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The purpose of this study is to investigate the impact of ankle foot orthoses (AFOs) on the spatial and temporal gait parameters, electromyography (EMG), walking endurance, and quality of life in select individuals living with MS. The hypotheses of the study are: 1. Individuals who are fit with an AFO will demonstrate improvements in spatial and temporal gait parameters 2. Individuals who are fit with an AFO will demonstrate improvements in walking endurance. 3. Individuals who are fit with an AFO will demonstrate improvements in muscle firing profiles/EMG measures. 4. Individuals who are fit with an AFO will demonstrate improvements in quality of life.
The aim of this study was to compare the intra-limb coordination during treadmill walking performed by
persons with Multiple Sclerosis (MS) and healthy adults. Twelve healthy adults (male = 5, female = 7) and
twelve age and gender matched MS patients (male = 5, female = 7) were selected non-randomly. All
participants walked on a treadmill for 20 strides on two occasions. The mean absolute relative phase was used to
compare 4 stages of the gait cycle (heel contact, mid stance, toe off, and mid swing) between the two groups.
Dependent variables were relative phase and angular position in the knee and ankle joints. Hotelling’s T2 test
and Cross-correlation coefficient were used to analysis the multiple sets of data. The shape of angle-angle plot
showed significant between-group differences in the patterns of gait (T2 = 35.02, F = 35.02, p < 0.05, η2 = 0.97).
Analysis of variance results showed that there were significant differences between the relative phase of the two
groups on heel contact (F = 13.09, p < 0.05, η2 = 0.65) and mid stance (F = 15.12, p < 0.05, η2 = 0.68) stages.
Cross-correlation function results showed that in the healthy group, there were no significant relationships
between the angular positions of two joints in the different stages, whereas in the MS group there was a
significant inverse relationship (CCF = -0.45, p < 0.05) between the angular positions of two joints. In
conclusion, the results of this study showed that in people with MS, intra-limb coordination patterns during
walking are different from healthy people
Background Evaluation of walking capacity and risk of falls in people with multiple sclerosis often are performed in rehabilitation. The Dynamic Gait Index (DGI) evaluates walking during different tasks, but the feasibility in identifying people at risk for falls needs to be further investigated.
Objective The objective of this study was to investigate (1) the construct validity (known groups, convergent, and discriminant) of the DGI and (2) the accuracy of predicting falls and establishing a cutoff point to identify fallers.
Design This trial was a multicenter, cross-sectional study.
Methods A convenience sample was composed of 81 people with multiple sclerosis with subjective gait and balance impairment who were able to walk 100 m (comparable to Expanded Disability Status Scale 1–6). Mean age of the participants was 49 years; 76% were women. The 25-Foot Timed Walk Test, Timed “Up & Go” Test, Four Square Step Test, Timed Sit-to-Stand Test, MS Walking Scale, Multiple Sclerosis Impact Scale, and self-reported falls during the previous 2 months were used for validation, to establish cutoff points for identifying fallers, and to investigate predictive values.
Results Significantly lower DGI scores (P≤.001) were found for participants reporting falls (n=31). High sensitivity (87%) in identifying fallers was found, with a cutoff score ≤19. The positive predictive value was 50%, and the negative predictive value was 87%. The positive likelihood ratio was 1.77, and the negative likelihood ratio was 0.26. The convergent validity was moderate to strong (ρ=0.58–0.80), with the highest correlation coefficient found for the 25-Foot Timed Walk Test. Discriminant validity was shown with low correlation for the psychological subscale of the Multiple Sclerosis Impact Scale.
Limitations The sample included ambulatory people participating in a randomized controlled trial investigating balance training.
Conclusions The DGI is a valid measure of dynamic balance during walking for ambulatory people with multiple sclerosis. With the cutoff point of ≤19, sensitivity was high in identifying people at risk of falls.
Cognitive processing speed has minimal influence on the construct validity of Multiple Sclerosis Walking Scale-12 scores.
Motl RW, Cadavid D, Sandroff BM, Pilutti LA, Pula JH, Benedict RH. J Neurol Sci. 2013 Sep 24.
The Multiple Sclerosis Walking Scale-12 (MSWS-12) has been a commonly used patient reported outcome for measuring walking impairment in research involving multiple sclerosis (MS).
We examined the possibility that cognitive processing speed (CPS) influences the association between MSWS-12 scores and other measures of ambulation (i.e., construct validity).
96 MS patients completed the MSWS-12, underwent a neurological examination for generating an Expanded Disability Status Scale (EDSS) score, and completed the Symbol Digit Modalities Test (SDMT), Timed 25-Foot Walk (T25FW), 4 trials on the GAITRite™ for generating the functional ambulatory profile (FAP) score, and Six-minute Walk (6MW).
The SDMT was significantly correlated with MSWS-12 scores (r=-.428) and T25FW (r=-.459), 6MW (r=.512), FAP (r=.275), and EDSS (r=-.404) scores. There were statistically significant correlations between MSWS-12 and T25FW (r=.568), 6MW (r=-.680), FAP (r=-.595), and EDSS (r=.737) scores. Lastly, four separate hierarchical linear regression analyses indicated that, after controlling for age, gender, disease duration, and clinical course, T25FW, 6MW, FAP, and EDSS scores individually were significant correlates of MSWS-12 scores, and the associations (i.e., standardized beta-coefficients) were still statistically significant with minimal attenuation when controlling for SDMT scores.
