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Oosterveer DM, Wouda NC, Volker G, van den Berg C, Terluin B, Hoitsma E. Reliability parameters of the Timed 25-Foot-Walk (T25FW) in patients with Multiple Sclerosis: Lower walking speed is associated with greater Smallest Detectable Change. Mult Scler Relat Disord 2024; 88:105731. [PMID: 38924934 DOI: 10.1016/j.msard.2024.105731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 05/10/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Reliability parameters of clinical measures should be sufficient in order to adequately monitor disease course and evaluate treatment in patients with Multiple Sclerosis (MS). The aim of this study was to assess the reliability of the Timed 25-Foot-Walk (T25FW) in patients with MS. METHODS MS patients performed the T25FW twice with approximately one year in between. After the second measurement, they answered an anchor question using a three-point Likert scale. Taking the non-normal distribution of the T25FW into account, intraclass correlation coefficient (ICCagreement), standard error of the mean (SEMagreement) and smallest detectable change (SDC) were computed. RESULTS 118 MS patients (76.3 % females, mean age 48.2 years) were included. Of these patients, 73 reported no change on the anchor question. They completed the T25FW at baseline in 4.7s (IQR 4.3-5.4s, n = 72) and at follow-up in 4.9s (IQR 4.3-5.9s, n = 73). The ICCagreement was 0.895, the SEMagreement was 0.037. The SDC was higher for higher mean T25FW and can be computed for each mean T25FW by 0.23*mean T25FW. CONCLUSION Overall, in patients with MS, the T25FW has a sufficient reliability as measured with the ICC, however the SDC of the T25FW increased when patients perform worse on the T25FW (i.e. have a lower walking speed). Because this test is often used in MS patients with limited walking ability, these findings are important to keep in mind when interpreting the re-test scores of the T25FW.
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Affiliation(s)
- Daniëlla M Oosterveer
- Basalt, Leiden/The Hague, The Netherlands; Department of Rehabilitation Medicine, Alrijne Hospital, Leiden, The Netherlands.
| | - Natasja C Wouda
- Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | | | | | - Berend Terluin
- Department of General Practice, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Elske Hoitsma
- Department of Neurology, Alrijne Hospital, Leiden, The Netherlands
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Abasıyanık Z, Kahraman T, Baba C, Sağıcı Ö, Ertekin Ö, Özakbaş S. Discriminative ability of the original and short form of the Activities-specific Balance Confidence scale and its individual items for falls in people with multiple sclerosis. Acta Neurol Belg 2024; 124:957-964. [PMID: 38483733 PMCID: PMC11139692 DOI: 10.1007/s13760-024-02515-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/23/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Balance confidence is an essential component of fall risk assessment in persons with multiple sclerosis (pwMS). AIMS The aims of this cross-sectional study were to 1) investigate the ability of the 16-item Activities-specific Balance Confidence scale (ABC-16), 6-item Activities-specific Balance Confidence scale (ABC-6), and each item of the ABC-16 for distinguishing fallers and 2) determine cutoff scores for these scales to discriminate fallers and non-fallers in pwMS. METHODS One hundred and fifty-six participants [fallers/non-fallers: 60 (38.5%)/96 (61.5%), median EDSS: 1.5] were enrolled. Balance confidence was assessed using the ABC-16 and ABC-6. The self-reported number of falls in the past three months was recorded. Descriptive assessments, including walking, balance, and cognition were performed. Logistic regression and receiver operating characteristic analyses were conducted to estimate the sensitivities and specificities of the ABC-16 and ABC-6. RESULTS Both the ABC-16 (AUC: 0.85) and ABC-6 (AUC: 0.84) had the discriminative ability for falls. Each item of the ABC-16 scale was a significantly related to falls [odds ratio (OR) range: 1.38 to 1.89]. Items 8 and 10 had the highest odds ratio (OR: 1.85; 95%CI: 1.47-2.33, OR: 1.89; 95%CI: 1.49-2.40; respectively). We found cutoff scores of ≤ 70 of 100 (sensitivity: 71.67, specificity: 86.46) and ≤ 65/100 (sensitivity: 76.67, specificity: 79.17) in discrimination between fallers and non-fallers for the ABC-16 and ABC-6, respectively. CONCLUSION Both original and short forms of the ABC scale are an efficient tool for discriminating fallers and non-fallers in pwMS. Although all items are related to falls, outdoor walking activities have the strongest associations with falls than other items.
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Affiliation(s)
- Zuhal Abasıyanık
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Turkey.
- Graduate School of Health Sciences, Dokuz Eylül University, Izmir, Turkey.
| | - Turhan Kahraman
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Turkey
- Department of Health Professions, Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
| | - Cavid Baba
- Graduate School of Health Sciences, Dokuz Eylül University, Izmir, Turkey
| | - Özge Sağıcı
- Graduate School of Health Sciences, Dokuz Eylül University, Izmir, Turkey
| | - Özge Ertekin
- Department of Neurological Physiotherapy-Rehabilitation, Faculty of Physical Therapy and Rehabilitation, Dokuz Eylül University, Izmir, Turkey
| | - Serkan Özakbaş
- Izmir University of Economics, Medical Point Hospital, Izmir, Turkey
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Henderson K, Reihm J, Koshal K, Wijangco J, Miller N, Sara N, Doyle M, Mallory A, Sheridan J, Guo CY, Oommen L, Feinstein A, Mangurian C, Lazar A, Bove R. Pragmatic phase II clinical trial to improve depression care in a real-world diverse MS cohort from an academic MS centre in Northern California: MS CATCH study protocol. BMJ Open 2024; 14:e077432. [PMID: 38401894 PMCID: PMC10895222 DOI: 10.1136/bmjopen-2023-077432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 01/25/2024] [Indexed: 02/26/2024] Open
Abstract
INTRODUCTION Depression occurs in over 50% of individuals living with multiple sclerosis (MS) and can be treated using many modalities. Yet, it remains: under-reported by patients, under-ascertained by clinicians and under-treated. To enhance these three behaviours likely to promote evidence-based depression care, we engaged multiple stakeholders to iteratively design a first-in-kind digital health tool. The tool, MS CATCH (Care technology to Ascertain, Treat, and engage the Community to Heal depression in patients with MS), closes the communication loop between patients and clinicians. Between clinical visits, the tool queries patients monthly about mood symptoms, supports patient self-management and alerts clinicians to worsening mood via their electronic health record in-basket. Clinicians can also access an MS CATCH dashboard displaying patients' mood scores over the course of their disease, and providing comprehensive management tools (contributing factors, antidepressant pathway, resources in patient's neighbourhood). The goal of the current trial is to evaluate the clinical effect and usability of MS CATCH in a real-world clinical setting. METHODS AND ANALYSIS MS CATCH is a single-site, phase II randomised, delayed start, trial enrolling 125 adults with MS and mild to moderately severe depression. Arm 1 will receive MS CATCH for 12 months, and arm 2 will receive usual care for 6 months, then MS CATCH for 6 months. Clinicians will be randomised to avoid practice effects. The effectiveness analysis is superiority intent-to-treat comparing MS CATCH to usual care over 6 months (primary outcome: evidence of screening and treatment; secondary outcome: Hospital Anxiety Depression Scale-Depression scores). The usability of the intervention will also be evaluated (primary outcome: adoption; secondary outcomes: adherence, engagement, satisfaction). ETHICS AND DISSEMINATION University of California, San Francisco Institutional Review Board (22-36620). The findings of the study are planned to be shared through conferences and publishments in a peer-reviewed journal. The deidentified dataset will be shared with qualified collaborators on request, provision of CITI and other certifications, and data sharing agreement. We will share the results, once the data are complete and analysed, with the scientific community and patient/clinician participants through abstracts, presentations and manuscripts. TRIAL REGISTRATION NUMBER NCT05865405.
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Affiliation(s)
- Kyra Henderson
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Reihm
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Kanishka Koshal
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Jaeleene Wijangco
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Nicolette Miller
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Narender Sara
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Marianne Doyle
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Alicia Mallory
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Judith Sheridan
- Patient Stakeholder, University of California San Francisco, San Francisco, California, USA
| | - Chu-Yueh Guo
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Lauren Oommen
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Anthony Feinstein
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Christina Mangurian
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
| | - Ann Lazar
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Riley Bove
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, California, USA
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Block VJ, Koshal K, Wijangco J, Miller N, Sara N, Henderson K, Reihm J, Gopal A, Mohan SD, Gelfand JM, Guo CY, Oommen L, Nylander A, Rowson JA, Brown E, Sanders S, Rankin K, Lyles CR, Sim I, Bove R. A Closed-Loop Falls Monitoring and Prevention App for Multiple Sclerosis Clinical Practice: Human-Centered Design of the Multiple Sclerosis Falls InsightTrack. JMIR Hum Factors 2024; 11:e49331. [PMID: 38206662 PMCID: PMC10811573 DOI: 10.2196/49331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/14/2023] [Accepted: 10/19/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Falls are common in people with multiple sclerosis (MS), causing injuries, fear of falling, and loss of independence. Although targeted interventions (physical therapy) can help, patients underreport and clinicians undertreat this issue. Patient-generated data, combined with clinical data, can support the prediction of falls and lead to timely intervention (including referral to specialized physical therapy). To be actionable, such data must be efficiently delivered to clinicians, with care customized to the patient's specific context. OBJECTIVE This study aims to describe the iterative process of the design and development of Multiple Sclerosis Falls InsightTrack (MS-FIT), identifying the clinical and technological features of this closed-loop app designed to support streamlined falls reporting, timely falls evaluation, and comprehensive and sustained falls prevention efforts. METHODS Stakeholders were engaged in a double diamond process of human-centered design to ensure that technological features aligned with users' needs. Patient and clinician interviews were designed to elicit insight around ability blockers and boosters using the capability, opportunity, motivation, and behavior (COM-B) framework to facilitate subsequent mapping to the Behavior Change Wheel. To support generalizability, patients and experts from other clinical conditions associated with falls (geriatrics, orthopedics, and Parkinson disease) were also engaged. Designs were iterated based on each round of feedback, and final mock-ups were tested during routine clinical visits. RESULTS A sample of 30 patients and 14 clinicians provided at least 1 round of feedback. To support falls reporting, patients favored a simple biweekly survey built using REDCap (Research Electronic Data Capture; Vanderbilt University) to support bring-your-own-device accessibility-with optional additional context (the severity and location of falls). To support the evaluation and prevention of falls, clinicians favored a clinical dashboard featuring several key visualization widgets: a longitudinal falls display coded by the time of data capture, severity, and context; a comprehensive, multidisciplinary, and evidence-based checklist of actions intended to evaluate and prevent falls; and MS resources local to a patient's community. In-basket messaging alerts clinicians of severe falls. The tool scored highly for usability, likability, usefulness, and perceived effectiveness (based on the Health IT Usability Evaluation Model scoring). CONCLUSIONS To our knowledge, this is the first falls app designed using human-centered design to prioritize behavior change and, while being accessible at home for patients, to deliver actionable data to clinicians at the point of care. MS-FIT streamlines data delivery to clinicians via an electronic health record-embedded window, aligning with the 5 rights approach. Leveraging MS-FIT for data processing and algorithms minimizes clinician load while boosting care quality. Our innovation seamlessly integrates real-world patient-generated data as well as clinical and community-level factors, empowering self-care and addressing the impact of falls in people with MS. Preliminary findings indicate wider relevance, extending to other neurological conditions associated with falls and their consequences.
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Affiliation(s)
- Valerie J Block
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
- Department of Physical Therapy and Rehabilitation Science, University of California San Francisco, San Francisco, CA, United States
| | - Kanishka Koshal
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Jaeleene Wijangco
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Nicolette Miller
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Narender Sara
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Kyra Henderson
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Jennifer Reihm
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Arpita Gopal
- Department of Physical Therapy and Rehabilitation Science, University of California San Francisco, San Francisco, CA, United States
| | - Sonam D Mohan
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Jeffrey M Gelfand
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Chu-Yueh Guo
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Lauren Oommen
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Alyssa Nylander
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - James A Rowson
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Ethan Brown
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Stephen Sanders
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Katherine Rankin
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
| | - Courtney R Lyles
- University of California San Francisco Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
- Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, United States
| | - Ida Sim
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Riley Bove
- Department of Neurology, University of California San Francisco Weill Institute, University of California San Francisco, San Francisco, CA, United States
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Kushner T, Mosquera-Lopez C, Hildebrand A, Cameron MH, Jacobs PG. Risky movement: Assessing fall risk in people with multiple sclerosis with wearable sensors and beacon-based smart-home monitoring. Mult Scler Relat Disord 2023; 79:105019. [PMID: 37801954 DOI: 10.1016/j.msard.2023.105019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/25/2023] [Accepted: 09/22/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND People with multiple sclerosis (PwMS) fall frequently causing injury, social isolation, and decreased quality of life. Identifying locations and behaviors associated with high fall risk could help direct fall prevention interventions. Here we describe a smart-home system for assessing how mobility metrics relate to real-world fall risk in PwMS. METHODS We performed a secondary analysis of a dataset of real-world falls collected from PwMS to identify patterns associated with increased fall risk. Thirty-four individuals were tracked over eight weeks with an inertial sensor comprising a triaxial accelerometer and time-of-flight radio transmitter, which communicated with beacons positioned throughout the home. We evaluated associations between locations in the home and movement behaviors prior to a fall compared with time periods when no falls occurred using metrics including gait initiation, time-spent-moving, movement length, and an entropy-based metric that quantifies movement complexity using transitions between rooms in the home. We also explored how fall risk may be related to the percent of times that a participant paused while walking (pauses-while-walking). RESULTS Seventeen of the participants monitored sustained a total of 105 falls that were recorded. More falls occurred while walking (52%) than when stationary despite participants being largely sedentary, only walking 1.5±3.3% (median ± IQR) of the time that they were in their home. A total of 28% of falls occurred within one second of gait initiation. As the percentage of pauses-while-walking increased from 20 to 60%, the likelihood of a fall increased by nearly 3 times from 0.06 to 0.16%. Movement complexity, which was quantified using the entropy of room transitions, was significantly higher in the 10 min preceding falls compared with other 10-min time segments not preceding falls (1.15 ± 0.47 vs. 0.96 ± 0.24, P = 0.02). Path length was significantly longer (151.3 ± 156.1 m vs. 95.0 ± 157.2 m, P = 0.003) in the ten minutes preceding a fall compared with non-fall periods. Fall risk also varied among rooms but not consistently across participants. CONCLUSIONS Movement metrics derived from wearable sensors and smart-home tracking systems are associated with fall risk in PwMS. More pauses-while-walking, and more complex, longer movement trajectories are associated with increased fall risk. FUNDING Department of Veterans Affairs (RX001831-01A1). National Science Foundation (#2030859).
