Searching for the "Active Ingredients" in Physical Rehabilitation Programs Across Europe, Necessary to Improve Mobility in People With Multiple Sclerosis: A Multicenter Study

Successful long-term management of spasticity in people with multiple sclerosis using a software application: Results from a randomized-controlled, multicenter study

BACKGROUND

Successful long-term treatment of spasticity in people with multiple sclerosis (pwMS) is challenging. We investigated the effects of multidisciplinary inpatient rehabilitation (MIR) and an individualized self-training program delivered by an App on spasticity in pwMS.

METHODS

First we assessed the efficacy of 4-weeks MIR in ambulatory pwMS (EDSS<7.0) with moderate to severe lower limb spasticity (defined by ≥4 points on the Numeric Rating Scale for spasticity (NRSs)) in a cohort of 115 pwMS in 7 rehabilitation centers in Austria. In case of a clinically relevant improvement in spasticity of ≥20% on the NRSs following MIR (n=94), pwMS were randomly allocated in a 1:1 ratio to either a newly designed "MS-spasticity App" or to a paper-based self-training program for 12 weeks. The primary outcome was change in NRSs (DRKS00023960).

RESULTS

MIR led to a significant reduction of 2.0 points on the NRSs (95% Confidence Interval (CI) 2.5 to 2.0; p<0.000). MIR was further associated with a statistically significant improvement in spasticity on the modified Ashworth scale, strength and all mobility outcomes. Following MIR, self-training with "MS-spasticity App" was associated with a sustained positive effect on the NRSs, while paper-based self-training led to a worsening in spasticity (median NRSs difference 1.0; 95% CI 1.7 to 0.3; p=0.009). "MS-spasticity App" was also associated with a significantly better adherence to self-training (95% versus 72% completion rate; p<0.001).

CONCLUSION

In pwMS, MIR is able to significantly improve lower-limb spasticity, strength and mobility. Following MIR, an individually tailored anti-spasticity program delivered by an App leads to sustained positive long-term management.

Perspectives From Persons With Multiple Sclerosis for a Comprehensive Real-World Change Therapy for Mobility

Objective

To assess the personal perspectives of persons with multiple sclerosis (MS) on the acceptability of a novel physical therapy program that is designed to transfer gains from the clinic to their real-world lower extremity (LE) use, termed LE constraint-induced therapy (CIT). The program includes several behavior change techniques (prescribed home exercises, daily structured therapist interviews and problem solving for LE activities, keeping an activity diary) and a concentrated physical treatment schedule.

Design

Anonymous internet survey.

Setting

Participants accessed the survey from computers in the community.

Participants

Five hundred adults (N=500) were recruited from an MS support organization's registry for having indicated from mild to total limb spasticity because they were anticipated to have markedly impaired LE use in the community.

Interventions

Not applicable.

Main Outcome Measures

Participants were offered the options on a nonnumerical Likert scale of “Very likely,” “Likely,” “Neutral,” “Unlikely,” or “Very unlikely” to indicate their personal acceptability for each of 5 different key treatment procedures after these were explained. Totals for each option within each key procedure were analyzed for their acceptability.

Results

Of the 281 persons who responded, 90% expressed interest in participating in LE CIT. A large majority of persons who completed the survey selected either “Very likely” or “Likely” for each key procedure (median=88%, range=65%-90%, P<.01). This indicated strong acceptance for the procedures of LE CIT. In addition, more respondents who already had had previous physical therapy accepted LE CIT than did respondents who had not had physical therapy (P<.01).

Conclusions

The results suggest there is strong acceptance of CIT for mobility with preliminary evidence of benefiting community LE use for persons with MS. The results support further clinical trials of LE CIT for persons with MS.

Baseline and overtime variations of soluble adhesion molecule plasma concentrations are associated with mobility recovery after rehabilitation in multiple sclerosis patients

Rehabilitative exercise outcomes and plasma concentrations of soluble adhesion molecules (sEndoglin, sE-Selectin, sL-Selectin, sICAM-1, sNCAM, sNCAM-1, sVCAM-1, sPECAM-1, sVAP-1) were evaluated in 60 severely disabled progressive multiple sclerosis (MS) patients at 4-time points. Changes of sE-Selectin, sL-Selectin, and sPECAM-1 concentrations were observed over time, and their variations were significantly correlated with rehabilitative outcome variations. Baseline sVAP-1 concentrations were able to predict functional mobility recovery. Our data suggest that the evaluation of adhesion molecules in plasma provides useful information to interpret rehabilitative exercise processes and to identify potential predictors of the rehabilitation-induced changes in mobility outcomes in MS patients.

Use of Participatory Action Research in the Development of a Survey of Physiotherapy Services for People with Multiple Sclerosis in Canada

Purpose: Currently, there is a paucity of research describing physiotherapy services for individuals with multiple sclerosis (MS) in Canada. Using qualitative methods, we aimed to develop a survey to examine physiotherapy practice patterns for people with MS receiving services in Canada. Method: We began by conducting a review of the current literature and combining participatory action research methods with the expertise of registered physiotherapists and individuals with MS. Semi-structured interviews were conducted with 10 participants to obtain their input into survey development. The interviews were then transcribed verbatim and analyzed thematically. Results: Five key themes emerged from the thematic analysis: (1) provide additional answer options, (2) reformat or clarify questions, (3) ensure that questions or options are appropriate, (4) ensure good readability and flow, and (5) determine the appropriate length of the survey. After a final revision, the survey consisted of 24 items in the following domains: demographics, MS programme and patient population, interdisciplinary care, and programme and service barriers. Conclusions: This survey is the first of its kind in Canada and is the first step toward improving the quality of health of people living with MS and the effectiveness of current physiotherapy practices for them.

