Effectiveness of the Proprioceptive Neuromuscular Facilitation Method on Gait Parameters in Patients With Stroke: A Systematic Review.

OBJECTIVE: To review the current evidence for the effectiveness of proprioceptive neuromuscular facilitation (PNF) techniques on gait parameters in patients with stroke. DATA SOURCES: The electronic platforms of CINAHL, MEDLINE, PubMed, and the Physiotherapy Evidence Database were searched using the relevant search terms. STUDY SELECTION: Intervention studies that had gait parameters as an outcome and in which PNF techniques were used in a poststroke population were reviewed. The studies were reviewed by both authors and a consensus was reached. The literature search identified 84 studies. Following screening, there were 5 studies that met the inclusion criteria for this review. DATA EXTRACTION: Data were extracted from the studies by both authors and independently reviewed. Methodological quality was assessed with the Physiotherapy Evidence Database scale of randomized controlled trials and with the Quality Assessment Tool for Quantitative Studies for nonrandomized controlled trials. DATA SYNTHESIS: Treatment using the PNF method led to a statistically significant improvement in gait outcome measures in patients with stroke in all the studies. Three of the studies also found that groups treated with PNF techniques had a significantly greater improvement in outcome measures than groups that received routine physiotherapy treatment. CONCLUSIONS: Although some limitations were identified in the methodological quality of the studies, current research suggests that PNF is an effective treatment for the improvement of gait parameters in patients with stroke. Further research is needed to build a robust evidence base in this area.

Social Cognitive Theory Correlates of Physical Activity in Inactive Adults with Multiple Sclerosis.

BACKGROUND: There is a growing body of evidence that physical activity (PA) improves symptoms of multiple sclerosis (MS). Despite the benefits of PA, people with MS are relatively inactive compared with their healthy counterparts. This study investigated associations between social cognitive theory (SCT) constructs and energy expenditure (EE) as an objective measure of PA in a sample of inactive people with MS. METHODS: Participants (n = 65) completed several questionnaires and were assessed using standardized outcome measures as part of a cross-sectional analysis of baseline data from a randomized controlled trial (Step it Up). RESULTS: The bivariate correlation analysis indicated that of all SCT constructs, only exercise self-efficacy was significantly correlated with EE (r = 0.297, P = .022). Multiple linear regression analysis found that exercise self-efficacy independently explained 9% of the variance in EE (R2 = 0.088). A model including exercise self-efficacy, exercise goal setting, exercise planning, and exercise benefits explained 17% of the variance in EE (F4,54 = 2.741, P = .038, R2 = 0.169). In this model, only exercise self-efficacy was significantly associated with EE scores (Exercise Self-Efficacy Scale ß = .320, P = .016). CONCLUSIONS: The constructs of SCT explained little of the variance of objectively measured PA in a sample of inactive people with MS who volunteered for an exercise trial. The only significant variable was exercise self-efficacy, which confirms the importance of enhancing it through PA interventions.

Do multiple sclerosis symptoms moderate the relationship between self-efficacy and physical activity in people with multiple sclerosis?

OBJECTIVE: To investigate the bivariate correlations between objective physical activity (PA), self-efficacy, and a range of multiple sclerosis (MS) symptom measures. Also, to determine whether any MS symptom measures moderate the relationship between self-efficacy and PA. METHOD: Baseline analysis from a randomized control trial exercise plus a behavior change intervention was used. Fifty-nine physically inactive people with a definite diagnosis of MS were included. Participants were asked to record 7-day objective PA with the SenseWear Armband. Additionally, measures of self-efficacy (Exercise Self-Efficacy Scale), walking endurance (6-min walk test), impact of walking (12-Item MS Walking Scale [MSWS-12]), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]) and fatigue (Modified Fatigue Impact Scale) were assessed before intervention. Pearson's correlations and moderation analysis were conducted. RESULTS: Self-efficacy was positively associated with PA (r = .30, p < .05). HADS-Depression (r = -.25, p < .05) and MSWS-12 (r = -.31, p < .01) demonstrated statistically significant negative correlations with self-efficacy but not with PA. Moderation analysis illustrated a significant interaction between anxiety and self-efficacy (r = .39, p < .03) with an R2 value of .15. The interaction was significant at lower values of anxiety, suggesting that the relationship between self-efficacy and PA is stronger when levels of anxiety are lower. CONCLUSION: This article confirms the potential role of MS symptoms, in particular anxiety, in explaining PA behavior in an inactive sample of persons with multiple sclerosis (pwMS). Further exploration is warranted, and future PA interventions should acknowledge the potential interplay of psychosocial constructs such as self-efficacy and anxiety in changing PA behavior among pwMS. (PsycINFO Database Record

Sources of Variability in Physical Activity Among Inactive People with Multiple Sclerosis.

