feys peter, international gait and balance symposium st louis 2013

A perspective from the Rehabilitation in Multiple Sclerosis (RIMS)

multicenter trials

MEASUREMENT OF GAIT

Peter Feys. Ass. Prof. Rehabilitation Sciences & Physiotherapy

Hasselt University BelgiumSIG Mobility – european RIMS

REVAL (SINCE 2005) BIOMED, UHASSELT, BELGIUM

3 yrs BAC – 2 yrs MA programRehabilitation Sciences & Physiotherapy

WALKING OUTCOME STUDIES WITHIN THE RIMS-NETWORK (SIG MOBILITY)

• dr. C. Vaney (former RIMS SIG chair and president): uniform measurements and understanding them (usual/fast)

• Elaborated since 2008 during SIG Mobility meetings (2 yearly)Workgroup

• Unfunded Data collection in 2010-11 • First Publications in MSJ in 2012

Goal of Medical treatment& Rehabilitation

WALKING Assesment& Rehabiliation

.Network of MS Centers, founded in 1993Network for best practice & research (2011)

www.euRIMS.org

Within SIG MOBILITYSince 2009

Unfunded Multi-center Joint data collection

Walking assessment (n=114 /189)• Substudy : n=80• Substudy : n=42Effect of Rehabilitation (n=293)

MLCW LCW CW

Fastest Speed Usual Speed20

30

40

50

60

70

80

90

100

Ste

p Le

ngth

(cm

), R

ight

Leg

CANE & SPEED ALTERATIONS

• Gianfrancesco, Lo et al (2011) Gait & Posture▪ 11 pwMS (6 use a cane)▪ Cane

▪ doesn’t impact on preferred speed but makes gait less variable & more symmetric

▪ facilitates acceleration

• Feys, Wens et al (2013) MSARD▪ 27 pwMS

▪ REVAL Hasselt ▪ Rehabilitation & MS Center Overpelt

▪ 3 subgroups based on usual gait speed ▪ CW>1,14m/s mean EDSS 2,89

community walker▪ LCW and mean EDSS 3,64

limited community walkers▪ MLCW<0,82m/s mean EDSS 6,79

most limited community walkers

▪ Slow walkers (MLCW) were not able to significantly accelerate when walking at fastest compared to usual speed

*

*

EFFECT OF SPEED INSTRUCTION

• No significant changes in MLCW LCW-CWVelocity, cadence & step length

M LC W LC W C W

Fastest Speed U sual Speed20

40

60

80

100

120

140

160

180

200

220

240

260

Vel

ocity

(m

/s)

*

*

1A

MLCW LCW CW

Fastest Speed Usual Speed20

30

40

50

60

70

80

90

100

Ste

p L

en

gth

(cm

), R

igh

t Le

g

*

*

Feys, Wens et al (2013) MSARD

• Guitierrez et al (2005) APMR

N=8 -- 8 weeks resistance training, 2X week (EDSS 2.5-5)

▪ Most affected leg: ↑ stance phase

▪ Less affected leg: ↑ step length

▪ Both legs: ↓ double-support phase

• Smedal, Kjell-Morton et al (2006) Phys Res Int

N=2 - 3 weeks of BOBATH training

• Sacco, Kesselring et al (2010) J Neurology

N=24 - 3 weeks In-patient rehabilitation program

decreased double support time, increased step length

REHABILITATION EFFECTS

EFFECT OF 2&6MWTON THE GAIT PATTERN

• 6MWT feasible in more disabled patients?Barett et al 2009, report of pauzes

• Does prolonged walking impacts the gait pattern?

• Some changes in the MLCW only (<0,82m/s), after the 6MWT only

M L CW L CW CW

P re 6 M W T P o st 6 M W T

Usu a l S p e e d

4 0

6 0

8 0

1 0 0

1 2 0

1 4 0

1 6 0

1 8 0

Ca

de

nce

(st

ep

s/m

inu

te)

* MLCW LCW CW

Pre 6MWT Post 6MWT

Fastest Speed

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

1,1

Ste

p Ti

me

L (s

) *

Feys et al (2013) MSARD. N=27

• Overview/Instructions• Psychometric properties

IJMSC 2011

MSJ 2012

CONCURRENT VALIDITYRELATIONSHIPS BETWEEN TESTS

Kieseier & Pozzili (2012) MSJ

T25FW(7,62m)

6MWT (30m hallway)

