Minimally important clinical difference of the Timed 25-Foot Walk Test: results from a randomized controlled trial in patients with multiple sclerosis

Exploring the effectiveness of circuit training rehabilitation on balance, gait, and fatigue in multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

People with Multiple Sclerosis (PwMS) often experience imbalance, gait dysfunction, and fatigue. Circuit Training (CT) can be viable for improving balance, gait, and fatigue in MS. To the author's knowledge, no studies have systematically reviewed the existing literature evaluating the effectiveness of CT in PwMS.

OBJECTIVES

To investigate the effectiveness of CT in improving balance, gait, and reducing fatigue in PwMS and provide a quantitative and qualitative synthesis of Randomized Controlled Trials (RCTs).

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, Google Scholar, and PEDro Database (Dec 2021 to May 2024).

STUDY SELECTION

RCTs using CT in PwMS including balance, gait, or fatigue outcomes.

DATA SYNTHESIS

Search inclusion criteria were: i) available full text, ii) CT rehabilitation, iii) balance, gait, or fatigue measured as outcomes, and iv) articles in English. Full text articles were analyzed by two screeners. If there was disagreement regarding inclusion, a further reviewer was consulted. No discrepancies were found.

RESULTS

We identified 878 studies, 14 studies were eligible including 716 PwMS with a mean (standard deviation) age of 49.9 (10.9) years, disease duration of 10.8 (7.2) years, and Expanded Disability Status Scale score of 4.3 (0.9) points. RevMan 5.4.1 was used to run the meta-analysis. We found a significant overall effect on Berg Balance Scale (Mean Difference (MD) = 6.07 points, 95%CI:1.40,10.75; p = 0.01) and in Fatigue Severity Scale (MD = 0.98 points, 95%CI:0.30,1.66; p = 0.005) in favor of CT. We did not find a significant effect in Timed Up and Go (MD = 0.46 second, 95%CI:-0.04,0.96; p = 0.07), in Six-Minute Walk Test (MD = 17.46 m, 95%CI:-8.06,42.97; p = 0.18), and in Modified Fatigue Impact Scale (MD = 3.34 points, 95%CI:-0.41,7.09; p = 0.08) in favor of CT. We assessed methodological quality using RoB 2.0, and quality of evidence using GRADE.

LIMITATIONS

Small number of studies, all identifying having some risk of bias.

CONCLUSION

Circuit training can have positive effects on PwMS in terms of increasing balance, gait, and reducing fatigue. Further research is needed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021286834. CONTRIBUTION OF THE PAPER.

Evaluation of the T25FW in minimally disabled people with multiple sclerosis

BACKGROUND

Walking impairment is one of the most prevalent symptoms in people with multiple sclerosis (pwMS). In this study, we aimed to explore the usefulness of a simple walking test, the Timed 25 Foot Walk (T25FW), in detecting subtle differences in "fully ambulatory" pwMS compared to HC.

METHODS

We therefore investigated retrospective data from a clinical real-life cohort of 650 pwMS. We first analyzed the amount of patients showing clinically relevant impairment in the T25FW (T25FW > 6 s) within different levels of disability according to the Expanded Disability Status Scale (EDSS). For detailed analysis in "fully ambulatory" pwMS, we formed four groups according to the respective levels of disability (EDSS 0, EDSS 1, EDSS 1.5-2, EDSS 2.5-3), and compared their walking speed to age- and sex-matched healthy controls (HC).

RESULTS

In our cohort, the number of patients showing clinically relevant slowing in the T25FW ranged from 15% in "fully ambulatory" patients (EDSS 0-3) to 69% in patients with moderate (EDSS 3.5-5.5) and 100% in patients with severe impairment (EDSS ≥6). Further analyses in "fully ambulatory" patients revealed that all EDSS-subgroups showed significant slowing compared to HC. The mean difference to walking speed of HC became gradually more pronounced from 0.15 m/s in asymptomatic patients (EDSS 0) to 0.5 m/s in patients with EDSS 2.5-3.

CONCLUSION

These findings underline the ability of the T25FW to detect slowing even in patients with minimal disability. While the difference to HC was slightly below clinical relevance in asymptomatic patients (EDSS 0), slowing gradually worsened from EDSS 1 onwards and exceeded published thresholds for clinical meaningfulness.

Investigating the effects of synbiotic supplementation on functional movement, strength and muscle health in older Australians: a study protocol for a double-blind, randomized, placebo-controlled trial

BACKGROUND

Aging has been associated with a progressive loss of skeletal muscle quality, quantity and strength, which may result in a condition known as sarcopenia, leading to a decline in physical performance, loss of independence and reduced quality of life. While the cause of impaired physical functioning observed in elderly populations appears to be multifactorial, recent evidence suggests that age-associated alterations in gut microbiota could be a contributing factor. The primary objective will be to assess the effects of a dietary synbiotic formulation on sarcopenia-related functional outcomes such as handgrip strength, gait speed and physical performance within older individuals living independently. The secondary objective will be to examine associations between changes in gut microbiota composition, functional performance and lean muscle mass.

METHODS

Seventy-four elderly (60-85 years) participants will be randomized in a double-blind, placebo-controlled fashion to either an intervention or control group. The intervention group (n = 37) will receive oral synbiotic formulation daily for 16 weeks. The control group (n = 37) will receive placebo. Assessments of physical performance (including Short Physical Performance Battery, handgrip strength and timed up-and-go tests) and muscle ultrasonography will be performed at 4 time points (baseline and weeks 8, 16 and 20). Likewise, body composition via bioelectric impedance analysis and blood and stool samples will be collected at each time point. Dual-energy X-ray absorptiometry will be performed at baseline and week 16. The primary outcomes will be between-group changes in physical performance from baseline to 16 weeks. Secondary outcomes include changes in body composition, muscle mass and architecture, fecal microbiota composition and diversity, and fecal and plasma metabolomics.

DISCUSSION

Gut-modulating supplements appear to be effective in modifying gut microbiota composition in healthy older adults. However, it is unclear whether these changes translate into functional and/or health improvements. In the present study, we will investigate the effects of a synbiotic formulation on measures of physical performance, strength and muscle health in healthy older populations.

TRIAL REGISTRATION

This study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622000652774) in May 2022.

Physical Telerehabilitation interventions for Gait and balance in Multiple sclerosis: A Scoping review

BACKGROUND

Gait and balance impairments affects approximately a quarter of people with multiple sclerosis (pwMS) at onset and increases to almost half by five years. Physical rehabilitation has been recognised as the gold standard method to restore physical function in multiple sclerosis (MS). Emerging evidence in the literature is suggesting that a remote therapy rehabilitation platform (Telerehabilitation) is cost-effective, beneficial, and satisfying for patients and health care practitioners. The overarching aim of this review is to identify and summarise the evidence on the different types of telerehabilitation interventions available to manage gait and balance.

METHODS

This review followed a methodological framework for conducting scoping reviews. PubMed, Science Direct and Web of Science were searched in April 2023 for relevant published literature. The inclusion criteria were peer-reviewed journal articles written in English which included telerehabilitation interventions for pwMS. Search keywords included multiple sclerosis and telerehabilitation. A reviewer screened titles and abstracts and eligible articles were fully reviewed. The included studies were categorised based on the type of intervention.

RESULTS

Eight studies were included in this review. The participants (n = 355) had an average age of 48 years (SD = 9.9) with 50% who had relapsing remitting multiple sclerosis who were living with MS for 12 years on average. Study designs included randomised control trials (n = 3), pilot studies and feasibility studies (n = 4). Two types of interventions were identified: Exergaming (n = 5) and Web-Based Physical Therapy (n = 2) of which exergaming appeared to be optimal in improving gait and balance.

CONCLUSION

This scoping review identified and summarised the evidence on telerehabilitation interventions used for gait and balance in MS. The evidence is showing that telerehabilitation could be used as an alternative to conventional rehabilitation methods for improving gait and balance. More robust trials with larger sample sizes are needed to build on the current evidence to enable telerehabilitation to be integrated into care pathways in the future.

Task-oriented exercise effects on walking and corticospinal excitability in multiple sclerosis: protocol for a randomized controlled trial

BACKGROUND

Multiple sclerosis (MS) is a degenerative disease of the central nervous system (CNS) that disrupts walking function and results in other debilitating symptoms. This study compares the effects of 'task-oriented exercise' against 'generalized resistance and aerobic exercise' and a 'stretching control' on walking and CNS function in people with MS (PwMS). We hypothesize that task-oriented exercise will enhance walking speed and related neural changes to a greater extent than other exercise approaches.

