The effect of cycling using active-passive trainers on spasticity, cardiovascular fitness, function and quality of life in people with moderate to severe Multiple Sclerosis (MS); a feasibility study

Progressive multiple sclerosis: Evaluating current therapies and exploring future treatment strategies

Progressive forms of multiple sclerosis (MS) include primary progressive MS (PPMS) and secondary progressive MS (SPMS). Unlike relapsing-remitting MS (RRMS), progressive MS is recognized by relentless progression with accumulating disability, rare to no relapses nor new activity on MRIs. Clinically, neurologic worsening in MS can occur in the relapsing-remitting (RRMS) phase of disease due to incomplete recovery from neuroinflammatory relapses. However, a progressive disease course is the dominant factor related to accumulating disability. There is persistent central nervous system (CNS) compartmentalized inflammation, mitochondrial dysfunction and altered immune responses. Unlike in RRMS, the efficacy of disease modifying agents (DMA) in progressive MS has been limited, highlighting the need for novel therapeutic approaches that address both inflammation and neurodegeneration. This article explores current management of progressive MS, and future directions in targeting the unique pathophysiology of this complex disease.

Physical training of wheelchair users with neuromuscular disorders: A systematic review

OBJECTIVE

Wheelchair users with neuromuscular disorders have symptoms related to the disease and complications to the sedentary lifestyle, such as constipation and lower back pain. Physical training might be beneficial. This systematic review investigates the potential benefits and harms of physical training for wheelchair users with neuromuscular disorders.

METHODS

We systematically searched PubMed including studies published until July 2024. Inclusion criteria: 1) participants with a neuromuscular disorder, 2) at least 60% of participants in a study were wheelchair users, 3) physical training and its effects were investigated, 4) studies were prospective, and 5) English language was used. Non-peer-reviewed articles were excluded. Search results were screened by title, abstract, and full text. Two independent authors assessed the quality with the Downs and Black Quality Index.

RESULTS

We included 14 studies of 140 patients from 5 types of neuromuscular disorders (Duchenne muscular atrophy, spinal muscular atrophy, limb-girdle muscular atrophy, facioscapulohumeral muscular dystrophy, and amyotrophic lateral sclerosis). The mean quality was low (16/32) due to flaws in study design, selection bias, and power. Even though many were of low quality and lacked descriptions of adverse events, they all showed positive effects. Most studies investigated physical training of mastication or respiration with improvements in both. Other findings were improvements in endurance, extremity strength, and range of motion.

CONCLUSIONS

Physical training of wheelchair users with neuromuscular disorders is not well investigated. Physical training seems safe and beneficial, but training of respiratory and masticatory muscles is the only well-documented exercise modality that can be advised in patients with Duchenne Muscular Dystrophy or Duchenne Muscular Dystrophy/Spinal Muscular Atrophy, respectively. Larger, high-quality trials, including other neuromuscular disorders, are needed to assess the effects and adverse events of physical training.

Physical activity improves cardiovascular fitness and reduces cardiovascular risk factors in adults with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Physical activity is known to be vital for cardiovascular health in the general population, but there is no comprehensive review on the effectiveness of physical activity to modify cardiovascular risk in multiple sclerosis (MS). This systematic review and meta-analysis aims to synthesize the evidence regarding the effectiveness of physical activity programs on modifying traditional cardiovascular risk factors in adults with MS.

METHODS

Six electronic databases (PubMed, Scopus, Web of Science, CINAHL, Embase, and SPORTDiscuss) provided literature from inception until August 2024. Randomized clinical trials examining physical activity interventions vs control (no intervention/alternative physical activity modality) and targeting cardiovascular risk factors in adults with MS were included. Study screening and quality was assessed using the Cochrane risk of bias tool were conducted by two independent reviewers. Meta-analysis was conducted using RevMan 5.3.