See also Kempen et al (2012) MSJ

6MWT AS GOLDEN STANDARD

• No Floor or ceiling effect T25FW/10MWT in fast walkers

• Normative data (age, sex) available

• Construct: Muscle ‘strength’ & ‘endurance’▪ Related to ‘muscle fatigue/fatiguability’ Broekmans et al (2012) MSJ

▪ Heart rate/Energy consumption Dalgas, Feys et al (2013) J Rehab Med

Motl et al (2012) BMC Neurology

MUSCLE FATIGUE DURING 6MWT?PACING PATTERN

Goldman et al (2008) MSJFor Cadence/Step lenght // disability level: Pilutti et al (2013) J Neurol

Sciences

PACING STRATEGY & HEART RATE ACCORDING DISABILITY LEVEL• N = 80 from 6 centers (part MCWS I)• Dalgas, Feys & RIMS group (2013) J Rehabil Med

PACING PATTERN: see also Goldman et al (2008) MSJ & Pilutti et al (2013) J Neurol Sci(Cadence/Step length // disability level)

HR: ▲38 bpm// ▲34 Savci 2005// ▲45 Paltamaa 2007

HR: ▲ greatest in mild MS// ▲ Bosnak-Guclu 2012

OXYGEN CONSUMPTION & HEART RATE ACCORDING DISABILITY LEVEL

• N = 80in Dalgas, Feys & RIMS group (2013) J Rehabil Med

• N = 95 in Motl et al (2012) BMC Neurology

EDSS 2,5 – 3,5: mildEDSS 4-5,5: moderateEDSS 6-6,5:severe

MODERATE INTENSITY

HR: 67% of predicted HRmax// 69% Savci 2005

<V02 maximal uptake

IMPACT OF SUBJECTIVE FATIGUE ON 6MWT?

Correlations vary in literature: f.e.• Savci et al 2005: NS • Goldman 2008: 0,66 (MFIS)• Andreasen 2009: NS (-0.27 phys)• Motl 2010 : 0,46 (FSS)

Eur J Phys Rehabil Med 2012• Motl 2012 NNR: 0,32 (FSS)• ...

Dalgas, Feys et al (2013)

MFISCut-off scores:

• Total: 38 NS• Part ‘physical’:15 -0,28

STATISTICS…HR: TAKING INTO ACCOUNT AGE

CONCURRENT VALIDITY BETWEEN TESTS

• High correlations between short and long walking tests

• Redundant?

INTERMEZZO: TEST INSTRUCTIONS RELATIONS BETWEEN TESTS

• Dynamic static start

• Usual fast speed

-----------------------------Differences in speed across two disability groups

Little for 6MWT & 10MWT usual speed

Gijbels, Feys, RIMS 2012 MSJN=189EDSS 4 as cut-off

CONCURRENT VALIDITY BETWEEN WALKING TESTS

Gijbels, Dalgas, Feys & RIMS Group (2012) MSJ12 centers in 9 different EU countries and 1 US, N=189+22Q/ What is relation between walking tests?

6M

WT

6M

WT

2MWT10WT

CONCURRENT VALIDITY BETWEEN WALKING TESTS

Gijbels, Dalgas, Feys & RIMS Group (2012) MSJ

Q/ What is relation between walking tests?A/ Prediction of 6MWT based on

10mWT: error up to 16% 2MWT: error up to 6%

<

- n=40- mean EDSS 3.4 ± 1.2- 8 walked with an aid

2MWT & 6MWT are highly correlated (r>0,95)

See also Learmonth et al (2013) MSJ

EFFECT OF TIME OF DAY

8 centers in 4 different countries (including US). N=114Q/ Effect of Time of Day on Walking & Fatigue? 6MWT Energy Level

Rochester Fatigue Diary


8 centers in 4 different countries (including US). N=114Q/ Effect of Time of Day on Walking & Fatigue?A/ Decreased energy, without effect on walking (any subgroup)

6MWT Energy Level

SUBGROUPS

SUBGROUPSBased on RFD changes • > -10mm• <-10 & 10• >10mm

6MWT?


