Deborah Severijns

Time course of trunk, arm, leg, and functional recovery after ischemic stroke

Background. Patterns of recovery provide useful information concerning the potential of physical recovery over time and therefore the setting of realistic goals for rehabilitation programs. Objective. To compare the time course of trunk recovery with the patterns of recovery of arm, leg, and functional ability. Methods . Consecutive stroke patients were recruited in 2 acute neurology wards. Participants were evaluated at 1 week, 1 month, and 3 and 6 months after stroke. Patients were assessed with the Trunk Impairment Scale, Fugl-Meyer arm and leg test, and Barthel Index. Results. Thirty-two patients were included in the study. There were no dropouts. Repeated measures analysis of the recovery patterns of motor and functional performance revealed the most striking improvement for all measures from 1 week to 1 month (P value between .0021 and <.0001) and a significant improvement from 1 month to 3 months after stroke (P value ranges from .0008 to <.0001). No significant improvement was found between 3 and 6 months after stroke for any of the measures. Statistical analysis revealed no significant difference between time course of trunk, arm, leg, and functional recovery (P = .2565). No significant differences in level of motor and functional recovery were found at the different time points. Conclusions. Separate analyses of motor and functional recovery patterns after stroke confirm the importance of the first month for recovery. Contrary to common belief, the time course of recovery of the trunk is similar to the recovery of arm, leg, and functional ability.

Upper Limb Rehabilitation in People With Multiple Sclerosis A Systematic Review

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.

Hand grip fatigability in persons with multiple sclerosis according to hand dominance and disease progression.

BACKGROUND Hand grip strength in both the dominant and non-dominant hands is often used to assess upper limb impairment. Excessive hand grip fatigability is another important measure, as fatigability may also influence activities of daily living. OBJECTIVE To investigate to what extent hand grip fatigability in multiple sclerosis is dependent on hand dominance, muscle strength and disease progression. METHODS Thirty persons with multiple sclerosis and 16 healthy controls performed 15 repeated maximal hand grip contractions and a 30 s sustained contraction in order to determine dynamic and static fatigue indices. Fatigability was compared between the dominant and non-dominant hands and between the more and less affected hands in a subgroup of persons with multiple sclerosis with asymmetrical hand grip strength impairment. Furthermore, fatigability was compared between controls and subgroups of persons with multiple sclerosis with different disease progression. RESULTS There was no difference in fatigability between dominant and non-dominant hands in healthy controls or in persons with multiple sclerosis. Similarly, there was no difference between the more and less affected hands in the subgroup of persons with multiple sclerosis with asymmetrical hand grip impairment. The dynamic fatigue index did not discriminate persons with multiple sclerosis from controls. While the static fatigue index was not different between healthy controls and persons with multiple sclerosis with low to moderate (< 6) Expanded Disability Status Scale (EDSS), it was significantly higher in persons with multiple sclerosis with high (≥ 6) EDSS scores. The static fatigue index was related to the EDSS score, but not to maximal grip strength. CONCLUSION Fatigability of hand grip strength in persons with multiple sclerosis is not influenced by hand dominance or muscle strength, but there is a correlation with disease progression. Differences in fatigability between healthy controls and, in particular, persons with multiple sclerosis with high EDSS, were found during sustained, but not during dynamic, contractions.

Prevalence of Walking-Related Motor Fatigue in Persons With Multiple Sclerosis Decline in Walking Distance Induced by the 6-Minute Walk Test

Objective. To investigate the individual occurrence of walking-related motor fatigue in persons with multiple sclerosis (PwMS), according to disability level and disease phenotype. Study design. This was a cross-sectional, multinational study. Participants. They were 208 PwMS from 11 centers with Expanded Disability Status Scale (EDSS) scores up to 6.5. Methods. The percentage change in distance walked (distance walked index, DWI) was calculated between minute 6 and 1 (DWI6-1) of the 6-Minute Walk Test (6MWT). Its magnitude was used to classify participants into 4 subgroups: (1) DWI6-1[≥5%], (2) DWI6-1[5%; –5%], (3) DWI6-1[–5%; > –15%], and (4) DWI6-1[≤−15%]. The latter group was labeled as having walking-related motor fatigue. PwMS were stratified into 5 subgroups based on the EDSS (0-2.5, 3-4, 4.5-5.5, 6, 6.5) and 3 subgroups based on MS phenotype (relapsing remitting [RR], primary progressive [PP], and secondary progressive [SP]). Results. The DWI6-1 was ≥5% in 16 PwMS (7.7%), between 5% and −5% in 70 PwMS (33.6%), between −5% and −15% in 58 PwMS (24%), and ≤−15% in 64 PwMS (30.8%). The prevalence of walking-related motor fatigue (DWI6-1[≤−15%]) was significantly higher among the progressive phenotype (PP = 50% and SP = 39%; RR = 15.6%) and PwMS with higher disability level (EDSS 4.5-5.5 = 48.3%, 6 = 46.3% and 6.5 = 51.5%, compared with EDSS 0-2.5 = 7.8% and 3-4 = 16.7%; P < .05). Stepwise multiple regression analysis indicated that EDSS, but not MS phenotype, explained a significant part of the variance in DWI6-1 (R2 = 0.086; P < .001). Conclusion. More than one-third of PwMS showed walking-related motor fatigue during the 6MWT, with its prevalence greatest in more disabled persons (up to 51%) and in those with progressive MS phenotype (up to 50%). Identification of walking-related motor fatigue may lead to better-tailored interventions.

