Gait Abnormalities in Multiple Sclerosis: Pathogenesis, Evaluation, and Advances in Treatment

Foot Drop in Orthopaedic Surgery: Anatomy, Etiology, Differential Diagnosis, and Treatment

» Foot drop is a problem encountered by orthopaedic surgeons from various subspecialties. The etiology can vary from the lower extremity to the spine and can be managed conservatively depending on functional limitations. Common nonsurgical interventions include ankle-foot orthoses, physical therapy, electrical nerve stimulation, and activity modification. Surgical options vary between nerve decompression and lower extremity tendon transfers. The purpose of this review was to provide an overview of the anatomy, etiology, diagnoses, and treatment options of foot drop.

Effect of an Internet-Based Pilates Telerehabilitation Intervention in People With Multiple Sclerosis: Protocol for a Randomized Controlled Trial

BACKGROUND

Physical activity (PA) has been recommended in multiple sclerosis (MS) to maintain good physical fitness and mental health, reduce the severity of symptoms and risk of relapse, and improve quality of life. Pilates has been suggested as an ideal PA to manage physical, cognitive, and psychological symptoms of MS and a useful method to maintain and improve balance and gait.

OBJECTIVE

This paper presents the protocol for a study that aims to evaluate the efficacy on the physical domain (specifically balance and gait) of a home-based, self-managed PA intervention delivered through the MS-FIT exergame (HELAGLOBE Società a responsabilità limitata). In addition, measures of cognitive performance, quality of life, and well-being will be considered.

METHODS

This is a 2-arm, multicenter, randomized controlled trial with 3 assessment points (baseline, 12 weeks postintervention, and 6 weeks follow-up). People with MS with mild disability, low risk of falling, preserved cognitive functions, and low anxiety and depression are potential eligible participants. The experimental group (MS-FIT) will self-administer the MS-FIT exergame at home in addition to their leisure-time physical activities. MS-FIT is an internet- and Pilates-based tool that uses the Microsoft Kinect Sensor V2. Participants in the control group will only have access to their leisure-time physical activities. Participants in the MS-FIT group will train at home with MS-FIT for 12 weeks and will be required to perform the exercises for a total of 30 minutes/day for at least 3 days/week. The primary outcome is the Timed Up and Go, a test designed to assess walking. We will also administer additional tests for motor function (visual analog scale 0-10, Timed 25-Foot Walk, Ambulation Index, 2-minute walk test, Twelve Item Multiple Sclerosis Walking Scale, Nine-Hole Peg Test), cognition (Brief International Cognitive Assessment for Multiple Sclerosis), fatigue (Modified Fatigue Impact Scale), quality of life (Multiple Sclerosis Quality of Life-54), well-being (Psychological Well-Being Scales), and PA (International Physical Activity Questionnaire and Minnesota Leisure Time Physical Activity Questionnaire). Acceptance and satisfaction with the intervention received (Client Satisfaction Questionnaire and an adapted version of the Tele-healthcare Satisfaction Questionnaire - Wearable Technology) and subjective impressions of changes in performance (Patients' Global Impression of Change) will also be assessed.

RESULTS

Recruitment for the trial started on March 16, 2022, and the first participant was randomized the same day. Data analysis and results are expected to be published in 2025.

CONCLUSIONS

Pilates has proven beneficial in several neurological diseases such as MS. With this study, we will provide evidence for the use in clinical practice of a digital tool for self-administered Pilates exercises at home as a complement to rehabilitation and for the continuity of care in MS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04011579; https://tinyurl.com/2p9n4d2t.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/58026.

Effect of individual physiotherapy and telerehabilitation on back pain and quality of life in people with multiple sclerosis with mild and moderate disability

BACKGROUND

Back pain is a common but often underestimated symptom of patients with MS that can negatively influence their quality of life. However there are only limited number of studies comparing the effect of different types of exercise and use of telerehabilitation on back pain in MS. Therefore, the aim of the study is to compare whether telerehabilitation alone is as effective as conventional outpatient physiotherapy followed by online exercise.

METHODS

This single-centre intervention study compared the impact of different individual outpatient physiotherapy treatments (Group 1 - individual Pilates exercise or Group 2 - strength training) and telerehabilitation alone (individual Pilates exercise with a physiotherapist online). The primary objective was to compare the effect of interventions on back pain (assessed using the Visual Analogue Scale and McGill Pain Questionnaire) and quality of life (Multiple Sclerosis Quality of Life-54). Secondary aims were to compare effect of interventions on spine and thorax mobility, functional mobility (assessed using the Timed 25 foot walk test, Six Spot Step test), respiratory muscle strenght and patient reported outcomes (assessed using he Hospital Anxiety and Depression Scale, Fatigue Severity Scale).

RESULTS

45 people with MS were enrolled in the study (3 men, age:48.4± SD 11,5, Expanded Disability Status Scale (EDSS): 3.3±SD 1,1) and 36 people completed the entire exercise program. All types of exercise intervention showed a positive effect on the reduction of back pain, quality of life and fatigue. The interventions also increased respiratory muscle strength and increased thorax mobility, but we did not find any effect of interventions on gait tests. There were no difference in effect on outcome measures between different types of exercise interventions.

CONCLUSION

Telerehabilitation, involving individual exercise sessions with a physiotherapist, has a comparable effect on reducing back pain, improving quality of life, and enhancing respiratory muscle strength in people with MS as individual Pilates or strength training.

Selective retinoid X receptor agonism promotes functional recovery and myelin repair in experimental autoimmune encephalomyelitis

Evidence that myelin repair is crucial for functional recovery in multiple sclerosis (MS) led to the identification of bexarotene (BXT). This clinically promising remyelinating agent activates multiple nuclear hormone receptor subtypes implicated in myelin repair. However, BXT produces unacceptable hyperlipidemia. In contrast, IRX4204 selectively activates the retinoid X receptor (RXR). Given compelling links between RXR activation and increased myelin repair, we employed IRX4204 to investigate the impact of RXR agonism alone on functional recovery in mice subjected to experimental autoimmune encephalomyelitis (EAE). Since gait deficits are common in MS, we used machine learning to obtain highly sensitive and reliable measurements of sagittal hindleg joint movements for mice walking on a treadmill. IRX4204 not only blocked the progressive loss of knee and ankle movements but also reversed joint movement impairments in EAE mice. Our biochemical, transcriptional and histological measurements in spinal cord suggest these gait improvements reflect increased axon survival and remyelination and reduced inflammation. Using microglia, astrocytes and oligodendrocyte progenitor cells, we present additional data suggesting that IRX4204 may act on multiple glial subtypes to orchestrate myelin repair. These results inform the discovery of restorative neural therapeutics for MS by demonstrating that selective RXR agonism is sufficient for effective myelin repair. Moreover, our findings support the therapeutic potential of IRX4204 to promote functional recovery in MS.

Sleep disturbances and progression of mobility disability: Longitudinal findings from the Nurses' Health Study

Objective

To examine longitudinal associations between self-reported sleep disturbances and mobility disability progression among women, including subgroups with multiple sclerosis (MS), diabetes, and osteoarthritis (OA).

Methods

Prospective cohort study using data from Nurses' Health Study long-form questionnaires (2008, 2012, 2014, 2016). Logistic regression was used to quantify associations between sleep-related variables at baseline and subsequent increase in mobility disability.

Results

Of 70,303 women (mean age 73), 392 had MS, 7,302 had diabetes, and 24,099 had OA. Between 2008-2016, mobility disability increased by 16.9 % overall, 27.8 % in the MS subgroup, 27.0 % in the diabetes subgroup, and 23.7 % in the OA subgroup. Known/suspected obstructive sleep apnea was significantly associated with an increase in mobility disability between 2008 and 2016, overall (OR:1.4, 95 %CI:1.2,1.5), and in the diabetes (OR:1.5, 95 %CI:1.2,1.9) and OA subgroups (OR:1.2, 95 %CI:1.0,1.4), but not in the MS subgroup (OR:2.3, 95 %CI:0.6,8.9); however, across 2012-2016, this association was significant for MS (OR:4.0, 95 % CI:1.0,16.1). Suboptimal sleep duration was significantly associated with increased odds of mobility disability progression overall, but not in disease subgroups. Perception of adequate sleep was associated with lower odds of mobility disability progression overall (OR:0.82, 95 %CI:0.78,0.87) and for the OA subgroup (OR:0.83, 95 % CI:0.76,0.91). Excessive daytime sleepiness was associated with mobility disability progression overall (OR:1.2, 95 %CI:1.1,1.4) and for the OA subgroup (OR:1.2, 95 %CI:1.0,1.4).

Conclusions

Prevalent sleep disturbances could increase disability progression among women. Chronic disease populations may be uniquely vulnerable. Informed by these data, future research could offer new insight into sleep-based strategies to ameliorate mobility decline.

Effect of task difficulty on dual-task cost during dual-task walking in people with multiple sclerosis

BACKGROUND

Cognitive-motor dual-task walking results a decrease in walking performance of patients with multiple sclerosis (PwMS) and it is known as dual-task cost (DTC). However, there is a lack of evidence about the effects of dual-tasks with hierarchical difficulty on DTC in PwMS.

RESEARCH QUESTION

This study aimed to investigate the effect of task difficulty on DTC during cognitive-motor dual-task walking in people with multiple sclerosis (PwMS).

