Efficacy of an Internet-Based Program to Promote Physical Activity and Exercise after Inpatient Rehabilitation in Persons with Multiple Sclerosis: A Randomized, Single-Blind, Controlled Study

Internet-based exercise and physical activity promotion for persons with multiple sclerosis: a randomized controlled trial

BACKGROUND

We evaluated the effects of a 12-week internet-based exercise and physical activity promotion program for persons with multiple sclerosis.

METHODS

We performed a multicenter, randomized, waitlist-controlled study. The intervention group (IG) received the 12-week program, followed by 12 weeks with usual care. The control group (CG) received usual care only. The main components of the 12-week program were: (1) a tailored home-based exercise prescription, (2) e-learning resources, (3) telephone and video meetings with an exercise therapist, (4) the provision of a consumer-based PA monitor. Measurements were taken at baseline, postintervention, and after 24 weeks. The primary outcome was device-measured steps/day. Other outcomes were device-measured moderate-to-vigorous physical activity, subjectively measured leisure-time and transportation physical activity and sport/exercise, physical activity-related health competence, walking ability, quality of life, fatigue, depression, and PA-related self-concordance. We compared changes from baseline to postintervention between groups and analyzed changes in the IG during the follow-up.

RESULTS

Analysis of 56 persons with multiple sclerosis (IG: n = 29, CG: n = 27, age: 45.6 ± 10.9) revealed no significant intervention effect on steps/day. However, significant improvements were observed in moderate-to-vigorous physical activity, sport/exercise, control competence, fatigue, and quality of life (physical). During the follow-up, sport/exercise and quality of life decreased significantly. Leisure-time and transportation physical activity increased significantly.

CONCLUSIONS

Our study provides first evidence that the developed program can increase control competence, aspects of physical activity and health in persons with multiple sclerosis. A trial with a larger sample is recommended to confirm our results and examine intervention mechanisms.

TRIAL REGISTRATION

Registry: Clinicaltrials.gov; registration number: NCT04367389; date of registration: 2020-04-21 (retrospectively registered).

Lifestyle changes and patient-reported outcomes over five years in a sample of people with multiple sclerosis after a single multimodal intensive lifestyle education workshop

INTRODUCTION

Modifiable lifestyle risk factors for progression of multiple sclerosis (MS) have been increasingly studied. This study employed a single-group design involving a one-off intensive live-in educational workshop on lifestyle modification for people with MS. We aimed to examine changes in a range of clinical and lifestyle variables and quality of life, self-efficacy, physical impact of MS and disability from baseline to 3- and 5-years post-intervention.

METHODS

95 participants completed the baseline survey. Data included lifestyle risk factors of diet quality, meat and dairy consumption, omega 3 and vitamin D supplementation, physical activity, stress reducing activities, and smoking status, and use of disease-modifying therapies (DMTs). Patient-reported outcomes included health-related quality of life, self-efficacy, physical impact of MS and disability. Generalised estimating equation models were used to account for within-participant correlation over time.

RESULTS

Sixty participants (63.2%) provided data at 3- and 5-years. Significant improvements in diet quality, omega 3 supplementation, and non-smoking were seen at both timepoints. Use of DMTs and disability remained unchanged. Mental (8.8- and 6.9-point) and physical (10.5- and 7.3-point) quality of life, and self-efficacy (2.4- and 1.9-point) improved significantly at 3- and 5-years, respectively. Physical impact of MS reduced from baseline to 3-years (-3.7 points) with a trend towards reduction at 5-years (-2.9 points; p = 0.079).

CONCLUSIONS

Education on lifestyle modification can lead to lifestyle modification and short and long-term improvements in mental and physical wellbeing outcomes. Results suggest potential value in lifestyle modification as an adjunctive component to standard therapy for MS.

