Energy expenditure and perceived effort during uphill and downhill walking in people with multiple sclerosis.

BACKGROUND: Walking on different slopes is a common daily activity for many ambulatory people with multiple sclerosis (pwMS) AIM: Investigate energy expenditure measures of walking on level, uphill and downhill slopes in pwMS. DESIGN: Observational case-control study. SETTING: Sheba Multiple Sclerosis Center, Tel-Hashomer, Israel. POPULATION: Eighteen pwMS; 10 women and 8 men, aged 39.7 (SD=6.8), mean EDSS was 2.9 (SD=1.2) and 23 healthy adults; 8 women and 15 men, aged 37.1 (S.D.=5.3). METHODS: Energy expenditure values were obtained via a metabolic device during four conditions: sitting, comfortable walking, uphill and downhill walking. Each walking trial, obtained on a treadmill, lasted 6-min and were separated by10-min recovery intervals. RESULTS: For both pwMS and healthy controls, the O2 rate and O2 cost was higher during uphill walking compared to level walking and lower during downhill walking compared with level walking. O2 rate and net O2 cost during uphill walking was lower in pwMS compared with the healthy controls. The most demanding effort was during uphill walking, with pwMS rating it more demanding compared with the healthy controls. CONCLUSIONS: Perceived effort of walking on different slopes is not consistent with changes in the energy expenditure values in pwMS. CLINICAL REHABILITATION IMPACT: pwMS describe the effort of walking on different slopes higher than normal, regardless of the energy expenditure values.

The Design, Development, and Testing of a Virtual Reality Device for Upper Limb Training in People With Multiple Sclerosis: Single-Center Feasibility Study.

BACKGROUND: Multiple sclerosis (MS) is a common nontraumatic, neurological, disabling disease that often presents with upper limb dysfunction. Exercise training has resulted in improvement for patients; however, there can be a lack of compliance due to access because of location and lack of MS experts. Virtual reality (VR) is a promising technology that can offer exercise therapy/rehabilitation at a distance. This type of remote training can be motivational and effective for patients with MS and can improve range of motion and muscle strength for those with upper limb dysfunction. OBJECTIVE: The aim of this study is to evaluate the safety and feasibility of the XRHealth software and the Oculus Rift Station for patients with MS with upper limb motor dysfunction. METHODS: A single-center, prospective, feasibility study was conducted with patients with MS who had upper limb motor dysfunction. Patients participated in a single 45-minute digital environment session with VR and completed a questionnaire about the quality of the training and fatigability. The clinician also completed a questionnaire to evaluate the suitability and safety of the training. RESULTS: Overall, 30 patients were enrolled between the ages of 20 and 81 years. Patients reported that the training sessions within the digital environment were helpful, challenging, fun, and simple to understand, and that they would be willing to repeat the sessions again. The physical therapist that oversaw the patients reported that the training was suitable for 87% (n=26) of the patients. Anticipated adverse events were fatigue, temporary dizziness, and temporary nausea. The operator complications included that the cable of the head-mounted display interrupted the training (n=2, 7%) and fatigue that caused cessation of the VR training session (n=2, 7%). No serious adverse events were reported. CONCLUSIONS: These preliminary results demonstrated that the use of the XRHealth software and Oculus Rift Station platform is feasible, safe, and engaging for patients, and has the potential to improve the functionality of the upper limbs in patients with MS. This study provides support for future studies of implementing a series of training sessions with virtual reality in a home-based environment.

Sex-Based Differences in Oxygen Cost of Walking and Energy Equivalents in Minimally Disabled Individuals With Multiple Sclerosis and Controls.

