ReviewGait deficits in people with multiple sclerosis: A systematic review and meta-analysis
Introduction
Multiple Sclerosis (MS) is a neurodegenerative disease characterised by the inflammatory-mediated demyelination of axons throughout the central nervous system [1]. With a predominantly young age of onset, MS is currently the leading cause of disability in young-middle aged adults in the developed world [2]. MS is notably heterogeneous in both its symptomatic presentation and clinical progression [3] with motor, sensory and cognitive impairments frequently observed in varying magnitudes [4]. These impairments predispose a reduction in postural control resulting in instability for people with multiple sclerosis (pwMS) stemming from a diversity of constraints and systems [5].
In terms of functional capacity, postural instability during gait poses a significant threat to the quality of life of the individual. Up to 85% of this population report mobility impairments [6] and gait is perceived as the most important bodily function across the MS disability spectrum [7]. Postural instability during gait increases an individual’s likelihood of experiencing a fall [8], [9]. PwMS frequently display a cautious gait pattern hypothesised to be an attempt to reduce such postural instability and increase the overall control of the movement [10]. However such proactive responses may contradictorily precipitate a loss of postural control through a reduction in quality of certain gait variables in favour of increasing the quality of others, consequently increasing the likelihood of falls occurring [10]. Falls are associated with significant physical, psychological and social morbidity for pwMS [11], [12], [13]. Fall rates in this population are considerably high; with recent literature indicating that approximately 56% will experience a fall in any three-month period [14]. Consistently studies report that the majority of these falls occur during activities involving gait [15], [16], [17] and an association between gait tasks and accidental falls in pwMS has been well documented [9].
The association between postural instability, gait abnormalities and falls in this population suggest that these are key factors that must be addressed by falls prevention interventions. To this end, the assessment, maintenance and promotion of mobility have become increasingly important in this development of falls prevention strategies for pwMS [18], [19]. Understanding the extent of and quantifying the deficits in gait is key to developing theory based interventions to reduce falls for pwMS.
A number of primary research studies have quantified the deficits in gait in pwMS when compared to their healthy peers. To date, no review has systematically pooled the evidence from these studies to quantify the totality of these deficits and investigate their association with falls. Accordingly, this systematic review and meta-analysis aims to identify and quantify deficits in gait in pwMS when compared to a healthy population, with the goal of informing falls prevention interventions for this population.
Section snippets
Study design
This study consists of a systematic review and meta-analysis of case-control studies. The recommendations of the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group [20] were followed to standardise the conduct and reporting of the review.
Search strategy
A literature search was conducted in May 2015. The search was carried out by a PhD student (L.C.) through the following databases; Ebsco (Academic Search Complete, AMED, CINAHL, Medline, PsychArticles, PsychInfo, SportDiscus, Biomedical
Study identification
Fig. 1 provides details of study identification and selection. A total of 8252 studies were retrieved through database searches, following duplicate removal 4979 studies remained. Exclusion based on title and abstract resulted in 81 full texts being examined for eligibility. Forty studies did not meet the prerequisite inclusion criteria. Kalron et al. [25], [26] reported the same outcomes across the same population in two papers therefore findings from the former study only were included to
Discussion
This systematic review and meta-analysis aimed to quantify the effect of MS on gait when compared to healthy controls. As postural instability during gait is associated with falls in pwMS it is important to understand this effect so that falls prevention interventions for this population address the relevant impairments.
The methodological quality of the 41 included case-control studies was varied. The findings demonstrate that there are significant differences across the groups, in particular
Conclusions
The results of this systematic review and meta-analysis indicate that MS has a significant effect on gait, both at a self-selected and increased pace. This effect is considerable despite the relatively low EDSS scores of the populations included and may be more pronounced in those with more advanced disease status. These findings highlight a number of clinical implications relating to both the assessment and treatment of gait for pwMS. Further investigation relating to the predictive or
Conflict of interest statement
The authors declare that there is no conflict of interest.
Acknowledgements
The authors wish to thank the Dr. Ross Anderson and the MS Research Team at the University of Limerick for their assistance and feedback throughout the preparation of this article. PhD student L.C. is funded by the Multiple Sclerosis Society of Ireland through the Ireland Fund.
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