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Neurorehabilitation in Multiple Sclerosis-A Review of Present Approaches and Future Considerations. J Clin Med 2022; 11:jcm11237003. [PMID: 36498578 PMCID: PMC9739865 DOI: 10.3390/jcm11237003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Multiple sclerosis is an increasingly prevalent disease, representing the leading cause of non-traumatic neurological disease in Europe and North America. The most common symptoms include gait deficits, balance and coordination impairments, fatigue, spasticity, dysphagia and an overactive bladder. Neurorehabilitation therapeutic approaches aim to alleviate symptoms and improve the quality of life through promoting positive immunological transformations and neuroplasticity. The purpose of this study is to evaluate the current treatments for the most debilitating symptoms in multiple sclerosis, identify areas for future improvement, and provide a reference guide for practitioners in the field. It analyzes the most cited procedures currently in use for the management of a number of symptoms affecting the majority of patients with multiple sclerosis, from different training routines to cognitive rehabilitation and therapies using physical agents, such as electrostimulation, hydrotherapy, cryotherapy and electromagnetic fields. Furthermore, it investigates the quality of evidence for the aforementioned therapies and the different tests applied in practice to assess their utility. Lastly, the study looks at potential future candidates for the treatment and evaluation of patients with multiple sclerosis and the supposed benefits they could bring in clinical settings.
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Atrsaei A, Dadashi F, Mariani B, Gonzenbach R, Aminian K. Toward a remote assessment of walking bout and speed: application in patients with multiple sclerosis. IEEE J Biomed Health Inform 2021; 25:4217-4228. [PMID: 33914688 DOI: 10.1109/jbhi.2021.3076707] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Gait speed as a powerful biomarker of mobility is mostly assessed in controlled environments, e.g. in the clinic. With wearable inertial sensors, gait speed can be estimated in an objective manner. However, most of the previous works have validated the gait speed estimation algorithms in clinical settings which can be different than the home assessments in which the patients demonstrate their actual performance. Moreover, to provide comfort for the users, devising an algorithm based on a single sensor setup is essential. To this end, the goal of this study was to develop and validate a new gait speed estimation method based on a machine learning approach to predict gait speed in both clinical and home assessments by a sensor on the lower back. Moreover, two methods were introduced to detect walking bouts during daily activities at home. We have validated the algorithms in 35 patients with multiple sclerosis as it often presents with mobility difficulties. Therefore, the robustness of the algorithm can be shown in an impaired or slow gait. Against silver standard multi-sensor references, we achieved a bias close to zero and a precision of 0.15 m/s for gait speed estimation. Furthermore, the proposed machine learning-based locomotion detection method had a median of 96.8% specificity, 93.0% sensitivity, 96.4% accuracy, and 78.6% F1-score in detecting walking bouts at home. The high performance of the proposed algorithm showed the feasibility of the unsupervised mobility assessment introduced in this study.
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Khalid S, Alnajjar F, Gochoo M, Renawi A, Shimoda S. Robotic assistive and rehabilitation devices leading to motor recovery in upper limb: a systematic review. Disabil Rehabil Assist Technol 2021:1-15. [PMID: 33861684 DOI: 10.1080/17483107.2021.1906960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Stroke, spinal cord injury and other neuromuscular disorders lead to impairments in the human body. Upper limb impairments, especially hand impairments affect activities of daily living (ADL) and reduce the quality of life. The purpose of this review is to compare and evaluate the available robotic rehabilitation and assistive devices that can lead to motor recovery or maintain the current motor functional level. METHODS A systematic review was conducted of the literature published in the years from 2016-2021, to focus on the most recent rehabilitation and assistive devices available in the market or research environments. RESULTS A total of 230 studies published between 2016 and 2021 were identified from various databases. 107 were excluded with various reasons. Twenty-eight studies were taken into detailed review, to determine the efficacy of robotic devices in improving upper limb impairments or maintaining the current level from getting worse. CONCLUSION It was concluded that with a good strategy and treatment plan; appropriate and regular use of these robotic rehabilitation and assistive devices do lead to improvements in current conditions of most of the subjects and prolonged use may lead to motor recovery.Implications for RehabilitationStroke, accidents, spinal cord injuries and other neuromuscular disorders lead to impairments. Upper limb impairments have a tremendous adverse affect on ADL and reduces quality of life drastically.Advancement in technology has led to the designing of many robotic assistive and rehabilitation devices to assist in motor recovery or aid in ADL.This review analyses different available devices for rehabilitation and assistance and points out that use of these devices in time does help in motor recovery. Most of the studies reviewed showed improvements for the user.Future devices should be more portable and easier to use from home.
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Affiliation(s)
- Sumayya Khalid
- College of Information Technology, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Fady Alnajjar
- College of Information Technology, United Arab Emirates University, Al Ain, United Arab Emirates.,Intelligent Behavior Control Unit, CBS-TOYOTA Collaboration Center, RIKEN, Nagoya, Japan
| | - Munkhjargal Gochoo
- College of Information Technology, United Arab Emirates University, Al Ain, United Arab Emirates.,School of Information and Communication Technology, Ulaanbaatar, Mongolia
| | | | - Shingo Shimoda
- Intelligent Behavior Control Unit, CBS-TOYOTA Collaboration Center, RIKEN, Nagoya, Japan
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4
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Hvid LG, Gaemelke T, Dalgas U, Slipsager MK, Rasmussen PV, Petersen T, Nørgaard M, Skjerbaek AG, Boesen F. Personalised inpatient multidisciplinary rehabilitation elicits clinically relevant improvements in physical function in patients with multiple sclerosis - The Danish MS Hospitals Rehabilitation Study. Mult Scler J Exp Transl Clin 2021; 7:2055217321989384. [PMID: 33643662 PMCID: PMC7894699 DOI: 10.1177/2055217321989384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/02/2020] [Accepted: 12/20/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose Evidence of the effects of inpatient multidisciplinary rehabilitation (MDR) on physical function in patients with multiple sclerosis (MS) is limited, particularly whether clinically relevant improvements can be achieved. The aim of this study, therefore, was to investigate the effects of personalised inpatient MDR on the physical function of MS patients. Methods Embedded in the Danish MS Hospitals Rehabilitation Study, a pragmatic study was performed in MS patients undergoing four weeks of inpatient MDR specifically targeting physical function. Outcomes were assessed at baseline (n = 142), at discharge (n = 137) and at six months follow-up (n = 126) using the six-minute walk test (6MWT), six-spot step test (SSST), five times sit to stand test (5STS), nine-hole peg test (NHPT), dynamic gait index (DGI) and 12-item MS walking scale (MSWS). Results From Baseline-to-Discharge, significant and clinically relevant improvements were found in all measures of walking capacity (6MWT, SSST, 5STS, DGI and MSWS; p < 0.05) along with significant (but not clinically relevant) improvements in upper extremity function (NHPT; p < 0.05). Whilst comparable improvements were observed within subgroups of MS phenotype (relapsing-remitting [RR] vs. secondary + primary progressive [SP + PP]), disease severity (moderate [EDSS2.5–5.5] vs. severe [EDSS6.0–7.5]) and age (young/middle-aged [Age24–59] vs. old [Age60–65]), an attenuated adaptation was nevertheless observed for 6MWT in the most affected and vulnerable subgroups (i.e. SP + PP, EDSS6.0–7.5 and Age60–65). The significant improvements in walking capacity and upper extremity function persisted at six months follow-up but did not exceed anymore the thresholds regarded as clinically relevant. Conclusion The results provide novel evidence that personalised inpatient MDR targeting physical function in MS patients elicits significant and clinically relevant improvements in physical function.
