Cost-effectiveness of cognitive behavioural and personalized exercise interventions for reducing fatigue in inflammatory rheumatic diseases.

OBJECTIVES: To estimate the cost-effectiveness of a cognitive behavioural approach (CBA) or a personalized exercise programme (PEP), alongside usual care (UC), in patients with inflammatory rheumatic diseases who report chronic, moderate to severe fatigue. METHODS: A within-trial cost-utility analysis was conducted using individual patient data collected within a multicentre, three-arm randomized controlled trial over a 56-week period. The primary economic analysis was conducted from the UK National Health Service (NHS) perspective. Uncertainty was explored using cost-effectiveness acceptability curves and sensitivity analysis. RESULTS: Complete-case analysis showed that, compared with UC, both PEP and CBA were more expensive [adjusted mean cost difference: PEP £569 (95% CI: £464, £665); CBA £845 (95% CI: £717, £993)] and, in the case of PEP, significantly more effective [adjusted mean quality-adjusted life year (QALY) difference: PEP 0.043 (95% CI: 0.019, 0.068); CBA 0.001 (95% CI: -0.022, 0.022)]. These led to an incremental cost-effectiveness ratio (ICER) of £13 159 for PEP vs UC, and £793 777 for CBA vs UC. Non-parametric bootstrapping showed that, at a threshold value of £20 000 per QALY gained, PEP had a probability of 88% of being cost-effective. In multiple imputation analysis, PEP was associated with significant incremental costs of £428 (95% CI: £324, £511) and a non-significant QALY gain of 0.016 (95% CI: -0.003, 0.035), leading to an ICER of £26 822 vs UC. The estimates from sensitivity analyses were consistent with these results. CONCLUSION: The addition of a PEP alongside UC is likely to provide a cost-effective use of health care resources.

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

BACKGROUND: The number of published studies of exercise training in multiple sclerosis (MS) has grown exponentially with increasing numbers of outcomes capturing exercise effects. This has complicated the selection of relevant indicators and interpretation of intervention effects. OBJECTIVES: The Outcomes subgroup of the MoXFo initiative aimed to (1) identify outcome measures and biomarkers in studies of exercise training in MS; (2) systematically map retrieved outcomes to International Classification of Functioning, Disability and Health (ICF) categories; (3) identify gaps where relevant ICF categories have been omitted. METHODS: Electronic databases and registers were searched from 2010 to July 2020 to identify systematic reviews or meta-analyses of controlled trials of exercise training on any outcome in MS. Retrieved outcomes/biomarkers were mapped to the corresponding ICF category. RESULTS: Eighty-one review articles reporting 235 different outcomes were included. The outcomes corresponded to 15 chapters and 45 categories within the ICF. Outcomes mapped primarily to body function (30 categories) and activities and participation (9 categories) components. Few outcomes mapped to body structures (2 categories) or environmental factors (1 category). CONCLUSION: This sets the stage to develop a resource for researchers/clinicians that will aid in the selection of appropriate outcomes/biomarkers when examining exercise effects in MS.

Proof of Concept for the Use of Immersive Virtual Reality in Upper Limb Rehabilitation of Multiple Sclerosis Patients.

Multiple sclerosis (MS) is a debilitating disease which gradually reduces motor function and mobility. Virtual reality (VR) has been successfully utilised in support of existing therapeutic approaches for many different conditions, and new innovative and experimental features could be the future of VR rehabilitation. The Quest is a new headset by Oculus, with its built-in tracking, relatively low cost, portability and lack of reliance on expensive processing heavy PCs to power it, and could be an ideal system to facilitate at-home or clinic-based upper limb rehabilitation. A hand-tracking-based rehabilitation game aimed at people with MS was developed for Oculus Quest using Unity. Two distinct games were made to replicate different types of hand exercises, piano playing for isolated finger flexion and maze tracking for coordination and arm flexion. This pilot study assesses the value of such approach along with evaluating intrinsic and extrinsic methods of providing feedback, namely, positive scoring, negative scoring and audio response. One physiotherapist and two individuals with MS were surveyed. Participant response was positive although small sample size impacts the user testing validity of the results. Future research is recommended to build off the data gathered as a pilot study and increase sample size to collect richer feedback.

An Exploration of Sedentary Behavior Patterns in Community-Dwelling People With Stroke: A Cluster-Based Analysis.

