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

Walking performance differs between people with multiple sclerosis who perform distinct types of exercise

Aim: To determine whether walking performance differed between people with multiple sclerosis (MS) who performed distinct types, volumes and intensities of exercise.Materials & methods: Forty-five people with relapsing-remitting MS performed two trials of the 2-min walk test, one at a preferred speed and another at a fast speed. Gait metrics were measured by wireless inertial sensors. Participants reported the type (aerobic, resistance), volume and intensity of exercise performed.Results: Walking speed reserve and gait variability were better in participants who performed combined aerobic and resistance exercises compared with those who performed aerobic-only exercise.Conclusion: Walking performance differs in people with mild MS disability based on the type and volume of exercise performed.

Towards a Comprehensive Framework for Complex Walking tasks: Characterization, Behavioral Adaptations, and Clinical Implications in Ageing and Neurological Populations

Complex walking tasks, including change of direction, patterns and rhythms, require more attentional resources than simple walking and significantly impact walking performance, especially among ageing and neurological populations. More studies are focusing on complex walking situations, with or without the addition of cognitive tasks, creating a multitude of walking situations. Facing the lack of a clear and extensive definition of complex walking, this narrative review aims to identify and more precisely characterize situations and related tests, gain a better understanding of the behavioral adaptations in ageing and neurological populations, and report the clinical applications of complex walking. Based on the studies gathered, we propose a framework that categorizes the different forms of complex walking, considering whether a cognitive task is added or not, as well as the number of distinct objectives within the situation. We observed that combining complex walking tasks with a cognitive assignment places even greater strain on attentional resources, resulting in a more pronounced decline in walking or cognitive performance, or both. This work highlights the relevance of the complex walking as a simple tool for the early detection of cognitive impairments and the risk of falls, and its potential value in cognitive-motor rehabilitation. Future studies should explore the diversity of complex walking tasks in real-life simulated through extended virtual environments.

Fatigue in individuals with multiple sclerosis: Is there a relationship with walking speed and mobility?

BACKGROUND

Fatigue is a common symptom in patients with multiple sclerosis and it can lead to activity limitations. Thus, it is important to analyze the relationship between fatigue and activity outcomes, such as walking speed and mobility.

OBJECTIVES

To investigate the relationship between fatigue and walking speed and mobility in individuals with multiple sclerosis.

METHODS

A cross-sectional study was performed. Adults with multiple sclerosis, without cognitive impairments and who were able to walk were recruited. Fatigue was assessed with the Modified Fatigue Impact Scale (MFIS). Walking speed, usual and fast, was assessed with the 10-meter Walk Test (10MWT), and mobility with the Timed Up and Go Test (TUG). Pearson correlation analysis was performed. A significance level of 5 % was used.

RESULTS

Thirty participants were included, most of the relapsing-remitting multiple sclerosis (n = 24, 80 %). A mean age of 41 (11) years and the median Expanded Disability Status Scale (EDSS) score was 2.65 (2.18) points. Mean MFIS score was 41.87 ± 19.42 points, mean usual walking speed was 1.02 ± 0.28 m/s, mean fast walking speed was 1.55 ± 0.48 m/s, and the mean total time in the TUG was 10.07 ± 3.05 s. A significant negative correlation of moderate magnitude was found between fatigue and usual walking speed (r=₋0.51, p < 0.05). A significant negative correlation of moderate magnitude was found between fatigue and fast walking speed (r=₋0.54, p < 0.05). A significant, positive correlation of moderate magnitude was found between fatigue and mobility (r = 0.54, p < 0.05).

CONCLUSION

There was a correlation between fatigue and walking speed and mobility in individuals with multiple sclerosis. These results highlight the need to assess fatigue in individuals with multiple sclerosis, since the presence of fatigue is associated with reduced walking speed and mobility.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

Actual and Imagined Music-Cued Gait Training in People with Multiple Sclerosis: A Double-Blind Randomized Parallel Multicenter Trial

BACKGROUND

Actual and imagined cued gait trainings have not been compared in people with multiple sclerosis (MS).

OBJECTIVE

To analyze the effects of cued motor imagery (CMI), cued gait training (CGT), and combined CMI and cued gait training (CMI-CGT) on motor, cognitive, and emotional functioning, and health-related quality of life in people with MS.

METHODS

In this double-blind randomized parallel-group multicenter trial, people with MS were randomized (1:1:1) to CMI, CMI-CGT, or CGT for 30 minutes, 4×/week for 4 weeks. Patients practiced at home, using recorded instructions, and supported by ≥6 phone calls. Data were collected at weeks 0, 4, and 13. Co-primary outcomes were walking speed and distance, analyzed by intention-to-treat. Secondary outcomes were global cognitive impairment, anxiety, depression, suicidality, fatigue, HRQoL, motor imagery ability, music-induced motivation, pleasure and arousal, self-efficacy, and cognitive function. Adverse events and falls were continuously monitored.

RESULTS

Of 1559 screened patients, 132 were randomized: 44 to CMI, 44 to CMI-CGT, and 44 to CGT. None of the interventions demonstrated superiority in influencing walking speed or distance, with negligible effects on walking speed (η2 = 0.019) and distance (η2 = 0.005) observed in the between-group comparison. Improvements in walking speed and walking distance over time corresponded to large effects for CMI, CMI-CGT, and CGT (η2 = 0.348 and η2 = 0.454 respectively). No severe study-related adverse events were reported.

CONCLUSIONS

CMI-GT did not lead to improved walking speed and distance compared with CMI and CGT alone in people with MS. Lack of a true control group represents a study limitation.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00023978.

The agreement between face-to-face and tele-assessment of balance tests in patients with multiple sclerosis

BACKGROUND

To investigate the reliability of balance tests administered using a tele-assessment method in patients with multiple sclerosis (MS).

METHODS

The participants were assessed both online and face-to-face. The assessments were performed synchronously by two physiotherapists. The first method to used to evaluate the participants was determined through randomization. The Berg Balance Scale (BBS), Dynamic Gait Index (DGI), and Timed Up and Go (TUG) were used in the evaluations. Three days were left between the assessment methods. Online platforms were used for tele-assessment. The agreement between and correlation of face-to-face and tele-assessments was analyzed by applying intra-class correlation coefficients (ICC), limits of agreement, and Pearson's correlation coefficient.

RESULTS

This study included 39 individuals with MS with an EDSS score of 3.03 ± 1.41. Intra-rater reliability of the tele-assessment was excellent (ICCBBS = 0.96; ICCDGI = 0.97; ICCTUG = 0.97). Very high correlations were observed in all BBS, DGI, and TUG measurements between face-to-face and tele-assessment methods according to the first and second assessors (rBBS1 = 0.92; rBBS2 = 0.93; rDGI1 = 0.94; rDGI2 = 0.95; rTUG1 = 0.94; rTUG2 = 0.95, respectively). The inter-rater reliability of tele-assessments (ICCBBS = 0.97; ICCDGI = 0.97; ICCTUG = 1.00) achieved excellent reliability.

CONCLUSION

BBS, DGI, and TUG are reliable and agreed tests that can be used with tele-assessments, offering similar data to face-to-face methods.

Task-oriented training for gait rehabilitation in people with multiple sclerosis: A systematic review

OBJECTIVES

This systematic review aims to examine the effects of task-oriented (TO) training on gait function in people with multiple sclerosis (MS) and to determine the most effective TO training protocol.

METHODS

We searched PubMed, Web of Science, Scopus, EMBASE, REHABDATA, and PEDro for studies that examined the effects of TO on gait ability (i.e., gait velocity, gait endurance, functional mobility) in people with MS from 1971 to October 2022. The quality of the selected studies was estimated using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Nine studies met the eligibility criteria. A total of 199 people with MS, 58.79% of whom were women, were included. Five studies revealed "good" quality, one revealed "fair", and three exhibited "poor" quality. Four studies administered TO training alone, and five combined TO training with conventional physiotherapy. The selected studies showed varied results for the influences of TO training on gait ability in people with MS.

CONCLUSIONS

The evidence for the impact of TO training on people with MS was limited. The optimal TO training protocol stills vague. Further studies with larger sample sizes are needed.

Vision-based motion capture for the gait analysis of neurodegenerative diseases: A review

BACKGROUND

Developments in vision-based systems and human pose estimation algorithms have the potential to detect, monitor and intervene early on neurodegenerative diseases through gait analysis. However, the gap between the technology available and actual clinical practice is evident as most clinicians still rely on subjective observational gait analysis or objective marker-based analysis that is time-consuming.

RESEARCH QUESTION

This paper aims to examine the main developments of vision-based motion capture and how such advances may be integrated into clinical practice.

METHODS

The literature review was conducted in six online databases using Boolean search terms. A commercial system search was also included. A predetermined methodological criterion was then used to assess the quality of the selected articles.

RESULTS

A total of seventeen studies were evaluated, with thirteen studies focusing on gait classification systems and four studies on gait measurement systems. Of the gait classification systems, nine studies utilized artificial intelligence-assisted techniques, while four studies employed statistical techniques. The results revealed high correlations of gait features identified by classifier models with existing clinical rating scales. These systems demonstrated generally high classification accuracies and were effective in diagnosing disease severity levels. Gait measurement systems that extract spatiotemporal and kinematic joint information from video data generally found accurate measurements of gait parameters with low mean absolute errors, high intra- and inter-rater reliability.

SIGNIFICANCE

Low cost, portable vision-based systems can provide proof of concept for the quantification of gait, expansion of gait assessment tools, remote gait analysis of neurodegenerative diseases and a point of care system for orthotic evaluation. However, certain challenges, including small sample sizes, occlusion risks, and selection bias in training models, need to be addressed. Nevertheless, these systems can serve as complementary tools, equipping clinicians with essential gait information to objectively assess disease severity and tailor personalized treatment for enhanced patient care.

Relationship between sensation and balance and gait in multiple sclerosis patients with mild disability

BACKGROUND

Patients with Multiple Sclerosis (PwMS) often experience sensory, balance, and gait problems. Impairment in any sensation may increase imbalance and gait disorder in PwMS. This study aimed to (1) compare foot plantar sensations, knee position sense, balance, and gait in PwMS compared to Healthy Individuals (HI) and (2) examine the relationship between plantar sensations, knee position sense, balance, and gait in PwMS.

