Quantifying muscle fatigue during walking in people with multiple sclerosis

BackgroundThis study aimed to examine muscle fatigue in lower leg muscles in of people with multiple sclerosis and healthy controls, and whether muscle fatigue coincided with potential changes in gait.MethodsIn this case-control study, people with multiple sclerosis (n = 8; 3male; mean age (SD) = 49.7 (9.6) yr) and age-matched healthy controls (n = 10; 4male; mean age (SD) = 47.4 (8.7) yr) walked on a treadmill for 12-min at self-paced speed. Muscle fatigue was indirectly quantified by a decrease in median frequency and increase in root mean square of surface electromyographic recordings of lower leg muscles. Walking speed, ankle push-off power and net ankle work were calculated from marker positions and force plate data using inverse dynamic calculations.ResultsPeople with multiple sclerosis showed larger decreases in median frequency of soleus (most affected leg: p = 0.003; least affected leg: p = 0.009) and larger increases in root mean square of soleus (most and least affected leg: p = 0.037), gastrocnemius medialis (most affected leg: p = 0.003; least affected leg: p = 0.005) and lateralis (most and least affected leg: p < 0.001) compared to controls. Walking speed (p = 0.001), ankle push-off power (most affected leg: p = 0.018; least affected leg: p = 0.001) and net work around the ankle (most affected leg: p = 0.046; least affected leg: p = 0.001) were lower in people with multiple sclerosis compared to controls, but increased in both groups.InterpretationThe results yield preliminary evidence that soleus muscles of people with multiple sclerosis fatigue during prolonged walking. Changes in electromyography of gastrocnemius muscles could however be related to muscle fatigue, changes in gait or a combination.     

Assessment of motor function in people with multiple sclerosis

Multiple sclerosis (MS) is a chronic progressive disease of the central nervous system (CNS) which predominantly affects young adults. In order to provide physiotherapy appropriate to the needs of individuals with MS, it is necessary to assess and evaluate the nature and degree of motor and functional deficits. The aim of this research was to develop a physiotherapy assessment which would consistently and objectively evaluate motor function in people with MS. The Motor Club Assessment (MCA), originally developed for use in stroke patients, was identified as exhibiting several features which were consonant with the required criteria. It was therefore modified for use in MS. The Amended MCA (AMCA) was tested for inter-rater agreement, which was found to be good for the lower limb motor section (weighted kappa = 0.80), the upper limb motor section (weighted kappa = 0.90), and the functional activities section (weighted kappa = 0.92). The internal consistency was high for the lower limb section (alpha = 0.97) and the functional activities section (alpha = 0.92), but could not be determined for the upper limb section due to a clear ceiling effect. The study demonstrated that the AMCA is a valid tool for assessment use by physiotherapists in MS patients, and that it has an acceptable level of reliability when used in a clinic setting by physiotherapists suitably experienced in the treatment of neurological patients.     

Short-duration robotic therapy in stroke patients with severe upper-limb motor impairment

Chronic motor deficits in the upper limb (UL) are a major contributor to disability following stroke. This study investigated the effect of short-duration robot-assisted therapy on motor impairment, as measured by clinical scales and robot-derived performance measures in patients with chronic, severe UL impairments after stroke. As part of a larger study, 15 individuals with chronic, severe UL paresis (Fugl-Meyer < 15) after stroke (minimum 6 mo postonset) performed 18 sessions of robot-assisted UL rehabilitation that consisted of goal-directed planar reaching tasks over a period of 3 weeks. Outcome measures included the Fugl-Meyer Assessment, the Motor Power Assessment, the Wolf Motor Function Test, the Stroke Impact Scale, and five robot-derived measures that reflect motor control (aiming error, mean speed, peak speed, mean:peak speed ratio, and movement duration). Robot-assisted training produced statistically significant improvements from baseline to posttreatment in the Fugl-Meyer and Motor Power Assessment scores and the quality of motion (quantified by a reduction in aiming error and movement duration with an increase in mean speed and mean:peak speed ratio). Our findings indicate that robot-assisted UL rehabilitation can reduce UL impairment and improve motor control in patients with severe UL paresis from chronic stroke.     

