Physical rehabilitation has a positive effect on disability in multiple sclerosis patients

A systematic review and meta-analysis of the effects of non-pharmacological interventions on quality of life in adults with multiple sclerosis

BACKGROUND

Multiple Sclerosis (MS) is a chronic debilitating disease that targets the central nervous system. Globally it is estimated that 2.8 million people live with MS (2018) and as there is no known cure; therefore, identifying methods to increase a patient's quality of life (QoL) is of considerable importance. Non-pharmacological interventions are a viable and effective option to increase QoL in patients with MS, however, to date, the literature lacks a complete systematic review of these interventions.

METHODS

A literature search was conducted for studies published up until March 4th 2022 in Scopus, Web of Science, CINAHL Plus, The Cochrane Library, Medline, and Embase. Studies were included if they were randomized control trials (RCTs) assessing a non-pharmacological intervention in adults with MS and measured QoL using the MSQOL-54, SF-36 or MSQLI tools for at least two time points. Quality assessment of each study was completed as well as a review of publication bias. Where possible, meta-analysis was conducted using a random effects model and for other studies a qualitative synthesis was presented.

RESULTS

Thirty studies were included in the meta-analysis and eleven studies were summarized qualitatively. The pooled effects across all non-pharmacological interventions showed a modest improvement in both the physical and mental components of QoL, with a standardized mean difference (SMD) of 0.44 (95% CI 0.26-0.61) and 0.42 (95% CI 0.24-0.60), respectively. Non-pharmacological interventions based around a physical activity were found to be particularly effective in improving both the physical composite score (PCS) and mental composite score (MCS), with an SMD of 0.40 (95% CI 0.14-0.66) and 0.31 (95% CI 0.08-0.55), respectively. Interventions incorporating balance exercises presented a significant advantageous solution for improving QoL, with an SMD of 1.71 (95% CI 1.22, 2.20) and 1.63(95% CI 1.15-2.12) for PCS and MCS respectively.

CONCLUSIONS

This systematic review and meta-analysis identified that non-pharmacological interventions can be an effective method of improving QoL in patients with MS, especially modalities with a physical activity component and balance interventions.

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

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

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

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

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

Construction of a User-Led Resource for People Transitioning to Secondary Progressive Multiple Sclerosis: Results of an International Nominal Group Study

Background: ManTra is a mixed-methods, co-production research project for developing an intervention (resource) for people with newly diagnosed secondary progressive multiple sclerosis (pwSPMS) in Italy and Germany. In previous project actions, six resources were outlined, meeting the needs prioritized by pwSPMS.

Aims: This study aims to achieve multiple-stakeholder consensus on the most suitable resource and to refine the consensus resource.

Methods: Two nominal group technique (NGT) meetings were held, one in Milan and one in Hamburg. Participants were pwSPMS (five in Italy/six in Germany), pwSPMS significant others (SOs, four/five), healthcare professionals (HPs, seven/four), and health service researchers/patient and citizen organizations representatives (HPCORs, five/five). Two of the four resources discussed in each meeting were the same in Italy and Germany: “Promoting the engagement of pwSPMS: a program for the patients and the HPs” and “Enriched physiotherapy program for pwSPMS.” The other two were “A personalized care plan for pwSPMS” and “Roadmap for social and economic benefits” in Italy and “Metacognitive and everyday life training for pwSPMS” and “Psychological support for pwSPMS” in Germany. Each meeting consisted of two plenary sessions and a parallel group session (four stakeholder groups: pwSPMS, SOs, HPs, and HPCORs) in between. Meetings' narratives were analyzed thematically.

Results: The two meetings were rich in participation and discussion. In Italy, the consensus resource was “A personalized care plan for pwSPMS.” Refinements included enrichment with pwSPMS engagement, inclusion of additional HPs, improved definition of the MS nurse's role within the interdisciplinary panel, and community care integration. In Germany, the consensus resource was “Psychological support for pwSPMS.” Refinements included reshaping this resource into a more comprehensive and adaptive rehabilitation intervention and training the psychologist in recognizing client's rehabilitative needs and enhancing his/her autonomy.

Conclusions: The NGT eased multiple-stakeholder deliberation and resource fine-tuning in both countries.

Neuroplasticity and brain reorganization associated with positive outcomes of multidisciplinary rehabilitation in progressive multiple sclerosis: A fMRI study

BACKGROUND

Multiple sclerosis (MS) is characterized by a range of symptoms, including motor, sensorimotor and cognitive impairments, that limit the quality of life. A multidisciplinary rehabilitation approach in people affected by multiple sclerosis was recently reported to improve the functional abilities of MS patients in daily activities. The purpose of the study was to assess the effect of multidisciplinary rehabilitation on the whole brain of MS patients by means of functional magnetic resonance imaging (fMRI).

METHODS

Thirty individuals affected by MS (49.9 ± 12.1 years; disease duration: 16.0 ± 8.5 years) with a medium-high severity of disease were enrolled. The fMRI examination assessed a range of action-related tasks involving passive movement, mental simulation of action and miming of action triggered by external stimuli, such as object photography. The three tasks were performed using each arm separately. The fMRI acquisitions were performed at T1 (inclusion in the study), T2 (3 months later, at the start of rehabilitation) and T3 (after 3 months of multidisciplinary rehabilitation).

RESULTS

The fMRI results revealed a significant reduction in the activity of brain areas related to task-specific networks as well as the activation of cerebral regions not usually involved in task-specific related network, such as the medial prefrontal area.

CONCLUSIONS

The effectiveness of multidisciplinary rehabilitation on activity and participation has been established in previous studies. Our study sheds new light on the effect of such treatment on brain reorganization.

Reaching People With Disabilities in Underserved Areas Through Digital Interventions: Systematic Review

Background

People with disabilities need rehabilitation interventions to improve their physical functioning, mental status, and quality of life. Many rehabilitation interventions can be delivered electronically ("digitally") via telehealth systems. For people with disabilities in underserved areas, electronically delivered rehabilitation interventions may be the only feasible service available for them.

Objective

The objective of this study was to evaluate the current status of digital interventions for people with disabilities in remote and underserved areas.

