Ilse Lamers

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

BackgroundFew research in multiple sclerosis (MS) has focused on physical rehabilitation of upper limb dysfunction, though the latter strongly influences independent performance of activities of daily living. Upper limb rehabilitation technology could hold promise for complementing traditional MS therapy. Consequently, this pilot study aimed to examine the feasibility of an 8-week mechanical-assisted training program for improving upper limb muscle strength and functional capacity in MS patients with evident paresis.MethodsA case series was applied, with provision of a training program (3×/week, 30 minutes/session), supplementary on the customary maintaining care, by employing a gravity-supporting exoskeleton apparatus (Armeo Spring). Ten high-level disability MS patients (Expanded Disability Status Scale 7.0-8.5) actively performed task-oriented movements in a virtual real-life-like learning environment with the affected upper limb. Tests were administered before and after training, and at 2-month follow-up. Muscle strength was determined through the Motricity Index and Jamar hand-held dynamometer. Functional capacity was assessed using the TEMPA, Action Research Arm Test (ARAT) and 9-Hole Peg Test (9HPT).ResultsMuscle strength did not change significantly. Significant gains were particularly found in functional capacity tests. After training completion, TEMPA scores improved (p = 0.02), while a trend towards significance was found for the 9HPT (p = 0.05). At follow-up, the TEMPA as well as ARAT showed greater improvement relative to baseline than after the 8-week intervention period (p = 0.01, p = 0.02 respectively).ConclusionsThe results of present pilot study suggest that upper limb functionality of high-level disability MS patients can be positively influenced by means of a technology-enhanced physical rehabilitation program.

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

Background: In persons with multiple sclerosis (PwMS) resistance training improves muscle strength but effects on walking capacity are inconsistent. Objective: The objective was to determine the relation between different types of upper leg muscle strength measurements and walking capacity in PwMS. Methods: An observational cross-sectional study design was applied. Upper leg muscle strength of 52 PwMS (Expanded Disability Status Scale, EDSS range 1.5–6.5) was measured using isometric (knee extensors and flexors) and isokinetic (knee extensors) dynamometry. Walking capacity was assessed using the Timed 25-Foot Walk, Timed Up and Go and Two Minute Walk Test. Subgroups with mild (EDSS 1.5–4.0, n=31) and moderate (EDSS 4.5–6.5, n=21) ambulatory dysfunction were distinguished, and results were hypothesized to differ depending on multiple sclerosis (MS)-related disability status. Correlation and regression analyses were performed on the data of the most affected leg. Results: Greatest (r: 0.2–0.7) and significant Pearson correlation coefficients were found in the moderate compared to mild MS subgroup. Within knee extensor measurements, it was found that isokinetic endurance strength related best to walking capacity. When comparing maximal isometric strength measurements, knee flexors (r: 0.5–0.7) related better to walking capacity than knee extensors (r: 0.1–0.4). Regression analyses confirmed endurance knee extensor strength (~25 %) and isometric knee flexor strength (~40%) as main predictors for walking capacity. Conclusion: Resistance training protocols may consider inclusion of exercises focusing on endurance knee extensor and isometric knee flexor strength when aiming to enhance walking capacity in persons with moderate ambulatory dysfunction.

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

Background: The real-life relevance of frequently applied clinical arm tests is not well known in multiple sclerosis (MS). Objective: This study aimed to determine the relation between real-life arm performance and clinical tests in MS. Methods: Thirty wheelchair-bound MS patients and 30 healthy controls were included. Actual and perceived real-life arm performance was measured by using accelerometry and a self-reported measure (Motor Activity Log). Clinical tests on ‘body functions & structures’ (JAMAR handgrip strength, Motricity Index (MI), Fugl Meyer (FM)) and ‘activity’ level (Nine Hole Peg Test (NHPT), Action Research Arm test) of the International Classification of Functioning were conducted. Statistical analyses were performed separately for current dominant and non-dominant arm. Results: For all outcome measures, MS patients scored with both arms significantly lower than the control group. Higher correlations between actual arm performance and clinical tests were found for the non-dominant arm (0.63–0.80). The FM (55%) was a good predictor of actual arm performance, while the MI (46%) and NHPT (55%) were good predictors of perceived arm performance. Conclusions: Real-life arm performance is decreased in wheelchair-bound MS patients and can be best predicted by measures on ‘body functions & structures’ level and fine motor control. Hand dominance influenced the magnitude of relationships.