Comparison of trunk impairment scale versions 1.0 and 2.0 in people with multiple sclerosis: A validation study

Background: Trunk control impairment often accompanies multiple sclerosis (MS). Trunk stability is necessary for movements of extremities, as are selective trunk movements for normal gait. Measuring trunk function is thus of interest. Methods: We examined the relationships between the Trunk Impairment Scale (TIS1.0 and TIS2.0) and the Berg Balance Scale (BBS), 5 sit-to-stand test (5STS), Timed Up and Go test (TUG), 10-m timed walk test (10TW), 2-min walk test (2MWT), Falls Efficacy Scale – International, and 12-item MS Walking Scale (MSWS-12) in 47 outpatients. We determined construct validity by calculating the degree to which the TIS versions produced different scores between known groups: use or nonuse of walking aid, MS disability status, and whether participants experienced a fall or not during 14 weeks. Results: TIS correlated moderately with BBS and 5STS; moderately (TIS1.0) or weakly (TIS2.0) with TUG, 10TW, and 2MWT; and weakly to moderately with MSWS-12 in subgroups with Expanded Disability Status Scale (EDSS) >6.0. No other clear correlation patterns were found. TIS did not discriminate between known groups. Conclusions: TIS1.0 is recommended for individuals with MS (EDSS score 4.0–7.5). Better trunk function correlates with better balance and walking ability. TIS has limited value in fall risk screening.     

Measuring fatigue in people with multiple sclerosis

Objective: To compare methods of assessing fatigue.

Design: Cross sectional.

Setting: Community.

Subjects: Forty Multile Sclerosis (MS) patients and 20 healthy controls.

Main outcome measures: Fatigue questionnaires, SDSA dot cancellation test, finger tapping test, TEA Lottery.

Results: The MS patients had significantly higher levels of fatigue than the controls on the Task Induced Fatigue Scale, Fatigue Severity Scale and Fatigue Impact Scale. The Task Induced Fatigue Scale completed whilst imagining oneself driving and the Fatigue Assessment Instrument did not differentiate between MS patients and controls. Finger tapping differentiated between MS patients and controls but there was no significant difference between MS patients and controls on visual and auditory concentration tests. A factor analysis indicated that questionnaire measures of fatigue were inter-related but independent of objective test performance.

Conclusions: Questionnaire measures can be used to assess fatigue in people with MS. The FSS differentiated MS patients from controls and is relatively short. It was therefore recommended for clinical use.     

Health promotion in people with multiple sclerosis

Chronic diseases like MS present unique challenges and opportunities for patients and the medical care system. Patients are challenged because they are under tremendous pressure to actively engage themselves in multiple prevention, treatment, and health maintenance behaviors, often before they feel ready. Health care providers are challenged because health-promotion activities require more time, counseling skills, and organizational resources than traditional, acute medical care. Patients, clinicians, and researchers face the challenge of determining which health-promotion activities are not only supported by the evidence but also appropriate for a given patient.New models of health promotion are being developed that integrate self-help and professional help. These approaches have been applied in other chronic diseases and should be adapted and studied among people with MS.     

Managing bladder symptoms in people with multiple sclerosis

Multiple sclerosis is a chronic disease of the central nervous system (brain and spinal cord). The cause is still unknown but there is evidence that suggests there is an autoimmune component to the disease that causes damage to the myelin sheath, a complex material that surrounds the axon of myelinated nerves (Fig 1). It affects 100-120 people per 100,000 population, approximately 75 per cent of whom will develop urinary symptoms (NICE, 2003). Bladder problems usually occur when the disease involves the spinal cord (Fig 2) and these can get worse as the disease progresses and the patient becomes less mobile. Bladder symptoms affect many aspects of daily life and their management is extremely important. As the disease progresses and symptoms worsen, a well-planned strategy can offer patients the most effective pathway to manage their bladder problems.     

Corpus callosal diffusivity predicts motor impairment in relapsing-remitting multiple sclerosis: a TBSS and tractography study

Motor deficits in relapsing remitting multiple sclerosis (RRMS) patients are monitored using standard measures of disability that assess performance ranging from walking ability to hand function, thus reflecting involvement of a variety of motor pathways. We investigated the relative contributions of diffuse white matter damage and focal lesions using diffusion tensor imaging (DTI), in predicting future worsening of hand function in RRMS. The nine hole peg test (NHPT), a test of fine hand motor control, was used to measure baseline upper limb function in 16 controls and 25 RRMS patients, and then performed at follow-up on 22 of these patients at 6 and 12 months. Tract-based spatial statistics (TBSS) were used across the whole brain as a non-hypothesis driven method for localizing white matter changes associated with motor deficits. Subsequently, we used probabilistic fiber tractography in the corticospinal tracts (CST) and the transcallosal hand motor (TCHM) fibers to assess the predictive power of diffusion metrics and/or functionally relevant visible lesion volumes on the decline of hand motor function over the next 12 months. While fractional anisotropy (FA) and radial diffusivity (RD) of both pathways were strongly associated with NHPT performance at baseline, only RD of the TCHM fibers was predictive of NHPT decline over the next 12 months. Neither total visible lesion load nor pathway specific lesion loads were indicative of NHPT performance or progression. The TCHM fibers may play an important role in modifying the effects of MS pathology on fine motor control, and RD in these fibers may be a sensitive biomarker for future disability.     

