Neurological Research

A Journal of Progress in Neurosurgery, Neurology and Neurosciences

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Combined effect of gender differences and

fatiguing task on postural balance, functional
mobility and fall risk in adults with multiple
sclerosis: A preliminary study

Sonda Jallouli, Imen Ben Dhia, Salma Sakka, Chokri Mhiri, Abdelmoneem
Yahia, Mohamed Habib Elleuch, Omar Hammouda & Sameh Ghroubi

To cite this article: Sonda Jallouli, Imen Ben Dhia, Salma Sakka, Chokri Mhiri, Abdelmoneem
Yahia, Mohamed Habib Elleuch, Omar Hammouda & Sameh Ghroubi (2022): Combined
effect of gender differences and fatiguing task on postural balance, functional mobility and
fall risk in adults with multiple sclerosis: A preliminary study, Neurological Research, DOI:
10.1080/01616412.2022.2112370

To link to this article: https://doi.org/10.1080/01616412.2022.2112370

Published online: 08 Sep 2022.

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NEUROLOGICAL RESEARCH
https://doi.org/10.1080/01616412.2022.2112370

Combined effect of gender differences and fatiguing task on postural balance,

functional mobility and fall risk in adults with multiple sclerosis: A preliminary
study
Sonda Jallouli a,b, Imen Ben Dhia a,b, Salma Sakkac, Chokri Mhiric, Abdelmoneem Yahiaa,
Mohamed Habib Elleucha, Omar Hammouda d,e# and Sameh Ghroubia#
a
Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of
Sfax, Sfax, Tunisia; bResearch Laboratory Education, Motricité, Sport et Santé, EM2S, LR19JS01, High Institute of Sport and Physical
Education of Sfax, University of Sfax, Tunisia; cLaboratory of Neurogenetics, Parkinson’s Disease and Cerebrovascular Disease (LR12SP19),
Habib Bourguiba University Hospital, University of Sfax, Sfax, Tunisia; dInterdisciplinary Laboratory in Neurosciences, Physiology and
Psychology: Physical Activity, Health and Learning (LINP2), UFR STAPS, UPL, Paris Nanterre University, Nanterre, France; eResearch
Laboratory, Molecular Bases of Human Pathology, LR19ES13, Faculty of Medicine, University of Sfax, Sfax, Tunisia

ABSTRACT ARTICLE HISTORY

Aim: To investigate the gender difference effect on postural balance, functional mobility, and Received 25 November 2021
fall risk after performing a fatiguing task in adults with multiple sclerosis (MS). Accepted 10 June 2022
Methods: Eleven women (30.91 ± 8.19 years) and seven men (30.29 ± 7.99 years) with KEYWORDS
relapsing-remitting MS performed a fatiguing task: three sets of the Five-repetition Sit-To- Multiple sclerosis;
Stand Test (5-STST) were performed before and after the six-minute WalkTest (6MWT). Bipedal neurodegenerative disease;
postural balance in eyes open and eyes closed conditions were assessed prefatigue (T0) and posturography; functional
postfatigue (T3) using a force platform. Unipedal balance, functional mobility (Timed Up and mobility; fall risk; fatiguing
Go Test), fall risk (Four Square Step Test) and fatigue [Visual Analogue Scale of Fatigue (VASF)] exercises; sex differences
were assessed at T0 and T3. Heart rate (HR) and Rating of Perceived Exertion (RPE) were
recorded before (only for HR), during and after the fatiguing task.
Results: Compared to women, men showed an impairment of posturographic parameters
[mean center of pressure (CoP) velocity (CoPVm) in both conditions (p < 0.05); CoP sway area
(CoPAr) in both conditions (p < 0.01)], unipedal balance on the dominant leg (p <0.001),
mobility (p<0.001) and an increased fall risk (p < 0.05). No gender differences were observed
in 6MWT, 5-STST, HR, RPE, and VASF.
Conclusion: This preliminary study showed that fatiguing task negatively affected postural
control, mobility and fall risk only in men. These gender differences were inconclusive but
could be taken into account in postural balance rehabilitation programs for MS persons.