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Affiliation(s)
- Taisa Kushner
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland OR, United States; Galois Inc, Portland OR, USA
| | - Clara Mosquera-Lopez
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland OR, United States
| | - Andrea Hildebrand
- Biostatistics and Design Program Core, Oregon Health & Science University, Portland OR, United States
| | - Michelle H Cameron
- Department of Neurology, VA Portland Health Care System, Oregon Health & Science University, Portland OR, United States
| | - Peter G Jacobs
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland OR, United States.
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Ozkan T, Yasa ME, Unluer NO, Korkmaz B, Uysal I, Vural G. Investigation of parameters related to lower extremity muscle strength and proprioception in Patients with Multiple Sclerosis: a cross-sectional study. Mult Scler Relat Disord 2023; 79:105042. [PMID: 37839364 DOI: 10.1016/j.msard.2023.105042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/12/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Patients with Multiple Sclerosis (PwMS) may experience a decline in balance, gait, and mobility as well as an increase in fear of falling (FoF) and fatigue due to weaker muscles and proprioceptive loss in their lower limbs. The study aimed to compare lower extremity muscle strength and proprioception, balance, functional mobility, gait, FoF, and fatigue between PwMS and healthy controls and to investigate the relationship between lower extremity muscle strength and proprioception and balance, functional mobility, gait, FoF, and fatigue in PwMS. METHODS The study was completed with 35 PwMS and 35 healthy controls with matching age and gender. The 5 Repetition Sit-to Stand Test (5-STS-test), knee and ankle reposition tests (using a digital inclinometer), the Berg Balance Scale (BBS), the Timed Up and Go (TUG) test, the Dynamic Gait Index (DGI), the Falls Efficacy-International (FES-I), and the Fatigue Severity Scale (FSS) were used for evaluations. RESULTS The 5-STS test, knee and ankle reposition tests, TUG, FES-I, and FSS Test scores were higher and BBS and DGI scores were lower in PwMS compared to healthy controls (p < 0.05). BBS, DGI, TUG, FES-I, and FSS were associated with 5-STS test and knee and ankle reposition tests except for some nondominant reposition tests in PwMS (r between 0.342 and -0.714; p < 0.05 for all). CONCLUSION Lower extremity muscle strength and proprioception were associated with balance, functional mobility, gait, FoF, and fatigue in PwMS. These results suggested that detailed assessment of neuromuscular parameters in lower extremity function is important in determining the appropriate rehabilitation programs.
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Affiliation(s)
- Taskin Ozkan
- Vocational School of Health Services, Therapy and Rehabilitation, Giresun University, Giresun 28200, Turkey.
| | - Mustafa Ertugrul Yasa
- Gulhane Faculty of Physiotherapy and Rehabilitation, Health Sciences University, Ankara, Turkey
| | - Nezehat Ozgul Unluer
- Gulhane Faculty of Physiotherapy and Rehabilitation, Health Sciences University, Ankara, Turkey
| | - Buse Korkmaz
- Gulhane Faculty of Physiotherapy and Rehabilitation, Health Sciences University, Ankara, Turkey
| | - Ismail Uysal
- Fethiye Vocational School of Health Services, Department of Health Care Services, Muğla Sıtkı Koçman University, Muğla, Turkey
| | - Gonul Vural
- Ankara Yıldırım Beyazıt University, Faculty of Medicine, Neurology Department, Ankara, Turkey
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Gopal A, Gelfand JM, Bove R, Block VJ. Fall Assessment and Monitoring in People With Multiple Sclerosis: A Practical Evidence-Based Review for Clinicians. Neurol Clin Pract 2023; 13:e200184. [PMID: 37720138 PMCID: PMC10503932 DOI: 10.1212/cpj.0000000000200184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/07/2023] [Indexed: 09/19/2023]
Abstract
Purpose of Review Falls occur in more than half of all people with multiple sclerosis (MS) but tend to be underdiagnosed and underreported in clinical encounters. This narrative review aims to summarize evidence-based approaches for evaluating fall risk and proven treatment strategies to reduce falling in people with MS to improve care for people with MS and to enhance interprofessional care coordination between treating neurologic and physical therapy (PT) teams. Recent Findings Screening not just for falls but for near-falls as well because fear of falling can improve fall assessment and identify patients who may benefit from fall prevention interventions. A number of barriers, including time constraints during visits and the fallacy that falling is inevitable in MS, can limit clinician awareness about patient falls and delay timely referral to PT. Consultation with physical therapists for individualized fall prevention treatment can reduce risk of falling. Interventional studies have also shown that PT-guided exercise programs improve balance confidence in people with MS. However, people with MS are often under-referred to PT by treating clinicians. Summary A clinical approach is provided to summarize practical, accessible, evidence-based, low-burden measurements and interventions likely to improve ascertainment of patients at risk of falling and optimize timely PT referral and treatment.
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Affiliation(s)
- Arpita Gopal
- UCSF Weill Institute for Neurosciences (AG, JMG, RB), MS and Neuroinflammation Clinic, Department of Neurology; and Department of Physical Therapy and Rehabilitation Science (VJB), University of California, San Francisco
| | - Jeffrey M Gelfand
- UCSF Weill Institute for Neurosciences (AG, JMG, RB), MS and Neuroinflammation Clinic, Department of Neurology; and Department of Physical Therapy and Rehabilitation Science (VJB), University of California, San Francisco
| | - Riley Bove
- UCSF Weill Institute for Neurosciences (AG, JMG, RB), MS and Neuroinflammation Clinic, Department of Neurology; and Department of Physical Therapy and Rehabilitation Science (VJB), University of California, San Francisco
| | - Valerie J Block
- UCSF Weill Institute for Neurosciences (AG, JMG, RB), MS and Neuroinflammation Clinic, Department of Neurology; and Department of Physical Therapy and Rehabilitation Science (VJB), University of California, San Francisco
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Abou L, Fritz NE, Kratz AL. Self-reported fatigue impact is associated with frequency of falls and injurious falls in people with multiple sclerosis. Mult Scler Relat Disord 2023; 78:104910. [PMID: 37499336 DOI: 10.1016/j.msard.2023.104910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/19/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Fatigue is the most common symptom associated with multiple sclerosis (MS). Fatigue as a risk factor for injurious falls and frequency of falls is understudied. Falling recurrently is associated with injurious falls which may lead to reduced functional independence and poor quality of life of people with MS. Identifying contributors of recurrent falls and injurious falls is clinically useful to develop effective interventions. OBJECTIVE To investigate the associations between fatigue impact and frequency of falls and injurious falls in people with MS. METHODS Fifty-one participants completed the Modified Fatigue Impact Scale (MFIS) and a survey of number of falls and injurious falls during the past year. Logistic regression analyses were conducted to investigate whether scores on the MFIS (Total, Physical, Cognitive, and Psychosocial) predicted odds of being a recurrent faller (> 2 falls) or infrequent faller (1- 2 falls) versus a non-faller, and odds of experiencing an injurious fall (yes/no). The analyses were adjusted for demographic and clinical characteristics and common symptoms of MS (depression, cognition, pain, and sleep disturbance). RESULTS Higher MFIS Total score was associated with higher odds of infrequent falls (OR = 1.07, 95% CI, 1.00 - 1.15, p = 0.05) and recurrent falls (OR = 1.10, 95% CI, 1.00 - 1.20, p = 0.04) relative to not falling in the past year. Higher scores on the MFIS Physical subscale were significantly associated with high odds of infrequent falls (OR = 1.15, 95% CI, 1.02 - 1.30, p = 0.03) and recurrent falls (OR = 1.19, 95% CI, 1.02 - 1.39, p = 0.03). MFIS Psychosocial subscale was significantly associated with higher odds of infrequent falls (OR = 2.01, 95% CI, 1.14 - 3.53, p = 0.02). MFIS Total and MFIS Cognitive subscale were significantly associated with higher odds of injurious falls (OR = 1.11, 95% CI, 1.00 - 1.23, p = 0.04) and (OR = 1.28, 95% CI, 1.02 - 1.60, p = 0.04), respectively. CONCLUSION The findings indicated self-reported fatigue impact and its specific domains were associated with an increased risk of falling and injurious falls. Further studies using prospective falls assessment and longitudinal evaluation of fatigue are warranted to extend our findings.
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Affiliation(s)
- Libak Abou
- Department of Physical Medicine & Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA.
| | - Nora E Fritz
- Departments of Health Care Sciences & Neurology, Wayne State University, Detroit, MI, USA
| | - Anna L Kratz
- Department of Physical Medicine & Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA
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Bilgin YOU, Koskderelioglu A, Gedizlioglu M. Fall risk is related to cognitive functioning in ambulatory multiple sclerosis patients. Neurol Sci 2023; 44:3233-3242. [PMID: 36997775 DOI: 10.1007/s10072-023-06770-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND AND AIMS Patients with multiple sclerosis (PwMS) may suffer severely from falling and gait disturbance. Cognitive dysfunction, a common condition in MS patients, may also increase falling rates, regardless of physical disability. We planned this study to determine the fall rate and risk factors in MS patients, follow patients for falls, and reveal the relationship between falls and cognitive dysfunction. METHODS The study was conducted on 124 patients who have RRMS diagnoses. Patients' gait speed, simultaneous gait speed during other tasks, functions of the upper extremity, balance rating, and fear of falling were evaluated with dual-task Timed-Up-and-Go-3 versions (TUG, TUG-C, TUG-M), Timed 25 Foot Walk (T25WFT), Nine Hole Peg Test (9HPT), Berg Balance Scale (BBS) and Falls Efficacy Scale-International (FES-I) tests. Cognitive functions, fatigue levels, and quality of life were measured with the Symbol Digit Modalities Test (SDMT), Fatigue Severity Scale (FSS), and Multiple Sclerosis Quality of Life (MSQoL) test. Two groups were formed as "fallers" and "non-faller patients". We monitored the patients in six months period. RESULTS Forty-six patients fell at least once in the last one year before the study began. Fallers were older, less educated, had lower SDMT scores and higher disability scores. Non-faller patients scored lower in FES-I, TUG, and FSS tests. SDMT scores showed statistically significant, linear, positive, and moderate correlation with BBS and 9HPT scores (r = 0.307, p = 0.038, and r = 0.320, p = 0.030, respectively). CONCLUSION We determined that advanced age, lower education level, and cognitive dysfunction adversely affect gait speed and balance. Among the fallers, those with lower SDMT and MoCA scores had higher falling rates. We determined that EDSS and BBS scores are predictive factors for falls in patients with MS. In conclusion, patients with cognitive impairment should be closely monitored for the risk of falling. Consideration of falls during follow-up examinations might be predictive of cognitive deterioration in patients with MS.
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Affiliation(s)
- Yaprak Ozum Unsal Bilgin
- Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey.
| | - Asli Koskderelioglu
- Department of Neurology, University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
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10
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Kaur R, Levy J, Motl RW, Sowers R, Hernandez ME. Deep Learning for Multiple Sclerosis Differentiation Using Multi-Stride Dynamics in Gait. IEEE Trans Biomed Eng 2023; 70:2181-2192. [PMID: 37819835 DOI: 10.1109/tbme.2023.3238680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
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.
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11
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Veldkamp R, D'hooge M, Sandroff BM, DeLuca J, Kos D, Salter A, Feinstein A, Amato MP, Brichetto G, Chataway J, Farrell R, Chiaravalloti ND, Dalgas U, Filippi M, Freeman J, Motl RW, Meza C, Inglese M, Rocca MA, Cutter G, Feys P. Profiling cognitive-motor interference in a large sample of persons with progressive multiple sclerosis and impaired processing speed: results from the CogEx study. J Neurol 2023; 270:3120-3128. [PMID: 36881147 DOI: 10.1007/s00415-023-11636-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Performing cognitive-motor dual tasks (DTs) may result in reduced walking speed and cognitive performance. The effect in persons with progressive multiple sclerosis (pwPMS) having cognitive dysfunction is unknown. OBJECTIVE To profile DT-performance during walking in cognitively impaired pwPMS and examine DT-performance by disability level. METHODS Secondary analyses were conducted on baseline data from the CogEx-study. Participants, enrolled with Symbol Digit Modalities Test 1.282 standard deviations below normative value, performed a cognitive single task ([ST], alternating alphabet), motor ST (walking) and DT (both). Outcomes were number of correct answers on the alternating alphabet task, walking speed, and DT-cost (DTC: decline in performance relative to the ST). Outcomes were compared between EDSS subgroups (≤ 4, 4.5-5.5, ≥ 6). Spearman correlations were conducted between the DTCmotor with clinical measures. Adjusted significance level was 0.01. RESULTS Overall, participants (n = 307) walked slower and had fewer correct answers on the DT versus ST (both p < 0.001), with a DTCmotor of 15.8% and DTCcognitive of 2.7%. All three subgroups walked slower during the DT versus ST, with DTCmotor different from zero (p's < 0.001). Only the EDSS ≥ 6 group had fewer correct answers on the DT versus ST (p < 0.001), but the DTCcognitive did not differ from zero for any of the groups (p ≥ 0.039). CONCLUSION Dual tasking substantially affects walking performance in cognitively impaired pwPMS, to a similar degree for EDSS subgroups.