Tele-exercise in multiple sclerosis: Systematic review and meta-analysis of effects on fatigue, depression, and overall health

BACKGROUND

Multiple sclerosis (MS) profoundly influences fatigue, depression, various physical and mental symptoms, and quality of life (QoL). Rehabilitation, including exercise training, has improved outcomes of MS, yet is often undertaken in facilities with direct supervision which present substantial barriers for accessibility and scalability. The delivery of exercise remotely via technology (tele-exercise) might overcome those barriers and improve outcomes in MS. This systematic review and meta-analysis examined the effect of tele-exercise for improving fatigue, depression, and overall health outcomes in MS patients.

METHOD

We undertook a comprehensive literature search across 5 electronic databases (PubMed, Scopus, Web of Science, The Cochrane Library, clinicaltrials.gov, and EMBASE) from inception through February 2024. Three reviewers screened all randomized controlled trials (RCTs) and assessed quality, and two reviewers extracted data. The meta-analysis used standardized mean difference (SMD) with Hedges' g method, a random effects model adjusted by Hartung-Knapp, and assessed heterogeneity (I² statistic), weighted studies (inverse variance), and evaluated publication bias (Begg's funnel plot and linear regression test).

RESULT

We located 13 RCTs for inclusion in the meta-analysis. Tele-exercise interventions demonstrated significant improvements across all outcomes: depression (SMD=-0.51, p < 0.001), fatigue (SMD=-0.58, p = 0.01), physical health (SMD=0.62, p = 0.001), QoL (SMD=0.38, p = 0.02), and mental health (SMD=-0.48, p = 0.001). Mind-Body Training consistently had larger effects than Combination Training.

CONCLUSION

Tele-exercise can improve fatigue, depression, mental and physical health, and overall QoL in MS patients. Further research is necessary to optimize tele-exercise protocols, assess long-term effects, and explore potential synergies with other intervention modalities such as telemedicine.

Impact of connected health on the psychological wellbeing and quality of life of people with multiple sclerosis and their caregivers: A systematic review

Background

Connected health (CH) interventions may improve psychological wellbeing and quality of life (QoL) in caregivers and people with multiple sclerosis (MS); however, this impact has not been rigorously evaluated. This systematic review aims to synthesize the literature assessing CH technology's impact on psychological wellbeing and/or QoL of people with MS (PwMS) and/or their caregivers.

Methods

This systematic review's protocol is registered with International Prospective Register of Systematic Reviews (PROSPERO) with identification number CRD42023402434. CINAHL, Web of Science, PubMed, Embase, and PsycINFO databases were searched with terms relating to (a) CH; (b) MS; (c) psychological wellbeing/QoL; and (d) caregivers/people with MS. Of 2821 screened articles, 47 met the eligibility criteria, with just three including MS caregivers.

Results

Heterogenous interventions supporting self-management (n = 20 studies), education (n = 17 studies), psychological (n = 14 studies) or physical (n = 9 studies) rehabilitation and peer support (n = 5 studies) were found. CH technologies had mixed effectiveness in improving psychological and QoL outcomes, with results potentially impacted by technology type, intervention and target group. The study's findings have limited generalizability to improve access across sub-national locations, with no studies disaggregating between urban and rural residence and the majority conducted in the USA and Western Europe.

Conclusion

CH technologies show promise in improving psychological wellbeing and QoL among PwMS and their caregivers. However, this necessitates further study comparing connected health and MS subtypes to improve reproducibility and effectiveness.

Exercise-based telerehabilitation for patients with multiple sclerosis using physical activity: a systematic review

BACKGROUND

Telerehabilitation is a practical option for individuals with multiple sclerosis (MS) to engage in sustained physical activity without -visiting a rehabilitation facility. The aim of this systematic review was to evaluate the feasibility, effectiveness, safety, and adherence of exercise-based telerehabilitation as compared with usual care for MS patients.

METHODS

A comprehensive literature search adhering to PRISMA guidelines was conducted, focusing on studies published in English since 2000. The systematic review protocol was registered in PROSPERO. The selection process involved strict criteria, including studies focusing on people with MS, telerehabilitation centred on regular exercise, a control group receiving usual care, valid exercise testing, and adherence to randomized controlled trial principles. Methodological quality was assessed using the TESTEX tool, ensuring rigour in study design and reporting.

