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

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.

Potentially modifiable associates of anxiety in people with multiple sclerosis: a systematic review

PURPOSE

A high percentage of people with multiple sclerosis (PwMS) experience anxiety, which can negatively impact quality of life. Despite this, anxiety in PwMS remains under researched. This review aims to identify associates with anxiety in PwMS that are amenable to change, with a view to informing the development of interventions in the area.

MATERIALS AND METHODS

The following databases were searched for studies investigating anxiety in PwMS from 2015 to 2021: PsycINFO, PubMed, EMBASE, Web of Science. The search consisted of keywords relating to MS and fear, anxiety or worry. Once screening was completed by two reviewers, a narrative synthesis was used to analyze the data, with the MMAT used for quality appraisal.

RESULTS

Of the 3117 unique abstracts screened, 39 studies met the criteria for inclusion. Evidence was found linking anxiety in PwMS to several modifiable factors broadly categorized as either psychological, social or lifestyle factors. Perceptions of self and one's ability to cope/adjust to MS emerged as important psychological factors. Physical activity and social support from friends were also linked with improved anxiety outcomes.

CONCLUSIONS

Anxiety in PwMS is linked to a number of modifiable factors. Findings may help inform the development of rehabilitation interventions to decrease anxiety in MS.Implications for rehabilitationThis review highlights interventions which have successfully lowered anxiety in people with MS (PwMS); however, there is a clear need for the development of further interventions which target the pathologically specific concerns surrounding anxiety in this population.We show how a number of factors amenable to change associate with anxiety, suggesting that these factors may be appropriate targets for anxiety interventions in PwMS.Enhancing physical activity and self-efficacy are important means in which healthcare professionals can reduce anxiety in MS.Identifying ways of encouraging positive coping and increasing social support are further targets for improving comorbid anxiety in PwMS.Focusing on the modifiable factors highlighted here offers considerable potential for enhancing psychological wellbeing in this group.

The Effect of Exercise Training and Royal Jelly on Hippocampal Cannabinoid-1-Receptors and Pain Threshold in Experimental Autoimmune Encephalomyelitis in Rats as Animal Model of Multiple Sclerosis

Cannabinoid-1-receptors (CB1R) are therapeutic targets for both the treatment of autoimmune diseases, such as multiple sclerosis (MS), and some related symptoms such as pain. The aim of this study was to evaluate the effect of aerobic training and two dosages of royal jelly (RJ) on hippocampal CB1R and pain threshold (PT) in an experimental autoimmune encephalomyelitis (EAE) model. To this end, 56 female Sprague-Dawley rats with EAE were randomly assigned to one of the following eight conditions: (1) EAE; (2) sham; (3) 50 mg/kg RJ (RJ50); (4) 100 mg/kg RJ (RJ100); (5) exercise training (ET); (6) ET + RJ50; (7) ET + RJ100; and (8) not EAE or healthy control (HC). Endurance training was performed for five weeks, four sessions per week at a speed of 11–15 m/min for 30 min, and RJ was injected peritoneally at doses of 50 and 100 mg/kg/day). One-way analysis of variance and Tukey’s post hoc tests were performed to identify group-related differences in pain threshold (PT) and CB1R gene expression. Endurance training had no significant effect on PT and hippocampal CB1R in rats with EAE. CB1R gene expression levels in the RJ100 group were higher than in the EAE group. Further, PT levels in the ETRJ50 and ETRJ100 groups were higher than in the EAE group. The combination of ET and RJ50 had a higher impact on PT and CB1R, when compared to the ET and RJ50 alone. Next, there was a dose-response between RJ-induced CB1R gene expression and RJ dosages: higher dosages of RJ increased the CB1R gene expression. The overall results suggest that the combination of ET and increasing RJ dosages improved pain threshold probably related to CB1R in an EAE model, while this was not observed for ET or RJ alone.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

IL-6 and TNF-α responses to acute and regular exercise in adult individuals with multiple sclerosis (MS): a systematic review and meta-analysis

Background

In both the general population and people with multiple sclerosis (PwMS), physical exercise is associated with improved mental well-being. Moreover, there is evidence of the possible protection of physical activity against disease progression in multiple sclerosis (MS). However, the question arises if acute or regular exercise has any impact on the immune system in PwMS. To answer this question, we performed a systematic review and meta-analysis on both plasma and serum cytokine levels (IL-6 and TNF-α) before and after acute and regular exercise among PwMS and compared to healthy controls.