METHODS

32 PwMS and 32 healthy controls were included. The 6-meter walking test (6-Meter WT) with comfortable speed was used as single-task walking condition. For dual-task conditions, walking tasks and cognitive tasks at two difficulty levels (simple and difficult) were combined and DTC for four cognitive-motor dual-task walking conditions as simple motor-simple cognitive (SM-SC), simple motor-difficult cognitive (SM-DC), difficult motor-simple cognitive (DM-SC) and difficult motor-difficult cognitive (DM-DC) were calculated. The 6-Meter WT was used also for simple dual-task walking task. The 6-Meter WT was applied by walking in a narrow base condition for creating a difficult dual-task walking task. For cognitive task difficulty, participants were asked to count backwards by 3 as simple cognitive task and by 7 as difficult cognitive task.

RESULTS

DTC was higher in PwMS than control subjects. DTC in all conditions were different (SM-SC

CONCLUSION

The results suggest that task difficulty affects the magnitude of DTC during cognitive-motor dual-task walking in PwMS. Moreover, difficult walking tasks combined with simple cognitive tasks result greater DCT on walking than simple walking tasks combined with difficult cognitive tasks.

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Key Words

• Dual-task
• Motor-cognitive tasks
• Multiple sclerosis
• Task difficulty
• Walking

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MESH Headings

• Humans
• Male
• Female
• Multiple Sclerosis/physiopathology
• Walking/physiology
• Adult
• Middle Aged
• Cognition/physiology
• Psychomotor Performance/physiology
• Task Performance and Analysis
• Case-Control Studies

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Affiliation(s)

Çağrı Gülşen Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Eskişehir Osmangazi University, Eskişehir, Turkey.
Fatih Söke Gulhane Faculty of Physiotherapy and Rehabilitation, University of Health Sciences, Ankara, Turkey
Fatma Aydin Diskapi Yildirim Beyazit Teaching and Research Hospital, Department of Neurology, University of Health Sciences, Ankara, Turkey
Elvan Özcan Gülşen Yunus Emre Vocational School, Department of Health Care Services, Program in Geriatric Care, Anadolu University, Eskişehir, Turkey
Öznur Yilmaz Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
Bilge Koçer Diskapi Yildirim Beyazit Teaching and Research Hospital, Department of Neurology, University of Health Sciences, Ankara, Turkey
Etem Çürük Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Korkut Ata University, Osmaniye, Turkey
Şeref Demirkaya Gulhane Faculty of Medicine, Department of Neurology, University of Health Sciences, Ankara, Turkey
Canan Yücesan Faculty of Medicine, Department of Neurology, Ankara University, Ankara, Turkey

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Unobtrusive measurement of gait parameters using seismographs: An observational study

Analyzing irregularities in walking patterns helps detect human locomotion abnormalities that can signal health changes. Traditional observation-based assessments have limitations due to subjective biases and capture only a single time point. Ambient and wearable sensor technologies allow continuous and objective locomotion monitoring but face challenges due to the need for specialized expertise and user compliance. This work proposes a seismograph-based algorithm for quantifying human gait, incorporating a step extraction algorithm derived from mathematical morphologies, with the goal of achieving the accuracy of clinical reference systems. To evaluate our method, we compared the gait parameters of 50 healthy participants, as recorded by seismographs, and those obtained from reference systems (a pressure-sensitive walkway and a camera system). Participants performed four walking tests, including traversing a walkway and completing the timed up-and-go (TUG) test. In our findings, we observed linear relationships with strong positive correlations (R2 > 0.9) and tight 95% confidence intervals for all gait parameters (step time, cycle time, ambulation time, and cadence). We demonstrated that clinical gait parameters and TUG mobility test timings can be accurately derived from seismographic signals, with our method exhibiting no significant differences from established clinical reference systems.

The relationship between sleep quality and gait in people with multiple sclerosis: A pilot study

Background

Gait deficits are common among people with multiple sclerosis (PwMS). Therefore, investigating factors that may influence walking in PwMS is important. Previous studies in older adults and other neurological populations demonstrated the relationship between sleep quality and gait performance. Despite the fact that the prevalence of poor sleep quality is very high among PwMS, little is known about the effect of sleep quality on gait among PwMS.

Objective

This study aimed to explore the relationship between sleep quality and gait performance in PwMS.

Methods

Forty-one PwMS participated in the study between February 2019 and December 2019. Participants were asked to walk at a self-selected speed over 10 m with an inertial measurement unit (IMU) attached over the back. Walking speed, step length (left and right), and step time were calculated. Sleep was estimated objectively using a wrist-worn triaxle-accelerometer; the derived parameters were sleep efficiency (SE) and the number of awakening after sleep onset (NASO).

Results

SE significantly correlated with step length (p = 0 . 02 ). Furthermore, the NASO significantly correlated with gait speed (p = 0 . 03 ), and step-time (p = 0 . 02 ). These correlations remained significant even after adjusting for age and disease duration.

Conclusion

We observed that when corrected for disease duration and age there were relationships between NASO and SE to gait parameters; these observations warrant further investigations.

Effects of non-pharmacological interventions on gait and balance of persons with Multiple Sclerosis: A narrative review

BACKGROUND

Multiple Sclerosis (MS) is among the most common reasons for disability in young adults. Mobility impairment, primarily related to gait and balance, is ranked as the preeminent concern among persons with MS (PwMS). Gait and balance dysfunction can directly affect the quality of life and activities of daily life in PwMS, hence the importance of effective treatment strategies. Previous studies have demonstrated the positive effect of various non-pharmacological rehabilitation methods, including physiotherapy and electrical stimulation, on gait and mobility in PwMS. Non-pharmacological methods can be tailored to the individual needs and abilities of each patient, allowing healthcare providers to create personalized training programs. Furthermore, these methods typically result in minimal or no side effects.

PURPOSE

This review provides a comprehensive overview of an array of non-pharmacological treatment approaches aimed at enhancing ambulatory performance in PwMS.

METHODS

We performed a narrative review of the original papers available in PubMed, investigating the effects of different nonmedical approaches on the gait and balance performance of the PwMS. Reviewed treatment approaches include "exercise, physical rehabilitation, dual-task (DT) rehabilitation, robot-assisted rehabilitation, virtual reality-assisted rehabilitation, game training, electrical stimulation devices, auditory stimulation, visual feedback, and shoe insoles".

RESULTS AND CONCLUSIONS

Eighty articles were meticulously reviewed. Our study highlights the positive effects of non-pharmacological interventions on patients' quality of life, reducing disability, fatigue, and muscle spasticity. While some methods, including exercise and physiotherapy, showed substantial promise, further research is needed to evaluate whether visual biofeedback and auditory stimulation are preferable over conventional approaches. Additionally, approaches such as functional electrical stimulation, non-invasive brain stimulation, and shoe insoles demonstrate substantial short-term benefits, prompting further investigation into their long-term effects. Non-pharmacological interventions can serve as a valuable complement to medication-based approaches.

Does non-invasive brain stimulation improve spatiotemporal gait parameters in people with multiple sclerosis? A systematic review and meta-analysis

BACKGROUND

Multiple sclerosis (MS) is a chronic autoimmune disease that causes progressive functional impairment, mainly in walking tasks. Noninvasive brain stimulation (NIBS) could influence the motor function and improving gait ability of patients.

OBJECTIVE

The aim was to analyze the effects of NIBS (transcranial direct current stimulation [tDCS] or transcranial magnetic stimulation [TMS] on functional locomotion in people with multiple sclerosis (PwMS).

METHODS

A search was conducted for randomized controlled trials published up to November 2023 comparing the application of NIBS versus a sham or control group. The primary outcome were spatiotemporal gait parameters and functional mobility. Two review authors independently assessed the risk of bias in the included studies, and we used the Grading of Recommendations Assessment, Development, and Evaluation methodology to rate the certainty of the evidence for each outcome. A meta-analysis was performed by pooling the appropriate data using RevMan Web.

RESULTS

A total of four clinical trials were included for metanalysis. We observed that there is no statistically significant difference in overall effect in gait speed (MD = 0.08; 95% CI: -0.08-0.24; p = 0.32), and cadence (MD = 0.22; 95% CI: -11.54-11.98; p = 0.97%) between groups. But there was a statistically significant difference in overall effect in stride length between groups (MD:0.19; 95% CI: 0.07-0.31; p = 0.002), mainly when the intervention performed by multiple sessions and associated with motor rehabilitation (MD = 0.29; 95% CI: 0.14-0.44; p = 0.0002).

CONCLUSIONS

tDCS applied by multiple session and combined with motor rehabilitation (i.e., aerobic and/or resistance training) can improve stride length in PwMS.

Agreement between video-based clinician-rated tools and patient-reported outcomes on gait assessment in individuals with multiple sclerosis

PURPOSE

To our knowledge, no studies compared the video-clinician-based tools and patient-reported questionnaires in assessing gait and balance in people with MS (pwMS). The present study investigated the correlation and agreement between video-clinician-based objective measurement tools and patient-reported outcome measures (PROMs) in gait and balance evaluation.

METHODS

A prospective cross-sectional study was conducted with 55 pwMS. Video analysis-based gait was evaluated by the Tinetti Gait Assessment (TGA), Gait Assessment and Intervention Tool (GAIT), and Functional Ambulation Classification Scale (FACS) by the clinician. Participants' self-reported gait and balance were assessed with the Multiple Sclerosis Walking Scale-12 (MSWS-12) and Activity-Specific Balance Confidence Scale (ABC).

RESULTS

There was a moderate positive correlation between ABC with TGA and FACS (r1: 0.552, r2: 0.510, p < 0.001). ABC was strongly correlated with GAIT (r: - 0.652, p < 0.001). A moderate positive correlation was observed between MSWS-12 with TGA and FACS (r1: - 0.575, r2: - 0.524, p < 0.001). In addition, there was a strong positive correlation between MSWS-12 and GAIT (r: - 0.652, p < 0.001). Clinician-rated tools and PROMs were within the agreement limits regarding the unstandardized beta values p < 0.001).