BACKGROUND AND PURPOSE: Long periods of daily sedentary time, particularly accumulated in long uninterrupted bouts, are a risk factor for cardiovascular disease. People with stroke are at high risk of recurrent events and prolonged sedentary time may increase this risk. We aimed to explore how people with stroke distribute their periods of sedentary behavior, which factors influence this distribution, and whether sedentary behavior clusters can be distinguished? METHODS: This was a secondary analysis of original accelerometry data from adults with stroke living in the community. We conducted data-driven clustering analyses to identify unique accumulation patterns of sedentary time across participants, followed by multinomial logistical regression to determine the association between the clusters, and the total amount of sedentary time, age, gender, body mass index (BMI), walking speed, and wake time. RESULTS: Participants in the highest quartile of total sedentary time accumulated a significantly higher proportion of their sedentary time in prolonged bouts (P < 0.001). Six unique accumulation patterns were identified, all of which were characterized by high sedentary time. Total sedentary time, age, gender, BMI, and walking speed were significantly associated with the probability of a person being in a specific accumulation pattern cluster, P < 0.001 - P = 0.002. DISCUSSION AND CONCLUSIONS: Although unique accumulation patterns were identified, there is not just one accumulation pattern for high sedentary time. This suggests that interventions to reduce sedentary time must be individually tailored.Video Abstract available for more insight from the authors (see the Video Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A343).

Moving exercise research in multiple sclerosis forward (the MoXFo initiative): Developing consensus statements for research.

Exercise as a subset of physical activity is a cornerstone in the management of multiple sclerosis (MS) based on its pleotropic effects. There is an exponential increase in the quantity of research on exercise in MS, yet a number of barriers associated with study content and quality hamper rapid progress in the field. To address these barriers and accelerate discovery, a new international partnership of MS-related experts in exercise has emerged with the goal of advancing the research agenda. As a first step, the expert panel met in May 2018 and identified the most urgent areas for moving the field forward, and discussed the framework for such a process. This led to identification of five themes, namely "Definitions and terminology," "Study methodology," "Reporting and outcomes," "Adherence to exercise," and "Mechanisms of action." Based on the identified themes, five expert groups have been formed, that will further (a) outline the challenges per theme and (b) provide recommendations for moving forward. We aim to involve and collaborate with people with MS/MS organizations (e.g. Multiple Sclerosis International Federation (MSIF) and European Multiple Sclerosis Platform (EMSP)) in all of these five themes. The generation of this thematic framework with multi-expert perspectives can bolster the quality and scope of exercise studies in MS that may ultimately improve the daily lives of people with MS.

Physical activity and sedentary behaviour and their associations with clinical measures in axial spondyloarthritis.

Engaging in physical activity (PA) is a key aspect in the management of axial spondyloarthritis (axial SpA), however, its relationship with clinical measures is unknown. Previous research has mainly focused on subjective methods of measuring PA and sedentary behaviour (SB). The aim of this study was to explore the associations between objectively measured PA and SB with clinical measures in people with established axial SpA. Fifty participants were recruited from secondary-care rheumatology outpatient services in Glasgow, UK. Clinical measures collected included; Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Ankylosing Spondylitis Quality of Life (ASQOL) and the Six Minute Walk Test (6MWT). PA and SB were measured using the activPAL3 tri-axial accelerometer. Data from forty-five participants were included (23 males, average age 49 ± 12 years). Participants accumulated an average of 93.2 ± 41.5 min/day walking with an average of 7200 ± 3397 steps/day. The majority of the day (65%) was spent sitting, accumulated in prolonged bouts. Walking time and steps taken/day were associated with better BASFI (r = - 0.395, p = 0.007 and r = - 0.404, p = 0.006), ASQOL (r = - 0.375, p = 0.011 and r = - 0.361, p = 0.015) and 6MWT (r = 0.396, p = 0.007 and r = 0.421, p = 0.004); while longer walking events were associated with better BASMI (rho = - 0.352, p = 0.018), BASFI (rho = - 0.316, p = 0.034) and 6MWT (rho = 0.404, p = 0.006). SB was associated with worse ASQOL (r = 0.380, p = 0.010) and 6MWT (6MWT, r = - 0.357, p = 0.016). In people with axial SpA PA is associated with better function, exercise capacity and spinal mobility, while SB is associated with lower exercise capacity and poor quality of life. These findings support the promotion of PA and reduction of SB in people with axial SpA.

Enabling More Accessible MS Rehabilitation Training Using Virtual Reality.

