Static Posturography and Falls According to Pyramidal, Sensory and Cerebellar Functional Systems in People with Multiple Sclerosis

The relationship between concentric and isometric strength of knee flexor and extensor muscles and postural stability in mild stage multiple sclerosis patients

BACKGROUND

Multiple sclerosis (MS) affects muscle strength and postural stability. However, the relationship between concentric and isometric strength of knee flexors and extensors and postural stability in mild stage MS is not well known. The aim of the study was to examine the relationship between concentric and isometric strength of knee flexors and extensors and postural stability in mild stage MS patients.

MATERIALS AND METHODS

The study included 21 mild-stage MS patients with an EDSS score of 4 or less and 21 healthy controls. The concentric and isometric strength of knee flexors and extensors was measured with the Biodex System 4 Dynamometer, and postural stability with the Biodex Balance System under eyes-open and eyes-closed conditions on a rigid surface.

RESULTS

Mild-stage MS patients had reduced concentric strength of knee extensors and flexors and increased postural sway compared with healthy controls (p < 0.05). Isometric strength of knee extensors and flexors in mild stage MS patients were similar to healthy controls (p > 0.05). There was a moderate positive correlation between concentric strength of knee extensors and flexors and isometric strength of knee flexors and open-eye postural stability indexes in mild stage multiple sclerosis patients (p < 0.05).

CONCLUSIONS

While isometric strength of knee extensors and flexors was preserved, concentric strength of knee extensors and flexors was decreased, and postural stability was adversely affected in mild stage MS patients. The increase in the strength of the knee muscles was associated with an increase in their postural sway in mild stage MS patients.

Cerebellar Volume Measures Differentiate Multiple Sclerosis Fallers from Non-Fallers

INTRODUCTION

The cerebellum is a common lesion site in persons with multiple sclerosis (PwMS). Physiologic and anatomic studies have identified a topographic organization of the cerebellum including functionally distinct motor and cognitive areas. In this study, a recent parcellation algorithm was applied to a sample of PwMS and healthy controls to examine the relationships among specific cerebellar regions, fall status, and common clinical measures of motor and cognitive functions.

METHODS

Thirty-one PwMS and twenty-nine age- and sex-matched controls underwent an MRI scan and motor and cognitive testing. The parcellation algorithm was applied to all images and divided the cerebellum into 28 regions. Mann-Whitney U tests were used to compare cerebellar volumes among PwMS and controls, and MS fallers and MS non-fallers. Relationships between cerebellar volumes and motor and cognitive function were evaluated using Spearman correlations.

RESULTS

PwMS performed significantly worse on functional measures compared to controls. We found significant differences in volumetric measures between PwMS and controls in the corpus medullare, lobules I-III, and lobule V. Volumetric differences seen between the PwMS and controls were primarily driven by the MS fallers. Finally, functional performance on motor and cognitive tasks was associated with cerebellar volumes.

CONCLUSIONS

Using the parcellation tool, our results showed that the volumes of motor and cognitive lobules impact both motor and cognitive performance, and that functional performance and cerebellar volumes distinguishes the MS fallers from non-fallers. Future studies should explore the potential of cerebellar imaging to predict falls in PwMS.

The effect of balance, walking capacity, and fear of falling on the level of community integration in individuals with Multiple Sclerosis: A cross-sectional study

BACKGROUND

Social participation levels of individuals with Multiple Sclerosis (iwMS) are lower than those of healthy individuals.

OBJECTIVE

This study aimed to evaluate to which extent the walking capacity, balance, and fear of falling (FoF) affect the community integration levels of iwMS.

METHODS

Thirty-nine iwMS were evaluated for their participation levels [The Community Integration Questionnaire (CIQ)], walking capacity [The Six-Minute Walk Test (6MWT)], balance [Kinesthetic Ability Trainer (SportKAT®)], and FoF [The Modified Falls Efficacy Scale (MFES)]. Correlation and regression analyses were performed to detect the effects of SportKAT®, 6MWT, and MFES on CIQ.

RESULTS

CIQ scores were significantly correlated with 6MWT (p = .043) and MFES (p = .005) scores, while CIQ was not related with static (for two feet test p = .356, for right single-leg stance test p = .412, for left single-leg stance test p = .730) and dynamic balance (for clockwise test p = .097, for counterclockwise test p = .540) measured with the SportKAT®. It was found that CIQ could be predicted by 6MWT and MFES at the level of 16% and 25%, respectively.

CONCLUSION

FoF and walking capacity are associated with community integration in iwMS. Therefore, physiotherapy and rehabilitation programs of iwMS should be combined with treatment goals to increase community integration, balance, and gait and decrease the disability and FoF from an early stage. Comprehensive studies examining other factors that may impact participation in iwMS with different levels of disability are needed.