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Affiliation(s)
| | | | | | - Mette K Slipsager
- Exercise Biology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Peter V Rasmussen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Thor Petersen
- Department of Regional Health Research, University Hospital of Southern Denmark, Odense, Denmark
| | | | | | - Finn Boesen
- MS Hospitals in Ry and Haslev, Haslev, Denmark
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5
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Gunn H, Andrade J, Paul L, Miller L, Creanor S, Stevens K, Green C, Ewings P, Barton A, Berrow M, Vickery J, Marshall B, Zajicek J, Freeman J. A self-management programme to reduce falls and improve safe mobility in people with secondary progressive MS: the BRiMS feasibility RCT. Health Technol Assess 2020; 23:1-166. [PMID: 31217069 DOI: 10.3310/hta23270] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Balance, mobility impairments and falls are common problems for people with multiple sclerosis (MS). Our ongoing research has led to the development of Balance Right in MS (BRiMS), a 13-week home- and group-based exercise and education programme intended to improve balance and encourage safer mobility. OBJECTIVE This feasibility trial aimed to obtain the necessary data and operational experience to finalise the planning of a future definitive multicentre randomised controlled trial. DESIGN Randomised controlled feasibility trial. Participants were block randomised 1 : 1. Researcher-blinded assessments were scheduled at baseline and at 15 and 27 weeks post randomisation. As is appropriate in a feasibility trial, statistical analyses were descriptive rather than involving formal/inferential comparisons. The qualitative elements utilised template analysis as the chosen analytical framework. SETTING Four sites across the UK. PARTICIPANTS Eligibility criteria included having a diagnosis of secondary progressive MS, an Expanded Disability Status Scale (EDSS) score of between ≥ 4.0 and ≤ 7.0 points and a self-report of two or more falls in the preceding 6 months. INTERVENTIONS Intervention - manualised 13-week education and exercise programme (BRiMS) plus usual care. Comparator - usual care alone. MAIN OUTCOME MEASURES Trial feasibility, proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls), feasibility of the BRiMS programme (via process evaluation) and economic data. RESULTS A total of 56 participants (mean age 59.7 years, standard deviation 9.7 years; 66% female; median EDSS score of 6.0 points, interquartile range 6.0-6.5 points) were recruited in 5 months; 30 were block randomised to the intervention group. The demographic and clinical data were broadly comparable at baseline; however, the intervention group scored worse on the majority of baseline outcome measures. Eleven participants (19.6%) withdrew or were lost to follow-up. Worsening of MS-related symptoms unrelated to the trial was the most common reason (n = 5) for withdrawal. Potential primary and secondary outcomes and economic data had completion rates of > 98% for all those assessed. However, the overall return rate for the patient-reported falls diary was 62%. After adjusting for baseline score, the differences between the groups (intervention compared with usual care) at week 27 for the potential primary outcomes were MS Walking Scale (12-item) version 2 -7.7 [95% confidence interval (CI) -17.2 to 1.8], MS Impact Scale (29-item) version 2 (MSIS-29vs2) physical 0.6 (95% CI -7.8 to 9) and MSIS-29vs2 psychological -0.4 (95% CI -9.9 to 9) (negative score indicates improvement). After the removal of one outlier, a total of 715 falls were self-reported over the 27-week trial period, with substantial variation between individuals (range 0-93 falls). Of these 715 falls, 101 (14%) were reported as injurious. Qualitative feedback indicated that trial processes and participant burden were acceptable, and participants highlighted physical and behavioural changes that they perceived to result from undertaking BRiMS. Engagement varied, influenced by a range of condition- and context-related factors. Suggestions to improve the utility and accessibility of BRiMS were highlighted. CONCLUSIONS The results suggest that the trial procedures are feasible and acceptable, and retention, programme engagement and outcome completion rates were sufficient to satisfy the a priori progression criteria. Challenges were experienced in some areas of data collection, such as completion of daily diaries. FUTURE WORK Further development of BRiMS is required to address logistical issues and enhance user-satisfaction and adherence. Following this, a definitive trial to assess the clinical effectiveness and cost-effectiveness of the BRiMS intervention is warranted. TRIAL REGISTRATION Current Controlled Trials ISRCTN13587999. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 27. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hilary Gunn
- School of Health Professions, Faculty of Health and Human Sciences, Peninsula Allied Health Centre, University of Plymouth, Plymouth, UK
| | - Jackie Andrade
- School of Psychology, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
| | - Lorna Paul
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Linda Miller
- Douglas Grant Rehabilitation Unit, Ayrshire Central Hospital, Irvine, UK
| | - Siobhan Creanor
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.,Medical Statistics Group, Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Kara Stevens
- Medical Statistics Group, Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Colin Green
- University of Exeter Medical School, Health Economics Group, University of Exeter, Exeter, UK
| | - Paul Ewings
- National Institute for Health Research (NIHR) Research Design Service (South West), Musgrove Park Hospital, Taunton, UK
| | - Andrew Barton
- National Institute for Health Research (NIHR) Research Design Service, Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Margie Berrow
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Jane Vickery
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | | | - John Zajicek
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Jennifer Freeman
- School of Health Professions, Faculty of Health and Human Sciences, Peninsula Allied Health Centre, University of Plymouth, Plymouth, UK
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6
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Timm A, Knecht S, Florian M, Pickenbrock H, Studer B, Schmidt-Wilcke T. Frequency and nature of pain in patients undergoing neurorehabilitation. Clin Rehabil 2020; 35:145-153. [PMID: 32914646 DOI: 10.1177/0269215520956784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This prospective study investigated the extent to which patients undergoing neurorehabilitation reported pain, how this pain developed during inpatient stay and whether patients were treated accordingly (using pain medication). METHODS The extent of pain, performance in daily activities, with a focus on possible impairment from pain, and pain medication were assessed at the beginning and the end of neurorehabilitation treatment. Overall 584 patients, with various neurological diagnoses, such as stroke, intracerebral hemorrhage, polyneuropathy, etc. were classified into four groups based on whether they reported having "no pain," "mild pain," "moderate pain," or "severe pain." All patients received conventional neurorehabilitation therapy in the Mauritius Hospital, Germany. RESULTS A total of 149 patients had clinically relevant pain at the beginning of their inpatient stay, at a group level this did not change significantly during the treatment period. At the end of inpatient stay, a slight increase was noted in patients reporting pain. Overall 164 patients suffered from moderate or severe pain, operationalized of pain scores >3 on the visual analog scale. A total of 145 patients who had pain at the end of inpatient stay, did not receive pain medication. There was a weak negative association between pain at baseline and activities of daily living at the end of the treatment period, such that, patients with higher pain levels tended to showed lower Barthel Index scores at the end. CONCLUSION In our study, about one-third of patients suffered from clinically relevant pain during neurorehabilitation treatment and most of them did not receive any pain medication.
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Affiliation(s)
- Alicja Timm
- Department of Neurology, Mauritius Hospital, Meerbusch, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Stefan Knecht
- Department of Neurology, Mauritius Hospital, Meerbusch, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Matthias Florian
- Department of Neuropediatrics, Mauritius Hospital, Meerbusch, Germany
| | | | - Bettina Studer
- Department of Neurology, Mauritius Hospital, Meerbusch, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Tobias Schmidt-Wilcke
- Department of Neurology, Mauritius Hospital, Meerbusch, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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7
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das Nair R, de Groot V, Freeman J. Beyond current research practice: Methodological considerations in MS rehabilitation research (is designing the perfect rehabilitation trial the Holy Grail or a Gordian knot?). Mult Scler 2020; 25:1337-1347. [PMID: 31469355 DOI: 10.1177/1352458519858271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Rehabilitation is an essential aspect of symptomatic and supportive treatment for people with multiple sclerosis (MS). The number of randomised controlled trials (RCTs) for rehabilitation interventions in MS has increased over the last two decades. The design, conduct and reporting quality of some of these trials could be improved. There are, however, some specific challenges that researchers face in conducting RCTs of rehabilitation interventions, which are often 'complex interventions'. This paper explores some of the challenges of undertaking robust clinical trials in rehabilitation. We focus on issues related to (1) participant selection and sample size, (2) interventions - the 'dose', content, active ingredients, targeting, fidelity of delivery and treatment adherence, (3) control groups and (4) outcomes - choosing the right type, number, timing of outcomes, and the importance of defining a primary outcome and clinically important difference between groups. We believe that by following internationally accepted RCT guidelines, by developing a critical mass of MS rehabilitation 'trialists' through international collaboration and by continuing to critique, challenge, and develop RCT designs, we can exploit the potential of RCTs to answer important questions related to the effectiveness of rehabilitation interventions.
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Affiliation(s)
- Roshan das Nair
- Clinical Psychology and Neuropsychology, Institute of Mental Health, University of Nottingham, Jubilee Campus, Nottingham, UK
| | - Vincent de Groot
- Department of Rehabilitation Medicine, MS Center Amsterdam, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jennifer Freeman
- Physiotherapy and Rehabilitation, School of Health Professions, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
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8
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Turner-Stokes L, Harding R, Yu P, Dzingina M, Gao W. Cost-efficiency of specialist inpatient rehabilitation for adults with multiple sclerosis: A multicentre prospective cohort analysis of the UK Rehabilitation Outcomes Collaborative national clinical dataset for rehabilitation centres in England. Mult Scler J Exp Transl Clin 2020; 6:2055217320912789. [PMID: 32206333 PMCID: PMC7079310 DOI: 10.1177/2055217320912789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/13/2020] [Accepted: 02/22/2020] [Indexed: 11/30/2022] Open
Abstract
Background Rehabilitation is effective for multiple sclerosis, but is it value for
money? Objectives To evaluate functional outcomes, care needs and cost-efficiency of specialist
inpatient rehabilitation for adults with multiple sclerosis (MS). Methods A multicentre cohort study of prospectively collected clinical data from the
UK Rehabilitation Outcomes Collaborative national clinical database. Data
included all adults with MS (n = 1007) admitted for
specialist inpatient (Level 1 or 2) rehabilitation in England,
2010–2018. Outcome measures Dependency/care needs: Northwick Park Dependency Scale/Care Needs Assessment,
Functional independence: UK Functional Assessment Measure (UK FIM+FAM).
