Brian M. Sandroff

Mobility, Balance and Falls in Persons with Multiple Sclerosis

Background There is a lack of information concerning the relation between objective measures of gait and balance and fall history in persons with MS (PwMS). This investigation assessed the relation between demographic, clinical, mobility and balance metrics and falls history in persons with multiple sclerosis (MS). Methods 52 ambulatory persons with MS (PwMS) participated in the investigation. All persons provided demographic information including fall history over the last 12 months. Disease status was assessed with Expanded Disability Status Scale (EDSS). Walking speed, coordination, endurance and postural control were quantified with a multidimensional mobility battery. Results Over 51% of the participants fell in the previous year with 79% of these people being suffering recurrent falls. Overall, fallers were older, had a greater prevalence of assistive devices use, worse disability, decreased walking endurance, and greater postural sway velocity with eyes closed compared to non-fallers. Additionally, fallers had greater impairment in cerebellar, sensory, pyramidal, and bladder/bowel subscales of the EDSS. Conclusions The current observations suggest that PwMS who are older, more disabled, utilize an assistive device, have decreased walking coordination and endurance and have diminished balance have fallen in the previous year. This suggests that individuals who meet these criteria need to be carefully monitored for future falls. Future research is needed to determine a prospective model of falls specific to PwMS. Additionally, the utility of interventions aimed at reducing falls and fall risk in PwMS needs to be established.

Quantifying gait abnormalities in persons with multiple sclerosis with minimal disability

Abnormalities in gait kinematics in persons with multiple sclerosis (PwMS) who have mild disability have been noted using motion capture systems. However, it is not clear if these abnormalities can be detected with clinically feasible technology. This investigation examined if the spatiotemporal markers of gait including variability metrics can distinguish between PwMS with minimal disability and controls with clinically feasible technology. 43 PwMS with minimal disability and 43 healthy controls completed four walking trials along a 26 foot long pressure sensitive pathway (GAITRite). Spatiotemporal markers of gait including variability metrics were determined. Statistical analysis revealed that PwMS walked slower, with fewer, shorter, wider steps and spent a greater percentage of a gait cycle in double support than controls. Additionally, PwMS had greater variability in the time between steps, single support percent and step width than controls. Collectively, the results highlight that PwMS, in the absence of clinical gait impairment, have subtle but detectable differences in gait and that these alterations can be detected with clinically feasible technology. The current results raise the possibility of targeting walking deviations earlier in disability progression in PwMS.

Physical activity and multiple sclerosis: new insights regarding inactivity.

There is increasing recognition that physical activity has beneficial consequences among persons with multiple sclerosis (MS), but there is concern regarding the current degree of physical inactivity in this population because of limitations with previous research and increased recognition of health behaviors in MS. This study compared physical activity levels between large samples of persons with mild MS and matched controls using validated measures of physical activity.

Randomized controlled trial of a behavioral intervention targeting symptoms and physical activity in multiple sclerosis

Background: Exercise training is beneficial, but most persons with multiple sclerosis (MS) are sedentary and physically inactive. This has prompted a new focus on the promotion of lifestyle physical activity in MS. We previously designed, tested, and refined a behavioral intervention delivered through the Internet that successfully increased lifestyle physical activity in MS, but have not evaluated the effects on secondary symptomatic and health-related quality of life (HRQOL) outcomes. Objective: We conducted a 6-month randomized controlled trial (RCT) that examined the efficacy of an Internet-delivered, behavioral intervention for improving outcomes of fatigue, depression, anxiety, pain, sleep quality, and HRQOL in 82 ambulatory persons with MS. The secondary aim was to replicate previous results regarding change in free-living physical activity. Results: There was a significant and positive effect of the intervention on fatigue severity (p=.001, ηρ2=.15) and its physical impact (p=.008, ηρ2=.09), depression (p=.006, ηρ2=.10), and anxiety (p=.006, ηρ2=.10). There were non-significant improvements in pain (p=.08, ηρ2=.04), sleep quality (p=.06, ηρ2=.05), and physical HRQOL (p=.06, ηρ2=.05). We replicated our previous results by demonstrating an increase in self-reported physical activity (p=.001, ηρ2=.13). Conclusions: Our results support behavioral interventions targeting lifestyle physical activity as an alternative approach for managing symptoms in MS.