METHODS

This study is a single-blinded, three-arm randomized controlled trial conducted in Saskatchewan, Canada. Eligible participants are those older than 18 years of age with a diagnosis of MS and an expanded Patient-Determined Disease Steps (PDDS) score between 3 ('gait disability') and 6 ('bilateral support'). Exercise interventions are delivered for 12 weeks (3 × 60-min per week) in-person under the supervision of a qualified exercise professional. Interventions differ in exercise approach, such that task-oriented exercise involves weight-bearing, walking-specific activities, while generalized resistance and aerobic exercise uses seated machine-based resistance training of major upper and lower body muscle groups and recumbent cycling, and the stretching control exercise involves seated flexibility and relaxation activities. Participants are allocated to interventions using blocked randomization that stratifies by PDDS (mild: 3-4; moderate: 5-6). Assessments are conducted at baseline, post-intervention, and at a six-week retention time point. The primary and secondary outcome measures are the Timed 25-Foot Walk Test and corticospinal excitability for the tibialis anterior muscles determined using transcranial magnetic stimulation (TMS), respectively. Tertiary outcomes include assessments of balance, additional TMS measures, blood biomarkers of neural health and inflammation, and measures of cardiorespiratory and musculoskeletal fitness.

DISCUSSION

A paradigm shift in MS healthcare towards the use of "exercise as medicine" was recently proposed to improve outcomes and alleviate the economic burden of MS. Findings will support this shift by informing the development of specialized exercise programming that targets walking and changes in corticospinal excitability in PwMS.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05496881, Registered August 11, 2022. https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05496881 . Protocol amendment number: 01; Issue date: August 1, 2023; Primary reason for amendment: Expand eligibility to include people with all forms of MS rather than progressive forms of MS only.

The Effectiveness of a Single Dry Needling Session on Gait and Quality of Life in Multiple Sclerosis: A Double-Blind Randomized Sham-Controlled Pilot Trial

INTRODUCTION

Gait disorders are a major cause of disability and reduced health-related quality of life in people with multiple sclerosis (pwMS). Dry needling (DN) has demonstrated positive results to improve gait parameters in patients with stroke. The main aim of this study was to evaluate the effect of a single session of DN in the gait performance of pwMS.

METHODS

A double-blind parallel randomized sham-controlled pilot trial was conducted. Study participants received a single session of active DN or sham DN in the gastrocnemius medialis muscle. Pre-treatment and immediately post-treatment measurements were taken, as well as at one and four weeks after the intervention. Outcomes related to gait performance (Timed 25-Foot Walk), self-perceived walking capacity (Multiple Sclerosis Walking Scale), risk of falls (Timed Up and Go test), disability level (Expanded Disability Status Score) and quality of life (Multiple Sclerosis Quality of Life-54 questionnaire and Analogic Quality of Life scale) were evaluated.

RESULTS

18 patients who had multiple sclerosis participated in the study. The group who received active DN showed within-group significant statistical differences immediately after treatment for gait performance (p = 0.008) and risk of falls (p = 0.008), as well as for self-perceived walking capacity at one week (p = 0.017) and four weeks (p = 0.011) and quality of life at four weeks (p = 0.014). Regarding the comparison between groups, only significant results were obtained in the physical domain of the quality of life at four weeks (p = 0.014).

CONCLUSIONS

DN seems to be a promising therapeutic tool for the treatment of gait disorders in pwMS. However, when results were compared with sham DN, no differences were found.

Dalfampridine as a promising agent in the management of hereditary spastic paraplegia: A triple-blinded, randomized, placebo-controlled pilot trial

Limited but encouraging results support the use of dalfampridine in patients with hereditary spastic paraplegia (HSP). Our aim was to investigate the effects of dalfampridine on walking speed, muscle length, spasticity, functional strength, and functional mobility in patients with HSP. In this triple-blinded, randomized, placebo-controlled pilot trial, four patients with HSP received dalfampridine (10 mg twice daily) in addition to physiotherapy (twice a week), and four patients received placebo in addition to physiotherapy for eight weeks. The group allocation was masked from the assessor, treating physiotherapists, and patients. The primary outcome was the Timed 25-foot Walk Test (T25FWT) at the end of the eight-week treatment. The secondary outcome measures were functional mobility, functional muscle strength, muscle length, and spasticity. The improvement in the T25FWT values was significantly higher in the experimental group than in the control group (p < 0.05). All patients in the experimental group exceeded the proposed minimally important clinical difference for T25FWT. The degrees of improvement in most muscle length and spasticity assessments and functional muscle strength were also higher in the experimental group (p < 0.05). No significant difference was observed between the groups regarding functional mobility (p > 0.05). No adverse events or side effects were noted. This pilot trial yields encouraging evidence that the combination of dalfampridine and physiotherapy may enhance muscle parameters and improve walking speed in patients with HSP. However, further research involving larger sample sizes and more comprehensive assessments is needed to validate these results and establish the clinical benefits of this treatment approach. Trial registration ID: NCT05613114 (https://clinicaltrials.gov/), retrospectively registered on November 14, 2022.

Minimal Clinically Important Difference (MCID) in Patient-Reported Outcome Measures for Neurological Conditions: Review of Concept and Methods

The concept of the minimal clinically important difference (MCID) emerged from the recognition that statistical significance alone is not enough to determine the clinical relevance of treatment effects in clinical research. In many cases, statistically significant changes in outcomes may not be meaningful to patients or may not result in any tangible improvements in their health. This has led to a growing emphasis on the importance of measuring patient-reported outcome measures (PROMs) in clinical trials and other research studies, in order to capture the patient perspective on treatment effectiveness. MCID is defined as the smallest change in scores that is considered meaningful or important to patients. MCID is particularly important in fields such as neurology, where many of the outcomes of interest are subjective or based on patient-reported symptoms. This review discusses the challenges associated with interpreting outcomes of clinical trials based solely on statistical significance, highlighting the importance of considering clinical relevance and patient perception of change. There are two main approaches to estimating MCID: anchor-based and distribution-based. Anchor-based approaches compare change scores using an external anchor, while distribution-based approaches estimate MCID values based on statistical characteristics of scores within a sample. MCID is dynamic and context-specific, and there is no single 'gold standard' method for estimating it. A range of MCID thresholds should be defined using multiple methods for a disease under targeted intervention, rather than relying on a single absolute value. The use of MCID thresholds can be an important tool for researchers, neurophysicians and patients in evaluating the effectiveness of treatments and interventions, and in making informed decisions about care.

Responsiveness of Persian 12-Item multiple sclerosis walking scale: a replication study

OBJECTIVE

To re-explore the responsiveness of the Persian version of Multiple Sclerosis Walking Scale-12 (MSWS-12p) to physiotherapy intervention and determine the minimally clinically important change (MCIC). This study followed a prospective cohort design. Patients with MS (PwMS) underwent physiotherapy treatment for 10 sessions. The outcome measures were the MSWS-12p and Timed 25-Foot Walk test (T25-FW). Data was collected before and after ten sessions of physiotherapy. The effect sizes and the area under receiver operating characteristics curve (AUC) and MCIC were calculated.

RESULTS

Thirty PwMS (16 female, mean age 43.07 years) participated in the study. The effect sizes for MSWS-12p were moderate (0.52, 0.64). The change scores of MSWS-12p showed excellent correlation with the dichotomized smallest detectable change (SDC) criterion (Eta coefficient test = 0.84). There was no correlation between the MSWS-12p total change scores and the T25-FW (r = - 0.14, p = 0.45). The AUC was perfect and the MCIC for the MSWS-12p was calculated 10.0 points. The MSWS-12p is responsive and demonstrates changes after physiotherapy. Changes > 10.0 points on MSWS-12p total score should be considered as true improvement after physiotherapy.

Dry needling for the treatment of muscle spasticity in a patient with multiple sclerosis: a case report

BACKGROUND

Spasticity is a common cause of disability in multiple sclerosis (MS), which can negatively affect the patient's walking and balance.

OBJECTIVE

To evaluate the immediate effect of dry needling (DN) on spasticity and mobility in a female with MS.

CASE DESCRIPTION

In this case, a 38-year-old female with a 4-year history of MS was treated. The hamstring muscles (biceps femoris and semitendinosus) were needled for 1 minute in a single session. The main outcome measures were the Modified Modified Ashworth Scale (MMAS) to evaluate spasticity, the Timed 25-Foot Walk (T25FW) for the assessment of mobility and leg function performance, and stiffness as a biomechanical index of spasticity measured by a dynamometer. The assessments were done before and immediately after DN.

