Beyond standard rehabilitation programmes: Working with people with MS for adequate goal setting and rehabilitation treatment evaluation

Navigating (un)certainty in 'downhill' trajectories: An ethnographic study about rehabilitees' and professionals' experiences of goal-setting in Parkinson's disease rehabilitation

OBJECTIVE

To explore rehabilitees' and professionals' experiences of goal-setting in a context of (un)certainty with a progressive neurodegenerative disease and how they navigate this (un)certainty in Parkinson's disease rehabilitation.

DESIGN

A long-term multi-sited ethnographic fieldwork (2019-2020) following 20 rehabilitees and their goals over time and settings. Observation at 30 goal-setting meetings.

PARTICIPANTS

Rehabilitees and professionals in Danish Parkinson's disease rehabilitation. Two randomly chosen groups of rehabilitees attending a Parkinson's disease course at a rehabilitation centre participated.

METHODS

Semi-structured interviews and participant observation.

RESULTS

Living with Parkinson's disease holds a certainty that the condition will progress yet an uncertainty regarding the pace and severity, as indicated by the notion (un)certainty. The (un)certainty challenges goal-setting. Reflecting on goal-setting, rehabilitees brought forth existential, economical, and societal considerations. Some expressed an ambivalent view, questioning the value of goal-setting with a progressive condition, yet finding own rehabilitation goals relevant. Others expressed a pragmatic view, attuning goals to fit the situation. Professionals found that the visible and invisible symptoms and the uncertain pace of Parkinson's made goal-setting challenging. They had to strike a balance between mentioning symptoms to come, yet not rendering the future too bleak.

CONCLUSIONS

Rehabilitees and professionals found that setting goals in a condition that progresses is no easy task. They made use of strategies such as observation, repetition, future-proofing strategies, and attuning goals to navigate the (un)certainty. In goal-setting, to maintain functioning with progressive Parkinson's disease was a viable goal. Participants found they just do the best they can to navigate (un)certainty.

Physiotherapist and participant perspectives from a randomized-controlled trial of physiotherapist-supported online vs. paper-based exercise programs for people with moderate to severe multiple sclerosis

PURPOSE

There is a gap in research on how best to support exercise in moderate to severe MS. The objective of this study is to share perspectives of people living with MS and physiotherapists on their experiences in a randomized clinical trial of online physiotherapy vs. an active comparator.

METHODS

Semi-structured exit interviews were conducted with volunteer participants from the online and comparator arms of the trial, and focus groups were held with study physiotherapists. Transcripts were analyzed using reflexive thematic analysis.

RESULTS

Perspectives from participants with MS yielded three themes: usability of their program, utility of their program, and motivation to participate. Visual and dexterity impairments limited the usability of the online program. Having an opportunity "to be pushed" was valued by participants in both trial arms. Motivation to exercise was variable, and participants desired periodic face-to-face contact with their physiotherapists. Perspectives from trial physiotherapists yielded similar and complementary findings concerning usability and utility.

CONCLUSIONS

Participants with MS and physiotherapists found the online physiotherapy platform useful for supporting exercise, yet they identified some limitations. As the appeal of online platforms has increased since the pandemic, it will be important to consider the needs of people with moderate to severe MS.

TRIAL REGISTRATION NUMBER

NCT03039400.IMPLICATIONS FOR REHABILITATIONPeople with moderate-to-severe MS and physiotherapists involved in a clinical trial found online physiotherapy useful for supporting exercise. Physiotherapists and participants using the online program desired improved platform accommodations for people living with MS with visual and dexterity impairments.Physiotherapists and people living with MS from both the online exercise program and comparator groups perceived a need for more face-to-face contact and opportunities to build therapeutic alliance.Perspectives from prescribing physiotherapists and people living with MS about supporting exercise online may have practice implications during and post-pandemic.

Shared decision making in the treatment of multiple sclerosis: A consensus based on Delphi methodology

Shared decision making is a way of incorporating patients' preferences and values into the decisions regarding the treatment and follow-up plan for the condition that affects them. It is currently applied mainly in the context of chronic disorders for which there is no cure available but nevertheless many therapeutic alternatives, such as multiple sclerosis (MS). Current views and opinions on shared decision making for the treatment of MS are discussed in this consensus based on a modified Delphi method that included a group of neurologists from Argentina. A set of statements was defined by the experts and seeks to serve as a guide to apply this concept in clinical practice.

Experiences of persons with multiple sclerosis with rehabilitation-a qualitative interview study

Background

Managing multiple sclerosis (MS) includes different treatment approaches. Rehabilitation is a key strategy in MS for improving functioning, activity and participation. As part of a larger study on overall patient experiences with different treatment approaches, this study aims to give an overview of different patients’ experiences and perspectives on inpatient rehabilitation in MS.

