched healthy control subjects. Moreover, the gait variability index was lower in the multiple sclerosis group compared with the values in the healthy adolescents: 85.4 (S.D. = 8.1) versus 96.5 (S.D. = 7.4).

CONCLUSIONS

We present gait parameters of adolescents with multiple sclerosis. From a clinical standpoint, our data could improve management of walking dysfunction in this relatively young population.

Gait pattern in patients with different multiple sclerosis phenotypes

BACKGROUND

Gait pattern is frequently impaired in multiple sclerosis (MS), however gait characteristics in patients with different MS phenotypes have not been fully elucidated.

METHODS

We analyzed spatio-temporal gait pattern characteristics in patients with relapsing-remitting (RR, n=52) and primary-progressive (PP, n=18) MS in comparison with age-matched healthy controls (HC, n=40). All subjects performed a standardized simple walking task, a dual motor- motor task, a dual motor-mental task, and a triple combined motor-mental task at a GAITRite electronic walkway of 5.5m active area. We measured: cycle time (CT), stride length (SL), swing time (ST), double support time (DST), gait velocity (GV) and calculated symmetry index (SI) for CT, SL and ST.

RESULTS

With each task performed, CT and DST in the total MS group were significantly longer while SL was significantly shorter and GV significantly lower than in HC. ST was similar in the total MS patient group and HC. In both MS patients and HC, CT and DST increased and SL and GV decreased over repeated assessments. Dual and triple tasks while walking influenced walking performance in both MS patients and HC. Although patients with PPMS differed significantly from those with RRMS in the majority of gait parameters, the subgroup analysis in patients matched for age and disability (Expanded Disability Status Scale Score -EDSS, 3.0-5.0) showed similar gait performance in RRMS and PPMS patients having the same level of disability, except for CT and ST- symmetry parameters that were more impaired in the PPMS group. The EDSS score correlated significantly with CT, DST, SL and GV, but no significant correlation was found with ST except at the triple combined motor-mental task.

CONCLUSION

A disturbed gait pattern in MS patients with different MS phenotypes depends on disability and reflects a cognitive-motor interference.

Gait deficits in people with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Multiple Sclerosis (MS) results in postural instability and gait abnormalities which are associated with accidental falls.

OBJECTIVE

This systematic review and meta-analysis aims to quantify the effect of MS on gait to inform the development of falls prevention interventions.

METHODS

A systematic literature search identified case-control studies investigating differences in gait variables between people with MS and healthy controls. Meta-analysis examined the effect of MS on gait under normal and fast paced conditions.

RESULTS

Forty-one studies of people with Expanded Disability Status Scale (EDSS) 1.8 to 4.5 were included, of which 32 contributed to meta-analysis. A large effect of MS was found on stride length (Standardised Mean Difference, SMD=1.27, 95% CI{0.93, 1.61}), velocity (SMD=1.12, 95% CI{0.85, 1.39}), double support duration (SMD=0.85, 95% CI{0.51, 1.2}), step length (SMD=1.15, 95% CI{0.75, 1.5})and swing phase duration (SMD=1.23, 95% CI{0.06, 2.41}). A moderate effect was found on step width and stride time with the smallest effect found on cadence (SMD=0.43, 95% CI{0.14, 0.72}). All effect sizes increased for variables investigated under a fast walking pace condition (for example the effect on cadence increased to SMD=1.15, 95% CI{0.42, 1.88}).

CONCLUSIONS

MS has a significant effect on gait even for those with relatively low EDSS. This effect is amplified when walking at faster speeds suggesting this condition may be more beneficial for assessment and treatment. No studies investigated the association between these deficits and falls. Further investigation relating to the predictive or protective nature of these deficits in relation to falls is warranted.

Effects on Balance and Walking with the CoDuSe Balance Exercise Program in People with Multiple Sclerosis: A Multicenter Randomized Controlled Trial

Background. Balance and walking impairments are frequent in people with multiple sclerosis (MS). Objective. The aim was to investigate the effects of a group-based balance exercise program targeting core stability, dual tasking, and sensory strategies (CoDuSe) on balance, postural sway, walking, perceived walking limitations, and balance confidence. Design. A single-blinded randomized multicenter trial. No intervention was given to controls. Participants. People with MS able to walk 100 meters but unable to maintain tandem stance ≥30 seconds. Eighty-seven participants were randomized to intervention or control. Intervention. The 60-minute CoDuSe group program, twice weekly for seven weeks, supervised by physical therapists. Measurements. Primary outcome was dynamic balance (Berg Balance Scale (BBS)). Secondary outcomes were postural sway, walking (Timed-Up and Go test; Functional Gait Assessment (FGA)), MS Walking Scale, and Activities-specific Balance Confidence (ABC) Scale. Assessments were performed before and after (week 8) the intervention. Results. 73 participants fulfilled the study. There were significant differences between the intervention and the control groups in change in the BBS and in the secondary measures: postural sway with eyes open, FGA, MS Walking Scale, and ABC scale in favor of the intervention. Conclusions. The seven-week CoDuSe program improved dynamic balance more than no intervention.

