Effects of Peripheral Cooling on Upper Limb Tremor Severity and Functional Capacity in Persons with MS

Upper limb intention tremor in persons with multiple sclerosis (pwMS) affects the ability to perform activities of daily life and is difficult to treat. The study investigated the effect of peripheral upper limb cooling on tremor severity and functional performance in MS patients with intention tremor. In experiment 1, 17 patients underwent two 15 min cooling conditions for the forearm (cold pack and cryomanchet) and one control condition. In experiment 2, 22 patients underwent whole arm cooling for 15 min using multiple cold packs. In both experiments, patients were tested at four time points (pre- and post-0, -25 and -50 min cooling) on unilateral tasks of the Test Evaluant les Membres supérieurs des Personnes Agées (TEMPA), Fahn's tremor rating scale (FTRS), Nine Hole Peg Test (NHPT). In experiment 1, the mean FTRS ranged from 13.2 to 14.1 across conditions. A two-way ANOVA showed mainly time effects, showing that cooling the forearm significantly reduced the FTRS, the performance on the NHPT, and three out of four items of the TEMPA, mostly independent of the cooling modality. In experiment 2, the mean FTRS was 13.1. A repeated measures ANOVA showed that cooling the whole arm reduced the FTRS and time needed to execute two out of four items of the TEMPA. These effects occurred immediately after cooling lasting at least 25 min. Cooling the whole upper limb led to a clinically noticeable effect on tremor severity and improved functional performance, which was pronounced during the first half-hour after cooling.

Reliability, validity and clinical usability of a robotic assessment of finger proprioception in persons with multiple sclerosis

BACKGROUND

Multiple sclerosis often leads to proprioceptive impairments of the hand. However, it is challenging to objectively assess such deficits using clinical methods, thereby also impeding accurate tracking of disease progression and hence the application of personalized rehabilitation approaches.

OBJECTIVE

We aimed to evaluate test-retest reliability, validity, and clinical usability of a novel robotic assessment of hand proprioceptive impairments in persons with multiple sclerosis (pwMS).

METHODS

The assessment was implemented in an existing one-degree of freedom end-effector robot (ETH MIKE) acting on the index finger metacarpophalangeal joint. It was performed by 45 pwMS and 59 neurologically intact controls. Additionally, clinical assessments of somatosensation, somatosensory evoked potentials and usability scores were collected in a subset of pwMS.

RESULTS

The test-retest reliability of robotic task metrics in pwMS was good (ICC=0.69-0.87). The task could identify individuals with impaired proprioception, as indicated by the significant difference between pwMS and controls, as well as a high impairment classification agreement with a clinical measure of proprioception (85.00-86.67%). Proprioceptive impairments were not correlated with other modalities of somatosensation. The usability of the assessment system was satisfactory (System Usability Scale ≥73.10).

CONCLUSION

The proposed assessment is a promising alternative to commonly used clinical methods and will likely contribute to a better understanding of proprioceptive impairments in pwMS.

Do people with multiple sclerosis perceive upper limb improvements from robotic-mediated therapy? A mixed methods study

BACKGROUND

Robot-mediated training is increasingly considered as a rehabilitation intervention targeting upper limb disability. However, experiences of such an intervention have been rarely explored in the multiple sclerosis population. This mixed methods study sought to explore the impact of an eight week upper limb robotic intervention on experiences of people with multiple sclerosis.

METHODS

Eleven participants (Median EDSS- score: 6.5) with moderate to severe upper limb impairment, performed eight week robot- mediated training of the most affected arm. The training involved a virtual learning platform called I-TRAVLE with duration of 30 min per training session, twice to three times per week. Two subjective questionnaires with items from the Intrinsic Motivation Inventory (IMI) and Credibility and Expectancy Questionnaire (CEQ) were collected bi-weekly during the intervention. Approximately one month after completing the training, three focus groups were conducted. Main themes were identified using thematic analysis.

RESULTS

Results from the IMI and CEQ indicated high patient satisfaction and expectation that the intervention will be beneficial for them. Two main themes were identified: (1) Effect of the intervention on impairment and activity in that participants felt that there was a positive impact of the training on strength, endurance and during activities of daily living and that it met their expectations; (2) Experiences based on system usage from the system in that participants expressed feelings of motivation and self-improvement. The participants also perceived the training as enjoyable and concluded that the use of games instigated a competitive spirit between the participants.

CONCLUSIONS

Robot-mediated training could have a motivating effect and induce a general positive experience while reducing disabilities of people with multiple sclerosis.

The content and effects of trunk rehabilitation on trunk and upper limb performance in people with multiple sclerosis: a systematic review

INTRODUCTION

Persons with multiple sclerosis (pwMS) could have an impaired trunk and reduced postural control, which negatively impacts activities of daily living. Evidence is growing to consider the positive effects of trunk training on fall incidence and balance problems. Effects on trunk and upper limb performance is unknown. This systematic review provides an overview of trunk training programs and their effects in MS, specifically focusing on the content of training modalities and the effects on trunk and upper limb performance.

EVIDENCE ACQUISITION

Two electronic databases were used: PubMed and Web Of Science (WOS). Intervention studies (with- and without control group) published in English, investigating the effects of active trunk training on trunk and upper limb performance in pwMS, were included.

EVIDENCE SYNTHESIS

Sixteen studies met the criteria, investigating different rehabilitation modalities. The included interventions in the review varied between more generic postural interventions such as Pilates (N.=8) and Ai Chi (N.=1), with a focus on abdominal muscle activation, breathing, neutral position and lower extremity movements. Further, specifically developed trunk training programs like GroupCoreDIST/ SIT / CoDuSe (N.=6) and Bobath based trunk training (N.=1) are detected, with the main focus on trunk strengthening and dynamic movements. An overall improvement in trunk performance was reported in several tests on trunk strength, stability and coordination. While the majority of the programs integrated the upper limb, only half of them used upper limb outcome measures to evaluate the effect. Here, overall significant improvements were found for the upper limb.