Testing protocols and measurement techniques when using pressure sensors for sport and health applications: A comparative review

Plantar pressure measurement systems are routinely used in sports and health applications to assess locomotion. The purpose of this review is to describe and critically discuss: (a) applications of the pressure measurement systems in sport and healthcare, (b) testing protocols and considerations for clinical gait analysis, (c) clinical recommendations for interpreting plantar pressure data, (d) calibration procedures and their accuracy, and (e) the future of pressure sensor data analysis. Rigid pressure platforms are typically used to measure plantar pressures for the assessment of foot function during standing and walking, particularly when barefoot, and are the most accurate for measuring plantar pressures. For reliable data, two step protocol prior to contacting the pressure plate is recommended. In-shoe systems are most suitable for measuring plantar pressures in the field during daily living or dynamic sporting movements as they are often wireless and can measure multiple steps. They are the most suitable equipment to assess the effects of footwear and orthotics on plantar pressures. However, they typically have lower spatial resolution and sampling frequency than platform systems. Users of pressure measurement systems need to consider the suitability of the calibration procedures for their chosen application when selecting and using a pressure measurement system. For some applications, a bespoke calibration procedure is required to improve validity and reliability of the pressure measurement system. The testing machines that are commonly used for dynamic calibration of pressure measurement systems frequently have loading rates of less than even those found in walking, so the development of testing protocols that truly measure the loading rates found in many sporting movements are required. There is clear potential for AI techniques to assist in the analysis and interpretation of plantar pressure data to enable the more complete use of pressure system data in clinical diagnoses and monitoring.

Exploring Factors Associated with Falls in Multiple Sclerosis: Insights from a Scoping Review

Multiple sclerosis (MS) is a chronic inflammatory condition that causes demyelination of the central nervous system accompanied by a wide range of symptoms. The high prevalence of falls among patients diagnosed with MS within the initial six months highlights the importance of this issue. The objective of this study is to identify factors associated with falls in MS patients in order to increase awareness and reduce the risk of falls. This scoping review used specific Mesh terms to formulate the literature search around falls and MS using Medline, Google Scholar, Scopus, and Embase search engines. English papers published between 2012 and 2022, studies with a clear definition of falls, McDonald's diagnostic criteria for MS, and those with Expanded Disability Status Scale (EDSS) or Patient Determined Disease Steps (PDDS) scores were included. Critical data from the selected articles were extracted and classified according to the different factors associated with falls in MS patients. Eighteen articles were included in this review. The most important factors associated with falls in MS patients identified were the severity and progression of the disease, mobility and balance problems, bladder dysfunction, fear of falling, fatigue, and cognitive dysfunction. In conclusion, this scoping review yielded the most common factors associated with falls in patients with MS. Study findings can be used to develop future interventions focusing on improving mobility, proprioception, and balance to decrease fall risk and injury amongst MS patients.

Cerebellar volume measures may differentiate multiple sclerosis fallers from non-fallers

Introduction

The cerebellum is a common lesion site in persons with multiple sclerosis (PwMS). Physiologic and anatomic studies have identified a topographic organization of the cerebellum including functionally distinct motor and cognitive areas. This study implemented a recent parcellation algorithm developed by Han et al., 2020 to a sample of PwMS and healthy controls to examine relationships among specific cerebellar regions, fall status, and common clinical measures of motor and cognitive functions.

Methods

Thirty-one PwMS and 29 age and sex-matched controls underwent an MRI scan and motor and cognitive testing. The parcellation algorithm was applied to all images and divided the cerebellum into 28 regions. Mann-Whitney U tests were used to compare cerebellar volumes among PwMS and controls, and MS fallers and MS non-fallers. Relationships between cerebellar volumes and motor and cognitive function was evaluated using Spearman correlations.

Results

PwMS performed significantly worse on functional measures compared to controls. We found significant differences in volumetric measures between PwMS and controls in the corpus medullare, lobules I-III, and lobule V. Volumetric differences seen between PwMS and controls were primarily driven by the MS fallers. Finally, functional performance on motor and cognitive tasks was associated with cerebellar volumes.

Conclusions

Using the parcellation tool, our results showed that volumes of motor and cognitive lobules impact both motor and cognitive performance, and that functional performance and cerebellar volumes distinguishes MS fallers from non-fallers. Future studies should explore the potential of cerebellar imaging to predict falls in PwMS.

Impact of textured surfaces on the orthostatic balance of patients with multiple sclerosis

OBJECTIVE

To perform posturographic measurements with eyes open or closed using floor coverings with different textured surfaces to study postural control in patients with multiple sclerosis (MS).

METHODS

Static posturographic recordings were performed with eyes open and eyes closed on a forceplate with no covering (control condition) or covered by a textured mat with small pimples (height 2 mm) or large pimples (height 7 mm). Several posturographic variables were measured, focusing on displacements of the center of pressure (CoP) including the average velocity (Vav), the total length (L) of all displacements, and the surface (S) of the confidence ellipse. The recordings made with the textured mats were compared to the control condition with eyes open or closed. Then, the differences between the recordings made with large vs. small pimples on the one hand, and with eyes closed vs. open were calculated to assess the impact of pimple height or eye closure on posturographic measurements. Clinical assessment was based on the Expanded Disability Status Scale (EDSS) and its functional system (FS) subscores, the Modified Fatigue Impact Scale (MFIS), the Unipodal Stance test (UST), and the Timed Up-and-Go test (TUG).

