Going home to die from critical care: A case study.

Much of the activity in critical care is complex but repetitive. In order to standardize care and maintain safety, delivery of care is often directed by protocols and care bundles. This case study will reflect on an instance where care transcended the standard protocol-directed path to be more individualized, creative and compassionate. Acts like these can be unique for the practitioners involved and require an element of positive risk taking, which happened here. It will look at the decision-making, planning and risk involved in preparing for a terminally ill patient, who was inotrope and high-flow oxygen dependent, to go home to have treatment withdrawn there instead of in the hospital. This was to fulfil his wish to die at home. In unpicking the circumstances where this positive risk taking led to the desired outcome and the relationship between safety, uncertainty and risk, three themes arose. These were the journey to safe uncertainty; decision-making with uncertain outcomes; and the importance of robust human factors, particularly effective communication and inter-professional teamwork. If positive risk taking can result in enhanced outcomes for the patient, then the question of how this behaviour can be fostered and encouraged must be addressed.

The willingness of informal caregivers to assist their care-recipient to use Home Medicines Review.

OBJECTIVES: Informal caregivers experience daily hassles - a form of persistent stress, as a consequence of caregiving. This study aimed to develop and test a new theoretical model of health information-seeking behaviour, the Knowledge Hassles Information Seeking Model (KHISM). KHISM hypothesized that the knowledge hassles of caregivers - daily stressors experienced while dealing with tasks which require knowledge about the safety and effectiveness of the care-recipients' medicines - would influence caregivers' willingness to assist their care-recipient to use an Australian medication management service, Home Medicines Review (HMR). METHODS: A cross-sectional postal survey was conducted among 2350 members of Carers (NSW, Australia). Respondents were included in the study if they were involved in medication-related tasks for their care-recipient and were not paid as caregivers. Also, their care-recipient needed to be taking more than five medicines daily or more than 12 doses daily and had not yet experienced HMR. Structural equation modelling was used to test the model. RESULTS: A total of 324 useable surveys were returned yielding a response rate of 14%. Respondents were quite willing to assist their care-recipient to use HMR (willingness). The model predicted 51% of the variation in willingness. Knowledge hassles increased positive outcome expectancy (ß = 0.40, P < 0.05) and indirectly increased willingness. CONCLUSIONS: The more caregivers experience hassles with medication knowledge, the more they perceive HMR to be a helpful information source and the more willing they are to use it. Targeted marketing centred on HMR as an information source may increase caregivers' demand for HMR. Further exploration of the phenomenon of knowledge hassles is warranted.

Chronic exercise confers neuroprotection in experimental autoimmune encephalomyelitis.

Multiple sclerosis (MS) is an autoimmune disease that affects the CNS, resulting in accumulated loss of cognitive, sensory, and motor function. This study evaluates the neuropathological effects of voluntary exercise in mice with experimental autoimmune encephalomyelitis (EAE), an animal model of MS. Two groups of C57BL/6J mice were injected with an emulsion containing myelin oligodendrocyte glycoprotein and then randomized to housing with a running wheel or a locked wheel. Exercising EAE mice exhibited a less severe neurological disease score and later onset of disease compared with sedentary EAE animals. Immune cell infiltration and demyelination in the ventral white matter tracts of the lumbar spinal cord were significantly reduced in the EAE exercise group compared with sedentary EAE animals. Neurofilament immunolabeling in the ventral pyramidal and extrapyramidal motor tracts displayed a more random distribution of axons and an apparent loss of smaller diameter axons, with a greater loss of fluorescence immunolabeling in the sedentary EAE animals. In lamina IX gray matter regions of the lumbar spinal cord, sedentary animals with EAE displayed a greater loss of α-motor neurons compared with EAE animals exposed to exercise. These findings provide evidence that voluntary exercise results in reduced and attenuated disability, reductions in autoimmune cell infiltration, and preservation of axons and motor neurons in the lumbar spinal cord of mice with EAE.

Core outcome measures for exercise studies in people with multiple sclerosis: recommendations from a multidisciplinary consensus meeting.