Methods

A systematic review was conducted on this topic. Keyword searches in multiple databases (PubMed, CINAHL, and Inspec) were performed to collect articles published in this field. The obtained articles were selected based on our selection criteria. Of the 198 identified articles, 16 duplicates were removed. After a review of the titles and abstracts of the remaining articles, 165 were determined to be irrelevant to this study and were therefore removed. The full texts of the remaining 17 articles were reviewed, and 6 of these articles were removed as being irrelevant to this study. The 11 articles remaining were discussed and summarized by 2 reviewers.

Results

These 11 studies cover a few types of disabilities, such as developmental disabilities and mobility impairments as well as several types of disability-causing disorders such as stroke, multiple sclerosis, traumatic brain injury, and facio-scapulo-humeral muscular dystrophy. Most of these studies were small-scale case studies and relatively larger-scale cohort studies; the project evaluation methods were mainly pre-post comparison, questionnaires, and interviews. A few studies also performed objective assessment of functional improvement. The intervention technology was mainly videoconferencing. Moreover, 10 of these studies were for people with disabilities in rural areas and 1 was for people in urban communities.

Conclusions

A small number of small-scale studies have been conducted on digital interventions for people with disabilities in underserved areas. Although the results reported in these studies were mostly positive, they are not sufficient to prove the effectiveness of telehealth-based digital intervention in improving the situation among people with disabilities because of the small sample sizes and lack of randomized controlled trials.

Functional and structural plasticity following action observation training in multiple sclerosis

BACKGROUND

Hand motor deficits contribute to multiple sclerosis (MS)-related disability. Action observation training (AOT) is promising to improve upper limb function in neurologic patients.

OBJECTIVES

In this preliminary study, we investigated AOT effects on dominant-hand motor performance in MS patients with upper limb motor impairment and performed an explorative analysis of their anatomical and functional magnetic resonance imaging (MRI) substrates.

METHODS

In total, 46 healthy controls (HC) and 41 MS patients with dominant-hand motor impairment were randomized to AOT (HC-AOT = 23; MS-AOT = 20; watching daily-life action videos and execution) or control-training (HC-Control = 23; MS-Control = 21; watching landscapes videos and execution). Behavioral, structural, and functional (at rest and during object manipulation) MRI scans were acquired before and after a 2-week training.

RESULTS

After training, MS groups improved in right upper limb functions, mainly in AOT group (p from 0.02 to 0.0001). All groups showed regional increased and decreased gray matter volume, with specific AOT effects in fronto-temporal areas in MS-AOT (p < 0.001), without white matter (WM) integrity modifications. Increased and reduced recruitments of the action observation matching system and its connections in MS-AOT were found (p < 0.001). Motor improvements were correlated with volumetric and functional MRI modifications (r from -0.78 to 0.77, p < 0.001).

CONCLUSION

The 10-day AOT promotes clinical improvements in MS patients through structural and functional modifications of the action observation matching system.

[New aspects of symptomatic MS treatment: Part 6 - cognitive dysfunction and rehabilitation]

The symptomatic treatment of multiple sclerosis (MS) is nowadays of similar importance as immunotherapy within a comprehensive treatment concept of this chronic disease. It makes a considerable contribution to the reduction of disabilities in activities of daily living as well as social and occupational life. Moreover, symptomatic treatment is of great importance for amelioration of the quality of life. Since our last survey of symptomatic MS treatment in 2004 and publication of the guidelines of the German Neurological Society and the Clinical Competence Network Multiple Sclerosis ("Klinisches Kompetenznetz Multiple Sklerose", KKN-MS) in 2014 several developments within the topics of mobility, bladder and sexual function, vision, fatigue, cognition and rehabilitation have taken place. These new findings together with further aspects of disease measurement methods and overall treatment strategies of the respective symptoms, as well as treatment goals are introduced in several individual contributions. In this article the symptoms of cognitive disorders and the growing impact of rehabilitation are discussed.

Different types of exercise in Multiple Sclerosis: Aerobic exercise or Pilates, a single-blind clinical study

BACKROUND

The aim of our study is to examine effects of aerobic and Pilates exercises on disability, cognition, physical performance, balance, depression and fatigue in relapsing-remitting Multiple Sclerosis (MS) patients as compared to healthy controls.

METHODS

The subjects were divided as aerobic exercise (n = 26), Pilates (n = 9), and the healthy control group (n = 21). We used MSFC, physical performance, Berg balance scale, Beck depression scale, fatigue impact scale. All evaluations were performed before and after exercise training.

RESULTS

There are statistically meaningful differences between Nine hole testing, PASAT 3, physical performance and fatique impact scale before and after aerobic exercise. Also we found significant difference for physical performance in the Pilates group. There are no significant differences in measures of fatique impact scale and depression between aerobic exercise group and the healthy controls after exercise. We found significant differences between Pilates and control group's after measurements except depression. There were significant differences between the Pilates and aerobic group for cognitive tests in favor of the Pilates group.

CONCLUSION

Aerobic exercise and clinical Pilates exercises revealed moderate changes in levels of cognitive, physical performance, balance, depression, fatigue in MS patients.

A Comparison of Implicit and Explicit Motor Sequence Learning in Patients with Relapsing-Remitting Multiple Sclerosis

This study tends to assess implicit and explicit types of motor learning in patients with Multiple Sclerosis (MS) and normal peers by means of a serial reaction time. Sample size was 15 for each group and Samples included 30 patients with MS and 30 normal peers and were assigned to implicit and explicit learning groups. A repeated measures ANOVA was used for measuring reaction time and response error, and a paired samples t-test was used to compare regular and irregular sequence data in each group. Comparison of these two types of learning in speed (response time) and accuracy (number of errors) showed the number of errors (P = 0.012) and response time (P = 0.012) in the implicit motor learning group of MS patients and the number of errors (P = 0.096) and response time (P = 0.954) in the explicit motor learning group of MS patients. Moreover, comparison showed the number of errors (P = 0.008) and response time (P = 0.05) in the implicit group of normal peers and the number of errors (P = 0.011) and response time (P = 0.442) in the explicit group of normal peers. The results showed that explaining and describing the task is less effective at training the motor sequence of MS patients and that these patients benefit more from implicit learning.

