Treadmill training for individuals with multiple sclerosis: a pilot randomised trial

Walking performance differs between people with multiple sclerosis who perform distinct types of exercise

Aim: To determine whether walking performance differed between people with multiple sclerosis (MS) who performed distinct types, volumes and intensities of exercise.Materials & methods: Forty-five people with relapsing-remitting MS performed two trials of the 2-min walk test, one at a preferred speed and another at a fast speed. Gait metrics were measured by wireless inertial sensors. Participants reported the type (aerobic, resistance), volume and intensity of exercise performed.Results: Walking speed reserve and gait variability were better in participants who performed combined aerobic and resistance exercises compared with those who performed aerobic-only exercise.Conclusion: Walking performance differs in people with mild MS disability based on the type and volume of exercise performed.

Comparison of the effects of mechanical hippotherapy and Cawthorne-Cooksey exercises in patients with multiple sclerosis: Randomized trial

BACKGROUND

Patients diagnosed with multiple sclerosis (MS) commonly encounter heightened postural instability and challenges in aligning their eyes, head, and bodily motions while engaging in specific tasks. This study aims to compare the effects of Cawthorne-Cooksey and mechanical hippotherapy exercises on fatigue, balance, gait, dizziness, and life quality in patients with MS.

METHODS

The MS patients were randomly divided into Cawthorne-Cooksey (n:25) and mechanical hippotherapy exercise (n:25) groups. In addition to the traditional physical therapy program, Cawthorne-Cooksey and hippotherapy exercises were applied to the groups 3 days a week, for 8 weeks. The trial's clinical number is NCT06005909. The Fatigue Severity Scale (FSS), Fatigue Impact Scale (FIS), Dizziness Handicap Inventory, Tinetti Balance and Gait Assessment Scale, and Ferrans&Powers Quality-of-Life Index were used for pre-and post-treatment assessment.

RESULTS

Both groups exhibited a significant decrease in FSS, FIS, and Dizziness Handicap Inventory scores, as well as an increase in Tinetti Balance and Gait Assessment Scale and Ferrans&Powers Quality-of-Life Index scores following treatment. In the inter-group comparison, the Tinetti balance and gait assessment and the Ferrans&Powers quality of life index scores were higher in the hippotherapy group compared to the Cooksey group.

CONCLUSIONS

Although both forms of physical activity have demonstrated effectiveness in reducing fatigue among individuals with MS, hippotherapy shows superior efficacy in enhancing balance, gait, and overall quality of life.

Effects of walking interventions in persons with multiple sclerosis-A systematic review

OBJECTIVE

The aim of the present systematic review was to investigate the effects of voluntary walking interventions in persons with multiple sclerosis (pwMS). For this purpose, we developed a framework to describe the components of walking interventions.

DATA SOURCES

Two databases (MEDLINE/PubMed and EMBASE) were searched in January 2023.

STUDY SELECTION

Included studies enrolled pwMS and evaluated walking interventions with a duration of 2 weeks or longer. Further, they evaluated at least one walking-related outcome. Both RCTs and non-controlled studies were enrolled.

DATA EXTRACTION

Data were extracted using a customized spreadsheet, which included detailed information on patient characteristics, interventions, outcomes, and results. Based on the extracted results, the effect sizes (ES, Hedge's g) of the walking interventions were calculated if possible. The methodological quality of the included studies and their reporting was determined using the TESTEX evaluation tool.

DATA SYNTHESIS

Data from a total of n = 200 pwMS was included from N = 7 RCT´s (from 3 we used within-group data) and N = 5 single-group studies. On average 91.7 ± 9.9 % of the planned walking sessions were attended, 8.7 ± 10.5 % of the participants dropped out, and very few adverse events occurred. Walking interventions improved walking performance during short distance walk tests (ES ranging from -0.21 to -0.72, "walking time") and long distance walk tests (ES ranging from 0.27 to 0.72, "walking distance").

CONCLUSIONS

Voluntary walking interventions appear to be safe and effective at improving walking performance in pwMS. However, well-powered walking intervention studies are needed to confirm these promising effects. The simplicity of walking interventions makes them highly relevant for ambulatory pwMS.

Effectiveness of physical activity interventions on reducing perceived fatigue among adults with chronic conditions: a systematic review and meta-analysis of randomised controlled trials

Fatigue is barrier of physical activity participation in adults with chronic conditions. However, physical activity alleviates fatigue symptoms. This systematic review and meta-analysis aimed to (1) synthesise evidence from randomised controlled trials (RCTs) exploring the effects of physical activity interventions on fatigue reduction and (2) evaluate their effectiveness. Medline/CINAHL/EMBASE/Web of Science and Scopus were searched up to June 24th, 2023. Two reviewers independently conducted study screening and selection (RCTs), extracted data and assessed risk of bias (RoB2). Outcome was the standardised mean difference (SMD) with 95% confidence intervals in fatigue between experimental and control groups. 38 articles met the inclusion criteria. Overall, physical activity interventions moderately reduced fatigue (SMD = 0.54, p < 0.0001). Interventions lasting 2-6 weeks demonstrated a larger effect on fatigue reduction (SMD = 0.86, p < 0.00001). Interventions with 18-24 sessions showed a large effect on fatigue reduction (SMD = 0.97, p < 0.00001). Aerobic cycling and combination training interventions had a large to moderate effect (SMD = 0.66, p = 0.0005; SMD = 0.60, p = 0.0010, respectively). No long-term effects were found during follow-up. Physical activity interventions moderately reduced fatigue among adults with chronic conditions. Duration, total sessions, and mode of physical activity were identified as key factors in intervention effectiveness. Further research is needed to explore the impact of physical activity interventions on fatigue.

Effect of Backward and Forward Walking on Lower Limb Strength, Balance, and Gait in Multiple Sclerosis: A Randomized Feasibility Trial

BACKGROUND

Backward walking (BW) interventions have improved gait and balance in persons with stroke, cerebral palsy, and Parkinson disease but have not been studied in persons with multiple sclerosis (MS). We examined the feasibility of a BW intervention and how it affected strength, balance, and gait vs forward walking (FW) in persons with MS.

METHODS

Sixteen persons with MS with a Patient-Determined Disease Steps (PDDS) scale score of 3 to 5 (gait impairment-late cane) were randomized to the FW (n = 8) or BW (n = 8) group. Participants did 30 minutes of FW or BW on a treadmill 3 times per week for 8 weeks (24 visits). Enrollment, adherence rate, and safety were tracked. The Timed Up and Go test, Six-Spot Step Test, single-leg stance, and abbreviated Activities-specific Balance Confidence scale were used to measure balance. Hip and knee flexion and extension strength (isometric peak torque), gait speed, and spatiotemporal gait parameters were measured. A 2×2 factorial multivariate analysis of covariance was used to examine changes in strength, balance, and gait, with the PDDS scale score as the covariate.

RESULTS

Treatment adherence rate was 99.7%, with no safety concerns. After controlling for baseline differences in disability (PDDS scale score; P = .041), the BW group improved dominant hip flexion strength preintervention to postintervention compared with the FW group (F 1,13 = 9.03; P = .010). No other significant differences were seen between groups.

CONCLUSIONS

This was the first study to look at BW as an intervention in persons with MS. Based on its feasibility, safety, and significant finding, BW should be studied in a larger, definitive trial in the future.

