(HIIT-The Track) High-Intensity Interval Training for People with Parkinson's Disease: Individual Response Patterns of (Non-)Motor Symptoms and Blood-Based Biomarkers-A Crossover Single-Case Experimental Design

INTRODUCTION

Physical exercise is receiving increasing interest as an augmentative non-pharmacological intervention in Parkinson's disease (PD). This pilot study primarily aimed to quantify individual response patterns of motor symptoms to alternating exercise modalities, along with non-motor functioning and blood biomarkers of neuroplasticity and neurodegeneration.

MATERIALS & METHODS

People with PD performed high-intensity interval training (HIIT) and continuous aerobic exercise (CAE) using a crossover single-case experimental design. A repeated assessment of outcome measures was conducted. The trajectories of outcome measures were visualized in time series plots and interpreted relative to the minimal clinically important difference (MCID) and smallest detectable change (SDC) or as a change in the positive or negative direction using trend lines.

RESULTS

Data of three participants were analyzed and engaging in physical exercise seemed beneficial for reducing motor symptoms. Participant 1 demonstrated improvement in motor function, independent of exercise modality; while for participant 2, such a clinically relevant (positive) change in motor function was only observed in response to CAE. Participant 3 showed improved motor function after HIIT, but no comparison could be made with CAE because of drop-out. Heterogeneous responses on secondary outcome measures were found, not only between exercise modalities but also among participants.

CONCLUSION

Though this study underpins the positive impact of physical exercise in the management of PD, large variability in individual response patterns to the interventions among participants makes it difficult to identify clear exercise-induced adaptations in functioning and blood biomarkers. Further research is needed to overcome methodological challenges in measuring individual response patterns.

Exercise therapy for fatigue in multiple sclerosis

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

The relationship between energy cost of walking, ankle push-off and walking speed in persons with multiple sclerosis

BACKGROUND

The energy cost of walking (ECw) is an important indicator of walking dysfunction in persons with multiple sclerosis (PwMS). However, its underlying causes and its relation with ankle push-off and walking speed are not well understood.

RESEARCH QUESTION

What is the contribution of ankle push-off and walking speed to increased ECw in PwMS?

METHODS

Ten PwMS with walking limitations and 10 individually gender- and age-matched healthy controls (HC) were included. All participants performed two 6-min walking trials on a treadmill at comfortable walking speed (CWS of PwMS) and fast walking speed (FWS, 130 % of CWS of PwMS). Kinetics and metabolic cost were evaluated. Generalized estimating equations were performed to investigate effects of group and walking speed, and their interaction. Spearman correlations were conducted to examine whether ECw was related to ankle push-off in PwMS, controlling for differences in walking speed in PwMS.

RESULTS

ECw at matched walking speed was significantly higher in PwMS compared to HC. Kinetic parameters were not different between the most impaired leg in PwMS and HC at matched walking speed, but asymmetry between both legs of PwMS was observed. At FWS, ECw reduced and ankle push-off increased similarly in both groups. ECw was inversely related to peak ankle power of the most impaired leg in PwMS at CWS.

SIGNIFICANCE

Slow walking speed is one factor that contributes to increased ECw in PwMS. Furthermore, PwMS who had a higher ECw showed a lower peak ankle power, independent of walking speed. This indicates that ankle push-off could be a contributor to increased ECw.

High-Intensity Interval Cycle Ergometer Training in Parkinson's Disease: Protocol for Identifying Individual Response Patterns Using a Single-Subject Research Design

Background: People with Parkinson's disease (PD) experience not only motor problems but also non-motor problems that seriously impede their daily functioning and quality of life. The current pharmacologic treatment of PD is symptomatic, and alternative rehabilitation treatments, which preferably also have a disease-modifying effect and promote neuroplasticity, are needed. Recent studies suggest that high-intensity interval training (HIIT) is promising for promoting neuroplasticity in human PD, with short training time and reduced burden. Biomarkers for neuroplasticity such as brain-derived neurotrophic factor (BDNF) and neurodegeneration (including neurofilament NfL and α-synuclein) may play a role, but their response to HIIT is not well-investigated.