RESULTS

Thirty studies were included in the qualitative synthesis and 21 were included in the meta-analysis involving 1,052 participants. Significant improvements in cardiovascular fitness indicators such as VO2 peak, mean difference [MD] = 166.77; 95 % CI: 62.77 to 272.77; P = 0.002, and HR peak [MD] = 3.02; 95 % CI: 1.16 to 4.87; P = 0.001, and peak power output [MD] = 24.28; 95 % CI: 5.73 to 42.83; P = 0.01 were observed. Physical activity was also effective at reducing traditional cardiovascular disease (CVD) risk factors of triglycerides [MD] = -13.64; 95 % CI:9.36 to -17.92; P < 0.00001 and LDL-cholesterol [MD] = -6.61; 95 % CI:8.82 to -4.40; P < 0.00001 and total cholesterol [MD] = -8.35; 95 % CI:15.26 to -1.45; P = 0.02 and resulted in a significant decrease in body fat percentage [MD] = -1.56; 95 % CI:2.36 to -0.76; P = 0.0001.

CONCLUSIONS

Physical activity appears beneficial in improving cardiovascular fitness and managing some traditional CVD risk factors in adults with MS. Tailored interventions such as Pilates, aerobic exercise, and combined aerobic and resistance training warrant further investigation due to their positive outcomes.

Physiological fitness in people with advanced multiple sclerosis

INTRODUCTION

Physiological fitness, encompassing cardiorespiratory fitness (CRF) and body composition, are important markers of overall health, functional capacity, and quality of life in general and clinical populations. Characterizing fitness is important for the development of tailored interventions and strategies to optimize well-being across the spectrum of disability in multiple sclerosis (MS). While existing research has explored fitness in people with mild-to-moderate disability, there is a scarcity of data in people with advanced MS (Expanded Disability Severity Scale, EDSS≥7.0).

OBJECTIVE

To characterize CRF and body composition and their associations with fatigue, quality of life, and function in individuals with advanced MS.

METHODS

Participants (n=18, mean age=60.7 years-old, median EDSS=7.5) underwent a cardiopulmonary exercise test and dual-energy X-ray absorptiometry scanning. Main outcomes included peak volume of oxygen uptake (V̇O2peak) and whole and regional body fat, lean mass, bone mineral content, and bone density. Symptoms of fatigue (Modified Fatigue Impact Scale, MFIS), quality of life (29-item MS Impact Scale, MSIS-29), and daily function (Late-Life Function and Disability Instrument, LLFDI) were collected.

RESULTS

Participants exhibited notably low CRF levels (V̇O2peak=9.8 mL/min/kg) and poor body composition (lower lean mass, bone mineral content and density) compared to previous studies in the general population and in individuals with MS with lower disability. V̇O2peak was most consistently associated with function in daily life (LLFDI scores, rs≥0.637, p≤0.004).

CONCLUSION

These findings reinforce the potential importance of physiological fitness to preserve function in people with advanced MS.

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.

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).

Effect of different types of exercise on fitness in people with multiple sclerosis: A network meta-analysis

BACKGROUND

It is assumed that people with multiple sclerosis (MS) who participate in programs of physical exercise improve their physical fitness.

OBJECTIVE

The aim of this network meta-analysis (NMA) was to analyze the effect of different types of exercise on muscular fitness and cardiorespiratory fitness (CRF) among people with MS and to determine the best type of exercise according to disease severity.

METHODS

MEDLINE, the Physiotherapy Evidence Database, the Cochrane Library, SPORTDiscus, Scopus, and Web of Science were searched from inception to April 2022 to identify randomized controlled trials (RCTs) concerning the effect of physical exercise on fitness in people with MS. We ranked the types of physical exercise by calculating the surface under the cumulative ranking (SUCRA).

RESULTS

We included 72 RCTs involving 2543 MS patients in this NMA. A ranking of five types of physical exercise (aerobic, resistance, combined [aerobic and resistance], sensorimotor training, and mind-body exercises) was achieved. Combined and resistance training had the highest effect sizes (0.94, 95% CI 0.47, 1.41, and 0.93, 95% CI 0.57, 1.29, respectively) and the highest SUCRA (86.2% and 87.0%, respectively) for muscular fitness. The highest effect size (0.66, 95% CI 0.34, 0.99) and SUCRA (86.9%) for CRF was for aerobic exercise.

