Ambulatory activity in individuals with multiple sclerosis

The role of sensory systems in the association between balance and walking in people with multiple sclerosis

BACKGROUND

In Multiple Sclerosis, it has been demonstrated that balance is related to performances in walking tasks at different levels of complexity. However, it is unknown how the different sensory systems involved in balance control contribute to walking. This observational study investigates the associations between somatosensory, vestibular, and visual systems and measures of self-reported walking and walking capacity at different complexity levels (i.e. low, medium, and high).

METHODS

People with MS with EDSS<6 were assessed through the Sensory Organization Test (SOT), 12-Item MS Walking Scale (MSWS-12), Timed 25-Foot Walk (T25FW), Timed Up-and-Go Test (TUG), and Six-Spot-Step-Test (SSST). T25FW, TUG and SSST are measures of low, medium and high walking capacity, respectively.

RESULTS

Forty-five PwMS were enrolled (EDSS: 3.4 ± 1.3). Capacity/ability walking measures were moderate-to-highly significantly associated (p < 0.01). Balance measures from SOT showed significant correlation (p < 0.05) between vestibular system and all the walking measures; between visual system and T25FW, SSST and MSWS-12; between the degree to which the patient relies on the visual system to maintain balance with conflicting visual surroundings information (VIS PREF) and T25FW and TUG. In the multivariate analyses, only VIS PREF significantly correlated (p < 0.05) with T25FW (std. Beta=0.42) and TUG (std. Beta=0.38).

CONCLUSIONS

Vestibular and visual systems are associated with walking capacity. However, tasks with higher complexity levels require more visual attention towards ground obstacles, as often seen in real-life activities, whereas simpler walking tasks seem to require visual attention towards the surroundings.

Physical activity and lifestyle modifications in the treatment of neurodegenerative diseases

Neurodegenerative diseases have reached alarming numbers in the past decade. Unfortunately, clinical trials testing potential therapeutics have proven futile. In the absence of disease-modifying therapies, physical activity has emerged as the single most accessible lifestyle modification with the potential to fight off cognitive decline and neurodegeneration. In this review, we discuss findings from epidemiological, clinical, and molecular studies investigating the potential of lifestyle modifications in promoting brain health. We propose an evidence-based multidomain approach that includes physical activity, diet, cognitive training, and sleep hygiene to treat and prevent neurodegenerative diseases.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

The moderating roles of self-efficacy and depression in dual-task walking in multiple sclerosis: A test of self-awareness theory

OBJECTIVE

Multiple sclerosis (MS) is a debilitating neurological disease associated with a variety of psychological, cognitive, and motoric symptoms. Walking is among the most important functions compromised by MS. Dual-task walking (DTW), an everyday activity in which people walk and engage in a concurrent, discrete task, has been assessed in MS, but little is known about how it relates to other MS symptoms. Self-awareness theory suggests that DTW may be a function of the interactions among psychological, cognitive, and motor processes.

METHOD

Cognitive testing, self-report assessments for depression and falls self-efficacy (FSE), and walk evaluations [DTW and single-task walk (STW)] were assessed in seventy-three people with MS in a clinical care setting. Specifically, we assessed whether psychological factors (depression and FSE) that alter subjective evaluations regarding one's abilities would moderate the relationships between physical and cognitive abilities and DTW performance.

RESULTS

DTW speed is related to diverse physical and cognitive predictors. In support of self-awareness theory, FSE moderated the relationship between STW and DTW speeds such that lower FSE attenuated the strength of the relationship between them. DTW costs - the change in speed normalized by STW speed - did not relate to cognitive and motor predictors. DTW costs did relate to depressive symptoms, and depressive symptoms moderated the effect of information processing on DTW costs.

CONCLUSIONS

Findings indicate that an interplay of physical ability and psychological factors - like depression and FSE - may enhance understanding of walking performance under complex, real-world, DTW contexts.

Patient and Clinician Perspectives of Physical Therapy for Walking Difficulties in Multiple Sclerosis

Gait speed is frequently the primary efficacy endpoint in clinical trials of interventions targeting mobility in people with multiple sclerosis (MS). However, it is unclear whether increased gait speed is a meaningful outcome for people living with MS. The purpose of this study was to identify the most important aspects of mobility for people with MS and physical therapists and to explore how patients and clinicians perceive whether physical therapy has been effective. Forty-six people with MS and 23 physical therapy clinicians participated in a focus group, one-on-one interview, or electronic survey. The focus group and interview data were transcribed and coded to identify themes. Free-text survey responses were also coded, and multiple-choice options were analyzed for frequency. Among people with MS, falls and difficulties getting out into the community were identified as highly important mobility limitations. Clinicians also identified falls and safety as a priority. Walking speed was infrequently described as a problem, and although gait speed is often measured by clinicians, improving gait speed is rarely a treatment goal. Despite their emphasis on safety, clinicians lacked certainty about how to objectively measure improvements in safety. People with MS evaluated physical therapy effectiveness based on the ease by which they can do things and acknowledged that "not getting worse" is a positive outcome. Clinicians evaluated effectiveness based on the amount of change in objective outcome measures and by patient and caregiver reports of improved function. These findings indicate that gait speed is not of major importance to people with MS or physical therapy clinicians. People with MS want to be able to walk further and without an assistive device, and they want to avoid falls. Clinicians want to maximize safety while improving functional ability. Clinicians and patients may differ in their expected outcomes from physical therapy.

Influence of Transcranial Direct Current Stimulation and Exercise on Fatigue and Quality of Life in Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system that leads to a great deterioration in the quality of life.

OBJECTIVE

We aimed to assess the effectiveness of two individual programs, one based on transcranial direct current stimulation (tDCS) and another based on the effect of physical exercise on fatigue and quality of life in patients with MS.

METHODS

A total of 12 patients with relapsing-remitting and progressive secondary MS participated. Fatigue and quality of life were assessed before and after intervention. The exercise program and tDCS were carried out over a 4-week period, with a washout period of 5 months.

RESULTS

The results show significant improvements in the different quality of life subscales after the application of tDCS, activities of daily living (r = 0.625; p = 0.037) (g = 0.465), psychological well-being (r = 0.856; p = 0.004) (g = 0.727) and coping (r = 0.904; p = 0.18) (g = 0.376), and in those after the application of exercise, activities of daily living (r = 0.853; p = 0.003) (g = 0.570) and psychological well-being (r = 0.693; p = 0.041) (g = 0.417). After the application of both therapies, more than 50% of the subjects did not have a positive fatigue score on the MFIS scale.

CONCLUSION

The major findings suggest that the application of both therapies produces a beneficial effect with significant improvements in the quality of life of this sample.

Determination of five times-sit-to-stand test performance in patients with multiple sclerosis: validity and reliability

PURPOSE/AIM

Although Five Times-Sit-To-Stand test (FTSST) performance is known to be a valid and reliable method in people with chronic stroke, Parkinson's disease, and balance disorder, it has not been widely studied in patients with Multiple sclerosis (MS). The main aim of this study was to evaluate validity and reliability of the FTSST in patients with MS.

METHODS

The first outcome measure of the study was the FTSST, which was conducted by two different researchers. Secondary outcome measures were Biodex Stability System (BSS), 10-meter walk test, time up go test (TUG), EDSS scoring, Fatigue Severity Scale (FSS), Barthel Index, Quadriceps Muscle strength test, Functional Reach test. Intraclass correlation coefficient (ICC) was used for the validity and reliability of the FTSST, which was made by two different researchers, and Pearson Correlation Analysis was used to determine its relationship with other measurements.