Method

We performed an online search via PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane Library till September 2021 to identify original studies on IL-6 and TNF-α changes after acute and regular exercise in PwMS and controls. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 11 original studies were included in the meta-analysis. Sensitivity analyses were used to identify the origins of heterogeneity. R 4.0.4 was used to perform the meta-analysis of IL-6 and TNF-α levels before and after acute and regular exercise in PwMS, compared to controls. This study does not qualify for a clinical trial number.

Results

IL-6 levels did neither increase nor decrease after acute and regular exercise in PwMS, and compared to controls (pre- vs. post-intervention: Standardized Mean Difference (SMD) -0.09, 95% CI [−0.29; 0.11], p-value = 0.37, PwMS vs. Control: SMD −0.08, 95% CI [−0.33; 0.16], p-value = 0.47). In PwMS, TNF-α levels decreased after regular exercise and when TNF-α levels of both acute and regular exercise were pooled (pre- vs. post-intervention: SMD −0.51, 95% CI [-0.91; 0.11], p-value = 0.01, PwMS vs. Control: SMD −0.23, 95% CI [−0.66; 0.18], p-value = 0.26). TNF-α levels did neither increase nor decrease after acute and regular exercise in PwMS, when compared to controls.

Conclusion

This systematic review and meta-analysis show that exercise does not lead to significant changes in peripheral levels of IL-6 in PwMS in contrast to the observed response in healthy subjects and other medical contexts. However, regular exercise had a specific anti-inflammatory effect on blood TNF-α levels in PwMS. It remains to be investigated why PwMS display this different exercise-induced pattern of cytokines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00814-9.

Exercise training improves participation in persons with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Although previous studies have examined the effects of exercise training on other International Classification of Functioning, Disability and Health (ICF) component levels in persons with multiple sclerosis (MS), the effects of exercise training on participation remain unclear. The objectives of this review were to: (1) characterize systematically the use of outcome measures that capture participation in exercise training studies; (2) quantify the effect of exercise training on participation in persons with MS.

METHODS

A search of 6 electronic databases (CINAHL, SPORTDiscuss, Embase, MEDLINE, Cochrane Central, and Scopus) was conducted to identify controlled and noncontrolled trials involving exercise training and participation in persons with MS. Search strings were built from Medical Subject Headings and CINAHL headings. ICF linking rules were used to identify participation chapters and categories captured. Meta-analysis was used to quantify the effect of exercise training on participation in randomized controlled trials comparing exercise effects to no intervention/usual care.

RESULTS

We included 49 articles involving controlled and noncontrolled exercise trials in the systematic review of outcome measures. We captured 16 different outcome measures that captured all 9 participation chapters and identified 89 unique participation categories. Across these 16 outcome measures, mobility was the most commonly represented participation chapter, with 108 items. A subsample of 23 randomized controlled trials was included in the meta-analysis. An overall effect of 0.60 (standard error = 0.12, 95% confidence interval: 0.36-0.84, z = 4.9, p < 0.001) was calculated, indicating a moderate, positive effect of exercise training on participation.

CONCLUSION

The current review provides information that can be used to guide the selection of outcome measures that capture participation in studies of exercise training in persons with MS. Exercise training has a positive effect on outcomes that capture participation, providing further evidence for the role of exercise training in promoting and maintaining engagement in everyday life.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Maximising Abilities, Negotiating and Generating Exercise options (MANAGE) in people with multiple sclerosis: A feasibility randomised controlled trial

OBJECTIVE

To investigate the feasibility and preliminary efficacy of a group self-management exercise and education program in people with multiple sclerosis.

DESIGN

Feasibility randomised controlled trial.

SETTING

Outpatient rehabilitation facility.

SUBJECTS

Twenty-three adults (age 48.6 (11.7) years) recruited from a Multiple Sclerosis Clinic register.

