Peter Feys

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.

Intrathecal baclofen for intractable cerebral spasticity: a prospective placebo-controlled, double-blind study.

OBJECTIVE To conduct a placebo-controlled prospective study of the effectiveness of intrathecal bolus injections and continuous administration of baclofen on functional parameters in patients with severe spasticity of cerebral origin. To compare this functional evaluation with spasticity scores in different muscle groups. METHODS In 11 patients with spasticity of cerebral origin (mainly cerebral palsy), double-blind scoring of spasticity (Ashworth scale score and visual analog score), spasms, pain, and functional abilities was performed during tests with bolus injections including a placebo control. Eight patients were considered good responders and received a subcutaneous device for intrathecal drug delivery. Six of these patients were followed up for 2 years, during which they underwent the same scoring procedures as after their bolus injections. These patients were subjected to a blinded dose reduction test. RESULTS There was a noticeable placebo effect on spasticity scores during tests with bolus injections. Eight patients demonstrated a significant beneficial effect of intrathecal bolus injections compared with this placebo effect. Functional improvements were noted in most patients. During continuous infusion, Ashworth scale scores were less favorable but still significantly lower than at baseline. Subjective evaluation (visual analog scores) remained positive, functional improvements were maintained, and patient comfort was invariably and significantly improved. CONCLUSION Intrathecal administration of baclofen is a safe and effective treatment for spasticity of cerebral origin. Functional improvement was demonstrated. The presence of a placebo effect on the spasticity scores suggests the need for double-blind screening in each patient.

Predicting habitual walking performance in multiple sclerosis: relevance of capacity and self-report measures

The objective was to establish the extent to which physical functioning capacity and self-report measures are able to predict the habitual walking performance in ambulatory persons with multiple sclerosis. Fifty persons with multiple sclerosis (Expanded Disability Status Scale, EDSS, 1.5—6.5) were tested on leg muscle strength as well as walking and balance capacity, and completed self-report indices on perceived physical functioning. Habitual walking performance, that is, the real amount of steps that is performed in the customary living environment, was registered by means of an ambulant accelerometer-based monitor during seven consecutive days. Mild (EDSS 1.5—4.0, n = 29) and moderate (EDSS 4.5—6.5, n = 21) multiple sclerosis subgroups were additionally distinguished as predictor variables and values were hypothesized to differ depending on multiple sclerosis severity and concomitant ambulatory function. Multiple regression analyses yielded a single most significant predictor for each (sub)group with other variables making no independent contribution to the variation in habitual walking performance. For the total study sample, this was the 6-Minute Walking Test (R2 = 0.458, p < 0.01). In the mild multiple sclerosis subgroup, the 6-Minute Walking Test was again most predictive, yet to a modest degree (R2 = 0. 187, p = 0.02). In the moderate multiple sclerosis subgroup, the 2-Minute Walking Test explained over half of the variance (R2 = 0.532, p < 0.01). Habitual walking performance is best reflected by longer walking capacity tests. The extent to which it can be predicted based on clinical testing is larger in a multiple sclerosis patient sample with more severe walking disability. Ambulatory monitoring, however, includes aspects of community ambulation not captured in the clinic, and must be considered as an additional outcome for evaluating interventions in multiple sclerosis.

Upper limb movement interruptions are correlated to freezing of gait in Parkinson’s disease

Freezing of gait (FOG) in patients with Parkinson’s disease (PD) is a common problem of unknown origin, which possibly reflects a general motor control deficit. We investigated the relationship between the frequency of freezing episodes during gait and during a bimanual task in control and subjects with PD with and without FOG. Group differences in spatiotemporal characteristics were also examined as well as the effects of visual cueing. Twenty patients with PD in the off‐phase of the medication cycle and five age‐matched controls performed a repetitive drawing task in an anti‐phase pattern on a digitizer tablet. The task was offered at two different speeds (comfortable and maximal) and two different amplitudes (small and large) with and without visual cueing. The results showed that freezing episodes in the upper limbs occurred in only 10.4% of patient trials and that their occurrence was correlated with FOG scores (Spearman’s rho = 0.64). Overall, few spatiotemporal differences were found between freezers, non‐freezers and controls, except for an overshooting of the target amplitude in controls. Effects of visual cueing were largely similar in all groups, except for the variability of relative phase, which decreased in non‐freezers and controls, and was unaffected in freezers. Despite the fact that general motor differences between subgroups were small, freezing episodes were manifest during a bimanual repetitive upper limb task and were correlated to FOG. Further study into upper limb movement breakdown is warranted to understand the parallel deficits that lead up to FOG.