Interference Effect of Prior Explicit Information on Motor Sequence Learning in Relapsing-Remitting Multiple Sclerosis Patients

BACKGROUND

Multiple sclerosis (MS) is the most widespread disabling neurological condition in young adults around the world. The purpose of this study was to investigate the impact of explicit information (EI) on motor-sequence learning in MS patients.

METHODS

Thirty patients with relapsing-remitting MS (RRMS), age: 29.5 (SD = 5.6) years and 30 healthy gender-, age-, and education-matched control group participants, age: 28.8 (SD = 6.0) years, were recruited for this study. The participants in the healthy group were then randomly assigned into an EI (n = 15) group and a no-EI (n = 15) group. Similarly, the participants in the control group were then randomly assigned into EI (n = 15) and no-EI (n = 15) groups. The participants performed a serial reaction time (SRT) task and reaction times. A retention test was performed after 48 hours.

RESULTS

All participants reduced their reaction times across acquisition (MS group: 46.4 (SD = 3.3) minutes, P < 0.001, and healthy group: 39.4 (SD = 3.3) minutes, P < 0.001). The findings for the within-participants effect of repeated measures of time were significant (F_{(5.06, 283.7)} = 71.33. P < 0.001). These results indicate that the interaction between group and time was significant (F_{(5.06, 283.7)} = 6.44. P < 0.001), which indicated that the reaction time in both groups was significantly changed between the MS and healthy groups across times (B1 to B10). The main effect of the group (MS and healthy) (F_{(1, 56)} = 22.78. P < 0.001) and also the main effect of no-EI vs EI (F_{(1, 56)} = 4.71. P < 0.001) were significant.

CONCLUSION

This study demonstrated that that RRMS patients are capable of learning new skills, but the provision of EI prior to physical practice is deleterious to implicit learning. It is sufficient to educate MS patients on the aim and general content of the training and only to provide feedback at the end of the rehabilitative session.

The effectiveness of Robot-Assisted Gait Training versus conventional therapy on mobility in severely disabled progressIve MultiplE sclerosis patients (RAGTIME): study protocol for a randomized controlled trial

Background

Gait and mobility impairments affect the quality of life (QoL) of patients with progressive multiple sclerosis (MS). Robot-assisted gait training (RAGT) is an effective rehabilitative treatment but evidence of its superiority compared to other options is lacking. Furthermore, the response to rehabilitation is multidimensional, person-specific and possibly involves functional reorganization processes. The aims of this study are: (1) to test the effectiveness on gait speed, mobility, balance, fatigue and QoL of RAGT compared to conventional therapy (CT) in progressive MS and (2) to explore changes of clinical and circulating biomarkers of neural plasticity.

Methods

This will be a parallel-group, randomized controlled trial design with the assessor blinded to the group allocation of participants. Ninety-eight (49 per arm) progressive MS patients (EDSS scale 6–7) will be randomly assigned to receive twelve 2-h training sessions over a 4-week period (three sessions/week) of either: (1) RAGT intervention on a robotic-driven gait orthosis (Lokomat, Hocoma, Switzerland). The training parameters (torque of the knee and hip drives, treadmill speed, body weight support) are set during the first session and progressively adjusted during training progression or (2) individual conventional physiotherapy focusing on over-ground walking training performed with the habitual walking device. The same assessors will perform outcome measurements at four time points: baseline (before the first intervention session); intermediate (after six training sessions); end of treatment (after the completion of 12 sessions); and follow-up (after 3 months from the end of the training program). The primary outcome is gait speed, assessed by the Timed 25-Foot Walk Test. We will also assess walking endurance, balance, depression, fatigue and QoL as well as instrumental laboratory markers (muscle metabolism, cerebral venous hemodynamics, cortical activation) and circulating laboratory markers (rare circulating cell populations pro and anti-inflammatory cytokines/chemokines, growth factors, neurotrophic factors, coagulation factors, other plasma proteins suggested by transcriptomic analysis and metabolic parameters).

Discussion

The RAGT training is expected to improve mobility compared to the active control intervention in progressive MS. Unique to this study is the analysis of various potential markers of plasticity in relation with clinical outcomes.

Trial registration

ClinicalTrials.gov, identifier: NCT02421731. Registered on 19 January 2015 (retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1838-2) contains supplementary material, which is available to authorized users.

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

Rationale

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

Methods

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

Results

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

Conclusions

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

Effect of integrated Yoga and Physical therapy on audiovisual reaction time, anxiety and depression in patients with chronic multiple sclerosis: a pilot study

BACKGROUND

Multiple sclerosis (MS) is characterized by a significant deterioration in auditory and visual reaction times along with associated depression and anxiety. Yoga and Physical therapy (PT) interventions have been found to enhance recovery from these problems in various neuropsychiatric illnesses, but sufficient evidence is lacking in chronic MS population. The aim of this study was to assess the effect of integrated Yoga and Physical therapy (IYP) on audiovisual reaction times, depression and anxiety in patients suffering from chronic MS.

METHODS

From a neuro-rehabilitation center in Germany, 11 patients (six females) suffering from MS for 19±7.4 years were recruited. Subjects were in the age range of 55.45±10.02 years and had Extended Disability Status Scores (EDSS) below 7. All the subjects received mind-body intervention of integrated Yoga and Physical therapy (IYP) for 3 weeks. The intervention was given in a residential setup. Patients followed a routine involving Yogic physical postures, pranayama, and meditations along with various Physical therapy (PT) techniques for 21 days, 5 days a week, 5 h/day. They were assessed before and after intervention for changes in audiovisual reaction times (using Brain Fit Model No. OT 400), anxiety, and depression [using Hospital Anxiety and Depression Scale (HADS)]. Data was analyzed using paired samples test.

RESULTS

There was significant improvement in visual reaction time (p=0.01), depression (p=0.04), and anxiety (p=0.02) scores at the end of 3 weeks as compared to the baseline. Auditory reaction time showed reduction with borderline statistical significance (p=0.058).

CONCLUSIONS

This pilot project suggests utility of IYP intervention for improving audiovisual reaction times and psychological health in chronic MS patients. In future, randomized controlled trials with larger sample size should be performed to confirm these findings.