INTERVENTIONS

The intervention group undertook a 12-week group program incorporating behaviour change education, exercise and community integration. This was compared with a waitlist control group.

MAIN MEASURES

Feasibility was measured by recruitment, adherence and safety. Efficacy outcomes included measures of physical function (6-metre and 6-min walk, Functional Reach) and self-report questionnaires (fatigue, quality of life, exercise benefits and barriers) at baseline, 6, 12 and 24 weeks.

RESULTS

Of 74 individuals identified through the register, 48 (65%) were contacted and deemed eligible, and 23 (48%) agreed to participate. There was high adherence for attendance at education (57 of 72, 79%) and exercise (135 of 174, 78%) sessions. No adverse safety events occurred within the intervention sessions. Missed attendances at assessment sessions was high (5 to 8 participants missed at each time point) predominately due to health issues. The intervention group demonstrated positive changes in walking endurance, Functional Reach and fatigue, whereas the control had some reductions in walking speed and more perceived exercise barriers.

CONCLUSIONS

The MANAGE program appears feasible and safe for people with mild-to-moderate multiple sclerosis, with high adherence to exercise and education sessions. Future trials should consider strategies such as flexible scheduling or alternative methods of data collection to improve follow-up assessment attendance.

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.

When Much Is Too Much-Compared to Light Exercisers, Heavy Exercisers Report More Mental Health Issues and Stress, but Less Sleep Complaints

BACKGROUND

Physical inactivity has become a global somatic and mental health issue. To counterbalance, promoting regular physical activity appears plausible, above all among adults, where physical inactivity is particularly high. However, some, but sparse, research also indicates that excessive exercising might be associated with unfavorable mental health dimensions. Here, we tested the hypothesis that excessive exercising was associated with more mental health issues. To this end, we assessed mental health issues, stress, mental toughness, and sleep disturbances among heavy and light adult exercisers.

METHODS

A total of 200 adults (mean age: 35 years; 62% females) took part in the study. Of those, 100 were heavy exercisers (18-22 h/week), and 100 were light exercisers (1-6 h/week). Participants completed questionnaires covering sociodemographic information, mental health issues, perceived stress, mental toughness, and sleep disturbances.

RESULTS

Compared with light exercisers, heavy exercisers reported higher mental health issues, more stress, but also higher mental toughness scores and less sleep disturbances. Higher age, lower mental toughness scores, heavy exerciser-status, and more sleep disturbances predicted higher mental health complaints.

CONCLUSIONS

Compared with light exercising, heavy exercising might be associated with more mental health issues. As such, it appears that the association between exercise frequency, intensity, and duration and psychological well-being might be related to an optimum point, but not to a maximum point. In a similar vein, heavily exercising athletes, their coaches, parents, and representatives of sports associations should get sensitized to possible adverse psychological effects of excessive physical activity patterns.

Home-based Pilates for symptoms of anxiety, depression and fatigue among persons with multiple sclerosis: An 8-week randomized controlled trial

BACKGROUND

Symptoms of anxiety, depression and fatigue are common comorbidities among persons with multiple sclerosis (PwMS). A previous pilot study supported Pilates as a feasible exercise modality that may improve these outcomes among PwMS.

OBJECTIVE

To quantify the effects of 8 weeks of home-based Pilates on symptoms of anxiety, depression and fatigue among PwMS.

METHODS

A total of 80 PwMS (69 female) were randomized to twice-weekly home-based Pilates guided by a DVD) or wait-list control. Validated questionnaires assessed anxiety, depressive and fatigue symptoms at baseline, weeks 2, 4, 6 and 8. Using intention to treat, repeated measures analysis of covariance (RM-ANCOVA) adjusted for baseline physical activity examined between-group differences across time. Hedges' d quantified the magnitude of differences in outcome change. Sensitivity analyses examined female-only samples.

RESULTS

Group × time interactions were statistically significant for all outcomes (all p ⩽ 0.005). Pilates significantly reduced (all p ⩽ 0.03) depressive symptoms (Quick Inventory of Depressive Symptomatology, d = 0.70; Hospital Anxiety and Depression Scale-Depression, d = 0.74), anxiety (State-Trait Anxiety Inventory, d = 0.30; Hospital Anxiety and Depression Scale-Anxiety, d = 0.49), cognitive (d = 0.44), physical (d = 0.78), psychosocial (d = 0.56) and total fatigue (d = 0.76). Female-only results were materially the same.

