Exercise in the community for people with multiple sclerosis--a follow-up of people with minimal gait impairment

Quality of reporting health behaviors for multiple sclerosis (QuoRH-MS): A scoping review to inform intervention planning and improve consistency of reporting

BACKGROUND

Multiple sclerosis (MS) is a neurological condition that necessitates a multidisciplinary approach to aid those living with MS in managing their disease. Health behavior, or lifestyle modification, is an emerging approach to MS self-management. MS researchers utilize measurement tools to ensure that interventions are best suited to the outcomes, thereby potentially influencing practice. The aim of this study was to investigate which tools are being used for health behavior management studies in people living with MS and develop an aid for tool selection.

METHODS

A scoping review guided by the PRISMA-Sc checklist and the JBI manual for evidence synthesis was employed with a systematic search strategy executed across four scientific databases: Medline, PubMed, CINAHL, and Cochrane Libraries. The types of assessment tools used were extracted from the included studies. Each tool was categorized into the health behavior intervention discipline (nutrition, exercise, and psychology) and then subcategorized by the tool's purpose. The frequency of use was determined for each tool. Reporting of validation of the assessment tools were collated to inform a tool selection checklist.

RESULTS

The review identified a total of 248 tools (12 nutrition, 55 exercise, and 119 psychology unique reports) from 166 studies. Seventy-seven multidimensional tools were identified including measures of quality of life, fatigue, and functional scales. Only 88 studies (53%) referred to the validity of the tools. The most commonly reported tools were the dietary habits questionnaire (n = 4, nutrition), 6-minute walk test (n = 17, exercise), Symbol Digits and Modalities Test, and Hospital Anxiety and Depression Scale (n = 15 each, psychology) with the Expanded Disability Status Scale reported 43 times.

CONCLUSION

Evidence from interventions may inform practice for health professionals. This review provides insights into the range of tools reported across health behavior intervention studies for MS and offers a guide toward more consistent reporting of study methods.

Effects of non-pharmacological interventions on gait and balance of persons with Multiple Sclerosis: A narrative review

BACKGROUND

Multiple Sclerosis (MS) is among the most common reasons for disability in young adults. Mobility impairment, primarily related to gait and balance, is ranked as the preeminent concern among persons with MS (PwMS). Gait and balance dysfunction can directly affect the quality of life and activities of daily life in PwMS, hence the importance of effective treatment strategies. Previous studies have demonstrated the positive effect of various non-pharmacological rehabilitation methods, including physiotherapy and electrical stimulation, on gait and mobility in PwMS. Non-pharmacological methods can be tailored to the individual needs and abilities of each patient, allowing healthcare providers to create personalized training programs. Furthermore, these methods typically result in minimal or no side effects.

PURPOSE

This review provides a comprehensive overview of an array of non-pharmacological treatment approaches aimed at enhancing ambulatory performance in PwMS.

METHODS

We performed a narrative review of the original papers available in PubMed, investigating the effects of different nonmedical approaches on the gait and balance performance of the PwMS. Reviewed treatment approaches include "exercise, physical rehabilitation, dual-task (DT) rehabilitation, robot-assisted rehabilitation, virtual reality-assisted rehabilitation, game training, electrical stimulation devices, auditory stimulation, visual feedback, and shoe insoles".

RESULTS AND CONCLUSIONS

Eighty articles were meticulously reviewed. Our study highlights the positive effects of non-pharmacological interventions on patients' quality of life, reducing disability, fatigue, and muscle spasticity. While some methods, including exercise and physiotherapy, showed substantial promise, further research is needed to evaluate whether visual biofeedback and auditory stimulation are preferable over conventional approaches. Additionally, approaches such as functional electrical stimulation, non-invasive brain stimulation, and shoe insoles demonstrate substantial short-term benefits, prompting further investigation into their long-term effects. Non-pharmacological interventions can serve as a valuable complement to medication-based approaches.

Psychosocial Aspects of Rehabilitation in Neurodegenerative Diseases and Fields of Approach

Psychosocial health is a concept included in definition of health by World Health Organization and corresponds to state of emotional and social well-being. In the context of neurological disorder, psychosocial health refers to social reintegration and psychological adjustment. Studies reporting that neurological diseases are associated with negative psychosocial health outcomes such as a decrease in the quality of life, a decrease in ability to establish and maintain social relationships, and an increase in high levels of depression, stress and anxiety have increased in recent years. Therefore, it is important to consider programs and interventions that can improve the psychosocial health of people with neurodegenerative diseases. Currently, it is not clear which psychosocial approaches can produce definitively positive results. The aim of this study is to examine how being an individual with Multiple Sclerosis and Parkinson's, which are the most common neurodegenerative diseases in the clinic, affects psychosocial health in the rehabilitation process and the existing evidence-based psychosocial approaches. For this purpose, a descriptive review was prepared by scanning English and Turkish articles with keywords on psychotherapeutic, psychosocial and mindfulness-based interventions and stress management, published in the determined databases in the last 10 years. Studies have shown that psychosocial approaches such as interventions for acquisition of social integration and adaptive coping strategies, cognitive and social behavioral therapy methods, concentration and movement-based mind-body exercises are effective in rehabilitation of neurodegenerative diseases. These approaches were reported to have benefits in reducing anxiety, depression and fatigue, improving sleep quality and quality of life, relationships, employment, level of participation, motivation and self-efficacy in exercise and physical activity, improving physical functions, facilitating difficult and personal experiences and adaptation to new life in rehabilitation processes and more evidence-based studies are needed.

