The meaningfulness of exploring one's own limits through interactions and enjoyment in outdoor high-intensity physiotherapy for people with multiple sclerosis: a qualitative study.

Background and purpose: Physical activity (PA) is often reduced in people with MS (pwMS), even when disability is low. Understanding the perspectives of pwMS on interventions aiming to improve PA is important to inform the development of such services. The aim of this study was to explore the experiences of pwMS participating in an outdoor, high-intensity and balance exercise group intervention. Methods: This qualitative study was nested within an RCT exploring a novel intervention integrating sensorimotor exercises with high-intensity intervals of running/walking. Individual, in-depth interviews with the intervention group (n = 15; 12 women, 3 men; age 38-66; EDSS score 0-3.5) were conducted postintervention (mean days = 14), analyzed using a phenomenological-inspired approach with systematic text condensation, and interpreted based on enactive theory. Results: Four categories were generated: (1) Exploration of one's own physical abilities: Challenging one's own limits was perceived by all participants to improve movement performance and/or intensity level. Such bodily changes engendered strong positive feelings. Some negative consequences of high-intensity training were described, increasing a feeling of loss. (2) New insights and beliefs: Participants experienced enhanced beliefs in their own capabilities, which they integrated in activities outside the intervention. (3) An engaging environment: The group setting was perceived as supportive, and the outdoor environment was perceived as stimulating activity. (4) Professional leadership, tailoring and co-creation of enjoyment: Physiotherapist-led, individualized interactions were regarded as necessary to safely revisit prior activities, such as running. Co-creating enjoyment facilitated high-intensity training and intervention adherence. Discussion: High-intensity training combined with detailed exercises in a physiotherapy outdoor group was perceived to create meaningful bodily changes and enhance PA and prospects for both PA and life. Importantly, however, some negative experiences were also reported from the high-intensity training. Enactive theory allowed for the illumination of new perspectives: the importance of embodiment for self-efficacy and of tailored physiotherapy and an outdoor-group environment for exploring one's own limits to physical capabilities. These aspects should inform future exercise interventions in pwMS with low disability.

Patients' experiences with early rehabilitation in intensive care units: A qualitative study about aspects that influence their participation.

AIM: To explore patients' experiences with early rehabilitation in the intensive care unit and what they perceive to influence their participation. DESIGN: A qualitative design anchored in phenomenological and hermeneutical traditions utilizing in-depth interviews. METHODS: Thirteen patients were interviewed from 5 to 29 weeks following discharge from three units, in January-December 2022. Analysed using systematic text condensation and the pattern theory of self. Reporting adhered to consolidated criteria for reporting qualitative research. RESULTS: Interviews described four main categories: (1) A foreign body, how the participants experienced their dysfunctional and different looking bodies. (2) From crisis to reorientation, the transformation the participants experienced from a state of crisis to acceptance and the ability to look forwards, indicating how bodily dysfunctions are interlinked to breakdowns of the patients' selves and the reorganization process. (3) Diverse expectations regarding activity: ambiguous expectations communicated by the nurses. (4) Nurse-patient: a powerful interaction, highlighting the essential significance of positive expectations and tailored bodily and verbal interaction for rebuilding the patient's outwards orientation. CONCLUSION: Outwards orientation and reorganization of the self through a reduction in bodily dysfunctions, strengthening the patients' acceptance of the situation, providing tailored expectations and hands-on and verbal interaction appear to be fundamental aspects of patient participation in early rehabilitation. IMPLICATIONS: Insights into patients' perceptions show how dysfunctional bodies cloud individuals' perceptual fields, causing inwards orientation and negative thoughts concerning themselves, their capabilities, environment and future. This knowledge can improve nurses' ability to tailor care to promote optimal recovery for patients. PATIENT OR PUBLIC CONTRIBUTION: User representative contributed to the design of the study.

The effect of exercise and physical activity-interventions on step count and intensity level in individuals with multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials.

