Do exergames combined with physical exercise improve upper limb motor function in people with multiple sclerosis? Randomized clinical trial.

Effect of immersive virtual reality training on hand-to-mouth task performance in people with Multiple Sclerosis: A quantitative kinematic study

Fatigue is the most prevalent symptom among people with multiple sclerosis (PwMS). Although exercise effectively reduces fatigue, the relationship between daily physical activity and fatigue has only recently been demonstrated. The aim of this study was to evaluate the prevalence of fatigue and to understand the relationship with several variables in French PwMS. Data were collected from 191 PwMS using Modified Fatigue Impact Scale (MFIS) and Fatigue Severity Scale (FSS) for fatigue, and the Godin Leisure-Time Exercise Questionnaire (GLTEQ) for physical activity. 110 PwMS (57%), 35 PwMS (18%) and 46 PwMS (24%) were considered as fatigued, non-fatigued and in the grey zone, respectively. Greater physical activity was observed in non-fatigued PwMS (20.2±19.8) compared to fatigued PwMS (12.5±14.1). FSS and MFIS scores were associated with physical activity (r = -0.28 and r = -0.25, respectively, p < 0.05). Using multivariate analysis, disability, physical activity and being unemployed explained 21% of the variance of the MFIS. The present study confirms that physical activity and fatigue are associated. Disability and unemployment status should also to be consider when assessing fatigue. Activity-oriented health policies should be redesigned to improve fatigue among PwMS.

A comparison of upper limb function in subjects with multiple sclerosis and healthy controls using an inertial measurement unit

Purpose The aim of the present study was to adapt and validate the Speech Pathology-Specific Questionnaire for Persons with Multiple Sclerosis (SMS) into the Greek language. Method The study sample consisted of 124 people with multiple sclerosis (PwMS) and 50 healthy controls (HCs). All PwMS underwent cognitive assessment using the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS). Both PwMS and HCs completed the SMS, the Eating Assessment tool (EAT-10), the Voice Handicap Index (VHI), and the Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39). Result Significant difference was found between PwMS and HCs for the EAT-10, SAQOL-39, the total SMS, and the SMS subscales. Discriminant validity analyses revealed a statistically significant difference between PwMS and HCs for the total and subscales SMS. Convergent validity analyses between the total SMS and the SMS subscales, and scores on the BICAMS, EAT-10, SAQOL-39, and VHI in PwMS were significantly correlated, with exception of the SMS Speech/Voice with the Symbol Digit Modalities Test (SDMT) and the Greek Verbal Learning Test-II (GVLT-II). Scores on the EAT-10, SAQOL-39, and VHI in PwMS were also correlated with the total SMS and the SMS subscales in PwMS, HCs, and the total sample. Construct validity analyses revealed that the total SMS and the SMS subscales were significantly correlated with the Expanded Disability Status Scale (EDSS) and years of education, while no associations were found with regards to age, MS subtype (relapsing-remitting MS [RRMS] vs progressive MS [PMS]), disease duration, or sex. The internal consistency of all items was excellent in PwMS and the total sample (Cronbach’s alpha was >0.7 after deletion of one item), with the exception of two items, which still fell within the acceptable range (>0.6) for PwMS and the total sample. Conclusion The Greek version of the SMS is a reliable and valid patient-reported outcome measure to assess speech-language and swallowing pathology related symptoms in PwMS, and can be used for research and clinical purposes.

Background: Isometric maximum force (MaxF) and rate of force development (MaxRFD) obtained from sustained contractions are two important outcomes used in clinical and research settings that evaluate strength and power of an individual, respectively. These outcomes are often impaired in people with multiple sclerosis (PwMS) and are associated with functional limitations. The values of these isometric outcomes can be influenced by the verbal instructions given to the participants prior to contraction. Objective: We investigated the effects of two common instructions - “as hard as possible” (AH) and “as fast and as hard as possible” (AFH) - on MaxF and MaxRFD in both upper and lower extremities in people with multiple sclerosis (PwMS) and in controls. Methods: Twenty-seven PwMS and age- and gender-matched healthy controls completed isometric assessments of grip force (GF) and knee extension (KE) under both AH and AFH instructions. Results: Instructions did not significantly affect MaxF in either group or muscle group (p&gt;0.05). However, AFH instruction yielded a significantly higher MaxRFD compared to AH in both GF and KE across both groups (p&lt;0.001). Conclusions: MaxF is unaffected by instruction type, while MaxRFD is sensitive to instruction that emphasizes both speed and magnitude of a contraction. Therefore, AFH instruction enables efficient and simultaneous assessment of both outcomes in neuromuscular evaluations, including clinical populations like PwMS where both outcomes may be impaired, and where the effects of disease could be more prevalent in the lower extremity than the upper extremity.

