Self-Report Measures of Fatigue for People With Multiple Sclerosis: A Systematic Review.

BACKGROUND AND PURPOSE: The symptom of fatigue impairs function in people with multiple sclerosis (MS). Choosing appropriate measures to assess fatigue is challenging. The purpose of this article is to report the findings of a systematic review of patient-reported fatigue measures for people with MS. METHODS: PubMed, CINAHL, and Embase databases were searched through January 2020 using terms related to fatigue and MS. Studies were included if the sample size was 30 or more or smaller samples if adequately powered, and if information about measurement characteristics (ie, test-retest reliability, content validity, responsiveness, interpretability, or generalizability) of the measure(s) could be extracted. Study quality was appraised with the 2-point COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Data about measurement characteristics, psychometrics, and clinical utility were extracted and results were synthesized. RESULTS: Twenty-four articles met inclusion criteria with information about 17 patient-reported fatigue measures. No studies had critical methodologic flaws. Measurement characteristic data were not available for all measures. Clinical utility varied in time to complete and fatigue domains assessed. DISCUSSION AND CONCLUSIONS: Five measures had data pertaining to all properties of interest. Of these, only the Modified Fatigue Impact Scale (MFIS) and Fatigue Severity Scale (FSS) had excellent reliability, responsiveness data, no notable ceiling/floor effects, and high clinical utility. We recommend the MFIS for comprehensive measurement and the FSS for screening of subjective fatigue in people with MS.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A443 ).

Reliability, Validity, and Responsiveness of the Patient-Specific Functional Scale for Measuring Mobility-Related Goals in People With Multiple Sclerosis.

BACKGROUND AND PURPOSE: This study's purpose was to investigate the reliability, validity, and responsiveness of the Patient-Specific Functional Scale (PSFS) for measuring mobility-related goals in people with multiple sclerosis (MS). METHODS: Data from 32 participants with MS who underwent 8 to 10 weeks of rehabilitation were analyzed (Expanded Disability Status Scale scores 1.0-7.0). For the PSFS, participants identified 3 mobility-related areas where they had difficulty and rated them at baseline, 10 to 14 days later (before starting intervention), and immediately after intervention. Test-retest reliability and response stability of the PSFS were calculated using the intraclass correlation coefficient (ICC 2,1 ) and minimal detectable change (MDC 95 ), respectively. Concurrent validity of the PSFS was determined with the 12-item Multiple Sclerosis Walking Scale (MSWS-12) and the Timed 25-Foot Walk Test (T25FW). PSFS responsiveness was determined using Cohen's d , and minimal clinically important difference (MCID) was calculated based on patient-reported improvements on a Global Rating of Change (GRoC) scale. RESULTS: The PSFS total score demonstrated moderate reliability (ICC 2,1 = 0.70, 95% CI: 0.46 to 0.84) and the MDC was 2.1 points. At baseline, the PSFS was fairly and significantly correlated with the MSWS-12 ( r = -0.46, P = 0.008) but not with the T25FW. Changes in the PSFS were moderately and significantly correlated with the GRoC scale (ρ = 0.63, P < 0.001), but not with MSWS-12 or T25FW changes. The PSFS was responsive ( d = 1.7), and the MCID was 2.5 points or more to identify patient-perceived improvements based on the GRoC scale (sensitivity = 0.85, specificity = 0.76). DISCUSSION AND CONCLUSIONS: This study supports the use of the PSFS as an outcome measure in people with MS to assess mobility-related goals.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A423 ).

Effects of Intermittent Versus Continuous Walking on Distance Walked and Fatigue in Persons With Multiple Sclerosis: A Randomized Crossover Trial.

BACKGROUND AND PURPOSE: Fatigue is a common, disabling symptom experienced by persons with multiple sclerosis (MS). Evidence shows that intermittent exercise is associated in improved performance and negligible fatigue. The purpose of this study was to examine whether subjects with MS walk greater distances with less fatigue under intermittent (INT) or continuous (CONT) walking condition. METHODS: Twenty-seven subjects with MS (median Extended Disability Severity Scale 3.5, interquartile range 1.6) walked in the CONT (ie, 6 uninterrupted minutes) and INT (ie, three 2-minute walking bouts) conditions in a randomized crossover. Distance was measured for the entire 6-minute walking period and each 2-minute increment. Fatigue was measured as the difference in a visual analog scale of fatigue (ΔVAS-F) immediately preceding and following each trial. RESULTS: Participants walked greater distances in the INT condition compared to the CONT condition (P = 0.005). There was a significant interaction of walking condition and time (P < 0.001), indicating that the distances walked in the INT condition changed across time. ΔVAS-F was significantly lower in the INT condition than in the CONT condition (P = 0.036). DISCUSSION AND CONCLUSION: Subjects with MS walked farther, and with less fatigue, when walking intermittently rather than continuously. Persons with MS may be able to tolerate a greater dose of walking training if the walking bouts are intermittent. Further study to determine the benefits of a walking exercise program using intermittent walking is recommended.Video Abstract available for additional insights from the authors (Supplemental Digital Content 1, http://links.lww.com/JNPT/A103).