Background: Reduced physical activity is a worldwide challenge in individuals with multiple sclerosis (MS). The aim of this systematic review and meta-analysis was to identify devise-measured effects of physical activity, exercise and physiotherapy-interventions on step count and intensity level of physical activity in individuals with MS. Methods: A systematic search of the databases of PubMed (including Medline), Scopus, CINHAL and Web of Science was carried out to retrieve studies published in the English language from the inception to the first of May 2023. All trials concerning the effectiveness of different types of exercise on step count and intensity level in people with MS were included. The quality of the included studies and their risk of bias were critically appraised using The modified consolidated standards of reporting trials and the Cochrane Risk of Bias tool, respectively. The pooled standardized mean difference (SMD) and 95% CI of the step-count outcome and moderate to vigorous intensity level before versus after treatment were estimated in both Intervention and Control groups using the random effect model. The Harbord test were used to account for heterogeneity between studies and assess publication bias, respectively. Further sensitivity analysis helped with the verification of the reliability and stability of our review results. Results: A total of 8 randomized clinical trials (involving 919 individuals with MS) were included. The participants (including 715 (77.8%) female and 204 (22.2%) male) had been randomly assigned to the Intervention (n = 493) or Control group (n = 426). The pooled mean (95% CI) age and BMI of participants were 49.4 years (95% CI: 47.4, 51.4 years) and 27.7 kg/m2 (95% CI: 26.4, 29 kg/m2), respectively. In terms of the comparison within the Intervention and the Control groups before and after the intervention, the results of the meta-analysis indicate that the pooled standardized mean difference (SMD) for step-count in the Intervention group was 0.56 (95% CI: -0.42, 1.54), while in the Control group it was 0.12 (95% CI: -0.05, 0.28). Furthermore, there was no significant difference in the pooled SMD of step-count in the physical activity Intervention group compared to the Controls after the intervention (pooled standard mean difference = 0.19, 95% CI: -0.36,0.74). Subgroup analysis on moderate to vigorous intensity level of physical activity revealed no significant effect of the physical activity intervention in the Intervention group compared to the Control group after the intervention, or within groups before and after the intervention. Results of meta regression showed that age, BMI, duration of disease and Expanded Disability Status Scale (EDSS) score were not the potential sources of heterogeneity (all p > 0.05). Data on the potential harms of the interventions were limited. Conclusion: The results of this meta-analysis showed no significant differences in step count and moderate to vigorous physical activity level among individuals with MS, both within and between groups receiving physical activity interventions. More studies that objectively measure physical activity are needed. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42022343621.

Feasibility of a new intervention addressing group-based balance and high-intensity training, physical activity, and employment in individuals with multiple sclerosis: a pilot randomized controlled trial.

Background and purpose: Impaired sensorimotor function, reduced physical activity and unemployment are common challenges in persons with multiple sclerosis (pwMS), even when disability is low. CoreDISTparticipation is a new, multidisciplinary intervention delivered across healthcare levels systematically addressing these elements. This study primarily aimed to evaluate the feasibility of CoreDISTparticipation in terms of process, resources, management, and scientific outcomes. The secondary aim was to evaluate initial efficacy in terms of possible short-term effects compared with the usual care on barriers to employment, balance, walking, health-related quality of life (HRQoL), and physical activity. Methods: This assessor-blinded prospective pilot randomized controlled trial included 29 pwMS [Expanded Disability Status Scale (EDSS): 0-3.5] randomly allocated to the intervention group (CoreDISTparticipation) (n = 15) or usual care (n = 14). CoreDISTparticipation consists of three phases: (1) hospital outpatient clinic: MS nurse work-focused session and physiotherapist exploring balance; (2) municipality: a digital meeting with pwMS, employer, MS nurse, and physiotherapist addressing employment and physical activity, 4 weeks indoor CoreDIST balance training (60 min × 2/week); and (3) 4 weeks outdoor CoreDIST balance training and high-intensity running/walking (60 min × 2/week). Assessments were undertaken at baseline and at weeks 6 and 11. Primary feasibility metric outcomes were the reporting of process, resources, management, and scientific outcomes. Efficacy measures included evaluation of the Multiple Sclerosis Work Difficulties Questionnaire-23 Norwegian Version (MSWDQ-23NV) and 6 Minute Walk-test as well as the Trunk Impairment Scale-modified Norwegian Version, Mini-Balance Evaluation Systems Test (Mini-BESTest), Multiple Sclerosis Walking Scale-12, Multiple Sclerosis Impact Scale-29 Norwegian Version (MSIS-29NV), ActiGraph wGT3x-BT monitors, and AccuGait Optimized force platform. The statistical analyses included repeated-measures mixed models performed in IBM SPSS Version 29. Results: The primary feasibility metric outcomes demonstrated the need for minor adjustments in regard to the content of the intervention and increasing the number of staff. In regard to the efficacy measures, one person attended no postintervention assessments and was excluded, leaving 28 participants (mean EDSS: 1.8, SD: 1). The mean percentage employment was 46.3 (SD: 35.6) and 65.4 (SD: 39.3) in the CoreDISTparticipation and usual care group, respectively. No between-group differences were found. MSWDQ-23NV demonstrated a within-group difference of 5.7 points from baseline to Week 11 (P = 0.004; confidence interval: 2.2-9.3). Mini-BESTest and MSIS-29NV demonstrated within-group differences. The study is registered in ClinicalTrials.gov (Identifier: NCT05057338). Discussion: The CoreDISTparticipation intervention is feasible to support pwMS when the identified feasibility metric outcomes in regard to process, resource, management, and scientific outcome metrics are adjusted to improve feasibility. Regarding efficacy measures, no between-group differences were detected; however, within-group differences in barriers to employment, balance, and HRQoL were detected for the CoreDISTparticipation group. A larger comparative trial is needed to explore between-group differences and should accurately and precisely define usual care and address the identified limitations of this study.

