The effect of exercise training in adults with multiple sclerosis with severe mobility disability: A systematic review and future research directions

Functional electrical stimulation combined with voluntary cycling accentuates VO2 response in people with severe multiple sclerosis: A pilot study

BACKGROUND

Lower limb muscle weakness and reduced balance due to disease progression in multiple sclerosis (MS) may make robust aerobic exercise difficult. Functional electrical stimulation (FES) cycling combined with voluntary cycling may allow people with severe MS to enhance the intensity of aerobic exercise. The aim of this study was to investigate the cardiorespiratory, power, and participant-reported perceptions during acute bouts of FES cycling, voluntary cycling, and FES cycling combined with voluntary cycling (FES assist cycling).

METHODS

Participants with severe MS (Expanded Disability Status Scale [EDSS] ≥ 6.0) undertook three exercise trials on a leg cycle ergometer. Trial 1 involved 30 min of FES cycling; Trial 2 involved two 10-minute bouts of voluntary cycling separated by 10 min rest; and Trial 3 was a combination of trials 1 and 2 (FES assist cycling). Outcome measures included VO2 (volume of oxygen consumption), cycle power output, heart rate, RPE, and post-exercise perceptions of pain and fatigue.

RESULTS

Ten people with severe MS participated (9 female; age 52.4 ± 9.98 y; EDSS 7.1 ± 0.6). The average VO2 during the 30-minute trials was significantly higher for FES assist cycling compared to voluntary cycling (429.7 ± 111.0 vs 388.5 ± 101.0 mL/min, 95% CI 23.4 to 113.0 mL/min, p = 0.01), with a large effect size (Hedges' g = 1.04). Participants reported similar rates of perceived exertion at the end of FES cycling (13 ± 2), voluntary cycling (14 ± 2), and FES assist cycling (15 ± 1); p = 0.14. Self-reported pain was higher during both FES cycling (5.4 vs 0.3; 95% CI 3.4 to 6.7, p = 0.01, Hedges' g = 2.07) and FES assist cycling (4.2 vs. 0.3; 95% CI 2.3 to 5.5, p = 0.01, Hedges' g = 1.71) than voluntary cycling, both with large effect sizes. There was no difference in self-reported fatigue at the end of each trial (p = 0.21).

CONCLUSION

This study found FES assist cycling produced significantly higher VO2 values than voluntary cycling, although the clinical significance of these differences is unknown. Participants performed FES assist cycling at a self-reported RPE consistent with moderate to vigorous intensity, however it was considered light-intensity exercise when expressed by METS. FES assist cycling was no more fatiguing post-exercise than the other modes.

Effects of Physical Therapy and Dalfampridine on Function and Quality of Life in Nonambulatory Individuals With Multiple Sclerosis: A Randomized Controlled Trial

BACKGROUND

Decreases in mobility, quality of life (QOL) and cognition are commonly seen in people with multiple sclerosis (MS). Physical therapy (PT) and exercise have been shown to improve many symptoms in ambulatory individuals with MS; however, evidence in nonambulatory people with MS is lacking. Dalfampridine is a US Food and Drug Administration-approved medication for MS that treats impaired ambulation by enhancing nerve conduction. To our knowledge, no study has examined the combined effect of PT and dalfampridine and very few studies have examined dalfampridine's effect on function in individuals with more progressive disease. The purpose of this study was to examine the effectiveness of PT combined with dalfampridine or a placebo on function, QOL, and cognition in nonambulatory individuals with MS. In addition, we explored the benefits of PT in all participants to increase the extremely limited research in this population.

METHODS

Adults with MS were randomly assigned to receive dalfampridine (n = 13) or placebo (n = 14) for 12 weeks in conjunction with PT treatment 2 times a week. Function, QOL, and cognition were assessed at baseline, 6 weeks, and 12 weeks.

RESULTS

There was a significant time × group interaction for the Multiple Sclerosis Quality of Life-54 favoring the placebo group. Both groups significantly improved on the 9-Hole Peg Test (left arm only), sitting lateral reach (right), transferring from wheelchair to mat, and repeated sit to stand.

CONCLUSIONS

The addition of dalfampridine to physical therapy did not improve function, QOL, or cognitive processing speed. Importantly, this study demonstrated an overall benefit in function and QOL with physical therapy 2 times a week for 12 weeks for nonambulatory individuals with MS.

A qualitative study of low-load resistance training with blood flow restriction in people with advanced multiple sclerosis

BACKGROUND

Blood flow restriction (BFR) combined with low-load resistance training could minimize exercise barriers and offer strength and mobility improvements for people with advanced Multiple Sclerosis (MS); but patient experience has not been evaluated.

PURPOSE

The purpose of this study was to assess the satisfaction, acceptability, and impact of combining low-load resistance training with BFR for individuals with advanced MS (Expanded Disability Status Scale: EDSS 6.0-7.0).

METHODS

We used an interpretive phenomenological research design and post-intervention interviews to explore participant experiences of a novel low-load resistance training program with BFR.

RESULTS

Interview participants (n = 14) were 55.4 ± 6.2 years old and were diagnosed with MS for 19.1 ± 10.7 years. Four themes were identified (satisfaction, acceptability, impact, program refinement) with 14 subthemes. Satisfaction was mixed based on overall expectations, yet all participants recommended the intervention. Acceptability was evidenced by all participants identifying comfortable/easy aspects, and modifiable elements that could improve comfort. Impact was evidenced with translation to everyday life activities, strength/self-efficacy/psychological improvements, effectiveness, and fatigue reduction.

CONCLUSIONS

Participants found BFR combined with low-load resistance training to be satisfactory (mixed initial expectations), acceptable (comfortable/easy), and impactful (translating to life improvements). Areas for program refinement were identified that should be targeted in future iterations.

Management of Osteoporosis, Fracture and Falls in People with Multiple Sclerosis: Systematic Review of Guidelines

People with multiple sclerosis (MS) have a higher prevalence of osteoporosis, falls and fractures. Guidelines for MS populations targeting the management of osteoporosis, fracture and falls risk may help reduce the burden of musculoskeletal disease in this population. We aimed to systematically review current guidelines regarding osteoporosis prevention, screening, diagnosis and management in people with MS. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, a systematic review of scientific databases (MEDLINE, CINAHL, Embase and Scopus) was performed (n = 208). In addition, websites from MS organisations and societies were screened for clinical guidelines (n = 28). Following duplicate removal, screening and exclusions (n = 230), in total six guidelines were included in this review. Three of the identified guidelines were specific to managing osteoporosis in MS, while two linked vitamin D to bone health and one was focused on the effect of acute glucocorticoid use for MS exacerbations on bone health. All guidelines were found to contain inadequate recommendations for osteoporosis screening, management and treatment in people with MS given the evidence of higher prevalence of osteoporosis at an earlier age and compounding risk factors in this population. Early diagnosis and treatment of osteoporosis in people with MS is necessary as fractures lead to significant morbidity and mortality. Development of structured clinical guidelines directed at specific healthcare services will ensure screening, appropriate management, and care of bone health in people with MS.

The effects of hybrid functional electrical stimulation interval training on aerobic fitness and fatigue in people with advanced multiple sclerosis: An exploratory pilot training study

BACKGROUND

Improving aerobic fitness in people with advanced multiple sclerosis (MS) may reduce fatigue, and lower the risk of cardiovascular disease, as has been found for people with mild to moderate MS. Training targeting aerobic fitness can be challenging due to paresis, access to suitable equipment and fatigue. The aim of this study was to investigate whether people with advanced multiple sclerosis could perform functional electrical stimulation (FES) cycling combined with arm crank interval exercise (hybrid FES interval training) training, and its effects on aerobic fitness and fatigue.

METHODS

Hybrid FES interval training was performed 2 d/wk for 12 weeks. Each session consisted of 40 min of continuous FES cycling with arm crank intervals of 30 s work/30 s rest added concurrently for 20 min. The intensity target was a minimum of 60 % of arm crank power and 'hard' measured by rate of perceived exertion (RPE). Attendance, compliance to intensity and time targets, adverse events, and drop outs were measured. Aerobic fitness was assessed by an arm crank maximal test. Fatigue was measured via the Modified Fatigue Impact Scale (MFIS).

RESULTS

Seven participants (6 female; age 57.1 ± 7.8y; Expanded Disability Status Scale 7.1 ± 0.8) with advanced MS attended 80 ± 10.4 % of the scheduled exercise sessions and there were no adverse events or drop outs. Average RPE at the end of each training session was 15.1 ± 2.1, representing vigorous intensity exercise. Aerobic fitness did not change pre- to post-intervention (14.2 ± 5.7 to 14.8 ± 6.0 mL/kg/min [p = 0.43]), and resulted in a small effect size (ES) (0.30). The reduction in fatigue during the intervention (31.0 ± 10.4 to 21.7 ± 11.4 [p = 0.10]), resulted in a moderate to large ES (-0.77).

CONCLUSION

Hybrid FES interval training could be performed 2 days per week for 12 weeks and represented vigorous intensity exercise, but there was no change in aerobic fitness. The reduction in participants' perceptions of fatigue represented a moderate to large ES, indicating hybrid FES interval training might be suitable for people with advanced MS who need exercise equipment appropriate for their condition.

CLINICAL TRIAL REGISTRATION

This study was registered with Australian and New Zealand Clinical Trials Register (U1111-1194-2040).

