The psychometric properties of the Six-Spot Step Test - a systematic review using the COSMIN guidelines.

OBJECTIVE: Accurate and reliable balance measures are important for prescribing fall prevention treatments and monitoring their effectiveness. Thus, we aimed to systematically review the psychometric properties of the Six-Spot Step Test, an increasingly used measure of dynamic balance. DATA SOURCES: A literature search using the free-text term "Six-Spot Step Test" was performed on 12 February 2024, in Medline, Embase, Rehabilitation & Sports Medicine and SPORTDiscus. Eligibility criteria were adults aged 18 or more, trials evaluating the psychometric properties of the Six-Spot Step Test, and English-language articles. Conference abstracts were excluded. REVIEW METHODS: Two investigators screened and selected data independently and assessed the methodological quality and evidence using the COSMIN Risk of Bias checklist and modified GRADE approach. One investigator extracted study characteristics such as design, population and psychometric properties. RESULTS: Of the 159 articles identified, 16, evaluating multiple measurement properties, were included in the final analysis. A total of 1319 people participated, including people affected by Stroke, multiple sclerosis, Parkison's disease, chronic inflammatory polyneuropathy and older adults with balance problems. Eight articles assessing reliability (n = 618, intraclass correlations coefficient ≥0.7, minimal detectable change = 22%) and 12 construct validity (n = 1082, 83% true hypothesis, area under the curve >0.7) exhibited sufficient methodological quality with high-level evidence, while two studies (n = 167) examining responsiveness showed very low evidence. CONCLUSION: Apart from responsiveness, robust evidence supports the reliability and validity of the Six-Spot Step Test for assessing dynamic balance in a specific group of individuals with neurological diseases and older adults. Further, it is considered feasible for clinical use.

Examining the test-retest reliability and construct validity of the Six-Spot Step Test in older adults with self-reported balance problems.

OBJECTIVE: To evaluate the test-retest reliability and construct validity of the Six-Spot Step Test in older adults. DESIGN: Cross-sectional study. SETTING: Outpatient clinics. SUBJECTS: Sixty-six adults aged ⩾65 years with self-reported balance problems. MAIN MEASURE: The Six-Spot Step Test was completed twice on day 1. Three days later, the Six-Spot Step Test, the Timed "Up and Go" test, Dynamic Gait Index, the Mini-BESTest, and standing balance test were conducted. Reliability and validity were estimated using Bland-Altman statistics, minimal detectable change, Intraclass Correlation Coefficient (ICC), and Spearman's rank correlation coefficient (ρ). RESULTS: Participants had a mean (SD) age of 75.5 (6.6) years, a median (Q1-Q3) Montreal Cognitive Assessment test score of 26 (24-27), and a median (Q1-Q3) Falls Efficacy Scale International score of 22 (20-26). The study found within-day and between-day limits of agreements of ±15.7% and ±18.1%, respectively. The minimal detectable changes at the 95% level of confidence for within-day and between-day were 17.5% and 21.6%, and the ICCs were 0.96 (CI: 0.92-0.98) and 0.94 (CI: 0.86-0.97), respectively. A learning effect was observed between the first and second Six-Spot Step Test. Moderate to strong correlations were found between the Six-Spot Step Test and Mini-BESTest (ρ = -0.62), Dynamic Gait Index (ρ = -0.55), and the Timed "Up and Go" test (ρ = 0.79). Weak correlations were identified between the Six-Spot Step Test and static standing balance test (ρ < 0.38). CONCLUSION: The Six-Spot Step Test shows excellent relative consistency and moderate to high construct validity in older adults. A change of 21.6% is a true change in outcome.

How do resistance training and balance and motor control training affect gait performance and fatigue impact in people with multiple sclerosis? A randomized controlled multi-center study.