Background: Elevated oxygen cost of walking and energy equivalents are reported for highly and moderately disabled individuals with multiple sclerosis (MS). However, less is known about minimally impaired individuals. Moreover, no sex-based data on the metabolic rates of individuals with MS are available. In this cross-sectional study, the metabolic rates and temporospatial parameters of gait during overground walking in minimally disabled individuals with MS versus matched controls were quantified and whether sex-based differences occur was examined. Methods: Sixty-nine minimally impaired adults with MS (37, relapsing-remitting MS [RRMS]; 32, clinically isolated syndrome [CIS]) and 25 matched controls completed two 6-minute walking bouts at comfortable and fast speeds. The oxygen cost of walking, energy equivalents, and respiratory exchange ratio were recorded through breath-by-breath open-circuit spirometry. Gait analysis was performed via a portable electronic walkway. Results: At comfortable but not at fast speed, men with RRMS showed higher oxygen cost of walking than men with CIS (+17.9%, P = .04) and male controls (+21.3%, P = .03). In the RRMS group, men showed higher oxygen cost of walking (+19.2%, P = .04) and energy equivalents (+19.2%, P = .02) than women. Elevated oxygen cost of walking and energy equivalents in men were paralleled by significantly larger base of support and step time asymmetry during walking. Conclusions: Metabolic demands are elevated while walking in minimally disabled individuals with RRMS. Furthermore, higher energy demands occur in men, probably due to increased step symmetry and base of support. Clinicians are advised to follow energy expenditure metrics collected while walking because they can indicate a decrease in fitness, even in the early phase of MS.

Physical activity behavior in people with multiple sclerosis during the COVID-19 pandemic in Israel: Results of an online survey.

Multiple sclerosis (MS) itself and first-line disease modifying therapies do not increase the risk of contracting COVID-19. However, home isolation is likely to result in a significant decrease in participation in leisure time physical activities and an increase in sedentary behavior. Therefore, using an online cross-sectional survey we examined the impact of the COVID-19 epidemic on physical activity (PA) behavior and fitness level in an Israeli cohort of people with multiple sclerosis (PwMS). The survey PA questionnaire included 10 questions. Specifically, participants reported on whether, and to what extent, the pandemic conditions had altered their PA behavior. One hundred and twenty PwMS filled out the online survey, 78 were females with a mean age of 43.0 (S.D.=12.9) years. PA behavior during the pandemic demonstrated that 17.5% who were engaged in PA before the COVID-19 pandemic, ceased PA, 33.3% reduced their PA, 20.0% continued their PA as before, 18.3% increased their PA during the pandemic, and 10.8% did not perform any PA in the past and did not so during the pandemic. As for the patient's self-reported fitness level, 31.7% reported that their fitness level had decreased during the pandemic, 60.0% felt no change, and 8.3% reported an improvement. Our findings serve as a call of action for all professionals involved in MS management to address physical activity behavior in PwMS during the COVID-19 epidemic.

Physical activity in mild multiple sclerosis: contribution of perceived fatigue, energy cost, and speed of walking.

Purpose: To clarify the relationship between leisure-time physical activity, perceived fatigue, and energy expenditure while walking in people with multiple sclerosis.Methods: Sixty-six people afflicted with multiple sclerosis (MS) (32 women) with a mild neurological disability, participated in this study. Energy expenditure was separately measured at rest, during comfortable walking and during fast walking via a portable metabolic device using breath-by-breath technology (COSMED K5, COSMED Srl, Rome, Italy). The Godin leisure-time exercise questionnaire assessed leisure-time physical activity. The Modified Fatigue Impact Scale determined the level of perceived fatigue.Results: Seventeen people with MS were classified as physically active; 49 were insufficiently active. Scores recorded on the Godin Leisure-Time Exercise Questionnaire were 47.8 (SD = 18.4), 7.0 (SD = 8.2), respectively. Insufficiently physically active people with MS walked slower at both normal and fast walking conditions. However, no differences between groups were observed in energy expenditure measures in both walking speeds. O2 cost was 0.20 (SD = 0.13) and 0.21 (SD = 0.06) in the active and insufficiently active group, respectively. The insufficiently active group reported more perceived fatigue compared with the active patients; 33.3 (SD = 18.6) vs. 15.0 (SD = 19.0), p value = 0.002. Perceived fatigue was a significant variable maintaining a 10.4% variance related to leisure-time physical activity.Conclusions: Leisure-time physical activity was inversely associated with perceived fatigue and walking speed in persons with mild MS. Rehabilitation professionals should be aware of these relationships when planning rehabilitation strategies.Implication for rehabilitationThis study found that perceived fatigue is a barrier to physical activity participation even in people with mild multiple sclerosis and minimal disability.Insufficiently active people with multiple sclerosis expend the same amount of energy while walking as active multiple sclerosis individuals, though walking slower.The relationship between perceived fatigue and physical activity participation requires further exploration in the multiple sclerosis population.

