Lifestyle management and brain MRI metrics in female Australian adults living with multiple sclerosis: a feasibility and acceptability study

BACKGROUND

Limited studies of multiple sclerosis (MS) exist whereby magnetic resonance imaging (MRI) of the brain with consistent imaging protocols occurs at the same time points as collection of healthy lifestyle measures. The aim of this study was to test the feasibility, acceptability and preliminary efficacy of acquiring MRI data as an objective, diagnostic and prognostic marker of MS, at the same time point as brain-healthy lifestyle measures including diet.

METHODS

Participants living with relapsing remitting MS partook in one structural MRI scanning session of the brain, completed two online 24-hour dietary recalls and demographic and self-reported lifestyle questionnaires (e.g. self-reported disability, comorbidities, physical activity, smoking status, body mass index (BMI), stress). Measures of central tenancy and level of dispersion were calculated for feasibility and acceptability of the research protocols. Lesion count was determined by one radiologist and volumetric analyses by a data analysis pipeline based on FreeSurfer software suite. Correlations between white matter lesion count, whole brain volume analyses and lifestyle measures were assessed using Spearman's rank-order correlation coefficient.

RESULTS

Thirteen female participants were included in the study: eligibility rate 90.6% (29/32), recruitment rate 46.9% (15/32) and compliance rate 87% (13/15). The mean time to complete all required tasks, including MRI acquisition was 115.86 minutes ( ± 23.04), over 4 days. Conversion to usual dietary intake was limited by the small sample. There was one strong, negative correlation between BMI and brain volume (rs = -0.643, p = 0.018) and one strong, positive correlation between physical activity and brain volume (rs = 0.670, p = 0.012) that were both statistically significant.

CONCLUSIONS

Acquiring MRI brain scans at the same time point as lifestyle profiles in adults with MS is both feasible and accepted among adult females living with MS. Quantification of volumetric MRI data support further investigations using semi-automated pipelines among people living with MS, with pre-processing steps identified to increase automated feasibility. This protocol may be used to determine relationships between elements of a brain-healthy lifestyle, including dietary intake, and measures of disease burden and brain health, as assessed by T1-weighted and T2-weighted lesion count and whole brain volume, in an adequately powered sample.

TRIAL REGISTRATION

The study protocol was retrospectively registered in the Australia New Zealand Clinical Trials Registry (ACTRN12624000296538).

Mobility, functionality and functional mobility: A review and application for canine veterinary patients

Mobility is an essential aspect of a dog's daily life. It is defined as the ability to move freely and easily and deviations from an animals' normal mobility capabilities are often an indicator of disease, injury or pain. When a dog's mobility is compromised, often functionality (ability to perform activities of daily living [ADL]), is also impeded, which can diminish an animal's quality of life. Given this, it is necessary to understand the extent to which conditions impact a dog's physiological ability to move around their environment to carry out ADL, a concept termed functional mobility. In contrast to human medicine, validated measures of canine functional mobility are currently limited. The aim of this review is to summarise the extent to which canine mobility and functionality are associated with various diseases and how mobility and functional mobility are currently assessed within veterinary medicine. Future work should focus on developing a standardised method of assessing functional mobility in dogs, which can contextualise how a wide range of conditions impact a dog's daily life. However, for a true functional mobility assessment to be developed, a greater understanding of what activities dogs do on a daily basis and movements underpinning these activities must first be established.

Effects of music therapy intervention on gait disorders in persons with multiple sclerosis: A systematic review of clinical trials

BACKGROUND

Music Therapy (MT) is a unique treatment method for Persons with Multiple Sclerosis (PwMS) that can accelerate their functional recovery. MT has been proven to adjust the gait performance of PwMS in a short period. Its therapeutic effects in gait disorders of PwMS for long-term intervention are also starting to draw interest, but it has yet to be investigated.

AIM

This review aimed to systematically examine the outcomes of PwMS with gait disorders after receiving MT intervention.

METHODS

A systematic review has been performed using several academic databases with keywords such as music therapy, multiple sclerosis, and gait. The study protocol was registered on PROSPERO (CRD42022365668).

RESULTS

A total of 405 studies were initially identified. After applying the inclusion and exclusion criteria, twelve studies were finally included. The results showed that all PwMS received MT intervention with different strategies, and ten studies confirmed that gait disorders of PwMS were effectively improved by MT intervention.

CONCLUSION

Most previous studies focused on the transient effects of MT on the gait performance of PwMS. This review bridges gaps in the long-term intervention of MT on gait disorders of PwMS and offers references for therapists to design treatment plans. According to this review, MT intervention has positive therapeutic effects on gait disorders in PwMS.

Improvement of Gait in Patients with Stroke Using Rhythmic Sensory Stimulation: A Case-Control Study

Patients with stroke suffer from impaired locomotion, exhibiting unstable walking with increased gait variability. Effects of rhythmic sensory stimulation on unstable gait of patients with chronic stroke are unclear. This study aims to determine the effects of rhythmic sensory stimulation on the gait of patients with chronic stroke. Twenty older adults with stroke and twenty age- and gender-matched healthy controls walked 60 m under four conditions: normal walking with no stimulation, walking with rhythmic auditory stimulation (RAS) through an earphone in the ear, walking with rhythmic somatosensory stimulation (RSS) through a haptic device on the wrist of each participant, and walking with rhythmic combined stimulation (RCS: RAS + RSS). Gait performance in the stroke group significantly improved during walking with RAS, RSS, and RCS compared to that during normal walking (p < 0.008). Gait variability significantly decreased under the RAS, RSS, and RCS conditions compared to that during normal walking (p < 0.008). Rhythmic sensory stimulation is effective in improving the gait of patients with chronic stroke, regardless of the type of rhythmic stimuli, compared to healthy controls. The effect was greater in patients with reduced mobility, assessed by the Rivermead Mobility Index (RMI).

Creating a Real-World Data, United States Healthcare Claims-Based Adaptation of Kurtzke Functional Systems Scores for Assessing Multiple Sclerosis Severity and Progression

Introduction

This article describes the development of a unique mapping of the Kurtzke Functional Systems Scores (KFSS) from International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes among multiple sclerosis (MS) patients within a US Integrated Delivery Network (IDN). Valid identification of increasing disability may allow deeper insight into MS progression and possible treatments.

Methods

This cohort study identified MS patients in the IDN, Intermountain Healthcare. Experienced clinicians and informaticists mapped electronic health record ICD-9-CM codes to KFSS components generating a modified Kurtzke Expanded Disability Status Scale (EDSS). Modified EDSS scores were used to assess disability progression by calculating means, medians, ranges, and changes in KFSS and modified EDSS scores.

Results

Overall, 608/2960 (20.5%) patients were identified as having MS progression and presented a wide range of scores on the EDSS 10-point scale. The median (range) first and second EDSS scores were 0 (0–6) and 5 (1–8), respectively. The median (range) change from first to second score was 5 (1–7.5). The median first KFSS score for all systems was 0, and the mean differed among components. The highest mean first KFSS score (1.06) was measured for sensory function and lowest (0.12) for cerebellar functions. Of the 544 patients with their first EDSS scores in the ≤ 2.5 group, 75.2% and 15.1% had their second EDSS scores in group 3–5.5 and ≥ 6, respectively. Of the 62 patients with their first EDSS score in the 3–5.5 group, 58.1% had their second EDSS scores in group ≥ 6.

Conclusion

This innovative mapping technique is a promising method for future comparative effectiveness and safety research of Disease-Modifying Therapy in Real-World Data repositories. Future research to validate and expand on this method in another healthcare database is encouraged.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01858-9.

