Outcome measures used in trials on gait rehabilitation in multiple sclerosis: A systematic literature review

The role of sensory systems in the association between balance and walking in people with multiple sclerosis

BACKGROUND

In Multiple Sclerosis, it has been demonstrated that balance is related to performances in walking tasks at different levels of complexity. However, it is unknown how the different sensory systems involved in balance control contribute to walking. This observational study investigates the associations between somatosensory, vestibular, and visual systems and measures of self-reported walking and walking capacity at different complexity levels (i.e. low, medium, and high).

METHODS

People with MS with EDSS<6 were assessed through the Sensory Organization Test (SOT), 12-Item MS Walking Scale (MSWS-12), Timed 25-Foot Walk (T25FW), Timed Up-and-Go Test (TUG), and Six-Spot-Step-Test (SSST). T25FW, TUG and SSST are measures of low, medium and high walking capacity, respectively.

RESULTS

Forty-five PwMS were enrolled (EDSS: 3.4 ± 1.3). Capacity/ability walking measures were moderate-to-highly significantly associated (p < 0.01). Balance measures from SOT showed significant correlation (p < 0.05) between vestibular system and all the walking measures; between visual system and T25FW, SSST and MSWS-12; between the degree to which the patient relies on the visual system to maintain balance with conflicting visual surroundings information (VIS PREF) and T25FW and TUG. In the multivariate analyses, only VIS PREF significantly correlated (p < 0.05) with T25FW (std. Beta=0.42) and TUG (std. Beta=0.38).

CONCLUSIONS

Vestibular and visual systems are associated with walking capacity. However, tasks with higher complexity levels require more visual attention towards ground obstacles, as often seen in real-life activities, whereas simpler walking tasks seem to require visual attention towards the surroundings.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS AND CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The six spot step test is superior in detecting walking capacity impairments compared to short- and long-distance walk tests in persons with multiple sclerosis

Background

Walking capacity is important not only to persons with multiple sclerosis but also to clinical practice and research. The present study aims to compare the extent of impairments (relative to healthy controls) across three commonly used walking capacity outcomes in persons with multiple sclerosis.

Methods

In a two-hospital cross-sectional study, walking capacity was assessed using the timed-25-footwalk-test (timed 25-ft walk test; 'walking speed'), the six-minute-walk-test ('walking endurance') and the six-spot-step-test ('walking balance and coordination'). Data were compared to normative reference data in healthy controls.

Results

A total of 228 persons with multiple sclerosis (68% females) were involved in the study: age 53.7 ± 11.6 y (range 26-81 y); patient-determined-disease-steps 3 [IQR; 1; 4] (range 0-7); time since diagnosis 12.6 ± 9.9 y (range 0-49 y); MS-phenotype (relapse remitting MS, secondary progressive MS, primary progressive MS) 146/39/41; and co-morbidity n = 80 (35%). Compared to healthy controls, deficits were observed across all walking capacity outcomes (p < 0.001): timed 25-foot walk test -26 [-30; -23]%, 6 minute-walk-test -36 [-39; -32]% and six-spot-step-test -44 [-47; -40]%. Deficits differed across walking capacity outcomes (p < 0.001).

Conclusion

Altogether, persons with multiple sclerosis performed substantially worse than healthy controls across all three walking capacity outcomes. The results showed that the six-spot-step-test was superior to the timed 25-foot walk test and the 6 minute-walk-test in detecting walking capacity impairments in persons with multiple sclerosis.

High intensity exercise training on functional outcomes in persons with multiple sclerosis: A systematic review

BACKGROUND

There is growing interest and evidence for high intensity training (HIT) in clinical populations, including persons with multiple sclerosis (MS). While HIT has been shown to be a safe modality in this group, it is still unclear what collective knowledge exists for HIT on functional outcomes. This study examined HIT modalities (e.g., aerobic, resistance, functional training) on functional outcomes such as walking, balance, postural control, and mobility in persons with MS.