A review of current rehabilitation practices and their benefits in patients with multiple sclerosis

Multiple sclerosis (MS) is a chronic, debilitating disease characterised by demyelination of the nerves of the central nervous system that results in patients progressively losing the ability to perform daily tasks. As there is no cure for this disease, rehabilitation therapy is an important aspect of care; assisting patients to regain or retain function and improve their physical, mental and social wellbeing. At present there is no current consistent model of care for MS, likely due to the variable symptom presentation. Various forms of rehabilitation therapy are available, and these include physical rehabilitation methods, such as balance and gait therapy, speech and respiration rehabilitation, and occupational therapy. Contrary to previous understanding, exercise-based therapies have shown various benefits for patients with MS, and in addition to improving MS-related physical symptoms, have been shown to reduce the risk of developing cardiovascular disease and can improve cognitive function. Cognition rehabilitation therapy specifically focuses on behavioural tasks and is divided into two main forms: compensatory rehabilitation, which offers cognitive functioning benefits, and restorative rehabilitation, which offers memory benefits. Excitation therapies include cranial stimulation and other stimulation rehabilitation methods such as focal muscle vibration therapy and these non-invasive techniques may improve patient's physical ability. Additionally, more novel rehabilitation methods include robot-assisted gait therapy and telerehabilitation, both of which are expected to play progressively more prominent roles in the future of rehabilitation therapy. The structure of the care team has been found to impact patient outcomes, and both in- and out-patient care settings have been found to be beneficial, dependant on the patient's circumstances, with certain patients better suited to a particular setting. While a single point of care is recommended for patients, a multidisciplinary care team and regular reassessment is recommended to manage changing symptoms and ensure continuity of care. The importance of the critical components of rehabilitation have been identified, and these are of vital importance in achieving beneficial outcomes. These components include the patients' participation in the treatment, goal setting with a multidisciplinary care team, a guiding-light purpose for the patient, which focusses on recognizing their personal potential and obtaining improvements through a tailored plan. The final critical component of rehabilitation is the results measurement, which highlights the need for a quantifiable reduction in impairment and improvement in activity and participation. Overall, a lack of standardisation in outcome measurements makes comparison challenging. This is particularly important when comparing standard methods of care with more novel rehabilitation techniques. However, within the broad area of rehabilitation therapies, it is clear that patients with MS can benefit from rehabilitation practices; physically, mentally and socially.

Molecular Mechanisms of Exercise and Healthspan

Healthspan is the period of our life without major debilitating diseases. In the modern world where unhealthy lifestyle choices and chronic diseases taper the healthspan, which lead to an enormous economic burden, finding ways to promote healthspan becomes a pressing goal of the scientific community. Exercise, one of humanity's most ancient and effective lifestyle interventions, appears to be at the center of the solution since it can both treat and prevent the occurrence of many chronic diseases. Here, we will review the current evidence and opinions about regular exercise promoting healthspan through enhancing the functionality of our organ systems and preventing diseases.

Functional intermuscular reduction in spasticity for people with multiple sclerosis

Background

Eighty-five percent of people with multiple sclerosis (MS) incur gait impairments debilitating enough to significantly impact their function.

Objectives

The aim of this study was to determine if a novel combination of intermuscular electrical stimulation, followed by functional electrical stimulation combined with supported bodyweight treadmill training, would improve gait, decrease spasticity and fatigue, and improve muscle strength.

Methods

Using a pre-post experimental design, we implemented this combination six-week protocol in 16 individuals with MS. We completed summary statistics and longitudinal pre-post results using Wilcoxon sign rank tests with Bonferroni adjustment.

Results

Participants responded with median increases of 29.4 feet (p < 0.0001) during the Six Minute Walk Test, median decreases of 0.7 s (p = 0.0011) in the 25-Foot Walk Test, median increases of 3.8 toe taps to fatigue (p = 0.0306) and median increases of 5.0 heel raises (p = 0.0093). Significant changes were noted in the Modified Ashworth Scale, both after intermuscular electrical stimulation (median change = −0.5 p = 0.0039) and after treadmill walking (median change = −0.5, p < 0.0005).

Conclusions

Results of this novel protocol suggest this intervention combination has the potential to decrease spasticity, and improve gait speed and endurance in individuals with MS. Observed changes in mobility occurred without accompanying increases in fatigue.

Dalfampridine for Mobility Limitations in People With Multiple Sclerosis May Be Augmented by Physical Therapy: A Non-randomized Two-Group Proof-of-Concept Pilot Study

Purpose: To demonstrate proof-of-concept for a combined physical therapy and pharmacological intervention and obtain preliminary estimates of the therapeutic efficacy of a motor-relearning physical therapy intervention with and without concurrent dalfampridine treatment on gait speed in people with mobility limitations due to multiple sclerosis (MS).

Methods: Using a non-randomized, two-group design, 4 individuals with MS newly prescribed dalfampridine as part of their routine medical care, and 4 individuals with MS not taking dalfampridine completed a 3-week drug run-in or no-treatment baseline, respectively. After 3 weeks, all participants commenced physical therapy twice weekly for 6 weeks. Participants taking dalfampridine took the medication for the study duration. The physical therapy program comprised functional strengthening, gait training, balance training, and dual-task training. The primary outcome was Timed 25-foot Walk (T25FW) at the end of the 6-week physical therapy program.

Results: For the 4 participants taking dalfampridine, average improvement in T25FW on drug only was 12.8% (95% CI 1.2 to 24.4%). During the 6-week physical therapy phase, both groups significantly improved T25FW, but the effect tended to favor the group taking dalfampridine (mean difference = −0.93 s, 95% CI −1.9 to 0.07 s, p = 0.064, d = 1.6). Whereas the physical therapy group had average T25FW improvement of 10.8% (95% CI 1.0 to 20.5%), the physical therapy plus dalfampridine group demonstrated average improvement of 20.7% (95% CI 3.8 to 37.6%).

Conclusions: Further research is warranted to examine whether dalfampridine for mobility impairment may be augmented by physical therapy in people with MS.

Systematic Review of Exercise Studies in Persons with Multiple Sclerosis: Exploring the Quality of Interventions According to the Principles of Exercise Training

INTRODUCTION

The objective of this systematic review is to explore the application and reporting of (i) the principles of exercise training in exercise trials, (ii) the components of exercise prescription, and (iii) the adherence towards the prescribed programmes in randomised controlled trials (RCTs) in persons with multiple sclerosis (pwMS).

METHODS

The MEDLINE, CINAHL, SPORTDiscus, PubMed and Embase electronic databases were searched from 1 January 2000 to 16 October 2020. RCTs comprising at least 3 weeks of aerobic and/or resistance exercise intervention in pwMS that reported at least one physiological outcome and were published in peer-reviewed journals were eligible for inclusion.

RESULTS

Out of 52 RCTs included in this review, 58 intervention arms were examined. None applied more than four principles of exercise training. Specificity was addressed by 85%, progression by 33%, overload by 59%, initial values by 26%, reversibility by 0% and diminishing returns by 2% of trials. Fifty-two percent of trials reported all components of exercise prescription, and 3% of trials reported the level of adherence to the prescribed exercise.