Feasibility of a physical exercise intervention for patients on a palliative care unit: a critical analysis

BACKGROUND

Recent exercise intervention studies have shown promising results in improving quality of life (QoL) and physical function (PF) in diverse chronic disease and advanced cancer patients. However, the effects of structured exercise in palliative care patients, having different therapeutic needs, lower life expectancies and PFs remain unknown. This study primarily aimed to assess the feasibility of an exercise intervention with follow-up by analysing recruitment numbers, screening procedures, acceptability, preferences, and safety of the exercise intervention as well as retention in follow-up. Our secondary aims related to changes in QoL and PF.

METHODS

This study comprised of a one-arm design without a control group. Over 6 months, every in-hospital palliative care unit (PCU) patient was screened for eligibility. Eligible patients were asked to participate in a 2-week exercise intervention consisting of resistance training and/or endurance training with moderate or high intensity based on personal preferences and a 4-week follow-up. Before and after the exercise intervention, QoL and PF were assessed and a qualitative interview after the intervention addressed expectations and experiences of the exercise intervention. For follow-up, patients were provided with information on independent training and after 1 and 4 weeks a QoL assessment and qualitative interview were conducted.

RESULTS

Of 124 patients screened, 10 completed the intervention with an adherence rate of (80 ± 25%), of which 6 patients completed follow-up. Endurance training was the most performed training type and only a few minor adverse events occurred in certain or likely connection to the exercise intervention. While physical QoL and PF measured by arm curl strength and time up and go performance improved, mental QoL and the other PF tests remained unchanged.

CONCLUSION

Despite the challenges that were faced in our screening and testing process, that are specific to the palliative patient population with their unique therapeutic requirements and varying mental-/ physical capabilities, we discovered the 2-week exercise intervention to be feasible, safe, and well tolerated by palliative care patients. Moreover, it seems that short-term improvements in QoL and PF are possible. Further full scale studies are required to confirm our findings.

TRIAL REGISTRATION

The study was retrospectively registered on 25.01.2022 in the German Clinical Trials Register (DRKS00027861).

Neuromuscular Electrical Stimulation Does Not Influence Spinal Excitability in Multiple Sclerosis Patients

(1) Background: Neuromuscular electrical stimulation (NMES) has beneficial effects on physical functions in Multiple sclerosis (MS) patients. However, the neurophysiological mechanisms underlying these functional improvements are still unclear. This study aims at comparing acute responses in spinal excitability, as measured by soleus Hoffmann reflex (H-reflex), between MS patients and healthy individuals, under three experimental conditions involving the ankle planta flexor muscles: (1) passive NMES (pNMES); (2) NMES superimposed onto isometric voluntary contraction (NMES+); and (3) isometric voluntary contraction (ISO). (2) Methods: In total, 20 MS patients (MS) and 20 healthy individuals as the control group (CG) took part in a single experimental session. Under each condition, participants performed 15 repetitions of 6 s at 20% of maximal voluntary isometric contraction, with 6 s of recovery between repetitions. Before and after each condition, H-reflex amplitudes were recorded. (3) Results: In MS, H-reflex amplitude did not change under any experimental condition (ISO: p = 0.506; pNMES: p = 0.068; NMES+: p = 0.126). In CG, H-reflex amplitude significantly increased under NMES+ (p = 0.01), decreased under pNMES (p < 0.000) and was unaltered under ISO (p = 0.829). (4) Conclusions: The different H-reflex responses between MS and CG might reflect a reduced ability of MS patients in modulating spinal excitability.

Predictive Model of Anxiety and Depression Perception in Multiple Sclerosis Patients: Possible Implications for Clinical Treatment

Multiple Sclerosis (MS) is a neurodegenerative disease characterized by motor and non-motor symptoms, including emotional distress, anxiety, and depression. These emotional symptoms currently have a pharmacological treatment with limited effectiveness; therefore, it is necessary to delve into their relationship with other psychological, functional, or prefrontal alterations. Additionally, exploring non-pharmacological therapeutic alternatives that have shown benefits in addressing emotional distress in MS patients is essential.

AIM

To establish a predictive model for the presence of anxiety and depression in MS patients, based on variables such as psychological well-being, functional activity, and prefrontal symptoms. Additionally, this study aimed to propose non-pharmacological therapeutic alternatives based on this model.

MATERIALS AND METHODS

A descriptive, observational, and cross-sectional study was conducted with a sample of 64 diagnosed MS patients who underwent functional and cognitive assessments using the following questionnaires and scales: Functional Activities Questionnaire (FAQ), Acceptance and Action Questionnaire (AAQ-II), Experiences Questionnaire (EQ), Self-Compassion Scale Short Form (SCS-SF), Beck Depression Inventory II (BDI-II), State-Trait Anxiety Inventory (STAI), and Prefrontal Symptoms Inventory (PSI).

RESULTS

The model showed an excellent fit to the data and indicated that psychological well-being was the most significant predictor of the criteria (β = -0.83), followed by functional activity (β = -0.18) and prefrontal symptoms (β = 0.15). The latter two are negatively related to psychological well-being (β = -0.16 and β = -0.75, respectively).

CONCLUSIONS

Low psychological well-being is the variable that most significantly predicts the presence of anxiety and depression in MS patients, followed by functional activity and prefrontal alterations. Interventions based on mindfulness and acceptance are recommended, along with nutritional interventions such as antioxidant-enriched ketogenic diets and moderate group physical exercise.

Leveraging Emerging Technologies to Expand Accessibility and Improve Precision in Rehabilitation and Exercise for People with Disabilities

Physical rehabilitation and exercise training have emerged as promising solutions for improving health, restoring function, and preserving quality of life in populations that face disparate health challenges related to disability. Despite the immense potential for rehabilitation and exercise to help people with disabilities live longer, healthier, and more independent lives, people with disabilities can experience physical, psychosocial, environmental, and economic barriers that limit their ability to participate in rehabilitation, exercise, and other physical activities. Together, these barriers contribute to health inequities in people with disabilities, by disproportionately limiting their ability to participate in health-promoting physical activities, relative to people without disabilities. Therefore, there is great need for research and innovation focusing on the development of strategies to expand accessibility and promote participation in rehabilitation and exercise programs for people with disabilities. Here, we discuss how cutting-edge technologies related to telecommunications, wearables, virtual and augmented reality, artificial intelligence, and cloud computing are providing new opportunities to improve accessibility in rehabilitation and exercise for people with disabilities. In addition, we highlight new frontiers in digital health technology and emerging lines of scientific research that will shape the future of precision care strategies for people with disabilities.

Feasibility of Low-Load Resistance Training Using Blood Flow Restriction for People With Advanced Multiple Sclerosis: A Prospective Cohort Study

OBJECTIVE

The objective of this study was to determine the feasibility of low-load resistance training with blood flow restriction (BFR) for people with advanced disability due to multiple sclerosis (MS).

METHODS

In this prospective cohort study, 14 participants with MS (Expanded Disability Status Scale [EDSS] score = 6.0 to 7.0; mean age = 55.4 [SD = 6.2] years; 71% women) were asked to perform 3 lower extremity resistance exercises (leg press, calf press, and hip abduction) bilaterally twice weekly for 8 weeks using BFR. Feasibility criteria were as follows: enrollment of 20 participants, ≥80% retention and adherence, ≥90% satisfaction, and no serious adverse events related to the intervention. Other outcomes included knee extensor, ankle plantar flexor, and hip abductor muscle strength, 30-Second Sit-to-Stand Test, Berg Balance Scale, Timed 25-Foot Walk Test, 12-Item MS Walking Scale, Modified Fatigue Impact Scale, Patient-Specific Functional Scale, and daily step count.

RESULTS

Sixteen participants consented, and 14 completed the intervention, with 93% adherence overall. All participants were satisfied with the intervention. A minor hip muscle strain was the only intervention-related adverse event. There were muscle strength improvements on the more-involved (16%-28%) and less-involved (12%-19%) sides. There were also changes in the 30-Second Sit-to-Stand Test (1.9 repetitions; 95% CI = 1.0 to 2.8), Berg Balance Scale (5.3 points; 95% CI = 3.2 to 7.4), Timed 25-Foot Walk Test (-3.3 seconds; 95% CI = -7.9 to 1.3), Modified Fatigue Impact Scale (-8.8 points; 95% CI = -16.5 to -1.1), 12-Item MS Walking Scale (-3.6 points; 95% CI = -11.5 to 4.4), Patient-Specific Functional Scale (2.9 points; 95% CI = 1.9 to 3.8), and daily step count (333 steps; 95% CI = -191 to 857).

CONCLUSION

Low-load resistance training using BFR in people with MS and EDSS scores of 6.0 to 7.0 appears feasible, and subsequent investigation into its efficacy is warranted.

IMPACT

Although efficacy data are needed, combining BFR with low-load resistance training may be a viable alternative for people who have MS and who do not tolerate conventional moderate- to high-intensity training because of more severe symptoms, such as fatigue and weakness.

LAY SUMMARY

Low-load strength training with BFR was feasible in people who have advanced disability due to MS. Using BFR may provide an alternative for people with MS who do not tolerate higher intensity training due to more severe symptoms, such as fatigue and weakness.

Physical Activity Together for Multiple Sclerosis (PAT-MS): A randomized controlled feasibility trial of a dyadic behaviour change intervention

Background

Many people with advanced multiple sclerosis (MS) and their care-partners do not engage in sufficient physical activity (PA) for health benefits. We developed "Physical Activity Together for MS (PAT-MS)", a 12-week dyadic behavioural intervention, to promote PA among these dyads. Herein, we evaluated the feasibility of PAT-MS before a definitive trial.