There was minimal evidence that CPS influenced the construct validity of MSWS-12 scores.
Predicting falls in people with multiple sclerosis: fall history is as accurate as more complex measures.
Cameron MH, Thielman E, Mazumder R, Bourdette D. Mult Scler Int. 2013;2013:496325.
Background. Many people with MS fall, but the best method for identifying those at increased fall risk is not known. Objective. To compare how accurately fall history, questionnaires, and physical tests predict future falls and injurious falls in people with MS.
Methods. 52 people with MS were asked if they had fallen in the past 2 months and the past year. Subjects were also assessed with the Activities-specific Balance Confidence, Falls Efficacy Scale-International, and Multiple Sclerosis Walking Scale-12 questionnaires, the Expanded Disability Status Scale, Timed 25-Foot Walk, and computerized dynamic posturography and recorded their falls daily for the following 6 months with calendars. The ability of baseline assessments to predict future falls was compared using receiver operator curves and logistic regression.
Results. All tests individually provided similar fall prediction (area under the curve (AUC) 0.60-0.75). A fall in the past year was the best predictor of falls (AUC 0.75, sensitivity 0.89, specificity 0.56) or injurious falls (AUC 0.69, sensitivity 0.96, specificity 0.41) in the following 6 months.
Conclusion. Simply asking people with MS if they have fallen in the past year predicts future falls and injurious falls as well as more complex, expensive, or time-consuming approaches
The relationship between fear of falling to spatiotemporal gait parameters measured by an instrumented treadmill in people with multiple sclerosis
Alon Kalronemail address, Anat Achiron Gait & Posture; Article in Press
People with multiple sclerosis (MS) identify mobility limitations as one of the greatest challenges of this disease. Continued loss of mobility and falls are among their greatest concerns for the future. Our objective was to determine if fear of falling is associated with spatial and temporal gait parameters in persons with MS, when measured by an instrumented treadmill. This observational case control study was performed at the MS Center, Center of Advanced Technologies in Rehabilitation, Sheba Medical Center, Tel Hashomer, Israel. Sixty-eight relapsing-remitting patients diagnosed with MS, 38 women, aged 40.9 (S.D.=11.9), participated in this investigation. Twenty-five healthy subjects, 14 women, aged 39.5 (S.D.=9.4) served as controls gait controls. Gait spatiotemporal parameters were obtained using the Zebris FDM-T Treadmill (Zebris® Medical GmbH, Germany). The Falls Efficacy Scale International was used to assess the level of concern relating to falls. Forty-one people with MS were classified as highly fearful of falling. Twenty-seven patients were slightly concerned. Highly fearful of falling patients walked slower had a shorter step length, a wider base of support and prolonged double support phase compared to slightly concerned patients. Fearful patients also demonstrated elevated variability of the center of pressure (CoP) trajectory compared to slightly concerned MS patients. Fear of falling and spatiotemporal gait alterations in people with MS are linked. Additionally, variability of the CoP during walking appears to be connected with the level of concern.
•Fear of falling is related to spatial and temporal gait parameters in people with MS.
•Fearful patients demonstrated a larger variability of the CoP trajectory during gait.
•CoP variability in the lateral plane was significantly correlated to fear of falling.
Strategies used by individuals with multiple sclerosis and with mild disability to maintain dynamic stability during a steering task.
Denommé LT, Mandalfino P, Cinelli ME. Exp Brain Res. 2014 Feb 22.
Changing direction during walking is a common task humans encounter every day. This destabilizing event requires the central nervous system (CNS) to quickly produce an appropriate response, maintain stability, and propel the body in the intended direction. Previous research has demonstrated that 'individuals with multiple sclerosis' (IwMS) with mild balance impairment display differences in gait characteristics during clinical tests compared with controls. The current study used dynamic stability margin [DSM, difference between COM (i.e. the weighted average of the central point of an individual's total body mass) and lateral BOS (i.e. the most lateral border of the foot that is in contact with the ground)] calculations in addition to gait kinematics to determine whether dynamic stability differences during a steering task were present between IwMS with mild balance impairment and 'healthy age-matched individuals' (HAMI) as well as between IwMS with mild balance impairment and 'community-dwelling older adults' (OA). All IwMS reported mild balance impairment with expanded disability status scale scores ranging between 1.0 and 3.0. The steering task required participants to walk 3 m towards a pressure sensitive trigger mat that would illuminate one of five lights to indicate the future direction of travel (i.e. straight, 45° or 60° to the left or right of the midline). Results revealed that IwMS displayed reduced walking speed and cadence during the approach phase in addition to a smaller DSM range (i.e. COM remained close to lateral BOS) during the entire steering task when compared with HAMI. However, when compared to OAs, IwMS did not display differences in any of the gait kinematics or DSM calculations. Findings suggest that the IwMS displayed a conservative gait strategy in order to maintain stability during the steering task. Lack of dynamic stability differences between IwMS and OAs indicate that both groups use similar strategies to adapt locomotion as a result of impaired somatosensory quality and/or processing.
Gait kinematics of people with Multiple Sclerosis and the acute application of Functional Electrical Stimulation
Marietta L. van der Linden, Sasha M. Scott, Julie E. Hooper, Paula Cowan, Thomas H. Mercer Gait & Posture; Article in Press
•We studied the gait kinematics in people with Multiple Sclerosis (MS) and controls.
