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Background: Gait deficits are common among people with multiple sclerosis (PwMS). Therefore, investigating factors that may influence walking in PwMS is important. Previous studies in older adults and other neurological populations demonstrated the relationship between sleep quality and gait performance. Despite the fact that the prevalence of poor sleep quality is very high among PwMS, little is known about the effect of sleep quality on gait among PwMS. Objective: This study aimed to explore the relationship between sleep quality and gait performance in PwMS. Methods: Forty-one PwMS participated in the study between February 2019 and December 2019. Participants were asked to walk at a self-selected speed over 10[Formula: see text]m with an inertial measurement unit (IMU) attached over the back. Walking speed, step length (left and right), and step time were calculated. Sleep was estimated objectively using a wrist-worn triaxle-accelerometer; the derived parameters were sleep efficiency (SE) and the number of awakening after sleep onset (NASO). Results: SE significantly correlated with step length ([Formula: see text]). Furthermore, the NASO significantly correlated with gait speed ([Formula: see text]), and step-time ([Formula: see text]). These correlations remained significant even after adjusting for age and disease duration. Conclusion: We observed that when corrected for disease duration and age there were relationships between NASO and SE to gait parameters; these observations warrant further investigations.

BACKGROUND: Musculoskeletal complaints associated with work are common health problems among physiotherapists due to overload exposure and unsuitable postures. OBJECTIVE: To assess work-related musculoskeletal disorders (WMSDs) among Jordanian physiotherapists and investigate the factors that might increase the risk of having WMSDs among physiotherapists by using the ICF model as a guiding framework. METHODS: A cross-sectional study was conducted on 139 physiotherapists. Participants’ ages ranged from 23 to 61 years with 53.2% who identified as female. To assess WMSDs the Quick Exposure Check was used. Furthermore, depression, sleep, social support and job satisfaction were all assessed using Beck Depression Inventory, Pittsburgh Sleep Quality Index, Multidimensional Scale of Perceived Social Support, and Minnesota Satisfaction Questionnaire, respectively. Furthermore, age, gender, body mass index (BMI), educational level, smoking status and marital status were also collected from all participants. RESULTS: The results showed that the most common musculoskeletal complaints were as follows: 100% of the participants reported overload occurrence in the cervical spine, 97.9% in the lumbar spine, 96.5% in the shoulder joint, and 24.1% in the wrist joint. There was a significant negative correlation between total exposure and gender. Also, total exposure was significantly and positively correlated with BMI and the Minnesota Satisfaction Questionnaire (MSQ). CONCLUSION: This study suggests a need to increased knowledge of self-protection strategies among physiotherapists to reduce the occurrence of musculoskeletal disorders. Understanding the factors that might increase WMSDs is useful for future research, quality improvement, and educational programs to reduce the rates of WMSDs among physiotherapists.

BACKGROUND: Sleep has been considered as a critical brain state that affects various body functions relevant to physiotherapy (PTs) practice such as motor learning and relearning, pain management, and cognitive function. Despite the importance of sleep for successful rehabilitation outcomes, sleep is often overlooked by PTs. OBJECTIVE: The purpose of this study was to assess the attitude and perception of PTs on the need to assess sleep and provide education about sleep for their patients, as well as the perceived need for PTs to be educated on sleep topics. METHODS: A survey questionnaire to assess physical therapist’s perceptions and attitudes about sleep was utilized in this study. RESULTS: 90 PTs fill out the survey. All respondents agreed that poor sleep is important to people’s health, 93% agreed that PTs should assess patients’ sleep habits and sleep quality and 88% agreed that addressing sleep issues may impact PTs outcomes. The majority did not receive education about sleep during PT education (75%) or following graduation (86%). Most respondents (95%) think PTs should receive education about sleep. CONCLUSIONS: our findings indicated that PTs recognize that sleep impacts their outcomes and patients’ sleep should be assessed, as well as the need to receive education about sleep. Therefore, PT education programs may consider incorporating education about sleep, and the development of continuing education courses is also needed.

Objective: Pain and fatigue are highly prevalent debilitating symptoms in Parkinson’s disease (PD), however, their relationship with physical performance, fear of falling (FOF) and falls is not clear. We aim in this pilot study to investigate the relationship of pain and fatigue with physical performance, FOF and falls in people with Parkinson’s disease (PwPD). Materials & methods: 53 PD patients were assessed for fall history, physical performance, FOF, pain and fatigue. Results: Pain and fatigue are significantly associated with physical performance and FOF (p ≤ 0.002). Pain and fatigue were different between fallers and non-fallers (p

People with Parkinson's (PwP) are suffering from reduced exercise capacity. However, little information is known about clinical correlates of exercise capacity in this population.This study aimed to evaluate correlations between motor and non-motor symptoms with exercise capacity in PwP.A total of 50 individuals with Parkinson's disease participated in the study. Exercise capacity was measured by 6 minutes' walk test (6MWT). Besides, the Movement Disorder Society-Unified Parkinson's Disease Rating Scale-Part III used to evaluate disease motor severity, Berg Balance Scale to assess balance, Montréal Cognitive Assessment to evaluate cognitive status, hospital anxiety and depression scale to assess depression and anxiety, Modified Fatigue Impact scale to evaluate fatigue, and the Pittsburgh Sleep Quality Index to evaluate sleep quality.The results showed that exercise capacity, when measured by the 6MWT, can be significantly predicted by balance, disease motor severity, anxiety, and age (RThese results suggest that exercise capacity in PwP is multifactorial and can potentially be predicted by balance, motor severity, anxiety, and age.