Objectives: The aims of this study were (1) to study the effects of 4 weeks of HIIT compared with 4 weeks of continuous aerobic exercise on motor and non-motor outcomes of PD and (2) to investigate the association between HIIT, motor/non-motor performances changes, and blood biomarker levels for neuroplasticity and neurodegeneration.

Study Design: Single-subject research design with alternating treatment setup (ABACA) and frequent repeated measurements was used. Each participant received different intervention conditions (B/C) interspersed with baseline periods (A, i.e., ABACA or ACABA), and frequent repeated assessment of outcome measures is done to quantify within-subject, individual response patterns with sufficient power for data analysis. Blood samples were collected once a week in the baseline and training phases (A1 and B/C) and once every 2 weeks in the washout phases (A2 and A3).

Intervention: Four subjects with PD on stable dopaminergic medication, two in Hoehn–Yahr stage 1–2, and two in Hoehn–Yahr stage 2.5–3 followed an ABACA or ACABA schedule, consisting of blocks with 30-min sessions of “B” (HIIT) or 50-min sessions of “C” [continuous aerobic exercise (CAE)] 3×/week for 4 weeks, separated by baseline “A” periods of 8 weeks for a total duration of 28 weeks.

Outcome Measures: Outcome measures include disease status [Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS)], blood biomarkers (BDNF, Nfl, and α-synuclein), measures for functional mobility (including an activity tracker), and activities of daily living, as well as cognition, mood, biorhythm (sleeping problems), and quality of life.

Data Analysis: Visual analysis of trends in level, slope, and variability in response patterns was carried out, confirmed by longitudinal regression analysis with phase (ABACA) as the independent variable.

Tablet App Based Dexterity Training in Multiple Sclerosis (TAD-MS): Research Protocol of a Randomized Controlled Trial

Introduction: Patients with Multiple Sclerosis exhibit disturbed dexterity, leading to difficulties in fine motor skills such as buttoning a T-shirt or hand-writing. Consequently, activities of daily living and quality of life are affected. The aim of the present study is to investigate the effectiveness of a tablet app-based home-based training intervention to improve dexterity in patients with Multiple Sclerosis.

Methods: An observer-blinded randomized controlled trial will be performed. Seventy patients with Multiple Sclerosis with self-reported difficulties in dexterity while executing activities of daily living will be recruited. After baseline assessment, participants are randomized to either an intervention group (n = 35) or control group (n = 35) by a computerized procedure. Blinded assessments will be done at baseline, post-intervention (after 4 weeks) and 12 weeks follow-up. The home-based intervention consists of a 4-week tablet app-based dexterity program. The app contains six dexterity games in which finger coordination, tapping, pinch grip is required. The control group will receive a Thera-band training program focused on strengthening the upper limb. The primary outcome is the Arm function of Multiple Sclerosis Questionnaire, a measure of patient-reported activities of daily living related dexterity. Secondary outcomes are dexterous function, hand strength, and quality of life.

Discussion: This study will evaluate the effects of tablet app-based training for dexterity in patients with Multiple Sclerosis. We hypothesize that a challenging app-based dexterity program will improve dexterity both in the short term and the long-term. The improved finger and hand functions are expected to generalize to improved activities of daily living and quality of life.

Respiratory muscle training for multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic disease of the central nervous system, affecting approximately 2.5 million people worldwide. People with MS may experience limitations in muscular strength and endurance - including the respiratory muscles, affecting functional performance and exercise capacity. Respiratory muscle weakness can also lead to diminished performance on coughing, which may result in (aspiration) pneumonia or even acute ventilatory failure, complications that frequently cause death in MS. Training of the respiratory muscles might improve respiratory function and cough efficacy.

OBJECTIVES

To assess the effects of respiratory muscle training versus any other type of training or no training for respiratory muscle function, pulmonary function and clinical outcomes in people with MS.