Pragmatic exercise intervention for people with multiple sclerosis (ExIMS Trial): Study protocol for a randomised controlled trial

BackgroundThe prevalence of multiple sclerosis (MS) is thought to be increasing among UK minority ethnic groups but little is known about their illness perceptions of its causation. These may influence...

Introduction Limitations associated with Multiple Sclerosis (MS) can restrain work capacity and productivity, reducing the possibility to remain in work. Whilst access to sickness compensation might be an option, transitions to other types of employment, such as self-employment, might be considered. We aim to investigate the association of Sickness Absence (SA) and Disability Pension (DP) with employment status among people with multiple sclerosis (PwMS) before and after MS diagnosis compared with people without MS. Methods A prospective longitudinal study was conducted using Swedish register data of 2,779 MS patients diagnosed with MS in 2008-2012 in working ages (20-59 years) and 13,863 population-based matched references. Levels of SA and DP one year before and four years after MS diagnosis were analyzed. Risk of annual SA and DP levels of more than 180 days were compared among the MS patients and references and, their different types of employment, by means of Cox proportional hazard models and adjusted for socio-demographic variables and SA and DP before MS diagnosis. Results In general, people with MS had higher levels of SA and DP before and shortly after MS diagnosis compared to references. PwMS showed a significantly higher probability of reaching over 180 days of SA (Hazard Ratio [HR]=4.89, 95% Confidence interval [CI]=4.43-5.40) and over 180 days of DP (HR = 6.31, 95% CI = 5.46-7.30)) than the references, regardless of type of employment. Moreover, when compared to employed references, self-employed PwMS had similar likelihood to reach over 180 days of SA than employed PwMS, (HR = 4.27, 95% CI = 3.81-4.77) and (HR = 3.83, 95% CI = 2.73-5.38), respectively. In contrast, self-employed references showed less probability (HR = 0.49, 95% CI = 0.31-0.78) to reach over 180 days of SA compared to the employed references. Conclusions In contrast to references, employed and self-employed PwMS had similar probabilities of reaching over 180 days of SA. Key messages This study emphasizes that in Sweden also self-employed have access to sickness compensation, independently of employment status condition. Access to sickness compensation is utilized by PwMS.

Dynamic balance during walking in people with multiple sclerosis: A cross-sectional study.

BackgroundVaccination campaign to contrast the spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has raised the issue of vaccine immunogenicity in special populations such as people with multiple sclerosis (PwMS) on highly effective disease modifying treatments (DMTs). While humoral responses to SARS-CoV-2 mRNA vaccines have been well characterized in the general population and in PwMS, very little is known about cell-mediated responses in conferring protection from SARS-CoV-2 infection and severe coronavirus disease-2019 (COVID-19).MethodsPwMS on ocrelizumab, fingolimod or natalizumab, vaccinated with two doses of mRNABNT162b2 (Comirnaty®) vaccine were enrolled. Anti-Spike (S) and anti-Nucleoprotein (N) antibody titers, IFN-gamma production upon S and N peptide libraries stimulation, peripheral blood lymphocyte absolute counts were assessed after at least 1 month and within 4 months from vaccine second dose administration. A group of age and sex matched healthy donors (HD) were included as reference group. Statistical analysis was performed using GraphPad Prism 8.2.1.ResultsThirty PwMS and 9 HDs were enrolled. All the patients were negative for anti-N antibody detection, nor reported previous symptoms of COVID-19. Peripheral blood lymphocyte counts were assessed in PwMS showing: (i) reduction of circulating B-lymphocytes in PwMS on ocrelizumab; (ii) reduction of peripheral blood B- and T-lymphocyte absolute counts in PwMS on fingolimod and (iii) normal B- and T-lymphocyte absolute counts with an increase in circulating CD16+CD56+ NK-cells in PwMS on natalizumab. Three patterns of immunological responses were identified in PwMS. In patients on ocrelizumab, anti-S antibody were lacking or reduced, while T-cell responses were normal. In patients on fingolimod both anti-S titers and T-cell mediated responses were impaired. In patients on natalizumab both anti-S titers and T-cell responses were present and comparable to those observed in HD.ConclusionsThe evaluation of T-cell responses, anti-S titers and peripheral blood lymphocyte absolute count in PwMS on DMTs can help to better characterize the immunological response after SARS-CoV-2 vaccination. The evaluation of T-cell responses in longitudinal cohorts of PwMS will help to clarify their protective role in preventing SARS-CoV-2 infection and severe COVID-19. The correlation between DMT treatment and immunological responses to SARS-CoV-2 vaccines could help to better evaluate vaccination strategies in PwMS.

