Randomised controlled pilot trial of an exercise plus behaviour change intervention in people with multiple sclerosis: the Step it Up study

Participant characteristics of existing exercise studies in persons with multiple sclerosis - A systematic review identifying literature gaps

BACKGROUND

Exercise is a cornerstone in rehabilitation of persons with multiple sclerosis (pwMS), which is known to elicit beneficial effects on various symptoms and to have a potential disease-modifying effect. However, it remains to be elucidated if the existing MS exercise literature covers the full age and disability span of pwMS.

OBJECTIVE

To systematically review MS exercise studies and provide a detailed mapping of the demographic and clinical characteristics of the included pwMS.

METHODS

A systematic review of MS exercise studies were performed using MEDLINE and EMBASE. From the resulting MS exercise studies, mean sample characteristics were extracted.

RESULTS

4576 records were identified, from which 202 studies were included. Of these, 166 studies (82.2%) enrolled pwMS aged 35-54 years, 10.9% enrolled pwMS <35 years, and 6.9% enrolled pwMS ≥55 years (only 1.5% enrolled pwMS ≥60 years). A total of 118 studies (58.4%) reported Expanded Disability Status Scale (EDSS), with 88.1% of included pwMS having an EDSS between 2.0 and 6.5, while only one study enrolled pwMS with an EDSS ≥7.0. Finally, 80% of the studies included pwMS having a disease duration of 5-14.5 years.

CONCLUSION

Exercise studies in pwMS included primarily middle-aged (35-54 years) pwMS having an EDSS of 2.0-6.5 and a disease duration of 5-14.5 years. Few exercise studies were identified in young and older pwMS, in pwMS with mild disability and severe disability, and in pwMS having shorter or longer disease durations. These findings highlight the need for further investigation of exercise in these specific subgroups of pwMS as benefits of exercise might not generalize across subpopulations.

Systematic review of participant characteristics in theory-based behavior change interventions for physical activity in multiple sclerosis: are we missing those with the greatest potential for lifelong benefits?

PURPOSE

This study examined participant characteristics, particularly disease duration, in theory-based physical activity behavior change trials in multiple sclerosis (MS) and summarized theoretical frameworks and changes in physical activity outcomes.

MATERIALS AND METHODS

PubMed, CINAHL, Embase, and Scopus were searched to identify potential trials. One reviewer screened titles and abstracts, and two reviewers then independently screened full-text articles based on predetermined eligibility criteria. Data were extracted by one reviewer and checked by a second reviewer.

RESULTS

Among 33 trials reviewed, only one trial reported a mean disease duration of less than five years (i.e., 4.5 years) for the sample. The remaining trials included samples with a mean disease duration of 6.7 years or longer. The most common theories used were Social Cognitive Theory, Trans-theoretical Model, and Motivational Interviewing. The effects on physical activity were heterogeneous; device-measured outcomes increased in 41.4% of studies, self-reported outcomes improved in 72.4%. Adherence (≥80%) was reported in 34.5% of studies.

CONCLUSIONS

There is little focus on persons with MS in the early disease course in physical activity behavior change interventions. Future research should include comprehensive theoretical approaches for more homogeneous effects across outcome measures when targeting those in the early stage and all MS populations.IMPLICATIONS FOR REHABILITATIONTheory-based physical activity behavior change interventions have not included persons with multiple sclerosis (MS) in the early disease course (<5 years since diagnosis).Disease duration has not been a criterion used to include or exclude participants in the reviewed theory-based behavior change interventions for physical activity in people with MS.The theory-based behavior change interventions in this review positively affected short-term physical activity levels in people with MS.

Targeting Physical Inactivity Using Behavioral Theory in Chronic, Disabling Diseases

Physical inactivity and comorbidities (e.g., hypertension) result in poor prognoses among persons with chronic, disabling conditions including multiple sclerosis, Parkinson disease, and stroke. Theory can guide the design of behavior change interventions that can be delivered remotely for broad scale implementation. We hypothesize that theory-based behavior change interventions can increase physical activity and reduce comorbidities and associated consequences among persons with chronic, disabling conditions.

The impact of the COVID-19 pandemic on physical activity and associated technology use in persons with multiple sclerosis: an international RIMS-SIG Mobility survey study

Objective

To investigate the impact of the COVID-19 pandemic on physical activity in persons with multiple sclerosis (PwMS).

Design

Multicenter international online survey study.

Setting

The survey was conducted within 11 participating countries. Each country launched the survey using online platforms from May to July 2021.