Summary of comprehensive systematic review: Rehabilitation in multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

OBJECTIVE

To systematically review the evidence regarding rehabilitation treatments in multiple sclerosis (MS).

METHODS

We systematically searched the literature (1970-2013) and classified articles using 2004 American Academy of Neurology criteria.

RESULTS

This systematic review highlights the paucity of well-designed studies, which are needed to evaluate the available MS rehabilitative therapies. Weekly home/outpatient physical therapy (8 weeks) probably is effective for improving balance, disability, and gait (MS type unspecified, participants able to walk ≥5 meters) but probably is ineffective for improving upper extremity dexterity (1 Class I). Inpatient exercises (3 weeks) followed by home exercises (15 weeks) possibly are effective for improving disability (relapsing-remitting MS [RRMS], primary progressive MS [PPMS], secondary progressive MS [SPMS], Expanded Disability Status Scale [EDSS] 3.0-6.5) (1 Class II). Six weeks' worth of comprehensive multidisciplinary outpatient rehabilitation possibly is effective for improving disability/function (PPMS, SPMS, EDSS 4.0-8.0) (1 Class II). Motor and sensory balance training or motor balance training (3 weeks) possibly is effective for improving static and dynamic balance, and motor balance training (3 weeks) possibly is effective for improving static balance (RRMS, SPMS, PPMS) (1 Class II). Breathing-enhanced upper extremity exercises (6 weeks) possibly are effective for improving timed gait and forced expiratory volume in 1 second (RRMS, SPMS, PPMS, mean EDSS 4.5); this change is of unclear clinical significance. This technique possibly is ineffective for improving disability (1 Class II). Inspiratory muscle training (10 weeks) possibly improves maximal inspiratory pressure (RRMS, SPMS, PPMS, EDSS 2-6.5) (1 Class II).

Factors influencing the desire to provide MS patient care in clinical practice among physiatrists

BACKGROUND

Rehabilitation care is an important part of care for individuals with multiple sclerosis (MS). Little is known about factors influencing physiatrists' desire to provide MS care.

OBJECTIVE

This study examines factors associated with physiatrists' attitudes towards providing MS care.

METHODS

We collaborated with the American Academy of Physical Medicine and Rehabilitation to survey a sample of 300 U.S. physiatrists. Analyses examined the association of exposure to MS care resources during residency, physician demographic and practice characteristics with attitudes toward providing MS care.

RESULTS

Physiatrists indicating negative factors limiting the number of MS patients seen in clinical practice were more likely to practice in a setting other than a major city and less likely to have interacted with MS specialists during residency. Physiatrists indicating factors having a positive influence on providing MS patient care were more likely to practice within a major city, see one or more MS patients per week, and serve as the primary physiatrist directing care for one or more MS patients.

CONCLUSIONS

Physiatrists indicated positive and negative attitudes towards MS care. Increasing exposure to MS patients, providing resources for MS care, and participating in continuing education on MS, may encourage physiatrists to provide MS patient care.

Biomechanical analysis of spasticity treatment in patients with multiple sclerosis

OBJECTIVES

New metrics for clinical spasticity are needed to assess motor performance, since scales such as the Ashworth and Tardieu are unreliable. Here, we assessed outcomes of baclofen treatment in patients with multiple sclerosis (MS) using biomechanical analysis of voluntary movements.

METHODS

Patients with MS and symptomatic limb spasticity were recruited for a pre-post baclofen titration study, along with age-matched healthy controls. Oral baclofen was titrated to optimize spasticity symptoms in all MS cases over 4 weeks. Clinical assessments included the Modified Ashworth Scale (MAS), Tardieu Scale (TS); elbow kinematics were measured via the Transient Acceleration Measurement Interface (TAMI); performance was measured as the score at 4 weeks minus the baseline score in all measures. Movement proficiency within TAMI was quantified through a scale-free smoothness measure, according to the regional excursion deviation (RED) from a constant-velocity approximant.

RESULTS

Twelve patients with MS [age: 47.8 ± 9.8 years; women: 4; disease duration: 20 ± 10 years; disease-modifying therapy use: 7; Expanded Disability Status Scale (EDSS): 6.8 ± 1.4] and eight age-matched healthy controls were evaluated concurrently (mean age: 49.5 ± 13.1 years; women = 3). In MS cases, no significant improvement in arm spasticity was observed with main effects: MAS: -41.6 ± 72.6 (p = 0.09); EDSS: -1.6 ± 10.4% (p = 0.49); and TS: -8.3 ± 2.1% (p = 0.32), -24.9 ± 63.6% (p = 0.42), and -30.7 ± 79.9% (p = 0.06), at slow, moderate, and fast speeds, respectively. However, voluntary motion smoothness, as measured by TAMI: RED, decreased significantly: 0.62 ± 0.08 versus 0.54 ± 0.09, p < 0.001, indicating significant increase in movement smoothness post treatment.

CONCLUSION

A simple biomechanical analysis of voluntary movements revealed a significant reduction of spasticity after 30 days of baclofen therapy in patients with MS that was not detected by clinical assessments.

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.

Home-based palliative approach for people with severe multiple sclerosis and their carers: study protocol for a randomized controlled trial

Background

Preliminary evidence suggests that palliative care may be useful for people with severe multiple sclerosis (MS). The aim of this study is to determine the effectiveness of a home-based palliative approach (HPA) for people with severe MS and their carers.

Methods/design

This is a single-blind randomized controlled trial with a nested qualitative study. Seventy-five severe MS-carer dyads are being randomized (at three centers, one in each area of Italy) to HPA or usual care (UC) in a 2:1 ratio. Each center has a specially trained team consisting of four professionals (physician, nurse, psychologist, social worker). The team makes a comprehensive assessment of the needs of the dyads. HPA content is then agreed on, discussed with the patient’s caring physician, and delivered over six months. The intervention is not intended to replace existing services. At later visits, the team checks the HPA delivery and reviews/modifies it as necessary.

HPA and UC dyads are assessed at home by a blind examiner at baseline, and three and six months later; they also receive monthly telephone interviews. Dyads assigned to UC receive the examiner’s visits and telephone interviews, but not the team visits.