多发性硬化患者的听神经损害

多发性硬化(multiplesclerosis,MS)是以中枢神经系统多灶炎症及脱鞘为特征的一种疾病。MS患者中存在听神经的损害的表现,有人观察到3.5%确诊的MS患者在急性期及复发期出现单侧或双侧听力下降。2%～10%MS患者出现脑干诱发电位(brainstemauditoryevokedpotential,BAEP)I波异常,表现为波I潜伏期延长、波幅降低甚至缺失。这些表现随病情的加重明显,随症状的减轻而减轻,甚至恢复正常。MRI显示MS患者听神经病灶,表明听神经周围部分的损害,其原因可能与听神经根的颅外部分出现脱髓鞘有关。     

Assessing quality of life in people with multiple sclerosis

Purpose : The quality of life of multiple sclerosis (MS) patients was assessed using two MS specific quality of life measures (FAMS and SF-54) and a short generic measure (EuroQol) in order to make recommendations for routine assessment. Factors contributing to quality of life within this population were also considered.

Method : Questionnaires were either sent by post or completed at interview. Ninety-six MS patients known to a consultant in rehabilitation medicine completed the questionnaires.

Results : Patients scored very low on subscales related to physical health. Correlations were high between the FAMS and SF-54 but low with the EuroQoL. Stepwise multiple linear regressions showed mood measures to account for the most variance on all quality of life composite scores. The MS patients within the study had much lower SF-36 quality of life scores than the general population and other illness groups.

Conclusions : The EuroQol did not measure the same aspects of quality of life as the FAMS and SF-54 and was not found to be a sensitive measure within this sample. The SF-54 suffered from floor effects on physical health subscales and therefore the FAMS was recommended.     

Manual wheelchair pushrim dynamics in people with multiple sclerosis

OBJECTIVES: To define differences in pushrim dynamics during manual wheelchair propulsion by users with multiple sclerosis (MS) relative to 2 control groups of subjects with spinal cord injury (SCI) and no disability (ND) and to investigate changes in propulsion biomechanics at different speeds and with fatigue. DESIGN: Case-control. SETTING: Biomechanics laboratory. PARTICIPANTS: A convenience sample of 42 people, 8 women and 6 men per group. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The propulsion pattern, mean maximum speed, percentage of time in push and recovery phases, push angle, push frequency, mean maximum resultant pushrim force, mean work and push cycle, and hand-to-pushrim coupling and decoupling effects. RESULTS: The MS groups tended to use an arcing propulsion pattern more than did the control groups (Pmax=.003). The MS group pushed at a lower mean maximum velocity (v) when allowed to choose the speed of propulsion (v(MS),.67+/-.20m/s; v(SCI), 1.10+/-0.23m/s; P=.001), when asked to push at 1m/s (v(MS),.91+/-.26m/s; v(SCI), 1.12+/-0.11m/s; v(ND), 1.05+/-0.13m/s; P=.010), and were unable to maintain a self-selected speed during a 5-minute trial (Deltav(MS),.15+/-.02m/s; Deltav(ND),.03+/-.06m/s; P<.001). The MS group spent a higher proportion of time in the push phase of propulsion (Pmax=.001). In general, the MS group had smaller push angles, but push frequencies similar to the controls. Statistically adjusted MS group pushrim forces and work per push measures varied depending on context, but in all trials the MS group displayed a braking effect when grasping and releasing the pushrim. The MS group had declines in most measures when pushing at a self-selected speed for 5 minutes. In all trials, the MS group was more likely to display asymmetry between right and left sides in biomechanic parameters. CONCLUSIONS: Manual wheelchair users with MS have difficulty grasping and releasing the pushrim and maintaining speed during a fatigue trial. This likely leads to a slow self-selected speed of propulsion that may not be functional. Clinicians should remember these results when prescribing manual wheelchairs for people with MS.     

Assessing quality of life in people with multiple sclerosis

Purpose : The quality of life of multiple sclerosis (MS) patients was assessed using two MS specific quality of life measures (FAMS and SF-54) and a short generic measure (EuroQol) in order to make recommendations for routine assessment. Factors contributing to quality of life within this population were also considered. Method : Questionnaires were either sent by post or completed at interview. Ninety-six MS patients known to a consultant in rehabilitation medicine completed the questionnaires. Results : Patients scored very low on subscales related to physical health. Correlations were high between the FAMS and SF-54 but low with the EuroQoL. Stepwise multiple linear regressions showed mood measures to account for the most variance on all quality of life composite scores. The MS patients within the study had much lower SF-36 quality of life scores than the general population and other illness groups. Conclusions : The EuroQol did not measure the same aspects of quality of life as the FAMS and SF-54 and was not found to be a sensitive measure within this sample. The SF-54 suffered from floor effects on physical health subscales and therefore the FAMS was recommended.     