•Non-impaired controls walked at their self-selected (SSWS) and slower speed.
•Gait kinematics in people with MS differed from controls walking at their SSWS.
•Not all gait differences persisted between MS group and controls at slower speed.
•Functional Electrical Stimulation for people with MS normalised most gait kinematics.
This study aimed to (i) compare the gait characteristics of people with Multiple Sclerosis (pwMS) to those of healthy controls walking at the same average speed, and (ii) assess the effects of the acute application of Functional Electrical Stimulation (FES) to the dorsiflexors.
Twenty-two people with pwMS (mean age 49 years), prescribed FES, and 11 age matched healthy controls participated. Three dimensional gait kinematics were assessed whilst (i) pwMS and healthy controls walked at self-selected speeds (SSWS), (ii) healthy controls also walked at the average walking speed of the pwMS group, and (iii) people with MS walked using FES.
Compared to healthy controls walking at their SSWS, pwMS walked slower and showed differences in nearly all gait characteristics (p<0.001). Compared to healthy controls walking at the same average speed, pwMS still exhibited significantly shorter stride length (p=0.007), reduced dorsiflexion at initial contact (p=0.002), reduced plantar flexion at terminal stance (p=0.008) and reduced knee flexion in swing (p=0.002). However, no significant differences were seen between groups in double support duration (p=0.617), or hip range of motion (p=0.291). Acute application of FES resulted in a shift towards more normal gait characteristics, except for plantar flexion at terminal stance which decreased.
In conclusion, compared to healthy controls, pwMS exhibit impairment of several characteristics that appear to be independent of the slower walking speed of pwMS. The acute application of FES improved most impaired gait kinematics. A speed matched control group is warranted in future studies of gait kinematics of pwMS.
Plantarflexor weakness negatively impacts walking in persons with multiple sclerosis more than plantarflexor spasticity.
Wagner JM, Kremer TR, Van Dillen LR, Naismith RT. Arch Phys Med Rehabil. 2014 Feb 27.
To determine if plantarflexor (PF) spasticity or ankle strength best predicts variance in walking capacity or self-perceived limitations in walking in persons with multiple sclerosis (pwMS), and if pwMS with PF spasticity are weaker and have greater walking dysfunction than pwMS without PF spasticity.
University research laboratory.
Forty-two pwMS (age: 42.9 ± 10.1 years; Expanded Disability Status Scale (EDSS): median = 3.0, range = 0-6) and 14 adults without disability (WD) (age: 41.9 ± 10.1 years).
MAIN OUTCOME MEASURES:
PF spasticity and dorsiflexion (DF) and PF maximum voluntary isometric torque (MVIT) were assessed using the Modified Ashworth Scale (MAS) and a computerized dynamometer, respectively. The Timed 25-Foot Walk Test (T25FWT) was the primary outcome measure of walking capacity. Secondary measures included the Six Minute Walk Test (6MWT) and 12-item Multiple Sclerosis Walking Scale (MSWS-12).
PF strength was the most consistent predictor of the variance in walking capacity (T25FWT: R2 change = 0.23 to 0.29, p ≤ 0.001; 6MWT: R2 change = 0.12 to 0.29, p ≤ 0.012), and self-perceived limitations of walking (MSWS-12: R2 change = 0.04 to 0.14, p < 0.18). There were no significant differences (p > 0.05) between the pwMS with PF spasticity and pwMS without PF spasticity for any of the outcome measures.
Our study suggests a unique contribution of PF weakness to walking dysfunction in pwMS, and highlights the importance of evaluating PF strength in this clinical population.
Reliability of spatial-temporal gait parameters during dual-task interference in people with multiple sclerosis. A cross-sectional study
Marco Monticone, Emilia Ambrosini, Roberta Fiorentini, Barbara Rocca, Valentina Liquori, Alessandra Pedrocchi, Simona Ferrante Gait & Posture; Articles in Press
•Performing cognitive tasks affects walking ability in people with multiple sclerosis.
•The reliability of gait assessment during dual-task was proved in multiple sclerosis.
•This is a valid reference for rehabilitation under dual-task conditions.
To evaluate the reliability and minimum detectable change (MDC) of spatial-temporal gait parameters in subjects with multiple sclerosis (MS) during dual tasking.
This cross-sectional study involved 25 healthy subjects (mean age 49.9 ± 15.8 years) and 25 people with MS (mean age 49.2 ± 11.5 years). Gait under motor-cognitive and motor-motor dual tasking conditions was evaluated in two sessions separated by a one-day interval using the GAITRite® Walkway System. Test-retest reliability was assessed using intraclass correlation coefficients (ICCs), standard errors of measurement (SEM), and coefficients of variation (CV). MDC scores were computed for the velocity, cadence, step and stride length, step and stride time, double support time, the % of gait cycle for single support and stance phase, and base of support.
All of the gait parameters reported good to excellent ICCs under both conditions, with healthy subject values of >0.69 and MS subject values of >0.84. SEM values were always below 18% for both groups of subjects. The gait patterns of the people with MS were slightly more variable than those of the normal controls (CVs: 5.88-41.53% vs 2.84-30.48%).
