[Supplementary online-only material for Poster Abstracts from the Fourth International

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1 [Supplementary online-only material for Poster Abstracts from the Fourth International Symposium on Gait and Balance in Multiple Sclerosis. Int J MS Care. 2014;16(4): ] Poster Abstracts from the Fourth International Symposium on Gait and Balance in Multiple Sclerosis: The Role of Cognition Cleveland Clinic Cleveland, Ohio, USA October 10 & 11, 2014 Editor s note: This online-only document contains the full poster abstracts. The abstract titles, authors, and author affiliations were also published in the print edition of IJMSC s Winter 2014 issue. (1) EFFECTS OF DIFFERENT PHYSICAL THERAPY MODALITIES ON FATIGUE AND MOBILITY: PRELIMINARY REPORT ON A TELE-REHABILITATION PILOT STUDY Gabriel Pardo, Amy Thiessen, Cecilie Fjeldstad Oklahoma Medical Research Foundation, MS Center of Excellence, Oklahoma City, OK Background: Fatigue is one of the most common symptoms in multiple sclerosis (MS) and is often disabling. Gait dysfunction is a frequent manifestation of MS. Physical therapy (PT) can improve both of these MS manifestations. Access to specialized PT is limited due to mobility, transportation, or geographic reasons. Objective: To examine fatigue and gait improvement following 8 weeks of PT intervention via tele-health, traditional one-on-one, or self-conducted

2 at-home exercises. Methods: Fifteen individuals with MS were equally randomized into one of three groups. All participants were asked to perform home exercises 5 days a week on their own after their initial assessment. Group 1 was composed of individuals who only performed the home exercises. In addition, group 2 participated in PT via tele-health twice weekly, and group 3 received individualized PT in the clinic. Fatigue was measured by the Modified Fatigue Impact Scale, and gait by the Functional Gait Assessment. Results: There was a trend for less fatigue after 8 weeks for all groups. Group effect did not reach statistical significance (P >.05). Gait improved for all groups, but again did not reach significant group effect (P >.05). Discussion: This report corresponds to a limited number of study participants who have completed the entire study. Improvement has been documented for both fatigue and gait with each one of the intervention modalities, without a group identified so far. The limited cohort does not allow for conclusions at this time and the study is ongoing. (2) BLADDER DYSFUNCTION IS ASSOCIATED WITH COGNITIVE SYMPTOMS AND WALKING SPEED IN MULTIPLE SCLEROSIS Valerie Block, 1 Evan T. Cohen, 2 John T. Marmarou, 3 Diane D. Allen 1 1 Department of Physical Therapy & Rehabilitation Science, University of California San Francisco/San Francisco State University, San Francisco, CA; 2 School of Health Related Professions and the Graduate School at Camden, Rutgers, the State University of New Jersey, Camden, NJ; 3 Total Rehab and Fitness, LLC, Cherry Hill, NJ Background: Multiple sclerosis (MS), as a neurodegenerative disease, presents with many debilitating impairments including loss of balance, gait disorders, bladder problems, and

3 cognitive dysfunction. While each impairment can affect quality of life (QOL) separately, people with MS can have multiple concurrent impairments that interact with each other, exacerbating their effects. Our purpose was to analyze cross-sectional data to determine associations between QOL and disruptions to gait, bladder, and cognitive functions in persons with MS. Methods: Data were collected through a retrospective chart review for 74 subjects and analyzed using the Pearson coefficient to ascertain any correlation between cognitive (Perceived Deficits Questionnaire [PDQ-5] and the 3-second Paced Auditory Serial Addition Test [PASAT-3]), bladder (Bladder Control scale [BLCS]), and gait (Timed 25-Foot Walk Test [25FWT] and 6- Minute Walk Test [6MWT]) dysfunction, and number of falls, hospitalizations, and MS exacerbations after the first quarter of enrollment in a multidisciplinary rehabilitation program for people with MS. Results: There was a moderate correlation between BLCS and PDQ-5 (P <.0001, r = 0.583) and between BLCS and 25FWT (P <.0001, r = 0.390). Significant correlations were also observed between 25FWT and 6MWT (P <.0001, r = 0.518), BLCS and PASAT-3 (P =.007, r = 0.303), and PDQ-5 and 25FWT (P =.001, r = 0.288). No statistically significant correlation was seen between falls in the last 3 months and any of the other measures. Discussion: The results reveal associations between bladder dysfunction, cognitive symptoms, and walking speed as assessed with the 25FWT. While all three impairments likely interact, numbers of falls, exacerbations, and hospitalizations were not associated with these measures. Assessment and management of each of these impairments may be required to promote the best functioning in people with MS. (3) BLADDER FUNCTION AND FALLS IN PEOPLE WITH MULTIPLE SCLEROSIS J Sung, RW Motl, JJ Sosnoff