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Affiliation(s)
- R Veldkamp
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium.
- UMSC, Hasselt-Pelt, Belgium.
| | - M D'hooge
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
- UMSC, Hasselt-Pelt, Belgium
- National MS Center Melsbroek, Steenokkerzeel, Belgium
| | - B M Sandroff
- Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - J DeLuca
- Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - D Kos
- National MS Center Melsbroek, Steenokkerzeel, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - A Salter
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
| | - A Feinstein
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, M5R 3B6, Canada
| | - M P Amato
- Department NEUROFARBA, Section Neurosciences, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - G Brichetto
- Scientific Research Area, Italian Multiple Sclerosis Foundation (FISM), Via Operai 40, 16149, Genoa, Italy
- AISM Rehabilitation Service, Italian Multiple Sclerosis Society (AISM), Via Operai 30, 16149, Genoa, Italy
| | - J Chataway
- Queen Square MS Centre, Department of Neuroinflammation, University College London (UCL) Queen Square Institute of Neurology, Faculty of Brain Sciences, UCL, London, UK
| | - R Farrell
- Queen Square MS Centre, Department of Neuroinflammation, University College London (UCL) Queen Square Institute of Neurology, Faculty of Brain Sciences, UCL, London, UK
| | - N D Chiaravalloti
- Kessler Foundation, East Hanover, NJ, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - U Dalgas
- Exercise Biology, Department of Public Health, Aarhus University, Dalgas Avenue 4, 8000, Aarhus, Denmark
| | - M Filippi
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, and Neurology Unit, IRCCS, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - J Freeman
- School of Health Professions, Faculty of Health, University of Plymouth, Devon, UK
| | - R W Motl
- Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, USA
| | - C Meza
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, M5R 3B6, Canada
| | - M Inglese
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - M A Rocca
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, and Neurology Unit, IRCCS, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - G Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, USA
| | - P Feys
- REVAL Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
- UMSC, Hasselt-Pelt, Belgium
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12
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VanDyk T, Meyer B, DePetrillo P, Donahue N, O'Leary A, Fox S, Cheney N, Ceruolo M, Solomon AJ, McGinnis RS. Digital Phenotypes of Instability and Fatigue Derived From Daily Standing Transitions in Persons With Multiple Sclerosis. IEEE Trans Neural Syst Rehabil Eng 2023; 31:2279-2286. [PMID: 37115839 PMCID: PMC10408384 DOI: 10.1109/tnsre.2023.3271601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Impairment in persons with multiple sclerosis (PwMS) can often be attributed to symptoms of motor instability and fatigue. Symptom monitoring and queued interventions often target these symptoms. Clinical metrics are currently limited to objective physician assessments or subjective patient reported measures. Recent research has turned to wearables for improving the objectivity and temporal resolution of assessment. Our group has previously observed wearable assessment of supervised and unsupervised standing transitions to be predictive of fall-risk in PwMS. Here we extend the application of standing transition quantification to longitudinal home monitoring of symptoms. Subjects (N=23) with varying degrees of MS impairment were recruited and monitored with accelerometry for a total of ∼ 6 weeks each. These data were processed using a preexisting framework, applying a deep learning activity classifier to isolate periods of standing transition from which descriptive features were extracted for analysis. Participants completed daily and biweekly assessments describing their symptoms. From these data, Canonical Correlation Analysis was used to derive digital phenotypes of MS instability and fatigue. We find these phenotypes capable of distinguishing fallers from non-fallers, and further that they demonstrate a capacity to characterize symptoms at both daily and sub-daily resolutions. These results represent promising support for future applications of wearables, which may soon augment or replace current metrics in longitudinal monitoring of PwMS.
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13
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Pike A, McGuckian TB, Steenbergen B, Cole MH, Wilson PH. How Reliable and Valid are Dual-Task Cost Metrics? A Meta-analysis of Locomotor-Cognitive Dual-Task Paradigms. Arch Phys Med Rehabil 2023; 104:302-314. [PMID: 35940246 DOI: 10.1016/j.apmr.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the retest reliability, predictive validity, and concurrent validity of locomotor and cognitive dual-task cost (DTC) metrics derived from locomotor-cognitive dual-task paradigms. DATA SOURCES A literature search of electronic databases (PubMed, PsycINFO, MEDLINE, CINAHL, and Scopus) was conducted on May 29th, 2021, without time restriction. STUDY SELECTION For 1559 search results, titles and abstracts were screened by a single reviewer and full text of potentially eligible papers was considered by 2 independent reviewers. 25 studies that evaluated retest reliability, predictive validity, and concurrent validity of locomotor-cognitive DTC in healthy and clinical groups met inclusion criteria. DATA EXTRACTION Study quality was assessed using the Consensus-Based Standards for the Selection of Health Measurement Instrument checklist. Data relating to the retest reliability, predictive validity, and concurrent validity of DTC were extracted. DATA SYNTHESIS Meta-analysis showed that locomotor DTC metrics (intraclass correlation coefficient [ICC]=0.61, 95% confidence interval [CI; 0.53.0.70]) had better retest reliability than cognitive DTC metrics (ICC=0.27, 95% CI [0.17.0.36]). Larger retest reliability estimates were found for temporal gait outcomes (ICC=0.67-0.72) compared with spatial (ICC=0.34-0.53). Motor DTC metrics showed weak predictive validity for the incidence of future falls (r=0.14, 95% CI [-0.03.0.31]). Motor DTC metrics had weak concurrent validity with other clinical and performance assessments (r=0.11, 95% CI [0.07.0.16]), as did cognitive DTC metrics (r=0.19, 95% CI [0.08.0.30]). CONCLUSIONS Gait-related temporal DTC metrics achieve adequate retest reliability, while predictive and concurrent validity of DTC needs to be improved before being used widely in clinical practice and other applied settings. Future research should ensure the reliability and validity of DTC outcomes before being used to assess dual-task interference.
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Affiliation(s)
- Alycia Pike
- Healthy Brain and Mind Research Centre, School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, Australia
| | - Thomas B McGuckian
- Healthy Brain and Mind Research Centre, School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, Australia.
| | - Bert Steenbergen
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Michael H Cole
- Healthy Brain and Mind Research Centre, School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, Australia
| | - Peter H Wilson
- Healthy Brain and Mind Research Centre, School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, Australia
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14
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VanNostrand M, Sogoloff B, Giroux C, Bergmans L, Kasser SL. Predicting falls in adults with multiple sclerosis using patient-reported measures: Are perceptions of dual-tasking missing? Mult Scler Relat Disord 2022; 68:104115. [PMID: 36057172 DOI: 10.1016/j.msard.2022.104115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/15/2022] [Accepted: 08/13/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mobility challenges and cognitive impairments prominent in adults with multiple sclerosis (MS) significantly increase the risk of falling. Examining perceptions of how the simultaneous performance of completing motor and cognitive tasks impacts fall risk may have clinical utility. The purpose of this study was to identify the most significant self-reported predictors of falling including perceived dual-tasking. METHODS Participants included 79 individuals with MS were surveyed and reported their fall history over the previous 3 months and completed the Multiple Sclerosis Walking Scale -12 (MSWS-12), Modified Fatigue Impact Scale (MFIS), Falls Efficacy Scale International (FES-I), and two Dual-Task Questionnaires (DTQ), a previously published original one and a newly expanded version. RESULTS Of the sample, 63 were classified as non-fallers and 16 as fallers. Backward stepwise regression analysis revealed that perceived ambulation disability and dual-tasking best predicted fall status (sensitivity of 57.7%, specificity of 90.6%, area under the receiving operating curve of 0.81 (95% CI 0.70-0.92). CONCLUSION The inclusion of self-reported dual-tasking perceptions has utility in predicting fall risk. Effective assessment toward this end offers the potential for early detection and intervention.
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Affiliation(s)
- Michael VanNostrand
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, United States of America
| | - Barbara Sogoloff
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, United States of America
| | - Carley Giroux
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, United States of America
| | - Lance Bergmans
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, United States of America
| | - Susan L Kasser
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, United States of America.
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15
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Abou L, Peters J, Fritz NE, Sosnoff JJ, Kratz AL. Motor Cognitive Dual-Task Testing to Predict Future Falls in Multiple Sclerosis: A Systematic Review. Neurorehabil Neural Repair 2022; 36:757-769. [PMID: 36320121 DOI: 10.1177/15459683221131791] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Mobility and cognitive impairments are often associated with increased fall risk among people with multiple sclerosis (PwMS). However, evidence on the concurrent assessment of gait or balance and cognitive tasks (dual-task) to predict falls appears to be inconsistent. OBJECTIVE To summarize the ability of gait or balance dual-task testing to predict future falls among PwMS. METHODS Seven databases including PubMed, Embase, Web of Science, Scopus, CINHAL, SPORTDiscuss, and PsycINFO were searched from inception to May 2022. Two independent reviewers identified studies that performed a dual-task testing among adults with multiple sclerosis and monitored falls prospectively for at least 3 months. Both reviewers also evaluated the quality assessment of the included studies. RESULTS Eight studies with 484 participants were included in the review. Most studies (75%) indicated that dual-task testing and dual-task cost did not discriminate prospective fallers (⩾1 fall) and non-fallers (0 fall) and were not found as predictors of future falls. However, dual-task cost of walking velocity (OR = 1.23, 95% CI 0.98-4.45, P = .05) and dual-task of correct response rate of serial 7 subtraction (OR = 1.34, 95% CI 1.04-3.74, P = .02) were significantly associated with increased risk of recurrent falls (≥2 falls). Pattern of cognitive-motor interference was also associated with an increased risk of falling. All studies presented with strong quality. CONCLUSION The scarce evidence indicates that dual-task testing is not able to predict future falls among PwMS. Further research with more complex motor and cognitive tasks and longer-term fall monitoring is required before dual-task testing can be recommended as a predictor of future falls in this population.
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Affiliation(s)
- Libak Abou
- Department of Physical Medicine & Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Joseph Peters
- Department of Kinesiology & Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Nora E Fritz
- Departments of Health Care Sciences & Neurology, Wayne State University, Detroit, MI, USA
| | - Jacob J Sosnoff
- Department of Physical Therapy, Rehabilitation Science, & Athletic Training, University of Kansas Medical Center, Kansas City, KS, USA
| | - Anna L Kratz
- Department of Physical Medicine & Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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16
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Meyer BM, Depetrillo P, Franco J, Donahue N, Fox SR, O’Leary A, Loftness BC, Gurchiek RD, Buckley M, Solomon AJ, Ng SK, Cheney N, Ceruolo M, McGinnis RS. How Much Data Is Enough? A Reliable Methodology to Examine Long-Term Wearable Data Acquisition in Gait and Postural Sway. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22186982. [PMID: 36146348 PMCID: PMC9503816 DOI: 10.3390/s22186982] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/10/2022] [Accepted: 09/13/2022] [Indexed: 06/12/2023]
Abstract
Wearable sensors facilitate the evaluation of gait and balance impairment in the free-living environment, often with observation periods spanning weeks, months, and even years. Data supporting the minimal duration of sensor wear, which is necessary to capture representative variability in impairment measures, are needed to balance patient burden, data quality, and study cost. Prior investigations have examined the duration required for resolving a variety of movement variables (e.g., gait speed, sit-to-stand tests), but these studies use differing methodologies and have only examined a small subset of potential measures of gait and balance impairment. Notably, postural sway measures have not yet been considered in these analyses. Here, we propose a three-level framework for examining this problem. Difference testing and intra-class correlations (ICC) are used to examine the agreement in features computed from potential wear durations (levels one and two). The association between features and established patient reported outcomes at each wear duration is also considered (level three) for determining the necessary wear duration. Utilizing wearable accelerometer data continuously collected from 22 persons with multiple sclerosis (PwMS) for 6 weeks, this framework suggests that 2 to 3 days of monitoring may be sufficient to capture most of the variability in gait and sway; however, longer periods (e.g., 3 to 6 days) may be needed to establish strong correlations to patient-reported clinical measures. Regression analysis indicates that the required wear duration depends on both the observation frequency and variability of the measure being considered. This approach provides a framework for evaluating wear duration as one aspect of the comprehensive assessment, which is necessary to ensure that wearable sensor-based methods for capturing gait and balance impairment in the free-living environment are fit for purpose.