PURPOSE: Evidence supports that physical activity (PA) improves symptoms of multiple sclerosis (MS). Although application of principles from Social Cognitive Theory (SCT) may facilitate positive changes in PA behaviour among people with multiple sclerosis (pwMS), the constructs often explain limited variance in PA. This study investigated the extent to which MS symptoms, including fatigue, depression, and walking limitations combined with the SCT constructs, explained more variance in PA than SCT constructs alone among pwMS. METHOD: Baseline data, including objectively assessed PA, exercise self-efficacy, goal setting, outcome expectations, 6-min walk test, fatigue and depression, from 65 participants of the Step It Up randomized controlled trial completed in Ireland (2016), were included. Multiple regression models quantified variance explained in PA and independent associations of (1) SCT constructs, (2) symptoms and (3) SCT constructs and symptoms. RESULTS: Model 1 included exercise self-efficacy, exercise goal setting and multidimensional outcomes expectations for exercise and explained ~14% of the variance in PA (R 2=0.144, p < 0.05). Model 2 included walking limitations, fatigue and depression and explained 20% of the variance in PA (R 2=0.196, p < 0.01). Model 3 combined models 1 and 2 and explained variance increased to ~29% (R 2=0.288; p<0.01). In Model 3, exercise self-efficacy (ß=0.30, p < 0.05), walking limitations (ß=0.32, p < 0.01), fatigue (ß = -0.41, p < 0.01) and depression (ß = 0.34, p < 0.05) were significantly and independently associated with PA. CONCLUSION: Findings suggest that relevant MS symptoms improved by PA, including fatigue, depression and walking limitations, and SCT constructs together explained more variance in PA than SCT constructs alone, providing support for targeting both SCT constructs and these symptoms in the multifactorial promotion of PA among pwMS.

Randomised controlled pilot trial of an exercise plus behaviour change intervention in people with multiple sclerosis: the Step it Up study.

OBJECTIVE: To investigate feasibility of multiple sclerosis (MS) exercise guidelines for inactive people with MS (PwMS) and to examine preliminary efficacy for walking. To investigate effect of augmenting that intervention with education based on social cognitive theory (SCT). DESIGN: Pilot multicentre, double-blind, randomised, parallel, controlled trial. SETTING: Community-delivered programme. PARTICIPANTS: Sixty-five physically inactive PwMS walked independently, scored 0-3 on the Patient Determined Disease Steps Scale, had no MS relapse or change in MS medication in 12 weeks. INTERVENTIONS: 10-week exercise plus SCT education (SCT) compared with exercise plus attention control education (CON). OUTCOME MEASURES: Six-Minute Walk Test (6MWT), Timed Up and Go (TUG) test and Multiple Sclerosis Walking Scale-12 (MSWS-12). RESULTS: 174 expressed interest, 92 were eligible and 65 enrolled (SCT, n=32; CON, n=33). The intervention was feasible and delivered as intended. 68% of SCT group and 50% of control group met the exercise guidelines after intervention. Using linear mixed effects models, intention-to-treat basis, there was insufficient evidence for difference between the groups over the trial (6MWT, p=0.30; TUG, p=0.4; MSWS-12, p=0.8). Using secondary analysis of a cohort with data for≥3 assessments (SCT, n=21; CON, n=20), there was significant treatment effect favouring the intervention group (p=0.04) with mean effect for 6MWT 39.0 m (95% CI 2.26 to 75.73) at 12 weeks and 40.0 m (95% CI 2.3 to 77.8) at 36 weeks. Both groups improved significantly in 6MWT following 10-week intervention (SCT, mean ∆=83.02, SD=60.1, p≤0.01; CON, mean ∆=56.92, SD=73.5, p≤0.01), TUG (SCT, ∆=-0.70, SD=1.25, p≤0.01; CON, ∆=-0.54, SD=0.95, p≤0.01) and MSWS-12 (SCT, ∆=-8.03, SD=16.18, p=0.02; CON, ∆=-0.86, SD=18.74, p=0.81). CONCLUSIONS: A 10-week exercise programme based on the MS exercise guidelines for improving walking in previously inactive PwMS was feasible. There is marginal evidence of a treatment effect in favour of the exercise plus SCT intervention at 12 and 36 weeks. TRIAL REGISTRATION NUMBER: NCT02301442; Results.