Multiple sclerosis (MS) is an autoimmune disorder caused by damage to the myelin that protects nerve fibres, resulting in demyelinated lesions and causing various symptoms, one of which is muscle weakness. Physical rehabilitation is an integral part of managing MS, as well as its symptoms, and over time, the forms of implementing rehabilitation have changed according to novel technologies. Virtual reality (VR) has already been successfully applied to many fields of life sciences. VR can recreate engaging virtual environments for the specific purpose of physical rehabilitation that one can experience from the home environment. As a proof of concept, three games were developed for multiple sclerosis (MS) through the ground-breaking game engine Unity: a Piano game, a Recycle game and a Tidy Up game. The Piano game had three levels, starting from learning simple keys and ending with small well-known songs, in order to gradually challenge the user as they progress through their rehabilitation. The Recycle game focused on entertainment; it was playful providing a simpler but engaging and fun experience that used items that are seen in everyday life. In addition, a scoring system was implemented in order to motivate the user. Finally, the Tidy Up game had three different levels giving the user goals to work towards; at each level, the time available to complete the game became shorter giving the user less time to tidy up the table. These games were presented to individuals with MS, who had never used VR. Feedback was collected in order to assess the usability and the perceived sense of presence generated by the proposed approach. The testing also aimed to better understand rehabilitation techniques including factors affecting motivation. The games for rehabilitation were warmly received, and feedback was positive regarding both the usability of the system and the perceived sense of presence within digital environments. Although the tested sample size limits were small, a limitation of the validity of the results, these initial findings suggest VR must be beneficial in MS physical rehabilitation of the upper limb although larger, more formal evaluation is required.

The Influence of Socio-economic Deprivation on Mobility, Participation, and Quality of Life Following Major Lower Extremity Amputation in the West of Scotland.

OBJECTIVE: Lower extremity amputation (LEA) is more common in people from lower socio-economic groups. This study examined this further by investigating the influence of socio-economic status on mobility, participation, and quality of life (QoL) after LEA. METHODS: Prospective data were gathered for all LEAs performed in one year in one Scottish Health Board, commencing March 2014. A postcode derived Scottish Index of Multiple Deprivation (SIMD) was applied by quintile (SIMD 1 = most deprived). Routine data were collected on the cohort of 171 patients; 101 participants consented and received postal questionnaires on QoL (EQ-5D-5L), participation (Reintegration to Normal Living Index [RNLI]), and mobility (Prosthetic Limb User Survey of Mobility), six (n = 67) and 12 months (n = 50) after LEA. RESULTS: The mean ± SD age of the cohort was 66.2 ± 11.4 years; 75% were male and 53% had diabetes. In total, 67% lived in SIMD 1 and 2 and 11.1% in SIMD 5. Sixty per cent had a transtibial amputation. Mortality was 6% at 30 days 17% at six, and 29% at 12 months. Those in SIMD 1 were significantly younger (62.9 years) than those in SIMD 5 (76.3 years). Significantly more participants with a transfemoral amputation (TFA) lived in SIMD 1 (44%) compared with SIMD 5 (11%) (p = .004). Participation was low (RNLI scores: 6 months = 55.7; 12 months = 56.6) and PLUS M scores suggested mobility was poor overall at six (39.1) and 12 months (38.9). Mean QoL was 0.37 at 6 months and 0.33 at 12 months. CONCLUSION: Although this study observed more LEAs in those from low socio-economic areas, it is impossible to conclude whether QoL after LEA is truly influenced by socio-economic status. There was an association between the disproportionately high rate of LEAs in SIMD groups 1 and 2 and the high prevalence of smoking, 61% vs. only 21% of those in the least deprived areas (SIMD 3, 4, and 5) being current smokers.