OUTCOMES

The MMAS scores decreased in the hamstrings (1 to 0) and quadriceps (2 to 1). The mobility improved as the time for T25FW decreased from 16.30 to 9.29 seconds. The stiffness of hamstring decreased after treatment (0.451 to 0.312).

CONCLUSION

One session of DN for the hamstring muscle decreased spasticity and improved mobility in this patient with MS. Further studies are suggested.

The Effects of Cooling Therapies on Fatigue, Physical Activity, and Quality of Life in Multiple Sclerosis: A Meta-Analysis

PURPOSE

This meta-analysis examined the effects of the cooling therapies on fatigue, physical activity, and quality of life (QoL) in patients with multiple sclerosis (MS).

METHODS

Articles published between 2000 and 2020 were searched in six databases. The standardized mean differences were determined by the upper and lower limits of 95% confidence intervals. Publication bias was assessed by conducting the Egger test, which uses linear regression. Publication bias was examined visually using a funnel plot.

RESULTS

Nine studies were included in this meta-analysis. The types of cooling therapies included cooling garment (n = 4), cooling device (n = 2), cooling room (n = 1), precooling (n = 1), and cold water ingestion (n = 1). The results indicated a significant decrease in fatigue and an increase in physical activity following cooling therapy. Cooling therapies improved the QoL of patients with MS. The Egger test indicated no significant publication bias. However, the funnel plot presented a slight asymmetry among studies.

CONCLUSIONS AND CLINICAL RELEVANCE

Cooling therapies have a beneficial effect on fatigue, physical activity, and the QoL of patients with MS. Healthcare professionals can use cooling methods to manage thermosensitive symptoms in patients with MS.

Foot-ankle therapeutic exercise program can improve gait speed in people with diabetic neuropathy: a randomized controlled trial

This study sought to determine whether a foot–ankle therapeutic exercise program can improve daily physical activity (i.e. number of steps) and fast and self-selected gait speed in people with diabetic peripheral neuropathy (DPN). In this single-blind randomized controlled trial and intention-to-treat analysis, 78 volunteers with DPN were allocated into a control group, which received usual care, and an intervention group (IG), which received usual care plus a 12-week foot–ankle exercise program. The adherence at 12 weeks rate in the IG was 92.3% (36 participants) and the dropout was 5.1% in the control group (2 participants). The number of steps and self-selected gait speed did not change significantly in either group (p > 0.05), although a 1,365-step difference between groups were observed at 1-year followup. The 12-week foot–ankle therapeutic exercises improved significantly fast-gait speed (primary outcome) (p = 0.020), ankle range of motion (p = 0.048), and vibration perception (secondary outcomes) (p = 0.030), compared with usual-care at 12 weeks. At 24 weeks, the IG showed better quality of life than controls (p = 0.048). At 1-year, fast-gait speed and vibration perception remained higher in the IG versus controls. Overall, the program may be a complementary treatment strategy for improving musculoskeletal and functional deficits related to DPN.

Trial registration ClinicalTrials.gov NCT02790931 (06/06/2016).

Functional intermuscular reduction in spasticity for people with multiple sclerosis

Background

Eighty-five percent of people with multiple sclerosis (MS) incur gait impairments debilitating enough to significantly impact their function.

Objectives

The aim of this study was to determine if a novel combination of intermuscular electrical stimulation, followed by functional electrical stimulation combined with supported bodyweight treadmill training, would improve gait, decrease spasticity and fatigue, and improve muscle strength.

Methods

Using a pre-post experimental design, we implemented this combination six-week protocol in 16 individuals with MS. We completed summary statistics and longitudinal pre-post results using Wilcoxon sign rank tests with Bonferroni adjustment.

Results

Participants responded with median increases of 29.4 feet (p < 0.0001) during the Six Minute Walk Test, median decreases of 0.7 s (p = 0.0011) in the 25-Foot Walk Test, median increases of 3.8 toe taps to fatigue (p = 0.0306) and median increases of 5.0 heel raises (p = 0.0093). Significant changes were noted in the Modified Ashworth Scale, both after intermuscular electrical stimulation (median change = −0.5 p = 0.0039) and after treadmill walking (median change = −0.5, p < 0.0005).

Conclusions

Results of this novel protocol suggest this intervention combination has the potential to decrease spasticity, and improve gait speed and endurance in individuals with MS. Observed changes in mobility occurred without accompanying increases in fatigue.

Effects of brain-computer interface with functional electrical stimulation for gait rehabilitation in multiple sclerosis patients: preliminary findings in gait speed and event-related desynchronization onset latency

Objective.Brain-computer Interfaces (BCI) with functional electrical stimulation (FES) as a feedback device might promote neuroplasticity and hence improve motor function. Novel findings suggested that neuroplasticity could be possible in people with multiple sclerosis (pwMS). This preliminary study explores the effects of using a BCI-FES in therapeutic intervention, as an emerging methodology for gait rehabilitation in pwMS.Approach.People with relapsing-remitting, primary progressive or secondary progressive MS were evaluated with the inclusion criteria to enroll the nine participants required by the statistically computed sample size. Each patient trained with a BCI-FES during 24 sessions distributed in eight weeks. The effects were evaluated on gait speed (Timed 25 Foot Walk), walking ability (12-item Multiple Sclerosis Walking Scale), quality of life measures, the true positive rate as the BCI-FES performance metric and the event-related desynchronization (ERD) onset latency of the sensorimotor rhythms.Main results.Seven patients completed the therapeutic intervention. A statistically and clinically significant post-treatment improvement was observed in gait speed, as a result of a reduction in the time to walk 25 feet (-1.99 s,p= 0.018), and walking ability (-31.25 score points,p= 0.028). The true positive rate showed a statistically significant improvement (+15.87 score points,p= 0.018). An earlier ERD onset latency (-180 ms) after treatment was found.Significance.This is the first study that explored gait rehabilitation using BCI-FES in pwMS. The results showed improvement in gait which might have been promoted by changes in functional brain connections involved in sensorimotor rhythm modulation. Although more studies with a larger sample size and control group are required to validate the efficacy of this approach, these results suggest that BCI-FES technology could have a positive effect on MS gait rehabilitation.

Measuring Treatment Response in Progressive Multiple Sclerosis-Considerations for Adapting to an Era of Multiple Treatment Options

Disability in multiple sclerosis accrues predominantly in the progressive forms of the disease. While disease-modifying treatment of relapsing MS has drastically evolved over the last quarter-century, the development of efficient drugs for preventing or at least delaying disability in progressive MS has proven more challenging. In that way, many drugs (especially disease-modifying treatments) have been researched in the aspect of delaying disability progression in patients with a progressive course of the disease. While there are some disease-modifying treatments approved for progressive multiple sclerosis, their effect is moderate and limited mostly to patients with clinical and/or radiological signs of disease activity. Several phase III trials have used different primary outcomes with different time frames to define disease progression and to evaluate the efficacy of a disease-modifying treatment. The lack of sufficiently sensitive outcome measures could be a possible explanation for the negative clinical trials in progressive multiple sclerosis. On the other hand, even with a potential outcome measure that would be sensitive enough to determine disease progression and, thus, the efficacy or failure of a disease-modifying treatment, the question of clinical relevance remains unanswered. In this systematic review, we analyzed outcome measures and definitions of disease progression in phase III clinical trials in primary and secondary progressive multiple sclerosis. We discuss advantages and disadvantages of clinical and paraclinical outcome measures aiming for practical ways of combining them to detect disability progression more sensitively both in future clinical trials and current clinical routine.

A Phase 3, double-blind, placebo-controlled efficacy and safety study of ADS-5102 (Amantadine) extended-release capsules in people with multiple sclerosis and walking impairment

Background:

ADS-5102, a delayed-release, extended-release (DR/ER) amantadine, improved walking speed in MS in a Phase 2 trial.

Objective:

The aim of this study was to present primary results of a Phase 3, double-blind, ADS-5102 trial (INROADS) for walking speed.

Methods:

Adult participants with MS and walking impairment, not currently using amantadine or dalfampridine, underwent 4-week placebo run-in before randomization 1:1:1 to placebo, 137 or 274 mg/day ADS-5102 for 12 weeks. Primary outcome was the proportion of responders (20% increase in Timed 25-Foot Walk (T25FW) speed) for 274 mg ADS-5102 versus placebo at end of double-blind (Study Week 16). Additional measures included Timed Up and Go (TUG), 2-Minute Walk Test (2MWT), and 12-item Multiple Sclerosis Walking Scale (MSWS-12).