RESULTS

Forty-six MS patients (mean EDSS score: 3.6) completed the study. Several posturographic variables, including Vav and L, deteriorated when measured on a textured mat, especially with large pimples and in eyes open condition. In contrast, no difference was found with small pimples and eyes closed, as compared to the control condition (no covering). The deleterious impact of pimple height on posturography correlated positively with the alteration of balance and gait clinically assessed by the UST and the TUG, and also with the MFIS physical and cerebral EDSS-FS subscores, and negatively with the cerebellar and brainstem subscores. On the other hand, the impact of eye closure on posturography was negatively correlated with the visual EDSS-FS subscore.

DISCUSSION

Static posturographic measurements made with different textured surfaces and visual conditions can be considered as a sensitive tool to measure "proprioceptive reserves". Actually, when cerebellar, brainstem, or visual functions are impaired, the resources of the sensory (proprioceptive) system, if preserved, can be recruited at a higher level and compensate for dysfunctions of other postural controls to maintain a satisfactory balance. In addition, this procedure of static posturographic examination can provide objective measurements correlated with clinical testing of balance and gait and could usefully complement EDSS scoring to assess disability affecting postural control and the risk of falling in MS patients.

Fall risk is related to cognitive functioning in ambulatory multiple sclerosis patients

BACKGROUND AND AIMS

Patients with multiple sclerosis (PwMS) may suffer severely from falling and gait disturbance. Cognitive dysfunction, a common condition in MS patients, may also increase falling rates, regardless of physical disability. We planned this study to determine the fall rate and risk factors in MS patients, follow patients for falls, and reveal the relationship between falls and cognitive dysfunction.

METHODS

The study was conducted on 124 patients who have RRMS diagnoses. Patients' gait speed, simultaneous gait speed during other tasks, functions of the upper extremity, balance rating, and fear of falling were evaluated with dual-task Timed-Up-and-Go-3 versions (TUG, TUG-C, TUG-M), Timed 25 Foot Walk (T25WFT), Nine Hole Peg Test (9HPT), Berg Balance Scale (BBS) and Falls Efficacy Scale-International (FES-I) tests. Cognitive functions, fatigue levels, and quality of life were measured with the Symbol Digit Modalities Test (SDMT), Fatigue Severity Scale (FSS), and Multiple Sclerosis Quality of Life (MSQoL) test. Two groups were formed as "fallers" and "non-faller patients". We monitored the patients in six months period.

RESULTS

Forty-six patients fell at least once in the last one year before the study began. Fallers were older, less educated, had lower SDMT scores and higher disability scores. Non-faller patients scored lower in FES-I, TUG, and FSS tests. SDMT scores showed statistically significant, linear, positive, and moderate correlation with BBS and 9HPT scores (r = 0.307, p = 0.038, and r = 0.320, p = 0.030, respectively).

CONCLUSION

We determined that advanced age, lower education level, and cognitive dysfunction adversely affect gait speed and balance. Among the fallers, those with lower SDMT and MoCA scores had higher falling rates. We determined that EDSS and BBS scores are predictive factors for falls in patients with MS. In conclusion, patients with cognitive impairment should be closely monitored for the risk of falling. Consideration of falls during follow-up examinations might be predictive of cognitive deterioration in patients with MS.

Analysis of the Stability of the Body in a Standing Position When Shooting at a Stationary Target-A Randomized Controlled Trial

Postural stability of the body depends on many factors. One of them is physical activity. It is especially important in the case of sports or professional work, which combine mobility with the accuracy of a shot in a standing position. The smaller the body fatigue, the more accurate the shot. The aim of the study was the assessment of the impact of physical effort on the center of gravity deflection and length of the COP (center of pressure) path, as well as the reaction of ground forces in people who do not engage in systematic physical activity. The study group included 139 people (23.1 ± 5.2 yr; M: 46.8%; F: 53.2%). The test consisted of performing a static test twice, shooting at the target in a multimedia shooting range. Group X performed the Harvard test between the static tests. Group Y made no effort. The reaction parameters of the ground forces were assessed using the Zebris PDM-L Platform. In Group X performing the Harvard test, an increase in the average COP, VCOP, and 95% confidence ellipse area was noted. The path length and the average velocity of COP speed increased. There were no differences in Group Y (p > 0.05). Physical effort significantly affected the postural stability of the studied people, increasing the average parameters assessing balance when adopting static firing position.

Cerebellar Contributions to Motor Impairments in People with Multiple Sclerosis

Although Charcot characterized classic cerebellar symptoms in people with multiple sclerosis (PwMS) in 1877, the impact of cerebellar dysfunction on MS symptoms has predominately been evaluated in the last two decades. Recent studies have clearly demonstrated the association between cerebellar pathology, including atrophy and reduced fractional anisotropy in the peduncles, and motor impairments, such as reduced gait velocity and time to complete walking tasks. However, future studies using novel imaging techniques are needed to elucidate all potential pathophysiology that is associated with disability in PwMS. Additionally, future studies are required to determine the most effective treatments for motor impairments in PwMS, including the specific type and duration of exercise interventions, and potential means to amplify their effects, such as transcranial direct current stimulation (tDCS). This mini-review critically discusses the distinct role of cerebellar dysfunction in motor impairments in PwMS, potential treatments, and directions for future studies.