Introduction
Multiple sclerosis (MS) is an inflammatory, neurode­
generative, and demyelinating disease of the central
nervous system [1]. MS is characterized by affecting
women two to four times more than men [2] but the
disease progression is faster and more severe in men
[3]. This gender difference incidence results from
a genetic, epigenetic [4] and behavioral factors such
as a reduced sun exposure in women compared to
men [5].
Fatigue represents one of the most disabling
symptoms that affects 81% of persons with MS
[6]. It has been reported that fatiguing task as
walking for long durations [i.e. Six-Minute Walk
test (6MWT)] can impair static and dynamic pos­
tural balance in MS persons [7,8]. In addition, Van
Emmerik et al. [9] found that postural balance
decreased following fatigue induced by strengthen­
ing protocol, only in challenging conditions of
reaching and leaning but not in quiet stance. In
this context, fatiguing calf raise task has been
shown to decrease postural balance in persons
with mild MS [mean Expanded Disability Status
Scale (EDSS) = 1.53] [10]. Besides, the association
of fatigue with functional mobility impairment has
been reported in MS persons [11]. In this sense,
Garg et al. [12] showed that the time required to
perform the Timed Up and Go Test (TUGT) was
longer in high-fatigue group than the low-fatigue
one. In contrast, Gervasoni et al. [13] reported that
postural balance and walking performance were not
affected by fatiguing treadmill session. Moreover,
an increased fatigue level has been shown to be
related to a high risk of falling in MS persons [14].
Regarding gender difference in fatigue perception,
results of previous studies are contradictory. It has
been reported that fatigue affects women more than
men with MS [6,15]. In contrast, Hadjimichael et al.

