Synopsis Proposal

Relationship of working memory with balance and proprioception of knee and ankle in patients with
multiple sclerosis.

REHAB ABID M-17940

RIMSHA M-17935

UNIVERSITY OF SOUTH ASIA

SUBMITTEED TO: DR. AIZA YOUSAF

SUBMITTED ON: 09-10-2023

1 SYNOPSIS PROPOSAL

1.1 TITTLE:
Relationship of working memory with balance and proprioception of knee and ankle in
patients with multiple sclerosis.

1.2 PICO:
Population: Patients with multiple sclerosis
Independent variable: Working Memory
Dependent variable: Balance and proprioception of knee and ankle

1.3 STUDY TYPE

Analytical Cross-Sectional study

1.4 RATIONALE
Multiple sclerosis (MS) is a neurological condition in which the called myelin sheaths,
of in the brain and are damaged. Multiple sclerosis is on the rise in Pakistan with approximately
10 out of every 100,000 people have MS. MS is known to cause cognitive impairments in up to
70% of patients, and many individuals also experience motor deficits. Patients with Multiple
sclerosis experience cognition dysfunction that may result in somatosensory system disturbance
which may further cause disturbance in balance and proprioception. Consequently, these deficits
may have greater impact on quality of life of MS patients

1.5 QUESTION
What is the relation of working memory with balance and joint position sense of knee
and ankle in multiple sclerosis patient?

1.6 OBJECTIVE
 The purpose of this study is to contribute to an understanding of relationship of working
memory with balance in multiple sclerosis patients.

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  The purpose of this study is to contribute to an understanding of relationship of working
memory with proprioception of knee and ankle in patients of multiple sclerosis.

1.7 HYPOTHESIS

1.7.1 Null:
 There will be no significant association between working memory and Balance in
multiple sclerosis patients.
 There will be no significant association between working memory and proprioception of
knee and ankle.

1.7.2 Alternate:
 There will be a significant association between working memory and balance in multiple
sclerosis patients.
 There will be a significant association between working memory and proprioception of
knee and ankle.

1.8 ELIGIBILITY CRITERIA

1.8.1 Inclusion Criteria

1. Patients with pre-diagnosed Multiple sclerosis with EDSS (Expanded disease status
score) ≤3.0 (1)
2. Nearly Full visual capability
3. Patients with multiple sclerosis types clinically isolated syndrome (CIS), relapsing-
remitting MS (RRMS), and secondary progressive MS (SPMS).

1.8.2 Exclusion criteria

1. Patients with Primary Progressive Multiple sclerosis
2. PwMS with other cognitive impairment, a primary psychiatric disorder, a substance use
disorder, any other major medical disorder, and relapse
3. Medical conditions affecting balance
4. An MS relapse occurring within 50 days prior to inclusion (1)

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 5. Treatment with intravenous corticosteroid or oral corticosteroid within 30 days prior to
inclusion

1.9 OUTCOME MEASURES

1.9.1 Tools

1. Fullerton Advanced Balance Scale

The test is mainly performed on the following population: cancer patients
(post-chemotherapy), older adults, Parkinson’s, neurological conditions and Traumatic brain
injuries.

1.9.1.1 Cutt-off scores

Older adults (>=65 years): (Hernandez and Rose, 2008; independently, healthy
functioning adults, without fall in previous 12 months, reported falling 2 or more times previous
12 months)

Score of 25/40 produces highest sensitivity (74.6%) and specificity (52.6%) in predicting
fall risk In 7 out of 10 cases an individual who scores 25 or lower is at a high risk for falls

1.9.1.2 Test-Retest Reliability

Excellent test-retest reliability (ICC=0.98)

1.9.1.3 Interrater/Interrater Reliability

Older Adults: Excellent test re-test reliability (r = 0.96) for total score

Breast cancer (post chemotherapy): (treated with taxane chemotherapy)

Excellent test-retest reliability (ICC=0.98) <u</u>

1.9.1.4 Internal Consistency

Older adults: Excellent internal consistency (H coefficients >0.75) for all 10 items

Older adults: Excellent internal consistency

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1.9.1.5 Content Validity
Older adults: Established through literature review, administration of test items to
15 older adults, reviewed by 4 experienced physical therapists

1.9.1.6 Interpretation
1. Fullerton advanced balance scale consists of 10 performance based questions. The FAB
takes 10-12 minutes to administer
2. 10 performance based activities in both static and dynamic phases
3. Score of 0-40/40 points possible (higher scores are better)
4. Items scored on a 5 point ordinal scale (0-4)
5. ICF domain, activity

1.9.1.7 Equipment

1. Stopwatch
2. Pencil
3. 2 and 36 inch rulers
4. 6 inch high bench (18’X18’ stepping surface)
5. Masking tape
6. 2 Airex® pads
7. Length of non-slip material between pads if floor is not carpeted -Metronome

1.9.2 Mini Mental State Examination

A Mini-Mental State Examination is a questionnaire which includes 11 questions that are
asked by the doctors or other health care professionals to check for cognitive
impairments (problems with thinking, communication, understanding and memory).

1.9.2.1 Validity
MMSE has a sensitivity of 88.3% (95% confidence interval [CI], 81.3% to
92.9%) and a specificity of 86.2% (95% CI, 81.8% to 89.7%) for dementia, with a score cutoff of
23 to 25 indicating significant impairment.

1.9.2.2 Test-retest reliablity

Has not fallen below 0.89

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1.9.2.3 Inter-rater reliablity
Has not fallen below 0.82

1.9.2.4 Internal consistency

0.78

1.9.3 Joint position sense by goniometer

Proprioception is our sense of joint / limb positioning. It is often measured through joint
position sense - active joint position sense (AJPS) and passive joint position sense (PJPS). Joint
position sense determines the ability of a person to perceive a presented joint angle and then,
after the limb has been moved, to actively or passively reproduces the same joint angle.

1.9.3.1 Procedure:
For Knee JPS using a goniometer test
1. First, the patient is asked to actively perform 40° knee flexion. The therapist will measure
this using a goniometer.
2. Then the pt. is instructed to close his/her eyes and perform the exact movement
3. A total of 2 readings are taken and their average is calculated.
For Ankle JPS a goniometer test using
1. First, the patient is asked to actively perform 7° plantar flexion. The therapist will
measure this using a goniometer.
2. Then the pt. is instructed to close his/her eyes and perform the exact movement
3. A total of 2 readings are taken and their average is calculated.

1.9.3.2 Test-Retest Reliability

Both knee flexion and extension in active and passive modes demonstrated high
reliability (ICC = 0.866–0.982; SEM = 0.63–0.31).

Proprioception Right Left

Readings 1st 2nd Average 1st 2nd Average
Knee
Ankle

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PARENT ARTICLE

Association between cognitive impairment and motor dysfunction among patients with
multiple sclerosis: a cross-sectional study
Impaired central drive to plantar flexors and minimal ankle proprioceptive deficit in
people with multiple sclerosis

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