GROUP-BASED INDIVIDUALIZED CORE-STABILITY INTERVENTION IMPROVES BALANCE, TRUNK CONTROL, WALKING, AND HEALTH-RELATED QUALITY OF LIFE IN INDIVIDUALS WITH MS: A RANDOMIZED CLINICAL TRIAL
Ellen Christin Arntzen1,2 and Britt Normann1,2
1Physiotherapy Department, Nordland Hospital Trust, Bodo, Norway; 2Department of Health and Care Science, UiT The Arctic University of Norway, Tromso, Norway
Background and Purpose: Individuals with multiple sclerosis (MS) often have balance and walking disturbances due to impairments such as somatosensory deficits, paresis, coordination problems, and impaired core muscle activation. Individualized interventions that interlink proximal and distal movement control with other prerequisites for balance and walking are needed, as are group-based interventions. The purpose of this study was to investigate short- and long-term effects of a new, individualized, group-based core stability and balance intervention called the GroupCoreDIST compared with standard care on balance, trunk control, walking, and health-related quality of life in individuals with MS.
Methods: This assessor-blinded, prospective, randomized controlled trial included 80 ambulatory individuals (Expanded Disability Status Scale [EDSS] scores 1-6.5) who were randomly allocated either to the GroupCoreDIST group (n = 40) or to the standard care group (n = 40), both conducted in 6 Norwegian municipalities. GroupCoreDIST was initiated by an individual examination, followed by tailored exercises in groups of 3 persons for 60 minutes, 3 times per week for 6 weeks, led by a trained physiotherapist. Standard care included 6 weeks of usual follow-up. Primary outcomes used at baseline and weeks 7, 18, and 30 included the Trunk Impairment Scale-Norwegian Version (TIS-NV) and the Mini-Balance Evaluation Systems Test (Mini-BESTest). Secondary outcomes were the 2-Minute Walk Test (2MWT), the 10-Meter Walk Test (10MWT), the MS Walking Scale-12 (MSWS-12), and the MS Impact Scale-29 (MSIS-29). Repeated-measures mixed models in IBM SPSS 24 were used for statistical analysis.
Results: One participant missed all posttests, leaving 79 subjects for intention-to-treat analysis. Significant between-group effects were found at all time points for TIS-NV: 2.63 points at week 7 (P < 0.001), 1.57 points at week 18 (P < 0.001), and 0.95 points at week 30 (P = 0.015); Mini-BESTest: 1.91 points at week 7 (P < 0.001), 1.28 points at week 18 (P < 0.001), and 0.91 points at week 30 (P = 0.04); and 2MWT: 16.7 m at week 7 (P < 0.001), 15.08 m at week 18 (P = 0.001), and 16.38 m at week 30 (P < 0.001). The 10MWT, MSIS-29, and MSWS-12 demonstrated significant between-group effects at weeks 7 and 18.
Discussion and Conclusions: Six weeks of GroupCoreDIST improved balance, trunk control, and walking distance significantly compared with standard care, and the effects lasted for 30 weeks. Significant effects on walking speed, experienced walking ability, and health-related quality of life lasted for 18 weeks. GroupCoreDIST is an effective contribution to clinical practice. Individualized exercises performed in small groups, which interlink proximal and distal movement control with other underlying aspects of balance, should be considered for individuals with MS. An individual examination may allow for individualization within small groups. Trunk control, balance, and walking were affected in individuals with both low and moderate disabilities (EDSS), indicating that detailed physiotherapy should be initiated even in the early phases of MS.
EFFECT OF DUAL-TASK EXERCISE ON COGNITIVE-MOTOR INTERFERENCE IN WALKING AND FALLS IN PEOPLE WITH CHRONIC STROKE: A RANDOMIZED CONTROLLED STUDY
Marco Pang1, Lei Yang,1,2,3 Huixi Ouyang,1,4 Freddy Man Hin Lam,1,5 Meizhen Huang,1 and Deborah Jehu6
1Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Kowloon, Hong Kong; 2Department of Rehabilitation Medicine, The 2nd Affiliated Hospital of Kunming Medical University, Kunming, China; 3Institute of Disaster Management and Reconstruction, Sichuan University-Hong Kong Polytechnic University, Chengdu, China; 4Department of Physical Therapy, Guangdong Provincial Work Injury Rehabilitation Hospital, Guangzhou, China; 5Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong; 6Physical Therapy Department, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
Background and Purpose: The ability to perform a mobility and cognitive task simultaneously (dual-tasking) is essential in functional ambulation and is often impaired after stroke. Compromised dual-task mobility may contribute to falls following stroke. This randomized controlled study aimed to examine the effects of dual-task exercise on cognitive-motor interference during ambulation and falls in people with chronic stroke.