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Affiliation(s)
- Brett M. Meyer
- M-Sense Research Group, University of Vermont, Burlington, VT 05405, USA
| | - Paolo Depetrillo
- Medidata Solutions, A Dassault Systèmes Company, New York, NY 10014, USA
| | - Jaime Franco
- Medidata Solutions, A Dassault Systèmes Company, New York, NY 10014, USA
| | - Nicole Donahue
- M-Sense Research Group, University of Vermont, Burlington, VT 05405, USA
| | - Samantha R. Fox
- M-Sense Research Group, University of Vermont, Burlington, VT 05405, USA
| | - Aisling O’Leary
- M-Sense Research Group, University of Vermont, Burlington, VT 05405, USA
| | - Bryn C. Loftness
- M-Sense Research Group, University of Vermont, Burlington, VT 05405, USA
| | - Reed D. Gurchiek
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA
| | - Maura Buckley
- Medidata Solutions, A Dassault Systèmes Company, New York, NY 10014, USA
| | - Andrew J. Solomon
- Department of Neurological Sciences, University of Vermont, Burlington, VT 05405, USA
| | - Sau Kuen Ng
- Medidata Solutions, A Dassault Systèmes Company, New York, NY 10014, USA
| | - Nick Cheney
- M-Sense Research Group, University of Vermont, Burlington, VT 05405, USA
| | - Melissa Ceruolo
- Medidata Solutions, A Dassault Systèmes Company, New York, NY 10014, USA
| | - Ryan S. McGinnis
- M-Sense Research Group, University of Vermont, Burlington, VT 05405, USA
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Soke F, Demirkaya S, Gulsen C, Yavuz N, Karakoc S, Ozcan Gulsen E, Yilmaz O, Kocer B, Kurtulus Aydin F, Yucesan C. The figure-of-eight walk test is a reliable and valid test for assessing walking skill in people with multiple sclerosis. Mult Scler Relat Disord 2022; 67:104099. [PMID: 35969935 DOI: 10.1016/j.msard.2022.104099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/30/2022] [Accepted: 08/08/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The ability to turn while walking is essential for people's activities of daily living. Difficulties in turning while walking are commonly shown in people with multiple sclerosis (PwMS). The figure-of-eight walk test (F8W) is a clinical test assessing walking skill in a curved pathway; however, its reliability and validity have not been systematically examined for PwMS. PURPOSES The study is aimed to investigate: (1) the test-retest reliability of the F8W in PwMS; (2) the standard error of measurement and minimum detectable change in the F8W times; (3) the concurrent and known-groups validity of the F8W times; and (4) the cut-off times that best discriminate fallers from non-fallers with MS. METHOD This cross-sectional study included 41 PwMS and 33 healthy people. The F8W was performed along with the Timed Up and Go Test (TUG), Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC), and Expanded Disability Status Scale (EDSS). To determine the test-retest reliability, the F8W was conducted twice, 7-10 days apart. The reliability was assessed using the intraclass correlation coefficient (ICC), Bland-Altman plots, standard error of measurement (SEM), and minimal detectable change (MDC). To examine validity, the correlations between the F8W and the TUG, BBS, ABC, and EDSS were assessed using correlation coefficients, and the completion times of the F8W were compared between PwMS and healthy people, and between fallers and non-fallers with MS. The receiver operating characteristic curve was constructed to determine the optimal F8W cut-off time discriminating fallers from non-fallers with MS. RESULTS The F8W had excellent test-retest reliability with an ICC of 0.916. Bland-Altman plots showed high agreement between sessions. The SEM and MDC were found to be 0.45 and 1.25, respectively. The F8W indicated a moderate to strong correlation with other outcome measures (correlation coefficients ranged from -0.596 to 0.839, p<0.05). On the F8W, PwMS had a longer time than healthy people while fallers had a longer time than non-fallers with MS (p<0.001, and p<0.001, respectively). The cut-off time of 8.52 s best discriminated the fallers from non-fallers with MS. CONCLUSIONS The F8W is a reliable and clinically available measurement tool for walking skill in PwMS.
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Affiliation(s)
- Fatih Soke
- University of Health Sciences, Gulhane Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Emrah Neighborhood, Etlik/Kecioren, Ankara 06018, Turkey.
| | - Seref Demirkaya
- University of Health Sciences, Gulhane Faculty of Medicine, Department of Neurology, Ankara, Turkey
| | - Cagri Gulsen
- Gazi University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Ankara, Turkey
| | - Numan Yavuz
- University of Health Sciences, Gulhane Institute of Health Sciences, Ankara, Turkey
| | - Selda Karakoc
- University of Health Sciences, Gulhane Institute of Health Sciences, Ankara, Turkey
| | - Elvan Ozcan Gulsen
- Anadolu University, Vocational School of Health Services, Elderly Care Program, Eskisehir, Turkey
| | - Oznur Yilmaz
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Department of Physiotherapy and Rehabilitation, Ankara, Turkey
| | - Bilge Kocer
- University of Health Sciences, Diskapi Yildirim Beyazit Teaching and Research Hospital, Department of Neurology, Ankara, Turkey
| | - Fatma Kurtulus Aydin
- University of Health Sciences, Diskapi Yildirim Beyazit Teaching and Research Hospital, Department of Neurology, Ankara, Turkey
| | - Canan Yucesan
- Ankara University, Faculty of Medicine, Department of Neurology, Ankara, Turkey
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18
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Little C, Moore C, Bean E, Peters DM, McGinnis RS, Kasser SL. Acute effects of axial loading on postural control during walking and turning in people with multiple sclerosis: A pilot study. Gait Posture 2022; 94:102-106. [PMID: 35259637 PMCID: PMC9086176 DOI: 10.1016/j.gaitpost.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 02/24/2022] [Accepted: 02/27/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Impaired sensory integration is heavily involved in gait control and accentuates fall risk in individuals with multiple sclerosis (MS). While axial loading has been found beneficial, little is known about the effect of non-specific axial loads on gait parameters and mobility tasks in those with MS. RESEARCH QUESTION What are the effects of non-specific axial loading via weighted vests on walking and turning in those with MS. METHODS Twelve participants with MS and eleven age- and gender-matched healthy controls participated in a cross-sectional study. All participants completed five trials of continuous walking with turns wearing weighted vests at 0%, 2%, 4%, 5%, and then 0% of their body weight. Gait parameters were measured using wireless inertial sensors. A 2 (group) x 5 (vest weight) multivariate analysis of variance (MANOVA) was performed to determine any significant differences between groups and across weighted vests for each gait variable. Post-hoc analysis and paired t-tests with corresponding effect sizes were also conducted. RESULTS A significant between groups main effect was found for group (F (6100) = 14.74, p = .000) in multiple gait parameters (p < 0.05), although no significant main effect was found for weighted vest. Within group analyses indicated significantly increased cadence and gait speed across varying weighted vests for both MS and control groups (p < 0 >05). Increased vest weight from 0%PRE to 2% also had large effect on shortening double support time and increasing stride length in the MS group. SIGNIFICANCE This study provided preliminary evidence that non-specific axial loads of varying weights appear to improve certain gait parameters. As such, this modality may offer mobility benefit and serve as an accessible home-based intervention alternative aimed at improving walking in individuals with MS.
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Affiliation(s)
- Casey Little
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, USA
| | - Connor Moore
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, USA
| | - Emily Bean
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, USA
| | - Denise M Peters
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, USA
| | - Ryan S McGinnis
- Department of Electrical and Biomedical Engineering, University of Vermont, Burlington, VT, USA
| | - Susan L Kasser
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, USA.
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Tulipani LJ, Meyer B, Allen D, Solomon AJ, McGinnis RS. Evaluation of unsupervised 30-second chair stand test performance assessed by wearable sensors to predict fall status in multiple sclerosis. Gait Posture 2022; 94:19-25. [PMID: 35220031 PMCID: PMC9086135 DOI: 10.1016/j.gaitpost.2022.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 02/03/2022] [Accepted: 02/13/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND One in two people with multiple sclerosis (PwMS) will fall in a three-month period. Predicting which patients will fall remains a challenge for clinicians. Standardized functional assessments provide insight into balance deficits and fall risk but their use has been limited to supervised visits. RESEARCH QUESTION The study aim was to characterize unsupervised 30-second chair stand test (30CST) performance using accelerometer-derived metrics and assess its ability to classify fall status in PwMS compared to supervised 30CST. METHODS Thirty-seven PwMS (21 fallers) performed instrumented supervised and unsupervised 30CSTs with a single wearable sensor on the thigh. In unsupervised conditions, participants performed bi-hourly 30CSTs and rated their balance confidence and fatigue over 48-hours. ROC analysis was used to classify fall status for 30CST performance. RESULTS Non-fallers (p = 0.02) but not fallers (p = 0.23) differed in their average unsupervised 30CST performance (repetitions) compared to their supervised performance. The unsupervised maximum number of 30CST repetitions performed optimized ROC classification AUC (0.79), accuracy (78.4%) and specificity (90.0%) for fall status with an optimal cutoff of 17 repetitions. SIGNIFICANCE Brief durations of instrumented unsupervised monitoring as an adjunct to routine clinical assessments could improve the ability for predicting fall risk and fluctuations in functional mobility in PwMS.
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Affiliation(s)
- Lindsey J. Tulipani
- M-Sense Research Group, Department of Electrical and Biomedical Engineering, University of Vermont, Burlington, VT, United States
| | - Brett Meyer
- M-Sense Research Group, Department of Electrical and Biomedical Engineering, University of Vermont, Burlington, VT, United States
| | - Dakota Allen
- M-Sense Research Group, Department of Electrical and Biomedical Engineering, University of Vermont, Burlington, VT, United States
| | - Andrew J. Solomon
- Department of Neurological Sciences, University of Vermont, Burlington, VT, United States
| | - Ryan S. McGinnis
- M-Sense Research Group, Department of Electrical and Biomedical Engineering, University of Vermont, Burlington, VT, United States
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20
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Frechette ML, Abou L, Rice LA, Sosnoff JJ. Relationship Between Lower Limb Function and Fall Prevalence in Ambulatory Adults With Spinal Cord Injury: A Systematic Review. Top Spinal Cord Inj Rehabil 2022; 28:153-175. [PMID: 35521058 PMCID: PMC9009199 DOI: 10.46292/sci21-00026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Falls are common, detrimental events among ambulatory individuals with spinal cord injury (SCI). Following SCI, changes to lower limb function are probable and likely to impact an individual's fall risk, yet no comprehensive review has been completed on the topic. Objectives This study systematically reviewed data on the relationship between lower limb function and fall prevalence in ambulatory individuals with SCI. Methods A literature search was conducted in PubMed, Web of Science, Scopus, and CINAHL. Two independent reviewers screened abstracts/titles and then full articles. Study details, participants' characteristics, lower limb function assessed, and fall-related data were extracted from the studies. A qualitative analysis of the relationship between lower limb function and fall prevalence was performed. The risk of bias was evaluated using the Newcastle-Ottawa Quality Assessment Scale. Results The search yielded 1553 articles. Eight prospective, two retrospective, and three cross-sectional studies met the eligibility criteria. These studies ranged from low to high risk of bias. Overall, the qualitative analysis provided little evidence to support the relationship between lower limb function recorded by clinical measures and fall prevalence. Conclusion This review highlights the inconsistent relationship between lower limb function and falls prevalence in ambulatory adults with SCI. Greater uniformity in methodology and consistent categorization of fallers and nonfallers among researchers is necessary to move the field forward. Investigating additional factors such as behavior traits, assistive device use, and environmental risk factors may be appropriate in understanding fall prevalence in this population.
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Affiliation(s)
- Mikaela L. Frechette
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign
| | - Libak Abou
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign
| | - Laura A. Rice
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign
- Center on Health, Aging, and Disability, University of Illinois at Urbana-Champaign
| | - Jacob J. Sosnoff
- Department of Physical Therapy, Rehabilitation Science and Athletic Training, University of Kansas Medical Center, Kansas City, Kansas
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21
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Block VJ, Pitsch EA, Gopal A, Zhao C, Pletcher MJ, Marcus GM, Olgin JE, Hollenbach J, Bove R, Cree BAC, Gelfand JM. Identifying falls remotely in people with multiple sclerosis. J Neurol 2022; 269:1889-1898. [PMID: 34405267 PMCID: PMC8370664 DOI: 10.1007/s00415-021-10743-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 10/29/2022]
Abstract
BACKGROUND Falling is common in people with multiple sclerosis (MS) but tends to be under-ascertained and under-treated. OBJECTIVE To evaluate fall risk in people with MS. METHODS Ninety-four people with MS, able to walk > 2 min with or without an assistive device (Expanded Disability Status Scale (EDSS ≤ 6.5) were recruited. Clinic-based measures were recorded at baseline and 1 year. Patient-reported outcomes (PROs), including a fall survey and the MS Walking Scale (MSWS-12), were completed at baseline, 1.5, 3, 6, 9, and 12 months. Average daily step counts (STEPS) were recorded using a wrist-worn accelerometer. RESULTS 50/94 participants (53.2%) reported falling at least once. Only 56% of participants who reported a fall on research questionnaires had medical-record documented falls. Fallers had greater disability [median EDSS 5.5 (IQR 4.0-6.0) versus 2.5 (IQR 1.5-4.0), p < 0.001], were more likely to have progressive MS (p = 0.003), and took fewer STEPS (mean difference - 1,979, p = 0.007) than Non-Fallers. Stepwise regression revealed MSWS-12 as a major predictor of future falls. CONCLUSIONS Falling is common in people with MS, under-reported, and under-ascertained by neurologists in clinic. Multimodal fall screening in clinic and remotely may help improve patient care by identifying those at greatest risk, allowing for timely intervention and referral to specialized physical rehabilitation.
