Transforming modeling in neurorehabilitation: clinical insights for personalized rehabilitation.

Practicing clinicians in neurorehabilitation continue to lack a systematic evidence base to personalize rehabilitation therapies to individual patients and thereby maximize outcomes. Computational modeling- collecting, analyzing, and modeling neurorehabilitation data- holds great promise. A key question is how can computational modeling contribute to the evidence base for personalized rehabilitation? As representatives of the clinicians and clinician-scientists who attended the 2023 NSF DARE conference at USC, here we offer our perspectives and discussion on this topic. Our overarching thesis is that clinical insight should inform all steps of modeling, from construction to output, in neurorehabilitation and that this process requires close collaboration between researchers and the clinical community. We start with two clinical case examples focused on motor rehabilitation after stroke which provide context to the heterogeneity of neurologic injury, the complexity of post-acute neurologic care, the neuroscience of recovery, and the current state of outcome assessment in rehabilitation clinical care. Do we provide different therapies to these two different patients to maximize outcomes? Asking this question leads to a corollary: how do we build the evidence base to support the use of different therapies for individual patients? We discuss seven points critical to clinical translation of computational modeling research in neurorehabilitation- (i) clinical endpoints, (ii) hypothesis- versus data-driven models, (iii) biological processes, (iv) contextualizing outcome measures, (v) clinical collaboration for device translation, (vi) modeling in the real world and (vii) clinical touchpoints across all stages of research. We conclude with our views on key avenues for future investment (clinical-research collaboration, new educational pathways, interdisciplinary engagement) to enable maximal translational value of computational modeling research in neurorehabilitation.

Leveraging Emerging Technologies to Expand Accessibility and Improve Precision in Rehabilitation and Exercise for People with Disabilities.

Physical rehabilitation and exercise training have emerged as promising solutions for improving health, restoring function, and preserving quality of life in populations that face disparate health challenges related to disability. Despite the immense potential for rehabilitation and exercise to help people with disabilities live longer, healthier, and more independent lives, people with disabilities can experience physical, psychosocial, environmental, and economic barriers that limit their ability to participate in rehabilitation, exercise, and other physical activities. Together, these barriers contribute to health inequities in people with disabilities, by disproportionately limiting their ability to participate in health-promoting physical activities, relative to people without disabilities. Therefore, there is great need for research and innovation focusing on the development of strategies to expand accessibility and promote participation in rehabilitation and exercise programs for people with disabilities. Here, we discuss how cutting-edge technologies related to telecommunications, wearables, virtual and augmented reality, artificial intelligence, and cloud computing are providing new opportunities to improve accessibility in rehabilitation and exercise for people with disabilities. In addition, we highlight new frontiers in digital health technology and emerging lines of scientific research that will shape the future of precision care strategies for people with disabilities.

Intervention fidelity and adaptation in a multi-site exercise training intervention for adults with multiple sclerosis.

BACKGROUND: Successful translation of evidence-based exercise training interventions from research to clinical practice depends on the balance of treatment fidelity and adaptability when delivering the exercise program across settings. The current paper summarizes fidelity of study design, provider training, and intervention delivery strategies from best practice recommendations, and reports challenges experienced and adaptations instrumented by behavioral coaches delivering the multi-site Supervised versus Telerehabilitation Exercise Programs for Multiple Sclerosis (STEP for MS) Trial. METHODS: Using a reflexive thematic analysis approach, open-ended survey questions were analyzed to explore experiences of behavioral coaches, transcripts from team meetings among behavioral coaches, and notes from audits of one-on-one sessions between behavioral coaches and participants. RESULTS: Themes related to the fidelity of study design and delivery of the STEP for MS Trial included adaptations to the intervention itself (e.g., completion of virtual supervised exercise sessions with behavioral coaches in place of face-to-face sessions during COVID-19 pandemic restrictions), modification of exercise equipment, and adjustments of program delivery. The adjustments of program delivery reported by behavioral coaches included increasing program fit, maintaining engagement, and addressing participant safety concerns; however, these adaptations did not jeopardize the content of the essential elements of the program model. CONCLUSIONS: The current paper demonstrates that when best practice recommendations are implemented, it is possible to address challenges to study design and evidence-based intervention delivery in ways that adaptations to overcome real-world obstacles can be accomplished without compromising fidelity.