Is Fatigue Associated With Aerobic Capacity and Muscle Strength in People With Multiple Sclerosis: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine the relationship between self-reported fatigue and aerobic capacity and muscle strength in people with multiple sclerosis (MS). DATA SOURCES: Four databases (Cumulative Index to Nursing and Allied Health, MEDLINE, ProQuest, and Web of Science Core Collections) were searched up to October 2018. STUDY SELECTION: Cross-sectional or longitudinal studies that reported the association between self-reported fatigue and aerobic capacity or objectively measured muscle strength in people with MS were included. DATA EXTRACTION: Study details, participant demographics, outcome measurement protocols, and the correlation coefficient derived from the association between fatigue and aerobic capacity or muscle strength at baseline was extracted, and methodological quality of included studies was assessed using the Joanna Briggs Institute Appraisal Checklist for Analytical Cross-sectional Studies. DATA SYNTHESIS: Ten studies were identified, of which 5 examined the association between fatigue and aerobic capacity and 7 examined the association between fatigue and muscle strength. Meta-analysis of the extracted correlation coefficients was performed using the Hedges-Olkin method, and pooled correlation coefficients demonstrated a moderate negative association between fatigue and aerobic capacity (r=-0.471; 95% CI, -0.644 to -0.251; P<.001) and a weak negative association between fatigue and muscle strength (r=-0.224; 95% CI, -0.399 to -0.032; P=.022). CONCLUSIONS: The results of this meta-analysis suggest that higher levels of aerobic capacity are associated with lower fatigue. Therefore, this finding highlights the potential role of aerobic exercise interventions in managing fatigue. Conversely, the relationship between fatigue and muscle strength was weak and inconsistent, and further studies are required to examine the association between these variables.

The clinical- and cost-effectiveness of functional electrical stimulation and ankle-foot orthoses for foot drop in Multiple Sclerosis: a multicentre randomized trial.

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.

Web-based physiotherapy for people affected by multiple sclerosis: a single blind, randomized controlled feasibility study.

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.

The Co-design of Hand Rehabilitation Exercises for Multiple Sclerosis Using Hand Tracking System.

Multiple sclerosis (MS) often affects motor function, leading to an adverse effect on daily living. Rehabilitation is important in terms of improving mobility and activities of daily living. Virtual environments (VE) are increasing in popularity within this research area, but research in terms of VE is still rare, for both the upper and lower limb, in people with MS. Leap Motion (LM), a hand motion tracking system, has demonstrated success in stroke research but has yet to be investigated within MS. Following a co-design approach, five participants with MS discussed in a focus group (FG) their hand mobility issues, their thoughts about this technology-based rehabilitation and motivational factors. Findings were incorporated into the design of a series of gamified upper limb rehabilitation exercises, using LM, on Unity Game Engine. Three participants returned and engaged in user testing session and a FG in order to evaluate and discuss their experience. Overall participants found the proposed technology-based exercises to be engaging, immersive and a desirable approach to rehabilitation. Participant feedback underlined the usefulness of co-creation, especially in accommodating the range of motivators and user preferences. However, the study highlighted the loss of tracking of hand movements with LM as one of the limitations. Participants stated they would be likely to use this approach at home if there was a definite rehabilitation benefit and related more to visualising which muscle groups or actions they were aiming to improve.

Balancing the Demands of Two Tasks: An Investigation of Cognitive-Motor Dual-Tasking in Relapsing Remitting Multiple Sclerosis.

BACKGROUND: People with relapsing remitting multiple sclerosis (PwRRMS) suffer disproportionate decrements in gait under dual-task conditions, when walking and a cognitive task are combined. There has been much less investigation of the impact of cognitive demands on balance. OBJECTIVES: This study investigated whether: (1) PwRRMS show disproportionate decrements in postural stability under dual-task conditions compared to healthy controls, and (2) dual-task decrements are associated with everyday dual-tasking difficulties. The impact of mood, fatigue, and disease severity on dual-tasking was also examined. METHODS: A total of 34 PwRRMS and 34 matched controls completed cognitive (digit span) and balance (movement of center of pressure on Biosway on stable and unstable surfaces) tasks under single- and dual-task conditions. Everyday dual-tasking was measured using the Dual-Tasking Questionnaire. Mood was measured by the Hospital Anxiety & Depression Scale. Fatigue was measured via the Modified Fatigue Index Scale. RESULTS: No differences in age, gender, years of education, estimated pre-morbid IQ, or baseline digit span between groups. Compared with controls, PwRRMS showed significantly greater decrement in postural stability under dual-task conditions on an unstable surface (p=.007), but not a stable surface (p=.679). Balance decrement scores were not correlated with everyday dual-tasking difficulties or fatigue. Stable surface balance decrement scores were significantly associated with levels of anxiety (rho=0.527; p=.001) and depression (rho=0.451; p=.007). CONCLUSIONS: RRMS causes dual-tasking difficulties, impacting balance under challenging conditions, which may contribute to increased risk of gait difficulties and falls. The relationship between anxiety/depression and dual-task decrement suggests that emotional factors may be contributing to dual-task difficulties. (JINS, 2018, 24, 247-258).