Comparison of the 2- and 6-minute walk test in multiple sclerosis.

The 6-minute walk test (6MWT) is often used to assess walking distance in multiple sclerosis (MS), but can be both time consuming for the investigator and exhausting for people with MS (pwMS). The present report compared the 6MWT scores of 40 ambulatory pwMS with their scores on the shorter 2-minute walk test (2MWT). The 2MWT estimated the 6MWT results with a mean relative error of 5% (R2 = 0.96; p < 0.01). As the last 4-minute period of the 6MWT seems redundant, the 2MWT may be considered as a practical replacement for the 6MWT in routine clinical assessment.

Which walking capacity tests to use in multiple sclerosis? A multicentre study providing the basis for a core set

Background: Many different walking capacity test formats are being used. It is unclear whether walking speed, obtained from short tests, and walking distance, obtained from long tests, provide different clinical information. Objectives: To determine the differential effect of various short and long walk test formats on gait velocity, and the actual relationship between walking speed and walking distance in multiple sclerosis (MS) patients with diverse ambulation status. Methods: A cross-sectional multicentre study design was applied. Ambulatory MS patients (Expanded Disability Status Scale (EDSS) 0–6.5; n = 189) were tested at 11 sites. Short tests consisted of the Timed 25-Foot Walk (static start, fastest speed) and 10-Metre Walk Test (dynamic start, usual and fastest speed). Long tests consisted of the 2- and 6-Minute Walk Tests (fastest speed). Subjects were divided into mild (EDSS 0–4; n = 99) or moderate (EDSS 4.5–6.5; n = 79) disability subgroups. Results: In both subgroups, the start protocol, instructed pace and length of test led to significantly different gait velocities. Fastest walking speed and 6-Minute walking distance showed the strongest correlation (R2 = 0.78 in mild and R2 = 0.81 in moderate MS; p < 0.01). Short tests’ relative estimation errors for 6-Minute walking distance were 8–12% in mildly and 15–16% in moderately affected subjects. Based on the 2-Minute Walk Test, estimation errors significantly reduced to approximately 5% in both subgroups. Conclusions: A single short test format at fastest speed accurately describes an MS patient’s general walking capacity. For intervention studies, a long test is to be considered. We propose the Timed 25-Foot Walk and 2-Minute Walk Test as standards. Further research on responsiveness is needed.

Responsiveness and Clinically Meaningful Improvement, According to Disability Level, of Five Walking Measures After Rehabilitation in Multiple Sclerosis A European Multicenter Study

Background. Evaluation of treatment effects on walking requires appropriate and responsive outcome measures. Objectives. To determine responsiveness of 5 walking measures and provide reference values for clinically meaningful improvements, according to disability level, in persons with multiple sclerosis (pwMS). Methods. Walking tests were measured pre- and postrehabilitation in 290 pwMS from 17 European centers. Combined anchor- and distribution-based methods determined responsiveness of objective short and long walking capacity tests (Timed 25-Foot Walk [T25FW] and 2- and 6-Minute Walk Tests [2MWT and 6MWT] and of the patient-reported Multiple Sclerosis Walking Scale–12 [MSWS-12]). A global rating of change scale, from patients’ and therapists’ perspective, was used as external criteria to determine the area under the receiver operating characteristic curve (AUC), minimally important change (MIC), and smallest real change (SRC). Patients were stratified into disability subgroups (Expanded Disability Status Scale score ≤4 [n = 98], >4 [n = 186]). Results. MSWS-12, 2MWT, and 6MWT were more responsive (AUC 0.64-0.73) than T25FW (0.50-0.63), especially in moderate to severely disabled pwMS. Clinically meaningful changes (MICs) from patient and therapist perspective were −10.4 and −11.4 for MSWS-12 (P < .01), 9.6 m and 6.8 m for 2MWT (P < .05), and 21.6 m (P < .05) and 9.1 m (P = .3) for 6MWT. In subgroups, MIC was significant from patient perspective for 2MWT (10.8 m) and from therapist perspective for MSWS-12 (−10.7) in mildly disabled pwMS. In moderate to severely disabled pwMS, MIC was significant for MSWS-12 (−14.1 and −11.9). Conclusions. Long walking tests and patient-reported MSWS-12 were more appropriate than short walking tests in detecting clinically meaningful improvement after physical rehabilitation, particularly the MSWS-12 for moderate to severely disabled pwMS.