RESULTS

Among the 281 records screened, 10 studies met the criteria. Telerehabilitation interventions varied in format and outcomes were assessed using diverse exercise tests and questionnaires. Despite variations, the studies collectively demonstrated promising feasibility and safety, with minimal withdrawals and minor adverse events. Effectiveness varied, with 5 out of 10 studies showing significant improvements in the intervention group. Adherence rates ranged from 38% to 100%.

CONCLUSION

In most of the assessed aspects, telerehabilitation is comparable to regular centre-based rehabilitation.

Trust, belief and transitions: people's experiences of multidisciplinary inpatient treatment for persistent physical symptoms. A qualitative study

PURPOSE

People with Persistent Physical Symptoms experience physical symptoms that are not wholly explained by a medical disorder or disease. Multidisciplinary treatment is recommended for people with severe difficulties and is provided in a small number of specialist centres in the UK. Only brief descriptions of this treatment are available, and the experiences of people receiving this treatment as an inpatient have not been explored. This study aimed to explore how people with persistent physical symptoms experience inpatient treatment from a specialist multidisciplinary team, and to identify which factors facilitated their engagement in the rehabilitation.

MATERIALS AND METHODS

18 people who had received inpatient multidisciplinary treatment for persistent physical symptoms participated in semi-structured interviews. The transcripts were analysed using reflexive thematic analysis.

RESULTS

Participants' experiences were influenced by whether they felt believed by the healthcare team, and whether they could place their own trust and belief in the staff team and the treatment approach. Their experiences involved a series of transitions; both in environment and understanding.

CONCLUSIONS

Improvements are possible for people receiving inpatient multidisciplinary treatment for severe PPS. Trusting relationships between patients and staff members take time to develop but play a major role in patients' experiences of treatment.

At home e-based physical exercise programs in patients with multiple sclerosis: a scoping review

Introduction

Physical exercise (PE) improves symptoms and quality of life in people with multiple sclerosis (pwMS). However, incorporating PE into daily lives of pwMS pose difficulties. As an alternative to in-person PE, e-based PE has been proposed because of its advantages in terms of accessibility and convenience.

Objective

To synthesize existing evidence on e-based PE at home in adults MS and discuss study designs, rehabilitation programs, intervention effects and possible knowledge gaps.

Methods

In this scoping review, a systematic search in electronic databases including Embase, Medline, CINAHL and Cochrane Library was conducted following the PRISMA guidelines. Peer-reviewed articles in English on e-based PE interventional studies at home involving adult pwMS, published from 2008 until April 2023, were identified and exported to Covidence. Data from the included studies were extracted and synthesized. This scoping review identified different types of e-based PE interventions used in pwMS across different study designs, but when evaluating intervention effects, this review focused solely on randomized controlled trials (RCTs).

Results

A total of 3,006 studies were retrieved and 179 studies were screened in full text, resulting in the inclusion of 54 studies with a total of 2,359 pwMS. Of those, 33 were RCTs and three were qualitative studies. The studies reported on various e-based interventions including video-based programs, telerehabilitation, and web-based programs. The interventions evaluated muscle strength, cardiorespiratory fitness, walking speed, endurance, balance, and fatigue, as well as symptoms of depression and cognitive dysfunction. E-based PE interventions at home in RCTs demonstrated improvement of depressive symptoms and anxiety, while inconsistent results were reported for fatigue, walking speed and balance. No significant benefits were observed regarding dexterity. Results were generally heterogeneous and were limited by small sample sizes. Several limitations were identified, such as lack of physical activity assessment prior to the intervention and poor reporting of duration, intensity, frequency and adherence to e-based PE interventions.

Conclusion

E-based PE interventions in pwMS may improve MS-related symptoms, but the study quality is generally low, and findings are often inconsistent. Several important limitations of the existing literature have been identified in the present review, which can guide future research.

