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 ).

A Core Set of Outcome Measures for Adults With Neurologic Conditions Undergoing Rehabilitation: A CLINICAL PRACTICE GUIDELINE.

BACKGROUND: Use of outcome measures (OMs) in adult neurologic physical therapy is essential for monitoring changes in a patient's status over time, quantifying observations and patient-reported function, enhancing communication, and increasing the efficiency of patient care. OMs also provide a mechanism to compare patient and organizational outcomes, examine intervention effectiveness, and generate new knowledge. This clinical practice guideline (CPG) examined the literature related to OMs of balance, gait, transfers, and patient-stated goals to identify a core set of OMs for use across adults with neurologic conditions and practice settings. METHODS: To determine the scope of this CPG, surveys were conducted to assess the needs and priorities of consumers and physical therapists. OMs were identified through recommendations of the Academy of Neurologic Physical Therapy's Evidence Database to Guide Effectiveness task forces. A systematic review of the literature on the OMs was conducted and additional OMs were identified; the literature search was repeated on these measures. Articles meeting the inclusion criteria were critically appraised by 2 reviewers using a modified version of the COnsensus-based Standards for the selection of health Measurement INstruments. (COSMIN) checklist. Methodological quality and the strength of statistical results were determined. To be recommended for the core set, the OMs needed to demonstrate excellent psychometric properties in high-quality studies across neurologic conditions. RESULTS/DISCUSSION: Based on survey results, the CPG focuses on OMs that have acceptable clinical utility and can be used to assess change over time in a patient's balance, gait, transfers, and patient-stated goals. Strong, level I evidence supports the use of the Berg Balance Scale to assess changes in static and dynamic sitting and standing balance and the Activities-specific Balance Confidence Scale to assess changes in balance confidence. Strong to moderate evidence supports the use of the Functional Gait Assessment to assess changes in dynamic balance while walking, the 10 meter Walk Test to assess changes in gait speed, and the 6-Minute Walk Test to assess changes in walking distance. Best practice evidence supports the use of the 5 Times Sit-to-Stand to assess sit to standing transfers. Evidence was insufficient to support use of a specific OM to assess patient-stated goals across adult neurologic conditions. Physical therapists should discuss the OM results with patients and collaboratively decide how the results should inform the plan of care. DISCLAIMER: The recommendations included in this CPG are intended as a guide for clinicians, patients, educators, and researchers to improve rehabilitation care and its impact on adults with neurologic conditions. The contents of this CPG were developed with support from the APTA and the Academy of Neurologic Physical Therapy (ANPT). The Guideline Development Group (GDG) used a rigorous review process and was able to freely express its findings and recommendations without influence from the APTA or the ANPT. The authors declare no competing interest.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A214.

High-Intensity Gait Training in an Individual With Neuromyelitis Optica and Research Recommendations for Individuals With Multiple Sclerosis.

BACKGROUND: Neuromyelitis optica (NMO), similar to multiple sclerosis (MS), is an autoimmune disorder affecting the central nervous system. In people with central nervous system diagnoses, high-intensity gait training (HIGT) can support neuroplasticity, improving functional mobility. While low- to moderate-intensity exercise is beneficial in improving outcomes in individuals with NMO and MS, the impact of HIGT has not been thoroughly explored. This case study explores the safety and efficacy of HIGT in an individual with NMO. METHODS: A 43-year-old man with NMO participated in a HIGT program utilizing the least amount of body weight support necessary to achieve a target heart rate of 60% to 80% of heart rate reserve or a Borg Rating of Perceived Exertion score of 15 to 17 during an in-patient rehabilitation stay. Interventions incorporated stair training, gait variances, and virtual reality. RESULTS: The patient successfully completed a 90-minute training session 4 to 7 times per week for 6 weeks following a HIGT regimen for 40% to 60% of each session. Meaningful gains in bed mobility, transfers, and gait allowed for discharge to his home. CONCLUSIONS: This case suggests that HIGT in patients with NMO can be safe and effective in improving functional mobility. Due to the similarities between NMO and MS, this case provides a framework to assist clinicians in developing a HIGT plan of care for individuals with MS. Additional research is needed to clarify HIGT parameters, including intensity and duration, to improve functional mobility in individuals with MS.

Interim guidelines for the assessment and treatment of pain in children with multiple sclerosis.