Estimating Walking Speed in the Wild

An individual's physical activity substantially impacts the potential for prevention and recovery from diverse health issues, including cardiovascular diseases. Precise quantification of a patient's level of day-to-day physical activity, which can be characterized by the type, intensity, and duration of movement, is crucial for clinicians. Walking is a primary and fundamental physical activity for most individuals. Walking speed has been shown to correlate with various heart pathologies and overall function. As such, it is often used as a metric to assess health performance. A range of clinical walking tests exist to evaluate gait and inform clinical decision-making. However, these assessments are often short, provide qualitative movement assessments, and are performed in a clinical setting that is not representative of the real-world. Technological advancements in wearable sensing and associated algorithms enable new opportunities to complement in-clinic evaluations of movement during free-living. However, the use of wearable devices to inform clinical decisions presents several challenges, including lack of subject compliance and limited sensor battery life. To bridge the gap between free-living and clinical environments, we propose an approach in which we utilize different wearable sensors at different temporal scales and resolutions. Here, we present a method to accurately estimate gait speed in the free-living environment from a low-power, lightweight accelerometer-based bio-logging tag secured on the thigh. We use high-resolution measurements of gait kinematics to build subject-specific data-driven models to accurately map stride frequencies extracted from the bio-logging system to stride speeds. The model-based estimates of stride speed were evaluated using a long outdoor walk and compared to stride parameters calculated from a foot-worn inertial measurement unit using the zero-velocity update algorithm. The proposed method presents an average concordance correlation coefficient of 0.80 for all subjects, and 97% of the error is within ±0.2m· s -1. The approach presented here provides promising results that can enable clinicians to complement their existing assessments of activity level and fitness with measurements of movement duration and intensity (walking speed) extracted at a week time scale and in the patients' free-living environment.

Construct Validity of the Gait Assessment and Intervention Tool (GAIT) in People With Multiple Sclerosis

INTRODUCTION

In clinical practice, observational scales are the most common approach used to assess gait pattern in people with neurological disorders. The Gait Assessment and Intervention Tool (GAIT) is an observational gait scale, and it has proved to be the most comprehensive, homogeneous, and objective of all the observational gait scales studied in people with neurological conditions.

OBJECTIVE

To study the construct validity of the GAIT in people with multiple sclerosis (MS).

DESIGN

An observational study was conducted.

SETTING

Multiple Sclerosis Foundation in Madrid (Spain).

PATIENTS

Thirty-five patients with MS were assessed.

MAIN OUTCOME MEASURE(S)

GAIT construct validity was assessed using the following scales: Rivermead Visual Gait Assessment (RVGA), Tinetti Gait Scale (TGS), 10-Meter Walking Test (10MWT), Timed Up&Go (TUG), Hauser Ambulatory Index (HAI), Multiple Sclerosis Walking Scale-12 (MSWS-12), Functional Gait Assessment (FGA), Modified Ashworth Scale (MAS), and Rivermead Mobility Index (RMI).

RESULTS

A total of 35 subjects with MS were assessed. The correlations between the GAIT and the RVGA were excellent (r > .90) and moderate with TGS (values between -.62 and -.59). Correlations with HAI, FGA, MSWS-12, and RMI were moderate (with values between .57 and .67). Correlations were lower for the velocity scales TUG and MAS.

CONCLUSIONS

The construct validity of the GAIT is high, as a measure of gait coordination in people with MS. Specifically, there was excellent correlation with the RVGA. There was a moderate correlation for the GAIT with measures of functional mobility, but a lesser correlation of the GAIT with measures restricted to temporal gait characteristics (speed measures) or measurements of impairments underlying gait patterns such as balance or muscle tone.

Effect of a strong desire to void on walking speed in individuals with multiple sclerosis and urinary disorders

BACKGROUND

Lower urinary tract symptoms, especially overactive bladder, are frequent and disabling in individuals with multiple sclerosis (IwMS). An association with gait disorders is common, which could aggravate continence difficulties and affect quality of life. The association between the need to void and walking has never been studied in this population.

OBJECTIVE

The primary aim of this study was to assess the effect of a strong desire to void (SDV) on walking speed in IwMS and lower urinary tract symptoms. The secondary aim was to identify clinical or urodynamic factors associated with walking speed impairment at SDV in this population.

METHODS

We included IwMS with urinary disorders and Expanded Disability Status Scale score<7 in this observational study. Individuals underwent 3 10-m walk tests (10MWT) and one Timed Up and Go (TUG) test at SDV and at post-void (PV).

RESULTS

Among the 72 IwMS included (mean [SD] age 50.6 [11.6] years; 46 [64%] females), the mean (SD) speed for 10MWT was 1.00 (0.31) m.s^-1 at SDV and 1.07 (0.30) m.s^-1 at PV (P<0.0001). Time for TUG was also increased when individuals felt SDV: mean 11.53 (4.6) sec at SDV versus 10.77 (3.8) sec at PV (P=0.004). No predictors of greater impairment of walking speed at SDV were identified.

CONCLUSION

This study suggests a clinical impact of bladder sensation on walking speed in IwMS and urinary disorders. None of the individual characteristics could predict greater decrease in gait velocity at SDV.

The effect of exercise on high-level mobility in individuals with neurodegenerative disease: a systematic literature review

OBJECTIVE

To investigate the effect of exercise on high-level mobility (i.e. mobility more advanced than independent level walking) in individuals with neurodegenerative disease.

DATA SOURCES

A systematic literature search was conducted in Medline, CINAHL, Scopus, SportDiscus and PEDro.

STUDY SELECTION

Randomised controlled trials of exercise interventions for individuals with neurodegenerative disease, with an outcome measure that contained high-level mobility items were included. High-level mobility items included running, jumping, bounding, stair climbing and backward walking. Outcome measures with high-level mobility items include the High Level Mobility Assessment Tool (HiMAT); Dynamic Gait Index; Rivermead Mobility Index (RMI) or modified RMI; Functional Gait Assessment and the Functional Ambulation Category.

STUDY APPRAISAL

Quality was evaluated with the Cochrane Risk of Bias Tool.

RESULTS

Twenty-four studies with predominantly moderate to low risk of bias met the review criteria. High-level mobility items were included within primary outcome measures for only two studies and secondary outcome measures for 22 studies. Eight types of exercise interventions were investigated within which high-level mobility tasks were not commonly included. In the absence of outcome measures or interventions focused on high-level mobility, findings suggest some benefit from treadmill training for individuals with multiple sclerosis or Parkinson's disease. Progressive resistance training for individuals with multiple sclerosis may also be beneficial. With few studies on other neurodegenerative diseases, further inferences cannot be made.

CONCLUSION

Future studies need to specifically target high-level mobility in the early stages of neurodegenerative disease and determine the impact of high-level mobility interventions on community participation and maintenance of an active lifestyle. Systematic review registration number PROSPERO register for systematic reviews (registration number: CRD42016050362).

A Survey of Assistive Technologies for Assessment and Rehabilitation of Motor Impairments in Multiple Sclerosis

Multiple sclerosis (MS) is a disease that affects the central nervous system, which consists of the brain and spinal cord. Although this condition cannot be cured, proper treatment of persons with MS (PwMS) can help control and manage the relapses of several symptoms. In this survey article, we focus on the different technologies used for the assessment and rehabilitation of motor impairments for PwMS. We discuss sensor-based and robot-based solutions for monitoring, assessment and rehabilitation. Among MS symptoms, fatigue is one of the most disabling features, since PwMS may need to put significantly more intense effort toward achieving simple everyday tasks. While fatigue is a common symptom across several neurological chronic diseases, it remains poorly understood for various reasons, including subjectivity and variability among individuals. To this end, we also investigate recent methods for fatigue detection and monitoring. The result of this survey will provide both clinicians and researchers with valuable information on assessment and rehabilitation technologies for PwMS, as well as providing insights regarding fatigue and its effect on performance in daily activities for PwMS.