Primary outcome measures are changes in symptoms (Palliative care Outcome Scale-Symptoms-MS, POS-S-MS), and quality of life (the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW), not assessed in patients with severe cognitive compromise) at three and six months. Other outcomes are changes in patient functional status and mood; changes in carer quality of life, mood and caregiving burden; costs; incorporation with standard care; unplanned hospital admissions; referrals to hospice; and deaths.

The experience of participants will be evaluated qualitatively by individual semi-structured interviews (HPA patients and carers) and focus group meetings (HPA patients’ caring physicians).

Discussion

The results of our study will show whether the HPA is feasible and beneficial to people with severe MS and their carers living in the three Italian geographic areas. The nested qualitative study will add to the understanding of the strengths and limitations of the intervention.

Trial registration

The trial was registered with Current Controlled Trials (identifier: ISRCTN73082124) on 19 June 2014.

Unmet needs of multiple sclerosis patients in the community

BACKGROUND

There is no evidence that disease modifying therapies (DMTs) are beneficial in progressive (non-relapsing) MS. However, these patients may benefit from multidiscipliniary interventions, and require financial and community support. Non-pharmacological needs of MS patients may be overlooked during fund allocation, and identification of unmet needs is important to optimise care and inform governmental resource distribution.

AIM

To identify unmet needs of MS patients in 3 areas during an Irish epidemiology study.

PATIENTS AND METHODS

Observational study in 3 regions in Ireland: South Dublin SCD (an urban area), Donegal DGL and Wexford WEX (rural counties).A validated Needs Assessment Questionnaire (NAQ) was completed by MS patients at research clinics, or by telephone if unable to attend.

RESULTS

We identified 632 patients with multiple sclerosis: 23% SCD (urban), 30.8% WEX, and 46.2% DGL.MS subtype was relapsing remitting (RR) in 51.1%, secondary progressive (SP) in 39.7%, and primary progressive (PP) in 9.2%. EDSS was </=6 in 86% and >6.5 in 14%. NAQ was completed by 325 (49.9%).Group A: 155 (47.7%) reported no unmet needs relating to MS.Group B: 170 (52.3%) reported unmet needs relating to MS,including all in a group continuing to use disease-modifying therapy without benefit (EDSS>6.5).Number of unmet needs per patient in group B: 1 need 27%, ≥2 needs 73%, ≥5 24%.Unmet needs overall correlated with EDSS >6.5 (p<0.001),MS subtype: RR 36.4%/SP 69.8%/PP 59.5% (p<0001),increased age (p 0.003) and MS duration (p 0.003). Multivariate analysis: presence of unmet needs related to higher EDSS (p<0.001), rural residence (p<0.05), SPMS (p<0.05).Financial unmet needs frequency differed by county: DGL 23.9%, WEX 17%, SCD 10.4% (p 0.045) and marital status: 24% single, 13.5% married (p 0.03).Multivariate analysis: related to rural residence (p<0.05), being single (p<0.05).Occupational therapy (OT) unmet needs frequency differed by subtype:RR 6%/SP 24.5%/ PP 19% (p 0.001), MS duration: 19.7 v 14.8y (p 0.003)and increasing age: 52.5 v 45.8y (p 0.0006).Multivariate analysis: rural, older age, higher EDSS (p<0.05).Physiotherapy unmet needs frequency differed by subtype: RR 17.2%/SP 43.4%/PP 31.7% (p<0.001), MS duration (p<0.001), and age (p 0.002).Multivariate analysis: related to higher EDSS (p<0.001).Employment unmet needs frequency differed by gender:male 22.9%, female 12.8% (p 0.02).Social unmet needs frequency differed by subtype: RR 12%/SP 39.2%/PP 32.5%, MS duration and age (p 0.001): multivariate analysis: SPMS (p<0.001).

DISCUSSION

More than 50% reported unmet needs relating to MS: suggesting non-pharmacological needs are not optimally addressed, particularly in older, single, rural residents, with greater EDSS and progressive non-relapsing MS. Physiotherapy offers significant benefits, but is the most frequently reported unmet need.These findings highlight the need for increased fund allocation, especially for development of community supports and multidisciplinary/ social services.Identifying unmet needs may help inform health service planning, and emphasises particular need for improved resources in a high-risk group of MS patients.

Do General and Multiple Sclerosis-Specific Quality of Life Instruments Differ?

Background:

Quality of life instruments provide information that traditional outcome measures used in studies of multiple sclerosis do not. It is unclear if longer, disease-specific instruments provide more useful information than shorter, more general instruments, or whether patients prefer one type to another.

Methods:

We conducted a cross-sectional study of quality of life in a multiple sclerosis clinic population using a mailed questionnaire that combined three different quality of life instruments; the SF-36, the Multiple Sclerosis Quality of Life Instrument-54, and the EuroQol EQ-5D. We assessed the feasability of using each instrument and patient preference for each, calculated correlation coefficients for the summary scores of each instrument and other measures of disease severity, and calculated odds ratios from proportional odds models comparing each instrument with the Expanded Disability Status Scale.

Results:

We did not find substantial differences between the three instruments. All were well-received by patients, and over 75% felt that the combination of the three instruments best assessed their quality of life. For each instrument there was substantial variability between patients with similar quality of life scores in terms of their disability (as assessed by the Expanded Disability Status Scale and their own perception of their disease severity and quality of life (on simple 1-10 scales).

Conclusion:

Quality of life instruments are easy to use and well-received by patients, regardless of their length. There do not appear to be clinically important differences between general and disease-specific instruments. Each instrument appears to measure something other than a patient’s disability or perception of their own disease severity or quality of life.

Abnormalities of motor imagery and relationship with depressive symptoms in mildly disabling relapsing-remitting multiple sclerosis

BACKGROUND AND PURPOSE

The effectiveness of motor imagery (MI) as an adjunct to physical rehabilitation has previously been shown. Motor imagery ability can be affected by neurologic disorders that affect motor and cognitive function. This study was designed to assess MI ability in persons with mildly disabling relapsing-remitting multiple sclerosis (RRMS) based on the functional and cognitive dysfunctions.