CONCLUSIONS

This systematic review showed that different types of trunk training programs can improve trunk and upper limb function in PwMS. The findings of this review suggest that a focus on trunk training to achieve effects on upper limb is reasonable. Future research is needed to further explore relations and the effect sizes.

Systematic evaluation of the guidelines for rehabilitation in multiple sclerosis patients: an overview according to ICF functioning domains

High-quality clinical practice guidelines (CPGs) can provide evidence-based recommendations for optimizing care on managing multiple sclerosis (MS). There is currently no review that compiles recommendations of high-quality CPGs to guide decision-making for MS rehabilitation. The aim was to identify evidence-based recommendations in high-quality multidisciplinary English CPGs for rehabilitation in MS. CPGs published in the last 10 years (2009-2019) that described recommendations on rehabilitation were searched in PubMed, Turning Research into Practice database, International Guideline databases, National Guideline databases and websites of MS organizations. Quality assessment of CPGs was conducted by two evaluators using the Appraisal of Guidelines for Research and Evaluation II instrument. Recommendations were classified according to the International Classification of Functioning, Disability and Health (ICF) and the International Classification of Health Intervention (ICHI) and documented in terms of strength of recommendation and level of evidence. Five CPGs satisfied the inclusion criteria. Of 120 recommendations, 38 had a strong level with moderate to low level of evidence, 61 were of weak strength and 18 were formulated by the consensus of experts. Recommendations were categorized into 12 domains and 1 chapter on the body function level, 1 chapter on activity level and 2 domains on external factors. The existing CPGs demonstrated more than 100 evidence level recommendations to be followed at the clinical practice, most in body functions of the ICF. Developing up-to-date CPGs with more focus on activity and participation domains for countries with various healthcare backgrounds may be useful for a best clinical practice.

European evidence-based recommendations for clinical assessment of upper limb in neurorehabilitation (CAULIN): data synthesis from systematic reviews, clinical practice guidelines and expert consensus

BACKGROUND

Technology-supported rehabilitation can help alleviate the increasing need for cost-effective rehabilitation of neurological conditions, but use in clinical practice remains limited. Agreement on a core set of reliable, valid and accessible outcome measures to assess rehabilitation outcomes is needed to generate strong evidence about effectiveness of rehabilitation approaches, including technologies. This paper collates and synthesizes a core set from multiple sources; combining existing evidence, clinical practice guidelines and expert consensus into European recommendations for Clinical Assessment of Upper Limb In Neurorehabilitation (CAULIN).

METHODS

Data from systematic reviews, clinical practice guidelines and expert consensus (Delphi methodology) were systematically extracted and synthesized using strength of evidence rating criteria, in addition to recommendations on assessment procedures. Three sets were defined: a core set: strong evidence for validity, reliability, responsiveness and clinical utility AND recommended by at least two sources; an extended set: strong evidence OR recommended by at least two sources and a supplementary set: some evidence OR recommended by at least one of the sources.

RESULTS

In total, 12 measures (with primary focus on stroke) were included, encompassing body function and activity level of the International Classification of Functioning and Health. The core set recommended for clinical practice and research: Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT); the extended set recommended for clinical practice and/or clinical research: kinematic measures, Box and Block Test (BBT), Chedoke Arm Hand Activity Inventory (CAHAI), Wolf Motor Function Test (WMFT), Nine Hole Peg Test (NHPT) and ABILHAND; the supplementary set recommended for research or specific occasions: Motricity Index (MI); Chedoke-McMaster Stroke Assessment (CMSA), Stroke Rehabilitation Assessment Movement (STREAM), Frenchay Arm Test (FAT), Motor Assessment Scale (MAS) and body-worn movement sensors. Assessments should be conducted at pre-defined regular intervals by trained personnel. Global measures should be applied within 24 h of hospital admission and upper limb specific measures within 1 week.

CONCLUSIONS

The CAULIN recommendations for outcome measures and assessment procedures provide a clear, simple, evidence-based three-level structure for upper limb assessment in neurological rehabilitation. Widespread adoption and sustained use will improve quality of clinical practice and facilitate meta-analysis, critical for the advancement of technology-supported neurorehabilitation.

Is mHealth a Useful Tool for Self-Assessment and Rehabilitation of People with Multiple Sclerosis? A Systematic Review

The development of mobile technology and mobile Internet offers new possibilities in rehabilitation and clinical assessment in a longitudinal perspective for multiple sclerosis management. However, because the mobile health applications (mHealth) have only been developed recently, the level of evidence supporting the use of mHealth in people with multiple sclerosis (pwMS) is currently unclear. Therefore, this review aims to list and describe the different mHealth available for rehabilitation and self-assessment of pwMS and to define the level of evidence supporting these interventions for functioning problems categorized within the International Classification of Functioning, Disability and Health (ICF). In total, 36 studies, performed with 22 different mHealth, were included in this review, 30 about rehabilitation and six for self-assessment, representing 3091 patients. For rehabilitation, most of the studies were focusing on cognitive function and fatigue. Concerning the efficacy, we found a small but significant effect of the use of mHealth for cognitive training (Standardized Mean Difference (SMD) = 0.28 [0.12; 0.45]) and moderate effect for fatigue (SMD = 0.61 [0.47; 0.76]). mHealth is a promising tool in pwMS but more studies are needed to validate these solutions in the other ICF categories. More replications studies are also needed as most of the mHealth have only been assessed in one single study.