CONTACT Omar Hammouda omar.hammouda@parisnanterre.fr Interdisciplinary Laboratory in Neurosciences, Physiology and Psychology:
Physical Activity, Health and Learning (LINP2), UFR STAPS, UPL, Paris Nanterre, Nanterre, France
#
Joint senior authors
© 2022 Informa UK Limited, trading as Taylor & Francis Group
2 S. JALLOULI ET AL.
[16] showed that severe fatigue was observed mainly in
males. Whereas, other researchers found that fatigue
was independent of gender [17–19]. In fact, high levels
of fatigue were positively correlated with several fac­
tors that depend on gender differences such as cogni­
tive impairments [20], depressive disorders [21],
anxiety and sleep problems [22] and decreased quality
of life [23]. Particularly, some previous studies showed
that males with MS were more vulnerable to cognitive
disorders mainly in term of alteration of delayed
memory [24], depression [25], and poor physical and
mental health [26], than their female counterparts. In
contrast, Miller and Dishon [27] reported a higher
quality of life in men with MS than women but psy­
chological buffer against the physical disability was
better in women. Furthermore, Askari et al. [28]
found no significant difference between men and
women in depression and anxiety. Other studies
showed that women experienced more anxiety [25]
and sleep disorders than men with MS [29]
Gender difference in postural balance has not yet
been examined in persons with MS. A study con­
ducted in healthy older adults revealed that men
have greater postural balance impairments than
women [30]. However, other studies have reported
greater impairment of static and dynamic postural
balance in older women than men [31,32]. For
functional mobility, a recent study revealed no dif­
ference between men and women with MS in TUG
performance [33]. Concerning fall risk, it was more
pronounced in men with MS compared to women
[34,35].
To the best of the authors’ knowledge, no study has
taken into account gender differences in response to
a fatiguing protocol regarding postural balance, func­
tional mobility, and fall risk in MS persons. Thus, the
present study aimed to investigate the combined effect
of gender differences and fatiguing task on postural
balance, functional mobility, and fall risk in MS adults.
Patients and Methods
Participants
Assessment for eligibility was performed on 51 per­
sons with MS from the neurology department of
Habib Bourguiba Hospital. MS adults were included
if they were aged between 19 and 45 years old; had
a relapsing-remitting MS (MS-RR); and had an EDSS
score <6. Participants were classified as ‘neither type’
(n = 10) and ‘morning type’ (n = 8) according to their
answers to the Caen Chronotype Questionnaire [36].
Exclusion criteria were as follows:
● Obesity (body mass index ≥30 kg/m2)
● Hospitalization for MS relapse and pregnancy
● Uncorrected visual and vestibular problems as
well as psychiatric disorders and cardiovascular
or respiratory problems.
● Orthopedic disorders and history of injury in the
past 12 months requiring medical attention [37]
Power analysis calculation
The sample size was calculated a priory according to
the formula of Kang et al. [38]: N = (Zα/2)2 x s2/d2,
where ‘Zα/2’ is the normal deviate for a two tailed
alternative hypothesis at a level of significance (Zα/
2 = 1.96 at an error rate of 0.05%), ‘s’ is the SD and ‘d’
is the accuracy of estimate. Based on a previous study
[39] where CoPVm in anterior-posterior direction in
healthy men was 26.76 ± 11.69 and 33.33 ± 12.69,
respectively, during pre-fatigue and post-fatigue, the
statistical indices were set at 12.19 for ‘s’ and 6.57 for
‘d’. In total, a minimum sample of 13 participants is
supposed to be sufficient to power the study. The
assumption of 25% for drop-out (non-attendance in
one of the two assessments) induced a revised sample
of 18 participants approximately (17.33 (N’) = N(13)/
(1-% dropout (0.25) [40]).
Ethical approval
This cross-sectional study was performed among
adults with MS at the Physical Medicine and
Functional Rehabilitation Department, Habib
Bourguiba University Hospital. It was approved from
the south institutional human research ethics commit­
tee and was registered at the Pan African Clinical Trial
Registry database (PACTR202007922243550). All
experimental procedures were carried out in accor­
dance with the ethical standards of the Declaration
of Helsinki. A written consent was obtained from all
participants.
Experimental procedure
Prior to testing, sociodemographic and clinical data
were recorded. A validated self-reported questionnaire
was used to determine levels of physical activity [41].
The fatiguing task involved three sets of the Five-
repetition Sit-To-Stand Test (5-STST) followed by
6MWT and another three sets of 5-STST (Figure 1).
The 5-STST represents a reliable and valid strength
test of lower limbs in MS adults [42] and the repetitive
STST serves as an adequate protocol to induce lower
limb muscle fatigue in older adults [43]. The 5-STST
consisted on standing up (knees in total extension)
and sitting down five times as quickly as possible.
Throughout the test participants had to keep their
arms crossed over their chest while fixing their feet

