Can aerobic treadmill training reduce the effort of walking and fatigue in people with multiple sclerosis: a pilot study

Effects of closed kinetic chain exercises on balance and gait in people with multiple sclerosis: A randomized controlled trial

INTRODUCTION

Balance and gait impairments are among the most common consequences of multiple sclerosis (MS). A closed kinetic chain enhances balance and gait abilities in people with multiple sclerosis (PwMS). This study aims to compare the effectiveness of an integrated Telko and conventional physical therapy (CPT) intervention versus CPT alone on gait and balance in PwMS.

METHODS

Twenty-six PwMS were enrolled in the trial, and they were randomized to either the combined Telko and CPT experimental group (n = 13) or the CPT alone control group (n = 13). All participants underwent 15-min sessions of CPT three times a week for four weeks. Additionally, participants in the experimental group received a 15-min Telko training session after each CPT session. Outcome measures consisted of the Berg Balance Scale (BBS), the 6-Minute Walk Test (6MWT), and the Timed Up and Go (TUG) assessment.

RESULTS

Twenty-four PwMS completed the study. The PwMS in the combined Telko and CPT experimental group exhibited significant improvements in balance, functional capacity, gait speed, and mobility following the intervention (P < 0.05). In the CPT group, PwMS also experienced significant improvements in functional capacity (P < 0.05). The between-group analysis revealed no significant differences among the outcome measures (P > 0.05).

CONCLUSIONS

The combined Telko and CPT intervention did not demonstrate superiority over CPT alone in improving balance and gait in PwMS. Further experimental studies are necessary to fully understand the effects of a closed kinetic chain for lower extremities on the balance and gait of individuals with PwMS.

Effects of walking interventions in persons with multiple sclerosis-A systematic review

OBJECTIVE

The aim of the present systematic review was to investigate the effects of voluntary walking interventions in persons with multiple sclerosis (pwMS). For this purpose, we developed a framework to describe the components of walking interventions.

DATA SOURCES

Two databases (MEDLINE/PubMed and EMBASE) were searched in January 2023.

STUDY SELECTION

Included studies enrolled pwMS and evaluated walking interventions with a duration of 2 weeks or longer. Further, they evaluated at least one walking-related outcome. Both RCTs and non-controlled studies were enrolled.

DATA EXTRACTION

Data were extracted using a customized spreadsheet, which included detailed information on patient characteristics, interventions, outcomes, and results. Based on the extracted results, the effect sizes (ES, Hedge's g) of the walking interventions were calculated if possible. The methodological quality of the included studies and their reporting was determined using the TESTEX evaluation tool.

DATA SYNTHESIS

Data from a total of n = 200 pwMS was included from N = 7 RCT´s (from 3 we used within-group data) and N = 5 single-group studies. On average 91.7 ± 9.9 % of the planned walking sessions were attended, 8.7 ± 10.5 % of the participants dropped out, and very few adverse events occurred. Walking interventions improved walking performance during short distance walk tests (ES ranging from -0.21 to -0.72, "walking time") and long distance walk tests (ES ranging from 0.27 to 0.72, "walking distance").

CONCLUSIONS

Voluntary walking interventions appear to be safe and effective at improving walking performance in pwMS. However, well-powered walking intervention studies are needed to confirm these promising effects. The simplicity of walking interventions makes them highly relevant for ambulatory pwMS.

Effectiveness of physical activity interventions on reducing perceived fatigue among adults with chronic conditions: a systematic review and meta-analysis of randomised controlled trials

Fatigue is barrier of physical activity participation in adults with chronic conditions. However, physical activity alleviates fatigue symptoms. This systematic review and meta-analysis aimed to (1) synthesise evidence from randomised controlled trials (RCTs) exploring the effects of physical activity interventions on fatigue reduction and (2) evaluate their effectiveness. Medline/CINAHL/EMBASE/Web of Science and Scopus were searched up to June 24th, 2023. Two reviewers independently conducted study screening and selection (RCTs), extracted data and assessed risk of bias (RoB2). Outcome was the standardised mean difference (SMD) with 95% confidence intervals in fatigue between experimental and control groups. 38 articles met the inclusion criteria. Overall, physical activity interventions moderately reduced fatigue (SMD = 0.54, p < 0.0001). Interventions lasting 2-6 weeks demonstrated a larger effect on fatigue reduction (SMD = 0.86, p < 0.00001). Interventions with 18-24 sessions showed a large effect on fatigue reduction (SMD = 0.97, p < 0.00001). Aerobic cycling and combination training interventions had a large to moderate effect (SMD = 0.66, p = 0.0005; SMD = 0.60, p = 0.0010, respectively). No long-term effects were found during follow-up. Physical activity interventions moderately reduced fatigue among adults with chronic conditions. Duration, total sessions, and mode of physical activity were identified as key factors in intervention effectiveness. Further research is needed to explore the impact of physical activity interventions on fatigue.

High intensity exercise training on functional outcomes in persons with multiple sclerosis: A systematic review

BACKGROUND

There is growing interest and evidence for high intensity training (HIT) in clinical populations, including persons with multiple sclerosis (MS). While HIT has been shown to be a safe modality in this group, it is still unclear what collective knowledge exists for HIT on functional outcomes. This study examined HIT modalities (e.g., aerobic, resistance, functional training) on functional outcomes such as walking, balance, postural control, and mobility in persons with MS.

METHODS

High intensity training studies, including RCTs and non-RCTs, that targeted functional outcomes in persons with MS were included in the review. A literature search was conducted in MEDLINE, EMBASE, PsycINFO, SPORTSDiscus, and CINAHL in April 2022. Other literature search methods were performed via website and citation searching. The methodological quality of included studies was assessed by TESTEX for RCTs and ROBINS-I for non-RCTs. This review synthesized the following data: study design and characteristics, participant characteristics, intervention characteristics, outcome measures, and effect sizes.

RESULTS

Thirteen studies (6 RCTs and 7 non-RCTs) were included in the systematic review. The included participants (N = 375) had varying functional levels (EDSS range: 0-6.5) and phenotypes (relapsing remitting, secondary progressive, primary progressive). HIT modalities involving high intensity aerobic training (n = 4), high intensity resistance training (n = 7), and high intensity functional training (n = 2), revealed a significant and consistent benefit on walking speed and walking endurance in response to HIT, while the evidence regarding balance and mobility improvement was less clear.

CONCLUSION

Persons with MS can successfully tolerate and adhere to HIT. While HIT appears to be an effective modality for improving some functional outcomes, the heterogeneous testing protocols, HIT modalities, and exercise doses among the studies preclude any conclusive evidence for its effectiveness thus necessitating future inquiry.

Effect of Nordic Walking Training on Walking Capacity and Quality of Life for People With Multiple Sclerosis

BACKGROUND

Although there is emerging evidence that aerobic training improves walking capacity in persons with multiple sclerosis (MS), data are limited about the potential benefits of Nordic walking (NW) for this population. This study evaluates the effectiveness of outdoor NW training on walking capacity and related quality of life for people with MS compared with cycloergometer and treadmill aerobic training.

METHODS

A single-blinded (evaluator), randomized, 2-arm clinical trial was designed.

RESULTS

A total of 57 patients with MS (38 women and 19 men; mean ± SD age, 51.98 ± 9.93 years; mean ± SD disease duration, 14.75 ± 8.52 years) were included. Both therapeutic modalities improved walking distance as measured by the 6-Minute Walk Test after the training period. The NW group showed significant improvement on the physical and emotional subscales of the Multiple Sclerosis Quality of Life-54 compared with the cycloergometer and treadmill group, which showed improvement only on the physical subscale.

CONCLUSIONS

Both training modalities proved to be of equal benefit in improving the walking capacity of people with MS, but outdoor NW training also seems to have a beneficial effect on the emotional component of health-related quality of life.