Feasibility of Low-Load Resistance Training Using Blood Flow Restriction for People With Advanced Multiple Sclerosis: A Prospective Cohort Study.

OBJECTIVE: The objective of this study was to determine the feasibility of low-load resistance training with blood flow restriction (BFR) for people with advanced disability due to multiple sclerosis (MS). METHODS: In this prospective cohort study, 14 participants with MS (Expanded Disability Status Scale [EDSS] score = 6.0 to 7.0; mean age = 55.4 [SD = 6.2] years; 71% women) were asked to perform 3 lower extremity resistance exercises (leg press, calf press, and hip abduction) bilaterally twice weekly for 8 weeks using BFR. Feasibility criteria were as follows: enrollment of 20 participants, ≥80% retention and adherence, ≥90% satisfaction, and no serious adverse events related to the intervention. Other outcomes included knee extensor, ankle plantar flexor, and hip abductor muscle strength, 30-Second Sit-to-Stand Test, Berg Balance Scale, Timed 25-Foot Walk Test, 12-Item MS Walking Scale, Modified Fatigue Impact Scale, Patient-Specific Functional Scale, and daily step count. RESULTS: Sixteen participants consented, and 14 completed the intervention, with 93% adherence overall. All participants were satisfied with the intervention. A minor hip muscle strain was the only intervention-related adverse event. There were muscle strength improvements on the more-involved (16%-28%) and less-involved (12%-19%) sides. There were also changes in the 30-Second Sit-to-Stand Test (1.9 repetitions; 95% CI = 1.0 to 2.8), Berg Balance Scale (5.3 points; 95% CI = 3.2 to 7.4), Timed 25-Foot Walk Test (-3.3 seconds; 95% CI = -7.9 to 1.3), Modified Fatigue Impact Scale (-8.8 points; 95% CI = -16.5 to -1.1), 12-Item MS Walking Scale (-3.6 points; 95% CI = -11.5 to 4.4), Patient-Specific Functional Scale (2.9 points; 95% CI = 1.9 to 3.8), and daily step count (333 steps; 95% CI = -191 to 857). CONCLUSION: Low-load resistance training using BFR in people with MS and EDSS scores of 6.0 to 7.0 appears feasible, and subsequent investigation into its efficacy is warranted. IMPACT: Although efficacy data are needed, combining BFR with low-load resistance training may be a viable alternative for people who have MS and who do not tolerate conventional moderate- to high-intensity training because of more severe symptoms, such as fatigue and weakness. LAY SUMMARY: Low-load strength training with BFR was feasible in people who have advanced disability due to MS. Using BFR may provide an alternative for people with MS who do not tolerate higher intensity training due to more severe symptoms, such as fatigue and weakness.

Effect of Backward and Forward Walking on Lower Limb Strength, Balance, and Gait in Multiple Sclerosis: A Randomized Feasibility Trial.

BACKGROUND: Backward walking (BW) interventions have improved gait and balance in persons with stroke, cerebral palsy, and Parkinson disease but have not been studied in persons with multiple sclerosis (MS). We examined the feasibility of a BW intervention and how it affected strength, balance, and gait vs forward walking (FW) in persons with MS. METHODS: Sixteen persons with MS with a Patient-Determined Disease Steps (PDDS) scale score of 3 to 5 (gait impairment-late cane) were randomized to the FW (n = 8) or BW (n = 8) group. Participants did 30 minutes of FW or BW on a treadmill 3 times per week for 8 weeks (24 visits). Enrollment, adherence rate, and safety were tracked. The Timed Up and Go test, Six-Spot Step Test, single-leg stance, and abbreviated Activities-specific Balance Confidence scale were used to measure balance. Hip and knee flexion and extension strength (isometric peak torque), gait speed, and spatiotemporal gait parameters were measured. A 2×2 factorial multivariate analysis of covariance was used to examine changes in strength, balance, and gait, with the PDDS scale score as the covariate. RESULTS: Treatment adherence rate was 99.7%, with no safety concerns. After controlling for baseline differences in disability (PDDS scale score; P = .041), the BW group improved dominant hip flexion strength preintervention to postintervention compared with the FW group (F 1,13 = 9.03; P = .010). No other significant differences were seen between groups. CONCLUSIONS: This was the first study to look at BW as an intervention in persons with MS. Based on its feasibility, safety, and significant finding, BW should be studied in a larger, definitive trial in the future.