Figure 1. Experimental protocol; FSST: Four Square Step Test; HR: Heart rate; RPE: Rating of Perceived Exertion; 5-STST: Five-
repetition Sit-To-Stand Test; 6MWT: Six-Minute Walk Test; TUGT: Timed Up and Go Test; VASF: Visual Analogue Scale of Fatigue.
flat on the ground [42]. The average time of three sets
was calculated as a final score for each 5-STST. The
6MWT was considered as a fatiguing task in MS
persons [7]. Participants were instructed to walk as
fast but safe as possible for 6 min, without jogging in
a hallway between two cones placed 20 m apart. As
soon as the test was stopped, the total walking distance
was calculated.
The fatiguing task intensity was controlled based on
participant Heart rate (HR) and Rating of Perceived
Exertion (RPE) [44]. Moreover, acute fatigue was
assessed by a100-mm Visual Analogue Scale of
Fatigue (VASF) with 0 mm indicates ''no fatigue”
and 100 mm ”severe fatigue” [45]. HR was recorded
prefatigue (T0: rest), after the first 3 sets of 5-STST
(T1), after the 6MWT (T2) and immediately postfati­
gue (T3: after the second 3 sets of 5-STST) using
a polar HR monitor (H10, Canada). Modified RPE
scale was assessed at T1, T2 and T3. Acute fatigue,
bipedal and unipedal postural balance performance,
functional mobility, and fall risk were assessed at T0
and T3 (Figure 1).
Posturographic assessment
A stabilometric platform (SATEL ®, France, frequency
40 Hz) was used to assess bipedal postural balance in
eyes open (EO) and eyes closed (EC) conditions.
Participants were instructed to stand barefoot on
a firm surface (heels 2 cm apart and feet externally
rotated at 30°) as still as possible and to keep their
arms alongside their bodies. In EO condition, partici­
pants looked at a fixed target placed 2 m apart on the
front wall. Participants were asked to give multiples of
three starting from zero, as a cognitive task during EO
NEUROLOGICAL RESEARCH 3
and EC. For each condition, signal acquisition lasted
52.1 s and the mean of three trials was used for ana­
lysis. The following parameters were selected: mean
center of pressure (CoP) velocity (CoPVm), CoP sway
area (CoPAr) and mean CoP path length (CoPL) [46].
Unipedal postural balance
Unipedal balance on the dominant and non-dominant
leg, was assessed in EO condition by a clinical test that
required to stand as long as possible on one leg while
flexing the contralateral knee, and to keep the arms
downward at either side of the body [47]. The domi­
nant leg was the one preferred to hit a ball [48]. The
test ended when the participant either was unable to
maintain the stance or a maximum of 180 s had
elapsed [48].
Functional mobility
The TUGT was used to assess mobility, which has
already been validated in patients with MS [49]. This
test involved the following steps: (1) getting up from
a seated position, (2) walking 3 m in a straight line at
a comfortable and usual speed, (3) turning around
a cone, (4) returning to the chair and (5) sitting
down [50]. The average of two timed-trials was calcu­
lated for analysis.
Fall risk assessment
To evaluate fall risk, we used the Four Square Step Test
(FSST), which validity and reliability were tested in
MS adults [51]. It required to step, as fast as possible,
4 S. JALLOULI ET AL.
Figure 2. The Four Square Step test [52].
over crossed four rods clockwise and counterclock­
wise, successively (Figure 2). During FSST, partici­
pants had to enter each square with both feet on the
floor while keeping a horizontal gaze [52]. In case of
losing stability or touching the rods, participants had
to repeat the test [51]. For analysis, the shorter time of