CONCLUSIONS

Clinician-based gait and balance tools demonstrate consistent results with PROMs in pwMS. Considering the low cost and practical use of PROMs, in cases where video-based clinician-based measurements cannot be provided (time, space, and technical inadequacies), questionnaires can provide concordant results at moderate and severe levels compared with objective tools.

Usability of the novel ankle training equipment with spring resistance-based plantar press exercises in the standing position: A focus on chronic stroke patients with hemiplegic gait

BACKGROUND

To improve gait disability in patients with chronic stroke, ankle muscle strengthening and calf muscle stretching exercises are required. However, currently available ankle training equipment limit ankle exercises based on the position. Recently developed ankle training equipment enables spring resistance-based plantar press exercises to be performed in the standing position with weight support.

OBJECTIVE

To conduct a usability test of the ankle training equipment in the standing position by stroke patients with hemiplegic gait and verify its effects on ankle movements.

METHODS

The ankle training equipment was applied to five patients with chronic stroke and hemiplegic gait. In the standing position, the patients performed forefoot and rearfoot press exercises in the affected side with a day's interval at 20 repetitions maximum (RM). During the exercises, surface electromyography (sEMG) was used to measure the maximum voluntary isometric contraction (%MVIC) of the leg muscles. The System Usability Scale (SUS) was used to assess the ankle training equipment. Wilcoxon signed-rank test was used to evaluate the differences in muscle activity between the two exercises.

RESULTS

Forefoot and rearfoot press exercises increased the %MVIC in the biceps femoris. Additionally, the tibialis anterior and medial gastrocnemius activity was significantly different between the two exercises. The SUS was 78.75% (SD 12.7).

CONCLUSION

The usability test of the passive-control foot press trainer (PFPT) that with improvements in the structure and functions for convenience, it could be commercialized. PFPT could be an alternative to the ankle rehabilitation robot that necessitates a sitting position.

Fampridine for gait imbalance in patients with multiple sclerosis (MS): a systematic review and meta-analysis

BACKGROUND

Gait imbalance is one of the frequent complications in subjects with multiple sclerosis (MS). Fampridine (4-aminopyridine) is a potassium-channel blocker that is administered for gait imbalance in MS. Different studies showed the effects of fampridine on gait status based on various tests in subjects with MS. Some showed significant improvement after treatment, and others did not. So, we designed this systematic review, and meta-analysis to estimate the pooled effects of fampridine on gait status in patients with MS.

METHODS

The main goal is the evaluation of times of different gait test pre and post fampridine treatment. Two independent expert researchers conducted a systematic and comprehensive search in PubMed, Scopus, EMBASE, Web of Science, and Google Scholar and also gray literature, including references of the references and conference abstracts. The search was done on September 16, 2022. Before-after studies trials reporting scores of the walking tests. We extracted data regarding the total number of participants, first author, publication year, country of origin, mean age, Expanded Disability Status Scale (EDSS), and the results of walking tests.

RESULTS

The literature search revealed 1963 studies; after deleting duplicates, 1098 studies remained. Seventy-seven full texts were evaluated. Finally, 18 studies were included for meta-analysis, while most of them were not placebo-controlled trials. The most frequent country of origin was Germany, and the mean age and EDSS ranged between 44 and 56 years and 4 and 6, respectively. The studies were published between 2013 and 2019. The pooled standardized mean difference (SMD) (after-before) of the MS Walking Scale (MSWS-12) was - 1.97 (95%CI: - 1.7, - 1.03) (I2 = 93.1%, P < 0.001). The pooled SMD (after-before) of the six-minute walk test (6MWT) was 0.49 (95%CI: 0.22, - 0.76) (I2 = 0%, P = 0.7). The pooled SMD (after-before) of T Timed 25-Foot Walk (T25FW) was - 0.99(95%CI: - 1.52, - 0.47) (I2 = 97.5%, P < 0.001).

CONCLUSION

This systematic review and meta-analysis show that fampridine improves gait imbalance in patients with MS.

Self-management interventions for people with multiple sclerosis: A systematic review and meta-analysis protocol

Background and Aims

Educational self-management interventions (SMI) have an important role in improving symptom management, preventing relapse of multiple sclerosis (MS) and promoting quality of life (QoL) of these patients; since there is little knowledge about overall effectiveness of MS self-management programs and which types of SMI improves the outcomes, this research aims to assess the efficacy of structured SMI in improving health outcomes in people with MS (PwMS) by synthesizing and compare outcomes from related randomized controlled trials.

Methods

In the present systematic review protocol, the keywords related to self-management and MS will be searched in electronic databases including (PubMed, Web of Science, Scopus, EMBASE, Cochrane Central Register of Controlled Trials [CENTRAL]), gray literature resources and key journals from 2000 to July 2023. Research-related articles will be collected and after removing duplicate articles, will be included in the study. In the screening step, titles and abstracts of articles will be reviewed and after deleting irrelevant articles, the full text of related articles will be evaluated independently by two researchers and data will be extracted from final articles and the findings will be categorized in an extraction table. Risk of bias will be assessed by using the Cochrane collaboration's tool. If possible, the data will be analyzed using random effect models and the statistical analysis will be performed using STATA software (version 14.2) developed by StataCorp.

Discussion

Comparative effectiveness of SMI is currently unknown. We will analyze outcome measures used to assess effectiveness of self-management education in improving QoL, depression, self-efficacy, pain, and fatigue. These findings will help identify the most promising components of SMIs, guiding targeted interventions for specific subpopulations, and facilitating the design of better interventions.

Can a passive unilateral hip exosuit diminish walking asymmetry? A randomized trial

BACKGROUND

Asymmetric walking gait impairs activities of daily living in neurological patient populations, increases their fall risk, and leads to comorbidities. Accessible, long-term rehabilitation methods are needed to help neurological patients restore symmetrical walking patterns. This study aimed to determine if a passive unilateral hip exosuit can modify an induced asymmetric walking gait pattern. We hypothesized that a passive hip exosuit would diminish initial- and post-split-belt treadmill walking after-effects in healthy young adults.

METHODS

We divided 15 healthy young adults evenly between three experimental groups that each completed a baseline trial, an adaptation period with different interventions for each group, and a post-adaptation trial. To isolate the contribution of the exosuit we compared a group adapting to the exosuit and split-belt treadmill (Exo-Sb) to groups adapting to exosuit-only (Exo-only) and split-belt only (Sb-only) conditions. The independent variables step length, stance time, and swing time symmetry were analyzed across five timepoints (baseline, early- and late adaptation, and early- and late post-adaptation) using a 3 × 5 mixed ANOVA.

RESULTS

We found significant interaction and time effects on step length, stance time and swing time symmetry. Sb-only produced increased step length asymmetry at early adaptation compared to baseline (p < 0.0001) and an after-effect with increased asymmetry at early post-adaptation compared to baseline (p < 0.0001). Exo-only increased step length asymmetry (in the opposite direction as Sb-only) at early adaptation compared to baseline (p = 0.0392) but did not influence the participants sufficiently to result in a post-effect. Exo-Sb produced similar changes in step length asymmetry in the same direction as Sb-only (p = 0.0014). However, in contrast to Sb-only there was no significant after-effect between early post-adaptation and baseline (p = 0.0885).

CONCLUSION

The passive exosuit successfully diminished asymmetrical step length after-effects induced by the split-belt treadmill in Exo-Sb. These results support the passive exosuit's ability to alter walking gait patterns.

Establishment of regression-based normative isometric strength values for major lower limb muscle groups in persons with multiple sclerosis

BACKGROUND

Limb weakness is a major impairment that affects mobility in persons with multiple sclerosis (PwMS). Specifically, lower limb (LL) weakness can greatly affect gait and balance, while increasing fall risk and decreasing quality of life. Numerous studies have compared LL strength of PwMS to healthy controls, however none have objectively measured strength in all major LL joints (hip, knee, and ankle) in a large number of PwMS. Additionally, while discrete normative values exist for knee extensors in PwMS, there has yet to be regression-based normative isometric strength values for all major LL muscle groups. Therefore, this study aimed to develop gender-specific regression-based normative prediction equations, with 95% confidence intervals, for maximal isometric peak torque of major LL muscles in PwMS. A secondary aim was to characterize the prevalence of LL weakness in PwMS, defined as ≥ 2 SD below values reported for healthy individuals.

METHODS

A convenience sample of 175 (women: n = 135) PwMS participated in a prospective, cross-sectional study where isometric peak torque of hip flexors, extensors, and abductors, knee flexors and extensors, and ankle plantarflexors and dorsiflexors were measured using the Biodex System 4 Pro-Dynamometer®. Demographics (age, height, and weight) and disease characteristics (disease duration and disability) were collected. Performances were separated for each muscle group into strongest limb and weakest limb. For each gender, regression-based equations were generated for the LL muscle groups by limb with age, height, weight, disability, and disease duration as the covariates. Descriptive statistics were used to examine the frequency of LL weakness by gender and disability level. For comparison purposes, age-stratified (<30, 30-39, 40-49, 50-59, 60-69, >70 years) and disability-stratified (mild, moderate, and severe ambulant) discrete peak torque values were also generated for each gender.