SEARCH METHODS

We searched the Trials Register of the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group (3 February 2017), which contains trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, LILACS and the trial registry databases ClinicalTrials.gov and WHO International Clinical Trials Registry Platform. Two authors independently screened records yielded by the search, handsearched reference lists of review articles and primary studies, checked trial registers for protocols, and contacted experts in the field to identify further published or unpublished trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that investigated the efficacy of respiratory muscle training versus any control in people with MS.

DATA COLLECTION AND ANALYSIS

One reviewer extracted study characteristics and study data from included RCTs, and two other reviewers independently cross-checked all extracted data. Two review authors independently assessed risk of bias with the Cochrane 'Risk of bias' assessment tool. When at least two RCTs provided data for the same type of outcome, we performed meta-analyses. We assessed the certainty of the evidence according to the GRADE approach.

MAIN RESULTS

We included six RCTs, comprising 195 participants with MS. Two RCTs investigated inspiratory muscle training with a threshold device; three RCTs, expiratory muscle training with a threshold device; and one RCT, regular breathing exercises. Eighteen participants (˜ 10%) dropped out; trials reported no serious adverse events.We pooled and analyzed data of 5 trials (N=137) for both inspiratory and expiratory muscle training, using a fixed-effect model for all but one outcome. Compared to no active control, meta-analysis showed that inspiratory muscle training resulted in no significant difference in maximal inspiratory pressure (mean difference (MD) 6.50 cmH₂O, 95% confidence interval (CI) -7.39 to 20.38, P = 0.36, I² = 0%) or maximal expiratory pressure (MD -8.22 cmH₂O, 95% CI -26.20 to 9.77, P = 0.37, I² = 0%), but there was a significant benefit on the predicted maximal inspiratory pressure (MD 20.92 cmH₂O, 95% CI 6.03 to 35.81, P = 0.006, I² = 18%). Meta-analysis with a random-effects model failed to show a significant difference in predicted maximal expiratory pressure (MD 5.86 cmH₂O, 95% CI -10.63 to 22.35, P = 0.49, I² = 55%). These studies did not report outcomes for health-related quality of life.Three RCTS compared expiratory muscle training versus no active control or sham training. Under a fixed-effect model, meta-analysis failed to show a significant difference between groups with regard to maximal expiratory pressure (MD 8.33 cmH₂O, 95% CI -0.93 to 17.59, P = 0.18, I² = 42%) or maximal inspiratory pressure (MD 3.54 cmH₂O, 95% CI -5.04 to 12.12, P = 0.42, I² = 41%). One trial assessed quality of life, finding no differences between groups.For all predetermined secondary outcomes, such as forced expiratory volume, forced vital capacity and peak flow pooling was not possible. However, two trials on inspiratory muscle training assessed fatigue using the Fatigue Severity Scale (range of scores 0-56 ), finding no difference between groups (MD, -0.28 points, 95% CI-0.95 to 0.39, P = 0.42, I² = 0%). Due to the low number of studies included, we could not perform cumulative meta-analysis or subgroup analyses. It was not possible to perform a meta-analysis for adverse events, no serious adverse were mentioned in any of the included trials.The quality of evidence was low for all outcomes because of limitations in design and implementation as well as imprecision of results.

AUTHORS' CONCLUSIONS

This review provides low-quality evidence that resistive inspiratory muscle training with a resistive threshold device is moderately effective postintervention for improving predicted maximal inspiratory pressure in people with mild to moderate MS, whereas expiratory muscle training showed no significant effects. The sustainability of the favourable effect of inspiratory muscle training is unclear, as is the impact of the observed effects on quality of life.

Design of the ExCersion-VCI study: The effect of aerobic exercise on cerebral perfusion in patients with vascular cognitive impairment

There is evidence for a beneficial effect of aerobic exercise on cognition, but underlying mechanisms are unclear. In this study, we test the hypothesis that aerobic exercise increases cerebral blood flow (CBF) in patients with vascular cognitive impairment (VCI). This study is a multicenter single-blind randomized controlled trial among 80 patients with VCI. Most important inclusion criteria are a diagnosis of VCI with Mini-Mental State Examination ≥22 and Clinical Dementia Rating ≤0.5. Participants are randomized into an aerobic exercise group or a control group. The aerobic exercise program aims to improve cardiorespiratory fitness and takes 14 weeks, with a frequency of three times a week. Participants are provided with a bicycle ergometer at home. The control group receives two information meetings. Primary outcome measure is change in CBF. We expect this study to provide insight into the potential mechanism by which aerobic exercise improves hemodynamic status.