Participants

This was an electronic survey study targeting PwMS (N=3725).

Intervention

Not applicable.

Main Outcome Measures

The survey ascertained physical activity performance and its intensity, the nature of the activities conducted, and the use of technology to support home-based physical activity before and during the pandemic.

Results

A total of 3725 respondents completed the survey. Prepandemic, the majority (83%) of respondents reported being physically active, and this decreased to 75% during the pandemic. This change was significant for moderate- and high-intensity activity (P<.0001). Activities carried out in physiotherapy centers, gyms, or pools decreased the most. Walking was the most frequently performed activity prepandemic (27%) and increased during the pandemic (33%). A total of 24% of those inactive during the pandemic had no intention of changing their physical activity behavior post pandemic. A total of 58% of the respondents did not use technology to support physical activity during the pandemic. Of those who did use technology, wearables were most used (24%). Of those currently nonactive (25%) expressed a preference for an in-person format to conduct physical activity post pandemic.

Conclusions

Physical activity performance, especially activities at moderate and high intensities, decreased during the pandemic in PwMS compared with prepandemic. Walking and using wearables gained popularity as ways to stay active. As we move toward an endemic COVID-19, a call for action to develop interventions focused on walking programs with specific emphasis on increasing physical activity of PwMS is proposed.

Interventions for Instrumental Activities of Daily Living Among Adults With Multiple Sclerosis: A Systematic Review

IMPORTANCE

Occupational therapy practitioners need updated information about interventions that may improve or maintain functional changes in instrumental activity of daily living (IADL) engagement caused by multiple sclerosis (MS).

OBJECTIVE

To conduct a narrative synthesis of updated evidence on interventions within the scope of occupational therapy to improve or maintain performance of and participation in IADLs among adults with MS.

DATA SOURCES

CINAHL, MEDLINE in PubMed, Cochrane, OTseeker, and PsycINFO. Study Selection and Data Collection: This systematic review followed the Cochrane Collaboration methodology and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting a systematic review. Inclusion criteria were Level 1 or 2 evidence, published in English, published from January 2011 to December 2018, intervention within the occupational therapy scope of practice, and at least one IADL outcome measure.

FINDINGS

Nineteen randomized controlled trials (including pilot and feasibility trials) and 1 preintervention-postintervention study met inclusion criteria. Results of this review show strong strength of evidence for coaching interventions in addressing physical activity (PA) routines and moderate support in addressing medication routines. Moderate strength of evidence was found with mixed results for interventions involving coaching plus prescribed PA in improving PA participation.

CONCLUSIONS AND RELEVANCE

This systematic review supports occupational therapy practitioners addressing PA and medication health management and maintenance IADLs through the use of coaching interventions when treating people with MS. Other IADLs were addressed by the articles in this review but require more evidence to make clinical recommendations. What This Article Adds: Occupational therapy practitioners' skills in promoting habits and routines paired with utilization of evidence-supported coaching interventions can support independence with health management and reduce the negative impact of MS on daily activity participation.

Interventions for Instrumental Activities of Daily Living in Adults With Multiple Sclerosis

Evidence Connection articles provide examples of how evidence from systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Project can be directly translated into clinical practice. These articles present a summary of the topic and case studies that demonstrate how the evidence from these reviews can inform clinical decision making. This Evidence Connection article includes findings from a systematic review of interventions within the scope of occupational therapy practice that improve or maintain performance of or participation in instrumental activities of daily living for people living with multiple sclerosis.

Experiences of people with multiple sclerosis participating in a social cognitive behavior change physical activity intervention

BACKGROUND

Understanding the experiences of people with MS taking part in physical activity interventions is critical to inform future interventions.

AIM

The aim was to gain insight into the experiences of people with MS taking part in a behavior change group physical activity intervention with a novel social cognitive theory component.

METHODS

A qualitative semi-structured interview format was utilized. Questions focussed on expectations, views and beliefs at being involved in the study, beliefs on physical activity, and subjective evaluation of the trial content and delivery. Seventeen people were interviewed and data were analyzed using thematic analysis.

RESULTS

Three themes were generated: psychological and social factors, intervention processes, and MS identity. The acceptance of MS as an identity acted as an initial barrier to exercise, with a more positive, exercise-enabling identity post-intervention. Psychological factors such as self-efficacy and anxiety, as well as social factors such as social support, were found to play an important role in how participants experienced the program. Similarly, intervention processes included support for group-based activities and structure of exercise classes, and were also inter-linked to the other themes.