Online Delivery of the Individualized Reduction of Falls Intervention for Persons With Multiple Sclerosis Who Use a Wheelchair or Scooter Full-time: A Pilot Study.

BACKGROUND: People with multiple sclerosis (MS) who use a wheelchair or scooter full-time fall frequently; however, fall prevention programming that meets the unique needs of this population is limited. This study examined the preliminary efficacy of a group-based online fall prevention and management intervention designed specifically for people with MS. METHODS: This pre/post intervention, mixed-methods study included people with MS who used a wheelchair or scooter full-time, experienced at least 1 fall within the past year, and transferred independently or with minimal or moderate assistance. Participants engaged in a 6-week, online, individualized, multicomponent fall prevention and management intervention: Individualized Reduction of Falls-Online (iROLL-O). RESULTS: No statistically significant change in fall incidence occurred after iROLL-O. However, fear of falling significantly decreased (P < .01) and knowledge related to fall management (P = .04) and fall prevention and management (P = .03) significantly improved. Qualitative results indicated that participants valued the opportunity for peer learning and iROLL-O's attention to diverse influences on fall risk. CONCLUSIONS: This study is the first to examine the preliminary efficacy of an online fall prevention and management intervention for people with MS who use a wheelchair or scooter full-time. iROLL-O has promise, and participants found it valuable. Further efforts are needed to retain iROLL-O participants with lower confidence and functional mobility, and more research is needed to investigate the impact of the intervention on key outcomes over time.

Investigating Relationships Among Interoceptive Awareness, Emotional Susceptibility, and Fatigue in Persons With Multiple Sclerosis.

BACKGROUND: Fatigue is a particularly debilitating symptom for people with multiple sclerosis (MS). Although personality traits and MS have been studied, interoception and emotional susceptibility and their links to fatigue have not yet been explored. METHODS: Study participants provided demographic information and completed standardized patient-reported outcomes of walking function, physical activity, subjective fatigue, interoceptive awareness, and emotional susceptibility. A subset of participants participated in semistructured interviews discussing fatigue, body sensations, emotions, and their effects on exercise. Quantitative data were analyzed using multiple regression. Qualitative data were analyzed using thematic analysis. RESULTS: Mean ± SD Fatigue Severity Scale scores (5.0 ± 1.3) indicated that fatigue was a problematic symptom. Mean ± SD Multidimensional Assessment of Interoceptive Awareness, Version 2 (2.8 ± 0.6) and Emotional Susceptibility Scale (3.0 ± 1.0) scores indicated lower levels of interoceptive awareness and emotional susceptibility. Quantitative data indicated no relationship between fatigue and interoceptive awareness (ß = -0.20; P = .88) and emotional susceptibility (ß = 0.03; P = .83), and neither were these related to physical activity (ß = -0.07; P = .64). Qualitative themes indicated strong fatigue experiences involving the whole body and individual limbs, anger and frustration, and effects on physical activity. CONCLUSIONS: Physically active people with MS report strong sensations of fatigue closely linked to frustration and helplessness. There was agreement between qualitative and quantitative assessments of fatigue but dissonance regarding interoceptive awareness and physical activity. The practice of clinicians, particularly those involved with facilitating or planning physical activity for persons with MS, would benefit from these findings about fatigue.

Characteristics and consequences of falls among people with multiple sclerosis who use wheelchairs or scooters: Differences between injurious and non-injurious falls.