Self-reported use of the upper limbs related to clinical tests in persons with multiple sclerosis

Abstract Purpose: This study investigated the relationship between self-reported use of the upper limbs and clinical tests in persons with multiple sclerosis (pwMS). Methods: This cross-sectional study involved 25 pwMS with upper limb dysfunction. The Motor Activity Log (MAL) was bilaterally applied to investigate the self-reported use of both upper limbs. Clinical tests on function level were the Motricity Index (MI) and the Brunnström–Fugl–Meyer (BFM). On activity level, the Action Research Arm test (ARAt) was conducted. To identify the relationship between the self-reported use and the clinical tests, Spearman correlation coefficients were calculated. Subgroups of dominant and non-dominant arms were differentiated, and compared with the Wilcoxon Signed rank test. Results: The highest correlations were found between the MAL and function level tests: MI (r = 0.83, p < 0.01) and BFM (r = 0.75, p < 0.01). A lower correlation was found between the MAL and the ARAt (r = 0.49, p < 0.01). For all outcome measures, the absolute scores were higher for the dominant hand. Higher correlations were found for the non-dominant compared to the dominant hand. Conclusion: The self-reported use of the upper limbs was highly associated with measures on function level. The association with activity level was, however, less pronounced. Magnitudes of relationships were influenced by hand dominance. Implications for Rehabilitation Self-reported use of the upper limbs in persons with MS, measured by the MAL, is highly associated with muscle strength and movement control. The ARAt (activity level of the ICF) is less associated with self-reported use compared to outcome measures at function level. The ARAt seems to be less sensitive to mild arm dysfunction. This study indicates that it is feasible and clinically relevant to apply the MAL as a self-reported outcome measure of upper limb use in MS.

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.

Investigation of Fatigability during Repetitive Robot-Mediated Arm Training in People with Multiple Sclerosis.

Background People with multiple sclerosis (MS) are encouraged to engage in exercise programs but an increased experience of fatigue may impede sustained participation in training sessions. A high number of movements is, however, needed for obtaining optimal improvements after rehabilitation. Methods This cross-sectional study investigated whether people with MS show abnormal fatigability during a robot-mediated upper limb movement trial. Sixteen people with MS and sixteen healthy controls performed five times three minutes of repetitive shoulder anteflexion movements. Movement performance, maximal strength, subjective upper limb fatigue and surface electromyography (median frequency and root mean square of the amplitude of the electromyography (EMG) signal of the anterior deltoid) were recorded during or in-between these exercises. After fifteen minutes of rest, one extra movement bout was performed to investigate how rest influences performance. Results A fifteen minutes upper limb movement protocol increased the perceived upper limb fatigue and induced muscle fatigue, given a decline in maximal anteflexion strength and changes of both the amplitude and the median frequency of EMG the anterior deltoid. In contrast, performance during the 3 minutes of anteflexion movements did not decline. There was no relation between changes in subjective fatigue and the changes in the amplitude and the median frequency of the anterior deltoid muscle, however, there was a correlation between the changes in subjective fatigue and changes in strength in people with MS. People with MS with upper limb weakness report more fatigue due to the repetitive movements, than people with MS with normal upper limb strength, who are comparable to healthy controls. The weak group could, however, keep up performance during the 15 minutes of repetitive movements. Discussion and Conclusion Albeit a protocol of repetitive shoulder anteflexion movements did not elicit a performance decline, fatigue feelings clearly increased in both healthy controls and people with MS, with the largest increase in people with MS with upper limb weakness. Objective fatigability was present in both groups with a decline in the muscle strength and increase of muscle fatigue, shown by changes in the EMG parameters. However, although weak people with multiple sclerosis experienced more fatigue, the objective signs of fatigability were less obvious in weak people with MS, perhaps because this subgroup has central limiting factors, which influence performance from the start of the movements.