Cost-efficiency. Patients were analysed in three dependency groups
(High/Medium/Low). Results All groups showed significant reduction in dependency between admission and
discharge on all measures (paired t-tests:
p < 0.001). Mean reduction in care costs/week was
greatest in the most dependent patients: High: £519 (95% CI: 447–597),
Medium: £148 (76–217), Low: £36 (12–83). Despite longer stays, time taken to
offset the cost of rehabilitation was shortest in the most dependent
patients: High: 12.9 (12.0–14.1) months; Medium: 29.3 (21.3–51.8); Low: 76.8
(0–36.1). Item-level changes corresponded with clinical experience. Conclusions Specialist rehabilitation provided good value for money in patients with MS,
yielding improved outcomes and substantial savings in ongoing care costs,
especially in high-dependency patients.
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Affiliation(s)
- Lynne Turner-Stokes
- Department of Palliative Care, Policy and Rehabilitation, Faculty of Nursing Midwifery and Palliative Care, King’s College London, UK
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, UK
| | - Richard Harding
- Department of Palliative Care, Policy and Rehabilitation, Faculty of Nursing Midwifery and Palliative Care, King’s College London, UK
| | - Peihan Yu
- Department of Palliative Care, Policy and Rehabilitation, Faculty of Nursing Midwifery and Palliative Care, King’s College London, UK
| | - Mendwas Dzingina
- Department of Palliative Care, Policy and Rehabilitation, Faculty of Nursing Midwifery and Palliative Care, King’s College London, UK
| | - Wei Gao
- Department of Palliative Care, Policy and Rehabilitation, Faculty of Nursing Midwifery and Palliative Care, King’s College London, UK
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9
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Cattaneo D, Coote S, Rasova K, Gervasoni E, Groppo E, Prokopiusova T, Reznickova J, Montesano A, Jonsdottir J. Factors influencing balance improvement in multiple sclerosis rehabilitation: A pragmatic multicentric trial. Ann Phys Rehabil Med 2019; 63:93-98. [PMID: 31212044 DOI: 10.1016/j.rehab.2019.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 05/02/2019] [Accepted: 05/04/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Treatment for progressive multiple sclerosis (pMS) is a key area of research. To date, whether MS type and the rehabilitation setting are associated with worse or better response to rehabilitation is unclear. We aimed to understand the association between balance and MS type, in/outpatient treatment and specificity of the intervention. METHODS We assessed 150 people with MS before and after in/outpatient rehabilitation. The Berg Balance Scale (BBS) was used to discriminate between responders (≥+3-point improvement in BBS score; a clinically meaningful improvement) and non-responders to specific or non-specific balance rehabilitation. Factors associated with balance were analyzed by univariate and multivariable logistic regression analyses, estimating odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Balance improved after rehabilitation: median (quartile 1 [Q1]-Q3) BBS score pre- and post-rehabilitation of 49 (45-53) and 52 (47-55) (P<0.001). Univariate logistic analysis revealed a clinically meaningful improvement in balance associated with pMS (OR 2.21 [95% CI 1.09-4.05]), inpatient therapy (0.41 [0.19-0.84]), using a walking aid (1.68 [1.06-2.69]), and low baseline BBS score (0.86 [0.81-0.92]). On multivariable analysis, probability of improvement was similar for participants with pMS and the relapsing-remitting form but was associated with low baseline BBS score and specific treatment (OR 0.81 [95% CI 0.74-0.89] and 5.66 [1.79-21.5]). CONCLUSION A clinically meaningful improvement in balance was more likely when MS individuals with moderate to high disability had specific exercises targeting balance, but MS type did not influence the outcome.
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Affiliation(s)
| | - Susan Coote
- School of Allied Health and Health Research Institute, University of Limerick, Limerick, Ireland
| | - Kamila Rasova
- Department of rehabilitation, Third Faculty of Medicine, Charles University in Prague, Czech Republic
| | | | | | - Terezie Prokopiusova
- Department of rehabilitation, Third Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Jitka Reznickova
- Department of rehabilitation, Third Faculty of Medicine, Charles University in Prague, Czech Republic
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10
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Disparity between perceived needs and service provision: a cross-sectional study of Italians with multiple sclerosis. Neurol Sci 2019; 40:1137-1144. [DOI: 10.1007/s10072-019-03780-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
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11
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Henze T, Feneberg W, Flachenecker P, Seidel D, Albrecht H, Starck M, Meuth SG. [New aspects of symptomatic MS treatment: Part 6 - cognitive dysfunction and rehabilitation]. DER NERVENARZT 2018; 89:453-459. [PMID: 29079868 DOI: 10.1007/s00115-017-0443-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- T Henze
- Praxisgemeinschaft für Neurologie, Psychiatrie, Psychotherapie, Günzstr. 1, 93059, Regensburg, Deutschland.
| | - W Feneberg
- Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gemeinnützige GmbH, Berg, Deutschland
| | - P Flachenecker
- Neurologisches Rehabilitationszentrum Quellenhof, Bad Wildbad, Deutschland
| | | | - H Albrecht
- Praxis für Neurologie, München, Deutschland
| | - M Starck
- Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gemeinnützige GmbH, Berg, Deutschland
| | - S G Meuth
- Department für Neurologie und Institut für Translationale Neurologie, Klinik für Allgemeine Neurologie, Universitätsklinikum Münster, Münster, Deutschland
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12
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Patterson KK, Wong JS, Prout EC, Brooks D. Dance for the rehabilitation of balance and gait in adults with neurological conditions other than Parkinson's disease: A systematic review. Heliyon 2018; 4:e00584. [PMID: 29862347 PMCID: PMC5968140 DOI: 10.1016/j.heliyon.2018.e00584] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To conduct a systematic review that examined the effect of dance interventions on balance, gait and functional mobility outcomes in adults with neurological conditions other than Parkinson's disease. METHODS A systematic search of relevant databases was conducted. Data extraction and methodological appraisal were performed by two independent authors. RESULTS Nine studies were included (4 pre-post studies with no control group, 3 case reports, and 2 controlled studies) and results of the methodological quality assessment ranged from poor to good. Study groups included stroke, multiple sclerosis, spinal cord injury, and Huntington's disease. Dance interventions varied in frequency, type and duration, and only 1 study reported intensity. Study dropout rates ranged from 20-44%, and 88-100% of dance classes were attended. Only 3 studies mentioned adverse events, of which there were none. A summary of results revealed significant changes in spatiotemporal gait parameters, Berg Balance Scale scores, Timed Up and Go test and six-minute walk test that were similar to or greater than those previously reported in a review of dance for individuals with Parkinson's disease. CONCLUSIONS There is emerging evidence to support the use of dance as a feasible intervention for adults with neurological conditions. Further investigation of the effects of dance with randomized controlled trials using larger sample sizes and better reporting of the intervention, participant tolerance, and adverse events is warranted.
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Affiliation(s)
- Kara K Patterson
- Department of Physical Therapy, University of Toronto, 160-500 University Ave, Toronto, ON, M5G 1V7, Canada
- Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada
- Rehabilitation Sciences Institute, University of Toronto, 160-500 University Ave, Toronto, ON, M5G 1V7, Canada
| | - Jennifer S Wong
- Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada
| | - Erik C Prout
- Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada
- Health System Quality and Funding Division, Ontario Ministry of Health and Long-Term Care, 1075 Bay St., Toronto, ON, M5S 2B1, Canada
| | - Dina Brooks
- Department of Physical Therapy, University of Toronto, 160-500 University Ave, Toronto, ON, M5G 1V7, Canada
- Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON, M5G 2A2, Canada
- Rehabilitation Sciences Institute, University of Toronto, 160-500 University Ave, Toronto, ON, M5G 1V7, Canada
- Department of Respiratory Medicine, West Park Healthcare Centre, 82 Buttonwood Ave, Toronto, ON, M6M 2E6, Canada
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Chu CY, Patterson RM. Soft robotic devices for hand rehabilitation and assistance: a narrative review. J Neuroeng Rehabil 2018; 15:9. [PMID: 29454392 PMCID: PMC5816520 DOI: 10.1186/s12984-018-0350-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 02/05/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The debilitating effects on hand function from a number of a neurologic disorders has given rise to the development of rehabilitative robotic devices aimed at restoring hand function in these patients. To combat the shortcomings of previous traditional robotics, soft robotics are rapidly emerging as an alternative due to their inherent safety, less complex designs, and increased potential for portability and efficacy. While several groups have begun designing devices, there are few devices that have progressed enough to provide clinical evidence of their design's therapeutic abilities. Therefore, a global review of devices that have been previously attempted could facilitate the development of new and improved devices in the next step towards obtaining clinical proof of the rehabilitative effects of soft robotics in hand dysfunction. METHODS A literature search was performed in SportDiscus, Pubmed, Scopus, and Web of Science for articles related to the design of soft robotic devices for hand rehabilitation. A framework of the key design elements of the devices was developed to ease the comparison of the various approaches to building them. This framework includes an analysis of the trends in portability, safety features, user intent detection methods, actuation systems, total DOF, number of independent actuators, device weight, evaluation metrics, and modes of rehabilitation. RESULTS In this study, a total of 62 articles representing 44 unique devices were identified and summarized according to the framework we developed to compare different design aspects. By far, the most common type of device was that which used a pneumatic actuator to guide finger flexion/extension. However, the remainder of our framework elements yielded more heterogeneous results. Consequently, those results are summarized and the advantages and disadvantages of many design choices as well as their rationales were highlighted. CONCLUSION The past 3 years has seen a rapid increase in the development of soft robotic devices for hand rehabilitative applications. These mostly preclinical research prototypes display a wide range of technical solutions which have been highlighted in the framework developed in this analysis. More work needs to be done in actuator design, safety, and implementation in order for these devices to progress to clinical trials. It is our goal that this review will guide future developers through the various design considerations in order to develop better devices for patients with hand impairments.