BACKGROUND: Falls are common among people living with multiple sclerosis (MS) who use wheelchairs or scooters. Falls may lead to severe consequences including physical injuries. However, very little is known about the circumstances associated with injurious falls in this population. Therefore, we aimed to explore the differences in fall-related characteristics between injurious and non-injurious falls among people with MS who use wheelchairs or scooters. METHODS: A convenience sample of 48 people with MS (age = 62.0 [13.0] years, gender = 81.3% female, primary mobility aid = power wheelchair) completed a fall-history survey that examined the characteristics and consequences of their most recent fall. Participants also completed standard questionnaires on quality of life, community participation, and fear of falling. RESULTS: Most falls (85.4%) reported by participants occurred inside the house. Twelve (25.0%) participants reported experiencing fall-related injuries such as bruises, cuts, muscle strains, and fractures. People who reported being injured after a fall had a higher proportion of falls that occurred during transfers compared to those who were not injured (n = 10, 83.3% vs n = 17, 47.2%). Most participants (45.8%) did not receive any information from healthcare professionals on how to manage their fall-risk after their fall experience. No differences between injurious and non-injurious fallers in quality of life, community participation, and fear of falling were observed. CONCLUSIONS: This cross-sectional investigation provides compelling evidence that people with MS who use wheelchairs or scooters are at high risk of fall-related injuries. The study findings underscore the importance of increasing health care providers' awareness about the frequency and consequences of falls. Further, it demonstrates the critical need for evidence-based interventions specifically designed to minimize fall-related injuries in this vulnerable population.

Skeletal Muscle Dysfunction in People With Multiple Sclerosis: A Physiological Target for Improving Physical Function and Mobility.

Impaired mobility is amongst the most debilitating symptoms reported by people with multiple sclerosis (MS). Historically, it has been viewed that walking impairments in people with MS are directly caused by the physical damage to the neurons in the central nervous system (CNS) which results from the immunopathology of MS. However, research from over the past 4 decades has revealed that physical function in people with MS is also affected by skeletal muscle dysfunction characterized by a reduced capacity to produce, regulate, and sustain the force-generating muscle contractions that propel human movement. While the immediate CNS damage caused by MS can alter the neural activation of muscle by disrupting neuromotor transmission, chronic reductions in mobility and extreme fatigue can lead to physically inactive lifestyles that negatively affect skeletal muscle through mechanisms of deconditioning. Consequently, people with MS can experience alterations in activation patterns, muscle mass and tissue composition, contractility, metabolism, and perfusion that contribute to reductions in muscle function that ultimately impair key physical functions such as walking. This article provides an overview of the cellular mechanisms that contribute to skeletal muscle dysfunction in people with MS and a discussion of the current evidence suggesting that skeletal muscle may be a key physiological target for interventions aiming to improve mobility in this population. We specifically highlight recent evidence demonstrating the potential for rehabilitation and exercise interventions to induce muscle plasticity in people with MS who have moderate to severe levels of disability. In conclusion, we discuss future directions in basic science and clinical research that may advance our understanding of muscle dysfunction in MS and lead to the development of more precise and effective treatment strategies.

Pilot Study of a Fall Prevention and Management Intervention Program for People With Multiple Sclerosis Who Use a Wheelchair or Scooter Full-Time.

Objective: To examine the efficacy of a fall prevention/management intervention among persons with multiple sclerosis (PwMS) who use a wheelchair (WC) or scooter full-time. Design: Pre-post/follow-up trial. Setting: Community and research laboratory. Participants: Twenty-one PwMS who used a WC or scooter full-time, self-reported at least 1 fall/12 months, and could transfer independently or with minimal/moderate assistance (N=21). Intervention: Six-week, group and community-based fall prevention and management intervention. The intervention included six 2-hour in-person weekly sessions led by a physical or occupational therapist featuring interactive group discussions, skill practice, and action planning opportunities. Main Outcome Measures: Fall frequency tracked 12 weeks pre- and 24 weeks post intervention. Outcomes were assessed pre- and post intervention and 12 weeks post intervention. Measures included surveys to examine fear of falling (FOF), fall prevention/management, quality of life, community participation, and assessment of functional mobility skills. Semistructured interviews were administered post intervention to ascertain overall experiences with the program and effect on daily life. A Friedman test with signed-rank post hoc analysis was run to determine differences across the 3 study visits. Results: After the intervention, fall incidence did not significantly change, but fall management strategies (P=.01-0.05), importance of community participation (P=.01), and transfer quality (P=.02) significantly improved. Moderate effect sizes were noted among concerns about falling, activity curtailment because of to FOF, and WC skills. Qualitative results indicate that participants found the intervention beneficial and applied intervention content in their daily lives. Conclusions: This study is the first to describe the effect of a multicomponent fall prevention/management intervention designed specifically for PwMS who use a WC or scooter full-time. Results indicate the program has potential to reduce fall risk; however, further testing is needed to fully examine the effect of the program.