Evidence shows that exercise is beneficial for people with multiple sclerosis (MS); however, statistical pooling of data is difficult because of the diversity of outcome measures used. The objective of this review is to report the recommendations of an International Consensus Meeting for a core set of outcome measures for use in exercise studies in MS. From the 100 categories of the International Classification of Function Core Sets for MS, 57 categories were considered as likely/potentially likely to be affected by exercise and were clustered into seven core groups. Outcome measures to address each group were evaluated regarding, for example, psychometric properties. The following are recommended: Modified Fatigue Impact Scale (MFIS) or Fatigue Severity Scale (FSS) for energy and drive, 6-Minute Walk Test (6MWT) for exercise tolerance, Timed Up and Go (TUG) for muscle function and moving around, Multiple Sclerosis Impact Scale (MSIS-29) or Multiple Sclerosis Quality of Life-54 Instrument (MSQoL54) for quality of life and body mass index (BMI) or waist-hip ratio (WHR) for the health risks associated with excess body fat. A cost effectiveness analysis and qualitative evaluation should be included where possible. Using these core measures ensures that future meta-analyses of exercise studies in MS are more robust and thus more effectively inform practice.

Repeatability of the timed 25-foot walk test for individuals with multiple sclerosis.

OBJECTIVE: The purpose of this study was to determine if there is a practice effect present in the timed 25-foot walk in ambulatory individuals with multiple sclerosis. DESIGN: Thirty six people (30 women and 6 men) diagnosed with relapsing remitting multiple sclerosis participated in two testing sessions, one week apart. Each participant performed two sequential trials of the timed 25-foot walk test per session and the walk performance was measured with a laser timing system. RESULTS: We observed improvements in walking speed between the two trials of session one (trial one: 6.42 (0.09) vs. trail two: 5.97 (0.08) seconds, p < 0.001). Within session two, performance remained stable (trial three: 5.71 (0.07) vs. trial four: 5.63 (0.07) seconds, p > 0.05). We also observed a significant improvement in walking speed when averages of the two trials were compared across sessions (session 1: 6.19 (0.09) vs. session 2: 5.67 (0.07) seconds, p < 0.01). CONCLUSIONS: Based on our results, familiarization of the timed 25-foot walk test improves stability of walk performance scores in ambulatory individuals with relapsing remitting multiple sclerosis.

Exercise and quality of life in women with multiple sclerosis.

The purpose of this study was to evaluate perceptions of quality of life after a 4-month progressive resistance training program for individuals with multiple sclerosis (MS). A second purpose was to examine participants' views about factors that facilitated or impeded exercise behavior. Qualitative interviews were conducted with eight females (Mage = 49.86, SD = 6.94) with relapsing remitting MS. Audio-tape recorded interviews were transcribed verbatim and coded. Walking performance improved (M = 13.08%, SD = 7.11). All participants perceived improvements in muscular strength and endurance while six indicated improvements in walking endurance and performance in tasks of daily living. Social benefits of participation were discussed by seven participants including interactions in the exercise environment. We concluded that supervised resistance training may promote improvements in QOL for women with relapsing remitting MS.

Medicine use of elderly Chinese and Vietnamese immigrants and attitudes to home medicines review.

There is a paucity of research into the perceptions of elderly Australian ethnic minorities towards public health services related to quality use of medicines. Among the six fastest growing ethnic groups in Australia, the Mandarin-speaking Chinese and Vietnamese constitute the largest elderly populations with poor English skills. This paper investigates the relationships of elderly Chinese and Vietnamese migrants with medicines, general practitioners and pharmacists, and how these relationships influence their awareness and attitudes of the home medicines review (HMR) program. Two semi-structured focus groups were held with a total of 17 HMR-eligible patients who have never received a HMR, one with Chinese and one with Vietnamese respondents, each in the respective community language. Confusion about medications and an intention to have a HMR were pronounced among all participants although none of them had heard of the program before participating in the focus groups. Respondents reported difficulties locating a pharmacist who spoke their native language, which contributed to an increased unmet need for medicine information. The Chinese group additionally complained about a lack of support from their general practitioners in relation to their medicine concerns and was adamant that they would prefer to have a HMR without the involvement of their general practitioner. Our results indicate a distinct HMR need but not use among elderly Chinese and Vietnamese eligible patients with poor English skills. Home medicines review service use and perceived medication problems are likely to improve with an increasing availability of bilingual and culturally sensitive health care providers.

A sociocognitive approach to service quality and adherence amongst elderly patients: a pilot study.