RESULTS

Interrater and test-retest reliability for the FTSST were excellent (Intraclass correlation coefficients of 0.98 and 0.99, respectively). A statistically significant correlation was found between all secondary outcome measures and FTSST (p < 0.05).

CONCLUSION

FTSST is considered to be a valid, reliable, easy, and rapid method for evaluating lower extremity muscle strength and balance in patients with MS.

Pedometers and Accelerometers in Multiple Sclerosis: Current and New Applications

Pedometers and accelerometers have become commonplace for the assessment of physical behaviors (e.g., physical activity and sedentary behavior) in multiple sclerosis (MS) research. Current common applications include the measurement of steps taken and the classification of physical activity intensity, as well as sedentary behavior, using cut-points methods. The existing knowledge and applications, coupled with technological advances, have spawned new opportunities for using those motion sensors in persons with MS, and these include the utilization of the data as biomarkers of disease severity and progression, perhaps in clinical practice. Herein, we discuss the current state of knowledge on the validity and applications of pedometers and accelerometers in MS, as well as new opportunities and strategies for the improved assessment of physical behaviors and disease progression, and consequently, personalized care.

The Role of Remote Monitoring in Evaluating Fatigue in Multiple Sclerosis: A Review

Fatigue is one of the most common multiple sclerosis (MS) symptoms. Despite this, monitoring and measuring fatigue (subjective lack of energy)- and fatigability (objectively measurable and quantifiable performance decline)- in people with MS have remained challenging. Traditionally, administration of self-report questionnaires during in-person visits has been used to measure fatigue. However, remote measurement and monitoring of fatigue and fatigability have become feasible in the past decade. Traditional questionnaires can be administered through the web in any setting. The ubiquitous availability of smartphones allows for momentary and frequent measurement of MS fatigue in the ecological home-setting. This approach reduces the recall bias inherent in many traditional questionnaires and demonstrates the fluctuation of fatigue that cannot be captured by standard measures. Wearable devices can assess patients' fatigability and activity levels, often influenced by the severity of subjective fatigue. Remote monitoring of fatigue, fatigability, and activity in real-world situations can facilitate quantifying symptom-severity in clinical and research settings. Combining remote measures of fatigue as well as objective fatigability in a single construct, composite score, may provide a more comprehensive outcome. The more granular data obtained through remote monitoring techniques may also help with the development of interventions aimed at improving fatigue and lowering the burden of this disabling symptom.

Making Every Step Count: Minute-by-Minute Characterization of Step Counts Augments Remote Activity Monitoring in People With Multiple Sclerosis

Background

Ambulatory disability is common in people with multiple sclerosis (MS). Remote monitoring using average daily step count (STEPS) can assess physical activity (activity) and disability in MS. STEPS correlates with conventional metrics such as the expanded disability status scale (Expanded Disability Status Scale; EDSS), Timed-25 Foot walk (T25FW) and timed up and go (TUG). However, while STEPS as a summative measure characterizes the number of steps taken over a day, it does not reflect variability and intensity of activity.

Objectives

Novel analytical methods were developed to describe how individuals spends time in various activity levels (e.g., continuous low versus short bouts of high) and the proportion of time spent at each activity level.

Methods

94 people with MS spanning the range of ambulatory impairment (unaffected to requiring bilateral assistance) were recruited into FITriMS study and asked to wear a Fitbit continuously for 1-year. Parametric distributions were fit to minute-by-minute step data. Adjusted R² values for regressions between distributional fit parameters and STEPS with EDSS, TUG, T25FW and the patient-reported 12-item MS Walking scale (MSWS-12) were calculated over the first 4-weeks, adjusting for sex, age and disease duration.

Results

Distributional fits determined that the best statistically-valid model across all subjects was a 3-compartment Gaussian Mixture Model (GMM) that characterizes the step behavior within 3 levels of activity: high, moderate and low. The correlation of GMM parameters for baseline step count measures with clinical assessments was improved when compared with STEPS (adjusted R² values GMM vs. STEPS: TUG: 0.536 vs. 0.419, T25FW: 0.489 vs. 0.402, MSWS-12: 0.383 vs. 0.378, EDSS: 0.557 vs. 0.465). The GMM correlated more strongly (Kruskal-Wallis: p = 0.0001) than STEPS and gave further information not included in STEPS.

Conclusions

Individuals' step distributions follow a 3-compartment GMM that better correlates with clinic-based performance measures compared with STEPS. These data support the existence of high-moderate-low levels of activity. GMM provides an interpretable framework to better understand the association between different levels of activity and clinical metrics and allows further analysis of walking behavior that takes step distribution and proportion of time at three levels of intensity into account.

Fitness, physical activity, and exercise in multiple sclerosis: a systematic review on current evidence for interactions with disease activity and progression

Background

A moderate to high level of physical activity, including regular exercise, represents an established behavioral and rehabilitative approach for persons with multiple sclerosis (pwMS). Although being increasingly proposed to limit disease activity and progression, high-quality evidence is lacking.

Objective

The objective of the study is to provide valuable information for MS clinicians and researchers by systematically evaluating the current state of evidence (i) whether exercise interventions affect established clinical measures of disease activity and progression in pwMS (i.e., EDSS, relapse rate, lesion load, brain volume, MSFC) and (ii) how the physical activity and fitness level interact with these measures.

Methods

Literature search was conducted in MEDLINE, EMBASE, CINAHL, and SPORTDiscus. Evaluation of evidence quality was done based on standards published by The American Academy of Neurology.

Results

It is likely that exercise improves the MSFC score, whereas the EDSS score, lesion load, and brain volume are likely to remain unchanged over the intervention period. It is possible that exercise decreases the relapse rate. Results from cross-sectional studies indicate beneficial effects of a high physical activity or fitness level on clinical measures which, however, is not corroborated by high evidence quality.

Conclusions

A (supportive) disease-modifying effect of exercise in pwMS cannot be concluded. The rather low evidence quality of existing RCTs underlines the need to conduct more well-designed studies assessing different measures of disease activity or progression as primary end points. A major limitation is the short intervention duration of existing studies which limits meaningful exercise-induced effects on most disability measures. Findings from cross-sectional studies are difficult to contextualize regarding clinical importance due to their solely associative character and low evidence quality.

PROSPERO registration number

CRD42020188774.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10935-6.

Commentary: Remote assessments of gait and balance - Implications for research during and beyond Covid-19

The COVID-19 pandemic has disrupted non-essential in-person research activities that require contact with human subjects. While guidelines are being developed for ramping up human subjects research, one component of research that can be performed remotely is participant screening for lower limb function and gait impairments. In this commentary, we summarize evidence-supported clinical assessments that have potential to be conducted remotely in a safe manner, to make an initial determination of the functional mobility status of persons with neurological disorders. We present assessments that do not require complex or costly equipment, specialized software, or trained personnel to administer. We provide recommendations to implement remote functional assessments for participant recruitment and continuation of lower limb neurorehabilitation research as a rapid response to the COVID-19 pandemic and for utilization beyond the current pandemic. We also highlight critical research gaps related to feasibility and measurement characteristics of remote lower limb assessments, providing opportunities for future research to advance tele-assessment and tele-rehabilitation.