The assessment of quantitative gait parameters in healthy subjects and people with MS is highly reliable under both of the investigated dual tasking conditions.
Relationship between foot vibration threshold and walking and balance functions in people with Multiple Sclerosis (PwMS)
Marcin Uszynski, Helen Purtill, Susan Coote Gait & Posture; Articles in Press
•We found a significant relationship between foot vibration threshold and function in ambulatory people with Multiple Sclerosis.
•The first metatarsophalangeal joint on the foot is the most strongly correlated point with balance and walking.
•The Neurothesiometer can distinguish between those people with Multiple Sclerosis with and without walking limitations.
The aim of this study was to investigate the relationship between foot vibration threshold and walking and balance functions in people with Multiple Sclerosis (PwMS). The study sample consisted of 34 participants with mean age of 49.5 years (SD 11.13). Participants were able to walk independently or with an assistive device. Participants underwent vibration threshold testing using the Neurothesiometer (NT), followed by the 6 minute walking test (6MWT), the Timed up and go test (TUG) and the Berg balance scale (BBS). We found a statistically significant relationship between foot vibration threshold and all outcome measures used. The first metatarsophalangeal joint had the strongest correlation with BBS (-0.585, p < 0.01), 6MWT (-0.557, p < 0.01) and TUG (0.498, p < 0.01). We also found that vibration threshold scores differed between those people with MS with and without walking limitations (Mann-Whitney U test, p < 0.01 for all testing points). In conclusion, these findings confirm the relationship between foot vibration threshold and clinical measures of walking and balance in PwMS and add to literature predictive validity of foot vibration threshold. They also suggest that vibration threshold may be important to consider when identifying people in need of intervention or when evaluating the effect of rehabilitation and exercise interventions.
The literature shows inconsistent evidence regarding the association between clinically assessed plantar-flexor (PF) spasticity and walking function in ambulatory persons with multiple sclerosis (pwMS). The use of a dynamometer-based spasticity measure (DSM) may help to clarify this association. Our cohort included 42 pwMS (27 female, 15 male; age: 42.9 +/- 10.1 yr) with mild clinical disability (Expanded Disability Status Scale score: 3.6 +/- 1.6). PF spasticity was assessed using a clinical measure, the modified Ashworth Scale (MAS), and an instrumented measure, the DSM. Walking function was assessed by the timed 25-foot walk test (T25FWT), the 6-minute walk test (6MWT), and the 12-item Multiple Sclerosis Walking Scale (MSWS-12). Spearman rho correlations were used to evaluate relationships between spasticity measures, measures of walking speed and endurance, and self-perceived limitations in walking. The correlation was small between PF spasticity and the T25FWT (PF maximum [Max] MAS rho = 0.27, PF Max DSM rho = 0.26), the 6MWT (PF Max MAS rho = -0.20, PF Max DSM rho = -0.21), and the MSWS-12 (PF Max MAS rho = 0.11, PF Max DSM rho = 0.26). Our results are similar to reports in other neurologic clinical populations, wherein spasticity has a limited association with walking dysfunction.
Multiple Sclerosis Walking Scale-12, Translation, Adaptation and Validation for the Persian language population
Noureddin Nakhostin Ansari, Soofia Naghdi, Roghaye Mohammadi, Scott Hasson Gait & Posture; Articles in Press
•The Multiple Sclerosis Walking Scale-12 (MSWS-12) was translated and culturally adapted according to the standard guidelines.
•Persian MSWS-12 (PMSWS-12) is a reliable and valid instrument for assessing walking ability in Persian speaking patients with MS.
•Factor analysis revealed that the PMSWS-12 has 2 factors, and the 9-item PMSWS is a unidimensional scale.
•PMSWS-12 is a suitable instrument for use in clinical and research settings.
•The PMSWS-12 can be used as an outcome measure for investigations in Persian-speaking population.
The Multiple Sclerosis Walking Scale-12 (MSWS-12) is a multi-item rating scale used to assess the perspectives of patients about the impact of MS on their walking ability. The aim of this study was to examine the reliability and validity of the MSWS-12 in Persian speaking patients with MS. The MSWS-12 questionnaire was translated into Persian language according to internationally adopted standards involving forward-backward translation, reviewed by an expert committee and tested on the pre-final version. In this cross-sectional study, 100 participants (50 patients with MS and 50 healthy subjects) were included. The MSWS-12 was administered twice 7 days apart to 30 patients with MS for test and retest reliability. Internal consistency reliability was Cronbach's α .96 for test and .97 for retest. There were no significant floor or ceiling effects. Test-retest reliability was excellent (intraclass correlation coefficient [ICC] agreement of 0.98, 95% CI, 0.95-0.99) confirming the reproducibility of the Persian MSWS-12. Construct validity using known group methods was demonstrated through a significant difference in the Persian MSWS-12 total score between the patients with MS and healthy subjects. Factor analysis extracted 2 latent factors (79.24% of the total variance). A second factor analysis suggested the 9-item Persian MSWS as a unidimensional scale for patients with MS. The Persian MSWS-12 was found to be valid and reliable for assessing walking ability in Persian speaking patients with MS.
To examine the relationship between gait initiation, fall history and physiological fall risk in individuals with multiple sclerosis (MS) during both cognitive distracting and non-distracting conditions.
Single time point cross sectional analysis.
University research laboratory.
