Autore: NSTDNS119

  • IMPATTO DELLA FATICA SUL CAMMINO E L’EQUILIBRIO IN SOGGETTI CON SCLEROSI MULTIPLA

    IMPATTO DELLA FATICA SUL CAMMINO E L’EQUILIBRIO IN SOGGETTI CON SCLEROSI MULTIPLA

    IMPATTO DELLA FATICA SUL CAMMINO E L’EQUILIBRIO IN SOGGETTI CON SCLEROSI MULTIPLA

    EFFECTS OF FATIGUE ON WALKING PERFORMANCE AND DYNAMIC BALANCE IN SUBJECTS WITH MULTIPLE SCLEROSIS

    Autori

    Anastasi Denise (Università degli studi di Sassari)

    Introduction

    Fatigability is a critical impairment in multiple sclerosis (MS) directly impacting activities of daily living [1]. Identification of the stability changes during a fatiguing task using an objective assessment, might result in early prediction of falls during activities of daily living, tailored rehabilitation programs, and better management of the pathology during daily activities for people with MS (PwMS). Several studies demonstrated the effectiveness of circuit training for improving walking and balance [2,3], but to date there are no studies focused on the effect of fatigue on motor skills.

    Thus, the aims of this  study are: 1) to assess the effect of experimentally induced exertion on walking and balance, and 2) to assess the effect of a “circuit training” intervention compared to a standard rehabilitation treatment on walking, dynamic balance and the impact of fatigue in PwMS.

    Methods

    Thirty-one PwMS (age: 51.52±11.28 years, EDSS 4(3.5-6)points) and 8 Healthy Subjects (HS, age: 46.25±6.27years) were recruited. Kinematic data were collected using a 9-camera SMART-D motion capture system. PwMS and HS were asked to walk over ground at a steady cadence (subjective spontaneous cadence augmented of the 15%). Subjects were asked to rate their physical exertion every minute on the Borg scale, and the test ended when PwMS referred a fatigue of 17 (very hard), while the HS test lasted 30 minutes. We computed the following gait parameters: speed, stride length, single stance time (SS), cadence, and stance time. While, for dynamic stability we considered: step width trunk range of motion on frontal (TRUNK _ML), and horizontal plane (TRUNK _AP), Center of Mass displacement on frontal plane (CoM_ML), and head range of movement on frontal plane (HEAD _ML). Finally, we calculated the percentage of mechanical energy recovery.

    A subgroup of 28 PwMS was included in a randomized controlled pilot study, in which there was an experimental group that performed a circuit rehabilitation program (CG) and a usual care control group (UG). The experimental intervention concerned an initial part of walking on a treadmill with alternating intense and recovery phases, followed by balance and functional strengthening exercises without breaks. Both treatments lasted 45 minutes, twice a week for 6 weeks. Clinical and instrumental assessment were repeat at the end of the rehabilitation intervention. A Linear Mixed model with random intercepts was used to analyse the between-group differences in gait and dynamic balance parameters before and after the intervention.

    Results

    PwMS reached a perceived fatigue “very hard” walking for15.6±11.3minutes) while HS walked for 30 minutes without exertion (RPE<11points). PwMS showed an increase in speed of 0.008%BH/s per minute, with respect HS who showed an increase of 0.0006%BH/s per minute (p <0.001, Figure 1) and a small reduction of cadence of 0.05 step/min per minute, while HS slight increase it of 012 step/min per minute. p <0.001), indicating a gait deterioration over time in PwMS. We also found changes in dynamic stability with a statistically significant between-group increase of HEAD _ML (PwMS: 0.59mm per minute, HS: 0.20mm per minute p <0.001) and TRUNK _ML (PwMS: 0.03 deg per minute, HS: 0.00744 deg per minute, p <0.001, Figure 2). No between group different were found in the other indexes.

    With respect the RCT study, the analysis of the primary outcome, the MFIS_PH, a greater reduction in perceived fatigue was observed in the EG than in the CG (CG: T0 = 15.6±9.0 pt, T1 = 11.6±7.7 pt, UG: T0 = 16.3±8.1 pt, T1 = 13.6±8.7 pt, F = 3.82, p=0.05). No statistically differences were found in the trends of the variables between CG and UG.

    Discussion and Conclusion

     

    The use of the fatiguing test can highlight motor changes due to fatigue, which vary in different subjects. It seems to have the potential to better guide rehabilitation treatment, highlighting characteristics not evident in normal assessments performed in a non-fatiguing condition. In future studies it could be used to better tailor the rehabilitation intervention and obtain greater effectiveness in managing fatigue in PwMS. The experimental intervention seems to improve the management of fatigue in ADL, it remains to be understood how to better direct the intervention based on the proposed assessment in a state of fatigue.

    REFERENCES

    [1] Mills, R. J., and Young, C. A. (2008). A medical definition of fatigue in multiple sclerosis. QJM 101, 49–60.