• Dalgas, Feys & RIMS subgroup 2013, J Rehab MEd• None

▪ Pacing pattern▪ Heart rate (changes)

6MWT’ = 6MWT ± 0.15 m/s or 54 m

10mWT (F)’ = 10mWT (F) ± 0.26 m/s

Feys, Dalgas & RIMS group (submitted)

Within-day VariabilityLimits of Agreements

• Variability increases with disability level, often >20%

• Variabily 2/6MWT << 10m

WALKING ASSESSEMENT

• Walking ability (subjectively):▪ MSWS-12

• Walking Capacity Walking speed▪ 10MWT at usual and fastest speed▪ T25FW at fastest speed ▪ 2MWT ▪ 6MWT▪ Other (5, 100, 500m) 2/6MWT superior to T25FW to

predict community walking (accelerometry); Gijbels et al MSJ 2010

See also US TASK FORCE on recommendations of outcome measures

MOBILITY TESTS & WALKING PERFORMANCE

• 6MWT correlates with walking performance in both groups. • Moderate MS group: EDSS ≥4,5

functional mobility measures (especially long walking capacity tests) correlate significantly with walking performance 53% of number of steps is explained by 6MWT/2MWT 38% by T25FW

MS subgroups

MS total (n=50) Mild MS (n=29) Moderate MS (n=21)

Variable Walking performance

Walking tests

Timed Up and Go (s) -0.52 ** -0.13 -0.69 **

Timed 25-Foot Walk (s) -0.56 ** -0.21 -0.62 **

2-Minute Walking Test (m) 0.65 ** 0.35 0.73 **

6-Minute Walking Test (m) 0.68 ** 0.43 * 0.73 **

Balance tests

Functional Reach (cm) 0.41 ** 0.28 0.46 *

Berg Balance Scale 0.57 ** 0.25 0.73 **

Gijbels, Feys et al (2010) MSJ

PREDICTION OF WALKING PERFORMANCE BASED ON WALKING CAPACITY TESTSGIJBELS, FEYS ET AL (2010) MSJ

6MWT is• best predictive walking capacity test for habitual walking

performance• Especially in ‘moderate MS’ (EDSS >4)

see also personal and environmental factors; Motl et al 2008

The 5 most predictive variables of walking performance per (sub)group (Sub)group Variable R2 SE t-value p

Mild MS (n=29)

1) 6-Minute Walking Test (m) 0.187 12.33 5.04 2.44 =0.02

2) Activities and Participation Questionnaire- 0.168 -1407.00 615.10 -2.29 =0.03

3) / / / / / /

4) / / / / / /

5) / / / / / /

Moderate MS (n=21)

1) 2-Minute Walking Test (m) 0.532 33.01 7.11 4.64 <0.01

2) 6-Minute Walking Test (m) 0.527 11.28 2.45 4.60 <0.01

3) Timed Up and Go (s) 0.481 -142.74 34.04 -4.19 <0.01

4) Timed 25-Foot Walk (s) 0.387 -213.36 61.60 -3.46 <0.01

5) Rivermead Mobility Index 0.376 449.64 133.02 3.88 <0.01

R2, predictive value; , estimate; SE, standard error

WALKING ASSESSEMENT

• Walking ability (subjectively):▪ MSWS-12

• Walking Capacity Walking speed▪ 10MWT at usual and fastest speed▪ T25FW at fastest speed ▪ 2MWT ▪ 6MWT▪ Other (5, 100, 500m)

RESPONSIVENESS TO REHABILITATION ??

See also US TASK FORCE on recommendations of outcome measures

ResponsivenessEffects of Rehabilitation

on walking capacity?

EFFECTS OF EXERCISE THERAPY ON WALKING

Meta-analysis of Motl & Snook (2009) NNR

Different outcome measures in studies

Different level of ambulatory function

MULTI-CENTER STUDY II: 2012-13

290 pwMS* from17 European centres in 9 countries

*cerebellar ataxia excluded

Responsiveness of walking measuresEffect of rehabilitation

Baert, Feys, Dalgas & RIMS workgroup Mobility (in revision) NNR

RESPONSIVENESSLongitudinal studies documenting ‘deterioration’fe. Groot et al (2006) Brain; Paltamaa et al (2008) APMR

Q/ Responsiveness of different gait measures to rehabilitation?A/ RIMS Multi-Center data collection in EU 17 Centers. N=290

Stratification• EDSS ≤ 4:

“mild”disability• EDSS > 4: “moderate –

severe” disability Baert, Feys & RIMS group (in revision) NNR

PRE & POST:T25FW

UsualFast speed

2MWT6MWTMSWS-12

POST: Clinical impression of change:Q. ‘Compared to before rehabilitation, how would you rate your walking now?’• (very) much worse• minimally worse• no change• minimally improved• (very) much improved