RESULTS

Regression-based normative data are presented for men and women, accounting for age, height, weight, disability, and disease duration. Men were significantly stronger (P < 0.001) than women for all LL, with the men's models accounting for a greater percent of muscle strength variation than women's models for all muscle groups, except for hip extension. Disability was inversely related to strength in all of the models. LL weakness was prevalent in hip flexion (m: 47.5%; w: 63.0%) and extension (m: 92.5%; w: 88.1%), knee extension (m: 30.0%; w: 33.3%) and flexion (m: 25.0%; w: 34.8%), and ankle plantarflexion (m: 15.0%; w: 10.4%) and dorsiflexion (m: 100.0%; w: 96.3%). PwMS with mild disability had a high prevalence of ankle dorsiflexion (94.9-100.0%) and hip extension (81.4-90.0%) weakness.

CONCLUSIONS

This study is the first to provide regression-based normative data of bilateral strength in all major LL muscle groups and clinically useful prevalence data on the occurrence of weakness in these muscles. Of note, PwMS had a high prevalence of ankle dorsiflexion and hip extension weakness even when they were only mildly disabled. These findings can help guide the direction of future interventions and treatments to improve muscle function in PwMS.

The association between cognition and gait disturbance in central nervous system demyelinating disorder with mild disability

INTRODUCTION

Gait disturbance in central nervous system (CNS) demyelinating disorders, including multiple sclerosis (MS) and neuromyelitis optica (NMO) is one of the most troublesome problems that has a direct impact on the quality of life. However, the associations between gait disturbance and other clinical variables of these two diseases have not been fully elucidated.

OBJECTIVE

This study aimed to evaluate gait disturbance using a computerized gait analysis system and its association with various clinical variables in patients with MS and NMO.

METHODS

A total of 33 patients (14 with MS and 19 with NMO) with minor disabilities, who were able to walk independently and had passed their acute phase, were enrolled in the study. Gait analysis were performed using a computer-based instrumented walkway system. (Walk-way MG-1000, Anima, Japan) Clinical variables, such as disease duration, medication, body mass index (BMI), hand grip power, and muscle mass were recorded. The Montreal Cognitive Assessment (MOCA), Beck Depression Inventory score-II (BDI), and fatigue scale were measured using the Functional Assessment of Chronic Illness Therapy-fatigue scale (FACIT-fatigue) scale. A trained neurologist scored the Expanded Disability Status Scale (EDSS).

RESULTS

Gait speed was the single parameter that showed a significant positive correlation with MOCA (p < 0.001). The stance phase time was the single parameter that showed a significant negative correlation with EDSS (p < 0.001). Hand grip strength showed a significant positive correlation with skeletal muscle mass as assessed by bioimpedance analysis (p < 0.05). The FACIT-fatigue scale score showed a significant negative correlation with the BDI (p < 0.001).

CONCLUSION

In our patients with MS/NMO with mild disability, cognitive impairment was significantly correlated with gait speed, and the degree of disability was significantly correlated with stance phase time. Our findings may imply that early detection of a decrease in gait speed and an increase in stance phase time can predict the progression of cognitive impairment in patients with MS/NMO with mild disability.

Study for the validation of the FeetMe® integrated sensor insole system compared to GAITRite® system to assess gait characteristics in patients with multiple sclerosis

OBJECTIVE

To determine the concordance and statistical precision in gait velocity in people with multiple sclerosis (pwMS), measured with FeetMe® (insoles with pressure and motion sensors) compared with GAITRite® (classic reference system of gait analysis) in the timed 25-Feet Walk test (T25WT).

METHODS

This observational, cross-sectional, prospective, single center study was conducted between September-2018 and April-2019 in pwMS aged 18-55 years, with Expanded Disability Status Scale (EDSS) 0-6.5 and relapse free ≥30 days at baseline. Primary endpoint was gait velocity. Secondary endpoints were ambulation time, cadence, and stride length assessment, while the correlation between gait variables and the clinical parameters of MS subjects was assessed as an exploratory endpoint.

RESULTS

A total of 207 MS subjects were enrolled, of whom, 205 were considered in primary analysis. Most subjects were women (66.8%) and had relapsing-remitting MS (RRMS) (82.9%), with overall mean (standard deviation [SD]) age of 41.5 (8.0) year and EDSS 3.1 (2.0). There was a statistically significant (p<0.0001) and strong agreement (intra-class correlation coefficient (ICC) >0.830) in gait velocity, ambulation time and cadence assessment between FeetMe® and GAITRite®.

CONCLUSIONS

Agreement between devices was strong (ICC≥0.800). FeetMe® is the first validated wearable medical device that allows gait monitoring in MS subjects, being potentially able to assess disease activity, progression, and treatment response.

Unwrapping the "black box" of balance training in people with multiple sclerosis - A descriptive systematic review of intervention components, progression, and intensity

BACKGROUND

Delineating the specific components of the existing balance training interventions in people with multiple sclerosis (PwMS) may contribute to a framework for future design and reporting of such interventions. Thus, we aimed to systematically synthesize how balance training frequency, intensity, time, type, duration, and progression are reported in balance training interventions for PwMS.

METHODS

A systematic literature search was conducted in Medline, Embase, Web of Science, and Cinahl. Search terms were MS, postural balance, walking, gait, and randomized/quasi-randomized controlled or clinical trials. Articles including ambulatory PwMS and interventions designed to challenge the balance control system were eligible. Two investigators screened, selected, and extracted data independently. Data on study characteristics such as design, population, and balance training content were extracted. Categorization of balance training based on balance control components was performed.

RESULTS

We included 40 studies grouped under five balance training categories. Balance interventions were well described regarding frequency, session time, and duration, but only two interventions described training intensity, and no systematic, gradual progression approach was reported for balance training adaptation over time. However, the balance training interventions included many sensory and motor components of the balance control system. Still, little focus was on reactive motor strategies, vestibular sense, and cognitive dual-tasking.

CONCLUSIONS

Existing balance training interventions in PwMS primarily consist of practicing sensory and motor strategies. Future balance training interventions are encouraged to systematically monitor individual advancements in balance training adaptations and to apply the progressive overload principle (i.e. continuous increase in balance exercise stimulus over time). Furthermore, we suggest that balance training in PwMS is performed with high intensity near an individual's balance capacity limits. Finally, individualized balance training is recommended to cover all relevant components of balance control using the proposed framework.

Gait quality and function after fampridine treatment in patients with multiple sclerosis - A prospective cohort study

BACKGROUND

Fampridine has shown to improve walking speed, motor control, and balance in patients with multiple sclerosis. However, potential fampridine-induced changes in gait quality and underlying mechanisms, evaluated by three-dimensional gait analysis, are poorly examined. The aim was to examine if two weeks of fampridine treatment would improve gait quality (using Gait Profile Score and Gait Variable Scores from three-dimensional gait analysis) and gait function (using performance-based tests, spatiotemporal parameters, and self-perceived gait function).

METHODS

14 participants with multiple sclerosis were included (9 women and 5 men, age 53.6 ± 12.8 years, disease duration 21 ± 9.1 years) in this cohort study. Tests were completed prior to fampridine and after 14 (± 1) days of treatment. Three-dimensional gait analyses were completed, and kinematic measures were calculated for overall gait quality using Gait Profile Score, and for joint-specific variables, Gait Variable Scores. Gait function was assessed using spatiotemporal parameters, performance-based tests, and a patient-reported outcome measure. Student's paired t-test/Wilcoxon signed rank test were used to compare baseline and follow-up variables. Sample size calculation for Gait Profile Score required at least 9 participants.

FINDINGS

No fampridine-induced improvements in gait quality were demonstrated. For gait function, improvements were found in performance-based tests (Timed 25-Foot Walk: -11.5%; Six Spot Step Test: -13.9%; 2-Minute Walk Test: 18.2%) and self-perceived gait function (12-itemMS Walking Scale: -35.2%).

INTERPRETATION

Although two weeks of fampridine treatment in patients with multiple sclerosis improved gait function, there was no change in overall kinematic quality of gait.

TRIAL REGISTRATION

This work was collected as a part of a registered clinical trial (MUST): ClinicalTrials.govNCT03847545.

Monitoring gait at home with radio waves in Parkinson's disease: A marker of severity, progression, and medication response

Parkinson's disease (PD) is the fastest-growing neurological disease in the world. A key challenge in PD is tracking disease severity, progression, and medication response. Existing methods are semisubjective and require visiting the clinic. In this work, we demonstrate an effective approach for assessing PD severity, progression, and medication response at home, in an objective manner. We used a radio device located in the background of the home. The device detected and analyzed the radio waves that bounce off people's bodies and inferred their movements and gait speed. We continuously monitored 50 participants, with and without PD, in their homes for up to 1 year. We collected over 200,000 gait speed measurements. Cross-sectional analysis of the data shows that at-home gait speed strongly correlates with gold-standard PD assessments, as evaluated by the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part III subscore and total score. At-home gait speed also provides a more sensitive marker for tracking disease progression over time than the widely used MDS-UPDRS. Further, the monitored gait speed was able to capture symptom fluctuations in response to medications and their impact on patients' daily functioning. Our study shows the feasibility of continuous, objective, sensitive, and passive assessment of PD at home and hence has the potential of improving clinical care and drug clinical trials.

The figure-of-eight walk test is a reliable and valid test for assessing walking skill in people with multiple sclerosis

BACKGROUND

The ability to turn while walking is essential for people's activities of daily living. Difficulties in turning while walking are commonly shown in people with multiple sclerosis (PwMS). The figure-of-eight walk test (F8W) is a clinical test assessing walking skill in a curved pathway; however, its reliability and validity have not been systematically examined for PwMS.