Effect of innovative vs. usual care physical therapy in subacute rehabilitation after stroke. A multicenter randomized controlled trial.

Background: Research on stroke rehabilitation often addresses common difficulties such as gait, balance or physical activity separately, a fragmentation contrasting the complexity in clinical practice. Interventions aiming for recovery are needed. The purpose of this study was to investigate effects of a comprehensive low-cost physical therapy intervention, I-CoreDIST, vs. usual care on postural control, balance, physical activity, gait and health related quality of life during the first 12 weeks post-stroke. Methods: This prospective, assessor-masked randomized controlled trial included 60 participants from two stroke units in Norway. Participants, who were randomized to I-CoreDIST (n = 29) or usual care physical therapy (n = 31), received 5 sessions/week when in-patients or 3 sessions/week as out-patients. Primary outcomes were the Trunk Impairment Scale-modified Norwegian version (TISmodNV) and activity monitoring (ActiGraphsWgt3X-BT). Secondary outcomes were the Postural Assessment Scale for Stroke, MiniBesTEST, 10-meter walk test, 2-minute walk test, force-platform measurements and EQ5D-3L. Stroke specific quality of life scale was administered at 12 weeks. Linear regression and non-parametric tests were used for statistical analysis. Results: Five participants were excluded and seven lost to follow-up, leaving 48 participants in the intention-to-treat analysis. There were no significant between-group effects for primary outcomes: TIS-modNV (p = 0,857); daily average minutes of sedative (p = 0.662), light (p = 0.544) or moderate activity (p = 0.239) and steps (p = 0.288), or secondary outcomes at 12 weeks except for significant improvements on EQ5D-3L in the usual care group. Within-group changes were significant for all outcomes in both groups except for activity levels that were low, EQ5D-3L favoring the usual care group, and force-platform data favoring the intervention group. Conclusions: Physical therapy treatment with I-CoreDIST improved postural control, balance, physical activity and gait during the first 12 weeks after a stroke but is not superior to usual care.

The precarity of patient participation - a qualitative interview study of experiences from the acute stroke and rehabilitation journey.

INTRODUCTION: Active patient participation is an important factor in optimizing post-stroke recovery, yet it is often low, regardless of stroke severity. The reasons behind this trend are unclear. PURPOSE: To explore how people who have suffered a stroke, perceive the transition from independence to dependence and whether their role in post-stroke rehabilitation influences active participation. METHODS: In-depth interviews with 17 people who have had a stroke. Data were analyzed using systematic text condensation informed by the concept of autonomy from enactive theory. RESULTS: Two categories emerged. The first captures how the stroke and the resultant hospital admission produces a shift from being an autonomous subject to "an object on an assembly line." Protocol-based investigations, inactivity, and a lack of patient involvement predominantly determine the hospital context. The second category illuminates how people who have survived a stroke passively adapt to the hospital system, a behavior that stands in contrast to the participatory enablement facilitated by community. Patients feel more prepared for the transition home after in-patient rehabilitation rather than following direct discharge from hospital. CONCLUSION: Bodily changes, the traditional patient role, and the hospital context collectively exacerbate a reduction of individual autonomy. Thus, an interactive partnership between people who survived a stroke and multidisciplinary professionals may strengthen autonomy and promote participation after a stroke.

Barriers to and facilitators for making emergency calls - a qualitative interview study of stroke patients and witnesses.

