To assess the efficacy of physiotherapy interventions, including exercise therapy, for the rehabilitation of people with progressive multiple sclerosis.
Five databases (Cochrane Library, ...Physiotherapy Evidence Database PEDro, Web of Science Core Collections, MEDLINE, Embase) and reference lists of relevant articles were searched.
Randomized experimental trials, including participants with progressive multiple sclerosis and investigating a physiotherapy intervention or an intervention containing a physiotherapy element, were included.
Data were independently extracted using a standardized form, and methodologic quality was assessed using the PEDro scale.
Thirteen studies (described by 15 articles) were identified and scored between 5 and 9 out of 10 on the PEDro scale. Eight interventions were assessed: exercise therapy, multidisciplinary rehabilitation, functional electrical stimulation, botulinum toxin type A injections and manual stretches, inspiratory muscle training, therapeutic standing, acupuncture, and body weight-supported treadmill training. All studies, apart from 1, produced positive results in at least 1 outcome measure; however, only 1 article used a power calculation to determine the sample size and because of dropouts the results were subsequently underpowered.
This review suggests that physiotherapy may be effective for the rehabilitation of people with progressive multiple sclerosis. However, further appropriately powered studies are required.
Multiple sclerosis (MS) is associated with chronic symptoms, including muscle stiffness, spasms, pain and insomnia. Here we report the results of the Multiple Sclerosis and Extract of Cannabis ...(MUSEC) study that aimed to substantiate the patient based findings of previous studies.
Patients with stable MS at 22 UK centres were randomised to oral cannabis extract (CE) (N=144) or placebo (N=135), stratified by centre, walking ability and use of antispastic medication. This double blind, placebo controlled, phase III study had a screening period, a 2 week dose titration phase from 5 mg to a maximum of 25 mg of tetrahydrocannabinol daily and a 10 week maintenance phase. The primary outcome measure was a category rating scale (CRS) measuring patient reported change in muscle stiffness from baseline. Further CRSs assessed body pain, spasms and sleep quality. Three validated MS specific patient reported outcome measures assessed aspects of spasticity, physical and psychological impact, and walking ability.
The rate of relief from muscle stiffness after 12 weeks was almost twice as high with CE than with placebo (29.4% vs. 15.7%; OR 2.26; 95% CI 1.24 to 4.13; p=0.004, one sided). Similar results were found after 4 weeks and 8 weeks, and also for all further CRSs. Results from the MS scales supported these findings.
The study met its primary objective to demonstrate the superiority of CE over placebo in the treatment of muscle stiffness in MS. This was supported by results for secondary efficacy variables. Adverse events in participants treated with CE were consistent with the known side effects of cannabinoids. No new safety concerns were observed.
NCT00552604.
Objective:
To explore the effectiveness and participant experience of web-based physiotherapy for people moderately affected with Multiple Sclerosis (MS) and to provide data to establish the sample ...size required for a fully powered, definitive randomized controlled study.
Design:
A randomized controlled pilot study.
Setting:
Rehabilitation centre and participants’ homes.
Subjects:
Thirty community dwelling adults moderately affected by MS (Expanded Disability Status Scale 5-6.5).
Interventions:
Twelve weeks of individualised web-based physiotherapy completed twice per week or usual care (control). Online exercise diaries were monitored; participants were telephoned weekly by the physiotherapist and exercise programmes altered remotely by the physiotherapist as required.
Main measures:
The following outcomes were completed at baseline and after 12 weeks; 25 Foot Walk, Berg Balance Scale, Timed Up and Go, Multiple Sclerosis Impact Scale, Leeds MS Quality of Life Scale, MS-Related Symptom Checklist and Hospital Anxiety and Depression Scale. The intervention group also completed a website evaluation questionnaire and interviews.
Results:
Participants reported that website was easy to use, convenient, and motivating and would be happy to use in the future. There was no statistically significant difference in the primary outcome measure, the timed 25ft walk in the intervention group (P=0.170), or other secondary outcome measures, except the Multiple Sclerosis Impact Scale (P=0.048). Effect sizes were generally small to moderate.
Conclusion:
People with MS were very positive about web-based physiotherapy. The results suggested that 80 participants, 40 in each group, would be sufficient for a fully powered, definitive randomized controlled trial.
To review the efficacy of functional electrical stimulation (FES) used for foot drop in people with multiple sclerosis (pwMS) on gait speed in short and long walking performance tests.