Results:

In total, 558 participants were randomized and received double-blind treatment. Significantly more participants responded with 274 mg ADS-5102 (21.1%) versus placebo (11.3%). Mean T25FW speed also significantly improved (0.19 ft/s) versus placebo (0.07 ft/s). Other measures were not significant using prespecified hierarchical testing procedure. Adverse events led to discontinuation for 3.8% (placebo), 6.4% (137 mg ADS-5102), and 20.5% (274 mg ADS-5102).

Conclusion:

INROADS met its primary endpoint, showing a significantly greater proportion of participants with meaningful improvement in walking speed for 274 mg ADS-5102 versus placebo. Numeric dose response was seen for some secondary efficacy outcomes and adverse events.

Outcome measures assisting treatment optimization in multiple sclerosis

Objective

To review instruments used to assess disease stability or progression in persons with multiple sclerosis (pwMS) that can guide clinicians in optimizing therapy.

Methods

A non-systematic review of scientific literature was undertaken to explore modalities of monitoring symptoms and the disease evolution of MS.

Results

Multiple outcome measures, or tools, have been developed for use in MS research as well as for the clinical management of pwMS. Beginning with the Expanded Disability Status Scale, introduced in 1983, clinicians and researchers have developed monitoring modalities to assess all aspects of MS and the neurological impairment it causes.

Conclusions

Much progress has been made in recent decades for the management of MS and for the evaluation of disease progression. New technology, such as wearable sensors, will provide new opportunities to better understand changes in function, dexterity, and cognition. Essential work over the decades since EDSS was introduced continues to improve our ability to treat this debilitating disease.

The efficiency of mirror therapy on drop foot in Multiple Sclerosis Patients

INTRODUCTION

Although the effectiveness of mirror therapy (MT) has been proved in stroke persons, there is no scientific evidence about the results in people with multiple sclerosis. The aim was to investigate whether adding MT to exercise training and neuromuscular electrical stimulation (NMES) has any effect on clinical measurements, mobility, and functionality in people with multiple sclerosis (MS).

METHODS

Ambulatory people with MS, with unilateral drop foot, were included. MT group (n = 13) applied bilateral ankle exercise program with mirror following NMES for 3 days a week at hospital and exercise program for 2 days a week at home. Control group (n = 13) performed same treatment without mirror box (6 weeks). The later 6 weeks both groups performed only exercise program. Clinical measurements included proprioception, muscle tone of plantar flexor muscles (MAS), muscle strength of dorsiflexor, ankle angular velocity, and range of motion (ROM) of ankle. Functionality (Functional Independence Measurement-FIM), mobility (Rivermead Mobility Index-RMI), ambulation (Functional Ambulation Scale-FAS), duration of stair climb test, and 25-foot walking velocity were assessed at the beginning, in 6th and 12th weeks.

RESULTS

More positive improvements were obtained in MT group than control group in terms of range of motion (0.012), muscle strength (0.008), proprioception (0.001), 25 feet walking duration (0.015), step test duration (0.001), FAS (0.005), RMI (0.001), and FIM (0.001) after 6 weeks treatment. It was seen that this improvement maintained to 12th week on all clinical and functional measurements (p < .05).

CONCLUSION

The trial revealed that adding MT to exercise training and NMES has more beneficial effects on clinical measurements, mobility, and functionality in people with multiple sclerosis with unilateral drop foot.

Early-warning signals for disease activity in patients diagnosed with multiple sclerosis based on keystroke dynamics

Within data gathered through passive monitoring of patients with Multiple Sclerosis (MS), there is a clear necessity for improved methodological approaches to match the emergence of continuous, objective, measuring technologies. As most gold standards measure infrequently and require clinician presence, fluctuations in the daily progression are not accounted for. Due to the underlying conditions of homogeneity and stationarity (the main tenets of ergodicity) not being met for the majority of the statistical methods employed in the clinical setting, alternative approaches should be investigated. A solution is to use a non-linear time series analysis approach. Here, Early-Warning Signals (EWS) in the form of critical fluctuations in Keystroke Dynamics (KD), collected using participant's smartphones, are investigated as indicators for a clinical change in three groups. These are patients with MS and changes in Magnetic Resonance Imaging (MRI), patients with MS but without changes in MRI, and healthy controls (HCs). Here, we report examples of EWS and changes in KD coinciding with clinically relevant changes in outcome measures in both patients with and without differences in the amount of MRI enhancing lesions. We also report no clinically relevant changes in EWS in the HC population. This study is a first promising step toward using EWS to identify periods of instability as measured by a continuous objective measure as a proxy for outcome measures in the field of MS.

Long-term worsening of different body functions in persons with progressive multiple sclerosis

Background

It is unclear whether EDSS is responsive to disability worsening in advanced MS.

Objective

To explore the dynamics of disability worsening in persons with advanced-stage MS (EDSS ≥5.5) using three disability worsening definitions (EDSS, Rivermead Mobility Index (RMI), 9-Hole Peg Test (9-HPT)).

Methods

EDSS-, RMI- and 9-HPT-based disability worsening were assessed over a minimum of two years in a cohort of 286 persons with advanced MS attending inpatient rehabilitation using Kaplan-Meier Curves and multivariable Cox regression. Furthermore, the correspondence between EDSS-, RMI- and 9-HPT-based disability worsening was analyzed.

Results

Disability progression was observed in 49% (9-HPT), 52% (EDSS) and 53% (RMI), with 9-HPT-based worsening slightly lagging behind. The Multiple Sclerosis Severity Score (MSSS) was the only consistent factor predicting disability worsening based on all three definitions (EDSS: hazard ratio 1.48 [1.30;1.68]; RMI: 1.12 [0.99;1.27]; 9-HPT: 1.36 [1.18;1.57]). Correspondence between EDSS and the other definitions (9-HPT and RMI) was 44.3% and 55.7% at time of EDSS progression and 65.1% and 72.5% overall, respectively.

Conclusion

In persons with advanced-stage MS, half still developed disability worsening in different functional systems over a median of 6 years. MSSS seems a valid predictor for disability worsening in all three outcome measures in advanced MS.

Aminopiridines in the treatment of multiple sclerosis and other neurological disorders

Symptomatic treatment has a great relevance for the management of patients with neurologic diseases, since it reduces disease burden and improves quality of life. Aminopyridines (APs) are a group of potassium (K+) channel blocking agents that exert their activity both at central nervous system level and on neuromuscular junction. This review describes the use of APs for the symptomatic treatment of neurological conditions. We will describe trials leading to the approval of the extended-release 4-aminopyridine for MS and evidence in support of the use in other neurological diseases.

Acceptability and outcomes of an individualized exergaming telePT program for veterans with multiple sclerosis: a pilot study

Background

Physical rehabilitation services are an important component of treatment for persons with multiple sclerosis (PwMS) to improve and maintain physical mobility. However, PwMS often have significant barriers to outpatient physical therapy (PT) services including mobility deficits and lack of transportation. The integration of exercise gaming (exergaming) and telehealth into clinical PT practices may overcome these barriers. The overarching purpose of this pilot study was to evaluate the acceptability and effects of an individualized telePT intervention using exergaming.

Methods

Ten individuals with multiple sclerosis (MS) completed a 12-week exergaming (Jintronix®) telerehabilitation intervention. In order to measure the acceptability of the telerehabilitation intervention, adherence was measured through the tablet-based rehabilitation software and each participant completed a satisfaction questionnaire. Clinical outcome measures were assessed at baseline and post-intervention. To evaluate the efficacy of this intervention, the following measures of physical function and fatigue were included; the Short Physical Performance Battery (SPPB), 25-Foot Walk (25FW), Modified Fatigue Impact Scale (MFIS), Multiple Sclerosis Walking Scale-12 (MSWS), and the 2-Minute Walk Test (2MWT). Clinical outcomes were analyzed using the Sign test and Wilcoxon signed rank test. All other data were evaluated using descriptive statistics.