4 Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL Objective: To determine the association between bladder function and falls in people with MS. Background: Falls are multifactorial. Bladder function (BF) is a modifiable falls risk factor. Both BF impairment and falls are commonly reported in multiple sclerosis (MS). Although BF has been associated with falls in various clinical populations (older adults and Parkinson s disease), the association between BF and falls in MS is not clear. Methods: This is a secondary data analysis of 74 ambulatory individuals with MS (mean age = 59.7 ± 7.4 y, female = 58) who were enrolled in one of three exercise-based randomized controlled trials. Participants provided self-reported bladder function, disability level (Expanded Disability Status Scale [EDSS] score), and number of falls in the previous 3 months. Physiological falls risk was quantified with physiological profile assessment (PPA). Participants were divided into two groups. Individuals who reported no or mild BF impairment were placed in the mild group (n = 34), while those with moderate or severe BF impairment were assigned to the severe group (n = 40). Number of falls as a function of group was examined with the Mann-Whitney U test. PPA score was placed in independent one-way (group) analysis of covariance controlling for self-reported EDSS score. Results: Median self-reported EDSS score was 6.0 (IQR = 4.5-6). Median number of falls was 1 (IQR = 0-3), while average PPA score was 1.69 ± The severe BF group (median = 1, IQR = 1-3) had a greater number of self-reported falls than the mild group (median = 2, IQR = 2-6) (P =.034). In contrast, there was no difference between the mild group (mean = 1.62 ± 1.51) and the severe group (mean = 1.76 ± 1.29) in physiological fall risk (P =.976). Conclusion: BF was related to past falls but was not associated with physiological falls risk. A potential interpretation

5 of these results is that the association between BF and falls is more behavioral (eg, rushing to the bathroom) than physiological in nature. Future research examining whether falls-prevention programs in MS should include bladder impairment management is warranted. (4) VALIDATION OF SEATED POSTURAL CONTROL MEASURES IN PEOPLE WITH MULTIPLE SCLEROSIS CM Ousley, ZJK Isaacs, DA Wajda, JJ Sosnoff, LA Rice Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL Background: Poor seated balance in nonambulatory individuals with multiple sclerosis (MS) is associated with falls and a potential target of rehabilitation. However, there is a lack of validated clinical measures of seated postural control in people with MS, and this limits evaluation of rehabilitation treatments. Purpose: The purpose of this study is to validate the Function in Sitting Test (FIST) as a measure of seated postural control in people with MS. Methods: Ten people with MS participated in seated postural assessments. Sitting balance was evaluated using the FIST and posturography. The FIST is a 14-item clinical functional assessment of sitting balance. Scores in the FIST range from 0 to 56, with 56 indicating maximal sitting balance. This test has been validated in adults with acute stroke. The seated posturography assessment involved participants sitting on a force platform without support for 30 s. The center of pressure was determined and the amount of seated postural sway was calculated. Results: The sample s age ranged from 27 to 58 years (mean = 51), and the duration of MS diagnosis ranged from 7 to 32 years (mean = 15). Performance on the FIST ranged from 31 to 56 (mean = 51), while the

6 postural sway area ranged from 8 to 383 mm 2 (mean = 87 mm 2 ). Performance on the FIST was negatively associated with seated postural sway (r = 0.561, P =.116). Conclusion: The observations provide evidence that FIST is a valid tool to assess seated postural control in nonambulatory people with MS, although potential questions about ceiling effects remain. (5) SEATED POSTURAL CONTROL IN NONAMBULATORY PEOPLE WITH MULTIPLE SCLEROSIS ZJK Isaacs, CM Ousley, DA Wajda, LA Rice, JJ Sosnoff Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL Background: The ability to maintain a seated position without support (ie, seated postural control) is a fundamental skill for nonambulatory people with multiple sclerosis (MS). However, there is a lack of information on seated postural control in nonambulatory people with MS. Purpose: To examine seated postural control in nonambulatory people with MS compared to healthy controls. Methods: Eight nonambulatory individuals with MS and eight healthy controls underwent a seated postural control assessment. To examine seated postural control, participants sat on a force platform and performed two experimental tasks: quiet sitting and maximal lean. In the maximal lean condition participants rotated their torso to their maximal stability boundary without upper-limb support. Seated postural control was indexed with two ecologically based measures: the average virtual time to contact (VTC) and seated instability index. The VTC is the estimated time for a single point of the center of pressure trajectory to reach the stability boundary. Seated instability index is the ratio of postural sway area during quiet sitting to the