BACKGROUND: Despite a shared purpose of improving functional capacity, the principles of progressive resistance training (PRT) and balance and motor control training (BMCT) are fundamentally different. OBJECTIVES: To investigate the effects of PRT and BMCT on gait performance and fatigue impact in people with multiple sclerosis (PwMS). METHODS: A multi-center, single-blinded, cluster-randomized controlled trial with two intervention groups (PRT and BMCT) and a control group (CON). The interventions lasted 10 weeks. A total of 71 participants with impaired mobility (Timed 25-Foot Walk (T25FW) > 5 seconds or Six Spot Step Test (SSST) > 8 seconds) were enrolled. Primary outcomes were the T25FW and the SSST. Fatigue impact, self-perceived gait function, 6-minute walk, balance, and muscle strength were secondary outcomes. RESULTS: In total, 83% completed the study. The primary comparisons showed that BMCT, but not PRT, improved T25FW, SSST, and self-perceived gait function when compared to CON. Secondary comparisons showed that BMCT improved SSST more than PRT, while T25FW did not differ. Both BMCT and PRT reduced the fatigue impact. Finally, the effect of BMCT was superior to PRT on dynamic balance, while PRT was superior to BMCT on knee extensor muscle strength. CONCLUSION: BMCT, but not PRT, was superior to CON in improving gait performance, while both BMCT and PRT reduced fatigue.

A study of the validity of the Six-Spot Step Test in ambulatory people with Parkinson's disease.

OBJECTIVE: The aim of this study was to evaluate the concurrent and divergent validity of the Six-Spot Step Test in mild to moderately impaired people with Parkinson's disease. DESIGN: Cross-sectional cohort study. SETTING: Outpatient clinics. SUBJECTS: Fifty-eight people with Parkinson's disease. MAIN MEASURE: The Six-Spot Step Test, the Timed "Up and Go" test, the mini-Balance Evaluation Systems Test (mini-BESTest), and postural sway were tested on the same day, and the Spearman's Rank Correlation Coefficient (ρ) was used for data analysis. RESULTS: Subjects had a median age of 68 years (Q1-Q3: 62-73), a median Hoehn and Yahr score of 2.5 (Q1-Q3: 2-3), a median Six-Spot Step Test score of 7.9 seconds (Q1-Q3: 6.5-9.2), a median Timed "Up and Go" test score of 7.0 seconds (Q1-Q3: 5.6-7.9), a median mini-BESTest score of 22.5 (Q1-Q3: 19.8-25.0), and a median postural sway score of 27.9 mm2 (Q1-Q3: 15.0-53.5) and 22.5 mm/s (Q1-Q3: 14.6-39.8). Statistical significant correlations were found between the Six-Spot Step Test and the Timed "Up and Go" test (ρ = 0.81) and the mini-BESTest (ρ = -0.64), whereas no significant relations were identified between the Six-Spot Step Test and postural sway (ρ = 0.18, P > 0.05). CONCLUSION: In patients with Parkinson's disease, the Six-Spot Step Test showed promising concurrent validity to other recommended clinical tests for encompassing balance capacity and capacity of functional mobility, making it a reasonable and easily administered alternative to existing assessment tools when measuring walking agility. As expected, weak correlates to postural sway revealed that the Six-Spot Step test is not a valid measure of standing balance.

Test-retest reliability and limits of agreement of the Six-Spot Step Test in people with Parkinson's disease.

OBJECTIVE:: The aim of this study was to evaluate the within-day and day-to-day agreement and reliability of the Six-Spot Step Test in mild to moderately disabled people with Parkinson's disease. DESIGN:: Cross-sectional cohort study. SETTING:: Outpatient clinics. SUBJECTS:: Forty-four people with Parkinson's disease. MAIN MEASURE:: The Six-Spot Step Test was completed twice on day 1. Two days later, the Six-Spot Step Test was completed again. The agreement was estimated by Bland-Altman statistics with 95% limits of agreement, and reliability was estimated by the intraclass correlation coefficient. RESULTS:: Subjects had a mean (SD) age of 67.8 (6.8) years, a median (range) Hoehn and Yahr score of 2.5 (1-4) and a mean (SD) Six-Spot Step Test score of 8.1 (1.8), 7.6 (1.7) and 7.6 (1.6) seconds on test occasions 1 to 3. An agreement for within-day and day-to-day of ±1.8 (±23.7%) and ±2.2 (±26.7%) seconds was found, respectively. The reliability was 0.81 and 0.76 within-day and day-to-day, respectively. A small learning effect was observed ( P < 0.05) between the first and second Six-Spot Step Test, but there was no learning between the second and third occasions. CONCLUSION:: The Six-Spot Step Test has an acceptable within-day and day-to-day agreement and reliability in mild to moderately disabled people with Parkinson's disease. A change of 2.2 seconds can be regarded as a true change. To minimize learning effects, test trials of the Six-Spot Step Test are recommended before use.