Internet-delivered behavioral intervention to increase physical activity in persons with multiple sclerosis: Sustainability and secondary outcomes

Physical activity is associated with many benefits, but persons with multiple sclerosis (MS) are less physically active than the general population. There is a critical need for research on methods of increasing and sustaining the physical activity levels of this population. This randomized controlled trial examined the efficacy of an Internet-delivered and theory-based behavioral intervention that was supplemented with video coaching for increasing and sustaining physical activity over time in persons with MS. Physically inactive, ambulatory persons with MS (N = 45) were randomly assigned to intervention (n = 22) or control (n = 23) conditions and completed a battery of questionnaires before, after, and three months after a 12-week intervention period. Data analyses were conducted in PASW 18.0. Partial eta squared ( ) effect size indicated that there was a large, statistically significant condition-by-time interaction on physical activity ( ). Cohens d effect sizes indicated that the intervention group had a large increase in physical activity after the 12-week trial (d = .98) that was sustained over a three-month follow-up (d = .79). The current study supports the efficacy of a behavioral intervention for increasing and sustaining physical activity in a sample of persons with MS.

Psychometric properties of the Fatigue Severity Scale and the Modified Fatigue Impact Scale

OBJECTIVE Fatigue is one of the most common, debilitating and life altering symptoms experienced by those with multiple sclerosis (MS) and has become the focus of therapeutic interventions and clinical rehabilitation. There is limited evidence regarding the psychometric properties and clinical relevance of fatigue outcomes for interpreting the effectiveness of intervention and rehabilitation strategies. This study determined the reliability, precision and clinically important change of the uni-dimensional Fatigue Severity Scale (FSS) and the multi-dimensional Modified Fatigue Impact Scale (MFIS). METHODS The FSS and MFIS along with physical, psychological and cognitive clinical outcomes were administered to a sample of 82 persons with MS in a clinical research setting on two time points, separated by six months. Intraclass correlation coefficient (ICC) analyses established reliability; standard error of measurement (SEM) and coefficient of variation (CV) determined precision; minimal detectable change (MDC) defined clinically important change. RESULTS Participants varied in type of MS and disability status, with 77% of participants classified as having substantial fatigue, based on the criteria of a mean FSS score ≥4. The MFIS (ICC=0.863) and the FSS (ICC=0.751) had acceptable reliability over six months. Precision was reasonable for both scales (based on SEM and CV estimates) but better for the FSS. MDC estimates were established and were lower for the FSS. CONCLUSION Reliability of the FSS and MFIS falls within acceptable ranges, and precision and clinically important change estimates provide guidelines for interpreting change in scores from these outcomes in clinical research of intervention and rehabilitation approaches for managing fatigue.

Cognitive dysfunction and multiple sclerosis: developing a rationale for considering the efficacy of exercise training

Cognitive impairment is a prevalent, disabling, and poorly managed consequence of multiple sclerosis (MS). This underscores the importance of considering alternative approaches, such as exercise training, for managing cognitive impairment in persons with MS. The consideration of exercise training is warranted based on evidence summarized in literature reviews and meta-analyses that (1) aerobic fitness, physical activity, and exercise training are associated with better cognitive function in older adults; and (2) exercise training has comparable effects on mobility and quality of life outcomes in older adults and persons with MS. To date, research examining aerobic fitness, physical activity, and exercise training effects on cognition in MS is nascent and mostly includes cross-sectional designs that provide preliminary evidence for a well-designed randomized controlled trial (RCT). We believe that a future RCT should adopt research methodologies and practices from gerontology when examining exercise training and cognition in MS. This will maximize the potential for successfully generating a body of knowledge on exercise training and cognition with the potential for impacting the lives of persons with MS.