7 seated stability boundary. To examine the differences in seated postural control metrics between people with MS and controls, a univariate analysis of variance was performed. Results: Among all participants, mean VTC was 1.34 s ( s) and mean seated instability index was 1.3 ( ). Statistical analysis revealed a significant group difference in VTC (MS 1.23 s ± 0.24 s vs. control 1.45 s ± 0.21 s, P =.03) and seated instability index (MS 2.16 ± 1.23 vs. control 0.32 ± 0.27, P <.01). Discussion: As expected, significant differences exist in both VTC and the seated instability index between nonambulatory people with MS and controls. These preliminary observations confirm the use of these objective metrics to assess seated postural control in this population. Further work examining the validity and reliability of these measures is necessary. (6) PERFORMANCE ON THE MODIFIED DYNAMIC GAIT INDEX IN PEOPLE WITH MULTIPLE SCLEROSIS COMPARED TO AGE-MATCHED CONTROLS Patricia Noritake Matsuda, Anne Shumway-Cook Department of Rehabilitation Medicine, Division of Physical Therapy, University of Washington, Seattle, WA Background: The modified Dynamic Gait Index (mdgi) measures the capacity to adapt gait to eight complex walking tasks using three dimensions of performance (Time, Gait Pattern, Level of Assistance). Previous research has demonstrated the validity and reliability of the mdgi; Rasch analysis verified measurement of a wider range of mobility function in the mdgi compared to the DGI. However, performance on the mdgi in people with multiple sclerosis (MS) has not been reported. Objective: To compare mdgi performance in people with multiple sclerosis (MS) and controls. Design: Cross-sectional, descriptive study. Methods: Fourteen

8 clinical sites provided data on mdgi performance in people with MS and age-matched controls. T tests with Bonferroni correction (P <.001) compared mdgi scores (total, performance, task) between groups. Cohen s d was used to evaluate the effect size of the differences between means. To investigate whether patterns of scores based on medical diagnosis could be generalized to individuals, box and whisker plots were used to visually demonstrate the betweenand within-group distributions of mdgi scores. Results: Thirty-one people with MS (mean age 49 y; 68% women; 48% used a gait device) and 31 controls (mean age 49 y, 80% women; 0% used gait device) participated. 75% of people with MS reported one or more falls in the previous 6 months. There were significant differences (P <.001) between groups for all scores. While task-specific score patterns were found in the group with MS, the range of performance was large. Limitations: Small sample size and lack of information on type of MS. Conclusions/Clinical Relevance: The mdgi is a valid and reliable test of mobility performance in people with MS; however, large within-group variability suggests that patterns of performance within individuals with MS could not be predicted based on diagnosis alone. (7) DUAL-TASK COST OF WALKING AND BALANCE CONFIDENCE IN INDIVIDUALS WITH MULTIPLE SCLEROSIS Kathleen L. Roeing, Douglas A. Wajda, Jacob J. Sosnoff Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL Background: Gait and cognitive impairments in multiple sclerosis (MS) compound when performed simultaneously; this is termed dual-task cost (DTC). DTCs during walking have

9 previously been associated with fall risk in MS and falls in older adults. There is little evidence to suggest whether DTCs in MS are due to attentional capacity limits or behavioral adaptations. Purpose: This study examined whether DTCs of walking were related to balance confidence in individuals with MS. We hypothesized that individuals with low balance confidence would have higher DTCs, possibly indicating a behavioral modification during dual-task conditions. Methods: Thirty-four individuals with MS completed single- and dual-task walking trials at a comfortable pace as well as the Activity-specific Balance Confidence (ABC) Scale and a demographic survey. DTC was calculated as the percent change in walking velocity from singleto dual-task walking conditions. A correlation analysis was performed to determine the relationship between DTC of walking velocity and ABC. Results: The sample consisted of 24 females and 10 males with a mean age of 61.7 y (SD = 8.6 y). The median SR-EDSS score was 6.0 (IQR = ). ABC score ranged from 0.0% to 95.0% with a mean of 57.5% (SD = 20.4%). Mean DTC of velocity was 10.8% (SD = 14.4%) and ranged from 22.3% to 42.2%. The correlation analysis revealed no significant association between ABC and DTC of walking velocity (P >.05). Discussion: The novel observation of this study was the lack of relationship between balance confidence and DTC of walking velocity. The observation suggests that altering one s gait while cognitively engaged is not a unique behavioral response in those with lower balance confidence. Overall, the findings are in contrast to a behavioral explanation of DTC in individuals with MS. (8) QUANTIFICATION OF POSTURAL MOTOR LEARNING DEFICITS IN PEOPLE WITH MULTIPLE SCLEROSIS Geetanjali Gera-Dutta, 1 Brett W. Fling, 1,2 Heather Schlueter, 1 Fay B. Horak 1,2