Multiple sclerosis is a neurodegenerative disease that causes balance deficits, even in early stages. Evidence suggests that people with multiple sclerosis (PwMS) rely more on vision to maintain balance, and challenging balance with optical flow perturbations may be a practical screening for balance deficits. Whether these perturbations affect standing balance in PwMS is unknown. Therefore, the purpose of this study was to examine how optical flow perturbations affect standing balance in PwMS. We hypothesized that perturbations would cause higher variability in PwMS compared with matched controls during standing and that standing balance would be more susceptible to anterior-posterior (A-P) perturbations than medial-lateral (M-L) perturbations. Thirteen PwMS and 13 controls stood under 3 conditions: unperturbed, M-L perturbation, and A-P perturbations. A-P perturbations caused significantly higher A-P trunk sway variability in PwMS than controls, although both groups had similar center-of-pressure variability. Both perturbations increased variability in A-P trunk sway and center of pressure. Trunk variability data supported the hypothesis that PwMS were more susceptible to optical flow perturbations than controls. However, the hypothesis that A-P perturbations would affect balance more than M-L perturbations was partially supported. These results suggest potential for optical flow perturbations to identify balance deficits in PwMS.

Fear of falling, not falls, impacts leisure-time physical activity in people with multiple sclerosis

Finding enjoyable and effective long-term approaches to rehabilitation for improving the upper limb (UL) function of people with multiple sclerosis (MS) is challenging. Virtual reality (VR) with its engagement, interaction, and real time feedback could be a solution, with immersive VR systems having preliminary evidence in stroke to be more effective in improving UL outcomes in comparison to non-immersive VR. However, immersive VR research is limited within the realm of MS rehabilitation. Therefore, the main aim of the PhD was to explore immersive VR as an approach for UL rehabilitation for people with MS (pwMS). This was achieved in four stages: 1) a systematic review of the current evidence for VR in UL rehabilitation in MS; 2) predevelopment focus groups to determine requirements for the development of bespoke immersive VR games; 3) software development of bespoke VR games to potentially improve UL function for pwMS; and 4) a feasibility study of the games and immersive VR for pwMS’ UL rehabilitation. The systematic review initially yielded ten articles with varying study design, VR intervention and UL outcome measures used. There were some statistically significant improvements after VR interventions in outcomes such as in nine-hole peg test (NHPT), hand grip strength and active range of motion. There were however conflicting results regarding if VR was more effective than conventional approaches. Whilst the review demonstrated there were positive results for VR improving UL function, most of the studies had small sample sizes and were inadequately powered, and the level of immersion on effectiveness in MS remains unknown. The predevelopment focus groups recruited ten pwMS and eight specialist clinicians to explore their views on immersive VR as an approach to UL rehabilitation and determine requirements to develop VR games for this purpose. PwMS commonly reported that their UL problems interfered with activities of daily living and resulted in the loss of meaningful hobbies such as writing. Many pwMS neglected UL exercise and found strategies for adapting to their UL impairments. Similarly, clinicians stated UL rehabilitation was neglected within their service and that it was challenging to find interesting treatment strategies. VR was suggested by both participant groups as a potential solution, as it was convenient for pwMS to access and could provide a more engaging and disguised approach to exercise. Although, there were shared concerns about cybersickness and disengagement while using VR approaches. Finally, both groups agreed games should be meaningful and adaptable for users but suggested different VR activities, with clinicians suggesting games directly reflecting activities of daily living and pwMS suggesting more abstract activities. Recommendations were made for the development of VR rehabilitation games which could be personalised and customisable for the varying abilities of pwMS. Using theme-based content analysis and requirement analysis, requirements for the software development of immersive VR games were created and developed using Unity game engine. Three games, “Piano”; “Catch-a-falling-star” and “VR Whack-a-mole” which targeted dexterity and strength for pwMS were developed, with different difficulty levels implemented to adapt to varying ability of pwMS. The final stage of this PhD was a randomised, controlled feasibility study to investigate an intervention of immersive VR involving the three co-produced games for pwMS’ UL rehabilitation. Participants were randomised to either an intervention group consisting of 30 minutes of VR co-produced games, twice/week, for eight weeks, or to a control group of usual care. Participants were recruited from the NHS and third sector organisations. Nineteen pwMS were recruited (intervention n=11, control n=8), with a recruitment rate of 3.2 participants/month. Only minor adverse events were reported (n=9), such as fatigue and UL pain. Adherence was good with 87% (±12%) session completed, and two dropouts were reported in the control group. There were positive trends for improving NHPT and hand grip strength, but there was an observed ceiling effect in the Action Research Arm Test. Participants reported high levels of satisfaction and good usability of the co-produced VR games, as measured by the USE questionnaire. Thematic analysis revealed participants enjoyed the distraction and atmospheres that immersive VR provided, and believed the games were fit for purpose with the majority of participants reporting improvements in their UL function. Participants suggested more variety and progression of exercises for future development. Overall, these studies show that immersive VR has the potential to be beneficial for UL rehabilitation and is feasible and safe for pwMS. Therefore, future work should refine VR games for long-term application and explore the clinical and cost effectiveness of this approach.