Content and effects of balance training in people with diabetic peripheral neuropathy - a systematic review and meta-analysis.

BACKGROUND: Diabetic Peripheral Neuropathy (DPN) impairs balance due to sensory loss, proprioceptive deficits, muscle weakness, altered gait, and delayed reflexes. Targeted aerobic and balance training seem promising to mitigate these issues. However, the exact content of a recommended training regime is yet to be determined. OBJECTIVE: To delineate and synthesise balance training content and efficacy for people with DPN. METHODS: The literature search was conducted on PubMed and Embase in accordance with the PRISMA-checklist. Last search was performed on April 29, 2024. Inclusion criteria were established using the PICO-framework. Methodological quality was assessed using the TESTEX Scale. Meta-analyses were exclusively applied to studies featuring a passive control group. RESULTS: A total of 2007 articles were identified. Twelve studies were included in the qualitative synthesis. Seven studies were included in the meta-analyses. Two studies were of high quality. Most studies reported the frequency, session time, duration, and setting of balance training, while none reported the intensity. The meta-analyses showed a standardized mean difference in favor of balance training compared to passive control for One-Legged Stance (openeyes) (0.89[0.5,1.28]), One-Legged Stance (closed eyes) (1.48[0.36, 2.60]), Postural sway (-0.71[-1.04, -0,37]), Timed Up and Go(-0.94[-1.78, -0.10]), and Berg Balance Scale (2.26[0.48, 4.05]), respectively. CONCLUSION: Studies are few and generally of low methodological quality. The content of balance training interventions is minimally described, especially concerning the applied intensity. However, balance training does seem to improve balance outcomes in people with DPN, but given the methodological limitations, interpretation must be cautious.

A study of the reliability and construct validity of the 1-minute sit-to-stand test for individuals with systemic sclerosis.

OBJECTIVE: This study seeks to assess the reliability and construct validity of the 1-minute sit-to-stand test as an efficient tool for evaluating the functional capacity of individuals with systemic sclerosis, considering its time and space effectiveness. METHODS: This cross-sectional study recruited forty-nine individuals with systemic sclerosis from a university hospital in Denmark. The 1-minute sit-to-stand test was conducted twice on the same day, with an interval of approximately 10 to 15 minutes between administrations, followed by a single administration of the 6-minute walk test. Reliability and validity were estimated using Bland-Altman statistics, intraclass correlation coefficient (ICC2,1), paired t-test, and Spearman's rank correlation coefficient (ρ). RESULTS: The 1-minute sit-to-stand test exhibited excellent test-retest reliability with an ICC2,1 (CI) of 0.97 (0.95-0.99). The minimal metrically detectable change between separate measures on a subject for the difference in the measures to be considered real at the 95% confidence level was 2.9 repetitions and 11%, respectively. A learning effect of one repetition was observed between repeated measures. High construct validity was observed between the 1-minute sit-to-stand and 6-minute walk test (ρ = 0.78, p < .001). CONCLUSIONS: This study demonstrates the 1-minute sit-to-stand test as highly reliable, with an 11% change indicating a true outcome change. It also demonstrates robust construct validity compared to the 6-minute walk test. The 1-minute sit-to-stand test appears feasible for assessing functional capacity in well-functioning individuals with systemic sclerosis, but prior familiarization with the task is recommended, as a small learning effect was observed with one repetition.