On-line pilates program as an alternative to conventional rehabilitation therapy for people with multiple sclerosis, pilot study

INTRODUCTION

Restrictions in physical activity during Covid-19 pandemic had an impact on exercise activities on people with chronic diseases such as multiple sclerosis, for whom regular exercise is important for managing the disease. Therefore, alternative forms of exercise and rehabilitation were in high demand. The aim of pilot study was to verify the feasibility and potential effect of an online Pilates exercise programme for people with mild to moderate disability due to multiple sclerosis.

METHODS

The exercise programme was scheduled for 12 weeks (2 times a week for 45 min of Pilates exercise combined with 30 min of aerobic activity based on participants preferences). The participants' adherence and the anthropometric parameters (weight, BMI, waist circumference) and the functional tests (Single-Leg Stance Test, Sit to Stand Test) were measured together with the patient reported outcomes to monitor patient's psychological well-being and exercise effect (General Self-efficacy Scale and Activity Balance Confidence Scale).

RESULTS

The total number of 22 women with multiple sclerosis completed the pilot programme. The exercise program proved to be feasible. After 12 weeks of the online Pilates exercise programme significant improvements were found only in the parameter waist circumference (p = 0.03) and in the functional test Sit to Stance (p = 0.01). For the other tests, despite some improvement (self-efficacy and subjective perceived balance performance), there was no significant statistical difference.

CONCLUSION

The online Pilates exercise programme supervised by a physiotherapist is feasible for people with mild to moderate neurological disability. It seems to have a positive impact on the anthropometric parameters, but this result needs to be evaluated on larger sample of patients.

Individualized activity recommendation based on a physical fitness assessment increases short- and long-term regular physical activity in people with multiple sclerosis in a retrospective cohort study

Background

Despite the evidence of beneficial effects of physical activity (PA), people with multiple sclerosis (pwMS) are less physically active than the general population. To increase PA in pwMS, we developed a structured individually tailored PA promotion program which is conducted within clinical practice in a university-based outpatient clinic since 2016. This study serves as retrospective quality control of this program.

Objective

In a retrospective cohort study, we assessed the physical fitness of pwMS and the impact of the program on short- and long-term PA changes and behavioral determinants.

Methods

The program consisted of four appointments each 2-4 weeks apart. Spiroergometric test results of female pwMS were compared to female non-MS controls who underwent a voluntary physical fitness analysis. The short version of the Freiburger questionnaire, self-developed questions and the modified Physical activity screening questionnaire (PASQ) were sent to all participants assessing the PA levels before the program, 3 months after the program (short-term), and at the time of the survey (long-term). Additionally, established questionnaires assessed behavioral determinants before the program and long-term.

Results

A total of 166 participants [mean age 38.32 (± 10.61 SD), mean EDSS 2.30 (±1.29 SD)] and mostly females (63.3%, n = 105) were included in the study and started the program. A total of 136 participants completed the program. Out of these 63.9% (n = 87) answered the questionnaires in 12.38 (±11.34 SD) months after finishing the program. At baseline female pwMS (n = 100) showed a lower physical fitness in comparison to non-MS controls (n = 26) (maximal workload (Watts): 138.86 ± 37.85 vs. 191.73 ± 45.25, p < 0.001; peak oxygen consumption (ml min-1 kg-1): 26.40 ± 7.23 vs. 31.56 ± 10.10, p = 0.020). pwMS were more regularly active in short- (62.1%) and long-term (55.2%) compared to baseline (24.2%, p < 0.001). Among the activated participants, we observed improved internal motivation (p = 0.002) and decreased perception of barriers (p = 0.006) compared to baseline.

Conclusion

PwMS showed a lower physical fitness in comparison to non-MS controls. An individually tailored PA promotion program might improve behavioral determinants and thereby increase short- and long-term PA levels of pwMS.

