Upper limb assessment in multiple sclerosis: a systematic review of outcome measures and their psychometric properties

Psychometric properties of the modified reaching performance scale in persons with multiple sclerosis

BACKGROUND

A valid and reliable assessment tool to describe the quality of the movement pattern of reaching can provide valuable insights into motor performance deficits in persons with MS (pwMS). The Reaching Performance Scale, developed for stroke, is a promising scale to assess movement patterns in pwMS. However, psychometric properties of the scale are lacking in pwMS.

OBJECTIVES

Firstly, to investigate the content validity of the modified Reaching Performance Scale for application in patients with MS (mRPS). Secondly, to investigate the psychometric properties (within- and between-session reliability and concurrent validity) of the mRPS for pwMS.

METHODS

Forty-five pwMS (mean EDSS 6.6 pt, IQR 6-7.5) executed the mRPS that rates the quality of movement patterns and compensations during reach to grasp tasks. The content validity was determined by an expert panel based on observations of subjects performing the RPS. The reliability was based on five repetitions within one day, and between two days. For the concurrent validity, outcome measures at two levels of the International Classification of Functioning were correlated with the mRPS: Body Structure and Function level: Fugl-Meyer Assessment of the Upper Limb (FMA-UL), maximal isometric hand grip strength (HGS; Activity level: Action Research Arm Test (ARAT), Box and Blocks Test (BBT), Nine Hole Peg Test (NHPT) and Trunk Impairment Scale 2.0 (TIS 2.0) as well as perceived performance by the Manual Ability Measure-36 (MAM-36).

RESULTS

Scale modifications were made only on the ratings of the trunk displacement subscale. The mRPS had excellent agreement scores for within-session reliability (range of Kappa between 0.85 and 0.98) and moderate-to-excellent agreement scores for between-session reliability (K: 0.66-1.00). Regarding validity, the mRPS was highly correlated with the ARAT (rho=0.74, p < 0.001), followed by moderate correlations with trunk performance (TIS 2.0, rho= 0.61, p < 0.001), hand function (BBT: rho=0.64, p < 0.001; NHPT: rho=-0.61, p < 0.001) and perceived performance (MAM36 rho= 0.53, p < 0.001).

CONCLUSION

The mRPS is a reliable measurement tool to describe the movement pattern quality and motor compensations used during reaching in pwMS. Concerning concurrent validity, the mRPS is partially related to other measures of upper limb and trunk performance.

Weak grip strength among persons with multiple sclerosis having minimal disability is not related to agility or integrity of the corticospinal tract

INTRODUCTION

Mobility impairment is common in multiple sclerosis (MS); however, agility has received less attention. Agility requires strength and neuromuscular coordination to elicit controlled propulsive rapid whole-body movement. Grip strength is a common method to assess whole body force production, but also reflects neuromuscular integrity and global brain health. Impaired agility may be linked to loss of neuromuscular integrity (reflected by grip strength or corticospinal excitability).

OBJECTIVES

We aimed to determine whether grip strength would be associated with agility and transcranial magnetic stimulation (TMS)-based indices of corticospinal excitability and inhibition in persons with MS having low disability. We hypothesized that low grip strength would predict impaired agility and reflect low corticospinal excitability.

METHODS

We recruited 34 persons with relapsing MS (27 females; median [range] age 45.5 [21.0-65.0] years) and mild disability (median [range] Expanded Disability Status Scale 2.0 [0-3.0]), as well as a convenience sample of age- and sex-matched apparently healthy controls. Agility was tested by measuring hop length during bipedal hopping on an instrumented walkway. Grip strength was measured using a calibrated dynamometer. Corticospinal excitability and inhibition were examined using TMS-based motor evoked potential (MEP) and corticospinal silent period (CSP) recruitment curves, respectively.

RESULTS

MS participants had significantly lower grip strength than controls independent of sex. Females with and without MS had weaker grip strength than males. There were no statistically significant sex or group differences in agility. After controlling for sex, weaker grip strength was associated with shorter hop length in controls only (r = 0.645, p < .05). Grip strength did not significantly predict agility in persons with MS, nor was grip strength predicted by corticospinal excitability or inhibition.

CONCLUSIONS

In persons with MS having low disability, grip strength (normalized to body mass) was reduced despite having intact agility and walking performance. Grip strength was not associated with corticospinal excitability or inhibition, suggesting peripheral neuromuscular function, low physical activity or fitness, or other psychosocial factors may be related to weakness. Low grip strength is a putative indicator of early neuromuscular aging in persons with MS having mild disability and normal mobility.

Influence of virtual reality and task complexity on digital health metrics assessing upper limb function

BACKGROUND

Technology-based assessments using 2D virtual reality (VR) environments and goal-directed instrumented tasks can deliver digital health metrics describing upper limb sensorimotor function that are expected to provide sensitive endpoints for clinical studies. Open questions remain about the influence of the VR environment and task complexity on such metrics and their clinimetric properties.

METHODS

We aim to investigate the influence of VR and task complexity on the clinimetric properties of digital health metrics describing upper limb function. We relied on the Virtual Peg Insertion Test (VPIT), a haptic VR-based assessment with a virtual manipulation task. To evaluate the influence of VR and task complexity, we designed two novel tasks derived from the VPIT, the VPIT-2H (VR environment with reduced task complexity) and the PPIT (physical task with reduced task complexity). These were administered in an observational longitudinal study with 27 able-bodied participants and 31 participants with multiple sclerosis (pwMS, VPIT and PPIT only) and the value of kinematic and kinetic metrics, their clinimetric properties, and the usability of the assessment tasks were compared.

RESULTS

Intra-participant variability strongly increased with increasing task complexity (coefficient of variation + 56%) and was higher in the VR compared to the physical environment (+ 27%). Surprisingly, this did not translate into significant differences in the metrics' measurement error and test-retest reliability across task conditions (p > 0.05). Responsiveness to longitudinal changes in pwMS was even significantly higher (effect size + 0.35, p < 0.05) for the VR task with high task complexity compared to the physical instrumented task with low task complexity. Increased inter-participant variability might have compensated for the increased intra-participant variability to maintain good clinimetric properties. No significant influence of task condition on concurrent validity was present in pwMS. Lastly, pwMS rated the PPIT with higher usability than the VPIT (System Usability Scale + 7.5, p < 0.05).

CONCLUSION

The metrics of both the VR haptic- and physical task-based instrumented assessments showed adequate clinimetric properties. The VR haptic-based assessment may be superior when longitudinally assessing pwMS due to its increased responsiveness. The physical instrumented task may be advantageous for regular clinical use due to its higher usability. These findings highlight that both assessments should be further validated for their ideal use-cases.

Advanced neuroimaging techniques to explore the effects of motor and cognitive rehabilitation in multiple sclerosis

INTRODUCTION

Progress in magnetic resonance imaging (MRI) technology and analyses is improving our comprehension of multiple sclerosis (MS) pathophysiology. These advancements, which enable the evaluation of atrophy, microstructural tissue abnormalities, and functional plasticity, are broadening our insights into the effectiveness and working mechanisms of motor and cognitive rehabilitative treatments.

AREAS COVERED

This narrative review with selected studies discusses findings derived from the application of advanced MRI techniques to evaluate structural and functional neuroplasticity modifications underlying the effects of motor and cognitive rehabilitative treatments in people with MS (PwMS). Current applications as outcome measure in longitudinal trials and observational studies, their interpretation and possible pitfalls and limitations in their use are covered. Finally, we examine how the use of these techniques could evolve in the future to improve monitoring of motor and cognitive rehabilitative treatments.

EXPERT COMMENTARY

Despite substantial variability in study design and participant characteristics in rehabilitative studies for PwMS, improvements in motor and cognitive functions accompanied by structural and functional brain modifications induced by rehabilitation can be observed. However, significant enhancements to refine rehabilitation strategies are needed. Future studies in this field should strive to implement standardized methodologies regarding MRI acquisition and processing, possibly integrating multimodal measures. This will help identifying relevant markers of treatment response in PwMS, thus improving the use of rehabilitative interventions at individual level. The combination of motor and cognitive strategies, longer periods of treatment, as well as adequate follow-up assessments will contribute to enhance the quality of evidence in support of their routine use.

Influence of cognition on the correlation between objective and subjective upper limb measures in people with multiple sclerosis

BACKGROUND

A comprehensive assessment of upper limb (UL) function is mandatory in people with multiple sclerosis (PwMS), and the use of multiple objective and subjective measures is advisable. Findings on the role of cognitive impairment on the assessment of UL function are scant and inconclusive. The present study investigated the influence of cognitive function on the distribution of objective and subjective UL measures and on their association.

METHODS

In the cross-sectional study, subjects with a diagnosis of MS, age ≥ 18 years, right-hand dominance, no presence of orthopedic UL impairment, or other neurological diseases were recruited. The assessment protocol included the Nine-Hole Peg Test (9-HPT), Box and Block Test (BBT), and hand grip strength (HGS), a validated PROM (MAM-36), and the Symbol Digit Modalities Test (SDMT).

RESULTS

Two hundred forty-six PwMS were recruited (158 females, mean age = 51.65 ± 13.45 years; mean EDSS = 5.10 ± 1.88) Subject with mild-to-moderate cognitive impairment (SDMT ≤  - 2 SD of normative values) scored lower on the 9-HPT and higher on the BBT and MAM-36 when compared with subject with no cognitive impairment. Cognitive impairment showed a small but significant effect on the association between 9-HPT scores and the MAM-36.