Physical Activity and the Health of Wheelchair Users: A Systematic Review in Multiple Sclerosis, Cerebral Palsy, and Spinal Cord Injury

OBJECTIVE

To understand the benefits and harms of physical activity in people who may require a wheelchair with a focus on people with multiple sclerosis (MS), cerebral palsy (CP), and spinal cord injury (SCI).

DATA SOURCES

Searches were conducted in MEDLINE, Cumulative Index to Nursing and Allied Health, PsycINFO, Cochrane CENTRAL, and Embase (January 2008 through November 2020).

STUDY SELECTION

Randomized controlled trials, nonrandomized trials, and cohort studies of observed physical activity (at least 10 sessions on 10 days) in participants with MS, CP, and SCI.

DATA EXTRACTION

We conducted dual data abstraction, quality assessment, and strength of evidence. Measures of physical functioning are reported individually where sufficient data exist and grouped as "function" where data are scant.

DATA SYNTHESIS

No studies provided evidence for prevention of cardiovascular conditions, development of diabetes, or obesity. Among 168 included studies, 44% enrolled participants with MS (38% CP, 18% SCI). Studies in MS found walking ability may be improved with treadmill training and multimodal exercises; function may be improved with treadmill, balance exercises, and motion gaming; balance is likely improved with balance exercises and may be improved with aquatic exercises, robot-assisted gait training (RAGT), motion gaming, and multimodal exercises; activities of daily living (ADL), female sexual function, and spasticity may be improved with aquatic therapy; sleep may be improved with aerobic exercises and aerobic fitness with multimodal exercises. In CP, balance may be improved with hippotherapy and motion gaming; function may be improved with cycling, treadmill, and hippotherapy. In SCI, ADL may be improved with RAGT.

CONCLUSIONS

Depending on population and type of exercise, physical activity was associated with improvements in walking, function, balance, depression, sleep, ADL, spasticity, female sexual function, and aerobic capacity. Few harms of physical activity were reported in studies. Future studies are needed to address evidence gaps and to confirm findings.

Outcome measures used in trials on gait rehabilitation in multiple sclerosis: A systematic literature review

Background

Multiple Sclerosis (MS) is associated with impaired gait and a growing number of clinical trials have investigated efficacy of various interventions. Choice of outcome measures is crucial in determining efficiency of interventions. However, it remains unclear whether there is consensus on which outcome measures to use in gait intervention studies in MS.

Objective

We aimed to identify the commonly selected outcome measures in randomized controlled trials (RCTs) on gait rehabilitation interventions in people with MS. Additional aims were to identify which of the domains of the International Classification of Functioning, Disability and Health (ICF) are the most studied and to characterize how outcome measures are combined and adapted to MS severity.

Methods

Pubmed, Cochrane Central, Embase and Scopus databases were searched for RCT studies on gait interventions in people living with MS according to PRISMA guidelines.

Results

In 46 RCTs, we identified 69 different outcome measures. The most used outcome measures were 6-minute walking test and the Timed Up and Go test, used in 37% of the analyzed studies. They were followed by gait spatiotemporal parameters (35%) most often used to inform on gait speed, cadence, and step length. Fatigue was measured in 39% of studies. Participation was assessed in 50% of studies, albeit with a wide variety of scales. Only 39% of studies included measures covering all ICF levels, and Participation measures were rarely combined with gait spatiotemporal parameters (only two studies).

Conclusions

Selection of outcome measures remains heterogenous in RCTs on gait rehabilitation interventions in MS. However, there is a growing consensus on the need for quantitative gait spatiotemporal parameter measures combined with clinical assessments of gait, balance, and mobility in RCTs on gait interventions in MS. Future RCTs should incorporate measures of fatigue and measures from Participation domain of ICF to provide comprehensive evaluation of trial efficacy across all levels of functioning.

Yoga Interventions Used for the Rehabilitation of Stroke, Parkinson's Disease, and Multiple Sclerosis: A Scoping Review of Clinical Research

Objectives: The current body of literature was reviewed to compile and describe yoga interventions that have been applied in clinical research and neurologic rehabilitation settings with patients affected by stroke, Parkinson's disease (PD), and multiple sclerosis (MS). Design: Available literature on yoga therapy (YT) was mapped following a five-stage framework to identify key concepts, knowledge gaps, and evidence to inform practice. Publications were identified through Medline, CINAHL, EMBASE, and PsycINFO. Selected studies required subjects with a clinical diagnosis of stroke, PD, and MS to participate in a yoga intervention and have physical, cognitive, and/or psychosocial outcome measures assessed. Results: A total of 50 studies were included in this review. Study characteristics, patient demographics, description of the yoga intervention, reported outcome measures and the main findings were extracted from the studies. Conclusion: Implementing YT in neurorehabilitation can help health care professionals integrate a more holistic approach that addresses the fundamental physical and psychological challenges of living with a chronic and debilitating neurologic disorder. The included studies described yogic interventions consisting of group or individual therapy sessions lasting 60-75 min that were carried out one to three times per week for 8-12 consecutive weeks across all three conditions. All studies described in this scoping review used different yoga protocols confirming the lack of specific interventional parameters available for implementing yoga into the rehabilitation of individuals affected by stroke, PD, or MS.

