A (0:00)

Hello. Hello. Thank you for tuning in. If you listened to our conversation from last week, you may recall that we talked about subjective functional outcome measures. And these are assessments or questionnaires, quizzes, whatever we want to call them, that are the gold standard in terms of measuring how you're feeling with your fatigue and your walking, specifically for people with multiple sclerosis. But today we're going to be talking about objective functional outcome measures. The biggest difference here is that subjective is the questionnaire style. So you are filling out how you feel about your walking, how you feel about your fatigue. Whereas with objective outcome measures, we are actually timing ourselves, we are timing how long it takes to do a certain thing, or we are recording how many repetitions we were able to do. So we are given an exact number for each test. Whereas numbers from these subjective tests, more so just come from adding up your scores of how you felt. So two very different types of tests, both are so, so important and they both can significantly help you understand and interpret if what, what you are currently doing to help you manage your Ms. Symptoms is actually helping or not. So if you are exercising, is it actually helping you get stronger? Is it actually helping you walk better, walk faster, whatever your goals are, or not? If you're focusing on nutrition, is that actually giving you more energy? Is that actually making any difference with your walking, with your overall strength, or not? Hydration, is that affecting you at all? So these are going to be really great for you to do, specifically if you are trying to assess if something that you've been doing to help with your Ms. Symptoms is working or not. The big question is, how does someone.

B (2:16)

With Ms. Actually improve their mobility and strength, energy independence?

A (2:22)

The list goes on.

B (2:24)

My name is Dr. Gretchen Holley, physical therapist and multiple sclerosis specialist. Welcome to the Missing Link podcast. Tune in as I share the top strategies and exercises to help you gain control over your life with ms, using research driven insights and advice from top industry experts. Whether you're newly diagnosed or have had Ms. For over 30 years, whether you have relapsing Ms. Or progressive MS, this podcast is for you. You're sure to feel empowered and inspired after each episode.

A (3:02)

Ready?

B (3:03)

Let's dive in.

A (3:12)