Physical activity participation according to the pyramidal, sensory, and cerebellar functional systems in multiple sclerosis.

The objective of the study was to examine the differences in physical activity participation with the pyramidal, cerebellar, and sensory functional systems in people with multiple sclerosis (PwMS). This cross-sectional study included 289 PwMS with a median EDSS of 2.0 (range 0-6.5) and a mean disease duration of 6.8 (SD = 8.4) years. The Godin leisure-time exercise questionnaire (GLTEQ) assessed physical activity participation. The sample was divided into seven groups according to the pyramidal, cerebellar, and sensory functional system scores derived from the EDSS data. Additionally, PwMS were divided into three physical activity subgroups (active, moderately active, and insufficiently active). Furthermore, PwMS were categorized into four levels of disability based on their global Expanded Disability Status Scale (EDSS) score [very mild (0-1.5), mild (2.0-3.5), moderate (4.0-5.5), and severe (6.0-6.5)]. In the physical activity subgroups, 159 (55.0%) were classified as insufficiently active, 59 (20.4%) as moderately active, and 71 (24.6%) as active. Pyramidal, cerebellar, and sensory impairments were demonstrated in 134 (46.4%), 73 (25.3%), and 85 (29.4%) patients, respectively. No differences were found for the GLTEQ scores for all seven functional system groups (P value = 0.168). As for the EDSS disability subgroups, the percentage of active patients (moderately at least) were 60%, 45.8%, 36.5%, and 15.4%, for the very mild, mild, moderate, and severe subgroups, respectively. This study found that participation in leisure-time physical activity is independent from the pyramidal, cerebellar, and sensory functional systems in PwMS.

The association between gait variability with the energy cost of walking depends on the fall status in people with multiple sclerosis without mobility aids.

BACKGROUND: Falls, gait variability and increased energy cost of walking are common in people with multiple sclerosis (PwMS). However, no studies have as yet examined this triple association in PwMS or in other neurological populations. RESEARCH QUESTION: Does a relationship exist between gait variability, falls and the energy cost of gait in PwMS? METHODS: This cross sectional study included 88 PwMS (50 women), mean age 39.8 (S.D = 13.0) and mean disease duration of 6.2 (SD = 8.2) years since diagnosis. Energy expenditure during walking was collected via a portable metabolic device (COSMED K5, COSMED Srl, Roma, Italy). Gait variability was measured by an electronic walkway (GAITRite™). Participants were divided into groups based on fall history (fallers and non-fallers). Differences between groups in terms of energy expenditure measures and gait variability metrics were determined by the analysis of variance test. The relationship between gait variability and energy cost of walking was examined by the Pearson's correlation coefficient test. RESULTS: Thirty-three PwMS were classified as fallers and 55 as non-fallers. Non-significant differences between groups were observed in the energy expenditure measures, including cost of walking. Fallers demonstrated higher step length variability compared with non-fallers (4.58 (S.D. = 2.42 vs. 3.40 (S.D. = 1.40); p-value = 0.005). According to the Pearson's correlation coefficient analysis, a significant relationship was found between step length variability and energy cost of walking in the non-fallers group (Rho = 0.372, P-value = 0.006) and the total group (Rho = 0.296, p-value = 0.005), but not in those PwMS with a history of falls. SIGNIFICANCE: We demonstrated a significant relationship between increased gait variability and energy expenditure while walking only in MS patients without a history of falls. This is important as there is evidence of the clinical relevance of increased gait variability, poor fitness level and high risk of falling in the MS population.

Is the dual-task cost of walking and texting unique in people with multiple sclerosis?

The objective of the study was to investigate cognitive-motor interference of walking while texting in people with multiple sclerosis (PwMS). The study included 30 PwMS, mean disease duration 11.8 (SD = 6.8) years, and 15 healthy controls. The investigation included a cognitive assessment; texting assessment based on 100 typed characters; and gait assessment under two different conditions: normal walking and walking while texting. Outcome measures included the Symbol Digit Modalities Test to assess cognition. Texting measures included accuracy (%) and duration(s). Gait was assessed with axial accelerometers to quantify temporal measures. The dual-task cost percentage for the walking tests and texting accuracy was determined by calculating the percentage change from a single task to a double task. The impact of texting while walking on gait measures was significantly higher in PwMS; furthermore, texting was less accurate compared to the healthy controls. The dual-task cost for texting accuracy in the PwMS group was 153.3 (SD = 105.7) compared to 8.9 (SD = 26.6) in the healthy group. A significant association was found solely in the PwMS group between cognition and texting accuracy while in a sitting position (R2 = 0.564) and while walking (R2 = 0.534). The dual-task cost of walking and texting appears to be unique in the MS population.