BACKGROUND: Assessing physical activity (PA) in people with multiple sclerosis (PwMS) is essential to follow-up the recommended PA level. The International Physical Activity Questionnaire (IPAQ) and the Incidental and Planned Exercise Questionnaire (IPEQ) have been widely used, but their validity has not been investigated previously in PwMS. OBJECTIVE: This study aimed to assess the convergent and criterion validity of the IPAQ and the IPEQ in PwMS. METHODS: 50 PwMS were asked to wear an Actigraph for seven days and to fill the IPAQ and IPEQ. Sedentary, moderate (MPA), vigorous (VPA) and moderate to vigorous PA (MVPA) levels were recorded. RESULTS: Significant correlations were found between sitting time as reported by IPAQ and sedentary time as recorded by Actigraph (r = 0.41, p = 0.003), VPA by IPAQ and VPA as recorded by Actigraph (r = 0.46, p = 0.001), and MVPA by IPAQ and MVPA by Actigraph (r = 0.36, p = 0.011). IPEQ showed poor both criterion and convergent validity when compared to the Actigraph. Both IPAQ and IPEQ overestimate the intensities of PA for all the derived parameters. CONCLUSIONS: Findings of this study are important as they suggest that IPAQ in particular had convergent validity when compared to Actigraph data, but still had the problem of overestimating PA levels.

The Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) has become the gold standard for evaluating different domains in Parkinson's disease (PD), and it is commonly used in clinical practice, research, and clinical trials.The objectives are to validate the Arabic-translated version of the MDS-UPDRS and to assess its factor structure compared with the English version.The study was carried out in three phases: first, the English version of the MDS-UPDRS was translated into Arabic and subsequently back-translated into English by independent translation team; second, cognitive pretesting of selected items was performed; third, the Arabic version was tested in over 400 native Arabic-speaking PD patients. The psychometric properties of the translated version were analyzed using confirmatory factor analysis (CFA) as well as exploratory factor analysis (EFA).The factor structure of the Arabic version was consistent with that of the English version based on the high CFIs for all four parts of the MDS-UPDRS in the CFA (CFI ≥0.90), confirming its suitability for use in Arabic.The Arabic version of the MDS-UPDRS has good construct validity in Arabic-speaking patients with PD and has been thereby designated as an official MDS-UPDRS version. The data collection methodology among Arabic-speaking countries across two continents of Asia and Africa provides a roadmap for validating additional MDS rating scale initiatives and is strong evidence that underserved regions can be energically mobilized to promote efforts that apply to better clinical care, education, and research for PD. © 2022 International Parkinson and Movement Disorder Society.

Objective Neurorehabilitation that involves learning new motor skills is one of the promising clinical methods for motor recovery in people with multiple sclerosis (PwMS); therefore, factors that influence the acquisition of motor skills in PwMS need to be investigated. Sleep disturbances are common in PwMS; however, no study has investigated the effect of sleep and sleep-related biomarkers on skill acquisition in PwMS. This study aimed to examine the effect of sleep and sleep-related biomarkers on motor acquisition in PwMS. Methods Forty participants with MS and 40 controls were recruited in this study. To assess motor acquisition, each participant was asked to perform a novel game through a virtual reality (VR) system 5 times (blocks). The main outcome measures for each block were the required time to complete the VR game and the recorded errors. The difference in scores between Block 5 and Block 1 for both outcomes were considered to represent motor skill acquisition. Sleep was assessed by self-report using the Pittsburgh Sleep Quality Index (PSQI) and objectively using sleep monitor technology. Serotonin level was assessed using means of enzyme-linked immunosorbent assay using plasma samples. Results There were significant positive correlations in both groups between motor skill acquisition and PSQI score. In PwMS, significant negative correlation between motor skill acquisition and sleep efficiency and significant positive correlation between motor skill acquisition and sleep latency were also observed. Interestingly, a significant negative correlation was observed between motor skill acquisition and the plasma serotonin level in both groups. Most of these correlations remained significant after controlling for disease severity, fatigue, baseline performance, and cognitive status. Conclusion Sleep quality may influence motor skill acquisition in PwMS. Circulatory serotonin level might explain this relationship. Impact Physical therapists are encouraged to be aware of sleep quality and sleep assessment. Sleep management strategies should be considered when treating PwMS.

This study aimed to evaluate the motor and non-motor factors associated with sit-to-stand performance in people with Multiple Sclerosis (PwMS).Observational cross-sectional study.A total of 88 individuals with MS participated in this study.Standing performance was measured using the five-times-sit-to-stand test (FTSTS). The Berg Balance Scale to assess balance, the 10-Meter Walking Test (10-MWT) was used to assess walking speed; the Patient Determined Disease Steps (PDDS) was used to assess disability level. Furthermore, Brief International Cognitive Assessment for MS (BICAMS) was used to assess cognitive status, Hospital Anxiety and Depression scale (HADS) to assess depression and anxiety, and the Modified Fatigue Impact scale (MFIS) to evaluate fatigue. Spearman correlation coefficient was used to determine the relationship between all these variables and the FTSTS. Furthermore, multiple linear regression was conducted to determine predictive factors of the FTSTS.FTSTS score was correlated significantly with BBS, PDDS, BICAMS, 10-MWT and MFIS (r ranged from 0.3 to 0.52;The study concludes that sit to stand is multifactorial and is potentially associated with walking speed, cognitive function and fatigue. These factors should be considered by healthcare professionals in interpreting the sit-to-stand performance of PwMS and in designing rehabilitation interventions.

