Francisco received the B.S. degree in Biomedical Engineering from Monterrey Institute of Technology and Higher Education, Mexico, in 2014. He is currently working towards his Ph.D at National University of Singapore, with research interests relating to biomechanics and muscle coordination of human walking, functional electrical stimulation (FES) and lower-limb robotic rehabilitation. He completed internships with the Center for Technology and Research in Biomedicine, in Mexico and Holland Bloorview Kids Rehabilitation Hospital, in Toronto ON, Canada, prior to joining the Biorobotics lab at National University of Singapore. He is currently engaged in the development of systems to improve walking and mobility for people with musculoskeletal and neuromuscular conditions by integrating FES with a novel robotic platform that enables patients post stroke to perform over-ground gait training at home or community rehab centers.

email: francisco.anaya@u.nus.edu


Falling and fear to fall has a profound effect on balance and gait performance in people with MS

Imagine doing your shopping: suddenly your leg gives out and you find yourself on the floor with a tipped-over basket. Falling is common for MS patients, but specific exercises and futuristic tech can compensate for the nerve damage and improve balance.

In 10 seconds? Research shows that despite the gradual decline in mobility that results from MS, patients can fight back to regain movement, suffer less dizziness and fatigue by following a tailored exercise programme. What’s the discovery? In a recent study of 88 MS patients, the group who followed a special exercise regime, achieved stability scores of 75 on the test scale, whilst the control group only hit 65. To compare, healthy adults reach at least 90 points. Patients who did the exercise also reported less MS-related dizziness and fatigue.

How did they do it? The scientists specifically chose stability exercises to target aspects of balancing, gait and vision usually eroded by MS. For example, the test group were asked to walk with or without head movement, do certain eye movements, and balance on different surfaces.

But what makes people with MS fall over? Damaged nerves in their brain affects their balance, vision and mobility. MS can also weaken just one side of the body, causing muscle stiffness and blurred vision. Patients might miss obstacles due to reduced detection of contrast or colours and fall. Additionally, they just might not feel where their feet are while walking. Can technology help? Yes! Studies have shown robot-assisted gait training is effective for MS patients with severe walking disabilities. Previously seen in sci-fi movies, powered exoskeletons are now here offering stability and power if you have leg weakness. They consist of an adjustable rigid frame that fits to the pelvis and to the thighs and legs, with powered footplates.

And what's the benefit? 3 words: quality of life. Scientists monitored the heart rate and oxygen consumption of an exoskeleton-wearing MS patient. They also looked at muscle activity and found that wearing the suit helped the patient to get further with less energy. Also, the device senses the user's centre of gravity and reacts to help them maintain natural gait. Being able to walk and avoid falls is great news for MS patients

Why the fear of falling is a risk in itself

Research shows that people with MS who have fallen once are statistically at a greater risk of falling again.

For some patients the fear of falling can be so huge that it can seriously affect their engagement in physical activity.

People with MS are therefore encouraged to learn to manage this fear, so that they just have enough fear to stay safe, but not be so afraid as to avoid getting on their feet at all.


Feasibility and safety of a powered exoskeleton for assisted walking for persons with multiple sclerosis: a single-group preliminary study.