The Impact of COVID-19 Lockdown Restrictions on Exercise Behavior Among People With Multiple Sclerosis Enrolled in an Exercise Trial: Qualitative Interview Study.

BACKGROUND: During spring and summer 2020, US states implemented COVID-19 pandemic restrictions, resulting in the closure of rehabilitation facilities and, with them, some of the clinical trials that were taking place. One such trial was the Supervised Versus Telerehabilitation Exercise Program for Multiple Sclerosis ("STEP for MS") comparative effectiveness multiple sclerosis (MS) exercise trial. Although 1 study arm was implemented via telerehabilitation, the comparative arm took place in rehabilitation facilities nationwide and was subsequently closed during this time frame. The experience of the STEP for MS participants provides insights into the impact of lockdown restrictions on exercise behavior by mode of exercise delivery (telerehabilitation vs conventional facility based). OBJECTIVE: This study sought to understand the impact of COVID-19 lockdown restrictions on exercise behavior among people with MS enrolled in an exercise trial at the time of the restrictions. METHODS: Semistructured phone and video interviews were conducted with a convenience sample of 8 participants representing both arms of the exercise trial. We applied reflexive thematic analysis to identify, analyze, and interpret common themes in the data. RESULTS: We identified 7 main themes and 2 different narratives describing the exercise experiences during lockdown restrictions. Although the telerehabilitation participants continued exercising without interruption, facility-based participants experienced a range of barriers that impeded their ability to exercise. In particular, the loss of perceived social support gained from exercising in a facility with exercise coaches and other people with MS eroded both the accountability and motivation to exercise. Aerobic exercises via walking were the most impacted, with participants pointing to the need for at-home treadmills. CONCLUSIONS: The unprecedented disruption of COVID-19 lockdown restrictions in spring and summer 2020 impacted the ability of facility-based STEP for MS exercise trial participants to exercise in adherence to the intervention protocol. By contrast, the participants in the telerehabilitation-delivered exercise arm continued exercising without interruption and reported positive impacts of the intervention during this time. Telerehabilitation exercise programs may hold promise for overcoming barriers to exercise for people with MS during COVID-19 lockdown restrictions, and potentially other lockdown scenarios, if the participation in telerehabilitation has already been established.

The role of worry in exercise and physical activity behavior of people with multiple sclerosis.

Purpose: This study is a secondary analysis of data from a mixed methods exploration of fatigue in people with multiple sclerosis (MS), a chronic autoimmune disease affecting the central nervous system. During initial analysis, worry emerged during discussions of the fatigue experience. The purpose of this study is to explore worry in relationship to exercise and physical activity behavior. Methods: Mixed methods were used to address the research question. 55 people with MS provided demographic and survey data (habitual physical activity, body perception, functioning). 35 participated in semi-structured interviews on the topics of fatigue, body sensations, emotions, and their effects on physical activity. Qualitative data were analyzed utilizing constructivist grounded theory. Quantitative data were analyzed utilizing multiple regression. Results: Qualitative theory described participants' thoughts and experiences regarding the consequences of fatigue during activity, and how they appear to influence subsequent actions. Worry played a critical role in thought processes regarding physical activity. Aspects of body perception were weak quantitative predictors of physical activity behavior after control of physical functionality. Conclusions: The most significant finding of this study was the description and dialogue about worry as a factor that shapes perceptions of the benefits and value of exercise and physical activity. Physical activity practitioners could benefit from seeking to understand physical-activity-related worry when examining physical activity behavior and designing programming.

Job Retention Among Individuals With Multiple Sclerosis: Relationship With Prediagnostic Employment and Education; Demographic Characteristics; and Disease Course, Severity, and Complications.