Walking measures to evaluate assistive technology for foot drop in multiple sclerosis: A systematic review of psychometric properties

BACKGROUND

Foot drop in people with multiple sclerosis (pwMS) often managed with assistive technologies, such as functional electrical stimulation and ankle foot orthoses. No evidence synthesis exists for the psychometric properties of outcomes used to evaluate the efficacy of these interventions.

OBJECTIVE

This systematic review aimed to identify the outcome measures reported to assess the benefits of assistive technology for pwMS and then synthesize the psychometric evidence in pwMS for a subset of these measures.

METHODS

Two searches in eight databases were conducted up to May 2017. Methodological quality was rated using the COSMIN guidelines. Overall level of evidence was scored according to the Cochrane criteria.

RESULTS

The first search identified 27 measures, with the 10 m walk test, gait kinematics and Physiological Cost Index (PCI) most frequently used. The second search resulted in 41 studies evaluating 10 measures related to walking performance. Strong levels of evidence were found for the internal consistency and test-retest reliability of the Multiple Sclerosis Walking Scale-12 and for the construct validity for Timed 25 Foot Walk. No psychometric studies were identified for gait kinematics and PCI in pwMS. There was a lack of evidence for measurement error and responsiveness.

CONCLUSION

Although a strong level of evidence exists for some measures included in this review, there was an absence of psychometric studies on commonly used measures such as gait kinematics. Future psychometric studies should evaluate a wider range of walking related measures used to assess the efficacy of interventions to treat foot drop in pwMS.

Evaluation of patients with multiple sclerosis using reverse nutech functional score and expanded disability status scale after human embryonic stem cell therapy

Background

The expanded disability status scale (EDSS) is a validated and reliable tool to assess the extent of disabilities in patients with multiple sclerosis (MS). However, the use of this tool has been found to be limited in assessing various symptoms of MS that are important. Our study aimed at evaluating the efficacy of a new scoring system, reverse nutech functional score (RNFS) as compared to EDSS in assessing patients with MS treated with human embryonic stem cell (hESC) therapy.

Methods

The MS patients were treated with hESC therapy for one treatment period. All the patients were evaluated with EDSS and RNFS at baseline and after the hESC therapy.

Results

The study included a total of 24 MS patients with mean age of 45 year. The patients showed an improvement in parameters (sleeping disorders, paralysis, paraesthesia, myalgia, muscle weakness, memory, language, irritability, eye pain, depression and coordination, communication, breathing pattern, attention and appetite) associated with MS when evaluated with RNFS. This improvement went unnoticed when the patients were assessed with EDSS.

Conclusion

RNFS can efficiently assess the effectiveness of hESC therapy in treating patients with MS. It could be a suitable scoring system for patients with MS as it can assess the slightest improvements in the patients. Use in other settings would be helpful in assessing its utility.

Regression Model-Based Walking Speed Estimation Using Wrist-Worn Inertial Sensor

Walking speed is widely used to study human health status. Wearable inertial measurement units (IMU) are promising tools for the ambulatory measurement of walking speed. Among wearable inertial sensors, the ones worn on the wrist, such as a watch or band, have relatively higher potential to be easily incorporated into daily lifestyle. Using the arm swing motion in walking, this paper proposes a regression model-based method for longitudinal walking speed estimation using a wrist-worn IMU. A novel kinematic variable is proposed, which finds the wrist acceleration in the principal axis (i.e. the direction of the arm swing). This variable (called pca-acc) is obtained by applying sensor fusion on IMU data to find the orientation followed by the use of principal component analysis. An experimental evaluation was performed on 15 healthy young subjects during free walking trials. The experimental results show that the use of the proposed pca-acc variable can significantly improve the walking speed estimation accuracy when compared to the use of raw acceleration information (p<0.01). When Gaussian process regression is used, the resulting walking speed estimation accuracy and precision is about 5.9% and 4.7%, respectively.

SaGA S, the Short and Graphic A bility Score: an alternative scoring method for the motor components of the Multiple Sclerosis Functional C omposite

The timed performances of the 10-m timed walk (TMTW) and the nine-ho le peg test (NHPT) of 881 consecutive patients with multiple sclerosis (MS) undergoing a rehabilitation stay, were expressed as a logarithmic function of time in two subscores to form a composite score called the Short and G raphic A bility Score (SaGA S). The subscores (sS) were constructed in such a way that any interval of 0.5 unit corresponds to a change of 25% in the tests. The SaGA S was computed as the mean of four subscores: SaGAS=(2×2-TMTWsS+NHPTsS right hand+NHPTsS left hand). With the aid of a nomogram, the timed values of the tests are easily transformed into the corresponding subscores, which are then displayed graphically to facilitate follow-up over time. The correlation coefficients between the SaGA S and the two motor components of the MS Functional C omposite (MSFC) (r =0.987), the Expanded Disability Status Scale (EDSS)(r = -0.83), the Nottingham EADL Index (r =0.80) and the Rivermead Mobility Index (RMI) (r =0.90) were all statistically significant (P B-0.001), supporting the validity of the measure. SaGA S had a similar sensitivity to the RMI, but was significantly more sensitive than the EDSS in detecting changes occurring during the rehabilitation stay (14.9% versus 5.0%; P B-0.001) and over a one-year follow-up (35.3% versus 19.7%; P B-0.001). C ompared with the motor components of the MSFC, with which it shares several features, SaGA S has several advantages: it does not depend on the stratification of the study population; it does not skew the results of the NHPT towards improvement at the lower end; and it offers an independent assessment of both hands. SaGA S is a simple, intuitive, nonphysician-based measure, which could provide consistent scoring in future clinical trials.

Efficacy, safety and tolerability of an orally administered cannabis extract in the treatment of spasticity in patients with multiple sclerosis: a randomized, double-blind, placebo-controlled, crossover study

Objective: Cannabis may alleviate some symptoms associated with multiple sclerosis (MS). This study investigated the effect of an orally administered standardized Cannabis sativa plant extract in MS patients with poorly controlled spasticity.

Methods: During their inpatient rehabilitation programme, 57 patients were enrolled in a prospective, randomized, double-blind, placebo-controlled crossover study of cannabis-extract capsules standardized to 2.5 mg tetrahydrocannabinol (THC) and 0.9 mg cannabidiol (CBD) each. Patients in group A started with a drug escalation phase from 15 to maximally 30 mg THC by 5 mg per day if well tolerated, being on active medication for 14 days before starting placebo. Patients in group B started with placebo for seven days, crossed to the active period (14 days) and closed with a three-day placebo period (active drug dose escalation and placebo sham escalation as in group A). Measures used included daily self-report of spasm frequency and symptoms, Ashworth Scale, Rivermead Mobility Index, 10-m timed walk, nine-hole peg test, paced auditory serial addition test (PASAT), and the digit span test.

Results: In the 50 patients included into the intention-to-treat analysis set, there were no statistically significant differences associated with active treatment compared to placebo, but trends in favour of active treatment were seen for spasm frequency, mobility and getting to sleep. In the 37 patients (per-protocol set) who received at least 90% of their prescribed dose, improvements in spasm frequency (P- 0.013) and mobility after excluding a patient who fell and stopped walking were seen (P- 0.01). Minor adverse events were slightly more frequent and severe during active treatment, and toxicity symptoms, which were generally mild, were more pronounced in the active phase.