METHODS

Twenty-two participants with RRMS and 23 age-, gender-, and education-matched comparison subjects were evaluated by a battery of MI tasks, including a kinesthetic and visual imagery questionnaire, a mental hand rotation task, and a visual guided pointing task.

RESULTS

There was no significant difference in MI vividness between the participants with MS and the comparison group, but the accuracy and temporal correspondence of MI in the participants with MS differed significantly from those in the comparison group. Depression scores were significantly higher in participants with MS (P < 0.001), and depression was significantly correlated with disability (r = 0.4; P < 0.05). The correlation between accuracy of MI in the participants with MS and their cognitive ability was significant (r = 0.57; P < 0.05). The MI duration of participants with MS was significantly correlated with their disability (r = 0.59; P < 0.05) and their cognitive ability (r = -0.38; P = 0.009).

DISCUSSION

The preservation of MI ability was observed in participants with RRMS; however, abnormalities in accuracy and temporal aspects of MI were observed even in the participants with mild disease. Abnormalities in temporal aspects and accuracy of MI were related to disability and cognitive ability, respectively. In participants with MS, depression should be considered as a confounding factor for the MI task results.

CONCLUSIONS

Our finding could be considered in the application of MI during the rehabilitation of persons with MS.

Influence of altered visual feedback on neck movement for a virtual reality rehabilitative system

This paper investigates altering visual feedback during neck movement through control-display (C-D) gain for a head-mounted display, for the purpose of determining the just noticeable difference (JND) for encouraging individuals with kinesiophobia (i.e. fear avoidance of movement due to chronic pain) to effectively perform therapeutic neck exercises. The JND was defined as .25 probability of detecting a difference from unity C-D gain (gain=1). A target-aiming task with two consecutive neck moves per trial was presented; one neck move had varying C-D gain and the other had unity gain. The VR system was able to influence neck moves without changing locations of the target. Participants indicated whether the two neck movements were the same or different. Logistic regression revealed that the JND gains were 0.903 (lower bound) and 1.159 (upper bound) as the participants could not discriminate a 55° turn, ranging from 49.7° to 63.7°. This preliminary study shows that immersive VR with altered visual feedback influenced movement. The feasibility for rehabilitation of individuals with kinesiophobia will next be assessed.

Effect of combination exercise therapy on walking distance, postural balance, fatigue and quality of life in multiple sclerosis patients: a clinical trial study

Background:

Multiple Sclerosis (MS) is a demyelinating disease of the nervous system which has numerous disabling effects on patients.

Objectives:

This study aimed at investigating the short- and long-term effects of a period of combination exercise therapy on walking distance, balance, fatigue and quality of life in multiple sclerosis patients referred to the physiotherapy clinic of Iran's Multiple Sclerosis Society in 2013.

Patients and Methods:

This study was a randomized controlled clinical trial on 59 patients divided into the intervention (n = 39) and control groups (n = 20). The intervention group received 10 weeks of combination therapy including aerobic, strengthening, balancing and stretching exercises. A week before, a week later and a year after the beginning of the exercises, both groups of patients received BBSS, six minute walking, Family Support Services (FSS), Expanded Disability Status Scale (EDSS) and quality of life tests. The scores of two groups were then compared using statistical tests such as repeated measures ANOVA test.

Results:

The results indicated significant changes in the intervention group in comparison to the control group in the second phase of the study comparing to the first one for all tests except EDSS (Mean difference scores of EDSS: -0.13), P-value = 0.60; FSS: -6.9, P-value = 0.02, Mental Quality of Life (QOL): 16.36, P-value = 0.001; Physical QOL: 12.17, P-value = 0.001, six minute walking: 137.2, P-value < 0.0001; and Berg: 3.34, P-value < 0.0001. These changes were not significant in the second phase of the study comparing to the third one; however, they were again significant in the third phase comparing to the first phase of the study (P < 0.05).

Conclusions:

Exercise has significant effect on improving symptoms of multiple sclerosis, and cessation of exercise may cause recurrence of symptoms in the intervention group with a slope similar to that of the control group. Therefore, continuous rather than short period exercises have valuable symptomatic and supportive relief effects in patients.

Developing a wellness program for people with multiple sclerosis: description and initial results

Because multiple sclerosis (MS) is a multidimensional chronic disease, effective management of the illness requires a multidimensional approach. We describe a wellness program that was designed to facilitate positive health choices throughout the course of MS and present initial data analyses. We hypothesized that over the course of the program, participants would demonstrate improvement in the domains assessed. The wellness program included educational sessions in physical, mental, social, intellectual, and spiritual domains specifically targeting improved self-efficacy, physical functioning, coping skills, symptom management, and nutrition. An outcomes data collection software program was adapted to facilitate real-time patient self-report and clinician entry data collection for many domains throughout the wellness program. Initial assessment of serial measures (intake to discharge) from 65 people with MS showed improvement in several domains, including functional status (P < .05), fatigue (P < .05), fear-avoidance beliefs regarding physical activities (P < .05), depression (P < .05), somatization (P < .05), and pain (P < .05). In addition, using a model of risk for interpersonal distress, patients whose risk of elevated depression and anxiety decreased over the course of the program reported greater gains in functional status (P < .05). The results suggest possible future treatment strategies and indicate strengths and weaknesses of the wellness program, which are being used to improve the program.