Motivation, Usability, and Credibility of an Intelligent Activity-Based Client-Centred Training System to Improve Functional Performance in Neurological Rehabilitation: An Exploratory Cohort Study

(1) Background: technology-based training systems are increasingly integrated in neurorehabilitation but are rarely combined with a client-centred task-oriented approach. To provide a low-cost client-centred task-oriented system, the intelligent activity-based client-centred task-oriented training (i-ACT) was developed. The objective was to evaluate the usability, credibility and treatment expectancy of i-ACT, and the motivation towards i-ACT use in rehabilitation over time. Additionally, this study will evaluate the upper limb treatment effects after training with i-ACT. (2) Methods: a mixed-method study was performed in four rehabilitation centres. Training with i-ACT was provided during six weeks, three times per week, forty-five minutes per day, additional to conventional care. (3) Results: seventeen persons with central nervous system diseases were included. High scores were seen in the system usability scale (score ≥ 73.8/100), credibility (score ≥ 22.0/27.0)/expectancy (score ≥ 15.8/27.0) questionnaire, and intrinsic motivation inventory (score ≥ 5.2/7.0), except the subscale pressure (score ≤ 2.0/7.0). Results from the interviews corroborate these findings and showed that clients and therapists believe in the i-ACT system as an additional training support system. Upper limb functional ability improved significantly (p < 0.05) over time on the Wolf motor function test. (4) Conclusion: i-ACT is a client-centred task-oriented usable and motivational system which has the potential to enhance upper limb functional training in persons with neurological diseases.

Clinical perspective on pain in multiple sclerosis

Pain is an important and frequent symptom in multiple sclerosis (MS), which leads to a low quality of life, increased disability level, and lack of employment and mental health. Recently, studies have shown increased interest in pain in MS and there is a growing evidence of its prevalence. However, the literature suffers from lack of experimental studies focusing on pain reduction. This topical review summarizes the current knowledge about pain in MS with its definitions, assessments, treatments and rehabilitation within a holistic perspective.

A data-driven framework for selecting and validating digital health metrics: use-case in neurological sensorimotor impairments

Digital health metrics promise to advance the understanding of impaired body functions, for example in neurological disorders. However, their clinical integration is challenged by an insufficient validation of the many existing and often abstract metrics. Here, we propose a data-driven framework to select and validate a clinically relevant core set of digital health metrics extracted from a technology-aided assessment. As an exemplary use-case, the framework is applied to the Virtual Peg Insertion Test (VPIT), a technology-aided assessment of upper limb sensorimotor impairments. The framework builds on a use-case-specific pathophysiological motivation of metrics, models demographic confounds, and evaluates the most important clinimetric properties (discriminant validity, structural validity, reliability, measurement error, learning effects). Applied to 77 metrics of the VPIT collected from 120 neurologically intact and 89 affected individuals, the framework allowed selecting 10 clinically relevant core metrics. These assessed the severity of multiple sensorimotor impairments in a valid, reliable, and informative manner. These metrics provided added clinical value by detecting impairments in neurological subjects that did not show any deficits according to conventional scales, and by covering sensorimotor impairments of the arm and hand with a single assessment. The proposed framework provides a transparent, step-by-step selection procedure based on clinically relevant evidence. This creates an interesting alternative to established selection algorithms that optimize mathematical loss functions and are not always intuitive to retrace. This could help addressing the insufficient clinical integration of digital health metrics. For the VPIT, it allowed establishing validated core metrics, paving the way for their integration into neurorehabilitation trials.

A Systematic Review of International Clinical Guidelines for Rehabilitation of People With Neurological Conditions: What Recommendations Are Made for Upper Limb Assessment?

Background: Upper limb impairment is a common problem for people with neurological disabilities, affecting activity, performance, quality of life, and independence. Accurate, timely assessments are required for effective rehabilitation, and development of novel interventions. International consensus on upper limb assessment is needed to make research findings more meaningful, provide a benchmark for quality in clinical practice, more cost-effective neurorehabilitation and improved outcomes for neurological patients undergoing rehabilitation.

Aim: To conduct a systematic review, as part of the output of a European COST Action, to identify what recommendations are made for upper limb assessment.

Methods: We systematically reviewed published guidance on measures and protocols for assessment of upper limb function in neurological rehabilitation via electronic databases from January 2007–December 2017. Additional records were then identified through other sources. Records were selected for inclusion based on scanning of titles, abstracts and full text by two authors working independently, and a third author if there was disagreement. Records were included if they referred to “rehabilitation” and “assessment” or “measurement”. Reasons for exclusion were documented.

Results: From the initial 552 records identified (after duplicates were removed), 34 satisfied our criteria for inclusion, and only six recommended specific outcome measures and /or protocols. Records were divided into National Guidelines and other practice guidelines published in peer reviewed Journals. There was agreement that assessment is critical, should be conducted early and at regular intervals and that there is a need for standardized measures. Assessments should be conducted by a healthcare professional trained in using the measure and should encompass body function and structure, activity and participation.

Conclusions: We present a comprehensive, critical, and original summary of current recommendations. Defining a core set of measures and agreed protocols requires international consensus between experts representing the diverse and multi-disciplinary field of neurorehabilitation including clinical researchers and practitioners, rehabilitation technology researchers, and commercial developers. Current lack of guidance may hold-back progress in understanding function and recovery. Together with a Delphi consensus study and an overview of systematic reviews of outcome measures it will contribute to the development of international guidelines for upper limb assessment in neurological conditions.

Intensity-dependent clinical effects of an individualized technology-supported task-oriented upper limb training program in Multiple Sclerosis: A pilot randomized controlled trial

BACKGROUND

Task-oriented training promotes functional recovery in Multiple Sclerosis (MS). Know-how to determine an individualized training intensity and intensity-dependent effects are, however, unknown. The objective of the study was to investigate the feasibility and the clinical effects of a task-oriented upper limb training program at different individualized training intensities with conventional occupational therapy.

