An approach to the management of multiple sclerosis

Balance performance in three forms of multiple sclerosis

OBJECTIVES

To compare and document balance performance between patients with multiple sclerosis (MS) and healthy control subjects and balance performance among patients with different MS forms using a set of clinical balance tests.

MATERIAL AND METHODS

Twenty eight primary progressive (PPMS), 34 secondary progressive (SPMS), and 62 relapsing remitting (RRMS), totalling 124 MS patients were included in the present study. Results from patients were compared with those of 31 healthy control subjects matching in age, gender, weight and height. Ashworth scale, mini-mental state examination and motricity index were used consecutively to evaluate spasticity, cognitive impairment and lower extremity muscle strength. Vision, sensation, proprioception, cerebellar and vestibular tests were also performed on the patients. The balance performance was evaluated using a set of clinical tests including steady stance tests (eyes in opened and closed positions, feet apart, feet together, stride stance, tandem stance and single stance), self-generated perturbations (functional reach, arm raise and step test), external perturbations, Tinetti-gait and 10 m gait time tests.

RESULTS

There were no differences in age, sex, weight, height, sense impairment and lower extremity strength in patients with the three MS forms (p>0.05). No difference was found among patients with the three MS forms and the control subjects in the test of eyes closed with feet apart (p>0.05). The PPMS patients in all the balance tests except tests of eyes closed with feet apart and eyes opened with feet together, SPMS patients in all the balance tests except that of eyes closed with feet apart and RRMS patients in tandem stance, single leg stance, self-generated perturbations, external perturbations, Tinetti-gait and 10 m gait time tests had weaker balance than the control subjects (p<0.001). There were some differences between patients in the PPMS and SPMS groups in the eyes closed and feet apart test, between patients in the PPMS and RRMS groups in all the balance tests except eyes closed and feet apart and eyes opened and feet together tests and between patients in SPMS and RRMS group in all the balance tests except right and left arm raised tests (p<0.001).

CONCLUSION

Balance in MS patients is impaired. The results of the present study show that there is more impairment in progressive MS forms than in RRMS. Meanwhile, patients with progressive MS are more likely to fall.

Resistance Training Improves Gait Kinematics in Persons With Multiple Sclerosis

OBJECTIVE

To evaluate the effects of an 8-week lower-body resistance-training program on walking mechanics in persons with multiple sclerosis (MS).

DESIGN

Repeated-measures design, evaluating gait kinematics before and after an 8-week progressive resistance-training intervention.

SETTING

Biomechanics laboratory and fitness center (with conventional, commercially available resistance-training equipment).

PARTICIPANTS

Eight ambulatory subjects with MS (age, 46.0+/-11.5 y) with Expanded Disability Status Scale scores ranging from 2.5 to 5.5.

INTERVENTION

An 8-week progressive resistance-training program.

MAIN OUTCOME MEASURES

Kinematic gait parameters including knee range of motion, duration of stance, swing, and double-support phases in seconds and as percentages of the stride time, percentage of stride time spent in stance, swing, and double-support phases, step length, foot angle, stride length, velocity, step width, and toe clearance for both the more affected and less affected lower limbs. Isometric strength, 3-minute stepping, fatigue, and self-reported disability were also measured.

RESULTS

After 2 months of resistance training, there were significant increases (P<.05) in percentage of stride time in the swing phase, step length, stride length, and foot angle; and significant decreases (P<.05) in percentage of stride time in the stance and double-support phases, duration of the double-support phase, and toe clearance. Isometric leg strength improved (P<.05) in 2 of the 4 muscle groups tested. Fatigue indices decreased (P=.04), whereas self-reported disability tended to decrease (P=.07) following the training program. Three-minute stepping increased by 8.7%.

CONCLUSIONS

Resistance training may be an effective intervention strategy for improving walking and functional ability in moderately disabled persons with MS.

Clinical tests of standing balance: performance of persons with multiple sclerosis

OBJECTIVE

To investigate differences in performance between people with multiple sclerosis (MS) and control subjects on clinical tests of balance, and to assess performance consistency on balance tests in people with MS from morning to afternoon.

STUDY DESIGN

Two factor repeated measures design with a two group sample of convenience.

SETTING

Kingston Centre and the Camberwell Centre of the MS Society of Victoria, Australia.

SUBJECTS

Fourteen people with MS and 14 control subjects matched for age, height, and sex.

MAIN OUTCOME MEASURES

Subjects were measured on their ability to maintain standing balance in steady stance, (feet apart, feet together, stride stance, tandem stance, and single leg stance), during self-generated perturbations (functional reach, arm raise, and step tests) and in response to an external perturbation. Participants with MS were also asked to rate their fatigue level in the morning and afternoon.

RESULTS

There were no differences between MS and control groups on the ability to maintain standing balance with feet apart, feet together, or in stride stance. Participants with MS performed more poorly than control subjects in tandem stance and single leg stance and in the functional reach test, arm raise test, step test, and in response to an external perturbation. There was little change in balance from morning to afternoon in participants with MS (ICCs (2,1) .70 to .94), despite an increase in self-rated fatigue (t(14) = -3.14, p = .008).

CONCLUSION

The ability to maintain balance in standing is a marked problem in people with MS despite the consistency of their performance from morning to afternoon.

Assessment of motor function in people with multiple sclerosis

Multiple sclerosis (MS) is a chronic progressive disease of the central nervous system (CNS) which predominantly affects young adults. In order to provide physiotherapy appropriate to the needs of individuals with MS, it is necessary to assess and evaluate the nature and degree of motor and functional deficits. The aim of this research was to develop a physiotherapy assessment which would consistently and objectively evaluate motor function in people with MS. The Motor Club Assessment (MCA), originally developed for use in stroke patients, was identified as exhibiting several features which were consonant with the required criteria. It was therefore modified for use in MS. The Amended MCA (AMCA) was tested for inter-rater agreement, which was found to be good for the lower limb motor section (weighted kappa = 0.80), the upper limb motor section (weighted kappa = 0.90), and the functional activities section (weighted kappa = 0.92). The internal consistency was high for the lower limb section (alpha = 0.97) and the functional activities section (alpha = 0.92), but could not be determined for the upper limb section due to a clear ceiling effect. The study demonstrated that the AMCA is a valid tool for assessment use by physiotherapists in MS patients, and that it has an acceptable level of reliability when used in a clinic setting by physiotherapists suitably experienced in the treatment of neurological patients.