Abstract: To examine the feasibility, safety, and secondary benefit potential of exoskeleton-assisted walking with one device for persons with multiple sclerosis (MS) DESIGN: Single-group longitudinal preliminary study with 8-week baseline, 8-week intervention, and 4-week follow-up.Outpatient MS clinic at tertiary care hospital.The 13 participants were mostly female who ranged in age from 38-62 years and on Expanded Disability Status Scale scores from 5.5-7.0.Exoskeleton-assisted walk training MAIN OUTCOME MEASURES: Primary outcomes were accessibility (enrollment/screen-pass), tolerability (completion/drop-out), learnability (time to event for standing, walking, and sitting with little or no assistance), acceptability (satisfaction on the device subscale of the Quebec User Evaluation of Satisfaction with assistive Technology version 2, or QUEST 2.0), and safety (event rates standardized to person-time exposure in the powered exoskeleton). Secondary outcomes were walking without the device (Timed 25 Foot Walk Test and 6 Minute Walk Test distance), spasticity (Modified Ashworth Scale), and health-related quality of life (PROMIS Pain Interference and Neuro-QoL fatigue, sleep disturbance, depression, and positive affect and well-being).The device was accessible to 11 and tolerated by 5 participants. Learnability was moderate, with 5-15 sessions required to walk with minimal assistance. Safety was good; the highest adverse event rate was for skin issues at 151/1000 hours exposure. Acceptability ranged from 'not very satisfied' to 'very satisfied.' Participants who walked routinely improved qualitatively on sitting, standing, or walking posture. Two participants improved and 2 worsened on one or more quality of life domain. The pattern of spasticity scores may indicate potential benefit.The device appeared feasible and safe for about a third of our sample, for whom routine exoskeleton-assisted walking may offer secondary benefits.

Pub.: 21 Mar '17, Pinned: 21 Mar '18

Lower Physical Activity in Persons with Multiple Sclerosis at Increased Fall Risk: A Cross-sectional Study.

Abstract: Persons with multiple sclerosis (MS) often report being afraid of falling, and this may have effects on physical activity (PA) engagement. This study investigated PA levels in persons with MS as a function of fall risk categories. Forty-seven persons with MS participated in the study and were categorized into either increased fall risk (IFR; n = 21; 55.5 ± 9.0 years) or normal fall risk (NFR; n = 26; 51.2 ± 12.9 years) groups based on scores from the Activities-Balance Confidence scale. PA was measured by accelerometer and expressed as average steps per day, and time spent in sedentary behavior, light PA, and moderate to vigorous physical activity over the course of 7 consecutive days. Univariate and covariate analyses were used to compare the differences in PA between fall risk groups. The average steps per day of the NFR group was significant higher compared with the IFR group (6024 ± 2533.1 vs. 2599 ± 1622.7 steps; P < 0.001), and the difference remained after controlling for disability level (5351 ± 2298.6 vs. 3432 ± 2363.6 steps; P = 0.016). There were no differences in light PA and moderate to vigorous physical activity between groups after controlling for disability level. Persons with MS at IFR accumulate fewer steps per day compared with those at NFR. This underscores the need for well-designed interventions targeting walking in this population who are far from the recommended 10,000 steps, particularly those with IFR.

Pub.: 18 Apr '17, Pinned: 16 Mar '18

Predicting falls among patients with multiple sclerosis: Comparison of patient-reported outcomes and performance-based measures of lower extremity functions.

Abstract: Accurate fall screening tools are needed to identify those multiple sclerosis (MS) patients at high risk of falling. The present study aimed at determining the validity of a series of performance-based measures (PBMs) of lower extremity functions and patient-reported outcomes (PROs) in predicting falls in a sample of MS patients (n = 84), who were ambulatory independent.Patients were assessed using the following PBMs: timed up and go (TUG), timed 25-foot walk (T25FW), cognitive T25FW, 2-min walk (2MW), and cognitive 2MW. Moreover, a series of valid and reliable PROs were filled in by participants including the activities-specific balance confidence (ABC), 12-item multiple sclerosis walking scale (MSWS-12), fall efficacy scale international (FES-I), and modified fatigue impact scale (MFIS). The dual task cost (DTC) of 2MW and T25FW tests were calculated as a percentage of change in parameters from single to dual task conditions. Participants were classified as none-fallers and fallers (⩾1) based on their prospective fall occurrence.In the present study, 41(49%) participants recorded ≥ 1 fall and were classified as fallers. The results of logistic regression analysis revealed that each individual test, except DTC of 2MW and T25FW, significantly predicted future falls. However, considering the area under the curves (AUCs), PROs were more accurate compared to PBMs. In addition, the results of multiple logistic regression with the first two factors extracted from principal component analysis revealed that both factor 1 (PROs) and factor 2 (PBMs) significantly predicted falls with a greater odds ratio (OR) for factor 1 (factor 1: P = <0.0001, OR = 63.41 (6.72-597.90)) than factor 2 (P <0.05, OR = 5.03 (1.33-18.99)).The results of this study can be used by clinicians to identify and monitor potential fallers in MS patients.