METHODS

Thirty PwMS with mild disability and 10 HI participated in this study. Light touch threshold, two-point discrimination, vibration duration, and knee position sense were examined on the Dominant Side (DS) and Non-Dominant Side (NDS). Balance and spatio-temporal gait analysis were evaluated in all participants.

RESULTS

PwMS had higher postural sway with eyes closed on the foam surface, longer swing phase of DS, longer single support phase of NDS, and shorter double support phase of DS compared to HI (p < 0.05). The results of regression analysis showed that the light touch thresholds of the 1st and 5th toes of the DS were associated with postural sway in different sensory conditions (p < 0.05). In contrast, the light touch thresholds of the 1st and 5th toes, two-point discrimination of the heel, vibration duration of the 1st metatarsal head and knee position sense of the NDS, and light touch threshold in the medial arch of both sides were associated with the gait parameters (p < 0.05).

CONCLUSION

PwMS, even with mild disabilities needs neurorehabilitation to improve plantar sensation and knee position sense.

The relationship between sleep quality and gait in people with multiple sclerosis: A pilot study

Background

Gait deficits are common among people with multiple sclerosis (PwMS). Therefore, investigating factors that may influence walking in PwMS is important. Previous studies in older adults and other neurological populations demonstrated the relationship between sleep quality and gait performance. Despite the fact that the prevalence of poor sleep quality is very high among PwMS, little is known about the effect of sleep quality on gait among PwMS.

Objective

This study aimed to explore the relationship between sleep quality and gait performance in PwMS.

Methods

Forty-one PwMS participated in the study between February 2019 and December 2019. Participants were asked to walk at a self-selected speed over 10 m with an inertial measurement unit (IMU) attached over the back. Walking speed, step length (left and right), and step time were calculated. Sleep was estimated objectively using a wrist-worn triaxle-accelerometer; the derived parameters were sleep efficiency (SE) and the number of awakening after sleep onset (NASO).

Results

SE significantly correlated with step length (p = 0 . 02 ). Furthermore, the NASO significantly correlated with gait speed (p = 0 . 03 ), and step-time (p = 0 . 02 ). These correlations remained significant even after adjusting for age and disease duration.

Conclusion

We observed that when corrected for disease duration and age there were relationships between NASO and SE to gait parameters; these observations warrant further investigations.

Home-Based Balance Training on Balance and Mobility in Persons With Multiple Sclerosis: A Systematic Review and Meta-analysis

OBJECTIVES

To (1) examine the effects of home-based balance training on balance and mobility outcomes; (2) evaluate comparable effects between home- and center-based balance training; (3) determine the effects of different levels of supervision on treatment effects; and (4) investigate dose-response relationships of home-based balance training on balance and mobility performance in persons with multiple sclerosis (MS).

DATA SOURCES

Literature searches were conducted in MEDLINE, EMBASE, PsycINFO, SPORTSDiscus, and CINAHL in April 2023. Other literature sources included website and citation searches.

STUDY SELECTION

The study included randomized controlled trials of home-based balance training that included balance and mobility outcomes in persons with MS.

DATA EXTRACTION

Data extracted from each study included (1) number of participants; (2) dropout rate; (3) sex; (4) MS phenotype; (5) age; (6) Expanded Disability Status Scale (range); (7) exercise dose; (8) level of supervision; (9) type of intervention; (10) exercise progression; (11) type of control; and (12) outcomes measures. For the meta-analysis, mean and SD of the balance and mobility outcomes in both the intervention and control groups were used. The methodological quality of included studies was evaluated by Tool for the Assessment of Study Quality and Reporting in Exercise.

DATA SYNTHESIS

Eleven studies were identified in this systematic review and meta-analysis. Each balance and mobility outcome was standardized using Hedges' g.

CONCLUSIONS

This meta-analysis revealed comparable results between home- and center-based balance training in terms of balance and mobility improvement. There was also no evidence for the superiority of home-based balance training over no training except for static steady-state balance. This study revealed that training sessions (>36 sessions) and total exercise time (>1100min) were significant moderators for overall balance improvements. Results also indicated that, when designing future interventions, at least an indirect level of supervision (eg, weekly or biweekly phone/video calls) is warranted to maintain adherence.

Comparison of the Clinical Effectiveness of Telerehabilitation with Traditional Rehabilitation Methods in Multiple Sclerosis Patients: A Systematic Review

Background: The rehabilitation process for multiple sclerosis (MS) patients is long and complex, which can lead to reduced rehabilitation outcomes and reduced quality improvement. Thus, there is a need to use new methods to boost traditional rehabilitation. Innovations such as telerehabilitation can be helpful to remove the obstacles to treatment, but evidence for their effectiveness is limited. The objective of this work was to compare the clinical effectiveness of telerehabilitation with traditional interventions in MS patients. Methods: Seven bibliographic databases (PubMed, Cochran Library, Scopus, Science Direct, Web of Science, Embase, and ProQuest) were used in this research. The initial search resulted in the extraction of 8,239 articles; after the review of the title, abstract, and full text, 11 articles were selected. In addition, backward reference list checking of the selected studies was conducted. Studies that were related to our objectives were included. Quality assessment was performed using the CONSORT checklist. Then, data extraction was done using the form set by the researcher in Word 2016 software. Results: Overall, telerehabilitation achieved more positive effects compared to traditional rehabilitation on physical (n = 6), cognitive (n = 3), cognitive, and physical outcomes (n = 2), respectively. Synchronous telerehabilitation was more effective than other modalities (n = 8). In four studies, virtual reality-based telerehabilitation was used. Also, telerehabilitation in home offered better clinical outcomes compared to rehabilitation center (n = 9). Conclusions: This review provides evidence for the potential effectiveness of telerehabilitation for the improvement of clinical outcomes in MS patients. However, more robust randomized controlled trials are needed to confirm the observed positive effects.

Backwards walking speed reserve in persons with multiple sclerosis

BACKGROUND

Decreased gait speed is common in persons with Multiple Sclerosis (PwMS) and has been associated with elevated fall risk. The walking speed reserve (WSR) indicates the ability to increase gait speed on demand and has previously been examined in PwMS. Backward walking is a sensitive measure of fall risk in PwMS; however, no studies have reported on the utility of backward walking speed reserve (BW-WSR) as a clinical assessment tool of functional mobility or fall risk in PwMS, nor have they associated this measure with cognition.

METHODS

23 PwMS completed walking trials at their preferred walking speed (PWS) and maximal walking speed (MWS). Participants performed these walking trials in both the forward (FW) and backward direction (BW). The forward walking speed reserve (FW-WSR) was calculated as the difference between MWS and PWS in the forward direction, while the backward walking speed reserve (BW-WSR) was calculated as the difference between MWS and PWS in the back backward direction. Correlation analyses examined the relationship between the FW- and BW-WSR with clinical assessments of functional mobility (the timed up-and-go) as well as cognitive functioning (the Symbol Digit Modalities Test, the Brief Visuospatial Memory Test-Revised, the California Verbal Learning Test, and the Trail Making Test A and B). Correlations also examined the relationship between FW- and BW-WSR with prospective falls.

RESULTS

A lower BW-WSR was associated with disease severity and poorer performance on clinical walking and balance assessment, as well as with decreased information processing speed and attentional performance. Interestingly, FW-WSR showed similar relations. Neither FW- or BW-WSR were associated with prospective risk in this small sample of PwMS.

CONCLUSION

The BW-WSR did not offer a distinct advantage over other measures, such as the FW-WSR, PWS, or MWS, in the forward or backward direction. The selection of the most sensitive clinical measures of functional mobility and fall risk is crucial; our study holds valuable clinical implications for PwMS by providing novel insights into functional mobility assessments in PwMS.

Intensive Aerobic Cycling Is Feasible and Elicits Improvements in Gait Velocity in Individuals With Multiple Sclerosis: A Preliminary Study

BACKGROUND

Aerobic exercise (AEx) has many potential benefits; however, it is unknown whether individuals with multiple sclerosis (MS) can attain the optimal intensity and duration to harness its effects. Forced-rate exercise (FE) is a novel paradigm in which the voluntary pedaling rate during cycling is supplemented to achieve a higher exercise intensity. The aim of this pilot trial was to investigate the feasibility and initial efficacy of a 12-week FE or voluntary exercise (VE) cycling intervention for individuals with MS.

METHODS

Twenty-two participants with MS (Expanded Disability Severity Scale [EDSS] 2.0-6.5) were randomly assigned to FE (n = 12) or VE (n = 10), each with twice weekly 45-minute sessions at a prescribed intensity of 60% to 80% of maximum heart rate (HR).

RESULTS

Eighteen individuals (FE = 11; VE = 7) completed the intervention, however, adaptations were required in both groups to overcome barriers to cycling. Overall, participants exercised for an average of 42.2 ± 2.3 minutes at an aerobic intensity of 65% ± 7% of maximum HR and a pedaling cadence of 67.3 ± 13.3 RPM. Cycling led to improved treadmill walking speed (0.61 to 0.68 m/sec, P = .010), with somewhat greater improvement with FE compared to VE (increase of 0.09 vs 0.03 m/s, respectively, P = .17) post intervention. Notably, the participant with the highest disability level (EDSS 6.5) tolerated FE but not VE.

CONCLUSIONS

Aerobic exercise is feasible for individuals with MS, although those with increased disability may require novel paradigms such as FE to achieve targeted intensity. Further trials are warranted to investigate the effects of FE across the MS disability spectrum.

Effects of exercise in people with multiple sclerosis: a systematic review and meta-analysis

Background

A growing body of studies have examined the effect of exercise in people with multiple sclerosis (MS), while findings of available studies were conflicting. This meta-analysis aimed to explore the effects of exercise on balance, walking ability, walking endurance, fatigue, and quality of life in people with MS.

Methods

We searched PubMed, Web of Science, Scopus, and Cochrane databases, through March 1, 2024. Inclusion criteria were: (1) RCTs; (2) included an intervention and control group; (3) had people with MS as study subjects; (4) had balance, walking ability, walking endurance, fatigue, or quality of life as the outcome measures. Exclusion criteria were: (1) non-English publications; (2) animal model publications; (3) review articles; and (4) conference articles. A meta-analysis was conducted to calculate weighted mean difference (WMD) and 95% confidence interval (CI). Cochrane risk assessment tool and Physiotherapy Evidence Database (PEDro) scale were used to evaluate the methodological quality of the included studies.