DISCUSSION

Findings suggest that cognitive impairment is associated with subjects' performance on 9-HPT, BBT, and MAM-36 (but not HGS), resulting in scores indicating a poorer UL function. Interestingly, cognitive impairment slightly affected the congruence between subjective and objective UL measures, although only minor differences in the correlation pattern across groups reporting different cognitive performances emerged.

Soft Robotics to Enhance Upper Limb Endurance in Individuals with Multiple Sclerosis

Multiple sclerosis (MS) is a chronic autoimmune disorder that affects the central nervous system and can result in various symptoms, including muscle weakness, spasticity, and fatigue, ultimately leading to the deterioration of the musculoskeletal system. However, in recent years, exosuits have emerged as a game-changing solution to assist individuals with MS during their daily activities. These lightweight and affordable wearable robotic devices have gained immense popularity. In our study, we assessed the performance of an elbow exosuit on eight individuals with MS using high-density electromyography to measure biceps muscle activity. The results demonstrated that our prototype significantly reduced muscle effort during both dynamic and isometric tasks while increasing the elbow range of motion. In addition, the exosuit effectively delayed the onset of muscle fatigue, enhancing endurance for people with MS and enabling them to perform heavy duty tasks for a longer period.

Tablet app-based dexterity training in multiple sclerosis (TAD-MS): a randomized controlled trial

PURPOSE

Mobile health applications (mHealth apps) may lead to health benefits. In recent years, the use of apps in multiple sclerosis (MS) has increased. Apps to train and improve dexterity in MS are scarce. This study investigated the effectiveness of a tablet app-based home-based training to improve dexterity in individuals with MS.

MATERIALS AND METHODS

In a randomized controlled trial, two standardized 4-week home-based interventions focussing on different aspects of dexterity and upper limb function were compared. Assessments were done at baseline, post-intervention and 12-week follow-up. The primary endpoint was the Arm Function in Multiple Sclerosis Questionnaire, a dexterity-related measure of patient-reported activities of daily living. Secondary endpoints were dexterous function, grip strength and health-related quality of life.

RESULTS

Forty-eight individuals were randomly assigned to a tablet app-based program (n = 26) or a control strengthening exercise program (n = 22). No significant differences were found for the primary endpoint (p = 0.35). Some significant differences in favour of the app-group were found in fine coordinated finger movements and strength. No significant differences were found at the 12-week follow-up for all endpoints. Adherence in both groups was above 90%.

CONCLUSIONS

App-based training was not superior compared to a control strengthening exercise program concerning the arm- and hand function from the participant's perspective. However, app-based training was found to be effective in improving specific dimensions (finger movements and strength), and can easily be applied at home. Therefore, individuals living with MS with impaired dexterity should consider app-based training.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT03369470.

Don't be late! Postponing cognitive decline and preventing early unemployment in people with multiple sclerosis: a study protocol

BACKGROUND

Up to 65% of people with multiple sclerosis (PwMS) develop cognitive deficits, which hampers their ability to work, participating in day-to-day life and ultimately reducing quality of life (QoL). Early cognitive symptoms are often less tangible to PwMS and their direct environment and are noticed only when symptoms and work functioning problems become more advanced, i.e., when (brain) damage is already advanced. Treatment of symptoms at a late stage can lead to cognitive impairment and unemployment, highlighting the need for preventative interventions in PwMS.

AIMS

This study aims to evaluate the (cost-) effectiveness of two innovative preventative interventions, aimed at postponing cognitive decline and work functioning problems, compared to enhanced usual care in improving health-related QoL (HRQoL).

METHODS

Randomised controlled trial including 270 PwMS with mild cognitive impairment, who have paid employment ≥ 12 h per week and are able to participate in physical exercise (Expanded Disability Status Scale < 6.0). Participants are randomised across three study arms: 1) 'strengthening the brain' - a lifestyle intervention combining personal fitness, mental coaching, dietary advice, and cognitive training; 2) 'strengthening the mind' - a work-focused intervention combining the capability approach and the participatory approach in one-on-one coaching by trained work coaches who have MS themselves; 3) Control group-receiving general information about cognitive impairment in MS and receiving care as usual. Intervention duration is four months, with short-term and long-term follow-up measurements at 10 and 16 months, respectively. The primary outcome measure of the Don't be late! intervention study will be HRQoL as measured with the 36-item Short Form. Secondary outcomes include cognition, work related outcomes, physical functioning, structural and functional brain changes, psychological functioning, and societal costs. Semi-structured interviews and focus groups with stakeholders will be organised to qualitatively reflect on the process and outcome of the interventions.

DISCUSSION

This study seeks to prevent (further) cognitive decline and job loss due to MS by introducing tailor-made interventions at an early stage of cognitive symptoms, thereby maintaining or improving HRQoL. Qualitative analyses will be performed to allow successful implementation into clinical practice.

TRIAL REGISTRATION

Retrospectively registered at ClinicalTrials.gov with reference number NCT06068582 on 10 October 2023.

Upper limb dysfunction in people with early-stage Multiple Sclerosis: Perceived performance can be misleading

BACKGROUND

Although the necessity of upper limb (UL) (dys)function assessment in people with Multiple Sclerosis (pwMS) has been demonstrated in recent years, this is still neglected at an early-stage.

OBJECTIVE

The aim of our study was to comprehensively examine bilateral UL in early-stage pwMS who are thought to have no or minimal involvement in activities of daily living for the UL.

METHODS

UL muscle strength, sensation and dexterity of 44 pwMS (EDSS score<4, disease duration<5 years, who did not report problems in daily living activities specifically for the UL) were evaluated bilaterally and compared with 44 healthy controls (HC). The relationship between UL function and muscle strength, sensation, cognitive function, fatigue, mood status, participation, EDSS, and disease duration were examined. The results of the outcome measures evaluating the UL function objectively and subjectively were analyzed.

RESULTS

Muscle strength, sensation and dexterity were similar in the dominant and nondominant extremities of pwMS and were affected compared to HC. A fair relationship was found between UL function and proximal muscle strength, fatigue, cognitive function, home participation and EDSS. According to the cut-off value (18 s) of Nine Hole Peg Test, only 9.09% of pwMS was unaffected, but 79.54% of affected pwMS had a full ABILHAND score.

CONCLUSION

Early-stage pwMS are unaware of the dysfunction since their UL involvement does not affect their daily living activities yet. Patient-reported outcome measures such as ABILHAND can be misleading and have a ceiling effect in the early-stage of the disease. Objective functional evaluations reveal that UL capacity is affected from the early period. Even if pwMS do not report UL involvement, clinicians and researchers should evaluate UL function and include it in the treatment program from an early-stage to prevent further disease burden.

The correlation between 9-HPT and patient-reported measures of upper limb function in multiple sclerosis: a systematic review and meta-analysis

Upper limb function is one of the most affected domains in people with multiple sclerosis (PwMS), as self-reported by 50% of patients. Heterogeneous results have been found about the correlation between objective and subjective upper limb function. The aim of the present study is to perform a systematic review and meta-analysis of studies presenting data on the strength of association between the gold standard for 9-Hole Peg Test scores and Patient-Reported Outcome Measures (PROMs) of manual ability. Primary research studies including assessments of 9-Hole Peg Test scores and Patient-Reported Outcome Measures were searched in Scopus, Web of Science, and PubMed. Meta analytical calculations were performed using a random-effects model. We retrieved n = 27 studies including n = 75 distinct effect sizes (N of subjects = 3263). The central tendency analysis showed a strong correlation between 9-HPT scores and PROMs (r = 0.51, 95% CI [0.44, 0.58]). Moderator analysis showed the effect size to be significantly larger in studies with a mean or median EDSS level indicating severe disability. The publication bias hypothesis was not supported; instead, we noted that studies based on larger samples also tend to report stronger effect sizes. Results of the study indicate that the correlation between 9-HPT and PROMs is strong, although the constructs measured by these instrument does not fully overlap. The correlation between 9-HPT and PROMs was stronger in larger studies and when samples include a sizeable subgroup of PwMS with severe disability, pointing out the importance of sample diversity.

Use of a physiological profile to document upper limb motor impairment in ageing and in neurological conditions

Profiling performance in the physiological domains underpinning upper limb function (such as strength, sensation, coordination) provides insight into an individual's specific impairments. This compliments the traditional medical 'diagnosis' model that is currently used in contemporary medicine. From an initial battery of 13 tests in which data were collected across the adult lifespan (n = 367, 20-95 years) and in those with neurological conditions (specifically, multiple sclerosis (n = 40), Parkinson's disease (n = 34), and stroke (n = 50)), six tests were selected to comprise a core upper limb physiological profile assessment (PPA). This comprised measures of handgrip strength, simple reaction time, finger dexterity, tactile sensation, bimanual coordination, and a functional task. Individual performance in each of these tests can be compared to a reference population score (devised from our database of healthy individuals aged under 60 years), informing the researcher or clinician how to best direct an intervention or treatment for the individual based on their specific impairment(s). Lastly, a composite score calculated from the average performance across the six tests provides a broad overview of an individual's overall upper limb function. Collectively, the upper limb PPA highlights specific impairments that are prevalent within distinct pathologies and reveals the magnitude of upper limb motor impairment specific to each condition.

