Determination of Walking Impairment in Multiple Sclerosis
assistive device was a strong predictor of performance and that a score of 45 (out of 56) was a fairly reliable cut-off value that discriminated those susceptible to falling from those who were not. Another such test instrument is the Tinetti Performance Overall Mobility Assessment (POMA), which has two subscales addressing balance and gait. In the balance section, the patient completes nine timed tests that involve movements associated with sitting, rising, standing and turning. Only limited data are available for the use of this test in MS. Using POMA to retrospectively analyse records from 126 patients with Parkinson’s disease showed good to excellent intra- and inter-rater reliability with an intra-class correlation coefficient of >0.80; the sensitivity and specificity of the test to identify fallers were 76 and 66%, respectively.41
Some other balance tests involve computer-controlled instrumentation, e.g. the Modified Clinical Test for Sensory Interaction on Balance.42
The
Methods requiring specialist equipment are confined to neurology centres and would not be available for assessing most MS patients.
patient stands on a platform that has either a firm or a foam surface, and the platform is rocked following a pre-set programme. The patient’s ability to balance is then tested with the eyes either open or closed to determine postural sway in different conditions. Using this equipment, the test–retest reliability was shown to be high, but the perception of imbalance of the patients did not correlate well with assessments of postural stability.43
centres, but it has the potential to monitor patient walking performance more accurately than most of the currently used tests.
Future Developments in Mobility Assessment and Management in Multiple Sclerosis Existing measures of disability are mostly elements of other tests that assess wider aspects of MS status and are too ‘general-purpose’ for an accurate assessment of walking ability and specific aspects of gait. The limitations of the more frequently used test methods may become more widely recognised, causing many neurologists to make greater use of more specific tests and questionnaires and to develop new instruments including wider-ranging questionnaires that will more accurately determine mobility and gait.
As mobility tests are inexpensive and require fewer resources than MRI or laboratory investigations, these new tests are likely to be increasingly used in clinical trials and routine monitoring of MS patients in clinical practice at MS centres and general clinics. These tests will be valuable when used in initial diagnosis, but their importance in monitoring pathological progression and for assessing the requirement for support and assistance of patients should not be underestimated.
Use of Devices to Monitor Mobility and Activity When studying mobility in MS patients, it is necessary to monitor movement and exertion over extended periods. To achieve this, some investigators have conducted trials using accelerometers worn by MS patients to continuously monitor activity. These devices provide a good measure of both physical activity and walking compared with patient self-report methods, which tend to be more restricted in the range of parameters reported and for various reasons are likely to be less accurate.44,45
Currently, the methods used both for general assessment of limitations of activities and social participation and for the more specific determination of walking ability, gait and balance are diverse and vary widely between treatment centres. As our understanding of the applicability of these tests to disease progression increases, we should begin to develop guidelines for the better assessment of mobility and gait in MS over time. This would also help to standardise methods used in clinical trials, making results more readily comparable, and would help, ensure that patient management and treatment are based on current best practice. n
In a study including 269 patients with RRMS, self- report questionnaires were effective at assessing either walking (using MSWS-12 and Patient-Determined Disease Steps) or physical activity (using the Godin Leisure-Time Exercise Questionnaire [GLTEQ] and International Physical Activity Questionnaire). However, no questionnaire was effective at assessing both aspects.45
The use of
accelerometers in the same set of patients provided an accurate assessment of both walking and physical activity.
A new tool for assessing gait in MS patients is the GaitRite® system, which consists of a portable walkway mat with an active area measuring 366x61cm containing a total of 13,820 pressure sensors.46 When a patient walks over the walkway, the system is able to capture the geometry of each footfall and computes multiple temporal and spatial parameters. This enables a rapid and detailed analysis of gait, monitors change in parameters and compares them with normal performance. The system can also assess muscle weakness and determine risk of falling. This type of system for monitoring walking is new and is currently restricted to a limited number of treatment
1. 2. 3.
Hobart JC, Riazi A, Lamping DL, et al., Measuring the impact of MS on walking ability: the 12-Item MS Walking Scale (MSWS-12), Neurology, 2003;60:31–6.
Hobart JC, Riazi A, Thompson AJ, et al., Getting the measure of spasticity in multiple sclerosis: the Multiple Sclerosis Spasticity Scale (MSSS-88), Brain, 2006;129:224–34.
McGuigan C, Hutchinson M, Confirming the validity and responsiveness of the Multiple Sclerosis Walking Scale-
Jürg Kesselring is a Professor of Clinical Neurology and Neurorehabilitation at the University of Bern and Head of the Department of Neurology and Neurorehabilitation at the Rehabilitation Centre of the Neuroscience Centre Zurich. He is also Chair of Neurorehabilitation at San Raffaele University in Milan, and lectures on clinical neuroscience and teaches an introductory neuroscience course at the Centre of Neuroscience at the University and ETH Zürich. Professor Kesselring is
the author of 140 original publications and the editor or co-author of 15 books, mainly related to multiple sclerosis, neurorehabilitation and magnetic resonance imaging. He is an ad hoc reviewer for various journals, including Acta Neurologica Scandinavica, Brain, European Neurology, the European Journal of Neurology, the Journal of Neurology, the Journal of Neurology, Neurosurgery and Psychiatry and Multiple Sclerosis. Professor Kesselring is President of the Swiss Multiple Sclerosis Society, Past President of the European Committee on Treatment and Research in Multiple Sclerosis (ECTRIMS), Past Chairman of the International Medical and Scientific Board of the Multiple Sclerosis International Federation (MSIF), the Research Committee on Demyelination of the World Federation of Neurology (WFN) and the World Health Organization (WHO) Working Group on Multiple Sclerosis, a founding member of the Swiss Society for Neurorehabilitation and an Honorary Senior Research Fellow of the Institute of Neurology.
12 (MSWS-12), Neurology, 2004;62:2103–5. 4.
Hutchinson B, Forwell SJ, Bennett S, et al., Toward a Consensus on Rehabilitation Outcomes in MS: Gait and Fatigue Report of a CMSC Consensus Conference, 28–29 November 2007, Int J MS Care, 2009;11:67–78.
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D'Souza M, Kappos L, Czaplinski A, Reconsidering clinical outcomes in Multiple Sclerosis: relapses, impairment, disability and beyond, J Neurol Sci, 2008;274:76–9.
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6.
Hobart J, Kalkers N, Barkhof F, et al., Outcome measures for multiple sclerosis clinical trials: relative measurement precision of the Expanded Disability Status Scale and Multiple Sclerosis Functional Composite, Mult Scler, 2004;10:41–6.
Thompson AJ, Hobart JC, Multiple sclerosis: assessment of disability and disability scales, J Neurol, 1998;245:189–96. 8. Kurtzke JF, Rating neurologic impairment in multiple
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