Postural behaviour in people with multiple sclerosis: A complexity paradox.

BACKGROUND: Balance deficits are a major concern for people with multiple sclerosis (pwMS). Measuring complexity of motor behaviour can offer an insight into MS-related changes in adaptability of the balance control system when dealing with increasingly complex tasks. QUESTION: Does postural behaviour complexity differ between pwMS at early stages of the disease and healthy controls (HC)? Does postural behaviour complexity change across increasingly complex tasks? METHODS: Forty-eight pwMS and 24 HC performed four increasingly complex postural tasks with eyes open (EO), eyes closed (EC), on firm (FS) and compliant surface (CS). Lumbar and sternum sensors recorded 3D acceleration, from which complexity index (CI) was calculated using multiscale sample entropy (MSE) in the frontal and sagittal planes. RESULTS: We found that only the complexity index in both planes during the eyes closed on compliant surface (EC-CS) task was significantly lower in pwMS compared to HC. We also found that complexity in pwMS was significantly lower during EC-CS compared to the other three tasks when using both lumbar and sternum sensors. SIGNIFICANCE: Increasing the complexity of postural tasks reduces the complexity of postural behaviour in pwMS. This paradox may reflect reduced adaptability of the sensorimotor integration processes at early stages of MS. CI can provide a different perspective on balance deficits and could potentially be a more sensitive biomarker of MS progression and an early indicator of balance deficit.

Sample Entropy Improves Assessment of Postural Control in Early-Stage Multiple Sclerosis.

Postural impairment in people with multiple sclerosis (pwMS) is an early indicator of disease progression. Common measures of disease assessment are not sensitive to early-stage MS. Sample entropy (SE) may better identify early impairments. We compared the sensitivity and specificity of SE with linear measurements, differentiating pwMS (EDSS 0-4) from healthy controls (HC). 58 pwMS (EDSS ≤ 4) and 23 HC performed quiet standing tasks, combining a hard or foam surface with eyes open or eyes closed as a condition. Sway was recorded at the sternum and lumbar spine. Linear measures, mediolateral acceleration range with eyes open, mediolateral jerk with eyes closed, and SE in the anteroposterior and mediolateral directions were calculated. A multivariate ANOVA and AUC-ROC were used to determine between-groups differences and discriminative ability, respectively. Mild MS (EDSS ≤ 2.0) discriminability was secondarily assessed. Significantly lower SE was observed under most conditions in pwMS compared to HC, except for lumbar and sternum SE when on a hard surface with eyes closed and in the anteroposterior direction, which also offered the strongest discriminability (AUC = 0.747), even for mild MS. Overall, between-groups differences were task-dependent, and SE (anteroposterior, hard surface, eyes closed) was the best pwMS classifier. SE may prove a useful tool to detect subtle MS progression and intervention effectiveness.

Exercise interveNtion outdoor proJect in the cOmmunitY - results from the ENJOY program for independence in dementia: a feasibility pilot randomised controlled trial.

