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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.