Imbalance in multiple sclerosis and neuromyelitis optica: association with deep sensation disturbance

Abnormality in balance is one of the most important causes of gait disturbance which has a direct impact to disability and medical cost in multiple sclerosis (MS) and neuromyelitis optica (NMO). However, characteristics of imbalance in these two diseases have not been fully elucidated. The aim of this study was to evaluate the degree and features of imbalance using stabilography, the degree of deep sensation disturbance using tibial nerve somatosensory evoked potentials (SEP), and their association with clinical impairment, in patients with MS and NMO. Seven NMO patients and seven MS patients with balance disturbance were examined. The relationship among stabilography measurements representing the degree and features of imbalance, height-adjusted P38 peak latency of SEP, and neurological functional disability, were analyzed. Stabilography evaluation showed a significantly severer degree of imbalance in NMO than in MS. Romberg quotient of the patients with brainstem lesions was significantly larger than those without them. In all patients, length of excursion per second significantly correlated positively with anterio-posterior-axis power spectra at intermediate frequency band. In all patients and in NMO, P38 peak latency adjusted by height significantly correlated positively with anterio-posterior-axis power spectra at intermediate frequency band. These findings suggest that the degree of imbalance of MS and NMO possibly correlate with deep sensation disturbance, which could be evaluated by anterio-posterior-axis power spectra at intermediate frequency band by stabilography. Severer imbalance in NMO than MS may be associated with the severe longitudinally extensive spinal cord lesions.

Cognitive Motor Interference in Multiple Sclerosis: Insights From a Systematic Quantitative Review

OBJECTIVE

To synthesize the evidence for differences in cognitive motor interference (CMI) between persons with multiple sclerosis (MS) and those without MS by using systematic review and meta-analysis.

DATA SOURCES

EMBASE, PubMed, ScienceDirect, Scopus, SPORTDiscus, and Web of Science. Our focused literature search was informed by past systematic reviews of CMI during walking in MS.

STUDY SELECTION

The key terms searched included Multiple sclerosis and synonyms of motor function (eg, Gait disorders, Gait, Walking, Balance, or Fall) and motor and cognitive functions (eg, Cognitive motor interference or Thinking).

DATA EXTRACTION

From the 116 abstract-identified articles, 13 experimental studies were selected for the final analysis and were rated using the Quality Assessment of Diagnostic Accuracy Studies tool. A meta-analysis was performed for all considered outcomes.

DATA SYNTHESIS

The results yielded a small overall effect size (ES) of .08 (SE=.17; 95% confidence interval, -.25 to .40; z=.49; P>.05), which indicated a nonsignificant minimal difference in CMI between persons with MS and those without MS. The moderator analysis for motor task (mobility task: ES, .22; postural task: ES, -.11) was not significantly different between persons with MS and those without MS. The moderator analysis for cognitive task (verbal fluency task: ES, .66; mental tracking task: ES, .04; discrimination and decision-making task: ES, -.30) resulted in a significant difference in CMI between persons with MS and those without MS (P<.05).

CONCLUSIONS

We provide evidence that overall there is a minimal difference in CMI between persons with MS and those without MS.

Dual task cost of cognition is related to fall risk in patients with multiple sclerosis: a prospective study

OBJECTIVE

To examine whether change in cognitive performance during dual task condition compared with a task in isolation, known as dual task cost, is related to fall risk of patients with multiple sclerosis.

DESIGN

Prospective cohort. During baseline assessment, data about balance, walking and cognitive performance of patients with multiple sclerosis were collected under a single and dual task condition. The dual task cost was calculated as a percentage of change in parameters from single to dual task conditions. Falls were recorded prospectively for six months and participants were classified as none/one time fallers and recurrent fallers (⩾2 falls). The association between dual task costs and fall status was evaluated by logistic regression.