Upper limb motor rehabilitation impacts white matter microstructure in multiple sclerosis

Upper limb impairments can occur in patients with multiple sclerosis, affecting daily living activities; however there is at present no definite agreement on the best rehabilitation treatment strategy to pursue. Moreover, motor training has been shown to induce changes in white matter architecture in healthy subjects. This study aimed at evaluating the motor behavioral and white matter microstructural changes following a 2-month upper limb motor rehabilitation treatment based on task-oriented exercises in patients with multiple sclerosis. Thirty patients (18 females and 12 males; age=43.3 ± 8.7 years) in a stable phase of the disease presenting with mild or moderate upper limb sensorimotor deficits were randomized into two groups of 15 patients each. Both groups underwent twenty 1-hour treatment sessions, three times a week. The "treatment group" received an active motor rehabilitation treatment, based on voluntary exercises including task-oriented exercises, while the "control group" underwent passive mobilization of the shoulder, elbow, wrist and fingers. Before and after the rehabilitation protocols, motor performance was evaluated in all patients with standard tests. Additionally, finger motor performance accuracy was assessed by an engineered glove. In the same sessions, every patient underwent diffusion tensor imaging to obtain parametric maps of fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity. The mean value of each parameter was separately calculated within regions of interest including the fiber bundles connecting brain areas involved in voluntary movement control: the corpus callosum, the corticospinal tracts and the superior longitudinal fasciculi. The two rehabilitation protocols induced similar effects on unimanual motor performance, but the bimanual coordination task revealed that the residual coordination abilities were maintained in the treated patients while they significantly worsened in the control group (p=0.002). Further, in the treatment group white matter integrity in the corpus callosum and corticospinal tracts was preserved while a microstructural integrity worsening was found in the control group (fractional anisotropy of the corpus callosum and corticospinal tracts: p=0.033 and p=0.022; radial diffusivity of the corpus callosum and corticospinal tracts: p=0.004 and p=0.008). Conversely, a significant increase of radial diffusivity was observed in the superior longitudinal fasciculi in both groups (p=0.02), indicating lack of treatment effects on this structure, showing damage progression likely due to a demyelination process. All these findings indicate the importance of administering, when possible, a rehabilitation treatment consisting of voluntary movements. We also demonstrated that the beneficial effects of a rehabilitation treatment are task-dependent and selective in their target; this becomes crucial towards the implementation of tailored rehabilitative approaches.

Self-perceived performance and satisfaction with performance of daily activities in persons with multiple sclerosis following interdisciplinary rehabilitation

PURPOSE

To assess self-perceived performance and satisfaction with performance of daily activities in persons with multiple sclerosis (MS) on admission to and at discharge from interdisciplinary rehabilitation.

METHOD

A retrospective study with a pre-post design. Twenty-seven women and 16 men with MS (mean age 51 years; median EDSS 6.5) participated in an individualised, goal-oriented, interdisciplinary, rehabilitation programme (average length 4 weeks). The Canadian Occupational Performance Measure (COPM) was used on admission to rehabilitation and at discharge.

RESULTS

On admission, the persons prioritised 216 activities that they perceived difficult to perform (mean number 3, range 2-8). Of these, 136 (63%) were in the COPM area of self-care, 52 (24%) in productivity and 28 (13%) in leisure. The lowest mean ratings of performance were found in the subgroups active recreation, community management and socialisation, and for satisfaction in the subgroup socialisation. For about 60% of the 216 prioritised activities, ratings of COPM performance as well as satisfaction were higher at discharge than on admission. For 18 (42%) and 24 (56%) persons, respectively, the mean change scores of performance and of satisfaction were equal to or greater than 2.0 at discharge, indicating a clinically significant change.

CONCLUSIONS

Persons with MS can experience problems with all types of daily activities upon admission to rehabilitation, but also perceive improvements in their performance and satisfaction with performance in these activities at discharge from rehabilitation. Using patient-reported outcome measures, such as the COPM, may contribute to a broader understanding of the benefits of interdisciplinary rehabilitation in persons with MS. Implications for Rehabilitation Persons with MS can perceive problems with all types of daily activities which have to be considered during interdisciplinary rehabilitation. Following interdisciplinary rehabilitation, persons with MS can perceive improvements in their performance and satisfaction with performance in all types of daily activities. Patient-reported outcome measures can contribute to a broader understanding of the benefits of interdisciplinary rehabilitation in persons with MS.

Resistance training and vibration improve muscle strength and functional capacity in female patients with multiple sclerosis

PURPOSE

The purpose of this study was to evaluate the effect of an eight-week progressive resistance training and vibration program on strength and ambulatory function in multiple sclerosis (MS) patients.

METHODS

Twenty-Four female MS patients with the following demographics: age 27-45 years, and expanded disability status scale (EDSS) 2-4, participated in this study. The subjects were randomly allocated to one of two groups. The exercise group (n = 12) trained according to a progressive program, mainly consisting of resistance training and vibration, three times a week for eight weeks and compared with subjects in the control group (n = 12) that received no intervention. Subjects completed one set of 5-12 reps at%50-70 maximal voluntary contraction (MVC). After 5-10 minutes rest, six postures on plate vibration were done. Isotonic MVC of knee extensors, abduction of the scapula and downward rotation of the scapular girdle muscle groups were predicted by using the Brzycki formula. Right leg balance (RLB), left leg balance (LLB), and walking speed (10-Meter Walk Test) were assessed before and after the training program. Descriptive statistics and Co-variance were used for analyzing data.

RESULTS

After eight weeks of training the exercise group showed significant increase in MVC of Knee extensors (32.3%), Abduction of the scapula (24.7%) and Downward Rotation Scapular (39.1%) muscle groups, RLB (33.5%), LLB (9.5%), and decrease in 10-Meter Walk Test (10MWT) (9.3%), (P<0.05).

CONCLUSIONS

The results of this study indicated this type of training can cause improvements in muscle strength and functional capacity in patients with multiple sclerosis.

Validation of the comprehensive ICF core set for multiple sclerosis from the perspective of physical therapists

BACKGROUND

The Comprehensive ICF Core Set for Multiple Sclerosis (MS) is an application of the International Classification of Functioning, Disability and Health (ICF) and represents the typical spectrum of problems in the functioning of people with MS.

OBJECTIVES

The objective of this study was to validate the Comprehensive ICF Core Set for MS from the perspective of physical therapists.

DESIGN

A 3-round survey based on the Delphi technique was used.

METHODS

Physical therapists experienced in the management of MS were asked about problems and resources of people with MS as well as environmental aspects treated by physical therapists (eg, use of assistive devices, support). Statements were linked to the ICF and compared with the Comprehensive ICF Core Set for MS.

RESULTS

Eighty physical therapists from 23 countries mentioned 2,133 issues that covered all of the ICF components. Two hundred thirty-eight ICF categories were linked to the statements. Forty-six categories in the Comprehensive ICF Core Set for MS were confirmed by physical therapists at the same level or a more specific level of classification. Nineteen additional ICF categories were reported by at least 75% of the participants.