Comparison of the Clinical Effectiveness of Telerehabilitation with Traditional Rehabilitation Methods in Multiple Sclerosis Patients: A Systematic Review

Background: The rehabilitation process for multiple sclerosis (MS) patients is long and complex, which can lead to reduced rehabilitation outcomes and reduced quality improvement. Thus, there is a need to use new methods to boost traditional rehabilitation. Innovations such as telerehabilitation can be helpful to remove the obstacles to treatment, but evidence for their effectiveness is limited. The objective of this work was to compare the clinical effectiveness of telerehabilitation with traditional interventions in MS patients. Methods: Seven bibliographic databases (PubMed, Cochran Library, Scopus, Science Direct, Web of Science, Embase, and ProQuest) were used in this research. The initial search resulted in the extraction of 8,239 articles; after the review of the title, abstract, and full text, 11 articles were selected. In addition, backward reference list checking of the selected studies was conducted. Studies that were related to our objectives were included. Quality assessment was performed using the CONSORT checklist. Then, data extraction was done using the form set by the researcher in Word 2016 software. Results: Overall, telerehabilitation achieved more positive effects compared to traditional rehabilitation on physical (n = 6), cognitive (n = 3), cognitive, and physical outcomes (n = 2), respectively. Synchronous telerehabilitation was more effective than other modalities (n = 8). In four studies, virtual reality-based telerehabilitation was used. Also, telerehabilitation in home offered better clinical outcomes compared to rehabilitation center (n = 9). Conclusions: This review provides evidence for the potential effectiveness of telerehabilitation for the improvement of clinical outcomes in MS patients. However, more robust randomized controlled trials are needed to confirm the observed positive effects.

Telecoaching of Individuals With Multiple Sclerosis After Inpatient Multidisciplinary Rehabilitation: The Danish MS Hospitals Rehabilitation Study

BACKGROUND

Inpatient rehabilitation improves health-related quality of life (HRQOL) for people with multiple sclerosis (MS). However, the obtained improvements decline once people return home. The challenge is to find ways to preserve the beneficial effects for the long term. We investigated whether monthly telecoaching after discharge would enhance the long-term carryover of improvements.

METHODS

We conducted a 1-year exploratory study with 2 delivery methods: telephone coaching and web-based coaching. After discharge, the telephone group received monthly calls; the web-based group responded to monthly online coaching questions. Based on their rehabilitation goals, we put patients into a neuropsychological group or a physical group. In addition, we matched each patient with similar wait-list control patients and treatment patients from the main study. The primary outcome was HRQOL measured by the Functional Assessment in Multiple Sclerosis (FAMS).

RESULTS

The neuropsychological group had long-term preservation of HRQOL with both delivery methods, with telephone coaching seeming to be superior. Mean differences in FAMS at the 12-month median follow-up for the neuropsychological group compared with the control wait-list control group were for the telephone group: + 15.4 (95% CI, 3.5-27.4; P = .011); for the web-based group: + 10.9 (95% CI, -3.3 to 25.2; P = .130); for the control treatment group: + 6.9 (95% CI, 0.6-13.3; P = .031). The physical group saw no beneficial effects from telecoaching.

CONCLUSIONS

Following inpatient multidisciplinary rehabilitation, monthly telecoaching of individuals with MS with neuropsychological challenges enhanced the long-term carryover of HRQOL, with one-on-one telephone coaching showing more pronounced improvements than web-based automated coaching.

Shedding Light on the Black Box of Rehabilitation: Differential Short- and Long-Term Effects of Multidisciplinary Multiple Sclerosis Rehabilitation

BACKGROUND

The study of the effectiveness of multidisciplinary rehabilitation (MDR) and how the symptoms and needs of individuals with multiple sclerosis (MS) interplay with the diversity of MDR interventions is still a conundrum, often referred to as a black box.

METHODS

We conducted a partial crossover randomized controlled trial with follow-ups at 1 (discharge), 6, and 12 months. Based on their rehabilitation goals, each patient was categorized into 1 of 5 main focus areas (MFAs) prior to admission: Resilience, Cognitive Function, Energy, Physical Function, and Personal Needs. The Functional Assessment of Multiple Sclerosis (FAMS) instrument scores were the primary outcome.

