Study protocol of a randomized controlled trial comparing backward walking to forward walking training on balance in multiple sclerosis: The TRAIN-MS trial.

Balance impairment and accidental falls are a pervasive challenge faced by persons with multiple sclerosis (PwMS), significantly impacting their quality of life. While exercise has proven to be an effective intervention for improving mobility and functioning in PwMS, current exercise approaches predominantly emphasize forward walking (FW) and balance training, with variable improvements in balance and fall rates. Backward walking (BW) has emerged as a promising intervention modality for enhancing mobility and strength outcomes; however, significant gaps remain. Specifically, there is limited knowledge about the efficacy of BW interventions on outcomes such as static, anticipatory, and reactive balance, balance confidence, falls, and cognition. This randomized controlled trial aims to determine the feasibility, acceptability, and impact of 8-weeks of backward walking training (TRAIN-BW) as compared to forward walking training (TRAIN-FW). Ninety individuals with MS with self-reported walking dysfunction or ≥ 2 falls in the past 6 months will be randomized in blocks, stratified by sex and disease severity to either the TRAIN-BW or TRAIN-FW intervention groups. Adherence and retention rates will be used to determine feasibility and the Client Satisfaction Questionnaire will be used to assess acceptability. The primary outcomes will be static, anticipatory, and reactive balance. Secondary outcomes include walking velocity, balance confidence, concern about falling, cognition, physical activity, and fall rates measured prospectively for 6 months after post-testing. Additionally, the extent to which cognitive functioning influences response to intervention will be examined. Backward walking training may be an innovative intervention to address balance impairments and falls in persons with MS.

The Impact of COVID-19 on Fatigue in Multiple Sclerosis.

BACKGROUND: Although the COVID-19 quarantine required everyone to make lifestyle changes, it may have had especially profound implications for individuals who experience multiple sclerosis (MS)-related fatigue. Individuals with MS who suffer from fatigue are at risk of worsening symptoms and already predisposed to inactivity and social isolation. The objective of this study was to examine the impact of the COVID-19 national quarantine and related restrictions on mental, emotional, and physical fatigue in persons with MS in the United States. METHODS: We conducted a survey open to all adults (>18 years) with MS within the United States. The survey gathered demographic information and asked how the COVID-19 pandemic impacted their physical, mental, and emotional fatigue. RESULTS: The survey was completed by 600 individuals, 478 with relapsing MS and 122 with progressive MS. There was a significant 2-way interaction of time by fatigue type; both physical and emotional fatigue significantly increased during the pandemic (P <.01) and remained significantly higher after the pandemic than prior to the pandemic (P <.01). Mental fatigue increased significantly during the pandemic (P <.01) and although it remained higher, on average, after the pandemic, it was not significantly different from the level before the pandemic. CONCLUSIONS: Individuals with MS experienced increases in physical, mental, and emotional fatigue over the course of the COVID-19 quarantine. Even after the lifting of quarantine restrictions, these levels have not returned to baseline. To adequately address fatigue, it is critical that health care professionals inquire about all types of fatigue in persons with MS.

Measurement Properties of Backward Walking and Its Sensitivity and Feasibility in Predicting Falls in People With Multiple Sclerosis.

BACKGROUND: People with multiple sclerosis (MS) experience mobility impairments that elevate fall risk, increasing the need to identify clinical measures that accurately predict falls. Backward walking (BW) better differentiates fallers from nonfallers in MS. However, no studies have reported the measurement properties of the backward walking Timed 25-Foot Walk (B-T25-FW) and BW metrics, like BW velocity. Additionally, it is unknown whether BW can predict future falls in MS or its link to activity levels. This study assessed the reliability and responsiveness of B-T25-FW and BW metrics, including BW velocity. It also examined whether BW could predict falls at 3 and 6 months and its association with activity levels. METHODS: During 2 separate visits, 23 people with MS completed the forward walking Timed 25-Foot Walk (F-T25-FW) and B-T25-FW, as well as forward walking and BW assessments in which spatiotemporal measures were recorded. Test-retest reliability was determined with intraclass correlation coefficients, and minimum detectable changes were calculated. Correlation analyses explored the relationship between BW velocity, B-T25-FW, prospective falls, and activity levels. RESULTS: B-T25-FW and BW velocity exhibited excellent test-retest reliability. Large effect sizes to interpret clinically meaningful change in the B-T25-FW and BW velocity were also found. Both metrics demonstrated modest negative correlations with falls at 3 and 6 months and correlated strongly with very active minutes at 3- and 6-months post study. CONCLUSIONS: The B-T25-FW and BW velocity are effective and reliable in clinical use for evaluating functional mobility in people with MS, are sensitive enough to detect subtle changes, and may be a meaningful marker for tracking disease progression and treatment efficacy.