Effects of Balance Exercise Interventions on Balance-Related Performance in People With Multiple Sclerosis: A Systematic Review and a Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Balance training covers a range of different modalities and complexity levels for people with multiple sclerosis (MS). When evaluating the effects of balance training across different kinds of interventions, determination of the specific intervention content that predict effects are needed. OBJECTIVE: To investigate the effects of balance training on gait and dynamic balance outcomes. METHODS: Four databases were systematically searched. Randomized controlled trials involving people with MS (Expanded Disability Status Scale [EDSS] score ≤7.5) where at least 50% of the intervention targeted balance control were included. Interventions were categorized based on training types. Risk-of-bias was assessed using the Tool for the Assessment of Study Quality and Reporting in Exercise (TESTEX). RESULTS: A total of 18 included studies involved 902 people with MS (EDSS range from 0 to 7.5). Interventions evaluated with a balance composite score or a mobility test showed a moderate effect size (ES = 0.46 [95% confidence interval (CI) = 0.18 to 0.74]; p < .01) and a small overall ES (ES = 0.19 [95% CI = 0.01-0.36]; p = .04), respectively, across different training types. Stepping and gait speed outcomes showed no effect. Cognitive dual-task training showed a significant effect (ES = 0.81 [95% CI = 0.24 to 1.37]) on subgroup level, when evaluated with a mobility outcome measure. The median TESTEX score on study quality and reporting was 11 (maximum score = 15). CONCLUSIONS: Improvements of balance were found across interventions when measured by balance composite scores and mobility tests, but not when measured by stepping or gait speed outcomes. Large training volume was positively associated with effect on balance. A definition of intensity in balance training is needed for evaluation of its impact on the effect of balance interventions.

A study of the discriminative properties of the Six-Spot Step Test in older adults at risk of falling and those not at risk.

OBJECTIVE: To investigate the discriminative properties of the Six-Spot Step Test in older adults with self-reported balance problems. METHODS: Seventy-five older adults aged ≥65 years completed the Six-Spot Step Test and the Timed "Up and Go" test. A Mini-BESTest score of ≤19 was used as a cutoff for defining the risk of falling, and a receiver operating characteristics curve was generated to determine relevant cutoff scores. RESULTS: An overall accuracy of 85% for the Six-Spot Step Test and 88% for the Timed "Up and Go" test were found. The probability of ruling out people at risk of falling increased with a test score shorter than 8.0 and 7.3 seconds on the Six-Spot Step Test and the Timed "Up and Go" test, respectively. Maximizing the total true positive and true negative test results generated a cutoff score of 8.8 seconds (accuracy 79%) and 8.3 seconds (accuracy 80%) for the Six-Spot Step Test and the Timed "Up and Go" test, respectively. CONCLUSIONS: The Six-Spot Step Test, which challenges the ability to adapt to more complex tasks during walking, discriminates accurately between older adults at risk of falling and those not at risk. Results as low as eight seconds qualify for fall-preventive interventions.

A study of the reliability and validity of the Six-Spot Step Test Cognitive in ambulatory persons with Parkinson's disease.

INTRODUCTION: Although dual-task walking deficits challenge ambulatory function in persons with Parkinson's disease (PwPD), ambulation measures that incorporate cognitive dual-task loads seem scarce. In its construct and instruction, the Six-Spot Step Test Cognitive (SSSTcog) ensures an equal focus on cognitive and motor tasks. The present study investigated the construct validity and test-retest reliability of the SSSTcog in PwPD. METHODS: Seventy-eight PwPD were recruited from outpatient clinics. The SSSTcog was completed twice within the same day and again three to seven days later. In addition, the cognitive Timed "Up and Go" test (TUGcog) and the Mini-BESTest were also conducted on the last day. Reliability and validity were estimated using Bland-Altman statistics, the minimal difference (MD), Intraclass Correlation Coefficient (ICC), and Spearman's rank correlation coefficient (ρ). RESULTS: The SSSTcog was found reliable (ICC: 0.84-0.89; MD: 23.7%-30.2%) and showed moderate construct validity to the TUGcog (ρ = 0.62, p < 0.001). Weak correlations to the Mini-BESTest (ρ = -0.33, p < 0.003) indicated low construct validity. Significantly (p < 0.001) higher dual-task costs were seen when performing the SSSTcog (77.6%) compared to the TUGcog (24.3%). CONCLUSIONS: In PwPD, the SSSTcog showed promising construct validity, acceptable to excellent reliability, making it a valid measure of functional mobility, including cognitive dual-tasking. Higher dual-task cost for the SSSTcog indicated actual cognitive-motor interference while performing the test.