Introduction: Pain in multiple sclerosis (MS) is common, but literature on pain in children with MS remains scarce. Pain has physical, psychological, and social implications in MS, and both comprehensive assessment and interdisciplinary management approaches are needed. We sought to develop an interdisciplinary interim guideline for the assessment and management of pain in children with MS. Methods and materials: We convened a modified Delphi panel composed of 13 experts in pediatric and adult MS neurology, physiotherapy, pain, patient lived-experience, advanced practice nursing, psychology, physiatry, and MS research. A survey was sent to panelists for anonymous completion. The panel discussed survey themes extracted by the panel chair. The process was repeated twice. Results: Thirteen assessment and treatment recommendations were produced regarding pain in children with MS. Discussion: Future studies will assess implementation of these pain assessment and treatment guidelines in the clinical setting.

Outcome measures in neurological physical therapy practice: part I. Making sound decisions.

Standardized outcome measures (OMs) are a vital part of evidence-based practice. Despite the recognition of the importance of OMs, recent evidence suggests that the use of OMs in clinical practice is limited. Selecting the most appropriate OM enhances clinical practice by (1) identifying and quantifying body function and structure limitations; (2) formulating the evaluation, diagnosis, and prognosis; (3) informing the plan of care; and (4) helping to evaluate the success of physical therapy interventions. This article (Part I) is the first of a 2-part series on the process of selecting OMs in neurological clinical practice. We introduce a decision-making framework to guide the selection of OMs and discuss 6 main factors-what to measure, the purpose of the measure, the type of measure, patient and clinic factors, psychometric factors, and feasibility-that should be considered when selecting OMs for clinical use. The framework will then be applied to a patient case in Part II of the series (see the article "Outcome Measures in Neurological Physical Therapy Practice: Part II. A Patient-Centered Process" in this issue).

Outcome measures in neurological physical therapy practice: part II. A patient-centered process.

Physical therapists working in neurological practice must make choices about which standardized outcome measures are most appropriate for each patient. Significant time constraints in the clinic limit the number of measures that one can reasonably administer. Therapists must choose measures that will provide results that guide the selection of appropriate interventions and are likely to show clinically meaningful change. Therefore, therapists must be able to compare the merits of available measures to identify those that are most relevant for each patient and setting. This article describes a process for selecting outcome measures and illustrates the use of that process with a patient who has had a stroke. The link between selecting objective outcome measures and tracking patient progress is emphasized. Comparisons are made between 2 motor function measures (the Fugl-Meyer Assessment [FMA] of Physical Performance vs the Stroke Rehabilitation Assessment of Movement), and 2 balance measures (Berg Balance Scale vs the Activities-specific Balance Confidence Scale). The use of objective outcome measures allows therapists to quantify information that previously had been described in subjective terms. This allows the tracking of progress, and the comparison of effectiveness and costs across interventions, settings, providers, and patient characteristics.

Reliability, Validity, and Responsiveness of the Mini-Balance Evaluation Systems Test in Ambulatory Individuals with Multiple Sclerosis.

Purpose: The purpose of this study was to determine the reliability, validity, and responsiveness of the Mini-Balance Evaluation Systems Test (MBT) in persons with multiple sclerosis (pwMS). Method: A total of 32 pwMS completed a questionnaire on disease severity, the Activities-specific Balance Confidence Scale (ABC), and the MBT. The MBT was re-administered 1 week later. Results: The interrater and test-retest reliability of the total MBT and subscales were excellent. The standard error of measurement for the total MBT, calculated from test-retest and interrater reliability, respectively, was 1.32 and 1.07. The minimal detectable change (MDC) for the total MBT was 3.74; the MDC for the subscales ranged from 0.98 (sensory) to 2.38 (gait). The correlations between individual subscale scores and the total MBT, among subscales, and between the total MBT and disease severity and ABC were excellent. Correlations between the total MBT and age, MS type, and fall and imbalance histories were moderate. Disease severity and ABC scores were the strongest predictors of MBT score. No floor effects were found. Ceiling effects were found for two subscales, but not for the total MBT. Conclusions: The MBT is reliable and valid in pwMS. MDC values will facilitate assessing the effectiveness of treatment. Because ceiling effects were found for two subscales, but not the total MBT, it is recommended that clinicians administer the MBT in its entirety.