Metabolic costs of walking and arm reaching in persons with mild multiple sclerosis

Movement slowness is a common and disruptive symptom of multiple sclerosis (MS). A potential cause is that individuals with MS slow down to conserve energy as a behavioral adjustment to heightened metabolic costs of movement. To investigate this prospect, we measured the metabolic costs of both walking and seated arm reaching at five speeds in persons with mild MS (pwMS; n = 13; 46.0 ± 7.7 yr) and sex- and age-matched controls (HCs; n = 13; 45.8 ± 7.8 yr). Notably, the cohort of pwMS was highly mobile and no individuals required a cane or aid when walking. We found that the net metabolic power of walking was approximately 20% higher for pwMS across all speeds (P = 0.0185). In contrast, we found no differences in the gross power of reaching between pwMS and HCs (P = 0.492). Collectively, our results suggest that abnormal slowness of movement in MS-particularly reaching-is not the consequence of heightened effort costs and that other sensorimotor mechanisms are playing a considerable role in slowing.NEW & NOTEWORTHY Individuals with multiple sclerosis (MS) often move more slowly than those without the disease. A possible cause is that movements in MS are more energetically expensive and slowing is an adaptation to conserve metabolic resources. Here, we find that while walking is more costly for persons with MS, arm-reaching movements are not. These results bring into question the driving force of movement slowness in MS and implicate other motor-related networks contributing to slowing.

Comparing Two Protocols of Exercise on Physical Fitness and Psychological Factors of Mild to Moderate Multiple Sclerosis Patients

Background: Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS). Previous studies have shown that aerobic activity is inversely related to MS symptoms and may be restorative and possibly protective. Objectives: This study aimed to compare the effects of high-intensity functional training (HIFT) protocols and aerobic exercise on functional fitness as well as the cognitive aspect of female patients with multiple sclerosis. Methods: This quasi-experimental and applied clinical trial study consisted of all patients with MS registered in an MS clinic. Among eligible individuals, 30 female RRMS patients were randomly and equally divided into three groups high-intensity functional training (n = 10); aerobic exercise (n = 10), and control group (n = 10). The forearm test, the 30-second standing test, and single leg stance test (SLST), The Timed Up and Go (TUG), expanded disability status scale (EDSS) were performed to assess physical factors as well as the 21-DAS questionnaire to assess cognitive aspects. Results: This study showed a meaningful difference between the intervention groups and the control group (P < 0.05), in the level of power in the upper body (P = 0.001), Lower torso strength (P = 0.001), Static balance (P = 0.001), Dynamic balance (P = 0.001). the psychological and behavioral components. Conclusions: Present study suggests that aerobic exercise and HIFT in women with MS can improve and further enhance physical function plus psychological and behavioral factors.

The effect of exercise on walking economy in patients with chronic neurological conditions: A systematic review and meta-analysis

Introduction

To investigate the effect of exercise on the walking economy (WE) of patients with chronic neurological conditions (CNCs) and to determine the type of physical activity that best improves the WE of patients with CNCs.

Methods

Four electronic databases were searched until December 2022 (Web of Science, PubMed, Cochrane, and CINAHL). Studies were screened using the following inclusion criteria: 1. randomized controlled or non-randomized controlled trials; 2. exercise interventions >4 weeks in duration; 3. patients aged ≥18 years with a diagnosis of CNCs. 4. walking economy of patients measured before and after the intervention. The PEDro scale was used to assess the methodological quality of the included studies.

Results and discussion

Twenty-two studies met the inclusion criteria. Meta-analysis results showed that exercise significantly improved WE (g = -0.352, 95% CI, -0.625 to -0.078, P = 0.012). Subgroup analysis revealed that patients who received exercise showed better WE compared with those who underwent no control intervention (g = -0.474, 95% CI, -0.636 to -0.311, P < 0.001). However, exercise therapy did not show a significant improvement of WE compared with control groups (g = -0.192, 95% CI, -0.451 to 0.067, P = 0.146). In addition, we found that endurance combined with resistance, high-intensity intermittent, and other training modalities resulted in better WE compared with the pre-intervention. Of these, interval training has the greatest effect on improving WE. In conclusion, exercise can improve WE in patients with CNCs. More randomized controlled trials are necessary for the future.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022361455, identifier: CRD42022361455.

The effect of intermittent vs. continuous walking on distance to fatigue in persons with multiple sclerosis

PURPOSE

Previous studies provided evidence that persons with Multiple Sclerosis (pwMS) who walk intermittently experience less fatigue and walk longer distances than when walking continuously. However, total distance pwMS can walk in either condition is unknown. We examined time and distance to fatigability in pwMS comparing intermittent walking (IW) to continuous walking (CW).

MATERIALS AND METHODS

18 pwMS, with Expanded Disability Status Scale median of 4.75 [range = 2-6.5, IQR = 2.5] participated in this randomized crossover study. The IW condition consisted of alternating 30 s treadmill walking and 30 s seated rests. The CW condition consisted of treadmill walking without breaks. Treadmill speed (TS) was determined by an overground 2-min walk test. Walking fatigability was determined by participants walking on the treadmill, until gait fatigue was noted by patient or examiners. Total time and distance to gait fatigue, and subjective fatigue as measured by the Visual analog scale of fatigue were recorded.

RESULTS

Participants had significantly longer duration and distance to fatigue in the IW condition than the CW condition (ps ≤ 0.037). No difference in VASF scores between the two conditions were noted.

CONCLUSION

In this sample, IW allowed pwMS to perform a greater volume of walking and can be an option to improve walking endurance in this population.IMPLICATIONS FOR REHABILITATIONMultiple sclerosis (MS) is a disease that progressively impacts walking, resulting in a decrease in the maximum distance that a person with MS can walk.Intermittent walking has been shown to improve 6-min walk test performance in persons with MS (pwMS) compared to continuous walking, but its effects on longer and shorter walks is not known.The use of distance to fatigue should be considered a viable option for measuring walking fatigability in pwMS as it does not exclude persons based on their ability to complete a 6-min walk, nor would it be too easy for persons with pwMS with mild disability.By using distance to fatigue as an outcome measure, this study provides evidence that intermittent walking results in less fatigability regardless of walking ability.PwMS, regardless of their walking ability, can walk longer distances intermittently than continuously, suggesting that clinical treatment of walking fatigability in pwMS should utilize intermittent rather than continuous walking training.

Effects and optimal dosage of resistance training on strength, functional capacity, balance, general health perception, and fatigue in people with multiple sclerosis: a systematic review and meta-analysis

PURPOSE

To analyze the effectiveness of resistance training programs (RTP) on strength, functional capacity, balance, general health perception, and fatigue for people with Multiple Sclerosis (MS) and to determine the most effective dose of RTP in this population.

METHODS

Studies examining the effect of RTP on strength, functional capacity, balance, general health perception, and fatigue in MS patients were included. 44 studies were included. The meta-analysis, subgroup analysis and meta-regression methods were used to calculate the mean difference and standardized mean difference.

RESULTS

Significant group differences were observed in knee extensor (p = 0.01) and flexor (p < 0.001), but not in 1-repetition maximum. Regarding functional capacity and balance, differences between groups, in favour of the RTP group, were found in the Timed Up and Go Test (p = 0.001), walking endurance, (p = 0.02) gait speed (p = 0.02) and balance (p = 0.02). No significant differences between groups were observed in fatigue or general health perception. The results regarding the optimal dose are inconsistent.

CONCLUSIONS

RTP improves strength, functional capacity, balance, and fatigue in people with MS. Registration: (PROSPERO): CRD42020182781Implications for rehabilitationResistance training is a valid strategy to improve isometric strength and functional capacity in MS patients.RTP using long durations (more than 6 weeks), high intensity (more than 80% 1-RM) and two-day weekly training frequency may be a correct stimulus to improve strength, functional capacity, balance, and fatigue in people with MS.Trainers and rehabilitators should consider these indicators in order to maximize muscular and functional adaptations in this population.

The added value of cognition-targeted exercise versus symptom-targeted exercise for multiple sclerosis fatigue: A randomized controlled pilot trial

BACKGROUND

Fatigue is considered one of the most common symptoms of multiple sclerosis (MS) and lacks a current standardized treatment. Therefore, the aim of this study was to examine the feasibility and effectiveness of a cognition-targeted exercise versus symptom-targeted exercise for MS fatigue.