PURPOSES

The study is aimed to investigate: (1) the test-retest reliability of the F8W in PwMS; (2) the standard error of measurement and minimum detectable change in the F8W times; (3) the concurrent and known-groups validity of the F8W times; and (4) the cut-off times that best discriminate fallers from non-fallers with MS.

METHOD

This cross-sectional study included 41 PwMS and 33 healthy people. The F8W was performed along with the Timed Up and Go Test (TUG), Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC), and Expanded Disability Status Scale (EDSS). To determine the test-retest reliability, the F8W was conducted twice, 7-10 days apart. The reliability was assessed using the intraclass correlation coefficient (ICC), Bland-Altman plots, standard error of measurement (SEM), and minimal detectable change (MDC). To examine validity, the correlations between the F8W and the TUG, BBS, ABC, and EDSS were assessed using correlation coefficients, and the completion times of the F8W were compared between PwMS and healthy people, and between fallers and non-fallers with MS. The receiver operating characteristic curve was constructed to determine the optimal F8W cut-off time discriminating fallers from non-fallers with MS.

RESULTS

The F8W had excellent test-retest reliability with an ICC of 0.916. Bland-Altman plots showed high agreement between sessions. The SEM and MDC were found to be 0.45 and 1.25, respectively. The F8W indicated a moderate to strong correlation with other outcome measures (correlation coefficients ranged from -0.596 to 0.839, p<0.05). On the F8W, PwMS had a longer time than healthy people while fallers had a longer time than non-fallers with MS (p<0.001, and p<0.001, respectively). The cut-off time of 8.52 s best discriminated the fallers from non-fallers with MS.

CONCLUSIONS

The F8W is a reliable and clinically available measurement tool for walking skill in PwMS.

Changes in Gait Characteristics During and Immediately After the 6-Minute Walk Test in Persons With Multiple Sclerosis: A Systematic Review

OBJECTIVE

There is limited information about gait patterns during prolonged walking in people with multiple sclerosis (PwMS). The aim of this review was to report on gait metrics during and immediately after the 6-Minute Walk Test (6MWT) in PwMS with different levels of disability.

METHODS

The systematic search was performed in 3 databases (PubMed, Web of Science, and SCOPUS) using keywords related to multiple sclerosis and 6MWT. Studies that reported on quantitative gait outcomes before and after the 6MWT or multiple time points during the 6MWT were included. The Hedges g effect size (ES) was calculated to determine the magnitude of change in each gait parameter.

RESULTS

Fourteen studies (n = 534 PwMS; n = 166 healthy controls) were eligible. Five studies investigated gait parameters prior to and immediately after the 6MWT. Nine studies collected gait measures during the 6MWT. Speed (ES = -0.43 to 0.19), cadence (ES = -0.46 to 0.16), step length (ES = -0.46 to 0.14), stability (ES = -0.35 to 0.33), and regularity (ES = -0.25 to -0.15) decreased in most studies. In the majority of included studies, step time (ES = 0 to 0.35), stance period (ES = 0.12 to 0.58), double support phase (ES = 0.03 to 0.62), variability (ES = -0.19 to 1.13), and asymmetry (ES = -0.79 to 0.62) increased following the 6MWT. The kinetic and kinematic (mainly in dorsiflexion angle [ES = -0.08 to -0.36]) features of gait were also negatively changed after 6 minutes of walking. Walking speed, cadence, step length, stride length, and stride time after 6MWT at a comfortable speed all increased. Changes in the majority of spatiotemporal parameters were more pronounced in PwMS with moderate-to-severe disability compared with PwMS with mild disability.

CONCLUSION

Most quantitative gait parameters deteriorated during the 6MWT, especially in PwMS with moderate-to-severe disability.

IMPACT

The deterioration of gait patterns should be considered when designing therapeutic interventions to increase sustained walking capacity.

Efficacy of Transcranial Direct Current Stimulation (tDCS) on Balance and Gait in Multiple Sclerosis Patients: A Machine Learning Approach

Transcranial direct current stimulation (tDCS) has emerged as an appealing rehabilitative approach to improve brain function, with promising data on gait and balance in people with multiple sclerosis (MS). However, single variable weights have not yet been adequately assessed. Hence, the aim of this pilot randomized controlled trial was to evaluate the tDCS effects on balance and gait in patients with MS through a machine learning approach. In this pilot randomized controlled trial (RCT), we included people with relapsing−remitting MS and an Expanded Disability Status Scale >1 and <5 that were randomly allocated to two groups—a study group, undergoing a 10-session anodal motor cortex tDCS, and a control group, undergoing a sham treatment. Both groups underwent a specific balance and gait rehabilitative program. We assessed as outcome measures the Berg Balance Scale (BBS), Fall Risk Index and timed up-and-go and 6-min-walking tests at baseline (T0), the end of intervention (T1) and 4 (T2) and 6 weeks after the intervention (T3) with an inertial motion unit. At each time point, we performed a multiple factor analysis through a machine learning approach to allow the analysis of the influence of the balance and gait variables, grouping the participants based on the results. Seventeen MS patients (aged 40.6 ± 14.4 years), 9 in the study group and 8 in the sham group, were included. We reported a significant repeated measures difference between groups for distances covered (6MWT (meters), p < 0.03). At T1, we showed a significant increase in distance (m) with a mean difference (MD) of 37.0 [−59.0, 17.0] (p = 0.003), and in BBS with a MD of 2.0 [−4.0, 3.0] (p = 0.03). At T2, these improvements did not seem to be significantly maintained; however, considering the machine learning analysis, the Silhouette Index of 0.34, with a low cluster overlap trend, confirmed the possible short-term effects (T2), even at 6 weeks. Therefore, this pilot RCT showed that tDCS may provide non-sustained improvements in gait and balance in MS patients. In this scenario, machine learning could suggest evidence of prolonged beneficial effects.

Transparent Quality Optimization for Machine Learning-Based Regression in Neurology

The clinical monitoring of walking generates enormous amounts of data that contain extremely valuable information. Therefore, machine learning (ML) has rapidly entered the research arena to analyze and make predictions from large heterogeneous datasets. Such data-driven ML-based applications for various domains become increasingly applicable, and thus their software qualities are taken into focus. This work provides a proof of concept for applying state-of-the-art ML technology to predict the distance travelled of the 2-min walk test, an important neurological measurement which is an indicator of walking endurance. A transparent lean approach was emphasized to optimize the results in an explainable way and simultaneously meet the specified software requirements for a generic approach. It is a general-purpose strategy as a fractional−factorial design benchmark combined with standardized quality metrics based on a minimal technology build and a resulting optimized software prototype. Based on 400 training and 100 validation data, the achieved prediction yielded a relative error of 6.1% distributed over multiple experiments with an optimized configuration. The Adadelta algorithm (LR=0.000814, fModelSpread=5, nModelDepth=6, nepoch=1000) performed as the best model, with 90% of the predictions with an absolute error of <15 m. Factors such as gender, age, disease duration, or use of walking aids showed no effect on the relative error. For multiple sclerosis patients with high walking impairment (EDSS Ambulation Score ≥6), the relative difference was significant (n=30; 24.0%; p<0.050). The results show that it is possible to create a transparently working ML prototype for a given medical use case while meeting certain software qualities.

Barriers to quality of life in patients with multiple sclerosis: a qualitative study

BACKGROUND

Multiple sclerosis (MS) is a chronic progressive disease of the central nervous system that affects the patients' quality of life. This research was conducted with the aim of identifying the barriers of quality of life in patients with MS.

METHODS

This qualitative study was conducted through a conventional content analysis approach. We used the purposeful sampling with maximum diversity in terms of gender, age, education, marital status and employment. Data were collected through semi-structured interviews with 18 patients with multiple sclerosis referred to the MS Association of Isfahan. Interviews were conducted to the point of information saturation.

RESULTS

Through the content analysis of the interviews, we identified 2 main categories and 11 sub-categories. The main categories include intrapersonal problems (physical problems, psychological disorders, turbulent future, functional limitations, job loss and pennilessness), and environmental barriers (disease and treatment process, fatigue of caregivers, information deficiency about MS, family tensions, lack of social support and fun and entertainment).

CONCLUSIONS

In order to improve the quality of life in these patients, there is a need for attention and practical measures in the field of identified factors. By removing barriers such as providing educational and counseling services to the patients and their families, adapting the urban structure, providing financial support and adequate insurance coverage, the authorities can take measures to ensure patients' health and improve their quality of life.

Use of Robotic Devices for Gait Training in Patients Diagnosed with Multiple Sclerosis: Current State of the Art

Multiple sclerosis (MS) is a neurodegenerative disease that produces alterations in balance and gait in most patients. Robot-assisted gait training devices have been proposed as a complementary approach to conventional rehabilitation treatment as a means of improving these alterations. The aim of this study was to investigate the available scientific evidence on the benefits of the use of robotics in the physiotherapy treatment in people with MS. A systematic review of randomized controlled trials was performed. Studies from the last five years on walking in adults with MS were included. The PEDro scale was used to assess the methodological quality of the included studies, and the Jadad scale was used to assess the level of evidence and the degree of recommendation. Seventeen studies met the eligibility criteria. For the improvement of gait speed, robotic devices do not appear to be superior, compared to the rest of the interventions evaluated. The methodological quality of the studies was moderate–low. For this reason, robot-assisted gait training is considered just as effective as conventional rehabilitation training for improving gait in people with MS.