two trials was taken.
Statistical Analysis
The Statistica 12 software (StatSoft, Maisons-Alfort,
France) was used to perform the statistical analyses.
After checking normality and homogeneity using the
Shapiro-Wilk W test and the Levenne test, respec­
tively, parametric tests were used and data were
expressed as mean (M) ± standard deviation (SD) in
the tables and as M ± standard error (SE) in the
figures.
The t-test for independent samples was used to
assess gender differences in demographic and clinical
data, and fatiguing task performances (6MWT walked
distance and 5-STST duration). VASF, RPE, HR,
TUGT, and FSST data were analyzed using two-way
repeated measures ANOVA [gender (women vs. men)
× fatigue (HR: T0 vs. T1 vs. T2 vs. T3; RPE: T1 vs. T2
vs. T3; VASF, TUGT and FSST: T0 vs T3)].
To analyze posturographic parameters and unipe­
dal stance time, the three-way repeated measures
ANOVA [gender (women vs. men)] × [vision factor
(EO vs. EC for bipedal posture) or leg factor for uni­
pedal balance (dominant leg vs. non-dominant leg)] ×
[fatigue (T0 vs. T3)] was used. Effect size (ES) was
calculated using partial eta-squared (ηp 2) to evaluate
ANOVA practical significance. When appropriate,
pairwise comparisons were assesed using the
Bonferroni post-hoc test . ES calculation was per­
formed using the Cohen’s d (d) for Bonferroni com­
parisons and changes in parameters measured by the
t-test [53]. A probability level of 0.05 was set for
statistical significance .
Results
Participants’ characteristics and fatiguing task
performance
From 51 patients with MS-RR, 18 patients were eligi­
ble and completed the whole protocol as presented in
Figure 3. There was no significant difference between
men and women in age, body mass index, EDSS, MS
duration, last relapse date, or physical activity level
(Table 1), walked distance (6MWT) and durations of
the first and second 3 sets of 5-STST (Table 2).
Bipedal postural balance
Regarding CoPVm and CoPAr, data analysis showed
a significant effect of vision (CoPVm: F = 7.48, p = 0.01,
ηp2 = 0.32; CoPAr: F = 24.03, p < 0.001, ηp2 = 0.74),
fatigue (CoPVm: F = 10.77, p < 0.01, ηp2 = 0.4; CoPAr:
F = 9.72, p < 0.01, ηp2 = 0.38) and a significant interac­
tion (fatigue × gender) (CoPVm: F = 4.84, p < 0.05,
ηp2 = 0.23; CoPAr: F = 9.56, p < 0.01, ηp2 = 0.37).
A significant interaction (vision × fatigue) was also
found for CoPVm (F = 6.58, p < 0.05, ηp2 = 0.29).
The post hoc test revealed that CoPVm and CoPAr
were significantly superior at T3 compared to T0 only
in men irrespective of vision (CoPVm: EO and EC:
p < 0.05, d = 2.5, d = 0.29, respectively; CoPAr in EO
and EC: p < 0.01; d = 0.66, d = 0.48 respectively)
(Figure 4a-b). Moreover, CoPAr was more elevated in
EC than EO at T0 and T3 irrespective of gender [at T0:
men (p = 0.029, d = 0.72); women (p < 0.001, d = 0.74)
and at T3: men(p < 0.01, d = 0.87); women (p = 0.001;
d = 0.6)] but the CoPVm increased only at T0 in EC
compared to EO condition only in women (p < 0.01;
d = 0.77) (Figure 4a-b).
For CoPL, the statistical analysis revealed only
a significant effect of vision (F = 15.07, p < 0.01,
ηp2 = 0.49).
Unipedal postural balance
The three-way ANOVA showed a significant effect of
fatigue (F = 5.93, p < 0.05, ηp2 = 0.27) and significant
interaction (fatigue ×leg × gender) (F = 16.95,
p < 0.001; ηp2 = 0.51). In men, the time of unipedal
stance on the dominant leg was longer at T0 compared
to T3 (p < 0.001; d = 0.52) and the balance perfor­
mance on the dominant leg was lower than on the
non-dominant leg only at T3 (p < 0.05; d = 0.36).
 NEUROLOGICAL RESEARCH 5