Wearable technologies to measure clinical outcomes in multiple sclerosis: A scoping review

Wearable technology refers to any sensor worn on the person, making continuous and remote monitoring available to many people with chronic disease, including multiple sclerosis (MS). Daily monitoring seems an ideal solution either as an outcome measure or as an adjunct to support rater-based monitoring in both clinical and research settings. There has been an increase in solutions that are available, yet there is little consensus on the most appropriate solution to use in either MS research or clinical practice. We completed a scoping review (using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines) to summarise the wearable solutions available in MS, to identify those approaches that could potentially be utilised in clinical trials, by evaluating the following: scalability, cost, patient adaptability and accuracy. We identified 35 unique products that measure gait, cognition, upper limb function, activity, mood and fatigue, with most of these solutions being phone applications.

The Effects of Powered Exoskeleton Gait Training on Cardiovascular Function and Gait Performance: A Systematic Review

Patients with neurological impairments often experience physical deconditioning, resulting in reduced fitness and health. Powered exoskeleton training may be a successful method to combat physical deconditioning and its comorbidities, providing patients with a valuable and novel experience. This systematic review aimed to conduct a search of relevant literature, to examine the effects of powered exoskeleton training on cardiovascular function and gait performance. Two electronic database searches were performed (2 April 2020 to 12 February 2021) and manual reference list searches of relevant manuscripts were completed. Studies meeting the inclusion criteria were systematically reviewed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. n = 63 relevant titles were highlighed; two further titles were identified through manual reference list searches. Following analysis n = 23 studies were included. Data extraction details included; sample size, age, gender, injury, the exoskeleton used, intervention duration, weekly sessions, total sessions, session duration and outcome measures. Results indicated that exoskeleton gait training elevated energy expenditure greater than wheelchair propulsion and improved gait function. Patients exercised at a moderate-intensity. Powered exoskeletons may increase energy expenditure to a similar level as non-exoskeleton walking, which may improve cardiovascular function more effectively than wheelchair propulsion alone.

What gait features influence the amount and intensity of physical activity in people with multiple sclerosis?

Although the mutual relationship between ambulation and physical activity (PA) in people with multiple sclerosis (pwMS) has been described in several studies, there is still a lack of detailed information about the way in which specific aspects of the gait cycle are associated with amount and intensity of PA. This study aimed to verify the existence of possible relationships among PA parameters and the spatio-temporal parameters of gait when both are instrumentally assessed.Thirty-one pwMS (17F, 14 M, mean age 52.5, mean Expanded Disability Status Scale (EDSS) score 3.1) were requested to wear a tri-axial accelerometer 24 hours/day for 7 consecutive days and underwent an instrumental gait analysis, performed using an inertial sensor located on the low back, immediately before the PA assessment period. Main spatio-temporal parameters of gait (i.e., gait speed, stride length, cadence and duration of stance, swing, and double support phase) were extracted by processing trunk accelerations. PA was quantified using average number of daily steps and percentage of time spent at different PA intensity, the latter calculated using cut-point sets previously validated for MS. The existence of possible relationships between PA and gait parameters was assessed using Spearman rank correlation coefficient rho.Gait speed and stride length were the parameters with the highest number of significant correlations with PA features. In particular, they were found moderately to largely correlated with number of daily steps (rho 0.62, P< .001), percentage of sedentary activity (rho = -0.44, P < .001) and percentage of moderate-to-vigorous activity (rho = 0.48, P < .001). Small to moderate significant correlations were observed between PA intensity and duration of stance, swing and double support phases.The data obtained suggest that the most relevant determinants associated with higher and more intense levels of PA in free-living conditions are gait speed and stride length. The simultaneous quantitative assessment of gait parameters and PA levels might represent a useful support for physical therapists in tailoring optimized rehabilitative and training interventions.

Overground Robotic Program Preserves Gait in Individuals With Multiple Sclerosis and Moderate to Severe Impairments: A Randomized Controlled Trial

OBJECTIVE

To determine how overground robotic (OR) training added to ongoing rehabilitation affects gait speed, lower extremity function, functional mobility, and fatigue in individuals with multiple sclerosis (MS) and moderate to severe gait impairments.

DESIGN

Randomized controlled trial.

SETTING

Outpatient setting at the Multiple Sclerosis Association of Bizkaia, an association serving MS patients in Bizkaia, Spain.

PARTICIPANTS

Individuals with MS (N=36) participated in this interventional study. Inclusion criteria were age of 18 years or older, Expanded Disability Status Scale score between 4.5 and 7, and the need for assistive devices for walking outdoors.

INTERVENTIONS

The control group (CG) engaged in an ongoing rehabilitation program consisting of weekly 1-hour individualized sessions. The intervention group (OR group) also participated in this program in addition to a twice-weekly individualized and progressive OR gait training intervention for 3 months, aiming to reach a maximum of 40 minutes by the end of the 3-month period.

MAIN OUTCOME MEASURES

Primary outcome was the 10-meter walking test (10MWT). Secondary variables included the Short Physical Performance Battery, the timed Up and Go (TUG) test, and the Modified Fatigue Impact Scale.

RESULTS

The OR group maintained 10MWT performance and significantly improved on the TUG test (P=.049, medium effect size) without increasing fatigue perception. The CG demonstrated a decline on the 10MWT (P=.044, small effect size) and reduced fatigue (P=.024, medium effect size). No time per group interaction was observed for any variable.

CONCLUSION

The evaluated intervention could preserve gait speed and significantly improve functional mobility without increasing perceived fatigue in participants. Thus, OR exoskeletons could be considered a tool to deliver intensive practice of good-quality gait training in individuals with MS and moderate to severe gait impairments. Further studies are necessary to confirm these preliminary results.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quantity and quality of gait and turning in people with multiple sclerosis, Parkinson's disease and matched controls during daily living

Clinical trials need to specify which specific gait characteristics to monitor as mobility measures for each neurological disorder. As a first step, this study aimed to investigate a set of measures from daily-life monitoring that best discriminate mobility between people with multiple sclerosis (MS) and age-matched healthy control subjects (MS-Ctl) and between people with Parkinson's disease (PD) and age-matched healthy control subjects (PD-Ctl). Further, we investigated how these discriminative measures relate to the disease severity of MS or PD. We recruited 13 people with MS, 21 MS-Ctl, 29 people with idiopathic PD, and 20 PD-Ctl. Subjects wore 3 inertial sensors on their feet and the lumbar back for a week. The Area Under Curves (AUC) from the receiver operator characteristic (ROC) plot was calculated for each measure to determine the objective measures that best separated the MS and PD groups from their respective control cohorts. Adherence wearing the sensors was similar among groups for 58-66 h of recording (p = 0.14). Quantity of mobility (activity measures, such as a median number of strides per gait bout, AUC = 0.93) best discriminated mobility impairments in MS from MS-Ctl. In contrast, quality of mobility (such as turn angle, AUC = 0.90) best discriminated mobility impairments in PD from PD-Ctl. Mobility measures with AUC > 0.80 were correlated with MS and PD clinical scores of disease severity. Thus, measures characterizing mobility impairments differ for MS versus PD during daily life suggesting that mobility measures for clinical trials and clinical practice need to be specific to each neurological disorder.