Results

Forty studies with a total of 56 exercise groups (n = 1,300) and 40 control groups (n = 827) were eligible for meta-analysis. Exercise significantly improved BBS (WMD, 3.77; 95% CI, 3.01 to 4.53, P < 0.00001), TUG (WMD, -1.33; 95% CI, -1.57 to -1.08, P < 0.00001), MSWS-12 (WMD, -2.57; 95% CI, -3.99 to -1.15, P = 0.0004), 6MWT (WMD, 25.56; 95% CI, 16.34 to 34.79, P < 0.00001), fatigue (WMD, -4.34; 95% CI, -5.83 to -2.84, P < 0.00001), and MSQOL-54 in people with MS (WMD, 11.80; 95% CI, 5.70 to 17.90, P = 0.0002) in people with MS. Subgroup analyses showed that aerobic exercise, resistance exercise, and multicomponent training were all effective in improving fatigue in people with MS, with resistance exercise being the most effective intervention type. In addition, a younger age was associated with a larger improvement in fatigue. Furthermore, aerobic exercise and multicomponent training were all effective in improving quality of life in people with MS, with aerobic exercise being the most effective intervention type.

Conclusion

Exercise had beneficial effects in improving balance, walking ability, walking endurance, fatigue, and quality of life in people with MS. Resistance exercise and aerobic exercise are the most effective interventions for improving fatigue and quality of life in people with MS, respectively. The effect of exercise on improving fatigue was associated with the age of the participants, with the younger age of the participants, the greater the improvement in fatigue.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=371056, identifier: CRD42022371056.

Neuro-orthopaedic check-up and walking in people with multiple sclerosis: toward a more specific assessment to improve rehabilitation results

The rehabilitation process of people with multiple sclerosis (PwMS) is a challenge, and decision-making requires a thorough assessment to increase the chances of success in rehabilitation planning. The aim of this study was to investigate the importance of the neuroorthopaedic check-Up (NOChU) for gait prognosis. Participated in the study 105 PwMS with different levels of impairment. The NOChU includes measurements of passive range of motion (ROM), muscle strength, and spasticity. Additionally, was carried out the spatial-temporal analysis of the walking, Timed Up and Go test, and 6-min walk test. ROM remained relatively preserved to perform daily life activities except for ankle dorsiflexion. Muscle strength was also relatively preserved. Spasticity affected especially the ankle muscles, clearly the sural triceps. Among the NOChU measurements the catch seemed to have the most impact on walking on its different phases and on other activities. Accurate NOChU measurements play a crucial role in clinical settings, guiding informed decisions in rehabilitation planning. Future research endeavours could focus on exploring the correlations between NOChU deficiencies and the decline in walking capabilities among PwMS, with the goal of proposing personalized treatment strategies that address their specific requirements.

Validity, reliability, and responsiveness of Persian version of mini-balance evaluation system test among ambulatory people with multiple sclerosis

BACKGROUND AND PURPOSE

Mini-Balance Evaluation Systems Test (mini-BESTest) is a widely used measure to assess balance impairments. This study aimed to assess the validity, reliability, responsiveness, and minimal clinically important change (MCIC) of the Persian mini-BESTest among ambulatory People with Multiple Sclerosis (PwMS).

METHODS

Fifty ambulatory PwMS participated in this study. Persian mini-BESTest validated against Berg Balance Scale (BBS) and Timed-Up and Go (TUG) with/without a cognitive task. To assess the reliability, the Persian mini-BESTest was re-administered for a sample of 30 participants after 1 week. Also, 32 PwMS were tested before and after a 4-week of balance and gait training to assess the responsiveness.

RESULTS

No floor/ceiling effect was found for the mini-BESTest total score. There were significant excellent correlations (p < .001) between mini-BESTest and BBS (r = 0.71), TUG (r = -0.76), and cognitive TUG (r = -0.73). No strong correlations were observed between the subscales (r = 0.37-0.55). Test-retest reliability and internal consistency of Persian mini-BESTest total score were excellent, with Intra-class Correlation Coefficient (ICC3,1 and Cronbach's alpha level of 0.89 and 0.80, respectively. The minimal detectable change was 4 points. The Persian mini-BESTest had acceptable responsiveness (AUC = 0.83), and MCIC was 5 points.

CONCLUSION

The Persian mini-BESTest is a valid, reliable, and responsive measure of balance performance in Iranian ambulatory PwMS.

Spatiotemporal gait characteristics across the adult lifespan: Reference values from a healthy population - Analysis of the COmPLETE cohort study

BACKGROUND

Gait changes with aging have been investigated, but few studies have examined a wide range of gait parameters across the adult lifespan. This study aimed to investigate gait differences across age groups stratified by sex.

METHODS

This cross-sectional study included 629 healthy, normal-weight (i.e., BMI < 30 kg/m2) participants from Switzerland of the COmPLETE cohort study, aged 20 to over 90 years. Gait metrics were assessed using an inertial measurement unit (IMU)-based gait analysis system, including speed, cycle duration variability, asymmetry, stride length, cycle duration, cadence, double support, stance (time foot is on the ground during a gait cycle), swing (time foot is in the air during a gait cycle), loading (early part of the stance phase), foot-flat (mid-stance phase when foot is flat), and pushing (late stance phase leading to toe-off) phases. Percentile curves were calculated using generalized additive models for location, scale, and shape.

RESULTS

Gait data from 545 participants (273 men and 272 women) were analyzed. Participants were equally distributed across the seven age decades, with an average of 40 men and 40 women representing every decade. Both men and women showed a reduction in gait speed and stride length, and an increase in cycle duration variability and asymmetry with aging. Gait speed and stride length declined across the age groups, with a significant difference found in participants aged 80 to 91 compared to younger age groups.

SIGNIFICANCE

Age-related changes in gait parameters were seen in both men and women. These may be attributed to the typical decline in muscle strength, balance, coordination, and neuromuscular function. The results of this study contribute to the understanding of gait changes throughout the lifespan and can be used for comparison with other populations and as reference values for individual patients.

Relative aerobic load of walking in people with multiple sclerosis

OBJECTIVE

To examine the energy demand of walking relative to aerobic capacity in people with multiple sclerosis.

DESIGN

Cross-sectional cohort study.

PATIENTS

A total of 45 people with multiple sclerosis (32 females), median disease duration 15 years (interquartile range (IQR) 9; 20), median Expanded Disability Status Scale 4 (min-max range: 2.0; 6.0).

METHODS

Aerobic capacity, derived from a cardiopulmonary exercise test and gas exchange measurements, assessed during a 6-min overground walk test at comfortable speed, were analysed. The relative aerobic load of walking was determined as the energy demand of walking relative to oxygen uptake at peak and at the first ventilatory threshold. Healthy reference data were used for clinical inference.

RESULTS

People with multiple sclerosis walk at a mean relative aerobic load of 60.0% (standard deviation 12.8%) relative to peak aerobic capacity, and 89.1% (standard deviation 19.9%) relative to the first ventilatory threshold. Fourteen participants walked above the first ventilatory threshold (31%). Peak aerobic capacity was reduced in 45% of participants, and energy demands were increased in 52% of participants.

CONCLUSION

People with multiple sclerosis walk at a relative aerobic load close to their first ventilatory threshold. A high relative aerobic load can guide clinicians to improve aerobic capacity or reduce the energy demands of walking.

Impact of textured surfaces on the orthostatic balance of patients with multiple sclerosis

OBJECTIVE

To perform posturographic measurements with eyes open or closed using floor coverings with different textured surfaces to study postural control in patients with multiple sclerosis (MS).

METHODS

Static posturographic recordings were performed with eyes open and eyes closed on a forceplate with no covering (control condition) or covered by a textured mat with small pimples (height 2 mm) or large pimples (height 7 mm). Several posturographic variables were measured, focusing on displacements of the center of pressure (CoP) including the average velocity (Vav), the total length (L) of all displacements, and the surface (S) of the confidence ellipse. The recordings made with the textured mats were compared to the control condition with eyes open or closed. Then, the differences between the recordings made with large vs. small pimples on the one hand, and with eyes closed vs. open were calculated to assess the impact of pimple height or eye closure on posturographic measurements. Clinical assessment was based on the Expanded Disability Status Scale (EDSS) and its functional system (FS) subscores, the Modified Fatigue Impact Scale (MFIS), the Unipodal Stance test (UST), and the Timed Up-and-Go test (TUG).

RESULTS

Forty-six MS patients (mean EDSS score: 3.6) completed the study. Several posturographic variables, including Vav and L, deteriorated when measured on a textured mat, especially with large pimples and in eyes open condition. In contrast, no difference was found with small pimples and eyes closed, as compared to the control condition (no covering). The deleterious impact of pimple height on posturography correlated positively with the alteration of balance and gait clinically assessed by the UST and the TUG, and also with the MFIS physical and cerebral EDSS-FS subscores, and negatively with the cerebellar and brainstem subscores. On the other hand, the impact of eye closure on posturography was negatively correlated with the visual EDSS-FS subscore.

DISCUSSION

Static posturographic measurements made with different textured surfaces and visual conditions can be considered as a sensitive tool to measure "proprioceptive reserves". Actually, when cerebellar, brainstem, or visual functions are impaired, the resources of the sensory (proprioceptive) system, if preserved, can be recruited at a higher level and compensate for dysfunctions of other postural controls to maintain a satisfactory balance. In addition, this procedure of static posturographic examination can provide objective measurements correlated with clinical testing of balance and gait and could usefully complement EDSS scoring to assess disability affecting postural control and the risk of falling in MS patients.

Smartphone-based gait assessment for multiple sclerosis

INTRODUCTION

Multiple Sclerosis causes gait alteration, even in the early stages of the disease. Traditional methods to quantify gait impairment, such as performance-based measures, lab-based motion analyses, and self-report, have limited ecological relevance. The Mon4t® app is a digital tool that uses sensors embedded in standard smartphones to measure various gait parameters.

OBJECTIVES

To evaluate the use of Mon4t® technology in monitoring MS patients.

METHODS

100 MS patients and age-matched healthy controls were evaluated using both a human rater and the Mon4t Clinic™ app. Three motor tasks were performed: 3m Timed up and go test (TUG), 10m TUG, and tandem walk. The digital markers were used to compare MS vs. HC, MS with EDSS=0 vs. HC, and MS with EDSS=0 vs. MS with EDSS>0. Within the MS EDSS>0 group, correlations between digital gait markers and the EDSS score were calculated.