    [2] Sethy, D., Bajpai, P., and Kujur, E. S. (2010). Effect of task related circuit training on walking ability in a Multiple Sclerosis subject. A single case study. NeuroRehabilitation 26, 331–337.

    [3] Tramonti, C., Di Martino, S., and Chisari, C. (2020). An intensive task-oriented circuit training positively impacts gait biomechanics in MS patients. NeuroRehabilitation 46, 321–331.

  • Cammino e fatica nelle Persone con Sclerosi Multipla: Strategie compensatorie per regolare la clearance nella fase di metà volo. Uno studio qualitativo.

    Walking and fatigue in People with Multiple Sclerosis: Gait compensatory strategies to control clearance during the mid-swing phase. A qualitative study.

    Introduction

    People with Multiple Sclerosis (PwMS) commonly experience falls or near falls, of which one-third seem to be associated with fatigue or tripping. Lately, different studies have inquired about changes in gait parameters related to fatigue, but none have depicted the clinical compensations in the swinging limb that PwMS implement when they get fatigued, to reduce the risk of tripping. The present study tries to describe the strategies that PwMS carry out to control the clearance of the swinging limb when they get fatigued.

    Methods

    Thirty-two PwMS (EDSS 3.0±1.5) and 8 healthy subjects (HS) were recruited. Kinematic data were collected using a SMART-D motion capture system (BTS, Milano, Italy) with LAMB protocol. Subjects were asked to walk continuously at a steady cadence (spontaneous + 15%) suggested by a metronome. Every minute physical exertion was recorded on the Borg scale (RPE); the test ended as the subject reached a score of 17 (very hard).

    We estimated the trend over time for clearance, foot drop, and lower limb length (LL), calculated as the distance between the ipsilateral anterior superior iliac spine and lateral malleolus. For each variable, we derived the slope trends and considered the slope coefficient (k) to describe our findings.

    Finite mixture models were used to provide a cluster analysis: a) Univariate model of k clearance; b) Multivariate model of k-LL and k-footdrop, considering the subjects with a negative clearance according to the previous univariate analysis.

    Results

    PwMS walked less time (13.9±10.22 vs 30.0±1 min) HS reaching an RPE of 17, while HS walked 30 minutes reaching an RPE≤11. The cluster analysis of the k clearance showed 2 different patterns (Figure 1): 1a) showing a minimal clearance variability -0.11(0.03)mm/min (light-blue dots); 1b) a higher clearance variability -0.62(1.1)mm/min (red dots).

    The multivariate model (Figure 2), considering subjects in 1b) and with a negative k-clearance, showed 3 different patterns related to k-LL and k-footdrop: the first group (green triangles) had an increased LL over time (k-LL=4.8(0.5)mm/min) and a reduction in the foot drop (k-footdrop=-2.0 (0.5)mm/min). The second group (red squares) showed a minimal variation in both parameters (k-footdrop=0.2(1.0)mm/min, k-LL = 0.3(1.0)mm/min). The third group (blue dots) had an increased k-footdrop (5.6(2.8)mm/min) associated with a reduction in the LL (k-LL=-4.8 (2.8)mm/min).

    Discussion and Conclusion

    The present findings seem to have the potential to better guide gait rehabilitation. In subjects with a stable clearance, the fatiguability seems associated more to deconditioning and general stability. For subjects who increase clearance (over-compensating), the treatment could be aimed toward more energy-conservative strategies. While, for subjects more at risk of tripping we found three different patterns: a group had a progressive deficit in ankle dorsiflexion partially compensated by a shortening of the limb in flight; another group had a slight change in both; finally, a third group had a deficit related to limb length in flight partially compensated by an increase in ankle dorsiflexion. Thus, rehabilitation intervention could be directed to proximal or, distal muscle function or both, and ankle-orthosis prescription could be suggested to subjects with a real need. Other factors (eg. trunk, pelvis) should be explored in future studies.

    REFERENCES

    Comber L, Galvin R, Coote S. Gait deficits in people with multiple sclerosis: A systematic review and meta-analysis. Gait Posture. 2017 Jan;51:25-35. doi: 10.1016/j.gaitpost.2016.09.026. Epub 2016 Sep 26. PMID: 27693958.

    Broscheid KC, Behrens M, Bilgin-Egner P, Peters A, Dettmers C, Jöbges M, Schega L. Instrumented Assessment of Motor Performance Fatigability During the 6-Min Walk Test in Mildly Affected People With Multiple Sclerosis. Front Neurol. 2022 May 9;13:802516. doi: 10.3389/fneur.2022.802516. PMID: 35614920; PMCID: PMC9125148.

    Fritz NE, Eloyan A, Baynes M, Newsome SD, Calabresi PA, Zackowski KM. Distinguishing among multiple sclerosis fallers, near-fallers and non-fallers. Mult Scler Relat Disord. 2018 Jan;19:99-104. doi: 10.1016/j.msard.2017.11.019. Epub 2017 Nov 22. PMID: 29182996; PMCID: PMC5803437.