BACKGROUND AND OBJECTIVES: Early access to hospital for diagnosis and treatment is strongly recommended for patients with acute stroke. Unfortunately, prehospital delay frequently occurs. The aim of the current study was to gain in-depth insight into patient experience and behavior in the prehospital phase of a stroke. METHODS: We conducted qualitative interviews with a purposive sample of 11 patients and six witnesses within four weeks post stroke. The interviews were audio recorded, transcribed, and analyzed utilizing Systematic Text Condensation. RESULTS: The material was classified according to two main categories each containing three subgroups. The first category contained the diversity of sudden changes that all participants noticed. The subgroups were confusing functional changes, distinct bodily changes and witnesses' observations of abnormal behavior or signs. The second category was delaying and facilitating factors. To trivialize or deny stroke symptoms, or having a high threshold for contacting emergency services, led to time delay. Factors facilitating early contact were severe stroke symptoms, awareness of the consequences of stroke or a witness standing by when the stroke occurred. CONCLUSIONS: Prehospital delays involved interrelated elements: (1) Difficulties in recognition of a stroke when symptoms were mild, odd and/or puzzling; (2) Recognition of a stroke or need for medical assistance were facilitated by interaction/communication; (3) High threshold for calling emergency medical services, except when symptoms were severe. The findings may be helpful in planning future public stroke campaigns and in education and training programs for health personnel.

Embodiment, tailoring, and trust are important for co-construction of meaning in physiotherapy after stroke: A qualitative study.

BACKGROUND AND PURPOSE: Physiotherapy, with an emphasis on high intensity, individually tailored, and person-centered treatment, is an effective route for recovery after a stroke. No single approach, however, has been deemed paramount, and there is limited knowledge about the patient experience of assessment, goal-setting, and treatment in physiotherapy. In this study, we seek to report patient experiences of I-CoreDIST-a new physiotherapy intervention that targets recovery-and those of usual care. The purpose is to investigate how individuals with stroke experience the bodily and interactive course of physiotherapy during their recovery process. METHODS: A qualitative study, nested within a randomized controlled trial, consisting of in-depth interviews with 19 stroke survivors who received either I-CoreDIST or usual care. Data were analyzed using systematic text condensation, and this analysis was informed by enactive theory. RESULTS: Interaction with the physiotherapist, which was guided by perceived bodily changes, fluctuated between being, on the one hand, formal/explicit and, on the other, tacit/implicit. The experiences of participants in the intervention group and the usual care group differed predominantly with regards to the content of therapy sessions and the means of measuring progress; divergences in levels of satisfaction with the treatment were less pronounced. The perception of positive bodily changes, as well as the tailoring of difficulty and intensity, were common and essential features in generating meaning and motivation. An embodied approach seemed to facilitate sense-making in therapy situations. In the interaction between the participants and their physiotherapists, trust and engagement were important but also multifaceted, involving both interpersonal skills and professional expertise. CONCLUSION: The embodied nature of physiotherapy practice is a source for sense-making and meaning-construction for patients after a stroke. Trust in the physiotherapist, along with emotional support, is considered essential. Experiencing progress and individualizing approaches are decisive motivators.

What is the distribution of trunk impairments and its relationship with disability level in individuals with multiple sclerosis?

BACKGROUND: Trunk control is essential for movement, balance and walking and is ignored in the regular medical follow-up. OBJECTIVE: First, to describe the distribution of trunk impairments in the full range of disability levels in individuals with MS. Second, to identify the relationship between trunk control, measured by the Trunk Impairment Scale (TIS 2.0.), and general disability measured by the Expanded Disability Status Scale (EDSS). METHODS: 154 individuals with MS were included (mean age 53.6; SD 11.06), EDSS ranging from 1.0- 8.5 (mean 4.47; SD 2.55). The relationship between EDSS and TIS 2.0. was calculated by Spearman correlation coefficient for the total sample and subgroups, EDSS ≤ 4 versus EDSS ≥ 4.5. RESULTS: Trunk impairments were detected throughout the full range of disability, including individuals with low disability. Pelvic elevation and lower trunk rotation appeared most difficult to perform. In the total sample, a moderate correlation was found (rho= -0.608**) between disability (EDSS) and trunk performance (TIS 2.0.). Sub-analyses revealed a poor correlation (rho= -0.193) for the EDSS ≤ 4 subgroup and a strong correlation for the EDSS ≥ 4.5 subgroup (rho= -0.712**). CONCLUSION: The results advocate for including trunk assessment already at early disease stages of MS, particularly of pelvic elevation and trunk rotation, and dedicated rehabilitation strategies.