SETTING

Balance research lab of university hospital.

PARTICIPANTS

A total of 60 patients with relapsing-remitting multiple sclerosis.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The dual task cost of the center of pressure sway area, walking velocity and correct response rate were outcome measures for balance, walking and cognitive performance, respectively.

RESULTS

A total of 79 falls were reported by 38 of the participants who experienced one or more falls; 26 (43.3%) of them had recurrent falls. Dual tasking resulted in increased sway area and decreased walking velocity and correct response rate during walking (all p values <0.05). Logistic regressions showed that the dual task cost of the correct response rate during walking and walking velocity were associated with increased risk of recurrent falls ( P = 0.02, odds ratio = 1.34; confidence interval (CI) 1.04-3.74; P =  0.05, odds ratio = 1.23, CI = 1.02-4.45, respectively).

CONCLUSIONS

The dual task cost of cognition was related to fall, which should be considered as a target for falls evaluation and prevention strategies.

Construct validity of the walk ratio as a measure of gait control in people with multiple sclerosis without mobility aids

Ambulatory limitations are a key component of disability in people with multiple sclerosis (PwMS). Various tools are employed to assess walking performance in PwMS; however, no ideal measure has as yet been attained. In this situation, a walk ratio might be more advantageous compared with other gait measures. The walk ratio, a simple index for describing temporal and spatial co-ordination, denotes the relationship between step length and cadence during walking. Hence, the primary objective of this study was to determine the relationship between the walk ratio and measures of other theoretically related constructs. The walk ratio was studied using the GAITRite™ system (CIR Systems, Inc. Havertown, USA). The study group included 229 PwMS (143 women) and a mean disease duration of 5.8 (SD=7.1) years. The walk ratio score of the total sample was 5.3 (SD=0.8). Significant differences based on the expanded disability status scale (EDSS) scores (F=11.616, P<0.001) were observed between the neurological disability subgroups. Scores of the very mild (EDSS 0-2.0), mild (EDSS 2.5-4.0) and moderate (EDSS 4.5-5.5) groups were 5.5 (SD=0.7), 5.2 (SD=0.7), 4.9 (SD=0.9), respectively. In terms of fall status, the MS fallers demonstrated a significant lower walk ratio compared to the MS non-fallers; 5.1 (SD=0.8) vs. 5.5 (SD=0.7); P<0.001. Modest significant correlation scores were found between walk ratio and ambulation tests. Scores were slightly higher in the short walking tests, timed 25-foot walk and timed up and go tests (Pearson's rho=0.369, 0.364) compared to the 6 and 2-min walk time tests (Pearson's rho=0.344, 0.308). Collectively, the current study supports the construct validity of the walk ratio index in PwMS without mobility aids.

The effects of prolonged wear of textured shoe insoles on gait, foot sensation and proprioception in people with multiple sclerosis: study protocol for a randomised controlled trial

BACKGROUND

Many people with multiple sclerosis experience problems with walking, which can make daily activities difficult and often leads to falls. Foot sensation plays an important role in keeping the body balanced whilst walking; however, people with multiple sclerosis often have poor sensation on the soles of their feet. Wearing a specially designed shoe insole, which enhances plantar sensory information, could help people with multiple sclerosis to walk better. This study will explore whether long-term wear of a textured insole can improve walking in people with multiple sclerosis.

METHODS

A prospective randomised controlled trial with two parallel groups will be conducted aiming to recruit 176 people with multiple sclerosis living in the community (Brisbane, Australia). Adults with a clinical diagnosis of multiple sclerosis, Disease Steps score 1-4, who are ambulant over 100 m and who meet specific inclusion criteria will be recruited. Participants will be randomised to a smooth control insole (n = 88) or textured insole (n = 88) group. The allocated insole will be worn for 12-weeks within participants' own footwear, with self-report wear diaries and falls calendars being completed over this period. Blinded assessors will conduct two baseline assessments and one post-intervention assessment. Gait tasks will be completed barefoot, wearing standardised footwear only, and wearing standardised footwear with smooth and textured insoles. The primary outcome measure will be mediolateral base of support when walking over even and uneven surfaces. Secondary measures include spatiotemporal gait parameters (stride length, stride time variability, double-limb support time, velocity), gait kinematics (hip, knee, and ankle joint angles, toe clearance, trunk inclination, arm swing, mediolateral pelvis/head displacement), foot sensation (light touch-pressure, vibration, two-point discrimination) and proprioception (ankle joint position sense). Group allocation will be concealed and all analyses will be based on an intention-to-treat principle.