METHODS

In this Pilot, parallel-group, randomized controlled trial, sixty participants with multiple sclerosis, were randomly assigned to either a Cognition-Targeted Exercise (CTE) (N = 30, mean age 41) or a Symptom-Targeted Exercise (STE) (N = 30, mean age 42). The participants in the experimental group received eight, 50-minute sessions of weekly Cognitive Behavior Therapy (CBT) in addition to a CTE Program; whereas, participants in the control group received eight, 50-minute sessions of weekly CBT in addition to the standardized physiotherapy program (STE Program). Feasibility was assessed through recruitment rate, participant retention, adherence and safety, in addition to clinical outcome measures, including: (1) Modified Fatigue Impact Scale (MFIS), (2) Work and Social Adjustment Scale (WSAS), (3) Hospital Anxiety and Depression Scale (HADS), and Perceived Stress Scale (PSS). All outcome measures were assessed at baseline (pretreatment), following completion of the eight visit intervention protocol, and at 3-months follow-up.

RESULTS

The recruitment rate was 60% and 93% of participants completed the entire study. The recruited participants complied with 98% of the required visits. No adverse events were recorded. A Generalized Estimation Equation Model revealed a significant difference over time as an interaction term during the post and follow up visit for all clinical outcome measures (p < .001).

CONCLUSION

The addition of CTE to CBT exhibited positive and more lasting influence on MS fatigue outcomes compared to Symptom-Targeted Exercise (STE). Feasibility and efficacy data from this pilot study provide support for a full-scale RCT of CTE as an integral component of Multiple Sclerosis fatigue management.

Exercise and Sports Science Australia (ESSA) position statement on exercise for people with mild to moderate multiple sclerosis

OBJECTIVES

Multiple sclerosis (MS), the most common chronic and progressive neurological condition of the central nervous system, affects 26,000 Australian adults. Exercise training has beneficial effects on MS-related impairments including reduced muscular strength, poor aerobic capacity and impaired mobility, and in consequence can improve quality of life. This Position Statement provides evidence-based recommendations for exercise prescription and delivery of exercise training for people with MS with mild to moderate disability.

DESIGN AND METHODS

Synthesis of published works within the field of exercise training in MS.

RESULTS

Exercise provides many benefits to people with MS. There is strong evidence that resistance and aerobic training, performed 2 to 3 times per week at a moderate intensity, are safe and can improve muscle strength, cardiorespiratory fitness, balance, fatigue, functional capacity, mobility and quality of life in people with MS with mild to moderate disability (Expanded Disease Severity Scale (EDSS) ≤ 6.5). However, the evidence for those with severe disability (EDSS >6.5) is less clear. The effects of exercise on MS pathogenesis, central nervous structures and other outcomes such as depression and cognitive impairment, have not been adequately investigated. Effective exercise interventions to improve balance, joint contractures and reduce falls in people with MS are also urgently needed as well as investigations of long-term (≥1 year) effects of exercise training.

CONCLUSIONS

Resistance and aerobic training exercises are effective to alleviate some characteristic signs and symptoms in MS and should be supplemented by balance exercise to prevent falls. Exercise training programs should be prescribed and delivered by qualified exercise professionals. It is important to recognise and accommodate exercise-associated complications such as fatigue and heat sensitivity.

[Rehabilitation of patients with multiple sclerosis]

Multiple sclerosis is a common cause of disability among young and middle-aged people. Despite the modern possibilities of diagnostics and therapy, over time, the disease acquires a secondary progressive character. Rehabilitation of patients at all stages of the disease plays an important role in improving well-being, improving the quality of life, adapting the patient and restoring motor skills. However, there is currently no clear recommendation for the application of specific techniques in each case. The aim of this work was to analyze the available methods of rehabilitation therapy, to highlight the most used and promising ones. Due to the progressive course of the disease, the benefits of rehabilitation measures are usually higher at the initial stages. Nevertheless, nowadays there is a large number of works devoted to rehabilitation measures in patients with moderate and high levels of disability. It has been shown that both inpatient and outpatient rehabilitation has a positive effect on the quality of life and improvement of clinical indicators. Our review describes the main techniques with recommendations for the scheme of application. A comprehensive assessment of the patient's health status, a multidisciplinary team and a personalized approach increase the quality and effectiveness of rehabilitation measures. We also describe our own experience in the treatment of spasticity in patients with a secondary progressive multiple sclerosis.

The Relationship Between Walking Speed and the Energetic Cost of Walking in Persons With Multiple Sclerosis and Healthy Controls: A Systematic Review

BACKGROUND

Persons with multiple sclerosis (pwMS) experience walking impairments, characterized by decreased walking speeds. In healthy subjects, the self-selected walking speed is the energetically most optimal. In pwMS, the energetically most optimal walking speed remains underexposed. Therefore, this review aimed to determine the relationship between walking speed and energetic cost of walking (Cw) in pwMS, compared with healthy subjects, thereby assessing the walking speed with the lowest energetic cost. As it is unclear whether the Cw in pwMS differs between overground and treadmill walking, as reported in healthy subjects, a second review aim was to compare both conditions.

METHOD

PubMed and Web of Science were systematically searched. Studies assessing pwMS, reporting walking speed (converted to meters per second), and reporting oxygen consumption were included. Study quality was assessed with a modified National Heart, Lung and Blood Institute checklist. The relationship between Cw and walking speed was calculated with a second-order polynomial function and compared between groups and conditions.

RESULTS

Twenty-nine studies were included (n = 1535 pwMS) of which 8 included healthy subjects (n = 179 healthy subjects). PwMS showed a similar energetically most optimal walking speed of 1.44 m/s with a Cw of 0.16, compared with 0.14 mL O₂/kg/m in healthy subjects. The most optimal walking speed in treadmill was 1.48 m/s, compared with 1.28 m/s in overground walking with a similar Cw.

CONCLUSION

Overall, the Cw is elevated in pwMS but with a similar energetically most optimal walking speed, compared with healthy subjects. Treadmill walking showed a similar most optimal Cw but a higher speed, compared with overground walking.

Dosage and Effectiveness of Aerobic Training on Cardiorespiratory Fitness, Functional Capacity, Balance, and Fatigue in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the benefits of aerobic training (AT) programs on cardiorespiratory fitness, functional capacity, balance, and fatigue in individuals with multiple sclerosis (MS) and to identify the optimal dosage of AT programs for individuals with MS via a systematic review with meta-analysis.

DATA SOURCES

Two electronic databases were searched until March 2020 (PubMed-Medline and Web of Science).

STUDY SELECTION

Studies examining the effect of AT program on cardiorespiratory fitness, functional capacity, balance, and fatigue were included.

DATA EXTRACTION

After applying the inclusion and exclusion criteria, we included 43 studies. A total sample of 1070 individuals with MS (AT group, n=680; control group, n=390) were analyzed.

DATA SYNTHESIS

The AT group demonstrated a significant increase in cardiorespiratory fitness (standardized mean difference [SMD], 0.29; P=.002), functional capacity (timed Up and Go Test: SMD, -1.14; P<.001; gait speed: SMD, -1.19; P<.001; walking endurance: SMD, 0.46; P<.001), and balance (SMD, 3.49; P<.001) after training. Fatigue perception also decreased (SMD, -0.45; P<.001). However, no significant differences were observed when compared with the control group in either cardiorespiratory fitness (SMD, 0.14; P=.19) or fatigue perception. Nevertheless, we observed significant differences between the AT and control groups in balance (P=.02), gait speed (P=.02), and walking endurance (P=.03), favoring the participants who performed AT. Regarding the subgroup analysis, no significant differences were observed between subgroups in any of the variables studied except for gait speed, for which a greater increase in posttraining was observed when the AT program applied the continuous method (χ²=7.75; P=.005) and the exercises were performed by walking (χ²=9.36; P=.002).