BACKGROUND Sleep disturbances are highly prevalent in people with multiple sclerosis(MS), and are associated with pain, fatigue, depression, and reduced quality of life (QoL). Importantly, sleep has been considered a critical brain state for motor learning and memory consolidation. Therefore, interventions that target sleep managementin people with MS are needed. OBJECTIVES To explore the effects of a six weeks moderate-intensity aerobic exercise intervention on sleep characteristics and sleep-related biomarkers specifically serotonin, melatoninand cortisol in people with MS using a pilot randomized controlled trial. METHODS Participants were randomly allocated to either a moderate-intensity aerobic exercise program (MAE, n = 20) or a home exercise program (HEP, n = 20). Participants were assessed at baseline and follow-up. Subjective and objective measures were used to assess sleep quality. The Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) were used to subjectively assess sleep. While Actigraphy was used to objectivelyassess sleep. Blood samples were collected for measurement of cortisol, melatonin and serotonin from MS participants in both groups at 8:00 am±1 hour. RESULTS Seventeen participants in the MAE and 13 in the HEP group completed the study. Compared to the HEP group, people with MS who participated in a moderate-intensity aerobic exercise experienced significant improvements (P

Background and Objectives: Despite the fact that sleep disturbances are among the most common and disabling manifestations of Parkinson's disease (PD), no study has investigated the effect of sleep quality and sleep-related biomarkers on motor skill acquisition in people with Parkinson's disease (PwPD).Objective: To examine the relationship between skill acquisition, sleep quality, and sleep-related biomarkers in PwPD using virtual reality (VR) system.Methods: This is a cross sectional study conducted on 31 PwPD and 31 healthy controls. To assess skill acquisition, each participant practiced a VR game 6 times (blocks). The main outcomes from the VR game were the required time to complete the VR game and the recorded errors. Motor skill acquisition was calculated as the difference of scores between block 6 and block 2 for both outcomes. Sleep was assessed subjectively using Pittsburgh Sleep Quality Index (PSQI) and objectively using the Actisleep. To assess sleep related biomarker, plasma serotonin level was examined.Results: PwPD and healthy controls demonstrated a practice-related improvement in performance as shown by the main effect of block for each of the VR outcome measures (p < 0.000, time required to complete VR game; p < 0.000, recorded errors). There was no interaction effect between Block X Group for both outcome measures. There were significant correlations in both groups (p < 0.05) between motor skill acquisition (as indicated by the difference of time required to complete the VR game between block 6 and block 2) and PSQI total score, wake after sleep onset, and sleep efficiency. Additionally, a significant correlation was observed in both groups between motor skill acquisition (as indicated by the difference of time required to complete the VR game between block 6 and block 2) and the plasma serotonin level (p < 0.05). These correlations in PwPD remained significant, even after adjusting for disease motor severity, cognitive status, depression, and daily dose of L-dopa.Discussion and Conclusions: Sleep quality may influence motor skill acquisition in PwPD. Healthcare professionals are encouraged to be aware about sleep quality and sleep assessment tools. Therapies may target improving sleep quality which could result in improving motor skill acquisition.

Background and purpose Assessing functional status in people with multiple sclerosis (PwMS) has a major role in determining how to help patients to reach their optimal level of living independently in the community. The Frenchay Activity Index (FAI) is a commonly used scale to evaluate functional status in rehabilitation research and practice settings. The aim of this study was to translate the FAI into the standard Arabic language through the process of cross-cultural adaptation and to explore the internal consistency and construct validity of the produced Arabic version of FAI (A-FAI) among a sample of Arabic-speaking PwMS. Method The English version of the FAI was translated into Arabic according to the published guidelines. Cronbach's α was used to assess the internal consistency of the A-FAI, and principal factor analysis was conducted to explore the construct validity. Results Hundred and six subjects participated in the study. The A-FAI has acceptable internal consistency as Cronbach's α was 0.70. The principal factor analysis revealed that the instrument has four main factors: domestic chore, leisure, hobbies, and work, rather than the original three factors scale. Discussion The A-FAI has acceptable internal consistency and validity. A-FAI provides essential information about the participation level in instrumental activities of daily living activities among PwMS speaking the Arabic language.

Background Patient-generated index (PGI) is one of the individualized measures used to measure the quality of life (QOL) in people with different chronic conditions including multiple sclerosis (MS). However, the psychometric properties of the Arabic version of the PGI have not been fully established in Jordanian living with MS. Therefore, the objective of this study is to identify what matters to Jordanian living with MS and to contribute evidence toward the psychometric properties of the Arabic version of the PGI. Methods A total of 75 participants with MS completed three QOL measures; PGI, the patient determined disease steps (PDDS), and EQ-5D. Generalized estimating equations were used to compare the total score of three QOL measures. Bland-Altman plot and Spearman's correlation coefficient were used to study the relationships and differences between the PGI and the other study measures (PDDS and EQ-5D). Results Only 66 (88%) of the participants were able to complete the PGI. Overall, 36 areas of QOL concern were nominated by the participants using the PGI with the top three areas were emotional function (47%), involuntary movement reaction functions (45.5%), and walking (44 %). The average global score of the PGI was lower (34 ± 22) than the global score of the EQ-5D (69 ± 23), and the PDDS (68 ± 24). PGI had a moderate correlation with EQ-5D and PPDS. Conclusion The Arabic version of the PGI is a feasible, acceptable, and valid measure among Jordanians with MS. PGI also captures more important areas that contribute to QOL than EQ-5D and PDDS. PGI could improve the decision making and guide healthcare professionals to provide appropriate intervention programs to reduce the burdens from MS disease and improve QOL.