DISCUSSION

This study will explore the effects of wearing textured insoles over 12-weeks on gait, foot sensation and proprioception in people with multiple sclerosis. The study has the potential to identify a new, evidence-based footwear intervention which has the capacity to enhance mobility and independent living in people with multiple sclerosis.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000421538 . Registered 4 May 2015.

Comparing Three Dual-Task Methods and the Relationship to Physical and Cognitive Impairment in People with Multiple Sclerosis and Controls

Dual-tasking (DT) is a measure to detect impairments in people with multiple sclerosis (MS). We compared three DT methods to determine whether cognitive (Montreal Cognitive Assessment (MoCA)) or physical disability (Expanded Disease Severity Scale; EDSS) was related to DT performance. We recruited MS participants with low disability (<3 EDSS, n = 13) and high disability (≥3 EDSS, n = 9) and matched controls (n = 13). Participants walked at self-selected (SS) speed on an instrumented walkway (Protokinetics, Havertown, USA), followed by DT walks in randomized order: DT ABC (reciting every second letter of the alphabet), DT 7 (serially subtracting 7's from 100), and DT 3 (counting upwards, leaving out multiples and numbers that include 3). DT 7 resulted in the most consistent changes in performance. Both MS and control groups reduced velocity and cadence and shortened step length during DT with no significant differences between groups. Control subjects widened stride width by about 1 cm while MS subjects (collapsed as one group) did not. MS subjects with higher disability significantly increased percentage time in double support during DT compared to SS (F = 12.95, p < 0.001). The change in DS was related to cognitive and not physical disability (r = 0.54,  p < 0.05).

Cognitive-Motor Related Brain Activity During Walking: Differences Between Men and Women With Multiple Sclerosis

OBJECTIVE

To determine if sex differences in glucose uptake, a marker of brain activity, are present in brain regions that facilitate walking performance in persons with multiple sclerosis (MS).

DESIGN

Cross-sectional, observational pilot.

SETTING

University laboratory.

PARTICIPANTS

Positron emission tomography with fluorine-18-labeled deoxyglucose (FDG) was performed on persons with MS and healthy controls (4 men and 4 women per group; N=16) after a 15-minute walking test.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Brain activity was quantified as the mean standardized uptake value (SUV).

RESULTS

The mean SUV was significantly lower in the thalamus (P=.029) and cerebellum (P=.029) for men with MS compared with women with MS, but not for the prefrontal (P=.057) or frontal (P=.057) cortices. Similar nonsignificant trends were found for healthy controls. No mean SUV group × sex interaction effects were found between the MS and healthy control groups (all P>.05).

CONCLUSIONS

To our knowledge, this is the first study of brain activity sex differences based on FDG uptake in persons with MS during walking. Significantly less FDG uptake in the thalamus and cerebellum brain regions important for walking performance was found in men with MS compared with women with MS; however, these comparisons were not significantly different in the healthy control group. No differences in FDG uptake were found between the MS and healthy control groups in any of the brain regions examined. Results from this study provide pilot data for larger studies aimed at identifying underlying mechanisms responsible for accelerated disability in men with MS.

Generalised cognitive motor interference in multiple sclerosis

Researchers have examined cognitive motor interference (CMI) for lower extremity function in MS, but have not examined this in the upper extremity. This study examined CMI for both lower and upper extremity motor tasks in persons with MS and without MS. Eighty-two persons walked on a GAITRite electronic walkway (velocity) and performed the nine-hole peg test (NHPT, seconds) without (single task) and with a cognitive challenge (dual task). The data were analysed with mixed-factor ANOVA and Pearson correlations. When comparing MS and controls, there were statistical significant and exceptionally large Task main effects on gait velocity (ηp(2)=.41; F1,60=55.78; p<.005) and NHPT performance (ηp(2)=.62; F1,60=127.8; p<.005). When considering disability status among those with MS, there were statistically significant and large Task main effects on velocity (ηp(2)=.38; F1,60=37.3; p<.005) and NHPT test (ηp(2)=.62; F1,60=95.7; p<.005). The dual task cost of walking and performing the NHPT were significantly correlated in the entire sample, those with MS and controls, and in those with MS who had mild, moderate, and severe disability (all |r|>.450). CMI occurs in both the lower and upper extremities, and is comparable between persons with and without MS and across MS disability level.