Oligodendrocyte-Specific Deletion of FGFR1 Reduces Cerebellar Inflammation and Neurodegeneration in MOG35-55-Induced EAE

Multiple sclerosis (MS) is a chronic inflammatory and degenerative disease of the central nervous system (CNS). MS commonly affects the cerebellum causing acute and chronic symptoms. Cerebellar signs significantly contribute to clinical disability, and symptoms such as tremor, ataxia, and dysarthria are difficult to treat. Fibroblast growth factors (FGFs) and their receptors (FGFRs) are involved in demyelinating pathologies such as MS. In autopsy tissue from patients with MS, increased expression of FGF1, FGF2, FGF9, and FGFR1 was found in lesion areas. Recent research using mouse models has focused on regions such as the spinal cord, and data on the expression of FGF/FGFR in the cerebellum are not available. In recent EAE studies, we detected that oligodendrocyte-specific deletion of FGFRs results in a milder disease course, less cellular infiltrates, and reduced neurodegeneration in the spinal cord. The objective of this study was to characterize the role of FGFR1 in oligodendrocytes in the cerebellum. Conditional deletion of FGFR1 in oligodendrocytes (Fgfr1^ind−/−) was achieved by tamoxifen application, EAE was induced using the MOG_35-55 peptide. The cerebellum was analyzed by histology, immunohistochemistry, and western blot. At day 62 p.i., Fgfr1^ind−/− mice showed less myelin and axonal degeneration compared to FGFR1-competent mice. Infiltration of CD3(+) T cells, Mac3(+) cells, B220(+) B cells and IgG(+) plasma cells in cerebellar white matter lesions (WML) was less in Fgfr1^ind−/−mice. There were no effects on the number of OPC or mature oligodendrocytes in white matter lesion (WML). Expression of FGF2 and FGF9 associated with less myelin and axonal degeneration, and of the pro-inflammatory cytokines IL-1β, IL-6, and CD200 was downregulated in Fgfr1^ind−/− mice. The FGF/FGFR signaling protein pAkt, BDNF, and TrkB were increased in Fgfr1^ind−/− mice. These data suggest that cell-specific deletion of FGFR1 in oligodendrocytes has anti-inflammatory and neuroprotective effects in the cerebellum in the EAE disease model of MS.

Is there a relationship between fall status, cognition and cerebellar lobule volume in patients with multiple sclerosis?

In this prospective case control study, relationship of detailed cerebellar volumetric data and cognition in patients with multiple sclerosis considering falling status using 3 D MRI and network analysis were evaluated. Participants consist of 106 adults with relapsing-remitting multiple sclerosis. Scores of Montreal cognitive assessment test, symbol digit modality Test, nine-hole peg test, berg balance scale test, timed up and go test, timed 25-foot walk test were worse in faller group than non faller group (p < 0.05 for all tests). There was no significant difference in terms of cerebellar lobule volumes between groups. But using artificial intelligence (AI) based network analysis, we brought a new perspective to interpreting the relationship between the cerebellum, cognition, gait, and balance. Overall, data from the study suggest a possible relationship between cerebellar volume changes and cognitive dysfunction through connectivity analysis in patients with multiple sclerosis. Further studies are needed to examine this issue by using connectivity analysis.

Quantitative gait and postural analyses in patients with diabetic polyneuropathy

BACKGROUND

Although gait disturbances are relatively common symptoms in diabetic polyneuropathy (DPN), few studies have quantitatively analyzed gait and posture in DPN patients. This study aimed to analyze gait and posture quantitatively in DPN patients and to determine the association between clinical and electrophysiological parameters and gait and posture parameters.

METHODS

Sixty-four DPN patients were enrolled in this study. DPN was clinically assessed using the Toronto clinical neuropathy score (TCNS). All participants underwent nerve conduction study (NCS), three-dimensional motion analysis, and static posturography. We evaluate the correlation of gait and posture parameters with electrophysiological and clinical parameters.

RESULTS

Foot height, step length, and stride length among gait parameters were inversely correlated with the TCNS. Anteroposterior range during eyes-closed and mediolateral distance and range during eyes-open and eyes-closed were inversely correlated with the sensory nerve action potential amplitude in the sural nerve. Mediolateral distance during eyes-open and eyes-closed was correlated with the compound muscle action potential amplitude in the peroneal nerve.

CONCLUSIONS

Gait parameters are associated with clinical parameters, and postural parameters are associated with electrophysiological parameters, particularly sensory NCS. Gait and postural analysis can be a useful tool for assessing the neurological status in DPN patients.

Gait Pattern in People with Multiple Sclerosis: A Systematic Review

The aim of the present systematic review was to describe the gait pattern in people with multiple sclerosis (MS) by compiling the main findings obtained from studies using three-dimensional capture systems of human movement. The search was carried out in PubMed, Web of Science, Physiotherapy Evidence Database (PEDro), and the Cumulative Index to Nursing and Allied Health (CINAHL) databases. Studies that used three-dimensional gait analysis systems and that analyzed spatiotemporal, kinematic, kinetic, or electromyographic parameters, were included. The quality of the studies was assessed using the Critical Review Form-Quantitative Studies scale. 12 articles were included with 523 (342 women and 181 men) people with a diagnosis of MS. The present work suggests that people with MS have a decrease in speed and stride length, as well as an increase in double-stance intervals during gait. Likewise, it is common to observe a decrease in hip extension during the stance period, a decrease in knee flexion in the swing period, a decrease in ankle dorsiflexion in the initial contact and a decrease in ankle plantar flexion during the pre-swing phase. The subjects with MS decrease the hip extensor moment and the ankle power during the stance period of walking.