Cerebellar volume measures may differentiate multiple sclerosis fallers from non-fallers.

Introduction: The cerebellum is a common lesion site in persons with multiple sclerosis (PwMS). Physiologic and anatomic studies have identified a topographic organization of the cerebellum including functionally distinct motor and cognitive areas. This study implemented a recent parcellation algorithm developed by Han et al., 2020 to a sample of PwMS and healthy controls to examine relationships among specific cerebellar regions, fall status, and common clinical measures of motor and cognitive functions. Methods: Thirty-one PwMS and 29 age and sex-matched controls underwent an MRI scan and motor and cognitive testing. The parcellation algorithm was applied to all images and divided the cerebellum into 28 regions. Mann-Whitney U tests were used to compare cerebellar volumes among PwMS and controls, and MS fallers and MS non-fallers. Relationships between cerebellar volumes and motor and cognitive function was evaluated using Spearman correlations. Results: PwMS performed significantly worse on functional measures compared to controls. We found significant differences in volumetric measures between PwMS and controls in the corpus medullare, lobules I-III, and lobule V. Volumetric differences seen between PwMS and controls were primarily driven by the MS fallers. Finally, functional performance on motor and cognitive tasks was associated with cerebellar volumes. Conclusions: Using the parcellation tool, our results showed that volumes of motor and cognitive lobules impact both motor and cognitive performance, and that functional performance and cerebellar volumes distinguishes MS fallers from non-fallers. Future studies should explore the potential of cerebellar imaging to predict falls in PwMS.

Establishing the Reliability of The Step Test Evaluation of Performance on Stairs (STEPS) in Multiple Sclerosis.

OBJECTIVE: To establish the inter- and intra-rater reliability of The Step Test Evaluation of Performance on Stairs (STEPS) for people with multiple sclerosis (PwMS) and examine its relation to clinical mobility measures, cognition, and activity levels. DESIGN AND SETTING: STEPS performance was rated by 3 raters at the initial visit. Two raters observed the STEPS performance via videotape at the initial visit and then 1 week later. Participants also completed in lab clinical mobility tests and cognitive assessments at their initial visit. Activity levels were tracked for the subsequent 6 months. PARTICIPANTS: In total, 23 people with relapsing-remitting MS (N=23). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Intraclass correlation coefficients (ICCs) were used to assess intra-rater and inter-rater reliability, while correlation analyses compared STEPS performance with cognition, clinical mobility assessments, and activity levels. The inter-rater reliability analysis among the 3 raters included scoring from only the initial evaluation. For the intra-rater reliability, 2 raters viewed and rated the videotaped session for each of the participants and then repeated the same process 1 week later. RESULTS: Total STEPS scores demonstrated excellent agreement by ICC for inter- (ICC=0.97) and intra-rater reliability (ICC>0.95) and significant correlations with established clinical mobility assessments in PwMS. Better performance on STEPS was associated with information processing speed and prospective activity levels in PwMS. CONCLUSIONS: Stair ambulation is a challenging task, integral for mobility and independence, therefore, having a sensitive and valid reliable assessment of stair performance is critical for PwMS. The STEPS assessment is a quick, easily administered, reliable, and valid tool for assessing stair ambulation in PwMS.

A nationwide update on prevalence of falls, injurious falls, concerns about falling, and fall prevention in persons with multiple sclerosis.