CONCLUSION

It appears that group-based exercise interventions are acceptable and feasible for people with MS. The qualitative findings support previously reported quantitative findings that the Step it Up intervention is effective at promoting physical activity and improving psychological outcomes.

Effects of nutrition education given to persons with multiple sclerosis and their families on diet quality and anthropometric and biochemical measurements

ABSTRACT Objective: In this study, it was aimed to investigate the effects of nutrition education given to persons with multiple sclerosis and their families on anthropometric and biochemical measurements and diet quality. Methods: Data from 51 persons with multiple sclerosis were analysed in this intervention study. The study was conducted with 3 groups. The education group consisted of only persons with multiple sclerosis, the family education group consisted of persons with multiple sclerosis and a family member living with them, and the control group consisted of persons with multiple sclerosis who had not received an education. Anthropometric and biochemical measurements and dietary quality assessments were made before (T1) and immediately after education (T2) and also 3 months after education (follow-up, T3). Results: The distribution of family education group diet quality scores showed a significant increase from “poor” to “needs improvement” at T3 compared to T1. The upper middle arm circumference measurements of the female control group were decreased at T2 and T3 [from 29.0 (23-34) cm to 28.0 (22-31) cm and to 27.5 (22-31) cm]. Women in family education group, levels of serum haemoglobin and haematocrit were higher than in control group at T2 and T3. Also, men in family education group, levels of alanine aminotransferase were lower than those in education group at follow up. Levels of total cholesterol and low-density lipoprotein cholesterol in education group were higher than those control group at T1, T2, and T3. Conclusion: This study indicates that nutrition education affects some biochemical and anthropometric measurements in persons with multiple sclerosis. Diet quality improved when receiving education together with families.

Feasibility of a theory-informed mobile app for changing physical activity in youth with multiple sclerosis

BACKGROUND

Youth with multiple sclerosis (MS) have high levels of disease activity, depression and fatigue, and lower moderate to vigorous physical activity (PA). PA participation is associated with lower disease activity, depression and fatigue as well as higher self-efficacy, goal setting and decreased barriers. These latter constructs may be targeted by an intervention program for behavior change, and such intervention must account for disease rarity, geographical proximity and time constraints which limit the feasibility, accessibility, and sustainability of implementing a PA intervention in youth with MS. We have developed a theory-informed mobile-app based PA promotion program to address these barriers, Active Teens with Multiple Sclerosis (ATOMIC) and herein report the feasibility of delivering this intervention in youth with MS.

OBJECTIVE

To determine the feasibility of delivering the ATOMIC program to youth with MS.

METHODS

Fifteen youth with MS (13F, 16.6 ± 1.2 years) followed at the Hospital for Sick Children were enrolled in the ATOMIC intervention. Participants underwent a standard clinical evaluation; an exercise test to determine cardiorespiratory fitness; 7-day PA monitoring with an accelerometer; and completed standardized depression, fatigue questionnaires at baseline and post-intervention. Social cognitive scales related to self-efficacy, self-management, goal setting, perceived barriers, outcome expectancy, and social support were completed at baseline, six and 12-weeks. The 12-week mobile app PA intervention was informed by Social Cognitive Theory (SCT) and included: individualized PA coaching, PA self-monitoring (Fitbit), goal setting, social support and MS specific educational modules. Feasibility was defined as (1) meeting the recruitment target of 15 participants within a one-year period; (2) completion of ≥80% of study related questionnaires and testing; (3) a drop-out rate of less than 20%, and (4) adherence to the ATOMIC intervention program components of ≥80% (Fitbit wear, PA coaching calls, modules).

RESULTS

From March 2018 to April 2019, 53% of youth approached agreed to participate (15/28). 13/15 participants completed the intervention. 36 of the possible 39 coaching calls (92%: 3 possible phone calls per participant); 89% wear adherence to Fitbit_Charge2 data (mean = 75 ± 16.6 days of 84 days); and 5/12 (42%) of modules were completed. An average 8.4% (SD= 40%, range = -74.0 to 176%) increase in Fitbit steps above the first week of the intervention were observed. PA level from accelerometry at 12-weeks, aerobic fitness, depression and fatigue were unchanged. SCT scales indicated an increase in social support from friends (0.67-points, T = 2.7, pholm=0.04), and a decrease in outcome expectancy (-2.7, T = 3.0, pholm=0.03). There were no differences in self-efficacy, self-management or perceived barriers post intervention.