RESULTS

MFA groups varied in age (P = .036), MS type (P = .002), Expanded Disability Status Scale score (P < .001), time since diagnosis (P = .002), and FAMS at baseline (P < .001), as well as in composition and quantity of MDR services. At discharge, significant FAMS improvements were found in all 5 MFA groups (FAMS change > 10.4, P < .05), but the affected subdimensions and persistence of improvements varied among MFA groups. At the 6-month follow-up, estimates of controlled differences in FAMS were 9.9 (P =.001), 5.6 (P = .196), 8.5 (P = .008), -1.4 (P = .548), and 17.9 (P = .012) for the Resilience, Cognitive Function, Energy, Physical Function, and Personal Needs groups, respectively.

CONCLUSIONS

This study demonstrated that inpatient MDR improves functioning and health-related quality of life in people with MS; the type, degree, and persistence of the benefits are associated with a patient's main focus area of rehabilitation, which signifies the importance of the goal-setting process in MDR.

High-intensity resistance training in people with multiple sclerosis experiencing fatigue: A randomised controlled trial

BACKGROUND

Exercise studies including only fatigued persons with multiple sclerosis (PwMS) with fatigue as primary endpoint are lacking.

OBJECTIVE

To evaluate the effects of high-intensity resistance training (HIRT) on self-reported fatigue in fatigued PwMS in a single center randomised controlled trial.

METHODS

We recruited 71 PwMS scoring ≥ 53 on the Fatigue Scale for Motor and Cognitive Functions (FSMC), who were randomised 1:1 to either twice (group A) or once (group B) weekly supervised HIRT for twelve weeks. A non-randomised FSMC score-matched group (n=69) served as non-intervention control.

RESULTS

Between HIRT-group differences were non-significant for primary and most secondary endpoints. Mean difference in FSMC score (95% confidence intervals) was -10.9 (-14.8; -6.9) in group A and -9.8 (-13.2; -6.3) in group B. Corresponding values for combined HIRT groups vs non-intervention control were -10.3 (-12.9; -7.7) and 1.5 (-0.6;3.6), respectively, p<0.001. Secondary endpoints also improved in both HIRT groups, though only Hospital Anxiety and Depression Scale anxiety and MS Impact Scale-29 psychological subscales significantly favoured the twice a week HIRT (group A). As an exploratory endpoint, changes in plasma inflammatory protein markers were associated with reduced FSMC scores in the pooled material.

CONCLUSION

The finding that HIRT in fatigued PwMS leads to clinically relevant reductions in self-reported fatigue, associated with changes in plasma inflammatory protein levels, provide evidence for recommending HIRT for fatigued PwMS.

Understanding lifestyle self-management regimens that improve the life quality of people living with multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Lifestyle self-management as an intervention for people living with multiple sclerosis (plwMS) is an emerging area of research. Previous reviews have highlighted a need to systematically identify effective self-management regimens that influence the health and well-being of plwMS using a common metric of success.

OBJECTIVES

To examine the effectiveness of lifestyle self-management strategies and interventions aimed at improving the quality of life (QOL), and/or disability of plwMS. The review also aimed to narratively explore common elements of self-management interventions that were effective at improving the outcomes of interest.

METHODS

A systematic search was performed using five scientific databases. The review process followed the Cochrane Handbook for Systematic Reviews of Interventions  and was registered with PROSPERO (Ref: CRD42021235982).

RESULTS

A total of 57 studies including 5830 individuals diagnosed with MS, met the inclusion criteria. Self-management interventions included physical activity, fatigue, dietary, stress/coping, emotional, symptom and medical management, and lifestyle and wellbeing programs. Self-reported QOL improved in 35 of 47 studies. Dietary intervention had no statistically significant overall effect on reducing MS disability, (P = 0.18). Heterogeneity limited the ability to pool the effects from a large number of eligible studies of the same design.