Comparison of Various Smoothness Metrics for Upper Limb Movements in Middle-Aged Healthy Subjects

BACKGOUND

Metrics for movement smoothness include the number of zero-crossings on the acceleration profile (N0C), the log dimensionless jerk (LDLJ), the normalized averaged rectified jerk (NARJ) and the spectral arc length (SPARC). Sensitivity to the handedness and movement type of these four metrics was compared and correlations with other kinematic parameters were explored in healthy subjects.

METHODS

Thirty-two healthy participants underwent 3D upper limb motion analysis during two sets of pointing movements on each side. They performed forward- and backward-pointing movements at a self-selected speed to a target located ahead at shoulder height and at 90% arm length, with and without a three-second pause between forward and backward movements. Kinematics were collected, and smoothness metrics were computed.

RESULTS

LDLJ, NARJ and N0C found backward movements to be smoother, while SPARC found the opposite. Inter- and intra-subject coefficients of variation were lowest for SPARC. LDLJ, NARJ and N0C were correlated with each other and with movement time, unlike SPARC.

CONCLUSION

There are major differences between smoothness metrics measured in the temporal domain (N0C, LDLJ, NARJ), which depend on movement time, and those measured in the frequency domain, the SPARC, which gave results opposite to the other metrics when comparing backward and forward movements.

Psychometric properties of performance-based measures of physical function administered via telehealth among people with chronic conditions: A systematic review

Background

Telehealth could enhance rehabilitation for people with chronic health conditions. This review examined the psychometric properties of performance-based measures of physical function administered via telehealth among people with chronic health conditions using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) approach.

Methods

This systematic review was registered with Prospero (Registration number: CRD42021262547). Four electronic databases were searched up to June 2022. Study quality was evaluated by two independent reviewers using the COSMIN risk of bias checklist. Measurement properties were rated by two independent reviewers in accordance with COSMIN guidance. Results were summarised according to the COSMIN approach and the modified GRADE approach was used to grade quality of the summarised evidence.

Results

Five articles met the eligibility criteria. These included patients with Parkinson’s Disease (n = 2), stroke (n = 1), cystic fibrosis (n = 1) and chronic heart failure (n = 1). Fifteen performance-based measures of physical function administered via videoconferencing were investigated, spanning measures of functional balance (n = 7), other measures of general functional capacity (n = 4), exercise capacity (n = 2), and functional strength (n = 2). Studies were conducted in Australia (n = 4) and the United States (n = 1). Reliability was reported for twelve measures, with all twelve demonstrating sufficient inter-rater and intra-rater reliability. Criterion validity for all fifteen measures was reported, with eight demonstrating sufficient validity and the remaining seven demonstrating indeterminate validity. No studies reported data on measurement error or responsiveness.

Conclusions

Several performance-based measures of physical function across the domains of exercise capacity, strength, balance and general functional capacity may have sufficient reliability and criterion validity when administered via telehealth. However, the evidence is of low-very low quality, reflecting the small number of studies conducted and the small sample sizes included in the studies. Future research is needed to explore the measurement error, responsiveness, interpretability and feasibility of these measures administered via telehealth.

Bibliometric Analysis of Research on the Use of the Nine Hole Peg Test

Manual dexterity is essential for performing daily life tasks, becoming a primary means of interaction with the physical, social, and cultural environment. In this respect, the Nine Hole Peg Test (NHPT) is considered a gold standard for assessing manual dexterity. Bibliometrics is a discipline that focuses on analyzing publications to describe, evaluate, and predict the status and development trends in certain fields of scientific research. We performed a bibliometric analysis to track research results and identify global trends regarding the use of the NHPT. The bibliographic data were retrieved from the Web of Science database and then analyzed using the Bibliometrix R package, resulting in the retrieval of a total of 615 publications from 1988 to 2021. Among the 263 journals investigated, the most prolific were the Multiple Sclerosis Journal, Clinical Rehabilitation, and Multiple Sclerosis and Related Disorders. North America and Europe were the areas with the highest production of publications, with the United States (n = 104) ranking first in terms of the number of publications, followed by the United Kingdom (n = 62) and Italy (n = 62). The analysis of keywords revealed that there were two main lines of research, with one related to the study of recovery and disability of the upper limbs caused by certain diseases and another related to the study of reliability and validity. Structured information can be useful to understand the research trajectory and the uses of this tool.

Mapping grip-force related brain activity after a fatiguing motor task in multiple sclerosis

BACKGROUND

Motor fatigue is common in multiple sclerosis (MS), but its pathophysiology is still poorly understood. Here we used functional magnetic resonance imaging (fMRI) to delineate how the acute induction of motor fatigue alters functional activity of the motor system and how these activity changes are related to motor fatigue.

METHOD

Forty-four right-handed mildly disabled patients with relapsing-remitting MS and 25 healthy controls performed a maximal tonic precision grip with their right hand until they developed motor fatigue. Before and after the fatiguing task, participants performed a non-fatiguing tonic grip force task, producing 15-20% of their maximum grip force based on visual feedback. Task related brain activity was mapped with blood-oxygen level dependent fMRI at 3 T. Statistical parametric mapping was used to identify relative changes in task-related activation from the pre-fatigue to the recovery MRI session.

RESULTS

Following fatigue induction, task performance was perturbed in both groups, and task-related activation increased in the right (ipsilateral) primary motor hand area. In patients with MS, task-related activity increased bilaterally during the recovery phase in the ventrolateral portion of the middle putamen and lateral prefrontal cortex relative to controls. The more patients increased task-related activity in left dorsal premotor cortex after the fatiguing task, the less they experienced motor fatigue during daily life.

CONCLUSION

Patients with MS show enhanced functional engagement of the associative cortico-basal ganglia loop following acute induction of motor fatigue in the contralateral hand. This may reflect increased mental effort to generate movements in the recovery phase after fatigue induction. The ability to recruit the contralateral dorsal premotor cortex after fatigue induction may constitute a protective mechanism against experiencing motor fatigue in everyday life.

Goal-directed upper limb movement patterns and hand grip forces in multiple sclerosis

Background

Upper limb disability in persons with Multiple Sclerosis (pwMS) leads to increased dependence on caregivers. To better understand upper limb disability, observer-based or time-based clinical assessments have been applied. However, these only poorly capture the behavioural aspects underlying goal-directed task performance.

Objective

We aimed to document alterations in goal-directed upper limb movement patterns and hand grip forces in a cohort of pwMS (n = 123) with mild to moderate upper limb impairments.

Methods

We relied on the Virtual Peg Insertion Test (VPIT), a technology-aided assessment with a goal-directed pick-and-place task providing a set of validated digital health metrics.

Results

All metrics indicated significant differences to an able-bodied reference sample (p < 0.001), with smoothness, speed, and grip force control during object manipulation being most affected in pwMS. Such abnormalities negatively influenced the time to complete the goal-directed task (p < 0.001, R2 = 0.77), thereby showing their functional relevance. Lastly, abnormalities in movement patterns and grip force control were consistently found even in pwMS with clinically normal gross dexterity and grip strength.

Conclusion

This work provides a systematic documentation on goal-directed upper limb movement patterns and hand grip forces in pwMS, ultimately paving the way for an early detection of MS sign using digital health metrics.

Quantification of upper limb dysfunction in the activities of the daily living in persons with multiple sclerosis

BACKGROUND

Dysfunction in upper limb (UL) function has been reported as an important indicator for disease progression in persons with multiple sclerosis (PwMS), thus a relevant outcome in clinical trials. However, standard assessment of UL function is limited to Nine-Hole Peg Test (NHPT) which assesses fine dexterity. This study aimed to deeply endophenotype UL involvement in PwMS and identify the most accurate set of measures needed to capture the complexity of UL dysfunction in the activities of daily living (ADL).

METHODS

257 PwMS underwent an extensive UL assessment using standardized measures of grip strength and endurance, coordination, vibratory and tactile sensation, dexterity, capacity and functionality. Limitation in ADL was defined from an objective perspective using a timed test (Test d'Evaluation de la performance des Membres Supérieurs des Personnes Âgées: TEMPA) and from a subjective perspective using a questionnaire (Disabilities of the Arm, Shoulder and Hand: DASH). Disease severity subgroups were compared utilizing the Kruskal-Wallis test and frequencies determined the prevalence of abnormal UL for each measure. The Jonckheere-Terpstra test compared tested variables with disease severity. Then Receiver operating characteristic (ROC) curve analysis was used to test the accuracy of each tested variable in defining abnormality in the TEMPA and DASH. Cut-off scores were calculated using the Youden index. The predictive value of various tests over TEMPA and DASH were tested using a linear regression analysis.

RESULTS

UL dysfunction was highly prevalent in all the modalities tested, even in participants with no/mild disability. Box and Block Test (BBT), finger-nose test (FNT), and NHPT were independently selected with ROC analyses as the most accurate measures in detecting abnormalities in TEMPA and DASH. In multivariate regression models, BBT and FNT, and NHPT all contributed to predicting TEMPA (adj. R² 0.795, P < 0.001), while only BBT and FNT predicted DASH.

CONCLUSIONS

UL dysfunction is highly prevalent in PwMS, even when global disability is mild. BBT and FNT are time-efficient and cost-effective measures that complement the NHPT for more precise monitoring of PwMS at all disease stages.