Exercise therapy for fatigue in multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system affecting an estimated 1.3 million people worldwide. It is characterised by a variety of disabling symptoms of which excessive fatigue is the most frequent. Fatigue is often reported as the most invalidating symptom in people with MS. Various mechanisms directly and indirectly related to the disease and physical inactivity have been proposed to contribute to the degree of fatigue. Exercise therapy can induce physiological and psychological changes that may counter these mechanisms and reduce fatigue in MS.

OBJECTIVES

To determine the effectiveness and safety of exercise therapy compared to a no-exercise control condition or another intervention on fatigue, measured with self-reported questionnaires, of people with MS.

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Trials Specialised Register, which, among other sources, contains trials from: the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 10), MEDLINE (from 1966 to October 2014), EMBASE (from 1974 to October 2014), CINAHL (from 1981 to October 2014), LILACS (from 1982 to October 2014), PEDro (from 1999 to October 2014), and Clinical trials registries (October 2014). Two review authors independently screened the reference lists of identified trials and related reviews.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) evaluating the efficacy of exercise therapy compared to no exercise therapy or other interventions for adults with MS that included subjective fatigue as an outcome. In these trials, fatigue should have been measured using questionnaires that primarily assessed fatigue or sub-scales of questionnaires that measured fatigue or sub-scales of questionnaires not primarily designed for the assessment of fatigue but explicitly used as such.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the articles, extracted data, and determined methodological quality of the included trials. Methodological quality was determined by means of the Cochrane 'risk of bias' tool and the PEDro scale. The combined body of evidence was summarised using the GRADE approach. The results were aggregated using meta-analysis for those trials that provided sufficient data to do so.

MAIN RESULTS

Forty-five trials, studying 69 exercise interventions, were eligible for this review, including 2250 people with MS. The prescribed exercise interventions were categorised as endurance training (23 interventions), muscle power training (nine interventions), task-oriented training (five interventions), mixed training (15 interventions), or 'other' (e.g. yoga; 17 interventions). Thirty-six included trials (1603 participants) provided sufficient data on the outcome of fatigue for meta-analysis. In general, exercise interventions were studied in mostly participants with the relapsing-remitting MS phenotype, and with an Expanded Disability Status Scale less than 6.0. Based on 26 trials that used a non-exercise control, we found a significant effect on fatigue in favour of exercise therapy (standardized mean difference (SMD) -0.53, 95% confidence interval (CI) -0.73 to -0.33; P value < 0.01). However, there was significant heterogeneity between trials (I(2) > 58%). The mean methodological quality, as well as the combined body of evidence, was moderate. When considering the different types of exercise therapy, we found a significant effect on fatigue in favour of exercise therapy compared to no exercise for endurance training (SMDfixed effect -0.43, 95% CI -0.69 to -0.17; P value < 0.01), mixed training (SMDrandom effect -0.73, 95% CI -1.23 to -0.23; P value < 0.01), and 'other' training (SMDfixed effect -0.54, 95% CI -0.79 to -0.29; P value < 0.01). Across all studies, one fall was reported. Given the number of MS relapses reported for the exercise condition (N = 25) and non-exercise control condition (N = 26), exercise does not seem to be associated with a significant risk of a MS relapse. However, in general, MS relapses were defined and reported poorly.

AUTHORS' CONCLUSIONS

Exercise therapy can be prescribed in people with MS without harm. Exercise therapy, and particularly endurance, mixed, or 'other' training, may reduce self reported fatigue. However, there are still some important methodological issues to overcome. Unfortunately, most trials did not explicitly include people who experienced fatigue, did not target the therapy on fatigue specifically, and did not use a validated measure of fatigue as the primary measurement of outcome.