Effect of yoga on health-related quality of life in central nervous system disorders: A systematic review

OBJECTIVE

Investigate the effect of yoga on health-related quality of life (HRQoL) in patients with central nervous system disorders.

METHODS

A systematic search was conducted on the PubMed-NCBI, EBSCO Host, Cochrane Library, Scopus and ScienceDirect databases until 05 April 2021. Only randomized control trials published in English or French were included and had to compare yoga to another intervention group or a control group. They also had to clearly measure HRQoL. Methodological quality was assessed with the revised Cochrane risk-of-bias tool for randomized trials and the quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

Sixteen studies were found, including six for multiple sclerosis, five for Parkinson's disease, two for stroke, one for dementia, one for epilepsy and one for brain tumour. Only 12 studies performed between-group statistics and 8 found a significant difference between groups after treatment. When yoga was compared to no intervention, the results were generally in favour of the yoga group, but when yoga was compared to another intervention programme, there was generally no significant difference between groups. There were many different HRQoL questionnaires, even within the same disease, which reduces the comparability of studies.

CONCLUSIONS

With low to moderate quality of the evidence, yoga seems effective to improve HRQoL in people with Parkinson's disease. For multiple sclerosis, stroke, dementia, epilepsy and brain tumour, the quality of the evidence is still insufficient to conclude of the effectiveness of yoga.

Center-Based Group and Home-Based Individual Exercise Programs Have Similar Impacts on Gait and Balance in People With Multiple Sclerosis: A Randomized Trial

BACKGROUND

Group and home-based exercises to improve function in people with multiple sclerosis (MS) are common but have little underpinning evidence.

OBJECTIVE

To determine the comparative effectiveness of a center-based group versus home-based individual 8-week exercise program to improve gait and balance in people with MS.

DESIGN

Prospective, randomized controlled trial.

SETTING

Community center-based and home-based exercise program.

PARTICIPANTS

Fifty people with MS were randomized and completed allocated intervention (n = 26 center, n = 24 home), 47 completed post-assessment and 44 follow-up assessment.

METHODS

The center- and home-based groups completed an 8-week progressive functional and balance training exercise program. The center-based groups of four to six were supervised by a physiotherapist. The home-based group was provided with telephone support.

MAIN OUTCOME MEASUREMENTS

The primary outcome was gait speed (10-meter walk test). Secondary outcomes were gait endurance (6-minute walk test) and balance (Berg Balance Scale). Outcome assessments were conducted at baseline, immediately postintervention and at 8-week follow-up.

RESULTS

There was no statistically significant difference between groups in gait speed post training, with a mean difference of 0.01 m/s, 95% CI -0.36 to 0.37. There were no group effects, time effects, or interactions for gait speed, endurance, or balance. In both groups, gait speed improved to a level that met minimal clinically important differences.

CONCLUSIONS

Gait speed, endurance, and balance did not statistically improve in either group; however, gait speed changes met minimally important differences.

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.

The ability of the instrumented tandem walking tests to discriminate fully ambulatory people with MS from healthy adults

BACKGROUND

People with multiple sclerosis (PwMS) experience walking and balance deficits at the initial phases of the disease, even when classified as only minimally disabled. Complex balance tasks, such as tandem walking, are probably more sensitive in detecting mild balance difficulties compared to the standard traditional tests in this population.

RESEARCH QUESTION

The aim was to investigate different types of 3-meter tandem walking tests in fully ambulatory PwMS.

METHODS

This observational case-control study included 50 participants; 25 PwMS, 17 women and 8 men, aged 35.2 (S.D = 8.6) and 25 healthy subjects, 18 women and 7 men, aged 34.3 (S.D = 6.1). The 3-meter tandem walk tests were performed during a single session. Each subject completed a sequence of 3 consecutive tests under 3 different task conditions: normal tandem walking, backward tandem walking and cognitive tandem walking. Tandem walking tests were evaluated via three small, lightweight axial wearable accelerometers (APDM, Oregon, USA).

RESULTS

The mean EDSS for the MS group was 1.6 (S.D = 0.6) indicating minimal disability. PwMS walked slower and at a slower pace, with a prolonged double support and decreased swing phase compared to healthy subjects in normal and backward conditions. In contrast, during the cognitive task, non-significant differences were found in gait measures between the PwMS and the healthy controls. Significant differences were found between task conditions for all participants. All reduced their walking speed and walked at a slower pace in both the cognitive and backward conditions compared to the normal tandem walk condition. However, non-significant scores were found for the condition X group factor.

SIGNIFICANCE

The study provides new insights into the 3-meter tandem walk test. Findings should improve evaluation and training of dynamic balance in fully ambulatory PwMS.

Social Cognitive Theory Correlates of Physical Activity in Inactive Adults with Multiple Sclerosis

BACKGROUND

There is a growing body of evidence that physical activity (PA) improves symptoms of multiple sclerosis (MS). Despite the benefits of PA, people with MS are relatively inactive compared with their healthy counterparts. This study investigated associations between social cognitive theory (SCT) constructs and energy expenditure (EE) as an objective measure of PA in a sample of inactive people with MS.

METHODS

Participants (n = 65) completed several questionnaires and were assessed using standardized outcome measures as part of a cross-sectional analysis of baseline data from a randomized controlled trial (Step it Up).