Pub.: 23 Oct '17, Pinned: 16 Mar '18

Distinguishing among multiple sclerosis fallers, near-fallers and non-fallers.

Abstract: Fall rates among adults with multiple sclerosis are consistently greater than 50%, but near-falls (i.e. a trip or stumble) are often undocumented. Furthermore, little is known about the circumstances surrounding fall and near-fall events. The purpose of this study was to examine the similarities and differences among non-fallers, near-fallers and fallers with multiple sclerosis, including the circumstances that surround falls and near-falls.In a single visit, 135 multiple sclerosis participants completed the Hopkins Falls Grading Scale, a custom questionnaire investigating circumstances surrounding falls and near-falls, and performed the Timed Up and Go and Timed 25-Foot Walk tests. Mann-Whitney tests were used to examine differences between fallers, near-fallers and non-fallers. Multiple logistic regression with AIC criterion was used to examine associations of circumstances with the odds of falling vs. near-falling. Cumulative odds ordinal logistic regression was used to analyze the association between each of the walking tests and the susceptibility of the individual for falls or near-falls.30% of individuals reported falls, while 44% reported near-falls over a 1-year period. Non-fallers completed the walking tests more quickly than near-fallers (p < 0.0045), and fallers (p < 0.0001); near-fallers and fallers demonstrated similar motor profiles. Individuals were more likely to sustain a fall rather than a near-fall under the following circumstances: transferring outside the home (p = 0.015) and tripping over an obstacle (p = 0.025). Performing 1-second slower on the walking tests increased the odds of a history of a fall by 6-20%.Near-falls occur commonly in individuals with MS; near-fallers and fallers reported similar circumstances surrounding fall events and demonstrated similar performance on standard timed walking tests. Clinicians monitoring individuals with MS should consider evaluation of the circumstances surrounding falls in combination with quantitative walking measures to improve determination of fall risk and appropriate rehabilitation interventions.

Pub.: 29 Nov '17, Pinned: 16 Mar '18

What is the opinion of patients with multiple sclerosis and their healthcare professionals about lower limb orthoses? A qualitative study using focus group discussions.

Abstract: The aim of this study was to collect patients' and healthcare professionals' opinions about lower limb orthoses (LL-orthoses): 1) the positive and negative aspects; 2) the differences in wearing them according to location; and 3) their recommendations for future modifications.Four focus group discussions were performed, with in total twenty patients with MS with a prescribed LL-orthosis and seven healthcare professionals. Audiotaped discussions were transcribed and qualitatively processed (NVivo11).Healthcare professionals and patients state that a LL-orthosis improves gait and reduces the risk of falling. Some negative aspects were indicated like stigmatization, difficulties to put on and off the LL-orthosis and the aesthetic aspects. Several patients mentioned that they did not get enough or no correct information about the adaptability and use of the orthoses. Opinions regarding differences in wearing according to location (e.g. in and outside the rehabilitation center) were diverse. Recommendations for future changes were e.g. more refined and firmer orthoses.The opinions collected are interesting for taking into account in the process of construction and delivering of LL-orthoses. Future research should focus on the opinions concerning different types of LL-orthosis in relation with the severity of the limitations of the patients.

Pub.: 06 Feb '18, Pinned: 16 Mar '18

Gait and cognitive impairments in multiple sclerosis: the specific contribution of falls and fear of falling