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Affiliation(s)
- Chia-Ye Chu
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, 76107 TX USA
| | - Rita M. Patterson
- Department of Family and Manipulative Medicine, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, 76107 TX USA
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Affiliation(s)
- Jeremy Gibson
- Alderbourne Rehabilitation Unit, Hillingdon Hospital, Pield Heath Road, Hillingdon UB8 3NN
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Boesen F, Nørgaard M, Trénel P, Rasmussen PV, Petersen T, Løvendahl B, Sørensen J. Longer term effectiveness of inpatient multidisciplinary rehabilitation on health-related quality of life in MS patients: a pragmatic randomized controlled trial - The Danish MS Hospitals Rehabilitation Study. Mult Scler 2017; 24:340-349. [PMID: 28984159 PMCID: PMC5846853 DOI: 10.1177/1352458517735188] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: There is insufficient evidence to support the effectiveness of multidisciplinary rehabilitation on the health-related quality of life (HRQoL) of MS patients. Objectives: To evaluate the longer term effectiveness of inpatient multidisciplinary rehabilitation on the HRQoL of MS patients. Methods: The study was a two-hospital, pragmatic, randomized controlled trial with a 6-month follow-up. Patients aged 18–65 years with MS and Expanded Disability Status Scale scores ≤7.5 were randomly assigned (1:1) to 4 weeks of inpatient multidisciplinary rehabilitation (20 days of scheduled rehabilitation) or 6 months on a wait list. The outcome measures were Functional Assessment in Multiple Sclerosis (FAMS), Multiple Sclerosis Impact Scale-29 (MSIS-29), EQ-5D-5L and 15D. Results: We randomized 213 patients to the wait-list control group and 214 patients to the treatment group. Trends in favour of the treatment group were observed across all measures. However, the difference was significant in only two of the six measures. The treatment effect was −2.7 (95% CI: −5.6 to (−0.1)), p = 0.046) for the MSIS-29 Psychological and 0.017 (95% CI: 0.005–0.030, p = 0.008) for the 15D. FAMS, which we used to calculate the sample size, was not significant. Conclusion: The results indicated that inpatient multidisciplinary rehabilitation is effective in improving the HRQoL of MS patients after 6 months.
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Affiliation(s)
| | | | | | | | - Thor Petersen
- Department of Neurology, Aarhus University hospital, Aarhus, Denmark
| | | | - Jan Sørensen
- Centre of Health Economics Research (COHERE), Department of Public Health, University of Southern Denmark, Odense, Denmark/Healthcare Outcome Research Center, Royal College of Surgeons in Ireland, Dublin, Ireland
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Grasso M, Broccoli M, Casillo P, Catani S, Pace L, Pompa A, Rizzi F, Troisi E. Evaluation of the Impact of Cognitive Training on Quality of Life in Patients with Multiple Sclerosis. Eur Neurol 2017; 78:111-117. [DOI: 10.1159/000478726] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 06/13/2017] [Indexed: 11/19/2022]
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Casadio M, Sanguineti V, Solaro C, Morasso PG. A Haptic Robot Reveals the Adaptation Capability of Individuals with Multiple Sclerosis. Int J Rob Res 2016. [DOI: 10.1177/0278364907084981] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A prerequisite for rehabilitation is that patients preserve their ability to adapt to novel dynamic environments, an ability that has been associated with the cerebellar system. In this study, we use a robot manipulandum to assess the ability of multiple sclerosis (MS) subjects in the early phase of the disease to adapt to a speed-dependent force field. Their performance is compared with an equal number of age-matched controls. We found that MS subjects display subtle in-coordination problems but do not significantly di fer from controls in their ability to adapt to the force field. These findings are discussed in terms of the possible benefits that MS subjects might receive from robot-assisted therapy that is specifically aimed at impaired visuomotor coordination.
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Affiliation(s)
- Maura Casadio
- Department of Informatics, Systems and Telematics University of Genova Via Opera Pia 13, 16145 Genova GE, Italy and Foundation 'Don Carlo Gnocchi' Via Cisa Vecchia, 19038 Sarzana SP, Italy,
| | - Vittorio Sanguineti
- Department of Informatics, Systems and Telematics and Research Center for Neuroscience and Neuroengineering University of Genova Via Opera Pia 13, 16145 Genova GE, Italy,
| | - Claudio Solaro
- Neurology Department, Hospital “P. Antero Micone' Via D. Oliva 22, 16158 Genova GE, Italy,
| | - Pietro G. Morasso
- Department of Informatics, Systems and Telematics University of Genova Via Opera Pia 13, 16145 Genova GE, Italy,
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Papeix C, Lubetzki C. Integrated multidisciplinary clinics should be the gold standard in managing progressive MS - NO. Mult Scler 2016; 22:1128-30. [PMID: 27225675 DOI: 10.1177/1352458516643397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Caroline Papeix
- Department of Neurology, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Catherine Lubetzki
- Department of Neurology, AP-HP, Pitié-Salpêtrière Hospital, Paris, France/Sorbonne Universités, UPMC, Paris, France
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Pappalardo A, D’Amico E, Leone C, Messina S, Chisari C, Rampello L, Torre L, Patti F. Inpatient versus outpatient rehabilitation for multiple sclerosis patients: effects on disability and quality of life. ACTA ACUST UNITED AC 2016. [DOI: 10.1186/s40893-016-0005-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Haselkorn JK, Hughes C, Rae-Grant A, Henson LJ, Bever CT, Lo AC, Brown TR, Kraft GH, Getchius T, Gronseth G, Armstrong MJ, Narayanaswami P. Summary of comprehensive systematic review: Rehabilitation in multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2016; 85:1896-903. [PMID: 26598432 DOI: 10.1212/wnl.0000000000002146] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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).
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Campbell E, Coulter EH, Mattison PG, Miller L, McFadyen A, Paul L. Physiotherapy Rehabilitation for People With Progressive Multiple Sclerosis: A Systematic Review. Arch Phys Med Rehabil 2016; 97:141-51.e3. [DOI: 10.1016/j.apmr.2015.07.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 07/08/2015] [Accepted: 07/29/2015] [Indexed: 01/29/2023]
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Motor programme activating therapy influences adaptive brain functions in multiple sclerosis: clinical and MRI study. Int J Rehabil Res 2015; 38:49-54. [PMID: 25325167 DOI: 10.1097/mrr.0000000000000090] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is still little scientific evidence for the efficacy of neurofacilitation approaches and their possible influence on brain plasticity and adaptability. In this study, the outcome of a new kind of neurofacilitation approach, motor programme activating therapy (MPAT), was evaluated on the basis of a set of clinical functions and with MRI. Eighteen patients were examined four times with standardized clinical tests and diffusion tensor imaging to monitor changes without therapy, immediately after therapy and 1 month after therapy. Moreover, the strength of effective connectivity was analysed before and after therapy. Patients underwent a 1-h session of MPAT twice a week for 2 months. The data were analysed by nonparametric tests of association and were subsequently statistically evaluated. The therapy led to significant improvement in clinical functions, significant increment of fractional anisotropy and significant decrement of mean diffusivity, and decrement of effective connectivity at supplementary motor areas was observed immediately after the therapy. Changes in clinical functions and diffusion tensor images persisted 1 month after completing the programme. No statistically significant changes in clinical functions and no differences in MRI-diffusion tensor images were observed without physiotherapy. Positive immediate and long-term effects of MPAT on clinical and brain functions, as well as brain microstructure, were confirmed.
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Papeix C, Gambotti L, Assouad R, Ewenczyck C, Tanguy ML, Pineau F, Houis MC, Mazevet D, Maillart E, Lubetzki C. Evaluation of an integrated multidisciplinary approach in multiple sclerosis care: A prospective, randomized, controlled study. Mult Scler J Exp Transl Clin 2015; 1:2055217315608864. [PMID: 28607706 PMCID: PMC5433398 DOI: 10.1177/2055217315608864] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/06/2015] [Indexed: 11/23/2022] Open
Abstract
Background Disabled multiple sclerosis (MS) patients often need intervention of multiple specialists, resulting in a complex organization of care. How this multidisciplinary care should be organized and structured has not been studied. Objective The objective of this article is to address the effectiveness of an integrated multidisciplinary approach versus usual care in MS patients. Methods This is a prospective, randomized, controlled, monocentric clinical trial in MS patients. Two treatment strategies were compared: (i) an integrated multidisciplinary (IMD) approach, consisting of a half-day individually tailored comprehensive assessment in the MS clinic; and (ii) a standard care. The primary outcome was the impact of the strategy on quality of life (QoL) measured using the MSIS-29 scale at inclusion and after six months. Results Fifty MS patients were included. Median MSIS 29 score decreased over six months in the control group (−4.89) and increased in the IMD group (+2.00), with a significant difference between the two groups (p = 0.03). However, in the multivariate analysis, after adjustment of HAD-D and INTERMED score, this difference was no longer significant. Conclusions This prospective, randomized study is the first attempt to evaluate the multidisciplinary approach in MS patients. The results show that, contrary to our expectations, an integrated multidisciplinary approach is not superior to usual care on QoL.
