Effectiveness of Technology-Based Distance Physical Rehabilitation Interventions for Improving Physical Functioning in Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: To study the effectiveness of technology-based distance physical rehabilitation interventions on physical functioning in stroke. DATA SOURCES: A systematic literature search was conducted in 6 databases from January 2000 to May 2018. STUDY SELECTION: Inclusion criteria applied the patient, intervention, comparison, outcome, study design framework as follows: (P) stroke; (I) technology-based distance physical rehabilitation interventions; (C) any comparison without the use of technology; (O) physical functioning; (S) randomized controlled trials (RCTs). The search identified in total 693 studies, and the screening of 162 full-text studies revealed 13 eligible studies. DATA EXTRACTION: The studies were screened using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and assessed for methodological quality and quality of evidence. Meta-analysis was performed if applicable. DATA SYNTHESIS: A total of 13 studies were included, and online video monitoring was the most used technology. Seven outcomes of physical functioning were identified-activities of daily living (ADL), upper extremity functioning, lower extremity functioning, balance, walking, physical activity, and participation. A meta-analysis of 6 RCTs indicated that technology-based distance physical rehabilitation had a similar effect on ADL (standard mean difference 0.06; 95% confidence interval: -0.22 to 0.35, P=.67) compared to the combination of traditional treatments (usual care, similar and other treatment). Similar results were obtained for other outcomes, except inconsistent findings were noted for walking. Methodological quality of the studies and quality of evidence were considered low. CONCLUSIONS: The findings suggest that the effectiveness of technology-based distance physical rehabilitation interventions on physical functioning might be similar compared to traditional treatments in stroke. Further research should be performed to confirm the effectiveness of technology-based distance physical rehabilitation interventions for improving physical functioning of persons with stroke.

A study of the psychometric properties of 12-item World Health Organization Disability Assessment Schedule 2.0 in a large population of people with chronic musculoskeletal pain.

OBJECTIVE: To assess the validity of the Finnish translation of the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0). DESIGN: Cross-sectional cohort survey study. SETTING: Physical and Rehabilitation Medicine outpatient university clinic. SUBJECTS: The 501 consecutive patients with chronic musculoskeletal pain. MAIN MEASURES: Exploratory factor analysis and a graded response model using item response theory analysis were used to assess the constructs and discrimination ability of WHODAS 2.0. RESULTS: The exploratory factor analysis revealed two retained factors with eigenvalues 5.15 and 1.04. Discrimination ability of all items was high or perfect, varying from 1.2 to 2.5. The difficulty levels of seven out of 12 items were shifted towards the elevated disability level. As a result, the entire test characteristic curve showed a shift towards higher levels of disability, placing it at the point of disability level of +1 (where 0 indicates the average level of disability within the sample). CONCLUSIONS: The present data indicate that the Finnish translation of the 12-item WHODAS 2.0 is a valid instrument for measuring restrictions of activity and participation among patients with chronic musculoskeletal pain.

Ten-year follow-up of health-related quality of life among ambulatory persons with multiple sclerosis at baseline.

PURPOSE: The aim of this 10-year follow-up study was to determine changes in health-related quality of life (HRQoL) over time among ambulatory persons with MS (PwMS) at the baseline using generic and disease-specific instruments. METHODS: Of 109 independently walking PwMS included in a population-based study in 2002, 77 (70.6 %) were re-assessed in 2012. HRQoL was captured using the 36-Item Short Form Survey Instrument (RAND-36), 15D instrument (15D), and the Multiple Sclerosis Quality of Life-54 (MSQOL-54). Repeated-measures ANOVA and effect size (ES) calculations (Cohen's d) were used in the statistical analysis. RESULTS: The RAND-36 physical health composite score (p = 0.003, ES = 0.26) and 15D total score (p = 0.012, ES = 0.25) declined from the baseline levels. In particular, lower scores were observed on the RAND-36 scales of physical functioning (p = 0.001, ES = 0.27), pain (p = 0.020, ES = 0.25), and general health perceptions (p = 0.002, ES = 0.36), on the MSQOL-54 scales of physical functioning (p = 0.001, ES = 0.27), pain (p = 0.040, ES = 0.21), sexual functioning (p = 0.003, ES = 0.43), and satisfaction with sexual functioning (p = 0.012, ES = 0.38), and in the 15D dimensions of mobility (p = 0.004, ES = 0.31) and sexual functioning (p ≤ 0.001, ES = 0.59). Improvement was observed on the RAND-36 scale of social functioning (p = 0.049, ES = 0.25). The other composite scores, scales, and dimensions remained unchanged. CONCLUSION: The results of this study suggest that ambulatory PwMS at baseline reported reduced HRQoL in physical functioning after a 10-year follow-up period, while emotional well-being was maintained and social functioning improved. The scores in the other HRQoL dimensions and scales remained unchanged. More long-term population-based studies are needed to precisely determine the development of HRQoL among PwMS.