Methods

A randomized controlled feasibility trial, with 1:1 allocation into the intervention or wait-list control condition. Predefined progression criteria included rates of recruitment, retention, safety, participant satisfaction and adherence. Changes in self-reported and accelerometer-measured PA were assessed at baseline and post-intervention using mixed-factor ANOVAs. Effects sizes were calculated as Cohen's d.

Results

The recruitment rate (i.e., 20 participants in 10 months) was not acceptable. However, retention (80%) was acceptable. No serious adverse events were reported. There were high levels of participant satisfaction with the intervention (content (median = 6 out of 7), facilitator (median = 7 out of 7), and delivery (median = 5 out of 7)) and adherence (92% of the group sessions, 83% of the individual support calls, and 80% of the practice activities were completed). There were statistically significant time-by-condition interactions on self-reported PA, steps/day, and %wear time and minutes in sedentary behaviour, and moderate-to-vigorous PA from baseline to post-intervention in people with MS and their family care-partners.

Conclusion

PAT-MS appears feasible, safe, and efficacious for PA promotion in MS dyads. We established effect size estimates to power a future definitive trial and identified necessary methodological changes to increase the efficiency of study procedures and improve the quality of the intervention.

Trial registration

ClinicalTrials.gov NCT04267185; Registered February 12, 2020, https://clinicaltrials.gov/ct2/show/NCT04267185.

Objective and subjective evaluation of walking ability with and without the use of a passive brace for hip flexor muscles in individuals with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) affects the cognitive and motor domains. Muscle weakness often leads to abnormal gait. Several solutions are rising, including the use of passive exoskeletons.

OBJECTIVE

The purpose of this study is to evaluate the effect of a first-ever use of a passive exoskeleton on walking ability in people with MS.

METHODS

We recruited 50 persons with MS. All subjects were assessed using the 2-min walking test, the timed 25-foot walk test, and a two-stage rate of perceived exertion (RPE) without the exoskeleton (T0) and with the exoskeleton (T1).

RESULTS

The data showed a significant decrease in walking endurance while the exoskeleton is worn (2-min walking test: T0: 65.19 ± 23.37 m; T1: 59.40 ± 22.99; p < 0.0001) and a not significant difference in walking speed on a shortened distance (T0: 15.71 ± 10.30 s; T1: 15.73 ± 11.86 s; p = 0.25). No significant differences were also found for the effort perception scale (RPE: T0: 13.24 ± 3.01; T1: 13.60 ± 2.9; p = 0.3). Seventy-two percent of subjects reported a positive or neutral global perceived effect.

CONCLUSIONS

The exoskeleton does not add any fatiguing or negative effects. Although the walking performance decreases, the overall perception of the subjects is positive. Further studies are needed to evaluate the effect of the exoskeleton on gait quality.

The MoXFo initiative - study design: Considerations related to study design and methodology in exercise research for people with multiple sclerosis

BACKGROUND

Exercise as a subset of physical activity is a cornerstone in the management of multiple sclerosis (MS) based on its pleiotropic effects, but continued progression of the field requires better future designs and methodologies.

OBJECTIVES

This paper outlines the work of the 'Study design and methodology' group of the MoXFo (moving exercise research forward) initiative, and addresses critical aspects and future directions when defining the research question of interest, and subsequently, designing the study and exercise intervention in MS patients.

METHODS

The work is based on the formation of an international expert panel formed within the MoXFo initiative. We provide a structured and concise synthesis of exercise-specific MS research challenges and considerations when designing randomized controlled trials (RCTs).

RESULTS

Challenges and considerations are presented using the Patient population, Intervention, Comparator, Outcomes, Timing, Setting (PICOTS) framework, thereby forming a new and specific MS exercise PICOTS framework.

CONCLUSION

We propose that researchers should carefully consider and align all elements of this MS exercise PICOTS framework when developing future research questions and study designs, ultimately improving the quality of new exercise studies in people with MS.

The MoXFo Initiative: Using consensus methodology to move forward towards internationally shared vocabulary in multiple sclerosis exercise research

BACKGROUND

Multiple sclerosis (MS) exercise terminology lacks consistency across disciplines, hindering research synthesis.

OBJECTIVE

The 'Moving exercise research in MS forward initiative' (MoXFo) aims to establish agreed definitions for key MS exercise terms.

METHODS

The Lexicon development methodology was employed. A three-step process identified key exercise terminology for people with multiple sclerosis (pwMS): (1) consensus and systematic review, (2) Delphi round 1 and consideration of existing definitions and (3) Delphi round 2 for consensus among MoXFo steering group and exercise experts. Final definitions and style harmonisation were agreed upon.

RESULTS

The two-stage Delphi process resulted in the selection and scoring of 30 terminology definitions. The agreement was 100% for resistance exercise, balance and physical activity. Most terms had agreement >75%, but 'posture' (60%) and 'exercise' (65%) had a lower agreement.

CONCLUSION

This study identified key terms and obtained agreement on definitions for 30 terms. The variability in agreement for some terms supports the need for clearly referencing or defining terminology within publications to enable clear communication across disciplines and to support precise synthesis and accurate interpretation of research.

Developing a community-engaged wheelchair exercise program for persons with MS: community advisory board formation and feedback

PURPOSE

Exercise is a safe, evidence-based approach for improving symptoms such as mobility impairment, cognitive dysfunction, and fatigue; however, persons with multiple sclerosis (MS) who use wheelchairs for mobility have been excluded from most research. This paper describes our approach for recruiting ten community advisor board (CAB) members and partnering with them on developing a novel home-based exercise training program for wheelchair users with MS.

MATERIALS AND METHODS

The exercise training program, which was developed based on initial qualitative research, includes a progressive exercise prescription, equipment, and one-on-one behavioural coaching based on Social Cognitive Theory. The CAB members convened in groups of five people for five meetings online, using virtual conference software. The CAB meetings each lasted approximately 1-hour and notes were transcribed into digital format for data analyses.

RESULTS

Content analysis identified elements that aligned with meeting foci (i.e., prescription, equipment, coaching, and outcomes). Feedback was divided into categories to refine the program, specifically modifying, adding, or retaining content and/or activities. CAB member feedback was very positive and emphasised potential additions to the materials presented. The research team proposed implementing modifications based on the CAB member feedback such as adding wrist weights to the equipment options for completing resistance training exercises.

CONCLUSIONS

The overall CAB feedback was invaluable for assessing the appropriateness of the proposed exercise training program before initiating feasibility testing. This report provides a model and guidance for researchers who seek community-engaged research approaches in creating products and interventions.Implication for RehabilitationCommunity advisory board participation was invaluable in creating and modifying a novel exercise training programmes for wheelchair users with multiple sclerosis (MS).The current study provides a framework for the creation of exercise interventions for subpopulations of persons with MS that may provide substantial rehabilitation benefits such as improved symptoms and quality of life.Health behaviour interventists targeting individuals with disabilities may consider the benefits of recruiting stakeholders from the community in creation of novel programmes.

Effects of Functional Electrical Stimulation Cycling Combined With Arm Cranking Exercise on Cardiorespiratory Fitness in People With Central Nervous System Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

To examine the evidence regarding the potential of hybrid functional electrical stimulation (FES) cycling for improving cardiorespiratory fitness for people with a mobility disability related to a central nervous system (CNS) disorder.

DATA SOURCES

Nine electronic databases: MEDLINE, EMBASE, Web of Science, CINAHL, PsycInfo, SPORTDiscus, Pedro, Cochrane, and Scopus, were searched from inception until October 2022.

STUDY SELECTION

Search terms included multiple sclerosis, spinal cord injury (SCI), stroke, Parkinson's disease, cerebral palsy, synonyms of FES cycling, arm crank ergometry (ACE) or hybrid exercise, and V̇o2. All experimental studies, including randomized controlled trials that included an outcome measure related to peak or sub-maximal V̇o2 were eligible.

DATA EXTRACTION

From a total of 280 articles, 13 were studies included. The Downs and Black Checklist was used to assess study quality. Random effects (Hedges' g) meta-analyses were undertaken to determine whether there were differences in V̇o2peak during acute bouts of hybrid FES cycling vs other modes of exercise and changes resulting from longitudinal training.

DATA SYNTHESIS

During acute bouts of exercise, hybrid FES cycling was moderately more effective than ACE (effect size [ES] of 0.59 (95% CI 0.15-1.02, P=.008) in increasing V̇o2peak from rest. There was a large effect on the increase of V̇o2peak from rest for hybrid FES cycling compared with FES cycling (ES of 2.36 [95% CI 0.83-3.40, P=.003]). Longitudinal training with hybrid FES cycling showed a significant improvement in V̇o2peak from pre to post intervention with a large, pooled ES of 0.83 (95% CI 0.24-1.41, P=.006).

CONCLUSIONS

Hybrid FES cycling produced higher V̇o2peak compared with ACE or FES cycling during acute bouts of exercise. Hybrid FES cycling can improve cardiorespiratory fitness in people with SCI. Additionally, there is emerging evidence that hybrid FES cycling might increase aerobic fitness in people with mobility disability related to CNS disorders.

