Innovative Approaches to Enhance Balance and Neuroplasticity in Multiple Sclerosis

Participants begin seated in a standard chair with their back against the chairrest and arms on the armrests. On the command "go," they stand up, walk 3 meters at a comfortable and safe pace, turn around, return to the chair, and sit down. The time to complete the task is recorded in seconds, with shorter times indicating better mobility. For the dual-task cognitive TUG, participants perform the same procedure while simultaneously completing a cognitive task (counting backward by threes). The score is the time in seconds to complete the task, with shorter times indicating better mobility.

The Timed 25-Foot Walk Test (T25FWT) is a standardized clinical measure of walking speed. Participants are instructed to walk a distance of 25 feet at their usual comfortable pace. Timing is recorded over the middle 6 meters to minimize the effects of acceleration and deceleration, with 2-meter lead-in and 2-meter lead-out zones. The test is performed twice, and the average walking speed (m/s) is calculated, with higher speeds indicating better mobility.

BBS is a 14-item clinical assessment of static and dynamic balance. Each item evaluates performance on a functional task such as standing unsupported, reaching forward, turning, or standing on one leg. Tasks are scored on a 5-point ordinal scale ranging from 0 (unable to perform) to 4 (independent performance), with a maximum total score of 56. Higher scores indicate better balance

For the static balance test, participants will stand for 100 seconds on a force plate under two conditions: (1) eyes open and (2) eyes closed. For the dynamic balance test, participants will stand on the force plate and lean as far as possible in the forward, backward, and sideways directions. During these tasks, body sway, postural movements will be recorded. Visual feedback of calculated body sway will be displayed on a monitor, and participants will be instructed to shift their body toward the indicated directions.

MSWS-12 is a self-reported questionnaire that measures the impact of Multiple Sclerosis on walking ability. It consists of 12 items in which participants rate, on a 5-point scale (from 1 = not at all to 5 = extremely), how much MS has affected various aspects of their walking during the past two weeks (e.g., walking distance, running, climbing stairs, balance while walking). Scores are summed, transformed to a 0-100 scale, and higher values indicate greater perceived walking limitation. The MSWS-12 is widely used in MS research and clinical practice and has demonstrated strong reliability and validity.

FES-I is a self-report questionnaire that assesses concern about falling during everyday activities. It includes 16 items rated on a 4-point scale (1 = not at all concerned to 4 = very concerned), covering a range of indoor and outdoor tasks such as getting dressed, bathing, walking on uneven surfaces, or going out sociall

ABC Scale is a 16-item self-report questionnaire that measures an individual's confidence in maintaining balance during common daily activities. Participants rate their confidence for each activity (e.g., standing on tiptoes, walking on icy sidewalks, reaching, or using an escalator) on a scale from 0% (no confidence) to 100% (complete confidence).

TAM-2 questionnaire is a validated self-report tool used to assess user acceptance of new technologies. It measures key domains including perceived usefulness (the extent to which the technology improves task performance), perceived ease of use (the degree to which the technology is user-friendly), attitudes toward use, and behavioral intention to use. Items are typically rated on a Likert-type scale, and higher scores indicate greater acceptance. Participants will also take part in semi-structured qualitative interviews guided by a previously developed framework based on TAM-2. The guide consists of open-ended questions and encourages participants to share their thoughts and experience regarding perceived benefits of the training program across different domains aligned with the TAM-2 framework (behavioral intention, perceived ease of use, usefulness, and usage behavior)

Feasibility outcomes will include recruitment rate, retention rate, and adherence. Recruitment rate refers to the percentage of eligible participants who enrolled relative to the number screened. Retention is defined as the proportion of participants who completed all three assessment time points, and adherence is measured by how many of the 12 training sessions each participant completed.

The strength of the connection between the brain and muscles will be measured using TMS. During this test, the participant sits comfortably in a chair while a small device placed over the head delivers brief magnetic pulses. These pulses activate specific brain areas and the responses in the muscles are recorded, providing information about brain-muscle communication.The MEP (motor evoked potential) score is the amplitude of the muscle response in microvolts (µV or mV), with larger amplitudes indicating stronger corticospinal excitability and smaller or absent responses reflecting weaker or impaired brain-muscle connectivity.

Spinal motor evoked potentials (SMEPs) will be assessed with double-pulse stimulation (Digitimer, Model DS7A, Welwyn Garden City, UK) delivered over L1-L2 (two monophasic pulses with 1ms pulse width and a 50 ms inter-stimulus interval). Surface EMG will be recorded from the more affected side or dominant side in case of symmetrical involvement from four lower-limb muscles: soleus, tibialis anterior, rectus femoris, and biceps femoris. The same amplifier will be used to both amplify and band-pass-filter the data, as described above. Recruitment curves will be generated by increasing stimulation intensity from 5 mA to the participant's maximal tolerable level in 5-mA increments. At each intensity, five paired-pulse stimulations were delivered with 5-second inter-trial intervals.