Specific ICF training is needed in clinical practice: ICF framework education is not enough.

The use of a common language in interprofessional collaboration is essential. The World Health Organization's International Classification of Functioning, Disability and Health (ICF) has been identified as a unifying framework for interprofessional collaboration and the identification of client needs. Higher education institutions (HEIs) offer ICF framework education to students but is it enough to enable graduated professionals to implement the ICF in clinical work? In our experience, the ICF education provided by HEIs does not meet the requirements of clinical practice, which might be due to gaps in teaching ICF to students (education) and specific requirements for teaching ICF to professionals already working in rehabilitation (training). This paper discusses the need for the ICF training in practice and ways to address it. Although many rehabilitation center professionals had previously received ICF education provided by the HEIs, the rehabilitation centers felt the need to develop their own practical training materials that could be applied to their own environment. Overall, 18 different ICF-based materials were developed during the Erasmus+ project called INPRO to promote person-centered and interprofessional practice in the rehabilitation centers. The practical training using real cases was considered valuable. It could be further developed in cooperation with HEIs and vice versa. It could also be used to teach students, i.e., future colleagues. To deepen and broaden the integration of the different materials based on the ICF, it is important to continue the interactive discussion between HEIs and clinical practice, and between management and its staff.

Effectiveness of constraint-induced movement therapy on activity and participation after stroke: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To examine the effect of constraint-induced movement therapy and modified constraint-induced movement therapy on activity and participation of patients with stroke (i.e. the effect of different treatment durations and frequency) by reviewing the results of randomized controlled trials. DATA SOURCES: A systematic literature search was conducted in MEDLINE, CINAHL, EMBASE, PEDro, OTSeeker, CENTRAL and by manual search. REVIEW METHODS: Randomized controlled trials for patients over 18 years old with stroke and published in Finnish, Swedish, English or German were included. Studies were collected up to the first week in May 2011. The evidence was high, moderate, low or no evidence according to the quality of randomized controlled trial and the results of meta-analyses. RESULTS: Search resulted in 30 papers reporting constraint-induced movement therapy, including 27 randomized controlled trials published between 2001 and 2011. Constraint-induced movement therapy practice for 60-72 hours over two weeks produced better mobility (i.e. ability to carry, move and handle objects) with high evidence compared to control treatment. Constraint-induced movement therapy for 20-56 hours over two weeks, 30 hours over three weeks and 15-30 hours over 10 weeks improved mobility of the affected upper extremity. However, with self-care as an outcome measure, only 30 hours of constraint-induced movement therapy practice over three weeks demonstrated an improvement. CONCLUSION: Constraint-induced movement therapy and modified constraint-induced movement therapy proved to be effective on affected hand mobility and to some extent self-care on the World Health Organization's International Classification of Functioning, Disability and Health activity and participation component, but further studies are needed to find out the optimal treatment protocols for constraint-induced movement therapy.

20 Years of ICF-International Classification of Functioning, Disability and Health: Uses and Applications around the World.

The International Classification of Functioning Disability and Health (ICF) was approved in 2001 and, since then, several studies reported the increased interest about its use in different sectors. A recent overview that summarizes its applications is lacking. This study aims to provide an updated overview about 20 years of ICF application through an international online questionnaire, developed by the byline authors, and sent to each World Health Organization Collaborating Centers of the Family of International Classifications (WHO-FIC CCs). Data was collected during October 2020 and December 2021 and descriptive content analyses were used to report main results. Results show how, in most of the respondent countries represented by WHO-FIC CCs, ICF was mainly used in clinical practice, policy development and social policy, and in education areas. Despite its applications in different sectors, ICF use is not mandatory in most countries but, where used, it provides a biopsychosocial framework for policy development in health, functioning and disability. The study provides information about the needs related to ICF applications, that can be useful to organize targeted intervention plans. Furthermore, this survey methodology can be re-proposed periodically to monitor the use of the ICF in the future.