Systematic review of cognitive reserve in multiple sclerosis: Accounting for physical disability, fatigue, depression, and anxiety

BACKGROUND

Cognitive reserve (CR) describes an individual's ability to adapt cognitive processes in response to brain atrophy, and has been reported to explain some of the discrepancy between brain atrophy and cognitive functioning outcomes in multiple sclerosis (MS). CR in MS is typically investigated by assessing an individual's pre- and/or post-diagnosis enrichment, which includes premorbid intellectual abilities, educational level, occupational attainment, and engagement in cognitively enriching leisure activities. Common MS symptoms (e.g., physical disability, fatigue, depression, anxiety) may impact an individual's ability to engage in various CR-enhancing activities post-diagnosis. It is unknown to what extent these MS symptoms have been taken into account in MS research on CR. As such, we identified whether studies assessed CR using measures of premorbid or continuous (including post-diagnosis) enrichment. For studies investigating continuous enrichment, we identified whether studies accounted for MS-impact, which MS symptoms were accounted for, and how, and whether studies acknowledged MS symptoms as potential CR-confounds.

METHODS

Three electronic databases (PsycINFO, PubMed, Scopus) were searched. Eligible studies investigated CR proxies (e.g., estimated premorbid intellectual abilities, vocabulary knowledge, educational level, occupational attainment, cognitively enriching leisure activities, or a combination thereof) in relation to cognitive, brain atrophy or connectivity, or daily functioning outcomes in adult participants with MS. We extracted data on methods and measures used, including any MS symptoms taken into account. Objectives were addressed using frequency analyses and narrative synthesis.

RESULTS

115 studies were included in this review. 47.8% of all studies investigated continuous enrichment. Approximately half of the studies investigating continuous enrichment accounted for potential MS-impact in their analyses, with only 31.0% clearly identifying that they treated MS symptoms as potential confounds for CR-enhancement. A narrative synthesis of studies which investigated CR with and without controlling statistically for MS-impact indicated that accounting for MS symptoms may impact findings concerning the protective nature of CR.

CONCLUSION

Fewer than half of the studies investigating CR proxies in MS involved continuous enrichment. Just over half of these studies accounted for potential MS-impact in their analyses. To achieve a more complete and accurate understanding of CR in MS, future research should investigate both pre-MS and continuous enrichment. In doing so, MS symptoms and their potential impact should be considered. Establishing greater consistency and rigour across CR research in MS will be crucial to produce an evidence base for the development of interventions aimed at improving quality of care and life for pwMS.

The MoxFo initiative - outcomes: Outcome measures in studies of exercise training in multiple sclerosis; scoping review of reviews and classification according to the ICF framework

BACKGROUND

The number of published studies of exercise training in multiple sclerosis (MS) has grown exponentially with increasing numbers of outcomes capturing exercise effects. This has complicated the selection of relevant indicators and interpretation of intervention effects.

OBJECTIVES

The Outcomes subgroup of the MoXFo initiative aimed to (1) identify outcome measures and biomarkers in studies of exercise training in MS; (2) systematically map retrieved outcomes to International Classification of Functioning, Disability and Health (ICF) categories; (3) identify gaps where relevant ICF categories have been omitted.

METHODS

Electronic databases and registers were searched from 2010 to July 2020 to identify systematic reviews or meta-analyses of controlled trials of exercise training on any outcome in MS. Retrieved outcomes/biomarkers were mapped to the corresponding ICF category.

RESULTS

Eighty-one review articles reporting 235 different outcomes were included. The outcomes corresponded to 15 chapters and 45 categories within the ICF. Outcomes mapped primarily to body function (30 categories) and activities and participation (9 categories) components. Few outcomes mapped to body structures (2 categories) or environmental factors (1 category).

CONCLUSION

This sets the stage to develop a resource for researchers/clinicians that will aid in the selection of appropriate outcomes/biomarkers when examining exercise effects in MS.

The lived experience of physical exertion for persons with advanced multiple sclerosis: making connections with the world

PURPOSE

To explore the lived experience of physical exertion for persons living with advanced multiple sclerosis (MS).

METHOD

An interpretive (hermeneutic) phenomenological approach was undertaken with 8 persons living with advanced MS. Interviews were conducted with exploratory questions that explored participants' experiences of physical exertion. Data was analysed using phenomenological methods and the findings presented as hermeneutic stories.

RESULTS

Participants conveyed physical exertion as a means of influencing their connection with the world. Interpretation identified four subthemes; Lived Body, Sense of Self, Purpose of exertion, and Attributes of the World and an overarching superordinate theme Body-World engagement. Hermeneutic stories illuminated the intertwined relationship between the themes and the idiographic nature of physical exertion.

CONCLUSION

The experience of physical exertion was meaningfully related to participants' sense of self, agency, and 'being in the world'.

The Early Initiation Advantages of Physical Therapy in Multiple Sclerosis-A Pilot Study

(1) Background: Multiple sclerosis (MS), a chronic progressive neurological disorder which affects the central nervous system (CNS), can result in disorders of all the functions controlled by the CNS: motor, sensory, cognitive and emotional. Physical therapy (PT), conducted through proprioceptive neuromuscular facilitation (PNF) techniques, can be customized to the individual patient's needs and has the potential to improve the patient's evolution. This study aims to establish if PT based on PNF techniques has a beneficial role in MS treatment. (2) Methods: We performed a prospective study on 40 patients who were diagnosed with MS and previously treated only with MS drug treatment (DT). These patients have participated in a PT program throughout one year. At the beginning and at the end of our study, after one year, we have assessed the following parameters: timed walk for 25 feet (Timed 25-Foot Walk test- T25FW test), dexterity of the upper limbs (9-Hole Peg Test-9HPT), disability level (Expanded Disability Status Scale-EDSS) and cognitive function (Paced Auditory Serial Addition Test-PASAT. (3) Results: In subjects in the early stages of MS, lower limb mobility improved significantly, T25FW decreasing from 6.46 to 5.80 (p < 0.001) and upper limb ability increased significantly in the dominant hand, 9HPT decreasing from 17.73 to 16.97 (p = 0.006) and not significantly in the non-dominant hand, 9HPT decreasing from 17.73 to 17.50 (p = 0.255). Furthermore, among these subjects, cognitive performance improved; their PASAT increased from 52.14 to 54.14 (p = 0.036), while the level of disability of these subjects improved only slightly, the EDSS scale evolving from 3.08 to 2.91 (p = 0.650). (4) Conclusions: In patients with early forms of MS, combining DT with a PT program based on PNF techniques results in: regaining muscle strength in the lower limbs, improving coordination while walking, correcting dexterity in the upper limbs and increasing the ability to concentrate.

Influence of Transcranial Direct Current Stimulation and Exercise on Physical Capacity and Gait in Multiple Sclerosis: A Cross-Over Pilot Study

Physical capacity provides a link between disease or impairment and limitations in activity; in multiple sclerosis (MS), it is limited and decreased. The aim of this study was to study the effects of exercise and transcranial direct current stimulation (tDCS) on the left dorsolateral prefrontal cortex area in MS patients with fatigue and an impaired gait ability. A cross-over design was carried out on fifteen patients with two disability associations, but three were excluded. Before and after each intervention, the 6 min walk test (6MWT) and the 2 min walk test (2MWT) were used to assess walking ability and the Modified Fatigue Impact Scale (MFIS) was used to assess fatigue. A total of twelve patients were enrolled (48.0 median age, Kurtzke Disability Scale (EDSS) 3.66 ± 1.3): five females and seven males. After the application of the exercise program, significant improvements were observed in the 6MWT (p < 0.001, g = 0.159) and 2MWT (p < 0.001, g = 0.182). Furthermore, fatigue was significantly reduced after the application of the exercise program (p < 0.05, g = 0.742) and after tDCS (p < 0.05, g = 0.525). We could consider therapeutic exercise in the future to improve the walking ability and fatigue in MS patients. Furthermore, tDCS did not exert a significant improvement in walking ability, but it appeared to influence fatigue. Clinical trial registration code: ACTRN12622000264785.

Relationship between foot pressure and spinal parameters in healthy adults - A systematic review

BACKGROUND

Foot pressure has an essential impact on the entire musculoskeletal chain. So far, the direct influence of foot pressure onto the spinal posture and vice versa is still unclear.

RESEARCH QUESTION

The aim of this study was to determine the relationship between foot pressure and spinal posture in healthy adults under static and dynamic conditions.

METHODS

Systematic research was conducted using PubMed to demonstrate the relationship between foot pressure and spinal posture. The search strategy was based on the PICOS selection criteria. The risk of bias within the studies was assessed using SIGN rankings.

RESULTS

Based on the search strategy, 719 articles were identified by screening title and abstract. 11 studies with moderate methodological quality partially showed a relationship between foot pressure and spinal posture (SIGN:2-1- and B-D). Apart from the foot pressure, the included studies analyzed parameters of muscle thickness (sonography), trunk displacement, head position, posterior tilt angle, trunk tilt, pelvic rotation, spinal range of motion, or spinal motion. Strength training and increased muscle thickness in the lumbar spine ensure decreased foot pressure. The head position partly induces a change of foot pressure under static conditions. No correlation was identified between spinal posture and foot pressure during forward and backward walking without manipulation. The static and dynamic measurements only show statistical correlations between foot and back muscles.

SIGNIFICANCE

Foot pressure and spinal posture seem to be interrelated under static and dynamic conditions. Static and dynamic measurements are necessary for body posture analysis, as the conditions do not always show consistent results. Due to the small number of studies and low sample sizes, further investigations are necessary to gain more precise perception of the interplay of the spine and foot pressure. For better comparison, more homogeneous studies investigating similar spine parameters are needed.