ANCHOR for ‘clinical importantchange’

RESPONSIVENESS MEASURES

• AUC (95% CI) area under the reciever operating characteristic curve (ROC)

• MIC: minimally important change

Y (t) = α + β1 * Y (t0) + β2 * deteriorated + β3 * minimally improved + β4 * much improved + β5 * very much improved + ε

• SRC: smallest real change

SRCind = 1.96 * SD (standard deviation) of score changes in the stable group

SRCgroup = SRCind/n (n= number of stable patients)

GLOBAL IMPRESSION OF CHANGE

very much worse

much worse minimally

worse no change minimally

improved much improved very

much improved

05

10152025303540

PatientTherapist

%


75% pwMS reported improvement

Similar results between pwMS & therapist

RESPONSIVENESS // PATIENT PERSPECTIVE*MSWS-12* >6MWT* ≥2MWT* >T25FW fastp=0,06 >T25FW usualns

Baert, Feys & RIMS group (in revision) NNR

EDSS≤4 EDSS 4,5-6,50

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Responsiveness // disability level

T25FW usual speed T25FW fast speed 2MWT6MWT MSWS-12

AU

C -

are

a u

nder

curv

e ** *

* *

*

P=0,06

P=0,06

VALUES FOR MINIMAL IMPORTANT CHANGE


outcome meausure β3 SE p-value β3 SE p-valueT25FW usual speed, s 0.02 0.6 0.98 -0.2 0.5 0.74T25FW fast speed, s -0.4 0.5 0.44 -0.01 0.4 0.982MWT, m 9.6 3.4 <0.01 6.8 3.1 0.036MWT, m 21.6 9.0 0.02 9.1 8.0 0.26MSWS-12 -8.3 2.5 <0.01 -9.1 2.4 <0.01

patient perspectiveMIC min improved

ns

deteriorated no change minimally improved

much improved very much improved

-25

-15

-5

5

15

25

35

45

55

65

75

T25FW PwMST25FW Ther2MWT PwMS2MWT Ther6MWT PwMS6MWT TherMSWS-12 PwMsMSWS-12 Ther

Test

un

its

COMPARING MIC SRC

• SRCind = 1.96 * SD of score changes in the stable group

• SRCgroup = SRCind/n (n= number of stable patients

outcome meausure AUC 95% CI p-value β3 SE p-value proportiona (%) SRCind SRCgroup proportion (%)

Whole groupT25FW usual speed 0.49 0.39 - 0.59 0.82 0.02 0.56 0.98 77.7 -4.91 -0.70 6.3T25FW fast speed 0.58 0.48 - 0.67 0.10 -0.37 0.48 0.44 54.1 -4.10 -0.57 3.52MWT 0.65 0.57 - 0.73 <0.01 9.63 3.40 <0.01 42.0 24.31 3.40 14.66MWT 0.67 0.60 - 0.75 <0.01 21.56 8.97 0.02 50.0 67.22 9.32 19.4MSWS-12 0.72 0.64 - 0.79 <0.01 -8.31 2.49 <0.01 47.0 -25.56 -3.54 11.4

T25FW usual speed 0.67 0.54 - 0.81 0.05 -0.59 0.41 0.16 42.7 -2.07 -0.57 6.7T25FW fast speed 0.63 0.50 - 0.77 0.10 -0.39 0.31 0.22 42.9 -0.72 -0.19 28.62MWT 0.73 0.60 - 0.86 <0.01 10.76 5.41 0.05 42.9 20.28 5.24 25.56MWT 0.74 0.63 - 0.86 <0.01 26.86 14.67 0.07 55.1 42.86 11.07 38.8MSWS-12 0.59 0.46 - 0.73 0.27 0.17 3.89 0.97 81.3 -17.36 -4.48 25.0

T25FW usual speed 0.44 0.32 - 0.56 0.25 0.23 0.77 0.76 81.8 -5.28 -0.88 5.5T25FW fast speed 0.55 0.43 - 0.66 0.39 -0.35 0.70 0.62 60.0 -4.81 -0.80 2.72MWT 0.60 0.50 - 0.70 0.06 8.17 4.26 0.06 42.1 26.04 4.34 12.06MWT 0.64 0.54 - 0.74 0.01 17. 39 11.37 0.13 51.1 75.42 12.40 15.1MSWS-12 0.77 0.69 - 0.86 <0.01 -11.27 3.03 <0.01 31.4 -26.23 -4.31 9.7