Five databases ...(Cochrane Library, CINAHL, Embase, MEDLINE, and PubMed) and reference lists were searched.
Studies of both observational and experimental design where gait speed data in pwMS could be extracted were included.
Data were independently extracted and recorded. Methodologic quality was assessed using the Effective Public Health Practice Project tool.
Nineteen studies (described in 20 articles) recruiting 490 pwMS were identified and rated as moderate or weak, with none gaining a strong rating. All studies rated weak for blinding. Initial and ongoing orthotic and therapeutic effects were assessed regarding the effect of FES on gait speed in short and long walking tests. Meta-analyses of the short walk tests revealed a significant initial orthotic effect (t=2.14, P=.016), with a mean increase in gait speed of .05m/s, and ongoing orthotic effect (t=2.81, P=.003), with a mean increase of .08m/s. There were no initial or ongoing effects on gait speed in long walk tests and no therapeutic effect on gait speed in either short or long walk tests.
FES used for foot drop has a positive initial and ongoing effect on gait speed in short walking tests. Further fully powered randomized controlled trials comparing FES with alternative treatments are required.
Objective:
To compare the clinical- and cost-effectiveness of ankle-foot orthoses (AFOs) and functional electrical stimulation (FES) over 12 months in people with Multiple Sclerosis with foot drop.
...Design:
Multicentre, powered, non-blinded, randomized trial.
Setting:
Seven Multiple Sclerosis outpatient centres across Scotland.
Subjects:
Eighty-five treatment-naïve people with Multiple Sclerosis with persistent (>three months) foot drop.
Interventions:
Participants randomized to receive a custom-made, AFO (n = 43) or FES device (n = 42).
Outcome measures:
Assessed at 0, 3, 6 and 12 months; 5-minute self-selected walk test (primary), Timed 25 Foot Walk, oxygen cost of walking, Multiple Sclerosis Impact Scale-29, Multiple Sclerosis Walking Scale-12, Modified Fatigue Impact Scale, Euroqol five-dimension five-level questionnaire, Activities-specific Balance and Confidence Scale, Psychological Impact of Assistive Devices Score, and equipment and National Health Service staff time costs of interventions.
Results:
Groups were similar for age (AFO, 51.4 (11.2); FES, 50.4(10.4) years) and baseline walking speed (AFO, 0.62 (0.21); FES 0.73 (0.27) m/s). In all, 38% dropped out by 12 months (AFO, n = 21; FES, n = 11). Both groups walked faster at 12 months with device (P < 0.001; AFO, 0.73 (0.24); FES, 0.79 (0.24) m/s) but no difference between groups. Significantly higher Psychological Impact of Assistive Devices Scores were found for FES for Competence (P = 0.016; AFO, 0.85(1.05); FES, 1.53(1.05)), Adaptability (P = 0.001; AFO, 0.38(0.97); FES 1.53 (0.98)) and Self-Esteem (P = 0.006; AFO, 0.45 (0.67); FES 1 (0.68)). Effects were comparable for other measures. FES may offer value for money alternative to usual care.
Conclusion:
AFOs and FES have comparable effects on walking performance and patient-reported outcomes; however, high drop-outs introduces uncertainty.
Objective:
To examine the feasibility of a trial to evaluate web-based physiotherapy compared to a standard home exercise programme in people with multiple sclerosis.
Design:
Multi-centre, randomized ...controlled, feasibility study.
Setting:
Three multiple sclerosis out-patient centres.
Participants:
A total of 90 people with multiple sclerosis (Expanded Disability Status Scale 4–6.5).
Interventions:
Participants were randomized to a six-month individualized, home exercise programme delivered via web-based physiotherapy (n = 45; intervention) or a sheet of exercises (n = 45; active comparator).
Outcome measures:
Outcome measures (0, three, six and nine months) included adherence, two-minute walk test, 25 foot walk, Berg Balance Scale, physical activity and healthcare resource use. Interviews were undertaken with 24 participants and 3 physiotherapists.
Results:
Almost 25% of people approached agreed to take part. No intervention-related adverse events were recorded. Adherence was 40%–63% and 53%–71% in the intervention and comparator groups. There was no difference in the two-minute walk test between groups at baseline (Intervention-80.4(33.91)m, Comparator-70.6(31.20)m) and no change over time (at six-month Intervention-81.6(32.75)m, Comparator-74.8(36.16)m. There were no significant changes over time in other outcome measures except the EuroQol-5 Dimension at six months which decreased in the active comparator group. For a difference of 8(17.4)m in two-minute walk test between groups, 76 participants/group would be required (80% power, P > 0.05) for a future randomized controlled trial.