Figure 3. Flow diagram of patients enrollment.

Table 1. Participants’ characteristics. However, no significant effect was found in women

Men (n = 7) Women (n = 11) p value (Figure 5).
Age (years) 30.29 ± 7.99 30.91 ± 8.19 0.88
BMI (Kg/m2) 22.27 ± 3.54 21.69 ± 3.99 0.76
EDSS 1.86 ± 0.89 2.04 ± 1.31 0.74 Functional mobility and fall risk
MS duration (years) 5.71 ± 3.59 4.73 ± 2.65 0.51
Last relapse date (years) 2.21 ± 1.11 2.18 ± 1.35 0.96 Statistical analysis revealed a significant effect of fati­
Physical activity level 15.57 ± 5.79 17.18 ± 6.11 0.58
(points) gue for TUGT (F = 39.69, p < 0.001, ηp2 = 0.69) and
Data are presented as mean ± standard deviation (SD) FSST (F = 7.72, p < 0.05, ηp2 = 0.33), and significant
BMI: body mass index, EDSS: Expanded Disability Status Score; MS: multi­ interaction (fatigue × gender) for TUGT (F = 9.37,
ple sclerosis.
p < 0.01, ηp2 = 0.37) and FSST (F = 5.68, p < 0.05,
ηp2 = 0.26). The post hoc tests showed that TUGT and

Table 2. Fatiguing task parameters.