Effects of multidisciplinary rehabilitation on chronic fatigue in multiple sclerosis: a randomized controlled trial

BACKGROUND

Several rehabilitation programmes aim at reducing the impact of fatigue in MS patients. Acute and chronic fatigue should require different management.

OBJECTIVES

To assess the effects of individually tailored, multidisciplinary outpatient rehabilitation (MDR) on chronic fatigue.

METHODS

Forty-eight ambulatory MS patients with chronic fatigue were randomized to MDR or to MS-nurse consultation. Fatigue was assessed by the Checklist Individual Strength (CIS-20R). Secondary outcomes included the Modified Fatigue Impact Scale, Fatigue Severity Scale, Functional Independence Measure, Disability and Impact Profile (DIP), Multiple Sclerosis Impact Scale and the Impact on Participation and Autonomy (IPA).

RESULTS

The primary outcome measure CIS-20R overall score showed no significant differences between groups at 12 weeks (P = 0.39) and 24 weeks follow-up (P = 0.14), nor for subscales (t = 12 and t = 24, 0.19≤P≤0.88). No significant within-group effects were found for both groups with respect to the primary (0.57≤p≤0.97) and secondary (0.11≤p≤0.92) outcome measures from baseline to 12 or 24 weeks.

CONCLUSION

Multidisciplinary rehabilitation was not more effective in terms of reducing self-reported fatigue in MS patients compared to MS-nurse consultation. Our results suggest that chronic fatigue in patients with MS may be highly invariant over time, irrespective of interventions.

TRIAL REGISTRATION

controlled-trials.com ISRCTN05017507.

Do Patients With Multiple Sclerosis Show Different Daily Physical Activity Patterns From Healthy Individuals?

Background Reduced physical activity is an important consequence of multiple sclerosis (MS). However, little is known about the real quantity and type of daily activities that people with MS perform in their own home environment.

OBJECTIVE

To gain insight into differences in the amount and patterns of physical activities performed over a 24-hour period in the own community environment of patients with MS and healthy individuals. Methods A total of 43 ambulatory patients with MS and 26 age- and gender-matched healthy individuals participated. Physical activity recorded with an ambulatory activity monitor was classified into postures and motions. Multilevel analyses were conducted to investigate whether the pattern of physical activities across daily periods (morning, afternoon, and evening) was dependent on the group (MS vs healthy individuals). Results Results showed a significant overall lower amount of dynamic activity as compared with a group of healthy controls (P < .001). Patients with MS started with lower physical activity levels already in the morning (P < .001), and this difference persisted in the afternoon (P = .002) and evening (P = .032). Conclusion Activity monitoring gives insight into real-world daily physical behavior. Our findings suggest that patients with MS may adopt a deliberate anticipatory strategy of lower activity in the morning, which persists throughout the day. Future trials evaluating daily changes in physical activity behavior should simultaneously sample self-report measures of energy levels and fatigue to elucidate the complex interaction between symptoms and physical activity.

Reproducibility of the Dutch version of the Western Ontario rotator cuff Index

BACKGROUND

The Western Ontario Rotator Cuff Index (WORC) is a disease-specific shoulder questionnaire, originally developed at the University of Western Ontario, to measure quality of life in patients with rotator cuff disease (RCD). The aim of the present study was to cross-culturally adapt the WORC for use in the Netherlands and to evaluate the reproducibility in patients with RCD.

MATERIALS AND METHODS

The WORC was translated into Dutch according to leading guidelines in the literature, and 52 patients with RCD completed the questionnaire twice within 2 weeks. The Cronbachs α and the intraclass correlation coefficient (ICC) were calculated, Bland-Altman analysis was applied, and the smallest detectable change (SDC) and reliable change index (RCI) were determined.

RESULTS

The Cronbachs α ranged from 0.91 to 0.97 for the total WORC score and for the 5 domains. High ICCs were found for the WORC total score (0.94) and for the separate domains (range, 0.85-0.91). Bland-Altman analyses showed no systematic differences between assessments. SDC was 355.7 for the total WORC score, varying from 80.4 to 148.0 for the domains, resulting in RCIs of 16.9% for the total WORC score and 24.7% to 30.2% for the domains.

