Susan Coote

The effect of the GENTLE/s robot-mediated therapy system on arm function after stroke

Objective: To evaluate the effect of robot-mediated therapy on arm dysfunction post stroke. Design: A series of single-case studies using a randomized multiple baseline design with ABC or ACB order. Subjects (n = 20) had a baseline length of 8, 9 or 10 data points. They continued measurement during the B — robot-mediated therapy and C — sling suspension phases. Setting: Physiotherapy department, teaching hospital. Subjects: Twenty subjects with varying degrees of motor and sensory deficit completed the study. Subjects attended three times a week, with each phase lasting three weeks. Interventions: In the robot-mediated therapy phase they practised three functional exercises with haptic and visual feedback from the system. In the sling suspension phase they practised three single-plane exercises. Each treatment phase was three weeks long. Main measures: The range of active shoulder flexion, the Fugl-Meyer motor assessment and the Motor Assessment Scale were measured at each visit. Results: Each subject had a varied response to the measurement and intervention phases. The rate of recovery was greater during the robot-mediated therapy phase than in the baseline phase for the majority of subjects. The rate of recovery during the robot-mediated therapy phase was also greater than that during the sling suspension phase for most subjects. Conclusion: The positive treatment effect for both groups suggests that robot-mediated therapy can have a treatment effect greater than the same duration of non-functional exercises. Further studies investigating the optimal duration of treatment in the form of a randomized controlled trial are warranted.

Falls in People With Multiple Sclerosis Who Use a Walking Aid: Prevalence, Factors, and Effect of Strength and Balance Interventions

OBJECTIVES To investigate falls prevalence, factors associated with falling, and the effects of balance and strengthening interventions on falls in persons with multiple sclerosis (MS). DESIGN Baseline and posttreatment data from a randomized controlled trial. SETTING Community. PARTICIPANTS People with MS (N=111) who use bilateral support for gait. INTERVENTIONS Group and one-on-one physiotherapy. MAIN OUTCOME MEASURES Falls prevalence was assessed using retrospective recall. Demographic information was collected, impairments of body function were assessed, and results from the Berg Balance Scale, 6-minute walk test (6MWT), Multiple Sclerosis Impact Scale-29 version 2 physical and psychological scores, and the Modified Fatigue Impact Scale (MFIS) were obtained. RESULTS The prevalence of falls in a 3-month period was 50.5% among participants with MS, of whom 28% had more than 1 fall. Fallers had a greater physical (mean difference, -3.9; P=.048) and psychological (median difference, -4.5; P=.001) impact of MS and a greater impact of fatigue (mean difference, -9.4; P=.002). A logistic regression analysis found that the MFIS score made a unique, significant contribution to the model (odds ratio=1.04; 95% confidence interval, 1.018-1.079), correctly identifying 68% of fallers. A 10-week group physiotherapy intervention significantly reduced both the number of fallers (58.3% before to 22.9% after intervention, P=.005) and the number of falls (63 before to 25 after intervention, P=.001). CONCLUSIONS The prevalence of falls is high in this population of persons with MS, and the impact of MS and of fatigue is greater in fallers. Development and evaluation of interventions to reduce falls risk and the transition to faller or multiple faller status are required.

Multiple sclerosis and exercise in people with minimal gait impairment: a review

Abstract Objectives: The objectives of this review are to describe the effect of exercise on body structure and function, activities and participation in people with multiple sclerosis (MS) with mild gait dysfunction, to evaluate the quality of research in this area and to guide therapists in determining which parameters of exercise programmes could be used. Methods: A systematic search of the literature was conducted. Quality was assessed using a simple method to evaluate bias. All trials since 2004 that have included people who walk with at most one stick have been included (i.e. EDSS ≤6). Results: Aerobic, progressive resistance exercise (PRE), combined exercises and other interventions appear to have positive effects on body structure and function, activities and participation in people with mild MS. No harmful effects were seen in any intervention. Both aerobic exercise and PRE have very defined and reproducible parameters. A combination of aerobic exercise and PRE is feasible and potentially offers the most favourable results in terms of the negative symptomology and physiological profile. Yoga and aqua aerobics also had positive effects and are feasible for this population. However, there is a moderate to high risk of bias in studies conducted since 2004 limiting their validity. Discussion: The effectiveness of interventions for patients with different impairments remains unclear due to the levels of bias in studies evaluating exercise in people with MS. Future studies should focus on the randomised controlled trial (RCT) paradigm. A high quality, RCT comparing a combined exercise programme, yoga and a control, with a long term follow up, is required.