Effects of long-term resistance training and simultaneous electro-stimulation on muscle strength and functional mobility in multiple sclerosis:

Background: Resistance training studies in multiple sclerosis (MS) often use short intervention periods. Furthermore, training efficiency could be optimized by unilateral training and/or electrical stimulation. Objective: To examine the effect(s) of unilateral long-term (20 weeks) standardized resistance training with and without simultaneous electro-stimulation on leg muscle strength and overall functional mobility. Methods: A randomized controlled trial involving 36 persons with MS. At baseline (PRE) and after 10 (MID) and 20 (POST) weeks of standardized (ACSM) light to moderately intense unilateral leg resistance training (RESO, n = 11) only or resistance training with simultaneous electro-stimulation (RESE, n = 11, 100 Hz, biphasic symmetrical wave, 400 µs), maximal isometric strength of the knee extensors and flexors (45°, 90° knee angle) and dynamic (60–180°/s) knee-extensor strength was measured and compared with a control group (CON, n = 14). Functional mobility was evaluated using the Timed Get Up and Go, Timed 25 Foot Walk, Two-Minute Walk Test, Functional Reach and Rivermead Mobility Index. Results: Maximal isometric knee extensor (90°, MID: +10 ± 3%, POST: +10 ± 4%) in RESO and knee flexor (45°, POST: +7 ± 4%; 90°, POST: +9 ± 5%) in RESE strength increased (p < 0.05) compared with CON but RESO and RESE did not differ. Also, impaired legs responded positively to resistance training (unilateral leg strength analysis) and functional reaching increased significantly in RESO (+18%) compared with CON. Dynamic muscle strength and the remaining functional mobility tests did not change. Conclusion: Long-term light to moderately intense resistance training improves muscle strength in persons with MS but simultaneous electro-stimulation does not further improve training outcome.

Motor Imagery Ability in Patients With Early- and Mid-Stage Parkinson Disease

Background. Motor imagery has recently gained attention as a promising new rehabilitation method for patients with neurological disorders. Up to now, however, it has been unclear whether this practice method can also be successfully applied in the rehabilitation of patients with Parkinson disease (PD). Objective. This study aimed to investigate whether the motor imagery ability of patients with PD is still intact despite basal ganglia dysfunctioning. Methods. A total of 14 patients with early- and mid-stage PD (Hoehn and Yahr 1-3) and 14 healthy controls were evaluated by means of an extensive imagery ability assessment battery, consisting of 2 questionnaires, the Chaotic Motor Imagery Assessment battery, and a test based on mental chronometry. Results. PD patients performed the imagery tasks more slowly than controls, but the motor imagery vividness and accuracy of most patients were well preserved. Conclusions. These results are promising regarding the potential use of motor imagery practice in the rehabilitation of patients with PD.

EXPLORING THE EFFECTS OF A 20-WEEK WHOLE-BODY VIBRATION TRAINING PROGRAMME ON LEG MUSCLE PERFORMANCE AND FUNCTION IN PERSONS WITH MULTIPLE SCLEROSIS

OBJECTIVE To investigate the acute effects of long-term whole-body vibration on leg muscle performance and functional capacity in persons with multiple sclerosis. DESIGN A randomized controlled trial. SUBJECTS Twenty-five patients with multiple sclerosis (mean age 47.9 ± 1.9 years; Expanded Disability Status Scale 4.3 ± 0.2) were assigned randomly to whole-body vibration training (n = 11) or to a control group (n = 14). METHODS The whole-body vibration group performed static and dynamic leg squats and lunges on a vibration platform (25-45 Hz, 2.5 mm amplitude) during a 20-week training period (5 training sessions per 2-week cycle), and the control group maintained their usual lifestyle. PRE-, MID- (10 weeks) and POST- (20 weeks) knee-muscle maximal isometric and dynamic strength, strength endurance and speed of movement were measured using isokinetic dynamometry. Function was determined through the Berg Balance Scale, Timed Up and Go, Two-minute Walk Test and the Timed 25-Foot Walk Test. RESULTS Leg muscle performance and functional capacity were not altered following 10 or 20 weeks of whole-body vibration. CONCLUSION Under the conditions of the present study, the applied 20-week whole-body vibration exercise protocol did not improve leg muscle performance or functional capacity in mild- to moderately impaired persons with multiple sclerosis during and immediately after the training programme.