The relationship between gait variability and cognitive functions differs between fallers and non-fallers in MS.

The objective of the study was to determine if cognitive function is associated with step time variability in people with multiple sclerosis (PwMS). The study included 355 PwMS (218 women), average age 41.1 (SD = 13.5), disease duration 5.9 (SD = 7.3) years, and a median expanded disability status scale score of 2.5. We separately analyzed the sample group of fallers and non-fallers based on their fall history. Gait variability was measured by an electronic walkway and all participants completed a computerized cognitive test battery designed to evaluate multiple cognitive domains. Fallers (43.7%) demonstrated elevated step time variability (%CV), 5.0 (SD = 3.4) vs. 3.5 (SD = 1.6), P < 0.001 compared to the non-faller subjects. According to the regression analysis in the non-fallers' group, step time variability was found significantly associated with the global cognitive score (P = 0.001), executive function subcategory (P = 0.038), and motor skills subcategory (P < 0.001). No relationship between step time variability and any cognitive domain was demonstrated in the faller group. This study illustrated that the association between gait variability and cognition occurs only in PwMS without a fall history. From a clinical standpoint, these findings might help medical professionals to create improved assessment tests and rehabilitation strategies in the MS population.

Gait Characteristics in Adolescents With Multiple Sclerosis.

BACKGROUND: Multiple sclerosis is a progressive autoimmune disease of the central nervous system. A presentation of multiple sclerosis before age18 years has traditionally been thought to be rare. However, during the past decade, more cases have been reported. PATIENT DESCRIPTION: We examined gait characteristics in 24 adolescents with multiple sclerosis (12 girls, 12 boys). Mean disease duration was 20.4 (S.D. = 24.9) months and mean age was 15.5 (S.D. = 1.1) years. The mean expanded disability status scale score was 1.7 (S.D. = 0.7) indicating minimal disability. Outcomes were compared with gait and the gait variability index value of healthy age-matched adolescents. RESULTS: Adolescents with multiple sclerosis walked slower with a wider base of support compared with age-matched healthy control subjects. Moreover, the gait variability index was lower in the multiple sclerosis group compared with the values in the healthy adolescents: 85.4 (S.D. = 8.1) versus 96.5 (S.D. = 7.4). CONCLUSIONS: We present gait parameters of adolescents with multiple sclerosis. From a clinical standpoint, our data could improve management of walking dysfunction in this relatively young population.

Pilates exercise training vs. physical therapy for improving walking and balance in people with multiple sclerosis: a randomized controlled trial.

OBJECTIVE: Evaluate the effects of a Pilates exercise programme on walking and balance in people with multiple sclerosis and compare this exercise approach to conventional physical therapy sessions. DESIGN: Randomized controlled trial. SETTING: Multiple Sclerosis Center, Sheba Medical Center, Tel-Hashomer, Israel. SUBJECTS: Forty-five people with multiple sclerosis, 29 females, mean age (SD) was 43.2 (11.6) years; mean Expanded Disability Status Scale (S.D) was 4.3 (1.3). INTERVENTIONS: Participants received 12 weekly training sessions of either Pilates ( n=22) or standardized physical therapy ( n=23) in an outpatient basis. MAIN MEASURES: Spatio-temporal parameters of walking and posturography parameters during static stance. Functional tests included the Time Up and Go Test, 2 and 6-minute walk test, Functional Reach Test, Berg Balance Scale and the Four Square Step Test. In addition, the following self-report forms included the Multiple Sclerosis Walking Scale and Modified Fatigue Impact Scale. RESULTS: At the termination, both groups had significantly increased their walking speed ( P=0.021) and mean step length ( P=0.023). According to the 2-minute and 6-minute walking tests, both groups at the end of the intervention program had increased their walking speed. Mean (SD) increase in the Pilates and physical therapy groups were 39.1 (78.3) and 25.3 (67.2) meters, respectively. There was no effect of group X time in all instrumented and clinical balance and gait measures. CONCLUSIONS: Pilates is a possible treatment option for people with multiple sclerosis in order to improve their walking and balance capabilities. However, this approach does not have any significant advantage over standardized physical therapy.

