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 ).

Standing data disproves biomechanical mechanism for balance-based torso-weighting.

OBJECTIVE: To test a proposed mechanism for the effect of balance-based torso-weighting (BBTW) in people with multiple sclerosis (MS) and healthy controls. The mechanism to be tested is that application of light weights to the trunk may result in a biomechanical shift of postural sway in the direction of weighting, mechanically facilitating maintenance of the center of mass over the base of support. DESIGN: Nonrandomized controlled trial. SETTING: Motion analysis laboratory. PARTICIPANTS: Participants with MS (n=20; average Expanded Disability Status Scale score, 4.1) and controls matched for sex, age, height, and weight (n=18). INTERVENTION: Light weights strategically placed according to the BBTW protocol were applied to all participants after at least 3 walking trials and 10 seconds of quiet standing with feet together and eyes open and then eyes closed. Measures were repeated after weighting. MAIN OUTCOME MEASURE: Forceplate center of pressure (COP) changes >1 standard error of measurement. RESULTS: With BBTW, people with MS had larger maximum changes in COP than healthy controls in the left-right direction but not in the anterior-posterior direction. COP changes >1 standard error of measurement occurred in the same direction of weighting 20% of the time (95% confidence interval, 5-34), ranging from 10% to 28% across conditions and directions of postural sway. Direction of greatest weight placement did not match the direction of change in the average COP in most participants with MS or the healthy controls in eyes open or eyes closed conditions (P<.001). CONCLUSIONS: If BBTW worked via a biomechanical shift of the center of mass, COP changes should match the direction of greatest weighting with BBTW. Our data allowed us to reject this hypothesis. Future research may explore alternative mechanisms of action underlying this intervention.

Patterns of balance loss with systematic perturbations in Parkinson's disease and multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) and Parkinson's disease (PD) may affect balance differently. However, no studies have compared loss of balance (LOB) patterns following multi-directional perturbations. OBJECTIVE: 1) determine reliability of LOB ratings following standardized manual perturbations; 2) compare LOB ratings in MS, PD, and healthy control (HC) groups following perturbations at upper/lower torso, in anterior/posterior, right/left, and rotational directions. METHODS: 1) reviewers rated videotaped LOB following perturbations applied by 4 clinicians in 6-10 HCs. 2) three groups (64 MS, 42 PD and 32 HC) received perturbations. LOB ratings following perturbations were analyzed using two-factor mixed ANOVAs for magnitude and prevalence. RESULTS: 1) LOB ratings showed moderate to good ICC and good to excellent agreement. 2) MS group showed greater magnitude and prevalence of LOB than PD or HC groups (p < .001). All groups showed greater LOB from right/left versus anterior/posterior perturbations (p < .01). PD showed greater LOB from perturbations at upper versus lower torso; MS and HC showed greater LOB from posterior versus anterior perturbations. CONCLUSIONS: Our reliable rating scale showed differences in patterns of LOB following manual perturbations in MS, PD, and HC. Clinically accessible and reliable assessment of LOB could facilitate targeted perturbation-based interventions and reduce falls in vulnerable populations.

Changes in standing stability with balance-based torso-weighting with cerebellar ataxia: A pilot study.

OBJECTIVES: People with cerebellar ataxia have few options to improve the standing stability they need for function. Strategic placement of light weights on the torso using the balance-based torso-weighting (BBTW) method has improved stability and reduced falls in people with multiple sclerosis, but has not been tested in cerebellar ataxia. We examined whether torso-weighting increased standing stability and/or functional movement in people with cerebellar ataxia. METHODS: Ten people with cerebellar ataxia and 10 matched controls participated in this single-session quasi-experimental pilot study. People with ataxia performed the Scale for the Assessment and Rating of Ataxia (SARA) prior to clinical testing. All participants donned inertial sensors that recorded postural sway; stopwatches recorded duration for standing and mobility tasks. All participants stood for up to 30 s on firm and foam surfaces with eyes open then eyes closed, and performed the Timed Up and Go (TUG) test. Light weights (0.57-1.25 kg) were strategically applied to a vest-like garment. Paired t tests compared within-group differences with and without BBTW weights. Independent t tests assessed differences from controls. All t tests were one-tailed with alpha set at .05. RESULTS: Duration of standing for people with ataxia was significantly longer with weighting (p = .004); all controls stood for the maximum time of 120 s with and without weights. More severe ataxia according to SARA was moderately correlated with greater improvement in standing duration with BBTW (Pearson r = .54). Tasks with more sensory challenges (eyes closed, standing on firm surface) showed less body sway with weighting. Duration for the TUG was unchanged by torso-weighting in people with ataxia. CONCLUSION: Strategic weighting improved standing stability but not movement speed in people with ataxia. BBTW has potential for improving stability and response to challenging sensory conditions in this population. Future studies should further examine gait stability measures along with movement speed.

Randomized clinical trial of balance-based torso weighting for improving upright mobility in people with multiple sclerosis.