New methods of posturographic data analysis may improve the diagnostic value of static posturography in multiple sclerosis

Background

Early and accurate diagnosis of multiple sclerosis (MS) is crucial for its effective treatment. In MS diagnostic, neuronal networks that control posture and movement are of particular importance, which performance can be assessed using static posturography. Unfortunately, most of the commercially available posturographic platforms are not equipped with the appropriate procedures.

Methods

To solve this problem, the postural sway trajectories have been recorded in 55 MS patients while standing quiet with eyes open (EO), and then with eyes closed (EC). The trajectories were analyzed using our novel methods of postural sway parametrization, including sway stability vector (SV), anteroposterior and mediolateral sway indices (DIAP and DIML).

Results

The results exhibited unique postural sway patterns that may be attributed to MS. Our novel parametrization methods of postural sway showed pathology specific increase of the postural sway velocity in EC tests. Additionally, we documented the abnormal alterations of the anteroposterior (AP) and the mediolateral (ML) sway indices that were also uniquely dependent on visual input. In EC tests, patients exhibited a characteristic pattern of sway increase in both AP and ML directions that correlated with the advance of the disease as measured by the EDSS Kurtzke scale and Functional System Scores.

Conclusions

The applied in the present study our novel posturographic metrics give the assessment a diagnostic value. It allows us to recommend the static posturography test as a simple and safe supplementary clinical tool in the diagnosis of MS. In the assessment of MS pathology or the effects of its treatment, the impact of vision on the sway stability vector seems the most important factor.

Vestibular rehabilitation in multiple sclerosis: study protocol for a randomised controlled trial and cost-effectiveness analysis comparing customised with booklet based vestibular rehabilitation for vestibulopathy and a 12 month observational cohort study of the symptom reduction and recurrence rate following treatment for benign paroxysmal positional vertigo

Background

Symptoms arising from vestibular system dysfunction are observed in 49–59% of people with Multiple Sclerosis (MS). Symptoms may include vertigo, dizziness and/or imbalance. These impact on functional ability, contribute to falls and significant health and social care costs. In people with MS, vestibular dysfunction can be due to peripheral pathology that may include Benign Paroxysmal Positional Vertigo (BPPV), as well as central or combined pathology. Vestibular symptoms may be treated with vestibular rehabilitation (VR), and with repositioning manoeuvres in the case of BPPV. However, there is a paucity of evidence about the rate and degree of symptom recovery with VR for people with MS and vestibulopathy. In addition, given the multiplicity of symptoms and underpinning vestibular pathologies often seen in people with MS, a customised VR approach may be more clinically appropriate and cost effective than generic booklet-based approaches. Likewise, BPPV should be identified and treated appropriately.

Methods/ design

People with MS and symptoms of vertigo, dizziness and/or imbalance will be screened for central and/or peripheral vestibulopathy and/or BPPV. Following consent, people with BPPV will be treated with re-positioning manoeuvres over 1–3 sessions and followed up at 6 and 12 months to assess for any re-occurrence of BPPV. People with central and/or peripheral vestibulopathy will be entered into a randomised controlled trial (RCT). Trial participants will be randomly allocated (1:1) to either a 12-week generic booklet-based home programme with telephone support or a 12-week VR programme consisting of customised treatment including 12 face-to-face sessions and a home exercise programme. Customised or booklet-based interventions will start 2 weeks after randomisation and all trial participants will be followed up 14 and 26 weeks from randomisation. The primary clinical outcome is the Dizziness Handicap Inventory at 26 weeks and the primary economic endpoint is quality-adjusted life-years. A range of secondary outcomes associated with vestibular function will be used.

Discussion

If customised VR is demonstrated to be clinically and cost-effective compared to generic booklet-based VR this will inform practice guidelines and the development of training packages for therapists in the diagnosis and treatment of vestibulopathy in people with MS.

Trial registration

ISRCTN Number: 27374299

Date of Registration 24/09/2018

Protocol Version 15 25/09/2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-020-01983-y.