The content and effects of trunk rehabilitation on trunk and upper limb performance in people with multiple sclerosis: a systematic review.

INTRODUCTION: Persons with multiple sclerosis (pwMS) could have an impaired trunk and reduced postural control, which negatively impacts activities of daily living. Evidence is growing to consider the positive effects of trunk training on fall incidence and balance problems. Effects on trunk and upper limb performance is unknown. This systematic review provides an overview of trunk training programs and their effects in MS, specifically focusing on the content of training modalities and the effects on trunk and upper limb performance. EVIDENCE ACQUISITION: Two electronic databases were used: PubMed and Web Of Science (WOS). Intervention studies (with- and without control group) published in English, investigating the effects of active trunk training on trunk and upper limb performance in pwMS, were included. EVIDENCE SYNTHESIS: Sixteen studies met the criteria, investigating different rehabilitation modalities. The included interventions in the review varied between more generic postural interventions such as Pilates (N.=8) and Ai Chi (N.=1), with a focus on abdominal muscle activation, breathing, neutral position and lower extremity movements. Further, specifically developed trunk training programs like GroupCoreDIST/ SIT / CoDuSe (N.=6) and Bobath based trunk training (N.=1) are detected, with the main focus on trunk strengthening and dynamic movements. An overall improvement in trunk performance was reported in several tests on trunk strength, stability and coordination. While the majority of the programs integrated the upper limb, only half of them used upper limb outcome measures to evaluate the effect. Here, overall significant improvements were found for the upper limb. CONCLUSIONS: This systematic review showed that different types of trunk training programs can improve trunk and upper limb function in PwMS. The findings of this review suggest that a focus on trunk training to achieve effects on upper limb is reasonable. Future research is needed to further explore relations and the effect sizes.

Group-based, individualized exercises can provide perceived bodily changes and strengthen aspects of self in individuals with MS: a qualitative interview study.

Background: Group-based physiotherapy is effective for individuals with MS; nevertheless individualization within groups is questioned and little is known regarding individuals´ experiences with individualization in small groups.Objective: We aimed to explore the short- and long-term experiences of individuals with MS participating in a 6-week, group-based, individualized physiotherapy-intervention.Methods: Within a randomized controlled trial (RCT), 25 in-depth interviews with a strategic sample of 13 people (9 women; age 25-79 years old; European Disability Status Scale (EDSS) 1-6.5) were conducted at weeks 7 and 30 using systematic text condensation, with dynamic systems theory and phenomenology as analytical frameworks.Results: The main categories were: 1) movement control, orientation and insights: Bodily improvements were associated with targeted exercises, specific adjustments by the physiotherapist, emotional engagement and re-access to activities; and 2) the individual within the group: Equal distributions of one-to-one interactions and attention were important for experiencing success. Less attention and improvements turned attention toward own disability. Physical changes felt particularly emotional short term, implying that individuals' feelings of ownership and control of body and movement, new views of themselves and changed affordances in daily life were involved.Conclusion: Equally distributed attention and engagement, targeted exercises and hands-on adjustments resulting in visible and perceived bodily changes were experienced as key factors of individualization in small groups.

Physiotherapy assessment of individuals with multiple sclerosis prior to a group intervention - A qualitative observational and interview study.

Assessment prior to both individual and group interventions is fundamental to neurological physiotherapy practice. However, knowledge is limited regarding how assessments are carried out, particularly assessments conducted prior to group interventions, which have recently gained increasing attention in clinical research. In this qualitative study, we investigated how physiotherapy assessments of patients with multiple sclerosis prior to a group exercise intervention were carried out and what physiotherapists considered vital elements in the assessment process. Data were gathered through 12 qualitative non-participatory video observations followed by in-depth interviews of physiotherapists. Systematic text condensation analysis was conducted within an enactive theoretical framework of participatory sense making. In the assessments, patients' bodily perceptions of movement changes appeared to be vital in establishing patient expectations for the forthcoming intervention. The extent of patient participation and an embodied approach to communication influenced both the physiotherapists' and patients' insights into the patients' movement problems, which were further utilized in the initial intervention planning. Significant differences in context from the assessment to the intervention require a systematic completion of the assessments in the course of the first clinical meeting, which should be considered in the further development of research and clinical practices.

Facilitation of movement: New perspectives provide expanded insights to guide clinical practice.