RESULTS

The bivariate correlation analysis indicated that of all SCT constructs, only exercise self-efficacy was significantly correlated with EE (r = 0.297, P = .022). Multiple linear regression analysis found that exercise self-efficacy independently explained 9% of the variance in EE (R2 = 0.088). A model including exercise self-efficacy, exercise goal setting, exercise planning, and exercise benefits explained 17% of the variance in EE (F4,54 = 2.741, P = .038, R2 = 0.169). In this model, only exercise self-efficacy was significantly associated with EE scores (Exercise Self-Efficacy Scale β = .320, P = .016).

CONCLUSIONS

The constructs of SCT explained little of the variance of objectively measured PA in a sample of inactive people with MS who volunteered for an exercise trial. The only significant variable was exercise self-efficacy, which confirms the importance of enhancing it through PA interventions.

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

OBJECTIVE

To investigate feasibility of multiple sclerosis (MS) exercise guidelines for inactive people with MS (PwMS) and to examine preliminary efficacy for walking. To investigate effect of augmenting that intervention with education based on social cognitive theory (SCT).

DESIGN

Pilot multicentre, double-blind, randomised, parallel, controlled trial.

SETTING

Community-delivered programme.

PARTICIPANTS

Sixty-five physically inactive PwMS walked independently, scored 0-3 on the Patient Determined Disease Steps Scale, had no MS relapse or change in MS medication in 12 weeks.

INTERVENTIONS

10-week exercise plus SCT education (SCT) compared with exercise plus attention control education (CON).

OUTCOME MEASURES

Six-Minute Walk Test (6MWT), Timed Up and Go (TUG) test and Multiple Sclerosis Walking Scale-12 (MSWS-12).

RESULTS

174 expressed interest, 92 were eligible and 65 enrolled (SCT, n=32; CON, n=33). The intervention was feasible and delivered as intended. 68% of SCT group and 50% of control group met the exercise guidelines after intervention. Using linear mixed effects models, intention-to-treat basis, there was insufficient evidence for difference between the groups over the trial (6MWT, p=0.30; TUG, p=0.4; MSWS-12, p=0.8). Using secondary analysis of a cohort with data for≥3 assessments (SCT, n=21; CON, n=20), there was significant treatment effect favouring the intervention group (p=0.04) with mean effect for 6MWT 39.0 m (95% CI 2.26 to 75.73) at 12 weeks and 40.0 m (95% CI 2.3 to 77.8) at 36 weeks. Both groups improved significantly in 6MWT following 10-week intervention (SCT, mean ∆=83.02, SD=60.1, p≤0.01; CON, mean ∆=56.92, SD=73.5, p≤0.01), TUG (SCT, ∆=-0.70, SD=1.25, p≤0.01; CON, ∆=-0.54, SD=0.95, p≤0.01) and MSWS-12 (SCT, ∆=-8.03, SD=16.18, p=0.02; CON, ∆=-0.86, SD=18.74, p=0.81).

CONCLUSIONS

A 10-week exercise programme based on the MS exercise guidelines for improving walking in previously inactive PwMS was feasible. There is marginal evidence of a treatment effect in favour of the exercise plus SCT intervention at 12 and 36 weeks.

TRIAL REGISTRATION NUMBER

NCT02301442; Results.

Development of a balance, safe mobility and falls management programme for people with multiple sclerosis

PURPOSE

To utilise stakeholder input to inform the structure, format and approach of a multiple sclerosis (MS) balance, safe mobility and falls management programme.

MATERIALS AND METHODS

Using a three-round nominal group technique, participants individually rated their agreement with 20 trigger statements, followed by a facilitated group discussion and re-rating. Three mixed groups included service users (n = 15) and providers (n = 19). Quantitative analysis determined agreement, whilst qualitative responses were analysed thematically.

RESULTS

Median scores for each of the 20 trigger statements did not change significantly over sequential rounds, however, deviations around the medians indicated more agreement amongst participants over time. Key recommendations were: Aims and approach: The programme should be tailored to the needs of people with MS. Falls and participation-based outcomes are equally important. Structure and format: The programme should balance expected burden and anticipated benefit, moving away from models requiring weekly attendance and promoting and supporting self-efficacy. Optimising engagement: Support to maintain engagement and intensity of practice over the long term is essential. Sustainability: Adequate funding is necessary. Staff should have MS specific knowledge and experience.

CONCLUSIONS

Participants collaboratively identified critical components of a MS balance, safe mobility and falls management programme. They also highlighted the importance of a collaborative, user-centred, MS-specific approach. Implications for Rehabilitation People with multiple sclerosis need condition-specific interventions focussed on maximising balance and safe mobility and reducing falls. Programme design should support self-efficacy and flexible engagement. Adequate support and funding are seen as essential by both service users and providers.

Effect of exercising at minimum recommendations of the multiple sclerosis exercise guideline combined with structured education or attention control education - secondary results of the step it up randomised controlled trial

BACKGROUND

Recent exercise guidelines for people with multiple sclerosis (MS) recommend a minimum of 30 min moderate intensity aerobic exercise and resistance exercise twice per week. This trial compared the secondary outcomes of a combined 10-week guideline based intervention and a Social Cognitive Theory (SCT) education programme with the same exercise intervention involving an attention control education.

METHODS

Physically inactive people with MS, scoring 0-3 on Patient Determined Disease Steps Scale, with no MS relapse or change in MS medication, were randomised to 10-week exercise plus SCT education or exercise plus attention control education conditions. Outcomes included fatigue, depression, anxiety, strength, physical activity, SCT constructs and impact of MS and were measured by a blinded assessor pre and post-intervention and 3 and 6 month follow up.

