Exercise and Rehabilitation for Individuals with Multiple Sclerosis

Pathogenesis and management of multiple sclerosis revisited

BACKGROUND

Multiple sclerosis is an autoimmune chronic inflammatory disease characterized by selective destruction of myelin in the CNS neurons (including optic nerve). It was first described in the 19th century and remained elusive owing to the disease's unique relapsing and remitting course. The widespread and debilitating prevalence of multiple sclerosis (MS) has prompted the development of various treatment modalities for its effective management.

METHODS AND OBJECTIVES

A literature review was conducted using the electronic databases PubMed and Google Scholar. The main objective of the review was to compile the advances in pathogenesis, classifications, and evolving treatment modalities for MS.

RESULTS

The understanding of the pathogenesis of MS and the potential drug targets for its precise treatment has evolved significantly over the past decade. The experimental developments are also motivating and present a big change coming up in the next 5 years. Numerous disease-modifying therapies (DMTs) have revolutionized the management of MS: interferon (IFN) preparations, monoclonal antibodies-natalizumab and ocrelizumab, immunomodulatory agents-glatiramer acetate, sphingosine 1-phosphate receptor 1 (S1PR1) modulators (Siponimod) and teriflunomide. The traditional parenteral drugs are now available as oral formulations improving patient acceptability. Repurposing various agents used for related diseases may reinforce the drug reserve to manage MS and are under trials. Although at a nascent phase, strategies to enhance re-myelination by stimulating oligodendrocytes are fascinating and hold promise for better outcomes in patients with MS.

CONCLUSIONS

The recent past has seen staggering inclusions to the management of multiple sclerosis catalyzing a significant turnabout in our approach to diagnosis, treatment, and prognosis. Since the advent of DMTs various other oral and injectable agents have been approved. The advances in MS therapeutics and diagnostics have laid the ground for further research and development to enhance the quality of life of afflicted patients.

Neuromuscular Electrical Stimulation in Conjunction with Conventional Swallowing Therapy in the Treatment of Dysphagia Caused by Multiple Sclerosis: A Single-Case Experimental Design

INTRODUCTION

Dysphagia as a consequence of multiple sclerosis (MS) puts individuals at higher risk of dehydration, malnutrition, and aspiration pneumonia. This study intended to investigate the effects of a combined program of neuromuscular electrical stimulation (NMES) and conventional swallowing therapy to improve swallow safety and efficiency, oral intake, and physical, emotional, and functional impacts of dysphagia in people with dysphagia and MS.

METHODS

In this single-case experimental study with ABA design, two participants with dysphagia caused by MS underwent 12 sessions therapy during 6 weeks following a baseline of 4 evaluation sessions. They were evaluated 4 more times in the follow-up phase after therapy sessions. Scores of Mann Assessment of Swallowing Ability (MASA), DYsphagia in MUltiple Sclerosis (DYMUS), and timed test of swallowing capacity were obtained at baseline, during treatment, and in the follow-up phases. The Dysphagia Outcome and Severity Scale (DOSS) based on videofluoroscopic swallow studies, Persian-Dysphagia Handicap Index (Persian-DHI), and Functional Oral Intake Scale (FOIS) were also completed before and after treatment. Visual analysis and percentage of nonoverlapping data were calculated.

RESULTS

MASA, DYMUS, FOIS, and DHI scores indicated significant improvement in both participants. Although the scores of the timed test of swallowing capacity in participant 1 (B.N.) and DOSS in participant 2 (M.A.) showed no changes, considerable improvements including reducing the amount of residue and the number of swallows required to clear bolus were seen in the posttreatment videofluoroscopic records of both participants.

CONCLUSION

NMES in conjunction with conventional dysphagia therapy based on motor learning principles could improve the swallowing function and decrease disabling effects of dysphagia on different aspects of life in participants with dysphagia caused by MS.

A 3-DoF robotic platform for the rehabilitation and assessment of reaction time and balance skills of MS patients

The central nervous system (CNS) exploits anticipatory (APAs) and compensatory (CPAs) postural adjustments to maintain the balance. The postural adjustments comprising stability of the center of mass (CoM) and the pressure distribution of the body influence each other if there is a lack of performance in either of them. Any predictable or sudden perturbation may pave the way for the divergence of CoM from equilibrium and inhomogeneous pressure distribution of the body. Such a situation is often observed in the daily lives of Multiple Sclerosis (MS) patients due to their poor APAs and CPAs and induces their falls. The way of minimizing the risk of falls in neurological patients is by utilizing perturbation-based rehabilitation, as it is efficient in the recovery of the balance disorder. In light of the findings, we present the design, implementation, and experimental evaluation of a novel 3 DoF parallel manipulator to treat the balance disorder of MS. The robotic platform allows angular motion of the ankle based on its anthropomorphic freedom. Moreover, the end-effector endowed with upper and lower platforms is designed to evaluate both the pressure distribution of each foot and the CoM of the body, respectively. Data gathered from the platforms are utilized to both evaluate the performance of the patients and used in high-level control of the robotic platform to regulate the difficulty level of tasks. In this study, kinematic and dynamic analyses of the robot are derived and validated in the simulation environment. Low-level control of the first prototype is also successfully implemented through the PID controller. The capacity of each platform is evaluated with a set of experiments considering the assessment of pressure distribution and CoM of the foot-like objects on the end-effector. The experimental results indicate that such a system well-address the need for balance skill training and assessment through the APAs and CPAs.

[The use of botulinum toxin type A in symptomatic therapy and medical rehabilitation of patients with multiple sclerosis]

The review of the current state of the problem of symptomatic therapy and medical rehabilitation (MR) of patients with multiple sclerosis (MS) is presented. The search was conducted in the databases Medline, Web of Science, PubMed and Scopus. Information is given about the most common symptoms of MS, among which sensory and motor disorders, bladder dysfunction, and pain have the greatest impact on the quality of life of patients, their functioning and independence in everyday life. The clinical characteristics of spasticity syndrome in MS and its relationship with quality of life indicators are considered. The features of the use of botulinum therapy (BT) in MS are considered. A high level of effectiveness of the use of BT in the treatment of neurogenic hyperactivity of detrusor and neurogenic bladder (the level of persuasiveness of recommendation A) and spasticity (the level of persuasiveness of recommendation B) is shown. Symptomatic treatment of MS and MR with the use of multidisciplinary programs helps to reduce disability, improve the quality of life of patients. When choosing symptomatic treatment and MR methods, it is customary to focus on the needs of patients.