CONCLUSION

Multicomponent self-management interventions, multimodal delivery methods, and cognitive behavioural theory principles were common elements of self-management interventions that improved the QOL of plwMS. However, these results should be interpreted with caution and care should be taken in its clinical application. This review has the potential to inform future management practices for plwMS and has revealed a significant gap in the literature, warranting high-quality, large-scale experimental, and observational studies that address lifestyle management.

Randomised controlled pilot and feasibility study of multimodal agility-based exercise training (MAT) versus strength and endurance training (SET) to improve multiple sclerosis-related fatigue and fatigability during inpatient rehabilitation (ReFEx): study protocol

INTRODUCTION

Subjective fatigue and objectively assessed fatigability are common symptoms in persons with multiple sclerosis (pwMS). Recent work has suggested a positive effect of balance and motor control training (BMCT) in reducing fatigue. It is unclear whether this effect can also be attained during inpatient rehabilitation. Multimodal agility-based exercise training (MAT) has been developed as a framework that incorporates BMCT with added agility components but has not been applied to pwMS. Therefore, this study will evaluate the feasibility of a randomised controlled trial comparing MAT against strength and endurance training (SET) for the improvement of MS-related fatigue and fatigability in a German neurological rehabilitation centre.

METHODS AND ANALYSIS

A total of 24 pwMS (Expanded Disability Status Scale ≤5.0, Fatigue Scale for Motor and Cognitive Functions ≥53) will be randomly assigned to either SET or land and water-based MAT for 4-6 weeks during inpatient rehabilitation. Assessments of subjective fatigue, motor and cognitive fatigability, cognitive and cardiorespiratory performance, and balance confidence will be performed at admission and discharge. Subjective fatigue will also be assessed at 1, 4 and 12 weeks after discharge. Feasibility outcomes will include patients' acceptance of study procedures and interventions, recruitment rate, retention rate, time needed to complete baseline assessments, intervention adherence and fidelity. All quantitative outcomes will be reported descriptively. A total of 12 pwMS (6 per group) will be interviewed to gain insights into participants' experiences during study participation.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Ethics Committee of the University of Bonn (reference number: 543/20). Dissemination of findings is planned via peer-reviewed journals, conferences and media releases.

TRIAL REGISTRATION NUMBER

DRKS00023943.

Attrition Within Digital Health Interventions for People With Multiple Sclerosis: Systematic Review and Meta-analysis

BACKGROUND

Digital health interventions have revolutionized multiple sclerosis (MS) care by supporting people with MS to better self-manage their disease. It is now understood that the technological elements that comprise this category of digital health interventions can influence participant engagement in self-management programs, and people with MS can experience significant barriers, influenced by these elements, to remaining engaged during a period of learning. It is essential to explore the influence of technological elements in mitigating attrition.

OBJECTIVE

This study aimed to examine the study design and technological elements of documented digital health interventions targeted at people with MS-digital health interventions that were intended to support a program of engagement over a defined period-and to explore how these correlated with attrition among participants of randomized controlled trials (RCTs).

METHODS

We conducted a systematic review and meta-analysis of RCTs (n=32) describing digital health self-management interventions for people with MS. We analyzed attrition in included studies, using a random-effects model and meta-regression to measure the association between potential moderators.

RESULTS

There were no measured differences in attrition between the intervention and control arms; however, some of the heterogeneity observed was explained by the composite technological element score. The pooled attrition rates for the intervention and control arms were 14.7% and 15.6%, respectively.

CONCLUSIONS

This paper provides insight into the technological composition of digital health interventions designed for people with MS and describes the degree of attrition in both study arms. This paper will aid in the design of future studies in this area, particularly for digital health interventions of this type.

Outcome measures used in trials on gait rehabilitation in multiple sclerosis: A systematic literature review

BACKGROUND

Multiple Sclerosis (MS) is associated with impaired gait and a growing number of clinical trials have investigated efficacy of various interventions. Choice of outcome measures is crucial in determining efficiency of interventions. However, it remains unclear whether there is consensus on which outcome measures to use in gait intervention studies in MS.