Background Cognitive dysfunction is an important feature and source of disability for patients with multiple sclerosis (MS). The correlation of cognitive function scales' scores and serum levels of the proinflammatory cytokine tumor necrosis factor-alpha (TNF-α) in MS is not well established. We aim to investigate the correlation of TNF-α serum levels with cognitive function as measured by multiple cognitive scales in patients with MS. Methods Eligible sequential MS patients attending neurology clinics between October 2018 and June 2019 at King Abdulla University Hospital (KAUH) in Jordan were included. Demographic data were collected from all participants. Motor disability was measured using the Expanded Disability Status Score (EDSS), the Functional System Score (FSS), as well as the Patient Determined Disease Steps (PDDS). The Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) and the Montreal Cognitive Assessment (MOCA) were used to evaluate the cognitive status. TNF-α serum levels were measured for each patient. Correlations of TNF-α levels with cognitive function scales' scores and motor disability scores were statistically analyzed. Results A total of 88 MS patients were included in the study. The mean age (± SD) was 35.78 (± 10.30) years, and 72.7% were females. The majority of patients (82) had relapsing multiple sclerosis (RMS). Serum TNF-α levels were significantly correlated with scores of motor disability scales in the whole patient cohort (EDSS: Pearson correlation coefficient r = 0.230, p=0.031; FSS: r = 0.260, p=0.022; and PDDS: r = 0.261, p=0.014) and in females, but not in males. In the whole cohort, the correlation between TNF-α and EDSS score was also statistically significant (r = 0.216, p=0.047) after adjustment for confounding factors including age, disease duration, and type of MS. Likewise, Serum TNF-α levels were correlated with the scores of cognitive function scales in the whole patient cohort (BICAMS: r = -0.328, p=0.002; and MOCA: r = -0.256, p=0.016). After adjusting for age, gender, education, type of MS, and EDSS score, cognitive performance was still negatively correlated with TNF-α levels (p Conclusion Our findings confirm the presence of a significant correlation between TNF-α levels and different cognitive scales' scores in MS patients.

Supplemental Digital Content is available in the text, Introduction: People with multiple sclerosis (PwMS) experience a wide range of disabilities which negatively impact their quality of life (QOL). Several interventions have been used in PwMS such as medication, physical therapy exercises and stem cell therapy to improve their QOL. However, there is a limited evidence on the benefits of combining interventions. The purpose of this study is to explore the effect of combining physical therapy exercises (PTE) and Wharton Jelly mesenchymal stem cell (WJ-MSCs) injections on motor and non-motor symptoms versus each intervention alone in PwMS. Methods: Sixty PwMS will be allocated to either PTE, WJ-MSCs, or a combined group, followed up for 12 months and examined using a comprehensive battery of measures. Participants in the PTE group will receive 2 sessions per week of a supervised exercise program for 6 months followed by a home exercise program for another 6 months. The WJ-MSCs group will receive 3 WJ-MSCs injections in the first 6 months then they will be encouraged to follow an active life style. The third group will receive both interventions. Discussion: This study will aid in a better understanding of the combined effect of physical therapy and mesenchymal stem cell therapy. The results from this proposed study may reduce disability, improve QOL in PwMS, and consequently, reduce the cost associated with the life-time care of these individuals worldwide. Trial registration number: NCT03326505

BACKGROUND Balance and gait impairments are common disorders in people with multiple sclerosis (MS). The Activities-specific Balance Confidence scale (ABC) is one of the important measures of balance confidence that can be used in people with MS. The Arabic version of the ABC was developed and validated in other than MS population. OBJECTIVE To examine the psychometric properties of the Arabic Activities-specific Balance Confidence scale (A-ABC) among patients with MS. METHODS A multicenter, reliability design was used to administer the A-ABC to a convenience sample of people with MS. The test-retest reliability of the A-ABC item and total scores were examined using the intraclass correlation coefficient (ICC) and 95% confidence interval (CI). Additionally, the validity of the A-ABC with Arabic Berg Balance Scale (A-BBS), Arabic Dynamic Gait Index (A-DGI), and Barthel Index (BI) was assessed using Spearman Correlation Coefficient (r). Moreover, the minimal detectable change for the A-ABC was established in people with MS. RESULTS Eighty nine patients with MS (mean [SD] age = 38 [10]; female = 58) were enrolled. The internal consistency of the A-ABC was 0.96 while the minimal detectable change was 11.28. The A-ABC (mean [SD] = 61 [29]) had significant correlations with A-BBS (r = 0.76, P

Background Patients Generated index (PGI) is one of the individualized measures used to measure the quality of life (QOL) in people with different chronic conditions including multiple sclerosis (MS). However, the psychometric properties of the Arabic version of the PGI have not been fully established in Jordanian living with MS. Therefore, the objective of this study is to identify what matters to Jordanian living with MS and to contribute evidence toward the psychometric properties of the Arabic version of the PGI. Method A total of 75 participants with MS completed three QOL measures; PGI, the Patient Determined Disease Steps (PDDS), and EQ-5D. Generalized Estimating Equations (GEE) were used to compare the total score of three QOL measures. Bland-Altman plot and Spearman’s correlation coefficient were used to study the relationships and differences between the PGI and the other study measures (PDDS and EQ-5D). Results Only 66 (88%) of the participants were able to complete the PGI. Overall, 36 areas of QOL concern were nominated by the participants using the PGI with the top 3 areas were an emotional function (47%), involuntary movement reaction functions (45.5%) and walking (44%). The average global score of the PGI was lower (34±22) than the global score of the EQ-5D (69±23) and the PDDS (68±24).PGI had a moderate correlation with EQ-5D and PPDS. Conclusion The Arabic version of the PGI is a feasible and acceptable measure among Jordanian with MS and it captures a wide spectrum of important areas that contribute to QOL than EQ-5D and PDDS. PGI could improve the decision making and guide health-care professionals to provide appropriate intervention programs to reduce the burdens from MS disease and improve QOL.