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Affiliation(s)
- Caroline Papeix
- AP-HP, Pitié-Salpêtrière Hospital, Neurology Department, France
| | | | - Rana Assouad
- AP-HP, Pitié-Salpêtrière Hospital, Neurology Department, France
| | | | | | - Fanny Pineau
- AP-HP, Pitié-Salpêtrière Hospital, Neurology Department, France
| | | | - Dominique Mazevet
- AP-HP, Pitié-Salpêtrière Hospital, Department of Rehabilitation, France
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Papeix C, Gambotti L, Assouad R, Ewenczyck C, Tanguy ML, Pineau F, Houis MC, Mazevet D, Maillart E, Lubetzki C. Evaluation of an integrated multidisciplinary approach in multiple sclerosis care: A prospective, randomized, controlled study. Mult Scler J Exp Transl Clin 2015. [PMID: 28607706 DOI: 10.1177/2055217315608864.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Disabled multiple sclerosis (MS) patients often need intervention of multiple specialists, resulting in a complex organization of care. How this multidisciplinary care should be organized and structured has not been studied. OBJECTIVE The objective of this article is to address the effectiveness of an integrated multidisciplinary approach versus usual care in MS patients. METHODS This is a prospective, randomized, controlled, monocentric clinical trial in MS patients. Two treatment strategies were compared: (i) an integrated multidisciplinary (IMD) approach, consisting of a half-day individually tailored comprehensive assessment in the MS clinic; and (ii) a standard care. The primary outcome was the impact of the strategy on quality of life (QoL) measured using the MSIS-29 scale at inclusion and after six months. RESULTS Fifty MS patients were included. Median MSIS 29 score decreased over six months in the control group (-4.89) and increased in the IMD group (+2.00), with a significant difference between the two groups (p = 0.03). However, in the multivariate analysis, after adjustment of HAD-D and INTERMED score, this difference was no longer significant. CONCLUSIONS This prospective, randomized study is the first attempt to evaluate the multidisciplinary approach in MS patients. The results show that, contrary to our expectations, an integrated multidisciplinary approach is not superior to usual care on QoL.
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Affiliation(s)
- Caroline Papeix
- AP-HP, Pitié-Salpêtrière Hospital, Neurology Department, France
| | | | - Rana Assouad
- AP-HP, Pitié-Salpêtrière Hospital, Neurology Department, France
| | | | | | - Fanny Pineau
- AP-HP, Pitié-Salpêtrière Hospital, Neurology Department, France
| | | | - Dominique Mazevet
- AP-HP, Pitié-Salpêtrière Hospital, Department of Rehabilitation, France
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Helland CB, Holmøy T, Gulbrandsen P. Barriers and Facilitators Related to Rehabilitation Stays in Multiple Sclerosis: A Qualitative Study. Int J MS Care 2015; 17:122-9. [PMID: 26052257 DOI: 10.7224/1537-2073.2014-007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Studies have shown the positive effects of multidisciplinary rehabilitation on disability and health-related quality of life in multiple sclerosis (MS). However, many patients do not seek such treatment, even if it is available free of charge. The aim of this study was to identify facilitators and barriers related to use of such treatment options. METHODS Five focus group interviews with 27 MS patients were conducted. Three groups included patients who had been admitted to a multidisciplinary MS rehabilitation institution, and two groups included outpatients of a university hospital who had not applied for specialized rehabilitation. Interviews were audiotaped and transcribed, and were analyzed qualitatively by means of a modified form of systematic text condensation. RESULTS Important factors influencing the use of an MS rehabilitation service were 1) the availability and suitability of initial information about the disease and the service, 2) assumptions and expectations about such a service, and 3) practical barriers in the patient's life. The prospect of having a retreat from work and family was described as a motivational factor. Lack of reorientation after diagnosis, fears and perceptions of being labeled as an MS patient, or having information overload and being confronted with disabled individuals were identified as barriers. CONCLUSIONS Communication skills, including information-giving skills, of neurologists in relation to newly diagnosed MS patients need improvement. Rehabilitation programs for MS patients should include stays of different durations and purposes to fit patients' needs. Health-care authorities should take measures to secure equal access to information about rehabilitation options across institutions and practicing physicians.
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Affiliation(s)
- Caroline Bruun Helland
- Department of Neurology (CBH) and HøKH Research Centre (PG), Akershus University Hospital, Lørenskog, Norway; and Institute of Clinical Medicine, Campus Ahus, University of Oslo, Norway (TH)
| | - Trygve Holmøy
- Department of Neurology (CBH) and HøKH Research Centre (PG), Akershus University Hospital, Lørenskog, Norway; and Institute of Clinical Medicine, Campus Ahus, University of Oslo, Norway (TH)
| | - Pål Gulbrandsen
- Department of Neurology (CBH) and HøKH Research Centre (PG), Akershus University Hospital, Lørenskog, Norway; and Institute of Clinical Medicine, Campus Ahus, University of Oslo, Norway (TH)
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Lonergan R, Kinsella K, Fitzpatrick P, Duggan M, Jordan S, Bradley D, Hutchinson M, Tubridy N. Unmet needs of multiple sclerosis patients in the community. Mult Scler Relat Disord 2015; 4:144-50. [PMID: 25787190 DOI: 10.1016/j.msard.2015.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 12/07/2014] [Accepted: 01/05/2015] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Roisin Lonergan
- Department of Neurology, St. Vincent׳s University Hospital, Elm Park, Dublin 4, Ireland.
| | - Katie Kinsella
- Department of Neurology, St. Vincent׳s University Hospital, Elm Park, Dublin 4, Ireland.
| | - Patricia Fitzpatrick
- College of Life Sciences, School of Public Health and Population Science, University College Dublin (UCD), Ireland.
| | - Marguerite Duggan
- Department of Neurology, St. Vincent׳s University Hospital, Elm Park, Dublin 4, Ireland.
| | - Sinead Jordan
- Department of Neurology, St. Vincent׳s University Hospital, Elm Park, Dublin 4, Ireland.
| | - David Bradley
- Department of Neurology, St. Vincent׳s University Hospital, Elm Park, Dublin 4, Ireland.
| | - Michael Hutchinson
- Department of Neurology, St. Vincent׳s University Hospital, Elm Park, Dublin 4, Ireland.
| | - Niall Tubridy
- Department of Neurology, St. Vincent׳s University Hospital, Elm Park, Dublin 4, Ireland.
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Le Teuff G, Abrahamowicz M, Wynant W, Binquet C, Moreau T, Quantin C. Flexible modeling of disease activity measures improved prognosis of disability progression in relapsing-remitting multiple sclerosis. J Clin Epidemiol 2014; 68:307-16. [PMID: 25541382 DOI: 10.1016/j.jclinepi.2014.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 09/16/2014] [Accepted: 11/18/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To illustrate the advantages of updating time-varying measures of disease activity and flexible modeling in prognostic clinical studies using the example of the association between the frequency of past relapses and occurrence of ambulation-related disability in multiple sclerosis (MS). STUDY DESIGN AND SETTING Longitudinal population-based study of 288 patients from Burgundy, France, diagnosed with relapsing-remitting MS in 1990-2003. The end point was a nonreversible moderate MS disability (European Database for Multiple Sclerosis score ≥ 3.0 derived from Extended Disability Status Scale). Alternative time-varying measures of attacks frequency included (1) conventional number of early MS attacks in the first 2 years after diagnosis; and two new measures, continuously updated during the follow-up; (2) cumulative number of past attacks; and (3) number of recent attacks, during the past 2 years. Multivariate analyses used Cox proportional hazards model and its flexible generalization, which accounted for time-dependent changes in the hazard ratios (HRs) for different attack frequency measures. RESULTS HRs for all measures decreased significantly with increasing follow-up time. The proposed updated number of recent attacks improved model's fit to data, relative to alternative measures of attack frequency, and was associated with a statistically significantly increased hazard of developing ambulation-related MS disability in the next 2 years during the entire follow-up period. CONCLUSION Updated measures of recent disease activity, such as frequency of recent attacks and modeling of their time-dependent effects, may substantially improve prognosis of clinical outcomes, such as development of MS disability.