CONCLUSION

This systematic review reveals that exercise training principles were not respected in the majority of included RCTs. The weak quality of reported exercise interventions limits the interpretation of the studies' results and potentially leads to an underestimation of 'exercise as medicine' in pwMS. Also, the vague descriptions of exercise prescription and adherence impede the reproducibility of results. Future studies must attend to all principles of exercise training and provide transparent information on the prescribed and performed programmes to develop specific and valid exercise recommendations for pwMS.

SYSTEMATIC REVIEW REGISTRATION

CRD42020162671, 28/04/2020, PROSPERO.

The added value of cognition-targeted exercise versus symptom-targeted exercise for multiple sclerosis fatigue: A randomized controlled pilot trial

BACKGROUND

Fatigue is considered one of the most common symptoms of multiple sclerosis (MS) and lacks a current standardized treatment. Therefore, the aim of this study was to examine the feasibility and effectiveness of a cognition-targeted exercise versus symptom-targeted exercise for MS fatigue.

METHODS

In this Pilot, parallel-group, randomized controlled trial, sixty participants with multiple sclerosis, were randomly assigned to either a Cognition-Targeted Exercise (CTE) (N = 30, mean age 41) or a Symptom-Targeted Exercise (STE) (N = 30, mean age 42). The participants in the experimental group received eight, 50-minute sessions of weekly Cognitive Behavior Therapy (CBT) in addition to a CTE Program; whereas, participants in the control group received eight, 50-minute sessions of weekly CBT in addition to the standardized physiotherapy program (STE Program). Feasibility was assessed through recruitment rate, participant retention, adherence and safety, in addition to clinical outcome measures, including: (1) Modified Fatigue Impact Scale (MFIS), (2) Work and Social Adjustment Scale (WSAS), (3) Hospital Anxiety and Depression Scale (HADS), and Perceived Stress Scale (PSS). All outcome measures were assessed at baseline (pretreatment), following completion of the eight visit intervention protocol, and at 3-months follow-up.

RESULTS

The recruitment rate was 60% and 93% of participants completed the entire study. The recruited participants complied with 98% of the required visits. No adverse events were recorded. A Generalized Estimation Equation Model revealed a significant difference over time as an interaction term during the post and follow up visit for all clinical outcome measures (p < .001).

CONCLUSION

The addition of CTE to CBT exhibited positive and more lasting influence on MS fatigue outcomes compared to Symptom-Targeted Exercise (STE). Feasibility and efficacy data from this pilot study provide support for a full-scale RCT of CTE as an integral component of Multiple Sclerosis fatigue management.

Which exercise and behavioural interventions show most promise for treating fatigue in multiple sclerosis? A network meta-analysis

BACKGROUND

Fatigue is a common, debilitating symptom of multiple sclerosis (MS) without a current standardised treatment.

OBJECTIVE

The aim of this systematic review with network meta-analyses was to estimate the relative effectiveness of both fatigue-targeted and non-targeted exercise, behavioural and combined (behavioural and exercise) interventions.

METHODS

Nine electronic databases up to August 2018 were searched, and 113 trials (n = 6909) were included: 34 were fatigue-targeted and 79 non-fatigue-targeted trials. Intervention characteristics were extracted using the Template for Intervention Description and Replication guidelines. Certainty of evidence was assessed using GRADE.

RESULTS

Pairwise meta-analyses showed that exercise interventions demonstrated moderate to large effects across subtypes regardless of treatment target, with the largest effect for balance exercise (SMD = 0.84). Cognitive behavioural therapies (CBTs) showed moderate to large effects (SMD = 0.60), with fatigue-targeted treatments showing larger effects than those targeting distress. Network meta-analysis showed that balance exercise performed significantly better compared to other exercise and behavioural intervention subtypes, except CBT. CBT was estimated to be superior to energy conservation and other behavioural interventions. Combined exercise also had a moderate to large effect.

CONCLUSION

Treatment recommendations for balance and combined exercise are tentative as the certainty of the evidence was moderate. The certainty of the evidence for CBT was high.

Effect of Exercise on Fatigue in Multiple Sclerosis: A Network Meta-analysis Comparing Different Types of Exercise

OBJECTIVE

A network meta-analysis (NMA) of current evidence was conducted to determine if physical exercise has a positive influence on multiple sclerosis (MS) fatigue and type of exercise with the largest effect on fatigue also according to disease severity.

DATA SOURCES

MEDLINE, Embase, SPORTDiscus, Physiotherapy Evidence Database, Cochrane Library, and Web of Science. The search strategy combined relevant terms related to (1) MS; (2) clinical trials; (3) exercise; and (4) fatigue from inception to February 2021.

STUDY SELECTION

Randomized controlled trials concerning the effectiveness of different types of exercise on total and physical fatigue in people with MS were included.

DATA EXTRACTION

The data were extracted into predesigned data extraction tables. Risk of bias was evaluated with the Cochrane Risk of Bias tool (RoB 2.0), and the Grading of Recommendations, Assessment, Development, and Evaluation tool was used to evaluate the quality of the evidence.

DATA SYNTHESIS

A total of 58 studies were examined. Data were pooled using a random-effects model. A ranking of 7 and 8 different exercise interventions for physical and total fatigue scores, respectively, was achieved. The highest effects for pairwise comparisons were for combined exercise and resistance training vs control (ranging between -0.74 and -1.24). In the NMA, combined exercise (-1.51; 95% confidence interval [CI], -2.01 to -1.01) and resistance training (-1.15; 95% CI, -1.81 to -0.49) compared with the control group achieved the highest effects for physical and total fatigue, respectively.

CONCLUSIONS

Exercise should be considered an effective fatigue management strategy. Among the different exercise modalities, combined exercise is the most effective exercise modality for improving both physical and total fatigue. Resistance training is also an effective exercise for total fatigue among people diagnosed with MS.

Exercise and Sports Science Australia (ESSA) position statement on exercise for people with mild to moderate multiple sclerosis

OBJECTIVES

Multiple sclerosis (MS), the most common chronic and progressive neurological condition of the central nervous system, affects 26,000 Australian adults. Exercise training has beneficial effects on MS-related impairments including reduced muscular strength, poor aerobic capacity and impaired mobility, and in consequence can improve quality of life. This Position Statement provides evidence-based recommendations for exercise prescription and delivery of exercise training for people with MS with mild to moderate disability.

DESIGN AND METHODS

Synthesis of published works within the field of exercise training in MS.

RESULTS

Exercise provides many benefits to people with MS. There is strong evidence that resistance and aerobic training, performed 2 to 3 times per week at a moderate intensity, are safe and can improve muscle strength, cardiorespiratory fitness, balance, fatigue, functional capacity, mobility and quality of life in people with MS with mild to moderate disability (Expanded Disease Severity Scale (EDSS) ≤ 6.5). However, the evidence for those with severe disability (EDSS >6.5) is less clear. The effects of exercise on MS pathogenesis, central nervous structures and other outcomes such as depression and cognitive impairment, have not been adequately investigated. Effective exercise interventions to improve balance, joint contractures and reduce falls in people with MS are also urgently needed as well as investigations of long-term (≥1 year) effects of exercise training.

CONCLUSIONS

Resistance and aerobic training exercises are effective to alleviate some characteristic signs and symptoms in MS and should be supplemented by balance exercise to prevent falls. Exercise training programs should be prescribed and delivered by qualified exercise professionals. It is important to recognise and accommodate exercise-associated complications such as fatigue and heat sensitivity.