Multiple sclerosis-related fatigue lacks a unified definition: A narrative review

Fatigue is the most common symptom in multiple sclerosis (MS). Although MS-related fatigue (MS-F) strongly affects quality of life and social performance of patients, there is currently a lack of knowledge about its pathophysiology, which in turns leads to poor objective diagnosis and management. Recent studies have attempted to explain potential etiologies as well as treatments for MS-F. However, it seems that without a consensus on its nature, these data could not provide a route to a successful approach. In this Article, we review definitions, epidemiology, risk factors and correlated comorbidities, pathophysiology, assessment methods, neuroimaging findings, and pharmacological and nonpharmacological treatments of MS-F. Further studies are warranted to define fatigue in MS patients more accurately, which could result in precise diagnosis and management.

Feasibility and initial efficacy of a high-intensity interval training program using adaptive equipment in persons with multiple sclerosis who have walking disability: study protocol for a single-group, feasibility trial

Background

There is considerable evidence for the efficacy of moderate-intensity continuous exercise benefitting clinically relevant outcomes in persons with multiple sclerosis (MS). However, persons with MS who have walking disability (pwMS-wd) are severely deconditioned and may achieve superior benefits by engaging in high-intensity interval training (HIIT), especially while utilizing adaptive equipment, such as recumbent arm/leg stepping (RSTEP). The proposed study will assess the feasibility of a 12-week, RSTEP HIIT program in pwMS-wd. The secondary aim will examine changes in aerobic fitness, physical activity, ambulation, upper arm function, cognition, fatigue, and depression as clinically relevant efficacy outcomes following the 12-week, RSTEP HIIT intervention.

Methods

The study will recruit 15 pwMS-wd. Feasibility will be measured via process, resource, management, and scientific outcomes throughout the entirety of the research study. The secondary, clinically relevant outcomes will consist of a neurological exam, aerobic capacity, physical activity, ambulation, cognition, upper arm function, fatigue, and depression. Outcomes will be assessed at baseline (T1), midpoint (T2, following 6 weeks), and post-intervention (T3, following 12 weeks). The intervention will involve 12 weeks of supervised, individualized HIIT sessions two to three times per week. The individual HIIT sessions will each involve 10 cycles of 60-s intervals at the wattage associated with 90% VO_2peak followed by 60 s of active recovery intervals at 15 W, totaling 20 min in length plus 5-min warm-up and cool-down periods.

Discussion

The feasibility design of the proposed study will provide experience and preliminary data for advancing towards a proof-of-concept study comparing HIIT to moderate-intensity continuous RSTEP for improving clinically relevant outcomes in a randomized control trial design. The results will be disseminated via manuscripts for publication and a report for distribution among the National Multiple Sclerosis Society.

Trial registration

ClinicalTrials.gov NCT04416243. Retrospectively registered on June 4, 2020

A Descriptive Cross-Sectional Study of Manipulative Dexterity on Different Subtypes of Multiple Sclerosis

Background

Manipulative dexterity impairments affect 76% of individuals with multiple sclerosis (MS). Patients with MS can experience reduced skill when performing both basic activities of daily living and instrumental activities of daily living. Many studies consider that physical rehabilitation leads to a decrease in the level of disability, especially at the mild and moderate stages of the disease. However, most studies fail to distinguish between the different MS subtypes.

Purpose

Our aims were (1) to describe the manipulative skills of people according to the different subtypes of MS, (2) to analyze the correlation between dexterity and self-perception variables, and (3) to identify possible predictors of functionality. Study Design. A descriptive cross-sectional study.

Methods

30 individuals with MS. The measurement tools used were the ABILHAND, the Purdue Pegboard Test (PPT), the Nine-Hole Peg Test, and the Box and Block Test.

Results

All subtypes of MS obtained lower scores for manipulative dexterity compared to normal skill levels, with individuals with primary progressive MS displaying the lowest values. However, the analysis of differences between the different subtypes did not reveal statistically significant intragroup differences. In addition, differences were found regarding the effect size of practically all the variables analyzed for both manipulative dexterity (PPT, NHPT, and BBT) and the self-perception of ADLs (ABILHAND), for which high values (d _r = 0.72) and very high values (d _r = 1.46) were obtained.

Conclusions

Although no significant differences were found between the different types of MS, the assessment of manual dexterity and perceived efficacy of daily activities must be considered as prognostic factors in the progression of the disease. These findings may help support further research on targeted interventions to improve dexterity deficiencies, as well as promote an improved quality of therapeutic interventions.

Exercise Training Guidelines for Multiple Sclerosis, Stroke, and Parkinson Disease: Rapid Review and Synthesis

The translation of knowledge from exercise training research into the clinical management of multiple sclerosis, stroke, and Parkinson disease requires evidence-based guidelines that are uniformly recognizable by healthcare practitioners and patients/clients. This article synthesized resources that reported aerobic and resistance training guidelines for people with multiple sclerosis, stroke, and Parkinson disease. Systematic searches yielded 25 eligible resources from electronic databases and Web sites or textbooks of major organizations. Data were extracted (exercise frequency, intensity, time, and type) and synthesized into three sets of recommendations. Exercise guidelines for multiple sclerosis consistently recommended 2-3 d/wk of aerobic training (10-30 mins at moderate intensity) and 2-3 d/wk of resistance training (1-3 sets between 8 and 15 repetition maximum). Exercise guidelines for stroke recommended 3-5 d/wk of aerobic training (20-40 mins at moderate intensity) and 2-3 d/wk of resistance training (1-3 sets of 8-15 repetitions between 30% and 50% 1 repetition maximum). Exercise guidelines for Parkinson disease recommended 3-5 d/wk of aerobic training (20-60 mins at moderate intensity) and 2-3 d/wk of resistance training (1-3 sets of 8-12 repetitions between 40% and 50% of 1 repetition maximum). This harmonization of exercise guidelines provides a prescriptive basis for healthcare providers, exercise professionals, and people with multiple sclerosis, stroke, and Parkinson disease regarding exercise programming.

Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations

BACKGROUND

Multiple sclerosis (MS) can result in significant mental and physical symptoms, specially muscle weakness, abnormal walking mechanics, balance problems, spasticity, fatigue, cognitive impairment and depression. Patients with MS frequently decrease physical activity due to the fear from worsening the symptoms and this can result in reconditioning. Physicians now believe that regular exercise training is a potential solution for limiting the reconditioning process and achieving an optimal level of patient activities, functions and many physical and mental symptoms without any concern about triggering the onset or exacerbation of disease symptoms or relapse.

MAIN BODY

Appropriate exercise can cause noteworthy and important improvements in different areas of cardio respiratory fitness (Aerobic fitness), muscle strength, flexibility, balance, fatigue, cognition, quality of life and respiratory function in MS patients. Aerobic exercise training with low to moderate intensity can result in the improvement of aerobic fitness and reduction of fatigue in MS patients affected by mild or moderate disability. MS patients can positively adapt to resistance training which may result in improved fatigue and ambulation. Flexibility exercises such as stretching the muscles may diminish spasticity and prevent future painful contractions. Balance exercises have beneficial effects on fall rates and better balance. Some general guidelines exist for exercise recommendation in the MS population. The individualized exercise program should be designed to address a patient's chief complaint, improve strength, endurance, balance, coordination, fatigue and so on. An exercise staircase model has been proposed for exercise prescription and progression for a broad spectrum of MS patients.

CONCLUSION

Exercise should be considered as a safe and effective means of rehabilitation in MS patients. Existing evidence shows that a supervised and individualized exercise program may improve fitness, functional capacity and quality of life as well as modifiable impairments in MS patients.

Neuromuscular fatigue during exercise: Methodological considerations, etiology and potential role in chronic fatigue

The term fatigue is used to describe a distressing and persistent symptom of physical and/or mental tiredness in certain clinical populations, with distinct but ultimately complex, multifactorial and heterogenous pathophysiology. Chronic fatigue impacts on quality of life, reduces the capacity to perform activities of daily living, and is typically measured using subjective self-report tools. Fatigue also refers to an acute reduction in the ability to produce maximal force or power due to exercise. The classical measurement of exercise-induced fatigue involves neuromuscular assessments before and after a fatiguing task. The limitations and alternatives to this approach are reviewed in this paper in relation to the lower limb and whole-body exercise, given the functional relevance to locomotion, rehabilitation and activities of daily living. It is suggested that under some circumstances, alterations in the central and/or peripheral mechanisms of fatigue during exercise may be related to the sensations of chronic fatigue. As such, the neurophysiological correlates of exercise-induced fatigue are briefly examined in two clinical examples where chronic fatigue is common: cancer survivors and people with multiple sclerosis. This review highlights the relationship between objective measures of fatigability with whole-body exercise and perceptions of fatigue as a priority for future research, given the importance of exercise in relieving symptoms of chronic fatigue and/or overall disease management. As chronic fatigue is likely to be specific to the individual and unlikely to be due to a simple biological or psychosocial explanation, tailored exercise programmes are a potential target for therapeutic intervention.

Feasibility and Impact of an 8-Week Integrative Yoga Program in People with Moderate Multiple Sclerosis-Related Disability: A Pilot Study

BACKGROUND

This pilot study determined the feasibility of a specifically designed 8-week yoga program for people with moderate multiple sclerosis (MS)-related disability. We explored the program's effect on quality of life (QOL) and physical and mental performance.

METHODS

We used a single-group design with repeated measurements at baseline, postintervention, and 8-week follow-up. Feasibility was examined through cost, recruitment, retention, attendance, and safety. Outcomes included the Multiple Sclerosis Quality of Life Inventory (MSQLI), 12-item Multiple Sclerosis Walking Scale (MSWS-12), Timed 25-Foot Walk test (T25FW), 6-Minute Walk Test (6MWT), Nine-Hole Peg Test (NHPT), Five-Times Sit-to-Stand Test (FTSTS), Multidirectional Reach Test (MDRT), maximum expiratory pressure, and Paced Auditory Serial Addition Test-3″ (PASAT-3″).

RESULTS

Fourteen participants completed the study. The program was feasible. There were significant main effects on the 36-item Short Form Health Status Survey Mental Component Summary (SF-36 MCS), Modified Fatigue Impact Scale (MFIS), Bladder Control Scale (BLCS), Perceived Deficits Questionnaire (PDQ), Mental Health Inventory (MHI), MSWS-12, T25FW, NHPT, PASAT-3″, 6MWT, FTSTS, and MDRT-Back. Improvements were found on the SF-36 MCS, MFIS, BLCS, PDQ, MHI, and MSWS-12 between baseline and postintervention. The effect on PDQ persisted at follow-up. Improvements were found on the T25FW, NHPT, 6MWT, FTSTS, and MDRT-Back between baseline and postintervention that persisted at follow-up. The PASAT-3″ did not change between baseline and postintervention but did between postintervention and follow-up.

CONCLUSIONS

The yoga program was safe and feasible. Improvements in certain measures of QOL and performance were seen at postintervention and follow-up.

Patient perspectives and experience with dalfampridine treatment in multiple sclerosis-related walking impairment: the step together program

Background

Dalfampridine extended-release tablets (dalfampridine-ER; in Europe, prolonged-release fampridine, and elsewhere, fampridine modified or fampridine sustained release), 10 mg twice daily, are available for the treatment of improvement of walking in patients with multiple sclerosis, as demonstrated by an increase in walking speed. On-drug patient perspectives and experiences are valuable to understand and manage this patient population.

Objective

The objective of this study was to examine perspectives and experiences of patients receiving dalfampridine-ER in a real-world setting.

Methods

Step Together, an ongoing program that captures real-world patient experience with dalfampridine-ER treatment, consists of a survey administered at baseline (before dalfampridine-ER initiation) and at 30 (first follow-up) and 60 days (second follow-up) after initiation. The survey includes modified versions of the 12-item Multiple Sclerosis Walking Scale (mMSWS-12) and the Sheehan Disability Scale (mSDS) to assess walking ability and functional impairment, respectively.

Results

As of September 2013, 2,248 patients participated in the baseline survey and 522 completed both follow-up surveys (completers). Among the completers, improvements in walking ability and function relative to baseline were significant at both follow-ups as measured by mMSWS-12 and mSDS scores, respectively. Notably, 69–74 % of completers at both follow-ups had improved mMSWS-12 scores, with scores greater than the range considered to be minimally clinically significant. Patients who completed the program expressed satisfaction with overall dalfampridine-ER treatment, and 69 % indicated that the survey would help them communicate better with their healthcare providers.