This article examines the relationship between patients' perceptions of emotional intelligence (EI), health competence, service quality, and adherence behavior in the Home Medicines Review (HMR) setting. Participants were purposively recruited from different urban and regional areas in Australia and qualitative data were obtained from in-depth interviews with 20 HMR patients. Service quality is conceptualized from a sociocognitive perspective by incorporating psycho-socio factors such as EI and health competence as moderators to overall service quality and adherence. The findings suggest that EI and health competence influence patient perceptions of service quality and nonadherence at multiple levels of abstraction. Implications are that staff training and development programs that incorporate EI could improve service delivery which could increase patient perceptions of service quality and adherence. Designing intervention initiatives aimed at increasing patient awareness and education of their health conditions could also improve service quality perceptions and adherence behavior.

Qualitative triadic study of the relational factors influencing the formation of quality in a community-based aged health care service network.

A service is produced through the interactions of the various service participants. This study aims to identify the factors that influence the interactions of the service providers, recipients, and enablers of a community-based aged health care service, within a single service network. Interviews were conducted with the manager, three care workers, and five clients using the convergent interview technique. Data were analyzed inductively using thematic content analysis. Client focus, client contribution, client empowerment, and provider empowerment were identified as key themes. Whilst these themes are independently supported by the literature, they have previously been studied largely in isolation to each other.

Stakeholders' views of service quality in community pharmacy: a qualitative study.

This study investigates the views of a range of stakeholders regarding the effectiveness of service quality as a differentiating position for community pharmacy. Using qualitative methodology, 20 in-depth interviews were conducted with various stakeholders of the retail pharmacy market, including community pharmacists. It was found that current service levels were perceived to be variable, with a strong level of concern evident that the rhetoric of professionalism in community pharmacy is not always matched by the reality. There was disagreement regarding whether potential market entrants such as supermarkets would be capable of delivering a high quality of service and indeed whether that would even be their objective.

Cytokine responses to acute and chronic exercise in multiple sclerosis.

Regular exercise reduces functional loss associated with multiple sclerosis (MS). However, the impact of exercise on inflammatory mediators associated with disease activity remains relatively unexplored. The purpose of this study was to determine whether ambulatory MS subjects would respond similarly to aerobic cycle training compared with matched controls on circulating immune variables, interleukin (IL)-6, tumor necrosis factor (TNF)-alpha and interferon (IFN)-gamma. Eleven MS and 11 non-MS control subjects (8 women and 3 men in both groups) matched in age, height, body mass, body fat, and peak O(2) uptake completed the study. Subjects completed 30 min of cycle ergometry at 60% of peak O(2) uptake, 3 day/wk for 8 wk. Plasma cytokine concentrations were determined before and after exercise at weeks 0, 4, and 8. MS and control subjects showed a similar cytokine responses to exercise. IL-6 at rest tended to decrease (P = 0.08) with training in both groups. Resting plasma TNF-alpha tended to be higher in MS compared with controls throughout the study (P = 0.08). MS subjects showed elevated resting TNF-alpha in MS at the end of the 8-wk program (P = 0.04), whereas resting TNF-alpha remained unchanged in controls (P > 0.05). Resting plasma IFN-gamma at rest was elevated in MS subjects (P = 0.008) and unchanged in controls at the end of the intervention (P > 0.05). The response of plasma IL-6, TNF-alpha, and IFN-gamma after a single bout of exercise was similar between MS and control subjects (P > 0.05). Additional research to understand the impact of exercise on immune variables in MS is warranted.

Exercise and brain health--implications for multiple sclerosis: Part 1--neuronal growth factors.

The benefits of regular exercise to promote general health and reduce the risk of hypokinetic diseases associated with sedentary lifestyles are well recognized. Recent studies suggest that exercise may enhance neurobiological processes that promote brain health in aging and disease. A current frontier in the neurodegenerative disorder multiple sclerosis (MS) concerns the role of physical activity for promoting brain health through protective, regenerative and adaptive neural processes. Research on neuromodulation, raises the possibility that regular physical activity may mediate favourable changes in disease factors and symptoms associated with MS, in part through changes in neuroactive proteins. Insulin-like growth factor-I appears to act as a neuroprotective agent and studies indicate that exercise could promote this factor in MS. Neurotrophins, brain-derived neurotrophic factor (BDNF) and nerve growth factor likely play roles in neuronal survival and activity-dependent plasticity. Physical activity has also been shown to up-regulate hippocampal BDNF, which may play a role in mood states, learning and memory to lessen the decline in cognitive function associated with MS. In addition, exercise may promote anti-oxidant defences and neurotrophic support that could attenuate CNS vulnerability to neuronal degeneration. Exercise exposure (preconditioning) may serve as a mechanism to enhance stress resistance and thereby may support neuronal survival under heightened stress conditions. Considering that axonal loss and cerebral atrophy occur early in the disease, exercise prescription in the acute stage could promote neuroprotection, neuroregeneration and neuroplasticity and reduce long-term disability. This review concludes with a proposed conceptual model to connect these promising links between exercise and brain health.