CONCLUSION

Home-based Pilates significantly improved anxiety, depressive and fatigue symptoms among PwMS with minimal-to-mild mobility disability, including moderate-to-large, clinically meaningful improvements in depressive and fatigue symptoms.Trial Registration: ClinicalTrials.gov (NCT04120207).

Behavior Change Techniques in Physical Activity Interventions for Multiple Sclerosis

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

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

BACKGROUND

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

AIMS

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

METHODS

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

CONCLUSIONS

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

Physical activity monitoring to assess disability progression in multiple sclerosis

Background

Clinical outcome measurement in multiple sclerosis (MS) usually requires a physical visit. Remote activity monitoring (RAM) using wearable technology provides a rational alternative, especially desirable when distance is involved or in a pandemic setting.

Objective

To validate RAM in progressive MS using (1) traditional psychometric methods (2) brain atrophy.

Methods

56 people with progressive MS participated in a longitudinal study over 2.5 years. An arm-worn RAM device measured activity over six days, every six months, and incorporated triaxial accelerometry and transcutaneous physiological variable measurement. Five RAM variables were assessed: physical activity duration, step count, active energy expenditure, metabolic equivalents and a composite RAM score incorporating all four variables. Other assessments every six months included EDSS, MSFC, MSIS-29, Chalder Fatigue Scale and Beck’s Depression Inventory. Annualized brain atrophy was measured using SIENA.

Results

RAM was tolerated well by people with MS; the device was worn 99.4% of the time. RAM had good convergent and divergent validity and was responsive, especially with respect to step count. Measurement of physical activity over one day was as responsive as six days. The composite RAM score positively correlated with brain volume loss.

Conclusion

Remote activity monitoring is a valid and acceptable outcome measure in MS.

Walking Training Enhances Corticospinal Excitability in Progressive Multiple Sclerosis-A Pilot Study

Background: Inflammatory lesions and neurodegeneration lead to motor, cognitive, and sensory impairments in people with multiple sclerosis (MS). Accumulation of disability is at least partially due to diminished capacity for neuroplasticity within the central nervous system. Aerobic exercise is a potentially important intervention to enhance neuroplasticity since it causes upregulation of neurotrophins and enhances corticospinal excitability, which can be probed using single-pulse transcranial magnetic stimulation (TMS). Whether people with progressive MS who have accumulated substantial disability could benefit from walking rehabilitative training to enhance neuroplasticity is not known.

Objective: We aimed to determine whether 10 weeks of task-specific walking training would affect corticospinal excitability over time (pre, post, and 3-month follow-up) among people with progressive MS who required walking aids.

Results: Eight people with progressive MS (seven female; 29–74 years old) with an Expanded Disability Status Scale of 6–6.5 underwent harness-supported treadmill walking training in a temperature controlled room at 16°C (10 weeks; three times/week; 40 min at 40–65% heart rate reserve). After training, there was significantly higher corticospinal excitability in both brain hemispheres, reductions in TMS active motor thresholds, and increases in motor-evoked potential amplitudes and slope of the recruitment curve (REC). Decreased intracortical inhibition (shorter cortical silent period) after training was noted in the hemisphere corresponding to the stronger hand only. These effects were not sustained at follow-up. There was a significant relationship between increases in corticospinal excitability (REC, area under the curve) in the hemisphere corresponding to the stronger hand and lessening of both intensity and impact of fatigue on activities of daily living (Fatigue Severity Scale and Modified Fatigue Impact Scale, respectively).