Effect of exercising at minimum recommendations of the multiple sclerosis exercise guideline combined with structured education or attention control education - secondary results of the step it up randomised controlled trial.

BACKGROUND: Recent exercise guidelines for people with multiple sclerosis (MS) recommend a minimum of 30 min moderate intensity aerobic exercise and resistance exercise twice per week. This trial compared the secondary outcomes of a combined 10-week guideline based intervention and a Social Cognitive Theory (SCT) education programme with the same exercise intervention involving an attention control education. METHODS: Physically inactive people with MS, scoring 0-3 on Patient Determined Disease Steps Scale, with no MS relapse or change in MS medication, were randomised to 10-week exercise plus SCT education or exercise plus attention control education conditions. Outcomes included fatigue, depression, anxiety, strength, physical activity, SCT constructs and impact of MS and were measured by a blinded assessor pre and post-intervention and 3 and 6 month follow up. RESULTS: One hundred and seventy-four expressed interest, 92 were eligible and 65 enrolled. Using linear mixed effects models, the differences between groups on all secondary measures post-intervention and at follow-up were not significant. Post-hoc, exploratory, within group analysis identified improvements in both groups post intervention in fatigue (mean ∆(95% CI) SCT -4.99(-9.87, -0.21), p = 0.04, Control -7.68(-12.13, -3.23), p = 0.00), strength (SCT -1.51(-2.41, -0.60), p < 0.01, Control -1.55(-2.30, -0.79), p < 0.01), physical activity (SCT 9.85(5.45, 14.23), p < 0.01, Control 12.92(4.69, 20.89), goal setting (SCT 7.30(4.19, 10.4), p < 0.01, Control 5.96(2.92, 9.01), p < 0.01) and exercise planning (SCT 5.88(3.37, 8.39), p < 0.01, Control 3.76(1.27, 6.25), p < 0.01) that were maintained above baseline at 3 and 6 month follow up (all p < 0.05). Only the SCT group improved at 3 and 6 month follow up in physical impact of MS(-4.45(-8.68, -0.22), -4.12(-8.25, 0.01), anxiety(-1.76(-3.20, -0.31), -1.99(-3.28, -0.71), depression(-1.51(-2.89, -0.13), -1.02(-2.05, 0.01)) and cognition(5.04(2.51, 7.57), 3.05(0.81, 5.28), with a medium effect for cognition and fitness (Hedges' g 0.75(0.24, 1.25), 0.51(0.01, 1.00) at 3 month follow up. CONCLUSIONS: There were no statistically significant differences between groups for the secondary outcomes once age, gender, time since diagnosis and type of MS were accounted for. However, within the SCT group only there were improvements in anxiety, depression, cognition and physical impact of MS. Exercising at the minimum guideline amount has a positive effect on fatigue, strength and PA that is sustained at 3 and 6 months following the cessation of the program. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02301442 , retrospectively registered on November 13th 2014.

Effects of Functional Electrical Stimulation on Reducing Falls and Improving Gait Parameters in Multiple Sclerosis and Stroke.

BACKGROUND: Loss of neuromuscular control of the ankle joint is a common impairment in neurologic conditions, leading to abnormal gait and a greater risk of falling. Limited information, however, is available on the effectiveness of functional electrical stimulation (FES) on reducing falls, and no studies have investigated its usefulness in improving lower limbs kinematics related to foot clearance and energy recovery. SETTING: Clinical setting. STUDY DESIGN: Prospective longitudinal study. PARTICIPANTS: Twenty-four subjects, 14 people with multiple sclerosis (mean age ± standard deviation 50.93 ± 8.72 years) and 10 people with stroke (55.38 ± 14.55 years). METHODS: The number of falls was assessed at baseline and after 8 weeks, and a clinical assessment was performed at the baseline, 4-week, and 8-week time points. A subsample of the 24 subjects comprising 5 people with multiple sclerosis and 5 people with stroke performed a gait analysis assessment at baseline and after 4 weeks. After receiving the equipment and the training schedule, subjects performed daily home walking training using FES for 8 weeks. MAIN OUTCOME MEASUREMENTS: The main outcomes were (1) the number of falls, (2) foot clearance, and (3) energy recovery. RESULTS: A reduction in the number of falls was observed from baseline (n = 10) to the 8-week assessment (n = 2), P = .02. Foot clearance increased (+5.26 mm, P = .04) between the baseline without FES and at 4 weeks with FES (total effect). No statistically significant differences were found in energy recovery between baseline and 4 weeks. CONCLUSIONS: The use of FES had an impact on gait, specifically reducing the number of falls and improving walking. A specific effect at the ankle joint was observed, increasing foot clearance during the swing phase of gait. This effect was not accompanied with a reduction in the energetic expenditure during walking in subjects with multiple sclerosis and stroke.