Effects and safety of exergaming in persons with multiple sclerosis during corticosteroid treatment: a pilot study

BACKGROUND

There is no information about the effects and usability of rehabilitation during corticosteroid treatment. This randomized clinical trial was conducted to evaluate and compare the effects and safety of exergaming and conventional rehabilitation (CR) on persons with multiple sclerosis (MS, pwMS) during corticosteroid treatment.

METHODS

The participants were randomly divided into two groups: Exergaming (n=15) and CR (n=15). Rehabilitation was applied by a physiotherapist who has expertise in MS. Measurements were done at baseline (T1), immediately after discharge (T2), and 1 month after discharge (T3). The outcome measures included upper extremity functions, walking, balance, cognitive functions, quality of life, depression, and fatigue.

RESULTS

The Nine Hole Peg Test, California Verbal Learning Test, Symbol Digit Modalities Test, MS Walking Scale-12, Six Spot Step Test showed a significant difference between T1 to T2 and T1 to T3 in the exergaming and CR groups (p < 0.05). The Timed 25 Foot Walk and Multiple Sclerosis International Quality of Life Questionnaire were significantly different between T1 to T3 in the exergaming and CR groups (p < 0.05). Brief Visuospatial Memory Test-Revised was significantly different between T1 to T3 and T2 to T3 in the exergaming and CR groups (p < 0.05). The MFIS showed a significant difference between T1 to T2 and T1 to T3 in the exergaming group (p < 0.05).

CONCLUSIONS

This study suggests that exergaming and CR are effective and safe methods for improving upper extremity, cognitive functions, fatigue, quality of life, balance, and walking ability in pwMS during the hospitalization period.

Assessing visually guided reaching in people with multiple sclerosis with and without self-reported upper limb impairment

The ability to accurately complete goal-directed actions, such as reaching for a glass of water, requires coordination between sensory, cognitive and motor systems. When these systems are impaired, like in people with multiple sclerosis (PwMS), deficits in movement arise. To date, the characterization of upper limb performance in PwMS has typically been limited to results attained from self-reported questionnaires or clinical tools. Our aim was to characterize visually guided reaching performance in PwMS. Thirty-six participants (12 PwMS who reported upper limb impairment (MS-R), 12 PwMS who reported not experiencing upper limb impairment (MS-NR), and 12 age- and sex-matched control participants without MS (CTL)) reached to 8 targets in a virtual environment while seeing a visual representation of their hand in the form of a cursor on the screen. Reaches were completed with both the dominant and non-dominant hands. All participants were able to complete the visually guided reaching task, such that their hand landed on the target. However, PwMS showed noticeably more atypical reaching profiles when compared to control participants. In accordance with these observations, analyses of reaching performance revealed that the MS-R group was more variable with respect to the time it took to initiate and complete their movements compared to the CTL group. While performance of the MS-NR group did not differ significantly from either the CTL or MS-R groups, individuals in the MS-NR group were less consistent in their performance compared to the CTL group. Together these findings suggest that PwMS with and without self-reported upper limb impairment have deficits in the planning and/or control of their movements. We further argue that deficits observed during movement in PwMS who report upper limb impairment may arise due to participants compensating for impaired movement planning processes.

Split-Belt Training but Not Cerebellar Anodal tDCS Improves Stability Control and Reduces Risk of Fall in Patients with Multiple Sclerosis

The objective of this study was to examine the therapeutic potential of multiple sessions of training on a split-belt treadmill (SBT) combined with cerebellar anodal transcranial direct current stimulation (tDCS) on gait and balance in People with Multiple Sclerosis (PwMS). Twenty-two PwMS received six sessions of anodal (PwMS_real, n = 12) or sham (PwMS_sham, n = 10) tDCS to the cerebellum prior to performing the locomotor adaptation task on the SBT. To evaluate the effect of the intervention, functional gait assessment (FGA) scores and distance walked in 2 min (2MWT) were measured at the baseline (T0), day 6 (T5), and at the 4-week follow up (T6). Locomotor performance and changes of motor outcomes were similar in PwMS_real and PwMS_sham independently from tDCS mode applied to the cerebellum (anodal vs. sham, on FGA, p = 0.23; and 2MWT, p = 0.49). When the data were pooled across the groups to investigate the effects of multiple sessions of SBT training alone, significant improvement of gait and balance was found on T5 and T6, respectively, relative to baseline (FGA, p < 0.001 for both time points). The FGA change at T6 was significantly higher than at T5 (p = 0.01) underlining a long-lasting improvement. An improvement of the distance walked during the 2MWT was also observed on T5 and T6 relative to T0 (p = 0.002). Multiple sessions of SBT training resulted in a lasting improvement of gait stability and endurance, thus potentially reducing the risk of fall as measured by FGA and 2MWT. Application of cerebellar tDCS during SBT walking had no additional effect on locomotor outcomes.

Efficacy of a technology-based client-centred training system in neurological rehabilitation: a randomised controlled trial

Background

A client-centred task-oriented approach has advantages towards motivation and adherence to therapy in neurorehabilitation, but it is costly to integrate in practice. An intelligent Activity-based Client-centred Training (i-ACT), a low-cost Kinect-based system, was developed which integrates a client-centred and task-oriented approach. The objectives were (1) to investigate the effect of additional i-ACT training on functioning. And (2) to assess whether training with i-ACT resulted in more goal oriented training.

Methods

A single-blind randomised controlled trial was performed in 4 Belgian rehabilitation centres with persons with central nervous system deficits. Participants were randomly allocated through an independent website-based code generator using blocked randomisation (n = 4) to an intervention or control group. The intervention group received conventional care and additional training with i-ACT for 3 × 45 min/week during 6 weeks. The control group received solely conventional care. Functional ability and performance, quality of life (QoL), fatigue, trunk movement, and shoulder active range of motion (AROM) were assessed at baseline, after 3 weeks and 6 weeks of training, and 6 weeks after cessation of training. Data were analysed using non-parametric within and between group analysis.

Results

47 persons were randomised and 45 analysed. Both intervention (n = 25) and control (n = 22) group improved over time on functional ability and performance as measured by the Wolf Motor Function Test, Manual Ability Measure-36, and Canadian Occupational Performance Measure, but no major differences were found between the groups on these primary outcome measures. Regarding QoL, fatigue, trunk movement, and shoulder AROM, no significant between group differences were found. High adherence for i-ACT training was found (i.e. 97.92%) and no adverse events, linked to i-ACT, were reported. In the intervention group the amount of trained personal goals (88%) was much higher than in the control group (46%).

Conclusions

Although additional use of i-ACT did not have a statistically significant added value regarding functional outcome over conventional therapy, additional i-ACT training provides more individualised client-centred therapy, and adherence towards i-ACT training is high. A higher intensity of i-ACT training may increase therapy effects, and should be investigated in future research.

Trial registration: ClinicalTrials.gov Identifier NCT02982811. Registered 29 November 2016.

Original articleQuantifying upper-limb motor impairment in people with multiple sclerosis: a physiological profiling approach

BACKGROUND

. Upper-limb sensory and motor impairments are common in people with multiple sclerosis (MS), yet the current gold standard criteria for documenting functional impairment largely focuses on mobility, balance and postural stability.

OBJECTIVE

. We aimed to determine the validity of the upper-limb Physiological Profile Assessment (PPA) in people with MS by investigating whether the included domains of muscle strength, dexterity, arm stability, position sense, skin sensation and bimanual coordination 1) are sensitive in differentiating people with MS from healthy controls and 2) correlate with a validated measure of upper-limb function and a scale for quantifying disability in MS.

METHODS

. In a cross-sectional study, 40 participants with MS and 80 healthy controls completed all 13 of the upper-limb PPA tests within a single session.

RESULTS

. People with MS were impaired across all physiological domains tested. Performance in 4 of the 13 tests was correlated with a validated measure of self-reported upper-limb function (Pearson's r or Spearman's rho -0.333-0.441), whereas 3 tests were associated with the degree of MS-specific disability (Spearman's rho -0.318; 0.456).

CONCLUSIONS

. The upper-limb PPA offers a valid and clinically suitable assessment of upper-limb function in people with MS. Clinicians should prioritise assessments of motor speed, fine motor control and functional tasks in their assessment of upper-limb function in people with MS because these domains are the most commonly and significantly impaired.

Evaluation of upper extremity ataxia through image processing in individuals with multiple sclerosis

BACKGROUND

Impaired dexterity is a frequently reported disability among people with ataxic multiple sclerosis (MS).

OBJECTIVE

To quantify and standardize the evaluation of upper extremity coordination disorder among patients with multiple sclerosis (MS), using the Tablet Ataxia Assessment Program (TAAP).

METHODS

The X and Y axis movements of 50 MS patients and 30 healthy individuals who were evaluated using the International Cooperative Ataxia Rating Scale (ICARS) were also assessed using TAAP. The functional times of the participants' right and left hands were recorded using the nine-hole peg test (NHPT). The upper extremity coordination of individuals with MS was evaluated using the upper extremity kinetic functions section of ICARS.