Methods

We conducted problem-centered interviews in 50 persons with MS in Germany, of whom most had relapsing–remitting MS. We used the maximum variation sampling method during recruitment. Data were analyzed thematically.

Results

As a result of the analysis, three major themes were identified: 1) factors contributing to the decision-making concerning rehabilitation, 2) experience with the rehabilitation setting, 3) benefits of rehabilitation treatments. The treating physicians’ attitude had a major impact on the decision to either opt for rehabilitation or not. Setting goals prior to rehabilitation was given a high priority. Exchanging experiences with other persons with MS presented a major benefit from rehabilitation while for some being separated from regular daily life resulted in a more ambiguous attitude ranging from appreciation of escaping daily hassles to substantial behavioral change management.

Conclusion

Patients reported various experiences in the process of decision-making with regard to rehabilitation. Physicians´ advice, goal setting and the selection of the most suitable rehabilitation clinic were considered most relevant.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08150-8.

Comparison of goals set by people with multiple sclerosis during two fatigue management interventions

BACKGROUND

Identifying the meaningful goals of people with multiple sclerosis (PwMS) can facilitate tailored treatment plans.

OBJECTIVES

To describe and compare the goals set by PwMS during two interventions, and explore the strategies used to meet their goals, the barriers and facilitators influencing goal achievement.

METHODS

Data from 56 community-dwelling PwMS were used in this secondary analysis: 45 used an interactive fatigue self-management website (MS INFoRm), and 11 received MS INFoRm coupled with occupational performance coaching (OPC) for 3 months. The International Classification of Functioning, Disability and Health (ICF) was used to map and compare the goals, strategies, facilitators and obstacles to goal achievement between the groups. Goals were also evaluated for being Specific, Measurable, Attainable, Relevant and Timely (SMART).

RESULTS

Most goals were related to 'looking after one's health' (n = 35) and 'recreation and leisure' (n = 17). Participants who received OPC set more SMART goals (75 vs. 24%, p < 0.01). Fatigue management strategies were identified. Personal and environmental factors were found as facilitators and obstacles to goal achievement.

CONCLUSION AND SIGNIFICANCE

Coaching can help PwMS with goal setting, and to adapt strategies to achieve their goals. Increased awareness of goals set by PwMS may equip clinicians to better assess their clients' needs.

Pain in Women: A Perspective Review on a Relevant Clinical Issue that Deserves Prioritization

Introduction

Gender equity and gender medicine are opportunities not to be missed, and this Expert Group Opinion Paper on pain in women aims to review the treatment of pain conditions mainly affecting women, as well as the fundamental aspects of the different clinical response to drug treatment between the genders, and what can be done for gender-specific rehabilitation.

Methods

Perspective review.

Results

Genotypic and phenotypic differences in pain between the sexes are conditioned by anatomical, physiological, neural, hormonal, psychological, social, and cultural factors, such as the response to pharmacological treatment to control pain. The examination of these factors shows that women are affected by pain diseases more frequently and severely than men and that they report pain more frequently and with a lower pain threshold than men. Some forms of pain are inherently related to gender differences, such as pain related to the genitourinary system. However, other forms of chronic pain are seen more frequently in women than men, such as migraine, rheumatological, and musculoskeletal pain, in particular fibromyalgia.

Discussion

Research is needed into the pathophysiological basis for gender differences in the generation of acute pain and maintenance of chronic pain, including the factors that put women at higher risk for developing chronic pain. In addition, different specialties need to collaborate to develop gender-related diagnostic and therapeutic guidelines, and healthcare professionals need to upskill themselves in the appropriate management of pain using existing diagnostic tools and therapeutic options.

The Dresden Protocol for Multidimensional Walking Assessment (DMWA) in Clinical Practice

Walking impairments represent one of the most debilitating symptom areas for people with multiple sclerosis (MS). It is important to detect even slightest walking impairments in order to start and optimize necessary interventions in time to counteract further progression of the disability. For this reason, a regular monitoring through gait analysis is highly necessary. At advanced stages of MS with significant walking impairment, this assessment is also necessary to optimize symptomatic treatment, choose the most suitable walking aid and plan individualized rehabilitation. In clinical practice, walking impairment is only assessed at higher levels of the disease using e.g., the Expanded Disability Status Scale (EDSS). In contrast to the EDSS, standardized functional tests such as walking speed, walking endurance and balance as well as walking quality and gait-related patient-reported outcomes allow a more holistic and sensitive assessment of walking impairment. In recent years, the MS Center Dresden has established a standardized monitoring procedure for the routine multidimensional assessment of gait and balance disorders. In the following protocol, we present the techniques and procedures for the analysis of gait and balance of people with MS at the MS Center Dresden. Patients are assessed with a multidimensional gait analysis at least once a year. This enables long-term monitoring of walking impairment, which allows early active intervention regarding further progression of disease and improves the current standard clinical practice.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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