OBJECTIVE: To estimate the current nationwide prevalence of falls, injurious falls, concerns about falling, and information on fall prevention among people with multiple sclerosis (PwMS). DESIGN: This is a cross-sectional national web-based survey that included 965 adult PwMS. Participants self-reported falls and injurious falls experienced in the past 6 months. Participants also provided information on their concerns about falling and information on fall prevention received. RESULTS: A total of 56% reported falling in the past 6 months. The prevalence of falls at the population level ranges between 53% and 59%. Most falls occur inside of participants' homes (68%). About 30% of fallers reported an injurious fall. Most respondents, 87% expressed being concerned about falling and 68% reported they had cut down on activities due to their concerns about falling. Among participants who received information about falling (64%), only 9% received a formal fall prevention course. CONCLUSION: Despite advances in falls research over the last decades, falling continues to be a highly prevalent problem for PwMS. About one-third of those falls result in injuries. Concerns about falling among fallers and non-fallers affect the performance of daily activities and independence. Few people receive a formal falls prevention education or training.

On the Move: Correlation of Impaired Mobility with Spatial Navigation Ability in Persons with Multiple Sclerosis.

Spatial navigation ability is essential for independent living, and it relies on complex cognitive and motor processes that are vulnerable to decline in persons with multiple sclerosis (pwMS). The role of mobility in the physical act of navigation has been well documented; however, its association with cognitive processing that supports efficient navigation and recall of the environment is unknown. This study examined the relation between clinical mobility function and spatial navigation ability in pwMS. In a clinical sample of 43 individuals with relapsing-remitting MS (MPDDS = 2; age 25-67 years), we assessed spatial navigation ability in a virtual Morris water maze that allowed for active search by controlling a joystick while seated at a computer, and subsequent free recall of environment details. Individuals with worse mobility (measured by slower forward and backward walking) traveled less efficient virtual navigation routes to the goal location and recalled fewer accurate details of the environment. A stratified analysis by disability revealed moderate-strong correlations for those with a low level of disability, and effects were attenuated in individuals with a high level of disability. Given that the virtual navigation task was performed while seated, evidence of any correlation with mobility suggests differences in navigation ability that cannot be ascribed to general walking impairment, and instead suggests a role for mobility impairment to modify cognitive processing supporting navigation in pwMS.

Backwards walking speed reserve in persons with multiple sclerosis.

BACKGROUND: Decreased gait speed is common in persons with Multiple Sclerosis (PwMS) and has been associated with elevated fall risk. The walking speed reserve (WSR) indicates the ability to increase gait speed on demand and has previously been examined in PwMS. Backward walking is a sensitive measure of fall risk in PwMS; however, no studies have reported on the utility of backward walking speed reserve (BW-WSR) as a clinical assessment tool of functional mobility or fall risk in PwMS, nor have they associated this measure with cognition. METHODS: 23 PwMS completed walking trials at their preferred walking speed (PWS) and maximal walking speed (MWS). Participants performed these walking trials in both the forward (FW) and backward direction (BW). The forward walking speed reserve (FW-WSR) was calculated as the difference between MWS and PWS in the forward direction, while the backward walking speed reserve (BW-WSR) was calculated as the difference between MWS and PWS in the back backward direction. Correlation analyses examined the relationship between the FW- and BW-WSR with clinical assessments of functional mobility (the timed up-and-go) as well as cognitive functioning (the Symbol Digit Modalities Test, the Brief Visuospatial Memory Test-Revised, the California Verbal Learning Test, and the Trail Making Test A and B). Correlations also examined the relationship between FW- and BW-WSR with prospective falls. RESULTS: A lower BW-WSR was associated with disease severity and poorer performance on clinical walking and balance assessment, as well as with decreased information processing speed and attentional performance. Interestingly, FW-WSR showed similar relations. Neither FW- or BW-WSR were associated with prospective risk in this small sample of PwMS. CONCLUSION: The BW-WSR did not offer a distinct advantage over other measures, such as the FW-WSR, PWS, or MWS, in the forward or backward direction. The selection of the most sensitive clinical measures of functional mobility and fall risk is crucial; our study holds valuable clinical implications for PwMS by providing novel insights into functional mobility assessments in PwMS.

Scale development to evaluate differences between concern about falling and fear of falling: the concern and fear of falling evaluation.