Exercise and brain health--implications for multiple sclerosis: Part II--immune factors and stress hormones.

Part I of this review addressed the possible modulatory role of exercise on neuronal growth factors to promote brain health in neurodegenerative diseases such as multiple sclerosis (MS), which is characterized by varied patterns of inflammation, demyelination and axonal loss. Part II presents evidence that supports the potential neuroprotective effect of exercise on the modulation of immune factors and stress hormones in MS. Many current therapies used to attenuate MS progression are mediated, at least in part, through alterations in the relative concentrations of pro- and anti-inflammatory cytokines. Exercise-induced alterations in local and systemic cytokine production may also benefit immune function in health and disease. Exercise immunomodulation appears to be mediated by a complex interaction of hormones, cytokines and neural factors that may favorably influence immune variables in MS. The promising interplay between exercise and brain health in MS deserves further investigation.

Ratings of perceived exertion during aerobic exercise in multiple sclerosis.

OBJECTIVE: To compare ratings of perceived exertion (RPEs) during aerobic exercise in people with multiple sclerosis (MS) and control participants. DESIGN: Prospective experimental study. SETTING: An exercise testing laboratory. PARTICIPANTS: Sedentary adults (n=12) with mild MS (Expanded Disability Status Scale score < or = 3) aged 30 to 45 years and sedentary age-matched and sex-matched controls (n=12). INTERVENTIONS: All participants underwent a graded aerobic exercise test on a cycle ergometer with breath-by-breath gas measurements and continuous heart rate monitoring. MAIN OUTCOME MEASURES: After completing the Modified Fatigue Impact Scale, participants rated their effort sense every 30 seconds during exercise using the modified Borg 10-point scale. RESULTS: The 2 study groups showed similar baseline characteristics except for higher fatigue scores in the MS group. There were no significant differences for any fitness measure, including oxygen cost slope (in VO(2) x min(-1) x W(-1)), VO(2), or work rate during exercise. Neither heart rate nor RPE--measured at 25%, 50%, 75%, and 100% of VO(2)peak--differed between groups. CONCLUSIONS: Despite greater reported fatigue levels, participants with MS showed similar RPE and physiologic responses to submaximal and maximal exercise compared with controls. In MS, the Borg 10-point scale may help improve evidence-based exercise prescriptions, which otherwise may be limited by fatigue, motor impairment, heat sensitivity, or autonomic dysfunction.

Early-phase neuroendocrine responses and strength adaptations following eccentric-enhanced resistance training.

The purpose of this study was to evaluate the early-phase muscular performance adaptations to 5 weeks of traditional (TRAD) and eccentric-enhanced (ECC+) progressive resistance training and to compare the acute postexercise total testosterone (TT), bioavailable testosterone (BT), growth hormone (GH), and lactate responses in TRAD- and ECC+-trained individuals. Twenty-two previously untrained men (22.1 +/- 0.8 years) completed 1 familiarization and 2 baseline bouts, 15 exercise bouts (i.e., 3 times per week for 5 weeks), and 2 postintervention testing bouts. Anthropometric and 1 repetition maximum (1RM) measurements (i.e., bench press and squat) were assessed during both baseline and postintervention testing. Following baseline testing, participants were randomized into TRAD (4 sets of 6 repetitions at 52.5% 1RM) or ECC+ (3 sets of 6 repetitions at 40% 1RM concentric and 100% 1RM eccentric) groups and completed the 5-week progressive resistance training protocols. During the final exercise bout, blood samples acquired at rest and following exercise were assessed for serum TT, BT, GH, and blood lactate. Both groups experienced similar increases in bench press (approximately 10%) and squat (approximately 22%) strength during the exercise intervention. At the conclusion of training, postexercise TT and BT concentrations increased (approximately 13% and 21%, respectively, p < 0.05) and GH concentrations increased (approximately 750-1200%, p < 0.05) acutely following exercise in both protocols. Postexercise lactate accumulation was similar between the TRAD (5.4 +/- 0.4) and ECC+ (5.6 +/- 0.4) groups; however, the ECC+ group's lactate concentrations were significantly lower than those of the TRAD group 30 to 60 minutes into recovery. In conclusion, TRAD training and ECC+ training appear to result in similar muscular strength adaptations and neuroendocrine responses, while postexercise lactate clearance is enhanced following ECC+ training.