Neurological Benefits, Clinical Challenges, and Neuropathologic Promise of Medical Marijuana: A Systematic Review of Cannabinoid Effects in Multiple Sclerosis and Experimental Models of Demyelination

Despite current therapeutic strategies for immunomodulation and relief of symptoms in multiple sclerosis (MS), remyelination falls short due to dynamic neuropathologic deterioration and relapses, leading to accrual of disability and associated patient dissatisfaction. The potential of cannabinoids includes add-on immunosuppressive, analgesic, neuroprotective, and remyelinative effects. This study evaluates the efficacy of medical marijuana in MS and its experimental animal models. A systematic review was conducted by a literature search through PubMed, ProQuest, and EBSCO electronic databases for studies reported since 2007 on the use of cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC) in MS and in experimental autoimmune encephalomyelitis (EAE), Theiler's murine encephalomyelitis virus-induced demyelinating disease (TMEV-IDD), and toxin-induced demyelination models. Study selection and data extraction were performed by 3 reviewers, and 28 studies were selected for inclusion. The certainty of evidence was appraised using the Cochrane GRADE approach. In clinical studies, there was low- and moderate-quality evidence that treatment with ~1:1 CBD/THC mixtures as a nabiximols (Sativex®) oromucosal spray reduced numerical rating scale (NRS) scores for spasticity, pain, and sleep disturbance, diminished bladder overactivity, and decreased proinflammatory cytokine and transcription factor expression levels. Preclinical studies demonstrated decreases in disease severity, hindlimb stiffness, motor function, neuroinflammation, and demyelination. Other experimental systems showed the capacity of cannabinoids to promote remyelination in vitro and by electron microscopy. Modest short-term benefits were realized in MS responders to adjunctive therapy with CBD/THC mixtures. Future studies are recommended to investigate the cellular and molecular mechanisms of cannabinoid effects on MS lesions and to evaluate whether medical marijuana can accelerate remyelination and retard the accrual of disability over the long term.

Physical and Mental Health Comorbidities Among Adults With Multiple Sclerosis

OBJECTIVE

To compare the incidence of and adjusted hazard ratios for common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities among adults with and without multiple sclerosis (MS).

PATIENTS AND METHODS

Beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for MS (n=9815) from a national private insurance claims database (Clinformatics Data Mart; OptumInsight). Adults without MS were also included (n=1,474,232) as a control group. Incidence estimates of common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities were compared at 5 years of continuous enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident morbidities.

RESULTS

Adults with MS had a higher incidence of any common cardiometabolic disease (51.6% [2663 of 5164] vs 36.4% [328,690 of 904,227]), musculoskeletal disorder (68.8% [3411 of 4959] vs 47.5% [512,422 of 1,077,737]), and psychological morbidity (49.4% [3305 of 6691] vs 30.8% [380,893 of 1,235,388]) than adults without MS, and differences were clinically meaningful (all P<.001). Fully adjusted survival models revealed that adults with MS had a greater risk for any (hazard ratio [HR], 1.37; 95% CI, 1.32 to 1.43) and all (HR, 1.19 to 1.48) common cardiometabolic diseases, any (HR, 1.59; 95% CI, 1.53 to 1.64) and all (HR, 1.22 to 2.77) musculoskeletal disorders, and any (HR, 1.57; 95% CI, 1.51 to 1.62) and all (HR, 1.20 to 2.51) but one (impulse control disorders) psychological morbidity.

CONCLUSION

Adults with MS have a significantly higher risk for development of common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities (all P<.001) than adults without MS. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of chronic physical and mental disease onset/progression in this higher risk population.

Digital Biomarkers in Multiple Sclerosis

For incurable diseases, such as multiple sclerosis (MS), the prevention of progression and the preservation of quality of life play a crucial role over the entire therapy period. In MS, patients tend to become ill at a younger age and are so variable in terms of their disease course that there is no standard therapy. Therefore, it is necessary to enable a therapy that is as personalized as possible and to respond promptly to any changes, whether with noticeable symptoms or symptomless. Here, measurable parameters of biological processes can be used, which provide good information with regard to prognostic and diagnostic aspects, disease activity and response to therapy, so-called biomarkers Increasing digitalization and the availability of easy-to-use devices and technology also enable healthcare professionals to use a new class of digital biomarkers-digital health technologies-to explain, influence and/or predict health-related outcomes. The technology and devices from which these digital biomarkers stem are quite broad, and range from wearables that collect patients' activity during digitalized functional tests (e.g., the Multiple Sclerosis Performance Test, dual-tasking performance and speech) to digitalized diagnostic procedures (e.g., optical coherence tomography) and software-supported magnetic resonance imaging evaluation. These technologies offer a timesaving way to collect valuable data on a regular basis over a long period of time, not only once or twice a year during patients' routine visit at the clinic. Therefore, they lead to real-life data acquisition, closer patient monitoring and thus a patient dataset useful for precision medicine. Despite the great benefit of such increasing digitalization, for now, the path to implementing digital biomarkers is widely unknown or inconsistent. Challenges around validation, infrastructure, evidence generation, consistent data collection and analysis still persist. In this narrative review, we explore existing and future opportunities to capture clinical digital biomarkers in the care of people with MS, which may lead to a digital twin of the patient. To do this, we searched published papers for existing opportunities to capture clinical digital biomarkers for different functional systems in the context of MS, and also gathered perspectives on digital biomarkers under development or already existing as a research approach.

Automated Analysis of the Two-Minute Walk Test in Clinical Practice Using Accelerometer Data

One of the core problems for people with multiple sclerosis (pwMS) is the impairment of their ability to walk, which can be severely restrictive in everyday life. Therefore, monitoring of ambulatory function is of great importance to be able to effectively counteract disease progression. An extensive gait analysis, such as the Dresden protocol for multidimensional walking assessment, covers several facets of walking impairment including a 2-min walk test, in which the distance taken by the patient in two minutes is measured by an odometer. Using this approach, it is questionable how precise the measuring methods are at recording the distance traveled. In this project, we investigate whether the current measurement can be replaced by a digital measurement method based on accelerometers (six Opal sensors from the Mobility Lab system) that are attached to the patient’s body. We developed two algorithms using these data and compared the validity of these approaches using the results from 2-min walk tests from 562 pwMS that were collected with a gold-standard odometer. In 48.4% of pwMS, we detected an average relative measurement error of less than 5%, while results from 25.8% of the pwMS showed a relative measurement error of up to 10%. The algorithm had difficulties correctly calculating the walking distances in another 25.8% of pwMS; these results showed a measurement error of more than 20%. A main reason for this moderate performance was the variety of pathologically altered gait patterns in pwMS that may complicate the step detection. Overall, both algorithms achieved favorable levels of agreement (r = 0.884 and r = 0.980) with the odometer. Finally, we present suggestions for improvement of the measurement system to be implemented in the future.

Motor symptoms and the quality of life of relapsing-remitting multiple sclerosis patients in a specialized center in South of Brazil

BACKGROUND

Spasticity, fatigue, muscle weakness and changes in gait are some of the main motor symptoms of Multiple Sclerosis (MS). These changes can interfere with the patients' quality of life.

OBJECTIVE

To characterize the motor and quality of life symptoms in patients with relapsing-remitting Multiple Sclerosis at a specialized center.

METHODS

Fifty five patients at the Neuroimmunology Outpatient Clinic of the Hospital de Clínicas de Porto Alegre were evaluated for fatigue (Fatigue Severity Scale - FSS), walking ability (Functional Ambulation Categories - FAC), impact of MS on walking (Multiple Sclerosis Walking Scale-12 - MSWS-12), walking speed (10-Meter Walk Test - 10MWT and the Times 25-foot Walk test - T25FW), functional independence (Barthel Index - BI), functional mobility (Timed Up and Go - TUG), and quality of life (Multiple Sclerosis Impact Scale - MSIS-29).

RESULTS

The patients were mostly women (69.1%), with average age of 43.3 (±12.1) years old, with time since diagnosis of 8.2 (±5.3) years, and EDSS average of 4.3 (±1.3). On the BI, the mean was 96.6 (±5.7) points and 80% of the patients had FAC 5. At MSIS-29, patients had a higher average score on the psychological scale (19.5±26.7) than on the physical scale (10.2±23.6). Most patients (69.1%) presented fatigue.

CONCLUSION

The patients had preserved functional independence and functional walking ability and presence of fatigue. There was minimal impact of MS on patients' quality of life.

[Options for the symptomatic treatment of chronic neurological gait disorders]

Gait and mobility impairments are common and relevant in patients with chronic neurological disorders. It reduces the health-related quality of life and induces falls with morbidity. Symptomatic treatment options are therefore necessary in order to improve the health status of patients with neurological disorders.By means of a selective literature research focusing on studies with specific gait-related outcome measures. We discuss the differential treatment options for (1) hypokinetic gait disorders (Parkinson´s disease, Normal pressure hydrocephalus, vascular encephalopathy), (2) gait unsteadiness with ataxia (sensory and cerebellar ataxia), and (3) gait with spasticity and paresis (due to multiple sclerosis). Therapeutical options for the symptomatic treatment of gait disorders comprise non-pharmacological and pharmacological approaches. Both address the functional domains of "locomotion", "postural control", "modulation" and "adaptability" of gait.Pharmacological options are orientated to pathophysiology of the underlying diseases. Supportive physiotherapeutic interventions offer broader and unspecific options for treatment. Clinical conditions that specifically disturb the execution of locomotion or gait can also be addressed by the provision of physical therapy or supportive devices.Effective options for the symptomatic treatment of patients with neurological gait disorders are available. Applications of options addressing the pathophysiology of the underlying disease, a functional domain-based exercise and physiotherapy program, and the provision of walking aides for specific symptoms that further worsen gait performance can be recommended.