OBJECTIVE

We aimed to identify the commonly selected outcome measures in randomized controlled trials (RCTs) on gait rehabilitation interventions in people with MS. Additional aims were to identify which of the domains of the International Classification of Functioning, Disability and Health (ICF) are the most studied and to characterize how outcome measures are combined and adapted to MS severity.

METHODS

Pubmed, Cochrane Central, Embase and Scopus databases were searched for RCT studies on gait interventions in people living with MS according to PRISMA guidelines.

RESULTS

In 46 RCTs, we identified 69 different outcome measures. The most used outcome measures were 6-minute walking test and the Timed Up and Go test, used in 37% of the analyzed studies. They were followed by gait spatiotemporal parameters (35%) most often used to inform on gait speed, cadence, and step length. Fatigue was measured in 39% of studies. Participation was assessed in 50% of studies, albeit with a wide variety of scales. Only 39% of studies included measures covering all ICF levels, and Participation measures were rarely combined with gait spatiotemporal parameters (only two studies).

CONCLUSIONS

Selection of outcome measures remains heterogenous in RCTs on gait rehabilitation interventions in MS. However, there is a growing consensus on the need for quantitative gait spatiotemporal parameter measures combined with clinical assessments of gait, balance, and mobility in RCTs on gait interventions in MS. Future RCTs should incorporate measures of fatigue and measures from Participation domain of ICF to provide comprehensive evaluation of trial efficacy across all levels of functioning.

Is mHealth a Useful Tool for Self-Assessment and Rehabilitation of People with Multiple Sclerosis? A Systematic Review

The development of mobile technology and mobile Internet offers new possibilities in rehabilitation and clinical assessment in a longitudinal perspective for multiple sclerosis management. However, because the mobile health applications (mHealth) have only been developed recently, the level of evidence supporting the use of mHealth in people with multiple sclerosis (pwMS) is currently unclear. Therefore, this review aims to list and describe the different mHealth available for rehabilitation and self-assessment of pwMS and to define the level of evidence supporting these interventions for functioning problems categorized within the International Classification of Functioning, Disability and Health (ICF). In total, 36 studies, performed with 22 different mHealth, were included in this review, 30 about rehabilitation and six for self-assessment, representing 3091 patients. For rehabilitation, most of the studies were focusing on cognitive function and fatigue. Concerning the efficacy, we found a small but significant effect of the use of mHealth for cognitive training (Standardized Mean Difference (SMD) = 0.28 [0.12; 0.45]) and moderate effect for fatigue (SMD = 0.61 [0.47; 0.76]). mHealth is a promising tool in pwMS but more studies are needed to validate these solutions in the other ICF categories. More replications studies are also needed as most of the mHealth have only been assessed in one single study.

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.

Physical activity behavior in people with multiple sclerosis during the COVID-19 pandemic in Israel: Results of an online survey

Multiple sclerosis (MS) itself and first-line disease modifying therapies do not increase the risk of contracting COVID-19. However, home isolation is likely to result in a significant decrease in participation in leisure time physical activities and an increase in sedentary behavior. Therefore, using an online cross-sectional survey we examined the impact of the COVID-19 epidemic on physical activity (PA) behavior and fitness level in an Israeli cohort of people with multiple sclerosis (PwMS). The survey PA questionnaire included 10 questions. Specifically, participants reported on whether, and to what extent, the pandemic conditions had altered their PA behavior. One hundred and twenty PwMS filled out the online survey, 78 were females with a mean age of 43.0 (S.D.=12.9) years. PA behavior during the pandemic demonstrated that 17.5% who were engaged in PA before the COVID-19 pandemic, ceased PA, 33.3% reduced their PA, 20.0% continued their PA as before, 18.3% increased their PA during the pandemic, and 10.8% did not perform any PA in the past and did not so during the pandemic. As for the patient's self-reported fitness level, 31.7% reported that their fitness level had decreased during the pandemic, 60.0% felt no change, and 8.3% reported an improvement. Our findings serve as a call of action for all professionals involved in MS management to address physical activity behavior in PwMS during the COVID-19 epidemic.