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Affiliation(s)
- Gwénaël Le Teuff
- Department of Biostatistics and Epidemiology, Institut Gustave Roussy, Villejuif, Paris, France
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Division of Clinical Epidemiology, McGill University Health Centre, Royal Victoria Hospital, 687 Pine Avenue West, V Building, Montreal, Quebec, Canada H3A 1A1
| | - Willy Wynant
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Division of Clinical Epidemiology, McGill University Health Centre, Royal Victoria Hospital, 687 Pine Avenue West, V Building, Montreal, Quebec, Canada H3A 1A1
| | - Christine Binquet
- INSERM, CIC 1432, 21000 Dijon, France; Clinical Investigation Center, Dijon University Hospital, Clinical Epidemiology/Clinical Trials Unit, Dijon, France
| | - Thibault Moreau
- Department of Neurology, Centre Hospitalier Universitaire de Dijon, BP 77908, 21079 Dijon Cedex, France
| | - Catherine Quantin
- INSERM, CIC 1432, 21000 Dijon, France; Clinical Investigation Center, Dijon University Hospital, Clinical Epidemiology/Clinical Trials Unit, Dijon, France; Department of Neurology, Centre Hospitalier Universitaire de Dijon, BP 77908, 21079 Dijon Cedex, France; Department of Biostatistics and Medical Informatics, Centre Hospitalier Universitaire de Dijon, BP 77908, 21079 Dijon Cedex, France.
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Tyler ME, Kaczmarek KA, Rust KL, Subbotin AM, Skinner KL, Danilov YP. Non-invasive neuromodulation to improve gait in chronic multiple sclerosis: a randomized double blind controlled pilot trial. J Neuroeng Rehabil 2014; 11:79. [PMID: 24885412 PMCID: PMC4017705 DOI: 10.1186/1743-0003-11-79] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 04/24/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND This study sought to examine the effect of targeted physical therapy with and without cranial nerve non-invasive neuromodulation (CN-NINM), on the walking ability of people with MS who exhibited a dysfunctional gait. We hypothesized that subjects who received electrical stimulation would have greater improvement than those who had a control device after a 14-week intervention. Gait disturbance is a common problem for people with multiple sclerosis (MS). Current management may include exercise, pharmacology, functional electrical stimulation, compensatory strategies, use of assistive devices, and implanted electrical devices. We have developed an effective rehabilitative strategy using neuromodulation of the cranial nerves via electrical stimulation of the tongue to enhance the plasticity of the brain. METHODS The study is a within-subject blinded randomized control design. Twenty chronic MS subjects with an identified gait disturbance were assigned to either an active or control group. Both groups completed a 14-week intervention program using a standardized combination of exercise and a device that provided electrical stimulation to the tongue. Those in the active group received electrical stimulation on the tongue that they could perceive. Those in the control group used a device that did not provide a physiologically significant stimulus and was not perceivable. Subjects were assessed with the Dynamic Gait Index (DGI). RESULTS The DGI scores improved for both groups. There were significant between-group differences, with the active group showing statistically greater improvement than the control group mean. CONCLUSION People with MS demonstrated improved gait with CN-NINM training in a pilot randomized controlled trial. This study suggests that tongue-based neurostimulation may amplify the benefits of exercise for improving gait in people with chronic MS.
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Affiliation(s)
- Mitchell E Tyler
- Department of Biomedical Engineering, University of Wisconsin, Madison, WI 53706, USA
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI 53706, USA
| | - Kurt A Kaczmarek
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI 53706, USA
| | - Kathy L Rust
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI 53706, USA
| | - Alla M Subbotin
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI 53706, USA
| | - Kimberly L Skinner
- Department of Biomedical Engineering, University of Wisconsin, Madison, WI 53706, USA
| | - Yuri P Danilov
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI 53706, USA
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Khan F, Amatya B, Ytterberg C, Johansson S, Kesselring J. Content comparison of multidimensional, patient-reported outcome measures in multiple sclerosis rehabilitation and the ICF. Neurodegener Dis Manag 2013. [DOI: 10.2217/nmt.13.57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Multiple sclerosis (MS) is a complex condition, with long-term physical, cognitive and behavioral disabilities, and lifestyle consequences. Individuals with MS require regular evaluation for persisting disability and psychological sequelae. This should incorporate patients’ perspectives on functioning and health. This review summarizes and compares the content of commonly used multidimensional, patient-reported outcome measures in MS in relation to the International Classification of Functioning, Disability and Health comprehensive MS Core set. The focused domains of these measures, the commonalities and discrepancies, and breadth and depth of coverage in relation to the MS Core set are discussed. Understanding of the content of these instruments is needed for clinicians/researchers to make an informed choice for the selection of the most appropriate instrument to capture the variability inherent in MS for treatment efficacy.
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Affiliation(s)
- Fary Khan
- Department of Medicine, Dentistry & Health Sciences, University of Melbourne, Victoria, Australia
| | - Bhasker Amatya
- Department of Rehabilitation Medicine, Royal Melbourne Hospital, 34–54 Poplar Road, Parkville, Melbourne, Victoria 3052, Australia
| | - Charlotte Ytterberg
- Department of Neurobiology, Care Sciences & Society, Karolinska Institutet, Huddinge, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Physical Therapy, Karolinska University Hospital, Stockholm, Sweden
| | - Sverker Johansson
- Department of Neurobiology, Care Sciences & Society, Karolinska Institutet, Huddinge, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Physical Therapy, Karolinska University Hospital, Stockholm, Sweden
| | - Jürg Kesselring
- Department of Neurology & Neurorehabilitation, Rehabilitation Center, Valens, Switzerland
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Liberatore G, Clarelli F, Nuara A, Ungaro D, Gatti R, Rovaris M, Martinelli V, Comola M, Comi G, Rossi P, Martinelli-Boneschi F. Predictors of effectiveness of multidisciplinary rehabilitation treatment on motor dysfunction in multiple sclerosis. Mult Scler 2013; 20:862-70. [PMID: 24166355 DOI: 10.1177/1352458513508834] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/15/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To identify clinical predictors of effectiveness of a motor rehabilitation treatment in a cohort of multiple sclerosis (MS) patients. MATERIALS AND METHODS We analysed 212 consecutive patients who underwent a short-term (3-7 weeks) intensive (two hours per day, five days per week), individualised, goal-oriented inpatient rehabilitation program. Activity limitation and impairment were measured on admission and discharge of the rehabilitation trial using the motor sub-items of the Functional Independence Measure (mFIM) and the Expanded Disability Status Scale (EDSS) score. Multivariate logistic regression models have been tested to evaluate the role of clinical baseline features on rehabilitation effectiveness. RESULTS According to pre-defined outcome measures, 75.1% of MS patients improved in either activity limitation (≥5 points delta mFIM) or impairment (≥1.0 delta EDSS score if baseline EDSS was ≤5.5, or ≥0.5 if baseline EDSS was >5.5), and 35.4% of MS patients improved in both outcomes. A relapsing-remitting course of disease, a more severe baseline impairment and activity limitation level, a shorter disease duration and a less severe balance dysfunction were predictive of the effectiveness of rehabilitation. DISCUSSION These data confirm that an intensive inpatient rehabilitation program is able to produce a short-term relevant improvement on clinical and functional outcome measures and suggest some clinical features which can be considered as potential predictors of the outcome of rehabilitative intervention.
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Affiliation(s)
- G Liberatore
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy Laboratory of Genetics of Neurological Complex Disorders, San Raffaele Scientific Institute, Italy
| | - F Clarelli
- Laboratory of Genetics of Neurological Complex Disorders, San Raffaele Scientific Institute, Italy
| | - A Nuara
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy
| | - D Ungaro
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy
| | - R Gatti
- Laboratory of Movement Analysis, San Raffaele Scientific Institute, Italy
| | - M Rovaris
- Neurorehabilitation Unit, Don C. Gnocchi Foundation ONLUS, Italy
| | - V Martinelli
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy
| | - M Comola
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy
| | - G Comi
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy
| | - P Rossi
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy Clinica Hildebrand, Centro Riabilitazione Brissago, Switzerland
| | - F Martinelli-Boneschi
- Neurorehabilitation Unit and Department of Neurology, San Raffaele Scientific Institute and Ospedale San Raffaele, Italy Laboratory of Genetics of Neurological Complex Disorders, San Raffaele Scientific Institute, Italy
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Mendez-Tellez PA, Nusr R, Feldman D, Needham DM. Early Physical Rehabilitation in the ICU: A Review for the Neurohospitalist. Neurohospitalist 2013; 2:96-105. [PMID: 23983871 DOI: 10.1177/1941874412447631] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Advances in critical care have resulted in improved intensive care unit (ICU) mortality. However, improved ICU survival has resulted in a growing number of ICU survivors living with long-term sequelae of critical illness, such as impaired physical function and quality of life (QOL). In addition to critical illness, prolonged bed rest and immobility may lead to severe physical deconditioning and loss of muscle mass and muscle weakness. ICU-acquired weakness is associated with increased duration of mechanical ventilation and weaning, longer ICU and hospital stay, and increased mortality. These physical impairments may last for years after ICU discharge. Early Physical Medicine and Rehabilitation (PM&R) interventions in the ICU may attenuate or prevent the weakness and physical impairments occurring during critical illness. This article reviews the evidence regarding safety, feasibility, barriers, and benefits of early PM&R interventions in ICU patients and discusses the limited existing data on early PM&R in the neurological ICU and future directions for early PM&R in the ICU.
