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Seebacher B1, Kuisma R2, Glynn A2, Berger T1
1Medical University of Innsbruck, Clinical Department of Neurology, Innsbruck, Austria, 2University of Brighton, School of Health Sciences, Eastbourne, United Kingdom
Background: Evidence indicates that motor imagery (MI) benefits motor function and rhythmic-auditory cueing has been shown to improve walking in people with neurological disorders. Neurophysiological theories suggest that combining these two interventions might increase the effect. Therefore, rhythmic-cued MI interventions for walking rehabilitation in people with multiple sclerosis (PwMS) were explored. Specific recommendations for physiotherapists in the field are provided.
Purpose: To investigate the effects of differently cued and non-cued MI compared to usual care on walking, fatigue and quality of life (QoL) in PwMS.
Methods: Four prospective randomised controlled single-centre trials enrolled 217 PwMS with mild to moderate disability (Expanded Disability Status Scale scores 1.5-4.5) and no cognitive deficits or depression. Participants followed a PETTLEP (physical, environment, timing, task, learning, emotion, perspective) approach based familiarisation with MI (40-50 minutes). PwMS practised MI at home, guided by recorded instructions; walking for 17 minutes, 6 times a week for 4 weeks. Participants were randomised into five groups: Gr1 additional music and verbal cueing, Gr2 metronome- and verbal cueing, Gr3 music-only cueing, Gr4 no cueing and Gr5 no intervention. Kinaesthetic MI was employed: “Feel yourself walking in time with the music/cues”. Metronome cues or instrumental music was played in 2/4 or 4/4 metre and at a tempo of 80-120 beats/minute, e.g. Toto, “Africa”, 100 beats/minute. Rhythmic-verbal cues were provided with emphasis on every first beat, or every first and third beat (e.g. “toe-off”). All groups received usual care and weekly telephone support. Primary outcomes were walking speed (Timed 25-Foot Walk) and walking distance (6-Minute Walk Test). Secondary outcomes were fatigue (Modified Fatigue Impact Scale) and QoL (Multiple Sclerosis Impact Scale-29). MI ability (Kinaesthetic and Visual Imagery Questionnaire-10, Time-Dependent Motor Imagery test) was explored in a representative subset of participants (n=75).
Results: Overall, 205 participants completed the studies (167 females; mean age 44.8±11.5 years), were fully compliant and reported no adverse events. All participants showed high MI ability, which improved post-intervention. Non-cued MI significantly improved mean walking speed (5.2±7.8%) and walking distance (5.5±8.1%; p-values 0.01). After music- or metronome-cued MI with verbal cueing, significant improvements in mean walking speed (13.8±6.2%; 14.7±6.3%) and walking distance (15.7±10.6%; 16.6±11.1%) were observed when compared to controls or non-cued MI (p-values 0.0001). Music-cued MI was superior to non-cued MI and control in improving walking (p 0.05). Clinically most significant improvements in fatigue and QoL were seen after music- and verbally-cued MI (p-values 0.01).
Conclusion(s): Rhythmic-cued and non-cued MI significantly improved walking in PwMS. Music and verbally-cued MI was found to be more effective than music-cued or non-cued MI in improving walking, fatigue and QoL.
Implications: Music- and verbally-cued MI can be recommended for physiotherapists to effectively treat walking impairment and fatigue in PwMS with mild to moderate disability. PwMS with physical fatigue may have impaired ability to engage in physical walking practice therefore, cued MI training could be a valuable treatment option for this group. Home-based rhythmic-cued MI practice with telephone-based support is a low-cost and safe treatment; remotely delivered by physiotherapists, it may also benefit PwMS with limited access to healthcare.
Keywords: multiple sclerosis, rhythmic-cued motor imagery, walking
Funding acknowledgements: This work was partially funded by the Austrian MS Research Society (no grant number).
Purpose: To investigate the effects of differently cued and non-cued MI compared to usual care on walking, fatigue and quality of life (QoL) in PwMS.
Methods: Four prospective randomised controlled single-centre trials enrolled 217 PwMS with mild to moderate disability (Expanded Disability Status Scale scores 1.5-4.5) and no cognitive deficits or depression. Participants followed a PETTLEP (physical, environment, timing, task, learning, emotion, perspective) approach based familiarisation with MI (40-50 minutes). PwMS practised MI at home, guided by recorded instructions; walking for 17 minutes, 6 times a week for 4 weeks. Participants were randomised into five groups: Gr1 additional music and verbal cueing, Gr2 metronome- and verbal cueing, Gr3 music-only cueing, Gr4 no cueing and Gr5 no intervention. Kinaesthetic MI was employed: “Feel yourself walking in time with the music/cues”. Metronome cues or instrumental music was played in 2/4 or 4/4 metre and at a tempo of 80-120 beats/minute, e.g. Toto, “Africa”, 100 beats/minute. Rhythmic-verbal cues were provided with emphasis on every first beat, or every first and third beat (e.g. “toe-off”). All groups received usual care and weekly telephone support. Primary outcomes were walking speed (Timed 25-Foot Walk) and walking distance (6-Minute Walk Test). Secondary outcomes were fatigue (Modified Fatigue Impact Scale) and QoL (Multiple Sclerosis Impact Scale-29). MI ability (Kinaesthetic and Visual Imagery Questionnaire-10, Time-Dependent Motor Imagery test) was explored in a representative subset of participants (n=75).
Results: Overall, 205 participants completed the studies (167 females; mean age 44.8±11.5 years), were fully compliant and reported no adverse events. All participants showed high MI ability, which improved post-intervention. Non-cued MI significantly improved mean walking speed (5.2±7.8%) and walking distance (5.5±8.1%; p-values 0.01). After music- or metronome-cued MI with verbal cueing, significant improvements in mean walking speed (13.8±6.2%; 14.7±6.3%) and walking distance (15.7±10.6%; 16.6±11.1%) were observed when compared to controls or non-cued MI (p-values 0.0001). Music-cued MI was superior to non-cued MI and control in improving walking (p 0.05). Clinically most significant improvements in fatigue and QoL were seen after music- and verbally-cued MI (p-values 0.01).
Conclusion(s): Rhythmic-cued and non-cued MI significantly improved walking in PwMS. Music and verbally-cued MI was found to be more effective than music-cued or non-cued MI in improving walking, fatigue and QoL.
Implications: Music- and verbally-cued MI can be recommended for physiotherapists to effectively treat walking impairment and fatigue in PwMS with mild to moderate disability. PwMS with physical fatigue may have impaired ability to engage in physical walking practice therefore, cued MI training could be a valuable treatment option for this group. Home-based rhythmic-cued MI practice with telephone-based support is a low-cost and safe treatment; remotely delivered by physiotherapists, it may also benefit PwMS with limited access to healthcare.
Keywords: multiple sclerosis, rhythmic-cued motor imagery, walking
Funding acknowledgements: This work was partially funded by the Austrian MS Research Society (no grant number).
Topic: Neurology
Ethics approval required: Yes
Institution: University of Brighton and Medical University of Innsbruck
Ethics committee: University of Brighton and Medical University of Innsbruck
Ethics number: 13 053; AN2014–0052 334/4.14358/5.13 (3743a)
All authors, affiliations and abstracts have been published as submitted.