Psychometric properties of the Assessment Tool for Perceived Agency (ATPA-22) - utility for the rehabilitation of young adults not in education, employment or training (NEETs).

BACKGROUND: Promoting and supporting agency have been at the heart of the debate multidisciplinary. To promote self-awareness of young people's agency and identify persons in need of support the Assessment Tool for Perceived Agency (ATPA-22) was developed. AIM: This study aims to evaluate the psychometric properties of the ATPA-22. Participants were young adults not in education, employment or training (NEETs) and students in higher education (HEI). MATERIALS AND METHODS: The main data analysis was implemented by Many Faceted Rasch (MFR) analysis. RESULTS: The ATPA-22 items defined a unidimensional construct with reasonable internal consistency and separation ability. The ATPA-22 was capable of detecting differences between HEI students and young adult NEETs. Nine differential functioning items emerged between the groups. CONCLUSIONS: ATPA-22 shows promise as a tool to assess young adults' perceived agency. Anyhow, as the individual life situation affects strongly to perceived agency, research on the stability of the ATPA-22 among different populations is needed. SIGNIFICANCE: The purpose of the ATPA-22 is to measure perceived agency of individuals, and to identify aspects of agency in need for support. ATPA-22 can be used as a tool for promoting self-awareness of occupational challenges.

Correlation between Oswestry disability index and 12-item self-administered version of World Health Organization Disability Assessment Schedule (WHODAS 2.0) in patients with chronic low back pain.

The objective of the study was to investigate the correlation between the 12-item WHO Disability Assessment Schedule (WHODAS 2.0) and the Oswestry disability index (ODI). Prospective cross-sectional study of 1379 patients (age 48 years) with chronic low back pain. The Spearman's rank correlation test was employed. Of all the possible 143 correlations, 46 (32%) were strong and nine (6%) were very strong. The strongest correlations ≥0.6 were seen for 'personal care' (ODI) vs. 'washing whole body' (WHODAS 2.0), 'personal care' (ODI) vs. 'getting dressed' (WHODAS 2.0), 'walking' (ODI) vs. 'walking long distances' (WHODAS 2.0) and 'social life' (ODI) vs. the WHODAS 2.0 total score. In conclusion, while items defining physical functioning were mostly strongly correlated, items defining social or psychological functioning were less associated. Both scales could be used together providing valuable information regarding the functioning of people with chronic low back pain.

Avoiding the Banality of Evil in Times of COVID-19: Thinking Differently with a Biopsychosocial Perspective for Future Health and Social Policies Development.

The COVID-19 pandemic provides the opportunity to re-think health policies and health systems approaches by the adoption of a biopsychosocial perspective, thus acting on environmental factors so as to increase facilitators and diminish barriers. Specifically, vulnerable people should not face discrimination because of their vulnerability in the allocation of care or life-sustaining treatments. Adoption of biopsychosocial model helps to identify key elements where to act to diminish effects of the pandemics. The pandemic showed us that barriers in health care organization affect mostly those that are vulnerable and can suffer discrimination not because of severity of diseases but just because of their vulnerability, be this age or disability and this can be avoided by biopsychosocial planning in health and social policies. It is possible to avoid the banality of evil, intended as lack of thinking on what we do when we do, by using the emergence of the emergency of COVID-19 as a Trojan horse to achieve some of the sustainable development goals such as universal health coverage and equity in access, thus acting on environmental factors is the key for global health improvement.

Measuring deterioration in international classification of functioning domains of people with multiple sclerosis who are ambulatory.