Conclusion: Our pilot results support that vigorous treadmill training can potentially improve neuroplastic potential and mitigate symptoms of the disease even among people who have accumulated substantial disability due to MS.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Treatment and management of cognitive dysfunction in patients with multiple sclerosis

Cognitive impairment is a common and devastating manifestation of multiple sclerosis (MS). Although disease-modifying therapies have been efficacious for reducing relapse rates in MS, such treatments are ineffective for treating cognitive dysfunction. Alternative treatment approaches for mitigating cognitive problems are greatly needed in this population. To date, cognitive rehabilitation and exercise training have been identified as possible candidates for treating MS-related cognitive impairment; however, cognitive dysfunction is still often considered to be poorly managed in patients with MS. This Review provides a comprehensive overview of recent developments in the treatment and management of cognitive impairment in people with MS. We describe the theoretical rationales, current states of the science, field-wide challenges and recent advances in cognitive rehabilitation and exercise training for treating MS-related cognitive impairment. We also discuss future directions for research into the treatment of cognitive impairment in MS that should set the stage for the inclusion of cognitive rehabilitation and exercise training into clinical practice within the next decade.

Clinical Characteristics and Disability Progression of Early- and Late-Onset Multiple Sclerosis Compared to Adult-Onset Multiple Sclerosis

Background: Compared to the adult onset of multiple sclerosis (AOMS), both early-onset (EOMS) and late-onset (LOMS) are much less frequent, but are often under- or misdiagnosed. The aims of the present study were: 1. To compare demographic and clinical features of individuals with EOMS, AOMS and LOMS, and 2. To identify predictors for disability progression from relapsing remitting MS (RRMS) to secondary progressive MS (SPMS). Method: Data were taken from the Isfahan Hakim MS database. Cases were classified as EOMS (MS onset ≤18 years), LOMS (MS onset >50 years) and AOMS (MS >18 and ≤50 years). Patients’ demographic and clinical (initial symptoms; course of disease; disease patterns from MRI; disease progress) information were gathered and assessed. Kaplan–Meier and Cox proportional hazard regressions were conducted to determine differences between the three groups in the time lapse in conversion from relapsing remitting MS to secondary progressive MS. Results: A total of 2627 MS cases were assessed; of these 127 were EOMS, 84 LOMS and 2416 AOMS. The mean age of those with EOMS was 14.5 years; key symptoms were visual impairments, brain stem dysfunction, sensory disturbances and motor dysfunctions. On average, 24.6 years after disease onset, 14.2% with relapsing remitting MS (RRMS) were diagnosed with secondary progressive MS (SPMS). The key predictor variable was a higher Expanded Disability Status Scale (EDSS) score at disease onset. Compared to individuals with AOMS and LOMS, those with EOMS more often had one or two relapses in the first two years, and more often gadolinium-enhancing brain lesions. For individuals with AOMS, mean age was 29.4 years; key symptoms were sensory disturbances, motor dysfunctions and visual impairments. On average, 20.5 years after disease onset, 15.6% with RRMS progressed to SPMS. The key predictors at disease onset were: a higher EDSS score, younger age, a shorter inter-attack interval and spinal lesions. Compared to individuals with EOMS and LOMS, individuals with AOMS more often had either no or three and more relapses in the first two years. For individuals with LOMS, mean age was 53.8 years; key symptoms were motor dysfunctions, sensory disturbances and visual impairments. On average, 14 years after disease onset, 25.3% with RRMS switched to an SPMS. The key predictors at disease onset were: occurrence of spinal lesions and spinal gadolinium-enhancement. Compared to individuals with EOMS and AOMS, individuals with LOMS more often had no relapses in the first two years, and higher EDSS scores at disease onset and at follow-up. Conclusion: Among a large sample of MS sufferers, cases with early onset and late onset are observable. Individuals with early, adult and late onset MS each display distinct features which should be taken in consideration in their treatment.

Exercise and lifestyle physical activity recommendations for people with multiple sclerosis throughout the disease course

Objectives:

To provide clinicians who treat multiple sclerosis (MS) patients with evidence-based or expert opinion–based recommendations for promoting exercise and lifestyle physical activity across disability levels.

Methods:

The National MS Society (“Society”) convened clinical and research experts in the fields of MS, exercise, rehabilitation, and physical activity to (1) reach consensus on optimal exercise and lifestyle physical activity recommendations for individuals with MS at disability levels 0–9.0 on the Expanded Disability Status Scale (EDSS) and (2) identify and address barriers/facilitators for participation.