Effects of aerobic, resistance, and combined exercise training on health-related quality of life in multiple sclerosis: Systematic review and meta-analysis

BACKGROUND

Multiple sclerosis (MS) is an immune-mediated, neurodegenerative disease of the central nervous system that manifests in symptoms that compromise health-related quality of life (HRQOL). HRQOL focuses on a person's overall, subjective evaluation of health status primarily in the physical and mental domains. Exercise training is a form of rehabilitation for managing MS-related outcomes that might influence HRQOL. Reviews on exercise training are available, but we are unaware of a recent comprehensive review and meta-analysis of exercise effects for improving physical and mental domains of HRQOL. This analysis provides an updated review and meta-analysis of randomized controlled trials (RCTs) examining interventions consisting of aerobic, resistance and combined exercise training for improving HRQOL in persons with MS. This systematic review 1) assessed the overall strength of evidence for exercise interventions on HRQOL, 2) evaluated the relative effect of exercise interventions on physical and mental domains of HRQOL, and 3) determined moderators of exercise intervention effects on HRQOL.

METHODS

Seven databases were searched for RCTs evaluating physical and/or mental domains of HRQOL with adults diagnosed with MS and undergoing an intervention of aerobic, resistance or combined exercise training compared with a non-exercise comparator. Data extraction included participant and intervention characteristics, and pre- and post-intervention HRQOL outcome data. Effect sizes (ESs) were calculated as standardized mean differences (SMDs) and a multilevel random-effects model was used to generate an aggregated SMD that compared exercise with non-exercise control conditions.

RESULTS

Twelve RCTs met the inclusion criteria and yielded 23 ESs to be analyzed. Participants (N = 593; 308 intervention vs. 285 control conditions) had a mean (±standard deviation) age of 42.4 (6.5) years and 80% (18.3%) were female. Results generated a medium effect of exercise for improving overall HRQOL (ES=0.64, p = 0.0001) with high heterogeneity (Q₁₁=58.8, I²=86.7%). Exercise training yielded a large effect on the physical domain (k = 12, ES=0.82, p<0.0009) and a medium effect on the mental domain (k = 11, ES=0.41, p<0.0001). Moderator analyses identified exercise modality, supervision level, intervention delivery and length, HRQOL tool, and number of participants with relapsing-remitting MS as significant influences of ES for HRQOL.

CONCLUSIONS

Exercise training is clinically effective for improving overall HRQOL in MS and produces greater improvements in the physical domain of HRQOL than the mental domain. The moderator analysis suggests that supervised, aerobic, and group-delivered exercise training of ≥3 months yields the most influence on HRQOL. Such results may have major implications for MS treatment and care.

Evaluation of the relationship between the morphometric structure of the pituitary gland and fatigue in patients with multiple sclerosis

BACKGROUND

The correlation between fatigue and disability in multiple sclerosis (MS) with the hypothalamus-pituitary-adrenal axis is known. This study aimed to investigate the relationship between the morphometric dimensions of the pituitary gland with fatigue and disability.

METHOD

This research, designed as a prospective and case-control study, included 85 MS patients and 45 healthy controls. The disability was evaluated using the expanded disability rating scale (EDSS), while fatigue was determined using the fatigue severity scale (FSS) and the neurological fatigue index (NFI-MS). The morphometric structure of the pituitary gland was measured using a coronal, T2-weighted, turbo-spin-echo sequence of magnetic resonance imaging.

RESULTS

FSS and NFI-MS scores were higher in MS patients than in the control group (p = 0.001). Patients with a progressive and moderate-to-severe disability had a higher FSS score (p = 0.015; p = 0.002, respectively). A positive correlation was determined between disease duration, attack frequency, and EDSS and physical fatigue subscale score (p = 0.001; r = 0.383; 0.373; 0.545, respectively). The height and width of the pituitary gland were higher in MS patients (p = 0.021; p = 0.001, respectively). Pituitary gland height was higher in fatigued patients (p = 0.041). A low-positive correlation was determined between the number of attacks and the height of the pituitary gland (p = 0.027, r = 0.231).

CONCLUSION

The difference in the dimensions of the pituitary gland in MS patients, especially in the fatigued group, supports the relationship of fatigue with morphometric features as well as the hypothalamus-pituitary-adrenal axis.

Participant characteristics of existing exercise studies in persons with multiple sclerosis - A systematic review identifying literature gaps

BACKGROUND

Exercise is a cornerstone in rehabilitation of persons with multiple sclerosis (pwMS), which is known to elicit beneficial effects on various symptoms and to have a potential disease-modifying effect. However, it remains to be elucidated if the existing MS exercise literature covers the full age and disability span of pwMS.

OBJECTIVE

To systematically review MS exercise studies and provide a detailed mapping of the demographic and clinical characteristics of the included pwMS.

METHODS

A systematic review of MS exercise studies were performed using MEDLINE and EMBASE. From the resulting MS exercise studies, mean sample characteristics were extracted.

RESULTS

4576 records were identified, from which 202 studies were included. Of these, 166 studies (82.2%) enrolled pwMS aged 35-54 years, 10.9% enrolled pwMS <35 years, and 6.9% enrolled pwMS ≥55 years (only 1.5% enrolled pwMS ≥60 years). A total of 118 studies (58.4%) reported Expanded Disability Status Scale (EDSS), with 88.1% of included pwMS having an EDSS between 2.0 and 6.5, while only one study enrolled pwMS with an EDSS ≥7.0. Finally, 80% of the studies included pwMS having a disease duration of 5-14.5 years.

CONCLUSION

Exercise studies in pwMS included primarily middle-aged (35-54 years) pwMS having an EDSS of 2.0-6.5 and a disease duration of 5-14.5 years. Few exercise studies were identified in young and older pwMS, in pwMS with mild disability and severe disability, and in pwMS having shorter or longer disease durations. These findings highlight the need for further investigation of exercise in these specific subgroups of pwMS as benefits of exercise might not generalize across subpopulations.

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

Background

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

Method

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

Results

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

Conclusion

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

Supplementary Information

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

Rehabilitation on a treadmill induces plastic changes in the dendritic spines of spinal motoneurons associated with improved execution after a pharmacological injury to the motor cortex in rats

Lesions to the corticospinal tract result in several neurological symptoms and several rehabilitation protocols have proven useful in attempts to direct underlying plastic phenomena. However, the effects that such protocols may exert on the dendritic spines of motoneurons to enhance accuracy during rehabilitation are unknown. Thirty three female Sprague-Dawley adult rats were injected stereotaxically at the primary motor cerebral cortex (Fr1) with saline (CTL), or kainic acid (INJ), or kainic acid and further rehabilitation on a treadmill 16 days after lesion (INJ+RB). Motor performance was evaluated with the the Basso, Beatie and Bresnahan (BBB) locomotion scale and in the Rotarod. Spine density was quantified in a primary dendrite of motoneurons in Lamina IX in the ventral horn of the thoracolumbar spinal cord as well as spine morphology. AMPA, BDNF, PSD-95 and synaptophysin expression was evaluated by Western blot. INJ+RB group showed higher scores in motor performance. Animals from the INJ+RB group showed more thin, mushroom, stubby and wide spines than the CTL group, while the content of AMPA, BDNF, PSD-95 and Synaptophysin was not different between the groups INJ+RB and CTL. AMPA and synaptophysin content was greater in INJ group than in CTL and INJ+RB groups. The increase in the proportion of each type of spine observed in INJ+RB group suggest spinogenesis and a greater capability to integrate the afferent information to motoneurons under relatively stable molecular conditions at the synaptic level.

Characterizing Relationships Between Cognitive, Mental, and Physical Health and Physical Activity Levels in Persons With Multiple Sclerosis

BACKGROUND

Although persons with multiple sclerosis (MS) are encouraged to engage in physical activity, they are less active than the general population and experience poorer emotional/cognitive health, underscoring the need for increased understanding of the factors independently associated with exercise in MS.

METHODS

Six hundred forty people with MS completed a detailed demographic survey, the Godin Leisure-Time Exercise Questionnaire, and Quality of Life in Neurological Disorders short forms. The average number of weekly sessions of exercise was examined as a count, as a binary variable (a weekly minimum of 4 sessions of physical activity), and as an ordinal variable of being active using multivariable zero-inflated negative binomial, logistic, and ordered logistic regression models, respectively. Primary predictors of interest included depression, cognitive function, positive affect, and lower extremity functioning as measured by the Quality of Life in Neurological Disorders short forms.

RESULTS

The study sample was 91% White race, 83% female, 65% with a relapsing-remitting MS diagnosis. The mean participant age was 52 years. Across analyses, body mass index and disability were inversely associated with exercising. Greater lower extremity impairment was associated with decreased odds of exercising and being active. A greater burden of depression symptoms was correlated with lower odds of engaging in physical activity. People with MS with higher self-reported cognitive functioning were less likely to engage in any exercise, but it was not associated with frequency of activities.

CONCLUSIONS

These results demonstrate associations between exercise and cognitive and emotional health in people with MS, underscoring the need to consider these factors when designing MS-targeted physical activity recommendations.

The Effectiveness of Physiotherapy Interventions for Mobility in Severe Multiple Sclerosis: A Systematic Review and Meta-Analysis

Background

People with Multiple Sclerosis (pwMS) prioritise gait as the most valuable function to be affected by MS. Physiotherapy plays a key role in managing gait impairment in MS. There is little evidence on the effectiveness of physiotherapy for severe MS.