Purpose: Individuals with multiple sclerosis (MS) experience fear of falling (FOF), which is associated with negative health and quality-of-life consequences. Prior research has used FOF and concern about falling (CAF) interchangeably, but persons with MS report that CAF and FOF represent separate constructs that lie on a continuum. Unfortunately, no scale exists to understand the differences between CAF and FOF. Therefore, we developed a novel questionnaire, the Concern and Fear of Falling Evaluation (CAFFE), in which respondents rank their CAF and FOF on a continuum across various activities. This study aims to describe the scale development process and examine its psychometric properties. Methods: In a single online survey, MS participants responded to demographic questionnaires, indicated whether they experience CAF and FOF, and completed the CAFFE. Psychometric evaluation of the CAFFE involved internal consistency, split-half cross validation, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA). Results: Out of 1,025 respondents, 64.6% reported CAF and 47.2% reported FOF. The EFA yielded a two-factor solution encompassing activities in open (factor 1) and closed environments (factor 2). The CFA replicated this two-factor solution and the CAFFE demonstrated excellent internal consistency (α = 0.98). Conclusion: The 27-item CAFFE is a highly reliable and valid measure capturing the tipping point at which point CAF moves to FOF. Future research should seek to define the tipping point from the MS community, as CAF may be an adaptive mechanism, whereas FOF may be a maladaptive behavior.

The Clinical Relevance of Autonomic Dysfunction, Cerebral Hemodynamics, and Sleep Interactions in Individuals Living With SCI.

A myriad of physiological impairments is seen in individuals after a spinal cord injury (SCI). These include altered autonomic function, cerebral hemodynamics, and sleep. These physiological systems are interconnected and likely insidiously interact leading to secondary complications. These impairments negatively influence quality of life. A comprehensive review of these systems, and their interplay, may improve clinical treatment and the rehabilitation plan of individuals living with SCI. Thus, these physiological measures should receive more clinical consideration. This special communication introduces the under investigated autonomic dysfunction, cerebral hemodynamics, and sleep disorders in people with SCI to stakeholders involved in SCI rehabilitation. We also discuss the linkage between autonomic dysfunction, cerebral hemodynamics, and sleep disorders and some secondary outcomes are discussed. Recent evidence is synthesized to make clinical recommendations on the assessment and potential management of important autonomic, cerebral hemodynamics, and sleep-related dysfunction in people with SCI. Finally, a few recommendations for clinicians and researchers are provided.

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 ).

Examination of Risk Factors Associated With Falls and Injurious Falls in People With Multiple Sclerosis: An Updated Nationwide Study.

OBJECTIVE: To provide an update on risk factors associated with falls and injurious falls among people with multiple sclerosis (PwMS) in the United States. DESIGN: Nationwide cross-sectional web-based survey. SETTING: Community setting. PARTICIPANTS: Adult PwMS (n=965). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants completed self-report surveys of demographics, clinical data, concerns about falling, occurrence of falls, factors associated with falls, and injurious falls in the past 6 months. Participants also completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures of depression, pain interference, and physical function, and the Fatigue Severity Scale. RESULTS: The most common self-reported factors associated with falls included personal factors such as poor balance (75%), muscle weakness (54%), and/or fatigue (35%), environmental factors such as general surface conditions (37%) and/or distraction (15%), and activities-related factors such as urgency to complete a task (35%) and/or multitasking (27%). Logistic regression analyses indicated that higher fatigue severity (OR=1.19, P<.01) and higher pain interference (OR=1.02, P<.01) were associated with higher odds of experiencing at least 1 fall. Any level of concern, even minimal concern about falling was also significantly associated with a higher odd of experiencing at least 1 fall (ORs range 2.78 - 3.95, all P<.01). Fair to very high concerns about falling compared with no concern about falling (ORs range=5.17 - 10.26, all P<.05) was significantly associated with higher odds of sustaining an injurious fall. CONCLUSIONS: Findings suggest falls prevention approaches in PwMS should be multifactorial and include personal, environmental, and activities-related factors. Particular attention on fatigue, pain, and concern about falling may be needed to reduce incidence of falls and injurious falls in this population.