The Seniors Exercise Park program is an evidence-based outdoor physical and social activity program designed originally for older people with no cognitive impairment. This study aimed to pilot this program for people living with dementia in residential aged care. We examined the feasibility of delivering the program, evaluating its structure, safety, and supervision needs. In addition, physical, social, health and cognitive benefits of participation were examined. Method This was a feasibility pilot randomised controlled design. Adults aged ≥ 60 years with symptoms of dementia and/or diagnoses of dementia were recruited from an aged care facility in Australia. Participants allocated to the intervention underwent a 12-week structured supervised physical activity program using the outdoor Seniors Exercise Park equipment followed by a 12-week maintenance phase, while the controls received usual care programs. Assessments occurred at baseline, 12 and 24-weeks. Feasibility evaluation included recruitment rate, retention, attendance, overall adherence, dropout rate, adverse events, program delivery modifications and supervision requirements. A suite of cognitive and health-related questionnaires and physical function measures were also collected. Results Sixteen participants were recruited (recruitment rate: 58.6%), eight for the intervention (83.3 ± 7.5 years, 87.5% women) and eight for the control (age 87.5 ± 3.0 years, 87.5% women). Eighty-eight percent completed the 12-week structured program, with 75% retention at 24-weeks. Across the 24-week period, 84.3% participation adherence was reported. No falls or adverse events occurred. Modifications of the program mainly related to method of communication, cueing and adjustments to suit individual personality and characteristics. A ratio of one trainer to two participants was practical and safe. There were no significant changes over time between groups in any of the secondary outcomes. High level of engagement, enjoyment and mood was reported throughout the exercise program. Conclusion The Seniors Exercise Park physical activity program was safe and feasible for people living with dementia in residential care, with high levels of enjoyment, positive attitude, and engagement reported in the intervention group. Individualised communication during program delivery was needed to facilitate motivation and participation. Further research is needed to assess the program effectiveness on physical and cognitive function on a larger scale. Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry-Registry Number ACTRN12620000733976 . Registered on the 13/07/2020.

The impact of strict lockdowns on the mental health and well-being of people living in Australia during the first year of the COVID-19 pandemic.

BACKGROUND: There are limited longitudinal studies on the effects of the COVID-19 pandemic on mental health and well-being, including the effects of imposed restrictions and lockdowns. AIMS: This study investigates how living in a pandemic, and related lockdowns and restrictions, affected the mental health of people living in Australia during the first year of the COVID-19 pandemic. METHOD: A total of 875 people living in Australia participated in a longitudinal survey from 27 May to 14 December 2020. This time period includes dates that span pre-, during and post-wave 2 lockdowns in Australia, with strict and sustained public health measures. Linear mixed models were fitted to investigate the effect of lockdown on depression and anxiety symptoms. RESULTS: Symptoms of depression and anxiety improved over time, during and after lockdowns. More adverse mental health symptoms were observed for people with a history of medical or mental health problems, caring responsibilities, more neurotic personality traits or less conscientiousness, and for people who were younger. People who reported being more conscientious reported better mental health. CONCLUSIONS: Despite notoriously strict lockdowns, participants did not experience a deterioration of mental health over time. Results suggest a lack of significant adverse effects of lockdown restrictions on mental health and well-being. Findings highlight cohorts that could benefit from targeted mental health support and interventions, so that public policy can be better equipped to support them, particularly if future strict public health measures such as lockdowns are being considered or implemented for the COVID-19 pandemic and other disasters.

Cost-Effectiveness of the ENJOY Seniors Exercise Park for Older People: A Pre-Post Intervention Study.

BACKGROUND: The Exercise interveNtion outdoor proJect in the cOmmunitY (ENJOY) Seniors Exercise Park program uses specialized outdoor equipment and a physical activity program to engage older people in physical activity, with multiple health benefits. We determined the cost-effectiveness of the ENJOY program. METHODS: The economic evaluation compared health care utilization costs 6 months prior to and 6 months post ENJOY program participation. Incremental cost-utility analysis for the primary aim (quality of life) and incremental cost-effectiveness analysis for the secondary aim (falls) were used. Analyses took a societal perspective inclusive of Australian government-funded health care and pharmaceuticals in addition to hospitalizations, community-based nursing and allied health, and community services. Productivity costs were also calculated. RESULTS: Fifty participants (average age 72.8 y [SD 7.4] and 78.0% [n = 39/50] women) were included. Participation in the ENJOY program reduced health care costs in the 6 months following the program: preintervention, $9764.49 (SD $26,033.35); postintervention, $5179.30 (SD $3826.64); observed postintervention reduction -$4.585.20 (95% confidence interval, -$12,113.99 to $2943.59; P = .227) without compromising quality of life (mean difference [MD] 0.011; 95% confidence interval, -0.034 to 0.056; P = .631) or increasing the likelihood of a fall (-0.5; 95% confidence interval, 0.00 to -0.50; P = .160). The ENJOY intervention is likely cost-effective. CONCLUSIONS: Planning for shared community spaces should consider the benefits of a Seniors Exercise Park as part of the built environment.