CONCLUSIONS

Aerobic training improves gait speed, walking endurance, and balance. Cardiorespiratory fitness and fatigue perception also improved after AT, but we found no differences with the control group. In addition, subgroup analysis suggested that training using continuous and walking methods could optimize gait speed.

Different Effects of Transcranial Direct Current Stimulation on Leg Muscle Glucose Uptake Asymmetry in Two Women with Multiple Sclerosis

Asymmetrical lower limb strength is a significant contributor to impaired walking abilities in people with multiple sclerosis (PwMS). Transcranial direct current stimulation (tDCS) may be an effective technique to enhance cortical excitability and increase neural drive to more-affected lower limbs. A sham-controlled, randomized, cross-over design was employed. Two women with MS underwent two 20 min sessions of either 3 mA tDCS or Sham before 20 min of treadmill walking at a self-selected speed. During walking, the participants were injected with the glucose analogue, [¹⁸F] fluorodeoxyglucose (FDG). Participants were then imaged to examine glucose metabolism and uptake asymmetries in the legs. Standardized uptake values (SUVs) were compared between the legs and asymmetry indices were calculated. Subject 2 was considered physically active (self-reported participating in at least 30 min of moderate-intensity physical activity on at least three days of the week for the last three months), while Subject 1 was physically inactive. In Subject 1, there was a decrease in SUVs at the left knee flexors, left upper leg, left and right plantar flexors, and left and right lower legs and SUVs in the knee extensors and dorsiflexors were considered symmetric after tDCS compared to Sham. Subject 2 showed an increase in SUVs at the left and right upper legs, right plantar flexors, and right lower leg with no muscle group changing asymmetry status. This study demonstrates that tDCS may increase neural drive to leg muscles and decrease glucose uptake during walking in PwMS with low physical activity levels.

Clinical assessment, management, and rehabilitation of walking impairment in MS: an expert review

INTRODUCTION

One of the most common and life-altering consequences of Multiple Sclerosis (MS) is walking impairment. The distance, speed, and Gait pattern functions are components of the International Classification of Functioning, Disability, and Health (ICF) and are also predictors of dependency in terms of daily living activities in patients with MS (pwMS).

AREAS COVERED

This article provides an overview of walking impairment in pwMS, with focus on the assessment of gait and the rehabilitation approaches.

EXPERT OPINION

The authors recommend that pwMS undergo gait assessment integrating the ICF perspective using validated clinical outcome measures that cover spatiotemporal gait parameters. Moreover, assessment of walking speed with short walking capacity tests such as the timed 25-foot walk (T25FW) or the 10-m walk test (10 MWT) and tests for walking distance with middle distance tests such as the 2-min walk test (2MWT) and the 6-min walk test (6MWT). This review further highlights strategies that may restore walking function including pharmacological symptomatic treatment and non-pharmacological rehabilitation approaches such as exercise and task-specific training providing an appraisal of mobility targeted therapies to be considered when planning multidisciplinary comprehensive-care of pwMS. Finally, new and novel strategies such as motor imagery and rhythmic auditory stimulation have been developed to improve walking speed and distance in pwMS.

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

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.

Program to improve mobility in aging (PRIMA) study: Methods and rationale of a task-oriented motor learning exercise program

Walking difficulty is a common and costly problem in older adults. A potentially important yet unaddressed strategy to enhance walking ability through exercise intervention is to add a timing and coordination component in gait training (i.e. task specific timing and coordination exercise intervention) to the usual strength, endurance, and flexibility training. We describe the methods and rationale of a randomized single-blind, physical therapist supervised, exercise intervention trial to compare the effects of a standard strength, endurance, and flexibility program to a standard plus timing and coordination program in community-dwelling older adults walking slower than the desired gait speed of 1.2 m/s. Exercise sessions are twice weekly for 12 weeks. Participants are assessed at baseline, 12 weeks (post intervention), 24 weeks and 36 weeks. The primary outcome is gait speed, secondary outcomes represent components of the interventions (strength, endurance, flexibility, timing and coordination), and tertiary outcomes are measure of activity and participation (Late Life Function and Disability Instrument and physical activity). The findings of this trial will (1) establish if a standard-plus task specific timing and coordination program is superior to a standard strength and endurance program in improving mobility, activity and participation and (2) determine if the improvements are sustained over time. The information derived from this project will provide valuable insight into the prevention and management of walking difficulty, which is so common in older Americans.

Comfortable walking speed and energy cost of locomotion in patients with multiple sclerosis

Comfortable walking speed and energy cost of walking are physiological markers of metabolic activity during gait. People with multiple sclerosis are characterized by altered gait biomechanics and energetics, related to the degree of disability and spasticity, which lead to an increased energy cost of walking. Several studies concerning the energy cost of walking in multiple sclerosis have been published. Nevertheless, differences in protocols and characteristics of the sample have led to different outcomes. The aim of the present meta-analysis is to summarize results from studies with specific inclusion characteristics, and to present data about the comfortable walking speed and the energy cost of walking at that speed. Moreover, a detailed discussion of the potential mechanisms involved in the altered metabolic activity during exercise was included. A total of 19 studies were considered, 12 of which were also part of the quantitative analysis. Despite the strict selection process, high between-group heterogeneity was found for both outcomes. Nevertheless, the overall results suggest a pooled mean comfortable walking speed of 1.12 m/s (95% CI 1.05-1.18) and energy cost of 0.19 mLO₂/kg/m (95% CI 0.17-0.21). These findings support the results of previous studies suggesting that energy cost of walking may be increased by 2-3 times compared to healthy controls (HC), and encourage the use of this marker in association with other parameters of the disease.

Effect of arm cycling and task-oriented exercises on fatigue and upper limb performance in multiple sclerosis: a randomized crossover study

Rehabilitation treatments have been proven to be a viable way to reduce fatigue and upper limb impairments in people with multiple sclerosis (PwMS). Our aim was to examine which treatment has better short-term and carryover effects on fatigue and manual dexterity in multiple sclerosis population. Twenty PwMS participated in a 16-week randomized crossover study composed of 20 sessions. The participants were divided into two groups (group A and group B). Sessions containing combined arm cycling and task-oriented exercises were administered by a physical therapist in hospital setting. Each group received 20 sessions of aerobic training and task-oriented exercises and then an 8-week rest period or vice versa with group A receiving sessions first. Fatigue was assessed by using the Modified Fatigue Impact Scale (MFIS) and Motor Fatigability Index (MFI), which was assessed using an engineered glove during a fatiguing finger tapping task. To measure manual dexterity, the nine hole peg test (NHPT) and a rate of tapping at maximum velocity task (RATE-MV) were utilized. Treatment effects were assessed by t-test or Mann-Whitney test at the end of both periods checking for carryover effects. After treatment the combined (Groups A and B) between-period differences were MFIS: 5.2 (10.7) points, P = 0.05; MFI: -0.007 (<0.001)Hz/s, P = 0.05 and RATE-MV: 0.2 (0.4) Hz/s, P = 0.05 in favor of the treatment period. No statistically significant between-period differences were found for the NHPT: 3.6 (25.0) s, P = 0.63. No carryover effects (P > 0.05) were observed. In conclusion, sessions of arm cycling and tailored task-oriented exercises have shown to be a viable resource for treating manual dexterity and fatigue in PwMS.

Response Heterogeneity With Exercise Training and Physical Activity Interventions Among Persons With Multiple Sclerosis

Multiple sclerosis (MS) is a heterogeneous disease, both in its pathology and symptomology. This poses a challenge for the medical management and rehabilitation of MS; however, physical activity and exercise training are rehabilitation approaches that have demonstrated beneficial effects on many of the burdensome consequences of MS such as mobility impairment and fatigue. Given the heterogeneous course of MS, it is possible that outcomes of physical activity and exercise training interventions demonstrate heterogeneity both in the magnitude and pattern of change, but there has been little focus on response heterogeneity with these interventions among persons with MS. In this narrative review, a search of the existing literature was performed to identify studies that reported individual participant data, which was used to describe the variability in the response to physical activity and exercise training interventions among persons with MS. Inter-individual variability seemingly occurs across outcomes and modalities, which underscores the consideration of factors that might influence response heterogeneity. Factors related to MS disease characteristics, nervous system damage, and the degree of MS-related disability might influence individual responsiveness. Large-scale studies that permit the examination of heterogeneity and its predictors will inform future research on the area of physical activity and exercise training in MS, and lead to the development of individually tailored rehabilitation approaches that will more effectively elicit change.