Conclusion

Results highlight the utility of patient-reported outcomes in the assessment of patient perspective and experience, providing a useful supplement to traditional objective measures used in clinical studies.

Electronic supplementary material

The online version of this article (doi:10.1007/s40271-014-0102-z) contains supplementary material, which is available to authorized users.

Aerobic exercise in people with multiple sclerosis: its feasibility and secondary benefits

The aims of this study were to explore the feasibility of structured aerobic exercise followed by a period of unstructured physical activity and determine the impact of such exercise on cognition, mood, and quality of life in people with multiple sclerosis (MS). A convenience sample of 9 individuals with relapsing-remitting MS performed 30 minutes of aerobic exercise (upper- and lower-extremity ergometry and treadmill ambulation) twice weekly for 8 weeks, followed by 3 months of unstructured physical activity. Eight participants completed the intervention and posttest; 6 returned for the 3-month follow-up. Cardiovascular fitness, cognition, mood (measured with the Beck Depression Inventory-II; BDI-II), and quality of life (measured with the Multiple Sclerosis Quality of Life-54; MSQOL-54) were assessed. Participants completed 27.9 minutes of exercise per session, with an 85.1% attendance rate. Evaluation using the Wilcoxon signed rank test revealed no deleterious effects and improved results on the BDI-II and MSQOL-54 mental subscale. Analysis of change scores using the one-sample t test revealed that the BDI-II and MSQOL-54 were changed from zero after structured exercise, but only the BDI-II maintained improvement after unstructured physical activity. Further analysis of BDI-II subscales revealed that improvement occurred only in the Somato-Affective subscale. In this study, program feasibility was demonstrated in several ways. There were no declines in cognitive function over the 5-month period. Despite unchanged cognitive function, participants may value the improved mood enough to continue both the structured and unstructured physical activity. The role of unstructured physical activity in concert with periodic structured exercise programs merits further investigation.

Exercise in multiple sclerosis

Exercise is an intervention that may be used in the management of multiple sclerosis (MS). Certain exercise physiology characteristics are commonly seen among persons with MS, particularly in the more debilitated. Studies have shown that properly prescribed exercise programs can improve modifiable impairments in MS. Exercise is generally safe and well tolerated. General guidelines are available for exercise prescription for the MS population. There are several recommendations that may help improve the quality of future MS exercise trials.

Utilization of aerobic exercise in adult neurological rehabilitation by physical therapists in Canada

BACKGROUND AND PURPOSE

Although aerobic exercise (AE) has been shown to improve aerobic capacity and reduce morbidity in neurological populations, its application is challenging. The purpose of this study was to survey Canadian physical therapists practicing in adult neurorehabilitation regarding the use of AE in clinical practice.

METHODS

Members of the Neurosciences Division of the Canadian Physiotherapy Association were invited to participate in a Web-based survey.

RESULTS

Response rate was 36% (N = 155) with every Canadian province represented. The majority of respondents were females in full-time practice for more than 15 years. The majority (88%) agreed/strongly agreed with the following: "AE should be incorporated into treatment programs of patients with neurological conditions." Although 77% prescribed AE, barriers to use included patient concerns (cardiac status, cognitive/perceptual deficits, fatigue) and operations (lack of staff, time, screening tools). The most commonly used screening tools were health records and patient responses to exercise and the least common was exercise stress tests. Overground walking and cycle ergometry were the most frequently used AE modes, and general response to exercise and patient feedback were most frequently used for determining exercise intensity and monitoring AE.

DISCUSSION AND CONCLUSIONS

Respondents clearly recognized the importance of AE in neurorehabilitation. Barriers to application of AE and limitations in the use of appropriate screening and training procedures need to be addressed to advance clinical utilization of AE in neurological practice. Understanding current patterns of utilization of AE is important for the development of professional education initiatives and clinical guidelines for best practices in AE for neurological populations. Video Abstract available (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A40) for more insights from the authors.

Constraint-induced movement therapy for the lower extremities in multiple sclerosis: case series with 4-year follow-up

OBJECTIVE

To evaluate in a preliminary manner the feasibility, safety, and efficacy of Constraint-Induced Movement therapy (CIMT) of persons with impaired lower extremity use from multiple sclerosis (MS).

DESIGN

Clinical trial with periodic follow-up for up to 4 years.

SETTING

University-based rehabilitation research laboratory.

PARTICIPANTS

A referred sample of ambulatory adults with chronic MS (N=4) with at least moderate loss of lower extremity use (average item score ≤6.5/10 on the functional performance measure of the Lower Extremity Motor Activity Log [LE-MAL]).

INTERVENTIONS

CIMT was administered for 52.5 hours over 3 consecutive weeks (15 consecutive weekdays) to each patient.

MAIN OUTCOME MEASURES

The primary outcome was the LE-MAL score at posttreatment. Secondary outcomes were posttreatment scores on laboratory assessments of maximal lower extremity movement ability.

RESULTS

All the patients improved substantially at posttreatment on the LE-MAL, with smaller improvements on the laboratory motor measures. Scores on the LE-MAL continued to improve for 6 months afterward. By 1 year, patients remained on average at posttreatment levels. At 4 years, half of the patients remained above pretreatment levels. There were no adverse events, and fatigue ratings were not significantly changed by the end of treatment.

CONCLUSIONS

This initial trial of lower extremity CIMT for MS indicates that the treatment can be safely administered, is well tolerated, and produces substantially improved real-world lower extremity use for as long as 4 years afterward. Further trials are needed to determine the consistency of these findings.

Fatigue in multiple sclerosis - a brief review

Fatigue is the most common and debilitating symptom in multiple sclerosis (MS) and is believed to be distinctly different from fatigue seen in other chronic conditions. It can affect a patient's mood, sleep and have a detrimental effect on their quality of life. In the recent years much literature has emerged in an attempt to elucidate the potential causes and treatment of this common symptom. This review article aims to examine the most recent theories on the pathophysiology of fatigue in MS as well as its association with sleep and depression. We describe the pharmacological and non-pharmacological approaches to its treatment and propose a multidisciplinary, patient enabled and individualised manner to the management of fatigue in MS.