Optimal sensor location and direction to accurately classify people with early-stage multiple sclerosis using gait stability.

BACKGROUND: The local divergence exponent (LDE) has been used to assess gait stability in people with multiple sclerosis (pwMS). Although previous studies have consistently found that stability is lower in pwMS, inconsistent methodologies have been used to assess patients with a broad range of disability levels. QUESTIONS: What sensor location and movement direction(s) are better able to classify pwMS at early stages of the disease? METHODS: 49 pwMS with EDSS ≤ 2.5 and 24 healthy controls walked overground for 5 min while 3D acceleration data was obtained from sensors placed at the sternum (STR) and lumbar (LUM) areas. Unidirectional (vertical [VT], mediolateral [ML], and anteroposterior [AP]) and 3-dimensional (3D) LDEs were calculated using STR and LUM data over 150 strides. ROC analyses were performed to assess classification models using single and combined LDEs, with and without velocity per lap (VELLAP) as a covariate. RESULTS: Four models performed equally well by using combinations of VELLAP, LUM3D, LUMVT, LUMML, LUMAP, STRML, and STRAP (AUC = 0.879). The best model using single sensor LDEs included VELLAP, STR3D, STRML, and STRAP (AUC = 0.878), whereas using VELLAP + STRVT (AUC = 0.869) or VELLAP + STR3D (AUC=0.858) performed best using a single LDE. SIGNIFICANCE: The LDE offers an alternative to currently insensitive tests of gait impairment in pwMS at early stages, when deterioration is not clinically evident. For clinical purposes, the implementation of this measure can be simplified using a single sensor at the sternum and a single LDE measure, but speed should be considered. Longitudinal studies to determine the predictive power and responsiveness of the LDE to MS progression are still needed.

Prevention of work-related musculoskeletal disorders among dental professionals: A scoping review.

BACKGROUND: Musculoskeletal disorders (MSDs) are highly prevalent among dental professionals. Studies examining the prevention of dental work-related MSDs have been completed globally. OBJECTIVE: To identify and evaluate the available evidence regarding MSD prevention in dental practice, and to identify knowledge gaps. METHODS: An electronic search was conducted across multiple scientific databases. Identified articles were assessed according to inclusion/exclusion criteria. Systematic reviews, interventions and published expert opinion were included. RESULTS: Five systematic reviews, 27 intervention studies and 21 expert opinion articles were included. There was overall consensus that use of ergonomic equipment is beneficial in MSD prevention. Knowledge gaps identified included: a lack of systematic reviews on the role of exercise and therapy in MSD prevention; a lack of high-quality intervention studies; a lack of research in general outside of ergonomic equipment use. Expert opinion articles have been published despite a lack of dental-specific research. CONCLUSIONS: Whilst more robust research is required, current evidence supports the use of optical enhancement, saddle chairs, and wide-diameter silicone-handled instruments in MSD prevention. Knowledge gaps were identified relating to the use of exercise, therapy, and education in the prevention of dental work-related MSDs. Further research is required, specifically high-quality intervention studies.

Exercise interveNtion outdoor proJect in the cOmmunitY-ENJOY program for independence in dementia: a feasibility pilot randomised controlled trial study protocol.