Objective

To undertake a systematic review and meta-analysis of the literature to identify evidence for the effectiveness of physiotherapy for gait impairment in severe MS. Methods. The available literature was systematically searched, using a predetermined protocol, to identify research studies investigating a physiotherapy intervention for mobility in people with severe MS (EDSS ≥ 6.0). Data on mobility related endpoints was extracted. Meta-analysis was performed where a given mobility end point was reported in at least 3 studies.

Results

37 relevant papers were identified, which included 788 pwMS. Seven mobility-related endpoints were meta-analysed. Robot-Assisted Gait Training (RAGT) was found to improve performance on the 6-minute walk test, 10-metre walk test, fatigue severity scale, and Berg Balance Scale. Neither body weight supported training nor conventional walking training significantly improved any mobility-related outcomes.

Conclusion

Physiotherapy interventions are feasible for mobility in severe MS. There is some evidence for the effectiveness of RAGT.

Comparative effectiveness of four exercise interventions followed by two years of exercise maintenance in multiple sclerosis: A randomized control trial

OBJECTIVE

To determine the effects of Exergaming on quality of life (QoL), motor, and clinical symptoms in Multiple Sclerosis. We compared the effects of exergaming (EXE), balance (BAL), cycling (CYC), proprioceptive neuromuscular facilitation (PNF), and a standard care wait-listed control group (CON) on clinical and motor symptoms and quality of life (QoL) in people with MS (PwMS) and determined the effects of subsequent maintenance programs for 2 years in a hospital setting.

DESIGN

A randomized clinical trial, using before-after test design.

SETTINGS

University Hospital Setting PARTICIPANTS: Of 82 multiple sclerosis outpatients, 70 were randomized, and 68 completed the study.

INTERVENTIONS

The initial high-intensity and -frequency interventions consisted of 25, 1-h sessions over 5 weeks. After the 5-wk-long initial intervention, the 2-year-long maintenance programs followed, consisting of 3 sessions per week, each for 1h.

MAIN OUTCOME MEASURES

The primary outcome: Multiple Sclerosis Impact Scale (MSIS-29).

SECONDARY OUTCOMES

Measures five aspects of health-related QoL (EQ-5D index), Beck Depression Inventory, six-minute walk test (6MWT), Berg Balance Scale (BBS), Tinetti Assessment Tool (TAT) and static balance (center of pressure, COP).

RESULTS

MSIS-29 improved most in EXE (11 points), BAL (6), and CYC (6, all p<0.05). QoL improved most in EXE (3 points) and CYC and BAL (2, all p<0.05). TAT and BBS improved significantly (p<0.05) but similarly (p>0.05) in EXE, BAL, and CYC. 6MWT improved most in EXE (57m), BAL (32m), and CYC (19m all p<0.001). Standing sway did not change. Maintenance programs further increased the initial exercise-induced gains, robustly in EXE.

CONCLUSION

25 sessions of EXE, BAL, CYC, and PNF, in this order, improved clinical and motor symptoms and QoL and subsequent, 2-y-long thrice weekly maintenance programs further slowed symptom-worsening and improved QoL. EXE was the most and PNF was the least effective to improve clinical symptoms, motor function, and QoL in PwMS.

Combined effects of cerebellar tDCS and task-oriented circuit training in people with multiple sclerosis: A pilot randomized control trial

Background: Balance and mobility impairments are frequent in people with multiple sclerosis, partly due to cerebellar dysfunctions. Task-oriented behavioural approaches were previously shown to promote physical function. The possibility exists that cerebellar transcranial direct current stimulation (ctDCS) applied during training, known to increase the excitability of the brain, can boost rehabilitation effects through modulation of cerebellum-brain inhibition. Objective: To test the efficacy of cerebellar ctDCS stimulation combined with motor training on mobility and balance in people with multiple sclerosis. Methods: 16 subjects were randomly assigned to receive real- or sham-ctDCS and task-oriented training daily over two weeks in a double-blind, randomised clinical pilot trial. Functional mobility, balance, walking performance and quality of life were tested before and after treatment and at two-week follow-up. Effects of cerebellar stimulation on psychological and executive functions were also recorded. Results: Walking performance, balance and quality of life improved for both groups at post-treatment assessment which was maintained at 2-weeks follow up. A two-way ANOVA revealed a significant time effect for balance and walking performance. A significant interaction effect of time–treatment (F = 3.12, df = 2,26; p = 0.03) was found for motor aspects of quality of life assessment in patients who received real-ctDCS. Conclusions: Task-oriented training improves balance and mobility in people with multiple sclerosis, but ctDCS does not boost motor training effects.

High-intensity interval training in people with mild multiple sclerosis: a mixed-methods feasibility study

Background/Aims

High-intensity interval training has received increased attention as a mode of exercise, including as a therapy in clinical populations. This study investigated the acceptability of a high-intensity interval training intervention in people with mild multiple sclerosis.

Methods

Participants attended two sessions a week for the 6-week intervention. Each session consisted of 6–10 sets of 60-second high-intensity intervals interspersed with 120 seconds of recovery. The acceptability, intervention adherence and safety of the high-intensity interval training protocol and estimates of treatment effects (fitness, physical activity levels, fatigue and quality of life) were used to determine intervention feasibility. Qualitative interviews were used to explore the acceptability of the intervention.

Results

A total of 11 people with mild multiple sclerosis consented to participate in a 6-week high-intensity interval intervention. One participant dropped out of the intervention. The participants expressed apprehension before the intervention but attendance at the exercise sessions was high (87%). Participants experienced some symptom exacerbation following sessions, although none were serious. Improvements were seen in fitness, physical activity, fatigue and health-related quality of life.

Conclusions

The study findings suggest that high-intensity interval training is acceptable, safe and may offer disease-related benefits for the participants. Participants did experience some symptom exacerbation and further studies are needed to determine the long-term appeal of high-intensity interval training for people with mild multiple sclerosis.

Use of Robotic Devices for Gait Training in Patients Diagnosed with Multiple Sclerosis: Current State of the Art

Multiple sclerosis (MS) is a neurodegenerative disease that produces alterations in balance and gait in most patients. Robot-assisted gait training devices have been proposed as a complementary approach to conventional rehabilitation treatment as a means of improving these alterations. The aim of this study was to investigate the available scientific evidence on the benefits of the use of robotics in the physiotherapy treatment in people with MS. A systematic review of randomized controlled trials was performed. Studies from the last five years on walking in adults with MS were included. The PEDro scale was used to assess the methodological quality of the included studies, and the Jadad scale was used to assess the level of evidence and the degree of recommendation. Seventeen studies met the eligibility criteria. For the improvement of gait speed, robotic devices do not appear to be superior, compared to the rest of the interventions evaluated. The methodological quality of the studies was moderate–low. For this reason, robot-assisted gait training is considered just as effective as conventional rehabilitation training for improving gait in people with MS.

Evaluating and Characterizing an Individually-Tailored Community Exercise Program for Older Adults With Chronic Neurological Conditions: A Mixed-Methods Study

A mixed-methods approach was used to study an individually-tailored community exercise program for people with a range of chronic neurological conditions (e.g., stroke, spinal cord injury, brain injury, multiple sclerosis, Parkinson's disease) and abilities. The program was delivered to older adults (mean age: 62 ± 9 years) with chronic neurological conditions across a 12-week and an 8-week term. Participants attended 88% of sessions and completed 89% of prescribed exercises in those sessions. There were no adverse events. Clinically important improvements were achieved by all evaluated participants (n = 8) in at least one testing domain (grip strength, lower-extremity strength, aerobic endurance, and balance). Interviews with participants identified key program elements as support through supervision, social connection, individualized programming, and experiential learning. Findings provide insight into elements that enable a community exercise program to meet the needs of a complex and varied group. Further study will support positive long-term outcomes for people aging with neurological conditions.

Identifying unanswered questions and setting the agenda for future systematic research in Multiple Sclerosis. A worldwide, multi-stakeholder Priority Setting project

BACKGROUND

Eliciting the research priorities of people affected by a condition, carers and health care professionals can increase research value and reduce research waste. The Cochrane Multiple Sclerosis and Rare Disease of CNS Group, in collaboration with the Cochrane Neurological Sciences Field, launched a priority setting exercise with the aim of prioritizing pressing questions to ensure that future systematic reviews are as useful as possible to the people who need them, in all countries, regardless of their economic status.

METHOD

Sixteen high priority questions on different aspects of MS were developed by members of a multi-stakeholder priority setting Steering Group (SG). In an anonymous online survey translated into 12 languages researchers, clinicians, people with MS (PwMS) and carers were asked to identify and rank, 5 out of 16 questions as high priority and to provide an explanation for their choice. An additional free-text priority research topic suggestion was allowed.