Neuroendocrine responses to an acute bout of eccentric-enhanced resistance exercise.

PURPOSE: The purpose of this study was to compare the total testosterone (TT), bioavailable testosterone (BT), growth hormone (GH), lactate, and ratings of perceived exertion (RPE) responses between a single bout of traditional (TRAD) and eccentric-enhanced resistance exercise (ECC+) of matched training volumes. METHODS: Twenty-two previously untrained males (21.9+/-0.8 yr) completed one familiarization and one baseline 1RM testing bout, for the bench press and squat exercises, and then two exercise bouts. During exercise bout 1, all subjects completed a TRAD protocol (four sets of six reps at 52.5% 1RM), and the subsequent exercise bout consisted of either a TRAD or an ECC+ protocol (three sets of six reps at 40% 1RM concentric and 100% 1RM eccentric) for the bench press and squat exercises. Blood samples acquired at rest, immediately after (T1), and 15, 30, 45, and 60 min after exercise were assessed for serum TT, BT, GH, and blood lactate concentrations. RESULTS: Resting and postexercise TT, BT, and GH were not significantly different between groups. Postexercise TT was not elevated during either bout or in either group, whereas BT increased 15-16% at T1 in both groups during bout 2. Postexercise GH concentrations were elevated 500-7000% above baseline after both protocols. Postexercise lactate accumulation and RPE were greater with ECC+ than TRAD. CONCLUSION: TRAD and ECC+ show similar neuroendocrine and differing metabolic responses during the early phase of resistance exercise in untrained, college-age men.

Cardiovascular/non-insulin-dependent diabetes mellitus risk factors and intramyocellular lipid in healthy subjects: a sex comparison.

Little is known about the relationship between intramyocellular lipid (IMCL) and coronary artery disease (CAD)/non-insulin-dependent diabetes mellitus risk factors. The aim of the study was to examine the relationship between IMCL and CAD/non-insulin-dependent diabetes mellitus risk factors in healthy male (n = 9) and female (n = 10) subjects with similar norm-based aerobic fitness and body composition. Nineteen volunteers (21-36 years) completed health and physical activity questionnaires, cardiovascular and body composition evaluation, and assessment of thigh IMCL using proton magnetic resonance spectroscopy. Outcome measures were blood pressure, total cholesterol, high-density lipoprotein cholesterol, C-reactive protein, interleukin 6, tumor necrosis factor alpha (TNF-alpha), homocysteine, insulin resistance (IR), percentage of body fat, waist-to-hip ratio, physical activity levels, and cardiovascular fitness. Analysis of variance was used for group comparisons. Correlation analyses were used to determine association between variables, and stepwise regression was used to determine predictive variables of IR. Women had 2-fold higher IMCL and greater IR than men (P < .05). Men had greater plasma homocysteine and interleukin 6 concentration (P < .05) as well as stronger correlations with CAD risk factors than female subjects. Correlation analyses using all subjects revealed a significant relationship between IMCL and waist-to-hip ratio, body weight, percentage of body fat, and IR. In the regression analysis, age, IMCL, and TNF-alpha were the strongest predictors of IR (R2 = 0.62, P < .01). Our results suggest that female subjects, matched for age and fitness, have higher IMCL compared with their male counterparts. IMCL was correlated with several CAD and prediabetes markers in both male and female subjects. In the final regression model, age, IMCL, and TNF-alpha were the strongest predictors of IR. Future studies with larger sample sizes are warranted.

Effect of resistance exercise on skeletal muscle myopathy in heart transplant recipients.