RESULTS

Significant differences were found between MS patients and HC in multiple gait parameters. When comparing MS patients with minimal disability (EDSS=0) and HC: On the 3m TUG task, MS patients took longer to complete the task (mean difference 0.167seconds, p =0.034), took more steps (mean difference 1.32 steps, p =0.003), and had a weaker ML step-to-step correlation (mean difference 0.1, p = 0.001). The combination of features from the three motor tasks allowed distinguishing a nondisabled MS patient from a HC with high confidence (AUC of 85.65 on the ROC). When comparing MS patients with minimal disability (EDSS=0) to those with higher disability (EDSS>0): On the tandem walk task, patients with EDSS>0 took significantly longer to complete 10 steps than those with EDSS=0 (mean difference 4.63 seconds, p < 0.001), showed greater ML sway (mean difference 0.2, p < 0.001), and had larger angular velocity in the SI axis on average (mean difference 2.31 degrees/sec, p = 0.01). A classification model achieved 81.79 ROC AUC. In the subgroup of patients with EDSS>0, gait features significantly correlated with EDSS score in all three tasks.

CONCLUSION

The findings demonstrate the potential of digital gait assessment to augment traditional disease monitoring and support clinical decision making. The Mon4t® app provides a convenient and ecologically relevant tool for monitoring MS patients and detecting early changes in gait impairment.

Feasibility of a new intervention addressing group-based balance and high-intensity training, physical activity, and employment in individuals with multiple sclerosis: a pilot randomized controlled trial

Background and purpose

Impaired sensorimotor function, reduced physical activity and unemployment are common challenges in persons with multiple sclerosis (pwMS), even when disability is low. CoreDISTparticipation is a new, multidisciplinary intervention delivered across healthcare levels systematically addressing these elements. This study primarily aimed to evaluate the feasibility of CoreDISTparticipation in terms of process, resources, management, and scientific outcomes. The secondary aim was to evaluate initial efficacy in terms of possible short-term effects compared with the usual care on barriers to employment, balance, walking, health-related quality of life (HRQoL), and physical activity.

Methods

This assessor-blinded prospective pilot randomized controlled trial included 29 pwMS [Expanded Disability Status Scale (EDSS): 0-3.5] randomly allocated to the intervention group (CoreDISTparticipation) (n = 15) or usual care (n = 14). CoreDISTparticipation consists of three phases: (1) hospital outpatient clinic: MS nurse work-focused session and physiotherapist exploring balance; (2) municipality: a digital meeting with pwMS, employer, MS nurse, and physiotherapist addressing employment and physical activity, 4 weeks indoor CoreDIST balance training (60 min × 2/week); and (3) 4 weeks outdoor CoreDIST balance training and high-intensity running/walking (60 min × 2/week). Assessments were undertaken at baseline and at weeks 6 and 11. Primary feasibility metric outcomes were the reporting of process, resources, management, and scientific outcomes. Efficacy measures included evaluation of the Multiple Sclerosis Work Difficulties Questionnaire-23 Norwegian Version (MSWDQ-23NV) and 6 Minute Walk-test as well as the Trunk Impairment Scale-modified Norwegian Version, Mini-Balance Evaluation Systems Test (Mini-BESTest), Multiple Sclerosis Walking Scale-12, Multiple Sclerosis Impact Scale-29 Norwegian Version (MSIS-29NV), ActiGraph wGT3x-BT monitors, and AccuGait Optimized force platform. The statistical analyses included repeated-measures mixed models performed in IBM SPSS Version 29.

Results

The primary feasibility metric outcomes demonstrated the need for minor adjustments in regard to the content of the intervention and increasing the number of staff. In regard to the efficacy measures, one person attended no postintervention assessments and was excluded, leaving 28 participants (mean EDSS: 1.8, SD: 1). The mean percentage employment was 46.3 (SD: 35.6) and 65.4 (SD: 39.3) in the CoreDISTparticipation and usual care group, respectively. No between-group differences were found. MSWDQ-23NV demonstrated a within-group difference of 5.7 points from baseline to Week 11 (P = 0.004; confidence interval: 2.2-9.3). Mini-BESTest and MSIS-29NV demonstrated within-group differences. The study is registered in ClinicalTrials.gov (Identifier: NCT05057338).

Discussion

The CoreDISTparticipation intervention is feasible to support pwMS when the identified feasibility metric outcomes in regard to process, resource, management, and scientific outcome metrics are adjusted to improve feasibility. Regarding efficacy measures, no between-group differences were detected; however, within-group differences in barriers to employment, balance, and HRQoL were detected for the CoreDISTparticipation group. A larger comparative trial is needed to explore between-group differences and should accurately and precisely define usual care and address the identified limitations of this study.

Does non-invasive brain stimulation improve spatiotemporal gait parameters in people with multiple sclerosis? A systematic review and meta-analysis

BACKGROUND

Multiple sclerosis (MS) is a chronic autoimmune disease that causes progressive functional impairment, mainly in walking tasks. Noninvasive brain stimulation (NIBS) could influence the motor function and improving gait ability of patients.

OBJECTIVE

The aim was to analyze the effects of NIBS (transcranial direct current stimulation [tDCS] or transcranial magnetic stimulation [TMS] on functional locomotion in people with multiple sclerosis (PwMS).

METHODS

A search was conducted for randomized controlled trials published up to November 2023 comparing the application of NIBS versus a sham or control group. The primary outcome were spatiotemporal gait parameters and functional mobility. Two review authors independently assessed the risk of bias in the included studies, and we used the Grading of Recommendations Assessment, Development, and Evaluation methodology to rate the certainty of the evidence for each outcome. A meta-analysis was performed by pooling the appropriate data using RevMan Web.

RESULTS

A total of four clinical trials were included for metanalysis. We observed that there is no statistically significant difference in overall effect in gait speed (MD = 0.08; 95% CI: -0.08-0.24; p = 0.32), and cadence (MD = 0.22; 95% CI: -11.54-11.98; p = 0.97%) between groups. But there was a statistically significant difference in overall effect in stride length between groups (MD:0.19; 95% CI: 0.07-0.31; p = 0.002), mainly when the intervention performed by multiple sessions and associated with motor rehabilitation (MD = 0.29; 95% CI: 0.14-0.44; p = 0.0002).

CONCLUSIONS

tDCS applied by multiple session and combined with motor rehabilitation (i.e., aerobic and/or resistance training) can improve stride length in PwMS.

Investigating the prognostic value of digital mobility outcomes in patients with chronic obstructive pulmonary disease: a systematic literature review and meta-analysis

BACKGROUND

Reduced mobility is a central feature of COPD. Assessment of mobility outcomes that can be measured digitally (digital mobility outcomes (DMOs)) in daily life such as gait speed and steps per day is increasingly possible using devices such as pedometers and accelerometers, but the predictive value of these measures remains unclear in relation to key outcomes such as hospital admission and survival.

METHODS

We conducted a systematic review, nested within a larger scoping review by the MOBILISE-D consortium, addressing DMOs in a range of chronic conditions. Qualitative and quantitative analysis considering steps per day and gait speed and their association with clinical outcomes in COPD patients was performed.

RESULTS

21 studies (6076 participants) were included. Nine studies evaluated steps per day and 11 evaluated a measure reflecting gait speed in daily life. Negative associations were demonstrated between mortality risk and steps per day (per 1000 steps) (hazard ratio (HR) 0.81, 95% CI 0.75-0.88, p<0.001), gait speed (<0.80 m·s-1) (HR 3.55, 95% CI 1.72-7.36, p<0.001) and gait speed (per 1.0 m·s-1) (HR 7.55, 95% CI 1.11-51.3, p=0.04). Fewer steps per day (per 1000) and slow gait speed (<0.80 m·s-1) were also associated with increased healthcare utilisation (HR 0.80, 95% CI 0.72-0.88, p<0.001; OR 3.36, 95% CI 1.42-7.94, p=0.01, respectively). Available evidence was of low-moderate quality with few studies eligible for meta-analysis.

CONCLUSION

Daily step count and gait speed are negatively associated with mortality risk and other important outcomes in people with COPD and therefore may have value as prognostic indicators in clinical trials, but the quantity and quality of evidence is limited. Larger studies with consistent methodologies are called for.

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.

Uncovering Subtle Gait Deterioration in People with Early-Stage Multiple Sclerosis Using Inertial Sensors: A 2-Year Multicenter Longitudinal Study

Limited longitudinal studies have been conducted on gait impairment progression overtime in non-disabled people with multiple sclerosis (PwMS). Therefore, a deeper understanding of gait changes with the progression of the disease is essential. The objective of the present study was to describe changes in gait quality in PwMS with a disease duration ≤ 5 years, and to verify whether a change in gait quality is associated with a change in disability and perception of gait deterioration. We conducted a multicenter prospective cohort study. Fifty-six subjects were assessed at baseline (age: 38.2 ± 10.7 years, Expanded Disability Status Scale (EDSS): 1.5 ± 0.7 points) and after 2 years, participants performed the six-minute walk test (6MWT) wearing inertial sensors. Quality of gait (regularity, symmetry, and instability), disability (EDSS), and walking perception (multiple sclerosis walking scale-12, MSWS-12) were collected. We found no differences on EDSS, 6MWT, and MSWS-12 between baseline and follow-up. A statistically significant correlation between increased EDSS scores and increased gait instability was found in the antero-posterior (AP) direction (r = 0.34, p = 0.01). Seventeen subjects (30%) deteriorated (increase of at least 0.5 point at EDSS) over 2 years. A multivariate analysis on deteriorated PwMS showed that changes in gait instability medio-lateral (ML) and stride regularity, and changes in ML gait symmetry were significantly associated with changes in EDSS (F = 7.80 (3,13), p = 0.003, R2 = 0.56). Moreover, gait changes were associated with a decrease in PwMS perception on stability (p < 0.05). Instrumented assessment can detect subtle changes in gait stability, regularity, and symmetry not revealed during EDSS neurological assessment. Moreover, instrumented changes in gait quality impact on subjects' perception of gait during activities of daily living.