Functional Mobility and Basic Motor Skills in Patients with Multiple Sclerosis and Its Relation to the Anthropometrical Status and Body Composition Parameters

Background and objectives: Patients with multiple sclerosis (MS) have many potential risk factors (spasticity, immobilization, glucocorticoids use) which can deteriorate the anthropometrical status and body composition and may have a potential negative impact on functional mobility and basic motor skill improvement after physiotherapy. The aim of the study was to assess the functional mobility and basic motor skills in patients with MS and to correlate them with disability and anthropometrical status and body composition parameters. Materials and Methods: Timed Up-and-Go Test (TUG) and six-min walk test (6MWT) were performed in 36 patients with MS before and after 4 weeks of physiotherapy. Body mass index (BMI), waist-to-height ratio (W/HtR), and waist-to-hip ratio (WHR) were assessed in this group. Body composition was evaluated by bioelectrical impedance analysis (BIA) and fat mass (FAT), fat free mass (FFM), total body water (TBW), and predicted muscle mass (PMM) were expressed as percentage of body mass. Clinical status was assessed by Expanded Disability Status Scale (EDSS) and Ambulatory Index (AI) scales. Results: After physiotherapy, there was a significant improvement in functional mobility and basic motor skills assessed by total distance in 6MWT (p < 0.001) and in TUG trials (p < 0.001). Positive significant correlations were found between the results obtained in both tests (either before and after physiotherapy) vs. FFM, TBW, and PMM, whilst worse results in functional mobility and basic motor skills correlated significantly with higher WHtR, WHR, and FAT (p < 0.05). Clinical status (EDSS) was significantly related to the WHtR and body composition parameters with the same manner as the results in the either 6MWT and TUG. However, there were no significant relationships between BMI vs. either clinical status (EDSS, AI) or functional mobility tests results in patients with MS. Conclusions: Functional mobility and basic motor skills may be significantly improved during physiotherapy, but they are related to the anthropometrical status and body composition of MS patients. Moreover, disability status is also significantly related to these parameters. Body composition deterioration seems to be the important target for the therapeutic intervention in MS patients. For proper nutritional status assessment in patients with MS, body composition analysis or WHtR instead BMI should to be used.

Rehabilitation to improve gaze and postural stability in people with multiple sclerosis: study protocol for a prospective randomized clinical trial

BACKGROUND

The use of vestibular rehabilitation principles in the management of gaze and postural stability impairments in people with multiple sclerosis (PwMS) has shown promise in pilot work completed in our lab and in a recently published randomized clinical trial (RCT). However, further work is needed to fully quantify the gaze and postural impairments present in people with multiple sclerosis and how they respond to rehabilitation.

METHODS/DESIGN

The study is a single blind RCT designed to examine the benefit of a gaze and postural stability (GPS) intervention program compared to a standard of care (SOC) rehabilitation program in dizzy and balance impaired PwMS. Outcomes will be collected across the domains of body structure and function, activity, and participation as classified by the World Health Organization International Classification of Functioning, Disability, and Health (ICF). Our primary outcomes are the Dizziness Handicap Inventory (DHI) and the Functional Gait Assessment (FGA). Secondary outcomes include other measures of gaze and postural stability, fatigue, and functional mobility. Participants who are interested and eligible for enrollment will be consented prior to completing a baseline assessment. Following the baseline assessment each participant will be randomized to either the GPS or SOC intervention group and will complete a 6 week treatment period. During the treatment period, both groups will participate in guided exercise 3x/week. Following the treatment period participants will be asked to return for a post-treatment evaluation and again for a follow-up assessment 1 month later. We anticipate enrolling 50 participants.

DISCUSSION

This study will be an innovative RCT that will utilize gaze and postural stability metrics to assess the efficacy of vestibular rehabilitation in PwMS. It will build on previous work by examining measures across the ICF and improve the current evidence base for treating PwMS.

TRIAL REGISTRATION

ClinicalTrials.gov, May 29th 2018, NCT03521557 .

Comparison of sedentary behaviour questionnaires in people with multiple sclerosis

Background: People with multiple sclerosis are at risk of developing co-morbidities associated with sedentary behaviour. Despite an increase in studies examining sedentary behaviour in multiple sclerosis, researchers have not yet examined the appropriateness of the content or format of questionnaires assessing sedentary behaviour in multiple sclerosis.Objective: Evaluate perceptions of sedentary behaviour questionnaires for people with multiple sclerosis.Methods: Fifteen people with multiple sclerosis completed six validated sedentary behaviour questionnaires: Longitudinal Ageing Study Amsterdam, Marshall Sitting Questionnaire, International Physical Activity Questionnaire, Measure of Older Adults Sedentary Time, Sedentary Behaviour Questionnaire and SIT-Q. Participants' perceptions regarding questionnaire content and format were explored by interviews.Results: Self-reported sedentary time ranged between a mean of 470 (standard deviation 260) (Measure of Older Adults Sedentary Time) and 782 (322) min (Longitudinal Ageing Study Amsterdam) per weekday. Analysis of variance revealed a significant effect of questionnaire on mean sitting time: Longitudinal Ageing Study Amsterdam and SIT-Q yielded higher mean estimates of weekday sitting time than other questionnaires. The questionnaires were viewed as being suitable for use in multiple sclerosis but failed to capture some sedentary activities. Variability of symptoms yielded difficulties in describing a "typical day".Conclusions: The questionnaires were considered suitable for multiple sclerosis but produced variation in estimated sedentary time. Future work might validate questionnaire data with device-based assessments of sedentary time.Implications for rehabilitationSelf-reported sitting time ranged from 7.8 to 13.0 h per day in people with multiple sclerosis.Sedentary behaviour questionnaires are suitable for multiple sclerosis but yield variable estimates of sitting time.Watching television was the most prevalent sedentary activity and may have implications for interventions that break up sedentary time.

Assessment of Clinically Meaningful Improvements in Self-Reported Walking Ability in Participants with Multiple Sclerosis: Results from the Randomized, Double-Blind, Phase III ENHANCE Trial of Prolonged-Release Fampridine

BACKGROUND

Walking impairment is a hallmark of multiple sclerosis (MS). It affects > 90% of individuals over time, reducing independence and negatively impacting health-related quality of life, productivity, and daily activities. Walking impairment is consistently reported as one of the most distressing impairments by individuals with MS. Prolonged-release (PR)-fampridine previously has been shown to improve objectively measured walking speed in walking-impaired adults with MS. The impact of PR-fampridine from the perspective of the individual with MS warrants full and detailed examination.

OBJECTIVE

The objective of this study was to evaluate whether PR-fampridine has a clinically meaningful effect on self-reported walking ability in walking-impaired participants with MS.

METHODS

ENHANCE was a phase III, randomized, double-blind, placebo-controlled study of PR-fampridine 10 mg twice daily in walking-impaired individuals age 18-70 years with either relapsing or progressive forms of MS and an Expanded Disability Status Scale (EDSS) score of 4.0-7.0 at screening. Participants were stratified by EDSS score (≤ 6.0 or 6.5-7.0) at randomization to ensure a balanced level of disability in the treatment groups. The primary endpoint was the proportion of participants with a mean improvement in the 12-item Multiple Sclerosis Walking Scale (MSWS-12) score exceeding the predefined threshold for clinically meaningful improvement (≥ 8 points) over 24 weeks. Secondary endpoints included the proportion with ≥ 15% improvement in Timed Up and Go (TUG) speed, and mean changes in Multiple Sclerosis Impact Scale physical impact subscale (MSIS-29 PHYS), Berg Balance Scale (BBS), and ABILHAND scores over 24 weeks.