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Affiliation(s)
- Pedro A Mendez-Tellez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Lexell EM, Flansbjer UB, Lexell J. Self-perceived performance and satisfaction with performance of daily activities in persons with multiple sclerosis following interdisciplinary rehabilitation. Disabil Rehabil 2013; 36:373-8. [PMID: 23735012 DOI: 10.3109/09638288.2013.797506] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Longitudinal 7-year follow-up of chronic pain in persons with multiple sclerosis in the community. J Neurol 2013; 260:2005-15. [DOI: 10.1007/s00415-013-6925-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/08/2013] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
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Martin A, Mills J. Parkinson's Disease Nurse Specialists and the King's College Hospital model of care. ACTA ACUST UNITED AC 2013. [DOI: 10.12968/bjnn.2013.9.1.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anne Martin
- King's College Hospital, Denmark Hill, London, SE5 9RS, England
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van der Zee CH, Baars-Elsinga A, Visser-Meily JMA, Post MWM. Responsiveness of two participation measures in an outpatient rehabilitation setting. Scand J Occup Ther 2013; 20:201-8. [PMID: 23312022 DOI: 10.3109/11038128.2012.754491] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The responsiveness of a new participation measure, the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-Participation) was compared with that of the Impact on Particpation and Autonomy (IPA). Furthermore, the concurrent validity of these two measures was assessed. METHOD Participants were patients with brain injury or neuromuscular disease, who received occupational therapy as part of a multidisciplinary outpatient rehabilitation programme. They completed the IPA and the USER-Participation at the start and end of the programme, and at three-month follow-up. Responsiveness was analysed using the effect size (ES) and the standardized response mean (SRM). RESULTS Responsiveness figures were small to moderate (-0.4 to 0.5) and similar for the IPA and the USER-Participation. The USER-Participation showed a consistent result, with Frequency scores declining and Restriction and Satisfaction scores inclining over time, and the IPA showed mixed results, with the different domain scores both inclining and declining over time. Correlations between IPA and USER-Participation scales were all significant, but by far strongest for the USER-Participation Satisfaction scale (-0.64 to -0.81). CONCLUSION The USER-Participation was at least as responsive as the IPA. Further, satisfaction with participation as measured with the USER-Participation is highly similar to the concept of autonomy in participation as measured with the IPA.
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Affiliation(s)
- Carlijn H van der Zee
- Rudolf Magnus Institute of Neuroscience and Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, the Netherlands
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A Protocol for Measuring the Direct Psychological Benefit of Neuropsychological Assessment with Feedback in Multiple Sclerosis. BRAIN IMPAIR 2012. [DOI: 10.1017/brimp.2012.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This article reports on the design of a two-arm, randomised controlled trial of neuropsychological assessment with feedback as a direct therapeutic intervention to improve psychological wellbeing in multiple sclerosis (MS). MS patients and their caregivers are randomly allocated to one of two groups: neuropsychological assessment with feedback (the intervention), or ‘sham wait-list’ control. The trial investigates: (1) whether the intervention directly benefits patients by leading to improved knowledge of their own specific cognitive strengths and weaknesses, and improved use of adaptive psychological strategies for coping with MS; and (2) whether the intervention directly benefits caregivers by leading to improved knowledge of the patients’ specific cognitive strengths and weaknesses, and to a more positive caregiving outcome. A range of primary and secondary measures is used to evaluate these outcomes. The protocol utilises a wait-list control method which is structured to effectively blind patients and caregivers to their group allocation. Publishing the protocol prior to the results of the trial being available has a number of important methodological benefits, and informs the research community of the work that is under way to allow for collaboration and to reduce duplication of research effort. (This trial has been registered on the ANZCTR; ACTRN12612000161820.)
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Ravnborg M. Rehabilitation therapy in MS; a short-term, expensive, placebo. Mult Scler 2012; 18:1377-8. [DOI: 10.1177/1352458512459787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Morley MA, Coots LA, Forgues AL, Gage BJ. Inpatient Rehabilitation Utilization for Medicare Beneficiaries With Multiple Sclerosis. Arch Phys Med Rehabil 2012; 93:1377-83. [DOI: 10.1016/j.apmr.2012.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 01/04/2012] [Accepted: 03/02/2012] [Indexed: 10/28/2022]
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Spooren AIF, Timmermans AAA, Seelen HAM. Motor training programs of arm and hand in patients with MS according to different levels of the ICF: a systematic review. BMC Neurol 2012; 12:49. [PMID: 22747894 PMCID: PMC3527200 DOI: 10.1186/1471-2377-12-49] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 06/06/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The upper extremity plays an important role in daily functioning of patients with Multiple Sclerosis (MS) and strongly influences their quality of life. However, an explicit overview of arm-hand training programs is lacking. The present review aims to investigate the training components and the outcome of motor training programs for arm and hand in MS. METHODS A computerized systematic literature search in 5 databases (PubMed, CINAHL, EMBASE, PEDro and Cochrane) was performed using the following Mesh terms: Multiple Sclerosis, Rehabilitation, Physical Education and Training, Exercise, Patient-Centered Care, Upper Extremity, Activities of Daily Living, Motor Skills, Motor Activity, Intervention Studies and Clinical Trial. The methodological quality of the selected articles was scored with the Van Tulder Checklist. A descriptive analyses was performed using the PICO principle, including scoring of training components with the calculation of Hedges'g effect sizes. RESULTS Eleven studies were eligible (mean Van Tulder-score = 10.82(SD2.96)). Most studies reported a specific improvement in arm hand performance at the ICF level that was trained at. The mean number of training components was 5.5(SD2.8) and a significant correlation (r = 0.67; p < 0.05) between the number of training components and effect sizes was found. The components 'client-centered' and 'functional movement' were most frequently used, whereas 'distribution based practice', 'feedback' and 'random practice' were never used. The component 'exercise progression' was only used in studies with single ICF body function training, with the exception of 1 study with activity level training. Studies including the component 'client-centred' demonstrated moderate to high effect sizes. CONCLUSION Motor training programs (both at the ICF body function and activity level) have shown to improve arm and hand performance in MS in which the value of the training specificity was emphasized. To optimize upper extremity training in MS the component 'client-centred' and 'exercise progression' may be important. Furthermore, given the importance attributed to the components 'distribution based practice', 'feedback' and 'random practice' in previous research in stroke patients, the use of these components in arm hand training should be explored in future research.
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Affiliation(s)
- Annemie IF Spooren
- Department of Healthcare, PHL University College Hasselt, Hasselt, Belgium
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
- Department of Rehabilitation Medicine, Maastricht University, Research School CAPHRi, Maastricht, The Netherlands
- Guffenslaan 39, 3500, Hasselt, Belgium
| | - Annick AA Timmermans
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
- Department of Rehabilitation Medicine, Maastricht University, Research School CAPHRi, Maastricht, The Netherlands
| | - Henk AM Seelen
- Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
- Department of Rehabilitation Medicine, Maastricht University, Research School CAPHRi, Maastricht, The Netherlands
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Affiliation(s)
- Ralph H B Benedict
- Jacobs Neurological Institute, State University of New York at Buffalo, Buffalo, NY, USA (RHBB); and Department of Neurology, University of Virginia, Charlottesville, VA, USA (KF)
| | - Kathleen Fuchs
- Jacobs Neurological Institute, State University of New York at Buffalo, Buffalo, NY, USA (RHBB); and Department of Neurology, University of Virginia, Charlottesville, VA, USA (KF)
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Conrad A, Coenen M, SchmalZ H, Kesselring J, Cieza A. Validation of the Comprehensive ICF Core Set for Multiple Sclerosis from the perspective of occupational therapists. Scand J Occup Ther 2012; 19:468-87. [DOI: 10.3109/11038128.2012.665475] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Basteris A, De Luca A, Sanguineti V, Solaro C, Mueller M, Carpinella I, Cattaneo D, Bertoni R, Ferrarin M. A tailored exercise of manipulation of virtual tools to treat upper limb impairment in Multiple Sclerosis. IEEE Int Conf Rehabil Robot 2012; 2011:5975509. [PMID: 22275705 DOI: 10.1109/icorr.2011.5975509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We developed a robot-assisted rehabilitation protocol, specifically designed to treat cerebellar and motor symptoms in subjects with Multiple Sclerosis. The task consists of controlling a `virtual' tool (a mass-spring system), under the effect of a resistive force. The exercise is designed in such a way that task difficulty and the degree of resistance are automatically adjusted to the individual patients' impairment. The protocol included a total of eight 40 min training sessions (2 sessions/week), and automatic regulation of difficulty and resistance was repeated at the beginning of each session. Preliminary results suggest that subjects improve their performance, both within and between sessions. Moreover, task difficulty and resistance tend to increase across sessions, indicating that subjects gradually improve their ability to deal with more challenging versions of the task.
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Affiliation(s)
- Angelo Basteris
- Dept. of Informatics, Systems and Telematics, University of Genoa, Genoa, Italy.