10 1 Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR; 2 Portland VA Medical Center, Portland, OR Background: Balance impairments are prevalent in people with multiple sclerosis (MS), adversely affecting their quality of life. It is currently unknown whether people with MS can learn to improve their postural responses. Purpose: The purpose of the current study was to investigate capacity for postural motor learning and to determine the relationship between postural motor learning and somatosensory balance impairments. Methods: For all participants (11 MS, 8 control) an Instrumented Clinical Test of Somatosensory Integration for Balance was performed using inertial sensors. The Romberg quotient was computed, where a higher value is reflective of somatosensory deficits. Subsequently, participants stood on a force platform, which translated forward and backward in a continuous, pseudorandom pattern to provide surface perturbations. Participants performed multiple trials over five blocks (acquisition) and were tested the following day to determine retention of postural motor learning responses. The extent of postural motor learning was quantified via the temporal relationship (relative phase) between center of mass and platform motion. The relative phase was expected to shift from a lag to a lead relationship with postural motor training. Results: There was no significant interaction during either the acquisition (group block; P =.96) or retention (group block; P =.34) of postural motor learning between the MS and control groups. At the end of the acquisition phase, the mean relative phase was significantly less than zero for the MS group (F = 8.11, P <.05) but not so for the control group (P =.7). Moreover, performance at baseline and at the end of acquisition was significantly related to somatosensory deficits in people with MS (first training block: r = 0.68, P <.05; last training block: r = 0.76, P <.05). Conclusions: As expected,

11 people with MS demonstrated poorer postural balance control at baseline and were unable to achieve a predictive strategy to control balance following training. However, people with MS did demonstrate the potential to improve postural responses with training, albeit to a lesser extent than age-matched controls. Finally, reduced performance at baseline and the end of the training was significantly related to somatosensory deficits. (9) ANGULAR VESTIBULO-OCULAR REFLEX (AVOR) AND DYNAMIC BALANCE FUNCTION IN PEOPLE WITH MULTIPLE SCLEROSIS Hina Garg, Lee Dibble, Michael Schubert, Eduard Gappmaier University of Utah, Salt Lake City, UT; Johns Hopkins University, Baltimore, MD Background: Demyelination of brainstem and cerebellar pathways may adversely affect angular vestibulo-ocular reflex (avor) and balance. To date, videographic-head impulse testing has not been utilized in people with multiple sclerosis (MS) to determine avor function, and its relationship with current balance tests remains unexplored. Purpose: This study aimed to determine the differences in avor and dynamic balance function in people with MS as compared to healthy controls. Additionally, correlations between avor and balance measures were examined. Methods: Two groups were tested (MS: 18 individuals with MS, no recent relapses, EDSS 6.5; control: 13 age- and gender-matched healthy participants). Dependent variables were avor function (passive horizontal avor gain; number of compensatory saccades per head rotation [CS/HR]; latency of CS onset) and dynamic balance function (Functional Gait Assessment [FGA]; Four Step Square Test [FSST]). avor gain was calculated as the ratio of eye to head velocity. Compensatory saccades (>5000 deg/s 2 ) opposite to the