CONCLUSIONS

The results of this study support the content and face validity of the Comprehensive ICF Core Set for MS. Areas of functioning and health that physical therapists believe should be assessed were identified. The findings of this study as well as the results of completed and ongoing validation studies will further elucidate the validity of the Comprehensive ICF Core Set for MS from different perspectives.

The effects of clinical interventions on health-related quality of life in multiple sclerosis: a meta-analysis

The objective is to estimate the extent to which existing health care interventions designed specifically to target health-related quality of life (HRQL) in persons with multiple sclerosis (MS) achieve this aim. The structured literature search was conducted using multiple electronic databases including Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trial, for the years 1960 to 2011. The methodological quality of selected randomized controlled trials (RCTs) was assessed using the Cochrane Collaboration's recommended domain-based method. Effect size (ES) was used to measure the effect of each intervention on HRQL. The studies were combined using a random-effects model to account for inter-study variation. Heterogeneity was tested for using the I-test and publication bias was assessed using funnel plots and the Egger weighted regression statistic. Thirty-nine RCTs met the criteria, all with acceptable methodological quality. Six major types of interventions were identified through the search. The smallest effect was observed for self-management and complementary and alternative medicine (ES=0.2), followed by medication (ES=0.3) then cognitive training and exercise (ES=0.4), and psychological interventions to improve mood (ES=0.7). The magnitude of positive effect on HRQL varied between the different types of interventions. The extent to which interventions are able to improve HRQL depends on delivering a potent intervention to those persons who have the potential to benefit.

Multiple Sclerosis-Related Dementia: Relatively Rare and Often Misunderstood

MS-related dementia is an under-recognised and misunderstood aspect of MS. It is relatively rare, occurring in approximately 10% of people with MS, while cognitive impairment in general occurs in 43% or more of people with MS. MS-related dementia is hard to detect on the basis of short social interactions or clinical interviews alone. There are very few clinically relevant scientific articles on this topic to help guide the management and support of people with MS-related dementia. This article was written in a preliminary attempt to address this problem: to describe the clinical presentation and characteristics of MS-related dementia, to alert health professionals to the sensitivities surrounding the use of dementia terminology within the MS community, and to outline the limited nature of the information, advice and support resources currently available in Australia for these middle-aged people with dementia.

Exercise in multiple sclerosis -- an integral component of disease management

Multiple sclerosis (MS) is the most common chronic inflammatory disorder of the central nervous system (CNS) in young adults. The disease causes a wide range of symptoms depending on the localization and characteristics of the CNS pathology. In addition to drug-based immunomodulatory treatment, both drug-based and non-drug approaches are established as complementary strategies to alleviate existing symptoms and to prevent secondary diseases. In particular, physical therapy like exercise and physiotherapy can be customized to the individual patient's needs and has the potential to improve the individual outcome. However, high quality systematic data on physical therapy in MS are rare. This article summarizes the current knowledge on the influence of physical activity and exercise on disease-related symptoms and physical restrictions in MS patients. Other treatment strategies such as drug treatments or cognitive training were deliberately excluded for the purposes of this article.

Robot-assisted gait training in multiple sclerosis patients: a randomized trial

Background: Preservation of locomotor activity in multiple sclerosis (MS) patients is of utmost importance. Robotic-assisted body weight-supported treadmill training is a promising method to improve gait functions in neurologically impaired patients, although its effectiveness in MS patients is still unknown.

Objective: To compare the effectiveness of robot-assisted gait training (RAGT) with that of conventional walking treatment (CWT) on gait and generalized functions in a group of stable MS patients.

Methods: A prospective randomized controlled trial of 12 sessions of RAGT or CWT in MS patients of EDSS score 5–7. Primary outcome measures were gait parameters and the secondary outcomes were functional and quality of life parameters. All tests were performed at baseline, 3 and 6 months post-treatment by a blinded rater.

Results: Fifteen and 17 patients were randomly allocated to RAGT and CWT, respectively. Both groups were comparable at baseline in all parameters. As compared with baseline, although some gait parameters improved significantly following the treatment at each time point there was no difference between the groups. Both FIM and EDSS scores improved significantly post-treatment with no difference between the groups. At 6 months, most gait and functional parameters had returned to baseline.

Conclusions: Robot-assisted gait training is feasible and safe and may be an effective additional therapeutic option in MS patients with severe walking disabilities.

Cognitive functioning in multiple sclerosis

In this article, the nature and course of cognitive dysfunction in MS are reviewed, particularly in the context of recent advances in our understanding of the diffuse nature of neuropathology in MS, and in the context of specific factors that may confer risk or protection for the development of cognitive impairment. In addition, assessment and screening approaches of MS-related cognitive dysfunction are discussed. MS is a condition not only restricted to the adult population, and this article includes a brief description of cognition in pediatric-onset MS. Finally, promising intervention approaches to treat cognitive problems in MS are summarized.

Rehabilitation challenges in multiple sclerosis

While current immunomodulating drugs aim to reduce multiple sclerosis (MS) exacerbations and slow disease progression, rehabilitation aims to improve and maintain the functional abilities of patients in the face of disease progression. An increasing number of journal articles are describing the value of the many rehabilitation interventions that can be used throughout the course of the disease, from the initial symptoms to the advanced stages. An integrated team of healthcare professionals is necessary to address a myriad of problems to reduce impairments, disabilities, and handicaps. The problems may be related to fatigue, weakness, spasticity, mobility, balance, pain, cognition, mood, relationships, bowel, bladder, sexual function, swallowing, speech, transportation, employment, recreation, and activities of daily living (ADL) such as dressing, eating, bathing, and household chores. The team can help prevent complications and secondary disabilities, while increasing patient safety. Improving neurologically related function, maintaining good relationships, and feeling productive and creative adds enormously to the quality of life of people with MS and their families. Rehabilitation is more than an 'extra' service that is given after medical therapies; it is an integral part of the management of the diverse set of problems encountered throughout the course of the disease. An interdisciplinary team may have many members, including physicians, nurses, physical therapists, occupational therapists, speech and language pathologists, psychotherapists, social workers, recreational therapists, vocational rehabilitation therapists, patients, families, and other caregivers.