Hands-on therapeutic interactions are essential to neurological physiotherapy. Facilitation of movement is a particular aspect of such interactions that potentiates self-initiation of movement. This process involves interactions between the physiotherapist and the patient through three integrated phases: (1) "make movement possible;" (2) "make movement necessary;" and (3) "let movement happen," in which communicative aspects are considered important. The purpose of this paper is to explore a theoretical foundation for this approach by utilizing an extended framework. Dynamic systems theory clarifies the physiotherapist's handling as the adjusted manipulation of the patient's constraints upon movement complemented by tailoring of the specific attributes of the task and environment; however, this theory provides inadequate coverage of the involved communicative aspects. Phenomenology, which perceives the body as the center of experience and expression, offers a path to understanding such hands-on interactions as a form of communication. Enactive theory clarifies these physical interactions of the physiotherapist and the patient as essential in co-construction of meaning that evolves as an interactive and dynamic process within a specific context. This extended framework, in which neuro- and movement sciences are integrated, provides an appropriate theoretical anchoring of facilitation of movement that is beneficial for guiding clinical practice and training.

Group-based, individualized, comprehensive core stability and balance intervention provides immediate and long-term improvements in walking in individuals with multiple sclerosis: A randomized controlled trial.

OBJECTIVES: Walking impairments are common in individuals with multiple sclerosis. Trunk control is a prerequisite for walking; however, knowledge regarding whether core stability and balance training influence walking is limited. This study aimed to investigate the immediate and long-term effects of a group-based, individualized, comprehensive core stability and balance intervention (GroupCoreDIST) compared with those of standard care on walking. METHODS: This assessor-blinded, prospective randomized controlled trial included 80 participants (Expanded Disability Status Scale scores 1-6.5) randomly allocated to GroupCoreDIST, conducted in groups of three for 60 min three times per week for 6 weeks (18 sessions) or standard care (n = 40/40). One participant attended no posttests, leaving 79 subjects for intention-to-treat analysis. The assessments were performed at baseline and at Weeks 7, 18, and 30. Outcomes included the 2-min walk test (2MWT), 10-m walk test-preferred/fast/slow speed (10MWT), Multiple Sclerosis Walking Scale-12 (MSWS-12), Patient Global Impression of Change-walking (PGIC-walking), Rivermead Visual Gait Assessment (RVGA), and ActiGraphsWgt3X-BT activity monitors (ActiGraph). The statistical analyses included repeated-measures mixed models performed in IBM SPSS Version 24. RESULTS: There were no significant between-group differences in the outcome measurements at baseline. The mean differences between groups were significant at all follow-up time points in favour of GroupCoreDIST for the 2MWT, 16.7 m at 7 weeks (95% CI [8.15, 25.25], 15.08 m at 18 weeks (95% CI [6.39, 23.77]) and 16.38 m at 30 weeks (95% CI [7.65, 25.12]; and the PGIC-walking, 0.89 points at 7 weeks (95% CI [1.34, 0.45]), 0.97 points at 18 weeks (95% CI [1.42, 0.52]), and 0.93 points at 30 weeks (95% CI [1.39, 0.48]; all p ≤ .001). The 10MWT-fast speed and the MSWS-12 showed significant between-group differences at 7 and 18 weeks and the RVGA at 7 weeks. No between-group differences were found regarding activity level (ActiGraph) or the 10MWT-preferred or slow speed. CONCLUSION: Compared with standard care, GroupCoreDIST significantly improved walking immediately after the intervention for up to 24 weeks of follow-up.

Group dynamics in a group-based, individualized physiotherapy intervention for people with multiple sclerosis: A qualitative study.

OBJECTIVE: Group-based physiotherapy is a common and beneficial intervention for people with multiple sclerosis (MS). Most group interventions are not individually adapted to each participant's needs. Evidence on how individualization and group elements can be combined in a clinical setting is lacking. The objective of this study is to expand the knowledge base in neurological physiotherapy by investigating the nature of group dynamics in a group-based, individualized intervention for people with MS. METHODS: This qualitative study included 13 nonparticipatory video observations (14 hr 38 min) of GroupCoreDIST exercise sessions complemented by 13 interviews (12 hr 37 min) with physiotherapists (PTs). The purposively sampled participants included 40 patients with MS (expanded disability scale of 1.0-6.5) and six PTs with expertise in neurological physiotherapy. Data were analysed using systematic text condensation in an enactive theoretical framework. RESULTS: Two main categories emerged from the material. (a) Individual systems affect group dynamics: Individual perceptions of success through adapted and embodied approaches positively affected the dynamics of the group. (b) Disease and exercise peer support: Social support was a substantial product of dynamic group processes and was enhanced through the PTs' strategic focus on experience sharing. CONCLUSION: The results revealed that group dynamics benefit from individualization and the PTs' focus on experience sharing. These findings are contrary to the prevailing view that individualization and group-based interventions are mutually exclusive and thus should be considered in group-based interventions for people with MS.