The benefits of exercise training in multiple sclerosis

Multiple sclerosis (MS) is an immune-mediated disease characterized by inflammatory demyelination and neurodegeneration within the CNS. This damage of CNS structures leads to deficits of body functions, which, in turn, affect patient activities, such as walking, and participation. The pathogenesis and resulting consequences of MS have been described as concepts within the International Classification of Functioning, Disability and Health (ICF) model--an international standard to describe and measure health and disability. Evidence suggests that exercise training in people with MS has the potential to target and improve many of the components outlined in the ICF model. Although the body of research examining the effects of exercise training on depression, cognition and participatory outcomes is not sufficiently developed, some preliminary evidence is promising. Exercise training is proposed to affect inflammation, neurodegeneration, and CNS structures, but current evidence is limited. In this Review, we discuss evidence from clinical trials that suggests beneficial effects of exercise training on muscle strength, aerobic capacity and walking performance, and on fatigue, gait, balance and quality of life. Issues with current studies and areas of future research are highlighted.

Dalfampridine: A Medication to Improve Walking in Patients with Multiple Sclerosis

OBJECTIVE:

To review the pharmacology, pharmacokinetics, efficacy, and safety of dalfampridine.

DATA SOURCES:

A search of PubMed (1966-March 2012) was conducted using the words dalfampridine and Ampyra. Bibliographies of retrieved articles were reviewed to identify additional references.

STUDY SELECTION AND DATA EXTRACTION:

All identified studies published in English involving the efficacy and safety of dalfampridine were reviewed.

DATA SYNTHESIS:

Dalfampridine (Ampyra) is a broad-spectrum potassium channel blocker that is indicated as a treatment to improve walking in patients with multiple sclerosis (MS). Dalfampridine is the only medication approved for this indication. Efficacy has been demonstrated in 2 Phase 3 trials involving patients with MS. Dalfampridine 10 mg twice daily improved walking, as shown by a higher proportion of timed walk responders in the dalfampridine-treated group (42.9% and 35%) versus the placebo-treated group (9.3% and 8%) during the 2 studies (p < 0.001). The maximum recommended dose of dalfampridine is 10 mg twice daily; higher doses are associated with an increased risk of seizures. At doses greater than 10 mg twice daily, the frequency of other adverse reactions and discontinuations was greater and showed no additional benefit. The average wholesale price of a 10-mg dalfampridine tablet is $21.12, which would make a 1-month supply of therapy cost $1267.20.

CONCLUSIONS:

In clinical trials, dalfampridine improved walking speed in approximately one third of patients with MS. The risk of seizures appears to be dose-related and the incidence is low at doses of 10 mg twice daily. Because of the cost, dalfampridine should be reserved for patients who meet criteria for the drug and continued only if they have an adequate response.

Multiple sclerosis and progressive resistance training: a systematic review

Recently progressive resistance training (PRT) has been recognised as an effective tool in the rehabilitation of persons with multiple sclerosis (MS). The objective of this study was to systematically review the literature of PRT studies for persons with MS. A comprehensive literature search (PubMed, SveMed+, Embase, Cochrane, PEDro, SPORTDiscus and Bibliotek.dk) was conducted. Identified papers were rated according to the PEDro-scale. Sixteen studies were included and scored between 3 and 8 of 11 total points on the PEDro-scale, showing a general lack of blinding. Strong evidence regarding the beneficial effect of PRT on muscle strength was observed. Regarding functional capacity, balance and self-reported measures (fatigue, quality of life and mood) evidence is less strong, but the tendency is overall positive. Indications of an effect on underlying mechanisms such as muscle morphological changes, neural adaptations and cytokines also exist, but the studies investigating these aspects are few and inconclusive. PRT has a positive effect on muscle strength for persons with MS. Heterogeneous results exist regarding the effect on functional capacity and self-reported measures probably because of differences in training protocols, samples sizes, type and severity of MS. The area of underlying mechanisms deserves more attention in future research.

Symptomatic therapy and rehabilitation in primary progressive multiple sclerosis

Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating disease of the central nervous system and a major cause of chronic neurological disability in young adults. Primary progressive MS (PPMS) constitutes about 10% of cases, and is characterized by a steady decline in function with no acute attacks. The rate of deterioration from disease onset is more rapid than relapsing remitting and secondary progressive MS types. Multiple system involvement at onset and rapid early progression have a worse prognosis. PPMS can cause significant disability and impact on quality of life. Recent studies are biased in favour of relapsing remitting patients as treatment is now available for them and they are more likely to be seen at MS clinics. Since prognosis for PPMS is worse than other types of MS, the focus of rehabilitation is on managing disability and enhancing participation, and application of a "neuropalliative" approach as the disease progresses. This chapter presents the symptomatic treatment and rehabilitation for persons with MS, including PPMS. A multidisciplinary approach optimizes the intermediate and long-term medical, psychological and social outcomes in this population. Restoration and maintenance of functional independence and societal reintegration, and issues relating to quality of life are addressed in rehabilitation processes.

Rehabilitation challenges in multiple sclerosis

While current immunomodulating drugs aim to reduce multiple sclerosis (MS) exacerbations and slow disease progression, rehabilitation aims to improve and maintain the functional abilities of patients in the face of disease progression. An increasing number of journal articles are describing the value of the many rehabilitation interventions that can be used throughout the course of the disease, from the initial symptoms to the advanced stages. An integrated team of healthcare professionals is necessary to address a myriad of problems to reduce impairments, disabilities, and handicaps. The problems may be related to fatigue, weakness, spasticity, mobility, balance, pain, cognition, mood, relationships, bowel, bladder, sexual function, swallowing, speech, transportation, employment, recreation, and activities of daily living (ADL) such as dressing, eating, bathing, and household chores. The team can help prevent complications and secondary disabilities, while increasing patient safety. Improving neurologically related function, maintaining good relationships, and feeling productive and creative adds enormously to the quality of life of people with MS and their families. Rehabilitation is more than an 'extra' service that is given after medical therapies; it is an integral part of the management of the diverse set of problems encountered throughout the course of the disease. An interdisciplinary team may have many members, including physicians, nurses, physical therapists, occupational therapists, speech and language pathologists, psychotherapists, social workers, recreational therapists, vocational rehabilitation therapists, patients, families, and other caregivers.