RESULTS

The deviations for the X and Y axis movements of the MS group were greater than those of the control group (p<0.05). Significant correlations were shown between TAAP scores and NHPT and ICARS scores. The strongest correlation was found between NHPT and ICARS in the dominant hand (rnhpt=0.356, pnhpt=0.001; ricars=0.439, picars=0.000). In correlating the Y axis with ICARS, the deviations in the Y axis were found to be greater in the non-dominant hand than those in the X axis (ryright=0.402, pyright=0.004; ryleft=0.691, pyleft=0.000).

CONCLUSION

Measurement using TAAP is more sensitive than other classical and current methods for evaluating ataxia. We think that TAAP is an objective tool that will allow neurorehabilitation professionals and clinicians to evaluate upper extremity coordination.

Personalized prediction of rehabilitation outcomes in multiple sclerosis: a proof-of-concept using clinical data, digital health metrics, and machine learning

Predicting upper limb neurorehabilitation outcomes in persons with multiple sclerosis (pwMS) is essential to optimize therapy allocation. Previous research identified population-level predictors through linear models and clinical data. This work explores the feasibility of predicting individual neurorehabilitation outcomes using machine learning, clinical data, and digital health metrics. Machine learning models were trained on clinical data and digital health metrics recorded pre-intervention in 11 pwMS. The dependent variables indicated whether pwMS considerably improved across the intervention, as defined by the Action Research Arm Test (ARAT), Box and Block Test (BBT), or Nine Hole Peg Test (NHPT). Improvements in ARAT or BBT could be accurately predicted (88% and 83% accuracy) using only patient master data. Improvements in NHPT could be predicted with moderate accuracy (73%) and required knowledge about sensorimotor impairments. Assessing these with digital health metrics over clinical scales increased accuracy by 10%. Non-linear models improved accuracy for the BBT (+ 9%), but not for the ARAT (-1%) and NHPT (-2%). This work demonstrates the feasibility of predicting upper limb neurorehabilitation outcomes in pwMS, which justifies the development of more representative prediction models in the future. Digital health metrics improved the prediction of changes in hand control, thereby underlining their advanced sensitivity.

Graphical Abstract

European evidence-based recommendations for clinical assessment of upper limb in neurorehabilitation (CAULIN): data synthesis from systematic reviews, clinical practice guidelines and expert consensus

BACKGROUND

Technology-supported rehabilitation can help alleviate the increasing need for cost-effective rehabilitation of neurological conditions, but use in clinical practice remains limited. Agreement on a core set of reliable, valid and accessible outcome measures to assess rehabilitation outcomes is needed to generate strong evidence about effectiveness of rehabilitation approaches, including technologies. This paper collates and synthesizes a core set from multiple sources; combining existing evidence, clinical practice guidelines and expert consensus into European recommendations for Clinical Assessment of Upper Limb In Neurorehabilitation (CAULIN).

METHODS

Data from systematic reviews, clinical practice guidelines and expert consensus (Delphi methodology) were systematically extracted and synthesized using strength of evidence rating criteria, in addition to recommendations on assessment procedures. Three sets were defined: a core set: strong evidence for validity, reliability, responsiveness and clinical utility AND recommended by at least two sources; an extended set: strong evidence OR recommended by at least two sources and a supplementary set: some evidence OR recommended by at least one of the sources.

RESULTS

In total, 12 measures (with primary focus on stroke) were included, encompassing body function and activity level of the International Classification of Functioning and Health. The core set recommended for clinical practice and research: Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT); the extended set recommended for clinical practice and/or clinical research: kinematic measures, Box and Block Test (BBT), Chedoke Arm Hand Activity Inventory (CAHAI), Wolf Motor Function Test (WMFT), Nine Hole Peg Test (NHPT) and ABILHAND; the supplementary set recommended for research or specific occasions: Motricity Index (MI); Chedoke-McMaster Stroke Assessment (CMSA), Stroke Rehabilitation Assessment Movement (STREAM), Frenchay Arm Test (FAT), Motor Assessment Scale (MAS) and body-worn movement sensors. Assessments should be conducted at pre-defined regular intervals by trained personnel. Global measures should be applied within 24 h of hospital admission and upper limb specific measures within 1 week.

CONCLUSIONS

The CAULIN recommendations for outcome measures and assessment procedures provide a clear, simple, evidence-based three-level structure for upper limb assessment in neurological rehabilitation. Widespread adoption and sustained use will improve quality of clinical practice and facilitate meta-analysis, critical for the advancement of technology-supported neurorehabilitation.

The Influence of Self-Perception on Manipulative Dexterity in Adults with Multiple Sclerosis

Background

Multiple sclerosis is a disorder which causes a loss of functionality, affecting the person's ability to perform activities of daily living, such as interpersonal interactions and relationship, dressing, self-care, or bathing, as well as having a negative impact on work and leisure activities.

Aims

This study examined the relationship (correlational or associations/predictive) between self-perceived quality of life and performance of manipulative dexterity. Also, this study sought to measure predictors of dexterity. Study Design. A cross-sectional study from two associations of MS within the Community of Madrid, Spain. Methods and Procedures. A final sample of 30 people with multiple sclerosis. The outcome measures used were the ABILHAND questionnaire, the Purdue Pegboard Test, the Nine Hole Peg Test, and the Box and Block Test.

Results

No significant correlations were found between dexterity and self-perception tests; however, correlations were found between perceived dexterity and quality of life (p < 0.001). Scores for the ABILHAND questionnaire, which measures the perception of skills in daily living, predicted up to 60% of the variance in the dexterity tests.

Conclusions

The results of this study suggest that interventions for improving the manipulative dexterity of people with multiple sclerosis should address the person's perception of improving their manipulative dexterity and the perceived of quality of life, as both factors may influence manipulative dexterity.

Italian translation and psychometric validation of the ABILHAND-26 and its correlation with upper limb objective and subjective measures in multiple sclerosis subjects

BACKGROUND

Upper limb (UL) function is affected in about 50% of people with Multiple Sclerosis (PwMS). In the last decade, Patient Reported Outcome Measures (PROM) are playing an important role in clinical trial and practice. ABILIHAND-26 is a PROM that assess self-perceived manual ability defined as the capacity to manage daily activities using the upper limbs. The aim of the study is to translate the ABILHAND-26 into Italian, to explore its psychometric properties examining the associations with demographics, clinical variables, 9-Hole Peg Test (9-HPT) and Manual Ability Measures-36 (MAM-36).

MATERIALS AND METHODS

Subjects were recruited in five Italian neurological centers. They were evaluated through ABILHAND-26, 9-HPT and MAM-36. Confirmatory factor analysis and Rasch analysis were adopted to investigate the psychometric properties of the ABILHAND-26.

RESULTS

Two hundred and forty-five patients were recruited. Rasch analyses showed adequate functioning and supported the unidimensionality of the scale. ABILHAND-26 showed negative correlations with age and disease duration, moderate negative correlation with EDSS and the 9-HPT scores for both arms and strong positive associations (ρ ≥ .84) with the MAM-36. Difference in ABILHAND-26 scores only emerged when comparing patients with severe disability (EDSS ≥ 6) with patients with either mild or moderate disability. t) and when comapring relapsing-remitting and secondary progressive patients.

CONCLUSION

The Italian version of the ABILHAND-26 is now available. It shows adequate reliability of the score, moderate criterion validity and strong convergent validity. ABILHAND-26 could represent a valid assessment for self-perceived ability to perform manual activity, especially for PwMS with moderate-to-high level of disability.

Motivation, Usability, and Credibility of an Intelligent Activity-Based Client-Centred Training System to Improve Functional Performance in Neurological Rehabilitation: An Exploratory Cohort Study

(1) Background: technology-based training systems are increasingly integrated in neurorehabilitation but are rarely combined with a client-centred task-oriented approach. To provide a low-cost client-centred task-oriented system, the intelligent activity-based client-centred task-oriented training (i-ACT) was developed. The objective was to evaluate the usability, credibility and treatment expectancy of i-ACT, and the motivation towards i-ACT use in rehabilitation over time. Additionally, this study will evaluate the upper limb treatment effects after training with i-ACT. (2) Methods: a mixed-method study was performed in four rehabilitation centres. Training with i-ACT was provided during six weeks, three times per week, forty-five minutes per day, additional to conventional care. (3) Results: seventeen persons with central nervous system diseases were included. High scores were seen in the system usability scale (score ≥ 73.8/100), credibility (score ≥ 22.0/27.0)/expectancy (score ≥ 15.8/27.0) questionnaire, and intrinsic motivation inventory (score ≥ 5.2/7.0), except the subscale pressure (score ≤ 2.0/7.0). Results from the interviews corroborate these findings and showed that clients and therapists believe in the i-ACT system as an additional training support system. Upper limb functional ability improved significantly (p < 0.05) over time on the Wolf motor function test. (4) Conclusion: i-ACT is a client-centred task-oriented usable and motivational system which has the potential to enhance upper limb functional training in persons with neurological diseases.

A Descriptive Correlational Study to Evaluate Three Measures of Assessing Upper Extremity Function in Individuals with Multiple Sclerosis

BACKGROUND

Activities of daily living and quality of life (QOL) are hindered by upper extremity (UE) impairments experienced by individuals with multiple sclerosis (iMS). The Nine-Hole Peg Test (9-HPT) is most frequently used to measure UE function. However, it does not measure peoples' ability to perform routine tasks in daily life and may not be useful in iMS who cannot pick up the pegs utilized in the 9-HPT. Therefore, we evaluated three measures to explore a more comprehensive assessment of UE function: Upper Extremity Function Scale (UEFS), Action Research Arm Test (ARAT), and the 9-HPT. The objectives were to quantitatively assess the relationship between these measures of UE function, understand if the measures correlate with QOL as calculated by the MS Quality of Life-54 (MSQOL-54), and to determine differences in the measures based on employment status.