RESULTS

In total, 636 participants with MS were randomized (PR-fampridine, n = 317; placebo, n = 319; modified intention-to-treat sample: PR-fampridine, n = 315; placebo, n = 318). At baseline in the PR-fampridine and placebo groups, 46% and 51% had a progressive form of MS, median [range] EDSS scores were 6.0 [4.0-7.0] and 5.5 [4.0-7.0], mean [range] MSWS-12 scores were 63.6 [0-100] and 65.4 [0-100], and mean [range] TUG speed was 0.38 [0.0-1.0] and 0.38 [0.0-1.2] feet/s, respectively. A significantly higher percentage of PR-fampridine-treated participants (136/315 [43.2%]) had clinically meaningful improvement in MSWS-12 score over 24 weeks versus placebo (107/318 [33.6%]; odds ratio 1.61 [95% confidence interval 1.15-2.26]; p = 0.006). For PR-fampridine versus placebo, significantly more participants had a ≥ 15% improvement in TUG speed, and there was significantly greater mean improvement in MSIS-29 PHYS score (p < 0.05); numerical improvements that were not statistically significant were observed in BBS/ABILHAND. Adverse events that were more common in the PR-fampridine group than placebo group (difference ≥ 3%) by Medical Dictionary for Regulatory Activities (MedDRA^®) Preferred Term were urinary tract infection and insomnia. There were no seizures reported.

CONCLUSIONS

PR-fampridine treatment resulted in sustained, clinically meaningful improvements over 24 weeks in self-reported walking and functional ability in walking-disabled participants with MS. CLINICALTRIALS.

GOV IDENTIFIER

NCT02219932.

Associations between activity and participation in adults with multiple sclerosis: a cross sectional study

OBJECTIVES

The aim of this study was to determine the association between walking ability in a clinical setting (activity capacity), walking ability in a person's daily environment (activity capability) and walking performance in daily life (activity performance), and the contribution of each activity construct to participation among people with multiple sclerosis (MS).

DESIGN

Cross-sectional study.

SETTING

Five MS therapy centres in England.

PARTICIPANTS

Fifty-two adults (13 males) with MS who were independently ambulatory with or without a walking aid (mean (SD) age 55.4 (9.1) year).

INTERVENTIONS

No intervention.

MAIN OUTCOME MEASURES

Activity capacity, capability, and performance were assessed using the Six Minute Walk Test (6MWT), Twelve Item MS Walking Scale (MSWS-12), and steps/day measured using a pedometer worn for 6 days, respectively. Participation was assessed using the Impact on Participation and Autonomy questionnaire (IPA).

RESULTS

Distance walked on the 6MWT was associated with MSWS-12 score (β=-0.56, 95% CI -0.87 to -0.22) and steps/day (β=129.49, 95% CI 48.48 to 207.57). MSWS-12 score was also associated with step count (β=-87.35, 95% CI -172.29 to -15.71). 6MWT distance was associated with the autonomy indoors subscale of the IPA (β=-0.02, 95% CI -0.04 to -0.01). No other activity measure was associated with participation.

CONCLUSIONS

Findings suggest that while activity capacity, capability and performance are related, activity is a poor predictor of participation. The strength of associations between constructs of activity, and activity and participation, however, are often small with wide confidence intervals, indicating that there is considerable uncertainty associated with effect estimates.

Responsiveness and meaningful improvement of mobility measures following MS rehabilitation

Objective

To determine responsiveness of functional mobility measures, and provide reference values for clinically meaningful improvements, according to disability level, in persons with multiple sclerosis (pwMS) in response to physical rehabilitation.

Methods

Thirteen mobility measures (clinician- and patient-reported) were assessed before and after rehabilitation in 191 pwMS from 17 international centers (European and United States). Combined anchor- and distribution-based methods were used. A global rating of change scale, from patients' and therapists' perspective, served as external criteria when determining the area under the receiver operating characteristic curve (AUC), the minimally important change (MIC), and the smallest real change (SRC). Patients were stratified into 2 subgroups based on disability level (Expanded Disability Status Scale score ≤4 [n = 72], >4 [n = 119]).

Results

The Multiple Sclerosis Walking Scale–12, physical subscale of the Multiple Sclerosis Impact Scale–29 (especially for the mildly disabled pwMS), Rivermead Mobility Index, and 5-repetition sit-to-stand test (especially for the moderately to severely disabled pwMS) were the most sensitive measures in detecting improvements in mobility. Findings were determined once the AUC (95% confidence interval) was above 0.5, MIC was greater than SRC, and results were comparable from the patient and therapist perspective.

Conclusions

Responsiveness, clinically meaningful improvement, and real changes of frequently used mobility measures were calculated, showing great heterogeneity, and were dependent on disability level in pwMS.

The Role of Wearable Devices in Multiple Sclerosis

Multiple sclerosis (MS) is the most common neurological disorder in young adults. The prevalence of walking impairment in people with MS (pwMS) is estimated between 41% and 75%. To evaluate the walking capacity in pwMS, the patient reported outcomes (PROs) and performance-based tests (i.e., the 2-minute walk test, the 6-minute walk test, the Timed 25-Foot Walk Test, the Timed Up and Go Test, and the Six Spot Step Test) could be used. However, some studies point out that the results of both performance-based tests and objective measures (i.e., by accelerometer) could not reflect patient reports of walking performance and impact of MS on daily life. This review analyses different motion sensors embedded in smartphones and motion wearable device (MWD) that can be useful to measure free-living walking behavior, to evaluate falls, fatigue, sedentary lifestyle, exercise, and quality of sleep in everyday life of pwMS. Caveats and limitations of MWD such as variable accuracy, user adherence, power consumption and recharging, noise susceptibility, and data management are discussed as well.

Sedentary Behavior and Blood Pressure in Patients with Multiple Sclerosis

Background

Sedentary behavior is a pervasive public health concern in the general population. To date, little is known regarding the possible health risks associated with sedentary behavior in patients with multiple sclerosis (MS), although this population has increased risks of comorbidities such as hypertension.

Methods

This cross-sectional study examined the association between sedentary behavior and blood pressure (BP) in 31 patients with MS and 31 matched controls. Self-reported sitting time, one form of sedentary behavior, was measured using the International Physical Activity Questionnaire. Using an automated oscillometric monitor, systolic BP, diastolic BP, and mean arterial pressure were measured in the supine position after 10 minutes of rest lying down in a quiet room.

Results

There were significant correlations between International Physical Activity Questionnaire-measured sitting time and systolic BP (r = 0.365, P = .044, 95% CI, 0.013-0.636), diastolic BP (r = 0.382, P = .034, 95% CI, 0.032-0.648), and mean arterial pressure (r = 0.425, P = .017, 95% CI, 0.084-0.677) in patients with MS but not in controls (P > .05). The associations in patients with MS were unchanged even after adjusting for body mass index in linear regression analyses.

Conclusions

This study identified a significant association between sitting time and BP outcomes in patients with MS, supporting the need for additional examinations of sitting time and its possible health consequences in patients with MS.

Randomised controlled pilot trial of an exercise plus behaviour change intervention in people with multiple sclerosis: the Step it Up study

OBJECTIVE

To investigate feasibility of multiple sclerosis (MS) exercise guidelines for inactive people with MS (PwMS) and to examine preliminary efficacy for walking. To investigate effect of augmenting that intervention with education based on social cognitive theory (SCT).