Twenty ambulatory individuals with MS ranging in age from 28 to 76 years.
Main Outcome Measure
Gait initiation time was quantified as the time to toe off of the first step following an auditory cue. Gait initiation was performed with and without concurrent cognitive challenge of reciting alternating letters of the alphabet. Additionally, participants underwent a test of fall risk utilizing the physiological profile assessment (PPA) and provided a self-report of number of falls in the previous three months.
Gait initiation times ranged from 0.67s to 1.12s during the single task condition and 0.73s to 1.84s during the cognitive challenge condition. PPA scores ranged from -0.80 to 3.87. Participants reported a median of 0.0 falls (IQR = 0.0-2.75) in the previous 3 months. There was a significant correlation between PPA score and gait initiation times only in the cognitive distraction condition (ρ=0.50). There was also a correlation between cognitive distraction gait initiation times and fall history (ρ=0.60).
The observations provide preliminary evidence that gait initiation during cognitive challenge may represent a target for fall prevention strategies in MS.
Time-to-Contact Analysis of Gait Stability in the Swing Phase of Walking in People With Multiple Sclerosis.
Remelius JG, van Emmerik RE. Motor Control. 2015 Feb 12.
This study investigated timing and coordination during the swing phase of swing leg, body center of mass (CoM) and head during walking in n=19 people with multiple sclerosis (MS; n=19) and controls (n=19). The MS group showed differences in swing phase timing at all speeds. At imposed but not preferred speeds, the MS group had less time to prepare for entry into the unstable equilibrium, as the CoM entered this phase of swing earlier. Time-to-contact coupling, quantifying the coordination between the CoM and the swing foot, was not different between groups. The projection of head motion on the ground occurred earlier after toe-off and was positioned closer to the body in the MS group, illustrating increased reliance on visual exproprioception in which vision of the body in relation to the surface of support is established. Finally, prospective control, linking head movements to the swing foot time-to-contact and next step landing area, was impaired in the MS group at higher gait speeds.
Quantitative sensory and motor measures detect change over time and correlate with walking speed in individuals with multiple sclerosis.
Zackowski KM, Wang JI, McGready J, Calabresi PA, Newsome SD Mult Scler Relat Disord. 2015 Jan;4(1):67-74.
Impairments of sensation, strength, and walking are common in multiple sclerosis(MS). The relationship among these abnormalities and how they change over time remains unclear.
To determine the extent that quantitative lower extremity sensory and motor measures detect abnormalities over time, relate to global disability, and to walking speed in individuals with MS.
This prospective, longitudinal analysis evaluated 136 MS subjects. Measures included measures of leg strength, sensation, the Expanded Disability Status Scale(EDSS) and timed 25-foot walk test(T25FW). Mixed effects regression models were used.
Our cohort's mean age is 44.3±10.8 years (mean±SD), EDSS score range 0-7.5, 66% were females, and follow-up time was 2.1±1.2 years. Strength significantly changed over time; the RRMS group demonstrated the greatest changes in ADF (3.3 lbs/yr) while the PPMS group showed significant HF changes (-2.1 lbs/yr). Walking speed was affected most by HF, especially in the weakest individuals (HF<20lbs); T25FW increased by 0.20 seconds(s) for each 1lb loss (p=0.001). Likewise T25FW changed by 0.19s for each 1lb change in ADF (p<0.01).
Quantitative measures detected changes in sensation and strength over time, despite a stable respective functional systems scores of the EDSS. Quantitative measurement tools may improve the sensitivity of disability measures in MS and further investigation of these tools as outcomes in future clinical trials of rehabilitative and neuroreparative interventions is warranted.
Reliability of gait in multiple sclerosis over 6 months
Jacob J. Sosnoff, Rachel Klaren, Lara A. Pilutti, Deirdre Dlugonski, Robert W. Motl Gait and Posture; Article in Press
•Reliability of gait over 6 months in the absence of an intervention was determined.
•Gait parameters of persons with MS had excellent reliability over 6 months.
•Experimentally determined reliability estimates will inform sample size estimates.
Gait impairment is ubiquitous in multiple sclerosis (MS) and is often characterized by alterations in spatiotemporal parameters of gait. There is limited information concerning reliability of spatiotemporal gait parameters over clinical timescales (e.g. 6 months). The current report provides novel evidence that gait parameters of 74 ambulatory persons with MS with mild-to-moderate disability are reliable over 6-months (ICC's range from 0.41-.92) in the absence of any intervention above and beyond standard care. Such data can inform clinical decision-making and power analyses for designing RCTs (i.e., sample size estimates) involving persons with MS.
Exercise as a therapy for improvement of walking ability in adults with multiple sclerosis: A meta-analysis.
Pearson M, Dieberg G, Smart N Arch Phys Med Rehabil. 2015 Feb 21
To quantify improvements in walking performance commonly observed in patients with Multiple Sclerosis (pwMS). A systematic literature search and meta-analysis was conducted quantifying the expected benefits of exercise on walking ability in pwMS.
Potential studies were identified by systematic search using PubMed (1966 to 31st March, 2014), EMBASE (1974 to 31st March, 2014), CINAHL (1998 to 31st March, 2014), SPORTSDiscus (1991-31st March, 2014) and the Cochrane Central Register of Controlled Trials (1966 to 31st March, 2014). The search used key concepts of "Multiple Sclerosis" AND "exercise".