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

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

A Multifactorial Model of Multiple Sclerosis Gait and Its Changes Across Different Disability Levels

OBJECTIVE

Mobility assessment is critical in the clinical management of people with Multiple Sclerosis (pwMS). Instrumented gait analysis provides a plethora of metrics for quantifying concurrent factors contributing to gait deterioration. However, a gait model discriminating underlying features contributing to this deterioration is lacking in pwMS. This study aimed at developing and validating such a model.

METHODS

The gait of 24 healthy controls and 114 pwMS with mild, moderate, or severe disability was measured with inertial sensors on the shanks and lower trunk while walking for 6 minutes along a hospital corridor. Twenty out of thirty-six initially explored metrics computed from the sensor data met the quality criteria for exploratory factor analysis. This analysis provided the sought model, which underwent a confirmatory factor analysis before being used to characterize gait impairment across the three disability groups.

RESULTS

A gait model consisting of five domains (rhythm/variability, pace, asymmetry, and forward and lateral dynamic balance) was revealed by the factor analysis, which was able to highlight gait abnormalities across the disability groups: significant alterations in rhythm/variability-, asymmetry-, and pace-based features were present in the mild group, but these were more profound in the moderate and severe groups. Deterioration in dynamic balance-based features was only noted in pwMS with a moderate and severe disability.

CONCLUSION

A conceptual model of gait for disease-specific mobility assessment in pwMS was successfully developed and tested.

SIGNIFICANCE

The new model, built with metrics that represent gait impairment in pwMS, highlighted clinically relevant changes across different disability levels, including those with no clinically observable walking disability. This shows the clear potential as a monitoring biomarker in pwMS.

Does gait bout definition influence the ability to discriminate gait quality between people with and without multiple sclerosis during daily life?

BACKGROUND

There is currently no consensus about standardized gait bout definitions when passively monitoring walking during normal daily life activities. It is also not known how different definitions of a gait bout in daily life monitoring affects the ability to distinguish pathological gait quality. Specifically, how many seconds of a pause with no walking indicates an end to one gait bout and the start of another bout? In this study, we investigated the effect of 3 gait bout definitions on the discriminative ability to distinguish quality of walking in people with multiple sclerosis (MS) from healthy control subjects (HC) during a week of daily living.

METHODS

15 subjects with MS and 16 HC wore instrumented socks on each foot and one Opal sensor over the lower lumbar area for a week of daily activities for at least 8 h/day. Three gait bout definitions were based on the length of the pause between the end of one gait bout and start of another bout (1.25 s, 2.50 s, and 5.0 s pause). Area under the curve (AUC) was used to compare gait quality measures in MS versus HC.

RESULTS

Total number of gait bouts over the week were statistically significantly different across bout definitions, as expected. However, AUCs of gait quality measures (such as gait speed, stride length, stride time) discriminating people with MS from HC were not different despite the 3 bout definitions.

SIGNIFICANCE

Quality of gait measures that discriminate MS from HC during daily life are not influenced by the length of a gait bout, despite large differences in quantity of gait across bout definitions. Thus, gait quality measures in people with MS versus controls can be compared across studies using different gait bout definitions with pause lengths ≤5 s.

Muscle Synergies in Patients With Multiple Sclerosis Reveal Demand-Specific Alterations in the Modular Organization of Locomotion

For patients with multiple sclerosis (MS), deficits in gait significantly reduce the quality of life. Using the concept of muscle synergies, this study investigated the modular organization of motor control during level and inclined walking in MS patients (MSP) compared with healthy participants (HP) to identify the potential demand-specific adjustments in motor control in MSP. We hypothesized a widening of the time-dependent activation patterns (motor primitives) in MSP to increase the overlap of temporally-adjacent muscle synergies, especially during inclined walking, as a strategy to increase the robustness of motor control, thus compensating pathology-related deficits. We analyzed temporal gait parameters and muscle synergies from myoelectric signals of 13 ipsilateral leg muscles using non-negative matrix factorization. Compared with HP, MSP demonstrated a widening in the time-dependent coefficients (motor primitives), as well as altered relative muscle contribution (motor modules), in certain synergies during level and inclined walking. Moreover, inclined walking revealed a demand-specific adjustment in the modular organization in MSP, resulting in an extra synergy compared with HP. This further increased the overlap of temporally-adjacent muscle synergies to provide sufficient robustness in motor control to accomplish the more demanding motor task while coping with pathology-related motor deficits during walking.

Urinary incontinence and impaired physical function are associated with expiratory muscle weakness in patients with multiple sclerosis

PURPOSE

Patients with multiple sclerosis (MS) with respiratory muscle weakness could have physical function impairments, given the functional/biomechanical link of the trunk stabilising system. Thus, clinicians could employ new treatment strategies targeting respiratory muscles to improve their physical function. This study pretends to evaluate the relationship between respiratory muscle strength, pulmonary function and pelvic floor function, and also to correlate these variables with physical function (gait function, disability and quality of life) in patients with MS.

METHODS

41 patients participated in this descriptive cross-sectional study. Respiratory muscle strength [maximal respiratory pressures (MIP/MEP)], pulmonary function (forced spirometry), pelvic floor function [urinary incontinence (UI)], physical function [Timed Up & Go (TUG) test, Barthel index and health status questionnaire (SF-12)] were evaluated.

RESULTS

Respiratory muscle strength and pulmonary function were moderately related to UI (MIP: rho = -0.312; MEP: rho = -0.559). MEP was moderately related to physical function (TUG: rho = -0.508; Barthel index: rho = 0.418). Patients with and without expiratory muscle weakness showed differences in UI, pulmonary and physical function.

CONCLUSION

Patients with MS with greater deterioration in pulmonary function and respiratory muscle strength, especially expiratory muscles, showed greater deterioration in UI and physical function. Expiratory muscle weakness had a negative impact on urinary, physical and pulmonary function.Implications for rehabilitationPulmonary function is associated with urinary incontinence and gait functionality in patients with multiple sclerosis (MS).Expiratory muscle weakness is associated with impaired urinary and physical function in patients with MS.The inclusion of respiratory muscle training to the rehabilitation programs of patients with MS could improve their pelvic floor disorders and physical function.

Modeling the cost-effectiveness of prolonged-release fampridine for the treatment of walking impairment in patients with multiple sclerosis in Sweden

Aims: To evaluate the cost-effectiveness of adding prolonged-release (PR)-fampridine to best supportive care (BSC) versus BSC alone for the improvement of walking ability in patients with MS.Methods: A cost-utility analysis based on a Markov model was developed to model responders and timed 25-foot walk (T25FW) scores, accumulated costs, and quality-adjusted life-years (QALY) in adults with MS and Expanded Disability Status Scale (EDSS) scores between 4 and 7. The analysis was conducted from a Swedish societal perspective.Results: In the base-case analysis, PR-fampridine plus BSC led to a higher QALY gain than BSC alone. The largest direct cost was professional care provision followed by hospital inpatient stays while the indirect cost was the loss of earnings due to days off work. The incremental cost-effectiveness ratio (ICER) for PR-fampridine plus BSC compared with BSC alone was 57,109 Swedish Kronor (kr)/QALY (€5,607/QALY [1 kr = €0.0981762 on 8 April 2021] and $6,675/QALY [1 kr = $0.116890 on 8 April 2021]). All sensitivity analyses performed resulted in ICERs below 500,000 kr (€49,088 and $58,445).Limitations: Resource use data were not specific to the Swedish market.Conclusions: PR-fampridine represents a cost-effective treatment for MS-related walking impairment in Sweden, due to improvements in patients' quality of life and reduced healthcare resource utilization.

Trends and Technologies in Rehabilitation of Foot Drop: A Systematic Review

INTRODUCTION

Foot Drop (FD) is a condition, which is very commonly found in post-stoke patients; however it can also be seen in patients with multiple sclerosis, and cerebral palsy. It is a sign of neuromuscular damage caused by the weakness of the muscles. There are various approaches of FD's rehabilitation, such as physiotherapy, surgery, and the use of technological devices. Recently, researchers have worked on developing various technologies to enhance assisting and rehabilitation of FD.

AREAS COVERED

This review analyzes different types of technologies available for FD. This include devices that are available commercially or still under research. 101 studies published between 2015 and 2020 were identified for the review, many were excluded due to various reasons, e.g., were not robot-based devices, did not include FD as one of the targeted diseases, or was insufficient information. 24 studies that met our inclusion criteria were assessed. These studies were further classified into two different categories: robot-based ankle-foot orthosis (RAFO) and Functional Electrical Stimulation (FES) devices.

EXPERT OPINION

Studies included showed that both RAFO and FES showed considerable improvement in the gait cycle of the patients. Future trends are inclining towards integrating FES with other neuro-concepts such as muscle-synergies for further developments.

Laboratory versus daily life gait characteristics in patients with multiple sclerosis, Parkinson's disease, and matched controls

BACKGROUND AND PURPOSE

Recent findings suggest that a gait assessment at a discrete moment in a clinic or laboratory setting may not reflect functional, everyday mobility. As a step towards better understanding gait during daily life in neurological populations, we compared gait measures that best discriminated people with multiple sclerosis (MS) and people with Parkinson's Disease (PD) from their respective, age-matched, healthy control subjects (MS-Ctl, PD-Ctl) in laboratory tests versus a week of daily life monitoring.