METHODS

People with MS (n = 20, EDSS range 4-8) were divided into three groups, receiving task-oriented training at 100% (n = 7) or 50% (n = 8) of their individual maximal number of repetitions, or conventional occupational therapy (n = 5). Effects were evaluated using different upper limb capacity and perceived performance measures on activity level, and measures on body functions and structures level.

RESULTS

Mixed model analyses revealed significant improvements (p < 0.05) over time on the Box and block test (BBT), Action Research Arm Test and the Manual Ability Measure-36. Significant interaction effects (group*time) in favor of the task-oriented group training at the highest intensity were found for BBT and static fatigue index during a maximal sustained handgrip strength test.

CONCLUSION

All participants were able to perform the task-oriented training at their individualized intensity without any adverse effects. Several improvements over time were found for all intervention groups, however the results suggest a superiority of task-oriented training at 100%. CLINICAL TRIAL REGISTRATION NUMBER ON CLINICALTRIALS.GOV: = NCT02688231.

Design and Characterization of a Robotic Device for the Assessment of Hand Proprioceptive, Motor, and Sensorimotor Impairments

Hand function is often impaired after neurological injuries such as stroke. In order to design patient-specific rehabilitation, it is essential to quantitatively assess those deficits. Current clinical scores cannot provide the required level of detail, and most assessment devices have been developed for the proximal joints of the upper limb. This paper presents a new robotic platform for the assessment of proprioceptive, motor, and sensorimotor hand impairments. A detailed technical evaluation demonstrated the capabilities to render different haptic environments required for a comprehensive assessment battery, and showed that the device is suitable for human interaction due to its ergonomic design. A preliminary study on proprioceptive assessment using a gauge position matching task with one healthy, one stroke, and one multiple sclerosis subject showed that the robotic system is able to rapidly and sensitively quantify proprioceptive deficits, and has the potential to be integrated into the clinical settings.

Cognitive-motor interference in persons with multiple sclerosis during five upper limb motor tasks with different complexity

BACKGROUND

Cognitive-motor interference in multiple sclerosis has been well examined during walking, but not during upper limb (UL) performance.

OBJECTIVES

To examine the dual-task cost (DTC) in persons with multiple sclerosis (pwMS) and healthy controls (HC) in various type and complexity of UL motor tasks.

METHOD

In total, 30 pwMS without major UL impairment and 30 HC performed five different UL tasks, in single condition and combined with the phonemic word list generation task. The percent change in performances was evaluated by the motor, cognitive, and combined DTC. The motor tasks consisted of four unimanual (sustained hand grip strength, box-and-block test, Purdue pegboard test, finger tapping task) and one bimanual task (Purdue pegboard test). Group and task differences were analyzed with unpaired and paired t-tests, respectively, and overall effect with a multivariate analysis of variance.

RESULTS

The motor DTC ranged between 10% (Purdue pegboard bimanual) and 35% (box-and-block test). The cognitive DTC ranged between -8% (finger tapping test) and +21% (bimanual Purdue pegboard). The magnitude of the combined DTC did not differ significantly between pwMS and HC in any task.

CONCLUSION

DTC is influenced by the complexity of the UL task, but was not significantly different between HC and cognitive intact, but mildly motor disabled pwMS.

Multidisciplinary data infrastructures in multiple sclerosis: Why they are needed and can be done!

Personalized treatment is highly desirable in multiple sclerosis (MS). We believe that multidisciplinary measurements including clinical, functional and patient-reported outcome measures in combination with extensive patient profiling can enhance personalized treatment and rehabilitation strategies. We elaborate on four reasons behind this statement: (1) MS disease activity and progression are complex and multidimensional concepts in nature and thereby defy a one-size-fits-all description, (2) functioning, progression, treatment, and rehabilitation effects are interdependent and should be investigated together, (3) personalized healthcare is based on the dynamics of system biology and on technology that confirms a patient's fundamental biology and (4) inclusion of patient-reported outcome measures can facilitate patient-relevant healthcare. We discuss currently available multidisciplinary MS data initiatives and introduce joint actions to further increase the overall success. With this topical review, we hope to drive the MS community to invest in expanding towards more multidisciplinary and longitudinal data collection.

Markerless motion capture systems as training device in neurological rehabilitation: a systematic review of their use, application, target population and efficacy

Background

Client-centred task-oriented training is important in neurological rehabilitation but is time consuming and costly in clinical practice. The use of technology, especially motion capture systems (MCS) which are low cost and easy to apply in clinical practice, may be used to support this kind of training, but knowledge and evidence of their use for training is scarce. The present review aims to investigate 1) which motion capture systems are used as training devices in neurological rehabilitation, 2) how they are applied, 3) in which target population, 4) what the content of the training and 5) efficacy of training with MCS is.

Methods

A computerised systematic literature review was conducted in four databases (PubMed, Cinahl, Cochrane Database and IEEE). The following MeSH terms and key words were used: Motion, Movement, Detection, Capture, Kinect, Rehabilitation, Nervous System Diseases, Multiple Sclerosis, Stroke, Spinal Cord, Parkinson Disease, Cerebral Palsy and Traumatic Brain Injury. The Van Tulder’s Quality assessment was used to score the methodological quality of the selected studies. The descriptive analysis is reported by MCS, target population, training parameters and training efficacy.

Results

Eighteen studies were selected (mean Van Tulder score = 8.06 ± 3.67). Based on methodological quality, six studies were selected for analysis of training efficacy. Most commonly used MCS was Microsoft Kinect, training was mostly conducted in upper limb stroke rehabilitation. Training programs varied in intensity, frequency and content. None of the studies reported an individualised training program based on client-centred approach.

Conclusion

Motion capture systems are training devices with potential in neurological rehabilitation to increase the motivation during training and may assist improvement on one or more International Classification of Functioning, Disability and Health (ICF) levels. Although client-centred task-oriented training is important in neurological rehabilitation, the client-centred approach was not included. Future technological developments should take up the challenge to combine MCS with the principles of a client-centred task-oriented approach and prove efficacy using randomised controlled trials with long-term follow-up.