Randomised controlled trials of exercise training in adult patients with MS.
Data on patient and study characteristics; walking ability; 10metre walk test (10mWT); Timed 25-foot walk test (T25FW); 2 minute walk test (2MWT); 6 minute walk test (6MWT); Timed up and go (TUG) were extracted and archived.
Data from 13 studies were included. Exercise produced significant improvements in walking speed, measured by 10mWT, mean difference (MD) reduction in walking time of -1.76 seconds (95%CI -2.47 to -1.06, p<0.001), but no change in the T25FW MD = -0.59s (95%CI -2.55 to 1.36, p=0.55). Exercise produced significant improvements in walking endurance as measured by 6MWT and 2MWT, with increased walking distance of MD=36.46 metres (95%CI 15.14 to 57.79, P<0.001) and MD=12.51 metres (95%CI 4.79 to 20.23, p=0.001), respectively. No improvement was found for TUG MD = -1.05s (95% CI -2.19 to 0.09, p=0.07).
Our meta-analysis suggests exercise improves walking speed and endurance in pwMS.
Longitudinal relationships among posturography and gait measures in multiple sclerosis.
Fritz NE et al Neurology. 2015 Apr 15.
Gait and balance dysfunction frequently occurs early in the multiple sclerosis (MS) disease course. Hence, we sought to determine the longitudinal relationships among quantitative measures of gait and balance in individuals with MS.
Fifty-seven ambulatory individuals with MS (28 relapsing-remitting, 29 progressive) were evaluated using posturography, quantitative sensorimotor and gait measures, and overall MS disability with the Expanded Disability Status Scale at each session.
Our cohort's age was 45.8 ± 10.4 years (mean ± SD), follow-up time 32.8 ± 15.4 months, median Expanded Disability Status Scale score 3.5, and 56% were women. Poorer performance on balance measures was related to slower walking velocity. Two posturography measures, the anterior-posterior sway and sway during static eyes open, feet apart conditions, were significant contributors to walk velocity over time (approximate R2 = 0.95), such that poorer performance on the posturography measures was related to slower walking velocity. Similarly, the anterior-posterior sway and sway during static eyes closed, feet together conditions were also significant contributors to the Timed 25-Foot Walk performance over time (approximate R2 = 0.83).
This longitudinal cohort study establishes a strong relationship between clinical gait measures and posturography. The data show that increases in static posturography and reductions in dynamic posturography are associated with a decline in walk velocity and Timed 25-Foot Walk performance over time. Furthermore, longitudinal balance measures predict future walking performance. Quantitative walking and balance measures are important additions to clinical testing to explore longitudinal change and understand fall risk in this progressive disease population.
Dalfampridine extended release 10mg tablets (D-ER) have demonstrated improvement in walking for ambulatory persons with multiple sclerosis (pwMS), termed "responders."
This study examined the extent additional aspects of gait and dexterity change for patients prescribed D-ER.
Over 14-weeks, walking endurance, dynamic gait, self-report walking ability andfine and gross dexterity were examined in pwMS prescribed D-ER as a part of routine clinical care.
The final results (n=39) validate that a subset of pwMS improve walking speed (Time 25-Foot Walk Test, p<0.0001). Significant improvements in gait and dexterity were observed even among participants who did not improve walking speed. Improvements were evident in gait and dexterity domains including Six Minute Walk Test, p=0.007, Six-Spot Step Test, p<0.0001, Multiple Sclerosis Walking Scale-12, p<0.0001, Nine Hole Peg Test, p<0.0001 dominant and non-dominant sides, and Box and Blocks Test, p=0.005 and 0.002, dominant and non-dominant sides, respectively.
These findings suggest that D-ER may be a potential treatment for gait impairments, beyond walking speed and dexterity in pwMS. Further investigation regarding D-ER response is warranted.
•Gait termination in individuals with MS and healthy controls was assessed.
•Normal and cognitively distracting conditions were used.
•Cognitive distracting conditions had highest failure rates in both groups.
•The MS group was more unstable compared to controls during gait termination.
Despite the ubiquitous nature of gait impairment in multiple sclerosis (MS), there is limited information concerning the control of gait termination in individuals with MS. The purpose of this investigation was to examine planned gait termination in individuals with MS and healthy controls with and without cognitive distractors. Individuals with MS and age matched controls completed a series of gait termination tasks over a pressure sensitive walkway under non-distracting and cognitively distracting conditions. As expected the MS group had a lower velocity (89.9 ± 33.3 cm/s) than controls (142.8 ± 22.4 cm/s) and there was a significant reduction in velocity in both groups under the cognitive distracting conditions (MS: 73.9 ± 30.7 cm/s; control: 120.0 ± 25.9 cm/s). Although individuals with MS walked slower, there was no difference between groups in the rate a participant failed to stop at the target (i.e. failure rate). Overall failure rate had a 10-fold increase in the cognitively distracting condition across groups. Individuals with MS were more unstable during termination. Future research examining the neuromuscular mechanisms contributing to gait termination is warranted.
•Gait termination in individuals with MS and healthy controls was assessed.
•Normal and cognitively distracting conditions were used.
•Cognitive distracting conditions had highest failure rates in both groups.
•The MS group was more unstable compared to controls during gait termination.