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Affiliation(s)
- Valerie J. Block
- grid.266102.10000 0001 2297 6811Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 1651 4th Street, Box 3126, San Francisco, CA 94143 USA
| | - Erica A. Pitsch
- grid.266102.10000 0001 2297 6811Department of Physical Therapy and Rehabilitation Science, University of California San Francisco, San Francisco, USA
| | - Arpita Gopal
- grid.266102.10000 0001 2297 6811Department of Physical Therapy and Rehabilitation Science, University of California San Francisco, San Francisco, USA
| | - Chao Zhao
- grid.266102.10000 0001 2297 6811Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 1651 4th Street, Box 3126, San Francisco, CA 94143 USA
| | - Mark J. Pletcher
- grid.266102.10000 0001 2297 6811Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA ,grid.266102.10000 0001 2297 6811Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Gregory M. Marcus
- grid.266102.10000 0001 2297 6811Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA
| | - Jeffrey E. Olgin
- grid.266102.10000 0001 2297 6811Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA
| | - Jill Hollenbach
- grid.266102.10000 0001 2297 6811Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 1651 4th Street, Box 3126, San Francisco, CA 94143 USA
| | - Riley Bove
- grid.266102.10000 0001 2297 6811Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 1651 4th Street, Box 3126, San Francisco, CA 94143 USA
| | - Bruce A. C. Cree
- grid.266102.10000 0001 2297 6811Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 1651 4th Street, Box 3126, San Francisco, CA 94143 USA
| | - Jeffrey M. Gelfand
- grid.266102.10000 0001 2297 6811Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 1651 4th Street, Box 3126, San Francisco, CA 94143 USA
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22
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Polhemus A, Delgado-Ortiz L, Brittain G, Chynkiamis N, Salis F, Gaßner H, Gross M, Kirk C, Rossanigo R, Taraldsen K, Balta D, Breuls S, Buttery S, Cardenas G, Endress C, Gugenhan J, Keogh A, Kluge F, Koch S, Micó-Amigo ME, Nerz C, Sieber C, Williams P, Bergquist R, Bosch de Basea M, Buckley E, Hansen C, Mikolaizak AS, Schwickert L, Scott K, Stallforth S, van Uem J, Vereijken B, Cereatti A, Demeyer H, Hopkinson N, Maetzler W, Troosters T, Vogiatzis I, Yarnall A, Becker C, Garcia-Aymerich J, Leocani L, Mazzà C, Rochester L, Sharrack B, Frei A, Puhan M. Walking on common ground: a cross-disciplinary scoping review on the clinical utility of digital mobility outcomes. NPJ Digit Med 2021; 4:149. [PMID: 34650191 PMCID: PMC8516969 DOI: 10.1038/s41746-021-00513-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023] Open
Abstract
Physical mobility is essential to health, and patients often rate it as a high-priority clinical outcome. Digital mobility outcomes (DMOs), such as real-world gait speed or step count, show promise as clinical measures in many medical conditions. However, current research is nascent and fragmented by discipline. This scoping review maps existing evidence on the clinical utility of DMOs, identifying commonalities across traditional disciplinary divides. In November 2019, 11 databases were searched for records investigating the validity and responsiveness of 34 DMOs in four diverse medical conditions (Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease, hip fracture). Searches yielded 19,672 unique records. After screening, 855 records representing 775 studies were included and charted in systematic maps. Studies frequently investigated gait speed (70.4% of studies), step length (30.7%), cadence (21.4%), and daily step count (20.7%). They studied differences between healthy and pathological gait (36.4%), associations between DMOs and clinical measures (48.8%) or outcomes (4.3%), and responsiveness to interventions (26.8%). Gait speed, step length, cadence, step time and step count exhibited consistent evidence of validity and responsiveness in multiple conditions, although the evidence was inconsistent or lacking for other DMOs. If DMOs are to be adopted as mainstream tools, further work is needed to establish their predictive validity, responsiveness, and ecological validity. Cross-disciplinary efforts to align methodology and validate DMOs may facilitate their adoption into clinical practice.
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Affiliation(s)
- Ashley Polhemus
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
| | - Laura Delgado-Ortiz
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Gavin Brittain
- Department of Neuroscience and Sheffield NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust & University of Sheffield, Sheffield, England
| | - Nikolaos Chynkiamis
- Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University Newcastle, Newcastle, UK
| | - Francesca Salis
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Heiko Gaßner
- Department of Molecular Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Michaela Gross
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Cameron Kirk
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Rachele Rossanigo
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Kristin Taraldsen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Diletta Balta
- Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy
| | - Sofie Breuls
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department of Respiratory Diseases, University hospitals Leuven, Leuven, Belgium
| | - Sara Buttery
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Gabriela Cardenas
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Christoph Endress
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Julia Gugenhan
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Alison Keogh
- Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland
| | - Felix Kluge
- Department of Artificial Intelligence in Biomedical Engineering, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sarah Koch
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - M Encarna Micó-Amigo
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Corinna Nerz
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Chloé Sieber
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Parris Williams
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ronny Bergquist
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Magda Bosch de Basea
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Ellen Buckley
- Insigneo Institute, Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
| | - Clint Hansen
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Lars Schwickert
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Kirsty Scott
- Insigneo Institute, Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
| | - Sabine Stallforth
- Department of Molecular Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Janet van Uem
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Beatrix Vereijken
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Andrea Cereatti
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
- Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy
| | - Heleen Demeyer
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department of Respiratory Diseases, University hospitals Leuven, Leuven, Belgium
- Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
| | | | - Walter Maetzler
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Thierry Troosters
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department of Respiratory Diseases, University hospitals Leuven, Leuven, Belgium
| | - Ioannis Vogiatzis
- Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University Newcastle, Newcastle, UK
| | - Alison Yarnall
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Clemens Becker
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Judith Garcia-Aymerich
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Letizia Leocani
- Department of Neurology, San Raffaele University, Milan, Italy
| | - Claudia Mazzà
- Insigneo Institute, Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
| | - Lynn Rochester
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Basil Sharrack
- Department of Neuroscience and Sheffield NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust & University of Sheffield, Sheffield, England
| | - Anja Frei
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Milo Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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23
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Kimura A, Takeshita K, Inoue H, Inose H, Yoshii T, Maekawa A, Endo K, Miyamoto T, Furuya T, Nakamura A, Mori K, Seki S, Kanbara S, Imagama S, Matsunaga S, Yamazaki M, Okawa A. The 5-question Geriatric Locomotive Function Scale predicts postoperative fall risk in patients undergoing surgery for degenerative cervical myelopathy. J Orthop Sci 2021; 26:779-785. [PMID: 33109435 DOI: 10.1016/j.jos.2020.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/10/2020] [Accepted: 08/30/2020] [Indexed: 02/09/2023]
Abstract
BACKGROUND Falling is one of the main reasons for which older adults require nursing care. Locomotive syndrome (LS) predicts the need for nursing care; however, the relationship between falling and LS remains unclarified. This study aimed to determine whether the 5-question Geriatric Locomotive Function Scale (GLFS-5) predicts postoperative fall risk in patients with degenerative cervical myelopathy (DCM). METHODS This study is a post hoc analysis of the data from a prospective cohort of patients undergoing surgery for DCM. Participants recorded their falls in a fall diary from the time of study enrollment (baseline) to 1 year postoperatively. Functional assessments were conducted at baseline, hospital admission for surgery, and 1 year postoperatively. Outcome measures included the GLFS-5, Japanese Orthopaedic Association score, Neck Disability Index, EuroQol 5 Dimensions, and 12-Item Short Form Health Survey. Risk factors for falls were investigated, including previous falls, number of medications, and grip strength. Fallers were divided into two categories: all fallers (≥1 falls), and recurrent fallers (≥2 falls). Variables that were significant in univariate analyses were applied in multiple logistic regression models to adjust for confounders. RESULTS From the initial group of 168 participants, 159 attended the 1-year follow-up, and 132 fall diaries were retrieved and analyzed. Of these 132 patients, 42 (32%) reported at least one fall, while 25 (19%) reported recurrent falls during the postoperative observation period. The GLFS-5 significantly increased from baseline to admission, and significantly decreased from admission to 1 year postoperatively. In multiple logistic regression analysis, the independent predictors of postoperative recurrent falls were previous falls and a higher baseline GLFS-5. The optimal cut-off value of GLFS-5 for predicting all falls/recurrent falls was 12. CONCLUSIONS The GLFS-5 reflected time-dependent functional changes in patients undergoing surgery for DCM. Previous falls and a higher baseline GLFS-5 were independent predictors of postoperative recurrent falls.
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Affiliation(s)
- Atsushi Kimura
- Department of Orthopaedics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Katsushi Takeshita
- Department of Orthopaedics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hirokazu Inoue
- Department of Orthopaedics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hiroyuki Inose
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Toshitaka Yoshii
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Asato Maekawa
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kenji Endo
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takuya Miyamoto
- Department of Orthopedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo Ward, Chiba, Chiba, 260-0856, Japan
| | - Takeo Furuya
- Department of Orthopedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo Ward, Chiba, Chiba, 260-0856, Japan
| | - Akira Nakamura
- Department of Orthopedic Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Kanji Mori
- Department of Orthopedic Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Shoji Seki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Shunsuke Kanbara
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan
| | - Shunji Matsunaga
- Department of Orthopedic Surgery, Imakiire General Hospital, 4-16 Shimotatsuo, Kagoshima, 892-8502, Japan
| | - Masashi Yamazaki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 2-1-1 Amakubo, Tsukuba, Ibaraki, 305-8576, Japan
| | - Atsushi Okawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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Pardo G, Coates S, Okuda DT. Outcome measures assisting treatment optimization in multiple sclerosis. J Neurol 2021; 269:1282-1297. [PMID: 34338857 PMCID: PMC8857110 DOI: 10.1007/s00415-021-10674-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 11/30/2022]
Abstract
Objective To review instruments used to assess disease stability or progression in persons with multiple sclerosis (pwMS) that can guide clinicians in optimizing therapy. Methods A non-systematic review of scientific literature was undertaken to explore modalities of monitoring symptoms and the disease evolution of MS. Results Multiple outcome measures, or tools, have been developed for use in MS research as well as for the clinical management of pwMS. Beginning with the Expanded Disability Status Scale, introduced in 1983, clinicians and researchers have developed monitoring modalities to assess all aspects of MS and the neurological impairment it causes. Conclusions Much progress has been made in recent decades for the management of MS and for the evaluation of disease progression. New technology, such as wearable sensors, will provide new opportunities to better understand changes in function, dexterity, and cognition. Essential work over the decades since EDSS was introduced continues to improve our ability to treat this debilitating disease.
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Affiliation(s)
- Gabriel Pardo
- OMRF Multiple Sclerosis Center of Excellence, Oklahoma Medical Research Foundation, 820 NE 15th Street, Oklahoma City, OK, 73104, USA.
| | | | - Darin T Okuda
- Department of Neurology, University of Texas Southwestern, Dallas, TX, USA
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25
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Psychometric Properties of Cognitive-Motor Dual-Task Studies With the Aim of Developing a Test Protocol for Persons With Vestibular Disorders: A Systematic Review. Ear Hear 2021; 41:3-16. [PMID: 31283530 DOI: 10.1097/aud.0000000000000748] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Patients suffering from vestibular disorders (VD) often present with impairments in cognitive domains such as visuospatial ability, memory, executive function, attention, and processing speed. These symptoms can be attributed to extensive vestibular projections throughout the cerebral cortex and subcortex on the one hand, and to increased cognitive-motor interference (CMI) on the other hand. CMI can be assessed by performing cognitive-motor dual-tasks (DTs). The existing literature on this topic is scarce and varies greatly when it comes to test protocol, type and degree of vestibular impairment, and outcome. To develop a reliable and sensitive test protocol for VD patients, an overview of the existing reliability and validity studies on DT paradigms will be given in a variety of populations, such as dementia, multiple sclerosis, Parkinson's disease, stroke, and elderly. DESIGN The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An extensive literature search on psychometric properties of cognitive-motor DTs was run on MEDLINE, Embase, and Cochrane Databases. The studies were assessed for eligibility by two independent researchers, and their methodological quality was subsequently evaluated using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). RESULTS AND CONCLUSIONS Thirty-three studies were included in the current review. Based on the reliability and validity calculations, including a static as well as dynamic motor task seems valuable in a DT protocol for VD patients. To evoke CMI maximally in this population, both motor tasks should be performed while challenging the vestibular cognitive domains. Out of the large amount of cognitive tasks employed in DT studies, a clear selection for each of these domains, except for visuospatial abilities, could be made based on this review. The use of the suggested DTs will give a more accurate and daily life representation of cognitive and motor deficiencies and their interaction in the VD population.
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Meyer BM, Tulipani LJ, Gurchiek RD, Allen DA, Adamowicz L, Larie D, Solomon AJ, Cheney N, McGinnis RS. Wearables and Deep Learning Classify Fall Risk From Gait in Multiple Sclerosis. IEEE J Biomed Health Inform 2021; 25:1824-1831. [PMID: 32946403 DOI: 10.1109/jbhi.2020.3025049] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Falls are a significant problem for persons with multiple sclerosis (PwMS). Yet fall prevention interventions are not often prescribed until after a fall has been reported to a healthcare provider. While still nascent, objective fall risk assessments could help in prescribing preventative interventions. To this end, retrospective fall status classification commonly serves as an intermediate step in developing prospective fall risk assessments. Previous research has identified measures of gait biomechanics that differ between PwMS who have fallen and those who have not, but these biomechanical indices have not yet been leveraged to detect PwMS who have fallen. Moreover, they require the use of laboratory-based measurement technologies, which prevent clinical deployment. Here we demonstrate that a bidirectional long short-term (BiLSTM) memory deep neural network was able to identify PwMS who have recently fallen with good performance (AUC of 0.88) based on accelerometer data recorded from two wearable sensors during a one-minute walking task. These results provide substantial improvements over machine learning models trained on spatiotemporal gait parameters (21% improvement in AUC), statistical features from the wearable sensor data (16%), and patient-reported (19%) and neurologist-administered (24%) measures in this sample. The success and simplicity (two wearable sensors, only one-minute of walking) of this approach indicates the promise of inexpensive wearable sensors for capturing fall risk in PwMS.