Both of these types of tests, these subjective and objective, give you the complete picture of Ms. Management. And these tests, again are the gold standard, meaning they have been proven in Ms. Specific research to be the best test to actually show us if there is a meaningful difference in our results, showing if something is helping or not helping. And these tests are used in physical therapy clinics in your neurologist clinic. And they can also be modified for home use. So today I'm going to be telling you what these tests are and how to do them in the clinic as well as at home. Because the reality is you might only see your neurologist once a year or twice a year, or I hear from a lot of my missing link members, just as needed, it might not be even once a year. And if the only time you are getting these tests done is at your neurologist office and you're only there once a year or twice a year, how are you to know between those times if what you're doing is actually helping? Or you will also likely hopefully do these tests with your physical therapist. But as we all know, unfortunately, insurance companies often will cut you off from physical therapy. So if you're in an episode where you're not going to pt, and how can we measure if you're still making improvements at home when you're not going into the PT clinic? This is how. What we're going to review today is how. And I really like objective outcome measures because numbers don't lie. It is quantifiable data. And also it can catch subtle changes. It can transition your mindset from I think I'm walking faster to I am walking faster. And that can be so motivating. I don't know if you're type A or motivated by numbers. I know I am. But seeing improvements in numbers is so powerful, and that can help you stay consistent or get consistent with your exercises, even if the numbers go down, even if it shows, oh, shoot, I'm actually walking a little bit slower now, or I didn't do as many repetitions. You can use that as motivation to keep working hard so that the next time you test yourself, ideally it will be a little bit better and you can share your results with your health care team. So the next time you go to your neurologist office or the physical therapy clinic, you can say, hey, it's been six months. Here's how I've been doing at home. And you give them your results to these tests. Just a few important disclaimers before we start. And then I promise you we're going to get into what these tests are. As I mentioned mentioned, you can do these in a clinic, physical therapy, neurology clinic, and at home. So we're going to discuss both. The home versions have more variables. The surface that you're walking on, the time of day, fatigue, the distance that you're walking. And that's okay. But in Order to compare apples to apples. We really want to try to make the home version as similar to the clinic version as possible. And, but at the end of the day that might not be realistic, but that's okay because we can at the very least compare all of your home version tests to each other. It might not directly translate to the clinic versions because it might be a different distance that you're walking. So of course your timing is going to be different because you're walking longer or shorter. But again, that's okay. We can keep comparing how you're doing at home with all of the tests that you're doing at home and we can compare how you're doing in the clinic with the other tests that you're doing at the clinic. Tracking trends in both locations is what matters most. We're not looking for perfect precision or the perfect setup for the test. We're just looking to repeat the same tests over and over again, several months apart, and look at the trends over time. We also want to make sure that we're being safe, especially with the home versions. Only do the tests that you can do safely. You can use mobility aids for all of these if needed. If you have a walk aid or a bioness or some form of electrical stimulation that you use for walking, you can use that as well. You just want to make notes of all of that because if you use a mobility aid one day but you don't, then during the next test, of course your numbers are probably going to be different. Or if you use electrical stimulation one day but not in another day, again that's probably going to cause some type of difference in your testing. And we want consistency. So try your best when you're doing these at home. To be in the same location, the same room, the same time of day, the same conditions, the same mobility aids, if you use armrests, even writing that down so that you remember to use armrests the next time, all of that because we want consistency, so we're comparing apples to apples. All right, so let's go ahead and dive in. This first test is the timed 25 foot walk test. And I really, really hope this is not the first time you are hearing of this test. This is one of the most common gold standard tests that you would do in a physical therapy clinic as well as an Ms. Neurologist clinic clinic. If this is the first time that you have heard of this, then there might be a bigger issue here. This is definitely something that you should request that your physical therapist and or neurologist do. With you next time. What this measures is walking speed over a short distance. It is, again, one of the most common tests in neurology clinics. And also it's part of a bigger test called multiple sclerosis Functional composite or Ms. Fc. If you're someone who looks at Ms. Research, you might see the MSFC quite frequently. It's used a lot in research to see if a specific intervention is helping improve walking or not. So when you are doing this in the physical therapy clinic, there is a distance that is marked and it's 25ft from one end to the other end. So sometimes there will be tape on the floor at one point and the other point, other times someone will know, okay, this hallway is exactly 25ft, but there's this distance of 25ft. You start at one end, you walk as quickly and safely as possible to the other end, and you are timed with a stopwatch. Usually it's done twice, and the average of the