CONCLUSIONS

The results of the present study suggest good reproducibility of the Dutch version of the WORC in Dutch-speaking patients with RCD. Additional research on the validation of the Dutch version of the WORC is required in the near future.

Self-report fatigue questionnaires in multiple sclerosis, Parkinson's disease and stroke: a systematic review of measurement properties

PURPOSE

To critically appraise, compare and summarize the measurement properties of self-report fatigue questionnaires validated in patients with multiple sclerosis (MS), Parkinson's disease (PD) or stroke.

METHODS

MEDLINE, EMBASE, PsycINFO, CINAHL and SPORTdiscus were searched. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to assess the methodological quality of studies. A qualitative data synthesis was performed to rate the measurement properties for each questionnaire.

RESULTS

Thirty-eight studies out of 5,336 records met the inclusion criteria, evaluating 31 questionnaires. Moderate evidence was found for adequate internal consistency and structural validity of the Fatigue Scale for Motor and Cognitive functions (FSMC) and for adequate reliability and structural validity of the Unidimensional Fatigue Impact Scale (U-FIS) in MS.

CONCLUSIONS

We recommend the FSMC and U-FIS in MS. The Functional Assessment of Chronic Illness Therapy Fatigue subscale (FACIT-F) and Fatigue Severity Scale (FSS) show promise in PD, and the Profile of Mood States Fatigue subscale (POMS-F) for stroke. Future studies should focus on measurement error, responsiveness and interpretability. Studies should also put emphasis on providing input for the theoretical construct of fatigue, allowing the development of questionnaires that reflect generic and disease-specific symptoms of fatigue.

The association between perceived fatigue and actual level of physical activity in multiple sclerosis

BACKGROUND

Both fatigue and reduced physical activity are important consequences of multiple sclerosis (MS). However, their mutual association is poorly understood.

OBJECTIVE

The objective of the study was to determine the relation between perceived fatigue and home-based recording of motor activity in patients with MS.

METHODS

Found associations were checked for confounding by age, Expanded Disability Status Scales (EDSS), disease duration, sub-type of MS, anxiety, and depression. Forty-three ambulatory patients with MS were recruited. Ambulatory physical activity was recorded for 24 hours. Fatigue was assessed with the Fatigue Severity Scale (FSS), the Modified Fatigue Impact Scale (MFIS) and the Checklist Individual Strength (CIS20R). Linear regression was applied after which potential confounding factors were introduced in a multivariate regression model.

RESULTS

No significant associations between physical activity and fatigue scores were found, except for the MFIS sub-scale 'physical activity' (ß(physical_activity) [ß(pa)] = -0.044; SE = 0.020). The association between physical activity and the FSS score was distorted by age, MS-type, anxiety and depression and the association between physical activity and the MFIS score by age and depression. The inverse association between MFIS sub-scale 'physical activity' and physical activity was significantly strengthened by adjusting for age (ß(pa) = - 0.052; SE = 0.019), sub-type of MS (ß(pa) = - 0.048; SE = 0.020), anxiety (ß(pa) = - 0.070; SE = 0.023) and depression (ß(pa) = - 0.083; SE = 0.023).

CONCLUSIONS

In MS, there is no, or at best a weak association between severity of perceived fatigue and physical activity. Depending on the fatigue questionnaire used, patient characteristics such as age, type of MS, depression and anxiety are factors that may affect this relationship.

Measuring fatigue in patients with multiple sclerosis: reproducibility, responsiveness and concurrent validity of three Dutch self-report questionnaires

PURPOSE

To determine the reproducibility, responsiveness and concurrent validity of Dutch versions of the Fatigue Severity Scale (FSS), Modified Fatigue Impact Scale (MFIS), and Checklist Individual Strength (CIS20R) in patients with multiple sclerosis (MS).

METHOD

Forthy-three ambulatory patients with MS (mean age 48.7 years; SD 7 years; 30 women; median Expanded Disability Status Scale score 3.5) completed the questionnaires twice within 1 week. The Intraclass Correlation Coefficients (ICCs), Bland and Altman analysis, the smallest detectable change (SDC) and the minimal detectable change (MDC) were calculated. Concurrent validity was determined by Pearson's correlation coefficients.