"Back at the same level as everyone else"-user perspectives on walking with an exoskeleton, a qualitative study.

Study design: Qualitative, in-depth research interviews led by a theme-based interview guide. Objectives: To generate new knowledge regarding user experiences of standing and walking with Ekso™ (Ekso Bionics, Richmond, CA, USA). Setting: In-patient rehabilitation hospital in Norway. Methods: Systematic inductive content analyses were used, utilizing a pattern theory of self as an analytical framework. Results: The participants shared powerful stories, describing largely positive but also challenging emotions and perceptions, related to standing and walking with Ekso™. Four themes emerged: (1) bodily positions, possibilities and feelings, (2) reactivation of loss and hope for the future, (3) to be free and restricted at the same time, and (4) to be controlled and take control. The results indicate that both walking and using a wheelchair involve more than getting from one place to another, as fundamental aspects of being human are touched, involving facilitating a coherent understanding of the self and, on the other hand, leading to an "objectification" of the body. Conclusions: This explorative study points toward contrasts involved when using Ekso™. More studies of lived experiences with walking in Ekso™ are needed, comprising larger samples, variations in participant characteristics and diagnoses as well as contexts.

Searching for the "Active Ingredients" in Physical Rehabilitation Programs Across Europe, Necessary to Improve Mobility in People With Multiple Sclerosis: A Multicenter Study.

BACKGROUND: Physical rehabilitation programs can lead to improvements in mobility in people with multiple sclerosis (PwMS). OBJECTIVE: To identify which rehabilitation program elements are employed in real life and how they might affect mobility improvement in PwMS. METHODS: Participants were divided into improved and nonimproved mobility groups based on changes observed in the Multiple Sclerosis Walking Scale-12 following multimodal physical rehabilitation programs. Analyses were performed at group and subgroup (mild and moderate-severe disability) levels. Rehabilitation program elements included setting, number of weeks, number of sessions, total duration, therapy format (individual, group, autonomous), therapy goals, and therapeutic approaches. RESULTS: The study comprised 279 PwMS from 17 European centers. PwMS in the improved group received more sessions of individual therapy in both subgroups. In the mildly disabled group, 60.9% of the improved received resistance training, whereas, 68.5% of the nonimproved received self-stretching. In the moderately-severely disabled group, 31.4% of the improved, received aerobic training, while 50.4% of the nonimproved received passive mobilization/stretching. CONCLUSIONS: We believe that our findings are an important step in opening the black-box of physical rehabilitation, imparting guidance, and assisting future research in defining characteristics of effective physical rehabilitation.

Group-Based Individualized Comprehensive Core Stability Intervention Improves Balance in Persons With Multiple Sclerosis: A Randomized Controlled Trial.

BACKGROUND: Balance and trunk control are often impaired in individuals with multiple sclerosis (MS). Interventions addressing these issues are needed. OBJECTIVE: The objective of this study was to compare the immediate and long-term effects of a 6-week individualized, group-based, comprehensive core stability intervention (GroupCoreDIST) with standard care on balance and trunk control in individuals with MS. DESIGN: This study was a prospective, assessor-masked, randomized controlled trial. SETTING: The GroupCoreDIST intervention was conducted by 6 physical therapists in 6 municipalities in Norway. Standard care included the usual care for individuals with MS in the same municipalities. Assessments at all time points took place at a Norwegian hospital. PARTICIPANTS: Eighty people with Expanded Disability Status scores of 1 to 6.5 participated in this trial. INTERVENTION: Randomized, concealed allocation was used to assign the participants to the GroupCoreDIST intervention (n = 40) or to standard care (n = 40). The GroupCoreDIST intervention was conducted with groups of 3 participants (1 group had 4 participants), for 60 minutes 3 times per week. MEASUREMENTS: Assessments were undertaken at baseline and at weeks 7, 18, and 30. Outcomes were measured with the Trunk Impairment Scale-Norwegian Version, Mini Balance Evaluation Systems Test, and Patient Global Impression of Change-Balance. Repeated-measures mixed models were used for statistical analysis. RESULTS: One individual missed all postintervention tests, leaving 79 participants in the intention-to-treat analysis. GroupCoreDIST produced significant between-group effects on the mean difference in the following scores at 7, 18, and 30 weeks: for Trunk Impairment Scale-Norwegian Version, 2.63 points (95% confidence interval [CI] = 1.89-3.38), 1.57 points (95% CI = 0.81-2.33), and 0.95 point (95% CI = 0.19-1.71), respectively; for Mini Balance Evaluation Systems Test, 1.91 points (95% CI = 1.07-2.76), 1.28 points (95% CI = 0.42-2.15), and 0.91 points (95% CI = 0.04-1.77), respectively; and for Patient Global Impression of Change-Balance, 1.21 points (95% CI = 1.66-0.77), 1.02 points (95% CI = 1.48-0.57), and 0.91 points (95% CI = 1.36-0.46), respectively. LIMITATIONS: Groups were not matched for volume of physical therapy. CONCLUSIONS: Six weeks of GroupCoreDIST improved balance and trunk control in the short and long terms compared with standard care in individuals who were ambulant and had MS. The intervention is an effective contribution to physical therapy for this population.