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Moreno-Navarro P, Manca A, Martinez G, Ventura L, Barbado D, Vera-García FJ, Deriu F. Test-Retest Reliability and Known-Groups Validity of Trunk Muscle Tests in People With Multiple Sclerosis: A Cross-Sectional, Case-Control Study. Phys Ther 2021; 101:6128528. [PMID: 33538837 DOI: 10.1093/ptj/pzab049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 10/25/2020] [Accepted: 11/29/2020] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Research on muscle performance testing reliability in people with multiple sclerosis (MS) has focused on limb performance while less is known about trunk strength and endurance. This work aims to 1) establish test-retest reliability of trunk flexion, lateral flexion, and extension strength tests, and plank, side bridge, and Biering-Sørensen endurance tests in people with MS and matched healthy controls (HCs); 2) analyze known-groups validity of these tests in people with MS and HCs; 3) to compare groups for side-to-side differences; and 4) to describe the relationships between trunk performance and functional mobility tests. METHODS Fifteen people with MS (median Expanded Disability Status Scale = 3) and 15 HCs underwent 2 trunk isometric strength and endurance testing sessions. Mobility was evaluated by Timed Up-and-Go test. Intraclass correlation coefficient, SEM, and minimal detectable change (MDC) were calculated. Between-group differences in trunk performance were tested using the t test for independent measures. Between-group differences in an asymmetry index were analyzed by independent t test. Bivariate correlations between trunk tests and mobility were also examined. RESULTS All trunk tests showed good-to-excellent relative reliability in both groups (intraclass correlation coefficient > 0.71). Regarding absolute reliability, strength tests were associated with low intersession variability in both groups (MDC: MS, 11.23%-36.45%; HCs, 26.60%-31.98%). Conversely, endurance tests showed higher variability scores in people with MS (MDC: MS, 69.55%-116.50%; HCs, 29.57%-54.40%). People with MS displayed significantly lower trunk performance. Likewise, the asymmetry index showed significantly higher scores in people with MS for endurance assessment but not in strength tests. Significant correlations were detected in people with MS between Timed Up-and-Go and several trunk tests (r = 0.63-0.70). CONCLUSIONS SEM and MDC scores revealed similar consistency and variability between groups for strength tests, whereas higher variability was observed for endurance tests in people with MS. Trunk strength tests are reliable and present discriminant validity to distinguish mildly disabled people with MS from HCs. Conversely, the high measurement error and variability of the endurance tests may hinder their application in intervention programs. IMPACT Determining the reliability and validity of the tests currently used to assess trunk function is of the greatest importance for people with MS (who show not only impaired trunk function but also wide fluctuations in performance), as it requires consistent and accurate measurements that are sensitive enough to detect minimal changes induced by rehabilitation.
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Affiliation(s)
- Pedro Moreno-Navarro
- Sports Research Centre, Department of Sport Sciences, Miguel Hernandez University of Elche, Alicante, Spain
| | - Andrea Manca
- Department of Biomedical Sciences, University of Sassari, Italy
| | | | - Lucia Ventura
- Department of Biomedical Sciences, University of Sassari, Italy
| | - David Barbado
- Sports Research Centre, Department of Sport Sciences, Miguel Hernandez University of Elche, Alicante, Spain
| | - Francisco J Vera-García
- Sports Research Centre, Department of Sport Sciences, Miguel Hernandez University of Elche, Alicante, Spain
| | - Franca Deriu
- Department of Biomedical Sciences, University of Sassari, Italy
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Cohen JN, Seng E, Foley FW. Cognitive and motor slowing mediate the relationship between depression and falls in multiple sclerosis patients. Mult Scler Relat Disord 2021; 50:102808. [PMID: 33596493 DOI: 10.1016/j.msard.2021.102808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 01/08/2021] [Accepted: 01/31/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Given the limited research concerning the relationship between depression and falls in multiple sclerosis (MS), this study aimed to examine the direct and indirect association between fall history and depressive symptoms. METHODS One hundred and forty seven MS patients had completed at least one neuropsychological assessment that included detailed information regarding fall history, as well as measures of depression, motor function, and cognitive processing speed. RESULTS Fall history was associated with higher depressive symptoms and poorer overall motor function. Higher self-reported depressive symptoms were associated with higher odds of falls in the last year (OR = 1.64, 95% CI 1.16, 2.31) in an age adjusted model. Cognitive and motor slowing serially mediated the relationship between depressive symptoms and fall history (estimate = 0.060, 95% CI = 0.01, 0.15). CONCLUSIONS With the extensive research on the cognitive and motor correlates of falls in MS, our findings suggest that depressive symptoms are also associated with falls in people with MS. Moreover, this study provides preliminary support for a pathway by which depressive symptoms are related to falls in part through their relationships with cognitive and motor slowing.
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Affiliation(s)
- Jenna N Cohen
- Ferkauf Graduate School of Psychology, Yeshiva University, 1300 Morris Park Avenue, Bronx, NY 10461, United States
| | - Elizabeth Seng
- Ferkauf Graduate School of Psychology, Yeshiva University, 1300 Morris Park Avenue, Bronx, NY 10461, United States; The Saul R Korey Department of Neurology, Albert Einstein College of Medicine, 1225 Morris Park Avenue, Van Etten Building, Bronx, NY 10461, United States
| | - Frederick W Foley
- Ferkauf Graduate School of Psychology, Yeshiva University, 1300 Morris Park Avenue, Bronx, NY 10461, United States; Holy Name Medical Center Multiple Sclerosis Center, 718 Teaneck Road, Teaneck, NJ 07666, United States.
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Abasıyanık Z, Kahraman T, Ertekin Ö, Baba C, Özakbaş S. Prevalence and determinants of falls in persons with multiple sclerosis without a clinical disability. Mult Scler Relat Disord 2021; 49:102771. [PMID: 33493789 DOI: 10.1016/j.msard.2021.102771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/20/2020] [Accepted: 01/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Falls are common in persons with Multiple Sclerosis (pwMS) and lead to destructive results, specifically with increasing disability. However, there is only scarce data investigating prevalence and determinants of falls in pwMS without a clinical disability. Therefore, this study aimed to investigate proportion of fallers and related factors in pwMS without a clinical disability. METHODS One hundred and four pwMS with no clinical disability (EDSS≤1.5) were recruited in this cross-sectional study. The outcome measures comprised of the Timed 25-Foot Walk (T25FW), Six Minute Walk Test (6MWT), Timed Up and Go Test (TUG), Multiple Sclerosis Walking Scale (MSWS-12), Single Leg Stance Test (SLS), Activities-Specific Balance Confidence Scale (ABC), Symbol Digit Modalities Test (SDMT), Modified Fatigue Impact Scale (MFIS), and Beck Depression Inventory-II (BDI-II). The number of falls during the last three months was recorded. RESULTS Twenty-five percent of the pwMS reported at least one fall in the last three months. The TUG and MSWS-12 scores were significantly greater in the fallers compared to non-fallers (p<0.05). Whereas the fallers had significantly less ABC scores (p<0.05). Increasing TUG and MSWS-12 score and decreasing ABC score was related with increased risk of being classified as a faller adjusting for EDSS score. CONCLUSION The present findings highlight that falls are frequent problem for pwMS, even if they do not have a clinical disability. Therefore, falls prevention strategies are also required in the early stages of the disease in clinical practice. The ABC scale, MSWS-12, and TUG test can be used by the clinicians and researchers to predict potential fallers of the pwMS without a clinical disability.
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Affiliation(s)
- Zuhal Abasıyanık
- Graduate School of Health Sciences, Dokuz Eylül University, Izmir, Turkey; Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Turkey.
| | - Turhan Kahraman
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Turkey
| | - Özge Ertekin
- School of Physical Therapy and Rehabilitation, Dokuz Eylül University, Izmir, Turkey
| | - Cavid Baba
- Department of Neurology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Serkan Özakbaş
- Department of Neurology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
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Effectiveness of Dry Needling versus Placebo on Gait Performance, Spasticity, Electromyographic Activity, Pain, Range-of-Movement and Quality of Life in Patients with Multiple Sclerosis: A Randomized Controlled Trial Protocol. Brain Sci 2020; 10:brainsci10120997. [PMID: 33561042 PMCID: PMC7766461 DOI: 10.3390/brainsci10120997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 12/27/2022] Open
Abstract
Dry needling (DN) is an emerging technique commonly used in neurological and musculoskeletal pain conditions, but there have been no previous studies in patients with multiple sclerosis (pwMS). This trial aims to assess the efficacy of deep DN, compared with sham placebo DN, on gait performance, spasticity level, pain, electromyographic activity, range-of-movement (ROM) and quality of life in pwMS. Forty adults with MS were randomly assigned to one study group. The DN group will undergo 2 sessions (once per week) using DN over the rectus femoris (RF) and gastrocnemius medialis (GM) muscles at the lower extremity with higher spasticity. The placebo group will receive the same protocol using a sham placebo needle (Dong Bang needle). Outcome measures will include gait performance, using the GaitRite® system, spasticity level with the Modified Ashworth Scale, superficial electromyographic activity of RF and GM, pain (pressure algometer), ROM (goniometer), and quality of life (Musiqol). This study is the first investigating the short-term effect of DN, compared with placebo, in pwMS, and taking into account the possible changes in the electromyographic activity of the lower limb. Therefore, the results may help to understand the suitability of using this technique in the clinical setting for this population. Trial registration: ACTRN12619000880145.
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Quinn G, Comber L, McGuigan C, Hannigan A, Galvin R, Coote S. Risk factors for falling for people with Multiple Sclerosis identified in a prospective cohort study. Clin Rehabil 2020; 35:765-774. [PMID: 33322921 DOI: 10.1177/0269215520973197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To identify risk factors for falling for people with Multiple Sclerosis. DESIGN Prospective cohort study. SETTING Neurology service in a tertiary hospital. SUBJECTS Participants were 101 people with Multiple Sclerosis and Expanded Disability Status Score of 3-6.5. One participant withdrew after the baseline assessment; data were analysed for 100 participants. INTERVENTIONS No intervention. MAIN MEASURES Outcome was rate of falls, and predictors were Timed Up and Go, Symbol Digit Modalities test, demographics and 15 self-report questions about various symptoms including fatigue, concentration, dual tasking, bladder and bowel control. Three-month prospective diaries recorded falls. RESULTS There were 791 falls reported over the 3-month period from a total of 56 fallers. Falls rate per person-year was 32.08 falls. Following multivariable regression analysis, the model with the greatest levels of clinical utility and discriminative ability (sensitivity 88% and area under the receiving operating curve statistic = 0.72, 95% CI 0.62-0.82), included the variables of history of a fall, not having visual problems, problems with bladder control and a slower speed on the Timed Up and Go. CONCLUSION This study confirms the high incidence of falls for people with Multiple Sclerosis and provides a risk prediction model including fall history, problems with bladder control, not having visual problems and a slower Timed Up and Go speed that may be used to identify those at greater risk and in need of tailored falls prevention intervention.
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Affiliation(s)
- Gillian Quinn
- School of Allied Health, Health Research Institute, University of Limerick, Limerick, Ireland.,Physiotherapy Department, St. James's Hospital, Dublin, Ireland
| | - Laura Comber
- School of Allied Health, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Chris McGuigan
- Neurology Department, St. Vincent's University Hospital, Dublin, Ireland
| | - Ailish Hannigan
- School of Medicine, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Susan Coote
- School of Allied Health, Health Research Institute, University of Limerick, Limerick, Ireland
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Hentzen C, Villaumé A, Turmel N, Chesnel C, Le Breton F, Haddad R, Amarenco G. Are falls in people with multiple sclerosis related to the severity of urinary disorders? Ann Phys Rehabil Med 2020; 64:101452. [PMID: 33186783 DOI: 10.1016/j.rehab.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Lower urinary tract symptoms (LUTSs), especially overactive bladder, are frequent in people with multiple sclerosis (PwMS). Urinary urgency and urge urinary incontinence could lead to precipitation and thus could increase the risk of falling in these individuals. OBJECTIVE We aimed to assess the association between severity of LUTSs and risk of falling in PwMS. METHODS PwMS with LUTSs were recruited in a neuro-urology department. Participants were asked about the number of falls in the past 3 months and their circumstances. Severity of LUTSs was assessed by the Urinary Symptoms Profile (USP) score, and individuals were classified as with or without urinary incontinence. RESULTS This cross-sectional study included 154 patients (69% women); the mean (SD) age was 50.1 (11.5) years and median EDSS was 5 (interquartile range 3-6). Overall, 20 (13%) patients reported one fall during the past 3 months, and 43 (28%) reported at least 2 falls. Only 9 (6%) patients reported a fall on the way to the toilet, 6 during a urinary urgency. No link was found between falls and urinary incontinence (P=0.71), type or severity of urinary symptoms (overactivity, voiding dysfunction or stress incontinence, P>0.05). Falls on the way to the bathroom was associated with high USP score related to overactive bladder (P=0.03) and severe nocturia (>2 nocturnal micturitions) (P<0.01). Falling at night was also associated with severe nocturia (P<0.001). CONCLUSIONS The severity of LUTSs and presence of urinary incontinence do not appear related to the risk of falling in PwMS and urinary disorders but rather to the specific risk of falling on the way to the bathroom. Severe nocturia increases the risk of falling at night. Further studies are needed to assess the impact of LUTS treatment on the risk of falling. ClinicalTrials.gov (NCT04338646).
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Affiliation(s)
- Claire Hentzen
- GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne Université, AP-HP, 75020 Paris, France.
| | - Anaïs Villaumé
- GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne Université, AP-HP, 75020 Paris, France
| | - Nicolas Turmel
- GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne Université, AP-HP, 75020 Paris, France
| | - Camille Chesnel
- GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne Université, AP-HP, 75020 Paris, France
| | - Frédérique Le Breton
- GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne Université, AP-HP, 75020 Paris, France
| | - Rebecca Haddad
- GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne Université, AP-HP, 75020 Paris, France
| | - Gérard Amarenco
- GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, hôpital Tenon, Sorbonne Université, AP-HP, 75020 Paris, France
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Coote S, Comber L, Quinn G, Santoyo-Medina C, Kalron A, Gunn H. Falls in People with Multiple Sclerosis: Risk Identification, Intervention, and Future Directions. Int J MS Care 2020; 22:247-255. [PMID: 33424479 DOI: 10.7224/1537-2073.2020-014] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Falls are highly prevalent in people with multiple sclerosis (MS) and result in a range of negative consequences, such as injury, activity curtailment, reduced quality of life, and increased need for care and time off work. This narrative review aims to summarize key literature and to discuss future work needed in the area of fall prevention for people with MS. The incidence of falls in people with MS is estimated to be more than 50%, similar to that in adults older than 80 years. The consequences of falls are considerable because rate of injury is high, and fear of falling and low self-efficacy are significant problems that lead to activity curtailment. A wide range of physiological, personal, and environmental factors have been highlighted as potential risk factors and predictors of falls. Falls are individual and multifactorial, and, hence, approaches to interventions will likely need to adopt a multifactorial approach. However, the literature to date has largely focused on exercise-based interventions, with newer, more comprehensive interventions that use both education and exercise showing promising results. Several gaps in knowledge of falls in MS remain, in particular the lack of standardized definitions and outcome measures, to enable data pooling and comparison. Moving forward, the involvement of people with MS in the design and evaluation of programs is essential, as are approaches to intervention development that consider implementation from the outset.