Exercise in the community for people with minimal gait impairment due to MS: an assessor-blind randomized controlled trial

Background: While there is an increasing body of evidence supporting the efficacy of exercise in people with multiple sclerosis (MS), additional information on the effectiveness of combining aerobic and resistance training, and yoga is required. Objectives: This study evaluated the effectiveness of community exercise interventions for people with MS having minimal gait impairment. Methods: A multi-centred, block-randomised, assessor-blinded, controlled trial was conducted. Participants were randomised in groups of eight to physiotherapist (PT)-led exercise (n = 80), yoga (n = 77), fitness instructor (FI)-led exercise (n = 86) and they took part in weekly community-based group exercise sessions. Those in the control group were asked not to change of their exercise habits (n = 71). The primary outcome was the Multiple Sclerosis Impact Scale (MSIS) 29v2 physical component, measured before and after the 10-week intervention. Secondary outcomes were the MSIS 29v2 psychological component, the Modified Fatigue Impact Scale (MFIS) and the 6-Minute Walk Test (6MWT). Results: The group x time interaction approached significance for the MSIS-29v2 physical component (f = 2.48, p = 0.061) and MFIS total (f = 2.50, p = 0.06), and it was significant for the MFIS physical subscale (f = 4.23, p = 0.006). All three exercise interventions led to a statistically significant improvement on the MSIS-29 psychological component and both the MFIS total and physical subscales, which were greater than the control (p < 0.05). Only the PT-led and FI-led interventions significantly improved the MSIS-29 physical and 6MWT to levels greater than the control (p < 0.05). Conclusions: This study provides evidence for the positive effect of exercise on the physical impact of MS and fatigue. The group nature of the classes may have contributed to the positive effects seen on the psychological impact of MS.

Top 10 research questions related to physical activity and multiple sclerosis

An estimated 2.5 million people worldwide are living with multiple sclerosis (MS), and this disease may be increasing in prevalence. MS is a disease of the central nervous system that is associated with heterogeneous symptoms and functional consequences, and the current first-line disease-modifying therapies often become ineffective later in the disease. There is increasing evidence for the benefits of physical activity (PA) in people with MS, but this population is generally physically inactive and sedentary. We proposed 10 research questions to guide future research on PA and MS: (1) Is PA an MS disease-modifying behavior? (2) What are the benefits of PA among people with MS? (3) What is the optimal PA prescription for people with MS? (4) What are the safety issues with PA in people with MS? (5) What characteristics of people with MS modify the benefits of PA? (6) What variables explain participation in PA among people with MS? (7) What are effective behavioral interventions for PA change in people with MS? (8) How do we translate PA research into clinical MS practice? (9) What is the role of sedentary behavior in people with MS? And (10) what is the optimal measurement of PA in people with MS? These questions are critical for informing our understanding of the short- and long-term consequences of PA in MS as well as for identifying approaches for promoting and sustaining PA in MS. Addressing these questions may greatly improve the lives of people with this chronic disease.

Using Functional Electrical Stimulation Mediated by Iterative Learning Control and Robotics to Improve Arm Movement for People With Multiple Sclerosis

Few interventions address multiple sclerosis (MS) arm dysfunction but robotics and functional electrical stimulation (FES) appear promising. This paper investigates the feasibility of combining FES with passive robotic support during virtual reality (VR) training tasks to improve upper limb function in people with multiple sclerosis (pwMS). The system assists patients in following a specified trajectory path, employing an advanced model-based paradigm termed iterative learning control (ILC) to adjust the FES to improve accuracy and maximise voluntary effort. Reaching tasks were repeated six times with ILC learning the optimum control action from previous attempts. A convenience sample of five pwMS was recruited from local MS societies, and the intervention comprised 18 one-hour training sessions over 10 weeks. The accuracy of tracking performance without FES and the amount of FES delivered during training were analyzed using regression analysis. Clinical functioning of the arm was documented before and after treatment with standard tests. Statistically significant results following training included: improved accuracy of tracking performance both when assisted and unassisted by FES; reduction in maximum amount of FES needed to assist tracking; and less impairment in the proximal arm that was trained. The system was well tolerated by all participants with no increase in muscle fatigue reported. This study confirms the feasibility of FES combined with passive robot assistance as a potentially effective intervention to improve arm movement and control in pwMS and provides the basis for a follow-up study.

Exercise in the community for people with multiple sclerosis--a follow-up of people with minimal gait impairment.