CONCLUSIONS

Our results indicate that the ATOMIC program is feasible for delivery in youth with MS. Future work is needed to understand how to best implement each element of SCT through added features in the mobile-app, and to evaluate how the individual components of SCT mediate change in PA behaviours of youth with MS.

Rehabilitation in multiple sclerosis in 2021

Patients with multiple sclerosis, despite advances in therapy, often suffer from locomotor impairment that limits their mobility and affect quality of life. Rehabilitation is part of the treatment of MS and has shown its beneficial effects in numerous studies. While traditional rehabilitation techniques remain in the limelight, new technologies are emerging and make it possible to improve the management of disabling symptoms. The aim of this update is to synthesize the new therapy techniques proposed in rehabilitation for patients with multiple sclerosis according to the symptoms as balance, gait, upper limb disorders, fatigue, spasticity and disease progression published over the past 5 years. With regard to balance and walking disorders, neuromotor rehabilitation, physical exercise, rhythmic auditory stimulation, gait robot training and exergaming are effective. Only physical exercise has shown a positive effect on fatigue management. Spasticity is improved by classic rehabilitation techniques however non-invasive brain stimulation are promising. The rehabilitation of upper limb dysfunctions uses various effective techniques such as the repetition of functional tasks in real or virtual situations. In case of a more severe disability, arm robots can be used to relearn the impaired movement. Action observation training in real or virtual situations is also effective. Finally, under certain conditions the constraint induced movement therapy is proposed. The effects of rehabilitation are not only positive on the pyramidal symptoms and fatigue but also increase neuroplasticity and perhaps a neuroprotective effect as shown in some studies.

Lifestyle, Exercise and Activity Package for People living with Progressive Multiple Sclerosis (LEAP-MS): adaptions during the COVID-19 pandemic and remote delivery for improved efficiency

The LEAP-MS (Lifestyle, Exercise and Activity Package for People living with Progressive Multiple Sclerosis) study has developed an individualised supported self-management approach for physical activity for people with progressive multiple sclerosis (MS) and severe disability. The intervention has been evaluated in a single-arm feasibility study with embedded process evaluation. The feasibility study was due to open to recruitment during the COVID-19 2020-2021 pandemic, 1 month into the first UK-wide lockdown. We worked rapidly to implement adaptions to the trial procedures and intervention delivery that we believe are applicable to randomised controlled trials. Recruitment became predominantly via self-referral. Electronic consent was employed, with consent discussions occurring over the telephone. Registration, consent, eligibility assessment and data collection as well as the intervention (online physical activity tool) were via a secure, encrypted multi-user web-based platform for participants, physiotherapists and researchers accessible via various hardware. Physiotherapy consultations, as well as the process evaluation, were conducted remotely using video conferencing software or the telephone. A remote training package for physiotherapists and site initiations was also developed and electronic site files employed. Our adaptions are extremely topical given the COVID-19 situation, and whilst not what we had originally planned, have enabled successful delivery of the feasibility study and are relevant to conducting randomised controlled trials and meeting the needs of people with MS who are far more isolated than ever before. TRIAL REGISTRATION: ClinicalTrials.gov NCT03951181 . Registered on 15 May 2019.

Web-based physical activity intervention for people with progressive multiple sclerosis: application of consensus-based intervention development guidance

OBJECTIVES

People with progressive multiple sclerosis (PwPMS) report that they recognise the benefits of activity on their physical and psychological health but need support to achieve their physical activity goals. We aimed to systematically develop a theoretically informed intervention that would enable PwPMS to more readily engage in regular physical activity.

DESIGN

We used an intervention mapping approach to inform intervention development.

SETTING

We conducted semistructured interviews with PwPMS and their families/carers and physiotherapists recruited from secondary care settings.

PARTICIPANTS

Fourteen PwPMS with an Expanded Disability Status Scale score of between 6 and 8 and 7 of their families/carers and 13 physiotherapists and 1 physiotherapy technician participated.

RESULTS

Interview data suggested that the development of supportive coaching relationships with physiotherapists could promote the ability of PwPMS to achieve a desirable and achievable physical activity plan. These interview data informed the prototype 'Lifestyle Exercise and Activity Package for Multiple Sclerosis' (LEAP-MS) consisting of a secure multiuser web-based platform (with an education and activity suite, interactive components enabling selection of exercises, goal setting and activity logging), up to six flexible face-to-face or web-based physiotherapy coaching sessions and remote support via an embedded web-based messaging function that all together draw on specific theory-based methods to achieve physical activity behaviour change, namely active learning, reinforcement, modelling, feedback, facilitation, goal setting and guided practice. Implementation is within a multiuser platform accessible to participants, trained physiotherapists and researchers.

