Determination of Walking Impairment in Multiple Sclerosis
Table 1 continued Test Method Type/Purpose
(Assessor)
Short Form-36 Questionnaire/physical and mental components. Includes
Details of Assessments Included
Equipment Needed, Validity of Data, Time to Perform and Cost
Components: vigorous activities (e.g. Test form, pen. running), moderate activities (e.g.
36 questions to determine QoL; bowling or playing golf), lifting or 9 questions concern mobility (supervised assessment by patient).
Barthel Index
Questionnaire/measures daily functioning focusing on the activities of daily living and mobility (trained examiner).
30 minutes. Minimal cost.
carrying groceries, climbing flights of stairs, bending, kneeling or stooping,
walking ≥1 mile, walking several blocks or one block.
10 questions on feeding, bathing, Test form, pen.
grooming, dressing, bowels, bladder, Few minutes toilet, transfer, mobility and stairs.
to complete.
Scored 0, 5, 10 or 15, or 0, 1, 2 or 3 Minimal cost. (maximum = 100 or 20).
Good variability and small floor and ceiling effects. Shown to be as good as the functional independence measure for evaluating change.53
9HPT = 9-hole peg test; HRQoL = health-related quality of life; PASAT = Paced Auditory Serial Addition Test; PHYS = physical; PSYCH = psychological; T25FW = 25-foot walk.
therefore, determination of mobility is only a component or subscale within a larger set of assessments. Thus, the detail these methods provide in determining mobility is limited, as they address many aspects of the disease. An overview of the more frequently used general methods for such assessment in MS is given in Table 1.
The most frequently used scale in MS mobility assessment is the Expanded Disability Status Scale (EDSS),8,9
which rates disability
progression on a range of 0.0–10.0 in increments of 0.5. The rating is usually performed by a neurologist. The criteria used to define the EDSS score are given in Table 2. EDSS is considered a ‘standard’ method and is almost universally recognised by neurologists. It has therefore often been used as part of the inclusion criteria for numerous MS clinical trials and is also commonly used to rate patients in clinical practice.7 Despite its wide utilisation, EDSS has also been much criticised because it defines ambulation only in terms of the distance a patient can walk and assistance needed; qualitative changes are not assessed and it is considered by some to be insufficient to fully assess disability.7 Further criticisms include poor psychometric properties,10 inter-rater reliability and lack of linearity.
a modest
Increasing disability, as indicated by rising EDSS scores, is closely associated with the degree of neurological pathology (particularly the extent of lesions and decreased brain volume) as detected by magnetic resonance imaging (MRI).11–13
In an analysis of multiple studies in MS, a cross-sectional correlation was reported between
MRI T2 parameters and EDSS scores in MS patients at different disease stages (correlation coefficients were 0.15 for secondary progressive MS (SPMS), 0.55 for CIS and 0.60 for relapsing–remitting MS [RRMS]). In a study of SPMS patients, a correlation of up to 0.81 between the presence of MRI black holes and EDSS scores was reported.11
In other studies, the correlation between disability and MRI lesions in MS patients was considered to be weak, most likely owing to the unpredictable consequences of damage at different brain sites and the variable effects seen on neurological function.12
Another study in The Netherlands showed that during 12 years of follow-up of 46 patients with confirmed MS, increasing lesion loads, atrophy and axonal loss were associated with disease severity as determined by the MS Severity Score (MSSS).13
The MSSS method is
based on the EDSS, but uses an algorithm that incorporates the distribution of disability in patients with similar disease durations.
EUROPEAN NEUROLOGICAL REVIEW
Consequently, MSSS provides information about disease progression as well as current disability status14
(see Table 1). 63 Table 2: The Expanded Disability Status Scale
EDSS Disability Stage/Description Score 0.0 Normal neurological exam 1.0 No disability, minimal signs on 1 FS 1.5 No disability, minimal signs on 2 of 7 FS 2.0 Minimal disability in 1 of 7 FS 2.5 Minimal disability in 2 FS 3.0 Moderate disability in 1 FS, or mild disability in 3–4 FS, although fully ambulatory
3.5 Fully ambulatory but with moderate disability in 1 FS and mild disability in 1 or 2 FS, moderate disability in 2 FS or mild disability in 5 FS
4.0 Fully ambulatory without aid, up and about 12 hours a day despite relatively severe disability; able to walk 500 metres without aid
4.5 Fully ambulatory without aid, up and about much of day, able to work a full day, may otherwise have some limitations of full activity or require minimal assistance; relatively severe disability; able to walk without aid for 300 metres
5.0 Ambulatory without aid for about 200 metres; disability impairs full daily activities
5.5 Ambulatory for 100 metres; disability precludes full daily activities 6.0 Intermittent or unilateral constant assistance (cane, crutch or brace) required to walk 100 metres with or without resting
6.5 Constant bilateral support (cane, crutch or braces) required to walk 20 metres without resting
7.0 Unable to walk beyond 5 metres even with aid, essentially restricted to wheelchair, wheels self, transfers alone; active in wheelchair about 12 hours a day
7.5 Unable to take more than a few steps, restricted to wheelchair, may need aid to transfer; wheels self, but may require motorised chair for full day’s activities
8.0 Essentially restricted to bed, chair, or wheelchair, but may be out of bed much of day; retains self-care functions, generally effective use of arms
8.5 Essentially restricted to bed much of day, some effective use of arms, retains some self-care functions
9.0 Helpless bed patient, can communicate and eat 9.5 Unable to communicate effectively or eat/swallow 10.0 Death due to MS
Levels of disability at each 0.5 increment in score. EDSS = Expanded Disability Status Scale; FS = functional systems (there are eight in EDSS); MS = multiple sclerosis. Source: Kurtzke, 1983.8
Advantages/Disadvantages
Widely used test method to assess overall QoL. Has several mobility elements but is not sufficiently
precise to adequately assess mobility.52
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