Management of bowel dysfunction in people with multiple sclerosis

Bowel dysfunction is a common problem for people with MS. It impacts upon both physical disability and psychosocial wellbeing. This article reviews the limited evidence underpinning best practice. The evidence highlights the importance of a thorough bowel assessment and adequate fluid and fibre intake together with the benefits of pelvic floor exercises. Biofeedback therapy, aerobic exercise and anal plugs are helpful for some people with MS. The use of pharmacological interventions needs to be considered with care.     

Prevalence of primary headaches in people with multiple sclerosis

The aim was to investigate the lifetime prevalence of headache and primary headache (diagnoses according to International Headache Society criteria) in multiple sclerosis (MS). The relationships between headache and clinical features of MS and MS therapy were also investigated. We studied 137 patients with clinically definite MS; 88 reported headache, 21 of whom developed headache after the initiation of interferon. The prevalence of all headaches in the remaining 116 patients was 57.7%. Migraine was found in 25.0%, tension-type headache in 31.9%, and cluster headache in one patient. A significant correlation (P = 0.007, Fisher's exact test) between migraine and relapsing-remitting MS was found. Primary headaches are common in MS patients. Further studies are needed to clarify the mechanisms underlying this association, particularly the association between migraine and relapsing-remitting MS, and the role of interferon in the development of new headache.     

Progressive resistance exercise for people with multiple sclerosis

Purpose. This study aimed to determine if participation in a progressive resistance exercise (PRE) programme can: (1) increase the ability to generate maximal muscle force, (2) increase muscle endurance, (3) increase functional activity, and (4) improve overall psychological function of people with multiple sclerosis (MS).

Methods. A pre-post single group research design with a 4-week baseline familiarisation phase was used. Nine people (mean age 45.6 years, SD 10.7) with MS attended a gymnasium three times over 4 weeks for familiarization. Participants then completed a twice-weekly 10-week PRE programme, with two sets of 10 – 12 repetitions of each exercise. Outcome measures of muscle strength (1RM for arms and legs), muscle endurance (repetitions at half 1RM), walking speed, the 2-min walk test (2MWT), a timed stairs test, and the impact of MS on physical and psychological function were taken at weeks 2, 4, and 14.

Results. Participants attended 94.3% (SD 8.2%) of the training sessions, with no adverse events. After accounting for baseline stability, significant improvements (P < 0.05) were found in arm strength (14.4%), leg endurance (170.9%), fast walking speed (6.1%), and there was a trend for increased distance in the 2MWT (P = 0.06). The perceived impact of MS on physical function was reduced (P = 0.02).

Conclusions. Adults with MS benefited from a PRE programme by improving muscle performance and physical activities, without adverse events. These findings suggest that PRE may be a feasible and useful fitness alternative for people with mild to moderate disability due to MS.     

Progressive resistance exercise for people with multiple sclerosis

PURPOSE: This study aimed to determine if participation in a progressive resistance exercise (PRE) programme can: (1) increase the ability to generate maximal muscle force, (2) increase muscle endurance, (3) increase functional activity, and (4) improve overall psychological function of people with multiple sclerosis (MS). METHODS: A pre-post single group research design with a 4-week baseline familiarisation phase was used. Nine people (mean age 45.6 years, SD 10.7) with MS attended a gymnasium three times over 4 weeks for familiarization. Participants then completed a twice-weekly 10-week PRE programme, with two sets of 10 - 12 repetitions of each exercise. Outcome measures of muscle strength (1RM for arms and legs), muscle endurance (repetitions at half 1RM), walking speed, the 2-min walk test (2MWT), a timed stairs test, and the impact of MS on physical and psychological function were taken at weeks 2, 4, and 14. RESULTS: Participants attended 94.3% (SD 8.2%) of the training sessions, with no adverse events. After accounting for baseline stability, significant improvements (P < 0.05) were found in arm strength (14.4%), leg endurance (170.9%), fast walking speed (6.1%), and there was a trend for increased distance in the 2MWT (P = 0.06). The perceived impact of MS on physical function was reduced (P = 0.02). CONCLUSIONS: Adults with MS benefited from a PRE programme by improving muscle performance and physical activities, without adverse events. These findings suggest that PRE may be a feasible and useful fitness alternative for people with mild to moderate disability due to MS.