The role of sensory systems in the association between balance and walking in people with multiple sclerosis.

BACKGROUND: In Multiple Sclerosis, it has been demonstrated that balance is related to performances in walking tasks at different levels of complexity. However, it is unknown how the different sensory systems involved in balance control contribute to walking. This observational study investigates the associations between somatosensory, vestibular, and visual systems and measures of self-reported walking and walking capacity at different complexity levels (i.e. low, medium, and high). METHODS: People with MS with EDSS<6 were assessed through the Sensory Organization Test (SOT), 12-Item MS Walking Scale (MSWS-12), Timed 25-Foot Walk (T25FW), Timed Up-and-Go Test (TUG), and Six-Spot-Step-Test (SSST). T25FW, TUG and SSST are measures of low, medium and high walking capacity, respectively. RESULTS: Forty-five PwMS were enrolled (EDSS: 3.4 ± 1.3). Capacity/ability walking measures were moderate-to-highly significantly associated (p < 0.01). Balance measures from SOT showed significant correlation (p < 0.05) between vestibular system and all the walking measures; between visual system and T25FW, SSST and MSWS-12; between the degree to which the patient relies on the visual system to maintain balance with conflicting visual surroundings information (VIS PREF) and T25FW and TUG. In the multivariate analyses, only VIS PREF significantly correlated (p < 0.05) with T25FW (std. Beta=0.42) and TUG (std. Beta=0.38). CONCLUSIONS: Vestibular and visual systems are associated with walking capacity. However, tasks with higher complexity levels require more visual attention towards ground obstacles, as often seen in real-life activities, whereas simpler walking tasks seem to require visual attention towards the surroundings.

The subjective minimal important change for the Six Spot Step Test in people with multiple sclerosis - The Danish MS Hospitals Rehabilitation study.

INTRODUCTION: The Six Spot Step Test has shown good psychometric properties in terms of validity and reliability in people with multiple sclerosis. Yet, the responsiveness and minimal important change are unknown. The objective was to investigate the responsiveness of the Six Spot Step Test against the perceived change of walking limitations and establish estimates for the minimal important change in people with multiple sclerosis. METHODS: The Six Spot Step Test was performed before and after four weeks of specialised multidisciplinary inpatient rehabilitation by 142 adults with mild to severe multiple sclerosis. Responsiveness was determined based on anchor- and distribution-based methods, using the Multiple Sclerosis Walking Scale-12 as external criterion. In a supplementary analysis, the Six-Minute Walking Test was used as an external criterion. RESULTS: The correlation between the baseline (r = 0.56, p < 0.01) and discharge (r = 0.55, p < 0.01) Multiple Sclerosis Walking Scale-12 and Six Spot Step Test scores were acceptable. Furthermore, the change scores were weakly associated (r = 0.1, p = 0.27). This trend was similar for the Six-Minute Walking Test when used as anchor. The smallest detectable change was estimated to 1.7 seconds. An improvement in the Six Spot Step Test exceeding 2.1 (95% CI - 0.9 to 5.0) sec and 4.9 (95% CI 1.2-8.6) sec may be considered clinically important on a group level based on the Multiple Sclerosis Walking Scale-12 and the Six-Minute Walking Test, respectively. CONCLUSION: In a sample of mild to severely disabled people with multiple sclerosis, the Six Spot Step Test showed fair responsiveness against a subjective and objective criterion, indicating a minimal important change between ≥ 2.1 and ≥ 4.9 seconds, respectively. However, a weak association between the change in the Six Spot Step Test and the subjective and objective external criterion calls for cautious interpretation. Hence, the results should be further verified against a valid external criterion.

The lived experience of uncertainty in everyday life with MS.

PURPOSE: This article examines how issues of control, certainty, and uncertainty are experienced and managed in everyday life with multiple sclerosis (MS) and explores the ways in which people living with MS make sense of these experiences. MATERIALS AND METHODS: Qualitative interviews with 23 women and men diagnosed with MS and four relatives were carried out in Denmark. Drawing on the notion of "phenomenological uncertainty," a thematic approach was used to analyse the interview data. RESULTS: Three themes characterise participants' experience of uncertainty: the body and issues of control; symptom fluctuations and disease progression; understanding and interpreting embodied MS experiences. Shared, between the themes, is a focus on the body and multi-faceted bodily aspects of uncertainty across diverse temporalities. CONCLUSION: Phenomenological uncertainty shapes and pervades the everyday lived experience of MS in the present and future. Gaining a sense of control and certainty in the face of daily uncertainty demands ongoing self-surveillance, and the evaluation and reconciliation of fluctuating MS symptom expressions and disease progression with personal needs, abilities, and management strategies.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals and physicians should consider the lived experience of uncertainty in everyday life with MS in all their contacts with people living with MS.The multi-faceted uncertainties experienced by people living with MS should be actively acknowledged and incorporated in discussions of MS rehabilitation options and when integrating MS guideline content into activities-of-daily-living advice.Discussions of MS medical treatment options should actively consider and integrate the multi-faceted uncertainties experienced by people living with MS.