"Self-care selfies": Patient-uploaded videos capture meaningful changes in dexterity over 6 months.

OBJECTIVE: Upper extremity function reflects disease progression in multiple sclerosis (MS). This study evaluated the feasibility, validity, and sensitivity to change of remote dexterity assessments applying human pose estimation to patient-uploaded videos. METHODS: A discovery cohort of 50 adults with MS recorded "selfie" videos of self-care tasks at home: buttoning, brushing teeth, and eating. Kinematic data were extracted using MediaPipe Hand pose estimation software. Clinical comparison tests were grip and pinch strength, 9 hole peg test (9HPT), and vibration, and patient-reported dexterity assessments (ABILHAND). Feasibility and acceptability were evaluated (Health-ITUES framework). A validation cohort (N = 35) completed 9HPT and videos. RESULTS: The modality was feasible: 88% of the 50 enrolled participants uploaded ≥3 videos, and 74% completed the study. It was also usable: assessments easy to access (95%), platform easy to use (97%), and tasks representative of daily activities (86%). The buttoning task revealed four metrics with strong correlations with 9HPT (nondominant: r = 0.60-0.69, dominant: r = 0.51-0.57, P < 0.05) and ABILHAND (r = -0.48, P = 0.05). Retest validity at 1 week was stable (r > 0.8). Cross-sectional correlations between video metrics and 9HPT were similar at 6 months, and in the validation cohort (nondominant: r = 0.46, dominant: r = 0.45, P < 0.05). Over 6 months, pinch strength (5.8-5.0 kg/cm2 , P = 0.05) and self-reported pinch (ABILHAND) decreased marginally. While only 15% of participants worsened by 20% on 9HPT, 70% worsened in key buttoning video metrics. INTERPRETATION: Patient-uploaded videos represent a novel, patient-centered modality for capturing dexterity that appears valid and sensitive to change, enhancing its potential to be disseminated for neurological disease monitoring and treatment.

Predictors of performance and perceived fatigability in people with multiple sclerosis.

BACKGROUND AND OBJECTIVE: Fatigability is a distinct construct from fatigue that has been reported to contribute to activity limitations in people with multiple sclerosis (PwMS). Identifying predictors of performance and perceived fatigability may guide the development of interventions to mitigate fatigability. This study investigated predictors of performance and perceived fatigability among PwMS. METHODS: PwMS (N = 51) completed self-report measures of demographics, clinical history, symptoms severity (Modified Fatigue Impact Scale), and functioning (PROMIS Physical Function and PROMIS Cognitive Function Abilities). Performance fatigability measures included Ambulatory Fatigue Index (AFI), Deceleration Index (DI), and Distance Walking Index (DWI). Perceived fatigability measures included Pittsburgh Fatigability Scale (PFS), Perceived Physical Exertion, and Perceived Fatigue Intensity. Performance and perceived fatigability measures were calculated based on the Timed 25-Foot Walk Test and the 6-Minute Walk Test. RESULTS: Multivariable linear regression analyses indicated that PROMIS Cognitive Function was a significant independent predictor of performance fatigability measured with AFI (ß = -0.515, p = 0.007), DI (ß = -0.511, p = 0.008), and DWI (ß = -0.516, p = 0.007). Regarding perceived fatigability, PROMIS Pain Intensity predicted Perceived Fatigue Intensity (ß = 0.325, p = 0.035). PROMIS Physical Function predicted PFS Mental fatigability (ß = -0.503, p < 0.001). PROMIS Physical Function (ß = -0.619, p < 0.001) and Cognitive Function (ß = -0.249, p = 0.037) predicted PFS Physical fatigability. CONCLUSIONS: Preliminary findings suggest that self-reported functioning levels, including physical and perceived cognitive function, are potential predictors of performance and perceived fatigability in MS. Notably, perceived fatigue impact showed no association with performance or perceived fatigability. Future studies are warranted to confirm and extend our findings.

Cognitive Contributors of Backward Walking in Persons with Multiple Sclerosis.