Methods: Eighty-four people with chronic stroke (24 women; age: 61.2 +/- 6.4 years; poststroke duration: 75.3 +/- 64.9 months) with independent mobility function and intact cognition were randomly allocated to the dual-task balance/mobility training group, single-task balance/mobility group, or upper-limb exercise (control) group. People in each group underwent their respective exercise training for three 1-hour sessions per week for 8 weeks. Outcome measurements were conducted at baseline, 1 week after, and 8 weeks after training by a blinded researcher. The time taken to complete the 3 mobility tasks (forward walking, Timed Up and Go, and obstacle crossing) and the correct response rate for the serial-3-subtractions and verbal fluency task were measured under dual-task conditions (primary outcome). In addition, fall incidence was recorded for a 6-month posttraining period.
Results: The results revealed an overall Group x Time interaction effect in walking time of 3 dual-task conditions (forward walking with verbal fluency, forward walking with serial-3-subtractions, and Timed Up and Go with verbal fluency) (P < 0.05). Post hoc analysis showed that only the dual-task group demonstrated reduced dual-task walking time posttraining (forward walking with verbal fluency, 9.5%, P = 0.014; forward walking with serial-3-subtractions, 9.6%, P = 0.035; and the Timed Up and Go with verbal fluency, 16.8%, P = 0.001). These improvements were largely preserved at the 8-week follow-up. On the contrary, the dual-task cognitive performance did not change over time, regardless of group allocation (P > 0.05). The dual-task exercise intervention significantly decreased the rate of falls and injurious falls by 25.0% (P = 0.037) and 22.2% (P = 0.023), respectively, during the 6-month follow-up period relative to the control group.
Discussion and Conclusions: The dual-task program improves dual-task mobility and reduces falls and related injuries in ambulatory individuals with chronic stroke who have intact cognitive function. The study results highlight the necessity to train dual-tasking to improve dual-tasking. This study can be used to inform the design of fall prevention interventions in community-dwelling individuals with chronic stroke and has the potential for widespread, economical, and sustainable applications in community- and home-based settings.
CHANGING PHYSICAL ACTIVITY BEHAVIOR FOR PEOPLE WITH MULTIPLE SCLEROSIS: RESULTS FROM THE ISTEP-MS FEASIBILITY RANDOMIZED CONTROLLED TRIAL
Jennifer Ryan,1,2Jennifer Fortune,1,2 Andrea Stennett,2 Cherry Kilbride,2 Grace Lavelle,2 Wendy Hendrie,3 Lorraine DeSouza,2 Mohamed Abdul,4 Debbie Brewin,5 Lee David,5 Nana Anokye,2 Christina Victor,2 and Meriel Norris2
1RCSI Royal College of Surgeons, Dublin, Ireland; 2Brunel University London, United Kingdom; 3MS Therapy Centre, Norwich, United Kingdom; 4Berkshire MS Therapy Centre, Reading, United Kingdom; 510 minute CBT, United Kingdom
Background and Purpose: People with multiple sclerosis (MS) are physically inactive and spend prolonged time in sedentary behavior. Behavior change interventions are coordinated sets of activities designed to change specified behavior patterns and represent a potential method to change physical activity. The iStep-MS trial examined the feasibility, acceptability, and safety of a behavior change intervention to increase physical activity and reduce sedentary behavior among people with MS.