[Rehabilitation of patients with multiple sclerosis]

Multiple sclerosis is a common cause of disability among young and middle-aged people. Despite the modern possibilities of diagnostics and therapy, over time, the disease acquires a secondary progressive character. Rehabilitation of patients at all stages of the disease plays an important role in improving well-being, improving the quality of life, adapting the patient and restoring motor skills. However, there is currently no clear recommendation for the application of specific techniques in each case. The aim of this work was to analyze the available methods of rehabilitation therapy, to highlight the most used and promising ones. Due to the progressive course of the disease, the benefits of rehabilitation measures are usually higher at the initial stages. Nevertheless, nowadays there is a large number of works devoted to rehabilitation measures in patients with moderate and high levels of disability. It has been shown that both inpatient and outpatient rehabilitation has a positive effect on the quality of life and improvement of clinical indicators. Our review describes the main techniques with recommendations for the scheme of application. A comprehensive assessment of the patient's health status, a multidisciplinary team and a personalized approach increase the quality and effectiveness of rehabilitation measures. We also describe our own experience in the treatment of spasticity in patients with a secondary progressive multiple sclerosis.

Enhancement of balance, and mobility in individuals with multiple sclerosis using visual cue guided multidirectional step training - A pilot study

BACKGROUND

Individuals with multiple sclerosis (MS) often experience limitations in mobility due to impairment of gait and balance. Rehabilitation approaches to improve balance and mobility in individuals with MS are limited. We have developed a novel visual cue guided multi-direction step (MDS) training method to improve balance and mobility in individuals with MS.

OBJECTIVE

To examine the effect of MDS training on balance, gait, and mobility in individuals with MS.

METHODS

Five individuals with relapsing- remitting MS participated in the 4-week training involving stepping in eight directions in response to a visual cue. Balance, gait, and mobility were assessed before and after training.

RESULTS

Training related improvements were seen in the limits of stability (p< .05), spatial and temporal gait parameters (p<.05), and performance of the Tinetti Mobility Assessment (p=.001), 10-Meter Walk test (p<.001), and Four-Square Step test (p<.002).

CONCLUSION

Balance, gait, and mobility in individuals with MS could be improved after 4 weeks of visual cue guided multi-direction stepping training. Outcomes from this feasibility study could help to refocus conventional rehabilitation strategies aimed at aiding individuals with MS to achieve maximal independence in mobility.

Dosage and Effectiveness of Aerobic Training on Cardiorespiratory Fitness, Functional Capacity, Balance, and Fatigue in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the benefits of aerobic training (AT) programs on cardiorespiratory fitness, functional capacity, balance, and fatigue in individuals with multiple sclerosis (MS) and to identify the optimal dosage of AT programs for individuals with MS via a systematic review with meta-analysis.

DATA SOURCES

Two electronic databases were searched until March 2020 (PubMed-Medline and Web of Science).

STUDY SELECTION

Studies examining the effect of AT program on cardiorespiratory fitness, functional capacity, balance, and fatigue were included.

DATA EXTRACTION

After applying the inclusion and exclusion criteria, we included 43 studies. A total sample of 1070 individuals with MS (AT group, n=680; control group, n=390) were analyzed.

DATA SYNTHESIS

The AT group demonstrated a significant increase in cardiorespiratory fitness (standardized mean difference [SMD], 0.29; P=.002), functional capacity (timed Up and Go Test: SMD, -1.14; P<.001; gait speed: SMD, -1.19; P<.001; walking endurance: SMD, 0.46; P<.001), and balance (SMD, 3.49; P<.001) after training. Fatigue perception also decreased (SMD, -0.45; P<.001). However, no significant differences were observed when compared with the control group in either cardiorespiratory fitness (SMD, 0.14; P=.19) or fatigue perception. Nevertheless, we observed significant differences between the AT and control groups in balance (P=.02), gait speed (P=.02), and walking endurance (P=.03), favoring the participants who performed AT. Regarding the subgroup analysis, no significant differences were observed between subgroups in any of the variables studied except for gait speed, for which a greater increase in posttraining was observed when the AT program applied the continuous method (χ²=7.75; P=.005) and the exercises were performed by walking (χ²=9.36; P=.002).

CONCLUSIONS

Aerobic training improves gait speed, walking endurance, and balance. Cardiorespiratory fitness and fatigue perception also improved after AT, but we found no differences with the control group. In addition, subgroup analysis suggested that training using continuous and walking methods could optimize gait speed.

A multi-modal virtual reality treadmill intervention for enhancing mobility and cognitive function in people with multiple sclerosis: Protocol for a randomized controlled trial

BACKGROUND

Gait and cognitive impairments are common in individuals with Multiple Sclerosis (MS) and can interfere with everyday function. Those with MS have difficulties executing cognitive tasks and walking simultaneously, a reflection of dual-task interference. Therefore, dual-task training may improve functional ambulation. Additionally, using technology such as virtual reality can provide personalized rehabilitation while mimicking real-world environments. The purpose of this randomized controlled trial is to establish the benefits of a combined cognitive-motor virtual reality training on MS symptoms compared to conventional treadmill training.

METHODS

This study will be a single-blinded, two arm RCT with a six-week intervention period. 144 people with MS will be randomized into a treadmill training alone group or treadmill training with virtual reality group. Both groups will receive 18 sessions of training while walking on a treadmill, with the virtual reality group receiving feedback from the virtual system. Primary outcome measures include dual-task gait speed and information processing speed, which will be measured prior to training, one-week post-training, and three months following training.

DISCUSSION

This study will provide insight into the ability of a multi-modal cognitive-motor intervention to reduce dual-task cost and to enhance information processing speed in those with MS. This is one of the first studies that is powered to understand whether targeted dual-task training can improve MS symptoms and increase functional ambulation. We anticipate that those in the virtual reality group will have a significantly greater increase in dual-task gait speed and information processing speed than those achieved via treadmill training alone.

Efficacy of robot-assisted gait training in multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Multiple sclerosis is a progressive disease responsible for gait disabilities and cognitive impairment, which affect functional performance. Robot-assisted gait training is an emerging training method to facilitate body-weight-supported treadmill training in many neurologic diseases. Through this study, we aimed to determine the efficacy of robot-assisted gait training in patients with multiple sclerosis.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials evaluating the effect of robot-assisted gait training for multiple sclerosis. We searched PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov registry for articles published before May 2019. The primary outcome was walking performance (gait parameters, balance, and ambulation capability). The secondary outcomes were changes in perceived fatigue, severity of spasticity, global mobility, physical and mental quality of life, severity of pain, activities of daily living, and treatment acceptance.

RESULTS

We identified 10 studies (9 different trials) that included patients with multiple sclerosis undergoing robot-assisted gait training or conventional walk training. The meta-analysis showed comparable effectiveness between robot-assisted gait training and conventional walking therapy in walking performance, quality of life, pain, or activities of daily living. The robot-assisted gait training was even statistically superior to conventional walking therapy in improving perceived fatigue (pooled SMD: 0.34, 95% CI: 0.02-0.67), spasticity (pooled SMD: 0.70, 95% CI: 0.08-1.33, I² = 53%), and global mobility (borderline) after the intervention.

CONCLUSION

Our results provide the most up-to-date evidence regarding the robot-assisted gait training on multiple sclerosis. In addition to the safety and good tolerance, its efficacy on multiple sclerosis is comparable to that of conventional walking training and is even superior in improving fatigue and spasticity.