Results

After the intervention, participants demonstrated significant improvements in ambulation speed during the 25FW (p = 0.04) and ambulation distance during the 2MWT (p = 0.002). Statistically significant increases of SPPB total score (p = .04) and sub-scores were also found. Participants did not demonstrate significant changes in the MFIS (p = 0.31) or MSWS-12 (p = 0.06) after the intervention. Participants had a 58.3% adherence rate during the intervention and performed their exercise program an average of 2.5 times per week. All participants reported that they were either ‘satisfied or ‘very satisfied’ with their telerehabilitation experience, would use telerehabilitation again, and would recommend telerehabilitation to others.

Conclusion

This individualized telerehabilitation intervention which integrates exergaming and clinical video teleconferencing is acceptable to patients and may offer a viable alternative to traditional PT for PwMS.

Trial registration

NCT03655431, retrospectively registered on August 31st, 2018.

What Are the Minimal Detectable Changes in SDMT and Verbal Fluency Tests for Assessing Changes in Cognitive Performance in Persons with Multiple Sclerosis and Non-Multiple Sclerosis Controls?

INTRODUCTION

Cognitive impairment is frequent in persons with multiple sclerosis (PwMS) and can impact on activities of daily living. The capacity to differentiate real changes from background statistical noise induced by human, instrumentational, and environmental variations inherent to the evaluation would improve cognitive assessments.

OBJECTIVE

To assess the short-term reproducibility of cognitive tests in non-multiple sclerosis (non-MS) persons and PwMS.

METHODS

Sixty-two PwMS and 19 non-MS persons performed 2 measurements, 1 week apart, of the Symbol Digit Modalities Test (SDMT) and phonological and semantic verbal fluency. Test-retest reliability was evaluated by the intraclass correlation coefficients (ICC) and agreement by standard error of measurement (SEM) and minimum detectable change (MDC).

RESULTS

The reliability of the cognitive variables studied had moderate to high ICC values (ICC > 0.8) in both populations. The threshold to consider a significant cognitive modification evaluated by SEM and MDC was lower in PwMS compared with non-MS persons.

CONCLUSIONS

SDMT and verbal fluency have good short-term reproducibility in PwMS. Specific SEM and MDC cutoffs based on the same design of evaluation (especially retest timing) and to the targeted pathological population (MS vs. healthy) should systematically be used to consider cognitive modification as significant in research protocol as well as in clinical practice.

Center-Based Group and Home-Based Individual Exercise Programs Have Similar Impacts on Gait and Balance in People With Multiple Sclerosis: A Randomized Trial

BACKGROUND

Group and home-based exercises to improve function in people with multiple sclerosis (MS) are common but have little underpinning evidence.

OBJECTIVE

To determine the comparative effectiveness of a center-based group versus home-based individual 8-week exercise program to improve gait and balance in people with MS.

DESIGN

Prospective, randomized controlled trial.

SETTING

Community center-based and home-based exercise program.

PARTICIPANTS

Fifty people with MS were randomized and completed allocated intervention (n = 26 center, n = 24 home), 47 completed post-assessment and 44 follow-up assessment.

METHODS

The center- and home-based groups completed an 8-week progressive functional and balance training exercise program. The center-based groups of four to six were supervised by a physiotherapist. The home-based group was provided with telephone support.

MAIN OUTCOME MEASUREMENTS

The primary outcome was gait speed (10-meter walk test). Secondary outcomes were gait endurance (6-minute walk test) and balance (Berg Balance Scale). Outcome assessments were conducted at baseline, immediately postintervention and at 8-week follow-up.

RESULTS

There was no statistically significant difference between groups in gait speed post training, with a mean difference of 0.01 m/s, 95% CI -0.36 to 0.37. There were no group effects, time effects, or interactions for gait speed, endurance, or balance. In both groups, gait speed improved to a level that met minimal clinically important differences.

CONCLUSIONS

Gait speed, endurance, and balance did not statistically improve in either group; however, gait speed changes met minimally important differences.

Vigorous cool room treadmill training to improve walking ability in people with multiple sclerosis who use ambulatory assistive devices: a feasibility study

BACKGROUND

Aerobic training has the potential to restore function, stimulate brain repair, and reduce inflammation in people with Multiple Sclerosis (MS). However, disability, fatigue, and heat sensitivity are major barriers to exercise for people with MS. We aimed to determine the feasibility of conducting vigorous harness-supported treadmill training in a room cooled to 16 °C (10 weeks; 3times/week) and examine the longer-term effects on markers of function, brain repair, and inflammation among those using ambulatory aids.

METHODS

Ten participants (9 females) aged 29 to 74 years with an Expanded Disability Status Scale ranging from 6 to 7 underwent training (40 to 65% heart rate reserve) starting at 80% self-selected walking speed. Feasibility of conducting vigorous training was assessed using a checklist, which included attendance rates, number of missed appointments, reasons for not attending, adverse events, safety hazards during training, reasons for dropout, tolerance to training load, subjective reporting of symptom worsening during and after exercise, and physiological responses to exercise. Functional outcomes were assessed before, after, and 3 months after training. Walking ability was measured using Timed 25 Foot Walk test and on an instrumented walkway at both fast and self-selected speeds. Fatigue was measured using fatigue/energy/vitality sub-scale of 36-Item Short-Form (SF-36) Health Survey, Fatigue Severity Scale, modified Fatigue Impact Scale. Aerobic fitness (maximal oxygen consumption) was measured using maximal graded exercise test (GXT). Quality-of-life was measured using SF-36 Health Survey. Serum levels of neurotrophin (brain-derived neurotrophic factor) and cytokine (interleukin-6) were assessed before and after GXT.

RESULTS

Eight of the ten participants completed training (attendance rates ≥ 80%). No adverse events were observed. Fast walking speed (cm/s), gait quality (double-support (%)) while walking at self-selected speed, fatigue (modified Fatigue Impact Scale), fitness (maximal workload achieved during GXT), and quality-of-life (physical functioning sub-scale of SF-36) improved significantly after training, and improvements were sustained after 3-months. Improvements in fitness (maximal respiratory exchange ratio and maximal oxygen consumption during GXT) were associated with increased brain-derived neurotrophic factor and decreased interleukin-6.

CONCLUSION

Vigorous cool room training is feasible and can potentially improve walking, fatigue, fitness, and quality-of-life among people with moderate to severe MS-related disability.

TRIAL REGISTRATION

The study was approved by the Newfoundland and Labrador Health Research Ethics Board (reference number: 2018.088) on 11/07/2018 prior to the enrollment of first participant (retrospectively registered at ClinicalTrials.gov: NCT04066972. Registered on 26 August 2019.

Functional Electrical Stimulation Cycling Exercise for People with Multiple Sclerosis

PURPOSE OF REVIEW

There has been substantial interest in the role of exercise for managing impairments, limitations, and disability progression among persons with multiple sclerosis (MS). Despite established benefits of exercise training for persons who have mild-to-moderate MS, the ability to deliver exercise to persons who experience higher disability remains challenging. One promising approach for exercise in this population is functional electrical stimulation (FES) cycling. This review provides a summary of the current evidence for FES cycling as an exercise training modality in persons with MS with respect to prescription, safety, tolerability, and acute and chronic effects.

RECENT FINDINGS

We searched the literature for studies involving FES cycling exercise in persons with MS published in English up until July 2019. Eight studies were retrieved: two studies examined acute effects, two studies examined chronic effects, and four studies reported on both acute and chronic effects of FES cycling exercise. The overall quality of the studies was low, with only one, small, randomized controlled trial (RCT). There is limited but promising evidence for the application of FES cycling exercise among persons with MS who have moderate-to-severe disability. Participants were capable of engaging in regular FES cycling exercise (~ 30 min, 2-3×/week), with few, mild adverse events experienced. Preliminary evidence from small, mostly uncontrolled trials supports the potential benefits of FES cycling on physiological fitness, walking mobility, and symptoms of fatigue and pain. High-quality RCTs of FES cycling exercise are necessary for providing recommendations for integrating exercise training in the management of advanced MS.

Rationale and design of the STEP for MS Trial: Comparative effectiveness of Supervised versus Telerehabilitation Exercise Programs for Multiple Sclerosis

BACKGROUND

We propose a Phase III trial that compares the effectiveness of an exercise training program delivered in a facility-based setting with direct, in-person supervision or a home-based setting with remote supervision via telerehabilitation for improving walking performance in persons with multiple sclerosis(MS) who have walking dysfunction and mobility disability.

