Identification of disability status in persons with multiple sclerosis by lower limb neuromuscular function – emphasis on rate of force development

Early Phase Multiple Sclerosis Patients Present Substantial Deficits in Physical-, Cognitive-, and Patient-reported Outcomes Compared to Matched Healthy Controls

BackgroundEarly identification of potential deficits is of utmost importance as early diagnosis and early treatment has been shown to be crucial to reduce disease activity and disease impact-leading to the notion of "Time matters" in multiple sclerosis (MS).ObjectiveThe aim of the present study was to compare physical-, cognitive-, and patient-reported outcomes in early phase MS patients with matched healthy controls (HC).MethodsThis cross-sectional study included 84 patients early in the disease course of MS (≤2 years from diagnosis) and 84 age- and sex-matched HC. All participants underwent a comprehensive test battery including physical-, cognitive-, and patient-reported outcomes.ResultsRelative deficits for patients with MS compared to HC corresponded to 7% to 35% in walking capacity (Timed 25-Foot Walk Test, 6 Spot Step Test, 6 Minute Walk Test), 5% for upper limb function (9 Hole Peg Test), 27% for aerobic capacity (maximal oxygen uptake), 17% to 38% for physical activity level (Baecke Sport Index and accelerometer counts/minute), 68% for fatigability (Walking Fatigability Index), 150% for fatigue (Modified Fatigue Impact Scale), 4% to 20% for cognitive function (Symbol Digit Modalities Test, Paced Auditory Serial Addition Test, and Selective Reminding Test), and lastly, 7% to 8% for quality of life (Short Form-36 health survey). Only the Symbol Digit Modalities Test and Selective Reminding Test Delayed did not differ between groups, statistically.ConclusionEarly phase MS patients present substantial deficits in physical-, cognitive-, and patient-reported outcomes compared to HC. These early impairments highlight the importance of early initiatives aimed at preserving and/or building of reserve capacity.

Role of Maximum and Explosive Strength in the Relationship Between the Expanded Disability Status Scale (EDSS) and Functional Capacity in People with Multiple Sclerosis: A Mediation Analysis

The relationship between functional capacity and disability status in individuals with Multiple Sclerosis (MS) is well established. However, to date, the interference of lower limb strength in this classic correlation has not been studied. Therefore, this study aimed to investigate the mediating role of muscle lower limb strength variables, including maximum strength (MVIC) and explosive strength (RFD), in the relationship between the disability status, measured by Expanded Disability Status Scale (EDSS), and functional test outcomes in a MS sample. A total of 49 patients performed 4 functional tests: timed up-and-go test (TUG), sit-to-stand (STS), 10-meter walk test (10MWT), and 6-minute walk test (6MWT), as well as the measurement of MVIC and RFD. A statistical mediation analysis was conducted to examine the influence of maximum and explosive strength on the relationship between EDSS and functional capacity. Regarding MVIC, the effect of EDSS on the 6MWT (indirect effect = 48%, p = .013), 10MWT (indirect effect = 18.1%, p = .015) and TUG test (indirect effect = 27.2%, p = .003) decreased. Regarding RFD late (0-200), the effect of EDSS on the 6MWT (indirect effect = 34.8% p = .0048), 10MWT (indirect effect = 18.0%, p = .021) and TUG test (indirect effect = 25.0%, p = .014) decreased. MVIC and RFD late variables play a significant role and influence the relationship between the EDSS and functional capacity.

The Association of Age, Sex, and BMI on Lower Limb Neuromuscular and Muscle Mechanical Function in People with Multiple Sclerosis

(1) Background: The countermovement jump (CMJ) on a force plate could be a sensitive assessment for detecting early lower-limb muscle mechanical deficits in the early stages of multiple sclerosis (MS). CMJ performance is known to be influenced by various anthropometric, physiological, and biomechanical factors, mostly investigated in children and adult athletes. Our aim was to investigate the association of age, sex, and BMI with muscle mechanical function using CMJ to provide a comprehensive overview of lower-limb motor function in people with multiple sclerosis (pwMS). (2) Methods: A cross-sectional study was conducted with pwMS (N = 164) and healthy controls (N = 98). All participants performed three maximal CMJs on a force plate. Age, sex, and BMI were collected from all participants. (3) Results: Significant age, sex, and BMI effects were found for all performance parameters, flight time, and negative and positive power for pwMS and HC, but no significant interaction effects with the group (pwMS, HC) were detected. The highest significant effects were found for sex on flight time (η2 = 0.23), jump height (η2 = 0.23), and positive power (η2 = 0.13). PwMS showed significantly lower CMJ performance compared to HC in middle-aged (31-49 years), with normal weight to overweight and in both women and men. (4) Conclusions: This study showed that age, sex, and BMI are associated with muscle mechanical function in pwMS and HC. These results may be useful in developing reference values for CMJ. This is a crucial step in integrating CMJ into the diagnostic assessment of people with early MS and developing individualized and effective neurorehabilitative therapy.