Abstract: Our goal was to identify the specific contribution of fear of falling (FoF) and falls with quantitative gait impairments and cognition capabilities in multiple sclerosis (MS) patients. Patients were separated into four individual subgroups as to the presence of FoF and falls (i.e., fearless/non-fallers, fearless/fallers, FoF/non-fallers and FoF/fallers). The Falls Efficacy Scale International questionnaire was used to assess the level of concern of falling. Participants were defined as “fallers” and “non-fallers” based on their fall history. Spatio-temporal parameters of gait were analyzed using an electronic mat. Cognitive performance was assessed by a computerized cognitive battery of tests. The study included 540 MS patients, 47% were defined as fallers and 61.9% reported a FoF. Non-significant differences were found between the fearless/non-fallers and fearless/fallers in all clinical, gait and cognitive scores. FoF/non-fallers walked significantly slower compared to fearless MS individuals who had previously fallen. Furthermore, the same patient group exhibited a poorer performance in the motor skills cognitive subdomain. A significant reverse relationship was found between FoF and cognitive motor skills in the fallers and non-fallers groups. FoF characterizes a more disabling symptom than falling in the MS population.

Pub.: 22 Jul '17, Pinned: 16 Mar '18

Corpus Callosum Structural Integrity Is Associated With Postural Control Improvement in Persons With Multiple Sclerosis Who Have Minimal Disability.

Abstract: Background Improvement of postural control in persons with multiple sclerosis (PwMS) is an important target for neurorehabilitation. Although PwMS are able to improve postural performance with training, the neural underpinnings of these improvements are poorly understood. Objective To understand the neural underpinnings of postural motor learning in PwMS. Methods Supraspinal white matter structural connectivity in PwMS was correlated with improvements in postural performance (balancing on an oscillating surface over 25 trials) and retention of improvements (24 hours later). Results Improvement in postural performance was directly correlated to microstructural integrity of white matter tracts, measured as radial diffusivity, in the corpus callosum, posterior parieto-sensorimotor fibers and the brainstem in PwMS. Within the corpus callosum, the genu and midbody (fibers connecting the prefrontal and primary motor cortices, respectively) were most strongly correlated to improvements in postural control. Twenty-four-hour retention was not correlated to radial diffusivity. Conclusion PwMS who exhibited poorer white matter tract integrity connecting the cortical hemispheres via the corpus callosum showed the most difficulty learning to control balance on an unstable surface. Prediction of improvements in postural control through training (ie, motor learning) via structural imaging of the brain may allow for identification of individuals who are particularly well suited for postural rehabilitation interventions.

Pub.: 10 Dec '16, Pinned: 16 Mar '18

Intervening to reduce the risk of future disability from multiple sclerosis: are we there yet?

Abstract: Disease-modifying therapies (DMTs) delay or may prevent the progression of patients with high-risk clinically isolated syndrome (CIS) to clinically definite multiple sclerosis (MS), and from relapsing-remitting MS to secondary progressive MS. Current evidence on the effects of DMT on disability in MS is supported by the use of the Expanded Disability Status Scale (EDSS), which is dominated by ambulation, and usually used as a secondary outcome measure. Less is known about the long-term effects of DMTs on other aspects of functional status, particularly cognition, which is a key determinant of ability to work. The time scale for measurements of disability is at most a few years, with scant data from more than ten years of observation. Longer prospective follow-up of large numbers of patients with CIS is needed to determine whether early intervention with a DMT influences long-term disease progression. Finally, the emergence of the radiologically isolated syndrome (RIS) as a clinical entity has shifted the debate about when to intervene to an even earlier time frame. Balancing the significant side-effects associated with DMT in general and the expected outcome of pharmacologic intervention is increasingly problematic for managing patients with uncertain prognosis, as many patients may have low-risk CIS, benign MS or patients with RIS only. Preventing long-term disability in MS should be recognised more clearly as an important outcome in its own right, with disability measured more consistently with more sensitive instruments beyond the use of the EDSS.

Pub.: 29 Dec '16, Pinned: 16 Mar '18

Balancing the Demands of Two Tasks: An Investigation of Cognitive-Motor Dual-Tasking in Relapsing Remitting Multiple Sclerosis.