METHODS

112 (79 female) iMS were prospectively recruited for this descriptive correlational study. Inclusion criteria were as follows: confirmed diagnosis of MS or clinically isolated syndrome, age ≥ 18 years, and ability to self-consent. All statistical analyses including Spearman's correlation coefficient (r s ) and Kruskal-Wallis tests were performed using SPSS.

RESULTS

A moderate correlation (r s = -0.51; p < 0.001) was found between the ARAT and 9-HPT scores for the more impaired hand. Likewise, a moderate correlation was found between UEFS and the physical health composite scores (PHCSs) of MSQOL-54 (r s = -0.59; p < 0.001). Finally, performances on ARAT, 9-HPT, and UEFS differed between the employed individuals and those on long-term disability (p = 0.007, p < 0.001, and p = 0.001).

CONCLUSION

The UEFS moderately correlated with the QOL measure, and considering the UESF is a patient-reported outcome, it could be used to complement routinely captured measures of assessing UE function. Further study is warranted to determine which measure, or combination of measures, is more sensitive to changes in UE function over time.

A comparison of upper limb function in subjects with multiple sclerosis and healthy controls using an inertial measurement unit

Upper limbs (UL) dysfunction is frequent in people with Multiple Sclerosis (PwMS). Several objective measures of UL function are proposed; however, their use is mostly confined to assess subjects with mild-to-moderate disability and requires fine motor skills, often impaired in high disability level subjects. Thus, a tool to score UL function in the advanced disease stage is lacking. The aim of the study is to analyse and compare UL unilateral and bilateral movements of healthy control (HC) and PwMS, at different disability levels, using an instrumented version (Inertial Measurement Unit, IMU) of the 15-seconds finger-to-nose test (FNT). Each movement cycle was segmented in going/adjusting/returning phases. The inter-hand interval (IHI) allowed assessing bilateral coordination (i.e. synchrony) in each phase. The larger IHI, the more severe the bilateral coordination impairment is. After stratifying PwMS for disability level (PwMS_LOW, Expanded Disability Status Scale, EDSS≤5.5 and PwMS_HIGH, EDSS≥6), the ANOVA on IHI showed significant differences between PwMS and HC (p<0.001) in all phases. However, only the going phase IHI showed significantly higher asynchrony in PwMS_HIGH than PwMS_LOW and HC (p<0.001) and no differences between PwMS_LOW and HC. The going phase IHI seems to be a clinical marker specific for high disability level PwMS. These findings suggest inertial sensors during FNT could be an easy-to-use method for a more detailed quantitative characterization of UL function in PwMS also in subjects with EDSS greater than 6.

Reliability and validity of the Upper Limb Functional Test (ULIFT) for women after breast cancer surgery

PURPOSE

To evaluate the reliability and convergent validity of the Upper Limb Functional Test (ULIFT) in women after breast cancer surgery.

MATERIALS AND METHODS

A cross-sectional study with 25 women (mean age 50 ± 7.3 years) with breast cancer submitted to a surgery intervention within a minimum period of three years. Intraclass correlation coefficients (ICCs) were calculated to assess the test-retest reliability. A Bland-Altman plot examined the agreement between the times to complete two tests. Validity was established by correlating the ULIFT and DASH total score. The receiver operating characteristic (ROC) curve was used to determine the cut-off point for ULIFT in order to discriminate patients with some level of upper limb dysfunction.

RESULTS

The ULIFT showed high reproducibility (ICC = 0.89; p < 0.001), learning effect of 7.21%, and a moderate correlation with the DASH total score (r = 0.536; R² = 0.28; p = 0.006). The standard error of measurement was 6.9 s and the smallest real difference was 19.1 s. The ROC curve indicated a cut-off point of 109.2 s (sensitivity = 68.7%; specificity = 77.8%; area under ROC curve = 0.77).

CONCLUSIONS

The ULIFT could be a valid and reliable test to assess upper limb functionality in patients submitted to breast cancer surgery.Implications for rehabilitationThe ULIFT is a reliable and valid test to assess upper limb function in women after breast cancer surgery, considering specifically the lifting and range of motion construct of unilateral upper limb function.The ULIFT could help identify those most at risk of developing upper limb dysfunction after breast cancer surgery and could benefit the follow-up of a postoperative rehabilitation program.Two ULIFTs should be performed in order to achieve patient's best performance.

Integrating patient-reported outcomes and quantitative timed tasks to identify relapsing remitting multiple sclerosis patient subgroups: a latent profile analysis

BACKGROUND

Multiple sclerosis (MS) patients experience wide-ranging symptoms with varied severity, and approaches that integrate patient-reported outcomes and objective quantitative measures will present opportunities for advancing clinical profiling. The primary objective of the current study was to conduct exploratory data analysis using latent variable modeling to empirically identify clusters of relapsing remitting (RR) MS patients with shared impairment patterns across three patient-reported outcomes and two timed task measures.

METHODS

Latent profile analyses and impairment data for 2,012 RRMS patients identified distinct patient clusters using timed task measures of upper and lower limb performance, and patient-reported outcomes measuring quality of life, depression symptom severity, and perceived global disability. Multinomial logistic regression models were used to characterize associations between socio-demographic attributes and assignment to the patient clusters.

RESULTS

There were 6 distinct clusters of RRMS patients that differed by symptom patterns, and by their socio-demographic attributes. Most notable were were no differences in age, sex, or disease duration between the least and most impaired classes, representing 14% and 4% of patients, respectively. Patients in the most impaired class were much more likely to be Black American, have a history of smoking, have a higher body mass index, and be of lower socioeconomic status than the least impaired class. There were positive relationships between age and classification to clusters of increasing moderately severe impairment but not the most severe clusters.

CONCLUSION

We present a framework for discerning phenotypic impairment clusters in RRMS. The results demonstrate opportunities for advancing clinical profiling, which is necessary for optimizing personalized MS care models and clinical research.

Psychometric properties of measures of upper limb activity performance in adults with and without spasticity undergoing neurorehabilitation-A systematic review

INTRODUCTION

This systematic review appraises the measurement quality of tools which assess activity and/or participation in adults with upper limb spasticity arising from neurological impairment, including methodological quality of the psychometric studies. Differences in the measurement quality of the tools for adults with a neurological impairment, but without upper limb spasticity, is also presented.

METHODS

29 measurement tools identified in a published review were appraised in this systematic review. For each identified tool, we searched 3 databases (Medline, Embase, CINAHL) to identify psychometric studies completed with neurorehabilitation samples. Methodological quality of instrument evaluations was assessed with use of the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Synthesis of ratings allowed an overall rating of the psychometric evidence for each measurement tool to be calculated.

RESULTS

149 articles describing the development or evaluation of psychometric properties of 22 activity and/or participation measurement tools were included. Evidence specific to tool use for adults with spasticity was identified within only 15 of the 149 articles and provided evidence for 9 measurement tools only. Overall, COSMIN appraisal highlighted a lack of evidence of measurement quality. Synthesis of ratings demonstrated all measures had psychometric weaknesses or gaps in evidence (particularly for use of tools with adults with spasticity).

CONCLUSIONS

The systematic search, appraisal and synthesis revealed that currently there is insufficient measurement quality evidence to recommend one tool over another. Notwithstanding this conclusion, newer tools specifically designed for use with people with neurological conditions who have upper limb spasticity, have emergent measurement properties that warrant further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014013190.

Prevalence and patterns of subclinical motor and cognitive impairments in non-disabled individuals with early multiple sclerosis: a multicenter cross-sectional study

BACKGROUND

Motor and cognitive disorders appear early in the course of multiple sclerosis (MS) and develop gradually over time.

OBJECTIVE

To study the frequency and pattern of subtle functional disorders in people with MS (PwMS) with no overt signs of disability in an early phase of the disease and their association with walking impairments in daily activities.

METHODS

In this cross-sectional study, we recruited PwMS with an Expanded Disability Status Scale (EDSS) score ≤ 2.5 and disease duration ≤ 5 years. Participants were assessed with functional scales rating walking endurance (6-Min Walk Test), perceived walking ability (Twelve-item Multiple Sclerosis Walking Scale), balance (Fullerton Advanced Balance scale_short), manual dexterity (Nine Hole Peg Test), fatigue (Fatigue Severity Scale), and cognitive impairments (Brief International Cognitive Assessment).

RESULTS

About 90% of the 82 PwMS (mean [SD] EDSS score 1.5 [0.7] and disease duration 2.2 [1.7] years) showed endurance values below the expected score; almost 30% showed impairment, and for 57%, perceived walking ability score was abnormal. Balance was impaired in 48% of participants, as was manual dexterity (29%) and fatigue (24%), but only a few showed cognitive impairments. Only 11% of PwMS had no abnormal score on the scales used in the assessment. As compared with EDSS score 0 to 1.5, with EDSS score 2 to 2.5, performance was worse for endurance (difference ±61.0 m, p=0.016), perceived walking ability (-11 points, p=0.002), balance (+1.9 points, p=0.005), manual dexterity (-2.8 sec, p=0.004), and fatigue (-1.3 points, p=0.013). Factors that predicted perceived walking ability were balance (B = -1.37, p<0.001) and fatigue (B = 5.11, p<0.001) rather than endurance (B = -0.01, p=048).