Recommendations:

Based on current evidence and expert opinion, the Society makes the following recommendations, endorsed by the Consortium of Multiple Sclerosis Centers:

Safety and Feasibility of Various Functional Electrical Stimulation Cycling Protocols in Individuals With Multiple Sclerosis Who Are Nonambulatory

Objective

To examine the safety, feasibility, and response to functional electrical stimulation (FES) cycling protocols requiring differing levels of effort in people with multiple sclerosis (MS) who are nonambulatory.

Design

Pilot study with pre-post intervention testing.

Setting

Outpatient clinic setting of a long-term acute care hospital.

Participants

Individuals (N=10) with MS (6 men; mean age 58.6±9.86y) who use a wheelchair for community mobility. Participants’ Expanded Disability Status Scale score ranged from 6.5 to 8.5 (median 7.5).

Intervention

Participants performed 3 or 4 FES cycling protocols requiring different levels of volitional effort during 6-8 testing sessions.

Main Outcome Measures

The primary outcome was safety, measured by adverse events and increase in MS symptoms, all assessed throughout, immediately post- and 1 day postsession. FES cycling performance for each protocol was also recorded. Exploratory outcome measures collected before and after all testing sessions included functional assessment of MS, MS Impact Scale, Exercise Self Efficacy Scale, Patient Health Questionnaire-9 item, and the Zarit Caregiver Burden Scale.

Results

All participants (4 women, 6 men) completed all testing sessions. There were no serious adverse events or differences in vitals or symptoms between protocols. Two participants had an isolated episode of mild hypotension. Changes in pain, spasticity, and fatigue were minimal. Five participants were able to cycle for 30 minutes and completed interval training protocols requiring increasing difficulty. The remainder cycled for <3 minutes and completed a rest interval protocol. There was modest improvement on the exploratory outcome measures.

Conclusions

People with MS who use a wheelchair for community mobility can safely perform FES cycling requiring more effort than previously reported research. Therefore, the individuals may experience greater benefits than previously reported. Further study is required to better understand the potential benefits for optimizing function and improving health in people with MS.

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People with multiple sclerosis who are nonambulatory can safely perform functional electrical stimulation (FES) cycling using parameters requiring more effort.

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FES cycling may offer an opportunity for increased exercise stimulus or neuromuscular training if individuals are adequately challenged using an appropriate cycling protocol.

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

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

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

Background:

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

Objective:

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

Methods:

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

Results:

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

Conclusions:

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

Compared to an active control condition, in persons with multiple sclerosis two different types of exercise training improved sleep and depression, but not fatigue, paresthesia, and intolerance of uncertainty

BACKGROUND

In persons with multiple sclerosis (MS), physical activity favorably impacts on psychological well-being. The aims of the present study were to investigate the influence of physical activity on depression, fatigue, sleep, paresthesia, and personality traits (intolerance of uncertainty), and to explore, if endurance training or coordinative training are superior to an active control condition.

METHODS

92 female individuals with MS (mean age: 37.36 years; mean EDSS: 2.43) took part in this intervention study. Participants were randomly assigned either to endurance training, coordinative training, or to an active control condition. At baseline, 4 weeks, and 8 weeks later at the end of the study, participants completed questionnaires on sleep, depression, fatigue, paresthesia and intolerance of uncertainty. Exercise training interventions took place three times/week for 45 min/session. Participants in the active control condition also met with the same duration and frequency.

RESULTS

Sleep complaints and symptoms of depression decreased over time, but more so in the exercising groups, compared to the active control group. No changes over time and between groups were observed for fatigue, paresthesia, and intolerance of uncertainty.

CONCLUSIONS

Both endurance and coordinative exercising had the potential to favorably impact on some aspects of cognitive-emotional processing, while also an active control condition appeared to have a positive impact.