Static Posturography and Falls According to Pyramidal, Sensory and Cerebellar Functional Systems in People with Multiple Sclerosis.

Balance impairment is common in people with multiple sclerosis (PwMS) and frequently impacts quality of life by decreasing mobility and increasing the risk of falling. However, there are only scarce data examining the contribution of specific neurological functional systems on balance measures in MS. Therefore, the primary aim of our study was to examine the differences in posturography parameters and fall incidence according to the pyramidal, cerebellar and sensory systems functional systems in PwMS. The study included 342 PwMS, 211 women and mean disease duration of 8.2 (S.D = 8.3) years. The study sample was divided into six groups according to the pyramidal, cerebellar and sensory functional system scores, derived from the Expanded Disability Status Scale (EDSS) data. Static postural control parameters were obtained from the Zebris FDM-T Treadmill (zebris® Medical GmbH, Germany). Participants were defined as "fallers" and "non-fallers" based on their fall history. Our findings revealed a trend that PwMS affected solely in the pyramidal system, have reduced stability compared to patients with cerebellar and sensory dysfunctions. Moreover, the addition of sensory impairments to pyramidal dysfunction does not exacerbate postural control. The patients in the pure sensory group demonstrated increased stability compared to each of the three combined groups; pyramidal-cerebellar, pyramidal-sensory and pyramidal-cerebellar-sensory groups. As for fall status, the percentage of fallers in the pure pyramidal, cerebellar and sensory groups were 44.3%, 33.3% and 19.5%, respectively. As for the combined functional system groups, the percentage of fallers in the pyramidal-cerebellar, pyramidal-sensory and pyramidal-cerebellar-sensory groups were 59.7%, 40.7% and 65%, respectively. This study confirms that disorders in neurological functional systems generate different effects on postural control and incidence of falls in the MS population. From a clinical standpoint, the present information can benefit all those engaged in physical rehabilitation of PwMS.

The effect of balance training on postural control in people with multiple sclerosis using the CAREN virtual reality system: a pilot randomized controlled trial.

BACKGROUND: Multiple sclerosis (MS) is a multi-focal progressive disorder of the central nervous system often resulting in diverse clinical manifestations. Imbalance appears in most people with multiple sclerosis (PwMS). A popular balance training tool is virtual reality (VR) with several advantages including increased compliance and user satisfaction. Therefore, the aim of this pilot RCT (Trial registration number, date: ISRCTN14425615, 21/01/2016) was to examine the efficacy of a 6-week VR balance training program using the computer assisted rehabilitation environment (CAREN) system (Motek Medical BV, Amsterdam, Netherlands) on balance measures in PwMS. Results were compared with those of a conventional balance exercise group. Secondary aims included the impact of this program on the fear of falling. METHODS: Thirty-two PwMS were equally randomized into the VR intervention group or the control group. Each group received balance training sessions for 6 consecutive weeks, two sessions per week, 30 min sessions. Clinical balance tests and instrumented posturography outcome measures were collected upon initiation of the intervention programs and at termination. RESULTS: Final analysis included 30 patients (19 females, 11 males; mean age, (S.D.) = 45.2 (11.6) years; mean EDSS (S.D.) = 4.1 (1.3), mean disease duration (S.D.) = 11.0 (8.9) years). Both groups showed a main effect of time on the center of pressure (CoP) path length with eyes open (F = 5.278, P = .024), sway rate with eyes open (F = 5.852, P = .035), Functional Reach Test (F = 20.841, P = .001), Four Square Step Test (F = 9.011, P = .031) and the Fear of Falls self-reported questionnaire (F = 17.815, P = .023). In addition, significant differences in favor of the VR program were observed for the group x time interactions of the Functional Reach Test (F = 10.173, P = .009) and fear of falling (F = 6.710, P = .021). CONCLUSIONS: We demonstrated that balance training based on the CAREN device is an effective method of balance training for PwMS.

The "butterfly diagram": A gait marker for neurological and cerebellar impairment in people with multiple sclerosis.