Interrater Reliability of Four Sensory Measures in People with Multiple Sclerosis.

BACKGROUND: Sensory disturbances are a major problem for people with multiple sclerosis (MS), and up to 80% of people with MS present with various sensory deficits. To date, only one study has investigated the reliability of sensory measures in people with MS. We sought to determine the interrater reliability of the verbal analogue scale (VAS), the Erasmus MC modifications to the revised Nottingham Sensory Assessment (EmNSA), Semmes-Weinstein monofilaments (SWMs), and the neurothesiometer (NT) in people with MS. METHODS: A random sample of 34 people with MS who could walk independently with or without a device was tested by two raters on the same day. For categorical data, percentage agreement, Cohen's kappa, and prevalence-adjusted bias-adjusted kappa were used. For continuous data, interclass correlation coefficient (ICC[2,1]) with 95% confidence intervals (95% CIs), Bland and Altman analysis, and standard error of measurement (SEM) were calculated. RESULTS: For NT, ICC(2,1) values were good, with the highest for first metatarsophalangeal joint (ICC[2,1] = 0.84, 95% CI = 0.69-0.92, SEM = 4.98). The highest ICC(2,1) for VAS was for the question relating to feeling numbness in the hand (ICC[2,1] = 0.93, 95% CI = 0.86-0.96, SEM = 0.64). Findings for EmNSA and SWMs need further verification owing to possible ceiling effects. CONCLUSIONS: The NT and VAS had good interrater reliability and should be considered for measuring sensation in ambulatory people with MS. Findings for EmNSA and SWMs revealed either questionable or poor reliability, suggesting the need for further investigation.

Cohort Study Comparing the Berg Balance Scale and the Mini-BESTest in People Who Have Multiple Sclerosis and Are Ambulatory.

BACKGROUND: The Berg Balance Scale (BBS) is a balance measure commonly used for people with multiple sclerosis (MS). The Mini-BESTest is an alternative based on balance systems. OBJECTIVE: The study objective was to compare the BBS and the Mini-BESTest for sensitivity to change, likelihood ratios for walking aid use and falls, and associations with clinical variables in people who have MS and are ambulatory. DESIGN: This was a cohort study with measurements before and after exposure to 8 weeks of routine physical therapy intervention. METHODS: For 52 participants who had a primary diagnosis of MS and who were independently mobile, with or without an aid, demographic details and a history of falls and near falls were collected. Participants completed the Mini-BESTest, Multiple Sclerosis Impact Scale-29, Multiple Sclerosis Walking Scale-12, BBS, Modified Fatigue Impact Scale, and Six-Minute Walk Test. RESULTS: No participant started with a baseline Mini-BESTest maximum score of 28, whereas 38.5% (n=20) started with a baseline BBS maximum score of 56. Statistically significant changes in the Mini-BESTest score (X̅=5.31, SD=3.5) and the BBS score (X̅=1.4, SD=1.9) were demonstrated. Effect sizes for the Mini-BESTest and the BBS were 0.70 and 0.37, respectively; standard response means for the Mini-BESTest and the BBS were 1.52 and 0.74, respectively. Areas under the receiver operating characteristic curves for the Mini-BESTest and the BBS were 0.88 and 0.77, respectively, for detecting mobility device use and 0.88 and 0.75, respectively, for detecting self-reported near falls. The Mini-BESTest had a higher correlation for each secondary measure than did the BBS. LIMITATIONS: This study involved a sample of convenience; 61% of the participants did not use a walking aid. The order of testing was not randomized, and fall status was obtained through retrospective recall. CONCLUSIONS: The Mini-BESTest had a lower ceiling effect and higher values on responsiveness tests. These findings suggest that the Mini-BESTest may be better at detecting changes in balance in people who have MS, are ambulatory, and have relatively little walking disability.

Comparing the effects of whole-body vibration to standard exercise in ambulatory people with Multiple Sclerosis: a randomised controlled feasibility study.