Symptomatic therapy in multiple sclerosis: a review for a multimodal approach in clinical practice

As more investigations into factors affecting the quality of life of patients with multiple sclerosis (MS) are undertaken, it is becoming increasingly apparent that certain comorbidities and associated symptoms commonly found in these patients differ in incidence, pathophysiology and other factors compared with the general population. Many of these MS-related symptoms are frequently ignored in assessments of disease status and are often not considered to be associated with the disease. Research into how such comorbidities and symptoms can be diagnosed and treated within the MS population is lacking. This information gap adds further complexity to disease management and represents an unmet need in MS, particularly as early recognition and treatment of these conditions can improve patient outcomes. In this manuscript, we sought to review the literature on the comorbidities and symptoms of MS and to summarize the evidence for treatments that have been or may be used to alleviate them.

Dalfampridine: a brief review of its mechanism of action and efficacy as a treatment to improve walking in patients with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) can cause progressive walking impairment that contributes to disability, loss of independence, and reduced quality of life. Dalfampridine (4-aminopyridine), a voltage-dependent potassium channel blocker, has been shown to improve walking in patients with MS, as demonstrated by an increase in walking speed.

OBJECTIVE

To summarize knowledge about the mechanism of action of dalfampridine in the context of clinical evidence of walking improvement in MS patients.

METHODS

Although this was not a systematic review, which is the primary limitation of this study, searches of PubMed were performed using relevant search terms to identify studies that examined the mechanism of action related to MS and its effects in patients with MS in clinical trials.

RESULTS

Voltage-gated potassium channels represent a family of related proteins that span cell membranes, open and close in response to changes in the transmembrane potential, and help regulate ionic potassium currents. Action potential conduction deficits in demyelinated axons result in part from the exposure after demyelination of the paranodal and internodal potassium channels that are distributed in the axonal membrane. This exposure leads to abnormal currents across the axonal membrane that can slow action potential conduction, result in conduction failure, or affect the axon's capacity for repetitive discharge. While dalfampridine is a broad-spectrum blocker of voltage-dependent potassium channels at millimolar concentrations, studies have shown improvement in action potential conduction in demyelinated axons at concentrations as low as 1 μM, and therapeutic plasma concentrations (associated with improved walking) are in the range of 0.25 µM. However, no specific potassium channel subtype has yet been characterized with significant sensitivity to dalfampridine in this range, and the effects of the drug at this low concentration appear to be quite selective. Improved conduction translates into clinical benefit as measured by objectively and subjectively assessed walking relative to placebo. Such improvements were observed in approximately one third of patients treated with an extended-release formulation of dalfampridine in clinical trials. These patients who responded to dalfampridine had an average increase in walking speed of approximately 25%, and greater improvements than nonresponders on a self-reported subjective measure of walking.

CONCLUSIONS

The extended-release formulation of dalfampridine has been shown in clinical trials to improve walking speed in approximately one third of MS patients with ambulatory impairment. The putative mechanism of action of dalfampridine is restoration of action potential conduction via blockade of an as yet uncharacterized subset of potassium channels in demyelinated axons.

Treatment of walking impairment in multiple sclerosis: an unmet need for a disease-specific disability

INTRODUCTION

Walking impairment is a clinical hallmark of multiple sclerosis (MS), a chronic neurologic disease characterized by axonal demyelination and dysfunction that results in progressive disability. Until recently, there were no therapies that specifically targeted the axonal dysfunction associated with walking impairment in MS.

AREAS COVERED

The purpose of this review is to discuss the unmet need for the treatment of walking impairment in MS patients and to evaluate how a new class of pharmacologic therapies, neurofunctional modifiers, potentially addresses this unmet need. Discussion is based on clinical experience and opinions supported by publications identified in the PubMed literature using the search terms 'multiple sclerosis' and 'mobility OR walking'.

EXPERT OPINION

The development and approval of new treatments for MS show promise for improving adherence to therapy and increasing the potential for clinical effectiveness. Renewed emphasis on integrating strategies that target the underlying pathophysiology with those that address symptoms of concern to patients also has the potential to improve the lives of MS patients and their caregivers. The introduction of neurofunctional modifiers, such as dalfampridine for the improvement of walking impairment, may be of benefit by improving function, mobility and overall quality of life for MS patients.

Cognition, aging, and disabilities: conceptual issues

This article reviews normative changes in cognition that are observed across the adult life span and considers how specific disabilities may interact with aging processes to increase functional decline in later life. Disabling conditions that directly affect the brain are contrasted with those that do not. The goal is twofold: to create a framework for thinking about how cognitive changes, aging, and disability may interact to help explain individual differences in coping, and to promote the inclusion of cognition in a comprehensive approach to assessment and care.

Exploring the Relation of Health-Promoting Behaviors to Role Participation and Health-Related Quality of Life in Women With Multiple Sclerosis: A Pilot Study

OBJECTIVE. We examined the relation of health-promoting behaviors to participation in life roles and health-related quality of life (HR–QOL) in women with multiple sclerosis.

METHOD. We used a correlational design. Frequency of health-promoting behaviors was obtained from the Health-Promoting Lifestyle Profile–II. Role participation was measured by the SF–36 Role-Physical, Role-Emotional, and Social Functioning scales, and HR–QOL was measured with the Physical and Mental Component scales.

RESULTS. Eleven significant positive correlations were found among specific health-promoting behaviors (e.g., nutrition, stress management, physical activity, positive interpersonal relations, spiritual growth), role participation, and HR–QOL.

CONCLUSION. The findings suggest that involvement in health-promoting behaviors is associated with greater participation in life roles and HR–QOL for women with multiple sclerosis. This study provides preliminary evidence for the use and development of health promotion in occupational therapy treatment.

Endurance exercise improves walking distance in MS patients with fatigue

OBJECTIVES

Effects of endurance training in multiple sclerosis (MS) patients complaining of motor fatigue.

MATERIALS AND METHODS

Thirty MS patients complaining of fatigue with low to moderate disabilities randomly allocated to the intervention (thrice weekly 45-min intervals of endurance exercise) or control treatment (three 45-min episodes of stretching, balance training and coordination), both as 'add-on' therapy for 3 weeks during inpatient rehabilitation.