The purpose of this study was to determine the efficacy of resistance exercise in reversing skeletal muscle myopathy in heart transplant recipients. Myopathy, engendered by both heart failure and immunosuppression with glucocorticoids, is a post-transplant complication. The sequelae of myopathic disease includes fiber-type shifts and deficits in aerobic metabolic capability. We randomly assigned patients to either 6 months of resistance exercise (training group; n = 8) or a control (control group; n = 7) group. Exercise was initiated at 2 months after transplant. Biopsy of the right vastus lateralis was performed before and after the 6-month intervention. Myosin heavy chain (MHC) composition was assessed using sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Biochemical assays were performed to determine citrate synthase, 3-hydroxyacyl-CoA-dehydrogenase, and lactate dehydrogenase activity. There were no group differences (p >or=0.05) in MHC composition and enzymatic reserve at baseline. Improvements in the training group for citrate cynthase (+40%), 3-hydroxyacyl-CoA-dehydrogenase (+10%), and lactate dehydrogenase activity (+48%) were significantly greater (p

The impact of patients' perceptions of the listening skills of the pharmacist on their willingness to re-use Home Medicines Reviews: a structural equation model.

BACKGROUND: Research has shown that consumers prefer a pharmacist who is skilled in communication and pays particular attention to friendliness, empathy and attentiveness. Medication management interviews tend to be more time consuming than other patient-pharmacist interactions. The extra time for these interviews provides patients with an opportunity to evaluate the quality of interpersonal care provided by the pharmacist. Patient evaluations of pharmacists may influence their intentions to use medication management services. In previous studies, a conceptual model based on information-seeking theory was developed and used to explain a significant amount of the variation in consumers' and caregivers' willingness to use Australia's Home Medicines Review (HMR) service. OBJECTIVE: The aim of this paper was to extend the conceptual model to include the influence of patients' evaluation of interpersonal care provided. We aimed to test the hypothesis that patients' perceptions of how well the pharmacist listened to them during their most recent HMR interview (Listening) would increase their willingness to re-use HMR (Willingness). METHODS: Patients (N = 595) who had experienced Australia's Home Medicines Review (HMR) within the previous 6 months completed questionnaires. Exploratory and confirmatory factor analyzes were used to validate the measurement scales. Structural equation modeling was used to test the model. RESULTS: The structural model provided a reasonable fit to the data and explained 53% of the variation in Willingness. The structural model revealed that Listening increased patients' perceptions that the HMR provided positive outcomes (Outcomes) (ß = 0.37, P < 0.05) and directly and indirectly increased Willingness (ß = 0.61, P < 0.05). CONCLUSION: These results suggest that patients' willingness to use a medication management service in the future is strongly influenced by their perceptions of how well the pharmacist listened to them during their last medication review interview. Improving pharmacist listening skills may be explored as a strategy for improving patient engagement with pharmacy services.

Sit-to-stand biomechanics of individuals with multiple sclerosis.

BACKGROUND: It is unclear how people with multiple sclerosis, who often have compromised strength and balance, compare to healthy controls during sit-to-stand movements. The purpose of this study was to compare sit-to-stand biomechanics among three groups: people with multiple sclerosis who exhibit leg weakness, people with multiple sclerosis who have comparable strength to controls, and healthy controls. METHODS: Twenty-one individuals with multiple sclerosis (n=10 exhibiting leg weakness: n=11 exhibiting comparable strength to controls), and 12 controls performed five sit-to-stand trials while kinematic data and ground reaction forces were captured. ANOVAs followed by Tukey's post-hoc tests (α=0.05) were used to determine group and limb differences for leg strength, movement time, and sagittal-plane joint kinematics and kinetics. FINDINGS: Persons with multiple sclerosis exhibiting leg weakness displayed decreased leg strength, greater trunk flexion, faster trunk flexion velocity and decreased knee extensor power compared to the other two groups (p<0.05; d≥0.87), and slower rise times compared to controls(p<0.03; d≥1.17). No differences were found between controls and the multiple sclerosis-comparable strength group. Across all 3 groups, leg strength was moderately correlated with trunk kinematics and knee extensor velocities, moments and powers of the sit-to-stand (p≤0.05). INTERPRETATION: Participants with multiple sclerosis exhibiting leg weakness took longer to stand and appeared to use a trunk-flexion movement strategy when performing the sit-to-stand. The majority of group differences appear to be a result of leg extension weakness. Treatment that includes leg strengthening may be necessary to improve sit-to-stand performance for people with multiple sclerosis.