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O'Malley N, Clifford AM, Comber L, Coote S. Fall definitions, faller classifications and outcomes used in falls research among people with multiple sclerosis: a systematic review. Disabil Rehabil 2020; 44:856-864. [PMID: 32628889 DOI: 10.1080/09638288.2020.1786173] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose: To identify the definitions of a fall, faller classifications and outcomes used in prospectively-recorded falls research among people with Multiple Sclerosis (MS).Methods: A systematic review of peer-reviewed journal articles was conducted using electronic databases. Relevant data were extracted by one reviewer and verified by a second independent reviewer.Results: Twenty-six papers met the inclusion criteria. A relative degree of heterogeneity existed amongst studies for the outcomes of interest to this review. Thirteen different fall definitions were identified. Fourteen different falls outcomes were used across the included studies, with six of these reported by only one study each. Data regarding injurious falls were presented by only eight papers. The majority (n = 17) of papers classified individuals as a faller if they fell at least once.Conclusions: This review highlights the large variation in fall definitions, faller classifications and outcomes used in this research field. This hinders cross-comparison and pooling of data, thereby preventing researchers and clinicians from drawing conclusive findings from existing literature. The creation of an international standard for the definition of a fall, faller classification and falls outcomes would allow for transparent and coordinated falls research for people with MS, facilitating progression in this research field.Implications for rehabilitationFalls are a common occurrence among people with Multiple Sclerosis (MS) resulting in numerous negative consequences.There is large heterogeneity in the definitions, methods and outcomes used in falls research for people with MS.This lack of standardisation prevents the accurate cross-comparison and pooling of data, impeding the identification of falls risk factors and effective falls prevention interventions for people with MS.Consequently, clinicians should interpret the outcomes of falls research for people with MS with caution, particularly when comparing studies regarding falls risk assessments and falls prevention interventions for use in clinical practice.
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Affiliation(s)
- Nicola O'Malley
- School of Allied Health, Faculty of Education and Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Amanda M Clifford
- School of Allied Health, Faculty of Education and Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland.,Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Laura Comber
- School of Allied Health, Faculty of Education and Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Susan Coote
- School of Allied Health, Faculty of Education and Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland
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Tulipani LJ, Meyer B, Larie D, Solomon AJ, McGinnis RS. Metrics extracted from a single wearable sensor during sit-stand transitions relate to mobility impairment and fall risk in people with multiple sclerosis. Gait Posture 2020; 80:361-366. [PMID: 32615409 PMCID: PMC7413823 DOI: 10.1016/j.gaitpost.2020.06.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Approximately half of the 2.3 million people with multiple sclerosis (PwMS) will fall in any three-month period. Currently clinicians rely on self-report measures or simple functional assessments, administered at discrete time points, to assess fall risk. Wearable inertial sensors are a promising technology for increasing the sensitivity of clinical assessments to accurately predict fall risk, but current accelerometer-based approaches are limited. RESEARCH QUESTION Will metrics derived from wearable accelerometers during a 30-second chair stand test (30CST) correlate with clinical measures of disease severity, balance confidence and fatigue in PwMS, and can these metrics be used to accurately discriminate fallers from non-fallers? METHODS Thirty-eight PwMS (21 fallers) completed self-report outcome measures then performed the 30CST while triaxial acceleration data were collected from inertial sensors adhered to the thigh and chest. Accelerometer metrics were derived for the sit-to-stand and stand-to-sit transitions and relationships with clinical metrics were assessed. Finally, the metrics were used to develop a logistic regression model to classify fall status. RESULTS Accelerometer-derived metrics were significantly associated with multiple clinical metrics that capture disease severity, balance confidence and fatigue. Performance of a logistic regression for classifying fall status was enhanced by including accelerometer features (accuracy 74%, AUC 0.78) compared to the standard of care (accuracy 68%, AUC 0.74) or patient reported outcomes (accuracy 71%, AUC 0.75). SIGNIFICANCE Accelerometer derived metrics were associated with clinically relevant measures of disease severity, fatigue and balance confidence during a balance challenging task. Inertial sensors could feasibly be utilized to enhance the accuracy of functional assessments to identify fall risk in PwMS. Simplicity of these accelerometer-based metrics could facilitate deployment for community-based monitoring.
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Affiliation(s)
- Lindsey J. Tulipani
- M-Sense Research Group, Department of Electrical and Biomedical Engineering, University of Vermont, Burlington, VT
| | - Brett Meyer
- M-Sense Research Group, Department of Electrical and Biomedical Engineering, University of Vermont, Burlington, VT
| | - Dale Larie
- M-Sense Research Group, Department of Electrical and Biomedical Engineering, University of Vermont, Burlington, VT
| | - Andrew J. Solomon
- Department of Neurological Sciences, University of Vermont, Burlington, VT
| | - Ryan S. McGinnis
- M-Sense Research Group, Department of Electrical and Biomedical Engineering, University of Vermont, Burlington, VT;,Corresponding Author: Dr. Ryan S. McGinnis (), Department of Electrical and Biomedical Engineering, 33 Colchester Avenue, Burlington, VT 05405
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Choobsaz H, ShahAli S, Salehi R, Noorizadeh Dehkordi S, Shanbehzadeh S. Discriminative ability of fall efficacy scale international in Iranian people with multiple sclerosis. Mult Scler Relat Disord 2020; 42:102083. [DOI: 10.1016/j.msard.2020.102083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 03/16/2020] [Accepted: 03/30/2020] [Indexed: 11/28/2022]
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Abasıyanık Z, Özdoğar AT, Sağıcı Ö, Kahraman T, Baba C, Ertekin Ö, Özakbaş S. Explanatory factors of balance confidence in persons with multiple sclerosis: Beyond the physical functions. Mult Scler Relat Disord 2020; 43:102239. [PMID: 32512478 DOI: 10.1016/j.msard.2020.102239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/12/2020] [Accepted: 05/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Balance confidence is considered a psychological element of falls and balance-demanding activities. The relationship of balance confidence with physical factors has been investigated; however, psychosocial correlates are not well known. The aim was to investigate the relationship between balance confidence and physical and psychosocial factors and to reveal the determinants of balance confidence in persons with MS (pwMS). METHODS A total of 445 pwMS were enrolled in the study. Balance confidence was assessed with the Activities-Specific Balance Confidence (ABC) Scale. Psychosocial-based measures included the Modified Fatigue Impact Scale (MFIS), Epworth Sleepiness Scale (ESS), Beck Depression Scale (BDI), and Symbol Digit Modalities Test (SDMT). The Godin Leisure-Time Exercise Questionnaire (GLTEQ), Timed 25-Foot Walk (T25FW), Six-Minute Walk Test (6MWT), and Single Leg Stance Test (SLS) were used to assess physical functions. RESULTS There was a significant correlation between the ABC score and all physical and psychosocial measures (p<0.05). Hierarchical linear regression analyses indicated that psychosocial factors were significantly associated with ABC accounting for 41% of the variance. The addition of physical variables explained an additional 35% of variance over psychosocial variables. The MFIS, SDMT, BDI, T25FW, 6MWT, and SLS were significantly predictive of the ABC. CONCLUSION This study emphasizes the importance of considering both physical and psychosocial factors for understanding balance confidence in pwMS. Besides, intervention strategies for enhancing balance confidence should aim to improve fatigue, depression, and cognition in addition to physical components.
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Affiliation(s)
- Zuhal Abasıyanık
- Graduate School of Health Sciences, Dokuz Eylül University, Inciralti, Izmir 35340, Turkey.
| | - Asiye Tuba Özdoğar
- Graduate School of Health Sciences, Dokuz Eylül University, Inciralti, Izmir 35340, Turkey
| | - Özge Sağıcı
- Graduate School of Health Sciences, Dokuz Eylül University, Inciralti, Izmir 35340, Turkey
| | - Turhan Kahraman
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Turkey
| | - Cavid Baba
- Department of Neurology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Özge Ertekin
- School of Physical Therapy and Rehabilitation, Dokuz Eylül University, Izmir, Turkey
| | - Serkan Özakbaş
- Department of Neurology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
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Salehi R, Mofateh R, Mehravar M, Negahban H, Tajali S, Monjezi S. Comparison of the lower limb inter-segmental coordination during walking between healthy controls and people with multiple sclerosis with and without fall history. Mult Scler Relat Disord 2020; 41:102053. [DOI: 10.1016/j.msard.2020.102053] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 11/28/2022]
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Monjezi S, Molhemi F, Shaterzadeh Yazdi MJ, Salehi R, Mehravar M, Kashipazha D. Responsiveness and clinically meaningful changes for the Persian versions of the multiple sclerosis walking scale-12 and the modified fatigue impact scale following balance and gait rehabilitation in people with multiple sclerosis. Physiother Theory Pract 2020; 38:464-470. [PMID: 32431220 DOI: 10.1080/09593985.2020.1762267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background and Purpose: The Multiple sclerosis walking scale-12 (MSWS-12) and the Modified Fatigue Impact Scale (MFIS) are two popular outcome measures applied widely for assessing self-perceived walking ability and fatigue in people with multiple sclerosis (PwMS). The present study aimed to examine responsiveness and clinically meaningful changes for the Persian versions of the MSWS-12 and the MFIS following balance and gait rehabilitation in PwMS.Methods: Fifty-eight PwMS completed the Persian versions of the MSWS-12 and the MFIS before and after 4 weeks of balance and gait rehabilitation. Also, a 7-point global rating scale as an external criterion of change was completed at the post-intervention evaluation. The area under the receiver operating characteristics curve (AUC) and the correlation analysis were used to assess the responsiveness. In addition, the minimally clinically important change (MCIC) was measured to determine clinically meaningful changes following rehabilitation.Results: The AUC values for the Persian MSWS-12 and MFIS were 0.74 and 0.73, respectively. There were good to excellent correlations between the global rating scale of change and the Persian MSWS-12 (Gamma = 0.77) also MFIS (Gamma = 0.80) change scores (p = .001). Moreover, the MCICs of 7.5 and 4 points were obtained for the Persian MSWS-12 and MFIS, respectively.Conclusion: The Persian versions of the MSWS-12 and the MFIS were responsive outcome measures for monitoring changes in walking and fatigue after balance and gait rehabilitation in PwMS. The calculation of MCIC values would enhance the interpretation of changes in clinical and research settings.
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Affiliation(s)
- Saeideh Monjezi
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Farshad Molhemi
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Reza Salehi
- Rehabilitation Research Center, Department of Rehabilitation Management, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehravar
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Davood Kashipazha
- Department of Neurology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Silva LGDOD, Sousa Neto IVD, Barboza EC, Melo TKMD, Godoi VMDS, Durigan JLQ, Marqueti RDC. Identificação de fatores de risco para quedas em indivíduos com esclerose múltipla: uma revisão sistemática de estudos prospectivos. FISIOTERAPIA E PESQUISA 2019. [DOI: 10.1590/1809-2950/18029426042019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO O objetivo deste estudo foi identificar, a partir de uma revisão sistemática, variáveis clínicas, instrumentais e demográficas associadas com maior risco de queda em indivíduos com esclerose múltipla (EM), com base em dados prospectivos. A pesquisa foi conduzida nas bases de dados Medline, Web of Science, Bireme e CINAHL, utilizando os descritores “esclerose múltipla”, “quedas”, “quedas acidentais”, “risco de quedas”, “controle postural” e “equilíbrio”, seguido de buscas manuais. Foram considerados elegíveis estudos de coorte prospectivos, com período mínimo de acompanhamento das quedas de três meses, que avaliassem a associação de determinada variável demográfica, clínica ou instrumental em relação a maior risco de queda em indivíduos com EM. A escala de Newcastle-Ottawa modificada foi utilizada para avaliação da qualidade metodológica dos estudos incluídos. Foram identificados 357 estudos, 12 dos quais foram incluídos na revisão sistemática, com total de 1.270 pacientes incluídos. Destes, 740 (58,26%) pacientes apresentaram um ou mais episódios de queda, 396 (31,18%) apresentaram episódios de queda recorrentes (2≥quedas no período estipulado), e 530 (41,74%) não apresentaram nenhum episódio. Com exceção da espasticidade e do impacto da dupla tarefa na velocidade da marcha, todas as variáveis investigadas apresentaram resultados conflitantes quanto às suas associações a maior risco de quedas. São necessários mais estudos que apresentem homogeneidade dos fenótipos clínicos de indivíduos com EM, além da utilização de instrumentos de avaliação validados, a fim de estabelecer uma associação robusta de outras variáveis clínicas, instrumentais e demográficas com maior risco de queda.
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The association between gait variability with the energy cost of walking depends on the fall status in people with multiple sclerosis without mobility aids. Gait Posture 2019; 74:231-235. [PMID: 31563824 DOI: 10.1016/j.gaitpost.2019.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/27/2019] [Accepted: 09/18/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Falls, gait variability and increased energy cost of walking are common in people with multiple sclerosis (PwMS). However, no studies have as yet examined this triple association in PwMS or in other neurological populations. RESEARCH QUESTION Does a relationship exist between gait variability, falls and the energy cost of gait in PwMS? METHODS This cross sectional study included 88 PwMS (50 women), mean age 39.8 (S.D = 13.0) and mean disease duration of 6.2 (SD = 8.2) years since diagnosis. Energy expenditure during walking was collected via a portable metabolic device (COSMED K5, COSMED Srl, Roma, Italy). Gait variability was measured by an electronic walkway (GAITRite™). Participants were divided into groups based on fall history (fallers and non-fallers). Differences between groups in terms of energy expenditure measures and gait variability metrics were determined by the analysis of variance test. The relationship between gait variability and energy cost of walking was examined by the Pearson's correlation coefficient test. RESULTS Thirty-three PwMS were classified as fallers and 55 as non-fallers. Non-significant differences between groups were observed in the energy expenditure measures, including cost of walking. Fallers demonstrated higher step length variability compared with non-fallers (4.58 (S.D. = 2.42 vs. 3.40 (S.D. = 1.40); p-value = 0.005). According to the Pearson's correlation coefficient analysis, a significant relationship was found between step length variability and energy cost of walking in the non-fallers group (Rho = 0.372, P-value = 0.006) and the total group (Rho = 0.296, p-value = 0.005), but not in those PwMS with a history of falls. SIGNIFICANCE We demonstrated a significant relationship between increased gait variability and energy expenditure while walking only in MS patients without a history of falls. This is important as there is evidence of the clinical relevance of increased gait variability, poor fitness level and high risk of falling in the MS population.