Impact of pre-cooling therapy on the physical performance and functional capacity of multiple sclerosis patients: A systematic review

Patients with multiple sclerosis experience many complications that gradually lead them to comorbidity and disability. Exercise could prevent and ameliorate the symptoms that comorbidity or inactivity generate. However, until recently it was suggested that multiple sclerosis patients should not participate in exercise training programs because these patients are characterized by thermoregulatory failure and the heat stress due to physical work could exacerbate the disease symptoms. Furthermore, taken into account that 60-80% of the multiple sclerosis patients present adverse clinical symptoms when their body temperature is increased (not only due to physical working but even when immerse in hot water or by exposure to infrared lamps or to the sun), the need for the development of treatment strategies to overcome the thermoregulatory problem in these patients is crucial. Given that pre-cooling has been proposed as an effective method, the aim of this systematic review is to discuss the current knowledge for the effects of cooling therapy on the functional capacity of multiple sclerosis patients. The relevant literature includes many articles, but only a handful of studies published thus far have used a cooling intervention in multiple sclerosis patients and have examined the effects of pre-cooling on functional capacity. These studies used active cooling methods, namely garments or other material that are cooled by circulating liquid through a tube, as well as passive, cooling methods. Passive cooling methods include passive cooling garments or other material namely garments that have ice or gel packs inside them. Overall, the results of all the studies analysed in this review demonstrated that pre-cooling therapy can prevent the symptom worsening due to increased body temperature in multiple sclerosis patients without causing adverse effects. Therefore, such strategies could serve as a complimentary therapeutic approach in multiple sclerosis patients.

Treadmill training may be an effective form of task-specific training for improving mobility in people with Parkinson's disease and multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Task-specific training is an effective form of rehabilitation for improving mobility in neurological conditions. However, it remains unclear if task-specific training is effective in people with progressive disease.

OBJECTIVE

To establish the efficacy of task-specific training on the mobility of individuals with progressive neurological conditions.

DATA SOURCES

Electronic databases MEDLINE, EMBASE, CINAHL and Cochrane Database of Systematic Reviews.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials investigating the effect of task-specific training on mobility and falls rate in individuals with progressive neurological conditions.

STUDY APPRAISAL/SYNTHESIS METHODS

Risk of bias of individual studies was assessed using the Physiotherapy Evidence Database (PEDro) Scale. Mean differences (MD) and 95% confidence intervals were calculated and combined in meta-analysis.

RESULTS

Analysis of 16 trials found treadmill training improved comfortable walking velocity (m/second) in people with Parkinson's disease (MD 0.21m/second, 95%CI 0.15 to 0.27) and multiple sclerosis (MD 0.36m/second, 95%CI 0.20 to 0.52). Treadmill training improved stride length (m) (MD 0.12m, 95%CI 0.02 to 0.23) and step length (m) (MD 0.12m, 95%CI 0.01 to 0.23) in people with Parkinson's disease and walking endurance in people with multiple sclerosis (MD 26.53m, 95%CI 12.23 to 40.84). Treadmill training had no effect on cadence and did not improve walking endurance in Parkinson's disease. Over-ground walking did not improve mobility in Parkinson's disease or multiple sclerosis.

LIMITATIONS

Study sample sizes were small and findings must be interpreted with caution.

CONCLUSION

Treadmill training may be effective for improving mobility in people with Parkinson's disease and multiple sclerosis. The effectiveness of over-ground walking is uncertain.

SYSTEMATIC REVIEW PROSPERO REGISTRATION NUMBER

CRD42016047334.

Characteristics of Adults With Neurologic Disability Recruited for Exercise Trials: A Secondary Analysis

This review examined demographic and clinical characteristics of participants from exercise trials in 3 neurologic disability conditions (multiple sclerosis, spinal cord injury, and traumatic brain injury) and compared these data with population-based statistics. The authors included 75 published studies from 2006 to 2016: 53 studies for multiple sclerosis (n = 2,034), 14 for spinal cord injury (n = 302), and 8 for traumatic brain injury (n = 272). Pooled data resembled some heterogeneous aspects of population data sets. However, many characteristics were not reported; samples were small and predominantly White, and 48.1% of the people screened were excluded. Thus, findings from these studies may not be translatable across the range of people with these three conditions, which warrant efforts to target the inclusion of underrepresented subgroups in future exercise trials.

Intensive Multimodal Training to Improve Gait Resistance, Mobility, Balance and Cognitive Function in Persons With Multiple Sclerosis: A Pilot Randomized Controlled Trial

Introduction: Persons with multiple sclerosis (MS) have deficits in many aspects of physical and cognitive functioning that can impact on mobility and participation in daily life. The effect of a 4 week intensive multimodal treadmill training on functional mobility, balance, executive functions and participation in persons with MS with moderate to severe disability was investigated.

Methods: Thirty eight persons with MS admitted to a rehabilitation center participated in a two arm randomized 2:1 controlled trial. Participants in the experimental group received supervised intensive treadmill training including cognitive and motor dual tasks (DT-group, N = 26), 5 sessions per week and a control group received the same amount of supervised strength training (S-group, N = 12). The participants were assessed before and after the rehabilitation period with the 2 Minutes Walking Test (2MWT), speed and, static and dynamic balance measures, the Frontal Assessment Battery and the Short Form-12 questionnaire. The main hypothesis was related to the superiority of the treadmill intervention based on a greater proportion of people making a clinically relevant gain (15% increase on 2MWT) in gait resistance following treatment. ANCOVA (Analysis of covariance) models adjusting for baseline measurement of the respective outcome variable, as well as sex and age, were used to evaluate differences in efficacy for all variables. P was set at 0.05.

Results: Nineteen out of 26 persons in the DT-group made a clinically relevant gain and two out of 12 in the S-Group (P = 0.001). The DT-group improved more in gait resistance, speed and mobility (P < 0.01). Balance and executive functions instead improved moderately in both groups following training while perception of health remained similar in both groups.

Conclusion: A four week multimodal training on treadmill was highly effective in augmenting gait resistance and mobility in moderately to severely affected persons with MS.

Effects of Rehabilitation on Gait Pattern at Usual and Fast Speeds Depend on Walking Impairment Level in Multiple Sclerosis

Background

Physical rehabilitation can improve walking capacity in persons with multiple sclerosis (MS). However, changes in spatiotemporal gait parameters after rehabilitation are not frequently evaluated, and it is unknown to what extent potential effects depend on baseline disability level. The objective was to investigate the effectiveness of rehabilitation programs on gait parameters at usual and fastest speeds in persons with MS categorized according to walking speed.

Methods

This nonrandomized multinational study in "real-world" settings evaluated participants before and after conventional rehabilitation. Outcome measurements included spatiotemporal gait parameters assessed by an electronic walkway (at usual and fastest speeds), walking capacity tests (Timed 25-Foot Walk test, 2-Minute Walk Test, 6-Minute Walk Test), and the patient-reported 12-item Multiple Sclerosis Walking Scale. Patients were allocated into three subgroups based on walking speed (<0.82 m/s and >1.14 m/s) and MS center. Results were calculated for the total group and subgroups.

Results

Forty-two persons with MS (26 women; mean ± SD age, 44.6 ± 11.0 years; mean ± SD Expanded Disability Status Scale score, 3.5 ± 1.5) receiving rehabilitation treatment were enrolled. After rehabilitation treatment, the group demonstrated a significant decrease in double support time and an increase in stride length and step length (left leg) at usual and fastest speeds. Velocity and step length (right leg) increased only at usual speed. Subgroup analysis revealed greatest and clinically meaningful improvements in more disabled persons with MS.