Effectiveness of transcranial direct current stimulation on balance and gait in patients with multiple sclerosis: systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Motor impairments are very common in neurological diseases such as multiple sclerosis. Noninvasive brain stimulation could influence the motor function of patients.

OBJECTIVE

The aim of this meta-analysis was to evaluate the effectiveness of transcranial direct current stimulation (tDCS) on balance and gait ability in patients with multiple sclerosis. Additionally, a secondary aim was to compare the influence of the stimulation location of tDCS on current effectiveness.

METHODS

A search was conducted for randomized controlled trials published up to May 2023 comparing the application of tDCS versus a sham or control group. The primary outcome variables were balance and gait ability.

RESULTS

Eleven studies were included in the qualitative analysis, and ten were included in the quantitative analysis, which included 230 patients with multiple sclerosis. The average effect of tDCS on gait functionality was superior to that of the control group (SMD = -0.71; 95% CI, -1.05 to -0.37). However, the overall results of the tDCS vs. sham effect on static balance did not show significant differences between groups (MD = 1.26, 95% CI, -1.31 to 3.82). No significant differences were found when different locations of tDCS were compared.

CONCLUSIONS

These results reveal that tDCS is an effective treatment for improving gait ability with a low quality of evidence. However, the application of tDCS has no effect on static balance in patients with multiple sclerosis with very low quality of evidence. Similarly, there seems to be no difference regarding the stimulation area with tDCS.

The reliability and validity of the 30-second chair stand test and modified four square step test in persons with multiple sclerosis

BACKGROUND

The 30-second Chair Stand Test (30s-CST) and Modified Four Square Step Test (mFSST) are used to determine the functional status of individuals with multiple sclerosis (MS). No other studies have demonstrated the reliability and validity of the 30s-CST and mFSST.

PURPOSE

To identify the test-retest reliability, concurrent validity and the known-group validity of the 30s-CST and mFSST in persons with MS.

METHODS

A total of 64 persons with MS were enrolled. 30s-CST, mFSST, Timed Up and Go Test (TUG) and Five Times Sit to Stand (FTST) tests were performed. 30s-CST and mFSST were conducted again one-hour later.

RESULTS

The mean age of the persons with MS were 37.9±11.3 years. The test-retest reliability of the 30s-CST and mFSST were excellent (ICC30s-CST = 0.974, 95%CI: 0.95-0.98; ICCmFSST = 0.992, 95%CI: 0.98-0.99). The 30s-CST was strongly correlated with FTST and TUG (r1 = -0.871, p1 = 0.0001; r2 = -0.741,p2 = 0.0001). There was a strong relationship between mFSST with TUG and FTST (r1 = 0.781,p1 = 0.0001;r2 = 0.788,p2 = 0.0001). The SEM95 and MDC95 values of the 30s-CST and mFSST were 0.41/1.13 and 0.34/0.94, respectively. Besides, there were significant differences between the persons with or without fall history in 30s-CST (MD: 1.66, CI: 0.27 to 3.05, p = .019) and mFSST CST (MD:-2.70, CI: -4.73 to -0.67, p = .010) performances.

CONCLUSION

The 30s-CST and mFSST are both valid and reliable in mildly-disabled individuals with MS.

Innovative multidimensional gait evaluation using IMU in multiple sclerosis: introducing the semiogram

Background

Quantifying gait using inertial measurement units has gained increasing interest in recent years. Highly degraded gaits, especially in neurological impaired patients, challenge gait detection algorithms and require specific segmentation and analysis tools. Thus, the outcomes of these devices must be rigorously tested for both robustness and relevancy in order to recommend their routine use. In this study, we propose a multidimensional score to quantify and visualize gait, which can be used in neurological routine follow-up. We assessed the reliability and clinical coherence of this method in a group of severely disabled patients with progressive multiple sclerosis (pMS), who display highly degraded gait patterns, as well as in an age-matched healthy subjects (HS) group.

Methods

Twenty-two participants with pMS and nineteen HS were included in this 18-month longitudinal follow-up study. During the follow-up period, all participants completed a 10-meter walk test with a U-turn and back, twice at M0, M6, M12, and M18. Average speed and seven clinical criteria (sturdiness, springiness, steadiness, stability, smoothness, synchronization, and symmetry) were evaluated using 17 gait parameters selected from the literature. The variation of these parameters from HS values was combined to generate a multidimensional visual tool, referred to as a semiogram.

Results

For both cohorts, all criteria showed moderate to very high test-retest reliability for intra-session measurements. Inter-session quantification was also moderate to highly reliable for all criteria except smoothness, which was not reliable for HS participants. All partial scores, except for the stability score, differed between the two populations. All partial scores were correlated with an objective but not subjective quantification of gait severity in the pMS population. A deficit in the pyramidal tract was associated with altered scores in all criteria, whereas deficits in cerebellar, sensitive, bulbar, and cognitive deficits were associated with decreased scores in only a subset of gait criteria.

Conclusions

The proposed multidimensional gait quantification represents an innovative approach to monitoring gait disorders. It provides a reliable and informative biomarker for assessing the severity of gait impairments in individuals with pMS. Additionally, it holds the potential for discriminating between various underlying causes of gait alterations in pMS.

Performance of a Mobile 3D Camera to Evaluate Simulated Pathological Gait in Practical Scenarios

Three-dimensional (3D) cameras used for gait assessment obviate the need for bodily markers or sensors, making them particularly interesting for clinical applications. Due to their limited field of view, their application has predominantly focused on evaluating gait patterns within short walking distances. However, assessment of gait consistency requires testing over a longer walking distance. The aim of this study is to validate the accuracy for gait assessment of a previously developed method that determines walking spatiotemporal parameters and kinematics measured with a 3D camera mounted on a mobile robot base (ROBOGait). Walking parameters measured with this system were compared with measurements with Xsens IMUs. The experiments were performed on a non-linear corridor of approximately 50 m, resembling the environment of a conventional rehabilitation facility. Eleven individuals exhibiting normal motor function were recruited to walk and to simulate gait patterns representative of common neurological conditions: Cerebral Palsy, Multiple Sclerosis, and Cerebellar Ataxia. Generalized estimating equations were used to determine statistical differences between the measurement systems and between walking conditions. When comparing walking parameters between paired measures of the systems, significant differences were found for eight out of 18 descriptors: range of motion (ROM) of trunk and pelvis tilt, maximum knee flexion in loading response, knee position at toe-off, stride length, step time, cadence; and stance duration. When analyzing how ROBOGait can distinguish simulated pathological gait from physiological gait, a mean accuracy of 70.4%, a sensitivity of 49.3%, and a specificity of 74.4% were found when compared with the Xsens system. The most important gait abnormalities related to the clinical conditions were successfully detected by ROBOGait. The descriptors that best distinguished simulated pathological walking from normal walking in both systems were step width and stride length. This study underscores the promising potential of 3D cameras and encourages exploring their use in clinical gait analysis.

Lower Myelin Content Is Associated With Lower Gait Speed in Cognitively Unimpaired Adults

Mounting evidence indicates that abnormal gait speed predicts the progression of neurodegenerative diseases, including Alzheimer's disease. Understanding the relationship between white matter integrity, especially myelination, and motor function is crucial to the diagnosis and treatment of neurodegenerative diseases. We recruited 118 cognitively unimpaired adults across an extended age range of 22-94 years to examine associations between rapid or usual gait speeds and cerebral myelin content. Using our advanced multicomponent magnetic resonance relaxometry method, we measured myelin water fraction (MWF), a direct measure of myelin content, as well as longitudinal and transverse relaxation rates (R1 and R2), sensitive but nonspecific magnetic resonance imaging measures of myelin content. After adjusting for covariates and excluding 22 data sets due to cognitive impairments or artifacts, our results indicate that participants with higher rapid gait speed exhibited higher MWF, R1, and R2 values, that is, higher myelin content. These associations were statistically significant within several white matter brain regions, particularly the frontal and parietal lobes, splenium, anterior corona radiata, and superior fronto-occipital and longitudinal fasciculus. In contrast, we did not find any significant associations between usual gait speed and MWF, R1, or R2, which suggests that rapid gait speed may be a more sensitive marker of demyelination than usual gait speed. These findings advance our understanding on the implication of myelination in gait impairment among cognitively unimpaired adults, providing further evidence of the interconnection between white matter integrity and motor function.

The effect of exercise and physical activity-interventions on step count and intensity level in individuals with multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials

Background

Reduced physical activity is a worldwide challenge in individuals with multiple sclerosis (MS). The aim of this systematic review and meta-analysis was to identify devise-measured effects of physical activity, exercise and physiotherapy-interventions on step count and intensity level of physical activity in individuals with MS.

Methods

A systematic search of the databases of PubMed (including Medline), Scopus, CINHAL and Web of Science was carried out to retrieve studies published in the English language from the inception to the first of May 2023. All trials concerning the effectiveness of different types of exercise on step count and intensity level in people with MS were included. The quality of the included studies and their risk of bias were critically appraised using The modified consolidated standards of reporting trials and the Cochrane Risk of Bias tool, respectively. The pooled standardized mean difference (SMD) and 95% CI of the step-count outcome and moderate to vigorous intensity level before versus after treatment were estimated in both Intervention and Control groups using the random effect model. The Harbord test were used to account for heterogeneity between studies and assess publication bias, respectively. Further sensitivity analysis helped with the verification of the reliability and stability of our review results.

Results

A total of 8 randomized clinical trials (involving 919 individuals with MS) were included. The participants (including 715 (77.8%) female and 204 (22.2%) male) had been randomly assigned to the Intervention (n = 493) or Control group (n = 426). The pooled mean (95% CI) age and BMI of participants were 49.4 years (95% CI: 47.4, 51.4 years) and 27.7 kg/m2 (95% CI: 26.4, 29 kg/m2), respectively. In terms of the comparison within the Intervention and the Control groups before and after the intervention, the results of the meta-analysis indicate that the pooled standardized mean difference (SMD) for step-count in the Intervention group was 0.56 (95% CI: -0.42, 1.54), while in the Control group it was 0.12 (95% CI: -0.05, 0.28). Furthermore, there was no significant difference in the pooled SMD of step-count in the physical activity Intervention group compared to the Controls after the intervention (pooled standard mean difference = 0.19, 95% CI: -0.36,0.74). Subgroup analysis on moderate to vigorous intensity level of physical activity revealed no significant effect of the physical activity intervention in the Intervention group compared to the Control group after the intervention, or within groups before and after the intervention. Results of meta regression showed that age, BMI, duration of disease and Expanded Disability Status Scale (EDSS) score were not the potential sources of heterogeneity (all p > 0.05). Data on the potential harms of the interventions were limited.