CONCLUSIONS

We have followed an inclusive, systematic and transparent process to develop the LEAP-MS intervention that enables detailed description of components, context and guiding principles to inform ongoing evaluation. Importantly, PwPMS expressed the need for autonomy in developing physical activity plans. This has been achieved through the embedding of self-management principles in the design and delivery of the LEAP-MS intervention.

Retention of Physical Gains in the Community Following Physical Training for Multiple Sclerosis: A Systematic Review and Implications

Multiple sclerosis (MS) is a progressive neurological illness whose typically young adult onset results in a nearly entire lifetime of worsening disability. But despite being an unrelenting neurodegenerative disease, numerous clinical trials over the past 40 years for MS have vigorously attempted to improve or at least stabilize declining physical function. Although the vast majority of the studies assessed training effects only within controlled laboratory or clinic settings, in recent years a growing interest has emerged to test whether newer therapies can instead benefit real-life activities in the community. Nonetheless, comparatively little attention has been paid to whether the training gains can be retained for meaningful periods. This review discusses the comparative success of various physical training methods to benefit within-community activities in MS, and whether the gains can be retained long afterward. This review will suggest future research directions toward establishing efficacious treatments that can allow persons with MS to reclaim their physical abilities and maximize functionality for meaningful periods.

Behavior Change Techniques in Physical Activity Interventions for Multiple Sclerosis

OBJECTIVE

To identify and summarize the behavior change techniques (BCTs) included in behavior change interventions for promoting physical activity in persons with multiple sclerosis (MS).

DATA SOURCES

PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Complete, Scopus, and Embase were initially searched in November 2019, and data extraction began in June 2020.

STUDY SELECTION

The inclusion criteria for studies were: adults older than 18 years with diagnosed MS, English language, clinical trial designs (ie, pre-post or randomized controlled trials), group or individual interventions, and home or community-based settings wherein physical activity was defined as a primary or secondary outcome. Exclusion criteria for studies included protocol manuscripts pending results, case studies, studies focused on populations with multiple chronic diseases, and interventions targeting multiple behaviors. Two researchers completed screening for study selection, and a third researcher served as a referee. Of the initially identified 8681 studies, 54 studies met selection criteria.

DATA EXTRACTION

Data extraction was completed by 3 researchers. Each article was coded by 2 of the 3 researchers, and a fourth researcher resolved discrepancies. Data extracted from each paper included study title, authors, country, year, sample size, study design, intervention details, physical activity outcomes, and BCTs.

DATA SYNTHESIS

Thirty-eight unique behavior change interventions were identified, and 53 of the 93 possible BCTs were included across the studies. The mean number of BCTs per study was 15, and studies and effect sizes across studies ranged from 0.04-1.49.

CONCLUSIONS

This review provides a comprehensive overview of BCTs as the active ingredients in behavior change interventions targeting physical activity in MS. Results from this study provide a compendium for future intervention development for increasing physical activity and improving overall health in MS.

Changing Behaviour towards Aerobic and Strength Exercise (BASE): Design of a randomised, phase I study determining the safety, feasibility and consumer-evaluation of a remotely-delivered exercise programme in persons with multiple sclerosis

BACKGROUND

Multiple sclerosis is a chronic progressive neurological disease. Evidence attests to the benefits of exercise, guidelines for exercise in multiple sclerosis are available. Remote-delivery of exercise adherence programmes based on the exercise guidelines require urgent testing.

AIMS

The design, and outcomes of Behaviour towards Aerobic and Strength Exercise in MS (BASE-MS), a remotely-delivered exercise training study based principles of behaviour change, will further evaluate the remote-delivery of the current exercise guidelines.

METHODS

BASE is a 4-month clinically relevant randomised controlled trial to explore the delivery of a remotely supervised, guidelines-based exercise programme for persons with multiple sclerosis, underpinned by principles of health behaviour change. Initially, 72 persons with mild to moderate multiple sclerosis will be randomised in a 1:1:1 allocation to receive the BASE programme, or act as controls continuing usual care. On programme completion, exercise participants will be further randomised to an optimised adherence treatment or usual adherence. Our online survey assesses the primary outcome of exercise participation, and secondary outcomes of symptoms, and correlates of behaviour change at baseline, month four, month five and month eleven. Online surveys will capture coach and participant feedback to identify the contexts, mechanisms and outcomes of BASE implementation.