RESULTS

Maximal walking distance before intervention averaged 1043 +/- 568 and 1163 +/- 750 m in the two groups. The intervention group increased its maximal walking distance by 650 +/- 474 m. The control group extended its walking distance by 96 +/- 70 m.

CONCLUSIONS

The present data confirm a strong effect of endurance exercise on maximal walking distance. Remarkably, there were no parallel improvements on the Modified Fatigue Impact Scale, the Beck Depression Inventory and the Hamburg Quality of Life Questionnaire for MS.

Comparing Individualized Rehabilitation to a Group Wellness Intervention for Persons with Multiple Sclerosis

Purpose.

Compare the efficacy of two interventions designed to promote health and physical activity (PA).

Design.

This study was a randomized clinical trial using a time series design. Subjects were randomized into individualized physical rehabilitation (IPR) and group wellness intervention (GWI). Primary questionnaires were administered twice preintervention and twice postintervention. Physical fitness and PA frequency were assessed preintervention and postintervention.

Setting.

Clinic based in a metropolitan area.

Subjects.

Fifty volunteers with multiple sclerosis.

Interventions.

IPR consisted of four physical therapy sessions plus three telephone calls. GWI consisted of seven educational sessions.

Measures.

Primary: SF-36 Health Survey, Modified Fatigue Impact Scale, Mental Health Inventory. Secondary: physical assessment, PA frequency.

Analysis.

Stability of primary questionnaires between the two pretests was examined. Efficacy of interventions was evaluated by multivariate analysis of variance (MANOVA) and effect sizes.

Results.

Primary measures were stable between pretests. MANOVA showed nonsignificant differences between interventions. Eight weeks postintervention, both groups had improved PA, fatigue, resting heart rate, and strength. Effect sizes suggested that IPR had a greater effect on preventing decline of physical health, whereas GWI had a greater effect on improving mental health.

Conclusion.

Preliminary evidence indicated that health and PA improved in both groups. Effect sizes suggested that participants benefited more physically from IPR and more mentally from GWI. Future research should determine whether combining therapeutic exercise with group education improves both mental and physical health.

Use of cognitive aids and other assistive technology by individuals with multiple sclerosis

PURPOSE

To investigate the use of assistive technology (AT), unmet needs for AT, and examine correlates of use of memory aids and cognitive strategies among individuals with multiple sclerosis (MS).

METHOD

A cross-sectional study of 1,063 community dwelling adults with MS in Washington State. A self-report survey assessed use of AT as well as depression, fatigue, mobility, and other demographic and disease related variables.

RESULTS

Some 70% of respondents reported using memory strategies and 50.7% reported using electronic memory aids. The strongest correlate of use of electronic memory aids was endorsement of difficulties thinking (OR: 2.09, p < 0.001) though younger age, higher education, and report of higher fatigue were also significant. Fatigue (OR: 1.27, p < 0.001) and depression (OR: 0.89, p < 0.001) were highly associated with use of memory strategies. Subjects who were older, unemployed, more depressed, and have more mobility disability were less likely to use memory strategies.

CONCLUSIONS

Use of AT for memory is widespread and further research should be conducted on efficacy of AT. Many individuals who might be presumed to need AT for memory most (older, less educated, more disability) are least likely to report use. Healthcare providers are urged to ask about memory AT and make appropriate referrals.

Exercise and quality of life among people with multiple sclerosis: looking beyond physical functioning to mental health and participation in life

OBJECTIVE

To describe the prevalence of exercise in a national sample of veterans with multiple sclerosis (MS) and the association of exercise with quality of life, including physical health, mental health, and participation restriction.

DESIGN

Cross-sectional cohort study linking computerized medical records to mailed survey data from 1999.

SETTING

Veterans Health Administration.

PARTICIPANTS

Veterans with MS (N=2995; 86.5% men) who received services in the Veterans Health Administration and returned survey questionnaires.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographic information, Veteran RAND 36-Item Health Survey (VR-36), self-reported exercise frequency.

RESULTS

Among all survey respondents with MS, only 28.6% (95% confidence interval, 26.9-30.2) endorsed any exercise. In adjusted logistic regression, exercise was associated with younger age, more education, living alone, lower levels of bodily pain, and higher body mass index. After adjusting for demographic variables and medical comorbidities, exercise was associated with better physical and mental health. People who exercised reported they had better social functioning and better role functioning (participation in life despite physical and emotional difficulties).

CONCLUSIONS

Exercise in veterans with MS is uncommon. In the context of chronic illness care, the identification of exercise patterns and promotion of physical activity may represent an important opportunity to improve mental health and quality of life among people with MS. Intervention should address factors associated with lower rates of exercise including age, education, and pain.

Effect of Exercise Training on Walking Mobility in Multiple Sclerosis: A Meta-Analysis

Objective. The study used meta-analytic procedures to examine the overall effect of exercise training interventions on walking mobility among individuals with multiple sclerosis. Methods. A search was conducted for published exercise training studies from 1960 to November 2007 using MEDLINE, PsychINFO, CINAHL, and Current Contents Plus. Studies were selected if they measured walking mobility, using instruments identified as acceptable walking mobility constructs and outcome measures for individuals with neurologic disorders, before and after an intervention that included exercise training. Results. Forty-two published articles were located and reviewed, and 22 provided enough data to compute effect sizes expressed as Cohen's d. Sixty-six effect sizes were retrieved from the 22 publications with 600 multiple sclerosis participants and yielded a weighted mean effect size of g = 0.19 (95% confidence interval, 0.09-0.28). There were larger effects associated with supervised exercise training ( g = 0.32), exercise programs that were less than 3 months in duration ( g = 0.28), and mixed samples of relapsing-remitting and progressive multiple sclerosis ( g = 0.52). Conclusions. The cumulative evidence supports that exercise training is associated with a small improvement in walking mobility among individuals with multiple sclerosis.

Physical activity correlates with neurological impairment and disability in multiple sclerosis

This study examined the correlation of physical activity with neurological impairment and disability in persons with multiple sclerosis (MS). Eighty individuals with MS wore an accelerometer for 7 days and completed the Symptom Inventory (SI), Performance Scales (PS), and Expanded Disability Status Scale. There were large negative correlations between the accelerometer and SI (r = -0.56; rho = -0.58) and Expanded Disability Status Scale (r = -0.60; rho = -0.69) and a moderate negative correlation between the accelerometer and PS (r = -0.39; rho = -0.48) indicating that physical activity was associated with reduced neurological impairment and disability. Such findings provide a preliminary basis for using an accelerometer and the SI and PS as outcome measures in large-scale prospective and experimental examinations of the effect of physical activity behavior on disability and dependence in MS.