Conclusion

The results of this meta-analysis showed no significant differences in step count and moderate to vigorous physical activity level among individuals with MS, both within and between groups receiving physical activity interventions. More studies that objectively measure physical activity are needed.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022343621.

mHealth Impact on Gait and Dynamic Balance Outcomes in Neurorehabilitation: Systematic Review and Meta-analysis

Gait and dynamic balance are two main goals in neurorehabilitation that mHealth systems could address. To analyze the impact of using mHealth systems on gait and dynamic balance outcomes in subjects with neurological disorders. Randomized controlled trials (RCT) published in PubMed, Web of Science, Scopus, and PEDro databases were searched up to April 2023. Studies including adults with neurological disorders, analyzing the effectiveness of mHealth systems on gait and dynamic balance compared with conventional therapy and/or not intervention, were included. The PEDro scale and the Cochrane Collaboration's 2.0 tool were used for the methodological quality and risk of bias assessment. The Review Manager 5.4 software was used to obtain meta-analyses. 13 RCT were included in the systematic review and 11 in the meta-analyses, involving 528 subjects. A total of 21 mobile applications were identified for gait and balance training, and to enhance physical activity behaviors. There were significant differences in gait parameters, speed by 0.10 s/m (95% confidence interval (CI)=0.07,0.13;p<0.001), cadence by 8.01 steps/min (95%CI=3.30,12.72;p<0.001), affected step length by 8.89 cm (95%CI=4.88,12.90;p<0.001), non-affected step length by 8.08 cm (5%CI=2.64,13.51;p=0.004), and in dynamic balance, Timed Up and Go by -7.15 s (95%CI=-9.30,-4.99;p<0.001), and mobility subscale of Posture Assessment Scale for Stroke by 1.71 points (95%CI=1.38,2.04;p<0.001). Our findings suggested the use of mHealth systems for improving gait in subjects with neurological disorders, but controversial results on dynamics balance recovery were obtained. However, the quality of evidence is insufficient to strongly recommend them, so further research is needed.

Deep Learning for Multiple Sclerosis Differentiation Using Multi-Stride Dynamics in Gait

OBJECTIVE

Multiple sclerosis (MS) is a chronic neurological condition of the central nervous system leading to various physical, mental and psychiatric complexities. Mobility limitations are amongst the most frequent and early markers of MS. We evaluated the effectiveness of a DeepMS2G (deep learning (DL) for MS differentiation using multistride dynamics in gait) framework, which is a DL-based methodology to classify multi-stride sequences of persons with MS (PwMS) from healthy controls (HC), in order to generalize over newer walking tasks and subjects.

METHODS

We collected single-task Walking and dual-task Walking-while-Talking gait data using an instrumented treadmill from a balanced collection of 20 HC and 20 PwMS. We utilized domain knowledge-based spatiotemporal and kinetic gait features along with two normalization schemes, namely standard size-based and multiple regression normalization strategies. To differentiate between multi-stride sequences of HC and PwMS, we compared 16 traditional machine learning and DL algorithms. Further, we studied the interpretability of our highest-performing models; and discussed the association between the lower extremity function of participants and our model predictions.

RESULTS

We observed that residual neural network (ResNet) based models with regression-based normalization were the top performers across both task and subject generalization classification designs. Considering regression-based normalization, a multi-scale ResNet attained a subject classification accuracy and F 1-score of 1.0 when generalizing from single-task Walking to dual-task Walking-while-Talking; and a ResNet resulted in the top subject-wise accuracy and F 1 of 0.83 and 0.81 (resp.), when generalizing over unseen participants.

CONCLUSION

We used advanced DL and dynamics across domain knowledge-based spatiotemporal and kinetic gait parameters to successfully classify MS gait across distinct walking trials and unseen participants.

SIGNIFICANCE

Our proposed DL algorithms might contribute to efforts to automate MS diagnoses.

Complementary use of statistical parametric mapping and gait profile score to describe walking alterations in multiple sclerosis: a cross-sectional study

Gait analysis is often used to study locomotor alterations in people with multiple sclerosis (PwMS), but the large number of extracted variables challenges the interpretability. In this paper, we analysed gait alterations by combining the Gait Profile Score (GPS), which summarizes kinematic locomotor deviations, and Statistical Parametric Mapping (SPM), which compares kinematics and kinetics over the whole gait cycle. Eleven PwMS and 11 speed-matched Healthy Controls (HC) underwent overground gait analysis. GPS were compared through independent-samples t-tests; sagittal-plane kinematics and power at hip, knee, and ankle were compared through SPM Hotelling's-T2 and SPM t-tests. Spearman's correlation coefficients (r) between GPS and clinical outcomes were also calculated. PwMS had higher GPS than HC (PwMS = 8.74 ± 2.13°; HC = 5.01 ± 1.41°;p < 0.001). Multivariate SPM found statistically significant differences at 0-49%, 70-80%, and 93-99% of stride (p < 0.05) and univariate analysis showed reduced ankle dorsiflexion, and lower knee flexion during pre-swing and swing. GPS correlated with Expanded Disability Status Scale (r = 0.65; 95%C.I.[0.04,0.91]; p = 0.04) and 2-Minute Walking Test (r = -0.65; 95%C.I.[-0.91,-0.04]; p = 0.04). GPS in conjunction with SPM revealed multi-joint kinematic alterations on sagittal plane involving distal joint angles, ankle and knee, during the stance phase with no changes at the proximal level. Gait deviations were more pronounced in PwMS with higher disability and walking limitations.

Split-Belt Treadmill Adaptation Improves Spatial and Temporal Gait Symmetry in People with Multiple Sclerosis

Multiple sclerosis (MS) is a neurodegenerative disease characterized by degradation of the myelin sheath resulting in impaired neural communication throughout the body. As a result, most people with MS (PwMS) experience gait asymmetries between their legs leading to an increased risk of falls. Recent work indicates that split-belt treadmill adaptation, where the speed of each leg is controlled independently, can decrease gait asymmetries for other neurodegenerative impairments. The purpose of this study was to test the efficacy of split-belt treadmill training to improve gait symmetry in PwMS. In this study, 35 PwMS underwent a 10 min split-belt treadmill adaptation paradigm, with the faster paced belt moving under the more affected limb. Step length asymmetry (SLA) and phase coordination index (PCI) were the primary outcome measures used to assess spatial and temporal gait symmetries, respectively. It was predicted that participants with a worse baseline symmetry would have a greater response to split-belt treadmill adaptation. Following this adaptation paradigm, PwMS experienced aftereffects that improved gait symmetry, with a significant difference between predicted responders and nonresponders in both SLA and PCI change (p < 0.001). Additionally, there was no correlation between SLA and PCI change. These findings suggest that PwMS retain the ability for gait adaptation, with those most asymmetrical at baseline demonstrating the greatest improvement, and that there may be separate neural mechanisms for spatial and temporal locomotor adjustments.

Impaired foot vibration sensitivity is related to altered plantar pressures during walking in people with multiple sclerosis

BACKGROUND

Balance and mobility impairment are two of the most common and debilitating symptoms among people with multiple sclerosis (MS). Somatosensory symptoms, including reduced plantar cutaneous sensation, have been identified in this cohort. Given the importance of the somatosensory system in gait, it is likely that impaired plantar sensation may play a role in the walking adaptations commonly observed in people with MS, including decreased stride length and increased stride width and dual support time, often described as a cautious gait strategy. Understanding the contributions of plantar sensation to these alterations may provide targets for interventions that seek to improve sensory feedback and normalize gait patterns. This cross-sectional study determined whether individuals with MS who demonstrate reduced sensitivity of the plantar surfaces also demonstrate altered plantar pressure distributions during walking compared to a control cohort.

METHODS

Twenty individuals with MS and twenty age- and sex-matched control participants walked barefoot at preferred and three matched speeds. Participants walked across a walkway with an embedded pressure plate used to quantify pressures within ten plantar zones. In addition, vibration perception thresholds were assessed at four sites on the plantar surface.

RESULTS

Individuals with MS demonstrated increased peak total plantar pressures compared to control participants, that increased with walking speed. For the MS group, plantar pressures were higher on the less sensitive foot, although pressures on both feet exceeded those of the control cohort. Positive correlations between vibration perception threshold and peak total pressure were evident, although generally stronger in the MS cohort.

CONCLUSION

A relationship between plantar vibration sensitivity and pressure could indicate that individuals with MS seek to increase plantar sensory feedback during walking. However, because proprioception may also be impaired, increased plantar pressure could result from inaccurate foot placement. Interventions targeting improved somatosensation may have the potential to normalize gait patterns and should be investigated.

Locomotor Strategy to Perform 6-Minute Walk Test in People with Multiple Sclerosis: A Prospective Observational Study

Two-thirds of people with Multiple Sclerosis (PwMS) have walking disabilities. Considering the literature, prolonged tests, such as the 6 min walk test, better reflect their everyday life walking capacities and endurance. However, in most studies, only the distance traveled during the 6MWT was measured. This study aims to analyze spatio-temporal (ST) walking patterns of PwMS and healthy people in the 6MWT. Participants performed a 6MWT with measures of five ST variables during three 1 min intervals (initial: 0'-1', middle: 2'30″-3'30″, end: 5'-6') of the 6MWT, using the GAITRite system. Forty-five PwMS and 24 healthy people were included. We observed in PwMS significant changes between initial and final intervals for all ST parameters, whereas healthy people had a rebound pattern but the changes between intervals were rather negligible. Moreover, ST variables' changes were superior to the standard measurement error only for PwMS between initial and final intervals for all ST parameters. This result suggests that the modification in PwMS' walking pattern is effectively due to their walking ability and not to a measurement, and suggests that PwMS could not manage their walking efficiently compared to healthy people, who could maintain their rhythm throughout the 6MWT. Further studies are needed to detect these patterns changes in the early evolution of the disease, identify clinical determinants involved in PwMS' walking pattern, and investigate whether interventions can positively impact this pattern.