Validity and reliability of VO2-max testing in persons with Parkinson's disease.

INTRODUCTION: Direct whole body assessment of maximal oxygen consumption (VO2-max test) is considered the gold standard when assessing cardiorespiratory fitness (VO2-max) in healthy people. VO2-max is also an important health and performance indicator for persons with Parkinson's disease (pwPD) and is often used when prescribing exercise and evaluating aerobic exercise interventions. However, no study has examined the content validity of the VO2-max test in pwPD as well as the test-retest reliability (i.e., day-to-day variation) in both the ON and OFF medication state. Therefore, the present study investigated the content validity and test-retest reliability of the VO2-max test in pwPD both ON and OFF medication. METHODS: Twenty pwPD completed four VO2-max tests (two tests ON and two tests OFF medication), in a randomized order, separated by four to sixteen days. The first tests ON and OFF medication were used to assess content validity based on attainment of five pre-defined end-criteria (one primary and four secondary). Reliability was examined by intraclass correlation coefficients (ICC) and the day-to-day variation of the two ON and OFF medication tests. RESULTS: In pwPD, 50% and 60% attained the primary end-criterion ON and OFF medication, respectively. A higher proportion (i.e., 70-90%) attained the secondary end-criteria both ON and OFF medication with no difference between medication states. Day-to-day variations were 1.2 and 1.8 ml O2/kg/min, while ICC2.1 were 0.97 (95%-CI: 0.92; 0.99) and 0.96 (95%-CI: 0.90; 0.98) ON and OFF medication, respectively. CONCLUSION: The VO2-max test has an acceptable content validity and excellent day-to-day reliability ON and OFF medication in pwPD.

Unwrapping the "black box" of balance training in people with multiple sclerosis - A descriptive systematic review of intervention components, progression, and intensity.

BACKGROUND: Delineating the specific components of the existing balance training interventions in people with multiple sclerosis (PwMS) may contribute to a framework for future design and reporting of such interventions. Thus, we aimed to systematically synthesize how balance training frequency, intensity, time, type, duration, and progression are reported in balance training interventions for PwMS. METHODS: A systematic literature search was conducted in Medline, Embase, Web of Science, and Cinahl. Search terms were MS, postural balance, walking, gait, and randomized/quasi-randomized controlled or clinical trials. Articles including ambulatory PwMS and interventions designed to challenge the balance control system were eligible. Two investigators screened, selected, and extracted data independently. Data on study characteristics such as design, population, and balance training content were extracted. Categorization of balance training based on balance control components was performed. RESULTS: We included 40 studies grouped under five balance training categories. Balance interventions were well described regarding frequency, session time, and duration, but only two interventions described training intensity, and no systematic, gradual progression approach was reported for balance training adaptation over time. However, the balance training interventions included many sensory and motor components of the balance control system. Still, little focus was on reactive motor strategies, vestibular sense, and cognitive dual-tasking. CONCLUSIONS: Existing balance training interventions in PwMS primarily consist of practicing sensory and motor strategies. Future balance training interventions are encouraged to systematically monitor individual advancements in balance training adaptations and to apply the progressive overload principle (i.e. continuous increase in balance exercise stimulus over time). Furthermore, we suggest that balance training in PwMS is performed with high intensity near an individual's balance capacity limits. Finally, individualized balance training is recommended to cover all relevant components of balance control using the proposed framework.

Muscle Strength, Oxygen Saturation and Physical Activity in Patients with Chronic Exertional Compartment Syndrome Compared to Asymptomatic Controls.