RESULTS

One hundred and seventy-four expressed interest, 92 were eligible and 65 enrolled. Using linear mixed effects models, the differences between groups on all secondary measures post-intervention and at follow-up were not significant. Post-hoc, exploratory, within group analysis identified improvements in both groups post intervention in fatigue (mean ∆(95% CI) SCT -4.99(-9.87, -0.21), p = 0.04, Control -7.68(-12.13, -3.23), p = 0.00), strength (SCT -1.51(-2.41, -0.60), p < 0.01, Control -1.55(-2.30, -0.79), p < 0.01), physical activity (SCT 9.85(5.45, 14.23), p < 0.01, Control 12.92(4.69, 20.89), goal setting (SCT 7.30(4.19, 10.4), p < 0.01, Control 5.96(2.92, 9.01), p < 0.01) and exercise planning (SCT 5.88(3.37, 8.39), p < 0.01, Control 3.76(1.27, 6.25), p < 0.01) that were maintained above baseline at 3 and 6 month follow up (all p < 0.05). Only the SCT group improved at 3 and 6 month follow up in physical impact of MS(-4.45(-8.68, -0.22), -4.12(-8.25, 0.01), anxiety(-1.76(-3.20, -0.31), -1.99(-3.28, -0.71), depression(-1.51(-2.89, -0.13), -1.02(-2.05, 0.01)) and cognition(5.04(2.51, 7.57), 3.05(0.81, 5.28), with a medium effect for cognition and fitness (Hedges' g 0.75(0.24, 1.25), 0.51(0.01, 1.00) at 3 month follow up.

CONCLUSIONS

There were no statistically significant differences between groups for the secondary outcomes once age, gender, time since diagnosis and type of MS were accounted for. However, within the SCT group only there were improvements in anxiety, depression, cognition and physical impact of MS. Exercising at the minimum guideline amount has a positive effect on fatigue, strength and PA that is sustained at 3 and 6 months following the cessation of the program.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02301442 , retrospectively registered on November 13th 2014.

A Multimodal, Nonpharmacologic Intervention Improves Mood and Cognitive Function in People with Multiple Sclerosis

OBJECTIVE

The objective of this study was to examine whether participation in a 12-month multimodal intervention would improve mood and cognitive function in adults with progressive multiple sclerosis (MS).

METHODS

In this one-arm, open-label feasibility trial, participants were prescribed a home-based multimodal intervention, including (1) a modified Paleolithic diet; (2) an exercise program (stretching and strengthening of the trunk and lower limb muscles); (3) neuromuscular electrical stimulation (EStim) of trunk and lower limb muscles; and (4) stress management (meditation and self-massage). Individuals completed measures of mood (Beck Anxiety and Depression Inventories) and cognitive (Cognitive Stability Index, Cognitive Screening Test, Delis-Kaplan Executive Function System) and executive function (Wechsler Adult Intelligence Scale) at baseline and 3, 6, 9, and 12 months after the start of the intervention. Dosage of the multimodal intervention was assessed at 3, 6, 9, and 12 months.

RESULTS

The more individuals participated in the intervention activities, the greater improvements they had from baseline to 12 months on self-report measures of anxiety (Beck Anxiety Inventory [BAI]; ps = 0.001 to 0.02), depression (Beck Depression Inventory [BDI]; ps = <0.0001 to 0.09), cognitive function (Cognitive Stability Index [CSI/T], Delis-Kaplan Executive Function System [DKEFS]; ps = 0.001 to 0.06), and executive function (Wechsler Adult Intelligence Scale [WAIS]; ps = <0.0001 to 0.09). Mood and cognitive improvements were more closely related to a higher intake of the modified Paleolithic diet than to exercise and stress management dosage. Anxiety and depression changes were evident after just a few months, whereas changes in cognitive function were generally not observed until later in the intervention period. Mood and cognitive function changes from baseline to 12 months were significantly associated with fatigue improvements (ps = <0.0001 to 0.03).

CONCLUSIONS

A modified Paleolithic diet, exercise, EStim, and stress management intervention like this one has the potential to improve the mood and cognitive symptoms that can lead to considerable suffering in people with MS, potentially improving quality of life and function for people with progressive MS.

Randomized control trial evaluation of a modified Paleolithic dietary intervention in the treatment of relapsing-remitting multiple sclerosis: a pilot study

BACKGROUND/OBJECTIVE

A Paleolithic diet may improve fatigue and quality of life in progressive multiple sclerosis (MS) patients, but past research has evaluated the effects of this dietary intervention in combination with other treatments such as exercise. Thus, the purpose of this pilot study was to evaluate a modified Paleolithic dietary intervention (MPDI) in the treatment of fatigue and other symptoms in relapsing-remitting MS (RRMS).

METHODS

We measured the effects of a MPDI in 17 individuals with RRMS. Of 34 subjects randomly assigned to control (maintain usual diet) and intervention (MPDI) groups, nine subjects (one man) completed the control group and eight subjects (one man) completed the MPDI.

RESULTS

Significant improvements were seen in Fatigue Severity Scale score and also in Multiple Sclerosis Quality of Life-54 and time to complete (dominant hand) 9-Hole Peg Test from baseline in MPDI subjects compared to controls. Increased vitamin K serum levels were also observed in MPDI subjects postprotocol compared to controls.