BACKGROUND: While the underlying neuropathology of dementia is not curable, interventions and treatment, such as physical activity, can offer physical and functional gains leading to better mobility, independence and quality of life. The Seniors Exercise Park program is an evidence-based physical and social activity program using an innovative design in outdoor exercise equipment specifically designed for older people. This unique program has never been tested with older people living with dementia. This study will evaluate the feasibility of delivering the Seniors Exercise Park program for people living with mild to moderate dementia in residential aged-care. This study will identify the optimal physical activity program, evaluate the safety of equipment usage and determine optimal supervision needs. The potential physical, social, quality of life and cognitive benefits of participation in the Seniors Exercise Park program will also be examined. METHODS: This is a feasibility pilot randomised controlled design with pre-post evaluation. Adults aged ≥ 60 years who have symptoms of dementia and/or who have been diagnosed with dementia will be recruited from an aged-care facility in Melbourne. Participants allocated to the intervention group will undergo a 12-week structured supervised physical activity program using the outdoor Seniors Exercise Park equipment followed by a 12-week maintenance phase (unstructured physical activity). Participants will be assessed at baseline, 3 and 6 months. Participants allocated to the control group will attend activities provided by the aged-care facility. A sample of 12 participants per group is the targeted sample size. Feasibility will be evaluated in terms of recruitment rate, retention, attendance, overall adherence, dropout rate, adverse events, modifications to the exercise program delivery and supervision needs. A comprehensive suite of cognitive and health-related questionnaires and physical function measures will also be collected. DISCUSSION: The ENJOY program for independence in dementia will determine the suitability of the Seniors Exercise Park program for people diagnosed with mild to moderate dementia. Outcomes could inform future design of dementia-friendly built environments to increase physical activity participation for residential aged-care facilities. TRIAL REGISTRATION: This trial is registered with the Australian New Zealand Clinical Trials Registry-Registry Number ACTRN12620000733976 . Registered on the 13th of July 2020.

Factors influencing thigh muscle volume change with cycling exercises in acute spinal cord injury - a secondary analysis of a randomized controlled trial.

Objective: To conduct a per-protocol analysis on thigh muscle volume outcomes from the Spinal Cord Injury and Physical Activity (SCIPA) Switch-On Trial.Design: Secondary analysis from an assessor-blind randomized, controlled trial.Setting: Four acute/sub-acute hospitals in Australia and New Zealand.Participants: 24 adults (1 female) within four weeks of motor complete or incomplete spinal cord injury (SCI)Intervention: Functional electrical stimulation-assisted cycling (FESC) or passive cycling (PC) 4x/week for 12 weeks.Outcome Measures: Whole thigh and muscle group volumes calculated from manually segmented MR images.Results: 19/24 participants completed ≥ twelve weeks of the intervention. Five participants experienced hypertrophy (4 FESC; 1 PC) and eight attenuation of atrophy (<20% volume loss) (3 FESC; 5 PC) in thigh muscle volume. Six participants were non-responders, exhibiting atrophy >20% (3 FESC; 3 PC). Mean (SD) change for FESC was -2.3% (25.3%) and PC was -14.0% (12.3%). After controlling for baseline muscle volumes, a strong significant correlation was found between mean weekly exercise frequency and quadriceps and hamstring volumes (r=6.25, P=0.006), regardless of mode. Average watts was highly correlated to quadriceps volumes only (r=5.92, P=0.01), while total number of sessions was strongly correlated with hamstring volumes only (r=5.91, P=0.01).Conclusion: This per-protocol analysis of FESC and PC early after SCI reports a partial response in 42% and a beneficial response in 25% of patients who completed 12 weeks intervention, regardless of mode. Strong correlations show a dose-response according to exercise frequency. Characteristics of non-responders are discussed to inform clinical decision-making.

Comparison of segmental lean tissue mass in individuals with spinal cord injury measured by dual energy X-ray absorptiometry and predicted by bioimpedance spectroscopy.