CONCLUSION

Even PwMS with no clinical disability and classified as having "no problem walking" present walking and other functional deficits when assessed with specific functional tests. The addition of specific tools could better identify subtle motor and cognitive deficits. Finally, the assessment of balance disorders and fatigue is important to understand individuals' perceived walking impairments in daily activities.

MAM-36 and ABILHAND as outcome measures of multiple sclerosis hand disability: an observational study

BACKGROUND

Impaired upper limb functionality and dexterity are common in people with multiple sclerosis (PwMS) and lead to increased dependency and reduced quality of life.

AIM

The aim of this study was to compare the ability of the Manual Abilites Measure 36 (MAM-36) and the ABILHAND questionnaire to recognize an involvement of the upper limbs in PwMS, and to compare their results with those of other patient reported outcomes (PRO) evaluating disability, functional independence, symptoms of anxiety and depression, fatigue and quality of life.

DESIGN

The study design was observational.

SETTING

The setting of the study was outpatient.

POPULATION

The study population included fifty-one PwMS (mean age of 56.31 years, age range of 33-82 years, 72.5% of patients were females).

METHODS

For each patient were collected MAM-36, ABILHAND questionnaire, expanded disability status scale (EDSS), Functional Independence measure (FIM), Hospital Anxiety and Depression Scale (HADS), Modified Fatigue Impact Scale (MFIS) and Life Satisfaction Index (LSI).

RESULTS

A strong correlation between MAM-36 and the ABILHAND questionnaire (Spearman r: 0.79; P<0.0001) were found. We obtained a significant correlation between MAM-36 and EDSS (Spearman r: -0.5; P=0.0002), FIM (Spearman r: 0.55; P<0.0001); we did not observe a correlation with MFIS (Spearman r: -0.33; P=0.02); moreover we found a similar trend between ABILHAND and EDSS (Spearman r: -0.47; P=0.0005), FIM (Spearman r: 0.61; P<0.0001), MFIS (Spearman r: -0.41; P=0.002).

CONCLUSIONS

In PwMS the assessment of upper limbs is fundamental since it closely related to the level of disability of the person. Both MAM-36 and ABILHAND Questionnaire are equally able to detect upper limb dysfunctions in PwMS.

CLINICAL REHABILITATION IMPACT

Both MAM-36 and ABILHAND can be used for upper limbs evaluation, within a multidimensional approach that seems to be the best way to evaluate PwMS.

Cross-cultural adaptation and psychometric properties of the Turkish version of the Manual Ability Measure-36 (MAM-36) in people with multiple sclerosis

OBJECTIVE

The Manual Ability Measure-36 (MAM-36) has been used to assess subjective upper limb function in people with several neurological and non-neurological diseases. Besides, the MAM-36 is one of the most commonly used patient-reported outcome measures (PROMs) in people with multiple sclerosis (pwMS). The aim was to translate and conduct cross-cultural adaptation of the MAM-36 into Turkish and investigate its psychometric properties in pwMS.

METHODS

The MAM-36 was translated and culturally adapted into Turkish. Two hundred pwMS were recruited for the psychometric study. Hand skills, handgrip strength, upper limb spasticity, disability level, and quality of life were evaluated by the validated performance-based tests and questionnaires including the Arm Function in Multiple Sclerosis Questionnaire (AMSQ) which is a validated MS-specific PROM to assess upper limb function.

RESULTS

MAM-36 was significantly correlated with the performance-based tests and questionnaires, EDSS, age, and disease duration (p < 0.05). MAM-36 and AMSQ were strongly correlated (r_s = - 0.90, p < 0.01). PwMS with spasticity had significantly lower MAM-36 scores compared to those without spasticity (p < 0.01). Internal consistency (Cronbach's alpha = 0.97) and test-retest reliability (ICC = 0.97) was high.

CONCLUSION

The Turkish version of MAM-36 has been found as a valid and reliable method for measuring upper limb function in pwMS.

Timed Up and Go in men and women with Multiple Sclerosis: Effect of muscular strength

OBJECTIVE

People with Multiple Sclerosis (pwMS) often exhibit generalized weakness that affects several activities of daily life, particularly those relying on balance and gait. While it is known that such a symptom has a strong impact on mobility, to what extent muscular strength is linked with functional mobility in men and women with MS remains mostly unexplored. The aim of this study is to assess the existence of possible sex-related differences in functional mobility in pwMS, also considering the muscular strength capacity.

METHODS

Functional mobility and hand-grip strength (HGS) were assessed in 49 pwMS with mild-moderate disability using instrumental Timed-up-and-go (TUG) test carried out using an inertial sensor and digital dynamometry. We investigated the existence of sex-related differences in the duration of each TUG sub-phase and their correlation with the HGS.

RESULTS

No sex-related differences in TUG performance (either in terms of overall or sub-phase time) were found. Similar large negative correlations were found in men and women with MS between HGS and overall TUG and walking phase duration. However, changes in strength have a more marked impact in women as indicated by the different slope of the HGS-TUG time relationship., In women, HGS also appears significantly correlated with all TUG sub-phases, while in men this occurs only for overall TUG and walking time.

CONCLUSIONS

Rehabilitation and training programs for pwMS should take into account the peculiar features associated with the interaction between strength and mobility specific for each individual's sex to optimize their effectiveness.

MRI correlates of clinical disability and hand-motor performance in multiple sclerosis phenotypes

Background:

Hand-motor impairment affects a large proportion of multiple sclerosis (MS) patients; however, its substrates are still poorly understood.

Objectives:

To investigate the association between global disability, hand-motor impairment, and alterations in motor-relevant structural and functional magnetic resonance imaging (MRI) networks in MS patients with different clinical phenotypes.

Methods:

One hundred thirty-four healthy controls (HC) and 364 MS patients (250 relapsing-remitting MS (RRMS) and 114 progressive MS (PMS)) underwent Expanded Disability Status Scale (EDSS) rating, nine-hole peg test (9HPT), and electronic finger tapping rate (EFTR). Structural and resting state (RS) functional MRI scans were used to perform a source-based morphometry on gray matter (GM) components, to analyze white matter (WM) tract diffusivity indices and to perform a RS seed-based approach from the primary motor cortex involved in hand movement (hand-motor cortex). Random forest analyses identified the predictors of clinical impairment.

Result:

In RRMS, global measures of atrophy and lesions together with measures of structural damage of motor-related regions predicted EDSS (out-of-bag (OOB)- R2 = 0.19, p-range = <0.001–0.04), z9HPT (right: OOB- R2 = 0.14; left: OOB- R2 = 0.24, p-range = <0.001–0.03). No RS functional connectivity (FC) abnormalities were identified in RRMS models. In PMS, cerebellar and sensorimotor regions atrophy, cerebellar peduncles integrity and increased RS FC between left hand-motor cortex and right inferior frontal gyrus predicted EDSS (OBB- R2 = 0.16, p-range = 0.02–0.04).

Conclusion:

In RRMS, only measures of structural damage contribute to explain motor impairment, whereas both structural and functional MRI measures predict clinical disability in PMS. A multiparametric MRI approach could be relevant to investigate hand-motor impairment in different MS phenotypes.

Motor fatigue is associated with asymmetric connectivity properties of the corticospinal tract in multiple sclerosis

Multiple Sclerosis (MS) is characterized by demyelination and neurodegeneration of the central nervous system and causes excessive fatigue in more than 80% of the patients. The pathophysiologic mechanisms causing fatigue are still largely unknown. In 46 right-handed patients with relapsing-remitting MS and 25 right-handed controls, we performed diffusion MRI and applied streamline based probabilistic tractography to derive unilateral anatomical connectivity maps for the white matter of the right and left hemispheres. The maps provide an indication how often a streamline has passed through a given voxel. Since tractography based anatomical connectivity mapping (ACM) is sensitive to disease-induced changes in anatomical connectivity, we used ACM to test whether motor fatigue is associated with altered ipsi-hemispherical anatomical connectivity in the major motor output pathway, the corticospinal tract (CST). Patients had higher mean ACM values in the CST than healthy controls. This indicated that a higher number of streamlines, starting from voxels in the same hemisphere, travelled through the CST and may reflect an accumulated disease-induced disintegration of CST. The motor subscale of the Fatigue Scale for Motor and Cognitive functions (FSMCMOTOR) was used to define sub-groups with (n = 29, FSMCMOTOR score ≥ 27) and without motor fatigue (n = 17, FSMSMOTOR score ≤ 26). Patients without fatigue only showed higher ACM values in right CST, while mean ACM values were unaltered in left CST. The higher the mean ACM values in the left relative to the right CST, the more patients reported motor fatigue. Left-right asymmetry in anatomical connectivity outside the CST did not scale with individual motor fatigue. Our results link lateralized changes of tractography-based microstructural properties in the CST with motor fatigue in relapsing-remitting MS.

Box and block test, hand grip strength and nine-hole peg test: correlations between three upper limb objective measures in multiple sclerosis

BACKGROUND AND PURPOSE

Limited data are available in the literature for upper limb impairment in multiple sclerosis (MS). This study aimed to report the distribution of values of hand grip strength (HGS), of the box and block test (BBT) and of the nine-hole peg test (9HPT) correlated with demographic and clinical data in subjects with MS.