Trial registration

Prospero registration number 42016035582.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-017-0270-x) contains supplementary material, which is available to authorized users.

The Assessment of Motor Fatigability in Persons With Multiple Sclerosis: A Systematic Review

Background. Persons with multiple sclerosis (PwMS) are often characterized by increased motor fatigability, which is a performance change on an objectively measured criterion after any type of voluntary muscle contractions. This review summarizes the existing literature to determine which protocols and outcome measures are best to detect or study motor fatigability and the underlying mechanisms in MS. Methods. Two electronic databases, PubMed and Web of Science, were searched for relevant articles published until August 2016 with a combination of multiple sclerosis, fatigability, muscle fatigue, and motor fatigue. Results. A total of 48 articles were retained for data extraction. A variety of fatigability protocols were reported; protocols showed differences in type (isometric vs concentric), duration (15 to 180 s), and number of contractions (fixed or until exhaustion). Also, 12 articles reported motor fatigability during functional movements, predominantly assessed by changes in walking speed; 11 studies evaluated the mechanisms underlying motor fatigability, using additional electrical nerve or transcranial magnetic stimulation. Three articles reported psychometrics of the outcomes. Conclusions. The disparity of protocols and outcome measures to study different aspects of motor fatigability in PwMS impedes direct comparison between data. Most protocols use maximal single-joint isometric contractions, with the advantage of high standardization. Because there is no head-to-head comparison of the different protocols and only limited information on psychometric properties of outcomes, there is currently no gold standard to assess motor fatigability. The disability level, disease phenotype, and studied limb may influence the assessment of motor fatigability in PwMS.

The Nine-Hole Peg Test as a manual dexterity performance measure for multiple sclerosis

Impaired manual dexterity is a frequently reported disability in people with multiple sclerosis (MS) and is increasingly prevalent with worsening disease. While various tests and patient-reported outcome measures are available, the Nine-Hole Peg Test (NHPT) is considered as a gold standard measure of manual dexterity and most frequently used in MS research and clinical practice. The MS Outcome Assessments Consortium (MSOAC) includes representatives from advocacy organizations, Food and Drug Administration (FDA), European Medicines Agency (EMA), National Institute of Neurological Disorders and Stroke (NINDS), academic institutions, and industry partners along with persons living with MS. Among the MSOAC goals are acceptance and qualification by regulators of performance outcomes that are highly reliable and valid, practical, cost-effective, and meaningful to persons with MS. A critical step for these neuroperformance metrics is elucidation of clinically relevant benchmarks, well-defined degrees of disability, and gradients of change that are deemed clinically meaningful. This article addresses the NHPT, the proposed MSOAC measure for upper extremity function. We find that the NHPT is reliable within and between test sessions, discriminates between healthy subjects and MS patients with different levels of upper limb impairment, and shows high convergent validity with other manual dexterity as well as more comprehensive upper limb measures. Ecological validity is established by its relation to perceived upper limb use in daily life and perceived difficulty in performing activities of daily living. The NHPT is responsive to deterioration in longitudinal studies, and research suggests that a 20% change in test score is commonly used to define clinically meaningful worsening, a definition that needs further validation in all stages of the disease.

Evaluation of upper extremity neurorehabilitation using technology: a European Delphi consensus study within the EU COST Action Network on Robotics for Neurorehabilitation

BACKGROUND

The need for cost-effective neurorehabilitation is driving investment into technologies for patient assessment and treatment. Translation of these technologies into clinical practice is limited by a paucity of evidence for cost-effectiveness. Methodological issues, including lack of agreement on assessment methods, limit the value of meta-analyses of trials. In this paper we report the consensus reached on assessment protocols and outcome measures for evaluation of the upper extremity in neurorehabilitation using technology. The outcomes of this research will be part of the development of European guidelines.

METHODS

A rigorous, systematic and comprehensive modified Delphi study incorporated questions and statements generation, design and piloting of consensus questionnaire and five consensus experts groups consisting of clinicians, clinical researchers, non-clinical researchers, and engineers, all with working experience of neurological assessments or technologies. For data analysis, two major groups were created: i) clinicians (e.g., practicing therapists and medical doctors) and ii) researchers (clinical and non-clinical researchers (e.g. movement scientists, technology developers and engineers).

RESULTS

Fifteen questions or statements were identified during an initial ideas generation round, following which the questionnaire was designed and piloted. Subsequently, questions and statements went through five consensus rounds over 20 months in four European countries. Two hundred eight participants: 60 clinicians (29 %), 35 clinical researchers (17 %), 77 non-clinical researchers (37 %) and 35 engineers (17 %) contributed. At each round questions and statements were added and others removed. Consensus (≥69 %) was obtained for 22 statements on i) the perceived importance of recommendations; ii) the purpose of measurement; iii) use of a minimum set of measures; iv) minimum number, timing and duration of assessments; v) use of technology-generated assessments and the restriction of clinical assessments to validated outcome measures except in certain circumstances for research.

CONCLUSIONS

Consensus was reached by a large international multidisciplinary expert panel on measures and protocols for assessment of the upper limb in research and clinical practice. Our results will inform the development of best practice for upper extremity assessment using technologies, and the formulation of evidence-based guidelines for the evaluation of upper extremity neurorehabilitation.