CONCLUSIONS

Combined and resistance training seem to be the most effective exercises to improve muscular fitness and aerobic exercise for CRF in people with MS.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Neurorehabilitation in Multiple Sclerosis-A Review of Present Approaches and Future Considerations

Multiple sclerosis is an increasingly prevalent disease, representing the leading cause of non-traumatic neurological disease in Europe and North America. The most common symptoms include gait deficits, balance and coordination impairments, fatigue, spasticity, dysphagia and an overactive bladder. Neurorehabilitation therapeutic approaches aim to alleviate symptoms and improve the quality of life through promoting positive immunological transformations and neuroplasticity. The purpose of this study is to evaluate the current treatments for the most debilitating symptoms in multiple sclerosis, identify areas for future improvement, and provide a reference guide for practitioners in the field. It analyzes the most cited procedures currently in use for the management of a number of symptoms affecting the majority of patients with multiple sclerosis, from different training routines to cognitive rehabilitation and therapies using physical agents, such as electrostimulation, hydrotherapy, cryotherapy and electromagnetic fields. Furthermore, it investigates the quality of evidence for the aforementioned therapies and the different tests applied in practice to assess their utility. Lastly, the study looks at potential future candidates for the treatment and evaluation of patients with multiple sclerosis and the supposed benefits they could bring in clinical settings.

The influence of COVID-19 pandemic lockdown on the physical activity of people with multiple sclerosis. The role of online training

BACKGROUND

COVID-19 pandemic has affected people with multiple sclerosis (PwMS) on various levels. Pandemic lockdown influenced the access to typical measures of physical activity such as out-door training or gym exercises.

METHODS

We performed a survey assessing physical activity during pandemic lockdown among PwMS treated in our MS center. The questionnaire encompassed questions regarding physical activity before and during lockdown, including the employment of online technologies.

RESULTS

The survey was completed by 262 PwMS. Physical activity before lockdown was declared by 74.4% of PwMS, regular exercises were declared by 30.9% of participants. Among physically active PwMS 50.5% limited their physical activity during the COVID-19 lockdown. The decrease in physical activity was reported more frequently by PwMS with higher levels of disability, particularly declaring regular exercises before lockdown. In the opinion of 39,7% of PwMS online training could replace standard exercises, however only 19,9% of PwMS were actively looking for online training during the lockdown. The interest in online exercise was greatest in the group ≤30 years of age and EDSS ≤2. Synchronous exercises were the preferred online training, particularly among PwMS with EDSS≥4.

CONCLUSION

Our findings indicate a need for systematic educational and organizational measures, promoting physical activity among PwMS and acknowledging pandemic conditions.

Use and subjective experience of the impact of motor-assisted movement exercisers in people with amyotrophic lateral sclerosis: a multicenter observational study

Motor-assisted movement exercisers (MME) are devices that assist with physical therapy in domestic settings for people living with ALS. This observational cross-sectional study assesses the subjective experience of the therapy and analyzes users' likelihood of recommending treatment with MME. The study was implemented in ten ALS centers between February 2019 and October 2020, and was coordinated by the research platform Ambulanzpartner. Participants assessed symptom severity, documented frequency of MME use and rated the subjective benefits of therapy on a numerical scale (NRS, 0 to 10 points, with 10 being the highest). The Net Promotor Score (NPS) determined the likelihood of a participant recommending MME. Data for 144 participants were analyzed. Weekly MME use ranged from 1 to 4 times for 41% of participants, 5 to 7 times for 42%, and over 7 times for 17%. Particularly positive results were recorded in the following domains: amplification of a sense of achievement (67%), diminution of the feeling of having rigid limbs (63%), diminution of the feeling of being immobile (61%), improvement of general wellbeing (55%) and reduction of muscle stiffness (52%). Participants with more pronounced self-reported muscle weakness were more likely to note a beneficial effect on the preservation and improvement of muscle strength during MME treatment (p < 0.05). Overall, the NPS for MME was high (+ 61). High-frequency MME-assisted treatment (defined as a minimum of five sessions a week) was administered in the majority of participants (59%) in addition to physical therapy. Most patients reported having achieved their individual therapeutic objectives, as evidenced by a high level of satisfaction with MME therapy. The results bolster the justification for extended MME treatment as part of a holistic approach to ALS care.

The effects of cycling using lower limb active passive trainers in people with neurological conditions: a systematic review

Background Active passive trainers are frequently used as a safe, feasible way for people with neurological disabilities to exercise. However, evidence regarding their efficacy is limited. The aim of this study was to review the literature investigating the effects of lower limb active passive trainer cycling, with or without functional electrical stimulation, on spasticity, cardiovascular fitness, function and quality of life in people with neurological conditions

Methods Five electronic databases were searched from inception to June 2021. Studies included: randomised controlled trials using lower limb active passive trainers as a cycling intervention; participants with neurological conditions, such as multiple sclerosis, spinal cord injury, stroke and Parkinson's disease; and at least one outcome related to spasticity, cardiovascular fitness, physical function or quality of life.