BACKGROUND AND PURPOSE: Measures to detect important effects related to physical therapy interventions must be able to detect an important change. The purpose of this study was to select the most responsive physical functioning measures for multiple sclerosis (MS) using the International Classification of Functioning, Disability and Health (ICF) as a framework. SUBJECTS: The participants were 120 people with MS who were ambulatory from a population-based sample. METHODS: Physical functioning was assessed by quantitative clinical measures of activities (n=5) and body functions (n=7) and by self-reported performance in self-care, mobility, and domestic life domains in the activities and participation component of the ICF at baseline and 2 years later. A participant's perception of change and a change in Expanded Disability Status Scale (EDSS) scores were used as external criteria in the analysis of the receiver operating characteristic curve and the minimally important change score. The minimal detectable change was calculated as distribution-based responsiveness. RESULTS: According to the external criteria, 51% of the participants showed deterioration as measured by their own perceptions compared with the 26% of the participants who showed deterioration as rated by the clinician. Regardless of the external criterion applied, the measures most responsive to deterioration were self-reported scores in self-care, mobility, and domestic life; distance walked and change in heart rate during a 6-minute walk test; 10-m walk test speeds, stride length, and cadence; repetitive squatting; and Box and Block Test scores. DISCUSSION AND CONCLUSION: The results show the relative responsiveness of different measures in the subsample who deteriorated and provide data that can facilitate the interpretation of score changes in people with MS who are ambulatory for future studies and in clinical practice.

Effectiveness of technology-based distance physical rehabilitation interventions on physical activity and walking in multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To determine the effectiveness of technology-based distance physical rehabilitation interventions in multiple sclerosis (MS) on physical activity and walking. DATA SOURCES: A systematic literature search was conducted in seven databases from January 2000 to September 2016. Randomized controlled trials of technology-based distance physical rehabilitation interventions on physical activity and walking outcome measures were included. METHODS: Methodological quality of the studies was determined and a meta-analysis was performed. In addition, a subanalysis of technologies and an additional analysis comparing to no treatment were conducted. RESULTS: The meta-analysis consisted of 11 studies. The methodological quality was good (8/13). The Internet, telephone, exergaming, and pedometers were the technologies enabling distance physical rehabilitation. Technology-based distance physical rehabilitation had a large effect on physical activity (standard mean difference (SMD) 0.59; 95% confidence interval (95% CI) 0.38 to 0.79; p < 0.00001) compared to control group with usual care, minimal treatment, and no treatment. A large effect was also observed on physical activity (SMD 0.59; 95% CI 0.34 to 0.83; p < 0.00001) when compared to no treatment alone. There were no differences in walking and the subanalysis of technologies. CONCLUSIONS: Technology-based distance physical rehabilitation increased physical activity among persons with MS, but further research on walking in MS is needed. Implications for Rehabilitation Technology-based distance physical rehabilitation interventions increase physical activity among persons with MS. This study was unable to identify if the technologies (Internet, telephone, or combinations) lead to differing effects on physical activity or walking in the distance physical rehabilitation interventions in MS. Further research on the effectiveness of technology-based distance physical rehabilitation interventions on walking in MS is needed.

Measures of physical functioning predict self-reported performance in self-care, mobility, and domestic life in ambulatory persons with multiple sclerosis.

OBJECTIVE: To determine the associations between clinically measured physical functioning variables and self-reported performance in mobility, self-care, and domestic life in ambulatory persons with multiple sclerosis (MS), using the International Classification of Functioning, Disability and Health (ICF) as a framework. DESIGN: Survey study. SETTING: Community setting in Finland. PARTICIPANTS: A population-based sample of 120 ambulatory persons with MS (30 men, 90 women) with mean age 45.0+/-10.8 years (range, 20-71 y), mean disease duration from symptom onset 12.3+/-8.8 years (range, 1-39 y), and mean Expanded Disability Status Scale 2.8+/-2.0 (range, 0-6.5). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The primary dependent variables were self-reported performance in self-care, mobility, and domestic life from the Functional Status Questionnaire. The physical functioning variables were drawn from the ICF activities (n=9) and body functions (n=14) categories. Age- and sex-adjusted odds ratios from multinomial logistic regression were estimated for the physical functioning variables associated with activities of daily living (ADL) performance. RESULTS: Overall, of this cohort 31% reported difficulties or dependence in self-care, 52% in mobility, and 68% in domestic life. The most significant predictors of perceived difficulties or dependence in ADL performance were: (1) lower scores in the Box and Block Test; (2) lower Berg Balance Scale scores; (3) greater velocity moment when standing with eyes open; (4) slower ten-meter walk test times and shorter stride length at normal speed; and (5) shorter distance in the six-minute walk test. CONCLUSIONS: Perceived difficulties and dependence were most prominent in domestic life. In particular, measures of activities predicted difficulties in ADL performance. Monitoring of physical functioning should be extended to those independent MS persons reporting difficulties in ADL performance.