Effects of downslope walking on Soleus H-reflexes and walking function in individuals with multiple sclerosis: A preliminary study

BACKGROUND

Downslope walking (DSW) is an eccentric-based exercise intervention that promotes neuroplasticity of spinal reflex circuitry by inducing depression of Soleus Hoffman (H)-reflexes in young, neurologically unimpaired adults.

OBJECTIVE

The objective of the study was to evaluate the effects of DSW on spinal excitability (SE) and walking function (WF) in people with multiple sclerosis (PwMS).

METHODS

Our study comprised two experiments on 12 PwMS (11 women; 45.3±11.8 years). Experiment 1 evaluated acute effects of a single 20-minute session of treadmill walking at three different walking grades on SE, 0% or level walking (LW), - 7.5% DSW, and - 15% DSW. Experiment 2 evaluated the effects of 6 sessions of DSW, at - 7.5% DSW (with second session being - 15% DSW) on SE and WF.

RESULTS

Experiment 1 showed significantly greater acute % H-reflex depression following - 15% DSW compared to LW (p = 0.02) and - 7.5% DSW (p = 0.05). Experiment 2 demonstrated significant improvements in WF. PwMS who showed greater acute H-reflex depression during the - 15% DSW session also demonstrated greater physical activity, long-distance WF, and the ability to have greater H-reflex depression after DSW training. Significant changes were not observed in regards to SE.

CONCLUSIONS

Though significant changes were not observed in SE after DSW training, we observed an improvement in WF which merits further investigation of DSW in PwMS.

Response Heterogeneity With Exercise Training and Physical Activity Interventions Among Persons With Multiple Sclerosis

Multiple sclerosis (MS) is a heterogeneous disease, both in its pathology and symptomology. This poses a challenge for the medical management and rehabilitation of MS; however, physical activity and exercise training are rehabilitation approaches that have demonstrated beneficial effects on many of the burdensome consequences of MS such as mobility impairment and fatigue. Given the heterogeneous course of MS, it is possible that outcomes of physical activity and exercise training interventions demonstrate heterogeneity both in the magnitude and pattern of change, but there has been little focus on response heterogeneity with these interventions among persons with MS. In this narrative review, a search of the existing literature was performed to identify studies that reported individual participant data, which was used to describe the variability in the response to physical activity and exercise training interventions among persons with MS. Inter-individual variability seemingly occurs across outcomes and modalities, which underscores the consideration of factors that might influence response heterogeneity. Factors related to MS disease characteristics, nervous system damage, and the degree of MS-related disability might influence individual responsiveness. Large-scale studies that permit the examination of heterogeneity and its predictors will inform future research on the area of physical activity and exercise training in MS, and lead to the development of individually tailored rehabilitation approaches that will more effectively elicit change.

Treadmill training may be an effective form of task-specific training for improving mobility in people with Parkinson's disease and multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Task-specific training is an effective form of rehabilitation for improving mobility in neurological conditions. However, it remains unclear if task-specific training is effective in people with progressive disease.

OBJECTIVE

To establish the efficacy of task-specific training on the mobility of individuals with progressive neurological conditions.

DATA SOURCES

Electronic databases MEDLINE, EMBASE, CINAHL and Cochrane Database of Systematic Reviews.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials investigating the effect of task-specific training on mobility and falls rate in individuals with progressive neurological conditions.

STUDY APPRAISAL/SYNTHESIS METHODS

Risk of bias of individual studies was assessed using the Physiotherapy Evidence Database (PEDro) Scale. Mean differences (MD) and 95% confidence intervals were calculated and combined in meta-analysis.

RESULTS

Analysis of 16 trials found treadmill training improved comfortable walking velocity (m/second) in people with Parkinson's disease (MD 0.21m/second, 95%CI 0.15 to 0.27) and multiple sclerosis (MD 0.36m/second, 95%CI 0.20 to 0.52). Treadmill training improved stride length (m) (MD 0.12m, 95%CI 0.02 to 0.23) and step length (m) (MD 0.12m, 95%CI 0.01 to 0.23) in people with Parkinson's disease and walking endurance in people with multiple sclerosis (MD 26.53m, 95%CI 12.23 to 40.84). Treadmill training had no effect on cadence and did not improve walking endurance in Parkinson's disease. Over-ground walking did not improve mobility in Parkinson's disease or multiple sclerosis.

LIMITATIONS

Study sample sizes were small and findings must be interpreted with caution.

CONCLUSION

Treadmill training may be effective for improving mobility in people with Parkinson's disease and multiple sclerosis. The effectiveness of over-ground walking is uncertain.

SYSTEMATIC REVIEW PROSPERO REGISTRATION NUMBER

CRD42016047334.

Effect of Rehabilitation on Fatigue Level in Patients with Multiple Sclerosis

BACKGROUND The objective of this study was to evaluate the effect of a rehabilitation program in changing the perception of fatigue in patients with multiple sclerosis. MATERIAL AND METHODS The study involved 65 respondents/patients with clinically confirmed multiple sclerosis (54 women, 11 men, average age 46.49 years). The evaluation of the effects of fatigue on the physical, psychological, and psychosocial aspects of life was assessed using the Modified Fatigue Impact Scale (MFIS). To test the effectiveness of the neurorehabilitation program, we enrolled 2 groups: the experimental group (EG, n=32, 29 women, 3 men, Expanded Disability Status Scale (EDSS) 4.8 average, SD±1.77, min. 1.5 max 8.0) participated in the intervention and rehabilitation program over a period of 12 weeks and the control group (CG, n=33, 25 women, 8 men. EDSS average 5.12±1.74 SD, min. 2.0 max. 8.0). Each group of patients was divided into 3 sub-groups according to the severity of EDSS: a) 1-3.5, b) 4-6, and c) 6.5-8. For the statistical evaluation of the significance of the observed changes, the MANOVA/ANOVA model was used. RESULTS Between the input and output assessment of the MFIS individual areas questionnaire between the EG and the CG, there existed a statistically significant in the physical area (p<0.000), psychological area (p<0.000), and psychosocial area (p=0.002). CONCLUSIONS Our results support the importance of an active approach in patients with multiple sclerosis using individualized rehabilitation intervention programs.

Balance, gait, and falls in multiple sclerosis

Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) and the most widespread nontraumatic cause of disability in young adults around the world. MS occurs in people of all ages, races, and ethnicities. MS is characterized by clinical symptoms resulting from lesions in the brain, spinal cord, or optic nerves that can affect balance, gait, and fall risk. Lesions accumulate over time and occur in different areas of the CNS causing symptoms that include weakness, spasticity, and fatigue, as well as changes in sensation, coordination, vision, cognition, and bladder function. Thus, it is not surprising that imbalance, gait dysfunction, and falls are common in people with MS. The overwhelming majority have abnormalities of postural control and gait even early in the disease course. In all, 50-80% have balance and gait dysfunction and over 50% fall at least once each year. Balance dysfunction in MS is conceptualized as three interrelated problems: decreased ability to maintain position, limited and slowed movement towards limits of stability, and delayed responses to postural displacements and perturbations. In addition, functional balance performance may be affected by impaired dual-task integration. Walking changes in MS include reduced gait speed, impaired walking balance, and reduced walking-related physical activity. Falls in people with MS are associated with injuries, reduced participation, and increased fear of falling. A wide and growing range of rehabilitation and medical interventions are available to address the changes in balance, gait, and fall risk associated with MS.