Results A total of 12 articles were included (n=423 participants, 52% male). Of these, six used functional electrical stimulation-assisted active passive trainer interventions, and the remaining six used active passive trainer interventions alone. A meta-analysis demonstrated statistically significant improvement in walking endurance; however, this only included stroke studies (6-Minute Walk Test performance, P<0.00001). No statistically significant improvement in walking speed was found (P=0.31). A significant improvement in spasticity was reported by three studies (two using the active passive trainer intervention alone, one using the active passive trainer with functional electrical stimulation). One study reported improvement in quality of life. Few studies considered cardiovascular fitness.

Conclusions The included studies featured heterogeneous designs, outcome measures, exercise prescriptions and participant disability levels, which made comparison difficult. Active passive trainer interventions appear to improve walking endurance in people with stroke; however, the effect on other outcomes and in other conditions remains unclear. It also remains uncertain as to whether functional electrical stimulation-assisted cycling is more beneficial than active passive trainer cycling alone.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Systematic Review of Exercise Studies in Persons with Multiple Sclerosis: Exploring the Quality of Interventions According to the Principles of Exercise Training

INTRODUCTION

The objective of this systematic review is to explore the application and reporting of (i) the principles of exercise training in exercise trials, (ii) the components of exercise prescription, and (iii) the adherence towards the prescribed programmes in randomised controlled trials (RCTs) in persons with multiple sclerosis (pwMS).

METHODS

The MEDLINE, CINAHL, SPORTDiscus, PubMed and Embase electronic databases were searched from 1 January 2000 to 16 October 2020. RCTs comprising at least 3 weeks of aerobic and/or resistance exercise intervention in pwMS that reported at least one physiological outcome and were published in peer-reviewed journals were eligible for inclusion.

RESULTS

Out of 52 RCTs included in this review, 58 intervention arms were examined. None applied more than four principles of exercise training. Specificity was addressed by 85%, progression by 33%, overload by 59%, initial values by 26%, reversibility by 0% and diminishing returns by 2% of trials. Fifty-two percent of trials reported all components of exercise prescription, and 3% of trials reported the level of adherence to the prescribed exercise.

CONCLUSION

This systematic review reveals that exercise training principles were not respected in the majority of included RCTs. The weak quality of reported exercise interventions limits the interpretation of the studies' results and potentially leads to an underestimation of 'exercise as medicine' in pwMS. Also, the vague descriptions of exercise prescription and adherence impede the reproducibility of results. Future studies must attend to all principles of exercise training and provide transparent information on the prescribed and performed programmes to develop specific and valid exercise recommendations for pwMS.

SYSTEMATIC REVIEW REGISTRATION

CRD42020162671, 28/04/2020, PROSPERO.

RCT of a Telehealth Group-Based Intervention to Increase Physical Activity in Multiple Sclerosis: eFIT

Objective

To conduct a pilot randomized controlled trial to determine whether participation in a group-based structured telehealth intervention increases physical activity in people with multiple sclerosis (MS).

Methods

In this parallel-arms trial, all study procedures were administered remotely. Adults diagnosed with MS (any subtype) were randomized to one of two 12-week (1 h/wk) active conditions: eFIT, online moderated structured groups; or eJournal, online independent journaling. For comparison, a treatment-as-usual (TAU; i.e., no eFIT/eJournal) group was enrolled. The primary outcome was feasibility (completion and adherence). The secondary efficacy outcomes included self-reported physical activity level (International Physical Activity Questionnaire, IPAQ).

Results

Participants were 37 adults with MS. The sample was diverse: 66.7% female; age range 23-64 years; 17.5% Hispanic, 12.5% Black; and progressive and relapsing-remitting disease subtypes. Regarding feasibility, 70.7% completed; average adherence was 74.9%. Physical activity in active groups increased by 34.2% (baseline IPAQ = 2,406.8 ± 1,959.7, follow-up = 3,229.4 ± 2,575.2) and decreased in the TAU group by 17.4% (baseline = 2,519.9 ± 1,500.1, follow-up = 2,081.2 ± 1,814.9); group × time interaction was not statistically significant [F(2,25) = 1.467, p = 0.250; partial η² = 0.105].