Despite the ubiquitous nature of gait impairment in multiple sclerosis (MS), there is limited information concerning the control of gait termination in individuals with MS. The purpose of this investigation was to examine planned gait termination in individuals with MS and healthy controls with and without cognitive distractors. Individuals with MS and age matched controls completed a series of gait termination tasks over a pressure sensitive walkway under non-distracting and cognitively distracting conditions. As expected the MS group had a lower velocity (89.9 ± 33.3 cm/s) than controls (142.8 ± 22.4 cm/s) and there was a significant reduction in velocity in both groups under the cognitive distracting conditions (MS: 73.9 ± 30.7 cm/s; control: 120.0 ± 25.9 cm/s). Although individuals with MS walked slower, there was no difference between groups in the rate a participant failed to stop at the target (i.e. failure rate). Overall failure rate had a 10-fold increase in the cognitively distracting condition across groups. Individuals with MS were more unstable during termination. Future research examining the neuromuscular mechanisms contributing to gait termination is warranted
?Symptomatic fatigue in PwMS is related to self-reported walking capabilities.
?Definite gait parameters are not closely related to symptomatic fatigue in MS.
?MSWS-12 score was found to explain 35.0% of the variance related to fatigue.
There is a general consensus relating to the multidimensional aspects of fatigue in people with multiple sclerosis (PwMS), however, the exact impact of this symptom on gait is not fully understood. Our primary aim was to examine the relationship between definite parameters of gait with self-reported symptomatic fatigue in PwMS according to their level of neurological impairment. Spatio-temporal parameters of gait were studied using an electronic walkway. The Multiple Sclerosis Walking Scale (MSWS-12) questionnaire, a patient-rated measure of walking ability was collected. The Modified Fatigue Impact Scale (MFIS) questionnaire was used to determine the level of symptomatic fatigue. One hundred and one PwMS (61 women) were included in the study analysis. Subjects were divided into mild and moderate neurological impaired groups. Fatigue was correlated with 5 (out of 14) spatiotemporal parameters. However, correlation scores were all <0.35, thus considered as weak correlations. In the mild group, the double support period was the only variable positively correlated to fatigue (Spearman's rho = 0.28, P = 0.05). In the moderate group, step and stride length were solely negatively correlated to fatigue (Spearman's rho = 0.32, P = 0.03). In contrast to the definite gait parameters, the MSWS-12 self-questionnaire was moderately positively correlated to the level of fatigue. Scores for the total, mild and moderate groups were 0.54, 0.57 and 0.51; P < 0.01, respectively. The present results indicate that modifications in spatio-temporal parameters of gait are not closely related to symptomatic fatigue in PwMS. On the contrary, the self-reported MSWS-12 questionnaire is predisposed to level of fatigue in PwMS.
Prolonged-release fampridine in multiple sclerosis: Improved ambulation effected by changes in walking pattern.
Z?rner B et al Mult Scler. 2016 Jan 13
Prolonged-release fampridine (PR-fampridine, 4-aminopyridine) increases walking speed in the timed 25-foot walk test (T25FW) in some patients (timed-walk responders) with multiple sclerosis (MS).
To explore the effects of PR-fampridine on different aspects of walking function and to identify associated gait modifications in subjects with MS.
In this prospective, randomized, placebo-controlled, double-blind, phase II study (FAMPKIN; clinicaltrials.gov, NCT01576354), subjects received a 6-week course of oral placebo or PR-fampridine treatment (10 mg, twice daily) before crossing over. Using 3D-motion-analysis, kinematic and kinetic parameters were assessed during treadmill walking (primary endpoint). Clinical outcome measures included T25FW, 6-minute walk test (6MWT), and balance scales. Physical activity in everyday life was measured with an accelerometer device.
Data from 55 patients were suitable for analysis. Seventeen subjects were timed-walk responders under PR-fampridine. For the total study population and for responders, a significant increase in walking speed (T25FW) and distance (6MWT) was observed. Gait pattern changes were found at the single-subject level and correlated with improvements in the T25FW and 6MWT. Physical activity was increased in responders.
PR-fampridine improves walking speed, endurance, and everyday physical activity in a subset of subjects with MS and leads to individual modifications of the gait pattern.
A guide to treating gait impairment with prolonged-release fampridine (Fampyra?) in patients with multiple sclerosis.
[Article in English, Spanish]
Rami?-Torrent? L et a Neurologia. 2016 Feb 9.
Gait impairment, a frequent sign in multiple sclerosis (MS), places a major burden on patients since it results in progressive loss of personal and social autonomy, along with work productivity. This guide aims to provide recommendations on how to evaluate gait impairment and use prolonged-release fampridine (PR-fampridine) as treatment for MS patients with gait impairment in Spain.
PR-fampridine dosed at 10mg every 12hours is currently the only drug approved to treat gait impairment in adults with MS. Additionally, PR-fampridine has been shown in clinical practice to significantly improve quality of life (QoL) in patients who respond to treatment. Treatment response can be assessed with the Timed 25-Foot Walk (T25FW) or the 12-item MS Walking Scale (MSWS-12); tests should be completed before and after starting treatment. The minimum time recommended for evaluating treatment response is 2 weeks after treatment onset. Patients are considered responders and permitted to continue the treatment when they demonstrate a decrease in their T25FW time or an increase in MSWS-12 scores. A re-evaluation is recommended at least every 6 months. The SF-36 (Short Form-36) and the MSIS-29 (MS Impact Scale-29) tests are recommended for clinicians interested in performing a detailed QoL assessment. This drug is generally well-tolerated and has a good safety profile. It should be taken on an empty stomach and renal function must be monitored regularly.