BACKGROUND Sleep dysfunctions impose a large burden on quality of life for patients with Parkinson's disease (PD). Several studies on PD reported potential therapeutic effects of transcranial direct current stimulation (tDCS) on motor and non-motor functions, but not related to sleep quality. Therefore, the present study examined sleep quality, depression perception, and quality of life changes after bilateral anodal tDCS in patients with PD. MATERIAL AND METHODS Twenty-one patients (n=21) with PD underwent 10 sessions (20 min each, 5 per week) of bilateral anodal tDCS stimulation applied simultaneously over the left and right prefrontal and motor areas. The Pittsburgh Sleep Quality Index (PSQI) total score and sub-scores, Geriatric Depression Scale (GDS), and Health-related quality of life questionnaire (SF-36) were measured pre/post bilateral tDCS anodal stimulation. RESULTS PSQI total score (P=0.045), sleep latency sub-score (P=0.02), and GDS total score (P=0.016) significantly decreased, and physical and mental components scores of SF-36 (P=0.018 and P=0.001, respectively) significantly increased after bilateral anodal tDCS stimulation. The GDS score decrease was directly correlated with decrease in PSQI total score (P=0.01), sleep latency sub-score (P=0.002), and sleep disturbance sub-score (P=0.003). In addition, the GDS score decrease was inversely correlated with increasing mental component score of SF-36 (P=0.001), which was directly correlated with an increase in sleep efficiency sub-score (P=0.03) and the physical component score of SF-36 (P=0.0001). CONCLUSIONS Bilateral anodal tDCS stimulation showed potential therapeutic effects in patients with PD in terms of sleep quality and depression level improvement, which together improved mental and physical quality of life in patients with PD.

Background Balance impairments are common and multifactorial among people with multiple sclerosis (MS). Depression is the most common psychological disorder in MS population and is strongly correlated with MS disease. Depression might be one of the factors that contribute to balance deficits in this population. However, the relationship between depression and balance impairments has not been explored in people with MS. Objective To investigate the association between depression and balance impairments in people with MS. Methods Cross sectional design was used in patients with MS. The Activities-specific Balance Confidence scale (ABC) and Berg Balance Scale (BBS) was used to assess balance. Beck Depression Inventory (BDI-II) was used to quantify depression and Kurtizki Expanded Disability Status Scale (EDSS) was utilized for the evaluation of MS disability severity. Pearson correlation coefficient was used to examine the association between depression and balance measurements. Multiple linear stepwise regressions were also conducted to find out if depression is a potential predictor for balance deficits. Results Seventy-five individuals with MS (Female = 69%) with a mean age (SD) of 38.8 (10) and a mean (SD) EDSS score of 3.0 (1.4) were recruited in this study. Depression was present in 53% of the patients. Depression was significantly correlated with balance measurements and EDSS. However, multiple linear stepwise regressions found that only depression and age significantly predict balance. Conclusion Depression and balance were found frequent and associated in people with MS. Importantly depression was a significant predictor for balance impairments in individuals with MS. Balance rehabilitation may be hindered by depression. Therefore, depression should be evaluated and treated properly in individuals with MS.

Aim: To examine BDNF, dopamine, and motor function changes after bilateral anodal transcranial direct current stimulation (tDCS) in patients with Parkinson's disease. Methods: 20 patients undertook ten sessions of bilateral anodal tDCS stimulation applied simultaneously over FC1/FC2, targeting left and right prefrontal and motor areas. Dopamine and BDNF serum levels, and Movement Disorders Society – Unified Parkinson's Disease Rating Scale part three (MDS-UPDRS-III) total score and disability sub-scores were examined pre/post-tDCS stimulation. Results: BDNF serum level increased significantly and came with significant improvement in motor functions (decrease in MDS-UPDRS-III total score/sub-scores), whereas dopamine level showed no changes. However, there was no significant statistical correlation between the motor functions’ improvement and BDNF level increase. Conclusion: Bilateral anodal tDCS is a safe stimulation protocol that leads to motor functions’ improvement and BDNF serum level increase in patients with Parkinson's disease, however the findings of this feasible study are preliminary and further study is needed.

BACKGROUND A number of studies have examined the therapeutic effects of transcranial direct current stimulation (tDCS) stimulation in patients with Parkinson's disease (PD) using unilateral anodal stimulation applied either on the left or right brain hemisphere. However, PD involves the dysfunctions of both brain hemispheres. OBJECTIVES This study investigates the therapeutic effects of bilateral anodal tDCS stimulation on balance and fear of fall outcomes in patient with PD. METHODS Eighteen patients with idiopathic PD completed the study. Ten sessions of bilateral anodal tDCS stimulation were applied over the FC1 and FC2 targeting both pre-frontal and motor areas for each patient, 5 sessions per week for 2 weeks. Berg Balance Scale (BBS), Falls Efficacy Scale-International (FES-I), and 10 meters walk test (10mwt) were applied before and after the stimulation therapy. RESULTS Paired t-test showed a significant increase in the BBS scores and decrease in the FES-I scores after the bilateral tDCS compared with those scores before tDCS therapy (P

Background and purpose Sleep has been shown to promote off-line motor learning in individuals following stroke. Executive function ability has been shown to be a predictor of participation in rehabilitation and motor recovery following stroke. The purpose of this study was to explore the association between executive function and off-line motor learning in individuals with chronic stroke compared with healthy control participants. Methods Seventeen individuals with chronic stroke (>6 months poststroke) and 9 healthy adults were included in the study. Participants underwent 3 consecutive nights of polysomnography, practiced a continuous tracking task the morning of the third day, and underwent a retention test the morning after the third night. Participants underwent testing on 4 executive function tests after the continuous tracking task retention test. Results Participants with stroke showed a significant positive correlation between the off-line motor learning score and performance on the Trail-Making Test from Delis-Kaplan Executive Function System (r = 0.652; P = 0.005), while the healthy control participants did not. Regression analysis showed that the Trail-Making Test-Delis-Kaplan Executive Function System is a significant predictor of off-line motor learning (P = 0.008). Discussion and conclusions This is the first study to demonstrate that better performance on an executive function test of attention and set-shifting predicts a higher magnitude of off-line motor learning in individuals with chronic stroke. This emphasizes the need to consider attention and set-shifting abilities of individuals following stroke as these abilities are associated with motor learning. This in turn could affect learning of activities of daily living and impact functional recovery following stroke.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A166).