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Monjezi S, Negahban H, Tajali S, Mofateh R, Molhemi F, Mostafaee N. Psychometric properties of the Persian-version of the Activities-specific Balance Confidence scale and Fall Efficacy Scale-International in Iranian patients with multiple sclerosis. Physiother Theory Pract 2019; 37:935-944. [PMID: 31455119 DOI: 10.1080/09593985.2019.1658247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Balance impairment and fear of falling are two common risk factors for falls in people with multiple sclerosis (PwMS). Clinicians should use valid, reliable, and responsive tools to assess these risk factors and identify individuals at increased risk for falls. So, this study aimed to examine psychometric properties of the Persian-version of the Activities-specific Balance Confidence (ABC) scale and Fall Efficacy Scale-International (FES-I) in Iranian PwMS. METHODS One hundred and fifty-three PwMS completed the Persian versions of ABC, FES-I, Multiple Sclerosis Walking Scale-12 (MSWS-12), and Berg Balance Scale (BBS) in the first session. To assess the test-retest reliability, 50 PwMS filled out ABC, and FES-I in retest session with an interval of 2-7 days. Also, for evaluating responsiveness, 50 PwMS completed ABC and FES-I before and after a 4-week treatment. RESULTS Intra-class Correlation Coefficients were 0.96 and 0.93 and Cronbach's alpha coefficients were 0.96 and 0.99 for the ABC and FES-I, respectively. There were significant correlations (p < .001) between ABC and BBS (r = 0.55), FES-I and BBS (r = -0.56), ABC and MSWS-12 (r = -0.72), and FES-I and MSWS-12 (r = 0.76). No floor or ceiling effect was found. ABC and FES-I had acceptable responsiveness (AUC > 0.70), and their minimally important difference (MID) were 10.5 and 9.5 points, respectively. CONCLUSION The Persian-versions of ABC and FES-I are reliable, valid, and responsive measures to quantify balance confidence and fear of falling in PwMS at both clinical and research settings. The MID can help clinicians to make a decision based on the clinical significance of changes in patients' status.
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Affiliation(s)
- Saeideh Monjezi
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hossein Negahban
- Department of Physical Therapy, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran.,Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shirin Tajali
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Razieh Mofateh
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Farshad Molhemi
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Neda Mostafaee
- Department of Physical Therapy, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
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Tajali S, Mehravar M, Negahban H, van Dieën JH, Shaterzadeh-Yazdi MJ, Mofateh R. Impaired local dynamic stability during treadmill walking predicts future falls in patients with multiple sclerosis: A prospective cohort study. Clin Biomech (Bristol, Avon) 2019; 67:197-201. [PMID: 31234121 DOI: 10.1016/j.clinbiomech.2019.05.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/14/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Falling is a significant problem in patients with multiple sclerosis (MS) and the majority of falls occur during dynamic activities. Recently, there have been evidences focusing on falls and local stability of walking based on dynamic system theory in the elderly as well as patients with cerebral concussion. However, in patient with MS, this relationship has not been fully investigated. The aim of this study was to investigate local stability of walking as a risk factor for falling in patients with MS. METHODS Seventy patients were assessed while walking at their preferred speed on a treadmill under single and dual task conditions. A cognitive task (backward counting) was used to assess the importance of dual tasking to fall risk. Trunk kinematics were collected using a cluster marker over the level of T7 and a 7-camera motion capture system. To quantify local stability of walking, maximal finite-time Lyapunov exponent was calculated from a 12-dimensional state space reconstruction based on 3-dimensional trunk linear and angular velocity time series. Participants were classified as fallers (≥1) and non-fallers based on their prospective fall occurrence. FINDINGS 30 (43%) participants recorded ≥1 falls and were classified as fallers. The results of multiple logistic regression analysis revealed that short-term local dynamic stability in the single task condition (P<0.05, odds ratio=2.214 (1.037-4.726)) was the significant fall predictor. INTERPRETATION The results may indicate that the assessment of local stability of walking can identify patients who would benefit from gait retraining and fall prevention programs.
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Affiliation(s)
- Shirin Tajali
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Mehravar
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Hossein Negahban
- Department of Physical Therapy, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran; Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Jaap H van Dieën
- Department of Human Movement Sciences, Research Institute MOVE, VU University, Amsterdam, the Netherlands
| | | | - Razieh Mofateh
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Major MJ. Fall Prevalence and Contributors to the Likelihood of Falling in Persons With Upper Limb Loss. Phys Ther 2019; 99:377-387. [PMID: 30561742 PMCID: PMC6684228 DOI: 10.1093/ptj/pzy156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 10/20/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Arms are important for locomotor stability and preventing falls by controlling whole-body angular momentum, redirecting the body's center of mass, and providing support to arrest descent. Hence, upper limb loss (ULL) can increase fall risk. However, the prevalence of falls and factors that influence fall risk have not previously been reported for people with ULL. OBJECTIVE This study quantified fall prevalence in persons with ULL at or proximal to the wrist and identified clinical factors that contributed to the likelihood of falling. DESIGN This was a cross-sectional study. METHODS Factors including body and health characteristics, activity level, fall history, prosthesis use, and balance confidence were determined for persons with ULL proximal to the wrist using an online survey. Logistic regression analyses assessed the contribution of these factors to the classification of fallers (≥2 falls in previous year) and nonfallers. RESULTS A percentage (28.6%) of participants (n = 105) reported experiencing 2 or more falls in the past year. The regression model (R2 = 0.473) correctly classified 84.5% of cases and indicated that increased likelihood of falling was significantly influenced by reduced balance confidence, use of upper limb prostheses, and reduced physical capabilities. LIMITATIONS Data were collected online from a convenience sample, and fall classification was based on retrospective data. CONCLUSIONS Falls in persons with ULL are prevalent, suggesting that clinicians should use screening methods to identify at-risk individuals. Balance confidence, use of upper limb prostheses, and perceived physical capabilities could be useful screening metrics. Research is warranted to better understand the factors that underlie fall risk in persons with ULL and the efficacy of therapeutic interventions capable of mitigating fall risk.
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Affiliation(s)
- Matthew J Major
- Department of Physical Medicine and Rehabilitation, Northwestern University, 680 N Lake Shore Dr, Suite 1100, Chicago, IL 60611 (USA); and Jesse Brown VA Medical Center, Chicago, Illinois
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The contribution of the instrumented Timed-Up-and-Go test to detect falls and fear of falling in people with multiple sclerosis. Mult Scler Relat Disord 2019; 27:226-231. [DOI: 10.1016/j.msard.2018.10.111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/16/2018] [Accepted: 10/26/2018] [Indexed: 11/20/2022]
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Quinn G, Comber L, McGuigan C, Galvin R, Coote S. Discriminative ability and clinical utility of the Timed Up and Go (TUG) in identifying falls risk in people with multiple sclerosis: a prospective cohort study. Clin Rehabil 2018; 33:317-326. [PMID: 30103642 DOI: 10.1177/0269215518793481] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE: To investigate discriminative ability and clinical utility of the Timed Up and Go under single- and dual-task conditions between fallers and non-fallers in multiple sclerosis (MS). DESIGN: Prospective cohort study. SETTING: Neurology service in a tertiary hospital. SUBJECTS: Participants were 101 people with MS and Expanded Disability Status Scale score of 3-6.5. One participant withdrew after the baseline assessment, and hence the data were analysed for 100 participants. INTERVENTIONS: No specific intervention. MAIN MEASURES: Timed Up and Go and Timed Up and Go-Cognitive. Three-month prospective diaries recorded falls. RESULTS: Mean age was 52.6 (SD 10.7) and 66 were female. Majority of the participants had progressive MS (72) and 73 used a walking aid; 56 participants recorded 791 falls. The area under the receiver operating characteristic curve values for Timed Up and Go and Timed Up and Go-Cognitive in distinguishing fallers (person with ⩾1 fall) from non-fallers are 0.60 and 0.57, respectively, and in distinguishing multiple fallers (⩾2 falls) the values are 0.46 and 0.43. A Timed Up and Go score of ⩾9 seconds has a sensitivity of 0.82 and a specificity of 0.34 to identify fallers and a sensitivity of 0.79 and a specificity of 0.27 to identify multiple fallers. A Timed Up and Go-Cognitive score of ⩾11 seconds has a sensitivity of 0.77 and a specificity of 0.30 to identify fallers and a sensitivity of 0.71 and a specificity of 0.26 to identify multiple fallers. CONCLUSION: The Timed Up and Go and Timed Up and Go-Cognitive do not demonstrate sufficient clinical utility or discriminative ability for assessing falls risk in MS.
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Affiliation(s)
- Gillian Quinn
- 1 School of Allied Health, Faculty of Education & Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland.,2 St. Vincent's University Hospital, Dublin, Ireland
| | - Laura Comber
- 1 School of Allied Health, Faculty of Education & Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland
| | | | - Rose Galvin
- 1 School of Allied Health, Faculty of Education & Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Susan Coote
- 1 School of Allied Health, Faculty of Education & Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland
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Quinn G, Comber L, Galvin R, Coote S. The ability of clinical balance measures to identify falls risk in multiple sclerosis: a systematic review and meta-analysis. Clin Rehabil 2017; 32:571-582. [DOI: 10.1177/0269215517748714] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To determine the ability of clinical measures of balance to distinguish fallers from non-fallers and to determine their predictive validity in identifying those at risk of falls. Data sources: AMED, CINAHL, Medline, Scopus, PubMed Central and Google Scholar. First search: July 2015. Final search: October 2017. Review methods: Inclusion criteria were studies of adults with a definite multiple sclerosis diagnosis, a clinical balance assessment and method of falls recording. Data were extracted independently by two reviewers. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 scale and the modified Newcastle–Ottawa Quality Assessment Scale. Statistical analysis was conducted for the cross-sectional studies using Review Manager 5. The mean difference with 95% confidence interval in balance outcomes between fallers and non-fallers was used as the mode of analysis. Results: We included 33 studies (19 cross-sectional, 5 randomised controlled trials, 9 prospective) with a total of 3901 participants, of which 1917 (49%) were classified as fallers. The balance measures most commonly reported were the Berg Balance Scale, Timed Up and Go and Falls Efficacy Scale International. Meta-analysis demonstrated fallers perform significantly worse than non-fallers on all measures analysed except the Timed Up and Go Cognitive ( p < 0.05), but discriminative ability of the measures is commonly not reported. Of those reported, the Activities-specific Balance Confidence Scale had the highest area under the receiver operating characteristic curve value (0.92), but without reporting corresponding measures of clinical utility. Conclusion: Clinical measures of balance differ significantly between fallers and non-fallers but have poor predictive ability for falls risk in people with multiple sclerosis.
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Affiliation(s)
- Gillian Quinn
- Department of Clinical Therapies, Faculty of Education and Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Laura Comber
- Department of Clinical Therapies, Faculty of Education and Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Rose Galvin
- Department of Clinical Therapies, Faculty of Education and Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Susan Coote
- Department of Clinical Therapies, Faculty of Education and Health Sciences, Health Research Institute, University of Limerick, Limerick, Ireland
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Mofateh R, Salehi R, Negahban H, Mehravar M, Tajali S. Effects of cognitive versus motor dual-task on spatiotemporal gait parameters in healthy controls and multiple sclerosis patients with and without fall history. Mult Scler Relat Disord 2017; 18:8-14. [PMID: 29141826 DOI: 10.1016/j.msard.2017.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 08/25/2017] [Accepted: 09/03/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of the current study was to compare the effects of cognitive or motor tasks on gait performance between healthy controls and multiple sclerosis (MS) patients with and without fall history. METHODS The investigation included MS patients with fall history (n = 25) and without fall history (n = 25) and matched healthy controls (n = 25). Participants walked at their preferred speed on a motorized treadmill under three walking conditions in a randomized order: walking only, walking while performing a concurrent cognitive task (counting backward aloud by 3s), and walking while performing a concurrent motor task (carrying a tray with glasses). RESULTS The findings showed that in patients with MS, regardless of fall history, spatiotemporal gait parameters were different compared to healthy controls. In contrast to average gait parameters, variability in stride length and stride time could discriminate between MS fallers and non-fallers. Simultaneous performance of cognitive task and walking resulted in higher dual-task costs (DTC) in gait performance compared to the motor dual-task. However, the pattern of change was not different among the three groups. All participants responded to the cognitive task challenges by increasing stride length and decreasing cadence and stride length variability while maintaining cognitive task performance. CONCLUSIONS The findings may reflect successful adaptation of locomotor system to preserve cognitive task performance under cognitive dual-task condition. Future studies should examine more complex concurrent cognitive and motor tasks to better understand the dual-task-related gait changes and their contribution to falls in patients with MS.
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Affiliation(s)
- Razieh Mofateh
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Reza Salehi
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Hossein Negahban
- Department of Physical Therapy, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran; Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Mohammad Mehravar
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Shirin Tajali
- Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Editors’ Welcome. Mult Scler Relat Disord 2017; 17:A1-A2. [DOI: 10.1016/j.msard.2017.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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