times is the number that you go with. Sometimes it's done three times and you take the average. But typically it's done more than once. And you would use your usual walking aid if you typically use one. Now, when you're doing this at home, you could potentially do the same exact thing. If you have a distance in your space that is 25ft or close to it, that would be ideal. Now, at home, again, we're not looking for perfection. We're just looking for as close as possible. So if you have a distance that's 20ft or even 15 or 30, you know, it can be different from exactly 25ft. But we're trying to get as close to 25 as possible. And you want to choose a distance that will not move. So maybe you do put tape on your floor, or if that's not really your vibe, then maybe you measure the distance from one wall to another wall. And walls are not moving. Unless you're getting construction on your home and you're remodeling, those walls are going to be there. So that is a very consistent thing. You wouldn't necessarily want to go from one chair to another if those chairs move, like if one chair is a kitchen chair, but that might move, that's not going to give us that consistency that we're looking for. So try your best to make sure that whatever is marking that distance for you so stays the same every time you do this test. And from there, it's very similar to the in clinic version. You're going to start at one point, ideally behind the start line. You or someone else that is at home with you is going to time you. And the timer starts when your first foot crosses that start line. And you're going to walk as fast and as safely as possible. And the timer stops when that first foot crosses the the end line again. You can use that mobility aid if you normally use one rest, which could be 30 seconds, it could be five minutes, however long you need, and then repeat the test and take the average of those two trials. When we're recording your results, you want to write down the time of day. You want to write down what date it is. I personally would record today. How are you feeling? Is this an average day for you? A great day, A bad day? Because that will be important for the next day that you choose to repeat this test. You want to choose similar days. Note any variables. Note your fatigue levels. Note any recent medications. Note the again, the time of day, morning versus evening. Did you use a mobility aid? Did you use electrical stimulation? Write all of this down. Because we want to replicate this as similarly as possible every single time. For the timed 25 foot walk test, typically this is what the results mean. If it's less than five seconds, then there is minimal to no walking impairment. If it's 5 to 10 seconds, it's mild to moderate impairment. If it's 10 seconds or more, it's moderate to severe impairment. But it's really important to remember that your improvement is what matters. So regardless of what your number shows, let's just say it did say a 5 or 10. Let's go with a 10. If it said 10 last time, technically that's moderate to severe impairment. But if next time it's an 8 or even a 9, that's technically faster. That is an improvement. So again, we're trying to track trends, we're trying to not associate good or bad with specific numbers here. However, research shows that for this specific test, the timed 25 foot walk test, a 20% improvement is what is clinically meaningful. Meaning if Your improvement is 20% better than the last time or several times ago, that is clinically meaningful. That means that you are actually improving. It wasn't just a randomly better day. The next test is called the timed up and go or the tug test. I don't know why, but this is one of my favorite ones. This one measures functional mobility. It combines multiple movements. So the first test we talked about, you just start at one end, walk to the other end, and that's pretty much it. But the timed up and go looks at standing up, walking, turning, walking back and sitting down. So it's lots of different movements. That's four movements right there. Standing up, walking, turning, and sitting down. So this isn't just looking at walking. It's also looking at strength, balance, and coordination all together. When you're doing this in the physical therapy clinic or neurologist clinic, the clinical version uses a typical standard, standard armless chair. So there's no armrests and the seat height is ideally around 46cm. There is a line that is marked in front of you. So if you're sitting in the chair, you're looking in front of you, about 3 meters or 10ft away from you, there is a line on the floor. And the clinician is going to time you of how long it takes you to stand up, walk down to that line, turn around, walk back, and sit down. So the time marks from when they say go until you are fully seated again. So again, you're starting sitting, you stand up, walk down to the line, turn around, walk back, and sit back down. So that's the same thing that we want to do at home. This setup is going to be as similar as possible, but I like to focus on safety at home. So preferably you are going to have a chair with armrests so that you can use them. Because as we all know, you can use armrests to help you stand up and to sit down. Just make sure to note in your notes, wherever you're logging this information, that you did use the armrest to stand up and or sit down when doing the test. But you're going to use a sturdy chair, ideally with armrests. You're going to measure about 10ft in front of you or 3 meters in front of you from the chair. Again, we're just trying to get as close as possible. If there's no place in your home where you have 10ft in front of you, then maybe you have 7ft, maybe it's 15. Whatever it is, just write it down so you can choose that same distance next time. And you're going to mark that spot with doesn't have to be tape. It can be an object. It could be a water bottle, it could be a doorway. Oftentimes when I'm sharing this test with my missing link members and I'm demonstrating how to do it, I will actually use the chair in my office, which never moves. I stand up, I walk down to the wall, I turn