12 direction of head motion were manually counted per head rotation. Between-group differences were determined by separate independent t tests. Results: The MS group included 3 males and 15 females with a mean (range) age of 52.4 (35-73) years, diagnosis duration of 15.9 (1-43) years, balance confidence (ABC, %) of 55.1 ( ), and dizziness handicap (DHI) of 47.4 (6-84). The control group included 4 males and 9 females with a mean (range) age of 52.9 (38-72) years, ABC of 96% ( ), and DHI of 0.4 (0-2). Relative to controls, the MS group demonstrated significant (P <.05) impairments in CS/HR, latency, FGA, and FSST; however, no significant difference was found in avor gain. FGA was significantly correlated with CS/HR (r = 0.49) and latency (r = 0.42). Conclusions: This study documents previously unreported gaze stability deficits and confirms the presence of postural stability deficits in people with MS relative to matched controls. Future research should investigate the relationships between anatomic, physiologic, and clinical assessments of vestibular function in people with MS. (10) DIFFERENCES IN COMPENSATORY EYE RESPONSES BETWEEN HIGH- AND LOW-VELOCITY HEAD ROTATIONS IN PEOPLE WITH MULTIPLE SCLEROSIS AND HEALTHY CONTROLS Hina Garg, Lee Dibble, Michael Schubert, Eduard Gappmaier University of Utah, Salt Lake City, UT; Johns Hopkins University, Baltimore, MD Background: Intact angular vestibulo-ocular reflex (avor) maintains gaze stability during activities that require head movements such as walking, running, and driving. The differences in avor function at high versus low head rotation velocities as measured by videographic-head impulse testing (vhit) are unknown in people with multiple sclerosis (MS) or healthy

13 individuals. Purpose: This study aimed to determine if, due to increased demands on the vestibulo-ocular system, avor function worsens at high head rotational velocities compared to low velocities in people with MS and healthy controls. Methods: Eighteen individuals with MS reporting no recent relapses or concurrent vestibular condition and 13 neurologically healthy individuals were recruited. Passive yaw head rotations were performed at high (>150 deg/s) and low (<150 deg/s) velocities and recorded via vhit (GN Otometrics). Dependent variables were avor gain, number of compensatory saccades per head rotation [CS/HR], and latency of CS onset. avor gain was calculated as the ratio of eye to head velocity during yaw head rotations. Compensatory saccades (>5000 deg/s 2 ) opposite to the direction of head motion were manually counted. Separate 2 (group) 2 (velocity level) RMANOVA were conducted for each dependent variable. Results: The MS group included 3 males and 15 females, with a mean (range) age of 52.4 (35-73) years and diagnosis duration of 15.9 (1-43) years, while the control group included 4 males and 9 females, with a mean (range) age of 52.9 (38-72) years. No significant interactions were found. At high head velocity, all participants demonstrated significantly (P <.01) decreased avor gain and increased CS/HR and latency as compared to low velocities. Relative to controls, the MS group demonstrated significantly increased CS/HR (P <.05). Conclusions: vhit indicated greater deficits in avor function at higher head velocities in people with MS and controls. Future research is needed to determine if velocity-dependent declines are present in pitch plane head movements as well as if people with MS differ from controls in their response to vestibular adaptation exercises. (11) RELATIONSHIPS BETWEEN PROPRIOCEPTIVE NEURAL PATHWAY STRUCTURAL CONNECTIVITY AND BALANCE IN PEOPLE WITH MULTIPLE

14 SCLEROSIS Brett W. Fling, 1,2 Geetanjali Gera-Dutta, 1 Heather Schlueter, 1 Michelle H. Cameron, 1,2 Fay B. Horak 1,2 1 Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR; 2 Portland VA Medical Center, Portland, OR Background: Mobility and balance impairments are a hallmark of multiple sclerosis (MS), affecting nearly half of patients at presentation, resulting in decreased activity participation, falls, injury, and reduced quality of life. A growing body of work suggests that balance impairments in people with mild MS (EDSS 4) are primarily the result of deficits in proprioception, the ability to determine body position in space in the absence of vision. Purpose: The purpose of the current study was to 1) map the cortical proprioceptive pathway in vivo using diffusion-weighted imaging and 2) assess relationships between proprioceptive pathway white matter microstructural integrity and performance on clinical and behavioral balance tasks. We hypothesized that people with MS would have reduced integrity of proprioceptive pathways in the brain, and that reduced white matter microstructure within these fiber tracts would be strongly related to proprioceptive-based balance deficits. Results: We report poorer balance control on proprioceptive-based tasks (F 1,35 = 3.9, P <.05) and reduced white matter microstructural integrity of the cortical proprioceptive tracts in people with MS (F 1,43 = 4.3, P <.05) compared to age-matched controls. Furthermore, microstructural integrity of this pathway (solely within the right hemisphere) was strongly related to proprioceptive-based balance control in both people with MS (r = 0.74, P <.001) and age-matched control participants (r = 0.47, P <.07). Conversely, while white matter integrity of the proprioceptive pathway was significantly