BACKGROUND AND PURPOSE People with multiple sclerosis (MS) who undergo rehabilitation need to perform new motor skills or relearn old motor skills. It is not clear whether people with MS retain the ability to improve motor performance or learning. Furthermore, factors that influence motor performance in people with MS need to be investigated. This study explored motor performance in people with MS using virtual reality (VR). The effect of fatigue and cognitive function on motor performance improvement in people with MS was investigated. METHODS Twenty MS participants and 20 controls were recruited into the study. To assess motor performance, each participant was asked to perform a VR game for five times (blocks). The main outcome was time to complete the VR game and number of recorded errors. To assess fatigue level and cognitive function, participants were asked to complete the Arabic versions of the Modified Fatigue Impact Scale (MFIS) and the Montreal Cognitive Assessment (MOCA), respectively. RESULTS MS participants and controls demonstrated a practice-related improvement in performance as shown by the main effect of block for each of the outcome measures (p

Vitamin D (Vit.D) deficiency is a risk factor for multiple sclerosis (MS) and correlates with its severity. Depression is also common in people with MS (PWMS). We aim to investigate Vit.D correlation with depression risk scores in PWMS.A cross-sectional cohort of PWMS were studied. Clinical and demographic data were collected. The Hospital Anxiety Depression Scale (HADS) and the Beck Depression Inventory-II (BDI-II) were used to evaluate the risk of depression. Expanded Disability Status Scale (EDSS) and Patient Determined Disease Steps (PDDS) were used to evaluate the disability. Serum concentrations of 25-hydroxyvitamin D were measured. Bivariate and partial correlations of Vit.D status and scores of depressive and disability scales were statistically analyzed. The IBM Statistical Package for Social Sciences software, version 25.0, was used for data processing.A total of 88 PWMS were enrolled. More than half of them had potential depression, and 68% had below-normal serum Vit.D levels (normal ≥ 30 ng/ml, insufficient = 21-29 ng/ml, and deficient ≤ 20 ng/ml). Serum Vit.D levels significantly correlated with scores of depression scales in both males and females, which was more robust in males. This association was maintained with a partial correlation analysis controlling for age, sex, body mass index, disease duration, type of MS, and EDDS HADS: r=-0.513, p0.001; BDI-II: r=-0.401, p0.001). Serum Vit.D had significant inverse correlations with EDSS score (r=-0.353, p = 0.001) and PDDS score (r=-0.341, p = 0.001), with more robust correlations in females compared to the whole group.Vit.D levels correlate with depression risk scores in PWMS with differential sex effects.

BACKGROUND Balance deficits are considered a risk factor for falls in MS patients. Therefore, developing innovative approaches such as virtual reality (VR) to improve balance in MS is required. OBJECTIVES The aims of this study were to develop and evaluate feasibility and acceptability of VR scenarios that target balance in MS using a pilot trial. METHODS Participants were randomly allocated to either a VR training (i.e. intervention group) (n = 20) or a control group (n = 20). Intervention group received VR training for 6 weeks. Control group received home-based traditional balance exercises without the VR. Participants were assessed at baseline and follow-up on Berg Balance Scale (BBS), Timed Up and Go (TUG), the 10 Meter Walk Test (10-MWT), the 3 Minute Walk Distance (3-MWD), the Modified Fatigue Impact Scale (MFIS) Fall Efficacy Scale- International (FES-I) and the Short Form 36 (SF-36). RESULTS Six VR scenarios weer developed. Sixteen participants in the intervention and 16 in the control group completed the study. Significant differences between the two groups were observed at on BBS, MFIS and several outcomes of the SF-36 survey (P

Background Multiple sclerosis (MS) symptoms are very heterogeneous and may lead to reduced physical, cognitive, and psychosocial functioning that can consequently impair aspects of individual's life. Many studies have examined the living experiences of individuals with MS and its impact on their daily lives. In developing countries and particularly in Jordan, there has been little attempt to conduct studies exploring the experiences of people living with MS. Such knowledge will provide a background to hidden aspects of human concepts, such as culture, perception, and attitudes about chronic diseases. Objective The purpose of this qualitative study was to explore and describe the daily living experiences and challenges of Jordanian individuals with MS. Methods A qualitative design was utilized. Sixteen individuals with MS took part in the study; they were interviewed and divided into 4 focus groups. Conversations were digitally recorded followed by a verbatim transcription. Transcripts were analysed using thematic analysis and validated via researcher triangulation and peer checking. Results Experiences of 16 Jordanian individuals with MS who participated in this study were categorized into the following major themes: (a) experiences related to the disease itself and (b) experiences related to the healthcare system. Disease-related experiences include physical decline, psychosocial withdrawal, and fear of the future. Participants' experiences with the healthcare system include difficulty of diagnosis, poor communication and rapport with healthcare providers, and lack of awareness about MS and its rehabilitation. Conclusions Findings of this study suggests that more attention should be given to the people with MS in Jordan. In particular, awareness about the disease should be improved among healthcare providers and the general public. Furthermore, rehabilitation services should be emphasized during the management of MS disease.