METHODS/DESIGN

The study was developed with stakeholder engagement and is a multi-site trial that follows a 2-stage, randomized choice design. The trial compares the effectiveness of a 16-week evidence-based, individualized exercise program delivered in a supervised, facility-based setting versus a remotely coached/guided, home-based setting using telerehabilitation in physically inactive and cognitively intact people with MS who have walking dysfunction and mobility disability(N = 500). The primary outcome is walking speed. The secondary outcomes are walking endurance, disability status, and patient-reported outcomes of physical activity, walking impairment, fatigue, and quality of life. The components of the exercise program itself are similar between the groups and follow the Guidelines for Exercise in MS protocol. This includes a program manual, exercise prescription, exercise equipment, social-cognitive theory materials including newsletters, logs, and calendars, and one-on-one behavioral coaching by exercise specialists with background in MS. The main difference between groups is the coaching approach and setting for delivering the exercise training program. The outcomes will be collected by treatment-blinded assessors at baseline(week 0), mid-intervention(week 8), post-intervention(week 16), and follow-up(week 52).

DISCUSSION

The proposed study will provide evidence for the effectiveness of a novel, widely-scalable program for delivering exercise training in persons with MS who have walking dysfunction and mobility disability.

Gait tests in multiple sclerosis: Reliability and cut-off values

BACKGROUND

Gait limitation is one of the most common disabilities in people with multiple sclerosis (MS). Several studies have used gait parameters to determine the effects of different therapies. However, few studies have determined their reproducibility, also the therapeutic effects could be overestimated.

RESEARCH QUESTION

To examine the reproducibility in gait measurements during short and long distances.

METHODS

In this cross-sectional study we recruited a group of MS patients and compare it to a control group. The participants performed the following tests in a fixed order: a 25-foot walk at a comfortable speed, at a fast speed and during a dual task, a timed up-and-go test (TUG) and a six- minute walk test (6MWT). Two measurements were conducted a week apart. Systematic error was evaluated by the Student t-test, reliability by the intra-class correlation coefficients (ICC) and agreement by the minimum detectable change (MDC₉₅).

RESULTS

A total of 58 people with MS and 19 healthy people were included. The absence of systematic error was only found for the fast speed condition. The reliability of the gait parameters had moderate to high ICC values (ICC > 0.7) except for the dual task cost (DTC) which was 0.45. The MDC₉₅ was higher in people with MS compared to healthy people, and it was higher in people with MS for gait speeds in all conditions (> 34%). For the TUG and 6MWT, the MDC₉₅ were 51.5% and 31.7% respectively. For people with MS the smallest MDC₉₅ was found for the stance time for all conditions (6.8%), whereas the highest was found for the dual task cost (158.7%).

SIGNIFICANCE

The MDC₉₅ values were higher than the cut-off point based on the minimally important clinical difference (MICD) proposed in previous studies. Thus, the MDC₉₅ should be used as a cut-off rather than MICD values.

Effects and feasibility of virtual reality system vs traditional physical therapy training in multiple sclerosis patients

Background/Aims:

Traditionally, physical therapy for gait and balance training takes place in a gym setting, which may not fully reproduce situations in everyday activities. The Computer Assisted Rehabilitation ENvironment system provides an immersive virtual environment, allowing a simulation of complex conditions conducive to gait and balance training. The purpose of this study was to determine: (1) the feasibility and safety of using the Computer Assisted Rehabilitation ENvironment system for physical therapy sessions with multiple sclerosis patients, and (2) pre-post treatment changes observed with the Computer Assisted Rehabilitation ENvironment system compared to traditional physical therapy.

Findings:

Data from functional outcome measures Berg Balance Scale, Timed Up and Go test, Timed 25-Foot Walk, and 6-Minute Walk Test were extracted from the medical records of 62 patients with multiple sclerosis who had at least three physical therapy sessions in either environment. Statistically significant within-group improvements were observed for all outcome measures in the physical therapy Computer Assisted Rehabilitation ENvironment system group (P<0.05), and only for Berg Balance Scale in the traditional physical therapy group. There was a significant between-group difference in favour of physical therapy with the Computer Assisted Rehabilitation ENvironment system for the Timed 25-Foot Walk (P=0.022).

Conclusions:

The results suggest the Computer Assisted Rehabilitation ENvironment system is a safe and effective tool for physical therapy-led gait and balance training for individuals with multiple sclerosis.

Combined walking outcome measures identify clinically meaningful response to prolonged-release fampridine

Background

Gait impairment is common in multiple sclerosis (MS) and negatively impacts patients' health-related quality of life (HRQoL). Prolonged-release fampridine (PR-fam) improves walking speed, but it is unclear which walking measures are the most suitable for identifying treatment response. Our aim was to assess the effect of PR-fam and the outcome measures that best identify short- and long-term clinically meaningful response.

Methods

We conducted a prospective study in 32 MS patients treated with PR-fam for a year. The assessments at 2 weeks, 3, 6 and 12 months included: timed 25-foot walk (T25FW), 6-minute walk test (6MWT), MS Walking Scale-12 (MSWS-12), a five-level version of the EuroQoL-5 dimensions, and accelerometry. PR-fam response was defined as an improvement in T25FW ⩾20%.

Results

Twenty-five (78%) patients were considered responders after 2 weeks of PR-fam and improved significantly in all measures. Responders to T25FW and MSWS-12 (n = 19) showed a significant improvement in HRQoL and accelerometer data compared with responders only to T25FW (n = 6). At 1 year, 15/20 (75%) patients remained responders, but only those with permanent response to T25FW and MSWS-12 (n = 8; 53%) showed a significant improvement in 6MWT and HRQoL.

Conclusion

The combination of T25FW and MSWS-12 identify better those patients with a clinically significant benefit of PR-fam.

Recommended outcome measures for inpatient rehabilitation of multiple sclerosis are not appropriate for the patients with substantially impaired mobility

BACKGROUND

In multiple sclerosis (MS) rehabilitation, most currently used outcome measures were validated in patients with a relapsing remitting MS and mild to moderate impairments. We aimed to assess whether these measures were also adequate in more impaired patients, frequently encountered in those with progressive MS (PMS).

METHODS

Outcome measurements were extracted from medical records of 229 patients with PMS undergoing 3 weeks of routine inpatient rehabilitation between 2011 and 2015. We assessed the acceptability of Nine-Hole Peg Test (9HPT), Timed 25-Foot Walk (T25FW), 2-Minute Walk Test (2MWT), Rivermead Mobility Index (RMI) and the Functional Independence Measure (FIM) by analysing their statistical distributions, concurrent validity by comparing Spearman correlations with pre-specified hypotheses, and responsiveness across impairment status by calculating standardized response means.

RESULTS

Our concurrent validity hypotheses were mainly satisfied. However, all outcome measures had skewed distributions, showed low variability, and thus were inadequately discriminative. Moreover, 9HPT was never responsive across the impairment states, whereas the T25FW was responsive for mildly impaired patients, and the 2MWT for mild to moderate MS, respectively. Generic multi-items measures such as RMI and FIM-motor were adequately responsive for all severity levels.

CONCLUSIONS

Currently used outcome measures are inadequate for patients with impaired mobility, and there is a dire need of specifically designed outcome measures for routine care that are less burdensome and short-term responsive.

Walking measures to evaluate assistive technology for foot drop in multiple sclerosis: A systematic review of psychometric properties

BACKGROUND

Foot drop in people with multiple sclerosis (pwMS) often managed with assistive technologies, such as functional electrical stimulation and ankle foot orthoses. No evidence synthesis exists for the psychometric properties of outcomes used to evaluate the efficacy of these interventions.

OBJECTIVE

This systematic review aimed to identify the outcome measures reported to assess the benefits of assistive technology for pwMS and then synthesize the psychometric evidence in pwMS for a subset of these measures.

METHODS

Two searches in eight databases were conducted up to May 2017. Methodological quality was rated using the COSMIN guidelines. Overall level of evidence was scored according to the Cochrane criteria.

RESULTS

The first search identified 27 measures, with the 10 m walk test, gait kinematics and Physiological Cost Index (PCI) most frequently used. The second search resulted in 41 studies evaluating 10 measures related to walking performance. Strong levels of evidence were found for the internal consistency and test-retest reliability of the Multiple Sclerosis Walking Scale-12 and for the construct validity for Timed 25 Foot Walk. No psychometric studies were identified for gait kinematics and PCI in pwMS. There was a lack of evidence for measurement error and responsiveness.

CONCLUSION

Although a strong level of evidence exists for some measures included in this review, there was an absence of psychometric studies on commonly used measures such as gait kinematics. Future psychometric studies should evaluate a wider range of walking related measures used to assess the efficacy of interventions to treat foot drop in pwMS.