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

BackgroundAlthough use of standardized and scientifically sound outcome measures is highly encouraged in clinical practice and research, there is still no clear recommendation on which tools should be preferred for upper extremity assessment after stroke. As the aims, objectives and methodology of the existing reviews of the upper extremity outcome measures can vary, there is a need to bring together the evidence from existing multiple reviews. The purpose of this review was to provide an overview of evidence of the psychometric properties and clinical utility of upper extremity outcome measures for use in stroke, by systematically evaluating and summarizing findings from systematic reviews.MethodsA comprehensive systematic search was performed including systematic reviews from 2004 to February 2014. A methodological quality appraisal of the reviews was performed using the AMSTAR-tool.ResultsFrom 13 included systematic reviews, 53 measures were identified of which 13 met the standardized criteria set for the psychometric properties. The strongest level of measurement quality and clinical utility was demonstrated for Fugl-Meyer Assessment, Action Research Arm Test, Box and Block Test, Chedoke Arm and Hand Activity Inventory, Wolf Motor Function Test and ABILHAND.ConclusionsThis overview of systematic reviews provides a comprehensive systematic synthesis of evidence on which outcome measures demonstrate a high level of measurement quality and clinical utility and which can be considered as most suitable for upper extremity assessment after stroke. This overview can provide a valuable resource to assist clinicians, researchers and policy makers in selection of appropriate outcome measures.

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

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

Upper Limb Assessment in Multiple Sclerosis: A Systematic Review of Outcome Measures and their Psychometric Properties

OBJECTIVE To provide an overview of applied upper limb outcome measures in multiple sclerosis (MS) according to the International Classification of Functioning, Disability and Health (ICF) levels and to review their psychometric properties in MS. DATA SOURCES PubMed and Web of Knowledge. STUDY SELECTION Articles published until June 2013 were selected when written in English, published in the last 25 years, peer reviewed, including >5 persons with MS, and including standardized clinical upper limb outcome measures. Included articles were screened based on title/abstract and full text by 2 independent reviewers. In case of doubt, feedback from a third independent reviewer was obtained. Additionally, references lists were checked for relevant articles. Of the articles, 109 met the selection criteria and were included for data extraction. DATA EXTRACTION All reported clinical upper limb outcome measures were extracted from the included studies and classified according to the ICF levels by 2 independent reviewers. In addition, available psychometric properties (reliability, validity, responsiveness) in MS were summarized and discussed. DATA SYNTHESIS A diversity of outcome measures assessing impairments on the body functions and structures level (n=33), upper limb capacity (n=11), and performance (n=8) on the activity level were extracted from 109 articles. Hand grip strength and the nine-hole peg test (NHPT) were the most frequently used outcome measures. However, multiple outcome measures are necessary to encapsulate the multidimensional character of the upper limb function. The psychometric properties were insufficiently documented for most of the outcome measures, except for the NHPT. CONCLUSIONS The results of this review may help with the selection of appropriate outcome measures and may guide future research regarding the psychometric properties in MS.

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

Background: There has been limited research on upper limb dysfunction in people with multiple sclerosis (PwMS). Objective: The objective of this paper is to study unilateral and bilateral upper limb dysfunction at different International Classification of Functioning (ICF) levels according to overall disability in PwMS. Methods: A total of 105 PwMS (16 with EDSS<4 (mild); 17 with EDSS 4–5.5 (moderate); 37 with EDSS 6–6.5 (severe); 35 with EDSS>6.5 (severe non-ambulant)) were recruited from two rehabilitation centers and assessed in a cross-sectional study. Results: The whole sample showed a diminished sensory function (median (first/third interquartile)) score of 3 (2/3) on the Monofilament Test and a reduced strength 91 (76/100) points on the Motricity Index (Body-Function level). Sensory dysfunction did not increase with higher EDSS while strength decreased from 100 (86/100) in the mild subgroups to 91 (80/100) points in the severe subgroup. All showed diminished dexterity, scoring 0.28 peg/s (0.17/0.35) on the Nine-Hole Peg Test (NHPT) (activity level). Score was better for the mild (0.38 (0.35/0.46)) peg/s compared to the severe subgroup (0.28 (0.17/0.35)). Sixty-eight percent, 44% and 75% of PwMS showed bilateral disorders in sensation, strength and dexterity, respectively. The Community Integration Questionnaire (participation level) showed a 35% reduction in home activities, even among PwMS with EDSS<4. Conclusion: This study showed uni-/bilateral upper limb abnormalities at all ICF levels increasing with the overall disability.

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

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

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.