Significant values are 'bold' marked

outcome meausure AUC 95% CI p-value

Whole groupT25FW usual speed 0.58 0.50 - 0.67 0.06 -0.17 0.50 0.74 67.6 -3.55 -0.46 9.0T25FW fast speed 0.62 0.54 - 0.71 <0.01 -0.01 0.43 0.98 64.7 -3.28 -0.42 5.32MWT 0.64 0.56 - 0.72 <0.01 6.81 3.10 0.03 49.5 26.64 3.41 12.16MWT 0.63 0.56 - 0.71 <0.01 9.06 8.02 0.26 62.0 68.32 8.68 18.9MSWS-12 0.68 0.61 - 0.76 <0.01 -9.08 2.36 <0.01 41.6 -28.69 -3.64 8.5

T25FW usual speed 0.64 0.50 - 0.78 0.06 -0.60 0.37 0.12 42.7 -2.33 -0.52 5.3T25FW fast speed 0.71 0.59 - 0.83 <0.01 -0.36 0.29 0.21 42.9 -1.11 -0.24 10.22MWT 0.67 0.54 - 0.81 0.02 11.07 4.98 0.03 39.8 24.16 5.27 16.36MWT 0.66 0.53 - 0.78 0.06 26.3 13.48 0.05 55.1 56.53 12.34 25.5MSWS-12 0.68 0.56 - 0.81 0.01 -4.43 3.79 0.25 64.6 -26.98 -5.89 12.5

T25FW usual speed 0.56 0.46 - 0.67 0.24 -0.18 0.72 0.80 86.2 -3.96 -0.63 11.0T25FW fast speed 0.59 0.48 - 0.69 0.09 0.19 0.64 0.76 85.9 -3.94 -0.62 6.52MWT 0.62 0.53 - 0.72 0.02 7.09 3.40 0.08 64.5 28.07 4.44 10.96MWT 0.62 0.52 - 0.71 0.02 9.87 10.52 0.35 55.4 73.98 11.55 16.7MSWS-12 0.68 0.59 - 0.78 <0.01 -9.48 2.90 <0.01 77.3 -29.63 -4.63 8.1


Table 5a. Combined anchor- and distribution based responsiveness (AUC, MIC, SRC) for improvement on walking using patient's perspective as external criteria

AUC MIC min improved SRC

No significant MIC for the T25FW at any speed

FURTHER COMPARISONS













Within-day variability

19m for 2MWT54m for 6MWT

Feys, Dalgas, RIMS et al

FURTHER COMPARISONS













6 months follow-up 6MWT: 88m MDC

MSWS-12: 22Learmont, Motl 2013

BLACK BOX OF PHYSICAL REHABILITATION

Therapist LevelOn-line Questionnaire

(>250 units)Knowledge & Use of

evaluation & treatment methods

Patient LevelMulti-center

joint data collectionRehabilitation &

Walking measures

continued

1A) STATE/REGION REPRESENTATIVE.

1B) CENTER http://cophyrequest.czware.cz/centre

2) THERAPIST/RESEARCHER:http://cophyrequest.czware.cz/content

You can win vouchers for 2014 RIMS annual conference!

http://cophyrequest.czware.cz/centre



http://cophyrequest.czware.cz/content

http://cophyrequest.czware.cz/content

TAKE HOME MESSAGESWalking • Multi-dimensional & measured at different ICF levels

Interaction with cognitive dysfunction

• Improvements after rehabilitation▪ Gait pattern: slow walkers (<1,14m/s)▪ Walking speed & ability: across disability levels (up to EDSS 6,5)

• Recommendations at activity level: 2MWT/6MWT & MSWS-12

• Use values of MIC & SRC (also for fampyra trials)

• Need for identification of factors in structured rehabunderlying treatment effects

MS TASK FORCE – UNITED STATESHTTP://WWW.NEUROPT.ORG/PROFESSIONAL-RESOURCES/NEUROLOGY-SECTION-OUTCOME-MEASURES-RECOMMENDATIONS/MULTIPLE-SCLEROSIS

ACKNOWLEDGEMENTS

Ilse Baert

feys peter, international gait and balance symposium st louis 2013

Health & Medicine

mwt msws

t25fw usual fast speed

fastest speed t25fw

feys rims group

rimsnetwork sig mobility

effect of rehabilitation

s t25fw fast speed

dalgas rims workgroup