Maximum walking speed in multiple sclerosis assessed with visual perceptive computing

BACKGROUND

Gait is often impaired in people with multiple sclerosis (PwMS), but detailed assessment of gait impairment in research and care remains challenging. In a previous pilot study we reported the feasibility of visual perceptive computing (VPC) for gait assessment in PwMS using the Short Maximum Speed Walk (SMSW), which assesses gait on recording distances confined to less than 4 meters.

OBJECTIVE

To investigate the equivalence of SMSW to rater-based timed 25ft. walk (T25FW) in a large cohort of PwMS, and to investigate the association of SMSW-derived gait parameters with clinical disability, as well as subjective and objective gait impairment, in order to validate the SMSW as a quick and objective measure of clinical relevance possibly superior to T25FW.

METHODS

95 PwMS and 60 healthy controls (HC) performed the SMSW using a VPC system with Microsoft Kinect. All participants received two immediate retests to establish test-retest-reliability. Both PwMS and HC performed the T25FW. PwMS were rated according to the Expanded Disability Status Scale (EDSS) and answered the 12-item Multiple Sclerosis Walking Scale (MSWS-12) as a measure of self-perceived walking impairment.

RESULTS

PwMS showed reduced average speed (p<0.001) and higher mediolateral deviation (p = 0.002) during SMSW than HC. Average speed was the most reliable SMSW parameter in PwMS and HC (intra-class correlation coefficient (ICC) in PwMS = 0.985, and in HC = 0.977). Average speed declined with age in PwMS and HC (r in PwMS = -0.648, and in HC = -0.452, both p<0.001). Correlation of SMSW average speed and T25FW speed was high in both groups (r in PwMS = 0.783, and in HC = 0.747, both p<0.001) and mean difference (0.0013 m/s) between methods was below smallest detectable change. Average speed correlated well with both clinical disability based on EDSS (r = -0.586, p<0.001) and self-perceived walking impairment based on MSWS-12 (r = -0.546, p<0.001).

CONCLUSION

VPC-assessed walking parameters during SMSW can reliably detect gait disturbance in PwMS over very short distance. Specifically, maximum gait speed can be obtained with high accuracy in this simple test set-up. Cross-sectional associations with disability and self-perceived walking impairment support clinical relevance. Given its objectivity in a simple test set-up, SMSW is superior to T25FW.

Multiple Sclerosis and Clinical Gait Analysis before and after Fampridine: A Systematic Review

BACKGROUND

Gait impairment is one of the most disabling symptoms in people with multiple sclerosis (PwMS). Fampridine, has demonstrated a positive effect on gait speed in PwMS after 14 days of treatment but the long-term effects have not yet been demonstrated. This study reviews the long-term effects of fampridine on gait in PwMS.

SUMMARY

This systematic review was conducted according to the PRISMA statement. Studies were considered long term if treatment exceeded 28 days. From the 498 studies identified, 18 (2,200 patients) fulfilled all eligibility criteria. Only 3 studies followed-up patients for >1 year and one of these showed a non-significant improvement in the gait speed. Key Messages: Fampridine seems to be beneficial at improving gait speed in PwMS in the long term. Further long-term studies are needed on related gait and functional parameters.

Fampridine Prolonged Release: A Review in Multiple Sclerosis Patients with Walking Disability

Oral fampridine prolonged release (PR) [Fampyra^®] is a lipid-soluble selective potassium channel blocker that is approved in the EU for the improvement of walking in adult multiple sclerosis (MS) patients with walking disability (expanded disability status scale score of 4-7). In clinical trials (MS-F203 and MS-F204) using an objective measure of walking improvement [the timed 25-foot walk (T25FW)], more than one-third of patients receiving fampridine PR achieved a consistent on-treatment improvement in walking speed (i.e. became TW responders) over 9-14 weeks of treatment. Fampridine PR recipients who fulfilled the definition of TW responder had mean improvements of ≈25% from baseline in T25FW walking speed. In a clinical trial (ENHANCE) that used a patient-rated measure of walking improvement [12-item MS walking scale (MSWS-12)], a significantly greater proportion of fampridine PR recipients than placebo recipients achieved a ≥8-point improvement on the MSWS-12 with 24 weeks of treatment. Where reported, adverse events were mostly mild or moderate in severity, and generally consistent with the underlying disease or mechanism of action of fampridine PR. Fampridine PR is a useful treatment option to consider in adult MS patients with walking disability.

Validity of the timed 25-foot walk as an ambulatory performance outcome measure for multiple sclerosis

The Multiple Sclerosis Outcome Assessments Consortium (MSOAC) includes representatives from advocacy organizations, Food and Drug Administration (FDA), European Medicines Agency (EMA), National Institute of Neurological Disorders and Stroke (NINDS), academic institutions, and industry partners along with persons living with multiple sclerosis (MS). One of the MSOAC goals is acceptance and qualification by regulators of performance outcomes that are highly reliable and valid, practical, cost-effective, and meaningful in MS. This article addresses the history, application, and psychometric properties of one such MSOAC metric of ambulation or walking namely, the timed 25-foot walk (T25FW). The T25FW has strong reliability over both brief and long periods of time in MS across a large range of disability levels. The outcome of walking speed from the T25FW has obvious real-world relevance and has correlated strongly with other measures of walking and lower extremity function. The T25FW is responsive for capturing intervention effects in pharmacological and rehabilitation trials and has an established value for capturing clinically meaningful change in ambulation. Directions for future research involve validating clinically meaningful improvements on the T25FW as well as determining whether 20% change is clinically meaningful across the disability spectrum. Researchers might further consider synchronizing accelerometers and motion sensors with the T25FW for capturing walking speed in everyday life and the patient's real environment.

Outcomes of Bariatric Surgery in Morbidly Obese Patients with Multiple Sclerosis

Obesity is common in patients with multiple sclerosis (MS); however, safety and efficacy of bariatric surgery in this population remain unclear. A database of 2,918 was retrospectively reviewed, yielding 22 (0.75%) severely obese patients with MS who underwent bariatric surgery. Sixteen surgical patients with complete follow-up data were matched to a nonsurgical control group of MS patients, based on age, BMI, MS subtype, and length of follow-up. MS relapse rates and trends in the timed twenty-five foot walk test (T25FW) were compared. In the surgical group (gastric bypass n = 19, sleeve gastrectomy n = 3), preoperative BMI was 46.5 ± 7.2 Kg/m² and average excess weight was 60.4 kg. Follow-up data was collected at 59.0 ± 29.8 months. There were two major and four minor complications. Five patients required readmission and there were no mortalities. Percent excess weight loss was 75.5 ± 27.0%. In the 16 patients with follow-up data, patients who underwent bariatric surgery were significantly faster on the T25FW compared to the nonsurgical population. In conclusion, bariatric surgery is relatively safe and effective in achieving weight loss in patients with MS. In addition, surgery may help patients maintain ambulation. Findings support the need for further studies on bariatric surgery and disease-specific outcomes in this population.

Fampridine and quality of life in individuals with multiple sclerosis

Background

Fampridine improves walking in patients with multiple sclerosis (pwMS). However, little is known about its impact on the quality of life (QoL) of pwMS.

Objectives

This study aimed to evaluate the contribution of fampridine on the QoL of pwMS and to determine if improvements in QoL are best associated with walk respondents.

Methods

Fifty pwMS were included in this study. The PERSEPP scale and the GaitRite system were used to evaluate QoL and gait respectively. QoL was evaluated 7 days before fampridine (Pre1), on the day the fampridine treatment was initiated (Pre2), and 14 and 21 days after fampridine (Post1 and Post2 respectively). Gait was assessed at Pre-1, Pre-2 and Post-1.

Results

For all patients, fampridine had significant effects (p = 0.05–10⁻⁴, d = 0.25–0.45) on the Overall, Relationship difficulties, Fatigue, Time perspective and Symptoms QoL indices and for gait parameters (p = 0.05–10⁻⁴, d = 0.17–0.38). Non-respondents scored significant effects (p < 0.05–0.01, d = 0.32–0.41) for Overall, Time perspective and Symptoms QoL indices, whereas respondents scored significant effects (p < 0.05–0.01, d = 0.51–0.8) for Overall, Relationship difficulties, Fatigue and Symptoms.

Conclusion

The QoL of pwMS improved after fampridine, suggesting a real benefit in their lives. However, the contributions to the overall QoL index seem different between groups.

Are Changes in Gait and Balance Across the Disease Step Rating Scale in Multiple Sclerosis Statistically Significant and Clinically Meaningful?