BACKGROUND: Torso weighting has sometimes been effective for improving upright mobility in people with multiple sclerosis, but parameters for weighting have been inconsistent. OBJECTIVE: To determine whether balance-based torso weighting (BBTW) has immediate effects on upright mobility in people with multiple sclerosis. METHODS: This was a 2-phase randomized clinical trial. In phase 1, 36 participants were randomly assigned to experimental and control groups. In phase 2, the control group was subsequently randomized into 2 groups with alternate weight-placement. Tests of upright mobility included: timed up and go (TUG), sharpened Romberg, 360-degree turns, 25-foot walk, and computerized platform posturography. Participants were tested at baseline and again with weights placed according to group membership. In both phases, a physical therapist assessed balance for the BBTW group and then placed weights to decrease balance loss. In phase 1, the control group had no weights placed. In phase 2, the alternate treatment group received standard weight placement of 1.5% body weight. RESULTS: People with BBTW showed a significant improvement in the 25-foot walk (P = .01) over those with no weight, and the TUG (P = .01) over those with standard weight placement. BBTW participants received an average of 0.5 kg, less than 1.5% of any participant's body weight. CONCLUSION: BBTW can have immediate advantages over a nonweighted condition for gait velocity and over a standardized weighted condition for a functional activity in people with multiple sclerosis (MS) who are ambulatory but have balance and mobility abnormalities.

Balance-based torso-weighting may enhance balance in persons with multiple sclerosis: preliminary evidence.

OBJECTIVE: To determine whether weight placed on the trunk in response to directional balance loss would enhance function and stability in people with multiple sclerosis (MS). DESIGN: Quasi-experimental study in which subjects served as their own controls. SETTING: Research laboratory. PARTICIPANTS: Subjects (N=16) age 20 to 65 years with MS recruited through the Northern California Chapter of the National Multiple Sclerosis Society. INTERVENTIONS: Balance-based torso-weighting where up to 1.5% body weight was placed in a garment on the trunk. Subjects were tested at baseline and then in randomly ordered balance-based torso-weighting and nonweighted garment conditions. MAIN OUTCOME MEASURES: Sharpened Romberg, eyes open (SREO) and Sharpened Romberg, eyes closed, computerized dynamic platform posturography (CDPP), Timed Up & Go (TUG), and 25-foot timed walk. RESULTS: Significant improvement (P<.014) was found with SREO in the balance-based torso-weighting compared with nonweighted conditions. CDPP eyes open and TUG showed improvements (P<.03) from baseline to balance-based torso-weighting and nonweighted conditions. CONCLUSIONS: Improved performance in a group of adults with MS was seen when light weights were placed on the torso to counteract balance loss. Placement of weights may have the potential to produce immediate improvements in balance in this population.

Effects of Torso-Weighting on Standing Balance and Falls During the Sensory Organization Test in People with Multiple Sclerosis.

BACKGROUND: In people with multiple sclerosis (MS), common gait and balance impairments can lead to falls, fear of falling, activity restriction, and social isolation. Sensory augmentation in the form of torso-weighting has resulted in improvement in gait and balance, but research on its effect on falls in MS is lacking. METHODS: 60 people with MS and 10 bin-matched controls completed the Sensory Organization Test (SOT) while nonweighted and again while weighted using the Balance-Based Torso-Weighting assessment method. This was a quasi-experimental pre-post intervention study. The SOT composite scores, equilibrium scores, and number of falls occurring across six SOT conditions were compared between and within groups using 2-way analysis of variance, α = .05 with planned t test analyses of weighting effects. RESULTS: A significant increase in composite score of 9.14 points nonweighted to weighted occurred in the MS group (P < .001) but not in controls (P = .626). Equilibrium scores were significantly higher with weights in the MS group (P < .001) but not in controls (P = .5). Falls during the SOT were reduced by 35% with weights in the MS group versus without weights (P < .001), with the greatest number of falls occurring in the most challenging SOT conditions. CONCLUSIONS: During a single testing session, torso-weighting produced significant improvements in postural stability and fall reduction during the SOT for people with MS but no change in controls. Further research is needed to determine whether torso-weighting has the potential to reduce falls in MS during real-world activities.

Gait changes with balance-based torso-weighting in people with multiple sclerosis.

BACKGROUND AND PURPOSE: People with multiple sclerosis (PwMS) commonly have mobility impairments that may lead to falls and limitations in activities. Physiotherapy interventions that might improve mobility typically take several weeks. Balance-based torso-weighting (BBTW), a system of strategically placing light weights to improve response to balance perturbations, has resulted in immediate small improvements in clinical measures in PwMS, but changes in spatiotemporal gait parameters are unknown. The purpose was to investigate the effects of BBTW on gait parameters in PwMS and healthy controls. METHODS DESIGN: This study is a non-randomized controlled experiment. PARTICIPANTS: This study included 20 PwMS and 20 matched healthy controls PROCEDURES: People with multiple sclerosis walked on an instrumented mat at their fastest speed for three trials each in two conditions: without BBTW then with BBTW. Healthy controls walked in both conditions at two speeds: their fastest speed and at velocities equivalent to their matched PwMS. RESULTS: Averaged gait trials showed that, with BBTW, PwMS had significantly increased velocity (p = 0.002), cadence (p = 0.007) and time spent in single-limb support (p = 0.014), with decreased time in double-limb support (p = 0.004). Healthy controls increased velocity (p = 0.012) and cadence (p = 0.015) and decreased support base (p = 0.014) in fast trials with BBTW; at matched velocities, step length (p = 0.028) and support base (p = 0.006) were significantly different from PwMS. All gait variables in healthy controls at fast speeds were significantly different from PwMS walking at their fastest speeds. DISCUSSION: All participants showed increases in gait velocity and cadence during fast walk with BBTW. Improvements in time spent in single-limb and double-limb support by PwMS with BBTW may reflect greater stability in gait. Future research might ascertain if these immediate improvements could enhance effectiveness of longer-term physiotherapy on functional 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.