The association between lower urinary tract symptoms and falls: Forming a theoretical model for a research agenda.

BACKGROUND: There is a well-recognised association between falls and lower urinary tract symptoms (LUTS) in older adults, with estimates of odd ratios for falls in the presence of LUTS ranging between 1.5 and 2.3. Falls and LUTS are both highly prevalent among older people and both are markers of frailty, with significant associated morbidity, mortality, and healthcare resource cost. This association is not well examined or explained in the literature. AIMS: We aimed to outline current knowledge of the association between falls and lower urinary tract symptoms and suggest a research program to further investigate this. MATERIALS AND METHODS: A consensus conference of experts in the field was convened to review the current literature and brainstorm potential future investigative avenues. RESULTS AND DISCUSSION: Despite the recognition of this association, there has been little research to examine its potential causes, and no intervention trial has established if reducing LUTS or urinary incontinence can reduce the risk of falls. The commonly held assumption that urgency causes falls through rushing to the toilet is likely incorrect. Falls and LUTS are both symptoms of frailty and have many common causes. Gait, balance, and continence are all processes requiring cognitive input, and the concept of dual tasking may be a further link. CONCLUSION: The significant association between lower urinary tract symptoms and falls is currently unexplained, and further research into the potential causes of this association is needed.

Functional Electrical Stimulation for Foot Drop in Multiple Sclerosis: A Systematic Review and Meta-Analysis of the Effect on Gait Speed.

OBJECTIVE: 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. DATA SOURCES: Five databases (Cochrane Library, CINAHL, Embase, MEDLINE, and PubMed) and reference lists were searched. STUDY SELECTION: Studies of both observational and experimental design where gait speed data in pwMS could be extracted were included. DATA EXTRACTION: Data were independently extracted and recorded. Methodologic quality was assessed using the Effective Public Health Practice Project tool. DATA SYNTHESIS: 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. CONCLUSIONS: 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.

Abdominal massage for the alleviation of symptoms of constipation in people with Parkinson's: a randomised controlled pilot study.

BACKGROUND: constipation is one of the most common non-motor features of Parkinson's affecting up to 90% of patients. In severe cases, it can lead to hospitalisation and is usually managed with laxatives which in themselves can lead to side effects. Abdominal massage has been used as adjunct in the management of constipation in various populations, but not in those with Parkinson's. OBJECTIVE: the primary objective was to test the recruitment, retention and the appropriateness of the intervention methods and outcome measures. METHODS: thirty-two patients with Parkinson's were recruited from three movement disorder clinics and were randomised to receive either 6 weeks of daily abdominal massage plus lifestyle advice on managing constipation (Intervention Group, n = 16) or lifestyle advice (Control Group, n = 16). Data were collected prior to group allocation (Baseline), at Week 6 (following intervention) and 4 weeks later (Week 10). Outcome tools included the Gastrointestinal Rating Scale and a bowel diary. RESULTS: constipation has a negative impact on quality of life. The study recruited to target, retention was high and adherence to the study processes was good. The massage was undertaken as recommended during the 6 weeks of intervention with 50% continuing with the massage at 10 weeks. Participants in both groups demonstrated an improvement in symptoms, although this was not significantly different between the groups. CONCLUSION: abdominal massage, as an adjunct to management of constipation, offers an acceptable and potentially beneficial intervention to patients with Parkinson's.

Physiotherapy Rehabilitation for People With Progressive Multiple Sclerosis: A Systematic Review.

OBJECTIVE: To assess the efficacy of physiotherapy interventions, including exercise therapy, for the rehabilitation of people with progressive multiple sclerosis. DATA SOURCES: Five databases (Cochrane Library, Physiotherapy Evidence Database [PEDro], Web of Science Core Collections, MEDLINE, Embase) and reference lists of relevant articles were searched. STUDY SELECTION: Randomized experimental trials, including participants with progressive multiple sclerosis and investigating a physiotherapy intervention or an intervention containing a physiotherapy element, were included. DATA EXTRACTION: Data were independently extracted using a standardized form, and methodologic quality was assessed using the PEDro scale. DATA SYNTHESIS: 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. CONCLUSIONS: This review suggests that physiotherapy may be effective for the rehabilitation of people with progressive multiple sclerosis. However, further appropriately powered studies are required.

The effectiveness of behaviour change interventions to increase physical activity participation in people with multiple sclerosis: a systematic review and meta-analysis.