Conclusions

Physical rehabilitation induced changes in spatiotemporal gait parameters in persons with MS. The magnitude of improvement was greater in participants with more walking impairment.

Is the Limit-Cycle-Attractor an (almost) invariable characteristic in human walking?

BACKGROUND

Common methods of gait analyses measure step length/width, gait velocity and gait variability to name just a few. Those parameters tend to be changing with fitness and skill of the subjects. But, do stable subject characteristic parameters in walking exist? Does the Limit-Cycle-Attractor qualify as such a parameter?.

RESEARCH QUESTION

The attractor method is a new approach focusing on the dynamics of human motion. It classifies the fundamental walking pattern by calculating the Limit-Cycle-Attractor and its variability from acceleration data of the feet. Our hypothesis is that the fundamental walking pattern in healthy controls and in people with Multiple Sclerosis (pwMS) is stable, but can be altered through acute interventions or rehabilitation.

METHODS

For this purpose, two investigations were conducted involving 113 subjects. The short-term stability was tested pre and post a 15 min passive/active MOTOmed (ergometer) session as well as up to 20 min afterwards. The long-term stability was tested over five weeks of rehabilitation once a week in pwMS. The main parameter of interest describes the velocity normalized average difference between two attractors (δM), which is an indicator for the change in movement pattern.

RESULTS

The Friedman's two-way ANOVA by ranks did not reveal any significant difference in δM. However, the conventional walking tests (6 min.10 m) improved significantly (p < 0.05) during rehabilitation. Contrary to our original hypothesis, the fundamental walking pattern was highly stable against controlled motor-assisted movement initiation via MOTOmed and rehabilitation treatment. Movement characteristics appeared to be independent of the improved fitness as indicated by the enhanced walking speed and distance.

SIGNIFICANCE

The individual Limit-Cycle-Attractor is extremely robust and might indeed qualify as an (almost) invariable characteristic in human walking. This opens up the possibility to encode the individual walking characteristics. Conditions as Parkinson, Multiple Sclerosis etc., might display disease specific distinctions via the Limit-Cycle-Attractor.

Motor Control-based Group Exercise: Can It be Delivered as Effectively by Lay Leaders?

PURPOSE

On the Move (OTM), a motor control-based group exercise program for community-dwelling older adults, has produced greater gains in mobility than a standard group exercise program when delivered by research leaders. The purposes of this study were:1) to examine the effectiveness of OTM versus a standard program when delivered by lay leaders and 2) to compare the outcomes of OTM when delivered by research versus lay leaders.

METHODS

Community-dwelling, medically stable older adults who could walk household distances participated. OTM consisted of warm-up, timing and coordination, strengthening, and stretching exercises. The seated standard program consisted of warm-up, aerobic, strengthening and stretching exercises. The primary outcome(s) of function and disability was the Late Life Function and Disability Instrument (LLFDI), and for walking ability were the Six Minute Walk Test and gait speed.

RESULTS

126 participants (mean age = 80.7±7.8 years, gait speed = 0.91 m/s) were randomized to OTM (n=49) or standard (n=77) programs. When taught by lay leaders, there were no significant between-intervention group differences in any of the outcomes (p>0.10). Comparing OTM outcomes between leaders, there was a statistical but not clinically meaningful difference in LLFDI disability (1.87±0.89, p=0.04) when taught by research versus lay leader, and moderate differences (p=0.06) in LLFDI overall function (1.89±1.02) and gait speed (0.05±0.03). Qualitative interview responses suggest that instructor-related concerns may have impacted program outcomes.

CONCLUSION

When delivered by lay leaders OTM was not more effective than a standard program for improving function, disability, and mobility in older adults. Health promotion programs designed to improve mobility in community-dwelling older adults and based on a motor control theoretical background, may be best taught by rehabilitation professionals.

Balance, gait, and falls in multiple sclerosis

Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) and the most widespread nontraumatic cause of disability in young adults around the world. MS occurs in people of all ages, races, and ethnicities. MS is characterized by clinical symptoms resulting from lesions in the brain, spinal cord, or optic nerves that can affect balance, gait, and fall risk. Lesions accumulate over time and occur in different areas of the CNS causing symptoms that include weakness, spasticity, and fatigue, as well as changes in sensation, coordination, vision, cognition, and bladder function. Thus, it is not surprising that imbalance, gait dysfunction, and falls are common in people with MS. The overwhelming majority have abnormalities of postural control and gait even early in the disease course. In all, 50-80% have balance and gait dysfunction and over 50% fall at least once each year. Balance dysfunction in MS is conceptualized as three interrelated problems: decreased ability to maintain position, limited and slowed movement towards limits of stability, and delayed responses to postural displacements and perturbations. In addition, functional balance performance may be affected by impaired dual-task integration. Walking changes in MS include reduced gait speed, impaired walking balance, and reduced walking-related physical activity. Falls in people with MS are associated with injuries, reduced participation, and increased fear of falling. A wide and growing range of rehabilitation and medical interventions are available to address the changes in balance, gait, and fall risk associated with MS.

Effects of an individual 12-week community-located “start-to-run” program on physical capacity, walking, fatigue, cognitive function, brain volumes, and structures in persons with multiple sclerosis

Background:

Exercise therapy studies in persons with multiple sclerosis (pwMS) primarily focused on motor outcomes in mid disease stage, while cognitive function and neural correlates were only limitedly addressed.

Objectives:

This pragmatic randomized controlled study investigated the effects of a remotely supervised community-located “start-to-run” program on physical and cognitive function, fatigue, quality of life, brain volume, and connectivity.

Method:

In all, 42 pwMS were randomized to either experimental (EXP) or waiting list control (WLC) group. The EXP group received individualized training instructions during 12 weeks (3×/week), to be performed in their community aiming to participate in a running event. Measures were physical (VO2max, sit-to-stand test, Six-Minute Walk Test (6MWT), Multiple Sclerosis Walking Scale-12 (MSWS-12)) and cognitive function (Rao’s Brief Repeatable Battery (BRB), Paced Auditory Serial Attention Test (PASAT)), fatigue (Fatigue Scale for Motor and Cognitive Function (FSMC)), quality of life (Multiple Sclerosis Impact Scale-29 (MSIS-29)), and imaging. Brain volumes and diffusion tensor imaging (DTI) were quantified using FSL-SIENA/FIRST and FSL-TBSS.

Results:

In all, 35 pwMS completed the trial. Interaction effects in favor of the EXP group were found for VO2max, sit-to-stand test, MSWS-12, Spatial Recall Test, FSMC, MSIS-29, and pallidum volume. VO2max improved by 1.5 mL/kg/min, MSWS-12 by 4, FSMC by 11, and MSIS-29 by 14 points. The Spatial Recall Test improved by more than 10%.

Conclusion:

Community-located run training improved aerobic capacity, functional mobility, visuospatial memory, fatigue, and quality of life and pallidum volume in pwMS.

Current Trends in Exercise Intervention Research, Technology, and Behavioral Change Strategies for People With Disabilities: A Scoping Review

This review synthesized physical activity and exercise intervention literature for the past 10 yrs for people with physical and cognitive disabilities including intervention characteristics, behavior change strategies, and types of technologies used to improve targeted outcomes. Systematic searches yielded 132 eligible studies. The major disability groups were multiple sclerosis (41%), stroke (15%), and spinal cord injury (12%). Research designs primarily involved randomized controlled trials (61%) versus quasi-experimental designs (39%). Approximately 20% of the interventions used some form of the following technology: information and communication technology (48%), interactive technology (37%), or electronic gauges (30%). Eighteen percent of studies used intervention strategies based on behavioral theory, which was typically combined with technology to promote activity and increase adherence in generally larger study samples. The three prevailing theories included social cognitive theory (58%), supportive accountability theory (21%), and transtheoretical model (21%). Upon completing the intervention, studies reported primarily significant outcomes (80%). Exercise research for PWD has grown in both quantity and quality, but several gaps remain. Study findings provide a roadmap for future exercise trials on understudied populations and highlight technology and behavior change theory as drivers of future intervention research.

Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations

BACKGROUND

Multiple sclerosis (MS) can result in significant mental and physical symptoms, specially muscle weakness, abnormal walking mechanics, balance problems, spasticity, fatigue, cognitive impairment and depression. Patients with MS frequently decrease physical activity due to the fear from worsening the symptoms and this can result in reconditioning. Physicians now believe that regular exercise training is a potential solution for limiting the reconditioning process and achieving an optimal level of patient activities, functions and many physical and mental symptoms without any concern about triggering the onset or exacerbation of disease symptoms or relapse.

MAIN BODY

Appropriate exercise can cause noteworthy and important improvements in different areas of cardio respiratory fitness (Aerobic fitness), muscle strength, flexibility, balance, fatigue, cognition, quality of life and respiratory function in MS patients. Aerobic exercise training with low to moderate intensity can result in the improvement of aerobic fitness and reduction of fatigue in MS patients affected by mild or moderate disability. MS patients can positively adapt to resistance training which may result in improved fatigue and ambulation. Flexibility exercises such as stretching the muscles may diminish spasticity and prevent future painful contractions. Balance exercises have beneficial effects on fall rates and better balance. Some general guidelines exist for exercise recommendation in the MS population. The individualized exercise program should be designed to address a patient's chief complaint, improve strength, endurance, balance, coordination, fatigue and so on. An exercise staircase model has been proposed for exercise prescription and progression for a broad spectrum of MS patients.

CONCLUSION

Exercise should be considered as a safe and effective means of rehabilitation in MS patients. Existing evidence shows that a supervised and individualized exercise program may improve fitness, functional capacity and quality of life as well as modifiable impairments in MS patients.

The effectiveness of Robot-Assisted Gait Training versus conventional therapy on mobility in severely disabled progressIve MultiplE sclerosis patients (RAGTIME): study protocol for a randomized controlled trial

Background

Gait and mobility impairments affect the quality of life (QoL) of patients with progressive multiple sclerosis (MS). Robot-assisted gait training (RAGT) is an effective rehabilitative treatment but evidence of its superiority compared to other options is lacking. Furthermore, the response to rehabilitation is multidimensional, person-specific and possibly involves functional reorganization processes. The aims of this study are: (1) to test the effectiveness on gait speed, mobility, balance, fatigue and QoL of RAGT compared to conventional therapy (CT) in progressive MS and (2) to explore changes of clinical and circulating biomarkers of neural plasticity.

Methods

This will be a parallel-group, randomized controlled trial design with the assessor blinded to the group allocation of participants. Ninety-eight (49 per arm) progressive MS patients (EDSS scale 6–7) will be randomly assigned to receive twelve 2-h training sessions over a 4-week period (three sessions/week) of either: (1) RAGT intervention on a robotic-driven gait orthosis (Lokomat, Hocoma, Switzerland). The training parameters (torque of the knee and hip drives, treadmill speed, body weight support) are set during the first session and progressively adjusted during training progression or (2) individual conventional physiotherapy focusing on over-ground walking training performed with the habitual walking device. The same assessors will perform outcome measurements at four time points: baseline (before the first intervention session); intermediate (after six training sessions); end of treatment (after the completion of 12 sessions); and follow-up (after 3 months from the end of the training program). The primary outcome is gait speed, assessed by the Timed 25-Foot Walk Test. We will also assess walking endurance, balance, depression, fatigue and QoL as well as instrumental laboratory markers (muscle metabolism, cerebral venous hemodynamics, cortical activation) and circulating laboratory markers (rare circulating cell populations pro and anti-inflammatory cytokines/chemokines, growth factors, neurotrophic factors, coagulation factors, other plasma proteins suggested by transcriptomic analysis and metabolic parameters).

Discussion

The RAGT training is expected to improve mobility compared to the active control intervention in progressive MS. Unique to this study is the analysis of various potential markers of plasticity in relation with clinical outcomes.

Trial registration

ClinicalTrials.gov, identifier: NCT02421731. Registered on 19 January 2015 (retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1838-2) contains supplementary material, which is available to authorized users.

Virtual street-crossing performance in persons with multiple sclerosis: Feasibility and task performance characteristics

OBJECTIVES

Multiple sclerosis (MS) is a neurological disease that commonly results in physical and cognitive dysfunction. Accordingly, MS might impact the ability to safely cross the street. The purpose of this study was to examine the feasibility of a simulated street-crossing task in persons with MS and to determine differences in street-crossing performance between persons with MS and non-MS controls.

METHODS

26 participants with MS (median Expanded Disability Status Scale [EDSS] score = 3.5) and 19 controls completed 40 trials of a virtual street-crossing task. There were 2 crossing conditions (i.e., no distraction and phone conversation), and participants performed 20 trials per condition. Participants were instructed that the goal of the task was to cross the street successfully (i.e., without being hit be a vehicle). The primary outcome was task feasibility, assessed as completion and adverse events. Secondary outcomes were measures of street-crossing performance.

RESULTS

Overall, the simulated street-crossing task was feasible (i.e., 90% completion, no adverse events) in participants with MS. Participants with MS waited longer and were less attentive to traffic before entering the street compared with controls (all P < .05). Participants with MS also took longer to cross the street and were closer to oncoming vehicles when exiting the street compared to controls (all P < .05). When distracted, all participants took longer to initiate crossing, took longer to cross the street, and made more head turns while crossing (all P < .05). There were no significant group by condition interaction effects (all P > .05).

CONCLUSIONS

A virtual street-crossing task is feasible for studying street-crossing behavior in persons with mild MS and most individuals with moderate MS. Virtual street-crossing performance is impaired in persons with MS compared to controls; however, persons with MS do not appear to be more vulnerable to a distracting condition. The virtual reality environment presents a safe and useful setting for understanding pedestrian behavior in persons with MS.

Errors in the ankle plantarflexor force production are related to the gait deficits of individuals with multiple sclerosis

BACKGROUND

Individuals with multiple sclerosis (MS) often have limited mobility that is thought to be due to the neuromuscular impairments of the ankle. Greater isometric motor control of the ankle has been associated with better standing postural balance but its relationship to mobility is less understood. The objectives of this investigation were to quantify the motor control of the ankle plantarflexors of individuals with MS during a dynamic isometric motor task, and explore the relationship between the ankle force control and gait alterations.

METHODS

Fifteen individuals with MS and 15 healthy adults participated in both a dynamic isometric ankle plantarflexion force matching task and a biomechanical gait analysis.

FINDINGS

Our results displayed that the subjects with MS had a greater amount of error in their dynamic isometric force production, were weaker, walked with altered spatiotemporal kinematics, and had reduced maximal ankle moment at toe-off than the control group. The greater amount of error in the dynamic force production was related to the decreases in strength, step length, walking velocity, and maximal ankle moment during walking.

INTERPRETATION

Altogether these results imply that errors in the ankle plantarflexion force production may be a limiting factor in the mobility of individuals with MS.

Stakeholder involvement in the design of a patient-centered comparative effectiveness trial of the "On the Move" group exercise program in community-dwelling older adults

BACKGROUND

Group exercise programs for older adults often exclude the timing and coordination of movement. Stakeholder involvement in the research process is strongly encouraged and improves the relevance and adoption of findings. We describe stakeholder involvement in the design of a clinical trial of a group-based exercise program that incorporates timing and coordination of movement into the exercises.

METHODS

The study was a cluster randomized, single-blind intervention trial to compare the effects on function, disability and mobility of a standard group exercise program and the "On the Move" group exercise program in older adults residing in independent living facilities and senior apartment buildings, and attending community centers. Exercise classes were twice weekly for 12weeks delivered by study exercise leaders and facility activity staff personnel.

OUTCOMES

The primary outcomes function, disability and mobility were assessed at baseline and post-intervention. Function and disability were assessed using the Late Life Function and Disability Instrument, and mobility using the Six-Minute Walk Test and gait speed.