METHODS

We recruited 15 people with MS (age mean ± SD: 49 ± 10 years), 16 MS-Ctl (45 ± 11 years), 16 people with idiopathic PD (71 ± 5 years), and 15 PD-Ctl (69 ± 7 years). Subjects wore 3 inertial sensors (one each foot and lower back) in the laboratory followed by 7 days during daily life. Mann-Whitney U test and area under the curve (AUC) compared differences between PD and PD-Ctl, and between MS and MS-Ctl in the laboratory and in daily life.

RESULTS

Participants wore sensors for 60-68 h in daily life. Measures that best discriminated gait characteristics in people with MS and PD from their respective control groups were different between the laboratory gait test and a week of daily life. Specifically, the toe-off angle best discriminated MS versus MS-Ctl in the laboratory (AUC [95% CI] = 0.80 [0.63-0.96]) whereas gait speed in daily life (AUC = 0.84 [0.69-1.00]). In contrast, the lumbar coronal range of motion best discriminated PD versus PD-Ctl in the laboratory (AUC = 0.78 [0.59-0.96]) whereas foot-strike angle in daily life (AUC = 0.84 [0.70-0.98]). AUCs were larger in daily life compared to the laboratory.

CONCLUSIONS

Larger AUC for daily life gait measures compared to the laboratory gait measures suggest that daily life monitoring may be more sensitive to impairments from neurological disease, but each neurological disease may require different gait outcome measures.

Pilot trial of speed-intensive gait training on balance and walking in people with multiple sclerosis

Background/Aims

Diminished walking speed and endurance is commonly experienced by individuals with multiple sclerosis. Speed-intensive gait training has led to improvements in walking speed and endurance in other neurological populations; however, its effect in persons with multiple sclerosis is unknown. This pilot study examined the feasibility, safety and efficacy of speed-intensive gait training in a sample of people with multiple sclerosis.

Methods

A total of eight participants (five women, median Expanded Disability Status Scale 3.5) underwent a 6-week, twice weekly speed-intensive gait training programme. Walking speed and endurance, balance and fatigue were measured pre- and post-intervention.

Results

Speed-intensive gait training was feasible, with excellent adherence and safety. It proved effective, with improvements in walking speed (P=0.05), walking endurance (P=0.036) and balance (P=0.041) without an increase in fatigue.

Conclusions

The intermittent design of speed-intensive gait training may enable individuals with multiple sclerosis to achieve higher training volumes than traditional models. Although further study is warranted, rehabilitation clinicians should consider adding speed-intensive gait training as an intervention to improve walking and balance in this patient group.

The Dresden Protocol for Multidimensional Walking Assessment (DMWA) in Clinical Practice

Walking impairments represent one of the most debilitating symptom areas for people with multiple sclerosis (MS). It is important to detect even slightest walking impairments in order to start and optimize necessary interventions in time to counteract further progression of the disability. For this reason, a regular monitoring through gait analysis is highly necessary. At advanced stages of MS with significant walking impairment, this assessment is also necessary to optimize symptomatic treatment, choose the most suitable walking aid and plan individualized rehabilitation. In clinical practice, walking impairment is only assessed at higher levels of the disease using e.g., the Expanded Disability Status Scale (EDSS). In contrast to the EDSS, standardized functional tests such as walking speed, walking endurance and balance as well as walking quality and gait-related patient-reported outcomes allow a more holistic and sensitive assessment of walking impairment. In recent years, the MS Center Dresden has established a standardized monitoring procedure for the routine multidimensional assessment of gait and balance disorders. In the following protocol, we present the techniques and procedures for the analysis of gait and balance of people with MS at the MS Center Dresden. Patients are assessed with a multidimensional gait analysis at least once a year. This enables long-term monitoring of walking impairment, which allows early active intervention regarding further progression of disease and improves the current standard clinical practice.

Walking in multiple sclerosis improves with tDCS: a randomized, double-blind, sham-controlled study

OBJECTIVE

To evaluate whether multiple sessions of transcranial direct current stimulation (tDCS) applied to the primary motor (M1) cortex paired with aerobic exercise can improve walking functions in multiple sclerosis (MS).

METHODS

MS participants were recruited for a double-blind, parallel-arm, randomized, sham-controlled trial and assigned to 10 sessions (5 d/wk for 2 weeks) of either active or sham tDCS paired with unloaded cycling for 20 minutes. Stimulation was administered over the left M1 cortex (2.5 mA; anode over C3/cathode over FP2). Gait spatiotemporal parameters were assessed using a wearable inertial sensor (10-meter and 2-minute walking tests). Measurements were collected at baseline, end of tDCS intervention, and 4-week postintervention to test for duration of any benefits.

RESULTS

A total of 15 participants completed the study, nine in the active and six in the sham condition. The active and sham groups were matched according to gender (50% vs. 40% female), neurologic disability (median EDSS 5.5 vs. 5), and age (mean 52.1 ± 12.9 vs. 53.7 ± 9.8 years). The active group had a significantly greater increase in gait speed (0.87 vs. 1.20 m/s, p < 0.001) and distance covered during the 2-minute walking test (118.53 vs. 133.06 m, p < 0.001) at intervention end compared to baseline. At 4-week follow-up, these improvements were maintained (baseline vs. follow-up: gait speed 0.87 vs. 1.18 m/s, p < 0.001; distance traveled 118.53 vs. 143.82 m, p < 0.001).

INTERPRETATION

Multiple sessions of tDCS paired with aerobic exercise lead to cumulative and persisting improvements in walking and endurance in patients with MS.

A multi-modal virtual reality treadmill intervention for enhancing mobility and cognitive function in people with multiple sclerosis: Protocol for a randomized controlled trial

BACKGROUND

Gait and cognitive impairments are common in individuals with Multiple Sclerosis (MS) and can interfere with everyday function. Those with MS have difficulties executing cognitive tasks and walking simultaneously, a reflection of dual-task interference. Therefore, dual-task training may improve functional ambulation. Additionally, using technology such as virtual reality can provide personalized rehabilitation while mimicking real-world environments. The purpose of this randomized controlled trial is to establish the benefits of a combined cognitive-motor virtual reality training on MS symptoms compared to conventional treadmill training.

METHODS

This study will be a single-blinded, two arm RCT with a six-week intervention period. 144 people with MS will be randomized into a treadmill training alone group or treadmill training with virtual reality group. Both groups will receive 18 sessions of training while walking on a treadmill, with the virtual reality group receiving feedback from the virtual system. Primary outcome measures include dual-task gait speed and information processing speed, which will be measured prior to training, one-week post-training, and three months following training.

DISCUSSION

This study will provide insight into the ability of a multi-modal cognitive-motor intervention to reduce dual-task cost and to enhance information processing speed in those with MS. This is one of the first studies that is powered to understand whether targeted dual-task training can improve MS symptoms and increase functional ambulation. We anticipate that those in the virtual reality group will have a significantly greater increase in dual-task gait speed and information processing speed than those achieved via treadmill training alone.

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.

Gait and Functional Mobility in Multiple Sclerosis: Immediate Effects of Transcranial Direct Current Stimulation (tDCS) Paired With Aerobic Exercise

Walking impairments are a debilitating feature of multiple sclerosis (MS) because of the direct interference with daily activity. The management of motor symptoms in those with MS remains a therapeutic challenge. Transcranial direct current stimulation (tDCS) is a type of non-invasive brain stimulation that is emerging as a promising rehabilitative tool but requires further characterization to determine its optimal therapeutic use. In this randomized, sham-controlled proof-of-concept study, we tested the immediate effects of a single tDCS session on walking and functional mobility in those with MS. Seventeen participants with MS completed one 20-min session of aerobic exercise, randomly assigned to be paired with either active (2.5 mA, n = 9) or sham (n = 8) tDCS over the primary motor cortex (M1). The groups (active vs. sham) were matched according to gender (50% vs. 60% F), age (52.1 ± 12.85 vs. 54.2 ± 8.5 years), and level of neurological disability (median Expanded Disability Status Scale score 5.5 vs. 5). Gait speed on the 10-m walk test and the Timed Up and Go (TUG) time were measured by a wearable inertial sensor immediately before and following the 20-min session, with changes compared between conditions and time. There were no significant differences in gait speed or TUG time changes following the session in the full sample or between the active vs. sham groups. These findings suggest that a single session of anodal tDCS over M1 is not sufficient to affect walking and functional mobility in those with MS. Instead, behavioral motor response of tDCS is likely to be cumulative, and the effects of multiple tDCS sessions require further study.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03658668.

Fuzziness of muscle synergies in patients with multiple sclerosis indicates increased robustness of motor control during walking

Deficits during gait poses a significant threat to the quality of life in patients with Multiple Sclerosis (MS). Using the muscle synergy concept, we investigated the modular organization of the neuromuscular control during walking in MS patients compared to healthy participants (HP). We hypothesized a widening and increased fuzziness of motor primitives (e.g. increased overlap intervals) in MS patients compared to HP allowing the motor system to increase robustness during walking. We analysed temporal gait parameters, local dynamic stability and muscle synergies from myoelectric signals of 13 ipsilateral leg muscles using non-negative matrix factorization. Compared to HP, MS patients showed a significant decrease in the local dynamic stability of walking during both, preferred and fixed (0.7 m/s) speed. MS patients demonstrated changes in time-dependent activation patterns (motor primitives) and alterations of the relative muscle contribution to the specific synergies (motor modules). We specifically found a widening in three out of four motor primitives during preferred speed and in two out of four during fixed speed in MS patients compared to HP. The widening increased the fuzziness of motor control in MS patients, which allows the motor system to increase its robustness when coping with pathology-related motor deficits during walking.