Conclusions

Telehealth represents an accessible, acceptable vehicle to deliver targeted behavioral treatments to a neurologic population. eFIT may be an effective intervention for increasing physical activity, a historically intractable treatment target, in individuals with MS. In addition, these results provide evidence for feasibility of conducting fully remote clinical trial research.

Classification of Evidence

This study provides Class II evidence that for people with MS, participation in a group-based structured telehealth intervention compared with TAU resulted in a (non-significant) increase in self-reported physical activity level. The percentage of participants who completed follow-up questionnaires did not differ between groups. The trial was registered at ClinicalTrials.gov (NCT03829267).

RCT of a Telehealth Group-Based Intervention to Increase Physical Activity in Multiple Sclerosis: eFIT

Objective

To conduct a pilot randomized controlled trial to determine whether participation in a group-based structured telehealth intervention increases physical activity in people with multiple sclerosis (MS).

Methods

In this parallel-arms trial, all study procedures were administered remotely. Adults diagnosed with MS (any subtype) were randomized to one of two 12-week (1 h/wk) active conditions: eFIT, online moderated structured groups; or eJournal, online independent journaling. For comparison, a treatment-as-usual (TAU; i.e., no eFIT/eJournal) group was enrolled. The primary outcome was feasibility (completion and adherence). The secondary efficacy outcomes included self-reported physical activity level (International Physical Activity Questionnaire, IPAQ).

Results

Participants were 37 adults with MS. The sample was diverse: 66.7% female; age range 23-64 years; 17.5% Hispanic, 12.5% Black; and progressive and relapsing-remitting disease subtypes. Regarding feasibility, 70.7% completed; average adherence was 74.9%. Physical activity in active groups increased by 34.2% (baseline IPAQ = 2,406.8 ± 1,959.7, follow-up = 3,229.4 ± 2,575.2) and decreased in the TAU group by 17.4% (baseline = 2,519.9 ± 1,500.1, follow-up = 2,081.2 ± 1,814.9); group × time interaction was not statistically significant [F(2,25) = 1.467, p = 0.250; partial η² = 0.105].

Conclusions

Telehealth represents an accessible, acceptable vehicle to deliver targeted behavioral treatments to a neurologic population. eFIT may be an effective intervention for increasing physical activity, a historically intractable treatment target, in individuals with MS. In addition, these results provide evidence for feasibility of conducting fully remote clinical trial research.

Classification of Evidence

This study provides Class II evidence that for people with MS, participation in a group-based structured telehealth intervention compared with TAU resulted in a (non-significant) increase in self-reported physical activity level. The percentage of participants who completed follow-up questionnaires did not differ between groups. The trial was registered at ClinicalTrials.gov (NCT03829267).

Dry needling for treating spasticity in multiple sclerosis

[Purpose] The aim of the study is to evaluate the efficacy of dry needling (DN) in the treatment of spasticity in patients with multiple sclerosis (MS). [Participants and Methods] Twelve participants (3 males and 9 females) with MS, with no evidence of a relapse in the last four weeks and with an EDSS (Expanded Disability Status Scale) greater than 2.5 points (related with pyramidal score) were recruited. DN was performed in lower limbs for 12 consecutive sessions and evaluated with: PSFS (Penn Spasm Frequency Scale), VAS (visual analogical scale) of spasticity, EDSS (Pyramidal item), Time up and go (TUG), 25 foot, 9hold peg test (9HPT) and the improvement or not in the quality of life (MSQol54) was verified before and after treatment. A follow up visit was carried out to assess improvement. [Results] All patients improved in: VAS scale, EDSS score, quality of life, 9HPT, 25 foot test and TUG and 90% of them showed a decrease in the number of spasms/hour (PSFS). [Conclusion] Dry needling produces positive changes in spasticity in patients with MS and their quality of life, as well as walking capacity and manual dexterity. Therefore, DN should be considered in the treatment of spasticity in patients with MS.