15 correlated with overall balance performance in healthy controls (r = 0.58, P <.05), this relationship was mitigated in people with MS (r = 0.31, P <.3). Conclusions: These results augment existing literature suggesting that balance control in people with MS may become more dependent upon 1) cerebellar-regulated proprioceptive control, 2) the vestibular system, and/or 3) the visual system. (12) MARGIN OF STABILITY DURING GAIT IS RELATED TO TRUNK MOTION AND STRIDE LENGTH IN PEOPLE WITH MULTIPLE SCLEROSIS Sahibjit Ranu, Sharon Lynch, Jessie Huisinga University of Kansas Medical Center, Kansas City, KS Background: Up to 50% of all falls in people with multiple sclerosis (MS) are reported to occur during walking. To determine an individual s risk for falls, it is necessary to understand how measures of walking performance are related to postural control during gait. Purpose: The purpose of this study was to evaluate the relationship between a laboratory-based measure of postural control during gait and measures of walking performance obtained with mobile inertial sensors. Methods: Twenty-five patients with MS (EDSS range ) and 25 age-matched healthy controls were recruited for dynamic postural control assessment with both laboratory and wireless inertial sensors. Subjects walked at a self-selected pace while kinematic and kinetic data were collected with a motion capture system and force platform so that margin of stability (MoS) could be calculated. MoS evaluates a person s step-to-step balance control to define their dynamic postural control during gait. Subjects also performed a 25-foot walk where wireless inertial sensors measured motion of the trunk as well as stride length and stride velocity.

16 Results: Pearson correlations were applied to evaluate relationships between MoS and the wireless sensor metrics. In people with MS, significant correlations were found between MoS and stride length (r = 0.556, P =.005), stride velocity (r = 0.780, P <.001), and velocity of the trunk in the frontal plane (r = 0.486, P =.016). In healthy controls, significant correlations were found between MoS and stride velocity (r = 0.746, P <.001) and velocity of the trunk in the horizontal plane (r = 0.463, P =.026) and the sagittal plane (r = 0.536, P =.008). A smaller MoS indicates a less stable gait pattern and one that is more likely to result in falls. Conclusions: The negative correlations between MoS and measures of gait indicate that subjects who have greater trunk velocity and longer strides have a smaller MoS and thus have reduced postural control during gait. (13) SENSORIMOTOR DELAYS ARE CORRELATED WITH VARIABILITY OF COGNITIVE PROCESSING SPEED IN PEOPLE WITH MULTIPLE SCLEROSIS Jessie Huisinga, 1 Doug Denney, 2 Sharon Lynch 1 1 University of Kansas Medical Center, Kansas City, KS; 2 University of Kansas Lawrence, Lawrence, KS Background: Delayed somatosensory conduction velocity, specifically within the spinal cord, is related to abnormal responses to postural perturbations, and is associated with movement deficits in people with multiple sclerosis (MS). While slowed somatosensory and motor conduction velocity likely have a basis in the loss of white matter in the spinal cord, white matter integrity in people with MS may be compromised in multiple brain and spinal cord pathways affecting both cognitive processing and motor and sensory function. However, no studies have examined this

17 possibility, so the purpose of the present study was to examine the relationship between sensorimotor delays and cognitive decline in people with MS. Methods: Forty-two subjects with MS participated in this study (EDSS range ). Subjects performed a simple reaction time test, choice reaction time test, and the Stroop test. Sensorimotor delays were measured as subjects stood on a translating surface (6 cm, 15 cm/s) while EMG recorded muscle activation in the tibialis anterior (forward translation) and gastrocnemius (backwards translation). Pearson correlations were performed to examine the relationship between sensorimotor delay and the mean score and standard deviation of each cognitive test. Results: Results showed significant correlations between sensorimotor delay of the gastrocnemius and choice reaction time (r = 0.396, P =.018), standard deviation of choice reaction time (r = 0.392, P =.011), and standard deviation of simple reaction time (r = 0.416, P =.007). We also found a significant correlation between sensorimotor delay of the tibialis anterior and the standard deviation of choice reaction time (r = 0.334, P =.033). Conclusions: Subjects with longer sensorimotor delays showed increased variability to simple and choice reaction time tasks. In other studies, variability of cognitive responses has also been associated with higher levels of cognitive fatigue in people with MS. It would be of interest to examine whether improving sensorimotor delays, either with pharmacological or rehabilitation-based therapies, also improves performance on cognitive tests and reduces cognitive fatigue. (14) CASE STUDY OF MAXIMAL STRENGTH TRAINING IN MULTIPLE SCLEROSIS Herb Karpatkin Program in Physical Therapy, Hunter College, City University of New York, New York, NY