How physiotherapists supervise to enhance practical skills in dedicated aides of toddlers with cerebral palsy: A qualitative observational study.

BACKGROUND: Physiotherapy from an early age is considered important for children with cerebral palsy (CP). In preschool, dedicated aides are responsible for the daily follow-up and training under the supervision of a physiotherapist (PT). Knowledge is sparse regarding what is created and achieved in clinical practice involving triads (i.e. the PT, aide, and child) with respect to the enhancement of practical skills in dedicated aides. The study purpose was to explore form and content in supervision. METHODS: Nonparticipating observations were performed on a purposive sample of seven triads, including seven PTs, seven dedicated aides, and seven preschool toddlers with CP with function level III-IV of the Gross Motor Function Classification System. Each triad was video-recorded once. Data consisted of 371 minutes of video recordings analyzed using content analysis and enactive theory on participatory sense-making. RESULTS: From the analysis, three supervision approaches emerged: (1) the Cognitive Supervision approach; (2) the Joint Action Supervision approach; and (3) the Embodied Supervision approach. Each approach gives rise to different types of sense-making processes, ranging from merely reflective ways of knowing through verbal and visual conveyance to mutual embodied ways of knowing through joint actions and physical interplay. To make use of all approaches, PTs require incorporated handling skills and action competence. CONCLUSION: Supervision is an emergent process where knowledge is transformed through interactions and shared sense-making processes. IMPLICATIONS: Clinicians should be aware of the context-dependent and interactional factors that drive the supervision process.

Effects of Rehabilitation on Gait Pattern at Usual and Fast Speeds Depend on Walking Impairment Level in Multiple Sclerosis.

BACKGROUND: Physical rehabilitation can improve walking capacity in persons with multiple sclerosis (MS). However, changes in spatiotemporal gait parameters after rehabilitation are not frequently evaluated, and it is unknown to what extent potential effects depend on baseline disability level. The objective was to investigate the effectiveness of rehabilitation programs on gait parameters at usual and fastest speeds in persons with MS categorized according to walking speed. METHODS: This nonrandomized multinational study in "real-world" settings evaluated participants before and after conventional rehabilitation. Outcome measurements included spatiotemporal gait parameters assessed by an electronic walkway (at usual and fastest speeds), walking capacity tests (Timed 25-Foot Walk test, 2-Minute Walk Test, 6-Minute Walk Test), and the patient-reported 12-item Multiple Sclerosis Walking Scale. Patients were allocated into three subgroups based on walking speed (<0.82 m/s and >1.14 m/s) and MS center. Results were calculated for the total group and subgroups. RESULTS: Forty-two persons with MS (26 women; mean ± SD age, 44.6 ± 11.0 years; mean ± SD Expanded Disability Status Scale score, 3.5 ± 1.5) receiving rehabilitation treatment were enrolled. After rehabilitation treatment, the group demonstrated a significant decrease in double support time and an increase in stride length and step length (left leg) at usual and fastest speeds. Velocity and step length (right leg) increased only at usual speed. Subgroup analysis revealed greatest and clinically meaningful improvements in more disabled persons with MS. CONCLUSIONS: Physical rehabilitation induced changes in spatiotemporal gait parameters in persons with MS. The magnitude of improvement was greater in participants with more walking impairment.