Background: One of the most common causes of exercise-induced pain in the lower leg is chronic exertional compartment syndrome (CECS). Research is limited on muscle strength, oxygen saturation and physical activity in patients with CECS. Purpose: To compare muscle strength, oxygen saturation, and daily physical activity between patients with CECS and matched asymptomatic controls. A secondary purpose was to investigate the association between oxygen saturation and lower leg pain in patients with CECS. Study Design: Case-control study. Method: Maximal isometric muscle strength of the ankle plantar and dorsiflexors was tested in patients with CECS and sex- and age-matched controls using an isokinetic dynamometer and oxygen saturation (StO2) during running was tested by near infrared spectroscopy. Perceived pain and exertion were measured during the test using the Numeric Rating Scale and Borg Rating of Perceived Exertion scale and the exercise-induced leg pain questionnaire. Physical activity was assessed by accelerometry. Results: Twenty-four patients with CECS and 24 controls were included. There were no differences in maximal isometric plantar or dorsiflexion muscle strength between patients and controls. Baseline StO2 was 4.5pp (95% CI: 0.7;8.3) lower for patients with CECS than for controls, whereas no difference existed when they experienced pain or reached exhaustion. No differences were found in daily physical activities, except that on average, patients with CECS spent less time cycling daily. During the StO2 measurement, patients experienced pain or reached exhaustion while running significantly earlier than the controls (p<0.001). StO2 was not associated with leg pain. Conclusion: Patients with CECS have similar leg muscle strength, oxygen saturation and physical activity levels as asymptomatic controls. However, patients with CECS experienced significantly higher levels of lower leg pain than the controls during running, daily activities and at rest. Oxygen saturation and lower leg pain were not associated. Level of Evidence: Level 3b.

Maximal isokinetic and isometric muscle strength of major muscle groups related to age, body mass, height, and sex in 178 healthy subjects.

The main objective of this study was to establish normative values for maximal concentric isokinetic strength and maximal isometric strength of all major muscle groups in healthy subjects applying sex, age, height, and body mass-adjusted statistical models. One hundred and seventy-eight (178) (93 male and 85 female) healthy non-athletic Danish volunteers aged 15-83 years were recruited. Eighteen test protocols for each sex were applied to determine isokinetic and isometric muscle strength at knee, ankle, hip, shoulder, elbow, and wrist using a dynamometer (Biodex System 3 PRO). Multiple linear regressions were performed with maximal muscle strength (peak torque) as dependent variable and age, height, and body mass as independent variables. Muscle strength significantly related to age in 24, to height in 13 and to body mass in 27 out of the 36 models. In gender-specific analyses, the variables age, height and body mass accounted for 25% (20-29) (95% confidence interval) of the variation (r (2)) in strength for men and 31% (25-38) for women. The r (2) was similar for the isokinetic models and the isometric models [31% (22-40) vs. 28% (23-34)]. Age, height, and body mass related to strength in most muscle groups and gender-specific models with estimated prediction intervals were established for maximal strength of major muscle groups.

The subjective minimal important change for the Six Spot Step Test in people with multiple sclerosis - The Danish MS Hospitals Rehabilitation study.

INTRODUCTION: The Six Spot Step Test has shown good psychometric properties in terms of validity and reliability in people with multiple sclerosis. Yet, the responsiveness and minimal important change are unknown. The objective was to investigate the responsiveness of the Six Spot Step Test against the perceived change of walking limitations and establish estimates for the minimal important change in people with multiple sclerosis. METHODS: The Six Spot Step Test was performed before and after four weeks of specialised multidisciplinary inpatient rehabilitation by 142 adults with mild to severe multiple sclerosis. Responsiveness was determined based on anchor- and distribution-based methods, using the Multiple Sclerosis Walking Scale-12 as external criterion. In a supplementary analysis, the Six-Minute Walking Test was used as an external criterion. RESULTS: The correlation between the baseline (r = 0.56, p < 0.01) and discharge (r = 0.55, p < 0.01) Multiple Sclerosis Walking Scale-12 and Six Spot Step Test scores were acceptable. Furthermore, the change scores were weakly associated (r = 0.1, p = 0.27). This trend was similar for the Six-Minute Walking Test when used as anchor. The smallest detectable change was estimated to 1.7 seconds. An improvement in the Six Spot Step Test exceeding 2.1 (95% CI - 0.9 to 5.0) sec and 4.9 (95% CI 1.2-8.6) sec may be considered clinically important on a group level based on the Multiple Sclerosis Walking Scale-12 and the Six-Minute Walking Test, respectively. CONCLUSION: In a sample of mild to severely disabled people with multiple sclerosis, the Six Spot Step Test showed fair responsiveness against a subjective and objective criterion, indicating a minimal important change between ≥ 2.1 and ≥ 4.9 seconds, respectively. However, a weak association between the change in the Six Spot Step Test and the subjective and objective external criterion calls for cautious interpretation. Hence, the results should be further verified against a valid external criterion.