Physical functioning in multiple sclerosis: a population-based study in central Finland.

OBJECTIVE: To describe multiple sclerosis and its impact on individuals' perceived problems in functioning, particularly in the domains of self-care, mobility and domestic life. DESIGN: A population-based study in a prevalence cohort of multiple sclerosis subjects in Central Finland region carried out in the year 2000. SUBJECTS: A total of 240 subjects with multiple sclerosis. METHODS: A postal questionnaire for assessing physical functioning was developed. RESULTS: Ninety percent of the study population completed the study. Subjects' average age was 48.2 years (range 20-76 years) and time since symptom onset was 15.8 years (range 0-56 years). Of the subjects, 82% were fully independent in self-care activities and 53% in domestic life, 50% were able to walk without any perceived problems and 38% had a permanent need for a walking aid. Fatigue was the most frequent complaint having an impact on subjects' daily life. Ninety-five subjects out of 240 (40%) were engaged in working life. CONCLUSION: These data give a clear indication of favourable functioning in mobility, self-care and domestic life. However, the fact remains that multiple sclerosis is a disabling and costly disease. These results provide information for use by local and national authorities in planning and co-ordinating rehabilitation interventions and social services.

Progressive resistance training in Parkinson's disease: a systematic review and meta-analysis.

OBJECTIVES: To investigate if there is evidence on effectiveness of progressive resistance training in rehabilitation of Parkinson disease. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Central, Medline, Embase, Cinahl, Web of Science, Pedro until May 2014. Randomised controlled or controlled clinical trials. The methodological quality of studies was assessed according to the Cochrane Collaboration's domain-based evaluation framework. DATA SYNTHESIS: random effects meta-analysis with test for heterogeneity using the I² and pooled estimate as the raw mean difference. PARTICIPANTS: Adults with primary/idiopathic Parkinson's disease of any severity, excluding other concurrent neurological condition. INTERVENTIONS: Progressive resistance training defined as training consisting of a small number of repetitions until fatigue, allowing sufficient rest between exercises for recovery, and increasing the resistance as the ability to generate force improves. COMPARISON: Progressive resistance training versus no treatment, placebo or other treatment in randomised controlled or controlled clinical trials. PRIMARY AND SECONDARY OUTCOME MEASURES: Any outcome. RESULTS: Of 516 records, 12 were considered relevant. Nine of them had low risk of bias. All studies were randomised controlled trials conducted on small samples with none or 1 month follow-up after the end of intervention. Of them, six were included in quantitative analysis. Pooled effect sizes of meta-analyses on fast and comfortable walking speed, the 6 min walking test, Timed Up and Go test and maximal oxygen consumption were below the level of minimal clinical significance. CONCLUSIONS: There is so far no evidence on the superiority of progressive resistance training compared with other physical training to support the use of this technique in rehabilitation of Parkinson's disease. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO 2014:CRD42014009844.

Reliability of physical functioning measures in ambulatory subjects with MS.

BACKGROUND AND PURPOSE: One of the primary reasons for measuring outcomes during rehabilitation is to determine the effect of physiotherapy. Repeated measurement situations are susceptible to several sources of error, including inconsistencies caused by the subject, the procedure, the instrument and the examiner. Therefore, the reliability of the measures needs to be examined. METHOD: The present study used a repeated-measures design. Two studies were undertaken to examine the test-retest and inter-rater reliability for physical functioning measures. The interval between the measurements was one week. The sample consisted of 19 ambulatory subjects with multiple sclerosis (MS) in the test-retest and nine subjects in the inter-rater reliability study. The measures were selected to assess different domains of the World Health Organization International Classification of Functioning, Disability and Health (WHO, 2001). Several parameters of the Box and Block Test (BBT), the Berg Balance Scale (BBS), the Kela Coordination test, the postural stability test, the timed 10-metre gait test, the six-minute walk test, the shoulder tug test, grip strength, maximal isometric force of the knee extensors, muscle endurance tests, the modified Ashworth Scale and passive straight leg raise test were examined in terms of reliability. RESULTS: The intra-class coefficient (ICC) values for test-retest reliability were >0.80 in 17 of 23 parameters, and correspondingly so in 20 out of 26 parameters for inter-rater reliability. Poor reliability (defined as ICC < or = 0. 60) was obtained only for the patient classification index (PCI) of the six-minute walk test in the test-retest reliability study. In general, the coefficient of variation was good. A moderate amount of variability was discovered for the Kela Coordination test, and for postural stability and muscle endurance tests. The data obtained from the modified Ashworth Scale and the shoulder tug test were highly skewed and the percentage of agreement ranged between 63.9% and 93.4%. CONCLUSIONS: The study revealed acceptable test-retest and inter-rater reliability of these measures in ambulatory subjects with MS, with the exception of the Modified Ashworth Scale and the shoulder tug test.