METHODS

High intensity training studies, including RCTs and non-RCTs, that targeted functional outcomes in persons with MS were included in the review. A literature search was conducted in MEDLINE, EMBASE, PsycINFO, SPORTSDiscus, and CINAHL in April 2022. Other literature search methods were performed via website and citation searching. The methodological quality of included studies was assessed by TESTEX for RCTs and ROBINS-I for non-RCTs. This review synthesized the following data: study design and characteristics, participant characteristics, intervention characteristics, outcome measures, and effect sizes.

RESULTS

Thirteen studies (6 RCTs and 7 non-RCTs) were included in the systematic review. The included participants (N = 375) had varying functional levels (EDSS range: 0-6.5) and phenotypes (relapsing remitting, secondary progressive, primary progressive). HIT modalities involving high intensity aerobic training (n = 4), high intensity resistance training (n = 7), and high intensity functional training (n = 2), revealed a significant and consistent benefit on walking speed and walking endurance in response to HIT, while the evidence regarding balance and mobility improvement was less clear.

CONCLUSION

Persons with MS can successfully tolerate and adhere to HIT. While HIT appears to be an effective modality for improving some functional outcomes, the heterogeneous testing protocols, HIT modalities, and exercise doses among the studies preclude any conclusive evidence for its effectiveness thus necessitating future inquiry.

Patient and Clinician Perspectives of Physical Therapy for Walking Difficulties in Multiple Sclerosis

Gait speed is frequently the primary efficacy endpoint in clinical trials of interventions targeting mobility in people with multiple sclerosis (MS). However, it is unclear whether increased gait speed is a meaningful outcome for people living with MS. The purpose of this study was to identify the most important aspects of mobility for people with MS and physical therapists and to explore how patients and clinicians perceive whether physical therapy has been effective. Forty-six people with MS and 23 physical therapy clinicians participated in a focus group, one-on-one interview, or electronic survey. The focus group and interview data were transcribed and coded to identify themes. Free-text survey responses were also coded, and multiple-choice options were analyzed for frequency. Among people with MS, falls and difficulties getting out into the community were identified as highly important mobility limitations. Clinicians also identified falls and safety as a priority. Walking speed was infrequently described as a problem, and although gait speed is often measured by clinicians, improving gait speed is rarely a treatment goal. Despite their emphasis on safety, clinicians lacked certainty about how to objectively measure improvements in safety. People with MS evaluated physical therapy effectiveness based on the ease by which they can do things and acknowledged that "not getting worse" is a positive outcome. Clinicians evaluated effectiveness based on the amount of change in objective outcome measures and by patient and caregiver reports of improved function. These findings indicate that gait speed is not of major importance to people with MS or physical therapy clinicians. People with MS want to be able to walk further and without an assistive device, and they want to avoid falls. Clinicians want to maximize safety while improving functional ability. Clinicians and patients may differ in their expected outcomes from physical therapy.

The reliability and validity of the Figure of 8 walk test in mildly disabled persons with multiple sclerosis

BACKGROUND

Figure of 8 Walk Test (F8WT) assesses the multidirectional and adaptive requirements of both straight and curved path walking. The study aimed to examine the reliability, validity, and minimal detectable change (MDC) of the F8WT in patients with Multiple Sclerosis (pwMS).

METHODS

45 mildly disabled pwMS (10 male, 35 female) were included in the study. Reliability of F8WT test was evaluated with Intraclass Correlation Coefficient (ICC). MDC estimates were calculated using baseline data. The correlation between the F8WT and Berg Balance Scale (BBS), The Timed Up and Go test (TUG), The Timed 25-Foot Walk Test (T25FW), The Four Square Step Test (FSST) was used for the validity.

RESULTS

The intra-rater (ICC 0.980-0.983) and inter-rater (ICC 0.976-0.985) reliability of the F8WT was determined to be excellent. MDC values for intra-rater were 1.04-1.08 s, and MDC values for inter-rater were 1.16-0.99 s. The correlation with F8WT and BBS (p = 0.000, r = -0.702), TUG (p = 0.000, r = 0.854), T25FW (p = 0.000, r = 0.784), FSST (p = 0.000, r = 0.748) was found to be statistically significant.

CONCLUSION

The F8WT has good reliability and validity in mildly disabled pwMS. According to the MDC results, small differences in pwMS can be adequately detected with F8WT. Therefore, it may be a clinically suitable test for detecting balance and walking.