Methods: The iStep-MS intervention was evaluated by a randomized controlled trial and parallel embedded process evaluation. The 12-week intervention consisted of 4 physiotherapist-led physical activity consultations supported by a handbook and a pedometer. Safety was determined by assessing pain (EQ-5D-5L) and fatigue (MFIS) at baseline and 3 and 9 months and recording the incidence of adverse events from baseline to 9 months. Feasibility and acceptability of the intervention were assessed by evaluating program fidelity and exploring the intervention experience through 15 participant interviews and a focus group with the intervention physiotherapists. Differences in pain and fatigue between groups at 3 and 9 months, respectively, adjusted for baseline values were investigated using analyses of covariance. Differences in the number of people experiencing an adverse event between groups were examined using logistic regression. Qualitative data were analyzed using Framework Analysis.
Results: Sixty adults with MS (age 56.8 +/- 9.1 years; 68% female; Expanded Disability Status Scale [EDSS] score = 0-6.5) were randomized in a 1:1 ratio to the intervention or usual care. Fifty-five (92%) and 52 participants (87%) attended the 3 and 9 month assessments, respectively. Twenty-nine participants completed at least 75% of sessions. Fidelity to intervention delivery and engagement was good (>70%). Fatigue was lower in the intervention group at 3 (P = 0.039) and 9 months (P = 0.016). There was no difference in pain at 3 months (P = 0.286). Pain was lower in the intervention group at 9 months (P = 0.017). At 9 months, there was no difference in the adverse event rate between groups. The intervention was feasible to deliver and acceptable to receive. Participants highlighted positive changes in their confidence to initiate and undertake physical activity. Confidence was facilitated through setting and achievement of incremental individualized goals and self-monitoring. Face-to-face empathic support from professionals who were specialists in MS created a supportive intervention environment where participants felt valued. Pedometer acceptability was poor, requiring exploration of alternative measurement options.
Discussion and Conclusions: A physiotherapist-led behavior change intervention focused on increasing physical activity and reducing sedentary behavior in people with MS is safe, feasible, and acceptable and has the potential to change physical activity behavior. A definitive trial of the intervention is warranted.
EVALUATION OF A SHORT ASSESSMENT FOR UPPER EXTREMITY ACTIVITY CAPACITY EARLY AFTER STROKE
Therese Kristersson,1,2 Hanna C. Persson,1,2 and Margit Alt Murphy1,2
1Institute of Neuroscience and Physiology, Clinical Neuroscience, Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 2Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
Background and Purpose: Upper extremity impairments are common after stroke. The recommended standardized outcome measures are time consuming and/or require special equipment. There is a clinical need for a short screening test for upper extremity early after stroke. The ARAT-2 consists of 2 items of the Action Research Arm Test (ARAT) and has shown to predict well functional outcome early after stroke, but its validity in the acute and subacute stages after stroke has not been evaluated in clinical settings. This study aimed to explore the floor-and-ceiling effect of ARAT-2, its concurrent validity, and responsiveness in comparison with the original ARAT and the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) during the first 4 weeks poststroke.
Methods: A nonselected cohort of 117 adults with first ever stroke and impaired upper extremity function were included 3 days poststroke. The activity capacity and motor function were assessed with ARAT and FMA-UE at 3 days, 10 days, and 4 weeks poststroke. ARAT-2 results were calculated from the ARAT.
Results: ARAT-2, similarly to ARAT, showed a floor effect at all time points. The ceiling effect was reached earlier using ARAT-2 than with ARAT and FMA-UE. The correlation between ARAT-2 and the other assessment scales was high (r = 0.92-0.97), and ARAT-2 showed statistically significant changes between all time points (effect size: r = 0.31-0.48). The effect sizes for the change in ARAT and FMA-UE varied from 0.44 to 0.53.
Discussion and Conclusions: The ARAT-2 appears to be valid and responsive screening assessment for upper extremity activity capacity early after stroke. However, when the highest score has been reached, the assessment needs to be complemented with other instruments.
The ARAT-2 can be used as a short first screening test in clinical settings during the first weeks after stroke to evaluate upper extremity activity capacity and to guide the selection of complementary assessments and treatment planning.
The article is now published: Kristersson T, Persson HC, Alt Murphy M. Evaluation of a short assessment for upper extremity activity capacity early after stroke. J Rehabil Med. 2019;51:257-263. doi:10.2340/16501977-2534.
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