The reliability, precision and clinically meaningful change of walking assessments in multiple sclerosis

Background: Assessing walking impairment in those with multiple sclerosis (MS) is common, however little is known about the reliability, precision and clinically important change of walking outcomes. Objective: The purpose of this study was to determine the reliability, precision and clinically important change of the Timed 25-Foot Walk (T25FW), Six-Minute Walk (6MW), Multiple Sclerosis Walking Scale-12 (MSWS-12) and accelerometry. Methods: Data were collected from 82 persons with MS at two time points, six months apart. Analyses were undertaken for the whole sample and stratified based on disability level and usage of walking aids. Intraclass correlation coefficient (ICC) analyses established reliability: standard error of measurement (SEM) and coefficient of variation (CV) determined precision; and minimal detectable change (MDC) defined clinically important change. Results: All outcome measures were reliable with precision and MDC varying between measures in the whole sample: T25FW: ICC=0.991; SEM=1 s; CV=6.2%; MDC=2.7 s (36%), 6MW: ICC=0.959; SEM=32 m; CV=6.2%; MDC=88 m (20%), MSWS-12: ICC=0.927; SEM=8; CV=27%; MDC=22 (53%), accelerometry counts/day: ICC=0.883; SEM=28450; CV=17%; MDC=78860 (52%), accelerometry steps/day: ICC=0.907; SEM=726; CV=16%; MDC=2011 (45%). Variation in these estimates was seen based on disability level and walking aid. Conclusion: The reliability of these outcomes is good and falls within acceptable ranges. Precision and clinically important change estimates provide guidelines for interpreting these outcomes in clinical and research settings.

Physical fitness, walking performance, and gait in multiple sclerosis

BACKGROUND Walking impairment is a prevalent, life-altering feature of multiple sclerosis (MS). There has been recent speculation that physiological deconditioning (i.e., reductions in aerobic capacity, balance, and muscular strength) contributes to walking and gait impairments in MS. OBJECTIVE This study examined the associations among aerobic capacity, balance, and lower-limb strength asymmetries, walking performance, and gait kinematics in 31 persons with MS and 31 matched controls. METHODS Participants underwent standard assessments of peak aerobic capacity, muscular strength (i.e., asymmetry between knee muscles), and balance. Walking performance was measured using the timed 25-ft walk (T25FW) and six-minute walk (6MW). Gait parameters were captured using a GaitRite™ electronic walkway. RESULTS Aerobic capacity, balance, and knee-extensor asymmetry were associated with walking performance and gait in persons with MS (r=.2-.6) and explained differences in walking and gait variables between MS and control groups (∆R(2)=.27-.34). Aerobic capacity and lower-limb strength asymmetries, but not balance, explained significant variance in walking performance and gait kinematics in the MS sample (R(2)=.32-.58). CONCLUSIONS Physiological deconditioning explains variability in walking disability in persons with MS and might represent a target of multimodal exercise training interventions for improving mobility outcomes in this population.

Energy cost of walking and its association with gait parameters, daily activity, and fatigue in persons with mild multiple sclerosis.

Background. Energy cost of walking (Cw) is elevated in persons with multiple sclerosis (MS), perhaps because of gait impairment, and may impact daily activity and fatigue. Objective. The authors examined for associations between Cw, spatiotemporal gait parameters, daily activity, and perceived fatigue in persons with mild MS. Methods. Forty-four participants completed 4 trials of walking on a GAITRite mat and one 6-minute trial of walking on a treadmill at a constant, controlled speed of 54 m min−1 while expired gases were analyzed for oxygen consumption. Participants also completed the Fatigue Severity Scale (FSS) and wore a waist-mounted accelerometer for 7 days. Results. C w was significantly and inversely associated with gait speed (r = −.25) and stride length (r = −.32) and positively associated with double limb support (r = .27). C w was significantly and inversely associated with daily accelerometer activity counts (r = −.35) and positively associated with FSS scores (ρ = .31). Conclusion. The results support the development and application of rehabilitation strategies to address impaired gait parameters as an approach to improve Cw, daily activities, and fatigue.