Men (n = 7) Women (n = 11) p value
First 3 sets of 5-STST (s) 13.29 ± 2.29 11.79 ± 2.72 0.22
6MWT (m) 543.14 ± 123.08 528.07 ± 111.82 0.92
Second 3 sets of 5-STST (s) 12.44 ± 2.13 11.51 ± 2.39 0.40
Data are presented as mean ± standard deviation (SD).
6MWT: Six-Minute Walk Test, 5-STST : Five-repetition Sit-To-Stand Test .
6 S. JALLOULI ET AL.

Figure 4. Effect of fatiguing task on mean center of pressure (CoP) velocity (CoPVm) and CoP sway area (CoPAr) in eyes open (EO)
and eyes closed (EC) conditions in men and women with MS. Data are presented as mean ± standard error. ** significant
difference from pre-post fatigue at p<0.01; ≠, ≠ ≠, ≠ ≠ ≠: significant difference between EO and EC at p < 0.05, p < 0.01and
p < 0.001, respectively

respectively) . While in women, no significant differ­

ence was found (Figure 6a-6b).

Fatigue perception and exercise intensity

Figure 5. Effect of fatiguing task on unipedal balance on
dominant and non-dominant leg in men and women with
MS. Data are presented as mean ± standard error. ***: sig­
nificant difference from pre-post fatigue at p<0.001. #: sig­
nificant difference between dominant and non-dominant leg
at p < 0.05.
FSST durations were higher at T3 compared to T0
only in men (p < 0.001, d= 3 and p < 0.05; d = 0.75,
Statistical analysis showed significant fatigue effect
for RPE (F = 172.7, p < 0.001, ηp2 = 0.91) and HR
(F = 71.5, p < 0.001, ηp2 = 0.82) and significant
interaction (fatigue × gender) for RPE (F = 3.55,
p = 0.04, ηp2 = 0.18) as well as for HR (F = 3.27,
p = 0.029, ηp2 = 0.17). RPE scores in men and
women were higher at T2 than at T1 (p < 0.001
for both genders; d = 2, d = 3, respectively), at T3
than at T2 (p < 0.001; d = 2 for both genders) and
at T3 than at T1 (p < 0.001 for the two genders;
d = 4, d = 5, respectively) but there were no gender
differences across all time points (Figure 7a).
Bonferroni test showed that HR in men and
women was lower at T0 when compared to T1
(p < 0.001, p = 0.0017; d = 1.53, d = 2.4, respec­
tively), T2 (p < 0.001 for both genders; d = 3.13,

Figure 6. Effect of fatiguing task on duration of Timed Up and Go Test (TUGT) (a) and Four Square Step Test (FSST) (b) in men and
women with MS. Data are presented as mean ± standard error. * , ***: : significant difference from pre-post fatigue at p<0.05 and
p < 0.001, respectively.
d = 4.47, respectively), and T3 (p < 0.001 for both
genders; d = 3.95, d = 4.15, respectively). For
women, HR at T1 was inferior to T2 (p < 0.001;
d = 2.21) and T3 (p < 0.001; d = 1.9). Whereas for
men, HR at T1 was only inferior to T3 (p = 0.0005;
d = 1.6) (Figure 7b). No gender difference was
detected in HR across all time points.
Regarding VASF score, ANOVA showed
a significant effect of gender (F = 6.59, p = 0.02,
ηp2 = 0.92) and fatigue (F = 21.79, p < 0.001,
ηp2 = 0.57) without significant interaction between
fatigue and gender. Fatigue was significantly higher
at T3 than at T0 regardless of gender (men:
p = 0.03, d = 2.11; women: p = 0.016, d = 1.58)
(Figure 8).
Discussion
The present study aimed to investigate the concomi­
tant effect of fatigue and gender differences on pos­
tural balance, functional mobility and fall risk in MS
adults. The main findings of this study revealed that
NEUROLOGICAL RESEARCH 7
only men showed: (i) an impairment in bipedal bal­
ance (increase in CoPVm and CoPAr) in EO and EC
conditions and unipedal balance (decrease in stance
duration on the dominant leg), (ii) an alteration of
functional mobility (increase in TUGT scores) and fall
risk (increase in FSST scores) after performing the
fatiguing task.
Regarding postural balance, there is no study that
investigated the effect of fatigue, with considering
gender difference, in MS population. Given the lack
of studies in MS persons, the present results are com­
pared with other populations. Indeed, the present
findings were similar with those of Bannon et al. [39]
who reported an alteration of single dominant leg
balance in healthy men but not in women after per­
forming a fatiguing lifting task. Similarly, Whyte et al.
[54] showed that intermittent exercise induced
a greater alteration in dynamic postural balance in
male athletes compared to their female counterparts.
In the present study, the unipedal postural balance in
men was affected only on dominant leg following the
fatiguing task. This result could be due to the excessive
8 S. JALLOULI ET AL.