OBJECTIVE: To identify how prediagnosis employment, education, demographic statuses, and disease factors relate to job retention among people with multiple sclerosis (MS). DESIGN: Cross-sectional logit model. SETTING: Data were collected at an academic Medical University and a specialty hospital, both in the Southeastern US. PARTICIPANTS: People with MS (N=1126) who were employed at the time of MS diagnosis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Job retention was measured by employment status at the time of follow-up assessment. RESULTS: Prediagnostic educational attainment was predictive of job retention. Among several prediagnostic employment characteristics, only working in production, transportation, and material moving was significantly related to a lower odds of job retention compared with those working in professional/managerial occupations. Aging factors were strongly related to job retention, with declines in job retention observed with increasing age and years since diagnosis. Non-Hispanic Black and Hispanic participants reported lower odds of job retention than non-Hispanic White participants, although there were no observed effects of sex. A significantly lower job retention rate was observed among those with progressive MS, compared with relapsing-remitting. Job retention was also less likely among people with greater MS severity and fatigue. CONCLUSIONS: Job retention strategies and interventions should target people with greater MS complications and severity, as well as non-Hispanic Black and Hispanic persons, because these characteristics are more highly related to job retention than our prediagnostic employment and vocational history.

Prediction of future falls among full-time wheelchair and scooter users with multiple sclerosis: A prospective study.

BACKGROUND: Seventy-five percent (75%) of full-time wheelchair or scooter users with multiple sclerosis (MS) experience at least one fall in a period of 6 months. Falls are detrimental for the independence, quality of life, and community participation. No previous prospective study has evaluated fall risk factors in this segment of MS community. OBJECTIVE: To develop a multivariable falls risk prediction model for people with MS (PwMS) who use a wheelchair or scooter full-time. METHODS: This prospective cohort study is a secondary data analysis that recruited PwMS from the community across the US. Forty-eight adults with MS who use a wheelchair or scooter as their main form of mobility were included. Dependent variable was fall incidence over 3-month recorded through diaries. Dependent variable was categorized as fallers (≥ 1 fall) and non-fallers (0 fall). Predictors were demographics, history of falls in the past 6 months, measures of fear of falling, Spinal Cord Injury- Falls Concern Scale, California Verbal Learning Test II, and Multiple Sclerosis Quality of Life- mental health. Multivariable logistic regression analyses were conducted to identity predictors of future falls. RESULTS: In total, 63 falls (range 0 - 8) were reported over the 3-month period from a total of 26 fallers (54%). Multivariate logistic regression analyses indicated that the risk factor with the best predictive ability of future falls included history of falls in the past 6 months (sensitivity 77%, specificity 54%, and area under the receiving operating curve statistic = 0.76, 95% CI 0.62 to 0.89). CONCLUSION: Findings highlight the importance of asking full-time wheelchair and scooter users with MS if they have fallen in the past 6 months to quickly identify those who are at increased fall risk and in need of follow up assessment and intervention to identify and address modifiable risk factors. More attention to fall risks among full-time wheelchair or scooter users with MS is suggested to increase the understanding among clinicians and researchers of modifiable risk factors.

Barriers and Facilitators to Employment: A Comparison of Participants With Multiple Sclerosis and Spinal Cord Injury.

OBJECTIVE: To compare self-reported barriers and facilitators to employment among employed and unemployed participants with multiple sclerosis (MS) and spinal cord injury (SCI). DESIGN: Cross-sectional study using self-report assessment obtained by mail or online. SETTING: Medical university in the southeastern United States. PARTICIPANTS: Participants (N=2624) identified from either a specialty hospital or a state-based surveillance system in the southeastern United States, including 1234 with MS and 1390 with SCI. All participants were aged <65 years at the time of assessment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported barriers and facilitators to employment. RESULTS: Overall, the MS participants reported more barriers, particularly stress, cognition, and fatigue, whereas those with SCI were more likely to report not having the proper education and training, resources, transportation, and attendant care. Follow-up analyses broken down by employment status indicated that several barriers and facilitators were significantly related to diagnosis for either employed or unemployed participants, but not both. Among those employed, participants with SCI were more likely to report they could not do the same types of jobs as they could pre-SCI and those with MS were more likely to state that they did not know much about jobs for people with disabilities (no differences were noted for these variables among unemployed participants). Unemployed individuals with SCI were more likely to report that the jobs for which they were trained were not accessible. CONCLUSIONS: The primary barriers for individuals with MS revolve around the condition itself, whereas the barriers for SCI appear to be more related to modifiable factors. Vocational rehabilitation specialists need to identify diagnostic-specific barriers to promote employment outcomes.