[1-min sit-to-stand test to assess functional capacity for people with chronic obstructive pulmonary disease].

In this review, we present the 1-min sit-to-stand test, a short, easy and validated functional test usable for general practitioners, among others, to assess functional capacity for people with chronic obstructive pulmonary disease (COPD). Possibly, this can motivate people with COPD to be more physically active. From the first interaction, healthcare professionals should provide information about the positive effects of physical activities and continuously assess functional capacity with a functional test in people with COPD to promote an active lifestyle.

How much does balance and muscle strength impact walking in persons with multiple sclerosis? - A cross-sectional study.

INTRODUCTION: Despite the multitude of rehabilitation interventions targeting gait impairments in persons with multiple sclerosis (PwMS), only little is known about the relative association of muscle strength and balance on different gait outcomes. AIM: To determine the relative association of balance and muscle strength to three gait performance outcomes in PwMS. METHOD: 90 PwMS were enrolled in this cross-sectional study (72% women; mean age=49.8 ±â€¯10.5 years; mean EDSS=3.7 ±â€¯1.3. Spearman correlation and multivariate linear regression analysis were used to determine associations between three (dependent) gait outcomes (six-minute walk test (6MW), Timed 25-Foot Walk (T25FW), and Six Spot Step Test (SSST)). Explanatory variables were maximal muscle strength of the knee extensors, kneeflexors, plantarflexors and dorsiflexors, static balance (postural sway), functional balance (Mini-BESTest) and age and gender. RESULTS: Static balance (r = 0.30 to 0.53; p<.05) and muscle strength of the knee extensors, knee flexors, plantarflexors and dorsiflexors (r = 0.28 to 0.47; p<.05) were weakly related to all gait performance outcomes, while functional balance showed strong relationships (r = 0.70 to 0.83; p<.05). Multivariate regression models including postural sway, muscle strength, and age and gender accounted for 32-39% of the variability in the 6MW, T25FW, and SSST. In 6MW and T25FW, with standardized beta coefficients for postural sway and muscle strength ranging from -0.34 to -0.37 (SE=0.09) and 0.18 to 0.35 (SE=0.10 to 0.12), respectively. For SSST, significant associations were only observed for balance. CONCLUSIONS: Balance and muscle strength are significantly associated with gait performance during fast walking, whereas only balance was associated with more complex walking tasks.

A study of the discriminative properties of the Six-Spot Step Test in people with Parkinson's disease at risk of falling.

BACKGROUND: Clinical tests that can discriminate between people at risk of falling and those not at risk are warranted. The discriminative properties of the Six-Spot Step Test was investigated in people with Parkinson's disease at risk of falling. METHODS: Eighty-one participants with a median age of 69 years (Q1-Q3:63-74) and a median Hoehn and Yahr score of 2.5 (Q1-Q3:2-3) completed the Six-Spot Step Test and the Timed "Up and Go" test. A mini-BESTest score of 19 or below was used as a cut-off for defining risk of falling, and a receiver operating characteristics curve was generated to determine clinical relevant cut-off scores. RESULTS: A cut-off score of 7.0 and 6.8 seconds identified people not at risk of falling, while 11.1 and 9.4 seconds identified people at risk of falling for the Six-Spot Step Test and the Timed "Up and Go" test, respectively. When maximizing the sensitivity and specificity a cut-off score of 9.2 (accuracy of 84%) and 8.1 seconds (accuracy of 70%) was found for the Six-Spot Step Test and the Timed "Up and Go" test, respectively. CONCLUSION: The Six-Spot Step Test discriminates accurately between people with Parkinson's disease at risk of falling and people not at risk.