CONCLUSIONS

The research and clinical landscape for MS management must remain in-step with public health and health communication. BASE tests the remote-delivery of the current exercise guidelines for exercise in persons with MS. Safety, feasibility and evaluative outcomes will provide rich data for future remote-delivery of exercise in neurological conditions.

Beyond current research practice: Methodological considerations in MS rehabilitation research (is designing the perfect rehabilitation trial the Holy Grail or a Gordian knot?)

Rehabilitation is an essential aspect of symptomatic and supportive treatment for people with multiple sclerosis (MS). The number of randomised controlled trials (RCTs) for rehabilitation interventions in MS has increased over the last two decades. The design, conduct and reporting quality of some of these trials could be improved. There are, however, some specific challenges that researchers face in conducting RCTs of rehabilitation interventions, which are often 'complex interventions'. This paper explores some of the challenges of undertaking robust clinical trials in rehabilitation. We focus on issues related to (1) participant selection and sample size, (2) interventions - the 'dose', content, active ingredients, targeting, fidelity of delivery and treatment adherence, (3) control groups and (4) outcomes - choosing the right type, number, timing of outcomes, and the importance of defining a primary outcome and clinically important difference between groups. We believe that by following internationally accepted RCT guidelines, by developing a critical mass of MS rehabilitation 'trialists' through international collaboration and by continuing to critique, challenge, and develop RCT designs, we can exploit the potential of RCTs to answer important questions related to the effectiveness of rehabilitation interventions.

Adherence and drop-out in randomized controlled trials of exercise interventions in people with multiple sclerosis: A systematic review and meta-analyses

BACKGROUND

The short-term benefits of exercise in people with multiple sclerosis (MS) are well established. To sustain benefits exercise needs to continue long-term. Despite important clinical implications, no systematic reviews have synthesized evidence on adherence and drop-out in MS exercise interventions.

OBJECTIVES

1) To summarize reported adherence and drop-out data from randomized controlled trials (RCTs) of exercise interventions, and 2) identify moderators related to adherence and drop-out.

METHODS

Nine databases were electronically searched in October 2018. Included studies were RCTs of exercise interventions in adults with MS published from January 1993 to October 2018. Abstracts and full texts were independently screened and selected for inclusion by two reviewers. Methodological quality was assessed using the TESTEX rating scale.

RESULTS

Ninety three articles reporting 81 studies were included. Forty one studies (51%) reported both adherence and drop-out data during the intervention period with three (4%) also reporting follow-up data. Of the 41 studies, < 25% pre-defined adherence or described how adherence was measured. Meta-analyses of 59 interventions (41 studies) showed a pooled adherence estimate of 0.87 (95% CI 0.83 to 0.90) and 0.73 (CI 0.68-0.78) when including drop-outs. Mean age, proportion of females and intervention duration were inversely associated with adherence.

CONCLUSION

Little consensus existed on definition of adherence or determination of drop-out in MS exercise studies, with reporting generally of poor quality, if done at all. Hence it is largely unknown what can moderate adherence and whether exercise continued following an exercise intervention. Researchers should ensure clear transparent measurement and reporting of adherence and drop-out data in future trials.

A systematic review of aerobic and resistance exercise and inflammatory markers in people with multiple sclerosis

Inflammation is a driver in the demyelination process in patients with multiple sclerosis (MS) and can influence disability levels. Both single and repeated bouts of exercise can decrease inflammatory markers in people with MS (PwMS). This systematic review evaluates whether exercise can influence inflammation and disability in individuals with MS. Experimental studies were reviewed that had to meet the following eligibility requirements: a sample of PwMS, an intervention of exercise (either aerobic, resistance, or a combination of each), and an outcome that included at least one inflammatory (cytokine) reaction. The main outcome measure was an evaluation of inflammation, as indicated by a change in any cytokine level. Other measures included muscle strength, balance, flexibility, walking ability, disability statues, and quality of life (QOL). A total of nine studies were included in the final review. Exercise interventions included predominantly cycling, although a few resistance training trials were mentioned. Small decreases were found in IL-17 and IFN-γ after exercise. Functional outcome measures and perceived disability status were improved posttraining. We conclude that while interventions such as exercise may impact QOL, they do not have a significant influence on inflammation associated with MS. Exercise is an accessible alternative that not only helps to decrease impairments but also limit the restrictions associated with participation in society. While functional outcomes after exercise improved, these improvements may not be attributable to changes in levels of cytokines or inflammatory markers.