RESULTS

The survey was accessible through MS advocacy associations' social media and Cochrane web pages from October 20, 2020 to February 6, 2021. 1.190 responses (86.73% of all web contacts) were evaluable and included in the analysis. Responses came from 55 countries worldwide, 7 of which provided >75% of respondents and 95% of which were high and upper-middle income countries. 58.8% of respondents live in the EU, 23% in the Americas, 8.9% in the Western Pacific, 2.8% in the Eastern Mediterranean and 0.3% in South Eastern Asia. About 75% of the respondents were PwMS. The five research questions to be answered with the highest priority were: Question (Q)1 "Does MRI help predict disability worsening of PwMS?" (19.9%), Q5 "What are the benefits and harms of treating PwMS with one disease-modifying drug compared to another?" (19.3%), Q3 "Does multidisciplinary care by teams of different social and health professionals improve health outcomes and experiences for PwMS?" (11.9%), Q16 "Does psychological health affect disease progression in PwMS?" (9.2%) and Q10 "What are the benefits and harms of exercise for PwMS?" (7.2%). The multivariable logistic regression analysis indicated a significant influence of geographic area and income level on the ranking of Q1 and a marginal for Q16 as top a priority after accounting for the effect of all other predictors. Approximately 50% of the respondents indicated that they had an important additional suggestion to be considered.

CONCLUSION

This international collaborative initiative in the field of MS offers a worldwide perspective on the research questions perceived as pivotal by a geographically representative sample of multiple stakeholders in the field of MS. The results of the survey could guide the prioritization of research on pharmacological and non-pharmacological interventions which could be meaningful and useful for PwMS and carers, avoiding the duplication of efforts and research waste. High quality systematic reviews elicited by priority setting exercises may offer the best available evidence and inform decisions by healthcare providers and policy-makers which can be adapted to the different realities around the world.

Frame running to confidence: the athlete-perceived impact of an adapted physical activity on aspects of physical fitness, functional mobility and psychosocial outcomes

Objective

Frame Running (RaceRunning) allows people with moderate-to-severe mobility impairments to participate in physical activity using a 3-wheeled frame with a saddle and handlebars. The aim of this study was to investigate athlete-perceived impact of Frame Running on aspects of physical fitness, functional mobility and psychosocial outcomes.

Design

Survey.

Participants

Frame Running athletes aged 5 years and over.

Methods

A survey was distributed to athletes through their club or sports organization.

Results

The survey was completed by 115 athletes (53 females). Median age was 17 years (range 5–62 years) and 64 (57%) used a wheelchair or walker for distances over 50 m. Many felt that Frame Running stretched their muscles (n = 93, 87%) and increased their self-confidence (n = 63, 93%). Four (4%) reported extreme fatigue or sore muscles after training (n = 17, 15%). Of the 110 athletes who had been participating in Frame Running for over 3 months, 46 (47%) reported being less out of breath during mobility tasks and 66 (66%) felt they had improved their functional mobility. However, 7 (7%) reported increased muscle tightness and 4 (4%) reported a Frame Running-related injury lasting more than 4 weeks.

Conclusion

Frame Running is a safe physical activity with athlete-perceived benefits on physical fitness, functional mobility and psychosocial outcomes.

Physical exercise therapy for autoimmune neuroinflammation: Application of knowledge from animal models to patient care

Physical exercise (PE) impacts various autoimmune diseases. Accordingly, clinical trials demonstrated the safety of PE in multiple sclerosis (MS) patients and indicated beneficial outcomes. There is also an increasing body of research on the beneficial effects of exercise on experimental autoimmune encephalomyelitis (EAE), the animal model of MS, and various mechanisms underlying these effects were suggested. However, despite the documented favorable impact of PE on our health, we still lack a thorough understanding of its effects on autoimmune neuroinflammation and specific guidelines of PE therapy for MS patients are lacking. To that end, current findings on the impact of PE on autoimmune neuroinflammation, both in human MS and animal models are reviewed. The concept of personalized PE therapy for autoimmune neuroinflammation is discussed, and future research for providing biological rationale for clinical trials to pave the road for precise PE therapy in MS patients is described.

Home-Based Tele-Exercise in Musculoskeletal Conditions and Chronic Disease: A Literature Review

Exercise training is an essential component in the treatment or rehabilitation of various diseases and conditions. However, barriers to exercise such as the burdens of travel or time may hinder individuals' ability to participate in such training programs. Advancements in technology have allowed for remote, home-based exercise training to be utilized as a supplement or replacement to conventional exercise training programs. Individuals in these home-based exercise programs are able to do so under varying levels of supervision from trained professionals, with some programs having direct supervision, and others having little to no supervision at all. The purpose of this review is to examine the use of home-based, tele-exercise training programs for the treatment of different disease states and conditions, and how these programs compare to conventional clinic-based exercise training programs.

Effects of Sensory Interventions on Fatigue in People With Multiple Sclerosis: A Systematic Review

BACKGROUND

Fatigue is 1 of the most common and annoying symptoms in patients with multiple sclerosis (MS). The purpose of this study was to investigate the effect of sensory interventions on fatigue in people with MS based on a systematic review of sensory evidence.

METHODS

The Google Scholar, PubMed, Scopus, and Cochrane Library databases were searched from January 1990 to July 2020. Studies with nonpharmacologic sensory interventions as a main or secondary intervention according to the assessment of fatigue as the primary or secondary therapy outcome in patients with MS were included.

RESULTS

Nine articles were reviewed by examining the inclusion and exclusion criteria. Four types of interventions were related to exercises, including sensory integration exercises, vestibular rehabilitation, Frenkel exercises, and exercises with or without vibration; and 2 types were performed using robots and 1 type using vibration only. Vestibular rehabilitation therapies, exercise-based sensory integration interventions, and the use of vibration have shown significant effects in relieving fatigue in patients with MS.

CONCLUSIONS

The evidence in this study is insufficient to show a dramatic effect of sensory integration therapy in various forms. However, despite the studies, sensory integration therapy can be considered a potential treatment for fatigue in patients with MS. Further studies with stronger methods are needed to make this treatment a reality.

Exercise Training for Multiple Sclerosis: A Narrative Review of History, Benefits, Safety, Guidelines, and Promotion

Background: There have been significant advances in the medical treatment and management of multiple sclerosis pathogenesis, relapse and disease progression over the past 30 years. There have been advancements in the symptomatic treatment of multiple sclerosis, including management of secondary multiple sclerosis expressions such as walking, cognitive dysfunction, fatigue and depression. Scientific evidence and expert opinion suggest that exercise may be the single most effective non-pharmacological symptomatic treatment for multiple sclerosis. This article presents the historical context of exercise training within the multidisciplinary management of multiple sclerosis. We guide neurologists and healthcare providers on the recommended prescription of exercise and practical, theoretical methods to overcome barriers to exercise. Method: We undertook a critical search of the historical and current literature regarding exercise and multiple sclerosis from the viewpoint of exercise promotion by neurologists and the multidisciplinary care team. Results: We highlight the ever-strengthening body of research indicating that exercise is safe and effective for improving symptoms of multiple sclerosis. Further, exercise training may be necessary for reducing disease progression. Conclusion: We seek to encourage neurologists and specialists in multidisciplinary healthcare teams to prescribe and promote exercise at diagnosis and across all stages of the disease trajectory using prescriptive guidelines as part of comprehensive MS care. Available tools include clinical education to dispel any historical myths related to exercise in multiple sclerosis, clinical exercise guidelines and behaviour change theory to overcome patients barriers to exercise.

Correlates of Objectively Measured Physical Activity Among People With Multiple Sclerosis: A Cross-Sectional Study

Background: Identifying correlates of physical activity (PA) for people with multiple sclerosis (MS) is essential to design effective PA interventions.

Methods: Participants completed a battery of questionnaires and wore an ActiGraph accelerometer. Light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) (min/day) were calculated. Associations were examined using multiple linear regression adjusted for demographic and clinical confounders.

Results: Fifty-eight adults with MS participated (mean ± SD age: 56.8 ± 9.2 yr; 67% women). MS type was associated with time in LPA. Participants with secondary progressive MS (B = −54.0, 95% CI −84.7 to −23.3) and primary progressive MS (B = −42.9, 95% CI −77.5 to −8.3) spent less time in LPA than those with relapsing remitting MS. Walking capacity, assessed using the 12-item MS walking scale (MSWS-12), was associated with time in MVPA (B = −0.36, 95% CI −0.72 to −0.01).

Conclusion: This work identifies walking capacity and type of MS as correlates of PA, which may indicate development of interventions to promote PA.

Minimal clinically important difference of modified dynamic gait index in people with neurological disorders

BACKGROUND

The minimal clinically important difference (MCID) of modified Dynamic Gait Index (mDGI) has not yet been determined for People with Neurological Disorders (PwND).

RESEARCH QUESTION

To establish the MCID of the mDGI to determine clinically meaningful improvement in balance and gait in PwND.

METHODS

In this longitudinal study from a randomised clinical trial, 55 participants both in and outpatients with neurological disorders, received fifteen 40-minute rehabilitation sessions. Inpatients received daily treatments over a period of three weeks while outpatients received three treatments/week over a period of five weeks. An anchor-based method using percentage rating of improvement in balance (Activities Balance Confidence scale, ABC) was used to determine the MCID of mDGI. The MCID was defined as the minimum change in mDGI total score (post - pre intervention) that was needed to perceive at least a 10 % improvement on the ABC scale. A Receiver Operating Characteristic curve was used to define the cut-off for the optimal MCID of the mDGI discriminating between improved and not improved participants.

RESULTS

The MCID of the mDGI total score was 6 points and Area under the Curve was 0.64. For the mDGI time sub-scores the MCID was 2 points and Area under the Curve was 0.6.

SIGNIFICANCE

The MCID of balance and gait improvement measured by mDGI was prudently establish at ≥7 points, meaning that this is the minimum improvement score PwND need to get to perceive a clinically relevant change in their balance and gait confidence. These reference values can be a tool incorporated into clinicians daily practice to interpret mDGI change scores helping to determine whether the intervention is effective; to develop clinical tailored intervention goals and to establish meaningful perceived change in PwND.