Can inpatient multidisciplinary rehabilitation improve health-related quality of life in MS patients on the long term - The Danish MS Hospitals Rehabilitation Study.

BACKGROUND: Inpatient multidisciplinary rehabilitation (MDR) can improve health-related quality of life (HRQoL) in multiple sclerosis (MS) patients. However, the evidence of a long-term benefit is limited. OBJECTIVES: To investigate the long-term effectiveness of inpatient MDR on HRQoL in MS patients. METHODS: We conducted a randomized controlled partial crossover trial with 427 MS patients. RESULTS: Statistical significant long-term improvements in HRQoL were found in three of the six outcome measures at 12-month follow-up. Three in four suggested minimal clinically important differences (MCIDs) were unmet. CONCLUSION: These results indicate that the administration of inpatient MDR may lead to long-lasting improvements in HRQoL in MS patients.

Test-retest agreement and reliability of the Six Spot Step Test in persons with multiple sclerosis.

BACKGROUND: The Six Spot Step Test (SSST) extends traditional walking outcomes in persons with multiple sclerosis (PwMS) by further challenging components of coordination and balance. Nonetheless, the test-retest agreement of the SSST has not been investigated. OBJECTIVE: To determine the within-day, day-to-day, and inter-rater agreement and reliability of the SSST in PwMS. A secondary aim was to investigate the validity of handheld timing. METHODS: A total of 38 PwMS with an Expanded Disability Status Scale (EDSS) <6.5 completed two SSSTs with a 5-minute break in-between. After 2 days, this procedure was repeated. Bland-Altman analysis was performed to determine the 95% Limits of Agreement (LOA) and Intraclass Correlation Coefficient (ICC) was calculated. In a subgroup of 18 PwMS, the SSSTs were video-recorded and timed by a second investigator. RESULTS: The relative LOA within and between days were ±15% and ±19%, while ICC were 0.987 and 0.983, respectively. A minor learning effect was found over four tests. The handheld timing error was ±0.5 seconds when compared to video-based timing. CONCLUSION: The SSST has an acceptable within- and between-day agreement and reliability. For interventional purposes, a change of >19% can be regarded as a real change. Valid timing can be performed by a handheld stopwatch.

Can we trust self-reported walking distance when determining EDSS scores in patients with multiple sclerosis? The Danish MS hospitals rehabilitation study.

BACKGROUND: In multiple sclerosis (MS), the Expanded Disability Status Scale (EDSS) reflects disease severity. Although parts of the EDSS are dependent on actual walking distance, self-reported statements are often applied. OBJECTIVES: The purpose of the present study was, therefore, to compare self-reported walking distance to actual walking distance to outline how this influences EDSS scoring. METHODS: MS patients with EDSS 4.0-7.5 (n = 273) were included from the Danish MS hospitals rehabilitation study (n = 427). All patients subjectively classified their maximal walking distance according to one of seven categories (>500; 300-499; 200-299; 100-199; 20-99; 5-19; 0-4 m). Subsequently, actual maximal walking distance was assessed and EDSS was determined from both self-reported walking distance (EDSSself-report) and actual walking distance (EDSSactual). RESULTS: In 145 patients (53%), self-reported walking distance was misclassified when compared to the actual walking distance. Misclassification was more frequent in patients using walking aids (64% vs. 44%, p < 0.05) and in patients with primary progressive MS (69%, p < 0.05). Misclassification of walking distance corresponded to incorrect EDSS scores (EDSSself-report vs EDSSactual) of ⩾0.5 point in 24%. CONCLUSION: In MS patients with EDSS 4.0-7.5, 53% misclassified their walking distance yielding incorrect EDSS scores in 24%. Therefore, correct EDSS determination must be based on measurement of actual walking distance.

Validity and variability of the 5-repetition sit-to-stand test in patients with multiple sclerosis.

PURPOSE: To investigate; (i) the relationship between the 5STS-test and lower extremity muscle strength and balance, and (ii) the variability of the 5STS-test in multiple sclerosis (MS) patients. METHOD: 22 MS patients were divided into two groups (Group A and Group B) who completed one 5STS familiarization test session and two testing sessions. In Group A, session 1 also included assessment of lower extremity muscle strength. Session 2 and 3 involved completion of two 5STS-tests and assessment of balance. In Group B, session 2 and 3 involved completion of two rounds of two 5STS-tests separated by a 30 min break. RESULTS: Significant correlations were found between the 5STS-test and isometric and isokinetic knee flexor and extensor muscle strength of the most affected leg (R = -0.60 to -0.77), and between the 5STS-test and balance performance (R = 0.69). Intra-assessor day-to-day variability, intra-assessor test-retest variability and intra-assessor variability within test were 25.5, 22.3, and 23.1%, respectively. Inter-assessor variability within test and inter-assessor variability were 23.4 and 5.9%, respectively. CONCLUSIONS: The 5STS-test is related to lower extremity muscle strength and to balance performance in MS patients. For interventional purposes, a change of >25% can be regarded as a real change.