STUDY DESIGN: Observational. OBJECTIVES: To compare two methods for predicting segmental (arms, legs, trunk) lean tissue mass (LTM: non-bone fat-free mass) from bioimpedance spectroscopy (BIS) against LTM measured from dual energy X-ray absorptiometry (DXA) in individuals with acute spinal cord injury (SCI). SETTING: Austin Health Victorian Spinal Cord Service, Victoria, Australia. METHODS: Fourteen participants (two female), within 8 weeks of traumatic SCI had BIS measured following an overnight fast and within 24 h of DXA scanning. Total body fat-free mass (FFM, body weight minus fat mass) and segmental LTM were predicted from BIS using manufacturer's proprietary software and a previously established SCI-specific prediction method. Appendicular LTM (ALM) was calculated from the sum of the LTM of the arms and legs. Agreement and strength of relationships with DXA for predicted LTM measures using both approaches were assessed using Lin's concordance coefficient and limits of agreement analysis (LOA). RESULTS: The BIS proprietary method performed better than the SCI-specific prediction method in predicting DXA LTM, demonstrating substantial concordance for total body FFM (rc = 0.80), ALM (rc = 0.78), arm (rc = 0.76) and leg LTM (rc = 0.65) and a smaller bias and LOA for ALM (+0.8 vs. -3.4 kg; LOA -4.9-6.4 vs. -11.9-5.1 kg), arm (+0.02 vs. -0.3 kg; LOA -1.1-1.1 kg vs. -2.2-1.6 kg) and leg (+0.4 vs. -1.4 kg; LOA -2.0-2.8 vs. -5.6-2.8) LTM. CONCLUSIONS: BIS can be used to accurately predict total body FFM, segmental LTM and ALM in individuals with acute SCI.

Comparison of estimated energy requirements using predictive equations with total energy expenditure measured by the doubly labelled water method in acute spinal cord injury.

STUDY DESIGN: Prospective, observational OBJECTIVES: To evaluate agreement between a reference method (doubly labelled water, DLW) of total energy expenditure (TEE) and published equations for estimating energy requirements in acute spinal cord injury (SCI). SETTING: Victoria, Australia METHODS: Twenty participants (18 male) within 8 weeks of traumatic SCI completed DLW, anthropometric and dietary intake assessments. Energy requirements were predicted using Harris-Benedict, Schofield, Henry, Nelson, Buchholz and Chun equations, multiplied by a combined activity and stress factor of 1.3, and the ratio method (kJ/kg body weight). Fat-free mass (FFM) and fat mass (FM) were calculated from TBW-derived DLW and from bioelectrical impedance spectroscopy (BIS). RESULTS: Median time since injury was 41 days. Median TEE was 9.1 MJ. Fair agreement was found between TEE and predicted energy requirements for the Chun (rc = 0.39), the Harris-Benedict equation (rc = 0.30), the ratio method (rc = 0.23) and the Buchholz (rc = 0.31) and Nelson equations (rc = 0.35), which incorporate measures of FFM and/or FM. Other equations showed weak concordance with DLW. When two hypermetabolic patients were removed, agreement between TEE and predicted energy requirements using the Buchholz equation increased to substantial (rc = 0.72) and using the Nelson (rc = 0.53) and Chun equations (rc = 0.53) increased to moderate. The Buchholz equation had the smallest limits of agreement (-2.4-2.3 MJ/d). CONCLUSION: The population-specific Buchholz equation that incorporates FFM, predicted from either BIS or DLW, demonstrated the best agreement in patients with acute SCI. SPONSORSHIP: The study was funded by grants from the Institute for Safety, Compensation and Recovery Research (ISCRR Project # NGE-E-13-078) and Austin Medical Research Foundation. M Panisset was supported by an Australian Postgraduate Award.

A novel neuromodulation technique for the rehabilitation of balance and gait: A case study.

Cranial-nerve non-invasive neuromodulation (CN-NINM) through the tongue has been proposed as an adjuvant intervention to improve efficacy of rehabilitation. However, CN-NINM effects have only been explored in multiple sclerosis and stroke populations. In this report we used CN-NINM during a 2-week (2 × 1.5 h sessions daily) physiotherapy program for the rehabilitation of a 57 y/o woman presenting with balance and gait impairments after a surgical resection of a fourth ventricular ependymoma. Clinical and instrumented balance and gait assessments showed improved performance in all tests and without adverse effects This study shows the beneficial effects and feasibility of combined physiotherapy and CN-NINM in this patient.