Effects of an individual 12-week community-located “start-to-run” program on physical capacity, walking, fatigue, cognitive function, brain volumes, and structures in persons with multiple sclerosis

Background:

Exercise therapy studies in persons with multiple sclerosis (pwMS) primarily focused on motor outcomes in mid disease stage, while cognitive function and neural correlates were only limitedly addressed.

Objectives:

This pragmatic randomized controlled study investigated the effects of a remotely supervised community-located “start-to-run” program on physical and cognitive function, fatigue, quality of life, brain volume, and connectivity.

Method:

In all, 42 pwMS were randomized to either experimental (EXP) or waiting list control (WLC) group. The EXP group received individualized training instructions during 12 weeks (3×/week), to be performed in their community aiming to participate in a running event. Measures were physical (VO2max, sit-to-stand test, Six-Minute Walk Test (6MWT), Multiple Sclerosis Walking Scale-12 (MSWS-12)) and cognitive function (Rao’s Brief Repeatable Battery (BRB), Paced Auditory Serial Attention Test (PASAT)), fatigue (Fatigue Scale for Motor and Cognitive Function (FSMC)), quality of life (Multiple Sclerosis Impact Scale-29 (MSIS-29)), and imaging. Brain volumes and diffusion tensor imaging (DTI) were quantified using FSL-SIENA/FIRST and FSL-TBSS.

Results:

In all, 35 pwMS completed the trial. Interaction effects in favor of the EXP group were found for VO2max, sit-to-stand test, MSWS-12, Spatial Recall Test, FSMC, MSIS-29, and pallidum volume. VO2max improved by 1.5 mL/kg/min, MSWS-12 by 4, FSMC by 11, and MSIS-29 by 14 points. The Spatial Recall Test improved by more than 10%.

Conclusion:

Community-located run training improved aerobic capacity, functional mobility, visuospatial memory, fatigue, and quality of life and pallidum volume in pwMS.

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.

Important considerations for feasibility studies in physical activity research involving persons with multiple sclerosis: a scoping systematic review and case study

BACKGROUND

Much research has been undertaken to establish the important benefits of physical activity in persons with multiple sclerosis (MS). There is disagreement regarding the strength of this research, perhaps because the majority of studies on physical activity and its benefits have not undergone initial and systematic feasibility testing. We aim to address the feasibility processes that have been examined within the context of physical activity interventions in MS.

METHOD

A systematic scoping review was conducted based on a literature search of five databases to identify feasibility processes described in preliminary studies of physical activity in MS. We read and extracted methodology from each study based on the following feasibility metrics: process (e.g. recruitment), resource (e.g. monetary costs), management (e.g. personnel time requirements) and scientific outcomes (e.g. clinical/participant reported outcome measures). We illustrate the use of the four feasibility metrics within a randomised controlled trial of a home-based exercise intervention in persons with MS.

RESULTS

Twenty-five studies were identified. Resource feasibility (e.g. time and resources) and scientific outcomes feasibility (e.g. clinical outcomes) methodologies were applied and described in many studies; however, these metrics have not been systematically addressed. Metrics related to process feasibility (e.g. recruitment) and management feasibility (e.g. human and data management) are not well described within the literature. Our case study successfully enabled us to address the four feasibility metrics, and we provide new information on management feasibility (i.e. estimate data completeness and estimate data entry) and scientific outcomes feasibility (i.e. determining data collection materials appropriateness).

CONCLUSION

Our review highlights the existing research and provides a case study which assesses important metrics of study feasibility. This review serves as a clarion call for feasibility trials that will substantially strengthen the foundation of research on exercise in MS.

Locomotor training using body weight support on a treadmill improves mobility in persons with multiple sclerosis: a pilot study

Rationale

The purpose of this protocol was to investigate the potential benefits and tolerability of locomotor training using body weight support on a treadmill (LTBWST) in persons with multiple sclerosis (MS).

Methods

Four persons with primarily spinal cord MS and severely impaired ambulation (Expanded Disability Status Scale score 7.0–7.5) were enrolled in LTBWST. Subjects completed an average of 40 training sessions over several months.

Results

Subjects showed improvement in muscle strength, spasticity, endurance, balance, walking speed, and quality of life at the end of the training sessions, and could tolerate training without fatigue or other adverse effects.

Conclusions

LTBWST is well tolerated by persons with MS and may produce improvements in parameters related to functional mobility. Multiple Sclerosis 2007; 13: 224–231. http://msj.sagepub.com

Errors in the ankle plantarflexor force production are related to the gait deficits of individuals with multiple sclerosis

BACKGROUND

Individuals with multiple sclerosis (MS) often have limited mobility that is thought to be due to the neuromuscular impairments of the ankle. Greater isometric motor control of the ankle has been associated with better standing postural balance but its relationship to mobility is less understood. The objectives of this investigation were to quantify the motor control of the ankle plantarflexors of individuals with MS during a dynamic isometric motor task, and explore the relationship between the ankle force control and gait alterations.

METHODS

Fifteen individuals with MS and 15 healthy adults participated in both a dynamic isometric ankle plantarflexion force matching task and a biomechanical gait analysis.

FINDINGS

Our results displayed that the subjects with MS had a greater amount of error in their dynamic isometric force production, were weaker, walked with altered spatiotemporal kinematics, and had reduced maximal ankle moment at toe-off than the control group. The greater amount of error in the dynamic force production was related to the decreases in strength, step length, walking velocity, and maximal ankle moment during walking.

INTERPRETATION

Altogether these results imply that errors in the ankle plantarflexion force production may be a limiting factor in the mobility of individuals with MS.

A combined exercise model for improving muscle strength, balance, walking distance, and motor agility in multiple sclerosis patients: A randomized clinical trial

BACKGROUND

Multiple sclerosis (MS) is a neurological disease with a variety of signs and symptoms. Exercise therapy has been shown to improve physical functions in MS. However, questions about an optimal exercise therapy remain. In this regard, we suggest a combined exercise therapy including aerobic and resistance exercises for MS patients. The study is designed to observe, test and compare the effects of proposed combined exercises on strength, balance, agility, fatigue, speed, and walking distance in people with mild to moderate MS [0 < expanded disability status scale (EDSS) < 5].

METHODS

A total of 40 people with relapse-remitting MS (16 male, 0 < EDSS < 5) were randomized into one of the four groups (3 intervention and one control). The intervention consisted of various combinations of aerobic and resistance exercises with different repetition rates. Pre- and post-intervention scores of fatigue severity scale (FSS), timed up and go (TUG) test, 6-minute walk test (6MWT), 10- and 20-MWT, Berg balance scale (BBS), and one repetition maximum (1RM) test were recorded and analyzed.

RESULTS

For most tests, post-intervention values of the group 1, with 3-aerobic and 1-resistance exercises, were significantly higher compared to control group (P < 0.050). However, no significant progression was observed in the other two intervention groups.

CONCLUSION

A combination of three aerobic exercises with one resistance exercise may result in improved balance, locomotion, and endurance in MS patients.