METHODS

This study involved five Italian neurological centres. The inclusion criteria were age ≥ 18, MS diagnosis, stable disease phase, right-hand dominance. All subjects underwent HGS, BBT and 9-HPT evaluation.

RESULTS

In all, 202 subjects with MS were enrolled: 137 females; mean age 48.4 years; mean Expanded Disability Status Scale (EDSS) 4.17; mean disease duration 14.12 years; disease course 129 relapsing-remitting, 21 primary progressive and 52 secondary progressive MS subjects; mean right HGS 25.3 kg, left 23.2 kg; mean right BBT 45.7 blocks, left 44.9 blocks; mean right 9-HPT 30.7 s, left 33.4 s. All results were statistically significantly different compared to healthy controls. HGS, BBT and 9-HPT were associated with age, EDSS and disease duration, whilst disease course correlated with BBT and 9-HPT. The BBT and 9-HPT scores significantly differed according to level of disability (EDSS ≤3.0, 3.5-5.5, ≥6.0).

CONCLUSION

Hand grip strength and BBT value distribution in a large MS population is reported. Correlations between HGS, BBT and 9-HPT were generally low.

Nine Hole Peg Test asymmetry in refining upper limb assessment in multiple sclerosis

BACKGROUND

The Expanded Disability Status Scale (EDSS) is the most frequently used scale to measure neurologic impairment and quantify the level of disability in Multiple Sclerosis (MS) even though the scale focuses on ambulation and undervalues upper limb (UL) impairment. The 9-Hole Peg Test (9-HPT) is the gold standard for UL assessment in MS, calculating a mean score from right and left arms, even though subjects with MS often show a lateralization of neurological deficit.

OBJECTIVE

The study aimed to determine whether an interaction exists between mean right-left 9-HPT scores or 9HPT score asymmetry (difference between right and left side) in predicting EDSS in MS subjects.

METHODS

Demographic and disease variables and 9-HPT scores were obtained from medical records of individuals with MS collected in an ad-hoc database. Subjects with 9-HPT score ≤180 s for each arm were included. An asymmetry score was represented as the absolute value of the difference between 9-HPT scores for both arms.

RESULTS

549 subjects were included: 67.8% female, mean age 45±13.14 years, mean EDSS 3.98±2.12, 356 relapsing-remitting, 68 primary and 125 secondary progressive, mean 9-HPT scores: right arm 30.20 ± 19.99 s, left arm 31.80 ± 20.35 s. Mean asymmetry was 9.35±18.20 s. Correlation between mean right-left 9-HPT scores and EDSS was 0.58 (p<.001). Significant interaction between mean right-left 9-HPT scores and 9-HPT asymmetry in predicting EDSS scores was found. Regression slope of EDSS on mean right-left 9-HPT score decreases as asymmetry value increases (non-significance area values ≥ 40.93 s).

CONCLUSIONS

Findings suggest interaction exists between mean right-left 9-HPT scores and asymmetry in predicting EDSS. A consequence of this is that, by disregarding information about asymmetry, studies exploring the association between mean right-left 9-HPT scores and global measures of disability may provide biased results. The bias tends to increase as asymmetry increases, and to be most prevalent among patients with EDSS scores > 6.

Persons with Multiple Sclerosis Exhibit Strength Asymmetries in both Upper and Lower Extremities

OBJECTIVE

To characterize strength asymmetries in the upper and lower extremities in persons with multiple sclerosis (PwMS) with severe disability, and examine associations between asymmetries and functional, symptomatic, and participatory outcomes.

DESIGN

Cross-sectional.

SETTING

University research laboratory.

PARTICIPANTS

25 PwMS with Expanded Disability Status Scale scores between 6.0-8.0.

MAIN OUTCOME MEASURES

Bilateral strength and asymmetry scores for muscle groups at the ankle, knee, and shoulder joints in addition to grip strength.

RESULTS

Significant differences were observed between all contralateral strength measures, with asymmetry scores ranging between 20-32%. A high prevalence of asymmetry (i.e., score>10%) was observed for all strength measures, with 92% of participants having four or more affected measures. Significant associations were observed between dorsiflexion asymmetry and physical health-related quality of life (ρ= -0.69; p<0.001), and between shoulder flexion asymmetry and lower extremity function (ρ= -0.62; p=0.001). Plantarflexion (ρ= 0.61; p=0.003) and knee flexion (ρ= 0.63; p=0.002) asymmetry were significantly associated with lower extremity functional asymmetry.

CONCLUSIONS

A high prevalence of asymmetry in the upper and lower extremities was observed, with asymmetry scores exceeding those previously reported in PwMS with mild-to-moderate disability. Rehabilitation strategies should consider a full body approach to address strength asymmetries.

Real-World Goal Setting and Use of Outcome Measures According to the International Classification of Functioning, Disability and Health: A European Survey of Physical Therapy Practice in Multiple Sclerosis

Goal setting is a core component of physical therapy in multiple sclerosis (MS). It is unknown whether and to what extent goals are set at different levels of the International Classification of Functioning, Disability and Health (ICF), and whether, and to which, standardized outcome measures are used in real life for evaluation at the different ICF levels. Our aim was to describe the real-world use of goal setting and outcome measures in Europe. An online cross-sectional survey, completed by 212 physical therapists (PTs) specialized in MS from 26 European countries, was conducted. Differences between European regions and relationships between goals and assessments were analyzed. PTs regularly set goals, but did not always apply the Specific, Measurable, Achievable, Realistic, Timed (SMART) criteria. Regions did not differ in the range of activities assessed, but in goals set (e.g., Western and Northern regions set significantly more goals regarding leisure and work) and outcome measures used (e.g., the Berg Balance Scale was more frequently used in Northern regions). Quality of life was not routinely assessed, despite being viewed as an important therapy goal. Discrepancies existed both in goal setting and assessment across European regions. ICF assists in understanding these discrepancies and in guiding improved health-care for the future.

Feasibility of a Home-Based Tablet App for Dexterity Training in Multiple Sclerosis: Usability Study

BACKGROUND

Persons with multiple sclerosis (MS) often experience dexterous difficulties during the performance of activities of daily living, such as fastening buttons, handling coins, or writing, therefore impacting their health-related quality of life. Mobile health (mHealth) solutions, such as tablet apps, may be used to train impaired dexterous skills. The feasibility of a tablet app-based dexterity home-based intervention in MS (TAD-MS) has not been explored yet in persons with MS.

OBJECTIVE

The aim of this pilot study was to evaluate the feasibility and usability of home-based dexterity training with a tablet app in both persons with MS and healthy subjects.

METHODS

A total of 9 persons with MS, aged 35-71 years, with an Expanded Disability Status Scale score between 2 and 7.5, performed the TAD-MS for 4 weeks, five times a week, with each training session lasting approximately 30 minutes. Participants' impaired dexterity was measured by the Nine-Hole Peg Test. A total of 10 age-matched healthy subjects also tested and rated the usability of the app. Outcome measures were the adherence rate as well as usability measured by the System Usability Scale and a Custom User Engagement Questionnaire (CUEQ).

RESULTS

High feasibility of the tablet app-based dexterity training program was shown by a 97% adherence rate to the training protocol (ie, mean 19.4/20 sessions completed, SD 0.8). High system usability scores (ie, mean 85.39%, SD 11.67) and overall high scores given in the CUEQ (ie, mean 8.2/10, SD 1.4) further point to high usability of the app. Neither demographic variables nor dexterity levels affected the use of the app.

CONCLUSIONS

This pilot study is the first to demonstrate high feasibility and usability of a new tablet app-based dexterity home-based training program among both persons with MS and healthy individuals. Whether this kind of training improves dexterity will need to be evaluated in a randomized controlled trial.

A data-driven framework for selecting and validating digital health metrics: use-case in neurological sensorimotor impairments

Digital health metrics promise to advance the understanding of impaired body functions, for example in neurological disorders. However, their clinical integration is challenged by an insufficient validation of the many existing and often abstract metrics. Here, we propose a data-driven framework to select and validate a clinically relevant core set of digital health metrics extracted from a technology-aided assessment. As an exemplary use-case, the framework is applied to the Virtual Peg Insertion Test (VPIT), a technology-aided assessment of upper limb sensorimotor impairments. The framework builds on a use-case-specific pathophysiological motivation of metrics, models demographic confounds, and evaluates the most important clinimetric properties (discriminant validity, structural validity, reliability, measurement error, learning effects). Applied to 77 metrics of the VPIT collected from 120 neurologically intact and 89 affected individuals, the framework allowed selecting 10 clinically relevant core metrics. These assessed the severity of multiple sensorimotor impairments in a valid, reliable, and informative manner. These metrics provided added clinical value by detecting impairments in neurological subjects that did not show any deficits according to conventional scales, and by covering sensorimotor impairments of the arm and hand with a single assessment. The proposed framework provides a transparent, step-by-step selection procedure based on clinically relevant evidence. This creates an interesting alternative to established selection algorithms that optimize mathematical loss functions and are not always intuitive to retrace. This could help addressing the insufficient clinical integration of digital health metrics. For the VPIT, it allowed establishing validated core metrics, paving the way for their integration into neurorehabilitation trials.