Sensory-motor and cardiorespiratory sensory rehabilitation associated with transcranial photobiomodulation in patients with central nervous system injury: Trial protocol for a single-center, randomized, double-blind, and controlled clinical trial

BACKGROUND

Central nervous system diseases such as stroke, spinal cord injury, traumatic brain injury, and multiple sclerosis can be fatal or cause sequelae, affecting sensorimotor and cardiorespiratory systems and quality of life. These subjects present a low response to aerobic and resistance exercise, due to decreased recruitment of muscle fibers and reduction of metabolic capacity. Aerobic exercises bring benefits in terms of fatigue retardation, gait improvement, regulation of the autonomic nervous system, neuroprotection of the brain, stimulation of the production of endogenous neutrotransmitters related to general well-being, and a favoring of neuroplasticity. Photobiomodulation (PBM Therapy) (previously known as low-level laser therapy), and especially transcranial PBM Therapy, has shown benefits in animals and humans such as cognitive improvement, memory, and behavioral improvement, including attenuation of depression and anxiety, and increased cortical oxygenation. The aims of this trial will be to evaluate the parameters related to the function of the musculoskeletal and cardiorespiratory system and the impact of PBM therapy on these parameters, as part of a rehabilitation and training program for people with reduced mobility.

METHODS

This is a randomized, double-blind, placebo-controlled trial with 3 groups: Control, only cardiorespiratory rehabilitation (CCR), CCR with PBM Therapy (CR-PBM), CCR and placebo PBM Therapy (CR-PlaceboPBM). n = 90, 30 per group. PBM Therapy parameters: 810 nm laser, 0.028 cm, 100 mW, 3.5 W/cm, 30 seconds per point, 3 J per point, 107.1 J /cm to 3 electroencephalogram points F7 and F8 and AFz. The trial will be conducted at the University Clinics and the sessions will be 1 hour twice a week for 9 weeks. Baseline, intermediate (4th week), final (9th week), and 2-month follow-up will be performed. Muscular activation, heart rate variability, lung volumes and capacities, fatigability, exercise tolerance, cognition, and quality of life at baseline will be evaluated. Subsequent to baseline evaluations, the PBM Therapy groups will be offered laser therapy (active or inactive); all groups will then receive CCR.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov ID - NCT03751306 (approval date: November 22, 2018).

Prolonged cortical silent period is related to poor fitness and fatigue, but not tumor necrosis factor, in Multiple Sclerosis

OBJECTIVE

Poor fitness among people with Multiple Sclerosis (MS) aggravates disease symptoms. Whether low fitness levels accompany brain functioning changes is unknown.

METHODS

MS patients (n = 82) completed a graded maximal exercise test, blood was drawn, and transcranial magnetic stimulation determined resting and active motor thresholds, motor evoked potential latency, and cortical silent period (CSP).

RESULTS

Sixty-two percent of participants had fitness levels ranked below 10th percentile. Fitness was not associated with disability measured using the Expanded Disability Status Scale (EDSS). Regression analyses revealed that, cardiorespiratory fitness, when controlling for disease demographics, contributed 23.7% (p < 0.001) to the model explaining variance in CSP. Regression analysis using cardiorespiratory fitness and CSP as predictors showed that CSP alone explained 19.9% of variance in subjective fatigue (p = 0.002). Tumor necrosis factor was not associated with any variable.

CONCLUSION

Low fitness was associated with longer CSP in MS. Longer CSP was, in turn, related to greater MS fatigue.

SIGNIFICANCE

MS patients had extremely low levels of cardiorespiratory fitness. Poor fitness predicted longer CSP, a marker of greater intracortical inhibition, which was linked to MS fatigue. Future research should examine whether aerobic training could shorten CSP and potentially lessen inhibition of cortical networks.

In Patients With Multiple Sclerosis, Both Objective and Subjective Sleep, Depression, Fatigue, and Paresthesia Improved After 3 Weeks of Regular Exercise