18 Introduction: Clinicians who treat mobility impairments in people with multiple sclerosis (MS) frequently utilize low-load resistance training, with the implicit assumption that higher-intensity training may not be well tolerated due to neurogenic fatigue. Recent evidence has suggested that maximal strength training (MST) in people with MS as well as in other CNS disorders may offer a unique and effective means of improving gait and balance, but its effects on gait and balance in people with MS have not been examined. The primary purpose of this ongoing study is to examine whether MST will result in improvements in gait and balance in people with MS. A secondary purpose was to determine whether MST could be tolerated by people with MS. Methods: Subjects one-repetition maximum (1RM) lift using a leg-press machine was determined for each leg, followed by baseline values for the 6-Minute Walk Test (6MWT), Berg Balance Scale (BBS), and MSIS-29. Subjects completed a 2 /week program for 8 weeks, performing 4 sets of 4 repetitions using the leg press for each leg at 85% to 95% of their 1RM. Increases in weight per session were determined by subject capability and preference. Fatigue was measured each session using the Visual Analog Scale of Fatigue. Results: To date, two subjects have completed the study. Subject 1 (55-year-old female, EDSS 6.5) improved her BBS from 31 to 39, right 1RM from 30 to 62.5 lbs, left 1RM from 100 to 220 lbs, while 6MWT decreased from 553 to 474 feet. Subject 2 (52-year-old male, EDSS 5.0) improved his BBS from 46 to 49, right 1RM from 145 to 265 lbs, left 1RM from 170 to 265 lbs, and 6MWT from 732 to 799 feet. Discussion: Although only two subjects have thus far completed the training, both achieved small improvements in functional measures and large improvements in 1RM, suggesting that this treatment is effective and well tolerated by people with MS. Further subjects will be tested in the following months.

19 (15) FALL REDUCTION DURING THE SENSORY ORGANIZATION TEST WITH AND WITHOUT BALANCE-BASED TORSO-WEIGHTING IN PEOPLE WITH MULTIPLE SCLEROSIS GL Widener, K Horn, C Gibson-Horn, DD Allen Samuel Merritt University, Oakland, CA, and San Francisco State University, San Francisco, CA Background: People with multiple sclerosis (MS) fall frequently. Balance-based torsoweighting (BBTW) can improve gait speed and static balance. However, the association between BBTW and falls has not been examined in MS. Purpose: Investigate BBTW effect on balance and fall frequency recorded by the sensory organization test (SOT) in MS and healthy controls (HC) matched for age and sex. Method: Sixty people with MS with self-identified gait and balance difficulties (Disease Steps 1-4) and 10 HC completed the SOT twice in a single session, once without weights and a second time following placement of weights using the BBTW method. SOT composite score (CS) recorded participants quiet standing for 3 trials in each of 6 conditions: eyes open (EO), eyes closed (EC), surround moving EO, platform moving EO, platform moving EC, and platform and surround moving together EO. Number of falls occurring in all trials of both no weight (NW) and weighted (WT) conditions were tallied. Falls were defined as touching the surround, taking a step, or being caught by an overhead harness. Dependent t tests compared CS and fall number within MS and HC; independent t test compared MS to HC with alpha set at.05. Results: A statistically significant change occurred in mean (SD) CS from NW to WT conditions, 50.5 (14.6) to 59.7 (14.5), respectively, in MS (P <.001). No change in CS occurred in NW to WT in HC, 73.9 (6.0) and 75.2 (9.5), respectively (P =.626). Thirty-eight people with MS (64%) and 3 HC (30%) increased their CS by at least 7