Impact of Moderate Individually Tailored Physical Activity in Multiple Sclerosis Patients with Fatigue on Functional, Cognitive, Emotional State, and Postural Stability

Multiple sclerosis (MS) is a chronic disease, with fatigue syndrome as one of the main symptoms. The aim of this study was to demonstrate that moderate physical activity (MPA) may have a beneficial effect on postural stability, balance, and clinical parameters. The research group consisted of 137 randomized patients hospitalized at the Department of Neurological Rehabilitation, Medical University of Lodz. Finally, 76 patients were qualified who were divided into two groups—high fatigue (HF) and low fatigue (LF). Participants were assessed twice: before and after a 4-week MPA program using: the Expanded Disability Status Scale (EDSS), the Fatigue Severity Scale (FSS), the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), the Beck Depression Inventory (BDI), and the Geriatric Depression Scale (GDS), and stabilometric platform tests were performed. Results obtained after the 4-week MPA program showed a positive effect of the MPA with differences between LF and HF groups. The MPA was more effective in MS patients with LF in cognitive functions, functional status, and postural stability but among HF patients in an emotional state, especially in MS patients below 65 years, although in total, both groups benefited from the MPA.

Health Promotion and Wellness in Neurologic Physical Therapy: Strategies to Advance Practice

BACKGROUND AND PURPOSE

Neurologic physical therapy (PT) can assist people with neurologic conditions and injuries to optimize their health and well-being by addressing barriers at the individual, relationship, community, and societal levels. The purpose of this special interest article is to provide consensus-driven strategies to address barriers to implementing health promotion and wellness (HPW)-related neurologic PT practice.

SUMMARY OF KEY POINTS

Environmental scan, literature review, and expert input were used to determine barriers and develop strategies. Barriers include lack of time; low knowledge, self-efficacy, and awareness; client complexity; and lack of HPW resources; as well as concerns regarding payment and scope of practice. Four key strategies emerged: (1) develop and disseminate a consensus-based scope of practice for HPW in neurologic PT; (2) increase knowledge of resources related to HPW; (3) promote delivery models for HPW-related neurologic PT; and (4) encourage advocacy, community building and partnership along the continuum of care.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Clinicians should practice to their full scope of HPW-related PT practice. This includes optimizing movement, including physical activity and fitness, as well as reinforcing the importance of healthy sleep, nutrition, stress, and smoking cessation. These activities address primary, secondary, and tertiary prevention. Clinicians are encouraged to report their experiences with HPW-focused delivery models and outcomes. Additional research is needed to understand the full impact of HPW on PT practice (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A364).

Exercise and Sports Science Australia (ESSA) position statement on exercise for people with mild to moderate multiple sclerosis

OBJECTIVES

Multiple sclerosis (MS), the most common chronic and progressive neurological condition of the central nervous system, affects 26,000 Australian adults. Exercise training has beneficial effects on MS-related impairments including reduced muscular strength, poor aerobic capacity and impaired mobility, and in consequence can improve quality of life. This Position Statement provides evidence-based recommendations for exercise prescription and delivery of exercise training for people with MS with mild to moderate disability.

DESIGN AND METHODS

Synthesis of published works within the field of exercise training in MS.

RESULTS

Exercise provides many benefits to people with MS. There is strong evidence that resistance and aerobic training, performed 2 to 3 times per week at a moderate intensity, are safe and can improve muscle strength, cardiorespiratory fitness, balance, fatigue, functional capacity, mobility and quality of life in people with MS with mild to moderate disability (Expanded Disease Severity Scale (EDSS) ≤ 6.5). However, the evidence for those with severe disability (EDSS >6.5) is less clear. The effects of exercise on MS pathogenesis, central nervous structures and other outcomes such as depression and cognitive impairment, have not been adequately investigated. Effective exercise interventions to improve balance, joint contractures and reduce falls in people with MS are also urgently needed as well as investigations of long-term (≥1 year) effects of exercise training.

CONCLUSIONS

Resistance and aerobic training exercises are effective to alleviate some characteristic signs and symptoms in MS and should be supplemented by balance exercise to prevent falls. Exercise training programs should be prescribed and delivered by qualified exercise professionals. It is important to recognise and accommodate exercise-associated complications such as fatigue and heat sensitivity.

The relationship between dysphagia, respiratory functions and anthropometry in patients with multiple sclerosis

BACKGROUND

It is known that many body systems are affected as a result of dysphagia. The aim of this study is to investigate the relationship between clinical features, respiratory functions, anthropometric measurements and dysphagia in patients with multiple sclerosis (MS).

METHOD

Seventy-five MS patients and 50 healthy controls were included in this prospective case-control study. Disability was assessed with expanded disability status scale (EDSS), and swallowing was assessed with questionnaire for the assessment of dysphagia (solid, liquid and total) for disease. Respiratory functions were demonstrated with computerized spirometry device. Body weight, height, waist, hip, and mid-arm circumference are measured. Body mass index and body fat percentage were calculated. The relationship of all these parameters with disease activity and dysphagia was investigated.

RESULTS

There were 75 MS patients with a mean age of 38.40 ± 11.27 years, and 50 (66.70%) were female in the study. The all type of dysphagia scores were higher in MS patients than control group (p = 0.001). Many respiratory function test scores and only hip circumference were lower in MS patients. However, especially low forced expiratory volume-1st second (FEV1), forced vital capacity (FVC) and peak expiratory flow (PEF) values were associated with disability. In addition, dysphagia scores were higher in progressive MS patients with severe disability and high frequency attacks (p = 0.001). Increased severity of dysphagia are associated with many lower anthropometric measurements (not height-especially mid-arm circumference) and respiratory function test scores.

CONCLUSION

MS affects swallowing and respiratory systems functions. They are associated with MS disease activity. Dysphagia and its severity are associated with many anthropometric measurements and respiratory functions test scores.

Home-Based Exercise Training in Multiple Sclerosis: A Systematic Review with Implications for Future Research

BACKGROUND

Substantial evidence supports the benefits of supervised exercise training (ET) in people with multiple sclerosis (MS). However, there are limitations such as transportation problems preventing physical activity for some people with MS. One opportunity for increasing physical activity participant in people with MS is home-based exercise training (HBET), yet we are unaware of a systematic review of HBET in people with MS. We undertook a systematic review for enhancing the knowledge about HBET in people with MS.

METHODS

To identify eligible studies, we included the medical subject headings (MeSH) keywords including 'multiple sclerosis' OR 'MS' OR 'degenerative nerve disease' AND 'home-based exercise' OR 'home-based training' OR 'home-based balance training' OR 'home-based rehabilitation' OR 'physical telerehabilitation' OR 'home-based walking' OR 'home-based step training.' Studies were included in this review that examined the effect of HBET in people with MS, were written in English, and available in full-text.

RESULTS

According to inclusion and exclusion criteria, 24 studies were judged eligible to be included in this systematic review. The results indicated that a total number of 10 studies had mainly implemented combined ET interventions. Balance and aerobic ET had been included in 5 studies. Three studies had further administered resistance ET interventions and one study had applied exergaming. Moreover, 13 studies had focused on the effects of ET on physical fitness, one article had reflected on the impact of ET on fatigue, and nine cases had included fatigue, quality of life, and fitness as outcome measures.

CONCLUSIONS

Home-based ET, 2-7 times per week, is beneficial, feasible, and safe in people with MS. Nevertheless, there were notable limitations, including (a) adherence to interventions, which needs to be addressed in future studies, and (b) disability-related outcomes which should be considered in future HBET studies.

Arm Ergometry to Improve Mobility in Progressive Multiple Sclerosis (AMBOS)-Results of a Pilot Randomized Controlled Trial

Background: Walking disability is one of the most frequent and burdening symptoms of progressive multiple sclerosis (MS). Most of the exercise intervention studies that showed an improvement in mobility performance were conducted in low to moderately disabled relapsing-remitting MS patients with interventions using the legs. However, MS patients with substantial walking disability hardly can perform these tasks. Earlier work has indicated that aerobic arm training might also improve walking performance and could therefore be a therapeutic option in already moderately disabled progressive MS patients. Methods: Patients with progressive MS and EDSS 4-6.5 were randomized using a computer-generated algorithm list to either a waitlist control group (CG) or an intervention group (IG). The IG performed a 12-week home-based, individualized arm ergometry exercise training program. Maximum walking distance as measured by the 6-min walking test (6MWT) was the primary endpoint. Secondary endpoints included aerobic fitness, other mobility tests, cognitive functioning, as well as fatigue and depression. Results: Of n = 86 screened patients, 53 with moderate disability (mean EDSS 5.5, SD 0.9) were included and data of 39 patients were analyzed. Patients in the IG showed strong adherence to the program with a mean of 67 (SD 26.4) training sessions. Maximum work load (P max) increased in the training group while other fitness indicators did not. Walking distance in the 6MWT improved in both training and waitlist group but not significantly more in trained patients. Similarly, other mobility measures showed no differential group effect. Cognitive functioning remained unchanged. No serious events attributable to the intervention occurred. Conclusion: Although maximum work load improved, 3 months of high-frequency arm ergometry training of low to moderate intensity could not show improved walking ability or cognitive functioning in progressive MS compared to a waitlist CG. The study was registered at www.clinicaltrials.gov (NCT03147105) and funded by the local MS self-help organization.