Investigation of isometric strength and control of the upper extremities in multiple sclerosis

Isometric force assessment can provide insights into strength and motor control in patients with neurological disabilities. This study investigated the connection between isometric strength and control in nine multiple sclerosis (MS) patients and four healthy subjects using a compact isometric setup. The participants carried out isometric assessment tasks in both upper extremities in six directions. Strength was measured through maximum voluntary force/torque (MVF/T), while control ability was measured by applying a constant force/torque of 25% of MVF/T. Isometric control was quantified using coefficient of variation, force directing ability, sample-entropy and spectral bandwidth. The MS patients were also assessed using two impairment measures (Motricity Index and hand-grip strength), and two activity measures (Action Research Arm Test and Nine Hole Peg Test). The results indicate that isometric strength and control (measured by spectral bandwidth) were correlated in most directions. Among the four control measures, spectral bandwidth – a measure introduced in this study – was found to be strongly related to the force/torque regularity as measured by sample-entropy. Isometric strength and spectral bandwidth for all directions were well correlated with the impairment measures, but their correlation with the activity scales was moderate and direction-dependent. Overall the results show potential for using the isometric setup and protocol for assessment in MS population.

Upper Limb Rehabilitation in People With Multiple Sclerosis

Background. There has been an increasing research interest in upper limb rehabilitation in multiple sclerosis (MS). The current changes in the research field inquire a new literature review. Objective. This systematic review aimed to provide an overview of the upper limb rehabilitation strategies in people with MS (PwMS). Methods. Articles published in PubMed and Web of Knowledge were selected when written in English, published in the past 25 years, peer reviewed, that included at least 5 PwMS, and described the effects of an intervention study including rehabilitation strategies targeting the upper limbs. Included articles were screened based on title/abstract and full text by 2 independent reviewers. Results. Thirty articles met the criteria and were included for data extraction. Only half of the included studies investigated the effects of a training program specially targeted toward the upper limbs, while in the other studies, a general whole body therapy was used. The therapy content and dosage varied greatly between the different included studies. Multidisciplinary and robot-based rehabilitation were the most investigated rehabilitation strategies and showed to improve upper limb capacity. Strength and endurance training improved the upper limb body functions and structures but did not influence the upper limb capacity and performance. Conclusions. The results of this systematic review indicated that different types of upper limb rehabilitation strategies can improve upper limb function in PwMS. Further research is necessary to compare directly the effects of different rehabilitation strategies and to investigate the optimal therapy dosage according to the upper limb disability level.

Robot-supported upper limb training in a virtual learning environment : a pilot randomized controlled trial in persons with MS

Background

Despite the functional impact of upper limb dysfunction in multiple sclerosis (MS), effects of intensive exercise programs and specifically robot-supported training have been rarely investigated in persons with advanced MS.

Aim

To investigate the effects of additional robot-supported upper limb training in persons with MS compared to conventional treatment only.

Methods

Seventeen persons with MS (pwMS) (median Expanded Disability Status Scale of 8, range 3.5–8.5) were included in a pilot RCT comparing the effects of additional robot-supported training to conventional treatment only. Additional training consisted of 3 weekly sessions of 30 min interacting with the HapticMaster robot within an individualised virtual learning environment (I-TRAVLE). Clinical measures at body function (Hand grip strength, Motricity Index, Fugl-Meyer) and activity (Action Research Arm test, Motor Activity Log) level were administered before and after an intervention period of 8 weeks. The intervention group were also evaluated on robot-mediated movement tasks in three dimensions, providing active range of motion, movement duration and speed and hand-path ratio as indication of movement efficiency in the spatial domain. Non-parametric statistics were applied.

Results

PwMS commented favourably on the robot-supported virtual learning environment and reported functional training effects in daily life. Movement tasks in three dimensions, measured with the robot, were performed in less time and for the transporting and reaching movement tasks more efficiently. There were however no significant changes for any clinical measure in neither intervention nor control group although observational analyses of the included cases indicated large improvements on the Fugl-Meyer in persons with more marked upper limb dysfunction.

Conclusion

Robot-supported training lead to more efficient movement execution which was however, on group level, not reflected by significant changes on standard clinical tests. Persons with more marked upper limb dysfunction may benefit most from additional robot-supported training, but larger studies are needed.

Trial registration

This trial is registered within the registry Clinical Trials GOV (NCT02257606).

An overview of systematic reviews on upper extremity outcome measures after stroke

BACKGROUND

Although use of standardized and scientifically sound outcome measures is highly encouraged in clinical practice and research, there is still no clear recommendation on which tools should be preferred for upper extremity assessment after stroke. As the aims, objectives and methodology of the existing reviews of the upper extremity outcome measures can vary, there is a need to bring together the evidence from existing multiple reviews. The purpose of this review was to provide an overview of evidence of the psychometric properties and clinical utility of upper extremity outcome measures for use in stroke, by systematically evaluating and summarizing findings from systematic reviews.

METHODS

A comprehensive systematic search was performed including systematic reviews from 2004 to February 2014. A methodological quality appraisal of the reviews was performed using the AMSTAR-tool.

RESULTS

From 13 included systematic reviews, 53 measures were identified of which 13 met the standardized criteria set for the psychometric properties. The strongest level of measurement quality and clinical utility was demonstrated for Fugl-Meyer Assessment, Action Research Arm Test, Box and Block Test, Chedoke Arm and Hand Activity Inventory, Wolf Motor Function Test and ABILHAND.

CONCLUSIONS

This overview of systematic reviews provides a comprehensive systematic synthesis of evidence on which outcome measures demonstrate a high level of measurement quality and clinical utility and which can be considered as most suitable for upper extremity assessment after stroke. This overview can provide a valuable resource to assist clinicians, researchers and policy makers in selection of appropriate outcome measures.

Unilateral and bilateral upper limb dysfunction at body functions, activity and participation levels in people with multiple sclerosis

BACKGROUND

There has been limited research on upper limb dysfunction in people with multiple sclerosis (PwMS).

OBJECTIVE

The objective of this paper is to study unilateral and bilateral upper limb dysfunction at different International Classification of Functioning (ICF) levels according to overall disability in PwMS.

METHODS

A total of 105 PwMS (16 with EDSS<4 (mild); 17 with EDSS 4-5.5 (moderate); 37 with EDSS 6-6.5 (severe); 35 with EDSS>6.5 (severe non-ambulant)) were recruited from two rehabilitation centers and assessed in a cross-sectional study.