CONCLUSION

A Paleolithic diet may be useful in the treatment and management of MS, by reducing perceived fatigue, increasing mental and physical quality of life, increasing exercise capacity, and improving hand and leg function. By increasing vitamin K serum levels, the MPDI may also reduce inflammation.

Perceptions of Participants in a Group, Community, Exercise Programme for People with Multiple Sclerosis

Purpose. The purpose of this study was to explore the perceptions of people with multiple sclerosis of a community based, group exercise programme. Method. A pragmatic programme evaluation approach using qualitative research design was adopted. Focus groups were used to gather data from 14 participants who had taken part in a RCT of community based exercise interventions for PwMS who used at most a stick to walk outdoors. Data were transcribed verbatim and thematic analysis was used to first identify categories and then to group them into themes. Results. Three themes emerged, psychological benefits, physical benefits, and knowledge gained. The psychological benefits included the role of the group as a social and motivational factor, empowerment, confidence, hope, sense of achievement, and pride. Physical benefits were improved energy and reduced fatigue and improved ability and participation. Knowledge gained caused a shift from thoughts that exercise might do harm, to sufficient knowledge that would give participants confidence to exercise themselves. The role of the group was a key element in the positive outcomes. Conclusions. The qualitative analysis supports the findings of the main trial confirming positive effects of community exercise interventions by reducing the impact of MS and fatigue and improving participation.

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.

Yoga as a method of symptom management in multiple sclerosis

Multiple Sclerosis (MS) is an immune-mediated process in which the body's immune system damages myelin in the central nervous system (CNS). The onset of this disorder typically occurs in young adults, and it is more common among women. Currently, there is no cure and the long-term disease progression makes symptomatic management critical for maintaining quality of life. Several pharmacotherapeutic agents are approved for treatment, but many patients seek complementary and alternative interventions. Reviews have been conducted regarding broad topics such as mindfulness-based interventions for people diagnosed with MS and the impact of yoga on a range of neurological disorders. The objective of the present review is to examine the potential benefits of yoga for individuals with MS and address its use in managing symptoms including pain, mental health, fatigue, spasticity, balance, bladder control, and sexual function.

Association between perceived fatigue and gait parameters measured by an instrumented treadmill in people with multiple sclerosis: a cross-sectional study

BACKGROUND

Multiple sclerosis (MS) is a multi-focal progressive disorder of the central nervous system often resulting in diverse clinical manifestations. Symptomatic fatigue is quite common in people with MS (PwMS), with prevalence as high as 85%. Nevertheless, it remains poorly understood and its association with walking capabilities unclear. Therefore, the objective of this investigation was to examine the relationship between symptomatic fatigue and spatio-temporal parameters of gait in PwMS based on an instrumented treadmill.

METHODS

One hundred and twenty-four relapsing-remitting patients diagnosed with MS, 84 women and 40 men aged 42.6 (S.D = 11.9), participated in this investigation. A convenience sample of 25 apparently healthy subjects, 15 women and 10 men aged 40.3 (S.D = 11.1), served as controls. Gait spatiotemporal parameters were obtained using the Zebris FDM-T Treadmill (Zebris1 Medical GmbH, Germany). The Modified Fatigue Impact Scale (MFIS), a self-reported questionnaire, was used to determine the level of symptomatic fatigue in the MS study group. PwMS were divided into two groups: fatigued and non-fatigued.

RESULTS

Forty-four PwMS were classified as suffering from fatigue (mean MFIS = 52.0, S.D = 13.7); 80 were classified as non-fatigued (mean MFIS = 14.5, S.D = 14.5). Individuals in the fatigued group walked slower than those in the non-fatigued group; 1.7 (S.D = 2.4) vs. 2.4 (S.D = 1.0); P < 0.001, respectively. Moreover, fatigued patients took smaller steps, had a shorter stride length, prolonged stance, double support phase and a shorter single support phase compared to the non-fatigued group. In the total group, fatigue was significantly correlated with 10 (out of 14) spatiotemporal parameters of gait, however, correlation scores <0.40 were considered as weak correlations. According to step one of the linear logistic regression analysis, the temporal gait component was found to explain 5.1% of the variance related to symptomatic fatigue, R2 = 0.051, χ2 (1) = 6.511, P = 0.011. Step two of the model added the gait spatial component, thus increasing the explaining variance to 9.3%; R2 = 0.093, χ2 (2) = 12.12, P = 0.002. The asymmetry gait parameter did not contribute to the equation.

CONCLUSIONS

Perceived fatigue is related to walking speed in PwMS, nevertheless its contribution to level of fatigue is limited.

A randomised controlled trial of an exercise plus behaviour change intervention in people with multiple sclerosis: the step it up study protocol

Background

Exercise has consistently yielded short-term, positive effects on health outcomes in people with multiple sclerosis (MS). However, these effects have not been maintained in the long-term. Behaviour change interventions aim to promote long-term positive lifestyle change. This study, namely, “Step it Up” will compare the effect of an exercise plus Social Cognitive Theory (SCT)-based behaviour change intervention with an exercise plus control education intervention on walking mobility among people with MS.