Trekking Poles to Aid Multiple Sclerosis Walking Impairment: An Exploratory Comparison of the Effects of Assistive Devices on Psychosocial Impact and Walking.

BACKGROUND: Walking dysfunction is reported by two-thirds of persons with multiple sclerosis (MS). Assistive devices are frequently recommended to improve walking; however, it is uncommon to consider their psychosocial impact, although many users abandon their assistive devices. The psychosocial impact, walking, balance, and fatigue associated with three assistive devices were compared to guide clinical decision making. METHODS: Twenty-five persons with MS (median Expanded Disability Status Scale score, 4.0; range, 2.5-6.0) who reported walking difficulty were trained in the use of three assistive devices-a single-point cane (SPC), a four-point cane (FPC), and a trekking pole (TP)-at 1- to 2-week intervals, then used the assistive device for their usual activities. Outcome measures included the Psychosocial Impact of Assistive Devices Scale (PIADS), the 6-Minute Walk Test (6MWT), walking speed, cadence, stride length, stride time, the 12-item Multiple Sclerosis Walking Scale (MSWS-12), the Activities-specific Balance Confidence (ABC) scale, the 5-item Modified Fatigue Impact Scale (MFIS-5), and a visual analogue scale of fatigue (VAS-F). RESULTS: The SPC and TP were more positive in the PIADS adaptability, competence, and self-esteem subscales. The SPC and TP resulted in higher 6MWT, walking speed, cadence, stride length, stride time, and MSWS-12 scores compared with the FPC. No differences were found in ABC scale, MFIS-5, or VAS-F scores. CONCLUSIONS: Participants reported more positive psychosocial impact, and walked faster and with higher quality, with the SPC and TP than with the FPC. Clinicians should consider suggesting an SPC or TP to patients who may benefit from assistive device use and for whom psychosocial impact is an important consideration.

Blood-Flow Restriction Training for a Person With Primary Progressive Multiple Sclerosis: A Case Report.

OBJECTIVE: Blood flow restriction (BFR) training, in which an inflatable cuff partially occludes blood flow around the proximal portion of a limb, coupled with low-intensity resistance training (LIRT) has resulted in gains comparable with traditional progressive resistive exercise in healthy populations. The use of BFR with LIRT may enable people with multiple sclerosis (MS) to improve strength without an increase in fatigue. The purpose of this case report is to describe the use of a BFR/LIRT program for a person with MS. METHODS: The patient was a 54-year-old woman with a 13-year history of primary progressive MS with an Extended Disability Severity Score of 3.0 out of 10. She received a BFR/LIRT program for both lower extremities biweekly for 12 weeks. Outcomes measured at baseline and at 6 and 12 weeks included the 12-item Multiple Sclerosis Walking Scale (MSWS-12), Fatigue Severity Scale, Patient-Specific Functional Scale (PSFS) (goals: running for exercise and pleasure for 45 minutes, 100% confidence in negotiating a flight of stairs, confidently and safely drive without restriction), and 14 lower extremity strength tests. RESULTS: The intervention was well tolerated without adverse events. After 6 weeks, the MSWS-12 score improved; however, it did not exceed minimum detectable change (MDC). Fatigue Severity Scale was unchanged. All PSFS goals improved beyond MDC, and improvements in strength exceeded MDC in 2 out of 14 tests. After 12 weeks, MSWS-12 improvements persisted and the Fatigue Severity Scale score improved, but neither exceeded MDC. The PSFS improvements persisted. There were improvements exceeding MDC for 8 out of 14 strength tests. The remaining 6 strength tests improved but did not exceed MDC. CONCLUSION: The patient had measurable improvements following the use of a BFR/LIRT program. BFR/LIRT may be an option for strength training in people with MS; however, research is needed to determine its safety and effectiveness across the population of people with MS. IMPACT: Traditional physical therapist interventions for people with MS have been shown to be beneficial; however, their usefulness has been limited by fatigue. A growing body of literature has demonstrated the effects of a BFR/LIRT program on strength and other measures of physical function in healthy populations and those with chronic disease. This case report adds missing information to the existing literature and suggests directions for research on the effectiveness of BFR/LIRT in people with primary progressive MS. LAY SUMMARY: Blood flow restriction, which has been used to help improve strength in healthy adults and in some people with chronic disease, applies pressure around the arm or leg to limit the flow of blood to that body part during exercise, helping to reduce fatigue. Blood flow restriction coupled with low-intensity strengthening exercises can be used for a person with MS.