Feasibility study of a 10-week community-based program using the WalkWithMe application on physical activity, walking, fatigue and cognition in persons with Multiple Sclerosis

BACKGROUND

People with Multiple Sclerosis (pwMS) show diverse symptoms, such as fatigue and decline in motor and cognitive function. Physical activity shows to have a positive impact on many of these symptoms. However, many pwMS lead sedentary lives. Objectives of this study were to evaluate the feasibility of prolonged use of the WalkWithMe, a personalized mobile application that supports pwMS in walking at home, and its effect on physical activity, walking, fatigue and cognition in persons with MS.

METHODS

Nineteen pwMS were enrolled in a 10-week home-based intervention with the WalkWithMe application after setting personal goals based on baseline testing values, where twelve patients completed the program. Before and after the intervention, motor (6MWT, T25FW, 5-STS, NHPT) and cognitive function (PASAT and SDMT) were evaluated, together with the patient reported impact on walking, physical activity, quality of life and fatigue by MSWS-12, IPAQ, SF-36, MSIS-29, MFIS and FSS, respectively.

RESULTS

Significant improvement was seen for some parts of self-reported physical activity and quality of life (IPAQ: walking, p = 0.04, leisure, p = 0.02; SF-36: physical functioning, p = 0.02), cognition (SDMT, p = 0.01), cognitive fatigability (PASAT, p = 0.05), lower limb strength (5-STS, p = 0.05) and dominant hand function (NHPT, p = 0.002).

CONCLUSION

This feasibility study was successful at improving categories of self-reported physical activity, lower limb functional strength, hand function and cognition, but results need to be interpreted with caution, given the small and not always clinically relevant changes. Larger sample sizes in a controlled experimental design are needed to confirm these results.

Informing the training of health care professionals to implement behavior change strategies for physical activity promotion in neurorehabilitation: a systematic review

Initiatives to increase physical activity (PA) are most effective when combined with behavior change strategies (BCS). However, this is not routinely done and perhaps can be attributed to health care professionals' (HCP) lack of confidence and understanding of how to best apply BCS. This review aimed to identify and synthesize the existing literature describing methods used to train HCP to deliver BCS for PA promotion for individuals living with neurological conditions. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eight databases were searched for articles describing how HCP were trained on BCS targeting PA and/or exercise for neurological pathology. Two researchers independently screened abstracts and used third-party consensus when needed. Studies must have described the planning/implementation of BCS targeting PA in adults with neurological disorders, with interventions delivered by a HCP. A data extraction table based on the study objective and the Cochrane Consumers and Communication Review Group's data extraction template was used. Risk of bias was assessed using the Quality Assessment Tools for Quantitative and Qualitative Studies. Included studies were also evaluated using the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations for reporting behavior change intervention content. Extraction and evaluation of risk of bias were completed independently by two researchers. Data were synthesized according to a who, what, when, and how approach. The search yielded 2,616 articles after duplicates removed, with 13 articles, representing eight unique interventions in individuals with spinal cord injury, stroke, multiple sclerosis, and Parkinson's disease included. Methodological quality ranged from strong to weak. Methods used to increase HCP knowledge and use of BCS were heterogeneous. Common training features included multiple resources, multiple sessions, expert input, and ongoing support, but a lack of evaluation of training effectiveness. The BCS were based on Social Cognitive Theory in seven interventions. Physiotherapists were the most common HCP trained. There was considerable variety in how HCP were trained to use BCS and a lack of evaluation of training effectiveness. Future work should include more description of the content and structure of HCP training and a direct measure of effectiveness. Researchers should consider implementation strategies during development and reporting of behavior change interventions. This review was not registered with PROSPERO.

Safety, feasibility, acceptability and effects of a behaviour-change intervention to change physical activity behaviour among people with multiple sclerosis: Results from the iStep-MS randomised controlled trial

Background:

There is limited information regarding the safety, feasibility and acceptability of behaviour-change interventions to increase physical activity (PA) and reduce sedentary behaviour among people with multiple sclerosis (MS). Prior to evaluating efficacy, it is important to identify problems with feasibility and acceptability, which may undermine effectiveness.

Objective:

To examine the safety, feasibility and acceptability of a behaviour-change intervention to increase PA and reduce sedentary behaviour among people with MS.