Conclusion: A standardized Cannabis sativa plant extract might lower spasm frequency and increase mobility with tolerable side effects in MS patients with persistent spasticity not responding to other drugs.

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

Impaired mobility in multiple sclerosis (MS) is associated with high-energy costs and effort when walking, gait abnormalities, poor endurance and fatigue. This repeated measures trial with blinded assessments investigated the effect of treadmill walking at an aerobic training intensity in 16 adults with MS. The intervention consisted of 12 sessions of up to 30 minutes treadmill training (TT), at 55–85% of age-predicted maximum heart rate. The primary outcome measure was walking effort, measured by oxygen consumption (mL/kg per metre), during treadmill walking at comfortable walking speed (CWS). Associated changes in gait parameters using the ‘Gait-Rite’ mat, 10-m time and 2-minute distance, and Fatigue Severity Scale were examined. Following training, oxygen consumption decreased at rest (P = 0.008), CWS increased (P = 0.002), and 10-m times (P = 0.032) and walking endurance (P = 0.020) increased. At increased CWS, oxygen consumption decreased (P = 0.020), with a decreased time spent in stance in the weaker leg (P = 0.034), and a greater stride distance with the stronger leg (P = 0.044). Reported fatigue levels remained the same. Aerobic TT presents the opportunity to alter a motor skill and reduce the effort of walking, whilst addressing cardiovascular de-conditioning, thereby, potentially reducing effort and fatigue for some people with MS.

The reliability of balance, mobility and self-care measures in a population of adults with a learning disability known to a physiotherapy service

Objective: To estimate the reliability of three measures of balance, mobility and activity for use in clinical and research physiotherapy, with adults with a learning disability.

Design: Prospective study to investigate test-retest and inter-rater reliability.

Setting: Participants' homes and day centres.

Measures: The Berg Balance Scale (BBS), the Rivermead Mobility Index (RMI) and the Barthel Activities of Daily Living Index (BI).

Participants: Of the 181 adults known to the Nottingham Community Physiotherapy Service for Adults with Learning Disabilities, 64 with a known Rivermead Mobility score of less than three were excluded. Of 117 randomized, a further 21 were found to fail this criteria, 27 had acute medical, social or behavioural problems, 22 were unable to participate or refused: therefore 47 entered the study.

Methods: Participants were visited in their own homes by two researchers on two occasions, one week apart and rated independently by each rater. Agreement was assessed with the kappa statistic (k) and percentage agreement for each item in each scale, and described using standard classification. Intraclass correlation coefficients for inter-rater and test-retest total scores and average differences of total scores, their standard deviations and limits of agreement, were calculated.

Results: For inter-rater observations, the Barthel Index and the Rivermead Mobility Index had almost perfect agreement (k=0.86–1.00 and 0.89–1.00 respectively), with the Berg Balance Scale having substantial to almost perfect agreement (k=0.74–1.00). For test–retest comparisons, both the Barthel Index and the Rivermead Mobility Index demonstrated moderate to almost perfect agreement (k=0.57–1.00 and 0.45–1.00 respectively). Kappa scores for the Berg Balance Scale varied from low to almost perfect agreement (k=0.37–1.00).

Conclusions: The Berg Balance Scale, Rivermead Mobility Index and Barthel Activities of Daily Living Index are all reliable clinical and research tools for physiotherapists working with adults with learning disabilities.

Correlates of the timed 25 foot walk in a multiple sclerosis outpatient rehabilitation clinic

The Timed 25 Foot Walk (T25FW), a test of maximum walking speed on a short distance, is commonly used to monitor ambulation status and to assess treatment outcomes in multiple sclerosis (MS). The main aim of this study was to determine how walking speed on the T25FW correlates with other clinician-reported and patient-reported measures in an outpatient MS rehabilitation clinic. We analyzed cross-sectional data systematically collected during a physiatry evaluation for the management of spasticity and walking limitations. In addition to demographic variables and the Expanded Disability Status Scale (EDSS), measures of body functions [lower extremity manual muscle testing (LE MMT), lower extremity Modified Ashworth Scale, Fatigue Severity Scale, leg pain], and measures of activity and quality of life (reported frequency of falls, Incapacity Status Scale, Rivermead Mobility Index, EQ5D health questionnaire, and Patient Health Questionnaire-9 items) were administered. A multivariate regression analysis was carried out. 199 patients were included in the analysis [age 49.41 (9.89) years, disease duration 15.40 (10.22) years, EDSS score 5.6 (1.2), and T25FW speed 70.93 (44.13) cm/s]. Both EDSS and LE MMT were correlated significantly with T25FW speed (R=0.692, P<0.001). After adjusting for EDSS and LE MMT, lower T25FW speed was associated with higher Incapacity Status Scale scores (R=0.316, P<0.001), lower Rivermead Mobility Index scores (R=0.540, P<0.001), and higher frequency of falls. EQ5D and Patient Health Questionnaire-9 items were not significantly associated with T25FW speed. Our findings support the clinical relevance of the T25FW in the rehabilitation of patients with MS.

Summary of comprehensive systematic review: Rehabilitation in multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

OBJECTIVE

To systematically review the evidence regarding rehabilitation treatments in multiple sclerosis (MS).

METHODS

We systematically searched the literature (1970-2013) and classified articles using 2004 American Academy of Neurology criteria.

RESULTS

This systematic review highlights the paucity of well-designed studies, which are needed to evaluate the available MS rehabilitative therapies. Weekly home/outpatient physical therapy (8 weeks) probably is effective for improving balance, disability, and gait (MS type unspecified, participants able to walk ≥5 meters) but probably is ineffective for improving upper extremity dexterity (1 Class I). Inpatient exercises (3 weeks) followed by home exercises (15 weeks) possibly are effective for improving disability (relapsing-remitting MS [RRMS], primary progressive MS [PPMS], secondary progressive MS [SPMS], Expanded Disability Status Scale [EDSS] 3.0-6.5) (1 Class II). Six weeks' worth of comprehensive multidisciplinary outpatient rehabilitation possibly is effective for improving disability/function (PPMS, SPMS, EDSS 4.0-8.0) (1 Class II). Motor and sensory balance training or motor balance training (3 weeks) possibly is effective for improving static and dynamic balance, and motor balance training (3 weeks) possibly is effective for improving static balance (RRMS, SPMS, PPMS) (1 Class II). Breathing-enhanced upper extremity exercises (6 weeks) possibly are effective for improving timed gait and forced expiratory volume in 1 second (RRMS, SPMS, PPMS, mean EDSS 4.5); this change is of unclear clinical significance. This technique possibly is ineffective for improving disability (1 Class II). Inspiratory muscle training (10 weeks) possibly improves maximal inspiratory pressure (RRMS, SPMS, PPMS, EDSS 2-6.5) (1 Class II).

Bridging the goal intention-action gap in rehabilitation: a study of if-then implementation intentions in neurorehabilitation

PURPOSE

To test the feasibility and acceptability of an implementation intention strategy (if-then plans) increasingly used in health psychology to bridge the goal intention-action gap in rehabilitation with people with neurological conditions who are experiencing difficulties with mobility.

METHODS

Twenty people with multiple sclerosis (MS) and stroke, randomised to an experimental and control group, set up to three mobility related goals with a physiotherapist. The experimental group also formulated if-then plans for every goal.