Figure 7. Representation of Rating of Perceived Exertion (RPE) and Heart Rate (HR) at T1: after the first 3 sets of five-repetition Sit-
To-Stand Test (5-STST), T2: after the six-minute Walk Test, T3: after the second 3 sets of 5-STST (immediately postfatigue) and at T0:
prefatigue only for HR, in men and women with MS. Data are presented as mean ± standard error. ***: significant difference from
pre-post fatigue at p< 0.05.

Figure 8. Effect of fatiguing task on Visual Analogue Scale of Fatigue (VASF) in men and women with multiple scelrosis (MS). Data
are presented as mean ± standard error. *: significant difference from pre-post fatigue at p <0.05 .

use of dominant leg during the fatiguing task, which
lead to more fatigue in this leg. It has been shown that
fatigue could reveal and amplify any postural differ­
ence between the dominant and non-dominant leg
[55]. The present study showed a greater impairment
of posturographic parameters in EC than EO condi­
tions regardless of the gender and fatigue effects.
Similar results have been found by Jackson and
Bigelow [7] showing that static postural balance was
impaired in the fatiguing condition only in the chal­
lenging EC but not in EO test in MS adults. This
finding can be explained by the role of visual affer­
ences elimination in increasing CoP oscillations [56]
because visual information is necessary for the main­
tenance of postural balance [57]. Particularly, it has
been shown that people with MS were more depen­
dent on vision than healthy persons to preserve their
postural balance because of their deficient sensory
system[58,59].
Regarding functional mobility, the greater decrease
of TUGT performance in men is in disagreement with
findings of Manty et al. [60] who reported that the
decrease of functional mobility was not dependent on
gender. The difference in participants’ characteristics
(i.e. age: young adults: 30.6 years vs. persons aged from
43 to 63 years) and pathology: MS vs. healthy persons)
could explain this discrepancy between findings [60].
Impairments of postural balance and functional mobi­
lity found only in men could be explained by the
greater inflammatory responses induced by fatiguei
in men than women with MS [61,62]. In addition
Ravaglia et al. [63] showed that inflammation was
linked to postural imbalance and poor gait.
In discordance with the present findings, Karpatkin
et al. [64] found that the increased risk of falling after
6MWT was not gender-dependent in people with MS.
The more pronounced fall risk in fatigued men in this
study could be explained by gender differences in
levels of oxidative stress biomarkers, which have
been shown to be higher in male than female rats
with MS [65]. In fact, oxidative stress have been
shown to be a predictor of increased fall risk [66]
through its negative impact on postural balance [67],
walking speed [68] and cognitive performance [69]. In
the present study, the increased fall risk could be
explained by postural balance and mobility impair­
ments observed only in men since the reduced mobi­
lity [70] and the postural imbalance [71] have been
associated with high fall risk in MS adults.
Therefore, the impairment in postural balance,
mobility and fall risk observed only in men could not
be explained by gender differences in exercise intensity
(RPE+HR), perceived fatigue and fatiguing task perfor­
mance, since we found an increase in VASF and RPE
from T1 to T3 and in HR from T0 to T3 regardless of
gender.
NEUROLOGICAL RESEARCH 9
This insignificant gender difference in VASF was
confirmed by Karpatkin and Rzetelny [72] who found
no effect of gender on increased fatigue induced by 6
min of continuous vs. intermittent walking in MS
adults. Concerning fatiguing task performance, no
gender differences were found in performing 6MWT
and 5-STST. Similarly, previous studies reported that
women and men did not differ in walked distance
during the 6MWT [73] and in the strength test dura­
tion [74]. However, Surakka et al. [75] showed that
muscle strength during 30s maximal sustained knee
flexors and extensors contraction, was strongly and
rapidly reduced in men compared to women with
MS. This discrepancy in results could be attributable
to the use of distinct fatiguing task and different data
analysis [10]. For exercise intensity, findings of this
study were different to those of Hunter et al. [76] who
observed a greater rate of increase in RPE and HR in
men compared to women (both healthy) following an
intermittent fatiguing task (6-s contraction of elbow
flexors, 4-s rest). These discrepant results could be
explained by the fact that in this latter study [76],
women maintained the fatiguing contraction longer
than men.
Limitations
This study presented some limitations. First, our
sample size is small although it seems sufficient to
power the study. Second, we were unable to gen­
eralize our results to adults with progressive MS
and moderate-to-severe disability because our sam­
ple was mildly disabled and presented the MS-RR
form. Third we did not assess parameters that can
explain the impaired postural and physical perfor­
mance in fatigued men, such as sleep quality and
cognitive impairment, which affect postural bal­
ance, mobility, and fall risk [77–80]. Fourth, other
possible confounders such as peripheral neuropathy
and spinal cord lesion burden were not taken into
consideration in this study despite their interest in
results explanation. Indeed, men with MS presents
more severe spinal cord lesions than their female
counterparts due to their lower density of nerve
fibers in the corticospinal tract of the spinal cord
[81]. In the other part, reduced velocity of soma­
tosensory spinal cord conduction has been shown
to be the main cause of postural balance impair­
ment related to MS [82]. Additionally, peripheral
nerves demyelination has been shown to be
involved in MS, although this latter is known as
a disease of the central nervous system. Besides, as
seen in persons with diabetes, peripheral neuropa­
thy could exacerbate postural balance disor­
ders [83].
10 S. JALLOULI ET AL.
Conclusion
Following a fatiguing task, men seemed more suscep­
tible to present an increased postural balance sway and
fall risk and a limited mobility. Although these gender
differences were inconclusive, therapists could con­
sider the present findings for further postural balance
rehabilitation programs in fatigued adults with RR-
MS.
Abbreviations
CoP, center of pressure; CoPL, CoP path length; CoPAr,
CoP sway area; CoPVm: mean CoP velocity, d, Cohen’s d;
EO, eyes open; EC, eyes closed; ES, effect size; FSST, Four
Square Step Test; FMS, faculty of Medicine; HR, heart rate;
MS, multiple sclerosis; MS-RR, relapsing-remitting MS; M,
mean; 6MWT, Six-Minute Walk test; MD-Phd, Doctorate of
Medicine and Philosophy; RPE, Rating of Perceived
Exertion; SD, standard deviation; 5-STST, Five-repetition
Sit-To-Stand Test; TUGT, Timed Up and Go test; T0, pre­
fatigue; T1, after the first 5-STST; T2, after the 6 MWT; T3,
immediately postfatigue; VASF, visual Analogue Scale of
Fatigue.
Disclosure statement
No potential conflict of interest was reported by the
author(s).
Funding
The author(s) reported there is no funding associated with
the work featured in this article.
Notes on contributor
All authors contributed to the study conception and design.
SJ and IBD performed the study experimentation. Data
analysis and interpretation as well as writing of the first
draft of the manuscript were realized by SJ. IBD and OH
revised critically the first version of this paper. OH, SG and
MHE provided the equipment needed to perform the
experimental protocol. SS and CM participated in the selec­
tion and the recruitment of patients as well as the collection
of their clinical data. All authors read and approved the final
version of the present paper.
ORCID
Sonda Jallouli http://orcid.org/0000-0003-2664-2290
Imen Ben Dhia http://orcid.org/0000-0002-2525-5443
Omar Hammouda http://orcid.org/0000-0002-5002-
687X
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