Is there an effect of dietary intake on MS-related fatigue? - A systematic literature review.

BACKGROUND: Fatigue is considered the most common symptom of persons with multiple sclerosis MS (pwMS), occurring in up to 90% of the patients at some point with two-thirds of pwMS experience fatigue as their most disturbing symptom. Pharmacological treatment options for MS-related fatigue show only limited and contradicting results. Consequently, many pwMS search for alternative options to control the symptom. A considerable interest in dietary interventions as a means of MS symptom management has advanced in the MS community. Yet, the few empirical studies focussing on the effect of holistic dietary intake on fatigue have not been systematically examined. The aim of this review was to systematically review the effect of holistic dietary intake and the subjective perception of fatigue in adult pwMS. METHODS: Embase, Medline, Web of Science, CINAHL Complete, SPORTDiscus, PsycInfo, and Rehabilitation and Sports Medicine (Ebsco Host) databases were systematically searched to locate relevant literature. Intervention trials studying the effect of a holistic dietary regimen on the subjective perception of fatigue in a sample of adult pwMS were considered for inclusion. Risk of bias was assessed using a modified Downs and Black checklist. RESULTS: A total of four studies met the inclusion criteria: one single arm intervention pilot trial, one randomised controlled pilot trial, one double-blinded randomised trial, and one assessor-blinded randomised controlled trial. Interventions were low fat diets, a low fat, starchy plant food diet, and modified paleo diets and ranged from three to 12 months duration. Two studies supplying an adequate amount of folate and magnesium with the intervention diet reported relevant improvements in fatigue scores. CONCLUSION: Dietary intake holds the potential to lower MS-related fatigue, but solid conclusions are not possible based on the existing evidence. Sparse evidence points towards an effect of adequate magnesium and folate intake and a trend for decreased fatigue.

How does strength training and balance training affect gait and fatigue in patients with Multiple Sclerosis? A study protocol of a randomized controlled trial.

INTRODUCTION: Multiple sclerosis (MS) is characterized by a demyelination that results in reduced conductivity in the somatosensory nervous system, decreased muscle strength, vestibular alteration, and severe fatigue. Progressive resistance training (PRT) has proven to be a promising intervention showing a positive effect on muscle strength. Another promising intervention frequently used in neuro-rehabilitation is task specific training where also Balance and Motor Control Training (BMCT) are incorporated. Interestingly, the principles of BMCT do fundamentally contrast the principles of PRT in terms of variation in movement pattern, loading and repetitions. Consequently, knowledge of any diverse effect would be of clinical relevance. AIM: To evaluate the effects of PRT and BMCT on gait, balance and fatigue in persons with MS. METHOD: A three-armed multi-center, single-blinded cluster randomized controlled trial with two intervention groups (1. PRT of the lower extremities. 2. BMCT that challenges gait function) and a control group that receives usual care while on a waitlist for a combined PRT + BMCT intervention performed after the two interventions groups have completed their interventions. The interventions last ten weeks with two sessions per week, in groups of 3-6 participants. Number of participants is 30 per intervention - 90 in total. Primary outcome measures for gait function are the Timed 25 Foot Walk (T25FW) and the Six Spot Step Test (SSST). Secondary outcomes are fatigue, perceived gait function, temporo-spatial gait characteristics, balance and strength.Inclusion criteria are: EDSS 2-6, SSST >8 sec and T25FW >5 sec. Exclusion: Recent attacks and ongoing intensive rehabilitation. ANALYSIS: The effects in the three groups are examined in a mixed effects regression analysis with group and time as fixed effects and center and patient within center as random effects. Spearman or Pearson correlation analysis will be conducted on baseline data to determine associations between the primary outcomes on gait function and the secondary outcomes on fatigue, spatial gait parameters, balance and patient reported measures. TRIAL REGISTRATION: The study is approved by the Regional ethical committee and registered at clinicaltrials.gov, NCT02870023.