The combined deleterious effects of multiple sclerosis and ageing on neuromuscular function

BACKGROUND

The prevalence of older (>60 years) people with multiple sclerosis (pwMS) is increasing. This introduces numerous challenges, as both MS and ageing independently contribute to the deterioration of neuromuscular function.

AIM

The aim was to compare the neuromuscular function in pwMS and healthy controls (HC) across three age groups: young, middle-aged, and old.

METHODS

Using a cross-sectional study design, the maximal muscle strength (Fmax) and rate of force development (RFD) of the knee extensors (KE) and plantar flexors (PF) were assessed using an isokinetic dynamometer. In addition, voluntary activation (VA) and resting twitch (RT) were measured using the interpolated twitch technique.

RESULTS

The Fmax, RFD, and VA of the KE were reduced in pwMS compared to HC across age groups. In pwMS, reductions were observed in PF Fmax, RFD, and RT, predominantly in the middle-aged and old age groups. Reductions increased with age in KE for both groups (except for VA) but in PF only for pwMS. The "trajectory" differed between pwMS and HC, as pwMS showed reductions from young to middle age, while HC showed reductions from middle to old age in KE.

CONCLUSION

The combined negative effects of MS and ageing on neuromuscular function were especially present in the PF but also substantial in the KE. RFD showed large deficits for pwMS compared to HC across age groups. The findings can partly be explained by a reduction in VA and RT, but further investigations of neural regulation are needed to explain large RFD deficits.

The rate of force relaxation scaling factor is highly sensitive to detect upper and lower extremity motor deficiencies in mildly affected people with multiple sclerosis

BACKGROUND

The motor symptoms affecting upper and lower extremity functioning in people with multiple sclerosis (PwMS) are considered the cardinal symptoms of multiple sclerosis. There is still a need for outcome measures that can sensitively evaluate these symptoms. We aimed to investigate the sensitivity of the isometric outcomes (maximum force; Fmax, maximum rate of force development; RFDmax, rate of force development scaling factor; RFD-SF, and rate of force relaxation scaling factor; RFR-SF) and standard clinical tests (9-hole peg test; 9HPT and timed 25-feet walk test; T25FW) in detecting the upper and lower extremity motor deficiencies in PwMS and also in a subgroup of mildly affected PwMS whose performance in standard clinical tests were similar to controls.

METHODS

Twenty-nine PwMS (age: 47.9 (8.6) years, relapsing-remitting type, expanded disability status scale: 2.5 (1.5)) and their age- and gender-matched controls completed an identical testing protocol in the upper (grip force muscles) and lower (knee extensors) extremities. For each extremity, we assessed Fmax, RFDmax, RFD-SF, and RFR-SF. Additionally, participants completed standard clinical tests for the evaluation of upper- (9HPT) and lower-extremity (T25FW) function. Comparisons were made between controls and PwMS 1) using all study participants and 2) including only mildly affected PwMS whose performance in standard functional tests was comparable to controls. Independent sample t-tests were utilized to compare groups, with a p-value set at 0.01 to correct for multiple comparisons. P-values and effect sizes were used to evaluate the sensitivity of the outcome measures in detecting group differences.

RESULTS

Our results indicate that most isometric outcomes and standard functional tests were sensitive in detecting motor deficiencies in both upper and lower extremities between groups (p<0.001). Among participants, 16 PwMS in 9HPT and 11 PwMS in T25FW demonstrated performance similar to that of the control group (9HPT: 18.85 (2.20) s vs 17.81 (2.19) s; p=0.19) and (T25FW: 3.60 (0.42) s vs 3.58 (0.29) s; p=0.92). The results of the comparisons between mildly affected PwMS and their controls indicate that RFR-SF is the only sensitive isometric outcome to detect differences between groups in the upper (-8.24 (0.76) 1/s vs -8.93 (0.6) 1/s; p=0.008) and lower extremity (-5.86 (1.13) 1/s vs -7.71 (1.11) 1/s; p<0.001).

CONCLUSION

The rate of force relaxation scaling factor, which assesses the ability to rapidly relax muscle forces after quick contractions, demonstrates high sensitivity in detecting motor deficiencies in PwMS, even when the current standard clinical outcomes fail to detect these differences. Our findings emphasize the importance of future randomized controlled trials focusing on rehabilitative and therapeutic interventions that specifically target muscle force relaxation to enhance motor functioning in PwMS.