RESULTS

The whole sample showed a diminished sensory function (median (first/third interquartile)) score of 3 (2/3) on the Monofilament Test and a reduced strength 91 (76/100) points on the Motricity Index (Body-Function level). Sensory dysfunction did not increase with higher EDSS while strength decreased from 100 (86/100) in the mild subgroups to 91 (80/100) points in the severe subgroup. All showed diminished dexterity, scoring 0.28 peg/s (0.17/0.35) on the Nine-Hole Peg Test (NHPT) (activity level). Score was better for the mild (0.38 (0.35/0.46)) peg/s compared to the severe subgroup (0.28 (0.17/0.35)). Sixty-eight percent, 44% and 75% of PwMS showed bilateral disorders in sensation, strength and dexterity, respectively. The Community Integration Questionnaire (participation level) showed a 35% reduction in home activities, even among PwMS with EDSS<4.

CONCLUSION

This study showed uni-/bilateral upper limb abnormalities at all ICF levels increasing with the overall disability.

Assessment of upper limb motor function in patients with multiple sclerosis using the Virtual Peg Insertion Test: a pilot study

Quantifying and tracking upper limb impairment is of key importance to the understanding of disease progress, establishing patient-tailored therapy protocols and for optimal care provision. This paper presents the results of a pilot study on the assessment of upper limb motor function in patients with multiple sclerosis (MS) with the Virtual Peg Insertion Test (VPIT). The test consists in a goal-directed reaching task using a commercial haptic display combined with an instrumented handle and virtual environment, and allows for the extraction of objective kinematic and dynamic parameters. Ten MS patients and eight age-matched healthy subjects performed five repetitions of the VPIT with their dominant and non-dominant hand. Upper limb movements were found to be significantly slower, less smooth and less straight compared to healthy controls, and the time to complete the VPIT was well correlated with the conventional Nine Hole Peg Test (r=0.658, p<0.01). Tremor in the range of 3-5 Hz could be detected and quantified using a frequency analysis in patients featuring intention tremor. These preliminary results illustrate the feasibility of using the VPIT with MS patients, and underline the potential of this test to evaluate upper limb motor function and discriminate characteristic MS related impairments.

Assessing upper limb function in multiple sclerosis

The need to fully assess upper limb function in multiple sclerosis (MS) has become increasingly clear with recent studies revealing a high prevalence of upper limb dysfunction in persons with MS leading to increased dependency and reduced quality of life. It is important that clinicians and researchers use tailored outcome measures to systematically describe upper limb (dys)function and evaluate potential deterioration or improvement on treatment. This topical review provides a comprehensive summary of currently used upper limb outcome measures in MS, classified according to the levels of the International Classification of Functioning (ICF). The clinical utility, strengths, weaknesses and psychometric properties of common upper limb outcome measures are discussed. Based on this information, recommendations for selecting appropriate upper limb outcome measures are given. The current shortcomings in assessment which need to be addressed are identified.

Upper limb assessment in multiple sclerosis: a systematic review of outcome measures and their psychometric properties

OBJECTIVE

To provide an overview of applied upper limb outcome measures in multiple sclerosis (MS) according to the International Classification of Functioning, Disability and Health (ICF) levels and to review their psychometric properties in MS.

DATA SOURCES

PubMed and Web of Knowledge.

STUDY SELECTION

Articles published until June 2013 were selected when written in English, published in the last 25 years, peer reviewed, including >5 persons with MS, and including standardized clinical upper limb outcome measures. Included articles were screened based on title/abstract and full text by 2 independent reviewers. In case of doubt, feedback from a third independent reviewer was obtained. Additionally, references lists were checked for relevant articles. Of the articles, 109 met the selection criteria and were included for data extraction.

DATA EXTRACTION

All reported clinical upper limb outcome measures were extracted from the included studies and classified according to the ICF levels by 2 independent reviewers. In addition, available psychometric properties (reliability, validity, responsiveness) in MS were summarized and discussed.

DATA SYNTHESIS

A diversity of outcome measures assessing impairments on the body functions and structures level (n=33), upper limb capacity (n=11), and performance (n=8) on the activity level were extracted from 109 articles. Hand grip strength and the nine-hole peg test (NHPT) were the most frequently used outcome measures. However, multiple outcome measures are necessary to encapsulate the multidimensional character of the upper limb function. The psychometric properties were insufficiently documented for most of the outcome measures, except for the NHPT.

CONCLUSIONS

The results of this review may help with the selection of appropriate outcome measures and may guide future research regarding the psychometric properties in MS.

Endurance training is feasible in severely disabled patients with progressive multiple sclerosis

This study tested whether upper-body endurance training (ET) is feasible and can be performed at sufficient intensity to induce cardiovascular adaptations in severely disabled patients with progressive multiple sclerosis (MS). Eleven progressive MS patients (6.5 ≤ EDSS ≤ 8.0) scheduled for a four-week inpatient rehabilitation program were randomized to a control group (CON, n = 5) that received standard individualized MS rehabilitation or an intervention group (EXE, n = 6) that in addition received 10 sessions of predominantly upper-body ET. One patient dropped out of the EXE group (drop-out rate: 1/6~17%) and no adverse events were recorded. The EXE group completed on average 9.3±0.8 sessions (~96.0±5%). During the ET sessions an average heart rate of 93.9±9.3beats*min(-1) were sustained corresponding to 91.6±6.8% of the maximal pre-intervention heart rate. In the EXE group a trend toward a time*group interaction was seen for VO2peak (p = 0.06). ET is feasible in severely disabled patients with progressive MS and it can probably be performed at sufficient intensity to induce cardiovascular adaptations.