DATA COLLECTION

Focus groups and interviews with participants and therapists; Patient Activation Measure (PAM), 10-m walk test, Rivermead Mobility Index, self-efficacy, subjective health status, quality of life.

RESULTS

Qualitative data highlighted one main theme: Rehabilitation in context, encapsulating the usefulness of the if-then strategy in thinking about the patient in the context of complexity, the usefulness of home-based rehabilitation, and the perceived need for a few more sessions. Changes in walking speed were in the expected direction for both groups; PAM scores improved over 3 months in both groups.

CONCLUSION

If-then plans were feasible and acceptable in bridging the goal intention-action gap in rehabilitation with people with MS and stroke, who are experiencing difficulties with mobility. This approach can now be adapted and trialled further in a definitive study.

IMPLICATIONS FOR REHABILITATION

Goal planning in rehabilitation necessitates specific strategies that help people engage in goal-related tasks. If-then plans aim to support people to deal more effectively with self-regulatory problems that might undermine goal striving and have been found to be effective in health promotion and health behaviour change. This feasibility study with people with a stroke and multiple sclerosis has demonstrated that if-then plans are feasible and acceptable to patients and physiotherapists in supporting goal-directed behaviour.

Systematic literature review and validity evaluation of the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC) in patients with multiple sclerosis

BACKGROUND

There are a number of instruments that describe severity and progression of multiple sclerosis and they are increasingly used as endpoints to assess the effectiveness of therapeutic interventions. We examined to what extent the psychometric properties of two accepted instruments--EDSS and MSFC--meet methodological standards and the value they have in clinical trials.

METHODS

We conducted a systematic literature search in relevant databases [MEDLINE (PubMed), ISI Web of Science, EMBASE, PsycINFO & PSYNDEX, CINAHL] yielding 3,860 results. Relevant full-text publications were identified using abstract and then full-text reviews, and the literature was reviewed.

RESULTS

For evaluation of psychometric properties (validity, reliability, sensitivity of change) of EDSS and MSFC, 120 relevant full-text publications were identified, 54 of them assessed the EDSS, 26 the MSFC and 40 included both instruments. The EDSS has some documented weaknesses in reliability and sensitivity to change. The main limitations of the MSFC are learning effects and the z-scores method used to calculate the total score. However, the methodological criterion of validity applies sufficiently for both instruments.For use in clinical studies, we found the EDSS to be preferred as a primary and secondary outcome measure in recent studies (50 EDSS, 9 MSFC).

CONCLUSIONS

Recognizing their strengths and weaknesses, both EDSS and MSFC are suitable to detect the effectiveness of clinical interventions and to monitor disease progression. Almost all publications identify the EDSS as the most widely used tool to measure disease outcomes in clinical trials. Despite some limitations, both instruments are accepted as endpoints and neither are discussed as surrogate parameters in identified publications. A great advantage of the EDSS is its international acceptance (e.g. by EMA) as a primary endpoint in clinical trials and its broad use in trials, enabling cross-study comparisons.

Danish translation and psychometric testing of the Rivermead Mobility Index

OBJECTIVES

The Rivermead Mobility Index (RMI) is widely used in several neurological conditions including multiple sclerosis (MS), but its psychometric properties have not been documented in Scandinavia. Therefore, the aim of the study was to translate RMI from UK English into Danish and conduct an initial psychometric testing of the Danish RMI.

MATERIALS AND METHODS

The Danish translation conducted by the forward-backward method was first field-tested regarding user-friendliness and relevance. It was then psychometrically tested among 40 outpatients with MS regarding unidimensionality (corrected item-total correlations, adherence to an assumed Guttman response pattern), reliability, and construct validity.

RESULTS

Field testing found the Danish RMI relevant and user-friendly. Corrected item-total correlations were ≥0.47 and item responses fitted the Guttman pattern. There was a 47.5% ceiling effect, and reliability was 0.91. Correlations supported construct validity.

CONCLUSION

The Danish RMI is user-friendly, unidimensional, reliable, and valid. The results correspond to those previously reported with the original UK RMI version. Ceiling effects are limiting but sample related. Larger samples representing a wider variety of MS severities are needed for firmer evaluation of the Danish RMI.

Gait impairment and optimizing mobility in multiple sclerosis

Multiple sclerosis (MS) is an immune-mediated disease that causes demyelination and degeneration within the brain and spinal cord. This may result in many impairments, including impaired ambulation, muscle weakness, abnormal tone, visual disturbances, decreased sensation, and fatigue. Rehabilitation helps patients with MS maximize independence by helping to manage and minimize impairments. Deficits seen in ambulation should be addressed to improve energy efficiency and reduce falls. Compensation through appropriate prescription of assistive devices, bracing, and wheelchairs will help improve safety. Rehabilitation can make a significant impact on achieving and maintaining quality of life and independence.

Energy conservation for fatigue management in multiple sclerosis: a pilot randomized controlled trial

Objective:

To develop and test the feasibility of an energy conservation programme to manage fatigue in multiple sclerosis.

Design:

A pilot randomized controlled trial.

Setting:

Community setting.

Subjects:

People with multiple sclerosis reporting fatigue.

Interventions:

An energy conservation programme was compared to a peer support group. Both interventions were delivered in group format with 2-hour sessions once a week for five weeks. Patients’ views about the interventions were sought in discussion groups one week post intervention.

Main measures:

The primary feasibility outcomes were recruitment and adherence. Other outcome measures were the Fatigue Impact Scale, Fatigue Severity Scale, MS-Impact Scale-29, MS Self-efficacy Scale, Beck’s Depression Scale-Fast Screen and Epworth Sleepiness Scale. Outcomes were administered at baseline, post intervention, 6-week and 3-month follow-up.

Results:

Almost 30% of the people approached to take part in the study did not commit to participation because of transport/time issues. Twenty-three patients took part in the study. Three patients dropped out, one reporting adverse effects. A power calculation indicated that a sample of 56 (28 per group) would be required for a main randomized controlled trial. Patients valued peer support and those in the energy conservation group described the programme as useful, but reported difficulties completing some practice activities.

Conclusion:

An energy conservation programme in the community is feasible and welcomed by people with multiple sclerosis. However, future research needs to consider longer follow-ups and practical issues to improve recruitment rate by accommodating to patients’ needs.

Assessing walking disability in multiple sclerosis

Most patients with multiple sclerosis (MS) eventually experience walking disability. The objective of this review was to evaluate the clinical utility of measures specific for walking in MS. Walking assessments had high reliability and were correlated with related measures, including the 12-item multiple sclerosis walking scale (MSWS-12). Shorter timed walking tests (Timed 25-foot Walk (T25FW), 10-metre Timed Walk, 30-metre Timed Walk) measure overall walking disability and are best suited for clinical settings, whereas longer timed or distance tests (100-metre Timed Walk, 6-minute Walk Test, 2-minute Walk Test) are better for the assessment of walking fatigability, distance limitations and functional capacity. The MSWS-12 measures different, but related, aspects of walking than the objective tests. The T25FW is the best characterised objective measure of walking disability and can be used across a wide range of walking disabilities. Additional work is needed to fully characterise the other objective walking assessments in MS.

Effect of time of day on walking capacity and self-reported fatigue in persons with multiple sclerosis: a multi-center trial

BACKGROUND

Many persons with multiple sclerosis (PwMS) report increased fatigue in the afternoon and evening compared with the morning. It is commonly accepted that physical capacity also decreases as time of day progresses, potentially influencing the outcomes of testing.

OBJECTIVE

The objective of this article was to determine whether self-reported fatigue level and walking capacity are influenced by time of day in PwMS.