Bedside quantification of fat-free mass in acute spinal cord injury using bioelectrical impedance analysis: a psychometric study.

STUDY DESIGN: Psychometric. OBJECTIVES: Assess the validity of bioimpedance-based measures of fat-free mass (FFM) in acute SCI and of current definitions of obesity based on body mass index (BMI). SETTING: Australia. METHODS: All admissions within eight weeks of a new traumatic SCI were screened. 29% were eligible. 71% of those consented. Twenty participants (18 male) completed deuterium dilution (DD) and bioimpedance-based measurements of FFM. Thirteen also underwent dual-energy x-ray absorptiometry. Strength of relationships and agreement were examined using Lin's concordance coefficient and limits of agreement analysis, respectively. Sensitivity and specificity were calculated for three BMI cutoffs for obesity, using percentage fat mass (%FM) obtained from DD as reference. RESULTS: Median time since injury was 41 days (IQR 28-48). FFM from DD and DXA were highly correlated but not identical. Concordance and agreement between DD and seven bioimpedance-based predictive equations are presented. The best-fitting equation demonstrated a low bias (+0.6 kg) and moderate dispersion (±5.2 kg). The cutoff for overweight in able-bodied people (BMI ≥25 kg/m2) provided sensitivity of 43.8%, compared to 25% for the cut-off for obesity (BMI ≥30 kg/m2). FM from bioimpedance gave the highest sensitivity (88.9%). CONCLUSIONS: BMI demonstrates poor specificity to classify obesity in acute SCI. Present findings support the utility of bioimpedance-based measurements for estimating FFM in acute SCI for group comparisons. These results are generalizable to traumatic SCI 4-8 weeks post injury; however, the present data reflect a high proportion of high cervical injuries. Further research is indicated to establish validity for assessment of individuals and for longitudinal monitoring. SPONSORSHIP: The present study was funded by a grant from the Institute for Safety, Compensation and Recovery Research (ISCRR Project #NGE-E-13-078). M Panisset was supported by an Australian Postgraduate Award. K Desneves was supported by the Austin Medical Research Foundation.

SCIPA Switch-On: A Randomized Controlled Trial Investigating the Efficacy and Safety of Functional Electrical Stimulation-Assisted Cycling and Passive Cycling Initiated Early After Traumatic Spinal Cord Injury.

Background. Substantial skeletal muscle atrophy after spinal cord injury (SCI) carries significant repercussions for functional recovery and longer-term health. Objective. To compare the efficacy, safety, and feasibility of functional electrical stimulation-assisted cycling (FESC) and passive cycling (PC) to attenuate muscle atrophy after acute SCI. Methods. This multicenter, assessor-blinded phase I/II trial randomized participants at 4 weeks post-SCI to FESC or PC (4 sessions per week, 1 hour maximum per session, over 12 weeks). The primary outcome measure was mean maximum cross-sectional area (CSA) of thigh and calf muscles (magnetic resonance imaging), and secondary outcome measures comprised body composition (dual energy X-ray absorptiometry), anthropometry, quality of life, and adverse events (AEs). Results. Of 24 participants, 19 completed the 12-week trial (10 FESC, 9 PC, 18 male). Those participants completed >80% of training sessions (FESC, 83.5%; PC, 85.9%). No significant between-group difference in postintervention muscle CSA was found. No significant between-group difference was found for any other tissue, anthropometric parameter, or behavioral variable or AEs. Six participants experienced thigh hypertrophy (FESC = 3; PC = 3). Atrophy was attenuated (<30%) in 15 cases (FESC = 7; PC = 8). Conclusions. Both cycle ergometry regimens examined were safe, feasible, and well tolerated early after SCI. No conclusions regarding efficacy can be drawn from our data. Further investigation of both modalities early after SCI is required.