Perceived and actual arm performance in multiple sclerosis: relationship with clinical tests according to hand dominance

BACKGROUND

The real-life relevance of frequently applied clinical arm tests is not well known in multiple sclerosis (MS).

OBJECTIVE

This study aimed to determine the relation between real-life arm performance and clinical tests in MS.

METHODS

Thirty wheelchair-bound MS patients and 30 healthy controls were included. Actual and perceived real-life arm performance was measured by using accelerometry and a self-reported measure (Motor Activity Log). Clinical tests on 'body functions & structures' (JAMAR handgrip strength, Motricity Index (MI), Fugl Meyer (FM)) and 'activity' level (Nine Hole Peg Test (NHPT), Action Research Arm test) of the International Classification of Functioning were conducted. Statistical analyses were performed separately for current dominant and non-dominant arm.

RESULTS

For all outcome measures, MS patients scored with both arms significantly lower than the control group. Higher correlations between actual arm performance and clinical tests were found for the non-dominant arm (0.63-0.80). The FM (55%) was a good predictor of actual arm performance, while the MI (46%) and NHPT (55%) were good predictors of perceived arm performance.

CONCLUSIONS

Real-life arm performance is decreased in wheelchair-bound MS patients and can be best predicted by measures on 'body functions & structures' level and fine motor control. Hand dominance influenced the magnitude of relationships.

Visualizing the third dimension in virtual training environments for neurologically impaired persons: beneficial or disruptive?

BACKGROUND

Many contemporary systems for neurorehabilitation utilize 3D virtual environments (VEs) that allow for training patients' hand or arm movements. In the current paper we comparatively test the effectiveness of two characteristics of VEs in rehabilitation training when utilizing a 3D haptic interaction device: Stereo Visualization (monoscopic vs stereoscopic image presentation) and Graphic Environment (2.5D vs 3D).

METHOD

An experimental study was conducted using a factorial within-subjects design. Patients (10 MS, 8 CVA) completed three tasks, each including a specific arm-movement along one of three directional axes (left-right, up-down and forward-backward).

RESULTS

The use of stereoscopy within a virtual training environment for neurorehabilitation of CVA and MS patients is most beneficial when the task itself requires movement in depth. Further, the 2.5D environment yields the highest efficiency and accuracy in terms of patients' movements. These findings were, however, dependent on participants' stereoscopic ability.

CONCLUSION

Despite the performance benefits of stereoscopy, our findings illustrate the non-triviality of choices of using stereoscopy, and the type of graphic environment implemented. These choices should be made with the task and target group, and even the individual patient in mind.

The relationship between upper leg muscle strength and walking capacity in persons with multiple sclerosis

Background:

In persons with multiple sclerosis (PwMS) resistance training improves muscle strength but effects on walking capacity are inconsistent.

Objective:

The objective was to determine the relation between different types of upper leg muscle strength measurements and walking capacity in PwMS.

Methods:

An observational cross-sectional study design was applied. Upper leg muscle strength of 52 PwMS (Expanded Disability Status Scale, EDSS range 1.5–6.5) was measured using isometric (knee extensors and flexors) and isokinetic (knee extensors) dynamometry. Walking capacity was assessed using the Timed 25-Foot Walk, Timed Up and Go and Two Minute Walk Test. Subgroups with mild (EDSS 1.5–4.0, n=31) and moderate (EDSS 4.5–6.5, n=21) ambulatory dysfunction were distinguished, and results were hypothesized to differ depending on multiple sclerosis (MS)-related disability status. Correlation and regression analyses were performed on the data of the most affected leg.

Results:

Greatest ( r: 0.2–0.7) and significant Pearson correlation coefficients were found in the moderate compared to mild MS subgroup. Within knee extensor measurements, it was found that isokinetic endurance strength related best to walking capacity. When comparing maximal isometric strength measurements, knee flexors ( r: 0.5–0.7) related better to walking capacity than knee extensors ( r: 0.1–0.4). Regression analyses confirmed endurance knee extensor strength (~25 %) and isometric knee flexor strength (~40%) as main predictors for walking capacity.

Conclusion:

Resistance training protocols may consider inclusion of exercises focusing on endurance knee extensor and isometric knee flexor strength when aiming to enhance walking capacity in persons with moderate ambulatory dysfunction.

The Armeo Spring as training tool to improve upper limb functionality in multiple sclerosis: a pilot study

Background

Few research in multiple sclerosis (MS) has focused on physical rehabilitation of upper limb dysfunction, though the latter strongly influences independent performance of activities of daily living. Upper limb rehabilitation technology could hold promise for complementing traditional MS therapy. Consequently, this pilot study aimed to examine the feasibility of an 8-week mechanical-assisted training program for improving upper limb muscle strength and functional capacity in MS patients with evident paresis.

Methods

A case series was applied, with provision of a training program (3×/week, 30 minutes/session), supplementary on the customary maintaining care, by employing a gravity-supporting exoskeleton apparatus (Armeo Spring). Ten high-level disability MS patients (Expanded Disability Status Scale 7.0-8.5) actively performed task-oriented movements in a virtual real-life-like learning environment with the affected upper limb. Tests were administered before and after training, and at 2-month follow-up. Muscle strength was determined through the Motricity Index and Jamar hand-held dynamometer. Functional capacity was assessed using the TEMPA, Action Research Arm Test (ARAT) and 9-Hole Peg Test (9HPT).

Results

Muscle strength did not change significantly. Significant gains were particularly found in functional capacity tests. After training completion, TEMPA scores improved (p = 0.02), while a trend towards significance was found for the 9HPT (p = 0.05). At follow-up, the TEMPA as well as ARAT showed greater improvement relative to baseline than after the 8-week intervention period (p = 0.01, p = 0.02 respectively).

Conclusions

The results of present pilot study suggest that upper limb functionality of high-level disability MS patients can be positively influenced by means of a technology-enhanced physical rehabilitation program.