Rehabilitation in multiple sclerosis in 2021

Patients with multiple sclerosis, despite advances in therapy, often suffer from locomotor impairment that limits their mobility and affect quality of life. Rehabilitation is part of the treatment of MS and has shown its beneficial effects in numerous studies. While traditional rehabilitation techniques remain in the limelight, new technologies are emerging and make it possible to improve the management of disabling symptoms. The aim of this update is to synthesize the new therapy techniques proposed in rehabilitation for patients with multiple sclerosis according to the symptoms as balance, gait, upper limb disorders, fatigue, spasticity and disease progression published over the past 5 years. With regard to balance and walking disorders, neuromotor rehabilitation, physical exercise, rhythmic auditory stimulation, gait robot training and exergaming are effective. Only physical exercise has shown a positive effect on fatigue management. Spasticity is improved by classic rehabilitation techniques however non-invasive brain stimulation are promising. The rehabilitation of upper limb dysfunctions uses various effective techniques such as the repetition of functional tasks in real or virtual situations. In case of a more severe disability, arm robots can be used to relearn the impaired movement. Action observation training in real or virtual situations is also effective. Finally, under certain conditions the constraint induced movement therapy is proposed. The effects of rehabilitation are not only positive on the pyramidal symptoms and fatigue but also increase neuroplasticity and perhaps a neuroprotective effect as shown in some studies.

Dosage and Effectiveness of Aerobic Training on Cardiorespiratory Fitness, Functional Capacity, Balance, and Fatigue in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the benefits of aerobic training (AT) programs on cardiorespiratory fitness, functional capacity, balance, and fatigue in individuals with multiple sclerosis (MS) and to identify the optimal dosage of AT programs for individuals with MS via a systematic review with meta-analysis.

DATA SOURCES

Two electronic databases were searched until March 2020 (PubMed-Medline and Web of Science).

STUDY SELECTION

Studies examining the effect of AT program on cardiorespiratory fitness, functional capacity, balance, and fatigue were included.

DATA EXTRACTION

After applying the inclusion and exclusion criteria, we included 43 studies. A total sample of 1070 individuals with MS (AT group, n=680; control group, n=390) were analyzed.

DATA SYNTHESIS

The AT group demonstrated a significant increase in cardiorespiratory fitness (standardized mean difference [SMD], 0.29; P=.002), functional capacity (timed Up and Go Test: SMD, -1.14; P<.001; gait speed: SMD, -1.19; P<.001; walking endurance: SMD, 0.46; P<.001), and balance (SMD, 3.49; P<.001) after training. Fatigue perception also decreased (SMD, -0.45; P<.001). However, no significant differences were observed when compared with the control group in either cardiorespiratory fitness (SMD, 0.14; P=.19) or fatigue perception. Nevertheless, we observed significant differences between the AT and control groups in balance (P=.02), gait speed (P=.02), and walking endurance (P=.03), favoring the participants who performed AT. Regarding the subgroup analysis, no significant differences were observed between subgroups in any of the variables studied except for gait speed, for which a greater increase in posttraining was observed when the AT program applied the continuous method (χ²=7.75; P=.005) and the exercises were performed by walking (χ²=9.36; P=.002).

CONCLUSIONS

Aerobic training improves gait speed, walking endurance, and balance. Cardiorespiratory fitness and fatigue perception also improved after AT, but we found no differences with the control group. In addition, subgroup analysis suggested that training using continuous and walking methods could optimize gait speed.

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

Objectives:

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

Methods:

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

Recommendations:

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

[Current trends and injuries in cycling: faster, further, e-bike?]

During the past decade, technical innovations (e.g., carbon as a new material, disk brakes, hydraulic shock absorbers, electric transmissions) and lifestyle changes have significantly influenced recreational and professional cycling. In contrast to the past, where ambitious leisure cyclists were primarily interested in the recreational value of nature and landscape, cyclists of all ages are nowadays increasingly focused on performance and self-optimization. Simultaneously, manufacturers have adapted to differing customer requirements: besides the traditional extremities of road and mountain bikes, many specialized models have been designed for special applications: trekking, cyclocross, gravel, full-suspension, single-track, hardtail, downhill, fatbike, etc. For biking fans who are no longer able to meet their own demands due to individual physical restrictions or defined health problems, electric-assist bikes (pedelecs or "e-bikes") were recently introduced. While these are becoming increasingly popular, they have also increased the number of accidents and injuries. The current work provides an update on relevant sport medical and orthopaedic challenges brought on by these developments in cycling.