Abstract: People with relapsing remitting multiple sclerosis (PwRRMS) suffer disproportionate decrements in gait under dual-task conditions, when walking and a cognitive task are combined. There has been much less investigation of the impact of cognitive demands on balance.This study investigated whether: (1) PwRRMS show disproportionate decrements in postural stability under dual-task conditions compared to healthy controls, and (2) dual-task decrements are associated with everyday dual-tasking difficulties. The impact of mood, fatigue, and disease severity on dual-tasking was also examined.A total of 34 PwRRMS and 34 matched controls completed cognitive (digit span) and balance (movement of center of pressure on Biosway on stable and unstable surfaces) tasks under single- and dual-task conditions. Everyday dual-tasking was measured using the Dual-Tasking Questionnaire. Mood was measured by the Hospital Anxiety & Depression Scale. Fatigue was measured via the Modified Fatigue Index Scale.No differences in age, gender, years of education, estimated pre-morbid IQ, or baseline digit span between groups. Compared with controls, PwRRMS showed significantly greater decrement in postural stability under dual-task conditions on an unstable surface (p=.007), but not a stable surface (p=.679). Balance decrement scores were not correlated with everyday dual-tasking difficulties or fatigue. Stable surface balance decrement scores were significantly associated with levels of anxiety (rho=0.527; p=.001) and depression (rho=0.451; p=.007).RRMS causes dual-tasking difficulties, impacting balance under challenging conditions, which may contribute to increased risk of gait difficulties and falls. The relationship between anxiety/depression and dual-task decrement suggests that emotional factors may be contributing to dual-task difficulties. (JINS, 2017, 23, 1-12).

Pub.: 25 Sep '17, Pinned: 16 Mar '18

Walking and talking: an investigation of cognitive-motor dual tasking in multiple sclerosis.

Abstract: Deficits in motor functioning, including walking, and in cognitive functions, including attention, are known to be prevalent in multiple sclerosis (MS), though little attention has been paid to how impairments in these areas of functioning interact.This study investigated the effects of performing a concurrent cognitive task when walking in people with MS. Level of task demand was manipulated to investigate whether this affected level of dual-task decrement.Eighteen participants with MS and 18 healthy controls took part. Participants completed walking and cognitive tasks under single- and dual-task conditions.Compared to healthy controls, MS participants showed greater decrements in performance under dual-task conditions in cognitive task performance, walking speed and swing time variability. In the MS group, the degree of decrement under dual-task conditions was related to levels of fatigue, a measure of general cognitive functioning and self-reported everyday cognitive errors, but not to measures of disease severity or duration.Difficulty with walking and talking in MS may be a result of a divided attention deficit or of overloading of the working memory system, and further investigation is needed. We suggest that difficulty with walking and talking in MS may lead to practical problems in everyday life, including potentially increasing the risk of falls. Clinical tools to assess cognitive-motor dual-tasking ability are needed.

Pub.: 12 Aug '09, Pinned: 16 Mar '18

Efficacy of Balance and Eye-Movement Exercises for Persons With Multiple Sclerosis (BEEMS).

Abstract: To determine whether a multifaceted vestibular-related rehabilitation program (Balance and Eye-Movement Exercises for Persons with Multiple Sclerosis; BEEMS) improves balance in persons with MS and whether there are differences in outcomes based on brainstem/cerebellar lesion involvement.A 2-arm, examiner-blinded, stratified (involvement vs no involvement of brainstem/cerebellar structures), randomized controlled trial was implemented. Eighty-eight participants were allocated to BEEMS or no treatment control. Computerized Dynamic Posturography-Sensory Organization Test (CDP-SOT) measured balance control. The Dizziness Handicap Inventory (DHI), Modified Fatigue Impact Scale (MFIS), and Short Form-36 Health Status Questionnaire (SF-36) were also administered. Linear mixed models were used to investigate the primary and secondary aims.From baseline to 6 weeks, BEEMS participants experienced greater improvements compared to control participants in CDP-SOT composite (model-estimated difference in change 4.9, 95% confidence interval 1.39-8.38, p = 0.006), DHI total (-13.5, -17.7 to -7.25, p < 0.0001), MFIS total (-11.4, -15.7 to -7.0, p < 0.0001), SF-36 Mental (5.6, 2.43-8.71, p = 0.0006), and SF-36 Physical (3.5, 1.12-5.81, p = 0.004) scores and from baseline to 14 weeks in CDP-SOT composite (8.3, 4.73-11.9, p < 0.0001), DHI total (-13.9, -19.3 to -8.62, p < 0.0001), MFIS total (-12.3, -16.7 to -7.79, p < 0.0001), SF-36 Mental (3.9, 0.70-7.16, p = 0.02), and SF-36 Physical (3.2, 0.79-5.62, p = 0.01) scores. From baseline to 6 weeks, BEEMS participants with brainstem/cerebellar lesion involvement experienced greater improvements compared to those without in CDP-SOT composite (5.26, 0.34-10.2, p = 0.04) and MFIS total (-7.6, -14.0 to -1.33, p = 0.02) scores.BEEMS improved multiple outcomes regardless of whether brainstem/cerebellar lesions were present, supporting the generalizability of BEEMS for ambulatory people with MS who have at least minimally impaired balance and fatigue.NCT01698086.This study provides Class I evidence that BEEMS training improves dynamic posturography-based balance, dizziness, fatigue, and quality of life in persons with MS.