Spatio-temporal gait parameters change differently according to speed instructions and walking history in MS patients with different ambulatory dysfunction

BACKGROUND Different walking capacity test formats are applied, but their impact on the gait pattern in persons with MS (pwMS) has not yet been investigated according to baseline velocity performance. OBJECTIVE To assess, in pwMS with different ambulation dysfunction, the impact of speed instructions and previous walking tests (2 and 6min walking test; 2MWT and 6MWT) on spatiotemporal gait parameters. METHODS 27 participants, divided in three groups based on usual gait speed (Most Limited Community Walkers; MLCW<0.82m/s, CW>1.14m/s, LCW show intermediate values), completed the 2MWT and 6MWT. Before and after each test, they walked on the GAITRite walkway system at both usual and fastest speed. Spatio-temporal gait parameters were measured and analyzed with ANOVA. RESULTS All gait parameters in the MLCW were significantly different from other groups. In contrast to the MLCW, the LCW and CW subgroups showed greater velocity in the fastest compared to usual speed condition, associated with a significant increase in cadence and step length. After the 6MWT, small changes in cadence at usual speed and step time at fastest speed were observed in the MLCW subgroup only. No impact of the 2MWT on gait parameters was found in any group. CONCLUSIONS The ability to accelerate was dependent on the severity of ambulatory dysfunction. Prolonged walking during the 6MWT has, in contrast to the 2MWT, some impact on gait parameters in the most disabled group only.

Motor fatigability after low-intensity hand grip exercises in persons with multiple sclerosis

INTRODUCTION During maximal, sustained contractions, persons with multiple sclerosis (PwMS) show higher motor fatigability in comparison with healthy persons. It is not known if motor fatigability is also different between PwMS and healthy persons during low-intensity exercises. Thus, the aim of this study was to determine the difference in hand grip fatigability between healthy persons and PwMS for both hands during low-intensity hand grip exercises. METHODS 19 PwMS and 19 healthy controls performed 18min of hand grip exercises at a maximum of 25% of the maximal voluntary strength, with an electronic hand dynamometer. Perceived fatigability, maximal hand grip strength and muscle activity (electromyography) of the wrist flexors and extensors were recorded in between these exercises for the dominant and non-dominant hand. RESULTS AND DISCUSSION There was a significant decrease in maximal hand grip strength after exercising in both groups and for both hands, mainly situated in the first 6min. In contrast to what was hypothesized, PwMS did not show more decline in strength than healthy controls, neither in the dominant nor the non-dominant hand. There was no group difference in the increase of the perceived fatigability in the dominant hand. However, for the non-dominant hand, the perceived fatigability after exercising increased more in PwMS than in healthy controls. Additionally, there was no relation between fatigue indices, as assessed with short maximal contractions and the strength decline after low-intensity repetitive exercises.

Is the impact of fatigue related to walking capacity and perceived ability in persons with multiple sclerosis? A multicenter study

BACKGROUND The relationship between fatigue impact and walking capacity and perceived ability in patients with multiple sclerosis (MS) is inconclusive in the existing literature. A better understanding might guide new treatment avenues for fatigue and/or walking capacity in patients with MS. OBJECTIVE To investigate the relationship between the subjective impact of fatigue and objective walking capacity as well as subjective walking ability in MS patients. METHODS A cross-sectional multicenter study design was applied. Ambulatory MS patients (n = 189, age: 47.6 ± 10.5 years; gender: 115/74 women/men; Expanded Disability Status Scale (EDSS): 4.1 ± 1.8 [range: 0-6.5]) were tested at 11 sites. Objective tests of walking capacity included short walking tests (Timed 25-Foot Walk (T25FW), 10-Metre Walk Test (10mWT) at usual and fastest speed and the timed up and go (TUG)), and long walking tests (2- and 6-Minute Walk Tests (MWT). Subjective walking ability was tested applying the Multiple Sclerosis Walking Scale-12 (MSWS-12). Fatigue impact was measured by the self-reported modified fatigue impact scale (MFIS) consisting of a total score (MFIStotal) and three subscales (MFISphysical, MFIScognitive and MFISpsychosocial). Uni- and multivariate regression analysis were performed to evaluate the relation between walking and fatigue impact. RESULTS MFIStotal was negatively related with long (6MWT, r = -0.14, p = 0.05) and short composite (TUG, r = -0.22, p = 0.003) walking measures. MFISphysical showed a significant albeit weak relationship to walking speed in all walking capacity tests (r = -0.22 to -0.33, p < .0001), which persisted in the multivariate linear regression analysis. Subjective walking ability (MSWS-12) was related to MFIStotal (r = 0.49, p < 0.0001), as well as to all other subscales of MFIS (r = 0.24-0.63, p < 0.001), showing stronger relationships than objective measures of walking. CONCLUSIONS The physical impact of fatigue is weakly related to objective walking capacity, while general, physical, cognitive and psychosocial fatigue impact are weakly to moderately related to subjective walking ability, when analysed in a large heterogeneous sample of MS patients.