OBJECTIVES: This study aimed firstly to investigate the feasibility of the study protocol and outcome measures, secondly to obtain data in order to inform the power calculations for a larger randomised controlled trial, and finally to investigate if whole-body vibration (WBV) is more effective than the same duration and intensity of standard exercises (EXE) in people with Multiple Sclerosis (PwMS). DESIGN: Randomised controlled feasibility study. SETTING: Outpatient MS centre. SUBJECTS: Twenty seven PwMS (age mean (SD) 48.1 (11.2)) with minimal gait impairments. INTERVENTIONS: Twelve weeks of WBV or standard EXE, three times weekly. MAIN MEASURES: Participants were measured with isokinetic muscle strength, vibration threshold, Timed Up and Go test (TUG), Mini-BESTest (MBT), 6 Minute Walk test (6MWT), Multiple Sclerosis Impact Scale 29 (MSIS 29), Modified Fatigue Impact Scale (MFIS) and Verbal Analogue scale for sensation (VAS) pre and post 12 week intervention. RESULTS: WBV intervention was found feasible with low drop-out rate (11.1%) and high compliance (90%). Data suggest that a sample of 52 in each group would be sufficient to detect a moderate effect size, with 80% power and 5% significance for 6 minute walk test. Large effect sizes in favour of standard exercise were found for vibration threshold at 5th metatarsophalangeal joint and heel (P=0.014, r= 0.5 and P=0.005, r=0.56 respectively). No between group differences were found for muscle strength, balance or gait (P>0.05). CONCLUSIONS: Data suggest that the protocol is feasible, there were no adverse effects. A trial including 120 people would be needed to detect an effect on walking endurance.

Relationship between foot vibration threshold and walking and balance functions in people with Multiple Sclerosis (PwMS).

The aim of this study was to investigate the relationship between foot vibration threshold and walking and balance functions in people with Multiple Sclerosis (PwMS). The study sample consisted of 34 participants with mean age of 49.5 years (SD 11.13). Participants were able to walk independently or with an assistive device. Participants underwent vibration threshold testing using the Neurothesiometer (NT), followed by the 6 min walking test (6MWT), the Timed Up and Go test (TUG) and the Berg balance scale (BBS). We found a statistically significant relationship between foot vibration threshold and all outcome measures used. The first metatarsophalangeal joint had the strongest correlation with BBS (-0.585, p < 0.01), 6 MWT (-0.557, p < 0.01) and TUG (0.498, p < 0.01). We also found that vibration threshold scores differed between those people with MS with and without walking limitations (Mann-Whitney U test, p < 0.01 for all testing points). In conclusion, these findings confirm the relationship between foot vibration threshold and clinical measures of walking and balance in PwMS and add to literature predictive validity of foot vibration threshold. They also suggest that vibration threshold may be important to consider when identifying people in need of intervention or when evaluating the effect of rehabilitation and exercise interventions.

Test-retest reliability of four sensory measures in people with multiple sclerosis.

This study investigated the test-retest reliability of the Neurothesiometer (NT), Verbal Analogue Scale for sensation (VAS), Erasmus modifications to the Nottingham Sensory assessment (EmNSA) and Semmes-Weinstein monofilaments (SWM) in people with multiple sclerosis (MS). A random sample of 34 people with MS who walked with or without an assistive device participated in this study. Participants were tested twice with the NT, VAS, EmNSA and SWM, 1 week apart. For categorical data, Cohen's kappa (Κ), percentage agreement (P0) and prevalence-adjusted bias-adjusted kappa (PABAK) were used. For continuous data, intraclass correlation coefficients [ICC (3,1)] with 95% confidence intervals (95% CI), Bland-Altman plots and standard error of measurement (SEM) were calculated. The ICC values for NT were good, being the highest for the plantar aspect of the heel (ICC=0.92, 95% CI 0.85-0.96, SEM=4.24). Good ICC values were obtained for VAS questions on numbness, pins and needles and temperature and were supported by low SEM. Κ values for SWM were poor, ranging from 0.11 to 0.46 for the upper limb and 0.12 to 0.29 for the lower limb. Findings for EmNSA need further verification because of a possible ceiling effect in this test. The NT and VAS assessments for sensation had good test-retest reliability and should be considered for measuring changes in sensation in ambulatory people with MS. In contrast, findings from EmNSA and SWM revealed either questionable or poor test-retest reliability, suggesting that these two measures need further investigation.