DESIGN

Pilot multicentre, double-blind, randomised, parallel, controlled trial.

SETTING

Community-delivered programme.

PARTICIPANTS

Sixty-five physically inactive PwMS walked independently, scored 0-3 on the Patient Determined Disease Steps Scale, had no MS relapse or change in MS medication in 12 weeks.

INTERVENTIONS

10-week exercise plus SCT education (SCT) compared with exercise plus attention control education (CON).

OUTCOME MEASURES

Six-Minute Walk Test (6MWT), Timed Up and Go (TUG) test and Multiple Sclerosis Walking Scale-12 (MSWS-12).

RESULTS

174 expressed interest, 92 were eligible and 65 enrolled (SCT, n=32; CON, n=33). The intervention was feasible and delivered as intended. 68% of SCT group and 50% of control group met the exercise guidelines after intervention. Using linear mixed effects models, intention-to-treat basis, there was insufficient evidence for difference between the groups over the trial (6MWT, p=0.30; TUG, p=0.4; MSWS-12, p=0.8). Using secondary analysis of a cohort with data for≥3 assessments (SCT, n=21; CON, n=20), there was significant treatment effect favouring the intervention group (p=0.04) with mean effect for 6MWT 39.0 m (95% CI 2.26 to 75.73) at 12 weeks and 40.0 m (95% CI 2.3 to 77.8) at 36 weeks. Both groups improved significantly in 6MWT following 10-week intervention (SCT, mean ∆=83.02, SD=60.1, p≤0.01; CON, mean ∆=56.92, SD=73.5, p≤0.01), TUG (SCT, ∆=-0.70, SD=1.25, p≤0.01; CON, ∆=-0.54, SD=0.95, p≤0.01) and MSWS-12 (SCT, ∆=-8.03, SD=16.18, p=0.02; CON, ∆=-0.86, SD=18.74, p=0.81).

CONCLUSIONS

A 10-week exercise programme based on the MS exercise guidelines for improving walking in previously inactive PwMS was feasible. There is marginal evidence of a treatment effect in favour of the exercise plus SCT intervention at 12 and 36 weeks.

TRIAL REGISTRATION NUMBER

NCT02301442; Results.

Validity and Reliability of Four Clinical Gait Measures in Patients with Multiple Sclerosis

BACKGROUND

The gold standards for assessing ambulation are the Expanded Disability Status Scale (EDSS) and the Timed 25-Foot Walk (T25FW) test. In relation with these measures, we assessed the reliability and validity of four clinical gait measures: the Timed Up and Go (TUG) test, the Dynamic Gait Index (DGI), the 2-Minute Walk Test (2MWT), and the 6-Minute Walk Test (6MWT). Patient self-report of gait was also assessed using the 12-item Multiple Sclerosis Walking Scale (MSWS-12).

METHODS

Individuals 20 years or older with a diagnosis of multiple sclerosis (MS) and an EDSS score of 2.0 to 6.5 completed the MSWS-12, T25FW test, TUG test, DGI, 2MWT, and 6MWT. All the tests were repeated 2 weeks later at the same time of day to establish their reliability and concurrent validity. Predictive validity was established using the EDSS.

RESULTS

Forty-two patients with MS were included. All measures showed high test-retest reliability. The TUG test, 2MWT, and 6MWT were significantly correlated with the T25FW test (Spearman ρ = -0.902, -0.919, and -0.905, respectively). The EDSS was also significantly correlated with all the walking tests. The MSWS-12 demonstrated the highest correlation to the EDSS (ρ = 0.788).

CONCLUSIONS

The TUG test, the DGI, the 2MWT, and the 6MWT exhibited strong psychometric properties and were found to be significant predictors of the EDSS score. Use of these tests to prospectively monitor the effects of medical and rehabilitation treatment should be considered in the comprehensive care of patients with MS.

Interval setting selection affects ambulatory activity outputs in children with cerebral palsy

INTRODUCTION

Accelerometer based devices have been widely used to assess the ambulatory activity of children with and without functional disabilities. Many researchers who utilize the StepWatch Activity Monitor (SAM) collect at a 60second (60sec) interval setting. The purpose of this study was to assess the effect of SAM interval settings on ambulatory activity outputs in children with cerebral palsy (CP) and typically developing youth.

METHODS

Participants wore a SAM which recorded the number of strides every 10seconds (10s) for one week. Raw 10s data was downsampled to combine strides into 60sec intervals. Strides were ensembled into walking bouts with the Intensity/Duration calculated as a percentage of Total Ambulatory Time (TAT).

RESULTS

Twenty-eight children with CP (14 boys; avg. 12 yrs. 4 mths.; GMFCS Level I n=4, Level II n=19, Level III n=5) completed testing and 28 age matched typically developing youth (14 boys; avg. 12 yrs. 6 mths.) were included. Using the 10sec interval, ∼80% of walking bouts in both groups were less than or equal to 60s. Data recorded at 60sec intervals had higher daily TAT but fewer walking bouts. In children with CP, daily steps were higher using the 60sec interval. At the Easy intensity, the 60sec interval reported an increased volume of Long duration walking, and it rarely identified any Moderate+ intensity activity.

CONCLUSIONS

60sec interval data overestimated low intensity and long duration ambulatory activity. It is imperative that investigators choose a finer interval setting (10sec) to maximize the detection of gait transitions and rest periods which are critical in describing community ambulation of patients with cerebral palsy.

What Adherence Measures Should Be Used in Trials of Home-Based Rehabilitation Interventions? A Systematic Review of the Validity, Reliability, and Acceptability of Measures

OBJECTIVE

To systematically review methods for measuring adherence used in home-based rehabilitation trials and to evaluate their validity, reliability, and acceptability.

DATA SOURCES

In phase 1 we searched the CENTRAL database, NHS Economic Evaluation Database, and Health Technology Assessment Database (January 2000 to April 2013) to identify adherence measures used in randomized controlled trials of allied health professional home-based rehabilitation interventions. In phase 2 we searched the databases of MEDLINE, Embase, CINAHL, Allied and Complementary Medicine Database, PsycINFO, CENTRAL, ProQuest Nursing and Allied Health, and Web of Science (inception to April 2015) for measurement property assessments for each measure.

STUDY SELECTION

Studies assessing the validity, reliability, or acceptability of adherence measures.

DATA EXTRACTION

Two reviewers independently extracted data on participant and measure characteristics, measurement properties evaluated, evaluation methods, and outcome statistics and assessed study quality using the COnsensus-based Standards for the selection of health Measurement INstruments checklist.

DATA SYNTHESIS

In phase 1 we included 8 adherence measures (56 trials). In phase 2, from the 222 measurement property assessments identified in 109 studies, 22 high-quality measurement property assessments were narratively synthesized. Low-quality studies were used as supporting data. StepWatch Activity Monitor validly and acceptably measured short-term step count adherence. The Problematic Experiences of Therapy Scale validly and reliably assessed adherence to vestibular rehabilitation exercises. Adherence diaries had moderately high validity and acceptability across limited populations. The Borg 6 to 20 scale, Bassett and Prapavessis scale, and Yamax CW series had insufficient validity. Low-quality evidence supported use of the Joint Protection Behaviour Assessment. Polar A1 series heart monitors were considered acceptable by 1 study.