Cooling via one hand improves physical performance in heat-sensitive individuals with multiple sclerosis: a preliminary study

Background

Many individuals afflicted with multiple sclerosis (MS) experience a transient worsening of symptoms when body temperature increases due to ambient conditions or physical activity. Resulting symptom exacerbations can limit performance. We hypothesized that extraction of heat from the body through the subcutaneous retia venosa that underlie the palmar surfaces of the hands would reduce exercise-related heat stress and thereby increase the physical performance capacity of heat-sensitive individuals with MS.

Methods

Ten ambulatory MS patients completed one or more randomized paired trials of walking on a treadmill in a temperate environment with and without cooling. Stop criteria were symptom exacerbation and subjective fatigue. The cooling treatment entailed inserting one hand into a rigid chamber through an elastic sleeve that formed an airtight seal around the wrist. A small vacuum pump created a -40 mm Hg subatmospheric pressure enviinside the chamber where the palmar surface of the hand rested on a metal surface maintained at 18–22°C. During the treatment trials, the device was suspended from above the treadmill on a bungee cord so the subjects could comfortably keep a hand in the device without having to bear its weight while walking on the treadmill.

Results

When the trials were grouped by treatment only, cooling treatment increased exercise durations by 33% (43.6 ± 17.1 min with treatment vs. 32.8 ± 10.9 min. without treatment, mean ± SD, p < 5.0·10^-6, paired t-test, n = 26). When the average values were calculated for the subjects who performed multiple trials before the treatment group results were compared, cooling treatment increased exercise duration by 35% (42.8 ± 16.4 min with treatment vs. 31.7 ± 9.8 min. without treatment, mean ± SD, p < 0.003, paired t-test, n = 10).

Conclusion

These preliminary results suggest that utilization of the heat transfer capacity of the non-hairy skin surfaces can enable temperature-sensitive individuals with MS to extend participation in day-to-day physical activities despite thermally stressful conditions. However, systematic longitudinal studies in larger cohorts of MS patients with specific deficits and levels of disability conducted under a variety of test conditions are needed to confirm these preliminary findings.

Use of goal attainment scaling in inpatient rehabilitation for persons with multiple sclerosis

OBJECTIVES

To use goal attainment scaling (GAS) to measure clinically important functional change in persons with multiple sclerosis (MS) and to assess its responsiveness compared with standard measures used to evaluate progress in rehabilitation.

DESIGN

Prospective, observational cohort study.

SETTING

Tertiary inpatient rehabilitation unit in Victoria, Australia.

PARTICIPANTS

Consecutive sample of 24 persons with MS admitted for comprehensive rehabilitation program. The male-to-female ratio was 10:14, and the mean age +/- standard deviation was 52.0+/-8.3 years (range, 37-62y). Over half (n=14 [58.3%]) had secondary progressive MS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

GAS scores were calculated for 5 to 10 priority goals set prospectively by each patient in agreement with the multidisciplinary treating team and compared with standard outcome measures-the FIM instrument and Barthel Index-rated on admission and discharge from the program. Patients were categorized into responders and nonresponders based on an overall clinical global impression.

RESULTS

Of 203 selected goals, 167 were achieved at the predicted level. GAS recorded outcomes for 105 individualized goals not measured by the FIM and Barthel Index. Although all 3 measures showed statistically significant change from admission to discharge (P<.001), only GAS scores strongly correlated with the Clinical Global Impression scale (rho=-.86, P<.001). GAS discharge scores differed significantly between the responder and nonresponder groups (Mann-Whitney, z=-3.78, P<.001). Different measures of effect size gave different results, but GAS was consistently more responsive than either the FIM or Barthel Index.

CONCLUSIONS

This preliminary study suggests that GAS is a responsive and useful outcome measure for the rehabilitation of persons with MS, providing added value to standardized outcome measurement.

Facteurs dont il faut tenir compte dans la création d’un guide d’activité physique pour les Canadiens qui ont un handicap physiqueCet article est tiré d’un supplément intitulé Advancing physical activity measurement and guidelines in Canada: a scientific review and evidence-based foundation for the future of Canadian physical activity guidelines (Favoriser les lignes directrices et la mesure de l’activité physique au Canada: examen scientifique et justification selon les données probantes pour l’avenir des lignes directrices de l’activité physique canadienne) publié par Physiologie appliquée, nutrition et métabolisme et la Revue canadienne de santé publique. On peut aussi mentionner Appl. Physiol. Nutr. Metab. 32 (Suppl. 2F) ou Can. J. Public Health 98 (Suppl. 2)

This paper provides a brief overview of the epidemiological data regarding Canadians with physical disabilities, with a particular emphasis on health status. A literature review is then presented, focusing on activity levels and the physiological and health-related quality of life benefits of activity for people with four different physical disabilities (arthritis, fibromyalgia, spinal cord injury, and multiple sclerosis). The unique physical activity barriers faced by people with physical disabilities are discussed. The paper concludes with recommendations for the development of a physical activity guide for Canadians with physical disabilities.

Considerations for the development of a physical activity guide for Canadians with physical disabilitiesThis article is part of a supplement entitled Advancing physical activity measurement and guidelines in Canada: a scientific review and evidence-based foundation for the future of Canadian physical activity guidelines co-published by Applied Physiology, Nutrition, and Metabolism and the Canadian Journal of Public Health. It may be cited as Appl. Physiol. Nutr. Metab. 32(Suppl. 2E) or as Can. J. Public Health 98(Suppl. 2)

This paper provides a brief overview of the epidemiological data regarding Canadians with physical disabilities, with a particular emphasis on health status. A literature review is then presented, focusing on activity levels and the physiological and health-related quality of life benefits of activity for people with four different physical disabilities (arthritis, fibromyalgia, spinal cord injury, and multiple sclerosis). The unique physical activity barriers faced by people with physical disabilities are discussed. The paper concludes with recommendations for the development of a physical activity guide for Canadians with physical disabilities.