Fear of Falling, Community Participation, and Quality of Life Among Community-Dwelling People Who Use Wheelchairs Full Time.

OBJECTIVES: To examine the differences in community participation and quality of life (QOL) among individuals who use wheelchairs full time with and without fear of falling (FOF). DESIGN: Cross-sectional study design. SETTING: University research laboratory. PARTICIPANTS: Individuals (N=85) who use a manual or power wheelchair full time who are living with various health conditions and have a history of at least 1 fall in the past 12 months (age, 45.4±15.8y; disability duration, 21.5±13.6y) were included. Forty-six (54%) were manual wheelchair users. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: To quantify FOF, participants responded (yes/no) to the question: "Are you worried or concerned that you might fall?" Community participation and QOL were indexed by the Community Participation Indicator (CPI) and the World Health Organization Quality of Life-Brief version (WHOQOL-BREF), respectively. A multivariate analysis of variance (MANOVA) was performed to examine the differences in CPI and WHOQOL-BREF scores among wheelchair users who reported FOF and no FOF. RESULTS: A total of 54 participants (63.5%) reported that they were worried or concerned about falling. The MANOVA revealed significant differences in overall CPI (F2,82=4.714; P=.012; Wilks' λ=0.897) and WHOQOL-BREF (F4,63=3.32; P=.016; Wilks' λ=.826) scores. Participants who reported FOF demonstrated significantly lower CPI and WHOQOL-BREF scores compared with those who did not report FOF. CONCLUSIONS: FOF and associated activity curtailment are prevalent and may be a factor influencing full time wheelchair users' community participation and QOL. Prospective research is needed to better understand how FOF influences community participation and QOL among individuals who use wheelchairs full time. Findings would support the development of interventions, specifically for individuals who use wheelchairs full time, to reduce FOF and improve community participation and QOL.

Effects of Functional Electrical Stimulation Cycling on Fatigue and Quality of Life in People with Multiple Sclerosis Who Are Nonambulatory.

BACKGROUND: Functional electrical stimulation (FES) cycling provides an exercise opportunity for people with multiple sclerosis (MS) who are nonambulatory. This study evaluated the efficacy of FES cycling for reducing fatigue and improving quality of life in people with MS who are nonambulatory and compared outcomes with those in a control group that did not take part in FES cycling. METHODS: Adults with MS with self-reported Expanded Disability Status Scale scores of 7.0 to 8.5 were randomized into a training group (n = 12) or a control group (n = 9). The training group performed FES cycling for 30 minutes, two to three times a week for 12 weeks. The primary outcome was safety, measured as the number and type of adverse events and any increase in symptoms. Other outcomes collected before and after the intervention were scores on the modified Ashworth Scale, manual muscle test, 5-item Modified Fatigue Impact Scale (MFIS-5), Fatigue Scale for Motor and Cognitive Functions (FSMC), Medical Outcomes Study Pain Effects Scale, Patient Health Questionnaire-9 (PHQ-9), Multiple Sclerosis Quality of Life-54 (MSQOL-54), and Exercise Self-Efficacy Scale. RESULTS: Twelve participants completed the study and were analyzed. Six participants completed training with no adverse events. The MFIS-5 (Cohen's d = 0.60), FSMC (Cohen's d = 0.37), and PHQ-9 (Cohen's d = 0.67) scores and the physical health composite of the MSQOL-54 (Cohen's d = 1.48) improved for the training group compared with the control group (n = 6). CONCLUSIONS: Functional electrical stimulation cycling is safe for people with MS who are nonambulatory and may reduce fatigue and improve measurements of quality of life.