RESULTS

ICCs ranged from 0.76 (FSS), to 0.85 (MFIS) to 0.81 (CIS20R). Bland and Altman analysis showed no significant systematic differences between assessments. MDCs were 20.7% (FSS), 19.23% (MFIS), and 17.7% (CIS20R). Pearson correlation coefficients were r = 0.66 (FSS-MFIS), r = 0.54 (MFIS-CIS20R) and r = 0.42 (CIS20R-FSS).

CONCLUSION

Despite good test-retest reliability of FSS, MFIS and the CIS20R, the present study shows that fatigue questionnaires are not very responsive for change in patients with MS. This finding suggests that future trials should monitor profiles of fatigue by repeated measurements rather than pre-post assessments alone. The moderate associations suggest that the three questionnaires largely measure different aspects of perceived fatigue.

How reproducible is home-based 24-hour ambulatory monitoring of motor activity in patients with multiple sclerosis?

OBJECTIVE

To determine the reproducibility of 24-hour monitoring of motor activity in patients with multiple sclerosis (MS).

DESIGN

Test-retest design; 6 research assistants visited the participants twice within 1 week in the home situation.

SETTING

General community.

PARTICIPANTS

A convenience sample of ambulatory patients (N=43; mean age ± SD, 48.7±7.0y; 30 women; median Expanded Disability Status Scale scores, 3.5; interquartile range, 2.5) were recruited from the outpatient clinic of a university medical center.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Dynamic activity and static activity parameters were recorded by using a portable data logger and classified continuously for 24 hours. Reproducibility was determined by calculating intraclass correlation coefficients (ICCs) for test-retest reliability and by applying the Bland-Altman method for agreement between the 2 measurements. The smallest detectable change (SDC) was calculated based on the standard error of measurement.

RESULTS

Test-retest reliability expressed by the ICC(agreement) was .72 for dynamic activity, .74 for transitions, .77 for walking, .71 for static activity, .67 for sitting, .62 for standing, and .55 for lying. Bland and Altman analysis indicated no systematic differences between the first and second assessment for dynamic and static activity. Measurement error expressed by the SDC was 1.23 for dynamic activity, 66 for transitions, .99 for walking, 1.52 for static activity, 4.68 for lying, 3.95 for sitting, and 3.34 for standing.

CONCLUSIONS

The current study shows that with 24-hour monitoring, a reproducible estimate of physical activity can be obtained in ambulatory patients with MS.

Postural control of the trunk during unstable sitting in Parkinson's disease

Postural instability and falls, both common in Parkinson's disease (PD), have been related to altered trunk control. In this study, we investigated dynamic trunk control with subjects balancing on a seat mounted on a hemisphere, for up to 15s in five trials. We compared eight PD patients with a fall-history, eight without a fall-history, and eight matched healthy subjects. The number of trials completed without balance loss and the time to balance loss were significantly lower in PD patients as compared to healthy controls, whereas the PD patients with a fall-history did not perform significantly less than the patients without a fall-history. Multivariate analysis of variance showed significant effects of group on movements of the center of pressure (CoP) under the seat with the largest amplitudes among the PD fallers and the smallest amplitudes among the healthy controls. Univariate analyses revealed that this effect was mainly based on a significantly larger root mean square CoP displacement in the medio-lateral direction, with significant post hoc differences between all three groups. Trunk angular deviations were significantly smaller among PD patients than controls. Finally, both CoP movements and trunk movements had a significantly lower frequency content and were thus slower in PD patients than in controls, except for anterior-posterior CoP movements. The results show that trunk control is affected in PD and suggest that these changes may be related to postural instability and fall risk.

Exercise therapy for multiple sclerosis

BACKGROUND

No intervention has proven effective in modifying long-term disease prognosis in Multiple Sclerosis (MS) but exercise therapy is considered to be an important part of symptomatic and supportive treatment for these patients.

OBJECTIVES

To assess the effectiveness of exercise therapy for patients with MS in terms of activities of daily living and health-related quality of life.