OBJECTIVE: A systematic review and meta-analysis was conducted to illustrate whether people with multiple sclerosis engage in more physical activity following behaviour change interventions. DATA RESOURCES: MEDLINE, CINAHL, PubMed, Web of Sciences, Cochrane Library, SCOPUS, EMBASE and PEDro were searched from their inception till 30 April 2015. TRIAL SELECTION: Randomized and clinical controlled trials that used behaviour change interventions to increase physical activity in people with multiple sclerosis were selected, regardless of type or duration of multiple sclerosis or disability severity. DATA EXTRACTION: Data extraction was conducted by two independent reviewers and the Cochrane Collaboration's recommended method was used to assess the risk of bias of each included study. RESULTS: A total of 19 out of 573 studies were included. Focusing on trials without risk of bias, meta-analysis showed that behaviour change interventions can significantly increase physical activity participation (z = 2.20, p = 0.03, standardised main difference 0.65, 95% confidence interval 0.07 to 1.22, 3 trials, I(2) = 68%) (eight to 12 weeks' duration). Behaviour change interventions did not significantly impact on the physical components of quality of life or fatigue. CONCLUSION: Behaviour change interventions provided for relatively short duration (eight to 12 weeks) may increase the amount of physical activity people with multiple sclerosis engage in, but appear to have no effect on the physical components of quality of life and fatigue. Further high quality investigations of the efficacy of behaviour change interventions to increase physical activity participation that focus on dose, long-term impact and method of delivery are warranted for people with multiple sclerosis.

Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone application: a pilot study.

BACKGROUND: Following stroke, people are generally less active and more sedentary which can worsen outcomes. Mobile phone applications (apps) can support change in health behaviors. We developed STARFISH, a mobile phone app-based intervention, which incorporates evidence-based behavior change techniques (feedback, self-monitoring and social support), in which users' physical activity is visualized by fish swimming. OBJECTIVE: To evaluate the potential effectiveness of STARFISH in stroke survivors. METHOD: Twenty-three people with stroke (12 women; age: 56.0 ± 10.0 years, time since stroke: 4.2 ± 4.0 years) from support groups in Glasgow completed the study. Participants were sequentially allocated in a 2:1 ratio to intervention (n = 15) or control (n = 8) groups. The intervention group followed the STARFISH program for six weeks; the control group received usual care. Outcome measures included physical activity, sedentary time, heart rate, blood pressure, body mass index, Fatigue Severity Scale, Instrumental Activity of Daily Living Scale, Ten-Meter Walk Test, Stroke Specific Quality of Life Scale, and Psychological General Well-Being Index. RESULTS: The average daily step count increased by 39.3% (4158 to 5791 steps/day) in the intervention group and reduced by 20.2% (3694 to 2947 steps/day) in the control group (p = 0.005 for group-time interaction). Similar patterns of data and group-time interaction were seen for walking time (p = 0.002) and fatigue (p = 0.003). There were no significant group-time interactions for other outcome measures. CONCLUSION: Use of STARFISH has the potential to improve physical activity and health outcomes in people after stroke and longer term intervention trials are warranted.

Core outcome measures for exercise studies in people with multiple sclerosis: recommendations from a multidisciplinary consensus meeting.

Evidence shows that exercise is beneficial for people with multiple sclerosis (MS); however, statistical pooling of data is difficult because of the diversity of outcome measures used. The objective of this review is to report the recommendations of an International Consensus Meeting for a core set of outcome measures for use in exercise studies in MS. From the 100 categories of the International Classification of Function Core Sets for MS, 57 categories were considered as likely/potentially likely to be affected by exercise and were clustered into seven core groups. Outcome measures to address each group were evaluated regarding, for example, psychometric properties. The following are recommended: Modified Fatigue Impact Scale (MFIS) or Fatigue Severity Scale (FSS) for energy and drive, 6-Minute Walk Test (6MWT) for exercise tolerance, Timed Up and Go (TUG) for muscle function and moving around, Multiple Sclerosis Impact Scale (MSIS-29) or Multiple Sclerosis Quality of Life-54 Instrument (MSQoL54) for quality of life and body mass index (BMI) or waist-hip ratio (WHR) for the health risks associated with excess body fat. A cost effectiveness analysis and qualitative evaluation should be included where possible. Using these core measures ensures that future meta-analyses of exercise studies in MS are more robust and thus more effectively inform practice.