OBJECTIVES

To explore differences in gait endurance, speed, and standing balance in people with multiple sclerosis (MS) across the Disease Step Rating Scale, and to determine if differences are statistically significant and clinically meaningful.

DESIGN

Observational study.

SETTING

Community rehabilitation - primary health care center.

PARTICIPANTS

Community-dwelling people with MS (N=222; mean age, 48±12y; 32% men).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants were categorized using the Disease Step Rating Scale. Demographics and clinical measures of gait endurance (6-minute walk test [6MWT]), gait speed (10-m walk test [10MWT] and 25-foot walk test [25FWT]), and balance (Berg Balance Scale [BBS]) were recorded in 1 session. Differences in these parameters across categories of the Disease Step Rating Scale were explored, and clinically meaningful differences were identified.

RESULTS

The 6MWT showed a greater number of significant differences across adjacent disease steps in those with less disability (P<.001), whereas the 10MWT and 25FWT demonstrated more significant changes in those with greater disability (P<.001). The BBS demonstrated significant differences across the span of the Disease Step Rating Scale categories (P<.001). Differences in gait and balance between adjacent Disease Step Rating Scale categories met most previously established levels of minimally detectable change and all minimally important change scores.

CONCLUSIONS

Our findings support the Disease Step Rating Scale is an observational tool that can be used by health professionals to categorize people with MS, with the categories reflective of statistically significant and clinically meaningful differences in gait and balance performance.

Distribution-based estimates of minimum clinically important difference in cognition, arm function and lower body function after slow release-fampridine treatment of patients with multiple sclerosis

OBJECTIVE

To provide distribution-based estimates of the minimal clinical important difference (MCID) after slow release fampridine treatment on cognition and functional capacity in people with MS (PwMS).

METHOD

MCID values were determined after SR-Fampridine treatment in 105 PwMS. Testing included the Timed 25 Foot Walk (T25FW), the Symbol Digit Modalities Test (SDMT), the Six Spot Step Test (SSST), the 9-Hole-Peg-Test (9-HPT), and the 5-Time-Sit-To-Stand test (5-STS).

RESULTS

MCID values: T25FW 17.8% (9.1-17.8), SDMT 17.1% (9.2-17.1), SSST 16.7% (8.5-16.7), 9-HPT 15.3% (0-15.3), and 5-STS 34.6% (16.9-34.6).

CONCLUSION

This study presents distribution-based estimates of MCID values for the SSST, the 9-HPT, and the 5-STS and confirms MCID estimates for the T25FW and the SDMT.

A guide to treating gait impairment with prolonged-release fampridine (Fampyra®) in patients with multiple sclerosis

INTRODUCTION

Gait impairment, a frequent sign in multiple sclerosis (MS), places a major burden on patients since it results in progressive loss of personal and social autonomy, along with work productivity. This guide aims to provide recommendations on how to evaluate gait impairment and use prolonged-release fampridine (PR-fampridine) as treatment for MS patients with gait impairment in Spain.

DEVELOPMENT

PR-fampridine dosed at 10mg every 12hours is currently the only drug approved to treat gait impairment in adults with MS. Additionally, PR-fampridine has been shown in clinical practice to significantly improve quality of life (QoL) in patients who respond to treatment. Treatment response can be assessed with the Timed 25-Foot Walk (T25FW) or the 12-item MS Walking Scale (MSWS-12); tests should be completed before and after starting treatment. The minimum time recommended for evaluating treatment response is 2 weeks after treatment onset. Patients are considered responders and permitted to continue the treatment when they demonstrate a decrease in their T25FW time or an increase in MSWS-12 scores. A re-evaluation is recommended at least every 6 months. The SF-36 (Short Form-36) and the MSIS-29 (MS Impact Scale-29) tests are recommended for clinicians interested in performing a detailed QoL assessment. This drug is generally well-tolerated and has a good safety profile. It should be taken on an empty stomach and renal function must be monitored regularly.

CONCLUSIONS

These recommendations will help ensure safer and more efficient prescription practices and easier management of PR-fampridine as treatment for gait impairment in Spanish adults with MS.

Longitudinal changes in self-reported walking ability in multiple sclerosis

Background

Patient-reported outcomes are increasingly used to understand the clinical meaningfulness of multiple sclerosis disability and its treatments. For example, the 12-item Multiple Sclerosis Walking Scale (MSWS-12) measures the patient-reported impact of the disease on walking ability.

Objective

We studied longitudinal changes in walking ability using the MSWS-12 in a cohort of 108 patients with relapsing-remitting multiple sclerosis and moderate-to-severe disability from a single US center cohort study investigating multiple sclerosis symptoms and physical activity.

Methods

The MSWS-12 was completed every 6 months over 2 years together with self-reported measures of disease impact on daily life (Multiple Sclerosis Impact Scale) and walking disability (Patient Determined Disease Steps scale).

Results

The results revealed a high frequency of self-reported changes in walking ability at the individual level, affecting approximately 80% of patients for all four time periods. MSWS-12 scores remained stable at the group level for all four time periods. The magnitude of observed changes at the individual level was higher than the proposed minimal clinically important differences of 4 or 6 points and correlated better with Multiple Sclerosis Impact Scale physical scores than psychological scores, but little with self-reported Patient Determined Disease Steps Scale scores.

Conclusions

This novel finding of frequent fluctuations in self-reported walking ability is new and requires further investigation.

Ecological validity of walking capacity tests in multiple sclerosis

Background

Ecological validity implicates in how far clinical assessments refer to real life. Short clinical gait tests up to ten meters and 2- or 6-Minutes Walking Tests (2MWT/6MWT) are used as performance-based outcomes in Multiple Sclerosis (MS) studies and considered as moderately associated with real life mobility.

Objective

To investigate the ecological validity of 10 Meter Walking Test (10mWT), 2MWT and 6MWT.

Methods

Persons with MS performed 10mWT, 6MWT including 2MWT and 7 recorded days by accelerometry. Ecological validity was assumed if walking tests represented a typical walking sequence in real-life and correlations with accelerometry parameters were strong.

Results

In this cohort (n=28, medians: age=45, EDSS=3.2, disease duration=9 years), uninterrupted walking of 2 or 6 minutes occurred not frequent in real life (2.61 and 0.35 sequences/day). 10mWT correlated only with slow walking speed quantiles in real life. 2MWT and 6MWT correlated moderately with most real life walking parameters.

Conclusion

Clinical gait tests over a few meters have a poor ecological validity while validity is moderate for 2MWT and 6MWT. Mobile accelerometry offers the opportunity to control and improve the ecological validity of MS mobility outcomes.

Effects of functional electrical stimulation on gait function and quality of life for people with multiple sclerosis taking dalfampridine

BACKGROUND

Multiple sclerosis (MS) can adversely affect gait, causing gait slowing, loss of balance, decreased functional mobility, and gait deficits, such as footdrop. Current treatments for gait dysfunction due to MS are pharmacologic, using dalfampridine, or orthotic, using an ankle-foot orthosis. Functional electrical stimulation (FES) to the fibular nerve stimulates active dorsiflexion and provides an alternative treatment for gait dysfunction caused by footdrop. The objective of this study was to determine the effect of FES on gait function and the impact of MS on walking and quality of life for people with MS taking a stable dalfampridine dose.

METHODS

Participants demonstrating gait slowing and footdrop completed the Timed 25-Foot Walk (T25FW) test, 6-Minute Walk (6MW) test, GaitRite Functional Ambulation Profile, 12-item Multiple Sclerosis Walking Scale (MSWS-12), and 36-item Short Form Health Status Survey (SF-36) at screening without FES; the measures were repeated with FES at baseline, 1 month, and 3 months.

RESULTS

Twenty participants (8 men and 12 women) completed this unblinded case series study. The mean age, duration of MS, and time taking dalfampridine were 51.7, 15.8, and 1.4 years, respectively. Changes from screening to baseline and screening to 3 months were analyzed. Significant improvement was noted from screening to baseline for the MSWS-12 (P = .024) and SF-36 Physical Function domain (P = .028) and from screening to 3 months for the T25FW (P = .015), MSWS-12 (P = .003), and SF-36 Physical Function (P = .032) and Role Limitation-Physical Health (P = .012) domains.

CONCLUSIONS

Improvements above those induced pharmacologically suggest that FES can augment pharmacologic intervention and significantly improve gait function, decrease the impact of MS on walking, and improve quality of life for people with MS.