Visual Feedback and Postural Control in Multiple Sclerosis

As people with multiple sclerosis (pwMS) manifest heterogeneous demyelinating lesions that could affect somatosensory or vestibular ways, visual stimulus as feedback could be especially relevant to achieve postural control. This has clinical importance for the development of preventive measures and rehabilitation therapies in order to avoid falls and accidents in this group. In our study, we objectively evaluated the influence of visual feedback on the stabilization of balance in pwMS versus healthy controls (HC) and its potential utility in clinical evaluation. Static posturography tests were performed in 99 pwMS and 30 HC. Subjects stood on a force platform with open and closed eyes. During this procedure, three balance parameters were obtained for both vision conditions: average sway, average speed, and average speed of sway. Neurostatus-Expanded Disease Disability Score (EDSS) and Multiple Sclerosis Functional Composite (MSFC) were performed in parallel as well. A two-way mixed repeated measures ANCOVA, controlling for sex and age, was performed to evaluate the effect of vision, MS diagnosis, and the interaction of both in static posturography parameters. The difference between both closed and open eyes conditions was calculated for each parameter and further analyzed according to MS-relevant clinical variables. The magnitude of the vision effect differed between pwMS and HC as a significant interaction between the vision and the MS diagnosis in the delineated area (p < 0.001) and average speed of sway (p = 0.001) was seen. These parameters had a greater increase in pwMS than in HC after closing eyes. For the average sway, a significant main effect of vision was present (p = 0.047). Additionally, the differences obtained between open and closed eyes conditions assessed with the delineated area and average speed of sway were moderately correlated to the assessed clinical tests EDSS (r = 0.405 and r = 0.329, respectively) and the MSFC (r = −0.385 and r = −0.259, respectively). In our study, pwMS were more dependent of visual feedback than HC to maintain postural control. This easy and short evaluation by static posturography could support the development of targeted preventive measures and interventions in pwMS.

Dalfampridine to Improve Balance in Multiple Sclerosis: Substudy from a Randomized Placebo-Controlled Trial

This was a substudy of a randomized, double-blind, placebo-controlled trial originally designed to explore the effect of dalfampridine on information processing speed (2013-002558-64 EU Clinical Trials Register) in patients with multiple sclerosis (MS). A total of 120 patients were originally randomized in a 2:1 ratio to receive dalfampridine 10 mg or placebo twice daily for 12 weeks. Here, we sought to explore the effect of dalfampridine on static balance in single-task and dual-task conditions in a subgroup of 41 patients. They underwent static posturography in quiet standing (single-task) and while performing the Stroop test (dual-task) at randomization (baseline), after 12 weeks and after a 4-week wash-out period. Baseline characteristics of active group (n = 27) did not differ from those of placebo group (n = 14). Dalfampridine treatment was associated with better balance control than placebo in both single-task (F = 4.80, p = 0.034) and dual-task (F = 6.42, p = 0.015) conditions, with small-to-moderate effect sizes (Cohen's f2 = 0.122-0.162). The beneficial effect of dalfampridine was not retained 4 weeks after its discontinuation. The rate of accidental falls per month did not differ between the two groups (p = 0.12). Our preliminary findings suggest that dalfampridine can be considered a potential option to treat balance impairment due to MS. Larger sample sizes are needed to verify if the beneficial effect of dalfampridine on balance can be translated into a reduced risk of accidental falls.

Balance Testing in Multiple Sclerosis-Improving Neurological Assessment With Static Posturography?

Background: Balance problems can severely limit the quality of life for people with Multiple Sclerosis (pwMS) already in the early stages of the disease. PwMS are usually assessed with the Expanded Disability Status Scale (EDSS), which includes a Romberg test for assessing balance. As the EDSS assessments are subjective to the examining neurologist, the postural stability of pwMS could be objectively quantified by implementing static posturography to detect balance problems and address preventive medical care. Methods: In this cross-sectional study, we added static posturography to the neurological EDSS examination in pwMS and healthy subjects to determine how this technique could supply additional information during the evaluation of the cerebellar functional system of the neurostatus EDSS as clinical outcome already in early disease stages. Static posturography was performed with subjects standing on a force platform while outcome variables such as delineated area, average speed and average sway were obtained. Unpaired t-test as well as (Welch's) analysis of variance (ANOVA) with pairwise post-hoc comparisons according to Games-Howell were used. Spearman rank correlations were implemented to study associations of balance outcomes with EDSS-associated outcomes. Results: A total of 99 pwMS (mean age: 35.01 years; EDSS median: 2.0, 68.69% females) and 30 healthy subjects (mean age: 34.03 years; 70% females) were enrolled. PwMS had worse performances in the three evaluated balance parameters than the healthy group (all p < 0.001). Even patients without postural instability as documented in the Romberg test score of the EDSS assessment showed significantly worse outcome regarding the delineated area [+1.97 cm², 95%-CI (0.61-3.34); p = 0.002] vs. healthy controls. Similar results were observed for the comparison between pwMS with normal cerebellar function EDSS-systems and healthy subjects. There were significant correlations with the EDSS, cerebellar function score and Romberg test for the delineated area and average speed (r's ranging from 0.330 to 0.537, p < 0.001). Conclusions: Static posturography can complement neurological assessment of EDSS as an objective and quantitative test, especially for MS patients in early stages of the disease.