Background: Although there are many studies evaluating exercise interventions, few studies have evaluated the effect at follow-up. Objectives: This paper presents follow-up data for participants who completed the exercise interventions in a large randomised controlled trial. Methods: One hundred twenty-one people with multiple sclerosis (MS) with minimal gait impairment who completed 10 weeks of community-based exercise interventions were evaluated by a blinded assessor 12 weeks after the intervention. The primary outcome measure was the Multiple Sclerosis Impact Scale-29 version 2 (MSIS-29,v2) physical component. Other outcomes were the MSIS-29 psychological component, the Modified Fatigue Impact Scale (MFIS) and the 6-minute walk test (6MWT) distance. Results: The positive effect on the physical impact of MS was not maintained from baseline to follow-up (−1.6, 95% CI −0.8, 4.0, p=0.189). The psychological impact and the impact of fatigue remained significantly improved (−3.5, 95% CI −6.1, −1.0, p = 0.006 and −4.68, 95% CI −6.9, −2.5, p < 0.001, respectively). There was no time effect for the 6MWT (f = 1.76, p = 0.179) although the trend suggests reversal of the benefits gained from the physiotherapist (PT)- and fitness instructor (FI)-led intervention. Conclusion: The maintained benefit on the psychological impact of MS and fatigue may have important personal and socioeconomic consequences; however, it is important to find ways to maintain the physical benefits of exercise over the long term.

Focus group study of student physiotherapists' perceptions of reflection.

Context  The reflective practice module in the physiotherapy programme at the University of Limerick, Ireland represents the first incidence of the inclusion of such a module within physiotherapy curricula in Ireland. However, research examining the contribution of reflection as a means of learning is limited, particularly from the student perspective.

Level of Mobility Limitations and Falls Status in Persons With Multiple Sclerosis

OBJECTIVE To investigate whether fall rates are constant across levels of mobility limitations. DESIGN Secondary analysis of baseline assessments from a stratified randomized controlled trial. SETTING Community. PARTICIPANTS Persons with multiple sclerosis (N=365) were divided into 5 groups based on the mobility section of the Guys Neurological Disability Scale (GNDS): no walking impairment (n=82); impaired walking, no aid (n=87); unilateral support (n=76); bilateral support to walk (n=78); or occasional wheelchair user (n=42). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Self-reported fall history (ie, retrospective) in the preceding 3 months. RESULTS One hundred twenty-four persons in the overall sample reported falling in the last 3 months (fall prevalence, 33.97%). Of the total sample, 17.8% reported 2 or more falls in the last 3 months. Chi-square analysis revealed a significant difference in the proportion of fallers across GNDS categories (χ(2)=42.64, P<.001). Post hoc analysis revealed that the group who walked with bilateral support had the greatest proportion of fallers (52.6%), while the group without walking impairment had the lowest proportion (15.9%). An examination of recurrent fallers as a function of group found that there were more recurrent fallers (70%) in the group that had a walking impairment but used no aid, relative to the other groups. CONCLUSIONS The current findings highlight that fall rates including recurrent fall prevalence are not uniform across mobility aid categories in persons with MS. Those using bilateral assistance for gait have the highest prevalence of fallers, and those with walking limitations and not yet using an aid had the greatest prevalence of multiple falls.

Gait deficits in people with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND Multiple Sclerosis (MS) results in postural instability and gait abnormalities which are associated with accidental falls. OBJECTIVE This systematic review and meta-analysis aims to quantify the effect of MS on gait to inform the development of falls prevention interventions. METHODS A systematic literature search identified case-control studies investigating differences in gait variables between people with MS and healthy controls. Meta-analysis examined the effect of MS on gait under normal and fast paced conditions. RESULTS Forty-one studies of people with Expanded Disability Status Scale (EDSS) 1.8 to 4.5 were included, of which 32 contributed to meta-analysis. A large effect of MS was found on stride length (Standardised Mean Difference, SMD=1.27, 95% CI{0.93, 1.61}), velocity (SMD=1.12, 95% CI{0.85, 1.39}), double support duration (SMD=0.85, 95% CI{0.51, 1.2}), step length (SMD=1.15, 95% CI{0.75, 1.5})and swing phase duration (SMD=1.23, 95% CI{0.06, 2.41}). A moderate effect was found on step width and stride time with the smallest effect found on cadence (SMD=0.43, 95% CI{0.14, 0.72}). All effect sizes increased for variables investigated under a fast walking pace condition (for example the effect on cadence increased to SMD=1.15, 95% CI{0.42, 1.88}). CONCLUSIONS MS has a significant effect on gait even for those with relatively low EDSS. This effect is amplified when walking at faster speeds suggesting this condition may be more beneficial for assessment and treatment. No studies investigated the association between these deficits and falls. Further investigation relating to the predictive or protective nature of these deficits in relation to falls is warranted.