Purpose: Individuals with multiple sclerosis (MS) are at an increased fall risk due to motor and cognitive dysfunction. Our past studies suggest that backward walking (BW) velocity predicts fall risk; however, specific cognitive domains associated with BW velocity remain understudied. The goal of this study was to determine the specific contributions of cognitive functioning to BW velocity in persons with MS. We hypothesized that better visuospatial memory, verbal immediate recall, and faster information processing speed would contribute to faster BW velocity, and deficits in these domains would partially account for disease severity-related impairment in BW velocity. Methods: Participants completed demographic questionnaires, walking tests, and cognitive assessments. Applied structural equation modeling was used to test our hypothesized model of competing cognitive mediators. Within the model, disease severity was a predictor of BW via three intercorrelated cognitive mediators. Results: Participants included 39 individuals with relapsing-remitting MS. Results indicated that 35.3% of the significant total effect of disease severity on BW was accounted for by specific cognitive deficits. Verbal immediate recall had the largest contribution, followed by visuospatial memory and information processing speed. Conclusions: When examining the unique effects of cognitive domains on disease severity-related deficits in BW, a meaningful source of impairment related to visuospatial memory and verbal immediate recall was demonstrated. Considering the utility of BW velocity as a predictor of falls, these results highlight the importance of assessing cognition when evaluating fall risk in MS. Cognitive-based intervention studies investigating fall prevention may find BW as a more specific and sensitive predictor of fall risk than forward walking.

Self-reported fatigue impact is associated with frequency of falls and injurious falls in people with multiple sclerosis.

BACKGROUND: Fatigue is the most common symptom associated with multiple sclerosis (MS). Fatigue as a risk factor for injurious falls and frequency of falls is understudied. Falling recurrently is associated with injurious falls which may lead to reduced functional independence and poor quality of life of people with MS. Identifying contributors of recurrent falls and injurious falls is clinically useful to develop effective interventions. OBJECTIVE: To investigate the associations between fatigue impact and frequency of falls and injurious falls in people with MS. METHODS: Fifty-one participants completed the Modified Fatigue Impact Scale (MFIS) and a survey of number of falls and injurious falls during the past year. Logistic regression analyses were conducted to investigate whether scores on the MFIS (Total, Physical, Cognitive, and Psychosocial) predicted odds of being a recurrent faller (> 2 falls) or infrequent faller (1- 2 falls) versus a non-faller, and odds of experiencing an injurious fall (yes/no). The analyses were adjusted for demographic and clinical characteristics and common symptoms of MS (depression, cognition, pain, and sleep disturbance). RESULTS: Higher MFIS Total score was associated with higher odds of infrequent falls (OR = 1.07, 95% CI, 1.00 - 1.15, p = 0.05) and recurrent falls (OR = 1.10, 95% CI, 1.00 - 1.20, p = 0.04) relative to not falling in the past year. Higher scores on the MFIS Physical subscale were significantly associated with high odds of infrequent falls (OR = 1.15, 95% CI, 1.02 - 1.30, p = 0.03) and recurrent falls (OR = 1.19, 95% CI, 1.02 - 1.39, p = 0.03). MFIS Psychosocial subscale was significantly associated with higher odds of infrequent falls (OR = 2.01, 95% CI, 1.14 - 3.53, p = 0.02). MFIS Total and MFIS Cognitive subscale were significantly associated with higher odds of injurious falls (OR = 1.11, 95% CI, 1.00 - 1.23, p = 0.04) and (OR = 1.28, 95% CI, 1.02 - 1.60, p = 0.04), respectively. CONCLUSION: The findings indicated self-reported fatigue impact and its specific domains were associated with an increased risk of falling and injurious falls. Further studies using prospective falls assessment and longitudinal evaluation of fatigue are warranted to extend our findings.

Standardized screening of cognitive and affective tendencies in persons with low back pain: A knowledge translation project.