Feasibility and Impact of an 8-Week Integrative Yoga Program in People with Moderate Multiple Sclerosis-Related Disability: A Pilot Study.

BACKGROUND: This pilot study determined the feasibility of a specifically designed 8-week yoga program for people with moderate multiple sclerosis (MS)-related disability. We explored the program's effect on quality of life (QOL) and physical and mental performance. METHODS: We used a single-group design with repeated measurements at baseline, postintervention, and 8-week follow-up. Feasibility was examined through cost, recruitment, retention, attendance, and safety. Outcomes included the Multiple Sclerosis Quality of Life Inventory (MSQLI), 12-item Multiple Sclerosis Walking Scale (MSWS-12), Timed 25-Foot Walk test (T25FW), 6-Minute Walk Test (6MWT), Nine-Hole Peg Test (NHPT), Five-Times Sit-to-Stand Test (FTSTS), Multidirectional Reach Test (MDRT), maximum expiratory pressure, and Paced Auditory Serial Addition Test-3″ (PASAT-3″). RESULTS: Fourteen participants completed the study. The program was feasible. There were significant main effects on the 36-item Short Form Health Status Survey Mental Component Summary (SF-36 MCS), Modified Fatigue Impact Scale (MFIS), Bladder Control Scale (BLCS), Perceived Deficits Questionnaire (PDQ), Mental Health Inventory (MHI), MSWS-12, T25FW, NHPT, PASAT-3″, 6MWT, FTSTS, and MDRT-Back. Improvements were found on the SF-36 MCS, MFIS, BLCS, PDQ, MHI, and MSWS-12 between baseline and postintervention. The effect on PDQ persisted at follow-up. Improvements were found on the T25FW, NHPT, 6MWT, FTSTS, and MDRT-Back between baseline and postintervention that persisted at follow-up. The PASAT-3″ did not change between baseline and postintervention but did between postintervention and follow-up. CONCLUSIONS: The yoga program was safe and feasible. Improvements in certain measures of QOL and performance were seen at postintervention and follow-up.

The Effect of Maximal Strength Training on Strength, Walking, and Balance in People with Multiple Sclerosis: A Pilot Study.

There is little literature examining the use of maximal strength training (MST) in people with multiple sclerosis (pwMS). This pretest-posttest study examined the effects of a MST program on strength, walking, balance, and fatigue in a sample of pwMS. Seven pwMS (median EDSS 3.0, IQR 1.5) participated in a MST program twice weekly for eight weeks. Strength was assessed with 1-repetition maximum (1RM) on each leg. Walking and balance were measured with the 6-Minute Walk Test (6MWT) and Berg Balance Scale (BBS), respectively. Fatigue was measured during each week of the program with the Fatigue Severity Scale (FSS). The program was well tolerated, with an attendance rate of 96.4%. Participants had significant improvements in right leg 1RM (t(6) = -6.032, P = 0.001), left leg 1RM (t(6) = -5.388, P = 0.002), 6MWT distance (t(6) = -2.572, P = 0.042), and BBS score (Z = -2.371, P = 0.018) after the MST intervention. There was no significant change in FSS scores (F(1, 3.312) = 2.411, P = 0.092). Participants in the MST program experienced improved balance and walking without an increase in fatigue. This MST program may be utilized by rehabilitation clinicians to improve lower extremity strength, balance, and mobility in pwMS.

Selecting Rehabilitation Outcome Measures for People with Multiple Sclerosis.

Despite the well-known benefits of using standardized outcome measures (OMs) in clinical practice, a variety of barriers interfere with their use. In particular, rehabilitation therapists lack sufficient knowledge in selecting appropriate OMs. The challenge is compounded when working with people with multiple sclerosis (MS) owing to heterogeneity of the patient population and symptom variability in individual patients. To help overcome these barriers, the American Physical Therapy Association appointed the Multiple Sclerosis Outcome Measures Task Force to review and make evidence-based recommendations for OM use in clinical practice, education, and research specific to people with MS. Sixty-three OMs were reviewed based on their clinical utility, psychometric properties, and a consensus evaluation of the appropriateness of use for people with MS. We sought to illustrate use of the recommendations for two cases. The first case involves a 43-year-old man with new-onset problems after an exacerbation. The second case pertains to an outpatient clinic interested in assessing the effectiveness of their MS rehabilitation program. For each case, clinicians identified areas that were important to assess and various factors deemed important for OM selection. Criteria were established and used to assist in OM selection. In both cases, the described processes narrowed the selection of OMs and assisted with choosing the most appropriate ones. The recommendations, in addition to the processes described in these two cases, can be used by clinicians in any setting working with patients with MS across the disability spectrum.