around and sit down. So the wall is my marker. In that case, and if possible, have someone else handle the stopwatch. You can do it yourself. It just adds a layer of complexity though. So it is helpful if you have someone else to use that stopwatch. So when you're doing the test, you're going to be sitting fully down, not like ready to go. You're sitting fully in the chair. The person that you are with, who's going to help with the stopwatch is going to say go. And on go, you stand up, walk down to the water bottle or line or door, whatever it is, turn around, walk back, sit down, use the armrest if you need to use a mobility aid. If you normally do, and we only do this test once, typically if you have energy to do it again, we could do twice and take the average. But typically we just do this once, especially at home. And similar to the first test, you're recording the time of day. Did you use a mobility aid? Did you use electrical stimulation? Did you notice any tripping? Did you lose your balance at all? Any near losses or almost falls? Did you use the armrests? All of these things are so important because with all of these tests you might notice that your score, your time actually stays the same, but you're no longer using a rollator, you're using trekking poles, or your score stays the same. Or maybe you're walking even slower, but you had zero instances of losing your balance and initially you lost your balance three times. So that's why these notes are so important, because sometimes the numbers won't actually change. But, but the quality of your walking is improving. And that is just as important with this specific test. The timed up and go. Here's what the scores mean. So if you score less than 10 seconds, generally that means you are freely mobile, you are independent. If Your score is 10 to 20 seconds, you are mostly independent with some mobility limitation. If Your score is 20 to 30 seconds, it's variable mobility. And it means that you might require an assistive device or a mobility aid. And if you have 30 seconds or more, then that typically indicates impaired mobility. The last test that I want to talk about today is the five time sit to stand test. However, there's another test that is very similar to this one, but it's called the 32nd sit to stand test. I'm going to explain both. They're very similar and in my opinion, you can choose whichever one you prefer, maybe whichever one is the least fatiguing or whichever one you enjoy the most. But these tests are really great because it measures lower body strength and power and it measures your functional ability to stand up from surfaces, from chairs, from the toilet from a bench anywhere. And it also looks at balance control. So pretty simple, pretty self explanatory. The five time sit to stand test. If you're doing this in the clinic, you're going to use a standard chair. Typically they use chairs without armrests. You're going to stand up and sit down fully five times as fast and as safely as possible. If you're able to, your arms will be crossed over your chest so that you can't use your arms. And from the time of your first movement, where you hinge forward to stand up to your final seated position is what your score will be. That's where you're timed with that stopwatch. The setup at home is the same. However, again at home, we're even more so prioritizing safety. So I do prefer to use a chair with armrests. Even if you don't need them, it just can feel a bit safer. And push that chair up to a wall or something that's not going to move because we don't want you to be in a situation where you go to sit down and you plop down and the chair moves and the chair falls and now you're on the floor too. So use a sturdy chair, ideally with armrests, push it up against a surface, countertop, table, wall, whatever it is. And ideally have someone time you. So you're going to start in that seated position. Your arms can be crossed if you want to try it without the armrest. Or your arms can be in front of you, which can help with momentum. Or you can actually use the armrest. Regardless, write down what your arms are doing so that we can try to do it the same way. Next time the person timing you is going to say go and on go. You are going to stand up fully, none of this, half standing. So often when people do this, they're so focused on just doing it quickly that they don't fully stand up. They like partially stand up, then sit back down. Fully stand up, fully sit down five times. You must fully extend your knees when standing and then your bottom must touch the seat when you're sitting. And that person recording you is going to see the total time that it took you for all five repetitions. You're going to write down if your arms were used or not. Did you have any balance issues? Did you lose your balance at all? Write all of that down. What time of day? All the same things we've been tracking for the other ones. And in terms of scoring, typically 12 seconds or less is good functional mobility. 12 to 15 seconds is moderate functional mobility. 15 seconds means it might be an indication of a fall risk or significant impairment. And then 30 seconds or more is severe impairment and definitely a fall risk. Now, I mentioned the 32nd sit to stand test. Again, it's so similar to this. The main difference is that instead of standing up and sitting down five times with someone timing you, someone's putting 30 seconds on a stopwatch and they are going to time how many repetitions you do in 30 seconds. So it's the same test. You're staying in that same chair, but you're going to stand up and sit down fully, just like with this original test, as many times as you can. And then the person timing you is going to say stop when you get to 30 seconds. So regardless of which one you choose, it's looking at the same thing. It's looking at your ability to stand up, it's looking at your leg strength, your balance strength, et cetera. When it comes to how often to test these, first and foremost, you do not need to do all of them. You can if you want to. It would probably be pretty fatiguing to do them all, especially on the same day, but you