A highly challenging balance training intervention for people with multiple sclerosis: a feasibility trial

BACKGROUND

Balance training interventions with a gradual progression of difficulty and highly challenging tasks designed specifically for people with multiple sclerosis (MS) are rare. The objective was to adapt a balance training intervention originally developed for Parkinson's disease through a co-design process and then conduct a pilot trial in MS to evaluate the feasibility of a large, full-scale study.

METHODS

Twelve people with MS with mild to moderate overall MS-disability were included in this single-group feasibility trial. Participants received one-hour training sessions twice or three times weekly for 10 weeks. The assessment included tests of physical and cognitive functioning and patient-reported quality of life-related outcomes. Data on feasibility aspects were collected at baseline and follow-up assessments and three times during the intervention period to inform the recruitment process, as well as to monitor retention and inclusion rates, study procedures, intervention delivery, and dynamic changes in the selected potential outcome measures. Progression criteria were used to determine whether to proceed to a full-scale trial. Descriptive statistics were used to present the data.

RESULTS

Out of six progression criteria, only retention and attendance at training sessions were not met. Reasons reported for not completing the intervention period mainly depended on external circumstances beyond the control of the study. In contrast, study procedures, intervention delivery, and intervention content (progression, adjustment, and control of challenge level of exercises) were considered feasible for a future, full-scale trial. The Mini-BESTest, which was used for the assessment of balance control, was considered suitable as the primary outcome in a full-scale trial with no ceiling or floor effects. Further, the Mini-BESTest showed a positive trend in outcome response with a median difference of 3.5 points between baseline and follow-up assessments. The power calculation performed suggests a feasible number of participants for recruitment.

CONCLUSIONS

Overall trial aspects and intervention delivery were deemed feasible for a full-scale trial, but adjustments are needed to increase retention and attendance.

Translingual neurostimulation combined with physical therapy to improve walking and balance in multiple sclerosis (NeuroMSTraLS): Study protocol for a randomized controlled trial

INTRODUCTION

Physical rehabilitation restores lost function and promotes brain plasticity in people with Multiple Sclerosis (MS). Research groups worldwide are testing the therapeutic effects of combining non-invasive neuromodulation with physical therapy (PT) to further improve functional outcomes in neurological disorders but with mixed results. Whether such devices enhance function is not clear. We present the rationale and study design for a randomized controlled trial evaluating if there is additional benefit to the synergistic pairing of translingual neurostimulation (TLNS) with PT to improve walking and balance in MS.

METHODS AND ANALYSIS

A parallel group [PT + TLNS or PT + Sham], quadruple-blinded, randomized controlled trial. Participants (N = 52) with gait and balance deficits due to relapsing-remitting or progressive MS, who are between 18 and 70 years of age, will be recruited through patient registries in Newfoundland & Labrador and Saskatchewan, Canada. All participants will receive 14 weeks of PT while wearing either a TLNS or sham device. Dynamic Gait Index is the primary outcome. Secondary outcomes include fast walking speed, subjective ratings of fatigue, MS impact, and quality of life. Outcomes are assessed at baseline (Pre), after 14 weeks of therapy (Post), and 26 weeks (Follow Up). We employ multiple methods to ensure treatment fidelity including activity and device use monitoring. Primary and secondary outcomes will be analyzed using linear mixed-effect models. We will control for baseline score and site to test the effects of Time (Post vs. Follow-Up), Group and the Group x Time interaction as fixed effects. A random intercept of participant will account for the repeated measures in the Time variable. Participants must complete the Post testing to be included in the analysis.

ETHICS AND DISSEMINATION

The Human Research Ethics Boards in Newfoundland & Labrador (HREB#2021.085) & Saskatchewan (HREB Bio 2578) approved the protocol. Dissemination avenues include peer-reviewed journals, conferences and patient-oriented communications.

Reliability of the Five Times Sit to Stand Test performed remotely by multiple sclerosis patients

INTRODUCTION

Multiple Sclerosis, known main cause of non-traumatic neurological disability in adults, leads to changes in muscle strength, especially in the lower limbs. Assessing muscle strength in these patients is thus essential and can be achieved by the Five Times Sit to Stand Test (FTSST), commonly performed in person. Due to the COVID-19 pandemic and social distancing measured adopted, Brazilian physiotherapists turned to remote monitoring and assessment, supported by Resolution n° 516/2020, which required proving the reliability of tests. Given this scenario, this study sought to evaluate the intra- and inter-rater reliability of the Five Times Sit to Stand Test performed remotely and synchronously by multiple sclerosis patients.

METHODS

A sample of 33 individuals with relapsing-remitting Multiple Sclerosis (18 women and 15 men, mean age 43.7 ± 13.4 years) were remotely and synchronously by video call. Inter-rater reliability was evaluated by analyzing FTSST execution time, in seconds, timed by two different raters on the same video call. In turn, intra-rater reliability was assessed by analyzing the execution time recorded in two different video calls made by the same rater, within a 24-28-h interval. Descriptive and inferential data analysis were performed using SPSS 20.0 software. Means and standard deviation were calculated for descriptive statistic. Intraclass correlation coefficient (ICC), with a 0.05 significance level, standard error of measurement (SEM) and minimal detectable change (MDC) were calculated for inferential analysis.

RESULTS

Data analysis showed excellent ICC values and low SEM and MDC values regarding inter-rater reliability (ICC: 0.993 (0.986-0.996); p-value: <0.001; SEM: 0.6 s; MDC: 1.6 s) and intra-rater reliability (ICC: 0.962 (0.925-0.981); p-value: <0.001; SEM: 1.4 s; MDC: 3.8 s).

CONCLUSION

Based on these values, FTSST performed remotely and synchronously by relapsing-remitting Multiple Sclerosis patients is reliable and can be used both by different raters, for assessment, or by the same rater, in pre- and post-test situations.

Upper limb contribution during tandem gait in multiple sclerosis: An early marker of balance impairments

Tandem gait is widely used during clinical exams to evaluate dynamic balance in chronic diseases, such as multiple sclerosis (MS). The early detection of balance impairments in MS is challenging to improve the understanding of patients' complaints. The objective was to propose two indexes to quantify the contributions and inefficiency of limb and trunk movements during tandem gait in early-stage MS patients. Fifteen patients with remitting-relapsed MS, with a median Expanded Disability Status Scale of 2.5 [0-4] were compared to 15 matched healthy participants. Three-dimensional motion analysis was performed during tandem gait to calculate spatiotemporal parameters, contribution and inefficiency indexes, based on the linear momentum of body segments. Compared to healthy participants, MS patients at the early stage of disease executed tandem gait with higher speed (p = 0.03) and increased step length (p = 0.03). The contribution indexes of upper limbs were significantly decreased during swing phase in MS patients. The inefficiency index for the upper limbs were around twice higher for MS patients compared to healthy participants. Since the additional movements concerned only light body segments and not contribute to the whole-body forward progression during tandem gait, they could reflected more both upper limb movements alterations and restoring movements to avoid loss of balance during tandem gait around swing phase in MS. These quantified indexes could be used as physical markers to quantify both the balance deterioration and the efficiency of rehabilitation program during the follow up of MS from the early stage of their disease.

Effect of Backward and Forward Walking on Lower Limb Strength, Balance, and Gait in Multiple Sclerosis: A Randomized Feasibility Trial

BACKGROUND

Backward walking (BW) interventions have improved gait and balance in persons with stroke, cerebral palsy, and Parkinson disease but have not been studied in persons with multiple sclerosis (MS). We examined the feasibility of a BW intervention and how it affected strength, balance, and gait vs forward walking (FW) in persons with MS.

METHODS

Sixteen persons with MS with a Patient-Determined Disease Steps (PDDS) scale score of 3 to 5 (gait impairment-late cane) were randomized to the FW (n = 8) or BW (n = 8) group. Participants did 30 minutes of FW or BW on a treadmill 3 times per week for 8 weeks (24 visits). Enrollment, adherence rate, and safety were tracked. The Timed Up and Go test, Six-Spot Step Test, single-leg stance, and abbreviated Activities-specific Balance Confidence scale were used to measure balance. Hip and knee flexion and extension strength (isometric peak torque), gait speed, and spatiotemporal gait parameters were measured. A 2×2 factorial multivariate analysis of covariance was used to examine changes in strength, balance, and gait, with the PDDS scale score as the covariate.

RESULTS

Treatment adherence rate was 99.7%, with no safety concerns. After controlling for baseline differences in disability (PDDS scale score; P = .041), the BW group improved dominant hip flexion strength preintervention to postintervention compared with the FW group (F 1,13 = 9.03; P = .010). No other significant differences were seen between groups.

CONCLUSIONS

This was the first study to look at BW as an intervention in persons with MS. Based on its feasibility, safety, and significant finding, BW should be studied in a larger, definitive trial in the future.

Clinical and MRI features of gait and balance disorders in neurodegenerative diseases

Gait and balance disorders are common signs in several neurodegenerative diseases such as Parkinson's disease, atypical parkinsonism, idiopathic normal pressure hydrocephalus, cerebrovascular disease, dementing disorders and multiple sclerosis. According to each condition, patients present with different gait and balance alterations depending on the structural and functional brain changes through the disease course. In this review, we will summarize the main clinical characteristics of gait and balance disorders in the major neurodegenerative conditions, providing an overview of the significant structural and functional MRI brain alterations underlying these deficits. We also will discuss the role of neurorehabilitation strategies in promoting brain plasticity and gait/balance improvements in these patients.

Combining robot-assisted therapy with virtual reality or using it alone? A systematic review on health-related quality of life in neurological patients

BACKGROUND

In the field of neurorehabilitation, robot-assisted therapy (RAT) and virtual reality (VR) have so far shown promising evidence on multiple motor and functional outcomes. The related effectiveness on patients' health-related quality of life (HRQoL) has been investigated across neurological populations but still remains unclear. The present study aimed to systematically review the studies investigating the effects of RAT alone and with VR on HRQoL in patients with different neurological diseases.

METHODS

A systematic review of the studies evaluating the impact of RAT alone and combined with VR on HRQoL in patients affected by neurological diseases (i.e., stroke, multiple sclerosis, spinal cord injury, Parkinson's Disease) was conducted according to PRISMA guidelines. Electronic searches of PubMed, Web of Science, Cochrane Library, CINAHL, Embase, and PsychINFO (2000-2022) were performed. Risk of bias was evaluated through the National Institute of Health Quality Assessment Tool. Descriptive data regarding the study design, participants, intervention, rehabilitation outcomes, robotic device typology, HRQoL measures, non-motor factors concurrently investigated, and main results were extracted and meta-synthetized.