Safety and Feasibility of Various Functional Electrical Stimulation Cycling Protocols in Individuals With Multiple Sclerosis Who Are Nonambulatory.

OBJECTIVE: To examine the safety, feasibility, and response to functional electrical stimulation (FES) cycling protocols requiring differing levels of effort in people with multiple sclerosis (MS) who are nonambulatory. DESIGN: Pilot study with pre-post intervention testing. SETTING: Outpatient clinic setting of a long-term acute care hospital. PARTICIPANTS: Individuals (N=10) with MS (6 men; mean age 58.6±9.86y) who use a wheelchair for community mobility. Participants' Expanded Disability Status Scale score ranged from 6.5 to 8.5 (median 7.5). INTERVENTION: Participants performed 3 or 4 FES cycling protocols requiring different levels of volitional effort during 6-8 testing sessions. MAIN OUTCOME MEASURES: The primary outcome was safety, measured by adverse events and increase in MS symptoms, all assessed throughout, immediately post- and 1 day postsession. FES cycling performance for each protocol was also recorded. Exploratory outcome measures collected before and after all testing sessions included functional assessment of MS, MS Impact Scale, Exercise Self Efficacy Scale, Patient Health Questionnaire-9 item, and the Zarit Caregiver Burden Scale. RESULTS: All participants (4 women, 6 men) completed all testing sessions. There were no serious adverse events or differences in vitals or symptoms between protocols. Two participants had an isolated episode of mild hypotension. Changes in pain, spasticity, and fatigue were minimal. Five participants were able to cycle for 30 minutes and completed interval training protocols requiring increasing difficulty. The remainder cycled for <3 minutes and completed a rest interval protocol. There was modest improvement on the exploratory outcome measures. CONCLUSIONS: People with MS who use a wheelchair for community mobility can safely perform FES cycling requiring more effort than previously reported research. Therefore, the individuals may experience greater benefits than previously reported. Further study is required to better understand the potential benefits for optimizing function and improving health in people with MS.

Effects of Treadmill Training on Muscle Oxidative Capacity and Endurance in People with Multiple Sclerosis with Significant Walking Limitations.

BACKGROUND: Exercise can improve muscle function and mobility in people with multiple sclerosis (MS). However, the effects of exercise training on skeletal muscle oxidative capacity and endurance in people with MS remain unclear, and few studies have evaluated muscle plasticity in people with MS who have moderate-to-severe disability. The present study evaluated the effects of treadmill training on muscle oxidative capacity and muscle endurance and examined the relationship to walking function in people with MS who have moderate-to-severe disability. METHODS: Six adults (mean ± SD age, 50 ± 4.9 years) with MS (Expanded Disability Status Scale score, 6.0-6.5) performed treadmill training for 24 minutes approximately twice per week for approximately 8 weeks (16 sessions total) using an antigravity treadmill system. The following measures were taken before and after the intervention phase: muscle oxidative capacity in the medial gastrocnemius using near-infrared spectroscopy after 15 to 20 seconds of electrical stimulation; muscle endurance in the medial gastrocnemius using accelerometer-based mechanomyography during 9 minutes of twitch electrical stimulation in three stages (3 minutes per stage) of increasing frequency (2, 4, and 6 Hz); and walking function using the 2-Minute Walk Test. RESULTS: Mean ± SD muscle oxidative capacity increased from 0.64 ± 0.19 min-1 to 1.08 ± 0.52 min-1 (68.2%). Mean ± SD muscle endurance increased from 80.9% ± 15.2% to 91.5% ± 4.8% at 2 Hz, from 56.3% ± 20.1% to 76.6% ± 15.8% at 4 Hz, and from 29.2% ± 13.1% to 53.9% ± 19.4% at 6 Hz of stimulation in the gastrocnemius. There were no significant improvements in walking function. CONCLUSIONS: Treadmill training can improve muscle oxidative capacity and endurance in people with MS who have moderate-to-severe levels of disability.