Can aerobic treadmill training reduce the effort of walking and fatigue in people with multiple sclerosis: a pilot study

Impaired mobility in multiple sclerosis (MS) is associated with high-energy costs and effort when walking, gait abnormalities, poor endurance and fatigue. This repeated measures trial with blinded assessments investigated the effect of treadmill walking at an aerobic training intensity in 16 adults with MS. The intervention consisted of 12 sessions of up to 30 minutes treadmill training (TT), at 55–85% of age-predicted maximum heart rate. The primary outcome measure was walking effort, measured by oxygen consumption (mL/kg per metre), during treadmill walking at comfortable walking speed (CWS). Associated changes in gait parameters using the ‘Gait-Rite’ mat, 10-m time and 2-minute distance, and Fatigue Severity Scale were examined. Following training, oxygen consumption decreased at rest (P = 0.008), CWS increased (P = 0.002), and 10-m times (P = 0.032) and walking endurance (P = 0.020) increased. At increased CWS, oxygen consumption decreased (P = 0.020), with a decreased time spent in stance in the weaker leg (P = 0.034), and a greater stride distance with the stronger leg (P = 0.044). Reported fatigue levels remained the same. Aerobic TT presents the opportunity to alter a motor skill and reduce the effort of walking, whilst addressing cardiovascular de-conditioning, thereby, potentially reducing effort and fatigue for some people with MS.

Neurorehabilitation Strategies Focusing on Ankle Control Improve Mobility and Posture in Persons With Multiple Sclerosis

BACKGROUND AND PURPOSE

The neuromuscular impairments seen in the ankle plantarflexors have been identified as a primary factor that limits the mobility and standing postural balance of individuals with multiple sclerosis (MS). However, few efforts have been made to find effective treatment strategies that will improve the ankle plantarflexor control. Our objective was to determine whether an intensive 14-week neurorehabilitation protocol has the potential to improve the ankle plantarflexor control of individuals with MS. The secondary objectives were to determine whether the protocol would also improve postural control, plantarflexion strength, and mobility.

METHODS

Fifteen individuals with MS participated in a 14-week neurorehabilitation protocol, and 20 healthy adults served as a comparison group. The primary measure was the amount of variability in the submaximal steady-state isometric torque, which assessed plantarflexor control. Secondary measures were the Sensory Organization Test composite score, maximum plantarflexion torque, and the spatiotemporal gait kinematics.

RESULTS

There was less variability in the plantarflexion torques after the neurorehabilitation protocol (preintervention, 4.15% ± 0.5%; postintervention, 2.27% ± 0.3%). In addition, there were less postural sway (preintervention, 51.87 ± 0.2 points; postintervention, 67.8 ± 0.5 points), greater plantarflexion strength (preintervention, 0.46 ± 0.04 Nm/kg; postintervention, 0.57 ± 0.05 Nm/kg), and faster walking speeds (preferred preintervention, 0.71 ± 0.05 m/s; preferred postintervention, 0.81 ± 0.05 m/s; fast-as-possible preintervention, 0.95 ± 0.06 m/s; postintervention, 1.11 ± 0.07 m/s). All of the outcome variables matched or trended toward those seen in the controls.

DISCUSSION AND CONCLUSIONS

The outcomes of this exploratory study suggest that the neurorehabilitation protocol employed in this investigation has the potential to promote clinically relevant improvements in the ankle plantarflexor control, standing postural balance, ankle plantarflexion strength, and the mobility of individuals with MS. Video abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A110).

Critical Appraisal of Evidence for Improving Gait Speed in People with Multiple Sclerosis: Dalfampridine Versus Gait Training

BACKGROUND

Research has not yet compared the treatment effects of dalfampridine with traditional rehabilitation of gait impairments in multiple sclerosis (MS). The purpose of this review was to critically appraise the evidence for dalfampridine and gait training for increasing gait speed in people with MS.

METHODS

A systematic search of the research literature was conducted. Consideration was given to only randomized controlled trials (RCTs), systematic reviews, and meta-analyses. For selection of gait training studies, only studies involving task-specific gait training interventions and measuring treatment effects on gait speed were considered.

RESULTS

Treatment effects on gait speed were extracted from four studies examining the efficacy of dalfampridine and six gait training RCTs. Overall mean increase in gait speed with dalfampridine was 0.07 m/s (95% confidence interval [CI], 0.04-0.09 m/s) compared to 0.06 m/s (95% CI, 0.02-0.10 m/s) for gait training. Among dalfampridine responders (38% of participants in RCTs), the mean increase in gait speed was 0.16 m/s (95% CI, 0.13-0.18 m/s). Mean increases for individual gait training interventions ranged from 0.01 to 0.39 m/s; however, CIs were wide due to small sample sizes.

CONCLUSIONS

Current evidence is insufficient to conclude whether dalfampridine or gait training is superior for improving gait speed in people with MS. These findings should be viewed cautiously due to differences in study populations and small sample sizes in gait training studies. Both treatment approaches provide only short-lived improvements. Head-to-head comparison trials and studies combining both treatment modalities are needed.

Orthotic and therapeutic effect of functional electrical stimulation on fatigue induced gait patterns in people with multiple sclerosis

PURPOSE

To assess the orthotic and therapeutic effects of prolonged use of functional electrical stimulation (FES) on fatigue induced gait patterns in people with Multiple Sclerosis (MS).

METHOD

Thirteen people with MS completed 3D gait analysis with FES off and on, before and after a fatiguing 6-minute walk, at baseline and after 8 weeks of use of FES.

RESULTS

Eleven participants completed all testing. An orthotic effect on gait was not evident on first use of FES. However, therapeutic effects on gait after 8 weeks use were generally positive, including increases in walking speed due to improved neuromuscular control and power generated at the hip and ankle of the more affected limb. The action of FES alone was not sufficient to overcome all fatigue related deficits in gait but there was evidence 8 weeks use of FES can ameliorate some fatigue effects on lower limb kinetics, including benefits to ankle mechanics involved in generating power around push-off during stance.

CONCLUSIONS

Eight-weeks of FES can benefit the gait pattern of people with MS under non-fatigued and fatigued conditions. Implications for rehabilitation In some people with MS prolonged use of FES may be necessary before observing positive orthotic effects. Improvements in the neuromuscular control of the more affected lower limb may develop with prolonged use of FES in people with MS. Only some therapeutic benefits of FES are maintained during fatigued walking in people with MS. FES may be considered as a gait retraining device as well as an orthotic intervention for people with MS.

Uphill and Downhill Walking in Multiple Sclerosis: A Randomized Controlled Trial

BACKGROUND

Various exercise protocols have been recommended for patients with multiple sclerosis (MS). We investigated the effects of uphill and downhill walking exercise on mobility, functional activities, and muscle strength in MS patients.

METHODS

Thirty-four MS patients were randomly allocated to either the downhill or uphill treadmill walking group for 12 sessions (3 times/wk) of 30 minutes' walking on a 10% negative slope (n = 17) or a 10% positive slope (n = 17), respectively. Measurements were taken before and after the intervention and after 4-week follow-up and included fatigue by Modified Fatigue Impact Scale; mobility by Modified Rivermead Mobility Index; disability by Guy's Neurological Disability Scale; functional activities by 2-Minute Walk Test, Timed 25-Foot Walk test, and Timed Up and Go test; balance indices by Biodex Balance System; and quadriceps and hamstring isometric muscles by torque of left and right knee joints. Analysis of variance with repeated measures was used to investigate the intervention effects on the measurements.