PurposeMultiple sclerosis (MS) prognosis is often uncertain. This literature review considers patients’ understanding of, and perspectives on, MS progression to better comprehend the unmet needs of people with MS (PwMS), in order to improve treatment adherence and quality of life (QoL).MethodsLiterature searches for peer-reviewed papers concerning patient perspectives on the progression of MS and comparable conditions, published between January 2000 and January 2020, were conducted.ResultsLittle qualitative evidence exists that examines PwMS’ perspectives on MS progression. The understanding and meaning ascribed to terms such as “disease progression” vary. Some PwMS find disease labels stigmatizing, confusing, and disconnected from reality. The lack of a clear definition of progression and discrepancies between PwMS and healthcare professional (HCP) perspectives may contribute to misunderstanding and poor communication. Patient descriptions of progression and relapses include symptoms in addition to those evaluated by standard severity and disability measures. Compared with HCPs, PwMS are still focused on relapse prevention but place higher priority on QoL and ascribe different relative importance to the causes of poor adherence to treatment plans. PwMS want to discuss progression and likely prognosis. Such communication needs to be personalized and delivered with sensitivity, at an appropriate time. Poor treatment adherence may arise from a lack of understanding and poor communication, particularly around treatment goals. The few studies that directly considered patient perspectives on the progression of comparable conditions supported and extended the perspectives of PwMS. Lack of adequate communication by HCPs was the most common theme.ConclusionPatient perspectives on disease progression in MS and other chronic progressive conditions are under-investigated and under-reported. The limited evidence available highlights the importance of providing adequate information and effective HCP communication. While further studies are needed, the current evidence base offers information and insights that may help HCPs to enhance patient care, well-being, and treatment adherence.

Background: The relationship between adult ADHD symptoms in People with Multiple Sclerosis (PwMS) is understudied. This study aimed to answer two questions: are PwMS more likely to experience higher ADHD symptoms versus healthy subjects? And what are the correlates of severe ADHD symptoms in PwMS? Methods: This study followed a cross-sectional design with predefined inclusion criteria. The Adult ADHD Self-Report Scale-V1.1 (ASRS) was used to assess the ADHD symptoms severity. Results: Data were analyzed from 171 PwMS and 200 controls. Regression analysis revealed that PwMS were at a significantly (B = 3.05, t = 2.24, 95% CI = 0.37-5.73, p = 0.02) higher risk to report higher ADHD scores versus controls. In addition, PwMS with relapses in the last 6 months and PwMS reporting smartphone addiction were at a significantly higher risk for severe ADHD (B = 7.19, t = 269, 95% CI = 1.91-12.48, p = 0.008) and (B = 9.18, t = 3.47, 95% CI = 3.97-14.41, p = 0.001), respectively. In conclusion, diagnosis with MS in our study was identified as a risk for higher ADHD symptoms. Conclusions: Further research is required to establish this relationship, and holistic medical and psychological interventions are required to improve the cognitive status of PwMS.