Evidence for the effectiveness of walking training on walking and self-care after stroke: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To examine the effect of randomized controlled trials of walking training on walking and self-care in patients with stroke. DATA SOURCES: MEDLINE, CINAHL, Embase, PEDro, OTSeeker, Central, and manual search to the end of August 2012. STUDY SELECTION: English, Finnish, Swedish, or German language walking training randomized controlled trials for patients over 18 years of age with stroke. DATA SYNTHESIS: The meta-analyses included 38 randomized controlled trials from 44 reports. There was high evidence that in the subacute stage of stroke, specific walking training resulted in improved walking speed and distance compared with traditional walking training of the same intensity. In the chronic stage, walking training resulted in increased walking speed and walking distance compared with no/placebo treatment, and increased walking speed compared with overall physio-therapy. On average, 24 training sessions for 7 weeks were needed. CONCLUSION: Walking training improves walking capacity and, to some extent, self-care in different stages of stroke, but the training frequency should be fairly high.

Reliability of the Dynamic Gait Index (Finnish version) in individuals with neurological disorders.

PURPOSE: To produce a Finnish version of the Dynamic Gait Index (DGI) and establish its reliability in people with neurological disorders affecting balance. METHOD: A consecutive sample of 33 participants in inter-rater and 30 participants in intra-rater sample were tested. The DGI was administered in two testing sessions 1-2 h apart. Reliability was assessed with the intra-class correlation coefficient (ICC), Bland-Altman 95% limits of agreement, coefficient of reproducibility (CR), and standard error of the mean (SEM). RESULTS: The instructions from the original DGI were preserved during the translation process with no need for cultural adaptations. The relative reliability of the total scores proved to be high in inter-rater (ICC = 0.90) and intra-rater (ICC = 0.91) testing. The relative reliability between single items varied from poor to high in inter-rater (r = 0.57-0.96) and intra-rater (r = 0.20-0.97) testing. Absolute reliability of the total score was high, and in single items, it varied similarly to relative reliability. The SEM was 1.2 points in inter-rater and 0.8 points in intra-rater testing. CONCLUSIONS: The Finnish version of DGI was produced and found to be a reliable tool for clinical testing of balance in neurological patients with balance disorder.

Effects of physiotherapy interventions on balance in multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To determine the effects of physiotherapy interventions on balance in people with multiple sclerosis. DATA SOURCES: A systematic literature search was conducted in Medline, Cinahl, Embase, PEDro, both electronically and by manual search up to March 2011. STUDY SELECTION: Randomized controlled trials of physiotherapy interventions in people with multiple sclerosis, with an outcome measure linked to the International Classification of Functioning, Disability and Health (ICF) category of "Changing and maintaining body position", were included. DATA EXTRACTION: The quality of studies was determined by the van Tulder criteria. Meta-analyses were performed in subgroups according to the intervention. DATA SYNTHESIS: After screening 233 full-text papers, 11 studies were included in a qualitative analysis and 7 in a meta-analysis. The methodological quality of the studies ranged from poor to moderate. Low evidence was found for the efficacy of specific balance exercises, physical therapy based on an individualized problem-solving approach, and resistance and aerobic exercises on improving balance among ambulatory people with multiple sclerosis. CONCLUSION: These findings indicate small, but significant, effects of physiotherapy on balance in people with multiple sclerosis who have a mild to moderate level of disability. However, evidence for severely disabled people is lacking, and further research is needed.