METHODS

A total of 102 PwMS from 8 centers in 5 countries, with a diverse level of ambulatory dysfunction (Expanded Disability Status Scale [EDSS] <6.5), participated. Patients performed walking capacity tests and reported fatigue level at three different time points (morning, noon, afternoon) during 1 day. Walking capacity was measured with the 6-Minute Walk Test (6MWT) and the 10-m walk test performed at usual and fastest speed. Self-reported fatigue was measured by the Rochester Fatigue Diary (RFD). Subgroups with mild (EDSS 1.5-4.0, n = 53) and moderate (EDSS 4.5-6.5, n = 49) ambulatory dysfunction were formed, as changes during the day were hypothesized to depend on disability status.

RESULTS

Subgroups had different degree of ambulatory dysfunction (p < 0.001) but reported similar fatigue levels. Although RFD scores were affected by time of day with significant differences between morning and noon/afternoon (p < 0.0001), no changes in walking capacity were found in any subgroup. Additional analyses on subgroups distinguished by diurnal change in self-reported fatigue failed to reveal analogous changes in walking capacity.

CONCLUSIONS

Testing of walking capacity is unaffected by time of day, despite changes in subjective fatigue.

Association between walking speed and age in healthy, free-living individuals using mobile accelerometry--a cross-sectional study

CONTEXT

Walking speed is a fundamental parameter of human motion and is increasingly considered as an important indicator of individuals' health status.

OBJECTIVE

To evaluate the relationship of gait parameters, and demographic and physical characteristics in healthy men and women.

DESIGN, SETTING, AND PARTICIPANTS

Recruitment of a subsample (n = 358) of male and female blood donors taking part in the Cambridge CardioResource study. Collection of demographic data, measurement of physical characteristics (height, weight and blood pressure) and assessment of 7-day, free-living activity parameters using accelerometry and a novel algorithm to measure walking speed. Participants were a median (interquartile range[IQR]) age of 49 (16) years; 45% women; and had a median (IQR) BMI of 26 (5.4).

MAIN OUTCOME MEASURE

Walking speed.

RESULTS

In this study, the hypothesis that walking speed declines with age was generated using an initial 'open' dataset. This was subsequently validated in a separate 'closed' dataset that showed a decrease of walking speed of -0.0037 m/s per year. This is equivalent to a difference of 1.2 minutes, when walking a distance of 1 km aged 20 compared to 60 years. Associations between walking speed and other participant characteristics (i.e. gender, BMI and blood pressure) were non-significant. BMI was negatively correlated with the number of walking and running steps and longest non-stop distance.

CONCLUSION

This is the first study using accelerometry which shows an association between walking speed and age in free-living, healthy individuals. Absolute values of gait speed are comparable to published normal ranges in clinical settings. This study highlights the potential use of mobile accelerometry to assess gait parameters which may be indicative of future health outcomes in healthy individuals.

Development and validation of a new method to measure walking speed in free-living environments using the actibelt® platform

Walking speed is a fundamental indicator for human well-being. In a clinical setting, walking speed is typically measured by means of walking tests using different protocols. However, walking speed obtained in this way is unlikely to be representative of the conditions in a free-living environment. Recently, mobile accelerometry has opened up the possibility to extract walking speed from long-time observations in free-living individuals, but the validity of these measurements needs to be determined. In this investigation, we have developed algorithms for walking speed prediction based on 3D accelerometry data (actibelt®) and created a framework using a standardized data set with gold standard annotations to facilitate the validation and comparison of these algorithms. For this purpose 17 healthy subjects operated a newly developed mobile gold standard while walking/running on an indoor track. Subsequently, the validity of 12 candidate algorithms for walking speed prediction ranging from well-known simple approaches like combining step length with frequency to more sophisticated algorithms such as linear and non-linear models was assessed using statistical measures. As a result, a novel algorithm employing support vector regression was found to perform best with a concordance correlation coefficient of 0.93 (95%CI 0.92–0.94) and a coverage probability CP1 of 0.46 (95%CI 0.12–0.70) for a deviation of 0.1 m/s (CP2 0.78, CP3 0.94) when compared to the mobile gold standard while walking indoors. A smaller outdoor experiment confirmed those results with even better coverage probability. We conclude that walking speed thus obtained has the potential to help establish walking speed in free-living environments as a patient-oriented outcome measure.

Community walking can be assessed using a 10-metre timed walk test

Background: A decline in mobility is a common feature of multiple sclerosis (MS). Community walking scales are used to categorize patients in their ability to move independently. The first purpose of this study was to determine which specific gait speed corresponded with the categories of the Modified Functional Walking Categories (MFWC). The second purpose was to determine the Minimally Important Change (MIC) in absolute gait speed using the MFWC and Expanded Disability Status Scale (EDSS) as external criteria.

Method: MS patients were measured six times in 6 years. Gait velocity was measured with the 10-metre timed walk test (10-m TWT), the severity of MS was determined with the EDSS, and community walking was assessed with the MFWC. For each category of the MFWC, Receiver Operating Characteristic (ROC) curves were used to find the best possible cut-off point on the 10-m TWT. The MIC in absolute gait speed was determined using a change of one category on the MFWC or one point on the EDSS.

Results: A strong relationship was found between gait speed and the MFWC; all areas under the ROC curves (AUCs) were between 0.74 and 0.86. The MIC in absolute gait speed could not be determined, because the AUCs were below the threshold of 0.70 and changes in gait speed were small.

Conclusions: Gait speed is related to community walking, but an MIC in absolute gait speed could not be determined using a minimally important change on the MFWC or the EDSS as external criteria.

The Modified Rivermead Mobility Index: reliability and convergent validity in a mixed neurological population

PURPOSE

To assess the inter-rater reliability, internal consistency and convergent validity of the Modified Rivermead Mobility Index (MRMI) in a mixed neurological population.

METHOD

The MRMI was scored for 30 consecutive patients (mean age 54.5+/-15.6 years) by two individual testers. Reliability was examined using intraclass correlation coefficients (ICC3,1) and Bland and Altman plots; internal consistency reliability using Cronbach's alpha (alpha) and convergent validity using Spearman's correlation coefficient (rho) test to compare the MRMI to the 10-m walk test as a gold standard of mobility. As the majority of patients had bilateral deficits, the MRMI was measured and added independently for both sides.

RESULTS

The inter-rater reliability was excellent: ICC (95% CI)=0.93(0.86, 0.96). The Bland and Altman plots contained most data points and there was perfect agreement between raters bilaterally in 27% of cases, with a difference of one point in 60% of cases on the left and 63% of cases on the right. Internal consistency was good at alpha=0.72 (Rater 1) and 0.80 (Rater 2). The Spearman rho between MRMI and the 10-m walk test was high at 0.86.

CONCLUSIONS

The MRMI was shown to have high levels of reliability in a mixed neurological population but we recommend that its psychometric properties are further investigated to establish the true clinical utility of this measure.

A randomized trial to investigate the effects of functional electrical stimulation and therapeutic exercise on walking performance for people with multiple sclerosis

Background

Functional electrical stimulation (FES), is a means of producing a contraction in a paralyzed or weak muscle to enable function through electrical excitation of the innervating nerve.

Objective

This two-group randomized trial assessed the effects of single channel common peroneal nerve stimulation on objective aspects of gait relative to exercise therapy for people with secondary progressive multiple sclerosis (SPMS).

Methods

Forty-four people with a diagnosis of SPMS and unilateral dropped foot completed the trial. Twenty patients were randomly allocated to a group receiving FES and the remaining 24 to a group receiving a physiotherapy home exercise program for a period of 18 weeks.