Comparing Clinical and Radiological Features in Familial and Sporadic Multiple Sclerosis

Objective To compare the initial presentation, clinical features, disease courses, and radiological parameters between familial multiple sclerosis (fMS) and sporadic multiple sclerosis (sMS) to determine if the two represent distinct clinical entities. Methods This retrospective study was conducted at the Neurology Clinic at Kocaeli University Hospital. Records of 114 fMS and 150 sMS patients, aged 18-65, diagnosed based on either the Poser criteria or the McDonald 2001 criteria were analyzed. Radiological data and Expanded Disability Status Scale (EDSS) evaluations were conducted by a specialist neurologist. Variables included age at MS onset, first symptoms, relapses, EDSS scores at diagnosis and last examination, and MRI findings. Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 28, Armonk, NY) was utilized for data analysis. Results Both fMS and sMS groups were comparable in age (43.55±12.50 and 42.35±10.61 years, respectively) and gender distribution (females: fMS 71.9%, sMS 71.3%). No significant difference was noted regarding disease onset age (fMS 29.83±10.77, sMS 30.42±9.7). Age of onset, final EDSS, and relapse rate didn't significantly vary among sMS, fMS with first-degree relatives having MS (fMS(1)), and fMS with second or third-degree relatives having MS (fMS(2)). The fMS group showed a significantly higher incidence of initial spinal cord lesions on MRI compared to the sMS group (38.6% vs. 17.3%; p<0.001). Within the fMS group, the presence of spinal cord lesions on initial MRI correlated with a higher relapse rate and elevated initial and final EDSS scores. Conclusion Despite overarching similarities between fMS and sMS, spinal cord lesions' prevalence and implications in fMS may point to a genetic underpinning warranting in-depth exploration.

Neuromuscular rate of force development discriminates fallers in ambulatory persons with multiple sclerosis - an exploratory study

BACKGROUND

Falls as well as fall-related injuries (e.g., bone fractures) are common in persons with multiple sclerosis (pwMS). Whilst some studies have identified lower extremity maximal muscle strength (Fmax) as one among several risk factors, no previous studies have investigated the association between rate of force development (RFD; ability to generate a rapid rise in muscle force) and falls in pwMS. Not only is RFD substantially compromised (and more so than Fmax) in pwMS, studies involving other neurodegenerative populations have shown that RFD - to a greater extent than Fmax - is crucial for counteracting unexpected perturbations and avoiding falling.

OBJECTIVE

To explore whether knee extensor RFD (and Fmax) can discriminate fallers from non-fallers in pwMS.

METHODS

Knee extensor neuromuscular function (comprising RFD_50ms and RFD_200ms (force developed in the interval 0-50 ms and 0-200 ms, respectively) as well as Fmax) of the weaker leg was assessed by isokinetic dynamometry. Falls were determined by 1-year patient recall, with pwMS subsequently being classified as non-fallers (0 falls), fallers (1-2 falls), or recurrent fallers (≥3 falls).

RESULTS

A total of n=53 pwMS were enrolled in the study, with n=24 classified as non-fallers (63% females, 48 years, EDSS 2.2), n=16 as fallers (88% females, 57 years, EDSS 3.3), and n=13 as recurrent fallers (46% females, 60 years, EDSS 4.2). Compared with non-fallers, neuromuscular function was reduced in both fallers (RFD₅₀ -4.42 [-7.47;-1.37] Nm^.s^-1.kg^-1, -48%; RFD₂₀₀ -1.45 [-2.98;0.07] Nm^.s^-1.kg^-1, -24%; Fmax -0.42 [-0.81;-0.03] Nm^.kg^-1, -21%) and recurrent fallers (RFD₅₀ -5.69 [-8.94;-2.43] Nm^.s^-1.kg^-1, -62%; RFD₂₀₀ -2.26 [-3.89;-0.63] Nm^.s^-1.kg^-1, -38%; Fmax -0.38 [-0.80;0.03] Nm^.kg^-1, -19%). Across all participants, associations were observed between RFD_50ms and falls (r_s = -0.46 [-0.67;-0.24], between RFD_200ms and falls (r_s = -0.34 [-0.59;-0.09]), and between Fmax and falls (r_s = -0.24 [-0.48;0.01]).

CONCLUSION

In this exploratory study, knee extensor neuromuscular function was able to discriminate fallers from non-fallers in pwMS, with RFD being superior to Fmax. Routine assessment of lower extremity neuromuscular function (RFD_50ms in particular) may be a helpful tool in identifying pwMS at future risk of falling.

How is neuromuscular fatigability affected by perceived fatigue and disability in people with multiple sclerosis?

Whereas fatigue is recognized to be the main complaint of patients with multiple sclerosis (PwMS), its etiology, and particularly the role of resistance to fatigability and its interplay with disability level, remains unclear. The purposes of this review were to (i) clarify the relationship between fatigue/disability and neuromuscular performance in PwMS and (ii) review the corticospinal and muscular mechanisms of voluntary muscle contraction that are altered by multiple sclerosis, and how they may be influenced by disability level or fatigue. Neuromuscular function at rest and during exercise are more susceptible to impairement, due to deficits in voluntary activation, when the disability is greater. Fatigue level is related to resistance to fatigability but not to neuromuscular function at rest. Neurophysiological parameters related to signal transmission such as central motor conduction time, motor evoked potentials amplitude and latency are affected by disability and fatigue levels but their relative role in the impaired production of torque remain unclear. Nonetheless, cortical reorganization represents the most likely explanation for the heightened fatigability during exercise for highly fatigued and/or disabled PwMS. Further research is needed to decipher how the fatigue and disability could influence fatigability for an ecological task, especially at the corticospinal level.