don't have to do all of them. I typically like to do these every four to eight weeks. That would be ideal. That gives you enough time to continue with the intervention of choice, the exercises, the massage, you know, whatever it is, and see every four to eight weeks or so. Have there been any changes yet? Again, we're trying to choose a similar time of day, similar type of day for you don't necessarily choose bad days. Try to wait for whatever your average day might be. But we are writing all this down because if you're only doing this every four to eight weeks, you might not remember if you used armrests or not, or you might not remember how many times you tripped when you were doing one of these tests. So write every detail down. I promise you you will thank yourself because oftentimes before the numbers improve, the quality actually improves first. And if you're only focused on the numbers, you might feel like you're getting worse or whatever you're doing isn't happening. But in reality, you are actually improving. You're tripping less, you're saying scuffing your toes less, your quality is getting better. We do have our Missing Link app where there's a course, it's absolutely free in there called track your progress. And in here you will be able to see videos of all of these tests being done. They're really short, I just demonstrate exactly what to do and how to do it. So if you are a visual person like me, definitely get the Missing link app, open the track your progress course and you'll watch those videos and you can even track in there what your score was and you can keep track of those on your own if you want, in just a journal or a simple spreadsheet. Again, including the date, the time of day scores, mobility aids, like all these things we've been talking about. And also note any changes. Did you do a new exercise routine? Did you add a new exercise? Did you change your medication? Did you have a recent relapse? If there's been any changes since the previous testing, write that down. It can't hurt. The more information we have, the better. And just as a reminder, we're looking for trends, not perfections. We're looking over the past three months, over the past six months, what are the trends that we are seeing? If you are fluctuating, which is very normal, you will likely see you're doing better today and then worse the next time. Better than worse, Better than worse. But when we look over the last six months, what you likely will notice is that your worst days with worse scores now at the six month mark is actually better than what your worst scores were initially. Or in a lot of cases, your worst scores at six months are actually better than your best scores initially. So you likely will not have a linear path where every time you do these, the numbers are improving. But when you look over time, you are gradually getting better and better. Day to day fluctuation is normal, because Ms. Fluctuation is normal. And also remembering that any improvement counts, research thresholds, these numbers that I've been giving you of what the numbers mean, those are just guidelines. Your lived experience matters most. So keep that in mind. That's one reason it's so important to write down all of these notes. Also keeping in mind that sometimes with Ms. The goal isn't necessarily improvements, or rather success isn't only when you're seeing improvements. Success is also maintenance. Ms. Is working hard against us. And so if we can maintain, in my eyes, and in a lot of clinicians eyes, that's actually improvement too. That is success. So don't think of success with these numbers and with these tests as just improvements in numbers, even just maintaining is still successful. And when your numbers don't match, how you're feeling, like if your numbers are showing, you're walking slower or you did fewer repetitions, but you're actually feeling stronger and you feel like you're walking better and like you're tripping less. Trust your experience first. These again are just tests that are measuring specific moments in time, but how you feel and your lived experience is going to be the number one thing that is important that we listen to to determine the if something is helping you or not. These tests are just one tool. They're not the only tool. Also, these are just a few of the objective functional outcome measures. There's a ton. The nine hole peg test is another really common one. The six minute walk test or two minute walk test. There's so many. These are just a few. But regardless, all of them are just tools. They don't capture the full picture. So you now have four different tests that you can do at home if you are looking to track any type of progress that may or may not be happening. You can pair these with the subjective outcome measures that we talked about last week for the complete picture. Again, your notes that you keep for all of these. The subjective as well as objective tests are going to be really important. If you are looking to see videos of these in particular, download the Missing Link app. A quick note there We've had the Missing Link app for many, many years now, but within this past year in 2025 we actually switched platforms. So if you haven't used the app in six months or so, just delete it and then re download the newer Missing Link app. It's so much better. It's so much more user friendly. Get the track your progress course. It's free right in that app and you'll be able to see all of those videos and I would even encourage you to start your baseline testing this week. Again, there's no numbers that are good or bad. It's just a number. But start this week. Pick which ones you want to do in four weeks from now or eight weeks from now. Track it again. But you've got this. Please know that progress is possible. I know it doesn't always feel that way with ms, but it is possible and I would love to hear from you which tests you are most excited about trying or maybe even most nervous. But a good type of nervous like you want to see how you do. So definitely reach out and let me know. Thank you for listening to today's show. I am so grateful to have you as listener.