Methods/design

People with a diagnosis of MS who walk independently, score of 0–3 on the Patient Determined Disease Steps, who have not experienced an MS relapse or change in their MS medication in the last 12 weeks and who are physically inactive will be randomised to one of two study conditions. The experimental group will undergo a 10-week exercise plus SCT-based behavioural change intervention. The control group will undergo a 10-week exercise plus education intervention to control for contact. Participants will be assessed at weeks 1, 12, 24 and 36. The primary outcome will be walking mobility. Secondary outcomes will include: aerobic capacity, lower extremity muscle strength, participant adherence to the exercise programme, self-report exercise intensity, self-report enjoyment of exercise, exercise self-efficacy, outcome expectations for exercise, goal-setting for exercise, perceived benefits and barriers to exercise, perceptions of social support, physical and psychological impact of MS and fatigue. A qualitative evaluation of Step it Up will be completed among participants post-intervention.

Discussion

This randomised controlled trial will examine the effectiveness of an exercise plus SCT-based behaviour change intervention on walking mobility among people with MS. To this end, Step it Up will serve to inform future directions of research and clinical practice with regard to sustainable exercise interventions for people with MS.

Trial registration

ClinicalTrials.gov, NCT02301442

Yoga for multiple sclerosis: a systematic review and meta-analysis

While yoga seems to be effective in a number of neuropsychiatric disorders, the evidence of efficacy in multiple sclerosis remains unclear. The aim of this review was to systematically assess and meta-analyze the available data on efficacy and safety of yoga in patients with multiple sclerosis. Medline/PubMed, Scopus, the Cochrane Central Register of Controlled Trials, PsycINFO, CAM-Quest, CAMbase, and IndMED were searched through March 2014. Randomized controlled trials (RCTs) of yoga for patients with multiple sclerosis were included if they assessed health-related quality of life, fatigue, and/or mobility. Mood, cognitive function, and safety were defined as secondary outcome measures. Risk of bias was assessed using the Cochrane tool. Seven RCTs with a total of 670 patients were included. Evidence for short-term effects of yoga compared to usual care were found for fatigue (standardized mean difference [SMD] = -0.52; 95% confidence intervals (CI)  =  -1.02 to -0.02; p = 0.04; heterogeneity: I2 = 60%; Chi2 = 7.43; p = 0.06) and mood (SMD = -0.55; 95%CI =  -0.96 to -0.13; p = 0.01; heterogeneity: I2 = 0%; Chi2 = 1.25; p = 0.53), but not for health-related quality of life, muscle function, or cognitive function. The effects on fatigue and mood were not robust against bias. No short-term or longer term effects of yoga compared to exercise were found. Yoga was not associated with serious adverse events. In conclusion, since no methodological sound evidence was found, no recommendation can be made regarding yoga as a routine intervention for patients with multiple sclerosis. Yoga might be considered a treatment option for patients who are not adherent to recommended exercise regimens.

Physical fitness assessment in multiple sclerosis patients: a controlled study

There is growing evidence to show the effectiveness of physical exercise for multiple sclerosis (MS) patients. Aim of this study was to evaluate aerobic capacity, strength, balance, and the rate of perceived exertion (RPE) after exercise, in ambulatory patients with mild MS and matched control healthy participants. Seventeen MS patients aged 48.09 ± 10.0 years, with mild MS disability (Expanded Disability Status Scale: EDSS 1.5 to 4.5) and 10 healthy sedentary age matched (41.9 ± 11.2 years) subjects volunteered for the study. MS patients underwent medical examination with resting electrocardiogram, arterial blood pressure, EDSS, and Modified Fatigue Impact Scale-MFIS. Both groups also underwent physical assessment with the Berg Balance Scale(,) test (Berg), Six Minutes Walking Test (6MWT), maximal isometric voluntary contraction (MIVC) of forearm, lower limb, shoulder strength test, and the Borg 10-point scale test. The one-way ANOVA showed significant differences for MFIS (F1.19=9.420; p<0.01), Berg (F1.19=13.125; p<0.01), handgrip MIVC (F1.19=4.567; p<0.05), lower limbs MIVC (F1.19=7.429; p<0.01), and 6MWT (F1.19=28.061; p<0.01) between groups. EDSS, Berg test and Borg scores explained 80% of 6MWT variation. Mild grade EDSS patients exhibited impaired balance, muscle strength, and low self pace-6MWT scores, whereas RPE response after the exercise was similar to that of sedentary individuals. Both groups showed similar global physiological adjustments to exercise.

Neuromuscular adaptations to long-term progressive resistance training translates to improved functional capacity for people with multiple sclerosis and is maintained at follow-up

Background:

Progressive resistance training (PRT) is acknowledged to effectively improve muscle strength for people with multiple sclerosis (PwMS), but diverging results exist regarding whether such improvements translates to improved functional capacity, possibly relating to insufficient duration and/or intensity in some previous studies.

Objective:

The purpose of this study was to evaluate potential changes in functional capacity and neuromuscular function after 24 weeks of supervised PRT, and whether improvements are maintained after an additional 24 weeks of self-guided exercise.

Methods:

This study was a randomised controlled trial, with a training group and a waitlist group undergoing supervised PRT for 24 weeks initially or after 24 weeks of habitual lifestyle, respectively. Functional capacity, isometric muscle strength of knee extensors and flexors, neural drive and thigh muscle cross-sectional area was measured at baseline, after 24 and 48 weeks.

Results:

The training group significantly improved neuromuscular function of the knee extensors and flexors, which translated to improvements in functional capacity. Furthermore, the improved functional capacity was maintained after 24 weeks of self-guided physical activity. The waitlist group produced similar patterns of changes after PRT.