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Schwartz I, Sajin A, Moreh E, Fisher I, Neeb M, Forest A, Vaknin-Dembinsky A, Karusis D, Meiner Z. Robot-assisted gait training in multiple sclerosis patients: a randomized trial. Mult Scler 2011; 18:881-90. [DOI: 10.1177/1352458511431075] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Isabella Schwartz
- Departments of Physical Medicine and Rehabilitation, Haddasah-Hebrew University Hospital, Jerusalem, Israel
| | - Anna Sajin
- Departments of Physical Medicine and Rehabilitation, Haddasah-Hebrew University Hospital, Jerusalem, Israel
| | - Elior Moreh
- Departments of Physical Medicine and Rehabilitation, Haddasah-Hebrew University Hospital, Jerusalem, Israel
| | - Iris Fisher
- Departments of Physical Medicine and Rehabilitation, Haddasah-Hebrew University Hospital, Jerusalem, Israel
| | - Martin Neeb
- Department of Physiotherapy, Haddasah-Hebrew University Hospital, Jerusalem, Israel
| | - Adina Forest
- Department of Physiotherapy, Haddasah-Hebrew University Hospital, Jerusalem, Israel
| | | | - Dimitrios Karusis
- Department of Neurology, Haddasah-Hebrew University Hospital, Jerusalem, Israel
| | - Zeev Meiner
- Department of Neurology, Haddasah-Hebrew University Hospital, Jerusalem, Israel
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Abstract
The development of neutralizing antibodies (NAbs) is a major problem in multiple sclerosis (MS) patients treated with interferon-beta (IFN-ß). Whereas binding antibodies (BAbs) can be demonstrated in the vast majority of patients, only a smaller proportion of patients develop NAbs. The principle in NAb in vitro assays is the utilization of cultured cell lines that are responsive to IFN-ß. The cytopathic effect (CPE) assay measures the capacity of NAbs to neutralize IFN- ß's protective effect on cells challenged with virus and the MxA induction assay measures the ability of NAbs to reduce the IFN-ß-induced expression of MxA, either at the mRNA or the protein level. A titer of >20 neutralizing units/ml traditionally defines NAb posi-tivity. NAbs in high titers completely abrogate the in vivo response to IFN-ß, whereas the effect of low and intermediate titers is unpredictable. As clinically important NAbs appear only after 9-18 months IFN- ß0 therapy, short-term studies of two years or less are unsuitable for evaluation of clinical NAb effects. All long-term trials of three years or more concordantly show evidence of a detrimental effect of NAbs on relapses, disease activity on MRI, or on disease progression. Persistent high titers of NAbs indicate an abrogation of the biological response and, hence, absence of therapeutic efficacy, and this observation should lead to a change of therapy. As low and medium titers are ambiguous treatment decisions in patients with low NAb titres should be guided by determination of in vivo mRNA MxA induction and clinical disease activity.
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Affiliation(s)
- Per Soelberg Sorensen
- Danish Multiple Sclerosis Research Center Department of Neurology 2082, Copenhagen University Hospital Rigshospitalet, DK-2100 Copenhagen, Denmark.
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Burks JS, Bigley GK, Hill HH. Rehabilitation challenges in multiple sclerosis. Ann Indian Acad Neurol 2011; 12:296-306. [PMID: 20182578 PMCID: PMC2824958 DOI: 10.4103/0972-2327.58273] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 10/18/2009] [Accepted: 10/18/2009] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Jack S Burks
- Medicine (Neurology), University School of Medicine, Reno, Nevada; and Chief Medical Officer, Multiple Sclerosis Association of America (MSAA), Cherry Hill, New Jersey, USA
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Maitra K, Hall C, Kalish T, Anderson M, Dugan E, Rehak J, Rodríguez V, Tamas J, Zeitlin D. Five-year retrospective study of inpatient occupational therapy outcomes for patients with multiple sclerosis. Am J Occup Ther 2010; 64:689-94. [PMID: 21073099 DOI: 10.5014/ajot.2010.090204] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE This study was a retrospective chart analysis spanning 5 yr that investigated associations between occupational therapy interventions and goal-based positive outcomes in patients with multiple sclerosis (MS) and related disorders at discharge in an urban inpatient rehabilitation setting. METHOD Using descriptive statistics, we examined demographic characteristics in the first analysis phase. In the second phase, we performed a series of correlational analyses to identify treatment variables associated with positive outcomes. RESULTS Generally, patients improved in their FIM scores at discharge. Increasing occupational therapy intensity had a positive effect on functional performance in all categories except feeding, with significant correlations in upper-extremity dressing (r = .153, p < .05) and memory (r = .204, p < .01). CONCLUSION Occupational therapy was associated with positive functional outcomes for patients with MS. Future treatment protocols should include cognitive skills training, community reintegration, and self-care, because these treatments were found to be significantly correlated with positive changes in FIM scores.
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Affiliation(s)
- Kinsuk Maitra
- Occupational Therapy Department, Rush University Medical Center, 600 South Paulina, Suite 1011, Chicago, IL 60612, USA.
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Clinical practice improvement approach in multiple sclerosis rehabilitation: a pilot study. Int J Rehabil Res 2010; 33:238-47. [DOI: 10.1097/mrr.0b013e328338b05f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vergaro E, Squeri V, Brichetto G, Casadio M, Morasso P, Solaro C, Sanguineti V. Adaptive robot training for the treatment of incoordination in Multiple Sclerosis. J Neuroeng Rehabil 2010; 7:37. [PMID: 20670420 PMCID: PMC2927907 DOI: 10.1186/1743-0003-7-37] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 07/29/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebellar symptoms are extremely disabling and are common in Multiple Sclerosis (MS) subjects. In this feasibility study, we developed and tested a robot therapy protocol, aimed at the rehabilitation of incoordination in MS subjects. METHODS Eight subjects with clinically defined MS performed planar reaching movements while grasping the handle of a robotic manipulandum, which generated forces that either reduced (error-reducing, ER) or enhanced (error-enhancing, EE) the curvature of their movements, assessed at the beginning of each session. The protocol was designed to adapt to the individual subjects' impairments, as well as to improvements between sessions (if any). Each subject went through a total of eight training sessions. To compare the effect of the two variants of the training protocol (ER and EE), we used a cross-over design consisting of two blocks of sessions (four ER and four EE; 2 sessions/week), separated by a 2-weeks rest period. The order of application of ER and EE exercises was randomized across subjects. The primary outcome measure was the modification of the Nine Hole Peg Test (NHPT) score. Other clinical scales and movement kinematics were taken as secondary outcomes. RESULTS Most subjects revealed a preserved ability to adapt to the robot-generated forces. No significant differences were observed in EE and ER training. However over sessions, subjects exhibited an average 24% decrease in their NHPT score. The other clinical scales showed small improvements for at least some of the subjects. After training, movements became smoother, and their curvature decreased significantly over sessions. CONCLUSIONS The results point to an improved coordination over sessions and suggest a potential benefit of a short-term, customized, and adaptive robot therapy for MS subjects.
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Affiliation(s)
- Elena Vergaro
- University of Genoa, Department of Informatics, Systems and Telecommunications, Via Opera Pia 13, Genoa, Italy
| | - Valentina Squeri
- University of Genoa, Department of Informatics, Systems and Telecommunications, Via Opera Pia 13, Genoa, Italy
- Italian Institute of Technology, Via Morego 30, Genoa, Italy
| | - Giampaolo Brichetto
- Department of Neuroscience, Ophthalmology and Genetics, University of Genoa, Via A. De Toni 5, Genoa, Italy
| | - Maura Casadio
- University of Genoa, Department of Informatics, Systems and Telecommunications, Via Opera Pia 13, Genoa, Italy
- Italian Institute of Technology, Via Morego 30, Genoa, Italy
| | - Pietro Morasso
- University of Genoa, Department of Informatics, Systems and Telecommunications, Via Opera Pia 13, Genoa, Italy
- Italian Institute of Technology, Via Morego 30, Genoa, Italy
| | | | - Vittorio Sanguineti
- University of Genoa, Department of Informatics, Systems and Telecommunications, Via Opera Pia 13, Genoa, Italy
- Italian Institute of Technology, Via Morego 30, Genoa, Italy
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Rasova K, Feys P, Henze T, van Tongeren H, Cattaneo D, Jonsdottir J, Herbenova A. Emerging evidence-based physical rehabilitation for multiple sclerosis - towards an inventory of current content across Europe. Health Qual Life Outcomes 2010; 8:76. [PMID: 20667079 PMCID: PMC2915974 DOI: 10.1186/1477-7525-8-76] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 07/28/2010] [Indexed: 11/10/2022] Open
Abstract
In Europe, theoretical approaches to physical therapy and rehabilitation in multiple sclerosis often appear significantly different. While there is general agreement that rehabilitation plays an important role in maintaining and improving function in persons with multiple sclerosis, no consensus exists on what may be the most effective approach to achieve the best possible functionality within an individual's limitations.The objective of this paper is to initiate an analysis of currently applied physical interventions for people with multiple sclerosis throughout Europe during inpatient or outpatient rehabilitation programs. A study of the content of rehabilitation may show presently performed treatment methods revealing the basic considerations that nowadays guide clinicians implicitly or explicitly in the treatment of persons with multiple sclerosis. Following this first step, comparative studies can be set up.
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Affiliation(s)
- Kamila Rasova
- Department of Rehabilitation, Third Medical Faculty, Charles University, Ruská 87, 100 00 Prague 10, Czech Republic.
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