CONCLUSIONS

Current rehabilitation adherence measures are limited. Some possess promising validity and acceptability for certain parameters of adherence, situations, and populations and should be used in these situations. Rigorous evaluation of adherence measures in a broader range of populations is needed.

Minimum number of days required for a reliable estimate of daily step count and energy expenditure, in people with MS who walk unaided

BACKGROUND AND PURPOSE

The purpose of this study was to examine the minimum number of days needed to reliably estimate daily step count and energy expenditure (EE), in people with multiple sclerosis (MS) who walked unaided.

METHODS

Seven days of activity monitor data were collected for 26 participants with MS (age=44.5±11.9years; time since diagnosis=6.5±6.2years; Patient Determined Disease Steps=≤3). Mean daily step count and mean daily EE (kcal) were calculated for all combinations of days (127 combinations), and compared to the respective 7-day mean daily step count or mean daily EE using intra-class correlations (ICC), the Generalizability Theory and Bland-Altman.

RESULTS

For step count, ICC values of 0.94-0.98 and a G-coefficient of 0.81 indicate a minimum of any random 2-day combination is required to reliably calculate mean daily step count. For EE, ICC values of 0.96-0.99 and a G-coefficient of 0.83 indicate a minimum of any random 4-day combination is required to reliably calculate mean daily EE. For Bland-Altman analyses all combinations of days, bar single day combinations, resulted in a mean bias within ±10%, when expressed as a percentage of the 7-day mean daily step count or mean daily EE.

CONCLUSIONS

A minimum of 2days for step count and 4days for EE, regardless of day type, is needed to reliably estimate daily step count and daily EE, in people with MS who walk unaided.

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

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

Subjective and objective assessment of physical activity in multiple sclerosis and their relation to health-related quality of life

Background

Physical activity (PA) is frequently restricted in people with multiple sclerosis (PwMS) and aiming to enhance PA is considered beneficial in this population. We here aimed to explore two standard methods (subjective plus objective) to assess PA reduction in PwMS and to describe the relation of PA to health-related quality of life (hrQoL).

Methods

PA was objectively measured over a 7-day period in 26 PwMS (EDSS 1.5–6.0) and 30 matched healthy controls (HC) using SenseWear mini® armband (SWAmini) and reported as step count, mean total and activity related energy expenditure (EE) as well as time spent in PA of different intensities. Measures of EE were also derived from self-assessment with IPAQ (International Physical Activity Questionnaire) long version, which additionally yielded information on the context of PA and a classification into subjects’ PA levels. To explore the convergence between both types of assessment, IPAQ categories (low, moderate, high) were related to selected PA parameters from objective assessment using ANOVA. Group differences and associated effect sizes for all PA parameters as well as their relation to clinical and hrQoL measures were determined.

Results

Both, SWAmini and IPAQ assessment, captured differences in PA between PwMS and HC. IPAQ categories fit well with common cut-offs for step count (p = 0.002) and mean METs (p = 0.004) to determine PA levels with objective devices. Correlations between specifically matched pairs of IPAQ and SWAmini parameters ranged between r .288 and r .507. Concerning hrQoL, the lower limb mobility subscore was related to four PA measures, while a relation with patients’ report of general contentment was only seen for one.

Conclusions

Both methods of assessment seem applicable in PwMS and able to describe reductions in daily PA at group level. Whether they can be used to track individual effects of interventions to enhance PA levels needs further exploration. The relation of PA measures with hrQoL seen with lower limb mobility suggests lower limb function not only as a major target for intervention to increase PA but also as a possible surrogate for PA changes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0783-0) contains supplementary material, which is available to authorized users.

Continuous daily assessment of multiple sclerosis disability using remote step count monitoring

Disability measures in multiple sclerosis (MS) rely heavily on ambulatory function, and current metrics fail to capture potentially important variability in walking behavior. We sought to determine whether remote step count monitoring using a consumer-friendly accelerometer (Fitbit Flex) can enhance MS disability assessment. 99 adults with relapsing or progressive MS able to walk ≥2-min were prospectively recruited. At 4 weeks, study retention was 97% and median Fitbit use was 97% of days. Substudy validation resulted in high interclass correlations between Fitbit, ActiGraph and manual step count tally during a 2-minute walk test, and between Fitbit and ActiGraph (ICC = 0.76) during 7-day home monitoring. Over 4 weeks of continuous monitoring, daily steps were lower in progressive versus relapsing MS (mean difference 2546 steps, p < 0.01). Lower average daily step count was associated with greater disability on the Expanded Disability Status Scale (EDSS) (p < 0.001). Within each EDSS category, substantial variability in step count was apparent (i.e., EDSS = 6.0 range 1097-7152). Step count demonstrated moderate-strong correlations with other walking measures. Lower average daily step count is associated with greater MS disability and captures important variability in real-world walking activity otherwise masked by standard disability scales, including the EDSS. These results support remote step count monitoring as an exploratory outcome in MS trials.

The e-MSWS-12: improving the multiple sclerosis walking scale using item response theory

BACKGROUND

The Multiple Sclerosis Walking Scale (MSWS-12) is the predominant patient-reported measure of multiple sclerosis (MS) -elated walking ability, yet it had not been analyzed using item response theory (IRT), the emerging standard for patient-reported outcome (PRO) validation. This study aims to reduce MSWS-12 measurement error and facilitate computerized adaptive testing by creating an IRT model of the MSWS-12 and distributing it online.

METHODS

MSWS-12 responses from 284 subjects with MS were collected by mail and used to fit and compare several IRT models. Following model selection and assessment, subpopulations based on age and sex were tested for differential item functioning (DIF).

RESULTS

Model comparison favored a one-dimensional graded response model (GRM). This model met fit criteria and explained 87 % of response variance. The performance of each MSWS-12 item was characterized using category response curves (CRCs) and item information. IRT-based MSWS-12 scores correlated with traditional MSWS-12 scores (r = 0.99) and timed 25-foot walk (T25FW) speed (r =  -0.70). Item 2 showed DIF based on age (χ ² = 19.02, df = 5, p < 0.01), and Item 11 showed DIF based on sex (χ ² = 13.76, df = 5, p = 0.02).

CONCLUSIONS

MSWS-12 measurement error depends on walking ability, but could be lowered by improving or replacing items with low information or DIF. The e-MSWS-12 includes IRT-based scoring, error checking, and an estimated T25FW derived from MSWS-12 responses. It is available at https://ms-irt.shinyapps.io/e-MSWS-12 .

Does the six-minute walk test measure walking performance or physical fitness in persons with multiple sclerosis?

BACKGROUND

There is psychometric evidence that supports the six-minute walk (6MW) as a measure of walking performance, whereas other psychometric data support it as a submaximal measure of physical fitness in persons with MS.

OBJECTIVE

The current cross-sectional study compared measures of walking performance and physical fitness as head-to-head predictors of 6MW distance in a sample of persons with MS across the disability spectrum.

METHODS

All participants completed the 6MW test, as well as other measures of walking performance (i.e., timed-25 foot walk, gait velocity captured by a GaitRite electronic walkway) and physical fitness (i.e., peak aerobic capacity, lower limb muscular strength).