Methods:

Sixty people received a 3-month intervention or usual care. Fatigue, pain and adverse events (AEs) were assessed. Feasibility and acceptability were explored through focus groups with physiotherapists and interviews with participants. Fidelity to intervention content, delivery skills, programme receipt and programme task were assessed.

Results:

There was no difference in AE rate between groups ( p = 0.965). Fatigue and pain were not higher in the intervention group at 3 or 9 months. Therapists reported the intervention was feasible to deliver and fidelity was acceptable. Twenty-nine participants (97%) attended at least 75% of sessions. Participants found the intervention acceptable but suggested some amendments were required to intervention components.

Conclusions:

The intervention was safe, feasible and acceptable. Although modifications are required to intervention components, the intervention warrants further evaluation in a future trial.

The effectiveness of interventions targeting physical activity and/or sedentary behaviour in people with Multiple Sclerosis: a systematic review

Background: Remaining physically active is important to maintain functional ability and reduce the incidence of co-morbidities in people with Multiple Sclerosis. The aim of this review was to evaluate the effectiveness of interventions on physical activity or sedentary behaviour in people with Multiple Sclerosis.Methods: A systematic search was conducted in May 2018 of the following databases: Web of Science Core Collections, Embase and Medline. Included studies were randomised controlled trials involving people with Multiple Sclerosis who completed an intervention, compared to any comparator. Outcomes included subjective or objective measures of physical activity or sedentary behaviour. Quality assessment was performed using the Physiotherapy Evidence Database scale.Results: Twenty-five trials were included covering 1697 participants, the majority of which had mild-moderate disability (average Physiotherapy Evidence Database score 6.2 ± 1.5). Experimental interventions included exercise prescription (n = 5), behaviour change interventions (n = 10), combined exercise, and behaviour change techniques (n = 7) and education (n = 3). Generally, subjective but not objective physical activity improved in those with mild-moderate disability. Insufficient data existed on the effectiveness on sedentary behaviour.Conclusions: A discrepancy seems to exists between the effectiveness of physical activity interventions in people with Multiple Sclerosis depending on whether physical activity was assessed objectively or subjectively, with the latter indicating effects. Effects on sedentary behaviour remain to be elucidated.Implications for RehabilitationRemaining physically active is important to maintain functional ability, independence, quality of life, and to reduce the incidence of co-morbidity.Exercise prescription, behaviour change interventions, combined exercise and behaviour change interventions, and health promotion education appear to subjectively improve physical activity in people with Multiple Sclerosis with mild-moderate disability, yet this is often not the case when measured objectively.There is a lack of evidence to support the effectiveness of these interventions on sedentary behaviour.

Fear of falling, not falls, impacts leisure-time physical activity in people with multiple sclerosis

BACKGROUND

There is a consensus that physical activity is imperative for people with MS (PwMS). However, regardless of the benefits, many PwMS do not participate in any meaningful physical activity.

AIM

To examine the relationship between leisure-time physical activity with clinical characteristics and common symptoms in PwMS.

METHODS

The sample included 190 PwMS (107 women), mean age 40.8 (S.D = 13.1) and mean disease duration of 6.4 (SD = 8.3) years since diagnosis. Outcome measures included the Godin Leisure-Time Exercise Questionnaire (GLTEQ), Four Square Step Test (FSST), 2-Minute Walk test (2 mWT), Timed Up and Go test (TUG), Timed 25-Foot Walk test (T25FW), fall status, Falls Efficacy Scale International (FES-I), Modified Fatigue Impact Scale (MFIS), walking speed and the Multiple Sclerosis Walking Scale self-reported questionnaire (MSWS-12).

RESULTS

Eighty-six PwMS were classified as active (GLTEQ = 31.6 (S.D = 16.7); 104 were insufficiently active (GLTEQ = 3.0 (S.D = 4.3). Insufficiently active PwMS demonstrated a slower walking speed, elevated fatigue, more concerns of falling and additional walking difficulties compared to active PwMS. Non-significant differences between groups were observed in the TUG, 2 mWT, FSST, T25FWT and fall status. According to the linear regression, by utilizing the FES-I we observed a 12.2% variance related to leisure-time physical activity. The independent variables: EDSS, MSWS-12, fatigue and walking speed were non-significant.

SIGNIFICANCE

The present findings highlight the impact of concern of falling on physical activity in PwMS. This knowledge may represent an opportunity to improve care and enhance physical activity in the MS population.