Predicting falls in multiple sclerosis: Do electrophysiological measures have a better predictive accuracy compared to clinical measures?

Protocol for an exploratory, randomised, single-blind clinical trial of aerobic exercise to promote remyelination in multiple sclerosis

INTRODUCTION

There is an urgent need for remyelinating therapies that restore function in people with multiple sclerosis (pwMS). Aerobic exercise is a promising remyelinating strategy because it promotes remyelination in animal models both independently and synergistically with medications. Here, in this study, we present an innovative, randomised, single-blind, clinical trial designed to explore: the relationship between demyelination and mobility (part 1), and if 24 weeks of aerobic exercise promotes remyelination in pwMS (part 2).

METHODS AND ANALYSIS

Sedentary participants (n=60; aged 18-64 years) with stable MS will undergo a baseline visit with the following outcomes to assess associations between demyelination and mobility (part 1): spinal cord demyelination (somatosensory-evoked potentials, SSEPs), mobility (6-Minute Timed Walk, Timed 25-Foot Walk, Timed Up and Go, 9-Hole Peg Test) and patient-reported outcomes (PROs). After baseline testing, participants with significantly prolonged SSEP latency will advance to the clinical exercise trial (part 2) and will be randomised 1:1 to active or control conditions for 24 weeks. The active condition will be aerobic stationary cycling three times per week with graded virtual supervision. The control condition will be monthly virtual MS symptom education groups (six sessions). SSEP latency (remyelination endpoint), mobility outcomes and PROs will be measured at 12 and 24 weeks in all clinical trial participants. A subset of 11 active and 11 control participants will undergo a brain MRI with quantitative T₁ myelin water fraction at baseline and 24 weeks (exploratory remyelination endpoint).

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Oregon Health & Science University Institutional Review Board (#21045). Dissemination of findings will include peer-reviewed publications, conference presentations and media releases. The proposed study will inform the feasibility, study design and sample size for a fully powered clinical trial of aerobic exercise to promote remyelination in pwMS.

TRIAL REGISTRATION NUMBER

NCT04539002.

Fall Prediction Based on Instrumented Measures of Gait and Turning in Daily Life in People with Multiple Sclerosis

This study investigates the potential of passive monitoring of gait and turning in daily life in people with multiple sclerosis (PwMS) to identify those at future risk of falls. Seven days of passive monitoring of gait and turning were carried out in a pilot study of 26 PwMS in home settings using wearable inertial sensors. The retrospective fall history was collected at the baseline. After gait and turning data collection in daily life, PwMS were followed biweekly for a year and were classified as fallers if they experienced >1 fall. The ability of short-term passive monitoring of gait and turning, as well as retrospective fall history to predict future falls were compared using receiver operator curves and regression analysis. The history of retrospective falls was not identified as a significant predictor of future falls in this cohort (AUC = 0.62, p = 0.32). Among quantitative monitoring measures of gait and turning, the pitch at toe-off was the best predictor of falls (AUC = 0.86, p < 0.01). Fallers had a smaller pitch of their feet at toe-off, reflecting less plantarflexion during the push-off phase of walking, which can impact forward propulsion and swing initiation and can result in poor foot clearance and an increased metabolic cost of walking. In conclusion, our cohort of PwMS showed that objective monitoring of gait and turning in daily life can identify those at future risk of falls, and the pitch at toe-off was the single most influential predictor of future falls. Therefore, interventions aimed at improving the strength of plantarflexion muscles, range of motion, and increased proprioceptive input may benefit PwMS at future fall risk.

Fall definitions, faller classifications and outcomes used in falls research among people with multiple sclerosis: a systematic review

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.

Identificação de fatores de risco para quedas em indivíduos com esclerose múltipla: uma revisão sistemática de estudos prospectivos

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.