SEARCH STRATEGY

We searched the Cochrane MS Group Specialised Register (searched: March 2004), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2004), MEDLINE (from 1966 to March 2004), EMBASE (from 1988 to March 2004 ), CINAHL (from 1982 to March 2004), PEDro (from 1999 to March 2004) . Manual search in the journal 'Multiple Sclerosis' and screening of the reference lists of identified studies and reviews. We also searched abstracts published in proceedings of conferences.

SELECTION CRITERIA

Randomised Controlled Trials (RCTs) that reported on exercise therapy for adults with MS, not presently experiencing an exacerbation; outcomes that include measures of activity limitation or health-related quality of life or both.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and methodological quality of the included trials. Disagreements were resolved by discussion. The results were analysed using a best-evidence synthesis based on methodological quality.

MAIN RESULTS

Nine high-methodological-quality RCTs(260 participants) met the inclusion criteria. Six trials focussed on comparison of exercise therapy versus no exercise therapy, whereas three trials compared two interventions that both met our definition of exercise therapy. Best evidence synthesis showed strong evidence in favour of exercise therapy compared to no exercise therapy in terms of muscle power function, exercise tolerance functions and mobility-related activities. Moderate evidence was found for improving mood. No evidence was observed for exercise therapy on fatigue and perception of handicap when compared to no exercise therapy. Finally, no evidence was found that specific exercise therapy programmes were more successful in improving activities and participation than other exercise treatments. No evidence of deleterious effects of exercise therapy was described in included studies.

AUTHORS' CONCLUSIONS

The results of the present review suggest that exercise therapy can be beneficial for patients with MS not experiencing an exacerbation. There is an urgent need for consensus on a core set of outcome measures to be used in exercise trials. In addition, these studies should experimentally control for 'dose' of treatment, type of MS and should include sufficient contrast between experimental and control groups.

Effects of overloading of the lower hemiparetic extremity on walking speed in chronic stroke patients: A pilot study

The objective of this pilot study was to investigate the carry-over effects on comfortable walking speed after overloading the lower hemiparetic extremity in chronic stroke patients. A single subject research study was conducted using a withdrawal design (A-B-A-B-A) on three patients with ischaemic middle cerebral artery infarction. Chronic stroke patients were recruited with stage 3 or 4 Fugl-Meyer scores in the lower extremity and the ability to ambulate independently without walking aids. Based on this withdrawal design, the daily procedure included walking at comfortable speeds 5x10 meters during the A_1 phase and 3x10 meters during all subsequent phases. This procedure was repeated for five consecutive days. Two lbs (B_1) and 6 lbs (B_2) weight cuffs were attached to the distal lower hemiparetic extremity and randomized over the two B phases. Control (A_1, A_2, A_3) and intervention (B_1, B_2) phases were alternated with brief resting periods. Mean comfortable walking speed for 10 meters constituted the outcome variable. All patients showed significant differences between phases (chi^2 = 34.187; p<0.001). However, with the exception of a carry-over effect between the A_1 (0.86 m/sec) and A_2 (0.89~m/sec) phases in one subject (p=0.043) no significant carry-over effects were found on ensuing A_2 and A_3 control phases. Although gradual improvements in comfortable walking speed between subsequent days were found the present pilot study did not demonstrate favorable group effects on comfortable walking speed as a result of limb overloading.

Retroactive interference effects of mentally imagined movement speed

In two retroactive interference experiments, we assessed the effect of mentally imagined movement speed on subsequent motor performance. All participants performed a sequential motor action at three speeds during a baseline test and a retention test. During the retention interval of Experiment 1, the participants (n = 50) physically performed the action at a slow speed, physically performed it at a fast speed, imagined it at a slow speed, imagined it at a fast speed, or performed a no-practice control task. In Experiment 2, the participants (n = 24) imagined the movement, overtly vocalized words, or both, all at a slow speed. The results revealed that the speed of the imagined motor action affected the speed of subsequent performance in the retention test and that imagery and physical practice were functionally equivalent. The results are consistent with Lang's bio-informational theory.