Background Sleep has been demonstrated to enhance simple motor skill learning “offline” in young adults. “Offline learning” refers to either the stabilization or the enhancement of a memory through the passage of time without additional practice. It remains unclear whether a functional motor task will benefit from sleep to produce offline motor skill enhancement. Physical therapists often teach clients functional motor skills; therefore, it is important to understand how sleep affects learning of these skills. Objective The purpose of this study was to determine whether sleep enhances the learning of a functional motor task. Design A prospective, cross-sectional, repeated-measures design was used. Methods Young participants who were healthy (N=24) were randomly assigned to either a sleep group or a no-sleep group. The sleep group practiced a novel walking task in the evening and underwent retention testing the following morning, and the no-sleep group practiced the task in the morning and underwent retention testing in the evening. Outcome measures included time around the walking path and spatiotemporal gait parameters. Results Only participants who slept after practicing the novel walking task demonstrated a significant offline improvement in performance. Compared with the no-sleep group, participants in the sleep group demonstrated a significant decrease in the time around the walking path, an increase in tandem velocity, an increase in tandem step length, and a decline in tandem step time. Limitations Time-of-day effect and inability to ensure a certain amount of sleep quantity and quality of participants were limitations of the study. Conclusions This study is the first to provide evidence that sleep facilitates learning clinically relevant functional motor tasks. Sleep is an important factor that physical therapists should consider when teaching clients motor skills.

STUDY OBJECTIVES:\ud The majority of individuals with multiple sclerosis (MS) suffer from sleep disorders. In this study, we investigated the relationship between physical activity and sleep characteristics in MS patients. \ud \ud METHODS:\ud Sixty MS patients were recruited in the study. Sleep characteristics were assessed using the Actisleep device while physical activity levels were assessed using mobility accelerometer.\ud \ud RESULTS:\ud The results showed that means (±SD) of sleep latency (SL) and sleep efficiency (ES) for MS patients were 23.89±13.23min and 87.52±76.89% respectively. The participants' total time in sleep (TST) and wake after sleep onset (WASO) were 353.25±63.98min and 83.84±42.23min respectively. With respect to physical activity levels, means (±SD) of light (LA), moderate (MA), vigorous (VA) activities and moderate to vigorous physical activity (MVPA) were 11,660.15±18,145, 212.04±148.67, 9.70±9.26 and 222.88±154.60 counts per minute, respectively. Pearson's correlation analysis showed that WASO correlated significantly with LA, MA and MVPA (P

Mayis Al-Dughmi,1 Alham Al-Sharman,2 Suzanne Stevens,3 Catherine F Siengsukon1 1Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, KS, USA; 2Department of Rehabilitation Sciences, Jordan University of Science and Technology, Irbid, Jordan; 3Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA Abstract: Changes in sleep characteristics in individuals with chronic stroke are not well described, particularly compared with healthy individuals. Therefore, the aim of this pilot study was to explore the sleep characteristics in individuals with chronic stroke compared to age- and sex-matched controls. Sixteen individuals with chronic stroke and ten age- and sex-matched controls underwent two nights of polysomnographic recording. The sleep characteristics of interest included total sleep time, sleep efficiency, and percent time, as well as time in minutes spent in stages N1, N2, and N3 and stage R sleep. The individuals with chronic stroke spent less percent time in stage N3 compared with controls (P=0.048). No significant differences in the other sleep characteristics were found between the stroke and control groups. Individuals with chronic stroke present with altered stage N3 sleep compared with healthy controls. These alterations in stage N3 sleep might be a sign of neuronal dysfunction and may impact recovery following stroke. A larger scale study is needed to confirm these findings. Keywords: sleep characteristics, sleep, chronic stroke, polysomnography

Background Mounting evidence demonstrates that individuals with stroke benefit from sleep to enhance learning of a motor task. While stage NREM2 sleep and REM sleep have been associated with offline motor skill learning in neurologically intact individuals, it remains unknown which sleep parameters or specific sleep stages are associated with offline motor skill learning in individuals with stroke. Methods Twenty individuals with chronic stroke (>6 months following stroke) and 10 control participants slept for three consecutive nights in a sleep laboratory with polysomnography. Participants practiced a tracking task the morning before the third night and underwent a retention test the morning following the third night. Offline learning on the tracking task was assessed. Pearson’s correlations assessed for associations between the magnitude of offline learning and sleep variables, age, upper-extremity motor function, stroke severity, depression, and time since stroke occurrence. Results Individuals with stroke performed with significantly less error on the tracking task following a night of sleep (p = 0.006) while the control participants did not (p = 0.816). Increased sleep efficiency (r = −0.285), less time spent in stage NREM3 sleep (r = 0.260), and more time spent in stage REM sleep (r = −0.266) were weakly-to-moderately associated with increased magnitude of offline motor learning. Furthermore, higher upper-extremity motor function (r = −0.400), lower stroke severity (r = 0.360), and less time since stroke occurrence (r = 0.311) were moderately associated with increased magnitude of offline motor learning. Conclusion This study is the first study to provide insight into which sleep stages and individual characteristics may be associated with offline learning in people with stroke. Further research is needed to delineate which factors or combination of factors promote offline motor learning in people with neurologic injury to best promote motor recovery in these individuals.