Does disability level impact the relationship of muscle strength to walking performance in people with multiple sclerosis? a cross-sectional analysis

BACKGROUND AND PURPOSE

Strength training can improve muscle weakness in people with multiple sclerosis (MS), but does not consistently improve walking. Disability level may impact the relationship of muscle weakness and walking performance in people with MS, but few studies have investigated the impact of disability on the relationship of strength and walking. The purpose of this study was to compare the relationships of strength in lower body and trunk muscles to walking performance between mild and moderate disability groups in people with MS.

METHODS

Data from 36 participants with MS who had mild disability (Expanded Disability Status Scale - EDSS 0 to 3.5) and 36 participants who had moderate disability (EDSS 4.0 to 5.5) were analyzed. Hand-held dynamometry measured strength in eight muscle groups from the ankle, knee, hip, and trunk. Timed 25-Foot Walk (T25FW) and 6-Minute Walk Test (6MWT) measured walking speed and endurance, respectively. Pearson correlations and beta coefficients (ß) were reported for each bivariate relationship of muscle strength to T25FW and 6MWT from both mild and moderate disability groups. Linear regression was then used to compare differences in beta coefficients (Δß) between disability groups for the relationship of each muscle variable to T25FW and 6MWT. A positive Δß indicated a stronger relationship of strength to walking performance in the mild disability group, while a negative Δß favored the moderate disability group.

RESULTS

Overall, there were stronger Pearson correlations between muscle strength variables to T25FW and 6MWT in the mild (r = 0.57 to 0.77) compared to moderate disability group (r = 0.10 to 0.54). The mild disability group had significantly greater beta coefficients for T25FW with ankle dorsiflexion (Δß = 0.67, 95%CI: 0.27-1.07), knee extension (Δß = 0.68, 95%CI: 0.28-1.08), and hip abduction (Δß = 0.77, 95%CI: 0.01-1.52); and for 6MWT with knee extension (Δß = 0.47, 95%CI: 0.06 to 0.88).

DISCUSSION AND CONCLUSION

For people with MS, muscle strength in the lower extremity and trunk may be a more important contributor to T25FW in mild versus moderate disability, but not for 6MWT. While more studies are needed, these results may help to inform rehabilitation intervention when prioritizing strength training to improve walking.

Content and Delivery of Physical Therapy in Multiple Sclerosis across Europe: A Survey

Background: Guidelines and general recommendations are available for multiple sclerosis rehabilitation, but no specific guidance exists for physical therapists. Describing aspects of physical therapy content and delivery in multiple sclerosis and its determinants and analysing whether general recommendations connected with physical therapy are implemented in practice is important for interpreting clinical and research evidence. Methods: An online cross-sectional survey of physical therapists specialized in multiple sclerosis (212 specialists from 26 European countries) was used. Results: There was distinct diversity in service delivery and content across Europe. Perceived accessibility of physical therapy varied from most accessible in the Western region, and least in the Southern region. Sixty-four physical therapists adjusted their approach according to different disability levels, less so in the Eastern region. Duration, frequency and dose of sessions differed between regions, being highest in Southern and Western regions. "Hands on treatment" was the most commonly used therapeutic approach in all apart from the Northern regions, where "word instruction" (providing advice and information) prevailed. Conclusions: The content and delivery of physical therapy differs across Europe. Recommendations concerning access to treatment and adjustment according to disability do not appear to be widely implemented in clinical practice.

Group-based, individualized exercises can provide perceived bodily changes and strengthen aspects of self in individuals with MS: a qualitative interview study

Background: Group-based physiotherapy is effective for individuals with MS; nevertheless individualization within groups is questioned and little is known regarding individuals´ experiences with individualization in small groups.Objective: We aimed to explore the short- and long-term experiences of individuals with MS participating in a 6-week, group-based, individualized physiotherapy-intervention.Methods: Within a randomized controlled trial (RCT), 25 in-depth interviews with a strategic sample of 13 people (9 women; age 25-79 years old; European Disability Status Scale (EDSS) 1-6.5) were conducted at weeks 7 and 30 using systematic text condensation, with dynamic systems theory and phenomenology as analytical frameworks.Results: The main categories were: 1) movement control, orientation and insights: Bodily improvements were associated with targeted exercises, specific adjustments by the physiotherapist, emotional engagement and re-access to activities; and 2) the individual within the group: Equal distributions of one-to-one interactions and attention were important for experiencing success. Less attention and improvements turned attention toward own disability. Physical changes felt particularly emotional short term, implying that individuals' feelings of ownership and control of body and movement, new views of themselves and changed affordances in daily life were involved.Conclusion: Equally distributed attention and engagement, targeted exercises and hands-on adjustments resulting in visible and perceived bodily changes were experienced as key factors of individualization in small groups.