Objectif : déterminer la fiabilité, la validité et la réactivité du mini-test des systèmes d'évaluation de l'équilibre (MBT) chez les personnes atteintes de sclérose en plaques (paSP). Méthodologie : au total, 32 paSP ont rempli un questionnaire sur la gravité de la maladie, l'échelle de confiance de l'équilibre lors des activités (ABC) et le MBT. Ils ont refait le MBT une semaine plus tard. Résultats : les chercheurs ont constaté une excellente fiabilité interévaluateur et test­retest du total de MBT et des sous-échelles. L'écart-type de la mesure de MBT total était de 1,32 et de 1,07, calculé à partir de la fiabilité test­retest et interévaluateur, respectivement. Le changement minimal décelable (CMD) du MBT total était de 3,74; les sous-échelles variaient entre 0,98 (expérience sensorielle) et 2,38 (démarche). Les corrélations étaient excellentes entre les scores des échelles individuelles et le total du MBT, entre les sous-échelles ainsi qu'entre le total du MBT, la gravité de la maladie et l'ABC. Celles entre le total du MBT et l'âge, le type de SP et les antécédents de chutes et de déséquilibres étaient modérées. La gravité de la maladie et les scores d'ABC étaient les prédicteurs les plus solides du score de MBT. Les chercheurs n'ont constaté aucun effet de plancher, mais des effets de plafonnement dans deux sous-échelles, sans inclure le total du MBT. Conclusions : Le MBT est fiable et valide chez les paSP. Les valeurs de CMD faciliteront l'efficacité du traitement. Compte tenu des effets de plafonnement de deux sous-échelles, mais pas du total du MBT, il est recommandé aux cliniciens d'effectuer l'intégralité du MBT.

Reliability, validity, and responsiveness of the Balance Evaluation Systems Test (BESTest) in individuals with multiple sclerosis.

BACKGROUND: The Balance Evaluation Systems Test (BESTest) measures various aspects of postural control, but little data exist in persons with multiple sclerosis (MS). The purpose of this study was to determine the psychometrics of the BESTest in MS. DESIGN: Observational study. METHODS: 21 ambulatory subjects with MS participated. In the first session, demographic data was collected; each subject completed a questionnaire of self-perceived disability level and the BESTest. The BESTest was re-administered 1 week later. RESULTS: Test-retest reliability (ICC 3,1) for the total BESTest was 0.94, ranging 0.66 to 0.93 for the subsections. Internal consistency (Chronbach's alpha) for the total BESTest was 0.97; subsections scores ranged 0.79 to 0.96. Minimal detectable change (MDC) scores ranged from 2.25 to 4.58 for subsections with 9.47 points for total BESTest. Weak to moderate correlations were found between individual subsection scores (0.12 to 0.78), and BESTest total and subsection scores to fall (-0.08 to -0.62) frequency and self-perceived disability level (-0.24 to -0.64). Strongest correlations were found between BESTest total and individual subsection scores. No floor effects were found; five BESTest subsections had ceiling effects. CONCLUSIONS: The BESTest is reliable and valid in individuals with MS. Total BESTest scores demonstrated higher reliability and a lack of a ceiling effect as compared to subsection scores, suggesting that clinicians use the BESTest in its entirety. The correlations among subsection scores indicate that each assesses a unique aspect of balance, supporting its construct validity. The MDC scores will assist clinicians in assessing patient change.

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.

Physical therapy during in-patient rehabilitation for a patient with Stiff-Person Syndrome.

BACKGROUND AND PURPOSE: Patients with Stiff-Person Syndrome (SPS) typically show stiffness and spasms, primarily of the trunk and proximal lower extremities. The purpose of this case report is to provide an overview of SPS and a description of the specific physical therapy management strategies used during a brief inpatient rehabilitation stay for a patient with SPS, illustrating the use of the patient/client management model in the Guide to Physical Therapist Practice. CASE DESCRIPTION: The patient was a 33-year-old with a 3- year history of SPS. He spent 10 days in an in-patient rehabilitation hospital where he received physical therapy daily. The initial examination revealed impairments of pain, range of motion, reflex integrity, and motor function, along with abnormalities of posture, balance, and function. The procedural interventions included therapeutic exercise and functional retraining. Stretching exercises were categorized according to their priority and level of difficulty to accommodate for the patient's varying symptoms, and relaxation exercises aimed to reduce the severity of the patient's spasms. The functional retraining program included transfer and progressive gait training. OUTCOMES: The patient showed improvements in ankle range of motion, posture, and gait (distance, speed, and independence), despite continued problems with stiffness, spasms, and pain. DISCUSSION: Physical therapists working with patients with SPS have challenges related to the paucity of information in the literature. The chronic, progressive, and variable nature of SPS indicates the need for life-long management, with the inclusion of an exercise program that can be adjusted accordingly, given the frequently changing symptoms experienced by the patient. As is shown with this case, it appears that physical therapy can improve function and some of the impairments associated with SPS.