Background: Multiple sclerosis (MS) patients suffer from various difficulties including sleep complaints, symptoms of depression and fatigue, paresthesia, and cognitive impairments. There is growing evidence that regular physical activity has a positive effect on both sleep and psychological functioning, though there is limited evidence of this kind for MS patients. The aim of the present study was therefore to investigate the impact on this patient group of a regular exercise program with respect to subjective and objective sleep, depression, paresthesia, fatigue, and cognitive performance. Methods: A total of 46 patients [mean age: 50.74 years; Expanded Disability Status Scale (EDSS): mean: 5.3, 78.4% females] completed this 3-week intervention study. At baseline and 3 weeks later, they answered questionnaires covering sociodemographic information, subjective sleep, depression, fatigue, paresthesia, and subjective physical activity. Objective sleep [sleep electroencephalogram (EEG) recordings] and cognitive performance were also assessed at both time points. Patients participated in a regular exercise activity every weekday for about 60 min. Results: Compared to the baseline, by the end of the study, objective sleep had significantly improved (sleep efficiency, sleep onset latency, and wake time after sleep onset), and symptoms of sleep complaints, depression, fatigue, and paresthesia were significantly reduced. Subjective physical activity (moderate and vigorous) and cognitive performance also increased over the course of the intervention. Conclusions: In patients with MS, participation in regular exercise impacted positively on their objective and subjective sleep, depression, paresthesia, fatigue, and cognitive performance.

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

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

A systematic critical review of physical activity aspects in clinical guidelines for multiple sclerosis

OBJECTIVE

This paper aims to evaluate the quality of clinical guidelines (CGs) for MS and to critically appraise physical activity-related recommendations.

DATA SOURCES

Medical databases (MEDLINE, TRIP), clearinghouses, and guideline developers. An expert was asked to confirm if the list of CGs was complete.

STUDY SELECTION

Evidence-based CGs specific to MS with recommendations including aspects of rehabilitation or physical activity were included.

DATA EXTRACTION

Two reviewers independently first assessed the methodological quality of the CGs based on the 23 items of the Appraisal of Guidelines for Research and Evaluation Instrument version two (AGREE II) and second evaluated the physical activity-related content quality using an instrument containing 14 items that was used for the development of the National Recommendations for Physical Activity in Germany.

DATA SYNTHESIS

For the AGREE II domains and the criteria for content quality, standardized domain scores were calculated.

RESULTS

Three CGs were included. The average scores for the methodological quality of the domains were: scope and purpose (91%), stakeholder involvement (81%), rigor of development (78%), clarity of presentation (93%), applicability (53%), and editorial independence (83%). The mean scores for physical activity-related content quality did not exceed 56% for any criteria.

CONCLUSIONS

Overall, this critical review shows that the methodological quality of CGs were moderate to good but physical activity-related content quality was heterogeneous and low. Results emphasize the need for more specific physical activity recommendations that incorporate multiple aspects of physical activity prescription.

Stability of Mental Toughness, Sleep Disturbances, and Physical Activity in Patients With Multiple Sclerosis (MS)-A Longitudinal and Pilot Study

Background: Previous research of patients with multiple sclerosis (MS) focused prevalently on fatigue, depression, and cognitive dysfunction during the clinical course. By contrast, research on the longer-term characteristics of physical activity (PA), psychological functioning, and sleep problems is scarce. The aims of the present study were therefore to examine changes in PA, mental toughness (MT) as a proxy of psychological functioning, and sleep disturbances over a 2-year period of time after disease onset. Methods: A total of 18 patients with diagnosed MS (mean age: M = 34.29 years) took part in this longitudinal study. First, 1-4 weeks after the first symptoms, a neurologist diagnosed the MS. Second, they completed a series of questionnaires covering socio-demographic data, PA, MT, and sleep disturbances. Third, the same questionnaires were completed again 2 years later (follow-up). Last, a neurologist assessed the degree of disability with the Expanded Disability Status Scale (EDSS). Results: Two years after MS onset, patients had lower levels of vigorous PA, but no statistically significant changes in moderate PA were observed. Further, walking time increased and sedentary time decreased. Patients with sleep disturbances at disease onset also reported poor sleep 2 years later. MT scores remained stable over time. EDSS scores worsened, though, change in EDSS was not associated with PA, MT, or sleep. Conclusions: Two years after disease onset, patients with MS reported similar MT levels and sleep disturbances. PA shifted from vigorous PA toward walking and a less sedentary lifestyle, while moderate PA remained unchanged. The pattern of results of the present pilot study suggests that at the early stage of the MS course, there is no obstacle for being physically active, nor did sleep and MT as a proxy of psychological functioning decrease in a substantial way.