These recommendations will help ensure safer and more efficient prescription practices and easier management of PR-fampridine as treatment for gait impairment in Spanish adults with MS.
Correlates of the timed 25 foot walk in a multiple sclerosis outpatient rehabilitation clinic.
Bethoux FA, Palfy DM, Plow MA. Int J Rehabil Res. 2016 Feb 29
The Timed 25 Foot Walk (T25FW), a test of maximum walking speed on a short distance, is commonly used to monitor ambulation status and to assess treatment outcomes in multiple sclerosis (MS). The main aim of this study was to determine how walking speed on the T25FW correlates with other clinician-reported and patient-reported measures in an outpatient MS rehabilitation clinic. We analyzed cross-sectional data systematically collected during a physiatry evaluation for the management of spasticity and walking limitations. In addition to demographic variables and the Expanded Disability Status Scale (EDSS), measures of body functions [lower extremity manual muscle testing (LE MMT), lower extremity Modified Ashworth Scale, Fatigue Severity Scale, leg pain], and measures of activity and quality of life (reported frequency of falls, Incapacity Status Scale, Rivermead Mobility Index, EQ5D health questionnaire, and Patient Health Questionnaire-9 items) were administered. A multivariate regression analysis was carried out. 199 patients were included in the analysis [age 49.41 (9.89) years, disease duration 15.40 (10.22) years, EDSS score 5.6 (1.2), and T25FW speed 70.93 (44.13) cm/s]. Both EDSS and LE MMT were correlated significantly with T25FW speed (R=0.692, P<0.001). After adjusting for EDSS and LE MMT, lower T25FW speed was associated with higher Incapacity Status Scale scores (R=0.316, P<0.001), lower Rivermead Mobility Index scores (R=0.540, P<0.001), and higher frequency of falls. EQ5D and Patient Health Questionnaire-9 items were not significantly associated with T25FW speed. Our findings support the clinical relevance of the T25FW in the rehabilitation of patients with MS.
Purpose: To assess the orthotic and therapeutic effects of prolonged use of functional electrical stimulation (FES) on fatigue induced gait patterns in people with Multiple Sclerosis (MS). Method: Thirteen people with MS completed 3D gait analysis with FES off and on, before and after a fatiguing 6-minute walk, at baseline and after 8 weeks of use of FES. Results: Eleven participants completed all testing. An orthotic effect on gait was not evident on first use of FES. However, therapeutic effects on gait after 8 weeks use were generally positive, including increases in walking speed due to improved neuromuscular control and power generated at the hip and ankle of the more affected limb. The action of FES alone was not sufficient to overcome all fatigue related deficits in gait but there was evidence 8 weeks use of FES can ameliorate some fatigue effects on lower limb kinetics, including benefits to ankle mechanics involved in generating power around push-off during stance. Conclusions: Eight-weeks of FES can benefit the gait pattern of people with MS under non-fatigued and fatigued conditions.
Implications for rehabilitation
In some people with MS prolonged use of FES may be necessary before observing positive orthotic effects.
Improvements in the neuromuscular control of the more affected lower limb may develop with prolonged use of FES in people with MS.
Only some therapeutic benefits of FES are maintained during fatigued walking in people with MS.
FES may be considered as a gait retraining device as well as an orthotic intervention for people with MS.
?The Disease Step Rating Scale is a useful tool for categorising the mobility of people with MS
?Clinical gait and balance measures were statistically different across many Disease Steps and met most previously reported MDC and all MIC levels.
?The 6MWT better differentiated performance in those with mild disability.
?The 10MWT and 25FWT demonstrated greater differences between individuals with moderate to severe disability.
?The BBS more consistently discriminated across the disease spectrum, showing differences between every two Disease Steps.
To explore differences in gait endurance, speed and standing balance in people with Multiple Sclerosis (MS) across the Disease Step Rating Scale (DSRS), and to determine if differences are statistically significant and clinically meaningful.
Observational Study. Setting/Participants: 222 community dwelling people with MS (Mean age 48 ? 12 years; 32% male)
Not applicable: Main Outcome Measures: Participants were categorised using the DSRS. Demographics and clinical measures of gait endurance (6 minute walk test - 6MWT), gait speed (10 meter walk test - 10MWT; 25foot walk test - 25FWT) and balance (Berg Balance Scale - BBS) were recorded in one session. Differences in these parameters across categories of the DSRS were explored and clinically meaningful differences identified.
The 6MWT showed a greater number of significant differences across adjacent Disease Steps in those with less disability (p < 0.001), while the 10MWT and 25FWT demonstrated more significant changes in those with greater disability (p < 0.001). The BBS demonstrated significant differences across the span of the DSRS categories (p < 0.001). Differences in gait and balance between adjacent DSRS categories met most previously established levels of minimally detectable change and all minimally important change scores.
Out findings support the DSRS is an observational tool that can be used by health professionals to categorise people with MS, with the categories reflective of statistically significant and clinically meaningful differences in gait and balance performance.