Results

The exercise group showed a statistically significant increase in 10 m walking speed and distance walked in 3 min, relative to the FES group who showed no significant change in walking performance without stimulation. At each stage of the trial, the FES group performed to a significantly higher level with FES than without for the same outcome measures.

Conclusion

Exercise may provide a greater training effect on walking speed and endurance than FES for people with SPMS. FES may provide an orthotic benefit when outcome is measured using the same parameters. More research is required to investigate the combined therapeutic effects of FES and exercise for this patient group.

Clinical relevance using timed walk tests and 'timed up and go' testing in persons with multiple sclerosis

BACKGROUND AND PURPOSE

One must understand the potentials and limitations of all tests used to evaluate interventions. The aim of the present study was to clarify the reproducibility, smallest percentage difference needed to be able to detect a genuine change and correlation regarding the 10-m and 30-m timed walks (10TW 30TW) and the 'timed up and go' (TUG) test in people with moderate multiple sclerosis (MS).

METHOD

A repeated-measures design was used, with randomization into two groups and different time intervals used for testing. The 10TW and 30TW were performed three times and TUG twice at each testing. Self-selected speed was used for 10TW and forced speed (quickly but safely) for 30TW and TUG. Forty-three people were tested on three occasions within one week. Each person was tested at approximately the same time of the day and by the same physiotherapist on each occasion.

RESULTS

The reproducibility was very high. For a single testing occasion, the intraclass correlation was 0.97 for the 10TW and 0.98 for the 30TW and TUG. The smallest percentage difference needed to be able to detect a genuine change in the entire study group was approximately -23% or +31% for either the 1OTW or TUG. It was evident from the 30TW testing results that lower values applied to those with less (-14% to +17%) rather than more (-38% or +60%) disability. The correlation between all tests for the entire study group was 0.85 (0.76-0.91).

CONCLUSION

It is sufficient to use only one attempt and to choose only one of the tests when evaluating people with moderate MS. In the case of the 30TW greater attention must be paid to the degree of disability when determining the smallest percentage difference needed to establish a genuine change, than

Multidisciplinary rehabilitation for adults with multiple sclerosis

BACKGROUND

Multidisciplinary rehabilitation (MD) is an important component of symptomatic and supportive treatment for Multiple sclerosis (MS), but evidence base for its effectiveness is yet to be established.

OBJECTIVES

To assess the effectiveness of organized MD rehabilitation in adults with MS. To explore rehabilitation approaches that are effective in different settings and the outcomes that are affected.

SEARCH STRATEGY

The sources used included: Cochrane Central Register of Controlled Trials "CENTRAL", MEDLINE (1966- 2005), CINAHL (1982- 2005), PEDro (1990- 2005), EMBASE (1988- 2005), the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register (NRR).

SELECTION CRITERIA

Randomized and controlled clinical trials that compared MD rehabilitation with routinely available local services or lower levels of intervention; or trials comparing interventions in different settings or at different levels of intensity.

DATA COLLECTION AND ANALYSIS

Three reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis based on methodological quality was performed. Trials were grouped in terms of setting and type of rehabilitation and duration of patient follow up.

MAIN RESULTS

Eight trials (7 RCTs; 1 CCT) (747 participants and 73 caregivers) were identified. Seven RCTs scored well and one CCT scored poorly on the methodological quality assessment. There was 'strong evidence' that despite no change in the level of impairment, inpatient MD rehabilitation can produce short-term gains at the levels of activity (disability) and participation for patients with MS. For outpatient and home-based rehabilitation programmes there was 'limited evidence' for short-term improvements in symptoms and disability with high intensity programmes, which translated into improvement in participation and quality of life. For low intensity programmes conducted over a longer period there was strong evidence for longer-term gains in quality of life; and also limited evidence for benefits to carers. Although some studies reported potential for cost-savings, there is no convincing evidence regarding the long-term cost-effectiveness of these programmes. It was not possible to suggest best 'dose' of therapy or supremacy of one therapy over another. This review highlights the limitations of RCTs in rehabilitation settings and need for better designed randomized and multiple centre trials.

AUTHORS' CONCLUSIONS

MD rehabilitation programmes do not change the level of impairment, but can improve the experience of people with MS in terms of activity and participation. Regular evaluation and assessment of these persons for rehabilitation is recommended. Further research into appropriate outcome measures, optimal intensity, frequency, cost and effectiveness of rehabilitation therapy over a longer time period is needed. Future research in rehabilitation should focus on improving methodological and scientific rigour of clinical trials.

Gait variability in people with multiple sclerosis

Patients with multiple sclerosis (MS) present with varying symptoms that can differ between and within individuals. As new interventions and drug treatments become available to MS patients, it is essential to understand the relationship between fatigue and the variability of functional mobility measures in order to define a meaningful change due to treatment within the MS population. The purpose of this study was to examine the within-day and between-day changes in gait variability for subjects with MS in fresh and fatigued conditions. Walking gait parameters were measured from 20 subjects diagnosed with MS and eight healthy control subjects. Standard deviations of hip, knee and ankle kinematic and kinetic variables were quantified as the measure of variability and analysed with a two-way (group by condition) ANOVA. Results indicated MS subjects had significantly greater hip (P <0.020), knee (P <0.011) and ankle (P <0.034) joint angle variability than control subjects, but variability was not different between conditions. Kinetic variability was not different between groups or conditions. MS subjects in this study walked more slowly than the healthy controls and they also reported more fatigue. Research examining treatment effects within the MS population should account for increased levels of kinematic gait variability.

Évaluation et sclérose en plaques

We conducted a review of existing assessment tools that can be useful to physical medicine and rehabilitation professionals involved in the management of patients with multiple sclerosis (MS). Most generic tools traditionally used in neurorehabilitation, such as gait tests, the functional independence measure, or the SF-36, can be applied to MS, but few have been tested on large patient samples. Disease-specific scales often seem more pertinent and sensitive to change, and their qualities and limitations are better known through clinical trials of disease-modifying therapies.

Exercise and Rehabilitation for Individuals with Multiple Sclerosis

It is the coexistence of physical and cognitive impairments, together with emotional and social issues in a disease with an uncertain course, that makes MS rehabilitation unique and challenging. Inpatient rehabilitation improves functional independence but has only limited success improving the level of neurologic impairment. Benefits are usually not long lasting. Severely disabled people derive equal or more benefit than those who are less disabled, but cognitive problems and ataxia tend to be refractory. There is now good evidence that exercise can improve fitness and function for those with mild MS and helps to maintain function for those with moderate to severe disability. Therapy can be performed over 6 to 15 weeks in outpatient or home-based settings or as a weekly day program lasting several months. Several different forms of exercise have been investigated. For most individuals, aerobic exercise that incorporates a degree of balance training and socialization is recommended. Time constraints, access, impairment level, personal preferences, motivations, and funding sources influence the prescription for exercise and other components of rehabilitation. Just as immunomodulatory drugs must be taken on a continual basis and be adjusted as the disease progresses, so should rehabilitation be viewed as an ongoing process to maintain and restore maximum function and QOL.

Locomotor Training and Virtual Reality-based Balance Training for an Individual with Multiple Sclerosis

BACKGROUND AND PURPOSE

Impaired walking ability, balance, and fatigue are common problems for people with multiple sclerosis (MS). The purpose of this case report is to describe the use of plan of care that included locomotor training using both a body weight support (BWS) with a treadmill (TM) and overground walking as well as a virtual reality (VR)-based balance intervention to improve walking ability, balance, and endurance for an individual with MS.