Physical activity participation according to the pyramidal, sensory, and cerebellar functional systems in multiple sclerosis

The objective of the study was to examine the differences in physical activity participation with the pyramidal, cerebellar, and sensory functional systems in people with multiple sclerosis (PwMS). This cross-sectional study included 289 PwMS with a median EDSS of 2.0 (range 0-6.5) and a mean disease duration of 6.8 (SD = 8.4) years. The Godin leisure-time exercise questionnaire (GLTEQ) assessed physical activity participation. The sample was divided into seven groups according to the pyramidal, cerebellar, and sensory functional system scores derived from the EDSS data. Additionally, PwMS were divided into three physical activity subgroups (active, moderately active, and insufficiently active). Furthermore, PwMS were categorized into four levels of disability based on their global Expanded Disability Status Scale (EDSS) score [very mild (0-1.5), mild (2.0-3.5), moderate (4.0-5.5), and severe (6.0-6.5)]. In the physical activity subgroups, 159 (55.0%) were classified as insufficiently active, 59 (20.4%) as moderately active, and 71 (24.6%) as active. Pyramidal, cerebellar, and sensory impairments were demonstrated in 134 (46.4%), 73 (25.3%), and 85 (29.4%) patients, respectively. No differences were found for the GLTEQ scores for all seven functional system groups (P value = 0.168). As for the EDSS disability subgroups, the percentage of active patients (moderately at least) were 60%, 45.8%, 36.5%, and 15.4%, for the very mild, mild, moderate, and severe subgroups, respectively. This study found that participation in leisure-time physical activity is independent from the pyramidal, cerebellar, and sensory functional systems in PwMS.

Anticipatory postural adjustment during gait initiation in multiple sclerosis patients: A systematic review

BACKGROUND

Multiple sclerosis (MS) causes balance and walking disorders. Gait initiation is the complex transition between standing and walking and is characterized by two distinct phases: the anticipatory postural adjustment (APA) phase followed by the execution of the first step phase.

RESEARCH AIM

To determine alterations in the APA during gait initiation in patients with MS.

METHODS

A systematic search was conducted in May 2018. The search was carried out by the use of the following databases: PubMed, Web of Science and the Cochrane Library. The following keywords were used: MS, gait initiation, step initiation, and postural adjustment(s). Outcomes of interest were the variables generally used to assess APA, including electromyography, force-plate data, or video-based data, duration of APA, and length of first step. The Ottawa scale was used to assess the quality of the studies.

RESULTS

Eight case-control studies were included; one was a transverse study. A total of 215 MS patients and 116 healthy subjects were included with ages ranging from 22 to 76 years old. In MS patients, Expanded Disability Status Scale (EDSS) scores ranged from 0 to 7. APA CoP displacements were smaller in the anteroposterior axis. Four studies evaluated muscle activation during APA. The latencies of all muscles were delayed, and smaller magnitudes of muscle activity during APA were found, even in the early stage of disease. The first step was shorter in MS patients than in healthy patients. No previous study has reported joint movement or trunk inclination during gait initiation.

SIGNIFICANCE

This review illustrates the gap in knowledge of APA alterations in MS patients. APA assessment in the early stage of MS could be an interesting measure to characterize balance, dynamic control and risk of fall for such patients.

Association of the Dynamic Gait Index to fall history and muscle function in people with multiple sclerosis

Background and purpose: This study examined the association of a commonly used gait assessment, the Dynamic Gait Index, with falls and lower extremity and trunk muscle function in people with multiple sclerosis.Materials and methods: Cross-sectional data from 72 people with multiple sclerosis (Expanded Disability Status Scale 3.5 ± 1.14) were used. The ability of the Dynamic Gait Index to identify fallers was evaluated using the receiver operating characteristic curve. Multiple linear regression determined contributions of muscle function variables to Dynamic Gait Index scores.Results: Thirty-seven participants reported at least one fall in the previous 3 months (51%). The area under the curve for the Dynamic Gait Index was 0.80 (95% CI: 0.69-0.90), indicating a good ability to identify fallers with a cutoff of ≤19/24. After adjusting for age, sex, and disability level, a one standard deviation increase in ankle plantarflexion (15.2 repetitions) and trunk flexion (15.1 repetitions) endurance were associated with an increase in Dynamic Gait Index score of 0.73 (95% CI: 0.07-1.39) and 0.62 (95% CI: 0.002-1.25), respectively.Conclusions: The Dynamic Gait Index may be a useful tool to identify fallers, and was associated with ankle plantarflexion and trunk flexion endurance.Implications for rehabilitationThe Dynamic Gait Index appears to be a useful tool to identify people with multiple sclerosis at increased risk for falls using a cutoff score of ≤19/24.The ability to do fewer than 13 single leg heel raises had a moderate ability to identify fallers in this study.Out of 11 lower extremity and trunk muscles, only ankle plantarflexion and trunk flexion muscle endurance were significant predictors of Dynamic Gait Index scores.Clinicians may consider targeting ankle plantarflexion and trunk muscle endurance to improve dynamic gait and fall risk in patients with multiple sclerosis.

Evaluation of the effects of sensorimotor exercise on physical and psychological parameters in breast cancer patients undergoing neurotoxic chemotherapy

INTRODUCTION

Breast cancer is the most common cancer disease of women in industrialized countries. Neurotoxic chemotherapy drugs are known to harm peripheral nerves and cause a chemotherapy-induced peripheral neuropathy (CIPN). CIPN is one of the most common adverse events associated with Paclitaxel chemotherapy and may remain present long after the termination of chemotherapy. Thus, it reduces the patients' quality of life (QoL) both during chemotherapy and onwards, and can impose a danger on breast cancer survivors due to an increased risk of falling and fall-related injuries.

METHODS

The aim of this randomized-controlled trial (RCT) (n = 36) (IG: intervention group, n = 17) (CG: control group, n = 19) was to determine whether sensorimotor exercises have a positive effect on physical and psychological parameters in breast cancer patients undergoing neurotoxic chemotherapy (Paclitaxel).