RESULTS

After the intervention, significant improvement was found in the downhill group versus the uphill group in terms of fatigue, mobility, and disability indices; functional activities; balance indices; and quadriceps isometric torque (P < .05). The results were stable at 4-week follow-up.

CONCLUSIONS

Downhill walking on a treadmill may improve muscle performance, functional activity, and balance control in MS patients. These findings support the idea of using eccentric exercise training in MS rehabilitation protocols.

Exercise therapy for fatigue in multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system affecting an estimated 1.3 million people worldwide. It is characterised by a variety of disabling symptoms of which excessive fatigue is the most frequent. Fatigue is often reported as the most invalidating symptom in people with MS. Various mechanisms directly and indirectly related to the disease and physical inactivity have been proposed to contribute to the degree of fatigue. Exercise therapy can induce physiological and psychological changes that may counter these mechanisms and reduce fatigue in MS.

OBJECTIVES

To determine the effectiveness and safety of exercise therapy compared to a no-exercise control condition or another intervention on fatigue, measured with self-reported questionnaires, of people with MS.

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Trials Specialised Register, which, among other sources, contains trials from: the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 10), MEDLINE (from 1966 to October 2014), EMBASE (from 1974 to October 2014), CINAHL (from 1981 to October 2014), LILACS (from 1982 to October 2014), PEDro (from 1999 to October 2014), and Clinical trials registries (October 2014). Two review authors independently screened the reference lists of identified trials and related reviews.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) evaluating the efficacy of exercise therapy compared to no exercise therapy or other interventions for adults with MS that included subjective fatigue as an outcome. In these trials, fatigue should have been measured using questionnaires that primarily assessed fatigue or sub-scales of questionnaires that measured fatigue or sub-scales of questionnaires not primarily designed for the assessment of fatigue but explicitly used as such.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the articles, extracted data, and determined methodological quality of the included trials. Methodological quality was determined by means of the Cochrane 'risk of bias' tool and the PEDro scale. The combined body of evidence was summarised using the GRADE approach. The results were aggregated using meta-analysis for those trials that provided sufficient data to do so.

MAIN RESULTS

Forty-five trials, studying 69 exercise interventions, were eligible for this review, including 2250 people with MS. The prescribed exercise interventions were categorised as endurance training (23 interventions), muscle power training (nine interventions), task-oriented training (five interventions), mixed training (15 interventions), or 'other' (e.g. yoga; 17 interventions). Thirty-six included trials (1603 participants) provided sufficient data on the outcome of fatigue for meta-analysis. In general, exercise interventions were studied in mostly participants with the relapsing-remitting MS phenotype, and with an Expanded Disability Status Scale less than 6.0. Based on 26 trials that used a non-exercise control, we found a significant effect on fatigue in favour of exercise therapy (standardized mean difference (SMD) -0.53, 95% confidence interval (CI) -0.73 to -0.33; P value < 0.01). However, there was significant heterogeneity between trials (I(2) > 58%). The mean methodological quality, as well as the combined body of evidence, was moderate. When considering the different types of exercise therapy, we found a significant effect on fatigue in favour of exercise therapy compared to no exercise for endurance training (SMDfixed effect -0.43, 95% CI -0.69 to -0.17; P value < 0.01), mixed training (SMDrandom effect -0.73, 95% CI -1.23 to -0.23; P value < 0.01), and 'other' training (SMDfixed effect -0.54, 95% CI -0.79 to -0.29; P value < 0.01). Across all studies, one fall was reported. Given the number of MS relapses reported for the exercise condition (N = 25) and non-exercise control condition (N = 26), exercise does not seem to be associated with a significant risk of a MS relapse. However, in general, MS relapses were defined and reported poorly.

AUTHORS' CONCLUSIONS

Exercise therapy can be prescribed in people with MS without harm. Exercise therapy, and particularly endurance, mixed, or 'other' training, may reduce self reported fatigue. However, there are still some important methodological issues to overcome. Unfortunately, most trials did not explicitly include people who experienced fatigue, did not target the therapy on fatigue specifically, and did not use a validated measure of fatigue as the primary measurement of outcome.

Exercise in the management of persons with multiple sclerosis

For decades, persons with multiple sclerosis (MS) were counseled to avoid excessive physical activity and exercise because of concerns about worsening disease activity. Recent studies indicate that, not only can those with MS tolerate physical exercise, but that it is helpful in managing symptoms, preventing complications and comorbidities, and may possibly have neuroprotective actions. This article reviews previous studies on the effects of different exercise protocols in people with MS, and provides summaries of suggested exercise regimens that may be appropriate and beneficial for this patient population.

A pilot study of an exercise-based patient education program in people with multiple sclerosis

There is increasing evidence that physical exercise leads to numerous positive effects in PwMS. However, long-term effects of exercise may only be achievable if training is implemented in daily routine. Enabling patients to exercise regularly, we developed a patient education program focused on evidence-based information of training. PwMS were educated in neurophysiological effects of physical exercise, exercise-induced benefits for PwMS, and risk factors (e.g., weather). Fifteen PwMS were analyzed before (T 0) and after (T 1) a 12-week patient education. Afterwards, participants performed their exercises autonomously for 32 weeks and were tested in sustainability tests (T 2). Guided interviews were carried out, additionally. Significant improvements from T 0 to T 1 were found in 6MWT, gait velocity, TUG, fatigue, and quality of life. Significant results of TUG and gait velocity from T 1 to T 2 demonstrated that participants kept few effects after the 32-week training phase. Qualitative analyses showed improved self-confidence and identified training strategies and barriers. This pilot study provides evidence that PwMS are able to acquire good knowledge about physical exercise and apply this knowledge successfully in training management. One might conclude that this exercise-based patient education seems to be a feasible option to maintain or improve patients' integral constitution concerning physical and mental health.

Rehabilitation and multiple sclerosis: hot topics in the preservation of physical functioning

In a chronic and disabling disease like multiple sclerosis, rehabilitation becomes of major importance in the preservation of physical, psychological and social functioning. Approximately 80% of patients have multiple sclerosis for more than 35 years and most will develop disability at some point of their lives, emphasising the importance of rehabilitation in order to maintain quality of life. An important aspect of multiple sclerosis rehabilitation is the preservation of physical functioning. Hot topics in the rehabilitation of physical function include (1) exercise therapy, (2) robot-assisted training and (3) pharmacological interventions. Exercise therapy has for many years been a controversial issue in multiple sclerosis rehabilitation and the advice generally given to patients was not to participate in physical exercise, since it was thought to lead to a worsening of symptoms or fatigue. However, a paradigm shift is taking place and it is now increasingly acknowledged that exercise therapy is both safe and beneficial. Robot-assisted training is also attracting attention in multiple sclerosis rehabilitation. Several sophisticated commercial robots exist, but so far the number of scientific studies that have evaluated these is limited, although some promising results have been reported. Finally, recent studies have shown that certain pharmacological interventions have the potential to improve functional capacity substantially, with the potassium channel blocker fampridine being one of the most promising. This drug has been shown to improve walking ability in some patients with multiple sclerosis, associated with a reduction of patients' self-reported ambulatory disability. Rehabilitation strategies involving these different approaches, or combinations of them, may be of great use in improving everyday functioning and quality of life in patients with MS.