Pub.: 02 Feb '18, Pinned: 16 Mar '18

The association between multiple sclerosis-related fatigue and balance as a function of central sensory integration.

Abstract: Fatigue and impaired upright postural control (balance) are the two most common complaints in persons with multiple sclerosis (MS), with limited evidence on how they are related.To examine the relationship between symptomatic fatigue and balance as a function of central sensory integration in persons with multiple sclerosis.Seventeen persons with relapsing-remitting MS were enrolled in this cross-sectional study. Primary measurements included fatigue (modified fatigue impact scale - MFIS); balance (dynamic posturography, sensory organization testing - SOT); and walking capacity (six-minute walk test - 6MWT).Fatigue scores were significantly associated with balance: MFIS total (r=-0.78; p<0.001), physical subscale (r=-0.77; p<0.001), cognitive subscale (r=-0.75; p=0.001) and psychosocial subscale (r=-0.53; p=0.030) scores. MFIS total score was a significant predictor of balance (p≤0.001), accounting for 62% of the variability in SOT composite scores. Significant differences in fatigue (d=1.75; p=0.005) and balance (d=1.74; p=0.005) were found for participants who had cerebellar and brainstem involvement compared to those without.Symptomatic fatigue is significantly related to balance and is a significant predictor of balance as a function of central sensory integration in persons with MS. Fatigue and balance are associated with cerebellar and brainstem involvement. This study provides early evidence supporting the theory that for those persons with MS who struggle to maintain steady balance during tasks that stimulate the central sensory integration process, complaints of significant levels of fatigue are probable.

Pub.: 04 Dec '12, Pinned: 16 Mar '18

Sensory integration balance training in patients with multiple sclerosis: A randomized, controlled trial.

Abstract: Impaired sensory integration contributes to balance disorders in patients with multiple sclerosis (MS).The objective of this paper is to compare the effects of sensory integration balance training against conventional rehabilitation on balance disorders, the level of balance confidence perceived, quality of life, fatigue, frequency of falls, and sensory integration processing on a large sample of patients with MS.This single-blind, randomized, controlled trial involved 80 outpatients with MS (EDSS: 1.5-6.0) and subjective symptoms of balance disorders. The experimental group (n = 39) received specific training to improve central integration of afferent sensory inputs; the control group (n = 41) received conventional rehabilitation (15 treatment sessions of 50 minutes each). Before, after treatment, and at one month post-treatment, patients were evaluated by a blinded rater using the Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC), Multiple Sclerosis Quality of Life-54, Fatigue Severity Scale (FSS), number of falls and the Sensory Organization Balance Test (SOT).The experimental training program produced greater improvements than the control group training on the BBS (p < 0.001), the FSS (p < 0.002), number of falls (p = 0.002) and SOT (p < 0.05).Specific training to improve central integration of afferent sensory inputs may ameliorate balance disorders in patients with MS. Clinical Trial Registration (NCT01040117).

Pub.: 15 Jan '15, Pinned: 16 Mar '18