Conclusion:

Compelling evidence is provided, that PRT performed over sufficiently long periods, improves functional capacity, likely due to neuromuscular adaptations.

Predictors of the physical impact of Multiple Sclerosis following community-based, exercise trial

Background:

Studies evaluating exercise interventions in people with multiple sclerosis (PwMS) demonstrate small to medium positive effects and large variability on a number of outcome measures. No study to date has tried to explain this variability.

Objective:

This paper presents a novel exploration of data examining the predictors of outcome for PwMS with minimal gait impairment following a randomised, controlled trial evaluating community-based exercise interventions ( N = 242).

Methods:

The primary variable was the physical component of the Multiple Sclerosis Impact Scale-29, version 2 (MSIS-29, v2) after a 10-week, controlled intervention period. Predictors were identified a priori and were measured at baseline. Multiple linear regression was conducted.

Results:

Four models are presented lower MSIS-29, v2 scores after the intervention period were best predicted by a lower baseline MSIS-29,v2, a lower baseline Modified Fatigue Impact Score (physical subscale), randomisation to an exercise intervention, a longer baseline walking distance measured by the Six Minute Walk Test and female gender. This model explained 57.4% of the variance (F (5, 211) = 59.24, p < 0.01).

Conclusion:

These results suggest that fatigue and walking distance at baseline contribute significantly to predicting MSIS-29, v29 (physical component) after intervention, and thus should be the focus of intervention and assessment. Exercise is an important contributor to minimising the physical impact of MS, and gender-specific interventions may be warranted.

Characteristics of randomized controlled trials of yoga: a bibliometric analysis

Background

A growing number of randomized controlled trials (RCTs) have investigated the therapeutic value of yoga interventions. This bibliometric analysis aimed to provide a comprehensive review of the characteristics of the totality of available randomized yoga trials.

Methods

All RCTs of yoga were eligible. Medline/PubMed, Scopus, the Cochrane Library, IndMED, and the tables of content of yoga specialty journals not listed in medical databases were screened through February 2014. Bibliometric data, data on participants, and intervention were extracted and analyzed descriptively.

Results

Published between 1975 and 2014, a total of 366 papers were included, reporting 312 RCTs from 23 different countries with 22,548 participants. The median study sample size was 59 (range 8–410, interquartile range = 31, 93). Two hundred sixty-four RCTs (84.6%) were conducted with adults, 105 (33.7%) with older adults and 31 (9.9%) with children. Eighty-four RCTs (26.9%) were conducted with healthy participants. Other trials enrolled patients with one of 63 varied medical conditions; the most common being breast cancer (17 RCTs, 5.4%), depression (14 RCTs, 4.5%), asthma (14 RCTs, 4.5%) and type 2 diabetes mellitus (13 RCTs, 4.2%). Whilst 119 RCTs (38.1%) did not define the style of yoga used, 35 RCTs (11.2%) used Hatha yoga and 30 RCTs (9.6%) yoga breathing. The remaining 128 RCTs (41.0%) used 46 varied yoga styles, with a median intervention length of 9 weeks (range 1 day to 1 year; interquartile range = 5, 12). Two hundred and forty-four RCTs (78.2%) used yoga postures, 232 RCTs (74.4%) used breath control, 153 RCTs (49.0%) used meditation and 32 RCTs (10.3%) used philosophy lectures. One hundred and seventy-four RCTs (55.6%) compared yoga with no specific treatment; 21 varied control interventions were used in the remaining RCTs.

Conclusions

This bibliometric analysis presents the most complete up-to-date overview on published randomized yoga trials. While the available research evidence is sparse for most conditions, there was a marked increase in published RCTs in recent years.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6882-14-328) contains supplementary material, which is available to authorized users.

Pragmatic intervention for increasing self-directed exercise behaviour and improving important health outcomes in people with multiple sclerosis: a randomised controlled trial

Background:

Exercise programmes that can demonstrate evidence of long-lasting clinical effectiveness are needed for people with multiple sclerosis (P wMS).

Objective:

The objective of this study was to assess the effects of a practically implemented exercise programme on self-directed exercise behaviour and important health outcomes in P wMS to nine months of follow-up.

Methods:

We conducted a parallel-arm, randomised controlled trial: 120 P wMS (Expanded Disability Status Scale (EDSS) 1.0–6.5) randomised to a three-month exercise intervention plus usual care, or usual care only. Two supervised plus one home-exercise session (weeks 1–6) were followed by one supervised and two home-exercise sessions (weeks 7–12). Cognitive-behavioural techniques promoted long-term exercise behaviour change. Outcomes were blindly assessed at baseline and at three and nine months after randomisation. The primary outcome was self-reported exercise behaviour (Godin Leisure Time Exercise Questionnaire (GLTEQ)). Secondary outcomes included fatigue and health-related quality of life (HRQoL).

Results:

The intervention increased self-reported exercise (9.6 points; 95% CI: 2.0 to 17.3 points; p = 0.01) and improved fatigue ( p < 0.0001) and many HRQoL domains ( p ≤ 0.03) at three months. The improvements in emotional well-being ( p = 0.01), social function ( p = 0.004) and overall quality of life ( p = 0.001) were sustained for nine months.

Conclusion:

This pragmatic approach to implementing exercise increases self-reported exercise behaviour, improves fatigue and leads to a sustained enhancement of HRQoL domains in P wMS.