RESULTS

6MW distance was strongly associated with measures of walking performance and physical fitness, though the correlations were significantly stronger for measures of walking performance than physical fitness (z >  4.04, p <  0.01). Walking performance explained a large portion of variance in 6MW distance (R2 >  0.85), and measures of physical fitness explained minimal variance in 6MW distance over-and-above that of measures of walking performance (ΔR2 <  0.06).

CONCLUSIONS

The current results suggest that 6MW distance is primarily a measure of walking performance rather than aerobic and muscular fitness in MS.

Critical Appraisal of Evidence for Improving Gait Speed in People with Multiple Sclerosis: Dalfampridine Versus Gait Training

BACKGROUND

Research has not yet compared the treatment effects of dalfampridine with traditional rehabilitation of gait impairments in multiple sclerosis (MS). The purpose of this review was to critically appraise the evidence for dalfampridine and gait training for increasing gait speed in people with MS.

METHODS

A systematic search of the research literature was conducted. Consideration was given to only randomized controlled trials (RCTs), systematic reviews, and meta-analyses. For selection of gait training studies, only studies involving task-specific gait training interventions and measuring treatment effects on gait speed were considered.

RESULTS

Treatment effects on gait speed were extracted from four studies examining the efficacy of dalfampridine and six gait training RCTs. Overall mean increase in gait speed with dalfampridine was 0.07 m/s (95% confidence interval [CI], 0.04-0.09 m/s) compared to 0.06 m/s (95% CI, 0.02-0.10 m/s) for gait training. Among dalfampridine responders (38% of participants in RCTs), the mean increase in gait speed was 0.16 m/s (95% CI, 0.13-0.18 m/s). Mean increases for individual gait training interventions ranged from 0.01 to 0.39 m/s; however, CIs were wide due to small sample sizes.

CONCLUSIONS

Current evidence is insufficient to conclude whether dalfampridine or gait training is superior for improving gait speed in people with MS. These findings should be viewed cautiously due to differences in study populations and small sample sizes in gait training studies. Both treatment approaches provide only short-lived improvements. Head-to-head comparison trials and studies combining both treatment modalities are needed.

Understanding walking activity in multiple sclerosis: step count, walking intensity and uninterrupted walking activity duration related to degree of disability

In multiple sclerosis (MS), physical activity (PA) is most commonly measured as number of steps, while also walking intensity and walking activity duration are keys for a healthy lifestyle. The aim of this study was to investigate (1) the number of steps persons with MS (PwMS) take; (2) the number of steps they take at low and moderate intensity; and (3) their walking activity duration for 2, 3, 6, 10, 12 and 14 uninterrupted minutes; all related to the degree of disability. 64 PwMS participated, distinguished in a mild (n = 31) and moderate MS subgroup (n = 34) based on their ambulatory dysfunction (Disease Steps). Standardized clinical tests were performed, and step data from the StepWatch Activity Monitor were collected for seven consecutive days. The results showed that (1) step count in PwMS was lower than PA recommendations, and is negatively influenced by a higher disability degree. (2) No walking was registered during 77 % of the day. PwMS are making steps for 22 % at low and only 1 % at moderate intensity. (3) Both MS subgroups rarely walk for more than six uninterrupted minutes, especially not at moderate intensity. PwMS need to be encouraged to make steps at moderate intensity, and to make steps for longer periods of time (minimal ten uninterrupted minutes).

Remote Physical Activity Monitoring in Neurological Disease: A Systematic Review

OBJECTIVE

To perform a systematic review of studies using remote physical activity monitoring in neurological diseases, highlighting advances and determining gaps.

METHODS

Studies were systematically identified in PubMed/MEDLINE, CINAHL and SCOPUS from January 2004 to December 2014 that monitored physical activity for ≥24 hours in adults with neurological diseases. Studies that measured only involuntary motor activity (tremor, seizures), energy expenditure or sleep were excluded. Feasibility, findings, and protocols were examined.

RESULTS

137 studies met inclusion criteria in multiple sclerosis (MS) (61 studies); stroke (41); Parkinson's Disease (PD) (20); dementia (11); traumatic brain injury (2) and ataxia (1). Physical activity levels measured by remote monitoring are consistently low in people with MS, stroke and dementia, and patterns of physical activity are altered in PD. In MS, decreased ambulatory activity assessed via remote monitoring is associated with greater disability and lower quality of life. In stroke, remote measures of upper limb function and ambulation are associated with functional recovery following rehabilitation and goal-directed interventions. In PD, remote monitoring may help to predict falls. In dementia, remote physical activity measures correlate with disease severity and can detect wandering.

CONCLUSIONS

These studies show that remote physical activity monitoring is feasible in neurological diseases, including in people with moderate to severe neurological disability. Remote monitoring can be a psychometrically sound and responsive way to assess physical activity in neurological disease. Further research is needed to ensure these tools provide meaningful information in the context of specific neurological disorders and patterns of neurological disability.

Sedentary behaviour in people with multiple sclerosis: Is it time to stand up against MS?

Historically, people with multiple sclerosis (MS) have been considered sedentary, although the actual scientific study of sedentary behaviour in MS did not originate until 2011. Sedentary behaviour, which is conceptually distinct from physical inactivity, is defined as any waking activity characterised by an energy expenditure ⩽ 1.5 metabolic equivalents and in a sitting or reclining posture. In the general population, the volume of sitting time is associated with increased risks of morbidity and mortality, independent of physical activity, and has been suggested to carry a greater risk of mortality than smoking behaviour. There are many symptoms of MS (e.g. mobility disability and fatigue) that could increase the prevalence of sedentary behaviour, and sedentary behaviour may have considerable implications for the development of comorbid conditions prevalent in MS. This review provides a summary of the rates, correlates, consequences and interventions attempting to reduce sedentary behaviour in MS. We provide a research agenda that guides future research on sedentary behaviour in MS. This paper provides a clarion call that it is time to 'stand up against MS'.

Systematic Review of Correlates and Determinants of Physical Activity in Persons With Multiple Sclerosis

OBJECTIVE

To review the current evidence regarding correlates and determinants of physical activity (PA) in persons with multiple sclerosis (pwMS).

DATA SOURCES

PubMed and Scopus (1980 to January 2015) and reference lists of eligible studies.

STUDY SELECTION

Eligible studies include adults with multiple sclerosis; have a cross-sectional or prospective observational design; or examine the effect of a theory-based intervention trial on PA, including a mediation analysis. Eligible studies also apply a quantitative assessment of PA and correlates or proposed mediators and are published in English or German language.

DATA EXTRACTION

Two reviewers independently evaluated the risk of bias, extracted data, and categorized variables according to the International Classification of Functioning, Disability and Health.

DATA SYNTHESIS

Consistency and the direction of associations were evaluated with a semiquantitative approach. Fifty-six publications with data from observational studies and 2 interventional studies provided evidence for 86 different variables. Consistent correlates of PA were the disability level, walking limitations in particular, PA-related self-efficacy, self-regulation constructs, employment status, and educational level. One interventional study provided evidence for a causal relation between self-regulation and PA. However, 59 of the 86 investigated variables in observational studies are based on 1 or 2 study findings, and most results stem from cross-sectional designs.

CONCLUSIONS

Beside the importance of the general disability level and walking limitations, the results highlight the importance of personal factors (eg, PA-related self-efficacy, self-regulatory constructs, sociodemographic factors). Limitations and implications of the current review are discussed. Research that is more rigorous is needed to better understand what affects PA in pwMS.