Conclusion:
No changes were found in the majority of outcome measures over time. This study was acceptable and feasible by participants and physiotherapists. An adequately powered study needs 160 participants.
Henri Bergson is frequently cited amongst the holy trinity of major influences on Modernism-literary and otherwise-alongside Sigmund Freud and William James. Gilles Deleuze's Bergsonism has ...re-popularized Bergson for the twenty-first century, so much so that, perhaps, our Bergson is Deleuze's Bergson. Despite renewed interest in Bergson, his influence remains understudied and consequently undervalued. While books examining the impact of Freud and James on Modernism abound, Bergson's impact, though widely acknowledged, has been closely examined much more rarely. Understanding Bergson, Understanding Modernism remedies this deficiency in three ways. First, it offers close readings and critiques of six pivotal texts. Second, it reassesses Bergson's impact on Modernism while also tracing his continuing importance to literature, media, and philosophy throughout the twentieth and into the twenty-first century. In its final section it provides an extended glossary of Bergsonian terms, complete with extensive examples and citations of their use across his texts. The glossary also maps the influence of Bergson's work by including entries on related writers, all of whom Bergson either corresponded with or critiqued.
The aim of the study was to establish the test-retest reliability, clinical significance and precision of four mobility and balance measures--the Timed 25-Foot Walk, Six-minute Walk, Timed Up and Go ...and the Berg Balance Scale--in individuals moderately affected by multiple sclerosis. Twenty four participants with multiple sclerosis (Extended Disability Status Score 5-6.5) were assessed on four measures of mobility and balance. The Timed 25-Foot Walk, Six-minute Walk and Timed Up and Go mobility outcome measures and the Berg Balance Scale were assessed by one assessor one week apart. Intraclass correlation coefficient (ICC) analysis was carried out to determine reliability. Minimal detectable change values were calculated to determine clinical significance; the standard error of each measurement was calculated to assess precision. All four outcome measures were found to be reliable: Timed 25-Foot Walk ICC = 0.94, Six-minute Walk Test ICC = 0.96, Timed Up and Go ICC = 0.97 and Berg Balance Scale ICC = 0.96. Minimal detectable change values were as follows: Timed 25-Foot Walk = 12.6 s, Six-minute Walk Test = 76.2 m, Timed Up and Go = 10.6 s and Berg Balance Scale = 7 points. Standard errors of measurement were as follows: Timed 25-Foot Walk = 4.56 s, Six-minute Walk Test = 27.48 m, Timed Up and Go = 3.81 s and Berg Balance Scale = 3 points. The test-retest reliability of these four outcome measures was found to be good. The calculated clinical significance and precision of these measures highlight the problems of assessing a heterogeneous clinical population.
Purpose: Functional electrical stimulation (FES) is effective in improving walking in people with multiple sclerosis (MS) with foot drop. There is limited research exploring people's experiences of ...using this device. This study aims to explore the utility, efficacy, acceptability, and impact on daily life of the device in people with MS.
Methods: An interpretative phenomenological approach was employed. Ten participants who had used FES for 12 months were interviewed. Transcripts were analysed, and emergent themes identified.
Results: Nine participants continued to use the device. Three relevant super-ordinate themes were identified; impact of functional electrical stimulation, sticking with functional electrical stimulation, and autonomy and control. Participants reported challenges using the device; however, all reported positive physical and psychological benefits. Intrinsic and external influences such as; access to professional help, the influence of others, an individual's ability to adapt, and experiences using the device, influenced their decisions to continue with the device. A thematic model of these factors was developed.
Conclusions: This study has contributed to our understanding of people with MS experiences of using the device and will help inform prescribing decisions and support the continued, appropriate use of FES over the longer term.
Implications for Rehabilitation
People with multiple sclerosis using functional electrical stimulation report benefits in many aspects of walking, improved psychological well-being and increased engagement in valued activities.
A number of challenges impact on functional electrical stimulation use. Factors such as; a positive experience using the device, access to professional help, the influence of others, a strong sense of personal autonomy and an individual's ability to adapt, influence an individual's decision to continue using functional electrical stimulation.
Clinicians prescribing functional electrical stimulation should be aware of these factors so that the right support and guidance can be provided to people with multiple sclerosis, thus improving outcomes and compliance over the long term.
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