BACKGROUND AND PURPOSE Although sleep has been shown to enhance motor skill learning, it remains unclear whether sleep enhances learning of a functional motor task in middle-aged and older individuals. The purpose of this study was to examine whether sleep enhances motor learning of a functional motor task in middle-aged and older adults. METHODS Twenty middle-aged and 20 older individuals were randomly assigned to either the sleep condition or the no-sleep condition. Participants in the sleep condition practiced a novel walking task in the evening, and returned the following morning for retesting. Participants in the no-sleep condition practiced the walking task in the morning and returned the same day in the evening for a retest. Outcome measures included time around the walking path and spatiotemporal gait parameters. RESULTS Only the middle-aged and older adults in the sleep condition demonstrated significant off-line improvement in performance, measured as a decline in time to walk around the novel path and improvement in spatiotemporal gait parameters. The middle-aged and older adults in the no-sleep condition failed to demonstrate off-line improvements in performance of this functional task. CONCLUSIONS This is the first study to provide evidence that sleep facilitates learning a clinically relevant functional motor task in middle-aged and older adults. Because many neurologic conditions occur in the middle-aged and older adults and sleep issues are very prevalent in many neurologic conditions, it is imperative that physical therapists consider sleep as a factor that may impact motor learning and recovery in these individuals. VIDEO ABSTRACT AVAILABLE (See Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A73) for more insights from the authors.

Alham Al-Sharman, Catherine F Siengsukon Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, KS, USA Abstract: There is increasing evidence that sleep promotes off-line enhancement of a variety of explicitly learned motor tasks in young adults. However, whether sleep promotes off-line consolidation of implicitly learned motor tasks is still under question. Furthermore, the role of sleep in promoting transfer of learning remains unknown. This study examined the role of sleep in learning and transfer of learning of an implicit continuous motor task. Twenty-three neurologically intact individuals (mean age 26.4 years) were randomly assigned to either a sleep group or a no-sleep group. The sleep group practiced a continuous tracking task in the evening and underwent retention and transfer testing the following morning, while the no-sleep group practiced the tracking task in the morning and underwent retention and transfer testing in the evening. The results show that in both the sleep and no-sleep groups, performance improved off-line without further practice for both the general skill and the sequence-specific skill. The results also indicate that sleep and time promote transfer of learning of both sequence-specific and general skill learning to a spatial and temporal variation of the motor task. These findings demonstrate that sleep does not play a critical role in promoting off-line learning and transfer of learning of an implicit continuous motor task. Keywords: sleep, off-line learning, implicit learning, transfer, continuous task

Catherine F Siengsukon, Alham Al-SharmanDepartment of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, KS, USABackground: Healthy young individuals benefit from sleep to promote offline enhancement of a variety of explicitly learned discrete motor tasks. It remains unknown if sleep will promote learning of other types of explicit tasks. The purpose of this study is to verify the role of sleep in learning an explicitly instructed discrete motor task and to determine if participants who practice an explicitly instructed continuous tracking task demonstrate sleep-dependent offline learning of this task.Methods: In experiment 1, 28 healthy young adults (mean age 25.6 ± 3.8 years) practiced a serial reaction time (SRT) task at either 8 am (SRT no-sleep group) or 8 pm (SRT sleep group) and underwent retention testing 12 ± 1 hours later. In experiment 2, 20 healthy young individuals (mean age 25.6 ± 3.3 years) practiced a continuous tracking task and were similarly divided into a no-sleep (continuous tracking no-sleep group) or sleep group (continuous tracking sleep group). Individuals in both experiments were provided with explicit instruction on the presence of a sequence in their respective task prior to practice.Results: Individuals in the SRT sleep group demonstrated a significant offline reduction in reaction time whereas the SRT no-sleep group did not. Results for experiment 1 provide concurrent evidence that explicitly learned discrete tasks undergo sleep-dependent offline enhancement. Individuals in the continuous tracking sleep group failed to demonstrate a significant offline reduction in tracking error. However, the continuous tracking no-sleep group did demonstrate a significant offline improvement in performance. Results for experiment 2 indicate that sleep is not critical for offline enhancement of an explicit learned continuous task.Conclusion: The findings that individuals who practiced an explicitly instructed discrete task experienced sleep-dependent offline learning while those individuals who practiced an explicitly instructed continuous task did not may be due to the difference in motor control or level of complexity between discrete and continuous tasks.Keywords: sleep, motor learning, discrete task, continuous task

Background: Sleep enhances motor skill learning in individuals with chronic stroke. However, the mechanisms underlying over-night (or off-line) motor skill enhancement remains unknown. Stage 2 non-REM and REM sleep have been associated with off-line motor skill learning in young adults. Therefore, we hypothesize that off-line motor skill learning in individuals with stroke will be positively correlated with time spent in stage 2 non-REM and REM sleep. Purpose: The purpose of this study was to assess which sleep parameters are associated with off-line motor skill learning in individuals with chronic (> 6 months) stroke. Methods: Eighteen individuals with chronic stroke underwent polysomnographic recording for three consecutive nights and practiced a continuous tracking (CT) task. The first night served as an acclimation night, and the second night served as a baseline night. The morning after the baseline night, participants practiced a CT task. Participants returned in the evening for polysomnographic recording. The following morning, participants performed a retention test of the CT task. Paired t-tests were used to assess improvement in tracking performance from the last practice block to the retention block. Pearson correlations were used to assess relationships between off-line motor skill learning and time spent in stage 2 non-REM and REM sleep. Results: Participants demonstrated an improvement in performance on the tracking task following a night of sleep as demonstrated by a significant reduction in tracking error from the last practice block to retention (t(17)=2.674, p=.016). Off-line learning was only weakly correlated with amount of time spent in stage 2 non-REM sleep (r= .123), but was moderately correlated with amount of time spent in REM sleep (r= .368). Conclusion: This study is the first to find that off-line motor skill learning is weakly associated with time spent in stage 2 non-REM sleep, but is moderately related to time spent in REM sleep for individuals with chronic stroke. In conclusion, sleep is a factor that should be considered when treating individuals following stroke. Future studies should determine if enhancing REM sleep pharmacologically would improve motor skill learning and potentially impact recovery following stroke.