RESULTS

As a result, we were able to show significant improvements in postural stability in monopedal stance [left leg 16.17 ± 3.67 vs. 21.55 ± 5.33 (p < 0.001) and right leg 15.14 ± 2.30 vs. 20.85 ± 5.05 (p < 0.001)] and in bipedal stance [T1 vs. T0, - 0.49 (IG) vs. + 1.14 (CG) p = 0.039].

DISCUSSION

These results in posturography correlate with the clinical presentation with intervention group patients scoring significantly better on the Fullerton Advanced Balance Scale [37.71 ± 2.73 vs. 34.47 ± 3.98 (p = 0.004)]. Moderate strength training successfully prevented a strength loss in the IG that was remarkable in the CG (- 1.60 vs. 0.60, p = 0.029). Concerning the psychological parameters assessed via EORTC- and MFI-questionnaires, no significant improvements were found.

CONCLUSION

Future studies should focus on the correlation of clinical and posturometry findings and subjective QOL such as the long-term-development of CIPN.

Cerebellum and cognition in multiple sclerosis: the fall status matters

Cerebellar volume has been linked with cognitive performances in MS; however, the association in terms of fall status has never been compared. Therefore, the objective of the current study was to compare cognitive performance with cerebellar volume between MS fallers and non-fallers. The cross-sectional study included 140 PwMS (96 women). MRI volumetric analysis was based on the FreeSurfer image analysis suite. Volumes of the cerebellar gray and white matter were identified as the region of interest. Cognitive function included scores obtained from a computerized cognitive battery of tests. The sample was divided into fallers and non-fallers. MS fallers demonstrated a lower global cognitive performance and reduced gray and white matter cerebellar volumes compared to non-fallers. A significant association was found between total gray and white matter cerebellar volume and visual spatial subdomain (P value = 0.044 and 0.032, respectively) in the non-fallers group. The association remained significant after controlling for the total cranial volume and neurological disability (P value = 0.026 and 0.047, respectively). A relationship was found between the visual spatial score and the left gray matter cerebellum volume; R² = 0.44, P value = 0.021. We believe that a unique relationship exists between the cerebellum structure and cognitive processing according to fall history in PwMS and should be considered when investigating the association between brain functioning and cognitive performances in MS.

Cerebellar ataxia

The cerebellum plays an integral role in the control of limb and ocular movements, balance, and walking. Cerebellar disorders may be classified as sporadic or hereditary with clinical presentation varying with the extent and site of cerebellar damage and extracerebellar signs. Deficits in balance and walking reflect the cerebellum's proposed role in coordination, sensory integration, coordinate transformation, motor learning, and adaptation. Cerebellar dysfunction results in increased postural sway, hypermetric postural responses to perturbations and optokinetic stimuli, and postural responses that are poorly coordinated with volitional movement. Gait variability is characteristic and may arise from a combination of balance impairments, interlimb incoordination, and incoordination between postural activity and leg movement. Intrinsic problems with balance lead to a high prevalence of injurious falls. Evidence for pharmacologic management is limited, although aminopyridines reduce attacks in episodic ataxias and may have a role in improving gait ataxia in other conditions. Intensive exercises targeting balance and coordination lead to improvements in balance and walking but require ongoing training to maintain/maximize any effects. Noninvasive brain stimulation of the cerebellum may become a useful adjunct to therapy in the future. Walking aids, orthoses, specialized footwear and seating may be required for more severe cases of cerebellar ataxia.

Measuring standing balance in multiple sclerosis: Further progress towards an automatic and reliable method in clinical practice

BACKGROUND

Balance deficits in multiple sclerosis (MS) are often monitored by means of observer-rated tests. These may provide reliable data, but may also be time-consuming, subject to inter-rater variability, and potentially insensitive to mild fluctuations throughout the clinical course. On the other hand, laboratory assessments are often not available. The Nintendo Wii Balance Board (WBB) may represent a low-cost solution. The purpose of the current study was to examine the methodological quality of WBB data in MS (internal consistency, test-retest reliability), convergent validity with observer-rated tests (Berg Balance Scale, BBS; Timed-Up and Go Test, TUG), and discriminative validity concerning clinical status (Expanded Disability Status Scale, EDSS).

METHODS

Standing balance was assessed with the WBB for 4min in 63 MS patients at two assessment points, four months apart. Additionally, patients were examined with the BBS, TUG and the EDSS.

RESULTS

A period of 4min on the WBB provided data characterized by excellent internal consistency and test-retest reliability. Significant correlations between WBB data and results of the BBS and TUG were obtained after merely 2min on the board. An EDSS median-split revealed that higher EDSS values (>3) were associated with significantly increased postural sway on the WBB.

CONCLUSIONS

WBB measures reflecting postural sway are methodologically robust in MS, involving excellent internal consistency and test-retest reliability. They are also characterized by convergent validity with other considerably lengthier observer-rated balance measures (BBS) and sensitive to broader clinical characteristics (EDSS). The WBB may hence represent an effective, easy-to-use monitoring tool for MS patients in clinical practice.