CASE DESCRIPTION

The client was a 48-year-old female with a 10-year history of MS. Her main goals were to improve walking ability, balance, and endurance. She presented with impaired gait, balance, motor function, and increased fatigue. Locomotor training using a BWS/TM system and overground and VR-based balance interventions were implemented 2 days a week for 12 weeks.

OUTCOMES

The client demonstrated improvements in gait speed, gait endurance, and balance postintervention and maintained the improvements at a 2-month follow up.

DISCUSSION

This case report is the first to report on the use of locomotor training with BWS/TM system and overground and VR-based balance interventions for a client with MS. The plan of care was formulated based on the patient's goals and the available literature on the use of the interventions with other patients with neurologic conditions to provide an intervention that was task-oriented, skilled, and intensive.

Psychometric properties of the Rivermead Mobility Index in Italian stroke rehabilitation inpatients

OBJECTIVE

To examine the internal consistency, validity, responsiveness and test scalability of the Rivermead Mobility Index (RMI) in Italian rehabilitation inpatients recovering from stroke.

DESIGN

Seventy-three stroke inpatients undergoing rehabilitation were assessed at admission (T0) and five weeks later (T1), using RMI, the motor (motFIM) and cognitive (cognFIM) subscales of the Functional Independence Measure, the 'leg' section of the Motricity Index and Trunk Control Test.

RESULTS

Cronbach's alpha of the RMI was 0.92. The item-to-total correlation coefficients (r(rb)) ranged from 0.36 to 0.83, all p < 0.003. All correlations between RMI scores and the other instruments, both at T0 and T1, were statistically significant (r > or = 0.49, all p < 0.0001), except those with cognFIM. The difference in RMI scores over the testing period was statistically significant (sign test: z = 7.1, p < 0.0001) and the effect size was 0.89. The coefficient of reproducibility was 0.95 at T0 and 0.93 at T1, and both coefficients of scalability were 0.67.

CONCLUSIONS

The study confirms the internal consistency, construct validity and responsiveness of the RMI, according to the classic psychometric indexes. However, some minor concerns arise regarding: (a) a floor effect of RMI in subacute rehabilitation stroke inpatients at admission and; (b) one item ('bathing') that seems sensitive to cultural and environmental factors. Moreover, even though RMI met the scaling criteria, the item hierarchy is not coincident with the one originally postulated. So, RMI should be considered only as a summated index with ordinal properties, and not a hierarchically ranked scale.

Rasch analysis of the Rivermead Mobility Index: a study using mobility measures of first-stroke inpatients

OBJECTIVE

To evaluate the validity and item unidimensionality of the Rivermead Mobility Index (RMI) by using Rasch analysis.

DESIGN

Application of Rasch analysis on the RMI partial data set.

SETTING

A stroke program at a rehabilitation hospital in Italy.

PARTICIPANTS

A total of 308 consecutive patients (155 women, 153 men; avg age, 62.79+/-11.94 y) hospitalized between 1990 and 1996. Average interval between stroke onset and admission was 52.48+/-36.22 days.

INTERVENTION

Medical inpatient rehabilitation.

MAIN OUTCOME MEASURES

Patients' mobility status was assessed using the RMI administered at admission and discharge. Ratings were assigned by 4 staff members working as a team. We performed separate Rasch analyses on the RMI data, gathered from different groups of first stroke inpatients examined before and after rehabilitation treatment.

RESULTS

asch analysis showed the overall good validity of the RMI, except for item 15, which did not fit the unidimensional continuum estimated through the Rasch rating model.

CONCLUSION

The RMI is a unidimensional scale with a hierarchy of easy-to-hard test questions. Item difficulty level was stable when processed on different groups of patients assessed on different occasions.

The Guy's Neurological Disability Scale in patients with multiple sclerosis: a clinical evaluation of its reliability and validity

OBJECTIVE

To establish reliability and validity of the Guy's Neurological Disability Scale (GNDS) for the assessment of patients with multiple sclerosis (MS) and to investigate whether it can be used by postal questionnaire.

DESIGN

An observational study assessing one group of 22 patients using the GNDS face-to-face, repeating the assessment two or three weeks later with other tests; and assessing a second group of 21 patients first using a postal version of the GNDS and then seeing them face-to-face.

SETTING

Patients in the community attending a day centre or a voluntary support group.

SUBJECTS

Patients with multiple sclerosis.

MEASURES

The GNDS was the primary measure, and was compared with the Barthel Index, the Expanded Disability Status Scale (EDSS), the Short Orientation Concentration and Memory Test, the Nine-hole Peg Test, the Rivermead Mobility Index, the Hospital Anxiety and Depression Scale, the Fatigue Severity Scale, visual acuity assessment, swallowing 50 ml of water, and a clinical assessment of dysarthria.

RESULTS

The test-retest reliability of the GNDS total score (r= 0.972) and each of its components (r varied from 0.685 to 0.987) was good. When compared with the EDSS or the Barthel, the GNDS had good validity (respectively r = 0.636 and r = -0.757). The validity was also measured for the different areas of the GNDS by comparison with corresponding indices or test. The results varied from good to excellent (r from -0.557 to 0.910). The results were only a little less reliable when a postal questionnaire was used.

CONCLUSION

The GNDS is a valid and reliable tool for the assessment of MS patients. The test-retest correlation varies from good to excellent. It can be used as postal questionnaire even if, as expected, the interviewer-administered method shows slightly better results.

Day-to-day variability of maximum walking distance in MS patients can mislead to relevant changes in the Expanded Disability Status Scale (EDSS): average walking speed is a more constant parameter

In this preliminary study we measured maximum walking distance and walking time on four consecutive days in 29 patients with clinically stable multiple sclerosis (MS). Patients were included in the study if they could achieve a maximum unaided walking distance of 100 up to 500 m. Our results showed a certain day-to-day variability of maximum walking distance, in some cases meaning changes up to 1.5 points in the expanded disability status scale (EDSS), which could be misinterpreted as a progression of the disease. Simultaneous measurements of maximum walking time showed a similar variability, unlike the mean walking speed which turned out to be more stable. Our results therefore suggest that scoring of MS patients should not be based on one single measurement of the maximum walking distance. The more reliable parameter appears to be the mean walking speed.

Evaluation of a German version of the Rivermead Mobility Index (RMI) in acute and chronic stroke patients

The English Rivermead Mobility Index (RMI) has been proposed as a simple, valid and reliable measure in stroke rehabilitation. A German version was established and validated in two centres. In centre A 46 acute (median: 3.0 days after onset) and in centre B 151 chronic (median: 88.0 days after onset) stroke patients participated. Interrater reliability of the German RMI was tested in 12 subjects in the acute stage of stroke and was found to be statistically significant (r = 0.98, P < 0.0001). In centre A, a statistically significant correlation was found between the German RMI and the 10-m walk time at baseline (r = 0.73, P < 0.0001) and after three weeks (r = 0.92, P < 0.0001). In centre B, the German RMI correlated significantly with the motor part of the Functional Independence Measure (motor-FIM) on admission (r = 0.78, P < 0.0001) and after three weeks (r = 0.79, P < 0.0001), respectively. The change of the RMI correlated significantly with the change in 10-m walk time in acute patients (r = 0.87, P < 0.0001) and with the change in motor-FIM in chronic patients (r = 0.54, P < 0.0001). A moderate ceiling-effect was detected in the chronic study population. The German RMI appears to be a reliable, valid and responsive measure for mobility disability in acute and chronic stroke patients.