BACKGROUND: The use of screening questionnaires (SQ) to evaluate affective or cognitive tendencies (CAT) in persons with low back pain (LBP) is recommended by clinical practice guidelines (CPG) yet few physical therapists (PTs) have adopted these recommendations. OBJECTIVE: To develop and implement a tailored knowledge translation (KT) intervention in an outpatient rehabilitation practice to facilitate the uptake of SQ for CAT in persons with LBP. METHODS: In a mixed-methods study, using the knowledge to action framework, PTs (n = 12) collaborated with research clinicians to improve the use of three SQ: 1) Primary Care Evaluation of Mental Disorders for Depressive Symptoms; 2) Fear-Avoidance Beliefs Questionnaire; and 3) Pain Catastrophizing Scale. Success of the intervention was measured through questionnaires, focus groups and chart audit. RESULTS: A multimodal intervention to overcome specific identified barriers (i.e. time, forgetfulness, and lack of knowledge) was implemented. There was a 10% increase in the use of at least one SQ. PTs reported increased knowledge and use of the SQ but reported time and lack of confidence as barriers to implementation. CONCLUSION: It was concluded that SQ for CAT can be successfully implemented; however, PTs felt unprepared to use the screening results to evaluate persons with CAT and more extensive training is recommended to change this practice pattern.

Examining the Influence of Cognition on the Relationship Between Backward Walking and Falls in Persons With Multiple Sclerosis.

BACKGROUND: Multiple sclerosis (MS) causes motor, cognitive, and sensory impairments that result in injurious falls. Current fall risk measures in MS (ie, forward walking [FW] speed and balance) are limited in their sensitivity. Backward walking (BW) velocity is a sensitive marker of fall risk and correlates with information processing speed (IPS) and visuospatial memory (VSM) in persons with MS. Backward walking is a complex motor task that requires increased cognitive demands, which are negatively affected by MS; however, whether cognitive function modifies the sensitivity of BW as a fall risk assessment in MS remains unknown. This study examines the influence of cognition on the relationship between BW and falls in persons with MS. METHODS: Measures of BW, FW, IPS, VSM, and retrospective falls were collected. Hierarchical regression tested moderation and included an interaction term predicting number of falls. Covariates for all analyses included age and disease severity. RESULTS: Thirty-eight persons with MS participated. Although BW, IPS, and covariates significantly predicted the number of falls (R 2 = 0.301; P = .016), there was no evidence of moderation. Backward walking, VSM, and covariates also significantly predicted number of falls (R 2 = 0.332, P = .008), but there was no evidence of moderation. The FW models generated comparable results. CONCLUSIONS: The relationship between BW velocity and falls was not conditional on IPS or VSM in this sample. Larger-scale studies examining additional cognitive domains commonly affected by MS and prospective falls are needed to characterize neurobiological processes relevant to BW and its clinical application in the assessment of fall risk.

Associations between myelin water imaging and measures of fall risk and functional mobility in multiple sclerosis.

BACKGROUND AND PURPOSE: Myelin water fraction (MWF) deficits as measured by myelin water imaging (MWI) have been related to worse motor function in persons with multiple sclerosis (PwMS). However, it is unknown if measures from MWI metrics in motor areas relate to fall risk measures in PwMS. The objective of this study was to examine the relationship between MWI measures in motor areas to performance on clinical measures of fall risk and disability in PwMS. METHODS: Sixteen individuals with relapsing-remitting MS participated (1 male, 15 female; age 47.1 years [12.3]; Expanded Disability Status Scale 4.0 [range 0-6.5]) and completed measures of walking and fall risk (Timed 25 Foot Walk [T25FW] and Timed Up and Go). MWF and the geometric mean of the intra-/extracellular water T2 (geomT2IEW ) values reflecting myelin content and contribution of large-diameter axons/density, respectively, were assessed in three motor-related regions. RESULTS: The geomT2IEW of the corticospinal tract (r = -.599; p = .018) and superior cerebellar peduncles (r = -.613; p = .015) demonstrated significant inverse relationships with T25FW, suggesting that decreased geomT2IEW was related to slower walking. Though not significant, MWF in the corticospinal tract and superior cerebellar peduncles also demonstrated fair relationships with the T25FW, suggesting that worse performance on the T25FW was associated with lower MWF values. CONCLUSIONS: MWI of key motor regions was associated with walking performance in PwMS. Further MWI studies are needed to identify relationships between pathology and clinical function in PwMS to guide targeted rehabilitation therapies aimed at preventing falls.