RESULTS

The searches identified 3025 studies, of which 70 met the inclusion criteria. An overall heterogeneous configuration was found regarding the study design adopted, intervention procedures and technological devices implemented, rehabilitation outcomes (i.e., related to both upper and lower limb impairment), HRQoL measures administered, and main evidence. Most of the studies reported significant effects of both RAT and RAT plus VR on patients HRQoL, whether they adopted generic or disease-specific HRQoL measures. Significant post-intervention within-group changes were mainly found across neurological populations, while fewer studies reported significant between-group comparisons, and then, mostly in patients with stroke. Longitudinal investigations were also observed (up to 36 months), but significant longitudinal effects were exclusively found in patients with stroke or multiple sclerosis. Finally, concurrent evaluations on non-motor outcomes beside HRQoL included cognitive (i.e., memory, attention, executive functions) and psychological (i.e., mood, satisfaction with the treatment, device usability, fear of falling, motivation, self-efficacy, coping, and well-being) variables.

CONCLUSIONS

Despite the heterogeneity observed among the studies included, promising evidence was found on the effectiveness of RAT and RAT plus VR on HRQoL. However, further targeted short- and long-term investigations, are strongly recommended for specific HRQoL subcomponents and neurological populations, through the adoption of defined intervention procedures and disease-specific assessment methodology.

Dynamic balance during walking in people with multiple sclerosis: A cross-sectional study

Dynamic balance disorders are common impairments in People with Multiple Sclerosis (PwMS) leading to gait disorders and a higher risk of falling. However, the assessment of dynamic balance is still challenging and instrumented indexes provide objective and quantitative data of CoM movement and Base of Support, which are considered that are two key factors describing dynamic balance. This study aims at validating recent instrumented indexes based on the inverted pendulum model and characterizing dynamic balance disorders in PwMS. We clinically assessed 20 PwMS and we collected instrumented gait data through an optoelectronic system. Data from 20 Healthy Subjects (HS) were also considered as normative reference. Margin of Stability by HoF (MoS_Hof) and by Terry (MoS_Terry) at midstance, and Foot Placement Estimator (D_FPE) at heel strike were calculated in mediolateral (ML) and anteroposterior (AP) directions, for both less affected and most affected sides for PwMS and for dominant and non-dominant side for HS. MoS_HOF well discriminated between PwMS and HS, followed by MoS_TERRY in ML direction (Mos_HOF: PwMS = 130.0 ± 27.2 mm, HS = 106.5 ± 18.6 mm, p < 0.001, MoS_TERRY: PwMS = 75.1 ± 24.3 mm, HS = 56.5 ± 23.4 mm, p < 0.02). MoS_HOF and MoS_TERRY discriminated between sides in both directions in PwMS. D_FPE did not discriminate between groups and sides. Moderate correlations were found between all three indexes and clinical balance scales (from r = 0.02 to r = 0.66), energy recovery (from r = -0.77 to r = -0.11), single stance time (from r = -0.11 to r = 0.80) and step length (from r = -0.83 to r = -0.20). MoS_HOF resulted in the best index to describe dynamic balance disorders in PwMS: they keep CoM position far from the lateral and as close as possible to the anterior boundary of the Base of Support as preventive strategies to control balance perturbations. Furthermore, PwMS seem to use different preventive strategies in accordance with the specific lower limb impairments. This alters the physiological gait mechanisms increasing the energy expenditure and decreasing gait quality and dynamic balance.

The increased perceived exertion during the six minute walking test is not accompanied by changes in cost of walking, gait characteristics or muscle fatigue in persons with multiple sclerosis

BACKGROUND

Persons with Multiple Sclerosis (pwMS) frequently experience walking difficulties, often expressed as a slower walking speed during the 6 Minute Walking Test (6MWT). In addition, slower walking speeds are also related to higher levels of perceived exertion. PwMS are also known to have a higher energetic Cost of walking (Cw) and may experience muscle fatigue during prolonged walking. In this study, we aimed to explore changes in Rate of Perceived Exertion (RPE) and the Cw within participants during the 6MWT in pwMS. Additionally, concomitant changes in the mean and variability of gait characteristics and changes in muscle activation describing muscle fatigue were assessed.

METHODS

The 6MWT was performed on an instrumented treadmill while three-dimensional motion capture and gas exchange were measured continuously. RPE on the 6-20 borg-scale was questioned directly before and after the 6MWT. Cost of walking was expressed in Joules/kg/m. Muscle fatigue was assessed by increases in Root Median Square (RMdS) and decreases in Median Frequency (MF) of the recorded EMGs. Wilcoxon-Signed Rank test was used to assess a difference in RPE before and after the 6MWT. Linear mixed models, while controlling for walking speed, were used to assess changes in Cw, mean and variability of gait characteristics and RMdS and MF of muscle activation.

RESULTS

28 pwMS (23 females, mean ± standard deviation age 46 ± 10 years, height 1.69 ± 0.08 meter, weight 76 ± 18 kilogram, EDSS 2.7 ± 1.3) were included. Although the RPE increased from 8 to 12, no changes in Cw were found. Walking speed was the only spatiotemporal parameter which increased during the 6MWT and RMdS of the gastrocnemius and tibialis anterior muscles increased. The soleus muscle decreased in MF over time.

CONCLUSION

The increases in RPE and walking speed was not accompanied by a change in Cw during the 6MWT which indicates that the perceived exertion was not accompanied by an increased physical exertion. Changes in muscle activation might give an indication for muscle fatigue but were inconclusive. Although the 6MWT reflects daily life walking challenges for pwMS, this test did not show the expected changes in gait parameters in our sample.

Non-equivalent, but still valid: Establishing the construct validity of a consumer fitness tracker in persons with multiple sclerosis

Tools for monitoring daily physical activity (PA) are desired by persons with multiple sclerosis (MS). However, current research-grade options are not suitable for longitudinal, independent use due to their cost and user experience. Our objective was to assess the validity of step counts and PA intensity metrics derived from the Fitbit Inspire HR, a consumer-grade PA tracker, in 45 persons with MS (Median age: 46, IQR: 40-51) undergoing inpatient rehabilitation. The population had moderate mobility impairment (Median EDSS 4.0, Range 2.0-6.5). We assessed the validity of Fitbit-derived PA metrics (Step count, total time in PA, time in moderate to vigorous PA (MVPA)) during scripted tasks and free-living activity at three levels of data aggregation (minute, daily, and average PA). Criterion validity was assessed though agreement with manual counts and multiple methods for deriving PA metrics via the Actigraph GT3X. Convergent and known-groups validity were assessed via relationships with reference standards and related clinical measures. Fitbit-derived step count and time in PA, but not time in MVPA, exhibited excellent agreement with reference measures during scripted tasks. During free-living activity, step count and time in PA correlated moderately to strongly with reference measures, but agreement varied across metrics, data aggregation levels, and disease severity strata. Time in MVPA weakly agreed with reference measures. However, Fitbit-derived metrics were often as different from reference measures as reference measures were from each other. Fitbit-derived metrics consistently exhibited similar or stronger evidence of construct validity than reference standards. Fitbit-derived PA metrics are not equivalent to existing reference standards. However, they exhibit evidence of construct validity. Consumer-grade fitness trackers such as the Fitbit Inspire HR may therefore be suitable as a PA tracking tool for persons with mild or moderate MS.

Improvements in gait and balance in patients with multiple sclerosis after treatment with coconut oil and epigallocatechin gallate. A pilot study

Multiple sclerosis (MS) is a neurodegenerative disease that progressively decreases the muscular and functional capacity. Thus, there is an alteration in the ability to walk that affects balance, speed and resistance. Since MS pathology involves neuroinflammation, cellular oxidation and mitochondrial alterations, the objective of the study was to assess the impact of a nutritional intervention with coconut oil and epigallocatechin gallate (EGCG) on gait and balance. In order to do this, 51 patients with MS were enrolled and randomly distributed into an intervention group and a control group, which received either a daily dose of 800 mg of EGCG and 60 ml of coconut oil, or a placebo, all during a period of 4 months and which followed a Mediterranean isocaloric diet. Initial and final assessments consisted of the evaluation of quantitative balance (Berg scale), perceived balance (ABC scale), gait speed (10MWT) and resistance (2MWT). Besides, muscle strength was measured using a dynamometer and levels of β-hydroxybutyrate (BHB) were measured in serum samples. In the intervention group, there was a significant improvement in the gait speed, quantitative balance and muscle strength of the right quadriceps; an improvement in gait resistance was observed in both groups. There were also significant and positive correlations between balance and gait scales. In conclusion, the administration of EGCG and coconut oil seems to improve gait speed and balance in MS patients, although the latter was not perceived by them. Furthermore, these variables appear to be related and contribute to functionality.

Motor and respiratory functions are main challenges to patients with multiple sclerosis

Abstract Introduction People with multiple sclerosis (MS) present wide and varied symptoms. Objective To investigate the impact of MS on subjects’ motor and respiratory functions. Methods One hundred one participants were enrolled in this study. The subjects had previous diagnosis of relapsing-remittent MS (n = 48) or presented no neurologic diseases (n = 53, control group). Assess-ments involved mobility (Timed Get Up and Go) and balance (Berg Balance Scale) tests. A force platform was used to evaluate postural stabilometry. Respiratory functions were assessed with a portable spirometer and a digital manovacuometer. Data analyses were carried out with Student´s t-tests, chi-square, and Pearson correlation index. Significance was set at 5%. Results Compared to control peers, participants with MS showed higher motor dysfunctions affecting mobility, balance, and postural stability. Spirometry indicated normal parameters for pulmonary flows and lung capacities in both groups. The manovacuometer, differently, pointed to a respiratory muscle weakness in 48% of participants with MS. Correlation analyses highlighted that respiratory functions are more associated to dynamic than to static motor tests. Conclusion Pathological changes in MS lead to motor dysfunction on mobility, balance and postural stability. Respiratory tests showed normal pulmonary flows and lung capacities in patients with MS, but with commitment of respiratory muscle strength. Respiratory functions were more impacted by dynamic tasks rather than static motor tasks.