People with multiple sclerosis (PwMS) frequently experience walking and balance impairments. In our previous report, we demonstrated that spatio-temporal gait parameters, collected by the Zebris FDM-T instrumented treadmill (Zebris Medical GmbH, Germany), serve as valid markers of neurological impairment in the MS population. In the current study, we focused on a unique outcome statistic of the instrumented treadmill, the "butterfly" diagram which reflects the variability of the center of pressure trajectory during walking. Therefore, the aim of the study was to examine the relationship between parameters related to the gait butterfly diagram and the level of neurological impairment in PwMS. Specifically we examined whether the gait butterfly parameters can differentiate between MS patients with normal cerebellar function and those suffering from ataxia. Demographic, neurological and gait parameters were collected from 341 PwMS, 213 women, aged 42.3 (S.D.=13.8). MS participants with ataxia demonstrated higher scores relating to the butterfly gait variability parameters compared to PwMS with normal or slightly abnormal cerebellar function. According to the results of the binary regression analysis, gait variability in the ant-post direction was found to explain 18.1% of the variance related to cerebellar function; R(2)=0.181, χ(2)(1)=67.852, P<0.001. Measurements derived from the butterfly diagram are proper estimators for important neurological functions in PwMS and should be considered in order to improve diagnosis and assessment of the MS population.

A personalized, intense physical rehabilitation program improves walking in people with multiple sclerosis presenting with different levels of disability: a retrospective cohort.

BACKGROUND: People with multiple sclerosis (PwMS) endure walking limitations. To address this restriction, various physical rehabilitation programs have been implemented with no consensus regarding their efficacy. Our objective was to report on the efficacy of an integrated tailored physical rehabilitation program on walking in people with multiple sclerosis categorized according to their level of neurological disability. METHODS: Retrospective data were examined and analyzed. Specifically, data obtained from all patients who participated in the Multiple Sclerosis Center's 3 week rehabilitation program were extracted for in depth exploration. The personalized rehabilitation program included three major components modified according to the patient's specific impairments and functional needs: (a) goal directed physical therapy (b) moderately intense aerobic exercise training on a bicycle ergometer and (c) aquatic therapy chiefly oriented to body structures appropriate to movement. Gait outcome measurements included the 10 meter, 20 meter, Timed up and go and 2 minute walking tests measured pre and post the rehabilitation program. Three hundred and twelve people with relapsing-remitting multiple sclerosis were included in the final analysis. Patients were categorized into mild (n = 87), moderate (n = 104) and severely (n = 121) disabled groups. RESULTS: All clinical walking outcome measurements demonstrated statistically significant improvements, however, only an increase in the 2 minute walking test was above the minimal clinical difference value. The moderate and severe groups considerably improved compared to the mild gait disability group. Mean change scores (%) of the pre-post intervention period of the 2 minute walking test were 19.0 (S.E. = 3.4) in the moderate group, 16.2 (S.E. = 5.4) in the severe group and 10.9 (S.E. = 2.3) in the mild gait disability group. CONCLUSIONS: We presented comprehensive evidence verifying the effects of an intense goal-directed physical rehabilitation program on ambulation in people with multiple sclerosis presenting with different neurological impairment levels.

Quantifying gait impairment using an instrumented treadmill in people with multiple sclerosis.

Background and Objective. Treadmill gait analysis has been proposed as an attractive alternative for overground walking measuring systems. The purpose of this study was twofold: first to determine spatiotemporal parameters of treadmill gait in patients with multiple sclerosis (MS) and second to examine whether these parameters are associated with specific functional impairments in this cohort. Method. Eighty-seven relapsing-remitting patients diagnosed with MS, 50 women and 37 men, aged 40.9 ± 11.9 with an expanded disability status scale (EDSS) score of 2.7 ± 1.6, participated in this study. Twenty-five apparently healthy subjects, 14 women and 11 men, aged 38.5 ± 9.4, served as controls. Spatiotemporal gait parameters were obtained using the Zebris FDM-T Treadmill (Zebris Medical GmbH, Germany). People with MS demonstrated significantly shorter steps, extended stride time, wider base of support, longer step time, reduced single support phase, and a prolonged double support phase compared to the healthy controls. The EDSS score was significantly correlated with all spatiotemporal gait parameters. Conclusion. The instrumented treadmill may be an effective tool in assessing ambulation capabilities of people with MS.