STAKEHOLDERS

Patient and provider stakeholders had significant input into the study aims, design, sample, intervention, outcomes and operational considerations.

SUMMARY

A community-based exercise program to improve walking can be developed to address both investigator identified missing components in current exercise to improve walking and stakeholder defined needs and interest for the activity program. Involvement of stakeholders substantially improves the relevance of research questions, increases the transparency of research activities and may accelerate the adoption of research into practice.

Targets for Health Interventions for Inflammatory Bowel Disease-fatigue

BACKGROUND AND AIMS

Fatigue is a complex, multifactorial, and multidimensional phenomenon. Recognition of modifiable correlates of fatigue can provide a further understanding of this phenomenon in patients with inflammatory bowel disease [IBD] and aid in the development of interventions tailored towards fatigue with potential for efficacy. Our aims were to systematically search and synthesise available evidence on potentially modifiable factors contributing to IBD-fatigue and what advances in the management of fatigue in individuals with IBD have been made.

METHODS

The process of selection of citations was based on an earlier review by Czuber-Dochan et al. [2013] and was undertaken in two phases: i] searching for new studies published since August 2012, using seven electronic databases; ii] re-selection of papers included in previous review according to the aims of the current review.

RESULTS

A total of 43 studies met the inclusion criteria. IBD-fatigue was consistently associated with disease activity, depression, anxiety, and sleep difficulties. However, most studies were cross-sectional; thus the direction of causation remains unknown. The relationship between biochemical factors, such as anaemia and inflammation, and fatigue was inconsistent. Solution-focused therapy, thiamine, and exercise showed promising effects on IBD-fatigue. Interventions continue to be sparse, with methodological limitations and only short-term effects reported.

CONCLUSIONS

The review identified a number of psychosocial and physical factors which could potentially be modified through targeted health interventions and improve fatigue in IBD. Research utilising prospective observational studies and randomized control trial [RCT] design is required to develop and test interventions to reduce fatigue, most likely within a biopsychosocial model of care.

Neurorehabilitation Strategies Focusing on Ankle Control Improve Mobility and Posture in Persons With Multiple Sclerosis

BACKGROUND AND PURPOSE

The neuromuscular impairments seen in the ankle plantarflexors have been identified as a primary factor that limits the mobility and standing postural balance of individuals with multiple sclerosis (MS). However, few efforts have been made to find effective treatment strategies that will improve the ankle plantarflexor control. Our objective was to determine whether an intensive 14-week neurorehabilitation protocol has the potential to improve the ankle plantarflexor control of individuals with MS. The secondary objectives were to determine whether the protocol would also improve postural control, plantarflexion strength, and mobility.

METHODS

Fifteen individuals with MS participated in a 14-week neurorehabilitation protocol, and 20 healthy adults served as a comparison group. The primary measure was the amount of variability in the submaximal steady-state isometric torque, which assessed plantarflexor control. Secondary measures were the Sensory Organization Test composite score, maximum plantarflexion torque, and the spatiotemporal gait kinematics.

RESULTS

There was less variability in the plantarflexion torques after the neurorehabilitation protocol (preintervention, 4.15% ± 0.5%; postintervention, 2.27% ± 0.3%). In addition, there were less postural sway (preintervention, 51.87 ± 0.2 points; postintervention, 67.8 ± 0.5 points), greater plantarflexion strength (preintervention, 0.46 ± 0.04 Nm/kg; postintervention, 0.57 ± 0.05 Nm/kg), and faster walking speeds (preferred preintervention, 0.71 ± 0.05 m/s; preferred postintervention, 0.81 ± 0.05 m/s; fast-as-possible preintervention, 0.95 ± 0.06 m/s; postintervention, 1.11 ± 0.07 m/s). All of the outcome variables matched or trended toward those seen in the controls.

DISCUSSION AND CONCLUSIONS

The outcomes of this exploratory study suggest that the neurorehabilitation protocol employed in this investigation has the potential to promote clinically relevant improvements in the ankle plantarflexor control, standing postural balance, ankle plantarflexion strength, and the mobility of individuals with MS. Video abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A110).

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.

Effects of Intermittent Versus Continuous Walking on Distance Walked and Fatigue in Persons With Multiple Sclerosis: A Randomized Crossover Trial

BACKGROUND AND PURPOSE

Fatigue is a common, disabling symptom experienced by persons with multiple sclerosis (MS). Evidence shows that intermittent exercise is associated in improved performance and negligible fatigue. The purpose of this study was to examine whether subjects with MS walk greater distances with less fatigue under intermittent (INT) or continuous (CONT) walking condition.

METHODS

Twenty-seven subjects with MS (median Extended Disability Severity Scale 3.5, interquartile range 1.6) walked in the CONT (ie, 6 uninterrupted minutes) and INT (ie, three 2-minute walking bouts) conditions in a randomized crossover. Distance was measured for the entire 6-minute walking period and each 2-minute increment. Fatigue was measured as the difference in a visual analog scale of fatigue (ΔVAS-F) immediately preceding and following each trial.

RESULTS

Participants walked greater distances in the INT condition compared to the CONT condition (P = 0.005). There was a significant interaction of walking condition and time (P < 0.001), indicating that the distances walked in the INT condition changed across time. ΔVAS-F was significantly lower in the INT condition than in the CONT condition (P = 0.036).

DISCUSSION AND CONCLUSION

Subjects with MS walked farther, and with less fatigue, when walking intermittently rather than continuously. Persons with MS may be able to tolerate a greater dose of walking training if the walking bouts are intermittent. Further study to determine the benefits of a walking exercise program using intermittent walking is recommended.Video Abstract available for additional insights from the authors (Supplemental Digital Content 1, http://links.lww.com/JNPT/A103).

Uphill and Downhill Walking in Multiple Sclerosis: A Randomized Controlled Trial

BACKGROUND

Various exercise protocols have been recommended for patients with multiple sclerosis (MS). We investigated the effects of uphill and downhill walking exercise on mobility, functional activities, and muscle strength in MS patients.

METHODS

Thirty-four MS patients were randomly allocated to either the downhill or uphill treadmill walking group for 12 sessions (3 times/wk) of 30 minutes' walking on a 10% negative slope (n = 17) or a 10% positive slope (n = 17), respectively. Measurements were taken before and after the intervention and after 4-week follow-up and included fatigue by Modified Fatigue Impact Scale; mobility by Modified Rivermead Mobility Index; disability by Guy's Neurological Disability Scale; functional activities by 2-Minute Walk Test, Timed 25-Foot Walk test, and Timed Up and Go test; balance indices by Biodex Balance System; and quadriceps and hamstring isometric muscles by torque of left and right knee joints. Analysis of variance with repeated measures was used to investigate the intervention effects on the measurements.

RESULTS

After the intervention, significant improvement was found in the downhill group versus the uphill group in terms of fatigue, mobility, and disability indices; functional activities; balance indices; and quadriceps isometric torque (P < .05). The results were stable at 4-week follow-up.

CONCLUSIONS

Downhill walking on a treadmill may improve muscle performance, functional activity, and balance control in MS patients. These findings support the idea of using eccentric exercise training in MS rehabilitation protocols.

Adapted Resistance Training Improves Strength in Eight Weeks in Individuals with Multiple Sclerosis

Hip weakness is a common symptom affecting walking ability in people with multiple sclerosis (MS). It is known that resistance strength training (RST) can improve strength in individuals with MS, however; it remains unclear the duration of RST that is needed to make strength gains and how to adapt hip strengthening exercises for individuals of varying strength using only resistance bands. This paper describes the methodology to set up and implement an adapted resistance strength training program, using resistance bands, for individuals with MS. Directions for pre- and post-strength tests to evaluate efficacy of the strength-training program are included. Safety features and detailed instructions outline the weekly program content and progression. Current evidence is presented showing that significant strength gains can be made within 8 weeks of starting a RST program. Evidence is also presented showing that resistance strength training can be successfully adapted for individuals with MS of varying strength with little equipment.