20 points. Fall occurrence was significantly reduced with BBTW in MS (P <.001), but not in HC (P =.484). Conclusion: A significant decline in falls and an increase in CS occurred with BBTW during a single testing session despite potential for fatigue. BBTW shows promise as an intervention that may lead to decreased falls in MS. (16) CASE REPORT: USING AN INTERDISCIPLINARY, INDIVIDUALIZED HEALTH AND WELLNESS PROGRAM TO ADDRESS GAIT AND BALANCE IMPAIRMENTS IN PEOPLE WITH MULTIPLE SCLEROSIS Tiffany Jordan, 1 Ashley Uyeshiro, 2 Noriko Yamaguchi 3 1 National MS Society, Southern California & Nevada Chapter, Los Angeles, CA; Occupational Therapy Faculty Practice, University of Southern California, Los Angeles, CA; Division of Biokinesiology and Physical Therapy, California Physical Therapy Associates, University of Southern California, Los Angeles, CA Introduction: Optimal Living with MS (OL) is a multiweek program designed in collaboration with the National MS Society, the Division of Physical Therapy (PT), and the Division of Occupational Therapy (OT) at the University of Southern California (USC). Students in USC s PT and OT programs engage in the assessment and personalized education of participants with mild to moderate MS and who are experiencing functional change in gait, mobility, balance, and behavioral health. The purpose of this case report is to highlight the outcomes of three participants from the 2014 program cycle, demonstrating how an interdisciplinary wellness program can be used to improve gait, balance, and emotional health in people with

21 MS. Methods: Program participants were recruited through the MS Society website. The program included 75 minutes of small group based OT, a 60-minute workshop discussion, and 60 minutes of individualized exercise with PT for 11 weeks. Outcome measures were customized based on the patient s health, wellness, fitness goals, and the patient s level of function. Results: All three participants reported using assistive devices (walker and cane) for community ambulation and reported fatigue to be a significant contributor to their decreased gait and balance. After completion of the OL program, measurable improvements were made in all participants. Gait velocity improved up to 22%, walking endurance improved 54%, and balance confidence increased 21.5%. Decreased impact of fatigue on function was made in the physical (up to 55%), cognitive (up to 40%), and psychosocial (67%) dimensions. Significant gains were also made in participants ratings of ADL and IADL performance (136%) and satisfaction (38%). Discussion: This case report highlights gait and balance improvements made through participation in an individualized, interdisciplinary wellness program. Optimal Living with MS exemplifies how institutions can collaborate to provide meaningful interventions that can improve a person s gait, mobility, balance, and behavioral health. (17) VALIDITY OF SPATIOTEMPORAL GAIT PARAMETERS AT SELF-SELECTED SPEED IN PATIENTS WITH MULTIPLE SCLEROSIS F Bethoux, 1 D Schindler, 2 JC Lee, 3 S Rao 4 1 Mellen Center for MS Treatment and Research, The Cleveland Clinic Foundation, Cleveland, OH; 2 Biomedical Engineering, The Cleveland Clinic Foundation, Cleveland, OH; 3 Quantitative Health Sciences, The Cleveland Clinic Foundation, Cleveland, OH; 4 Schey Center for Cognitive Neuroimaging, The Cleveland Clinic Foundation, Cleveland, OH

22 Background: Gait disturbance frequently occurs in multiple sclerosis (MS). Common deviations of spatiotemporal (ST) gait parameters were described in individuals with MS, but these parameters have not been fully validated. Objectives: To assess the test-retest reproducibility, ability to distinguish between MS and HC and between levels of MS-related disability, and concurrent validity of ST gait parameters. Methods: Assessments were performed on individuals with MS and healthy controls (HC), and repeated several hours later. Patients were instructed to walk at a self-selected pace on a computerized walkway, and ST gait parameters were collected (cadence, velocity, stride and step length, double support time, H-H base of support [HH], normalized velocity, and functional ambulation profile [FAP]). The Expanded Disability Status Scale (EDSS), Timed 25-Foot Walk (T25FW), and MS Performance Scales (MSPS) were also administered. Results: Forty-three MS and 32 HC subjects were included in the analysis. Statistically significant differences were observed between MS and HC for all ST gait parameters with the exception of mean normalized velocity. The FAP exhibited the largest effect size (P <.0001, Cohen s d = 0.97). Within the MS group, statistically significant differences in ST gait parameters were observed based on assistive device use (largest effect size for cadence, P <.0001, d = 2.04), with the exception of HH and FAP. Test-retest reproducibility was excellent (concordance correlation coefficient ), with the exception of HH. There were statistically significant correlations between ST gait parameters and age, symptom duration, EDSS, T25FW, and relevant MSPS items, with the exception of HH and FAP. Conclusions: Our results further validate ST gait parameters in MS patients, and provide information on the differential performance of individual parameters. Further studies are needed, particularly regarding the responsiveness of ST gait parameters to changes in disability over time and to the

23 results of interventions to improve walking.